Week 2 Flashcards
A 65-year-old undomiciled man presents to your emergency department with complaints of fever, productive cough, and shortness of breath. He has a 40-pack-year history of smoking and daily alcohol consumption. His chest radiograph demonstrates a right upper lobe lung infiltrate with an air-fluid level. What is the most likely etiology for this finding?
Klebsiella pneumoniae
- gram-negative encapsulated organism
- Patients with klebsiella pneumonia commonly present with shaking chills, cyanosis, pleuritic chest pain, and a productive cough with characteristic currant-jelly sputum
- Chest radiography reveals an infiltrate that is often in the upper lobes (most commonly the right) and is associated with a bulging fissure. If untreated, the infiltrate will progress into a necrotizing lesion with air-fluid levels, and can ultimately lead to development of an empyema.
What is a typical chest radiograph finding in acute mitral regurgitation?
Normal cardiac silhouette with severe pulmonary edema.
Which of the following is the most common location of aspirated foreign bodies in children?
Right main bronchus
Hemoptysis+hx of tobacco use, weight loss
malignancy
What is the study of choice in an unstable patient to confirm the diagnosis of aortic dissection?
Transesophageal echocardiogram.
A 17-year-old girl with a history of well-managed cystic fibrosis is being evaluated for a steadily worsening chronic cough with shortness of breath and wheezing. She is producing copious purulent malodorous sputum and occasional hemoptysis. Crackles are heard at her bilateral lung bases. Which of the following findings would be most expected on this patient’s chest radiograph?
ADilated, thickened bronchi with “tram-track” marks
BLow lung volumes and ground glass opacities
CLung hyperinflation with flattening of the diaphragm
DNormal chest radiograph
ADilated, thickened bronchi with “tram-track” marks
Dilated, thickened bronchi are classic radiograph findings in patients with bronchiectasis,
Antibiotics are usually needed with the choice being guided by sputum cultures. Haemophilus influenza, Streptococcus pneumonia, and Staphylococcus aureus are often isolated. In addition to proper antibiotic coverage, bronchiectasis should be treated with daily chest physiotherapy and inhaled bronchodilators.
Carcinoid tumors commonly secrete which of the following substances?
AAcetylcholine
BCalcium
CMelatonin
DSerotonin
DSerotonin
A 72-year-old man is sent to the interventional radiology department by his primary care doctor to undergo a thoracentesis after a chest radiograph revealed a moderate left-sided pleural effusion. Analysis reveals a pleural fluid/serum protein ratio > 0.9 and a pleural fluid/serum LDH ratio > 0.8. Based on these findings, what is the most likely diagnosis?
Malignancy
- malignancy is the only one associated with an exudative effusion.
- exudative effusions are protein rich.
- They occur due to increased permeability of the pleura or impaired lymphatic drainage.
A 23-year-old woman presents with a dry cough, malaise, sore throat, and subjective fever for the last two weeks. She was seen at an urgent care four days ago and was prescribed amoxicillin. She has been taking this, along with an over-the-counter cough syrup. Physical examination reveals diffuse crackles. Vital signs are within normal limits. Which of the following is the most appropriate treatment?
PE will show rales with auscultation of lung fields
Azithromycin
- Azithromycin is the treatment of choice for atypical pneumonia in this age group.
- The most common pathogen that causes community acquired pneumonia (CAP) is Strep pneumonia;
- however, the most common pathogen causing atypical CAP in this age group is Mycoplasma pneumoniae which responds to macrolide treatment.
the most common dysrhythmia in cardiac arrest patients is?
Ventricular fibrillation
A 74-year-old woman presents with complaints of fever, productive cough with bloody sputum, shortness of breath, and headache. These symptoms developed and worsened drastically over the past 3 days. She recently recovered from an influenza infection 1 week ago. Her medical history otherwise includes only well-controlled hypertension. Vital signs on presentation are as follows: T 39°C, HR 106, BP 110/75, RR 30, oxygen sat 95% RA. A chest radiograph is obtained and a subsequent CT scan of the chest demonstrates multiple cavitary lung lesions. Which of the following organisms is most likely responsible for this patient’s presentation?
