MCQ R2

MED R2
A 22 year old man with acute myeloid leukemia was treated with allogenic bone marrow transplant 3 months ago. He received cyclosporin 200 mg/day and cotrimoxazole. He had fever and nonproductive cough for 2 days prior to this admission. On physical examination revealed fever 38.3 c and fine crepitation both lungs. He had no skin rash. The CXR was bilateral interstitial infiltrations. What is the MOST likely diagnosis?
A. B. C. D. E.
PCP pneumonia Mycoplasma pneumonia CMV pneumonia Staphylococcus pneumonia Aspergillus pneumonia
Respiratory complication after HSCT
Immune system after HSCT

Phase I (pre engraftment) 0-30 days Host defence deficits 1 Neutropenia 2 Damage mucocutaneous barrier translocation of GI and cutaneous bacteria to bloodstream 3 Indwelling intravenous catheter septic emboli
Organism Bacteria gram negative Klebsiella, Pseudomonas, Enterobacteriaceae gram positive Staphylococcus (coagulase postive and negative), Enterococcus Fungus Candida spp, Aspergillois Virus HSV
Risk for infection

Allogenic = Autologous
Resolve
ANC > 500, platelet > 20,000 * 3 days
Phase II ( 30-100 days) Decrease or discontinue corticosteroid restore PMN function decrease risk for bacteria and funfus BUT Still has immune system dysfunction especially Increased risk for Decreased CD4/CD8 ratio CMV Decreased IgA, IgG PJP Aspergillosis
Allogenic HSCT Acute GVHD skin, GI and liver manifestration
Phase III ( > 100 days) Cellular and humoral immune deficit macrophage dysfunction, impaired PMN chemotaxic long lasting IgA and IgG deficiency Risk for encapsulated organism ( S.pneumoniae, H.influenza, N.meningitidis) Norcadia,mycoplasma PCP CMV
Allogenic HSCT chronic GVHD bronchiolitis obliteran scleroderma sicca syndrome
Febrile neutropenia
AIDS
A 22 year old man with acute myeloid leukemia was Suppress T cell treated with allogenic bone marrow transplant 3 months ago. He received cyclosporin 200 mg/day and cotrimoxazole. He had fever and nonproductive cough for 2 days prior to this admission. On physical examination revealed fever 38.3 c and fine crepitation both lungs. He had no skin rash. The CXR was bilateral interstitial infiltrations. What is the MOST likely diagnosis?
A. B. C. D. E.
PCP pneumonia Rapid onset of fever ,non productive Mycoplasma pneumonia cough,dyspnea and hypoxemia Interstitial pattern with tiny pulmonary CMV pneumonia nodules Staphylococcus pneumonia Aspergillus pneumonia
Staphylococcus pneumonia
Arterial blood gas was drawn from a 16 year-old female immediately after her intubation for a severe asthmatic attack. PaO2 was 350 mm Hg, PaCO2 was 50 mm Hg and pH was 7.30. She remained sedated and paralyzed, breathing at the machine set rate of 12 /min and with a tidal volume of 400 cc. What should the rate be to normalize PaCO2 at 40 mmHg?
A. 14 B. 15 C. 16 D. 17 E. 18
ALVEOLAR VENTILATION EQUATION
CO2 production PACO2 alveolar ventilation PACO2 PaCO2
VD
VT
VA
VT = VA + VD VA = VT VD Alveolar ventilation = RR x VA = RR (VT-VD)
Alveolar ventilation equation
PACO2 = k x VCO2/RR (VT-VD)

PACO2 = k x VCO2/RR (VT-VD)
PaCO21 = k x CO2 production 1 PaCO22 alveolar ventilation 1 k x CO2 production 2 alveolar ventilation 2

PaCO21 = alveolar ventilation 2 PaCO22 alveolar ventilation 1 = [Vt(2)-Vd(2)] x RR(2) [Vt(1)-Vd(1)] x RR(1)
VT
PaCO21 = [Vt(2)-Vd(2)] x RR(2) PaCO22 [Vt(1)-Vd(1)] x RR(1)
50
= RR(2)
40
12
RR(2) = 15/min
Arterial blood gas was drawn from a 16 year-old female immediately after her intubation for a severe asthmatic attack. PaO2 was 350 mm Hg, PaCO2 was 50 mm Hg and pH was 7.30. She remained sedated and paralyzed, breathing at the machine set rate of 12 /min and with a tidal volume of 400 cc. What should the rate be to normalize PaCO2 at 40 mmHg?
A. 14
C. 16 D. 17 E. 18
A 30 year old woman, previously healthy, develop smear positive pulmonary TB. After receiving INH, RIF, Ethambutol and PZA one daily before bedtime for 1 week, she developed progressive nausea vomiting and malaise, the physical findings are unremarkable. The LFT reveals: TB/DB 2.8/1.6, AST/ALT 180/170, Alk phos 150. What is the MOST immediate appropiate management?
A. B. C. D. E. Switch to ethambutol, olfoxacin and streptomycin Stop only PZA and continue the rest 3 drugs Replace RIF with olfloxacin Add domperidone Split INH to 3 times daily after meal
A 30 year old woman, previously healthy, develop smear positive pulmonary TB. After receiving INH, RIF, Ethambutol and PZA one daily before bedtime for 1 week, she developed progressive nausea vomiting and malaise, the physical findings are unremarkable. The LFT reveals: TB/DB 2.8/1.6, AST/ALT 180/170, Alk phos 150.
Management of drug-induced hepatitis

