Obstructive Lung Diseases Full Presentation: Kinder

Question 1

Case 1

• 40 yo male presents with gradual onset of dyspnea, cough, and wheezing over the last 2-3 years.
• Family History is remarkable for a father deceased at age 53 with cirrhosis.
• Social History: 20 pack year history of tobacco use
• Physical Examination: decreased breath sounds to auscultation, lungs are hyperinflated by percussion, peripheral cyanosis and clubbing of the digits
• Pulmonary Function Testing
• FEV1 1.06 L 36% of predicted
• FEV1/FVC 38%
• No significant improvement with bronchodilator treatment
• Pick the letter that best describes this patient’s disorder

A) Sweat testing confirms diagnosis

B) Purified protein derivative skin testing will confirm diagnosis

C) This disorder is caused by an imbalance in neutrophil elastase

D) Sputum cytology will confirm diagnosis

E) Acid fast sputum stain will confirm diagnosis

Answer 1

Case 1

•Pick the letter that best describes this patient’s disorder

A) Sweat testing confirms diagnosis

B) Purified protein derivative skin testing will confirm diagnosis

C) This disorder is caused by an imbalance in neutrophil elastase

D) Sputum cytology will confirm diagnosis

E) Acid fast sputum stain will confirm diagnosis

Question 2

Alpha-1 Antitrypsin Deficiency

Answer 2

• Genetic risk factor for COPD
• Etiology of 1-2% of COPD cases
• Serine protease inhibitor secreted by the liver that protects the lung tissue against the action of neutrophil elastase and serine proteases.
• Patients are very susceptible to damage from cigarette smoking.
• Should be considered in young patients with COPD
• Can lead to LFT abnormalities and cirrhosis

Question 3

Case 2

• 19 year old male presents to the emergency room in acute respiratory distress. He has had a productive cough for several days
• Past Medical History: Frequent bouts of sinusitis, hospital admission 2 years ago with pneumonia, and meconium ileus at birth
• Physical Examination: Oxygen Saturation 93% on 2L NC, nostril flaring, subcostal retractions, wheezes, rhonchi, and clubbing of the fingers
• Pulmonary Function Testing with moderate airway obstruction.
• Which statement is true regarding this disorder?

A) B Vitamin Malabsorption is common in this disorder.

B) 95% of males with this disorder are sterile.

C) This disease is characterized by non-caseating granulomas

D) This is an autosomal dominant disorder

E) All siblings will be gene carriers

Answer 3

Case 2

• Pulmonary Function Testing with moderate airway obstruction.
• Which statement is true regarding this disorder?

A) B Vitamin Malabsorption is common in this disorder.

B) 95% of males with this disorder are sterile.

C) This disease is characterized by non-caseating granulomas

D) This is an autosomal dominant disorder

E) All siblings will be gene carriers

Question 4

Cystic Fibrosis

Answer 4

• Autosomal recessive disorder caused by mutation of the cystic fibrosis transmembrane conductance regulator protein.
• Organs affected include lungs, pancreas, intestines, liver, sweat gland, sinuses, and the vas deferens.
• Lung disease leads to death in 90% of patients.
• Median survival 37 years

•

Question 5

Lung Manifestations in CF

Answer 5

• Cough, dyspnea, decreased exercise tolerance, fatigue, and increased sputum production
• Steep decline in lung function at adolescence
• Daily productive cough
• Airway infection with Pseudomonas aeruginosa is the primary pathogen. Staphylococcus aureus, and methicillin resistant Staphylococcus aureus are also common.

Other infections include bronchopulmonary mycoses, and nontuberculous mycobacterial infections

Question 6

Pancreatic Manifestations of CF

Answer 6

• Exocrine pancreatic insufficiency can lead to impaired growth
• Signs of malabsorption include bulky, foul smelling stools and flatulence.
• Malabsorption of fat soluble vitamins occur.

Question 7

Liver Manifestations of CF

Answer 7

• Hepatomegaly
• Splenomegaly
• Hematemesis secondary to esophageal or gastric varices from portal hypertension

Question 8

Sweat Gland in CF

Answer 8

• Failure of chloride absorption from the lumen into the ductal lining cell.
• Marked elevation of chloride and sodium in sweat

Question 9

Vas deferens in CF

Answer 9

•Almost all males are sterile

Question 10

Other clinical manifestations in CF

Answer 10

• Endocrine Pancreas: 1/3 of patients have diabetes by age 30
• Electrolyte abnormalities can lead to nausea/vomiting, decreased appetite, circulatory collapse, and seizures
• Musculoskeletal: decreased bone density secondary to decreased absorption of vitamin D, glucocorticoid treatment, and decreased exercise.
• Kidney: nephrolithiasis

