High-Yield Review for the Pulmonary/Allergy/ENT Module Exam and USMLE Step 1 Matthew Warndorf, M4 Nicholas Detore, M4 January

16, 2009 Notes from the presentation 1. A woman in her 30s with dyspnea for several years. No cough or sputum. Hyperresonance to percussion. CT with decreased attenuation throughout. a. Alpha 1 antitrypsin deficiency b. Lab finding is decreased serum alpha 1 antitrypsin c. Panacinar emphysema (thus decreased attenuation throughout on CT) d. May also have cirrhosis of liver e. Phenotype is PI ZZ 2. A man previously treated with penicillin receives an IM dose of the drug and quickly develops hypotension and shock. a. Anaphylaxis b. IgE-mediated c. IgE bound to mast cell, reexposure to antigen cross-links Igerelease of mediators 3. A week post-op from surgery for cancer an elderly woman walks to the bathroom and upon returning to bed gets suddenly dyspneic and diaphoretic with chest pain. a. Pulmonary embolus b. Usually from DVT (leg/pelvic vein), can come from right atrium (atrial fib), thrombogenic catheters c. Risk factors are immobilization, cancer, fracture (recall Virchows triad) d. Usually CT angiography, can also do V/Q scan. Gold standard is pulmonary angiography (invasive) e. Saddle embolus is large clot that lodges at main PA bifurcation f. Pulmonary infarction can be a complication of PE (pleural-based, wedgeshaped) 4. A young girl suddenly develops wheezing and coughs up a mucus plug. Has had symptoms like this before. Chest is quiet on auscultation. CXR shows hyperinflation. a. Asthma, a chronic inflammatory disease of the airways b. Reversible (increase in FEV1 of 12% or 200mL) c. Triggers: URI, smoke, allergens, stress d. Treatment mainstay is short acting B agonist (albuterol). Any persistent asthma should have a controller (like an inhaled corticosteroid). i. B2 agonists albuterol (short), salmeterol (long) [remember, B1=heart, B2=lung], relax bronchial smooth muscle ii. Muscarinic agents Ipratropium (block muscarinic receptors)

iii. Methylxanthines Theophylline, narrow therapeutic index iv. Corticosteroids Prednisone (inhibit the synthesis of virtually all cytokines) v. Leukotriene inhibitors Zileuton, zafirlukast/montelukast e. Obstructive vs. Restrictive Disease i. Obstructive: decrease in FEV1, increased or normal FVC, decreased FEV1:FVC ratio 1. Common examples are COPD and asthma 2. In general, asthma=reversible; COPD=not fully reversible ii. Restrictive: decrease in FEV1 and FVC, normal or increased FEV1:FVC ratio 1. Common example is IPF 2. Smaller lung volumes and they desaturate with exertion 5. A young man with hemoptysis, edema, hypertension, hematuria, proteinuria and RBC casts. a. Goodpasture syndrome b. Type II hypersensitivity reaction c. Antibodies against basement membrane leads to recurrent pulmonary hemorrhage and glomerulonephritis d. Treatment options are limited: steroids, plasmapheresis, immunosuppressive medicines 6. A young, previously health female with fever, nasal discharge with purulence, anosmia, and complains of facial pressure and pain, especially over the frontal bone and bridge of the nose. Symptoms have persisted for 10 days. a. Acute sinusitis b. Often presents as unrelenting progression of a viral URI or allergic rhinitis beyond the normal 5 to 7 day course. c. Periorbital pressure/pain, nasal obstruction, mucopurulent discharge, fatigue, fever, headache. d. Thought to be 2o to decreased ciliary action of the sinus mucosa and edema causing obstruction of the sinus ostia. e. Most common bacterial causes are Strep pneumoniae, Staph aureus, H. influenzae. f. Treatment: amoxicillin, TMP/SMX 7. A 60 year-old man with a 60 pack-year smoking history presents with hemoptysis and weight loss. Sputum exam shows atypical cells. Serum calcium is elevated. Where is the lesion? a. Likely a large hilar mass, a squamous cell carcinoma (assoc. with PTH-rp and thus the hypercalcemia) b. Central tumors (think of central tumors with a paraneoplastic syndrome) i. Squamous, clear link to Smoking, ectopic PTH-related peptide (incr. Ca++) ii. Small cell, clear link to Smoking, ectopic hormone production (ADH, ACTH). Lambert-Eaton Syndrome (Abs against NM junction Ags, similar to MG) c. Peripheral tumors

