The answer is E. The patient presents with the signs and symptoms of emphysema. The patient has an FEV1/FVC ration of <70% which indicates an obstructive condition as well as diminished lung sounds which are consistent with emphysema. Chronic bronchitis patients will typically be overweight and cyanotic while those with emphysema will present with a barrel chest, accessory muscle use, and will appear underweight utilizing a puff-like inhalation technique.
Pulmonary function tests (PFTs) are used to confirm the diagnosis and help to determine the type of COPD that a patient has as well as the effectiveness of treatment regimens. The most widely accepted criteria in determining the appropriate treatment according to the disease stage is the GOLD criteria which is composed of 4 stages. Stage 1 = FEV1  80% and the patient should receive a short acting bronchodilator as well as vaccines for pneumonia and influenza. Stage 2 = FEV1 of 50-79% and the patient should add a long acting bronchodilator. Stage 3 = FEV1 of 30-50% and the patient should undergo pulmonary rehabilitation as well as receive an inhaled corticosteroid for acute flare-ups. Stage 4 = cor pulmonale, heart or respiratory failure or an FEV1  30%. These patients should add oxygen therapy to their regimen. Additionally, if the SPO2% drops below 88% or the PaO2 drops below 55mmHg then the patient should also begin oxygen therapy.

References:
1. COPD. dynamed.com. http://www.dynamed.com/topics/dmp~AN~T115557#Epidemiology. Published January 19, 2018. Accessed February 7, 2018.
2. Ferguson G, Make B. Management of Stable Chronic Obstructive Pulmonary Disease. UpToDate.
3. Papadakis MA, McPhee SJ, Rabow MW. 2017 Current medical diagnosis and treatment. New York.,
NY: McGraw Hill Education; 2017.
4. Williams DA. PANCE prep pearls: a medical study and review guide for the PANCE, PANRE & medical
examinations. North Charleston, SC: CreateSpace Independent Publishing Platform; 2017.
5. https://ginasthma.org/wp-content/uploads/2020/04/Main-pocket-guide_2020_04_03-final-wms.pdf

The correct answer is E. Systemic steroids such as IV solumedrol have been shown to improve lung function, diminish symptoms of shortness of breath, and decrease the length of hospital stay for patients experiencing an acute exacerbation of COPD. Giving this medication is a means to rapidly address the patient’s compromised respiratory status. Zithromax is often used in conjunction with steroids for COPD exacerbations, mainly to protect the patient from an ongoing bacterial infection that may actually caused the flare. It is not going to help this patient in a more immediate sense, however. Advair is a maintenance medication for COPD and is not indicated acutely. Mucinex helps to clear bronchial secretions and can be used in these patients, but it is not the best answer. Some mucoactive agents may actually make patients’ symptoms worse. Finally, magnesium is sometimes utilized in the treatment of respiratory emergencies, specifically asthma exacerbations. With asthma it has been shown to have a bronchodilating effect. It is important to note however, this is not true of COPD.

References

PubMed. Controlled clinical trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency. Albert RK, Martin TR, Lewis SW. Ann Intern Med. 1980;92(6):753.

PubMed. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. Niewoehner DE, Erbland ML, Deupree RH, Collins D, Gross NJ, Light RW, Anderson P, Morgan NA. N Engl J Med. 1999;340(25):1941.

PubMed. Effect of intravenous magnesium sulfate on chronic obstructive pulmonary disease exacerbations requiring hospitalization: a randomized placebo-controlled trial. Abreu González J1, Hernández García C, Abreu González P, Martín García C, Jiménez A.
Arch Bronconeumol. 2006 Oct;42(10):491.

Correct A. This patient presents with an acute exacerbation of congestive heart failure with a decrease in exertional capacity, dyspnea, significant weight gain, JVD, and signs of fluid overload. The most appropriate treatment would be a loop diuretic like Furosemide, which is the most effective treatment for symptom relief of mod-severe CHF with fluid overload. It works by inhibiting water transportation across the loop of Henle resulting in an increased excretion of water, chloride, sodium and potassium.5,7,8 Since this patient is having an acute onset, intravenous treatment is necessary for rapid relief of symptoms.

Incorrect B This patient has negative troponins and a normal EKG and is not currently having angina or AMI. Isosorbide mononitrate does decrease the preload via venous relaxation but it is not the most effective treatment for immediate symptom relief.

Incorrect C ACE inhibitors along with diuretics are first line treatment for CHF patients, but the Lisinopril takes 7-10 days for its pharmacological effect. ACE inhibitors are initiated as first line if the patient is not in fluid overload. Therefore, a diuretic would be the most appropriate rather than lisinopril.5,7

Incorrect D Metoprolol Succinate takes about 7-10 days for its pharmacological effects to take place. It works by decreasing the patients HR and BP, improving the left ventricular function and dilation, improving symptoms within 7-10 days. It does not help with fluid excretion or the immediate relief of symptoms after the first dose, like Furosemide.5,7

Reference: Mann D, Chakinala M. Heart Failure and Cor Pulmonale. In: Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012: 1901-1913

Answer:  Pleural effusion.  There is opacification from the base to the mid-lung fields well delineated with a horizontal cutoff and darker (normal) lung above.

Pleural effusions are accumulation of fluid within the pleural space secondary to either an abnormality of absorption by the pleural lymphatics or by excess production via the pleural capillaries.  Cirrhosis leads to an increase in fluid production either by causing a decrease in oncotic pressure or by migration of fluid from ascites through the lymphatic system.  Other etiologies of pleural effusions are:  congestive heart failure, pneumonia, uremia, pancreatitis, ARDS, TB, malignancy and trauma to the thoracic duct (Chylothorax) or a blood vessel (hemothorax).

The patient’s symptoms are generally related to the length of time that the effusion takes to develop.  A slow developing effusion allows for compensation whereas a rapid accumulation results in acute shortness of breath.  Effusions can also be associated with pleuritic pain, dry cough and even fever depending on the underlying etiology.  Physical exam will reveal diminished breath sounds over the affected lung base, depending on the size of the effusion.  Dullness to percussion and decreased tactile fremitus are also present depending on the size of the effusion.  Tachypnea and hypoxia will be present with large or rapidly accumulating effusions.

A chest x-ray is the most commonly used modality to diagnose a pleural effusion.  As little as 50ml of fluid can be visualized on the lateral x-ray compared to a minimum of 175-200ml being needed to be visible on a frontal view.  The first indication of an effusion is blunting of the normally sharp costophrenic angle(s).  Poor demarcation of the hemi-diaphragm and atelectasis may also be present.  A lateral decubitus film may be useful to distinguish between loculated and free flowing effusions.  Ultrasound can detect as little as 3-5ml of pleural fluid but is usually reserved for the treatment phase.

Treatment may involve observation if small and asymptomatic however for symptom relief or to assist in diagnosis a thoracentesis is generally performed and the fluid obtained can be sent for analysis.  Lights criteria can aid in the determination between exudative and transudative fluids.  Exudative fluids must meet at least one of the following characteristics:  pleural fluid protein to serum protein ration > 0.5, or pleural fluid LDH to serum LDH ration of > 0.6, or pleural fluid LDH > 2/3rds of the upper limit of normal serum LDH.  Other treatment options include thoracostomy or pleurodesis for frequent reoccurrences.

The patient in this case has required bi-weekly thoracentesis for some time and frequently has approximately 2L removed.  Despite this rather large amount of fluid, her PO2 was 100% RA.

References:

Longo DL, Kasper D, Jameson J, Fauci A, Hauser S, Loscalzo J. Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2012.

Papadakis, Maxine A., Stephen J. McPhee, and Michael W. Rabow. 2015 Current Medical Diagnosis & Treatment. New York: McGraw-Hill Education/Medical, 2015. Print.

Pleural Effusion. In DynaMed Plus, EBSCO Information Services (Accessed April 1, 2016)

Correct Answer: D. Pulmonary embolism: PE is very difficult to diagnose & you must be vigilant to ensure that you do not miss it, as the clinical presentation is variable. The clinical findings depend on both the size of the embolus & the patient’s pre-existing cardiovascular status. The utilization of the PERC criteria & Wells criteria have been very helpful in determining whether to pursue PE as a diagnosis. The PERC rule can be applied to patients where the diagnosis of PE is being considered, but the patient is deemed low-risk. A patient deemed low-risk by provider’s gestalt who is also The hallmark of PE is dyspnea unexplained by auscultory findings, ECG changes, or obvious diagnosis on chest x-ray. Dyspnea occurs in 75-85% & pain on inspiration occurs in 65-75% of patients with PE. Routine cardiopulmonary testing in the ED generally demonstrates non-specific findings. The most common findings for PE on EKG are sinus tachycardia seen in about 44% of all cases & non-specific ST-T wave changes. When the PE causes the right ventricular systolic pressure to exceed 40 mm Hg the EKG begins to manifest more specific changes including T wave inversion in V1-V4 & leads II, III, & aVF, incomplete or complete right bundle branch block.. However an S1-Q3-T3 indicative of cor pulmonale is the classic finding on EKG for PE. On chest x-ray the most common finding is clear lungs & absence of pulmonary edema. However the Westermark sign from complete lobar artery obstruction & Hampton’s Hump indicative of pulmonary infarction are relatively specific findings seen in <5% of patient’s. The definitive diagnostic test is chest CT angiography which identifies a clot as a filling defect in contrast enhanced pulmonary arteries.

The time to treatment with therapeutic anticoagulation has an inverse relationship with outcome & anticoagulation should be initiated in any patient with high suspicion for PE while waiting for the diagnostic confirmation. The use of low molecular weight heparin (1 mg/kg BID or 1.5 mg/kg daily) as a bridge to therapeutic anticoagulation with Warfarin sodium (dosing based on the INR) has become the standard of treatment.