Question 11

Cystic Fibrosis Diagnosis

Answer 11

• Screening with immunoreactive trypsinogen which is a marker of pancreatic injury
• Genetic mutation analysis
• Diagnosis confirmed with sweat testing
• The sweat test measures chloride concentration in sweat that is stimulated by pilocarpine iontophoresis.
• 5% of diagnosis are made after the age of 18

Question 12

Pulmonary function testing in CF

Answer 12

• Obstruction

Question 13

Chest x-ray in CF

Answer 13

• Hyperinflation
• Bronchiectasis

Question 14

Oral Antibiotics in CF

Answer 14

• Azithromycin [25-40 kg] 250 mg PO every Mon, Wed, Fri; [> 40 kg] 500 mg PO every Mon, Wed, Fri
• Patients ≥ 6 years of age with Pseudomonas aeruginosa meet criteria for use
• Trimethoprim/sulfamethoxazole 20 mg/kg/day PO divided every 6-8 hours
• Ciprofloxacin 40 mg/kg/day PO divided every 12 hours

•

Question 15

IV antibiotics in CF

Answer 15

• Aztreonam 200 mg/kg/day IV divided every 6-8 hours
• Cefepime 150 mg/kg/day IV divided every 8 hours
• Ceftazidime 200 mg/kg/day IV divided every 8 hours
• Ciprofloxacin 30 mg/kg/day IV divided every 8-12 hours
• Meropenem 120 mg/kg/day IV divided every 8 hours

Question 16

IV antibiotics in CF

Part II

Answer 16

• Piperacillin/tazobactam 400 mg/kg/day divided every 4-6 hours
• Tobramycin 7.5-15 mg/kg/day IV divided every 8-24 hours
• [Higher dose, extended interval dosing may be more effective and less nephrotoxic]
• Vancomycin 60 mg/kg/day divided IV every 6-8 hours

•

Question 17

Inhaled antibiotics in CF

Answer 17

• Tobramycin 300 mg inhaled twice daily in 28 day cycle
• Aztreonam 75 mg inhaled three times daily in 28 day cycle

Question 18

Other CF Treatments

Answer 18

• Pancreatic enzymes, vitamin supplementation, bronchodilators, hypertonic saline inhalation, dornase alfa(rhDNase), ibuprofen, oxygen, bronchodilators, lung transplant
• Chest percussion and postural drainage

Question 19

Case 3

• 55 year old male with a history of chronic obstructive pulmonary disease complains of increased shortness of breath, dyspnea with minimal exertion, and decreased exercise tolerance.
• Past Medical History : Multiple hospital admissions for COPD exacerbations, intubated last admit
• Social History: 40 pack year history of tobacco use
• Medications: maximal doses of inhaled steroid, salmeterol, and tiotropium. He frequently has been treated with oral antibiotics and oral steroids.
• Which of the following Pulmonary Function Test results are most likely in this patient?

A) Decreased FEV1/FVC

B) Decreased functional residual capacity

C) Decreased total lung capacity

D) Increased FEV1

E) Increased FEV1/FVC

Answer 19

Case 3

•Which of the following Pulmonary Function Test results are most likely in this patient?

A) Decreased FEV1/FVC

B) Decreased functional residual capacity

C) Decreased total lung capacity

D) Increased FEV1

E) Increased FEV1/FVC

Question 20

Chronic Obstructive Pulmonary Disease

Answer 20

• Progressive, mostly irreversible airflow obstruction
• Onset: Middle age or elderly 20-30 years after exposure
• 4th leading cause of mortality in the United States
• Cigarette smoking is the leading cause of COPD
• Smokers have a 40ml/year reduction in FEV1 after age 30
• Lung growth can be impaired by maternal smoking in pregnancy and second hand smoke in childhood
• Other exposures: workplace dusts from mining, cotton mills, and grain handling facilities

Question 21

Lung Mechanics in COPD

Answer 21

• Elastic recoil is the lungs innate ability to deflate following inflation.
• Elastic fibers in the lung parenchyma, along with surface tension at the alveolar air-liquid interface are responsible for elastic recoil
• Elastic recoil maintains the patency of small airways
• Elastic recoil is markedly decreased in COPD
• Airway resistance is increased in COPD
• The sites of airflow obstruction are distal airways less than 2mm diameter

Question 22

COPD History

Answer 22

• Current or past cigarette use
• Dyspnea with slow progression
• History of acute bronchitis
• History of a chronic cough
• Sputum production
• Wheezing

Question 23

Physical Findings COPD

Answer 23

• Barrel Chest
• Prolonged expiratory phase
• Accessory muscle use
• Low Diaphragm
• Distant Heart Sounds
• Diminished Breath Sounds
• Rhonchi
• Wheezing

Question 24

Physical Findings COPD

part 2

Answer 24

• Cyanosis
• Pedal Edema
• Distended Jugular Veins
• Hepatic congestion
• Cachexia
• “Blue Bloaters”
• “Pink Puffers”

