BOARD REVIEW 1/21/2016

Question 1 A 63-year-old man is evaluated for progressive dyspnea on exertion for the past several months. He is able to walk two to three blocks on a flat surface but becomes short of breath when going upstairs or uphill. He also notes shortness of breath when he lies down. He does not have cough or sputum production. He has a 7.5-pack-year history of smoking but quit 20 years ago. He takes no medications. On physical examination, he is alert, oriented, and in no acute distress. Temperature is 37.0 °C (98.6 °F), blood pressure is 115/75 mm Hg, pulse rate is 78/min, and respiration rate is 22/min; BMI is 26. No jugular venous distention is noted. Pulmonary examination discloses minimal crackles and reduced breath sounds at the lung bases. Cardiac examination is normal. There is no leg edema. Pulmonary function tests reveal an FEV1 of 75% of predicted, an FVC of 68% of predicted with no change after administration of a bronchodilator, a total lung capacity of 68% of predicted, and a residual volume of 125% of predicted. FEV1/FVC ratio is 82%. Chest radiograph shows low lung volumes with suggested bibasilar atelectasis

Which of the following is the most likely diagnosis? A) COPD B) Heart Failure C) Interstitial Pulmonary fibrosis D) Extra-thoracic Restrictive lung disease

ANSWER IS D

STEP 1 - Pulm vs cardiac etiology STEP 2 – is it IPF ?

Obstructive vs Restrictive FEV1 FEV1/FVC TLC DLCO RV COPD ASTHMA Restrictive Intrathoracic Extrathoracic

Obstructive vs Restrictive FEV1 FEV1/FVC TLC DLCO RV COPD ASTHMA N/ Restrictive Intrathoracic N Extra-thoracic

Question 2 A 22 year old women presents with Shortness of breath and wheezing. She has been on inhaled beta 2 agonists, inhaled steroids and has used increasing doses of oral steroids for the past year without much relief. On exam Vital signs essentially benign with O2 saturation of 96% on room air. patient has a puffy face. Bilateral wheezing on inspiration . The Inspiration to expiration ratio is 1.

Which of the following Flow volume loops is suggestive of the disease process? B C

ANSWER IS A- vocal cord dysfunction Option B – Dynamic intra thoracic obstruction – tracheomalacia Option C – Tracheal stenosis

Question 3 A 55-year-old woman is evaluated for a recent increase in asthma symptoms characterized by daily cough and dyspnea. She reports waking up two to three nights per week with asthma symptoms. She has no postnasal drip, nasal discharge, fever, or heartburn. Her current medications are medium-dose inhaled corticosteroids and albuterol as needed. She is able to demonstrate proper use of her metered-dose inhalers. On physical examination, she appears comfortable and is in no respiratory distress. Pulse rate is 76/min, and respiration rate is 18/min. Pulmonary examination reveals bilateral wheezing. The remainder of the examination is normal.

Which of the following is the most appropriate next step in management? A. Increase the inhaled corticosteroid B. Add long acting beta 2 agonist C. Add Ipratropium MDI D. Perform a bronchial challenge test

Answer. B Add long acting beta 2 agonist

Which of the following is the most appropriate next step in management? A. Increase the inhaled corticosteroid Therapy B. Add long acting beta 2 agonist Therapy C. Add theophylline Therapy D. Perform a bronchial challenge test Diagnostic test

How severe is the asthma?

Daytime symptoms Nighttime symptoms Treatment Severe Persistent Mod Persistent Mild Persistent Intermittent

Daytime symptoms Nighttime symptoms Treatment Severe Persistent Continuous Frequent High dose inhaled steroids + PO steroids Mod Persistent Daily >5/month Low dose inhaled steroids Long acting beta 2 agonists Mild Persistent >2/week <1/day >2/month Or Chromolyn Na Montelukast Intermittent <2/week <2/month No daily meds PRN short acting beta 2 agonists

Question 4 A 45-year-old woman is evaluated for worsening asthma symptoms. She has a lifelong history of asthma, which had been under good control. However, her symptoms have become severe over the past few years, with persistent productive cough, dyspnea, and wheezing. The symptoms have not been well controlled despite the use of an inhaled short-acting β2-agonist, a long-acting β2-agonist in combination with inhaled corticosteroid therapy, and low-dose oral corticosteroids. She has extensive allergies but is otherwise healthy. On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/70 mm Hg, pulse rate is 74/min, and respiration rate is 18/min; BMI is 33. Pulmonary examination discloses scattered wheezing and rhonchi, particularly over the upper lung fields. Examination is otherwise unremarkable. Laboratory studies reveal a leukocyte count of 9200/µL (9.2 × 109/L) with 50% neutrophils, 30% lymphocytes, 13% eosinophils, and 7% monocytes. Chest radiograph shows a patchy upper-lobe infiltrate with increased bronchial markings. Chest CT reveals proximal bronchiectasis with suggestion of mucus plugging

Which of the following is the most appropriate diagnostic test to perform next? A. Sweat chloride testing B. Bronchoscopy with BAL and biopsy C. Sputum gram stain and culture D. Allergy skin testing for Aspergillus

Answer is D Allergy skin testing for Aspergillus In patients with difficult-to-control asthma and a history of recurrent pulmonary infiltrates, allergic bronchopulmonary aspergillosis (ABPA) should be considered. ABPA is related to a hypersensitivity response to Aspergillus fumigatus in patients with asth It is characterized by persistent asthma symptoms and pulmonary infiltrate with bronchiectasis. Patients typically have elevated serum IgE levels and eosinophilia . All patients with ABPA have evidence of sensitization to A. fumigatus that is best demonstrated by allergy skin testing.

Question 5 A 35 Year old female who has paroxysmal non productive cough and shortness of breath for >6 months duration. She denies any other symptoms of wheezing, cold or heartburn. She works in a car factory and feels like her SOB is worse at work and better on days off.

What do you recommend A. Isocyanates antibodies B. Treat symptomatically with cough suppressants C. Peak flow at work and at home D. Methacholine challenge test

Answer is C Peak flow at work and at home

Question 6 An 18-year-old man is evaluated for cough, chest tightness, and wheezing that occur after sprints that he runs for his school track team, particularly on cold days. Symptoms resolve after a few minutes of rest. He has no other daytime or nighttime symptoms. He has a history of hay fever with worsening of rhinitis symptoms during the fall and spring, but he is otherwise healthy. Several family members have allergies and/or asthma. His PCP prescribed inhaled short-acting β2-agonist 15 minutes before exercise but patient continues to have symptoms. On physical examination, pulse rate is 70/min, respiration rate is 14/min, and BMI is 25. Lung examination findings are normal. Spirometry shows an FEV1 of 95% of predicted, and the FEV1/FVC ratio is 85%. FEV1 measured after intense exercise is 76% of predicted.

What is the next step in management? A. Physical conditioning program B. Inhaled corticosteroids C. Add Chromolyn sodium D. Add Ipratropium

Answer C Add Chromolyn sodium 1st line – Inhaled Beta 2 agonist 15 minutes before exercise 2nd line - mast cell stabilizer 3rd line - Inhaled corticosteroids