References

Slovis B. MDCalc. http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/. Accessed June 16, 2016

Slovis B. MDCalc. http://www.mdcalc.com/perc-rule-for-pulmonary-embolism/. Accessed June 16, 2016

Longo, DL, Kasper D, Jameson J, Fauci A, Hauser S, Loscalzo J. Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2012

Mahadevan SV, Garmel GM. An Introduction to Clinical Emergency Medicine. Cambridge: Cambridge University Press; 2012

Papadikis, Maxine A., Stephen J. McPhee, and Michael W. Rabow. 2011 Current Medical Diagnosis & Treatment. New York: McGraw-Hill Education/Medical, 2011. Print

Tintinalli JE, Stapczynski,JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill Pub. Division; 2011

A. Is incorrect because COPD is a obstructive breathing issue and the PFT test shows results for a restrictive breathing issue.
B. Asthma is incorrect because most asthma is diagnosed as a child and not in 60 year olds. Also, asthma is an obstructive breathing issue and the PFT test shows results for a restrictive breathing issue.
C. Pneumonia is not the answer because symptoms have been going on for a few months with no signs of infection, fever, fatigue, or myalgias.
D. Pleural effusion is not the answer because on physical exam you would find decreased or absent breath sounds at the bases from the fluid collection.
E. Interstitial pulmonary fibrosis is the correct answer because of the worsening symptoms, the work place environment that could be causing her to breath in pollutants and chemicals for the past 40 years. Also, IPF is a restrictive lung disease which is consistent with the PFT findings.

Interstitial lung disease (ILD) is a large umbrella term for many different lung issues. The most common type of ILD is idiopathic pulmonary fibrosis (IPF) which accounts for 40% of all ILDs. IPF is a common cause of restrictive lung disease that causes scar tissue formation in the parenchymal of the lungs (Meltzer and Noble, 2008). It can be caused by inhalation of harmful substances, drugs, infections, radiation or autoimmune conditions (Martino 2016). One of these come in contact with the lungs causing a hypersensitivity reaction which causes inflammation. Our bodies are in charge of wound healing and if something goes wrong in the process our lungs can develop fibrosis or scarring to the tissue. The lung fibrosis then has an issue with expanding causing decreased ventilation, hypoxemia and a restrictive lung disease.

The prevalence of IPF is 20 cases per 100,000 persons for males and 13 cases per 100,000 persons for female. 66% of patients who are diagnosed with IPF are 60 years of age or older and have a poor prognosis estimating 2-5 years to live from diagnosis (Martino 2016). When these patients arrive to their primary providers most of the symptoms are nonspecific. The most common symptoms are dyspnea on exertion and or a nonproductive cough. The most important part of diagnosis IPF is getting a complete history. The patient could have a social history of smoking, travel history, occupational history of exposure to pollutants, exposure history of asbestos in a house or medications that cause lung fibrosis years after use like Amiodarone, Bleomycin and Nitrofurantoin. Other history needs to be ruled out also such as tuberculosis and human immunodeficiency virus. The physical exam on IPF patients could be positive for fine bibasilar inspiratory crackles which is called Velcro crackles in IPF. The patient should be evaluated for digital clubbing which could occur slowly overtime and found in 50% of IPF patients (Meltzer and Noble, 2008).

The most important work up for IPF is a pulmonary function test which will show restrictive lung disease. The Total Lung Capacity (TLC) will be reduced, Forced Expiratory Volume in 1 second (FEV1) will be increased, Forced Vital Capacity (FVC) will be reduced and FEV1/FVC will be increased (Martino 2016). Chest x-rays are also useful which will show small irregular opacities less than 1.5mm in diameter, ground-glass opacities, and honey combing which is small translucency in the lungs. The more superior option to diagnosing IPF is by using a High-Resolution Computed Tomography (HRCT). This will imaging tool will diagnosis, assesses disease severity and can find ILD in patients with a negative chest x-ray. The next step in IPF is getting a lung biopsy. Depending on the location of the IPF biopsies can be taken by bronchoscopy, bronchoalveolar lavage or thoracoscopic wedge biopsy.

The definitive treatment for IPF is lung transplant. There are some new medications that can help with the disease if the patient is not a lung transplant candidate which is Tyrosine Kinase Inhibitors and Antifibrotic Agents. Tyrosine Kinase Inhibitor called Nintedanib was FDA approved for the treatment of IPF in 2014 after it found improvement of FVC in patients and less acute exacerbations (Godfrey, 2017). The common side effect of the medication is diarrhea which caused less than 5% of patients to stop treatment. Nintedanib targets platelet derived growth factor receptors, vascular endothelial growth factor receptors and fibroblast growth factor. The FDA also approved an Antifibrotic Agent called Pirfenidone for IPF in 2014 after it was found to improve FVC over a 52 week time span and less progression of the disease and longer survival (Raghu, 2017). Complications of IPF are increased pulmonary pressures causing pulmonary hypertension or cor pulmonale, repeat acute exacerbations of pulmonary fibrosis or pneumonia (Martino 2016). All IPF patients need to be evaluated for obstructive sleep apnea and lung cancer. If the patient is a current smoker they should be given smoking cessation. These patients need to receive the influenza and pneumococcal vaccine due to their high risk of development with an underlying lung condition. These patients need to stay active, exercise regularly, loss weight if needed, eat a healthy diet. Their provider should start by prescribing pulmonary rehab to help them.

References

Godfrey, Amanda M K. Emedicine.medscape.com. (2017). Idiopathic Pulmonary Fibrosis Medication: Tyrosine Kinase Inhibitors, Antifibrotic Agents, Corticosteroid, Systemic, Immunosuppressant Agent. [online] Available at: https://emedicine.medscape.com/article/301226-medication [Accessed 25 Oct. 2017].
Martino, Linda. Idiopathic pulmonary fibrosis. MCPHS PowerPoint Lecture on April 4, 2016.
Meltzer, E. and Noble, P. (2008). Idiopathic pulmonary fibrosis. Orphanet Journal of Rare Diseases, [online] 3(1), p.8. Available at: https://ojrd.biomedcentral.com/articles/10.1186/1750-1172-3-8 [Accessed 25 Oct. 2017].
Raghu, G. Selman, M. Atsjournals.org. (2017). Nintedanib and Pirfenidone. New Antifibrotic Treatments Indicated for Idiopathic Pulmonary Fibrosis Offer Hopes and Raises Questions | American Journal of Respiratory and Critical Care Medicine. [online] Available at: http://www.atsjournals.org/doi/full/10.1164/rccm.201411-2044ED [Accessed 25 Oct. 2017].

X-ray findings for a tension pneumothorax would show increased radiolucency on the side of the pneumothorax where the air is collecting in the pleural space, tracheal and mediastinal deviation to the contralateral side of the pneumothorax due to the compression caused by the air leak. Because of this, answer A is correct, as it is not a radiologic finding consistent with a tension pneumothorax. Choices B, C, and D are all radiologic findings in a tension pneumothorax.