Of the first-line anti-TB drugs, isoniazid, pyrazinamide and rifampicin can all cause liver damage (drug-induced hepatitis). Try to rule out other possible causes before deciding that the hepatitis is induced by the TB regimen. The management of hepatitis induced by TB treatment depends on: whether the patient is in the intensive or continuation phase the severity of the liver disease the severity of the TB the capacity of the health unit to manage the side-effects of TB treatment
If liver disease is caused by the anti-TB drugs all drugs should be stopped. If the patient is severely ill with TB and it is unsafe to stop TB treatment non-hepatotoxic regimen consisting of streptomycin, ethambutol and fluoroquinolone should be started
If TB treatment has been stopped wait for LFT to revert to normal and clinical symptoms (nausea, abdominal pain) to resolve restart the anti-TB drugs. If it is not possible to perform LFT wait an extra 2 weeks after resolution of jaundice and upper abdominal tenderness before restarting TB treatment. If the signs and symptoms do not resolve and the liver disease is severe non-hepatotoxic regimen consisting of streptomycin, ethambutol and a fluoroquinolone should be started (or continued) for a total of 1824 months
When resolve rechallenge antiTB one by one. If symptoms recur or LFT abnormal after rechallenge last drug added should be stopped. In patients who have experienced jaundice but tolerate the rechallenge of rifampicin and isoniazid, it is advisable to avoid pyrazinamide.
Drug causes hepatitis

Rifampicin 2SHE 10 HE INH 6-9 REZ PZA 2 HRE 7 HR INH and RIF 18-24 EOS
A 30 year old woman, previously healthy, develop smear positive pulmonary TB. After receiving INH, RIF, Ethambutol and PZA one daily before bedtime for 1 week, she developed progressive nausea vomiting and malaise, the physical findings are unremarkable. The LFT reveals: TB/DB 2.8/1.6, AST/ALT 180/170, Alk phos 150.
A. B. C. D. E. Switch to ethambutol, olfoxacin and streptomycin Stop only PZA and continue the rest 3 drugs Replace RIF with olfloxacin Add domperidone Split INH to 3 times daily after meal
A 65 year old man, 50 kg, was recently diagnosed with active pulmonary TB. He was started on INH 300 mg/day, RIF 600 mg/day, ethambutol 800 mg/day and PZA 1500 mg/day. After 2 weeks of treatment, he complaint of nausea after taking medication. LFT showed AST 130 ALT 120 Alk phos 100, normal TB and DB. What is the MOST appropiate management>
A. Continue medications, close follow up LFT and symptoms B. Stop all medications, follow up LFT, restart medications after LFT normalize C. Stop only INH but continue others, follow up LFT D. Switch to streptomycin, ethambutol and ofloxacin E. Decrease PZA to 1000 mg/day and follow up LFT
A 65 year old man, 50 kg, was recently diagnosed with active pulmonary TB. He was started on INH 300 mg/day, RIF 600 mg/day, ethambutol 800 mg/day Active + symptom + and PZA 1500 mg/day. After 2 weeks of treatment, AST/ALT > 3 times he complaint of nausea after taking medication. LFT showed AST 130 ALT 120 Alk phos 100, normal TB and DB. What is the MOST appropiate management>
A. Continue medications, close follow up LFT and symptoms B. Stop all medications, follow up LFT, restart medications after LFT normalize C. Stop only INH but continue others, follow up LFT D. Switch to streptomycin, ethambutol and ofloxacin E. Decrease PZA to 1000 mg/day and follow up LFT
Which one is incorrect reguarding the toxicity of antiTB drugs? A. B. C. D. E. PZA and hepatitis Ethambutol and retrobulbar neuritis Rifampicin and peripheral neuropathy Streptomycin and renal toxicity Isoniazid and hepatotoxicity
Side effect of antiTB drugs

Isoniazid Systemic or cutaneous hypersensitivity reactions Sleepiness or lethargy Peripheral neuropathy, optic neuritis, toxic psychosis and generalized convulsions hepatitis lupus-like syndrome, pellagra, anemia, and arthralgias monoamine (histamine/tyramine) poisoning
Rifampicin Orange discoloration of body fluids pruritis with/without rash Severe Hypersensitivity Hepatotoxicity Transient asymptomatic hyperbilirubinemia Hepatitis cholestatic pattern Influenza like syndrome GI upset : Nausea, anorexia, abdominal pain Immunological reaction : thrombocytopenia, hemolytic anemia ,acute renal failure
Pyrazinamide gastrointestinal intolerance hypersensitivity reactions rises in serum transaminase concentrations hepatotoxicity hyperuricaemia Contraindication in porphyria Arthralgia Rare adverse events sideroblastic anaemia and photosensitivity dermatitis
Streptomycin Hypersensitivity reactions are rare. nephrotoxicity ototoxicity vertigo
Ethambutol
Retrobulbar neuritis (blurred vision, central scotomata, red-green color blindness) : dose related 50 mg/kg : 15% 25 mg/kg : 1%- 5% 15 mg/kg : < 1% Peripheral neuritis : rare Cutaneous reaction Monitoring VA, color 1. Dose > 15-25 mg/kg 2. Receive drug > 2 month 3. Renal insuff. Discontinue drug immediatley and permanent if there any sign of visual toxicity
Which one is incorrect reguarding the toxicity of antiTB drugs? A. B. C. D. E.
INH PZA and hepatitis Ethambutol and retrobulbar neuritis Rifampicin and peripheral neuropathy Streptomycin and renal toxicity Isoniazid and hepatotoxicity
Which effect of rifampicin is absolute contraindication for prescribing it in future? A. B. C. D. E. Flu like symptoms Hepatitis Maculopapular rash Urine discoloration Immune thrombocytopenia
Contraindication for remedication

