Pulmonology/Allergy/ENT

Pulmonology/Allergy/ENT
Kelly Covey Eric Robinette

1. A 32yo AA woman c/o mild fevers, fatigue X1 mo. No sig PMH. T 38
1. A 32yo AA woman c/o mild fevers, fatigue X1 mo. No sig PMH. T 38.1, BP 115/70, P 75, R 18. Nontender, mobile, cervical and axillary lymphadenopathy noted. Fine crackles B/L. CXR: hilar adenopathy, diffuse interstitial infiltrates. Lymph node biopsy: noncaseating granulomas. Appropriate treatment? Allopurinol ACE inhibitor Cyclosporine Glucocorticoids Isoniazid

Sarcoidosis Peak age: 20-40 More common in AA females
Restrictive lung disease Noncaseating granulomas: lungs, heart, skin, etc. Typical CXR appearance-B/L hilar LAD, interstitial infiltrates ACE levels may be high, but ACE inhibitors have no benefit Erythema nodosum, Bell’s palsy. May be asymptomatic & found via CXR. Tx: Steroids, usually prednisone

1. A 32yo AA woman c/o mild fevers, fatigue X1 mo. No sig PMH. T 38
1. A 32yo AA woman c/o mild fevers, fatigue X1 mo. No sig PMH. T 38.1, BP 115/70, P 75, R 18. Nontender, mobile, cervical and axillary lymphadenopathy noted. Fine crackles B/L. CXR: hilar adenopathy, diffuse interstitial infiltrates. Lymph node biopsy: noncaseating granulomas. Appropriate treatment? Allopurinol ACE inhibitor Cyclosporine Glucocorticoids Isoniazid Gout Htn Immunomodulator Correct TB-caseating granulomas

2. 56 yo woman with 60-pack-year smoking hx c/o fatigue, dyspnea with minimal exertion, & productive cough each morning. Which is most likely finding in this pt? Normal diffusing capacity of lung for carbon monoxide Decreased residual volume Normal to slightly increased forced expiratory volume in first second (FEV1) Decreased forced expiratory volume in first second/forced vital capacity (FEV1/FVC) Decreased forced vital capacity (FVC)

COPD Air trapping in lungs, leads to hyperinflation.
Hallmark is decreased FEV1/FVC ratio CXR: hyperinflated lungs, flat diaphragms Air can’t get out of lungs vs. restrictive lung dz: air can’t get into lungs. Can also be caused by alpha-1-antitrypsin deficiency (will be young pt with insignificant smoking hx, +/- cirrhosis) Tx: Only treatments proven to reduce mortality: Quit smoking Supplemental oxygen used continuously Other treatments: inhaled tiotropium, albuterol, oral prednisone, antibiotics in exacerbations. Tiotropium is a anticholinergic bronchodilator. Albuterol is bronchodilator. Chronic steriod use leads to osteoporosis, glucose intolerance.

2. 56 yo woman with 60-pack-year smoking hx c/o fatigue, dyspnea with minimal exertion, & productive cough each morning. Which is most likely finding in this pt? Normal diffusing capacity of lung for carbon monoxide Decreased residual volume Normal to slightly increased forced expiratory volume in first second (FEV1) Decreased forced expiratory volume in first second/forced vital capacity (FEV1/FVC) Decreased forced vital capacity (FVC) A)Diffusing capacity usually decreased, not normal. B) Increased residual volume c) Greatly decreased FEV1 D) Correct E) Decreased FVC

Restrictive Vs. Obstructive
Poor breathing mechanics-extrapulm. Poor muscular effort-polio, myasthenia gravis Poor structural apparatus-scoliosis, obesity Interstitial Lung Dz ARDS, sarcoid, drug toxicity (chemo), pulmonary fibrosis, neonatal resp distress Chronic bronchitis Emphysema Asthma Bronchiectasis (think CF) Restrictive: other granulomatous diseases like histiocytosis X, Wegener’s granulomatosis (c-anca).

