Interstitial Lung Disease CIS Flashcards
75 year old male with an abnormal chest x-ray. He had a normal chest x-ray six months ago. He has a 60 pack year smoking history. Three weeks ago he noticed myalgias in his shoulder and neck along with fatigue and a sinus infection. He was treated with antibiotics 2 weeks ago by another doctor with no results. In the past four days he has had hemoptysis with blood streaked sputum. He has had a 20 lb weight loss for the past month. Exam reveals a temperature of 99F. Scattered crackles are heard bilaterally. There are no skin findings and no joint findings. Your office chest x-ray shows bilateral lung nodules, some of which have cavitated
Hgb 9.2g/dL WBC 10,700 Na 131 K 5.2 CA 8.0mg/dl Creatinine 6 mg/dl UA 51-100 rbc/hpf, 4-10 WBC/hpf
The most likely diagnosis is:
A. Acute interstitial fibrosis B. Disseminated histoplasmosis C. Wegner’s granulomatosis D. Metastatic bronchoalveolar cell carcinoma E. Goodpasture’s syndrome
wgeners granulomatosis
Differential Diagnosis of Cavitary Lung Lesions
C Carcinoma: squamous cell, melanoma, cervical, sarcoma metastasis
A Autoimmune: Wegner’s, rheumatoid lung
V Vascular: bland/septic emboli
I Infection: TB, fungal (coccidio, aspergillosis, cryptosporidia, nocardia) bacterial ( esp. GNR, staph, strep
T Trauma
Y Young congenital lesions (bronchogenic cyst or communicating sequestration
61 year old male has worsening shortness of breath over the last year. He now becomes short of breath walking only a short distance, and has trouble with simple activities of daily living. This resolves when he lies down. He has a hacking cough that is nonproductive. He admits to a 50 pack year history of smoking, though he quit 5 years ago. Past medical history is significant for atrial fibrillation, hypertension, rheumatoid arthritis, and depression. Current medications include amiodarone, hydrochlorothiazide, and methotrexate.
BP 135/85 mm Hg, P 83/min, RR 25/min, and Temp 98.6 F Chest examination reveals diffuse, dry, “Velcro-like” crackles two thirds of the way up the chest. Cardiac examination shows an elevated jugular venous pressure and a widely split S2. The extremities have 1+ pitting lower extremity edema and marked clubbing. A chest radiograph shows mild bibasilar interstitial reticular markings and some possible atelectasis.
PFT’s show:
FVC 2.31 L 52% of predicted
FEV1 1.89 L 51% of predicted
FEV1/FVC 0.81 98% of predicted
Which of the following is the most appropriate next step in management?
A. Perform a methacholine challenge test.
B. Empiric trial of interferon and steroids
C. Start him on high dose oral corticosteroids
D. Stop amiodarone and methotrexate, follow pulmonary function tests
E. Initiate bronchodilator therapy with albuterol and add an inhaled steroid
stop amiodarone and methotrexate, follow pulmonary function tests
Amiodarone Lung
Usually 2-4 months at doses greater than 400 mg/day
Lipid laden foamy alveolar macrophages
Organizing pneumonia
25% of cases. Mimics infectious pneumonia
ARDS
Post surgical. Diffuse alveolar damage with interstitial pneumonitis 1-4 days post intubation.
Diffuse alveolar hemorrhage
Rare. First few days to 6 months
Solitary Pulmonary Mass
rare
50 year old male complains of increasing shortness of breath with exercise over the last year. Previously he has been healthy. He denies any fever, palpitations, hemoptysis, or weight loss. He denies any occupational exposure. He reports a dry cough. He does not take any medications and has no known drug allergies. He denies a smoking history. His oxygen saturation is 93% on room air. Lungs have a fine crackle pattern. Heart is regular. Examination of the extremities shows clubbing. Chest x-ray reveals diffuse linear opacities. Pulmonary function tests show a restrictive pattern. He has a decreased diffusion capacity.
Which of the following is the most likely diagnosis?