RFP: thrombocytopenia , hemolytic anemia , acute interstitial nephritis Etham : visual impairment strep : eight nerve damage PZA: jaundice
Management of cutaneous reaction

Itching without rash symptomatic Rx with antihistamine and continue anti TB drug Rash stop all anti TB when resolved restart one by one with small challenge dose
Which effect of rifampicin is absolute contraindication for prescribing it in future? A. B. C. D. E. Flu like symptoms Hepatitis Maculopapular rash Urine discoloration Immune thrombocytopenia
Isoniazid Rifampicin Ethambutol Pyrazinamide streptomycin
Bactericidal Bactericidal Bacterioistatic Weakly bactericidal Bactericidal
CNS penetration INH Rifam

Excellent
Renal excretion
Safe
Pregnancy
Safe
10-20% of serum level
Safe
Safe
PZA
CNS = serum
Should reduce
limit data but benefit > risk

Safe
Etham
Only inflammation
Should reduce
Streptomy Slight cin
Used with caution
X (fetal hearing loss)
Dose (mg/kg/day)
Cycloserine Cs Ethionamide Et Amikacin / kanamycin / Capreomycin Am/Km/Cm PAS
Bacteristatic Bactericidal Bactericidal
10-15 bid (500-750) 15-20 od/bid (500-750) 15 IM/IV Complete X resistant 5-7 day/weeks between Am/Km but Sm resistant are (750-1,000) susceptible to Am/Km
Bacteristatic
Bactericidal Bactericidal
150 bid/tid (8-12 g)

7.5-15 (600-800) 10-20 (1,000-1,500) X resistant between O Cx and levofloxacin Divalent ion interfere absorption
Ofloxacin O Ciprofloxacin Cx
AFB per ml
Number of colonies on culture
Culture report
Number of AFB on smear (1000X, ZiehlNelsen)
Number of AFB on smear (200-250X ,Fluorescen)
AFB smear report
< 10
10-500
0
< 50
Actual count
0
0
0
0
500-1,000
1,000-2,000 2,000-5,000 5,000-60,000
50-100
100-200(almost confluent) >500 (confluent) >500 (confluent)
1+
2+ 3+ 4+
0
0 1-2 / 300 field 1-9 / 100 field
0
0 1-2 / 30 field 1-9 / 10 field
1+
60,000600,000
600,0006,000,000 6,000,00060,000,000
>500 (confluent)
>500 (confluent) >500 (confluent)
4+
4+ 4+
1-9 / 10 field
1-9 / field > 9 / field
1-9 / field
10-90 / field > 90 / field
2+
3+ 4+
A patient with AIDS was admitted due to severe dyspnea. CXR showed bilateral upper lobe infiltraton and sputum smear showed AFB4+. He was isolated with air borne precaution. On transport him to radiology department for CT chest, you would advise: A. Surgical mask formpateint and N 95 mask for trolley pusher B. Surgical mask for patient and trolley pusher C. N 95 mask for patient and surgical mask for trolley pusher D.N 95 mask for patient and trolley pusher E. N 95 mask for patient only
Airborne precaution
Particle < 5 um HEPA filter 2%lysol 5% hypochloride surgical mask
Sputum pot N 95 mask Surgical mask

Chicken pox HZV SARS
pulmonary tuberculosis measle
A patient with AIDS was admitted due to severe dyspnea. CXR showed bilateral upper lobe infiltraton and sputum smear showed AFB4+. He was isolated with air borne precaution. On transport him to radiology department for CT chest, you would advise: A. Surgical mask formpateint and N 95 mask for trolley pusher B. Surgical mask for patient and trolley pusher C. N 95 mask for patient and surgical mask for trolley pusher D.N 95 mask for patient and trolley pusher E. N 95 mask for patient only
A 63 year old man, a 30 pack year smoker, present with increasing cough with sputum production, fever and progressive weight loss. He worked in a stone quarry for 20 years. Which one of following in UNLIKELY to be found in is current evaluation?
A. B. C. D. E.
Infection caused by Mycobacteria tuberculosis Malignant mesothelioma Upper lobe lung nodule Eggshell calcification Positive ANA in serum
Silica dust
Diseases associated with exposure to silica dust

Slilicosis chronic silicosis accelerated silicosis acute silicosis progressive massive fibrosis COPD emphysema chronic bronchitis small airway Mycobacterial infection MTB NTM Immune related PSS RA CRF SLE
Silicosis
Risk factors for TB

HIV Hematologic malignancy and cancer chemotherapy DM Uremia Undernutrition Gastrectomy Silicosis ( increased risk 2-30 times)
Risk factor of mesothelioma asbestos exposure ionizing radiation chronic inflammation of pleura Mediterranian fever
A. B. C. D. E.
Infection caused by Mycobacteria tuberculosis Malignant mesothelioma Upper lobe lung nodule Eggshell calcification Positive ANA in serum
PAH Fc II
Thai guideline for Dx and Rx PH 2011

Pulmonary hypertension mean pulmonary arterial pressure >= 25 mmHg Pulmonary arterial hypertension mean pulmonary arterial pressure >= 25 mmHg PCWP < 15 mmHg PVR > 3 wood
Pulmonary hypertension Diagnostic classification

JACC June 2009:54(1)suppl S: S43-541.4
1.Pulmonary arterial hypertension
1.1. Idiopathic (IPAH) 1.2. Familial (FPAH) 1.3. Associated with (APAH): 1.3.1. Connective tissue disorder 1.3.2. Congenital systemic-to-pulmonary shunts 1.3.3. Portal hypertension
1.3.4. HIV infection