Question 25

Pulmonary Function Testing in COPD

Answer 25

Stage and Severity

• I: Mild
  
  • FEV1/FVC < 70%
  • FEV1/FVC = 80% of predicted
• II: Moderate
  
  • FEV1/FVC < 70%
  • 50% <= FEV1 < 80% of predicted
• III: Severe
  
  • FEV1/FVC < 70%
  • 30% <= FEV1 < 50% of predicted
• IV: Very Severe
  
  • FEV1/FVC <70%
  • < 30% of predicted or FEV1 < 50% of predicted plus chronic respiratory failure

Question 26

Chest x-ray in COPD

Answer 26

• Hyperinflation
• Flattened Diaphragms
• Increased restrosternal space
• Bullae
• Can be normal in mild to moderate COPD

Question 27

Differential Diagnosis of COPD

Answer 27

• Asthma
• Bronchiectasis
• Bronchiolitis obliterans

Question 28

Emphysema

Answer 28

• Enlargement of the air spaces distal to the terminal bronchiole with destruction of the alveolar walls
• Centriacinar: affects respiratory bronchioles distal to the terminal bronchiole, remainder of the acinus spared. Occurs with smoking
• Panacinar: alveolar ducts, adjacent alveoli, coalescence and bullae formation. Common in alpha 1 antitrypsin deficiency. Occurs in smoking
• Most severe COPD patients have a combination of centriacinar and panacinar emphysema

Question 29

Chronic Bronchitis

Answer 29

•Enlargement of bronchial mucous glands and increased epithelial goblet cell production leads to cough and increased mucous production.

Question 30

Case 4

• 45 year old female with a history of asthma complains of a daily cough and increased dyspnea. She now wakes up 2 or 3 nights a week with symptoms. Her current medicine is a medium dose inhaled steroid and albuterol inhaler as needed.
• Physical Examination: Pulse 80, Respiratory Rate 16 Lung examination is remarkable for bilateral expiratory wheezing.
• How would you categorize this patient’s asthma?

A) Intermittent asthma

B) Mild persistent asthma

C) Moderate persistent asthma

D) Severe persistent asthma

Answer 30

Case 4

•How would you categorize this patient’s asthma?

A) Intermittent asthma

B) Mild persistent asthma

C) Moderate persistent asthma

D) Severe persistent asthma

Question 31

Case 4

• 45 year old female with a history of asthma complains of a daily cough and increased dyspnea. She now wakes up 2 or 3 nights a week with symptoms. Her current medicine is a medium dose inhaled steroid and albuterol inhaler as needed.
• Physical Examination: Pulse 80, Respiratory Rate 16 Lung examination is remarkable for bilateral expiratory wheezing

•What is the most appropriate addition to this patient’s treatment?

A) Add a long acting B2-agonist inhaler

B) Add an ipratropium metered-dose inhaler

C) Double the dose of inhaled corticosteroid

D) Start a 10-day course of a macrolide antibiotic

Answer 31

Case 4

•What is the most appropriate addition to this patient’s treatment?

A) Add a long acting B2-agonist inhaler

B) Add an ipratropium metered-dose inhaler

C) Double the dose of inhaled corticosteroid

D) Start a 10-day course of a macrolide antibiotic

Question 32

Asthma

Answer 32

• Clinical syndrome of unknown etiology with 3 distinct components
• 1) Recurrent airway obstruction that resolves spontaneously or with treatment.
• 2) Airway hyperresponsiveness: exaggerated bronchoconstrictor response to stimuli that have little or no effect on nonasthmatic patients.
• 3) Airway Inflammation

Question 33

Population Affected by Asthma

Answer 33

• 8% of Adults
• Boys more common than girls before puberty
• Women more common than men
• Most cases start before age 25, but can occur at any age
• 15 million outpatient visit per year
• 2 million hospitalizations per year

Question 34

Asthma Pathology

Answer 34

• Mild Asthma: edema and hyperemia of the mucosa and infiltration of the mucosa with mast cells, eosinophils, and lymphocytes.
• Moderate Asthma: chemokines eotaxin, RANTES, macrophage inflammatory protein 1 alpha, and interleukin 8 lead to inflammation and smooth muscle constriction
• Severe: hypertrophy and hyperplasia of airway glands and smooth muscle lead to severe airway thickening

Question 35

Airway Obstruction

Answer 35

•Caused by a combination of

1) constriction of airway smooth muscle
2) thickening of airway epithelium
3) liquids in the airway

Question 36

Asthma Triggers

Answer 36

• Atopy
• Allergy
• Cold Air
• Smoking or Smoke in the environment
• Pollution
• Climate Changes
• Emotion
• Medications
• Occupational
• Food

Question 37

Asthma Mediators

Answer 37

• Acetylcholine: released from intrapulmonary motor nerves stimulate M3 muscarinic receptors causing airway smooth muscle constriction
• Histamine: released from mast cells – minor role
• Leukotrienes and Lipoxins: derived by the lipoxygenation of arachidonic acid released from the target cell membrane phospholipids during cellular activation
• Nitric Oxide: produced by airway epithelial cells and by inflammatory cells found the asthmatic lung. High levels found during asthma attacks