Acid-fast bacilli and caseating granulomas
3. 55yo homeless, alcoholic man who has recently been binge drinking c/o 2 wks of fever, malaise, productive cough & pain on deep inspiration. 60-pack-yr hx. CXR: infiltrate of superior portion of rt lower lobe with a cavity containing an air fluid level. A biopsy is likely to show: Acid-fast bacilli and caseating granulomas Anaplastic squamous cells with numerous mitotic figures Fibrosis and needle-like ferruginous bodies Gram-positive diplococci in chains Mixture of anaerobic organisms TB-often seen in homeless alcoholics. Usually more protracted rather than acute presentation. Cavities usu in upper lungs. Squamous cell carcinoma. Hx of smoking. Usu longer presentation. Asbestosis. Progressive exertional dyspnea and fibrosis. No hx of asbestos and usu takes a longer course. Pneumococcal PNA. Most common community-acquired PNA. Usu doesn’t cavitate, usu more acute than 2 weeks. Correct! Aspiration PNA with resultant lung abscess. Binge drinking is key. Rt lower lobe indicative-most things you aspirate go into rt bronchus b.c it’s straighter. Remember kids with foreign bodies will usually aspirate into Rt bronchus.

4. 37 yo florist comes to employee health for a routine eval
yo florist comes to employee health for a routine eval. Healthy without complaints. Five units of tuberculin protein (PPD) is injected intradermally. He returns to clinic hrs later. Which of the following would be a positive rxn in this pt? 5mm erythema and 5 mm induration 10 mm erythema and 5 mm induration 15 mm of erythema and 5 mm induration 15 mm of erythema and 15 mm induration 20 mm of erythema and 10 mm induration

Mantoux Test (PPD) Degree of erythema not important
5 mm induration positive for: Pts at high risk: immunocompromised pts, household contacts of TB pts, CXR consistent with. 10 mm induration positive for: Pts at elevated risk: healthcare workers 15 mm induration positive for: Pt at low risk: general population. False positive: BCG vaccine

4. 37 yo florist comes to employee health for a routine eval
yo florist comes to employee health for a routine eval. Healthy without complaints. Five units of tuberculin protein (PPD) is injected intradermally. He returns to clinic hrs later. Which of the following would be a positive rxn in this pt? 5mm erythema and 5 mm induration 10 mm erythema and 5 mm induration 15 mm of erythema and 5 mm induration 15 mm of erythema and 15 mm induration 20 mm of erythema and 10 mm induration

TB Mycobacterium tuberculosis Caseating granulomas
Presents with cough, fever, hemoptysis, night sweats, wt loss Primary TB Hilar LAD, Ghon focus (usually lower lobes) Ghon complex Secondary TB (Reactivation) Cavity lesions in upper lobes Tx: Active: isoniazid, rifampin, pyrazinamide Tx: Latent (pos PPD, no sympts): isoniazid Pyridoxine (vit B6) added to prevent peripheral neuropathy

5. 38 yo woman c/o SOB that started suddenly on the morning of presentation. Otherwise healthy. Takes oral contraceptives, 10-pack-yr smoking hx. Appears anxious. Resp 30, P 110, BP 120/80, stable. Most appropriate initial step? Aspirin Coumadin Heparin IV fluid Streptokinase

Pulmonary Embolus Risk factors: smoking, OCPs, immobility, recent surgery, factor V leiden, pregnancy, malignancy Tachypnea, tachycardia, pain on respiration Sudden onset Massive PE’s can cause shock-BP would be unstable EKG: can show afib, or S1Q3T3 (S wave in lead I, Q wave in lead III, inverted T wave in lead III) Elevated d-dimer, Abnl V/Q scan, Abnl CT, CXR usually normal Usually from DVTs Initial tx: Anticoagulation with heparin Coumadin takes several days to become effective. IVF and streptokinase if pt hemodynamically unstable

5. 38 yo woman c/o SOB that started suddenly on the morning of presentation. Otherwise healthy. Takes oral contraceptives, 10-pack-yr smoking hx. Appears anxious. Resp 30, P 110, BP 120/80, stable. Most appropriate initial step? Aspirin Coumadin Heparin IV fluid Streptokinase

6. 45 yo alcoholic man admitted with acute pancreatitis
6. 45 yo alcoholic man admitted with acute pancreatitis. Req’d large volumes IVF, but was improving at 24 hrs and stable. On 4th hospital day pt develops rapidly progressive resp distress, with labored breathing and tachypnea. T 37, P 100, R 24, BP 128/75. Intercostal retractions and crackles are noted on chest exam. Hct 42%, Leukocytes 9800/mm3, Glucose 110, BUN 20, AST 98, ALT 60, Amylase 280, ABG: pH 7.32, PaO2 52, PaCO2 51. CXR: diffuse B/L infiltrates, air bronchograms, normal cardiac silhouette, minimal pleural effusions. Dx?