Clostridum perfringens
Escherichia coli
Mycobacterium tuberculosis
Staphylococcus aureus
This patient’s presentation of pneumonia with multiple cavitary lesions on imaging is consistent with a post-viral secondary necrotizing pneumonia. The most common organism in necrotizing pneumonia, particularly after a viral upper respiratory infection, is S. aureus.
tx: vancomycin or linezolid, piperacillin/tazobactam
A preceding viral infection brings a large number of immune cells to the lung tissue, such that when secondary bacterial infection strikes, there is a catastrophic activation and destruction of immune mediators that damage lung tissue and lead to necrotizing pneumonia.
A 55-year-old man presents to his pulmonologist with progressive shortness of breath over the past year. He was previously healthy and now can barely make it up the stairs in his home. A chest radiograph shows enlargement of the pulmonary arteries with a normal sized cardiac shadow and normal-appearing lung fields. An echocardiogram is performed showing a normal-shaped left ventricle and thickened myocardium in the right ventricle. Which diagnosis is most likely in this patient?
Primary pulmonary hypertension
Given the clear lung fields with enlargement of the pulmonary arteries on chest radiograph and the thickened right ventricle on the echocardiogram, this patient most likely has primary pulmonary hypertension.
Beta-2-agonists promote bronchodilation by increasing cyclic adenosine monophosphate
Beta-2-agonists promote bronchodilation by increasing cyclic adenosine monophosphate
Which of the following features can differentiate myocardial infarction from pericarditis?
Reciprocal ST-segment depressions should never be seen in patients with pericarditis; therefore, an ECG with this finding should always be assumed to be from myocardial ischemia or infarction.
A 67-year-old woman presents with one month of progressive wheezing. On review of systems she also reports recent diarrhea. Which of the following findings on this patient’s physical exam is most consistent with the diagnosis of carcinoid tumors?
Flushed skin
- Carcinoid tumors are rare neuroendocrine tumors
- These tumors secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides resulting in a variety of symptoms.
- The diagnosis of carcinoid syndrome is best confirmed by measuring the 24-hour excretion of 5-hydroxyindoleacetic acid (5-HIAA) in the patient’s urine
ST elevations in V1 and V2
Location: Septal involvement is reflected by changes in V1 and V2
Vessel: Left anterior descending (LAD)
Lung hyperinflation with flattening of the diaphragms (
expected finding in chronic obstructive pulmonary disease (COPD).
A 70-year-old woman with a history of hypertension presents to the Emergency Department with a complaint of abdominal pain. On physical examination, there is a pulsatile mass in the midline of her abdomen. Which of the following is the most common risk factor for the development of this condition?
Smoking history
Smoking is the most common risk factor associated with the development of an abdominal aortic aneurysm (AAA).
A 42-year-old woman who spent two days hospitalized after she underwent an appendectomy three weeks ago presents with cough, green sputum and fever. Her vitals are T 100.7°F, HR 94, BP 123/76, RR 18, and oxygen saturation 97%. She is well appearing and her blood work (CBC and BMP) is unremarkable. A chest X-ray shows a left lower lobe infiltrate. Which of the following represents the best management for this patient?
Start IV antibiotics and admit
This patient has a health-care associated pneumonia (HCAP) requiring IV antibiotics and admission. HCAP is defined as infection occurring within 90 days of a 2-day or longer hospitalization; in a nursing home or long-term care residence; within 30 days of receiving intravenous antibacterial therapy, chemotherapy, or wound care or after a hospital or hemodialysis clinic visit.
Treatment: (one from each category 1, 2, 3)
- Cefepime, Ceftazidime, Pipercillin/Tazo, or imipenem/cilastatin
- Ciprofloxacin, Levofloxacin, Azitrhomycin
- Vancomycin, Linezolid
A 65-year-old woman presented to the emergency department with sub-sternal chest pain and dyspnea. Her cardiac biomarkers were mildly elevated and there was ST-segment elevation in the anterior leads. Apical ballooning was seen on echocardiography and coronary angiography revealed normal coronary arteries. She has no past medical history and takes no medications. Recently the patient lost her husband of 40 years. What is the most likely diagnosis?
- Stress-induced cardiomyopathy, also called Takotsubo cardiomyopathy and “broken heart” syndrome, is an increasingly reported syndrome characterized by transient cardiac dysfunction with ventricular apical ballooning, usually triggered by intense emotional or physical stress.
- This syndrome mimics acute myocardial infarction, but in the absence of obstructive coronary artery disease.