Question 38

Asthma History

Answer 38

• Dyspnea, cough, wheezing, and anxiety
• Exercise induced, aspirin ingestion, extrinsic(allergen induced), or intrinsic(unknown)
• Cough, hoarseness, or inability to sleep through the night
• Rapid changes in temperature or humidity may lead to an attack
• Consider occupation exposures

Question 39

Asthma Differential Diagnosis

Answer 39

• Asthma Differential Diagnosis
• COPD
• Congestive Heart Failure
• Pneumothorax
• Pulmonary Embolism
• Large Airway Obstruction
• Vocal Cord Dysfunction

Question 40

Asthma Categories

Answer 40

• Mild intermittent: symptoms present for 2 days/week or less, or 2 nights/month or less
• Mild persistent: symptoms present for > 2 days/week but less than once daily, or > 2 nights/ month
• Moderate persistent: symptoms present daily or greater than once/night
• Severe persistent asthma: symptoms are continual during the day and frequent at night

Question 41

Asthma Physical Examination

Answer 41

• Often normal between attacks
• Vital Signs tachypnea with respiratory rate often between 25-40 breaths per minute, tachycardia, and pulsus paradoxus.
• Accessory muscle use, hyperinflation, prolonged expiratory phase
• Wheezing loudest during expiration, but can also be heard during inspiration. Wheezing is polyphonic.
• Decreased breath sounds in asthma patients is an indication of severe obstruction.
• Ominous signs are inability to speak or drink, fatigue, drowsiness, confusion, and cyanosis.

Question 42

Testing For Asthma (case 4)

Answer 42

• ABG Often mild hypocapnea. If PaCO2 normalizes during a severe attack, this may indicate impending respiratory failure.
• PFT: obstruction
• CBC: Eosinophilia(Hypersensitivity Only), Elevated IgE
• Chest X-ray is often normal, hyperinflation, in severe asthma may have pneumothorax or pneumomediastinum
• EKG: sinus tachycardia is usual, May see right axis, RBBB, P pulmonale, and even ST-T changes in a severe attack that will resolve after treatment.
• Sputum often contains eosinophils

Question 43

Outpatient Treatment of Asthma

Step 1

Answer 43

•Step 1 Intermittent Asthma

No daily medication

Short-acting beta-2 agonist as needed

Question 44

Outpatient Treatment of Asthma

Step 2

Answer 44

•Step 2 Mild Persistent Asthma

Short acting beta-2 agonist as needed

Inhaled corticosteroid

Alternate treatments mast-cell stabilizer, leukotriene- receptor antagonist, or theophylline

Question 45

Outpatient Treatment of Asthma

Step 3

Answer 45

•Step 3 Moderate Persistent Asthma

Short-acting beta-2 agonist as needed

Low to medium dose inhaled corticosteroid

Long-acting beta-2 agonist

Alternate treatments: increase in inhaled corticosteroids within medium dose range; or low to medium dosed inhaled corticosteroids and either a leukotriene-receptor antagonist or theophylline

Question 46

Outpatient Treatment of Asthma

Step 4

Answer 46

•Step 4 Severe Persistent Asthma

Short-acting beta-2 agonist as needed

High-dose inhaled corticosteroid and long-acting beta-2 agonist

If symptoms persist, 2mg/kg/day of prednisone may be required, generally not to exceed 60mg/day

Question 47

Outpatient Treatment of Asthma

Other Txs

Answer 47

•Other Treatments

Omalizumab: monoclonal antibody in patients with moderate to severe persistent asthma who have shown reactivity to an allergen and whose symptoms are inadequately controlled by an inhaled corticosteroid.

•

Question 48

Case 5

• 60 year old male presents with a complaint of increased cough productive of purulent sputum, dyspnea, hemoptysis, pleuritic chest pain, and weight loss.
• Physical Examination: wheezing and rales on auscultation of the lungs.
• X-ray:
• Which of the following disorders is the most likely cause of this patient’s airway dilation?

A) Asthma

B) Atelectasis

C) Adult Respiratory Distress Syndrome

D) Bronchiectasis

E) Churg-Strauss Syndrome

Answer 48

Case 5

•Which of the following disorders is the most likely cause of this patient’s airway dilation?

A) Asthma

B) Atelectasis

C) Adult Respiratory Distress Syndrome

D) Bronchiectasis

E) Churg-Strauss Syndrome

Question 49

Bronchiectasis

Answer 49

• Abnormal permanent dilatation of the bronchi and bronchioles caused by repeated cycles of airway infection and inflammation.
• Abnormalities of cilia, mucous clearance, mucus rheology, airway drainage, and host defenses can lead to bronchiectasis.
• Patients develop chronic infections that lead to lung destruction.

