Just Breathe
This is the most likely diagnosis in a 30-year-old asymptomatic patient with a routine CXR showing bilateral symmetric hilar prominence with clear lung fields
What is stage I pulmonary sarcoidosis?
Pulmonary sarcoidosis is a granulomatous disease of unknown cause. Clinical presentations of sarcoidosis that do not require a biopsy include asymptomatic stage I pulmonary sarcoidosis, Löfgren syndrome, and Heerfordt syndrome. The overall prognosis of stage I pulmonary sarcoidosis is excellent, with spontaneous regression of radiographic abnormalities observed in most patients.
This vasopressor is first-line in septic shock, and it has this mechanism of action.
What is norepinephrine? α1 agonist (with some β1 activity at lower infusion rates).
Norepinephrine increases systemic vascular resistance without compromising myocardial performance (stroke volume or cardiac output).
This ventilator strategy has been shown to reduce mortality in ARDS patients.
What is low tidal volume ventilation (6 mL/kg ideal body weight)?
Low tidal volume ventilation prevents volutrauma and barotrauma from overdistending injured alveoli. Always calculate tidal volume using ideal body weight, not actual body weight.
A smoker with weight loss, hemoptysis, and a central hilar mass most likely has this subtype of lung cancer.
What is squamous cell carcinoma?
Squamous cell carcinoma is strongly associated with smoking and often presents as a central cavitary lesion. It may produce PTHrP, causing hypercalcemia.
This bedside ultrasound finding is suggestive of pneumothorax.
What is absence of lung sliding?
Loss of lung sliding suggests pneumothorax, but false positives occur with pleurodesis, mainstem intubation, apnea, or severe bullous disease.
A patient with difficult-to-control asthma and eosinophilia has cenrtral bronchiectasis and elevated IgE. This diagnosis should be suspected.
What is allergic bronchopulmonary aspergillosis (ABPA)?
ABPA can occur in asthma or cystic fibrosis. It should be suspected with persistent asthma symptoms, peripheral eosinophilia, elevated IgE levels, positive skin tests to Aspergillus antigens, increased Aspergillus-specific IgE and IgG levels, and either central bronchiectasis or infiltrates. Treatment includes corticosteroids +/- itraconazole.
This is the most common cause of cardiogenic shock.
What is myocardial infarction?
Tachycardia and vasoconstriction in CS increase afterload and myocardial oxygen demand, often precipitating a further decrease in cardiac output. Initial evaluation should include a focused physical examination, laboratory testing for myocardial ischemia and heart failure, chest radiograph, electrocardiogram, and transthoracic echocardiogram.
This imaging finding is required for the diagnosis of ARDS according to the Berlin criteria.
What are bilateral pulmonary infiltrates/opacities?
ARDS requires bilateral opacities on chest imaging not fully explained by pleural effusions, collapse, or heart failure. The infiltrates reflect diffuse alveolar injury and pulmonary edema.
This imaging modality is preferred for further evaluation of a pulmonary nodule larger than 8 mm with a moderate-high probability of malignancy.
What is PET-CT?
PET-CT helps assess metabolic activity and malignancy risk in pulmonary nodules >8 mm. Probability of malignancy is measured using the Brock University calculator. False positives occur with infection or inflammation; false negatives occur in slow-growing tumors like carcinoid.
A patient with schizophrenia taking risperidone presents with fever, muscle rigidity, tachycardia and tachypnea after taking an antiemetic. This is the diagnosis and most appropriate management.
What is neuroleptic malignant syndrome? What is discontinuation of the triggering agent, active cooling, and supportive care?
Neuroleptic malignant syndrome is characterized by fever, mental status changes, muscle rigidity, and dysautonomia and is seen with both first-generation antipsychotics and newer atypical antipsychotics and antiemetics.
These 2 medications have shown to prevent COPD exacerbations in patients with frequent episodes.
What is azithromycin and roflumilast?
Bonus for 100 points: name 3 nonpharmacologic interventions that decrease frequency of exacerbations.
This medication is recommended in refractory septic shock requiring ongoing vasopressors despite adequate fluid resuscitation.
What is corticosteroids, i.e. hydrocortisone?
Although there is not a clear mortality benefit, glucocorticoids are associated with a faster time to shock recovery and fewer days with organ failure or requirement for mechanical ventilation. ACTH testing is not recommended. There is no role for glucocorticoids in sepsis without shock!
A patient with severe ARDS remains hypoxemic despite low tidal volume ventilation and high PEEP. This next step in management may improve oxygenation and mortality.
What is prone positioning?
Proning improves V/Q matching, recruits dependent alveoli, and reduces ventilator-induced lung injury. It is most beneficial in severe ARDS (P/F <150) when used early and for prolonged sessions.
A solitary pulmonary nodule that has been stable for this amount of time is generally considered benign.