DISCUSSION:
The patient in the above case was diagnosed with a spontaneous tension pneumothorax. A pneumothorax occurs when there is a presence of air in the pleural cavity and can occur for a variety of different reasons and can have different levels of severity. A tension pneumothorax is “a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function” (Daley, 2016). Patients are at the highest risk for developing a pneumothorax during the neonatal period. The incidence in neonates is 1-2% (Daley, 2016). Neonates who are male, preterm, delivered by c-section, low birth weight, low 1 minute Apgar scores, require resuscitation at birth, have RDS, PIE and receive ventilator treatment are at high risk for developing pneumothoraxes as represented by the patient in the above case. Other risk factors include receiving positive pressure ventilation or CPAP, vacuum extraction, pneumonia, pulmonary hypoplasia, CPR, perinatal asphyxia and urinary tract anomalies. The incidence of pneumothorax development has increased since the start of ventilator use in neonates. In those receiving positive pressure ventilation, the risk is 15-30% (Gomella, 2013). The incidence of tension pneumothorax is unknown.
Pneumothorax can either be spontaneous or due to trauma. There are two types of spontaneous pneumothorax (primary and secondary). Primary spontaneous pneumothoraxes are without known pulmonary disease and usually occur in tall, thin younger males. They are more at risk if they are smokers, or have a positive family history however; this cause is rare during the neonatal period. A secondary spontaneous pneumothorax occurs in the presence of pulmonary disease, such as Pulmonary Interstitial Emphysema or RDS as seen in the above case. PIE is seen almost exclusively in very low birth weight infants on ventilatory support like Twin Boy B and usually develops in the first 48-72 hours of life (Gomella, 2013). In adults, diseases such as COPD put you at increased risk for a pneumothorax. A pneumothorax can also be iatrogenic from ventilation use or traumatic.
In a pneumothorax, air gets displaced into the pleural space due to the pressure gradient of either the alveoli and pleural space or the pleural space and the atmospheric pressure (traumatic). Alveoli are under a greater pressure than the intrapleural space, with the pressure in the intrapleural space being less than atmospheric pressure. Normally, a pneumothorax will “seal itself off” when the pressure between the two is equalized. Tension pneumothorax can result from any of these when the intrapleural pressure exceeds the atmospheric or alveolar pressure (Epocrates, 2017). This acts as a one-way valve and does not allow for air to escape (back into the lung or through a trauma induced puncture) with exhalation (Gamella, 2013). The pressure in your thoracic cavity increases causing collapse of the lung tissue/volume. If it is a tension pneumothorax, the pressure continues to collapse the lung and causes a shift of the trachea and mediastinum to the contralateral side. This further causes an increase in pulmonary vascular resistance and central venous pressure. With the heart compressed, cardiac output and the venous return to the heart can become decreased. The result is hypoxia and acute respiratory failure (Gamella, 2013).
As for history and physical findings, it becomes more challenging to catch with neonatal patients. Generally, a tension pneumothorax presents itself as a medical emergency with sudden and rapid deterioration of the patient. Especially in neonates, this is not always that apparent and can present more subtly as with the patient’s presentation in the above case. Signs to look for in the infant include grunting, irritability, and/or restlessness. Most commonly, a patient will present with worsening chest pain, dyspnea, anxiety or fatigue and occasionally epigastric pain. However, neonates cannot provide you with this information so you have to rely on physical exam. Physical exam findings include cyanosis, hypoxia, tachypnea, increased work of breathing, retractions, diminished or absent breath sounds, and an asymmetric chest rise. If mechanically ventilated, you may see an increase in oxygen demand. The cardiovascular exam can show tachycardia or bradycardia, an increase in blood pressure with narrowed pulse pressure and eventually hypotension (Gomella, 2013). The PMI will be displaced to the contralateral side. Infants may present with a “cyanotic upper half and pale lower half” of their body (Gomella, 2013). Not as commonly in patients you may see JVD and tracheal shift and have hyper resonance on percussion (Epocrates 2016). Pneumothoraxes are found incidentally in 1-2% of neonates without any suggesting signs or symptoms (Gomella 2013). When looking at labs, a blood gas may show respiratory acidosis as seen with the above patient giving a decreased PaO2 and and increased PCO2.
Imaging that is useful in the diagnosis of a pneumothorax include ultrasound, xray and on rare occasions CT if patient is hemodynamically stable with a high index of suspision but a pneumothorax cannot be ruled out by CXR/US. In neonates, transillumination of the thorax may also be used. Ultrasound will show an absence of lung sliding/absence of the normal “sea shore” sign. In a tension pneumothorax a CXR will show a shift in the mediastinum and trachea to the contralateral side of the air leak, depression of the diaphragm on the ipsilateral side, a radiolucent band of air with a lack of lung markings on the ipsilateral side of the air leak and decreased radiolucency on the contralateral side of the air leak where the lungs are being collapsed (Gorrochategui, 2017).
Treatment differs for a tension vs. nontension pneumothorax. If suspecting a tension pneumothorax, do not delay for confirmation on CXR. If the air is not evacuated immediately it can be fatal. Treatment includes a needle decompression followed by chest tube placement on the side of the air leak with a confirmatory CXR after decompression/tube placement. Chest tube placement is not always necessary for pneumothorax following needle decompression, especially if the patient is not using any form of mechanical ventialation. The needle can be placed at either the second intercostal space – midclavicular line or the fourth intercostal space – anterior axillary line with needle insertion on top of the rib. Removal of the chest tube requires pain medication and can be done once there is no longer bubbling of the underwater seal or presence of air on xray for 24-48 hours. If hemodynamicaly stable and a non-tension pneumothorax, conservative measures such as oxygen supplementation may be all that is necessary. If patient is currently on or requiring mechanical ventilation, High Frequency Oscillatory Ventilation is preferred as it has lower mean airway pressures and is a gentler mode of ventilation for these patients (Gomella, 2013). If patient is hyperinflated or has atelectasis after reinflation, bronchodilators can be used as well as proper positioning of the infant (hyperinflated side down/atelectatic side up).
With the above case the differential diagnosis included pneumothorax, displaced ET tube, pneumonia, pneumomediastinum, pleural effusion, pericardial effusion, pneumopericardium, anemia. Although pneumothorax was high on suspicion, due to baby’s risk factors of RDS, PIE and mechanical ventilation, the diagnosis of tension pneumothorax was quite surprising. The infant had subtle signs of respiratory distress but was not at all hemodynamically unstable. Bacteremia/sepsis would have been considered however this could be ruled out with blood cultures showing no growth for 48 hours. Obstruction of the infant’s nares by a mucus plug was ruled out after no relief after suction by the nurse. The displaced ET tube was the most likely and most easily correctable diagnosis second to a pneumothorax but this was ruled out with the XRAY along with the pleural effusion, pericardial effusion and pneumopericardium. Anemia could have contributed to some of the symptoms but not all and could not be the cause of the pneumothorax; this was eventually corrected with a blood transfusion. Pneumomediastinum would have resulted in an elevated appearance of the thymus with air outlining the heart. Pneumopericardium and tension pneumothoraxes can both present with rapid deterioration of the patient although the patient did not present in this way. Pneumothorax is the more common of these diagnoses and the diagnosis can be differentiated on CXR. Pneumonia was a likely diagnosis before the XRAY as the patient had multiple risk factors and had a subtle presentation of symptoms. Infants with pneumonia may also have decreased breath sounds, rales, and tachypnea but may also present with increased respiratory secretions, fever/hypothermia and an altered white blood cell count.

References
Daley BJ. Pneumothorax. http://emedicine.medscape.com/article/424547-overview. Published August 18, 2017. Accessed September 24, 2017.
Gomella TL, Cunningham MD, Eyal FG. Neonatology: management, procedures, on-Call problems, diseases, and drugs. 7th ed. New York, NY: McGraw-Hill Education Medical; 2013.
Pneumothorax History & Exam – Epocrates Online. https://online.epocrates.com/diseases/50433/Pneumothorax/History-Exam. Accessed September 24, 2017.
Gorrochategui M. Pneumothorax | Radiology Reference Article. Radiopaedia.org. https://radiopaedia.org/articles/pneumothorax. Accessed September 24, 2017.

The correct answer is spontaneous pneumothorax (A). This patient demonstrates the classic presentation of an individual with this condition. A spontaneous pneumothorax is most commonly diagnosed in individuals between the ages of 10 and 40. Additionally, this patient recently went through a growth spurt, demonstrating that he is most likely tall and thin. His physical exam findings of diminished breath sounds, hyperresonance on percussion, and decreased tactile fremitus are typical of patients with this condition.1 Hypertrophic cardiomyopathy (B) is incorrect. Although this patient developed symptoms during exercise, most patients with HCM develop other symptoms such as dyspnea, presyncope, syncope, heart palpitations, and/or dizziness. The absence of a fourth heart sound (S4) or a heart murmur combined with his abnormal lung exam do not support the diagnosis of HCM.7 Pleural effusion (C) is also incorrect. While this patient’s physical exam findings of diminished breath sounds, hyperresonance on percussion, and decreased tactile fremitus support the diagnosis of a pleural effusion, the background information makes this diagnosis inaccurate. Most patients diagnosed with a pleural effusion suffer from an underlying cardiac or pulmonary disease.8 Pulmonary embolism (D) is incorrect. Although this patient experienced a sudden onset of chest pain, the remainder of his presentation does not support the diagnosis of a PE. This diagnosis is more common in overweight women rather than thin men. Most patients with a PE have an antecedent deep vein thrombosis (DVT) and experience lower extremity pain or swelling. Additionally, patients are at an increased risk of developing a PE if they meet the criteria for Virchow’s triad: venous stasis, vessel wall injury, and hypercoagulability. This patient does not meet these criteria. This patient’s history, physical exam findings, and chest x-ray findings do not support the diagnosis of a PE.9

References
1 Daley BJ. Pneumothorax. Medscape. http://emedicine.medscape.com/article/424547-overview. Updated July 20, 2016. Accessed April 19, 2017.
2 Chesnutt MS, Prendergast TJ. Chapter 9: Pulmonary disorders. In: Papadakis MA, McPhee SJ, ed. Current Medical Diagnosis and Treatment. 54th ed. New York, NY: McGraw-Hill Education. 2015: 312-313.
3 Gonzales, CA. Spontaneous pneumothorax in children. In: DynaMed [database online]. Ipswich, MA: EBSCO Information Services. http://web.b.ebscohost.com.ezproxymcp.flo.org/dynamed/detail?vid=2&sid=c01dbb52-d28a-438f-b577-5c4bc2c6c9c9%40sessionmgr101&hid=118&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#AN=306335&db=dme. Updated January 11, 2016. Accessed April 19, 2017.
4 Patel A. Spontaneous pneumothorax in adults. In: DynaMed [database online]. Ipswich, MA: EBSCO Information Services. http://web.b.ebscohost.com.ezproxymcp.flo.org/dynamed/detail?sid=c01dbb52-d28a-438f-b577-5c4bc2c6c9c9%40sessionmgr101&vid=3&hid=118&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#AN=114714&db=dme. Updated January 9, 2017. Accessed April 19, 2017.
5 Mayo Clinic Staff. Pneumothorax. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/pneumothorax/home/ovc-20179880. Updated January 28, 2016. Accessed April 19 2017.
6 Gluckman W. Pediatric Pneumothorax. Medscape. http://emedicine.medscape.com/article/1003552-overview. Updated October 26, 2015. Accessed April 19, 2017.
7 Shah SN. Hypertrophic Cardiomyopathy. Medscape. http://emedicine.medscape.com/article/152913-overview. Updated January 5, 2016. Accessed April 19, 2017.
8 Rubins J. Pleural Effusion. Medscape. http://emedicine.medscape.com/article/299959-overview. Updated March 30, 2017. Accessed April 19, 2017.
9 Ouellette DR. Pulmonary Embolism. Medscape. http://emedicine.medscape.com/article/300901-overview. Updated June 22, 2016. Accessed April 19, 2017.

