medicinal pulmonology
A student comes to the ER before his exam. He is jittery and complains of chest pain, racing heartbeat, chest tightness, sweating, and trembling. On history, he is diagnosed with anxiety, and repeated panic attacks.
Which acid-base disorder will be seen on ABGs in this patient?
Acute Respiratory Alkalosis
A patient develops shortness of breath after abdominal surgery. He has shallow breathing because of postoperative pain. The x-ray is shown.
What is the most likely diagnosis?
Atelectasis
A 25-year-old man suddenly develops severe shortness of breath and right-sided pleuritic chest pain. On examination, the right side of the chest is hyperresonant, with absent breath sounds.
What is the most likely diagnosis?
Tension pneumothorax
What is the most common lung cancer in smokers vs non-smokers?
smokers: small cell carcinoma
non-smoker: Adenocarcinoma.
minus 50 points
An elderly patient presents to the clinic with a 3-day history of fever, productive cough, and increasing shortness of breath. The chest pain worsens with inspiration. She is producing a copious amount of green-colored sputum.
The x-ray shows consolidation in the lungs as shown below. Identify the correct pathology with the anatomical location.
Right upper lobe pneumonia
A 60-year-old patient with a large pleural effusion requires thoracocentesis. The clinician plans to insert the needle through the 8th intercostal space, just above the 9th rib.
Why is the needle inserted above the 9th rib rather than below it?
To avoid injury to the intercostal neurovascular bundle (VAN), which runs along the inferior border of the 8th rib.
A patient develops complete upper-airway obstruction and requires an emergency surgical airway. A needle or incision is made through the membrane located between the thyroid cartilage and cricoid cartilage.
Through which membrane is the incision made in emergency?
cricothyroid membrane
A 58-year-old chronic smoker presents with persistent cough, weight loss, and recurrent hemoptysis. Chest CT reveals a centrally located hilar mass. Bronchoscopy shows an endobronchial lesion, and biopsy demonstrates malignant cells with keratin pearls and intercellular bridges.
What is the most likely histological type of lung cancer?
Squamous cell carcinoma of the lung.
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62 year old man with 30 pack year smoking history presents with progressive shortness of breath, chronic cough and sputum production.
Spirometry shows
FEV1= 1.4 (normal: 3.0)
FVC=3.2 (normal: 4.0)
FEV1/FVC= 44 (normal: 75)
Is this spirometry pattern obstructive or restrictive disease?
COPD
A patient undergoes an emergency tracheostomy. Several hours later, he develops rapidly increasing respiratory distress, subcutaneous emphysema, and difficulty ventilating through the tracheostomy tube.
What is the most likely complication?
Tracheostomy tube displacement (false passage)
A 25-year-old trauma patient suddenly becomes severely dyspneic and hypotensive. On examination, there are absent breath sounds and hyperresonance on the right side, with tracheal deviation to the left. His condition is rapidly deteriorating.
What is the immediate life-saving intervention?
Needle/finger thoracostomy followed by chest tube insertion
A 60-year-old man with a large right-sided hilar lung mass develops facial swelling, distended neck veins, and prominent superficial veins over the upper chest. CT shows compression of the superior vena cava.
The mass is located above the point where the brachiocephalic veins join to form the SVC.
Relative to the carotid artery, where is the obstruction most likely located?
Distal to the carotid artery
You now have an advantage of asking for help from a friend in the audience in only one question from now on!
A 30-year-old man was previously diagnosed with pulmonary tuberculosis involving the right lower lobe. He completed treatment and his symptoms and radiographic findings resolved.
Two years later, he presents with a chronic cough, night sweats, and weight loss. Chest imaging shows a new cavitary lesion.
If this represents reactivation of TB, where would the new lesion most classically be located, and why?
Upper lobe, especially the apical/posterior region. Because the upper lobes have a higher ventilation-perfusion ratio and higher oxygen tension
A 55-year-old man presents with progressive shortness of breath and a persistent cough. Imaging reveals a solitary peripheral lung mass suspicious for malignancy. The lesion is considered resectable, and the patient has adequate pulmonary reserve.
What surgical procedure involves removal of an entire anatomical lobe of the lung?
Lobectomy
A 68-year-old patient with severe pneumonia becomes confused and hypotensive. After receiving adequate IV fluids, his blood pressure remains 82/50 mmHg. Blood cultures are pending, and he has elevated serum lactate.
Which vasopressor is recommended as the first-line agent for septic shock when hypotension persists despite adequate fluid resuscitation?
Norepinephrine
A 60-year-old chronic smoker presents with progressive unilateral hoarseness for 3 months. Laryngoscopy demonstrates unilateral vocal cord paralysis. He has no history of recent neck surgery or intubation.
What is the most likely underlying diagnosis responsible for his vocal cord paralysis?
Bronchogenic Carcinoma
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A 68-year-old man with progressive dyspnea and bilateral leg swelling is found to have a pleural effusion. Thoracentesis gives the following results:
Pleural fluid protein: 3.0 g/dL
Serum protein: 6.0 g/dL
Pleural fluid LDH: 180 U/L
Serum LDH: 300 U/L
Upper limit of normal serum LDH: 200 U/L
Using Light’s criteria, is this pleural effusion transudative or exudative?
Exudative
A patient undergoes a tracheostomy. The surgeon accidentally places the tracheostomy too low, below the usual recommended tracheal rings.
What serious complication can occur due to a low tracheostomy?
Tracheo-innominate fistula
A 24-year-old man presents with a large traumatic pneumothorax requiring an intercostal chest drain. The surgeon chooses the “safe triangle” as the insertion site.
What are the boundaries of the safe triangle used for chest tube insertion?
Anterior: lateral border of pectoralis major
Posterior: anterior border of latissimus dorsi
Inferior: 5th intercostal space
Superior: base of the axilla
A 65-year-old chronic smoker presents with confusion, nausea, and generalized weakness. Laboratory investigations reveal:
Chest imaging reveals a central hilar mass.
What is the most likely diagnosis?
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) due to ectopic ADH production by small-cell lung carcinoma.
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