cardio.pulm Flashcards
A 17 year old is seen for chronic nasal obstruction. She reports inability to breathe through her nose for several months. She has a history of recurrent bronchitis, sinusitis, and chronic cough. Review of systems is pertinent for bulky stools with a greasy film left in the toilet. The family history is noncontributory. On physical examination, her weight is at the 80th percentile and body mass index is at the 78th percentile. There is bilateral nasal obstruction with polypoid material filling both antra. Her oropharynx is clear. Chest examination is notable only for a few inspiratory crackles in the left upper chest posteriorly; no wheezing is heard. Point of maximum cardiac impulse is in the left midclavicular line. Her abdomen is soft and there is no hepatosplenomegaly. There is no digital clubbing.
Serum IgE values are normal and radioallergosorbent test for multiple inhalant antigens shows negative results. Pulmonary function testing shows a mild combined restrictive and obstructive pattern with no bronchodilator response.
Of the following, the MOST appropriate next diagnostic step is
A. CFTR mutation analysis
B. computed tomography of the sinuses
C. quantitative immunoglobulin determination
D. sweat chloride measurement
sweat chloride measurement
nasal polyposis, chronic cough with nonreversible obstruction on pulmonary function testing, and signs of malabsorption make cystic fibrosis. Measurement of chloride in a sample of sweat obtained via pilocarpine iontophoresis
An expectant mother is seen for a prenatal visit. Prenatal genetic testing performed on her fetus showed karyotype 45,X. She will be meeting with a genetic counselor in the coming days.
Of the following, the MOST likely cardiac disorder to be seen in this fetus is
A. aortopulmonary window
B. coarctation of the aorta C. tetralogy of Fallot D. truncus arteriosus
coarctation of the aorta
ndividuals with Turner syndrome can have congenital heart disease in the form of coarctation of the aorta, bicuspid aortic valve, aortic dilation, anomalous pulmonary venous drainage, persistent left superior vena cava, sinus tachycardia, and prolonged QT.
Although the occurrence is rare, individuals with Turner syndrome can have aortic dissection, which typically is fatal.
Individuals with Turner syndrome can have involvement of multiple organ systems, including renal, endocrine, skeletal, auditory, and visual.
Individuals with Turner syndrome typically do not have intellectual or motor delays.
A 16-year-old adolescent is having a sports preparticipation physical examination 1 week before the start of the cross country running season. Based on her responses on the required history and physical examination form (Item Q69), additional information is obtained about a syncopal event that occurred while she was running in the first meet of her cross country season last year. She recovered immediately, and finished the remainder of her season without incident. The girl and her mother attribute this episode to dehydration and low blood sugar, though no medical evaluation was performed. Her medical history is significant for anxiety; the mother reports that her daughter gets very nervous before her track meets.
On physical examination, the girl’s lungs are clear to auscultation, cardiac findings are normal, and pulses are symmetrically present in all extremities. The remainder of her physical examination findings are within normal limits.
Of the following, the BEST next management step for this girl is to
A. provide clearance for full participation and counseling on pre-exercise nutrition and hydration B. provide provisional clearance with the girl’s commitment to pursue cognitive behavioral therapy C. withhold clearance for all sports participation pending cardiac evaluation D. withhold clearance pending results of fasting blood glucose level, electrolyte levels, and complete blood cell count
withhold clearance for all sports participation pending cardiac evaluation
Syncope during exertion is a potentially ominous event, and children with exercise-associated syncope should be withheld from any activity requiring significant exertion until they have had a full cardiac evaluation.
Collapse during high levels of exertion is more concerning than collapse after completion of high level exertion activity.
Children who have had a syncopal event should undergo a physical examination with a cardiac assessment including:
Vital signs
Peripheral pulses: symmetry, amplitude, and timing
Cardiac auscultation when supine and standing, with or without the Valsalva maneuver.
Heat syncope is a less severe form of heat-related illness that typically occurs with prolonged standing and is less common during exercise. Exertional hyponatremia is typically described in endurance events longer than 4 hours in duration, and is much less common in events of shorter duration. However, some athletes who aggressively rehydrate with hypotonic fluid and do not replenish dietary sodium in between exercise sessions may be at increased risk with multiple rigorous exercise sessions per day
A 15-year-old adolescent girl is evaluated in the office for a 2-month history of chronic nonproductive cough associated with fatigue, 5- to 10-lb weight loss, low-grade fever, and mildly painful nodules on her arms and legs. She has not traveled out of the state or had any known sick exposures. On pulse oximetry, her oxygen saturation is 98% on room air. On physical examination, the girl has no respiratory distress, and no crackles or wheezes are heard. She has several 1- to 3-cm diameter, tender, nonerythematous, nonexcoriated nodules on the extensor surfaces of both arms and legs.