The answer is A. Exudative pleural effusions form due to an underlying disease. This patient presented with shortness of breath, which is one of the most common symptoms patients present with when they have a pleural effusion. This patient also has newly diagnosed breast cancer, which was indicated by her breast mass stated in the question and supported by her chest x-ray. Effusions can oftentimes occur in patients who have malignancies because of changes in the permeability of pleural membranes secondary to malignancy (10). A diagnosis of an exudative effusion can then be made confirmed if because the pleural fluid LDH is greater than two thirds of the upper limit of normal for serum LDH. Light’s criteria is diagnostic tool used to help differentiate between exudative and transudative causes of effusions.

Choice B is incorrect because transudative pleural effusions are usually caused by disease processes such as congestive heart failure, cirrhosis or pneumonia renal failure (9). Evaluation of the pleural fluid is used to confirm the diagnosis.

Choice C is incorrect because patients with TB have a productive cough of bloody sputum and chest pain. Although she has a cough, it is non-productive and she denies chest pain. The classic chest x-ray finding of tuberculosis is an upper lobe cavitary opacification. Another common symptom is fever, but she is afebrile because her vitals show her temperature at 98°F (7).

Choice D is incorrect because, like TB, patients with bacterial pneumonia usually have a fever, productive cough, and chest pain. This patient denies these symptoms. Her chest x-ray showed blunting of the left costophrenic angle and a hyperdense area in the left apical lung. These findings suggest a cancerous mass and a pleural effusion in the base of the left lung, and not a lobar infiltrate commonly seen on a chest x-ray that is positive for bacterial pneumonia (6)

References
1. Pleural Effusion Clinical Presentation: History, Physical Examination. Emedicinemedscapecom. 2017. Available at: http://emedicine.medscape.com/article/299959-clinical#showall. Accessed April 24, 2017.
2. What Are Pleural Effusions?. WebMD. 2017. Available at: http://www.webmd.com/lung/pleural-effusion-symptoms-causes-treatments#1-4. Accessed April 24, 2017.
3. Management of the Patient With a Malignant Pleural Effusion. Medscape. 2017. Available at: http://www.medscape.com/viewarticle/736939_3. Accessed April 24, 2017.
4. Management of Malignant Pleural Effusions. Uptodatecom. 2017. Available at: https://www.uptodate.com/contents/management-of-malignant-pleural-effusions. Accessed April 24, 2017.
5. Pleural Effusion: Background, Anatomy, Etiology. Emedicinemedscapecom. 2017. Available at: http://emedicine.medscape.com/article/299959-overview#a6. Accessed April 24, 2017.
6. Pneumonia-Exams and Tests. WebMD. 2017. Available at: http://www.webmd.com/lung/tc/pneumonia-exams-and-tests. Accessed April 24, 2017.
7. CDC | TB | Basic TB Facts | Signs & Symptoms. Cdcgov. 2017. Available at: https://www.cdc.gov/tb/topic/basics/signsandsymptoms.htm. Accessed April 24, 2017.
8. Light J. Diagnostic Approach to Pleural Effusion in Adults – American Family Physician. Aafporg. 2017. Available at: http://www.aafp.org/afp/2006/0401/p1211.html. Accessed April 24, 2017.
9. Light’s Criteria: Light’s Criteria. Emedicinemedscapecom. 2017. Available at: http://emedicine.medscape.com/article/2172232-overview#a1. Accessed April 24, 2017.
10. Fluid Around the Lungs or Malignant Pleural Effusion. CancerNet. 2017. Available at: http://www.cancer.net/navigating-cancer-care/side-effects/fluid-around-lungs-or-malignant-pleural-effusion. Accessed April 24, 2017.

COPD Exacerbation is the most likely diagnosis in this patient. The patient has a 50 pack year history and is currently not on any COPD treatment regimens. His recent history of a fever/cold, with increased shortness of breath are the pertinent positives to focus on in the vignette. He may be compensating for this exacerbation with an increase in blood pressure, but it is important to not be distracted by the vital sign of an alarming home blood pressure number, when his BP was significantly reduced at time of ED presentation, and the reliability of his home blood pressure monitor is unknown.

COPD exacerbations are common among smokers, most common etiologies include recent respiratory illness, or environmental pollutants. Most COPD patients have 1-2 exacerbations per year. This patient quit smoking two years ago and is probably experiencing his first moderate exacerbation, which is why he thought the main problem was his blood pressure, his anxiety over his shortness of breath and blood pressure readings most likely contributed to his hypertensive urgency. The pertinent findings for COPD exacerbation include increased shortness of breath, increased sputum production, quality of sputum, and general malaise. Because he has all three of the major signs of sputum quantity, quality, and dyspnea- this is classified as a severe COPD exacerbation (Lareau, Amer. Thoracic Society).

Diagnostic imaging (CXR), and pulse oximetry monitoring was performed along with a breathing treatment of DuoNeb 3mL once and a reevaluation of dyspnea post treatment. The patients dyspnea was improved. The patient was advised to see his PCP to begin a routine COPD exacerbation prophylaxis regimen, and possibly adjust his hypertensive medications.

The patient is already on ideal medications for hypertension in a COPD patient, as beta-blockers can cause resistance to the therapeutic effects of bronchodilators, and ACEi’s have a common side effect of cough which makes ARBs the hypertension medication of choice in a COPD patient (Weinberger, UpToDate). It is unclear why this patient with such a significant pack year history had not been put on any treatment regimen for COPD or even a rescue inhaler. Evidence based medicine indicates that he should be on a LAMA/LABA/INGC w/ a SABA for rescue. An appointment was made for follow-up with his PCP as his vitals were stable enough to discharge after ED treatment (Merck Manuals).

Hyptensive emergency is incorrect because it is characterized by a systolic BP > 180 and a diastolic BP > 120 with signs of end organ damage. This patient does not have signs of end organ damage, and even the less severe classification of hypertensive urgency is not indicated with his reduced blood pressure measurements in the ED (Varon, UpToDate). Chronic heart failure is not indicated in this patient because more than likely he would have pink frothy sputum, marked peripheral edema, and chest discomfort upon acute presentation. Pneumonia is not indicated in this patient because his chest X-ray does not show any consolidations or infiltrates, only mild hyperinflation of emphysema. His sputum was not yellow, and his lung sounds did not indicate a pneumonia of a specific lobe and pulmonary special tests were negative.

References:

Lareau, Suzanne RN, MS, Moseson, Erika MD, MA, Slatore, Christopher G MD, MS. Am J Respir Crit Care Med Vol. 198, P21-P22, 2018 ATS Patient Education Series © https://www.thoracic.org/patients/patient-resources/resources/copd-exacerbation-ecopd.pdf. 2018 American Thoracic Society.

Varon, Joseph MD et al.. Management of severe asymptomatic hypertension (hypertensive urgencies) in adults. UpToDate: https://www.uptodate.com/contents/management-of-severe-asymptomatic-hypertension-hypertensive-urgencies-in-adults?search=hypertensive%20urgency&source=search_result&selectedTitle=1~25&usage_type=default&display_rank=1. UpToDate; 2018.

Weinberger, Stephen MD. Treatment of Hypertension in Asthma and COPD. UpToDate: https://www.uptodate.com/contents/treatment-of-hypertension-in-asthma-and-copd?csi=5a3fe23e-c5d6-41b4-8cfb-9da776d05943&source=contentShare. UpToDate; 2018.

Wise, Robert A., MD. Treatment of Stable COPD. Merck Manuals Professional Version. https://www.merckmanuals.com/professional/pulmonary-disorders/chronic-obstructive-pulmonary-disease-and-related-disorders/treatment-of-stable-copd. November 2018.

Answer: C. Outpatient management with Doxycycline. The most likely diagnosis is community acquired bacterial pneumonia based on clinical presentation of cough with sputum and fever as well the right middle lobe infiltrate visualized on chest x-ray (1, 2). Therefore, antibiotics are indicated in this patient making option B incorrect. Conservative symptomatic treatment can be used when a viral upper respiratory infection or common cold is likely and a patient with similar symptoms of a shorter duration and no evidence of infiltrate on chest x-ray would not be treated with antibiotics (3). Option A is not indicated because in this clinical picture the patient is under 65 years old, has no major comorbidities, and vitals are stable, so hospital admission is not indicated. In patients with community acquired pneumonia O2 saturations below 92 indicate hospital admission (1). The CURB-65 tool can be used to help decide whether a patient should be treated in the outpatient or hospital setting (1). Option D is incorrect because respiratory fluoroquinolones such as Levofloxacin should be reserved for areas with macrolide and doxycycline resistance or patients who have recently used antibiotics (1,4). Finally, doxycycline is the most appropriate antibiotic because the patient has a macrolide allergy. Normally a macrolide such as azithromycin would be first line option for this patient (4).

Discussion:

The patient featured in this case presented to urgent care with community acquired pneumonia. Community acquired pneumonia is one of the world’s most prevalent infectious diseases (2). There are many causes of community acquired pneumonia. The most common bacteria found is Strep. pneumoniae followed by Haemophilus influenzae and Moraxella catarrhali (2,5). Cases caused by one of these three bacteria are termed typical (2). It is also worth noting that often no bacteria can be pinpointed even with microbiological techniques (2). These bacteria are not part of normal lung microflora, and after they are introduced, and in cases of pneumonia these foreign bacteria multiply. Replication of foreign bacteria can be stopped by macrophages in the alveoli, but pneumonia is an outcome of both particularly virulent strains of bacteria and dysfunctional macrophages (2). Once foreign bacteria has colonized, the macrophages signal to phagocytes which release cytokines to allow for white blood cells and other proteins and fluids consolidating in the alveolar space (2).