Acute bilateral bronchopneumonia
Adult respiratory distress syndrome (ARDS) Cardiogenic pulmonary edema Exacerbation of acute pancreatitis Pulmonary embolism

Acute bilateral bronchopneumonia
Adult respiratory distress syndrome (ARDS) Cardiogenic pulmonary edema Exacerbation of acute pancreatitis Pulmonary embolism Acute bilateral bronchopneumonia-usually see fever, productive cough. CXR not consistent with this. Adult respiratory distress syndrome (ARDS)- may be triggered by acute pancreatitis. Usually develops hours after initiating event, 3-4 days after acute pancreatitis. Cardiogenic pulmonary edema-Normal cardiac silhouette and pulmonary changes on CXR don’t support this. Exacerbation of acute pancreatitis- excluded by labs-no hyperglycemia, only mildly elevated WBCs. Symptoms don’t fit well. Pulmonary embolism-CXR often normal. ABG will show hypoxemia and hypocapnia.

ARDS Causes: trauma, sepsis, shock, gastric aspiration, uremia, acute pancreatitis, amniotic fluid embolism. Diffuse alveolar damage increased alveolar capillary permeability leakage into alveoli  formation of intra-alveolar hyaline membrane Acute respiratory failure unresponsive to oxygen Tx: treat underlying condition, mechanical ventilation with PEEP. PEEP=positive end expiratory pressure

yo man with acute pancreatitis develops severe SOB 15 minutes after undergoing placement of a catheter in his subclavian vein. BP 100/60, P 124, R 50. Cyanotic, obvious distress, distended neck veins, trachea deviates to left. Breath sounds diminished on right side of chest. Next step? CXR Removal of catheter Endotracheal intubation Needle thoracostomy in second right intercostal space Tube thoracostomy in the left fifth intercostal space

Pneumothorax Punctured pt’s lung apex with catheter
Hypotension, tachycardia, tachypnea, cyanosis, distended neck veins, diminished breath sounds, tracheal deviation Tx: needle thoracostomy at second right intercostal space followed by chest tube insertion at right fifth intercostal space

This is an extreme example, would likely be less extreme if given on USMLE.

yo man with acute pancreatitis develops severe SOB 15 minutes after undergoing placement of a catheter in his subclavian vein. BP 100/60, P 124, R 50. Cyanotic, obvious distress, distended neck veins, trachea deviates to left. Breath sounds diminished on right side of chest. Next step? CXR Removal of catheter Endotracheal intubation Needle thoracostomy in second right intercostal space Tube thoracostomy in the left fifth intercostal space Unnecessary. Can be diagnosed clinically. Waiting for CXR before treating could be fatal. Wouldn’t treat the punctured lung Wouldn’t help the pneumothorax and therefore wouldn’t help the respiratory status Correct Would eventually need chest tube on the RIGHT, but not in the left, as the pneumo is on the right.

8. 55 yo man with hx of alcoholism presents with fever and cough productive of mucopurulent sputum for 2 days. T 39, BP 120/75, P 110, R 26. Chest exam: rales and decreased breath sounds in left lower lung field. CXR: infiltrate in lower left lobe. Most likely pathogen? Influenza virus Klebsiella pneumoniae Legionella pneumophila Mycoplasma pneumoniae Pneumocystis carinii Staph aureus

8. 55 yo man with hx of alcoholism presents with fever and cough productive of mucopurulent sputum for 2 days. T 39, BP 120/75, P 110, R 26. Chest exam: rales and decreased breath sounds in left lower lung field. CXR: infiltrate in lower left lobe. Most likely pathogen? Influenza virus Klebsiella pneumoniae Legionella pneumophila Mycoplasma pneumoniae Pneumocystis carinii Staph aureus Symptoms may mimic PNA, but CXR doesn’t usually reveal lobar pulm infiltrates unless there’s a superimposed bacterial infection. Correct-most common organism causing community-acquired PNA in chronic alcoholics. “Currant jelly sputum” A common cause of community acquired PNA. Usually affects pts with some degree of immune impairment or respiratory damage, esp heavy smokers and pts with COPD. Most frequently agent of atypical PNA, usually with dry cough, low-grade fever. “walking PNA” PNA in severly immunocompromised pts. High fever, frequently leads to respiratory failure. Usually causes PNA in hospitalized pts or as a complication of influenza. May cavitate.