1.3.5. Drugs and toxins
1.3.6. Other (thyroid disorders, glycogen storage disease,Gauchers disease, hereditary hemorrhagic
telangiectasia,
hemoglobinopathies, chronic myeloproliferative disorders, splenectomy)
1.Pulmonary arterial hypertension
1.4. Associated with significant venous or capillary involvement 1.4.1. Pulmonary veno-occlusive disease (PVOD) 1.4.2. Pulmonary capillary hemangiomatosis (PCH)
1.5. Persistent pulmonary hypertension of the newborn
2. Pulmonary hypertension with left heart disease 2.1. Left-sided atrial or ventricular heart disease 2.2. Left-sided valvular heart disease
3. Pulmonary hypertension associated with lung diseases and/or hypoxemia 3.1. Chronic obstructive pulmonary disease 3.2. Interstitial lung disease 3.3. Sleep disordered breathing 3.4. Alveolar hypoventilation disorders 3.5. Chronic exposure to high altitude 3.6. Developmental abnormalities
4. Pulmonary hypertension due to chronic thrombotic and/or embolic disease (CTEPH) 4.1. Thromboembolic obstruction of proximal pulmonary arteries 4.2. Thromboembolic obstruction of distal pulmonary arteries 4.3. Nonthrombotic pulmonary embolism (tumor, parasites,foreign material)
5. Miscellaneous Sarcoidosis, histiocytosis X, lymphangiomatosis, compression of pulmonary vessels (adenopathy,tumor, fibrosing mediastinitis)
PH
1 (PH diagnosis)
Hx and PE CXR EKG Echo RHC
2 (PH classicication)
Blood test :antiHIV Cr LFT CBC ANA O2Sat, ABG CTA or V/Q PFT PSG RHC
PAH
PAH
Avoid pregnancy Influenza and pneumococcal vaccination Exercise Psychosocial support Diuretic O2 Oral anticoagulant Digoxin
Acute vasoreactivity test
Acute vasoreactivity test
vasoreactive
Non vasoreactive/ not perform
Fc I-III CCB
PAH specific drug
F/U 3-6 month Good response
Poor response yes no
Combination Tx
Continue CCB Poor response
Atrial septostomy Lung transplant
1++ 2++ 3+
Fc II Sildenafil, bosentan
Fc III Sidenafil, bosentan, iloprost inhaled
Fc IV
Iloprost IV/inhale Cmbination Rx beraprost Bosentan, sidenafil
OSA; criteria for Dx

Symptom PSG AHI >=5/hr + R/O other disease No symptom PSG AHI >= 15/hr + R/O other disease
Risk factor of OSA

1 neck size > 17 inches in male and > 16 inches in female 2 nasal feature eg polyp 3 lingual feature eg macroglossia 4 palatal feature eg low lying soft palate 5 enlarge tonsil and adenoid 6 oropharynx narrowing 7 hereditar syndrome eg Down syndrome 8 smoking 9 obesity 10 hypothyroid, acromegaly 11 neuro eg stroke, Dchene 12 alcohol 13 medication BZs 14 familial Hx of OSA 15 ESRD 16 CHF 17 HT
Symptoms
1 excessive daytime sleepiness 2 morning headache 3 nocturia 4 nocturnal chocking 5 witnessed apnea
Consequences
1 HT 2 CAD esp nocturnal ischemia 3 arrhymia esp sinus arrhymia, bradycardia, sinus pause, sinus arrest, VT PVC, AV block 4 CHF in Pt with LVEF < 45%, AHI > 15 increase mortality 5 PH 6 Insulin resistance 7 Erectile dysfunction 8 depression 9 GERD 10 stroke 11 floppy eyelid syndrome, gluacoma,papilledema
Rx
1 CPAP 2 uvulopalatopharyngeaopasty 3 oral appliance in mild to moderate pt 4 oromaxillofacial Sx 5 tracheostomy GOLD STANDARD 6 positional Rx 7 weight reduction
A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?
A. uvuloplasty B. methylphenidate C. weight reduction D. sleep hygiene and reassure E. continuous positive airway pressure
A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?
NARCOLEPSY
Classic tetrad
Excessive daytime sleepiness (EDS) Cataplexy : an loss of skeletal muscle tone (triggered by the occurrence of sudden emotion) Sleep paralysis : a brief loss of voluntary muscle control with an inability to move or speak Hypnagogic Hallucinations : visual or auditory and occasionally involve other senses e.g., tactile or vestibular
NARCOLEPSY
Nonpharmacologic Management
Behavioral approaches
Scheduled naps (15-20 min, 2-3 times/day) Regular sleep wake schedule Avoidance of frequent time zone changes
Good sleep hygiene
Pharmacologic Management
modafinil and armodafinil sodium oxybate, amphetamines, methylphenidate
63. A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?
A. uvuloplasty
C. weight reduction D. sleep hygiene and reassure E. continuous positive airway pressure
A 60-year-old nonsmoker female with a 2-cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilar or mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?
A. Left upper lobe lobectomy B. Follow up CXR within 2 months C. Review her last year CXR, if available
D. Empirical treatment with anti-TB drugs: HRZE E. Percutaneous transthoracic needle aspiration
A 60-year-old nonsmoker female with a 2cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilar or mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?
Solitary pulmonary nodule

Focal, round or oval areas of increased opacity
Defined as <3 cm Not associated with atelectasis or adenopathy 90% incidental findings