Question 50

Bronchiectasis Etiologies

Answer 50

• One half of patients have cystic fibrosis
• One third have an infectious etiology often years before the onset of disease.
• Infectious etiologies include pertussis, TB, Mycobacterium avium-intracellulare. MAI typically involve the right middle lobe and lingula
• Genetic etiologies include cystic fibrosis, primary ciliary dyskinesia, and alpha 1 antitrypsin deficiency.

Question 51

Bronchiectasis anatomic etiologies

Answer 51

• Anatomic etiologies include esophageal dysfunction with aspiration, COPD, allergic bronchopulmonary aspergillosis, endobronchial tumors, extrinsic compression by lymph nodes and foreign bodies.
• Immune and autoimmune etiologies include primary hypogammaglobulinemia, immunoglobulin G deficiencies, HIV, Sjogren’s syndrome, and rheumatoid arthritis

Question 52

Bronchiectasis Symptoms

Answer 52

• Chronic cough with purulent sputum production
• Dyspnea
• Intermittent hemoptysis
• Pleuritic chest pain
• Weight loss
• Fatigue

Question 53

Bronchiectasis Physical Exam

Answer 53

• Wheezing, rales
• Slow decline in pulmonary function
• Decline more rapid if patient has Pseudomonas aeruginosa

Question 54

Bronchiectasis Imaging

Answer 54

• High Resolution CT used to make diagnosis
• Findings:
• Lack of bronchial tapering
• Bronchi visible in the peripheral 1 cm of the lungs
• Internal bronchial diameter greater than the diameter of the accompanying bronchial artery

Question 55

Bronchiectasis Location

Answer 55

• Cystic Fibrosis: upper lobe predominance
• Aspiration: lower lobe predominance
• MAI: right middle lobe and lingular predominance
• Bronchopulmonary aspergillosis: central bronchiectasis

Question 56

Bronchiectasis Testing

Answer 56

• PFT: demonstrates obstruction
• Bronchoscopy: Used to detect airway abnormalities including tumors, structural deformities, and foreign bodies. Most helpful if the bronchiectasis is localized
• Sputum cultures and bronchial alveolar lavage used to assess infectious etiologies

Question 57

Bronchiectasis Testing

•Other Testing

Answer 57

• Other Testing
• Serum Immunoglobulin levels
• Genetic disease screening
• Sweat chloride to diagnose cystic fibrosis
• Electron microscopy of airway mucosal cilia to diagnose primary ciliary dyskinesia
• Alpha 1 antitrypsin levels
• Rheumatoid Factor for rheumatoid arthritis
• SSA, SSB for Sjogren’s Syndrome

Question 58

Bronchiectasis Treatment

Answer 58

• Treat underlying condition
• Specific antimicrobials
• Anti-inflammatory – inhaled steroids, macrolide antibiotics
• Surgery for localized or refractory disease
• Transplantation for end-stage disease

Question 59

Case 1

• A 63 year-old has worsening dyspnea, there is no fever or chills. He has a long history of COPD and has had exacerbations in the past. He is in moderate respiratory distress and has trouble speaking in full sentences.
• Vital Signs: T98.6, BP 148/90, P 112, RR 28/min, Pulse Ox 84% on room air
• Chest examination reveals diffusely diminished breath sounds, scattered end-expiratory wheezes, and rare rhonchi. The rest of the examination is normal
• ABG pH 7.3, PCO2 65 mm Hg, and PO2 55 mm Hg
• CXR hyperinflation and flattened diaphragms
• The intern caring for this patient orders continuous nebulized breathing treatments with albuterol and ipratropium, starts IV methylprednisolone, and places the patient on 6L NC O2.
• The patient continues to have respiratory distress and becomes increasingly somnolent, becoming arousable only to pain. A repeat ABG reveals a pH of 7.24, PCO2 of 82 mm Hg, and a PO2 of 72 mm Hg.
• The patient is prepared for intubation and transferred to the ICU
• Which of the following may have prevented this patient’s acute increase in PCO2?
• A. Chest physiotherapy and mucolytics
• B. Delay supplemental oxygen
• C. Early administration of IV antibiotics
• D. Theophylline
• E. Use of a Venturi mask

Answer 59

Case 1

• Which of the following may have prevented this patient’s acute increase in PCO2?
• A. Chest physiotherapy and mucolytics
• B. Delay supplemental oxygen
• C. Early administration of IV antibiotics
• D. Theophylline

•E. Use of a Venturi mask

Question 60

Case 2

• 41 year old nonsmoking carpenter is referred to you for treatment of asthma. He initially described cough, wheezing, and dyspnea in the evening which was controlled with his albuterol inhaler.
• He now experiences symptoms during work hours and is using his inhaler more frequently. During vacation last month, at the beach, he had no symptoms, but upon returning to his work his symptoms have returned. His exam is unremarkable. A bronchoprovocation test with western red cedar produces a 30% decrease in his FEV1.
• The best way to manage this patient’s occupational asthma is ?