Chest radiography suggests hilar adenopathy. Computed tomography additionally demonstrates interstitial changes in the pulmonary parenchyma. Pulmonary function testing shows a mild restrictive pattern with a decrease in forced vital capacity and total lung capacity. Carbon monoxide diffusion is slightly decreased for age and hemoglobin concentration. A tuberculin skin test has a negative result 60 hours after placement.
Of the following, the BEST next step in the evaluation of this adolescent is
A. biopsy of a skin nodule
B. bronchoscopy and bronchoalveolar lavage
C. repeat spirometry after administration of albuterol
D. 6-minute walk test
biopsy of a skin nodule
Sarcoidosis is diagnosed based on the presence of noncaseating granulomas in affected tissues.
The lungs, skin, eyes, and lymph nodes are the organs most commonly affected by sarcoidosis.
Sarcoidosis is 4 times more common in black than white populations, and more common in women than men.
A male neonate born several hours ago is transferred to the special care nursery because of cyanosis noted by the nurse. His mother received limited prenatal care but had unremarkable prenatal laboratory results. The neonate is afebrile. He has a heart rate of 160 beats/min, a blood pressure of 75/45 mm Hg in the right upper extremity, a blood pressure of 78/46 mm Hg in the right lower extremity, a respiratory rate of 60 breaths/min, and an oxygen saturation of 70% that increases to 74% after the addition of supplemental oxygen. He is breathing comfortably and has clear breath sounds. His heart rate is regular with a normal S1 and S2 and a grade 3/6 pansystolic murmur heard best at the lower left sternal border. His hands and feet are slightly cool, but he is otherwise warm and well-perfused. His liver is palpated 2 to 3 cm below the costal margin. A chest radiograph is obtained (Item Q91).
Of the following, the MOST likely diagnosis for this neonate is
A. Ebstein anomaly B. hypoplastic left heart syndrome C. truncus arteriosus D. ventricular septal defect
Ebstein anomaly
Cyanotic congenital heart disease occurs as a result of complete intracardiac mixing, decreased pulmonary blood flow, obstructed pulmonary venous return, or transposition physiology with inadequate intracardiac mixing.
Many cyanotic congenital heart disease lesions (not truncus arteriosus or total anomalous pulmonary venous connection) require the initiation of prostaglandin infusion shortly after birth.
A 6-month-old girl with Down syndrome and a complete atrioventricular septal defect is admitted for surgical repair of the heart defect. On postoperative day 5, she develops a fever. Her vital signs include a temperature of 39.6°C, heart rate of 158 beats/min, respiratory rate of 53 breaths/min, and blood pressure of 85/41 mm Hg. She is receiving mechanical ventilation. Her breath sounds are coarse. There is a II/VI systolic murmur, and the liver edge is palpable 3 cm below the costal margin.
Laboratory tests show the following:
Laboratory Test
Result
White blood cells
14,500/µL (14.5 × 109/L)
Hemoglobin
9.0 g/dL (90 g/L)
Platelet count
270 × 103/µL (270 × 109/L)
Differential count
72% segmented neutrophils, 12% lymphocytes, 16% monocytes
C-reactive protein
5.9 mg/L (56 nmol/L)
Blood culture
Enterococcus gallinarum
Urinalysis
Slightly cloudy, protein 1+, nitrite negative, leukocyte negative
Of the following, the diagnostic study MOST indicated in this patient is
A. abdominal ultrasonography B. chest radiography C. echocardiography D. urine culture
echocardiography
Endocarditis should be considered in the setting of enterococcal bacteremia in children with congenital heart disease or children with prolonged bacteremia after appropriate treatment and source control (ie, vascular device removal).
Invasive enterococcal infections are largely nosocomial in origin.
Enterococci can cause a wide array of human infections including those of the urinary tract, abdominal cavity, and bloodstream and, less commonly, present as endocarditis and meningitis.
Endocarditis should be considered in the setting of enterococcal bacteremia in children with congenital heart disease or children with prolonged bacteremia after appropriate treatment and source control (ie, vascular device removal). After staphylococci and streptococci, enterococci are the third most common cause of endocarditis.