Most SPN: benign
30-40% of SPN are malignant Patients with best prognosis are stage IA: 61-75% 5-year survival
Differential diagnosis
Neoplasm Benign Malignant
Hamartoma Inflammory pseudotumor Bronchogenic carcinoma Carcinoid tumor Lymphoma (NHL) Metastasis Mycobacteria Fungi Bacteria (anaerobes, Staph, gram negative) Pneumococci Echinococcus Dirofilaria (dog heartworm)
Infection
Granuloma Septic emboli Abscess Round pneumonia Parasitic
(Leef III JL, Klein JS. The solitary pulmonary nodule. Radiol Clin N Am 2002;40:123-143
Differential diagnosis
Inflammatory CNT Sarcoidosis Vascular AVM Hematoma Pulmonary infarct
Wegeners granulomatosis Rheumatoid nodule
Pulmonary artery aneurysm

Pulmonary venous varices Airway Congenital lesion Bronchogenic cyst Bronchial atresia
Mucocele
Infected bulla Leef III JL, Klein JS. The solitary pulmonary nodule. Radiol Clin N Am 2002;40:123-143

95% fall into one two groups
- Malignant: either primary or metastatic - Benign Infectious ;granulomas (either TB or fungal)

Benign tumors: hamartomas present in middle age, grow slowly over years

First step: ensure that the nodule is in fact solitary and truly arises in the lung parenchyma. Up to 20% prove to be entities mimicking a SPN
Pseudonodule (a) Close-up PA radiograph of the right lung shows a smoothly marginated nodular area of increased opacity projecting over the lung (arrow). (b) Front and back views of the EKG lead attachment pad
Erasmus JJ. Radiographics 2000;20:43-58
Bone island in a 61-year-old man with melanoma. (a) Close-up PA CXR shows a focal area of increased opacity overlying the right seventh rib posteriorly (arrow). (b) Fluoroscopic images show a well-marginated intraosseous lesion (arrow). This finding is consistent with a bone island and obviated further investigation.
Diagnostic evaluation
Second step Aim to distinguish benign VS malignant Clinical features Radiographic features Quantitative models : used to determine the probability that the nodule is malignant
Clinical features
Age - Risk of malignancy increases with age
3% at age 35-39 years 15% at age 40-49 years 43% at age 50-59 years
greater than 50% in patients > 60 years
Smoking history History of prior malignancy

Manocha S, Sharma S. Solitary pulmonary nodule.
Clinical Features
Travel history - Travel to areas with endemic mycosis or a high prevalence of tuberculosis
Occupational risk factors - Exposure to asbestos, radon, nickel, chromium, vinyl chloride, and polycyclic hydrocarbons
Manocha S, Sharma S. Solitary pulmonary nodule.
Radiographic features
Size Border Calcification Density Growth Metabolic activity
Size
Generally, smaller nodule, more likely to be benign
80% of benign nodules are less than 2 cm in diameter

Small size alone not exclude lung cancer - 15% of malignant are less than 1 cm - 42% are less than 2 cm
Low
Margins and Contours

Smooth, most are benign, not at all: 21% of malignant have well-defined margins
Lobulated implies uneven growth, up to 25% of benign nodules
Irregular: more malignant Spiculated (sunburst or corona radiata appearance): 84-90% are malignant
Hign
Margin and Contour
smooth
lobulated
Irregular and spiculated
benign
malignant
Internal Characteristics
Overlap of benign and malignant
Homogeneous attenuation: benign (55%) and malignant (20%)

Air bronchograms and Pseudocavitation: bronchioloalveolar cell carcinoma or lymphoma
Bronchioloalveolar cell carcinoma: pseudocavitation
Air bronchogram: lymphoma

Calcification
Benign
most often seen in hamartomas
Diffuse Central Popcorn Laminar

typical of a granuloma
Indeterminant ;likely malignant
Stipple Eccentric
Time
Volume Doubling time: most malignant = 30-400 days
SPN that stable over 2-year indicator of benignity
*Yankelevitz, Am J Roentgenol 1997;168:325-
Satellite nodule
Tiny nodules associate with dominant pulmonary nodule
High likelihood to be benign PPV for benignity: approximately 90%
LRs for Selected Radiologic Features of Nodules and Patient Characteristics

Feature or Characteristic
Spiculated margin Size > 3 cm Age > 70 yr Malignant growth rate Smoker Upper lobe location Size < 1 cm Smooth margins 30-39 yr Never smoked 20-29 yr Benign calc Benign growth rate
LR
5.54 5.23 4.16 3.40 2.27 1.22 0.52 0.30 0.24 0.19 0.05 0.01 0.01
(Erasmus JJ. Radiographics 2000;20:59-66)
A 60-year-old nonsmoker female with a 2-cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilar or mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?
B. Follow up CXR within 2 months C. Review her last year CXR, if available
D. Empirical treatment with anti-TB drugs: HRZE E. Percutaneous transthoracic needle aspiration

LR
5.54 5.23 4.16 3.40 2.27 1.22 0.52 0.30 0.24 0.19 0.05 0.01 0.01
A 75 year old man with severe dementia is found to have a 3 cm nodule in Right lower lobe. He smoked 30 pack years and quit after develop dementia. His family bought him to nursing home last 2 year because of no care giver at home. A CXR at 2 years ago was within normal limit. Which of the following is the MOST appropiate management?
A. Symptomatic and supportive treatment B. Repeat CXR in next 3 months C. Inform his family and discuss the most likely diagnosis and prognosis D.Obtain CT chest include upper abdomen E. Request for diagnosis bronchoscopy