A. Acute interstitial pneumonia B. Asbestosis C. Idiopathic cardiomyopathy D. Idiopathic pulmonary fibrosis E. Sarcoidosis
idiopathic pulmonary fibrosis
27 year old female complains of feeling short of breath recently. Her exercise tolerance has dwindled and she must rest at the top of a flight of stairs. She had been previously healthy and had attributed the change to deconditioning. She denies fever, but has an occasional dry cough. She has no allergies and does not smoke or use illicit drugs. On review of systems, she sleeps well, is able to lie flat in bed, has not had any rashes and there has been no change in bowel habits or vison. Temp 98.6 F, BP 132/68 mm Hg, pulse 88/min, and RR 18/min. O2 Sat on room air is 98% resting and 92% after 5 minutes of exercise. Spirometry is normal.
Physical examination reveals scattered crackles, but no wheezes in the lungs, normal cardiac rhythm, with no murmurs, no cyanosis, clubbing, or edema of the extremities. Chest x-ray reveals bilateral hilar lymph nodes. Purified protein derivative (PPD) is negative. Pulmonary function testing demonstrates a restrictive ventilatory defect.
Which of the following is the next most appropriate step?
1) Begin empiric antimicrobial therapy with a macrolide antibiotic
2) Obtain a transbronchial lymph node biopsy
3) Obtain a Quantiferron Gold test
4) Start her on inhaled corticosteroids
obtain a transbronchial lymph node biopsy
61 year old female with 3 day history of progressive shortness of breath, nonproductive cough, and fever. At present, the patient is able to ambulate 15 feet before becoming dyspneic. Prior she was functional and walked 2 miles in the evening after dinner with her husband. Additionally, she report one episode of hemoptysis the evening before this presentation. The hemoptysis was approximately 3 ml and maroon. She has had no prior episodes of hemoptysis and denies any lightheadedness. She has a history of SLE, and 5 years ago was diagnosed with cerebritis and lupus nephritis by renal biopsy
The patient is on prednisone and trimethoprim/sulfamethoxazole.
If pulmonary function tests reveal an increased DLCO in this patient, which of the following is the most likely diagnosis?
A. ARDS B. Diffuse alveolar hemorrhage C. Pneumonia D. Pulmonary edema E. Pulmonary embolism
Her vital signs are: Temp 100.4F, BP 151/87 mm Hg, pulse 98/min, RR 16/min and oxygen sat of 91% on 6L O2 by nasal cannula. Chest x-ray reveals diffuse infiltrates bilaterally.
a couple of things can cause this
increased diffusion of co, either alveolar hemorrhage or polycythemia
asnwer is b
30 year old male is brought to the ER after a syncopal episode. He has not had episodes in the past. He has no fever, chills, shakes, nausea, or vomiting. He denies chest pain or palpitations. He takes no medications and has no allergies. He denies drug use. Vital signs are stable. Cardiac examination is unremarkable. Rhythm strip reveals nonsustained ventricular tachycardia. Laboratory studies are normal. Chest x-ray reveals bilateral hilar adenopathy. He has a history of a positive skin test for anergy. His serum calcium is elevated. Echocardiogram reveals segmental wall motion abnormality. He undergoes a biopsy of the myocardium and you are awaiting the results.
You correctly ascertain that upon receiving the biopsy results you will?
A. Observe at home with a holter monitor
B. Begin treatment for a disorder associated with noncaseating granulomas
C. Administer a PPD test
D. Perform a DLCO test
E. Begin therapy with antifungals for treating histoplasmosis
sarcoidosis elevated calcium noncaseating anergy skin test (no ppd or pos tst for candida) vtac (anything wrong with ehart)
b
30 year old male with a 15 pack year history of smoking. Three weeks ago he developed a URI, treated with Azithromycin.
Three days ago he developed marked SOB and a cough associated with marked hemoptysis. Examination reveals a BP of 160/95 and a RR of 20. Heart exam reveals a sinus tachycardia. His lips are cyanotic. He has 2+ pretibial edema. His BUN is 60 and Creatinine is 4.0. Urinalysis demonstrates microscopic hematuria.
Which of the following would help confirm the most likely diagnosis?