i. Adenocarcinoma (most common) ii. Bronchioalveolar (thought not related to smoking) iii. Large cell (undifferentiated) d. Mets are common (brain, bone, liver) e. Complications (Pancoast tumor, SVC syndrome, paraneoplastic syndromes) 8. A student on a wilderness vacation develops a rash with varying degrees of erythema, edema, and vesiculations. What type of hypersensitivity? a. Type IV (poison ivy) b. Sensitization phase - Occurs after an initial contact with antigen, which leads to memory T-cell production c. Effector phase - Upon 2o exposure to antigen, large numbers of cytokines are released, followed by influx of macrophages, neutrophils, release of lytic enzymes, and extensive tissue damage 9. A young man suddenly develops severe dyspnea. Absent breath sounds on the right. CXR shows atelectasis of the right lung. a. Pneumothorax b. In what space does air collect? Pleural space, between parietal and visceral pleura a. Etiologies: spontaneous (young, thin men), penetrating trauma, chronic lung disease, barotrauma b. Tension vs. non-tension c. Sudden SOB, CP, subcutaneous emphysema d. Absent breath sounds, hyperresonance e. Evacuation by chest tube/needle decompression 10. Diseases like lupus and serum sickness are associated with immune complex deposition. What kind of hypersensitivity? a. Type III b. Secondary to formation of antigen-antibody complexes; which deposit on tissues. c. Inflammation is main feature of reaction as a result of complement fixation causing tissue damage. d. Serum sickness is classic pathogenesis of this reaction, characterized by urticarial skin eruptions, arthralgia, lymphadenopathy, and fever. 11. A woman delivers at baby at 29 weeks of gestation. The baby has respiratory distress requiring intubation and mechanical ventilation. CXR shows opacification of lungs. a. Neonatal respiratory distress syndrome b. Hyaline membrane disease of the newborn c. Surfactant deficiency leading to increased surface tension, resulting in alveolar collapse d. Surfactant is made in Type II pneumocytes most abundantly after 35th week. Stored as lamellar bodies e. Lecithin to sphingomyelin ratio usually <1.5 in NRDS (>2=maturity) f. RF include prematurity, diabetic mom g. Maternal steroids before birth and artificial surfactant for the infant

12. A child returns from vacation in Florida with complaints of earache and whitish discharge from the ear. No fever/chills/URI symptoms. a. Otitis Externa (Swimmers Ear) b. Generalized infection of external ear canal and often the tympanic membrane. c. Characterized by ear pain (otalgia), swelling of external ear, ear canal, or both; erythema; pain on manipulation of the auricle; debris in canal; otorrhea. d. Often associated with prolonged water exposure and damaged squamous epithelium of the ear canal (i.e. swimming, hearing aid use). e. Most frequently caused by Pseudomonas. f. Malignant otitis externa in diabetics g. Treatment: keep ear dry, remove debris if present, local steroid and antibiotic drops (polymyxin, bacitracin, neomycin), analgesics. 13. A young man in involved in an MVC leading to blood loss and prolonged hyptension. He is placed on a ventilator. He has increasing O2 and PEEP requirements but remains afebrile. He dies after 4 days. a. ARDS b. Pathology similar to neonatal respiratory distress syndrome/hyaline membrane disease c. Proteinaceous fluid leaks into alveoli d. The final event following lung injury from a variety of serious illnesses or accidents (shock, trauma, sepsis, aspiration) e. Clinically i. Acute onset ii. Hypoxemia iii. Bilateral pulmonary infiltrates on CXR iv. Absence of primary left heart failure NONCARDIOGENIC pulmonary edema f. Mechanical ventilation, PEEP 14. A NEOUCOM student falls asleep under a tree on a cold night and wakes with right facial weakness. There are no signs of stroke after evaluation at the ED. a. Bells Palsy b. Sudden onset, unilateral facial weakness or paralysis in absence of CNS, ear, or cerebellopontine angle disease (i.e. no identifiable cause). c. Pathogenesis: unknown, although accepted hypotheses include viral etiology (i.e. herpes virus) and long term exposure to cold. d. Pathology: related to swelling of facial nerve (CN VII) e. Treatment: usually none is required, as most cases spontaneously resolve in ~4 weeks, protect eye with drops, some ENTs advocate steroids and acyclovir. f. Oveall 90% of patients recover completely. 15. A young child has sudden onset of dyspnea and wheezing after being left alone to play with her toys. On exam she has absent breath sounds on the right. a. Foreign body aspiration b. All that wheezes is not asthma!