Based on demographics and past medical history, the patient was relatively unlikely to develop pneumonia. The patient in this case was a healthy 57 year old white female seen in September. Pneumonia incidence increases with age especially after 65, and is more likely in African Americans than Caucasians and males than females (5). It also increases incidence in Winter months (5), and patient was seen in mid September. Pneumonia is also more prevalent in patients with chronic lung diseases, those who smoke, or patients with other comorbidities such as diabetes (1, 5).

The patient’s history in this case is what is alarming for community acquired pneumonia. Classic symptoms include cough with sputum, fever, shortness of breath, and pleuritic chest pain (1,2). Although the patient does not have a fever and office and did not report one with a thermometer, she does report chills and sweats. Severe pneumonia that would warrant hospitalization or ICU admission can present with septic features and respiratory distress (1). On exam adventitious lung sounds such as rales and ronchi are commonly heard over areas of consolidation of WBC’s, proteins, and fluid in the alveoli discussed earlier (1). In this case rales were auscultated bilaterally, but consolidation only noted on the right side upon chest x-ray. Other tests which were not used in this case like egophony and tactile fremitus can be used to detect pneumonia (1,2).

The most useful thing to do when pneumonia is suspected is to image the chest (1,2) as was done in this case. AP and lateral view chest x-ray is most commonly used as first line, and if pneumonia is suspected with a negative chest x-ray, then a chest CT would be warranted (1). Chest x-ray is often not reliable for determining etiology of pneumonia but can be with certain atypical pneumonia (2). For instance a chest x ray with perihilar infiltrates in a HIV patient would make Pneumocystis jiroveci a likely etiology (2). Another diagnostic test that can be used is sputum gram stain and culture. This is not routinely used in outpatient settings as empiric antimicrobial therapy is usually successful (1). Gram stain and culture also may not be helpful in elderly as sometimes cannot produce a proficient sample (2).

Management of patients with community acquired pneumonia depends on the severity, so we use two tools to assess severity and disposition of these patients: the CURB-65 and Pneumonia Severity Index (PSI) (1). These scoring tools help us decide whether the patient should be treated outpatient, on the general hospital floor, or in the ICU (1). The patient in this case scored 1 on the CURB-65 score allowing them to be treated in the outpatient setting. Healthy patients with no recent antibiotic use should use Azithromycin first line and doxycycline as a second option (4). Azithromycin has been linked to major cardiac events especially in the elderly population (4), so that is also something to consider. If a patient has a serious comorbidity or the case in a region of macrolide resistance, a respiratory fluoroquinolone (Levofloxocin) is indicated, or, a beta-lactam (Amoxicillin or Augmentin) can be added to the macrolide of choice (4).

References

1.Ramirez JA. Overview of community-acquired pneumonia in adults. UpToDate. https://www.uptodate.com/contents/overview-of-community-acquired-pneumonia-in-adults?source=history_widget. Published August 2019. Accessed September 22, 2019.
2.Baer S. Community-Acquired Pneumonia (CAP). MedScape. https://emedicine.medscape.com/article/234240-overview. Published August 29, 2019. Accessed September 22, 2019.
3.Sexton D, McClain M. The common cold in adults: Diagnosis and clinical features. UpToDate. https://www.uptodate.com/contents/the-common-cold-in-adults-diagnosis-and-clinical-features?search=viral uri&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Published August 2019. Accessed September 22, 2019.
4.Prasad P. Antibiotics for Adult Outpatients With Community-acquired Pneumonia. DynaMed. https://www-dynamed-com.ezproxymcp.flo.org/management/antibiotics-for-adult-outpatients-with-community-acquired-pneumonia. Published November 30, 2018. Accessed September 22, 2019.
5.File T. Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults. UpToDate. https://www.uptodate.com/contents/epidemiology-pathogenesis-and-microbiology-of-community-acquired-pneumonia-in-adults?search=inpatient pneumonia treatment&topicRef=7027&source=see_link. Published August 2019. Accessed September 22, 2019.

The answer is C. The patient in the vignette is diagnosed with pertussis due to his physical presentation of persistent and paroxysmal coughing. Pertussis is caused by the gram-negative bacteria, Bordetella pertussis¹. Supportive care is not effective in eradicating the infection. Macrolide antibiotics have been the mainstay of both treatment and prophylaxis for patients with pertussis and azithromycin is the only recommended for neonates less than one-month old². The primary goal for postexposure prophylaxis is to prevent serious complications and death in high risk individuals. High risk individuals include infants less than 12 months, women in their third trimester, immunocompromised patients and anyone that would have close contact with these individuals⁸. In this way, macrolide antibiotics should be administered to both the patient and the exposed infants at the daycare he works.

References:

1. Locht C. Live pertussis vaccines: will they protect against carriage and spread of pertussis? Clinical Microbiology and Infection. 2016;22:S96-S102. doi:10.1016/j.cmi.2016.05.029.
2. Kilgore PE, Salim AM, Zervos MJ, Schmitt H-J. Pertussis: Microbiology, Disease, Treatment, and Prevention. Clinical microbiology reviews. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4861987/. Published July 2016. Accessed September 22, 2019.
3. Skoff TH, Hadler S, Hariri S. The epidemiology of nationally reported pertussis in the United States, 2000
4. Pickering LK, Baker CJ, Freed GL, Gall SA, Poland GA, Rodewald LE, Schaffner W, Stinchfield P, Zimmerman RK, Orenstein WA. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America. Clinical Infectious Disease. 2009;49(6):817.
5. Pawloski LC, Queenan AM, Cassiday PK, Lynch AS, Harrison MJ, Shang W, Williams MM, Bowden KE, Burgos-Rivera B, Qin X, Messonnier N, Tondella ML. Prevalence and molecular characterization of pertactin-deficient Bordetella perstussis in the United States. Clinical Vaccine Immunology. 2014 Feb;21(2):119-25. doi: 10.1128/CVI.00717-13.
6. Centers for Disease Control and Prevention. Pertussis (Whooping Cough). https://www.cdc.gov/pertussis/surv-reporting.html (Accessed on September 22, 2019).
7. Cherry JD, Grimprel E, Guiso N, Heininger U, Mertsola J. Defining pertussis epidemiology: clinical, microbiologic and serologic perspectives. Pediatric Infectious Disease. 2005 May;24(5 Suppl):S25-34.
8. Von König CH. Use of antibiotics in the prevention and treatment of pertussis. Pediatric Infect Dis J. 2005;24(5 Suppl):S66–8.

Pneumonia is an infection of the lungs that affects all age groups and demographics. It continues to be a leading cause of death worldwide. There are many different types of pneumonia depending on where it was contracted and what type of organism caused the infection. Community acquired pneumonia (CAP), also called walking pneumonia, has between 4-12% mortality depending on age, comorbidities, and severity . One leading cause of a bacterial CAP is strep pneumoniae. Risk factors include increased age, smoking, and chronic conditions (heart disease, COPD, diabetes). Those who are elderly, institutionalized, or in nursing care are at increased risk as well. Patients most commonly present with symptoms of fever and a cough, the cough may be productive or non-productive. Dyspnea, tachypnea, and pleuritic chest pain may also be present. In elderly patients, especially those with dementia, may only have weakness or increased confusion as a sign of pneumonia. The patient will have leukocytosis on CBC and lobar consolidation on chest x-ray. For patients presenting with signs and symptoms of pneumonia the CURB-65 and pneumonia severity index (PSI) are tools that can be utilized to determine need for hospitalization or intensive care. Treatment varies based on the causative organism, however, for CAP, empiric treatment typically begins with a macrolide or doxycycline. Differential diagnosis for CAP includes pulmonary embolism, congestive heart failure, COPD exacerbation, or viral URI.

(A) Kerley B lines are seen with pulmonary edema, typically in heart failure patients, that are caused by fluid in the interstitium. (C) An enlarged cardiac silhouette is seen with cardiomegaly caused diseases such as by congestive heart failure, hypertension, and valvular abnormalities. (D) Hyperinflation of the lungs where the lung outlines are larger than normal is typically seen in COPD.

References:

1. Dabelić A. Respiratory Problems. In: South-Paul JE, Matheny SC, Lewis EL. eds.CURRENT Diagnosis & Treatment: Family Medicine, 4e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.ezproxymcp.flo.org/content.aspx?bookid=1415&sectionid=77057157.
2. O’Connell C. A Comprehensive Review For The Certification And Recertification Examinations For Physician Assistants. 5th ed. Lippincott Raven; 2015
3. DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 115170, Community-acquired pneumonia in adults; [updated 2018 Oct 30]; [about 36 screens]. http://www.dynamed.com/login.aspx?direct=true&site=DynaMed&id=115170
4. South-Paul JE, Matheny SC, Lewis EL. eds.CURRENT Diagnosis & Treatment: Family Medicine, 4e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.ezproxymcp.flo.org/content.aspx?bookid=1415&sectionid=77057157.

Correct answer is A. Chronic bronchitis is a subtype of COPD which also includes emphysema and chronic obstructive asthma. Chronic bronchitis is defined as a productive cough lasting at least 3 months in 2 consecutive years with other etiologies being excluded. All other answers above are consistent with an emphysema pathophysiology. Chronic bronchitis pattern has been described as a “blue bloater” (cyanotic & overweight) whereas an emphysema etiology presents as a “pink puffer” (less hypoxia & thin habitus). Use of the GOLD ABCD tool can help with determining treatment options with the mainstay being long-acting bronchodilators.