9. 48 yo man with extensive smoking hx presents to ER with c/o difficulty breathing for 2 days. T 38.3, BP 120/70, P 103. Dullness to percussion and decreased breath sounds over right lower lung. CXR: significant right pleural effusion. Diagnostic thoracentesis shows: Pleural fluid: pH 7.18, Glucose 40, Protein 3.8, LDH 220 Serum: protein 7.0, LDH 320. Likely etiology of effusion? Exudate of infectious etiology Exudate of malignant etiology Transudate of infectious etiology Transudate of noninfectious etiology

Light’s Criteria Exudate if 1+ criteria met
Pleural protein : serum protein >0.5 Pleural LDH : serum LDH >0.6 Pleural LDH >2/3 upper limits of normal for serum Different labs have different ULN, use whatever value given on exam

Transudate vs Exudate protein content CHF Nephrotic syndrome
Hepatic cirrhosis Spec grav <1.012 protein content Cloudy Malignancy Pneumonia Collagen vascular disease Spec grav >1.020 Must be drained!

Exudate of infectious etiology Exudate of malignant etiology
9. 48 yo man with extensive smoking hx presents to ER with c/o difficulty breathing for 2 days. T 38.3, BP 120/70, P 103. Dullness to percussion and decreased breath sounds over right lower lung. CXR: significant right pleural effusion. Diagnostic thoracentesis shows: Pleural fluid: pH 7.18, Glucose 40, Protein 3.8, LDH 220 Serum: protein 7.0, LDH 320. Likely etiology of effusion? Pleural protein:serum protein is >0.5, pleural LDH to serum LDH is >0.6. Infectious likely b.c acute onset, temp. Malignancy less likely. Not a transudate Not a transudate. Exudate of infectious etiology Exudate of malignant etiology Transudate of infectious etiology Transudate of noninfectious etiology

10. 55 yo pt presents with chronic cough
yo pt presents with chronic cough. Pt has gained weight recently with the development of a “buffalo hump” and Cushingoid features. A CXR demonstrates a mass involving the central area of the chest. Bronchoscopy is performed and a biopsy taken. Which is most likely diagnosis? Adenocarcinoma Bronchioloalveolar carcinoma Large cell carcinoma Small cell carcinoma Squamous cell carcinoma

10. 55 yo pt presents with chronic cough
yo pt presents with chronic cough. Pt has gained weight recently with the development of a “buffalo hump” and Cushingoid features. A CXR demonstrates a mass involving the central area of the chest. Bronchoscopy is performed and a biopsy taken. Which is most likely diagnosis? Adenocarcinoma Bronchioloalveolar carcinoma Large cell carcinoma Small cell carcinoma Squamous cell carcinoma Usually peripheral. NOT linked to smoking. Usually peripheral. Correct. Usually central. Can produce ACTH leading to Cushingoid syndrome seen in this pt. Strong association with smoking. Can produce lots of bioactive substances like ADH, ACTH, prostaglandins, calcitonin, gonadotropins, serotonin. Basically if it’s secreting something and you don’t know for sure what it is, guess small cell. Other cancers secrete things too, but small cell is usual offender. Usually central. Clearly linked to smoking. Can produce PTHrP leading to hypercalcemia.

