Pulmonary Blueprint - PowerPoint Presentation

Slide1

Pulmonary Blueprint

Questions, Answers and ExplanationsSlide2

Question 1

1. Your patient is a 12 month old male that presents with stridor, drooling, and respiratory distress. This started suddenly. Chest x ray reveals a thumb print sign. Patients vital signs are as follows: HR 172, Temp 102, SaO2 91% RR 64. Which of the following is the best management plan?

A. Racemic Epinephrine Aerosol and supplemental oxygen

B. Decadron 4 mg IM

C. Heated aerosolized mist

D. IntubationSlide3

Answer 1

1. Choice D is the correct answer. Given the thumb print sign on x ray, drooling, and stridor this patient has epiglottis clinically. This patient is not stable and needs his airway protected, intubation is the correct answer. Aerosols and intramuscular injections should be avoided so the child does not get agitated and get more upper airway edema. Heated aerosolized mist may actually make the child worse.Slide4

Question 2

2. A 28 year old female who is healthy presents with a productive cough and fever. He has had shaking episodes and chills. Her sputum has been rusty colored. Her chest x ray shows a RML pneumonia. Gram stain is positive for gram positive shaped diplococci. Which of the following is the most likely diagnosis?

A. Tuberculosis

B. Pneumococcal pneumonia

C. Legionella

D. Pulmonary EmbolusSlide5

Answer 2

2. Choice B is the correct answer. Pneumococcal pneumonia presents usually in young, healthy individuals with a lobar pneumonia. Patients frequently will have chills and shakes. Tuberculosis presents with hemoptysis, night sweats, weight loss, and cavitary lesions in the upper lobes on chest x-ray. Pulmonary emboli typically will not have a lobar pneumonia with it.Slide6

Question 3

3. A 34 year old with multiple comorbidities presents with "flu like" symptoms that resolved 48 hours ago. He has a high fever and cough still. His chest exam reveals rales and rhonchi throughout. His gram stain reveals large gram positive cocci occurring in pairs. Which of the following is the most likely diagnosis?

A. Influenza pneumonia

B. Mycoplasma Pneumonia

C. Haemophilus Influenzae

D. Staphylococcal PneumoniaSlide7

Answer 3

3. Choice D is the correct answer. Staphylococcus on gram stain are cocci that occur in pairs. Influenza would not grow on gram stain. Mycoplasma can be confirmed by sputum culture or cold agglutinin titer. Haemophilus is usual in vaccinated individuals.Slide8

Question 4

4. Which of the following is true regarding influenza pneumonia?

It presents with as a lobar pneumonia

It is the most common cause of viral pneumonia in children

Ceftriaxone is the drug of choice

It causes significant morbidity and mortalitySlide9

Answer 4

4. Choice D is the correct answer. Influenza pneumonia causes significant morbidity and mortality in children. It usually presents as more of an interstitial pneumonia. The most common viral pneumonia in children is RSV. Ceftriaxone is a third generation cephalosporin and is not effective against influenza. Tamiflu is the drug of choice in the appropriate age group and if started in the first 48 hours of onset of symptoms. Slide10

Question 5

5. Which of the following is not a characteristic of bacterial pneumonias?

A. Usually lobar pneumonias

B. Usually accompanied by a pleural effusion

C. Usually have bulging fissures

D. Usually are in the upper lobesSlide11

Answer 5

5. Choice D is the correct answer. Bacterial pneumonias are usually found in the middle and lower lobes. They are usually lobar. Upper lobes pneumonia should make the clinician suspicious for tuberculosis. Slide12

Question 6

6. Your patient is a 54 year old that just underwent a thoracentesis. His results are as follows: serum protein < 0.5, LDH 100 IU/mL, specific gravity of < 1.016, ratio of pleural fluid LDH to serum LDH of < 0.6, and pleural fluid protein of 2 gram/dL. Which of the following is the most likely diagnosis?

A. Infection

B. Pulmonary Embolism

C. CHF

D. InfarctionSlide13

Answer 6

6. Choice C is the correct answer. These are transudate findings with pleural fluid. The low serum protein, the low low LDH, and the low pleural fluid to serum LDH ratio. CHF is the most common cause of transudative pleural effusions.Slide14

Question 7

7. Your patient is a 24 year old healthy male that presents with hemoptysis. The remainder of his past medical history, exam, and vital signs are normal. Which of the following is the most likely diagnosis?

A. Pneumonia

B. Tuberculosis

C. Bronchogenic Carcinoma

D. BronchitisSlide15

Answer 7

7. Choice D is the correct answer. Bronchitis is the most common cause of hemoptysis in the US. With pneumonia and tuberculosis you would expect some abnormal history or physical findings. It would be unusual for a healthy 24 year old to develop bronchogenic carcinoma.Slide16

Question 8

8. Your patient is a 24 year old male that presents with left sided chest pain and shortness of breath. His vitals are as follows HR 112, RR 24, Temp 98.7, SaO2 94%. His chest x ray is below. Which of the following is the best management plan?



A. Arrange for immediate bronchoscopy and biopsy

B. Start on Levaquin 750 mg IV daily

C. Insert a 28 French chest tube on the left side at the 4th or 5th interspace

D. Observation and oxygen supplementationSlide17

Answer 8

8. Choice C is the correct answer. This patient has over a 15 percent pneumothorax on the left side. So observation is not appropriate. This pneumothorax does not appear to have any blood so a 28 or 32 french is appropriate. If there is a hemothorax a 36 or 40 French would be

appropriate so it can drain effectively. This finding on the left side is not a pneumonia or mass. There is missing lung markings consistent with a pneumothorax.Slide18

Question 9

9. Your patient is a 50 year old that presents with blood in his mouth. The blood is frothy, red with a normal pH. Which of the following is the most likely source of the blood?

A. Pulmonary

B. Upper GI

C. Stomach

D. DuodenumSlide19

Answer 9

9. Choice A is the correct answer. Frothy red sputum tends to be pulmonary in origin because it mixes with edema. In addition the pH is normal so this essentially excludes a GI etiology. Another possibility but not likely is a nosebleed. Blood from a nosebleed typically is not frothy.Slide20

Question 10

10. Your patient is a 34 year old male that presents with an acute asthma attack. He has had Solumedrol 125 mg IV, and a two hour continuous aerosol of albuterol and is feeling better. His lungs are clear, his vital signs are normal and he wants to go home. Which of the following things to consider in his history before you discharge him home that may make you consider him high risk for discharge?

A. He cannot pay for his medicine

B. He is a smoker

C. He was intubated 2 months ago

D. All of the following make him high risk for discharge and should be observedSlide21

Answer 10

10. Choice D is the correct answer. This patient should likely be observed given he is a smoker, and had a recent intubation. These make him high risk for relapse and morbidity and mortality. In addition if he cannot afford his medications, this would make him high risk for discharge. Social services should be involved in his care.