Surgery+med 1

Question 1

A pt with extensive chest trauma is found to have pneumothorax n chest tube is inserted. 2 hrs later there is persistent air leak despite adequate seal at the chest wall n all connection points.
Best next step?

Answer 1

Bronchoscopy can help to make the dx of tracheobronchial injury prior to surgical repair.

Question 2

A pt on chemotherapy comes with 3days of fever pleuritic chest pain n cough productive of bloody sputum. Chest CT shows pulmonary nodules with surrounding ground glass opacities ( halo sign)
Most likely Dx?

Answer 2

Invasive aspergillosis

Question 3

Which inhaled agents r the mainstays of symptomatic Rx in COPD?

Answer 3

Animuscarinics like ipratropium

Question 4

A man comes after a high speed motor vehicle accident. On arrival BP-78/40 PR- 135, bruising on the anterior chest, midline trachea, clear breath sounds on the rt but diminished on the left. Heart sounds r normal. Pale cold extremities, collapsed neck veins. CXR- multiple rib fractures, opacification of the left hemithorax n widened mediastinum
Most likely Dx?

Answer 4

Thoracic aortic injury.
A complete rupture would have caused an immediate death unless contained by a hematoma or surrounding tissues
CXR findings are suggestive.

Question 5

A 4 yr old boy is brought to the ED with vague chest discomfort. Two months ago he was involved in a high speed motor vehicle collision but sustained only minor injuries. Auscultation of the lungs shows decreased air entry into the left lower base.
Most likely Dx?
Definitive dx is made by?

Answer 5

Diaphragmatic rupture- traumatic diaphragmatic injury may initially have no sxs and can present months to yrs later after progressive expansion of the defect.
X-ray May show bowel loops within the thoracic cavity n mediastinal shift.
Definitive dx- CT of chest n abdomen

Question 6

Criteria for extubation readiness ( spontaneous breathing trial)
PH, FiO2, PEEP

Answer 6

• PH>7.25

- Adequate oxygenation on minimal support (ie, FiO2

Question 7

A 76yr old man is intubated n on mechanical ventilation for ARDS. Tidal volume 370 ( 7ml/kg), RR 22/min, PEEP5mm Hg, FiO2 70%
ABG analysis shows pH-7.45, PaO2-54, PaCO2- 30, HCO3- 21
The best next step in the mx regarding the mechanical ventilation?

Answer 7

INCREASE PEEP.( as long as normal plateau pressure can b maintained to reduce the risk of barotrauma)
PaO2 is 54(<6mm Hg) reflecting inadequate oxygenation which can be improved by increasing either FiO2 or PEEP. But FiO2 is already high in this pt(>60% increases the risk for oxygen toxicity)

Question 8

A 52 yr old woman with colon adenocarcinoma undergone surgery. On the 4th POD, she started having persistent tachycardia, sob n intermittent rt sided chest pain. ECG- sinus tachycardia, CXR- rt basal atelectasis
The best next step in the mx?

Answer 8

CT pulmonary angiography because PE is likely in this pt

Question 9

Assessment of postoperative pulmonary morbidity in a pt planned to have pneumonectomy is made by which parameters?

Answer 9

FEV1, DLCO- these r measured preoperatively n then used to estimate their corresponding postop values. FEV1 or DLCO of less than 40% r at elevated risk of morbidity

Question 10

Sudden onset respiratory distress following removal of central venous catheter is most likely due to?
Mx? Positioning n…

Answer 10

Venous air embolism- which can obstruct the RV outflow tract; or can further go to the pulmonary circulation.
Mx- position pt on the left lateral decubitus head down( tredlenburg) or left lateral decubitus which traps the air on the RV lateral wall
-high flow oxygen

Question 11

If PE is likely after clinical assessment, anticoagulation is considered before Ix especially if no relative contraindications (eg pud) or pt in distress otherwise Dx is confirmed first with—?

Answer 11

CT angio

Question 12

Pseudoallergic drug rxn is?

Answer 12

NSAIDs/ ASA induced exacerbation of asthma or sinusitis; not IgE mediated but leukotrine…

Question 13

3 most common causes of clubbing

Answer 13

Malignancy, cystic fibrosis, cyanotic HD.

Hypoxemia (eg. COPD) is not a cause

Question 14

45yr old white man comes with SOB, cough, hemoptysis for the past 2days. He has chronic rhino sinusitis. Auscultation of lung- patchy rales bilaterally. Cr-2, CXR- bilateral lung nodules with cavitation, bronchoscopy- several areas of tracheal narrowing and ulceration
Most likely Dx?