Lung CA Leading cause of cancer death.
Presents with cough, hemoptysis, bronchial obstruction, wheezing, lesion on CXR. Mets to brain, bone, liver Complications: SVC syndrome, pancoast tumor, horner’s syndrome, paraneoplastic syndromes, effusions

11. A medical consultant for a managed care organization receives a call from a hospital administrator who is concerned about the health care dollars spent on patients with lung CA over the past 5 years. The administrator wants to reduce the expenditures for treatment by implementing a screening test for lung CA. What should the consultant advise the administrator? Annual CXR after age 50 Annual CXR after age 40 for all smokers Annual physical exam with PFTs Annual questionnaire to look for high risk behavior No effective screening program is available

11. A medical consultant for a managed care organization receives a call from a hospital administrator who is concerned about the health care dollars spent on patients with lung CA over the past 5 years. The administrator wants to reduce the expenditures for treatment by implementing a screening test for lung CA. What should the consultant advise the administrator? Annual CXR after age 50 Annual CXR after age 40 for all smokers Annual physical exam with PFTs Annual questionnaire to look for high risk behavior No effective screening program is available This is a lame but high yield question. They love to ask screening questions like this. PSA screening is another one they like to ask.

yo man with extensive smoking hx presents with drooping right eyelid. Pt denies HA or weight loss. C/o occasionally productive cough but otherwise is in good health. Exam: right ptosis, small right pupil. EOMI. Visual acuity normal. Right side of face appears warm and dry. Next most appropriate diagnostic step? CXR Lab testing for syphilis MRI of head Opthalmologic referral Tonometric measurement

yo man with extensive smoking hx presents with drooping right eyelid. Pt denies HA or weight loss. C/o occasionally productive cough but otherwise is in good health. Exam: right ptosis, small right pupil. EOMI. Visual acuity normal. Right side of face appears warm and dry. Next most appropriate diagnostic step? CXR Lab testing for syphilis MRI of head Opthalmologic referral Tonometric measurement Extensive smoking hx, productive cough, [ptosis, miosis, anhydrosis=Horner’s syndrome]. Think of Pancoast Tumor! Syphilis has argyll-robertson pupil-”prostitute pupil”-will accommodate but won’t react Not useful here Referral is rarely correct choice on USMLE. If glaucoma symptoms present- unilateral eye pain, redness, dilated and fixed pupil, blurry vision.

Pancoast Tumor Carcinoma in apex of lung
Affects cervical sympathetic plexus Causes Horner’s syndrome Ptosis, miosis, anhydrosis.

13. Elderly Asian man comes to ER because of rapid onset of severe pain and blurred vision in right eye. Also reports seeing halos around lights. Eye is red, pupil is fixed and dilated. Only med is imipramine for depression. Which diagnostic procedure should be performed at this time? Direct ophthalmoscopy MRI of head Slit-lamp exam Tonometry Visual field assessment

13. Elderly Asian man comes to ER because of rapid onset of severe pain and blurred vision in right eye. Also reports seeing halos around lights. Eye is red, pupil is fixed and dilated. Only med is imipramine for depression. Which diagnostic procedure should be performed at this time? Direct ophthalmoscopy MRI of head Slit-lamp exam Tonometry Visual field assessment They mention imipramine b.c side effect is acute angle closure glaucoma. If pt has hx of glaucoma, imipramine is contraindictated. This fact isn’t likely to appear on Step 1, but wanted to throw in why they mentioned it.

Narrow-angle Glaucoma
Red eye, extreme pain, blurred vision with halos around lights. Impaired flow of aqueous humor inc’d intraocular pressure Tonometry to diagnose, although eye is often hard on palpation Emergency Immediate treatment to lower intraocular pressure acetazolamide or osmotic diuretics (glycerol, mannitol) Less common than open angle which is “silent” and painless

yo man presents with 5 episodes of severe vertigo with N/V over the past 6 months. Episodes begin with a sense of fullness in his right ear, often with tinnitus and a sense of hearing loss in the right ear. Each episode lasts hrs to days and then resolves. Otoscopic exam of right ear is normal. Dx? Benign paroxysmal positional vertigo Herpes zoster oticus Meniere disease Purulent labyrinthitis Vestibular neuronitis