•

• A. Continue symptomatic treatment with his albuterol
• B. Avoid any further exposure to wood dust
• C. Wear a specialized respirator at work
• D. Add inhaled corticosteroids
• E. Daily oral corticosteroids

Answer 60

Case 2

• The best way to manage this patient’s occupational asthma is ?
• A. Continue symptomatic treatment with his albuterol
• B. Avoid any further exposure to wood dust
• C. Wear a specialized respirator at work

•D. Add inhaled corticosteroids

•E. Daily oral corticosteroids

Question 61

Case 4

• 35 year old white male come to your office complaining of difficulty breathing that has been worsening over the last 8 months.
• He states he is now short of breath even when not moving. He has a 5 pack year history of smoking and quit 3 years ago when he first noticed difficulty breathing. This has persisted until now.
• His family history is unknown because the patient was adopted. The patient denies sputum production, fever, or chills.
• His blood pressure is 105/70 mm Hg in his right arm, pulse is 120/min and regular, RR 29/min at rest.
• Examination shows intercostal retraction during breathing. On auscultation of his chest there are diminished breath sounds throughout both lungs and wheezes bilaterally. The rest of his examination is unremarkable
• PFT
• TLC 115% of predicted
• RV 110% of predicted
• FEV1/FVC 30% or predicted
• DLco 55% of predicted
• Which of the following is the most likely diagnosis?
• A. Alpha-1 antitrypsin deficiency
• B. Bronchial asthma
• C. Bronchiectasis
• D. Chronic bronchitis
• E. Chronic obstructive pulmonary disease of the emphysematous type

Answer 61

Case 4

•Which of the following is the most likely diagnosis?

•A. Alpha-1 antitrypsin deficiency

• B. Bronchial asthma
• C. Bronchiectasis
• D. Chronic bronchitis
• E. Chronic obstructive pulmonary disease of the emphysematous type

Question 62

Case 5

• 65 year old white female is seen with a chronic productive cough. She produces over 2 tablespoons of sputum each day and her current cough has been present for 3 months. History reveals that she had a similar episode of chronic, productive cough that lasted more than 3 months each year for the last 2 years, but at different seasons of the year.
• The most appropriate diagnosis of this patient is:
• A. Seasonal allergies
• B. Emphysema
• C. Chronic bronchitis
• D. Asthma
• E. Sino-bronchial syndrome

Answer 62

Case 5

• The most appropriate diagnosis of this patient is:
• A. Seasonal allergies
• B. Emphysema

•C. Chronic bronchitis

• D. Asthma
• E. Sino-bronchial syndrome

Question 63

Case 6

• 20 year old female with symptoms of wheezing and shortness of breath for the past 3 months.
• It is worse with exercise. Her past medical history is consistent with seasonal conjunctivitis and rhinitis.
• She moved into her college dormitory 4 months ago and noticed she became worse after the move. Her roommate has a pet cat that sleeps on her bed.
• Which of the following would best assess the possible etiology of her condition?
• A. Serum IGE level
• B. Circulating eosinophil count
• C. Nasal smear for eosinophils
• D. Antibody titers for Mycoplasma pneumonia
• E. Reid index

Answer 63

Case 6

•Which of the following would best assess the possible etiology of her condition?

•A. Serum IGE level

• B. Circulating eosinophil count
• C. Nasal smear for eosinophils
• D. Antibody titers for Mycoplasma pneumonia
• E. Reid index

Question 64

Case 7

• 35 year old dairy farmer who has never smoked. He has a chronic cough for the past two years. On physical examination he is afebrile, he has a mild wheeze heard on expiration. Spirometry reveals a mild decreased FEV1, and a decreased FVC.
• Chest x-ray is normal. Lab reveals an eosinophilia and clusters of eosinophils are noted in his sputum.
• He has serum precipitins to Thermoactinomyces vulgaris in his blood work
• The most likely diagnosis is
• A. Farmer’s lung
• B. Chronic bronchitis
• C. Bronchial asthma
• D. Sarcoidosis
• E. Wegner’s granulomatosis

Answer 64

Case 7

•The most likely diagnosis is

•A. Farmer’s lung

• B. Chronic bronchitis
• C. Bronchial asthma
• D. Sarcoidosis
• E. Wegner’s granulomatosis

Question 65

Case 7

•Acute Farmer’s Lung

Answer 65

• Acute Farmer’s Lung
• Develops after large exposure to moldy hay or contaminated compost
• Symptoms often spontaneously resolve within 12 hours to days if antigen exposure is eliminated or avoided
• Acute farmer’s lung manifest as new onset of fever, chills, nonproductive cough, chest tightness, dyspnea, headache , and malaise.
• If the inhalational exposure is large, patients may develop acute respiratory failure

Question 66

Case 7

•Subacute Farmer’s Lung

Answer 66

• Subacute Farmer’s Lung
• Manifest as chronic cough, dyspnea, anorexia, and weight loss
• Subacute disease is insidious in onset and may occur over weeks to months.