LR
5.54 5.23 4.16 3.40 2.27 1.22 0.52 0.30 0.24 0.19 0.05 0.01 0.01
A. Symptomatic and supportive treatment B. Repeat CXR in next 3 months C. Inform his family and discuss the most likely diagnosis and prognosis D.Obtain CT chest include upper abdomen E. Request for diagnosis bronchoscopy
A 55-year-old man with previous history of stroke came to your clinic for smoking cessation program. He smokes15 cigarettes/day. He begins his first cigarette of the day after breakfast, and the remaining after lunch and dinner.What is the most appropriate method for smoking cessation in this patient?
A. cold turkey
B. cold turkey + behavioral therapy C. cold turkey + behavioral therapy + bupropion D. cold turkey + behavioral therapy + varenicline
E. cold turkey + behavioral therapy + nicotine replacement therapy
Smoking Cessation
NONPHARMACOLOGIC INTERVENTION 5A (ASK,
ADVISE, ASSESS, ASSIST, ARRANGE) : COLD TURKEY + BEHAVIORAL THERAPY
First line Medication

Nicotine Replacement Therapy : Gum, Patch
Bupropion SR Varenicline
Combination therapy
A 55-year-old man with previous history of stroke came to your clinic for smoking cessation program. He smokes15 cigarettes/day. He begins his first cigarette of the day after breakfast, and the remaining after lunch and dinner.What is the most appropriate method for smoking cessation in this patient?
A. cold turkey B. cold turkey + behavioral therapy
C. cold turkey + behavioral therapy + bupropion
E. cold turkey + behavioral therapy + nicotine replacement therapy
< 80%
250/310 80%
76. Which of the following is not likely to be the potential underlying cause of bronchiectasis?
A. Kartagener's syndrome B. Churg Strauss syndrome C. Panhypogammaglobulinemia D. Endobronchial carcinoid tumor E. Allergic bronchopulmonary aspergillosi
bronchiectasis
1. Airway obstruction endobronchial tumor, foreign body 2. Defective host defenses hypogammaglobulinemia 3. Cystic fibrosis 4. Young's syndrome combination of obstructive azoospermia (with normal spermatogenesis) and chronic sinopulmonary infections (bronchiectasis and sinusitis) 5. Rheumatic and other systemic diseases rheumatoid arthritis Sjgren's syndrome 6. Dyskinetic cilia Kartagener's syndrome 7. Alpha-1 antitrypsin deficiency 8. Pulmonary infections TB 9. Allergic bronchopulmonary aspergillosis
76. Which of the following is not likely to be the potential underlying cause of bronchiectasis?
A. Kartagener's syndrome
C. Panhypogammaglobulinemia D. Endobronchial carcinoid tumor E. Allergic bronchopulmonary aspergillosis
53. A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is related to this patient?
A. Bihilar lymphadenopathy B. Normal chest radiography C. Water balloonshaped heart D. Bilateral upper lobe infiltrates
E. Situs inversus and diffuse reticular infiltration
A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is relate to this patients?
Kartageners syndrome
Manes Kartagener first recognized this clinical triad
is inherited via an autosomal recessive pattern Symptoms result from defective cilia motility
bronchiectasis situs inversus chronic sinusitis Immotile spermatozoa or infertility

Confirmation with biopsy of respiratory mucosa or microscopic examination of sperms
A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is related to this patient?
A. Bihilar lymphadenopathy
B. Normal chest radiography C. Water balloonshaped heart D. Bilateral upper lobe infiltrates
A flow volume loop of spirometry shows plateau of the inspiratory loop only. What is the most likely cause of this pattern?
A. Small airways narrowing B. Fixed intra-thoracic obstruction C. Fixed extra-thoracic obstruction D. Variable intra-thoracic obstruction E. Variable extra-thoracic obstruction
Spirometry in Upper Airway Obstruction

Extrathoracic airway Intrathoracic airway
Nose, mouth, pharynx, larynx and the 2 to 4 cm. of the trachea cephaled to the thoracic inlet
Trachea to the main carina
Variable Extrathoracic Obstruction

0 0 0 + -0 0 0
++
Variable Intrathoracic Obstruction

0
0 0 0
0
0
++
--
Fixed Obstruction
A flow volume loop of spirometry shows plateau of the inspiratory loop only. What is the most likely cause of this pattern?
A. Small airways narrowing B. Fixed intra-thoracic obstruction C. Fixed extra-thoracic obstruction D. Variable intra-thoracic obstruction
Interpretation of spirometry
Adequate or inadequate test Obstructive, restrictive or combine pattern If obstructive disease,response to bronchodilator Severity Flow-Volume loop
Adequate or inadequate
No artifacts : cough or glottic closure, leak, early termination, obstructed mouthpiece Sharp peak flow (time to PEF < 120msec.) Expiratory duration greater than 6 seconds or plateau in volume time curve Age, sex, height 2/3 highest FEV1 , FVCvariation < 0.2L (reproducibility)
Normal Spirometry
Reproducible
Early Terminate
COUGH
Poor Effort
Poor Effort
What is pattern of spirometry?

FEV1/FVC (75%) airflow limitation
FVC - FEV1 15 pure obstructive pattern FVC - FEV1 < 15 restrictive
What is pattern of spirometry?

