![]() |
Good qs - arrythmia - Printable Version +- USMLE Forum - Largest USMLE Community (https://www.usmleforum.com) +-- Forum: USMLE Forum (https://www.usmleforum.com/forumdisplay.php?fid=1) +--- Forum: Step 2 CK (https://www.usmleforum.com/forumdisplay.php?fid=3) +--- Thread: Good qs - arrythmia (/showthread.php?tid=328518) Pages:
1
2
|
Good qs - arrythmia - ArchivalUser - 08-15-2008 1)A 24-year-old Caucasian woman comes to the clinic complaining of progressive shortness of breath over the last 4 weeks. There is no particular pattern to the dyspnea and it seems to be getting worse. She denies any associated symptoms of pain or fever, and although she admits to œsmoking like a chimney, she has not had a cough. She has had multiple respiratory problems in the past, having suffered two spontaneous pneumothoraces over the last 3 years, as well as intermittent dyspnea. Although no one has been able to determine why she suffers these respiratory problems, she has been told she likely has adult onset asthma. She has tried an albuterol inhaler, the only medication she takes other than birth control pills, but has had little improvement. Other than her respiratory complaints, review of systems and past medical history is unremarkable. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 138/88 mm Hg, pulse 72/min, and respirations 24/min. Chest examination reveals diminished breath sounds and dullness to percussion over the right side of the chest and faint end-expiratory wheezes. A chest radiograph reveals a large right side effusion, together with flattened diaphragms and bilateral reticulonodular interstitial opacities. Reviewing her chart, you see that a previous workup has included a ventilation perfusion scan, read as œlow probability, and a set of pulmonary function tests that were read as œmixed obstructive/restrictive pattern with a markedly reduced DLCO. A diagnostic thoracentesis reveals a milky white effusion. Shortly after the specimen is sent, the laboratory calls to report a triglyceride level of 120 mg/dL and the presence of numerous chylomicrons in the sample. Which of the following primary pathologic abnormalities explains this woman™s lung disease? A. Congenital reduction in antiprotease production in the lungs B. Interstitial lung disease related to undiagnosed HIV infection C. Pan-acinar destruction of alveoli from tobacco use D. Proliferation of atypical smooth muscle cells, compressing surrounding tissue E. Stage IV cystic/nodular sarcoidosis resulting in obstructive granuloma formation 2) A 71-year-old man comes to the emergency department complaining of progressive shortness of breath over the last 2 weeks. He also reports an increase in his baseline cough with purulent sputum production. He denies fever, chills, or chest pain. He reports his diet has been poor lately and he has been eating large amounts of salty foods. He believes this is contributing to his breathing problems. His past medical history is significant for hypertension and a chronic œsmoker™s cough. He takes verapamil for blood pressure control and he occasionally uses an inhaler when he feels short of breath but cannot remember what the inhaler is called. He tells you that he formerly smoked two packs of cigarettes per day for 35 years but now is down to three cigarettes each day. He has several drinks of vodka each day but denies any drug use. His temperature is 38.1 C (100.6 F), blood pressure is 190/70 mm Hg, pulse is 113/min, and respirations are 28/min. His oxygen saturation is 81% on room air and improves to 92% on 6 L of oxygen by way of nasal cannula. Physical examination reveals a thin man in mild to moderate respiratory distress, breathing rapidly. His pulse is regular but tachycardic. His breath sounds are coarse and decreased bilaterally with occasional wheezes. His abdomen is benign and his lower extremities have no edema. An electrocardiogram shows sinus tachycardia, left ventricular hypertrophy, and diffuse nonspecific T-wave changes Which of the following statements is true concerning this patient™s management? A. On the basis of the information given, this patient needs to be intubated immediately B. Empiric antibiotics, systemic steroids, oxygen, and nebulized ipratropium bromide and albuterol are indicated C. He will likely improve with diuresis and a low salt diet D. Inhaled steroids, ipratropium bromide, and albuterol by way of metered dose inhaler (MDI) are indicated E. Supplemental oxygen should be avoided because it may cause respiratory depression 0 - ArchivalUser - 08-15-2008 3) A 64-year-old man with chronic obstructive pulmonary disorder (COPD) is hospitalized for an acute exacerbation of chronic bronchitis (AECB). At the time of admission, the patient is suffering from dyspnea, a productive cough with green-tinged sputum, and pleuritic chest pain. At that time his oxygen saturation is 80%. A blood gas reveals a pH of 7.35, a pO2 of 51 mm Hg, and a pCO2 of 58 mm Hg. The patient is treated with oxygen therapy, nebulized ipratropium and albuterol treatments, and azithromycin. Over the course of 5 days, the patient™s respiratory status improves. His cough and sputum production diminish and he is weaned from supplemental oxygen. At the time of discharge, his oxygen saturation is 90% on room air. A blood gas reveals a pH of 7.37, a pCO2 of 50 mm Hg, and a pO2 of 70 mm Hg. At this time, which of the following is an appropriate treatment for this patient? A. Continued antibiotics B. Home oxygen therapy C. Inhaled steroids D. Leukotriene inhibition E. Pneumococcal vaccine 0 - ArchivalUser - 08-15-2008 d b.. 0 - ArchivalUser - 08-15-2008 b, 0 - ArchivalUser - 08-15-2008 D), for 1 any body could confirm? 0 - ArchivalUser - 08-15-2008 1st D) The correct answer is D. This patient has pulmonary lymphangioleiomyomatosis (LAM), a disease characterized by atypical interstitial smooth muscle proliferation and cyst formation. Although the disease is uncommon on the wards, its peculiar presentation makes it popular on board examinations: a chylous effusion in a premenopausal female who may have been misdiagnosed with COPD or asthma. Recurrent pneumothoraces are common. Further imaging should include a high-resolution CT scan. Treatment involves hormonal manipulation (first by stopping oral contraceptive pills, as estrogen hastens disease progression) and lung transplant. Congenital reductions in antiprotease production (choice A) are seen in alpha-1 antitrypsin deficiency, a form of congenital emphysema (often with liver involvement also). Chylous effusions are not commonly associated with emphysema. Reduced immune function, particularly with HIV (choice B), can result in chronic lung disease, particularly pulmonary hypertension, though rarely interstitial disease. Recurrent opportunistic infections or chronic lung disease are unlikely to give this presentation. Pan-acinar destruction from tobacco use (choice C) can result in emphysema but is unlikely in a 24-year-old patient. Further, it does not explain the chest radiograph findings of reticulonodular opacities (though COPD would produce air trapping) or the chylothorax. Stage IV pulmonary sarcoidosis (choice E) is characterized by cystic lung changes and diffuse parenchymal involvement that can appear as reticulonodular opacities. In the US the age-adjusted annual incidence rate is 10.9 per 100,000 Caucasians, and 35.5 per 100,000 African- Americans. Because the disease is often misdiagnosed or goes unrecognized, prevalence and incidence rates are likely to be an underestimate. A chylothorax would be unlikely in sarcoidosis. Hi Guest 0 - ArchivalUser - 08-15-2008 dac 0 - ArchivalUser - 08-15-2008 1.D 2.B 3.E 0 - ArchivalUser - 08-15-2008 Thanks arrythmia for the good Q 0 - ArchivalUser - 08-15-2008 2. b 3. b |