A 57-year-old man presents to your clinic complaining of two days of productive cough, fever, and dyspnea on exertion. He describes his sputum as foul smelling. He denies chest pain. He admits to drinking six to eight alcohol drinks per day and often experiences “blackouts” at night. Vital signs are BP 145/75, HR 114, T 100.8°F, RR 22, and pulse oxygenation 95 percent on room air. On exam, you note poor dentition and right-sided pulmonary rales. A chest X-ray is seen above. Which of the following is the most likely diagnosis?
Pneumonia caused by anaerobic bacteria
- Right upper lobe infiltrates
- Treatment is clindamycin
- Comments: Most common cause of lung abscess
A 67-year-old man with diabetes mellitus, chronic lower back pain and previously stable systolic heart failure now has increasing orthopnea and shortness of breath. Physical exam reveals pulmonary crackles, jugular venous distention and lower extremity edema. He is on carvedilol, lisinopril, furosemide, insulin and ibuprofen. Which of the following is appropriate for management of this patient?
AAdd a calcium channel blocker
BDecrease the dosage of furosemide
CDiscontinue the carvedilol
DDiscontinue the ibuprofen
DDiscontinue the ibuprofen
Non-steroidal anti-inflammatory drugs (e.g. ibuprofen) can worsen symptoms of heart failure.
What is the most common causative organism in community acquired pneumonia?
Streptococcus pneumoniae;
Streptococcus pneumoniae is a gram positive cocci and is the most common organism causing community acquired pneumonia.
most common, rusty colored sputum, rigors, gram+ paired lancets
A transudative pleural effusion is identified after thoracentesis. Which of the following clinical scenarios is most consistent with this type of effusion?
27-year-old woman with a lupus flare
47-year-old woman alcoholic with an elevated lipase
65-year-old man with an ejection fraction of 15% and pulmonary edema
72-year-old man recently diagnosed with lung cancer
65-year-old man with an ejection fraction of 15% and pulmonary edema
Mycoplasma pneumoniae tx
Clarithromycin/ azithromycin
___
Atypical Pneumonia
Patient will be complaining of gradual onset of dry cough, dyspnea, and extra-pulmonary symptoms such as headache, myalgias, fatigue, and GI disturbance
PE will show rales with auscultation of lung fields
Most commonly caused by Mycoplasma pneumoniae
acute presentation of sarcoidosis characterized by the triad of hilar adenopathy, erythema nodosum and polyarthralgia, with or without parenchymal infiltrates or fever, and is seen primarily in women with sarcoidosis.
Löfgren syndrome
Which of the following medications can be used in the treatment of hemodynamically stable atrial fibrillation with concomitant Wolff-Parkinson-White syndrome?
AAdenosine
BDiltiazem
CIbutilide
DMetoprolol
CIbutilide
Ibutilide can be used for rhythm control in hemodynamically stable atrial fibrillation with concomitant Wolff-Parkinson-White syndrome, which is also referred to as preexcited atrial fibrillation.
ST depressions in V1, V2, large R waves
Location: Posterior wall infarctions
Vessel: n/a
What is the INR range for patients taking warfarin for atrial fibrillation?
INR 2-3.
Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm?
Abdominal mass
An abdominal mass is most suggestive of an asymptomatic abdominal aortic aneurysm. An abdominal aortic aneurysm is defined as a focal, full-thickness dilation of the aorta that is greater than 50% larger than its normal diameter.
Risk population: Any man between the ages of 65 and 75 years who has ever smoked.
ST elevation in leads V5–V6 , I , and aVL
Location: Lateral wall infarctions
Vessel:
- left anterior descending
- right coronary
- left circumflex
Hemoptysis+trauma
pulmonary contusion
A 55-year-old man presents to the emergency department complaining of palpitations, nausea, and dizziness for 30 minutes. He is afebrile, his pulse is 140 beats per minute, and his blood pressure is 78/50 mm Hg. As the nurse attaches him to the cardiac monitor, you see the rhythm strip seen above. What is the most appropriate treatment?
Rhythm: wide complex tachycardia
Synchronized cardioversion at 200 joules
Clinically, he is hypotensive and unstable, which necessitates the use of electrical rather than pharmacologic treatment. Synchronized cardioversion is indicated for the treatment ofunstable tachydysrhythmias, including certain supraventricular dysrhythmias as well as monomorphic ventricular tachycardia.