A. DLCO
B. Anti Glomerular Basement Membrane Antibody ( Anti-GBM)
C. C-ANCA
D. Alpha-1-Antitrypsin
E. Kveim test, Serum Calcium, Serum ACE levels
c anca
37 year old African American man is seen with raised red lesions on the anterior aspect of both legs. He has difficulty breathing, especially while walking at a fast pace, associated with a dry cough for the last 2-3 months. He denies fever, night sweats, weight loss, or any other symptoms. He has never smoked. BP 135/80 mm Hg, Pulse 52/min, RR 14/min. He is afebrile. Auscultation of his chest reveals discreet dry rales bilaterally with no wheezing. Heart auscultation reveals an irregular rhythm. Examination of his lower extremities shows raised red-purplish lesions on both anterior aspects of both legs. His PaO2 is 97 mm Hg at rest on room and becomes 94 mm Hg with exercise
An EKG shows episodes of second-degree AV block.
A chest x-ray reveals a diffuse bilateral reticulonodular pattern and bilateral hilar adenopathy. A bronchoscopy with transbronchial biopsy reveals noncaseating granulomas A PFT shows a decreased TLC and RV with an FEV1/FVC of 95%of predicted. Laboratory studies show minimally elevated calcium and ACE levels. Other lab studies are normal.
After you review this patient’s clinical presentation and findings, which of the following is the most appropriate treatment plan at this time?
A. Begin therapy with high-dose systemic corticosteroids
B. Follow ACE levels, Chest x-rays, and O2 sats, and employ “watchful waiting”
C. Place a transvenous pacemaker
D. Start treatment for TB
E. Start an appropriate antibiotic regimen accepted for this condition
a sarcoidosis
75 year old male comes to the office complaining of severe dyspnea that has been ongoing for the past 1 year. He denies a cough, chest pain, hemoptysis, or weight loss. He has a significant smoking history of two pack per day for the past 50 years. He has no other medial issues. He has no allergies and takes no medications
He worked as a stone engraver until 10 years ago when he retired. His vital signs are stable. Pulmonary examination reveals end expiratory crackles bilaterally. He has clubbing. His chest x-ray reveals multiple sub centimeter nodules and eggshell calcifications of hilar lymph nodes.
Which of the following is the most likely diagnosis
A. Adenocarcinoma B. Asbestosis C. Idiopathic pulmonary fibrosis D. Silicosis E. Tuberculosis
D
egg shell cacifications are pathenemonic for this
50 year old female presents with acute dyspnea. Her symptoms began with dry cough, shortness of breath, malaise, and fever seen days earlier. She is brought to the ER in acute hypoxemic ventilatory failure. pH 7.30, PaCO2 65, PaO2 55 on 100% FiO2 intubated and on ventilator.
Her chest x-ray demonstrates diffuse alveolar infiltrates and air space consolidation suggestive of ARDS.
A CT scan reveals bilateral air apace consolidation with areas of ground glass opacities with little honeycombing. Septal thickening and subpleural distribution of the opacities is noted
A lung biopsy reveals diffuse alveolar damage.
She is treated with mechanical ventilation, steroids, and antibiotics. She dies two days later.
Which of the following is the most likely diagnosis?
A. Acute interstitial pneumonia B. Asbestosis C. Idiopathic cardiomyopathy D. Idiopathic pulmonary fibrosis E. Sarcoidosis
A, rapid, sever hypxia, ards on xray
49 year old man has a chest x-ray as part of a pre-op workup before gastric bypass surgery. The surgeon who reviews the film is concerned because there appear to be small nodules in the lateral aspects of the left lung field. A high resolution CT scan is ordered, which further defines these nodules.