References:
1.UpToDate.com
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005599/

Correct answer is E. The x-ray is unremarkable, and the history is most consistent with a viral bronchitis which should be treated with supportive care measures for at least 10 days at which point antibiotics may be warranted if the condition is worsening, persistent fevers are present and/or other risks are present including smoking, COPD, HIV, etc. An albuterol inhaler may help with symptoms. Other measures include use of a humidifier, non-narcotic analgesics, cough suppressant, and rest/fluids. Isoniazid is used in the treatment of Tuberculosis, which is classically represented on a CXR as apical cavitary infiltrates and/or hilar adenopathy.
Azithromycin is the preferred antibiotic for presumed bacterial community-acquired pneumonia. Isoniazid is used in the treatment of tuberculosis. Oral corticosteroids are more appropriate for acute exacerbations of asthma or COPD. Racemic epinephrine is ideal for croup.
References:
1.UpToDate
2.https://www.ncbi.nlm.nih.gov/books/NBK448067/

The correct answer is D.  Bronchioltis is diagnosis typically made in a child < 2 with recent upper respiratory symptoms that have progressed io involve the lower respiratory tract resulting with some degree of respiratory distress as manifested by retractions, tachypnea, and hypoxia, along with wheezing or crackles.  Hyperinflation, peribronchial thickening (cuffing), or atelectasis may be present on CXR.  If a consolidation is present on CXR or localized adventitious breath souds are present, pneumonia should be diagnosed.  A nasal swab or nasopharyngeal washing & aspiration is used to diagnose RSV.  Treatment is supportive in most cases.  Occasionally hospitalization may be necessary for supplemental oxygenation.  Saline or albuterol nebulizers have not been shown to be effective.

Adenovirus primarily manifests with upper respiratory symptoms.  Coronavirus is less likely to affect infants and very young children.  The parainfluenza virus is associated with croup, which usually results in stridor and a classic “barking cough”.  Streptococcus is a cause of pneumonia which would less likely result in upper respiratory symptoms.

References:

1. UpToDate
2. https://www.ncbi.nlm.nih.gov/books/NBK11847/?report=reader

The correct answer is A. The x-ray demonstrates an enlarged epiglottis (circle), also known as a “thumb print sign” as well as a loss of a deep, sharp vallecular space (triangle). Epiglottitis has been highly associated with H. flu and the addition of this vaccination into the childhood schedule has made it much less common where the median age has now gone from 3 to 6-12. Unvaccinated children are obviously at risk as well as elderly whose immunity has worn off although it is usually less severe. A muffled voice, drooling, and a toxic appearance are the hallmark findings. Tripodding may occur as well in an attempt to open the airway. A thumbprint sign or blunting of the vallecula on a soft tissue neck x-ray are highly specific. Laryngoscopy is the gold standard for diagnosis but is generally only reserved for when a pt is able to be simultaneously intubated in the operating room. Most patients will require immediate intubation while awaiting antibiotics (3rd-generation cephalosporin plus vancomycin) activity.

Laryngotracheobronchitis (croup) will demonstrate a steeple sign (narrowing of the upper trachea). A retropharyngeal abscess is associated with prevertebral soft tissue swelling. X-ray is usually not used in the diagnosis of retropharyngeal abscess. A CT scan or ultrasound is preferred.

References:
1.UpToDate
2.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498669/

The correct answer is C. The presentation and x-ray (steeple sign) are consistent with laryngotracheobronchitis (croup). Croup is most common in the winter months and in children up to age 3. It is often preceded by upper respiratory tract symptoms and then an abrupt awakening in the middle of the night accompanied with the classic “barking cough”. Nebulized racemic epinephrine helps with initial spasm. Decadron 0.6mg/kg PO, IM, or IV will minimize exacerbations until the virus runs its course.
Hemophilus influenza type B (Hib) is associated with epiglottitis which usually presents with drooling in a toxic-appearing child and a thumb print sign on x-ray. Influenza (flu) should not cause soft tissue neck radiographic abnormalities. Respiratory syncytial virus (RSV) is associated with bronchiolitis which usually results in mild bilateral wheezing or rales and no specific radiographic changes. Streptococcus pyogenes is associated with strep throat, possibly progressing to a peritonsillar abscess which should not result in any x-ray findings.

References:
1. UpToDate
2. https://www.aafp.org/afp/2018/0501/p575.html

The correct answer is D. The CDC recommends withholding treatment for all but high-risk patients (see below). If given, medications should be started within 48 hours from onset of symptoms. Treating influenza is most common via oral preparation however an IV preparation is available as well. High risk patients are defined as: those with severe presentations, ≥65 years of age, pregnant or within 2 weeks postpartum, residents of long-term care facilities, Native and Alaskan Americans and Alaska, morbid obesity, immunocompromising condition, chronic lung/heart/kidney disorders chronic heart disease, and glucocorticoid use.
References:
1. UpToDate
2. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm

The correct answer is C. Fungal pneumonias are most common in patients who are immunocompromised. Consider fungal etiology in an immunocompromised patient with symptoms consistent with pneumonia but unremarkable CXR or in cases of unresolved or very slowly resolving pneumonia despite adequate antibacterial treatment. Voriconazole, amphotericin, and fluconazole are common antifungal medications.
References:
1.UpToDate
2.https://www.jacpjournal.org/article.asp?issn=2320-8775;year=2015;volume=3;issue=2;spage=41;epage=47;aulast=Shamim

The correct answer is D. This is a typical presentation of Pneumocystis for which trimethoprim-sulfamethoxazole (Bactrim) is appropriate. Most HIV pt’s who are immunocompromised are on prophylactic Bactrim. An elevated lactate dehydrogenase (LDH) is usually present in these patients. Beta-D-glucan is another serum test that can help. Other treatment options include: atovaquone, trimethoprim plus dapsone or clindamycin plus primaquine.
Clindamycin and dapsone must be used in combination with other drugs and pentamidine is indicated for severe disease presentation and should be administered IV.
References:
1. UpToDate
2. https://www.cdc.gov/fungal/diseases/pneumocystis-pneumonia/index.html

The correct answer is B. Patchy, bilateral interstitial infiltrates are most consistent with viral pneumonia. The rest are more consistent with a bacterial etiology. Other features that may suggest viral include gradual onset of symptoms, lack of purulent sputum, tachycardia or tachypnea out of proportion to fever, associated rash, and others. Influenza is the most common viral etiology but others include respiratory syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza, hantavirus, coronavirus and others. Many are managed with supportive care with specific antiviral meds including oseltamivir, ribavirin, and acyclovir, to mention a few.
References:
1. UpToDate
2. https://www.ncbi.nlm.nih.gov/books/NBK513286/

The correct answer is C. These areas demonstrate peribronchial thickening (cuffing) associated with RSV-related bronchiolitis. Supportive care is all that is needed for the majority of cases with supplemental oxygenation used if hypoxic.
Asbestosis usually creates a honeycombing effect or pleural plaques. Mycobacterium causes apical consolidation with cavitary lesions and hilar adenopathy. Streptococcus usually causes lobar consolidation.
References:
1. UpToDate
2.https://www.aafp.org/afp/2017/0115/p94.html

The correct answer is C. The patient’s diagnosis is most likely tuberculosis. The chest x-ray demonstrated bilateral hilar adenopathy which is a common finding in tuberculosis. Hepatomegaly is found in many patients with systemic (miliary) tuberculosis, as well as splenomegaly and altered mental status with the majority having fevers. Risk factors for acquiring tuberculosis include: immunocompromise state, substance abuse, and being a resident or employee in facilities such as correctional facilities, long-term care facilities, homeless shelters, and hospitals. A Mantoux test is used in making the diagnosis. Treatment involves an initial 8-week phase of quadruple medication regime (isoniazid, rifampin, pyrazinamide, ethambutol) followed by 18 weeks of isoniazid plus rifampin (or another combination).
Albuterol is used in disorders with bronchoconstriction such as asthma and COPD. Azithromycin is used for bacterial pneumonia which should have evidence of lobar consolidation which is not present on this x-ray. Prednisone would be the primary treatment for sarcoidosis, which would cause hilar adenopathy as well as hepatomegaly (20% of cases), however, given the other risk factors, tuberculosis should be considered the most likely diagnosis. Thoracentesis is used when a pleural effusion is present, which is not demonstrated on this x-ray.
References:
1. UpToDate
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068897/

The correct answer is A. In order from most to least common: Adenocarcinoma, squamous, large, small. While smoking is by far the most common risk factor for developing lung cancer, others include radiation therapy, asbestos, radon, metal exposure (arsenic, chromium, and nickel), ionizing radiation, pulmonary fibrosis, HIV infection, and genetics. Common areas of metastasis include the liver, adrenal glands, bones, and brain. Approximately 50% of all lung cancers will result in liver metastasis with 30-40% of small cell cancers resulting in bone metastasis (20% for non-small cell). Tumor, Node, Metastasis (TNM) staging at presentation in patients with NSCLC has the greatest impact on prognosis. Resection, radiation therapy, and adjunctive chemotherapy are the primary treatment options.
References:
1.UpToDate
2.https://www.aafp.org/afp/2015/0215/p250.html

The correct answer is B. Lung neuroendocrine (carcinoid) tumors arise from neuroendocrine cells with GI locations being the most common and lung being the second-most common sites. Smoking is a likely risk factor although it has not been proven with certainty. These tumors arise in the proximal airways, resulting in a persistent cough or recurrent pneumonia in the same location, hemoptysis, or chest pain. Pulmonary carcinoids cause serotonin syndrome with less frequency than GI locations.
References:
1. UpToDate
2. https://www.annalsofoncology.org/article/S0923-7534(19)31831-9/fulltext

The correct answer is B. Risk is determined by patient age, size & location of nodule, presence of spiculation, smoking history, and family history. For those considered to have a “benign appearance”, a 12-month low-dose CT should be performed. For “probably benign”, a 6-month follow-up is recommended and for “very suspicious”, a CT with IV contrast, PET scan, and/or tissue sampling should be considered.