FEV1/FVC FEV1, FVC ( > 80%)

FEV1>FVC restrictive pulmonary disease FEV1<FVC mixed obstructive with restrictive pulmonary disease
FEF25-75 65%
65% normal PFT 65% small airway disease
Response to bronchodilator
pre-post bronchodilator 15 min. FEV1,FVC improved 12%(15%) and 200cc. FEF25-75 improved 35%
FEV1/FVC <75% obstructive 75% FEV1,FVC abnormal FVC-FEV1 normal
>15%
Pure obstructive
<15%
FVC<FEV1
restrictive
FVC>FEV1
FEF 25-75
65%
normal
<65%
Small airway disease
Possible mixed restrictive
Mixed obstructive with restrictive
Severity
Obstructive
Mild 60-79% Moderate 41-59% Severe 40%
Restrictive
Mild 60-79% Moderate 51-59% Severe 50%
Flow-Volume Loop
Emphysema
Extra thoracic Obstruction
Intra thoracic Obstruction
Fixed Obstruction
An asthmatic patients spirometry reveal FEV1 of 1000 ml FVC 2000 ml FEV1/FVC 50%. After salbutamol inhalation, which spirometric results show the best bronchodialtor response?
A. B. C. D. E.
FEV1 1100 ml FVC 2000 ml FEV1/FVC 55% FEV1 1100 ml FVC 1500 ml FEV1/FVC 73% FEV1 1200 ml FVC 2200 ml FEV1/FVC 54% FEV1 1000 ml FVC 1200 ml FEV1/FVC 83% FEV1 900 ml FVC 2100 ml FEV1/FVC 55%
Response to bronchodilator
pre-post bronchodilator 15 min. FEV1,FVC improved 12%(15%) and 200cc. FEF25-75 improved 35%
An asthmatic patients spirometry reveal FEV1 of 1000 ml FVC 2000 ml FEV1/FVC 50%. After salbutamol inhalation, which spirometric results show the best bronchodialtor response?
A. B. C. D. E.
FEV1 1100 ml FVC 2000 ml FEV1/FVC 55% FEV1 1100 ml FVC 1500 ml FEV1/FVC 73% FEV1 1200 ml FVC 2200 ml FEV1/FVC 54% FEV1 1000 ml FVC 1200 ml FEV1/FVC 83% FEV1 900 ml FVC 2100 ml FEV1/FVC 55%
DDx orthopnea CHF V/Q mismatch in posteria part of lung diaphragmatic paralysis
Unilateral diaphragmatic paralysis Phrenic nerve injury Herpes zoster, poliomyelitis, and other viral infections Cervical spondylosis Clinical manifestations usually asymptomatic at rest may have exertional dyspnea and decreased exercise performance Imaging CXR upright elevated hemidiaphragm PFT FVC decrease 15-20% in supine position
Bilateral diaphragmatic paralytic Etiology Spinal cord disease Motor neuron disease Neuropathy Neuromuscular junction disease Muscle disease
Symptom orthopnea PE abdominal wall paradox hypoxemia CXR bilateral, smooth elevation of the hemidiaphragms and small lung volumes PFT FVC may decrease 15 to 25 percent in the supine position
Pulmonary embolism
Symptoms dyspnea pleuritic chest pain substernal chest pain cough hemoptysis syncope
Signs tachycardia tachypnea sign of DVT fever cyanosis
On the first day following a cesarean section, the patient complains of acute shortness of breath. Her respiratory rate is 26/min. Her pulse is 112/min. Her oxygen saturation is 85% on room air. Her lung are clear. Homans sign is negative. What is the most likely diagnosis?
1. Pneumonia
2. Atelectasis 3. Popliteal thrombosis with PE 4. Iliofemoral thrombosis with PE 5. Pulmonary edema
1. Pneumonia 2. Atelectasis
3. Pulmonary edema
Pulmonary Embolism
The risk for thrombosis is increased in pregnancy, partly because of the increase in the coagulation factors, particularly V, VIII, X, and von Willebrand factor Ag, and partly because of a marked fall in protein S Venous stasis, an important contributor to thrombosis, is caused by uterine compression of the inferior vena cava and the left iliac vein Local trauma to pelvic veins at the time of delivery probably accounts for the peak incidence of thromboembolism in the postpartum period, especially after cesarean section.
1. Pneumonia
2. Atelectasis 3. Popliteal thrombosis with PE 4. Iliofemoral thrombosis with PE 5. Pulmonary edema
A 25 year old man was intubated on A/C mode ventilation for status asthmaticus. He was sedated and paralyzed. His lung examination showed expiratory rhochi diffusely. The set tidal volume was 400 cc., RR 15/min, FiO2 0.4, PEEP of 0 cmH2O, PF 80 L/min. PIP 38 cmH2O Ppla 25 cmH2O TV 300-400 cc O2 sat 99%. The patient was given NB salbutamol q 1 hr, IV steroid, tube feeding and IV fluid. He had positive fluid balance of 1500 cc/day during the past 2 days. On third day of admission, his ventilator alarm went off. The ventilator setting were not changed. His lung examination showed no wheeze, the PIP was 50 cmH2O and Ppla 26 cmH2O Which one of these condition would be the cause of the ventilator alaem?
1.Fluid overload 2.Pneumothorax 3.HAP 4.Lt.lung atelectasis 5.Bited on the ET tube
PIP
Peak inspiratory pressure = P resistance + P elastance
LUNG MECHANIC
LUNG MECHANICS
Paw = AIRWAY PRESSURE
Raw = RESISTANCE Crs = COMPLIANCE
Paw
= PRaw + PCrs (Pplat)
LUNG MECHANIC
PAW = PR + PE = Pmusi P AW =Peak airway pressure
PR = PE = Pmusi =
LUNG MECHANIC
Paw = PRaw + Pclung Raw = Pressure (cmH2O) Flow (L/Sec) = Pdyn - Pstat Flow
Compliance =
Volume (ml) Pressure (cmH2O) = Volume (ml) Pstat - PEEP
PIP 38 cmH2O Ppla 25 cmH2O
PIP was 50 cmH2O and Ppla 26 cmH2O
Pressure Resistance
1.Fluid overload 2.Pneumothorax 3.HAP 4.Lt.lung atelectasis 5.Bited on the ET tube
A 70 year-old man with COPD, presented with dyspnea on exertion. Physical examination revealed engorged neck vein, right ventricular heaving and pansystolic murmur grade II at left lower sternal border. His current medications were Ipratropium bromide inhaler and slow release theophylline. ABG: PaO2 53mmHg, PaCO2 45 mmHg, pH7.38, O2Sat 87%. What is the most appropriate treatment?
A. Prednisolone B. Steroid inhaler C. Inhale iloprost D.Long term oxygen therapy E. Noninvasive positive pressure ventilation
COPD and Pulmonary Hypertension