Answer 14

Granolomatosis with polyangitis
Caucasian 30-50yr; URT- rhinosinusitis; LRT - tracheal narrowing n ulceration( very characteristic), lung nodules n cavitation

Question 15

Undiagnosed pleural effusion is best diagnosed —?

Answer 15

Thoracentesis except in pts with clear-cut evidence of CHF.

Question 15

A 25 yr old man comes with 3months progressive dyspnea n dry cough. Clear lungs, not in RD, X-ray shows mediastinal fullness n scattered reticular opacities in the upper lungs. Lab- normal except hypercalcemia.
Pulmonary function test would show FEV1, DLCO, TLC

Answer 15

Sarcoidosis

Restrictive pattern- FEV1 and FVC-normal or reduced; their ratio- normal or increased, DLCO- decreased

Question 16

Inspiratory hold maneuver is used to measure plateau pressure ( elastic pressure + PEEP) which reflects——?

Answer 16

Pulmonary compliance

Question 17

A 68 yr old man comes with progressive dyspnea, nonproductive cough over the past yr. he had asthma during childhood but otherwise had no respiratory sxs until a yr ago. No smoking hx, no travel. Inspiratory crackles at the base of the lungs. normal heart sounds, no other abnormalities
PFT would show? TLC, FEV1/FVC, DLCO

Answer 17

Pt likely has idiopathic pulmonary fibrosis - sxs + fine crackles , non smoker + his age(50-70) r suggestive
- restrictive pattern. Decreased TLC n DLCO n normal FEV1/FVC ratio

Question 18

A 36 yr old with 4 months of cough productive of whitish sputum and worsens at night. He tried diphenhydramine without improvement.
He takes omeprazole for GERD. No other abnormalities. The best next step in the evaluation of this patient is?

Answer 18

PFT!!!
Asthma should b considered because the most common causes of chronic cough(>8 wks) include upper airway cough syndrome, GERD n asthma

Question 19

Which of the following is the effect of abnormal diaphragmatic contour in COPD or asthmatic pts?
A) increased expiratory flow B) increased thoracic wall recoil C) increased work of breathing

Answer 19

Decreased alveolar elasticity causes lung hyperinflation-> increased TLC, FRC( functional residual capacity), RV and diaphragmatic flattening. -> flattened diaphragm has more difficulty contracting to expand the thoracic cavity, result in INCREASED WORK OF BREATHING.

Question 20

A 36 yr old at her 24wks gestation comes with dry cough n sob since last night. Has DM n asthma. Six days ago she was started on nitrofurantoin for UTI. T- 38.2, PR 104, crackles at lung base bilaterally. CXR - bilateral parenchymal opacities predominantly on the mid n lower lung zones, eosinophils- 12%
Dx?

Answer 20

Nitrofurantoin induced lung injury( hypersensitivity pneumonitis)

Question 22

A 66yr old man comes with sxs of COPD exacerbation. PR- 114 irregular, ECG- irregular, narrow complex tachycardia with 3different p wave morphologies n a variable PR interval. Serum electrolytes r normal
The best next step in the mx of his arrhythmia is?

Answer 22

Monitoring while treating the underlying cause( COPD exacerbation)
- ECG finding is typical for MAT( multifocal atrial tachycardia) - which can occur secondary to -exacerbation of pulmonary disease eg. COPD; -catecholamine surge eg. Sepsis; electrolyte disturbances

Question 23

Empiric Rx of CAP

Answer 23

Outpatient- 1)healthy- macrolide or doxycycline 2) comorbidities-fluoroquinolone or betalactam + macrolide
Inpatient-(fluoroquinolone or betalactam + macrolide ) IV
ICU- betalactam + macrolide or betalactam + fluoroquinolone

Question 24

Upper airway cough syndrome is treated with 1st generation antihistamines. Mechanism is?

Answer 24

Decreased nasal secretions.

The cough is triggered in such pts( allergic rhinitis…) by nasal secretions stimulating afferent cough reflex

Question 25

The most sensitive indicator of hypovolemia is?

Answer 25

Urinary sodium

Question 26

A 37 yr old woman with MS since 5 yrs back comes with sudden onset sob n left sided chest pain. She is wheelchair bound due to spastic paraparesis n has saccadic speech. Vital signs r normal. CXR shows small left pleural effusion without infiltration. The most likely cause of this patient’s pleural effusion is?

Answer 26

Pulmonary embolism- pts usually develop pleural effusion n it tends to b exudative n grossly hemorrhagic.