Etiology/RF
A 32-year-old fair skinned female with red hair and a history of blistering sunburns in childhood presents to your clinic for a regular health check-up. She has no past medical history. Family history is positive for maternal melanoma. Which of her risk factors are modifiable and which are non-modifiable?
Non-modifiable - fair skin, family history
A 25 year old presents with urticaria, wheeze, and hypotension after being stung by a bee. Explain the pathophysiology of her symptoms in relation to her presentation.
What is a type 1 hypersensitivity anaphylactic shock reaction. Previous sensitization to bee venom —> current exposure to bee venom —> IgE cross linking on mast cells/basophils —> degranulation —> release of histamine and other mediators —> vasodilation (leading to hypotension), increased vascular permeability (leading to urticaria) and bronchospasm (leading to wheeze)
A 67 year old man with a history of alcohol use disorder presents with a 2-day history of fevers, chills, rigors, SOB, and cough productive of dark yellow sputum. He had a recent binge of alcohol use that ended 2 days before admission and he woke up with these symptoms. On physical exam, his temp is 39.5 C, his RR is 30 breaths/min and he is in moderate respiratory distress. His lower right lung field has inspiratory crackles on auscultation.
What is aspiration pneumonia?
A 66yo smoker has a chronic cough, sputum and exertional dyspnea. What test confirms the diagnosis & what do you expect the result to be?
What is PFT/Spirometry? Shows reduced FEV1/FVC ratio <0.7 which is NON-reversible
A 32 year old male develops stridor, urticaria and hypotension after eating peanuts. What is your first-line treatment?
What is IM epinephrine?
A competitive swimmer presents with severe ear pain, swollen moist ear canal, and purulent discharge. Which organisms cause this condition?
Staphylococcus Aureus
Pseudomonas Aeruginosa
An 8 year old has recurrent nocturnal cough and wheeze which is triggered by cold air and viral infections. His symptoms resolve with salbutamol. What are the main pathophysiologic features of his disease presentation?
What is chronic airway inflammation (often TH2/eosinophilic mediated) causes airway hyperresponsiveness, bronchoconstriction, mucous plugging and reversible airflow obstruction?
An unvaccinated 4 year old presents with drooling and respiratory distress. On examination he is toxic in appearance and sitting in a tripod positioning. He has a muffled voice. This is the diagnosis and classic causative organism based on his history.
What is Epiglottitis caused by HiB (haemophilus influenzae type B).
Clinical diagnosis - patient is SICK. Secure airway & treat with IV antibiotics (3rd generation cephalosporin)
A 40 year old who recently arrived to Canada from Indonesia presents with 3 days cough, night sweats, weight loss and upper lobe cavitary lesion on chest x-ray. What is the key microbiological work-up?
Sputum for AFB smear
Sputum mycobacterial culture
NAAT
All requiring multiple samples
72 year old female who is admitted to the surgical floor after a bowel resection 18 hours ago. The nurse notes that she has been complaining of abdominal pain even though she has been using her PCA pump. Currently, she is alert and oriented and complaining of pain. The nurse calls the overnight team and they order another 1 mg of HM. 2 hours later, the nurse re-assesses the patient and she is lethargic, difficult to rouse. Her RR is 6 breaths/min and he has pinpoint pupils. What medication do you order?
What is naloxone?
A 2.3 year old presents with a barking cough, hoarse voice and stridor after 2 days of low-grade fever and rhinorrhea. What are common pathogens of this condition?
Parainfluenza Virus (type 1/3) - most common
Influenza A
RSV
Adenovirus
A 52 year old man presents with concerns of snoring and daytime sleepiness. He notes his wife wakes him up often throughout the night because she is worried he stopped breathing. What is the mechanism that contributes to his symptoms?
What is loss of pharyngeal dilator muscle tone during sleep causing upper airway collapse, leading to intermittent hypoxemia, hypercapnia and arousals?
72 year old man presents to the ED with progressively worsening dyspnea. He has a history of COPD & uses 2L/min of home O2, he is usually able to walk around the house without limitation. Over the past 4 days, he has had increasing dyspnea on exertion and increased cough productive of thick green sputum. He has not had chest pain or worsening of his chronic mild ankle edema. He has a 100 pack year smoking history. Physical exam shows tachycardia, tachypnea, and decreased breath sounds with diffuse wheezing bilaterally.