A 47-year-old woman presents with several months of a persistent cough that recently resulted in hemoptysis. A review of system also confirms episodes of diarrhea, rash, and flushing. Physical exam is normal with the exception of focal wheezing over the right upper lobe. Which of the following is the most likely diagnosis?
Bronchial carcinoid tumors commonly cause persistent coughing with hemoptysis and focal wheezing.
Which of the following is the most common dysrhythmia associated with the diagnosis of pulmonary embolism?
Sinus tachycardia
What is the treatment for influenza?
Oseltamivir if used within 48 hours of symptoms onset
The X-ray would show a sharp cut-off of pulmonary vessels with distal hypoperfusion.
Westermark sign is a rare indication of pulmonary embolus (PE) on X-ray.
Which of the following murmurs is associated with an increase in right atrial pressure?
Tricuspid regurgitation
In tricuspid regurgitation, there is incomplete forward flow from the right atrium into the right ventricle and blood flows from the right ventricle into the right atrium during systole. This backflow of blood results in increased right atrial pressure.
A 55-year-old business executive comes to the emergency department with a 6-hour history of shortness of breath, cough, and chest pain. He smokes 1 to 2 packs of cigarettes daily and drinks 2 to 3 alcoholic beverages every night. He occasionally uses cocaine for recreational purposes. Physical examination reveals an erythematous and edematous right calf and a palpable cord. Auscultation of the lungs reveals rales and decreased breath sounds on the right side. Which of the following is the most likely diagnosis?
Pulmonary embolism
Uveitis, bilateral hilar adenopathy, and a dry cough most likely indicate
sarcoidosis
Elevated levels of serum angiotensin converting enzyme (ACE) are typically elevated in about 75% of patients with sarcoidosis.
A 55-year-old man presents complaining of a 2-day history of cough, fatigue and fever which came on suddenly. He denies chronic medical problems and takes no medications. He does not smoke. He is ill-appearing, though in no distress. His temperature is 101.6°F; pulse 112; BP 122/78; RR 24; and pulse oximetry 92% on room air. Physical exam is remarkable for rales along the right side of his lung fields. What is the most appropriate next step in evaluating his condition?
Chest X-ray
dx: community-acquired bacterial pneumonia (CAP).
MC bacteria: Streptococcus pneumoniae
tx: azithromycin or doxycycline if allergic
A patient presents with acute dyspnea and pleuritic chest pain. You suspect pulmonary embolism. Which of the following is the most appropriate test to confirm the diagnosis of a pulmonary embolus?
Computed tomography angiography
Pulmonary angiography is the definitive, or “gold standard”, test for the diagnosis of PE.
____
Pulmonary Embolism
- Patient will be complaining of dyspnea (most common symptom)
- PE will show tachypnea (most common sign)
- ECG will show sinus tachycardia, nonspecific ST segment and T wave changes, right heart strain, S1Q3T3 (classic finding)
- CXR will show nonspecific abnormalities, Hampton’s hump (pleural-based wedge infarct), Westermark’s sign (vascular cutoff sign)
- Diagnosis is made by CT pulmonary angiography (test of choice in moderate to high probability cases)
- Most commonly originate in the lower extremities and pelvis
- Treatment is anticoagulation (heparin, LMWH), supportive care, thrombolytics in hemodynamically unstable patients
- Comments: In low clinical suspicion: negative D-dimer excludes PE
A 26-year-old man presents with a 2-week history of fever and a cough. He was diagnosed with HIV four months ago and is not on any antiretroviral medications. His vital signs are BP 122/76, HR 78, RR 16, oxygen saturation 92% on room air, and temperature 99.2°F. Chest X-ray demonstrates diffuse interstitial infiltrates bilaterally. Given this presentation, it is suspected that he has pneumonia secondary to Pneumocystitis jiroveci. Which of the following antibiotics is used to treat suspected pneumonia caused by Pneumocystitis jiroveci?
Trimethoprim-sulfamethoxazole
Pneumonia in the settin gof chronic lung disease/mechanical ventilation
Pseudomonas aeruginosa
A 33-year-old man presents to the clinic with a sudden onset of dry cough, fever, myalgias, nasal congestion, and headache. He has a benign past medical history. His physical exam is remarkable for a temperature of 38.4°C, pharyngeal injection, conjunctival injection, and clear rhinorrhea. His lung sounds are clear to auscultation and there are no adventitious sounds heard. Which of the following diagnostic tests would be most useful at this time?