References:
1. UpToDate
2. https://www.mdcalc.com/fleischner-society-guidelines-incidental-pulmonary-nodules
3. https://www.mdcalc.com/solitary-pulmonary-nodule-spn-malignancy-risk-score-mayo-clinic-model
4. https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/LungRADS_AssessmentCategories.pdf

The correct answer is D. The patient has a history and exam consistent with pleuritis due to a recent viral upper respiratory tract infection. The adventitious sound described is referred to as a pleural friction rub. It has also been described as the sound made when walking on fresh snow or a “grating” sound. It can be unilateral, bilateral and focal or diffuse. Because it is generated by inflammation of the pleura, it is usually noticed through both inspiration and expiration and can also generate a palpable vibration.

A post-viral infection is the most common cause of a pleuritis. When associated with a viral etiology, supportive care with anti-inflammatories is usually all that is needed with steroids being added if not resolving. An antiviral would not be effective. Since there was a viral prodrome, an antibiotic is not warranted. An anticoagulant would be necessary if the patient had suspicion and risk factors for a pulmonary embolism. Antihistamines are used for seasonal or environmental allergic reactions.
References
1. UpToDate
2. https://www.ncbi.nlm.nih.gov/books/NBK537118/

The correct answer is B. The murmur description is that of tricuspid regurgitation. This collection of symptoms and findings is classic for cor pulmonale. COPD is the most common cause of cor pulmonale. When pulmonary hypertension results in an enlarged and/or dysfuctional right ventricle, cor pulmonale is diagnosed. In addition to COPD, other chroinc causes include interstitial lung diseases and sleep apnea, while acute causes include a massive pulmonary embolus and high-altitude esposures. Echocardiogram and right heart catheterization (measurement of pulmonary capillary wedge pressures) are the diagnostic modalities of choice. Oxygen, calcium channel blockers, diuretics, and digoxin are treatment options prior to considering lung transplantation.
Congenital heart disease would unlikely be silent until adulthood. A pulmonary embolism is a cause of acute cor pulmonale but less would not be ongoing for months before the patient presents for evaluation. Rheumatic fever results in a mitral regurgitation murmur heard best over the apex.
References:
1. UpToDate
2. https://www.ncbi.nlm.nih.gov/books/NBK430739/

The correct answer is D. Pulmonary hypertension usually presents with a complaint of exercise intolerance, lethargy or fatigue and will eventually lead to angina, syncope, edema, and/or hepatic congestion as increased right ventricular afterload progresses. A mean pulmonary artery pressure > 25 mm Hg at rest confirms the diagnosis. Most cases of pulmonary htn are idiopathic but other causes include scleroderma, schistosomiasis, HIV, congenital disease, pulmonary thrombosis, and portal hypertension resulting from cirrhosis. Female experience at a greater rate than males. Treatment includes addressing the underlying cause, if one is determined, along with diuretics, oxygen, and digoxin as well as encouraging exercise.
None of the other modalities are able to measure the pulmonary artery pressure to confirm the diagnosis. An echocardiogram can contribute to the work-up by assessing for right ventricular dilation or dysfunction. A ventilation-perfusion scan is used primarily for diagnosing a pulmonary embolism.

References:
1. UpToDate
2. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2015/09/15/15/19/2015-esc-ers-guidelines-for-the-diagnosis-and-treatment-of-ph

The correct answer is C. Pneumoconioses are lung diseases caused by inhalation of airborne dusts, usually occupational or environmental in nature. Asbestosis is found in insulation, brakes, and shipbuilding. “Black lung” is usually referred to as coal worker’s pneumoconiosis (CWP), and silicosis is associated with the mining, drilling, and sandblasting industries. Treatment is supportive including oxygen and bronchodilators, in addition to avoidance of dust or other airborne particles and smoking. Complications include eventual respiratory or heart failure as well as cancer.
References:
1. UpToDate
2. https://www.hopkinsmedicine.org/health/conditions-and-diseases/pneumoconiosis

The correct answer is D. The exact etiology of Sarcoidosis is unknown. It is 3-4 times more prevalent in African Americans who also have, on average, a 10-year earlier onset. Most diagnoses are made between the ages of 20-60 with a large percentage made on incidental findings on CXR. Symptoms include cough, fatigue, fever, weight loss, vision changes, dry eyes/mouth, parotid gland swelling, and joint pain with pulmonary involvement being the most common. Restrictive cardiomyopathy can also occur. A serum ACE level is elevated in approximately 75% of cases but should not be solely relied on to confirm the diagnosis. The mainstay of sarcoidosis treatment is with prednisone. Typical dosing is 20-40mg daily with a tapering over 3-6 months. Low-dose maintenance therapy may be used after the initial phase. Some cases may remit spontaneously within a few months.
Lupus can affect the lungs but usually causes a ground glass appearance or patchy infiltrates as opposed to the classic sarcoidosis finding of hilar adenopathy as demonstrated in the x-ray. Lymphoma causes mediastinal rather than hilar adenopathy.
References:
1. UpToDate
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6713839/

The correct answer is D.  The patient likely has obstructive sleep apnea (OSA), which is best confirmed with polysomnography, either in a lab setting or at home.  Obesity is by far the biggest risk factor for developing OSA with daytime sleepiness being the most common complaint.  Many individuals also complain of morning headaches or partners may report loud snoring interrupted by periods of apnea or choking sounds.  Numerous screening tools are available for use in the initial stages of the workup to help guide the need for polysomnography ordering.  Complications of OSA include myocardial infarction, heart failure, hypertension, arrhythmias, as well as poor cognition/concentration or even motor vehicle accidents secondary to chronic sleep deprivation.  Treatment options include lateral decubitus sleeping position, weight loss, alcohol avoidance, and continuous positive airway pressure (CPAP).

CT angiogram is used in the work-up of stroke.  Echocardiogram may show evidence of cardiomyopathy resulting from OSA but would not make the diagnosis of OSA.  Electroencephalography is used if seizure is suspected and can be added to polysomnography if the differential dictates.  A ventilation-perfusion scan is used for pulmonary embolism evaluation.

References:

1. UpToDate
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549693/

The correct answer is E.  In the early stages of ARDS, a CT or CXR may show only minor findings.  ARDS should be highly suspected in a patient with dyspnea and an increasing requirement for oxygen within 6 to 72 hours of an inciting event.  These events include recent diagnosis of sepsis, aspiration or infectious pneumonia, trauma, massive transfusion, pulmonary contusion, smoke inhalation, and others.  As severity progresses, CXR or CT will usually demonstrate diffuse, bilateral alveolar opacities and atelectasis.  An arterial blood gas (ABG) usually demonstrates hypoxemia with a respiratory alkalosis but this is not specific to ARDS.  Treatment is aimed at oxygen supplementation and avoidance of excess fluid accumulation.  High flow oxygen via face mask or nasal cannula, and noninvasive positive pressure ventilation (CPAP, BiPAP) can be attempted prior to intubation.  Prone positioning when intubated may be helpful as well as using low tidal volume settings.

References:

1. UpToDate
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4828494/#:~:text=Severe%20ARDS%20is%20often%20associated,are%20essential%20to%20improve%20survival.

The correct answer is C.  CF is an autosomal dominant disorder found in Caucasians with the media survival age being < 50.  A prenatal diagnosis can be made if there is evidence of meconium peritonitis on ultrasound and through amniocentesis testing. Most CF pt’s will have pancreatic insufficiency but if the symptoms do not develop until late childhood; there is a good prognosis for maintaining some level of enzyme sufficiency.  Median age of diagnosis is 6-8 months old with the majority being diagnosed by the age of 1.  After birth, the primary test utilized is the sweat chloride test.  A result of ≤ 29mmol/L is considered normal and CF can be ruled-out.  Chronic sinus and pulmonary symptoms are the most common findings.  Use of long-term inhaled hypertonic saline after age 6 is advised to improve lung function and reduce exacerbations.  Other treatments include CFTR modulators, DNase nebulizer, chest physiotherapy, regular aerobic exercise, bronchodilators, maintaining immunization status, and chronic use of azithromycin for its anti-inflammatory properties and prophylaxis against common pathogens.

References:

1. UpToDate
2. https://www.nice.org.uk/guidance/ng78/chapter/Recommendations

The correct answer is E.  Approximately half of foreign bodies end up in the right mainstem.  Another 20% are found in the left mainstem with significantly smaller percentages for the carina, larynx and trachea.  Peanuts are the most common aspirate.  Infants and toddlers are more commonly associated with food foreign bodies while older children prefer toys.  A chest x-ray may not reveal the actual foreign body but may demonstrate hyperinflation of one lung vs the other, atelectasis, trachea shift or even pneumonia if the incident was subacute.  Bronchoscopy is used in both locating and retrieving the object.  In cases of suspected complete airway obstruction, back blows or chest compressions should be used in infants and the Heimlich maneuver for older children and adults.  For patients who are able to speak or cough and exhibit good oxygenation, these maneuvers should be avoided and bronchoscopy attempted.

References:

1. UpToDate
2. https://www.ncbi.nlm.nih.gov/books/NBK531480/

The correct answer is D.  Hyaline membrane disease is the result of decreased surfactant production found in premature deliveries.  This results in alveoli collapse and diminished oxygen exchange capabilities.  Diagnosis is usually made clinically based on progressive respiratory failure shortly after pre-term delivery.  A chest x-ray may demonstrate low lung volume and air bronchograms with diffuse reticulogranular ground glass appearance.  Treatment options include nasal CPAP, exogenous surfactant, and intubation.  Maternal steroids before delivery can accelerate the lung maturity.