After review by the radiologist, the opacities seen on chest radiograph are felt to be pleural-based. At least eight focal areas of pleural plaques are visible, as well as areas of diffuse pleural thickening, subpleural linear densities, and areas of basilar fibrosis. Although the patient states that he has no respiratory complaints and he never smokes, a set of pulmonary function tests reveal a borderline restrictive pattern and a diminished diffusion capacity of the lung for carbon monoxide (DLCO)
Which of the following aspects of this patient’s history is most likely to explain these abnormal findings? A. Dietary/nutritional review B. Family medical history C. Occupational history D. Review of symptoms E. Travel history
first thought is asbestosis, that is rigth so answer is C
37 year old male presents with 2-3 weeks of increasing dyspnea, occasional hemoptysis, sinusitis, and on episode of epistaxis. Renal function is normal. His UA reveals 10-15 RBCs and 2 WBCs. His chest x-ray demonstrates bilateral nodular infiltrates. One is cavitary.
Which of the following is true?
A. His diagnosis is most likely Tuberculosis
B. His diagnosis is most likely Goodpastures syndrome
C. He will have a positive test for c-ANCA
D. He will have an elevated ACE level
E. He will soon develop congestive heart failure
c anca wegeners
27 year old female presents to the ER with cough, fever, dyspnea, weight loss, malaise, and night sweats for the past week. She complains of recent onset of wheezing during this time as well. Her CBC demonstrates a marked eosinophilia with over 35% eosinophils. Her chest x-ray demonstrates peripheral, nonsegmental alveolar infiltrates and possible non-cavitating lung lesions. You suspect asthma and a superimposed infection. You treat her with albuterol by inhalation and large doses of oral corticosteroids. The infiltrates on the chest x-ray resolve in 2 days and she becomes asymptomatic.
She is sent home and returns to the ER in three weeks with the same symptoms. She has also now developed symptoms of diarrhea and abdominal pain with diarrhea.
Your correct diagnosis is? A. Asthma with associated mucus plugs and atelectasis B. Bronchiectasis C. Chronic eosinophilic pneumonia D. Churg – Strauss Syndrome E. Goodpasture’s variant
c and both have eosinophilia
Patient is a 50 year old female that presents with increased difficulty breathing, cough, and exertional dyspnea. She is a non-smoking housewife. She is married. Her husband is a wood worker and fixes / remodels old buildings and warehouses for a living. Physical exam demonstrates bibasilar fine crackles on auscultation along with the presence of clubbing. Chest x-ray shows basilar opacities and bilateral calcified pleural plaques.
Based upon the history and these findings, you expect to diagnose?
A. Idiopathic pulmonary fibrosis B. Asbestosis C. BOOP D. Kaplan’s syndrome E. Collagen vascular disease of the lung
asbestosis
65 year old male that has been retired for the past four years. He is sent to you for evaluation because of an abnormal chest x-ray. As you review the x-ray you note that there are rounded opacities, 1-5 mm in size in the upper lung zones. Egg-shell calcifications are noted in the region of the hilar and mediastinal lymph nodes. He tells you that he has been having increasing SOB for the last 2 years. He is thin and using accessory muscles of respiration. BP is 140/80, Pulse 90 and regular, Lung sounds exhibit decreased flow and some fine crackles at the end of expiration.
Based upon your presumptive diagnosis, you correctly :
A. Apply a PPD intermediate skin test
B. Place this patient on a Beta 2 agonist
C. Place this patient on inhaled corticosteroids
D. Start him on chemotherapy
E. Order an echocardiogram
a he has silicosis and you cant treat it but he is susceptivle to tb
65 year old male who retired to Pueblo, CO after working the mines of West Virginia for twenty-five years. Over the years he has had increasing difficulty with shortness of breath. He can no longer walk up the stairs to his bedroom, and now sleeps on the living room sofa. Physical exam reveals right-sided heart failure with 2+ pretibial edema, a prolonged expiratory phase, and diffuse wheezing
The underlying pathology in this patient is:
A. Localized fibrous plaques or, rarely, diffuse pleural fibrosis
B. Coalescence of particle containing macules that form discrete areas of interstitial fibrosis causing distention of the respiratory bronchioles, forming focal areas of emphysema.