yo man presents with 5 episodes of severe vertigo with N/V over the past 6 months. Episodes begin with a sense of fullness in his right ear, often with tinnitus and a sense of hearing loss in the right ear. Each episode lasts hrs to days and then resolves. Otoscopic exam of right ear is normal. Dx? Benign paroxysmal positional vertigo Herpes zoster oticus Meniere disease Purulent labyrinthitis Vestibular neuronitis BPPV is characterized by violent vertigo induced by moving the head to certain positions. Would’ve mentioned something about position. Pain is prominent in this, no pain mentioned in question. Characterized by pain, hearing loss, vertigo, sometimes paralysis of facial nerve. Correct. Caused by endolymphatic hydrops. Vertigo, tinnitus, fluctuating to progressive hearing loss. Affects any age or sex, peaks in 4th and 5th decades of life. Tx is pharmacologic (anticholinergics, antihistamines, barbiturates, diazepam). Bacterial infectino of inner ear, complication of acute otitis media or purulent meningitis. Presents with an initial, persistent, severe episode of vertigo that eventually fades to paroxysmal form which usually completely disappears within 1-2 years.

15. A term neonate is healthy at birth and receives routine perinatal care. Infant is discharged from hospital on day 3. Ten days after delivery, infant develops severe erythema and edema in both eyelids with associated watery discharge that soon becomes copious and mucopurulent, with presence of pseudomembranes. Which condition is this infant most at risk for? Corneal ulceration Encephalitis Pneumonia Sepsis Silver toxicity

15. A term neonate is healthy at birth and receives routine perinatal care. Infant is discharged from hospital on day 3. Ten days after delivery, infant develops severe erythema and edema in both eyelids with associated watery discharge that soon becomes copious and mucopurulent, with presence of pseudomembranes. Which condition is this infant most at risk for? Corneal ulceration Encephalitis Pneumonia Sepsis Silver toxicity Gonorrheal opthalmia produces acute purulent conjuncivitis appearing 2-5 days after birth and can lead to corneal ulceration if tx is delayed, not 10 days after birth. Encephalitis can result from herpes simplex keratoconjunctivitis. Correct. Infant has neonatal chlamydial infection acquired from infected mom. Can be mild to severe (as in this case). Timeline for chlamydial infection is 5-14 days after birth. Neonatal PNA common with chlamydial infection and appears within 2-19 weeks of age. Sepsis can be a complication but it’s less common than PNA Chemical conjunctivitis can result from prophylactic use of silver nitrate in neonates. Will appear 6-8 hrs after application and resolves in hrs. Silver tox is not typical.

yo boy brought to doc due to persistent nasal obstruction for 6 months. No personal or family hx of allergic disorders. Nasal fossae exam reveals B/L ethmoidal polyps. Most appropriate next step in diagnosis? Cutaneous allergen testing Excisional biopsy Nasal provocation testing Pilocarpine iontophoresis sweat test Radioallergosorbent test (RAST)

Nasal Polyps Not neoplasms
Hyperplastic response of mucosa to chronic inflammation Allergic rhinitis/sinusitis is most common underlying condition…BUT think of cystic fibrosis in children Also consider aspirin allergy: triad of nasal polyps, asthma, & sinusitis

yo boy brought to doc due to persistent nasal obstruction for 6 months. No personal or family hx of allergic disorders. Nasal fossae exam reveals B/L ethmoidal polyps. Most appropriate next step in diagnosis? Cutaneous allergen testing Excisional biopsy Nasal provocation testing Pilocarpine iontophoresis sweat test Radioallergosorbent test (RAST) If considering allergic etiology. Necessary only when polyps haven’t regressed with pharmacologic therapy (steriods). Direct allergen challenge performed by inhalation of allergens thru the nose-this test may allow identification of involved allergens in case of a positive rxn. Correct. Test for cystic fibrois. If considering allergic etiology. Detects allergen-specific serum IgE in vitro.

Cystic Fibrosis Autosomal recessive defect in CFTR gene on Chromosome 7, usually deletion of Phe 508. Defective chloride channel leads to secretion of abnormally thick mucous that plugs the lungs, pancreas, and liver Recurrent pulmonary infections (esp. Pseudomonas and S. aureus) Chronic bronchitis, bronchiectasis, pancreatic insufficiency, meconium ileus in newborns, nasal polyps. Tx: N-acetylcysteine—loosens mucous plugs. Can remember chromosome 7 because “cystic” has 6 letters, “fibrosis” has 8 letters, so 7 is right in the middle.