Question 67

Case 7

•Chronic Farmer’s Lung

Answer 67

• Chronic Farmer’s Lung
• Results from prolonged and continuous exposure to antigen
• Patients may have irreversible lung damage
• Patients may experience severe dyspnea at rest or with exertion

Question 68

Case 8

• 42 year old male with asthma since childhood. He has never smoked cigarettes but does smoke marijuana. He now has low grade fevers, a productive cough, and mild exercise induced dyspnea. He denies chest pain or hemoptysis. Six weeks ago a persistent cough had developed with sputum production. His temperature is 100.6 F, and he has expectorated thick brown cords in the phlegm. The patient was given a diagnosis of pneumonia and received a dose of azithromycin without benefit. His WBC count is 11, 200 with 35% eosinophils. His chest x-ray shows diffuse pulmonary infiltrates.
• The most likely diagnosis is?
• A. Acute asthma
• B. Pneumococcal pneumonia
• C. Acute bronchopulmonary aspergillosis
• D. Tuberculosis
• E. Wegner’s granulomatosis

Answer 68

Case 8

• The most likely diagnosis is?
• A. Acute asthma
• B. Pneumococcal pneumonia

•C. Acute bronchopulmonary aspergillosis

• D. Tuberculosis
• E. Wegner’s granulomatosis

Question 69

Case 11

• 35 year old woman come to the ER with urticaria, SOB, and wheezing. She is stabilized with epinephrine and antihistamines. One hour prior to symptoms she had a headache and took an OTC cold medication. She ate a meal of a tuna fish sandwich on white bread with lettuce, tomato, and a diet cola. She has no known food allergies and has not had this problem prior. Her PMH is positive for perennial nasal congestion treated with a nasal steroid. She was diagnosed with asthma 5 years earlier and takes an inhaled steroid and rescue inhaler. She saw an allergist one year ago and all “prick tests” to common allergies were negative.
• Physical exam reveals small bilateral nasal polyps, the chest is clear to auscultation now.
• The most likely cause of her reaction is:
• A. Tuna fish allergy
• B. Scombroid poisoning
• C. Allergy to food coloring in the diet cola
• D. Sensitivity to ASA or NSAIDS
• E. Aspergillosis

Answer 69

Case 11

• The most likely cause of her reaction is:
• A. Tuna fish allergy
• B. Scombroid poisoning
• C. Allergy to food coloring in the diet cola

•D. Sensitivity to ASA or NSAIDS

•E. Aspergillosis

Question 70

Case 11

•Samter’s Triad

Answer 70

• Samter’s Triad
• Asthma
• Nasal Polyps
• ASA, NSAID sensitivity

Question 71

Case 13

• 32 year old white female who is a ranch hand from Craig, CO. She presents with signs and symptoms of COPD. She has hypoxia, a prolonged expiratory phase of respiration, and a poor FEV1. She has never smoked , but does have a family history of early emphysema.
• This person should be evaluated for which of the following disorders?
• A. Farmer’s lung
• B. Silo fillers lung
• C. Alpha 1 antitrypsisn deficiency
• D. Agammaglobulinemia
• E. Pulmonary fibrosis

Answer 71

Case 13

• This person should be evaluated for which of the following disorders?
• A. Farmer’s lung
• B. Silo fillers lung

•C. Alpha 1 antitrypsisn deficiency

• D. Agammaglobulinemia
• E. Pulmonary fibrosis

Question 72

Case 14

• 23 year old female has a history of asthma. She is using an albuterol rescue inhaler about 4 times a week and wakes up once a week with symptoms.
• How would you classify her asthma?
• A. Mild intermittent
• B. Mild persistent
• C. Moderate persistent
• D. Severe persistent
• E. Sleep induced

Answer 72

Case 14

• How would you classify her asthma?
• A. Mild intermittent

•B. Mild persistent

• C. Moderate persistent
• D. Severe persistent
• E. Sleep induced

Question 73

Case 15

• 42 year old nurse is evaluated because of coughing, wheezing, and shortness of breath for the past 2 months. She relates the onset of her illness to a heavy exposure during an accidental spill of glacial acetic acid at work. At the time of exposure, she experienced dyspnea, eye irritation, and nasal congestion. She now complains of frequent paroxysms of cough, chest tightness, and awakening at night with SOB. Her physical exam is normal and her spirometry only reveals a decreased FEF25-75 at 45% of predicted. This improves to 65% of predicted with inhalation of albuterol.
• Which of the following is the most likely diagnosis?
• A. Reactive airways dysfunction syndrome (RADS)
• B. Atopic asthma
• C. Allergic occupational asthma
• D. Chronic bronchitis
• E. Alpha-1-antitrypsin disease

Answer 73

Case 15

•Which of the following is the most likely diagnosis?