C. The development of noncaseating granuloma formation.
D. Fibrosis secondary to the effects of anti-GBM antibody
E. The development of chronic mucopurulent infections causing dilation of the respiratory bronchioles
b
sleeping downstairs bc he is too short of breath
coalwerkers pneumoconiosis
35 year old coal miner that has a history of rheumatoid arthritis. He is being treated with Methotrexate, gold injections, and Aspirin. Your are asked to consult based upon an abnormal chest x-ray that demonstrates multiple calcified pulmonary nodules throughout the lung fields bilaterally. The presence of a pleural effusion is also noted in the left lower lung field.
You correctly diagnose:
A. Silicosis B. Caplan’s syndrome C. Sarcoidosis D. Miliary Tuberculosis E. Coal Workers Pneumoconiosis
b
arthritis causes
47 year old roofer from Malawi who is seeing you because of increased shortness of breath of increasing duration. He smokes 1 pack of “Lucky Strike” cigarettes daily and has done so for the last thirty years. He has been in the US for the last two years and now works in the roofing industry here in Colorado. He has a chronic non productive cough. His chest x-ray demonstrates small, irregular, shadows in lower lung zones along with thickened pleural calcified plaques present under diaphragms and lateral chest wall.
Physical exam reveals fine end respiratory crackles heard more predominantly in the lung bases bilaterally and digital clubbing is noted.
Pulmonary function testing shows a decreased vital capacity, decreased total lung capacity, and a decreased DLCO.
You expect to find which of the following on lung biopsy?
A. Caseating granulomas
B. Discrete pale nodules in the upper zones of the lungs that have coalesced into hard, collagenous scars.
C. Golden brown, fusiform rods with a translucent center consisting of particulate fibers coated with an iron-containing proteinaceous material
D. A lymphocytic alveolitis leading to pulmonary fibrosis
E. Lymphocytes, plasma cells, and macrophage aggregates resulting in interstitial fibrosis and obliterative bronchiolitis
c
64 year old male with a chief complaint of increasing SOB, a 20 lb weight loss over the last three months, and non pleuritic chest pain.
On examination he has dullness to percussion on the right lung base and bilaterally diminished breath sounds that is more pronounced on the right. He has positive JVD, distant heart sounds, and a pulsus paradoxus of 18 mm. There is low voltage on the EKG
Chest x-ray reveals a nodular, irregular pleural thickening noted on the right side with a right sided pleural effusion and a pericardial effusion with a greatly enlarged heart. He has never smoked. He immigrated to the United States from Ireland where he was employed as a ship builder and “shipyard worker for 50 years. He has helped build battle ships, cruise ships, and heavy freighters.
You perform a thoracentesis to retrieve pleural fluid for diagnostic purposes, expecting to find:
A. Pleural fluid that stains positive for Acid Fast Bacilli.
B. Pleural fluid analysis with an uncharacteristically low random sugar.
C. Pleural fluid analysis compatible with a transudate as seen in CHF
D. Pleural fluid analysis with beryllium residue
E. Pleural fluid analysis with cells compatible with malignant mesothelioma
E
may have to do pleural biopsy
Light Criteria for Exudate
- Pleural fluid protein/serum protein > 0.5
- Pleural fluid LDH/Serum LDH > 0.6
- Pleural fluid LDH more than two-thirds normal upper limit for serum
35 year old male who has a complaint of progressive dyspnea on exertion, anorexia, night sweats, and a 10 lb weight loss over the last five months. He is employed as a nuclear technician at a power plant in Louisiana. Because of hurricane Katrina, he evacuated La, and is now in Fort Worth. On examination, he has mildly decreased breath sounds bilaterally. The remainder of the examination is normal. Chest x-ray examination reveals bilateral fibrosis with marked bilateral hilar adenopathy. He was previously diagnosed as having sarcoidosis. You review his chart and note that he has positive skin tests to mumps and trichophyton, a normal serum ACE level, and a normal serum calcium.
Because you are a “sharp clinician” you correctly:
A. Perform a pleural biopsy looking for asbestosis
B. Perform a BAL for a beryllium lymphocyte proliferation test
C. Perform a bronchoscopy looking for a non-caseating granuloma.
D. Perform a BAL looking for ACE levels in the aspirate
E. Perform a parotid gland biopsy for Heerfordt’s syndrome
b