What is 2 years?
Most malignant pulmonary nodules grow over time. Stability for 2 years on serial imaging strongly suggests a benign etiology, especially for solid nodules.
A patient presents with altered mental status, hyperthermia, and hypotension after prolonged exertion in hot weather. These are the first AND second line therapies.
What is evaporative cooling, rapid external cooling?
Heat stroke is defined by core temperature ≥40°C (104°F) plus CNS dysfunction. It carries a mortality of up to 60% if untreated. The cornerstone of treatment is evaporative cooling, with rapid external cooling (immertion in ice water) used for exertional heat stroke when unresponsive.
Per ATS guidelines, this lab value should be obtained once in all patients with a new diagnosis of COPD.
What is α1-antitrypsin level?
A pattern of basilar emphysema, associated liver disease or panniculitis, or a strong family history of emphysema in patients with COPD suggests possible α1-antitrypsin deficiency, but none of these features is sufficiently sensitive for the condition.
This lab value may be used to support shortening the duration of antibiotic therapy in patients with sepsis or as a marker to support discontinuing therapy in patients who initially were thought to have sepsis but do not.
What is procalcitonin?
This was suggested in the 2021 sepsis guidelines. Evidence shows algorithms that use procalcitonin as a decision support tool lead to decreased overall use of antibiotics. Procalcitonin should NOT be used in the initial determination regarding the initiation of antibiotic therapy.
This PaO₂/FiO₂ ratio defines severe ARDS.
What is PaO₂/FiO₂ <100?
ARDS severity is classified by the P/F ratio on at least 5 cm H₂O of PEEP:
Lower ratios correlate with worse mortality.
A lifelong smoker is found to have a 2.5 cm spiculated upper lobe pulmonary nodule on CT scan. This is the next best step in management if malignancy risk is high.
What is surgical resection (after staging evaluation)?
A spiculated upper lobe nodule in a smoker is highly concerning for malignancy. In patients with a high pretest probability of cancer, proceeding directly to resection after staging is preferred over serial surveillance or needle biopsy, especially if operable.
A patient presents with headache, nausea, malaise, confusion, perioral cyanosis, and metallic taste after being rescued from a house fire. VS are HR 110, BP 110/90, RR 28, SpO2 98%. Lactic acid is 6. This is the most likely diagnosis and best next step in management.
What is cyanide poisoning, hydroxicobalamin?
Hydroxocobalamin avidly binds to cyanide to produce cyanocobalamin, which is soluble, nontoxic, and readily excreted. Other antidotes include nitrites to induce methemoglobin, which in turn binds cyanide, as well as sodium thiosulfate, which donates sulfur to combine with cyanide, producing harmless thiocyanate.
A 50 year old man presents with 2 months of cough, fever, and malaise. CXR showing RML consolidation. Symptoms persist after he was treated by his PCP with Augmentin for 7 days.
This is the most likely diagnosis AND most appropriate treatment.
What is Cryptogenic Organizing Pneumonia (COP) and glucocorticoids?
COP has a subacute presentation with cough, fever, and malaise over weeks to months. Initial CXR typically shows patchy opacities that mimic pneumonia. Failure to respond to abx should raise suspicion for COP.
Per the Surviving Sepsis Campaign guidelines, ALL (5) of these should be done within the first hour of diagnosing septic shock (Hour-1 bundle)
What is...
1. Measure lactate level
2. Obtain BCx before abx
3. Administer broad spectrum abx
4. Rapid administration of crystalloid 30 cc/kg for hypotension or lactate >4 mmol/L
5. Start vasopressors for persistent hypotension during/after fluid resuscitation, with goal MAP >65.
This ventilator measurement reflects alveolar pressure at end inspiration, and should be kept below this level to reduce ventilator-induced lung injury.
What is plateau pressure, 30 cm H₂O?
Elevated plateau pressures increase risk of barotrauma and volutrauma. Targeting <30 cm H₂O is a cornerstone of lung-protective ventilation.
These are some specific gene mutations that can be targeted in advanced-stage adenocarcinoma or mixed lung cancers. (at least 2)
What is EGFR mutation, ALK translocation, ROS1 translocation, and PDL-1 activity?
Targeted therapy and immunotherapy is a growing field in lung cancer. Genetic testing is now part of the workup in specific tumors.
A mechanically ventilated ICU patient develops sudden hypoxemia shortly after placement of a subclavian central venous catheter. Wheezing is present bilaterally. The ventilator shows rising peak inspiratory pressures with unchanged plateau pressures. This complication should be suspected.
What is bronchospasm?
↑ Peak pressure + normal plateau pressure = increased airway resistance (bronchospasm, mucus plugging)
↑ Peak + ↑ Plateau pressures = decreased lung compliance (ARDS, pulmonary edema, pneumothorax)