Chloride is related to cystic fibrosis.  Glucocorticoids are administered to the mother at 23 to 34 weeks’ gestation who are at increased risk of preterm delivery within the following seven days.  Meconium aspiration is in the differential for any newborn with respiratory distress but is not the cause of hyaline membrane disease.

References:

1. UpToDate
2. https://www.researchgate.net/publication/326817024_Diagnostic_and_Management_of_Hyaline_Membrane_Disease

The correct answer is E.  The circled area represents a Hampton hump.  Also seen is a Westermark sign (see second circled area), a dark/increased transparency area which occurs distal to a clot in a large pulmonary artery.  Fleischner (Palla) sign, not clearly seen on this x-ray, is another finding seen with pulmonary embolism.  This presents as a prominent (more visible) pulmonary artery near the hilum.

A cancerous tumor is certainly a possibility but would less likely result in shortness of breath given the size of the abnormality.  Classic congestive heart failure findings include Kerly B lines (small, horizontal lines in the peripheral lung fields), prominent hilum vasculature, bat’s wing pattern, pleural effusions, and cardiomegaly.  Pleural effusions cause blunting of the costophrenic angle(s).  There is no evidence of a patchy infiltrate consistent with pneumonia.

References

1. UpToDate
2. https://www.aafp.org/afp/2009/1201/p1289.html

Correct answer is C.  Intermittent = daily symptoms < 2 d/wk and < 2 nighttime awakenings per month.  Mild persistent = >2 days with symptoms per week but not daily and 3-4 nighttime awakenings.  Severe persistent = symptoms throughout the day and nightly episodes.   Inhaled corticosteroids are now indicated starting at the mild persistent level and should be strongly considered even at the intermittent category.

References:

1. UpToDate
2. https://pedsinreview.aappublications.org/content/40/11/549/tab-figures-data

Correct answer is C.  The patient’s history is concerning for having underlying COPD which is also confirmed on the x-ray with the increased lung volumes and flattened hemidiaphragms.  However, a complete pneumothorax is noted of the right lung.  The pneumothorax is demonstrated by the absence of lung markings (replaced by air in the pleural cavity) resulting in a darkened right lung field.  This degree of collapse has created what appears to be a large mass along the area of the right hilum which is actually just the consolidation of the collapsed lung itself.  A smaller pneumothorax would be more subtle and possibly visible only in the apical area with a crescent-shaped area of darkness.

The most common cause of a secondary spontaneous pneumothorax COPD which has resulted the formation of a bleb with subsequent rupture.  Needle decompression followed by formal chest tube placement is indicated for a pneumothorax of this size because of the resulting hemodynamic compromise.  Duoneb, solumedrol, and magnesium are effective for a COPD exacerbation.  Intubation would not be effective treatment for a pneumothorax.  Surgical resection is not indicated for the reasons discussed above.

References:

1. UpToDate
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366759/

Correct answer is C.  The most common causes of community acquired are streptococcus and influenza.  Staphylococcus is the most common pathogen associated with healthcare acquired pneumonia.  Mycoplasm is generally associated with immunocompromise, specifically, HIV.

Common risk factors for aspiration include dementia, stroke, alcohol intoxication, and others.  Diagnosis is usually based on risk factor and history.  Most cases have a fairly abrupt onset of symptoms.  A chest x-ray will typically show patchy infiltrates in the superior segments of the lower lobes and the posterior segments of the upper lobes since these are the vulnerable areas when a patient is a recumbent position.

References:

1. https://www.ncbi.nlm.nih.gov/books/NBK470459/
2. UpToDate

The correct answer is B.  October is the recommended month in the northern hemisphere with April being the recommendation in the southern hemisphere.  Vaccinations can be administered beyond these months as well.  The vaccine is recommended for all patients over 6 months of age and should especially be encouraged for higher risk individuals:  pregnancy, immunocompromised, health care worker and age > 65.  Intranasal and high-pressure jet injector options are available for those who are afraid of needles.

References:

1. UpToDate
2. https://www.cdc.gov/flu/professionals/vaccination/index.htm

The correct answer is B.  Endotracheal intubation should be the last resort for managing status asthmaticus because of the potential for causing or exacerbating dynamic hyperinflation.  This hyperinflation can result in cardiogenic shock, barotrauma (pneumothorax, subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum), and increased work of breathing.  The other treatment options listed, in addition to standard asthma treatments, should be considered prior to intubation unless respiratory failure has occurred or is imminent in the eyes of the practitioner.

References:

1. UpToDate
2. https://www.ncbi.nlm.nih.gov/books/NBK526070/

The correct answer is E.  Studies have shown honey to be an effective cough suppressant (see reference 2). Most studies have shown no significant improvement in cough with all others listed compared to placebo.  The combination of guaifenesin + benzonatate did seem to show statistical significance over placebo.

Most cases of bronchitis are considered viral in etiology and should be managed with supportive care.  Albuterol inhalation can be beneficial in the treatment of cough, especially if there is a history of underlying pulmonary disease or who are having detectible wheezing.

Antibiotics are not indicated in the treatment of bronchitis unless comorbidities are present:  significant heart/lung/renal/liver/neuromuscular disease, immunosuppression, young children who were born premature, or > 65 years old with 2 or more of the following criteria (hospitalization in previous year, diabetes, congestive heart failure, use of oral corticosteroids)

References:

1. https://www.sciencedirect.com/science/article/pii/S0954611108004538
2. https://pubmed.ncbi.nlm.nih.gov/18056558/
3. https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/bronchitis.html
4. https://www.nice.org.uk/guidance/ng120/documents/draft-guideline
5. UpToDate

The correct answer is D.  The scenario described is most consistent with a diagnosis of croup. Croup is an inflammatory response of the upper airway caused by the Parainfluenza virus usually in children from 6 months to 3 years of age. The cough it produces has been described as “barking” and can also result in expiratory stridor.

Racemic epinephrine is a temporizing measure that improves symptoms while the steroid, Decadron, is given time to work. A single does is all that is necessary. Albuterol is indicated for lower respiratory tract spasm. Cool mist humidification was previoiusly used for bronchiolitis but has not been demonstrated to be effective. Endotracheal intubation would be warranted if airway compromise from epiglottitis or retropharyngeal abscess was present.

References:

1. UpToDate
2. https://www.aafp.org/afp/2018/0501/p575.html

The correct answer is B. There is a left pleural effusion (arrows), which, in the setting of trauma, is consistent with a hemothorax. Treatment consists of tube thoracotomy (chest tube). An exudative effusion is commonly caused by pneumonia, tuberculosis, and malignancy amongst other disorders. Transudative effusions are commonly caused by heart failure, nephrotic syndrome and cirrhosis. A pneumothorax is high on the differential in this setting however there is not visible pleural line with lateral darkened lung field. A pulmonary contusion is more common with blunt trauma and is not represented with a well demarcated line (arrows).

References:

1. UpToDate
2. https://www.ncbi.nlm.nih.gov/books/NBK448189/
3. https://www.ncbi.nlm.nih.gov/books/NBK538219/

The correct answer is C.  Calcium channel blockers should be initiated after onset of symptoms.  Additional therapeutics include endothelin receptor antagonists, phosphodiesterase type 5 inhibitor, or a soluble guanylate cyclase stimulator, or prostanoids.  Other causes of pulmonary hypertension (left heart disease, primary lung disease, chronic thromboembolic) are best managed by addressing the underlying cause.

Prognosis varies depending on numerous factors, but early intervention and close follow-up yields the best outcomes.  The following findings area associated with a worse prognosis:  right atrium or ventricle dilation, pericardial effusion, low cardiac index, and increased right atrial pressures.

References:

1. UpToDate
2. https://www.aafp.org/afp/2016/0915/p463.html
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484794/

The correct answer is B.  Continuous Positive Airway Pressure (CPAP) provides enough constant airway pressure to prevent or significantly minimize the upper airway collapse which leads to sleep apnea.  Bilevel Positive Airway Pressure (BiPAP) may be better tolerated than CPAP however, CPAP is the gold standard.  A nonrebreather mask is used to administer high flow supplemental oxygen in a patient with hypoxia.  A Venturi mask is used for oxygen supplementation in a patient with COPD where CO2 retention is a concern.  Sleeping on the side rather than supine is beneficial in minimizing upper airway collapse.  Management of sleep apnea improves quality of life and can help to minimize hypertension and heart strain.

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4847952/
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4803254/

The correct answer is C.  The appropriate order based on response to treatment is C, B, D, A. ARDS is an inflammatory disorder in the lungs resulting in pulmonary edema.  These factors result in hypoxia, decreased lung compliance, dead space, and depletion of lung surfactant. Risk factors for developing ARDS include: CHF, female, metastatic cancer, diabetes, chronic pulmonary disease, hypertension, and obesity, amongst others.

References:

1. UpToDate
2. https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-019-0540-9/figures/1
3. https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A1826

The correct answer is A. If a patient is eligible, based on genotyping, they should receive a CFTR modulator as a mainstay of chronic treatment of cystic fibrosis.  Hypertonic saline inhalation is usually given as a 7% solution.  Other treatment options include bronchodilators and anti-inflammatories (azithromycin, ibuprofen, inhaled or systemic steroids).  Influenza, pneumococcal and RSV vaccines should be administered.

Heliox is sometimes used in the treatment of vocal cord dysfunction, croup, or asthma/COPD exacerbations.  Hyperbaric oxygen is utilized for carbon monoxide poisoning.  Racemic epinephrine is generally reserved for croup.

References:

1. UpToDate
2. https://www.uspharmacist.com/article/cystic-fibrosis-update-on-treatment-guidelines-and-new-recommendations