c. More commonly right mainstem less acute angle d. Review V/Q mismatch and why 100% FiO2 will not fully correct the ABG disturbance in this child (the same as a child with congenital heart disease like TOF of Transposition that is chronically hypoxic). This is shunt, the opposite of physiologic dead space. 16. A 70-year-old man has had dyspnea for a year. He worked in construction all his life. CXR shows pleural plaques. Sputum cytology shows no atypical cells. FVC is reduced but FEV1/FVC is normal. a. Asbestosis b. Diffuse pulmonary interstitial fibrosis caused by inhaled asbestos fibers. c. Risk of pleural mesothelioma (thirty years later) and bronchogenic carcinoma. d. Ferruginous bodies in lung (asbestos fibers coated with hemosiderin, phagocytosed by macrophages) e. Ivory-white pleural plaques f. Shipbuilders and plumbers. 17. A 2-year-old girl with respiratory distress. Low-grade fever, inspiratory wheeze, retractions, barking cough. This developed a few days after a URI. a. Croup (Laryngotracheobronchitis) b. Parainfluenza viral infection of the larynx and trachea, generally affecting children and seen most often in autumn months. c. Causes respiratory distress, low-grade fever, and steeple sign on A-P neck x-ray indicating subglottic narrowing. d. Classic symptom is barking seal-like cough. e. Treatment: keep child calm, aerosolized racemic epinephrine, cool mist, and steroids. 18. A 70-year-old woman develops fever, dyspnea and sputum production and is found to have a RLL infiltrate on CXR. She is in ill health and her family decides not to treat her acute illness. She dies four days later. a. Pneumonia b. Lobar Commonly pneumococcus. Intra-alveolar exudate consolidation. Red, then grey hepatization Fever, chills, malaise, sputum, hemoptysis. c. Bronchopneumonia S. Aureus, H. Flu, Klebsiella, S. Pyogenes. Elderly, infants. Acute inflammatory infiltrates from bronchioles into adjacent alveoli, patchy distribution over <= 1 lobe d. Atypical (interstitial) Viral (RSV), Mycoplasma, Legionella, Chlamydia. Diffuse patchy inflammation localized to interstitial areas at alveolar walls, no alveolar exudate. Dry, hacking cough. e. Alcoholics/diabetics think of Klebsiella (currant jelly sputum) f. Pulmonary abscess can be a complication of pneumonia. Air-fluid level, foul-smelling sputum. g. Patient likely developed sepsis i. SIRS 1. Temperature > 38C or < 36C 2. Heart rate > 90 beats/min

ii. iii. iv. v.

3. Respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg 4. WBC count > 12,000/mm3 , < 4000/mm3 , or > 10% immature (band) forms Sepsis SIRS in response to infection (i.e., there is a known source) Severe sepsis Associated hypotension/ hypoperfusion/organ dysfunction (oliguria, AMS, lactic acidosis) Septic shock Sepsis-induced hypotension despite adequate fluid resuscitation MODS Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention.

19. Sources a. Lange Q&A for USMLE Step 1, 6th Ed. McGraw-Hill 2008 b. First Aid Q&A for USMLE Step 1, McGraw-Hill 2007 c. First Aid For USMLE Step 1, McGraw-Hill 2006 d. Webpath i. http://library.med.utah.edu/WebPath/webpath.html