What is COPD exacerbation
75 year old male presents to your office with a 2 month history of shortness of breath, particularly worse on exertion. He denies any wheezing, chest pain, or any other symptoms. He is a retired plumber and a lifelong non-smoker. On examination, he appears slightly cachectic but otherwise well. He does not have any increased work of breathing or signs of respiratory distress. His vitals are within normal limits, specifically his SpO2 is 93% on room air. His exam reveals mild velcro-like crackles to the bases bilaterally. He has no peripheral edema or other signs of volume overload. What is the diagnostic test you would order?
PFT’s to assess for restrictive lung disease 2/2 ILD likely asbestos exposure
A 7 year old presents with a history of fever, sore throat, and rash. You decide to do a throat swab and it comes back positive for Group A Strep. What antibiotic class are you going to treat with?
B-Lactam (Penicillin or amoxicillin acceptable)
A 66 year old non-smoker female is diagnosed with lung adenocarcinoma. She has lived for 30 years in a house with a basement. What environmental exposure is the second leading cause of lung cancer?
What is radon gas? (After tobacco smoke; also asbestos and second hand smoke)
An 82 year old male develops severe hypoxemic respiratory failure after presenting with sepsis. His PaO2 of 52 mmHg on room air and shows minimal improvement on 100% FiO2. Chest imaging reveals bilateral diffuse pulmonary opacities without evidence of cardiogenic pulmonary edema. Which V/Q abnormality explains this response in relation to the pathophysiology of the disease.
What is intrapulmonary shunt?
diffuse alveolar inflammation and injury —> alveolar flooding/collapse —> perfusion of unventilated (0), fluid-filled/injured alveoli —> true shunt (0/Q = 0)
A 34 year old female presents with 12 days of nasal congestion, purulent nasal discharge and facial pressure with no improvement. What is your diagnosis and what other things on presentation could confirm it?
What is acute bacterial sinusitis?
Other symptoms can include: 10+ days without improvement, fever > 39 C, purulent discharge
A 25 year old presents with intermittent wheeze and cough but baseline spirometry is normal. What is your next step if you have a strong suspicion of asthma?
If spirometry (pre-bronchodilator) was positive for airflow obstruction. What is your next step and what result would confirm a diagnosis of asthma?
What is PFT + methacholine challenge(bronchoprovocation)?
What is repeat spirometry/PFT post-bronchodilator. If FEV1 improves by >12% and >200 mL from baseline = Asthma/Variable airflow obstruction
A 70 year old with COPD presents with worsened dyspnea, increased sputum volume and increased sputum purulence. What is your treatment?
What are:
SABA +/- SMAA
Corticosteroids (oral or systemic)
Antibiotic (b-lactam + macrolide)
O2 target 88-92% if chronic CO2 retainer
Consider NIV (BiPAP) if respiratory acidosis
A 38 year old never smoker presents with early onset COPD and a family history of liver disease. What inherited condition do you suspect?
Alpha 1 antitrypsin deficiency
A 68 year old with severe COPD becomes drowsy and tired. ABG pH7.24 PaCO2 78 bicarb 30. Explain the pathophysiology of this type of respiratory failure in this context and compare it to the other type.
Hypercapnic Resp Failure: Failure of ventilation. Inadequate alveolar ventilation due to airflow obstruction, mucous, bronchospasm, and respiratory muscle fatigue —> increased dead space —> CO2 is not cleared —> respiratory acidosis.
Hypoxic Resp Failure: failure of oxygenation
An 18 year old who is being treated with amoxicillin for pharyngitis presents with worsening sore throat, fever, marked fatigue, posterior cervical lymphadenopathy, splenomegaly and rash. What is your diagnosis and what investigation could you order to confirm it?
Likely mistreated as Strep Pharyngitis when patient presented with Infectious Mononucleosis (EBV). Can order MonoSpot for Epstein Barr Virus.
A 55 year old is admitted with severe pneumonia. His vitals BP 110/70, HR 110, RR 34, SpO2 80% on RA. ABG shows pH 7.49, PaCO2 29 mmHg, HCO3 22 mmol/L. Interpret this ABG & link it to the presentation.
Respiratory alkalosis without renal compensation
Type 1 respiratory failure with acute respiratory alkalosis.
A 27 year old with asthma presents in the ED wheezing and SOB after contracting COVID At work. What are your first line treatments for this exacerbation?
SABA +/- SAMA if moderate/severe
systemic corticosteroids
oxygen with target SpO2 >92%
IV MgSo4 (if severe)