17. 10yo girl has recurrent attacks of wheezing and dyspnea
17. 10yo girl has recurrent attacks of wheezing and dyspnea. Attacks occur mostly at home or soon after exercise when outdoors. Exacerbations are noted in spring. Severity of symptoms is mild. PFTs show peak expiratory flow and FEV1 are reduced during an attack but are normal otherwise. CBC shows 8% eosinophils. Allergy testing shows pt allergic to variety of allergens: dust mites, animal dander, pollens. Most effective step in management? Avoid exercise Avoid respiratory irritants Use air cleaners at home Administration of multiple-drug regimens Immunotherapy against identified allergens

17. 10yo girl has recurrent attacks of wheezing and dyspnea
17. 10yo girl has recurrent attacks of wheezing and dyspnea. Attacks occur mostly at home or soon after exercise when outdoors. Exacerbations are noted in spring. Severity of symptoms is mild. PFTs show peak expiratory flow and FEV1 are reduced during an attack but are normal otherwise. CBC shows 8% eosinophils. Allergy testing shows pt allergic to variety of allergens: dust mites, animal dander, pollens. Most effective step in management? Avoid exercise Avoid respiratory irritants Use air cleaners at home Administration of multiple-drug regimens Immunotherapy against identified allergens A) Not appropriate B) correct. Girl has asthma. Most crucial step in management of asthma is avoidance of triggers (ie allergens and irritants). C) Not been shown effective D) Should try to use fewest number of drugs at lowest effective doses. Typically use one drug ( a bronchodilator or inhaled corticosteriod) for mild-moderate cases or two drugs for more severe cases. E) Sometimes useful when a single allergen is involved, but not with multiple airborne allergens.

18. 12 yo girl has mild case of PNA
yo girl has mild case of PNA. Treated with IM injection of penicillin. 15 mins later, develops extreme itchiness & wheals scattered over her chest and extremities. Pt begins to wheeze and c/o difficulty breathing. Lips and face remain rosy. Which is the following is the most appropriate first step in management? Epinephrine injection IV corticosteriods Intubation Oral corticosteroids No specific therapy is needed

18. 12 yo girl has mild case of PNA
yo girl has mild case of PNA. Treated with IM injection of penicillin. 15 mins later, develops extreme itchiness & wheals scattered over her chest and extremities. Pt begins to wheeze and c/o difficulty breathing. Lips and face remain rosy. Which is the following is the most appropriate first step in management? Epinephrine injection IV corticosteriods Intubation Oral corticosteroids No specific therapy is needed She’s having anaphylactic rxn to penicillin. First step is epi injection. Sometimes given after epi in severe cases, especially when stimulating antigen can’t be immediately removed. Usually not indicated, since epi usually reverse the airway edema within a few mins. If situation worsens with desats or if resp arrest occurs, would do this. But not the first step. Used as prophylaxis when anaphylaxis may occur or sometimes after milder cases of anaphylaxis in which antigen may not have been completely removed. Totally wrong, patient may die without treatment.

Type I Hypersensitivity Anaphylaxis
Itchiness and wheals result from changes in small cutaneous vessels that favor shift of fluid out of the vascular space. SOB and wheeze are due to edema and bronchoconstriction of upper airways. Free antigen cross-links IgE on presensitized mast cells, triggering release of vasoactive amines (histamine).

Type II Hypersensitivity
Antibody mediated IgM, IgG bind to antigen on enemy cell, leading to lysis by complement or phagocytosis. Hemolytic anemia, pernicious anemia, ITP, erythroblastosis fetalis, rheumatic fever, bullous pemphigoid, pemphigus vulgaris, Graves’ disease, myasthenia gravis. ITP=idiopathic thrombocytopenic purpura

Type III Hypersensitivity
Immune complex Antigen-antibody complex activates complement, which attracts neutrophils, which release lysosomal enzymes Serum sickness-usually caused by drugs. Fever, urticaria, arthralgias, proteinuria, LAD 5-10 days after antigen exposure. 5 days to produce the antibodies to the antigens-then complex forms, gets deposited and leads to damage. Arthus rxn-intradermal injection of antigen attracts antibodies, form complex in skin. Edema, necrosis.

Type IV Hypersensitivity
Delayed T-cell mediated Sensitized T cells encounter antigen and release lymphokines leading to macrophage activation PPD test Contact dermatitis – poison ivy Transplant rejections

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