•A. Reactive airways dysfunction syndrome (RADS)

• B. Atopic asthma
• C. Allergic occupational asthma
• D. Chronic bronchitis
• E. Alpha-1-antitrypsin disease

Question 74

Case 16

• 44 year old female has progressive difficulty with breathing for several years since her hysterectomy/bilateral oophorectomy. She takes thyroid supplements for borderline thyroid function, hormone therapy, eye drops for signs of early glaucoma, and water pills for weight gain. She does not smoke. Her mother has hay fever. Physical exam reveals a slender nervous woman with wheezing noted only on forced expiration. The rest of the exam is normal, Chest x-ray is normal and her FEF25-75 is 45% of predicted.
• The most likely cause of her respiratory disorder is:
• A. Psychological dyspnea
• B. Beta-blocker induced asthma
• C. NSAID induced asthma
• D. Sarcoidosis
• E. Pulmonary artery hypertension

Answer 74

Case 16

• The most likely cause of her respiratory disorder is:
• A. Psychological dyspnea

•B. Beta-blocker induced asthma

• C. NSAID induced asthma
• D. Sarcoidosis
• E. Pulmonary artery hypertension

Question 75

Case 17

• 22 year old male with a 2 year history of asthma has worsening respiratory function. He has seen a couple of doctors and tried a couple of inhalers, but has not had much success in controlling his asthma exacerbations. He has had two episodes of pneumonia in the last 2 years and often suffers from episodes of coughing and wheezing. These episodes are associated with blood-tinged, greenish sputum, fever, malaise, and expectoration of brownish mucous plugs. Past medical history and review of symptoms are otherwise unremarkable. Vital signs: T 98.6, BP 120/72 mm Hg, pulse 68/min, RR 28/min.
• Examination reveals an ill appearing male in moderate distress. Respiratory examination reveals rare inspiratory crackles in the left lung base and coarse breath sounds in both upper lung lobes. The rest of the examination is normal. A chest x-ray reveals a small amount of parenchymal infiltrates in the upper lobes, some plate-like atelectasis at the left lung base, and some branched tubular radiodensities that the radiologist describes as “gloved finger” shadows. Serum IgE levels are sent and come back as 1,500ng/mL (normal is less than 1,000 ng/mL
• Which of the following is the most appropriate therapy?
• A. Amphotericin B
• B. Caspofungin
• C. Fluconazole
• D. Prednisone
• E. Surgery

Answer 75

Case 17

• Which of the following is the most appropriate therapy?
• A. Amphotericin B
• B. Caspofungin
• C. Fluconazole

•D. Prednisone

•E. Surgery

Question 76

Case 17

•Allergic bronchopulmonary aspergillosis

Answer 76

• Occurs in asthmatics and CF patients from a hypersensitivity reaction to Aspergillus colonization of the tracheobronchial tree
• This syndrome may cause fever and pulmonary infiltrates that are unresponsive to antibacterial therapy.
• Patients often have a cough and produce mucous plugs, which may form bronchial casts. Possible hemoptysis.
• People with asthma who have ABPA are usually poorly controlled asthmatics with difficulty tapering off oral corticosteroids
• ABPA may occur in conjunction with allergic fungal sinusitis, with symptoms including chronic sinusitis with purulent sinus drainage.

Question 77

Case 19

• 65 year old woman with a long-standing history of smoking quit smoking 10 years ago when she was told that she had severe emphysema. She has been treated since then with prednisone 15 mg daily, albuterol, and ipratropium inhalers, inhaled steroids, theophylline, and leukotriene inhibitors. She is also on 24 hour supplemental oxygen. She now comes to the office with increasing shortness of breath and an inability to complete the minimal activities of daily living. She is essentially bedridden now. She denies a cough, fever, chills, shakes, shortness of breath, or chest pain.
• Her oxygen saturation is 69% on 4 liters of oxygen. Lungs have poor air movement with no wheezing. Heart is regular, rate, and rhythm. She has no pedal edema. Laboratory studies are unremarkable. Electrocardiogram is normal sinus rhythm with evidence of right sided strain. Chest x-ray shows hyperinflated lungs. PFTs indicate an FEV1 that is 18% of predicted value
• Which of the following is the next appropriate step in management?
• A. Increase the dose of prednisone
• B. Increase the frequency of inhalers
• C. Obtain a CT of the chest
• D. Refer for lung transplant
• E. Schedule an echocardiogram

Answer 77

Case 19

• Which of the following is the next appropriate step in management?
• A. Increase the dose of prednisone
• B. Increase the frequency of inhalers
• C. Obtain a CT of the chest

•D. Refer for lung transplant

•E. Schedule an echocardiogram