Oxygen therapy
Long term administration of oxygen (>15h/day) to patients with chronic respiratory failure has been shown to increase survival (evidence B)
Indication for long term oxygen therapy (LTOT)

1. PaO2 < 55 mmHg or SaO2 at or below 88% with or without hypercapnea confirmed twice over a three week period 2. PaO2 < 55mmHg or SaO2 at or below 88% if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive
cardiac failure or polycytemia( Hct>55%)
GOLD Guideline 2011
GOLD Guideline 2011
GOLD Guideline 2011
ICS + LABA or LAMA
ICS + LABA and LAMA
SABA or
SAMA
LABA
or LAMA
GOLD Guideline 2011
19. A 70 year-old man with COPD, presented with dyspnea on exertion. Physical examination revealed engorged neck vein, right ventricular heaving and pansystolic murmur grade II at left lower sternal border. His current medications were Ipratropium bromide inhaler and slow release theophylline. ABG: PaO2 53mmHg, PaCO2 45 mmHg, pH7.38, O2Sat 87%. What is the most appropriate treatment? A. Prednisolone B. Steroid inhaler C. Inhale iloprost E. Noninvasive positive pressure ventilation
NIV Improve respiratory acidosis Decrease RR Decrease breathlessness Decrease VAP Decrease LOS Decrease ETT Decrease mortality
Clue
AE asthma silent chest drowsiness air hunger on BD + steroid On MV : VCV vt 600 ml RR 20 PF 60 FiO2 0.6 Paw 50 Ppl 25 ABG: pH 7.45 PCO2 30 PO2 200
How to set MV in asthma

Low tidal volume High PF to short Ti Low RR Short Ti prolong Te PEEP 3-5 cmH2O : not need to adjust 80% autoPEEP FiO2 : lowest to keep PaO2 > 60 mmHg, SaO2 > 90% Set alarm
Answer
On MV : VCV vt 600 ml RR 20 PF 60 FiO2 0.6
Accept due to Ppl not above limit but accept if decrease Vt, RR, FiO2 but should avoid pH < 7.2 and PaO2 < 60
Paw 50 Ppl 25 :
Ppl accept : set high Vt alarm to avoid volume trauma
ABG: pH 7.45 PCO2 30 PO2 200

Accept but and decrease FiO2
Mx except 1. Decrease VT 2. Decrease RR 3. PF ? 4. Decrease FiO2 5. Increase PEEP : not necessary

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Respiratory complication after HSCT

Immune system after HSCT

Risk for infection

Allogenic HSCT Acute GVHD skin, GI and liver manifestration

Allogenic HSCT chronic GVHD bronchiolitis obliteran scleroderma sicca syndrome

ALVEOLAR VENTILATION EQUATION

CO2 production PACO2 alveolar ventilation PACO2 PaCO2

VT = VA + VD VA = VT VD Alveolar ventilation = RR x VA = RR (VT-VD)

Alveolar ventilation equation

PACO2 = k x VCO2/RR (VT-VD)

Alveolar ventilation equation

Alveolar ventilation equation

Management of drug-induced hepatitis

Drug causes hepatitis

Side effect of antiTB drugs

Streptomycin Hypersensitivity reactions are rare. nephrotoxicity ototoxicity vertigo

Which one is incorrect reguarding the toxicity of antiTB drugs? A. B. C. D. E.

Contraindication for remedication

Management of cutaneous reaction

Isoniazid Rifampicin Ethambutol Pyrazinamide streptomycin

Bactericidal Bactericidal Bacterioistatic Weakly bactericidal Bactericidal

CNS penetration INH Rifam

10-20% of serum level

limit data but benefit > risk

Streptomy Slight cin

Used with caution

X (fetal hearing loss)

Bacteristatic Bactericidal Bactericidal

150 bid/tid (8-12 g)

Number of colonies on culture

Number of AFB on smear (1000X, ZiehlNelsen)

Number of AFB on smear (200-250X ,Fluorescen)

AFB smear report

Particle < 5 um HEPA filter 2%lysol 5% hypochloride surgical mask

Sputum pot N 95 mask Surgical mask

pulmonary tuberculosis measle

Diseases associated with exposure to silica dust

Risk factors for TB

Thai guideline for Dx and Rx PH 2011

Pulmonary hypertension Diagnostic classification

1.3.4. HIV infection

hemoglobinopathies, chronic myeloproliferative disorders, splenectomy)

1.Pulmonary arterial hypertension

Acute vasoreactivity test

Acute vasoreactivity test

Non vasoreactive/ not perform

PAH specific drug

F/U 3-6 month Good response

Poor response yes no

Continue CCB Poor response

Atrial septostomy Lung transplant

Fc III Sidenafil, bosentan, iloprost inhaled

Iloprost IV/inhale Cmbination Rx beraprost Bosentan, sidenafil

OSA; criteria for Dx

Risk factor of OSA

Solitary pulmonary nodule

Solitary pulmonary nodule

Solitary pulmonary nodule

Granuloma Septic emboli Abscess Round pneumonia Parasitic

Solitary pulmonary nodule

Wegeners granulomatosis Rheumatoid nodule

Pulmonary artery aneurysm