Interstitial Lung disease CIS (Kinder) 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
Wegner’s !!
most likely b/c there was sinus infection, lung involvement and kidney involvement
differential diagnosis for Cavitary lesions
CAVITY
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
A. Perform a methacholine challenge test. - NO this is for asthma
B. Empiric trial of interferon and steroids -
C. Start him on high dose oral corticosteroids
D. Stop amiodarone and methotrexate, follow pulmonary function tests *** this is the answer
E. Initiate bronchodilator therapy with albuterol and add an inhaled steroid
amiodarone lung
-looks like pneumonia on CXR
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
D. 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
Which of the following is the next most appropriate step?
2) Obtain a transbronchial lymph node biopsy
the patient most likely has sarcoidosis– many pt’s with this disease are asymptomatic at the initial diagnosis
high levels of ACE in sarcoidosis
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.
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.
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
Answer–> B. Diffuse alveolar hemorrhage
increased blood absorbs the CO
or polycythemia does this as well
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
the patient has sarcoidosis
Begin treatment for a disorder associated with noncaseating granulomas
place defibrillator potentially
22 year old female complains of severe dyspnea on exertion that has been gradual in onset over the last 6 months. She has had an extensive workup for her symptoms. Arterial blood gas monitoring and pulse oximetry reveal oxygen desaturation with exercise. A chest radiograph reveals markedly enlarged pulmonary vasculature, but no infiltrates or evidence of parenchymal disease. A lung ventilation-perfusion (V/Q) scan is normal. An EKG and echocardiogram show evidence of right heart strain, but no evidence of intrinsic cardiac disease. Her DLCO and PFT’s are normal.
Which of the following is the next test to order for the diagnosis of this patient’s diseases?
A. Neuropsychiatric testing B. No further testing necessary C. Pulmonary arteriography for pulmonary embolus D. Right-heart catheterization E. Transbronchial Biopsy
D. Right-heart catheterization
we know she doesn’t have pulmonary embolus
look for the cause of her pulmonary HTN
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. C-ANCA
patient has wegeners
the big clue is because of upper respiratory infection!!
Kveim test- ground up spleen of someone who has sarcoidosis–> see if they develop a noncaseating granuloma
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
The patient has sarcoidosis
A. Begin therapy with high-dose systemic corticosteroids
he is symptomatic ! so that’s why you want to treat
if it was just hilar lymph nodes with no symptoms you would do watchful waiting
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. Silicosis
eggshell calcifications of hilar lymph nodes. important clinical clues
with asbestosis you would see pleural plaques
with TB you would see hilar adenopathy, upper lungs with cavitary lesions
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. Acute interstitial pneumonia- ARDS type picture, very poor prognosis
ground glass opacities are more treatable whereas fibrosis is not responsive to treatment
Not asbestosis- b/c they would have construction, ship building history, present 20-30 years later, insiduous onset
Not idiopathic pulmonary fibrosis- rapidly fatal BUT its not days… its months
Not sarcoidosis–> would see reticulonodular pattern
38 year old man comes to the clinic for a prescription refill. He uses a variety of inhalers, including albuterol, salmeterol, ipratropium, and a steroid inhaler. He is currently on a steroid taper, after having an elevated aspergillus-specific IgE level.
While going over his medications, the patient begins to hack and cough, producing a moderate amount of purulent, blood tinged sputum. Upon questioning, he states that he has had this cough for years, and that he attributes it to his 60 pack year tobacco history. His daily sputum production is more purulent and he produces four “teacups” of sputum per day.
He also report numerous episodes of dyspnea, hemoptysis, and pleurisy type chest pain over the years.
Physical exam reveals diffuse crackles and rhonchi over both hermithoraces. A chest radiograph is ordered to further define the extent of this patient’s disease.
Which the following are findings on chest radiograph that are consistent with his disease?
A. Bilateral areas of opacification evidence of consolidation
B. Hyperlucent lung fields with flattened diaphragms and reduced vasculature
C. Bilateral hilar lymphadenopathy
D. Parallel linear opacities and mucus-filled dilated bronchi
E. Vascular redistribution towards the apices
he has elevated aspergillus-specific IgE level–>acut allergic bronchopulmonary aspergillosus
D. Parallel linear opacities and mucus-filled dilated bronchi
the patient has bronchiectasis
vascular redistribution towards the apices would be in someone who has heart failure- they have fluid overload and their vessels are enlarged and move towards the apices
bilateral areas of opacification evidence of consolidation - pneuomnia
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
C. Occupational history
Asbestosis
working in old houses, breaks, shipbuilding
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. He will have a positive test for c-ANCA
wegener’s