Nasopharyngeal swab
A nasopharyngeal swab can be sent for rapid immunofluorescence assay to detect influenza.
tx: Oseltamivir
A 25-year-old man presents for evaluation of fever and cough. He reports last week that he was diagnosed with influenza. In the last two days he developed a worsening cough productive of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR 18, and 95% oxygen saturation on room air. His chest X-ray demonstrates a lobar infiltrate in the left lower lobe. Which of the following would you most likely expect to see on the patient’s Gram stain?
Gram positive cocci in clusters
Staphylococcus aureus pneumonia as Postinfluenza Pneumonia
Blood Transfusion Reactions
Urticaria or hives
Allergic reaction
Symptomatic care; antihistamines
likely due to antibody-mediated response to donor’s plasma
Most common cause of CAP
Streptococcus pneumoniae
ECG is abnormal in 90% of cases and abnormalities include left ventricular hypertrophy, “dagger-like” Q waves in the inferior and lateral leads, and nonspecific ST segment changes.
Hypertrophic cardiomyopathy
diagnosis: echocardiogram
vignette:
A 32-year-old man presents after a syncopal episode. He was running on the track when he developed shortness of breath followed by witnessed syncope. He was not post-ictal and had no seizure activity. He reports that his father’s brother died while playing basketball. Physical examination is notable for a midsystolic crescendo-decrescendo murmur
Blood Transfusion Reactions
Rash, elevated LFT’s and pancytopenia [deficiency of all three cellular components of the blood (red cells, white cells, and platelets)]
Transfusion-associated graft versus host disease
STOP TRANSFUSION; Supportive care
immunocompromised patients; use irradiated blood products
A 19-year-old college student presents dead-on-arrival to the ED. An autopsy reveals significant calcification of the aortic valve cusps. Upon review of his medical history, you would most likely find documentation of a murmur heard in which of the following locations?
Proper cardiac auscultation begins with an understanding of which chest wall location is associated with which valve-sound. The aortic valve is best appreciated in the right, second intercostal space just lateral to the sternum.
A 33-year-old man presents with five days of gradual onset nonproductive cough, fatigue, and fever. He also notes a 15 pound weight loss over the last month. He is tachypneic with a heart rate of 105 beats/minute, temperature of 38.2oC, and an oxygen saturation of 89% on room air. On examination, white plaques are noted on his tongue and his lungs are clear on auscultation. His chest X-ray is shown above. Which of the following is the most likely causative agent?
Pneumocystis jiroveci
Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) is an opportunistic fungal pathogen which primarily affects immunocompromised patients including those with HIV/AIDS, as well as cancer and organ transplant patients on immunosuppressants. PCP is one of the most common AIDS-defining opportunistic infections.
CD4 counts are typically < 200 cells/mm3.
tx: Intravenous trimethoprim-sulfamethoxazole is the antibiotic of choice
the most common cause of hemoptysis (responsible for 15%-30% of cases)
bronchitis
ST elevations in V3, V4
Location: Anterior wall myocardial infarction
If V1-V4 it is anteroseptal
Vessel: Left anterior descending (LAD)
ST elevations in V4R, V5R
Location: Right ventricular
A man presents to the ED with angina during exertion that has increased in intensity and duration over the past 18 hours. An ECG shows T wave inversion in 4 leads. Which of the following risk stratification tools is used in the acute management of this type of angina?
TIMI Score
Thrombolysis in Myocardial Infarction (TIMI) risk tool.
A 47-year-old woman, with no past medical history and no hospitalizations, presents with cough, green sputum, and fever. Her vitals are T 100.7°F, HR 94, BP 123/76, RR 18, oxygen saturation 97%. She is well appearing and her blood work (CBC and BMP) is unremarkable. A chest X-ray shows a left lower lobe infiltrate. Which of the following represents the best management for this patient?
Discharge home with oral antibiotics and follow up
ST elevation in leads II, III, and aVF
Location: Inferior wall infarctions
Vessel:
- right coronary artery (right dominant)
- left circumflex artery (left dominant)
