DIAGNOSIS
TREATMENT
COMPLICATIONS
WHY DO I...
PALMGHETTO RETURNS
100
A 64-year-old man is evaluated in the office for dyspnea that has gradually worsened over the past 6 months. He now has dyspnea with minimal exertion, such as walking from his bed to the bathroom. He does not have cough, chest pain, weight gain, or ankle edema. He is slightly more short of breath lying down, but he has no difficulty sleeping, generally feels refreshed when he awakens, and does not have daytime headache or somnolence. He has a 46-pack-year history of cigarette smoking. His medical history includes only hypertension, treated with hydrochlorothiazide and atenolol.
What is the most likely cause of this patient's dyspnea?
COPD
100
What is the initial treatment for a patient with COPD?
Short-acting bronchodilators, both beta agonists and anticholinergics are the mainstay of medication therapy for COPD.
100
A 55-year-old man with PMHx of COPD is evaluated in the office for a 2-week history of nasal congestion and cough. The cough was initially nonproductive but over the past week has become productive of greenish-yellow sputum. He also states that his anterior chest is sore, especially when he coughs. He has not had fevers, chills, or dyspnea. The patient is otherwise healthy.
The physical examination, including vital signs, is normal.
Should the pt receive an antibiotic?
Yes
The presence of COPD is an indication for antibiotic treatment of acute bronchitis.
100
Why do I always feel out of breath? My doctor says I have chronic bronchitis.
In chronic bronchitis, the airways that carry air to the lungs get inflamed and make a lot of mucus. This can narrow or block the airways, making it hard for you to breathe.
100
CPO (Critical Patient Overflow) has been affectionately renamed what by most interns, residents, and students?
THE DUNGEON
200
Pneumonia
200
In general, when do you begin to treat a COPD patient with inhaled corticosteroids?
Inhaled corticosteroids are recommended for people with moderate to severe COPD who often experience worsening symptoms (exacerbations) or have experienced recurrent hospitalization due to their COPD.
200
What is the common psychiatric disease seen in COPD patients?
Major Depressive Disorder
Difficulty breathing can keep you from doing activities that you enjoy. And it can be very difficult to deal with a disease that is progressive and incurable.
200
Why do I feel short of breath? I have emphysema, but I don't understand why I'm short of breath.
In a healthy person, the tiny air sacs in the lungs are like balloons. As you breathe in and out, they get bigger and smaller to move air through your lungs. But with emphysema, these air sacs are damaged and lose their stretch. Less air gets in and out of the lungs, which makes you feel short of breath.
200
You are walking to the cafeteria to grab a drink when you hear," CODE STEMI EMERGENCY DEPT SOUTH, CODE STEMI EMERGENCY DEPT SOUTH" over the PA system. You do not panic because <3 minutes later you know you will here what?
CODE STEMI CANCELLED
300
A 50-year-old man is evaluated in the emergency department for a 3-day history of productive cough, fever, chills, pleuritic chest pain, and difficulty breathing. His only medical problem is heart failure after a myocardial infarction 2 years ago, and his medications are metoprolol, enalapril, furosemide, and aspirin.
On physical examination, temperature is 38.9 °C (102 °F), blood pressure is 130/78 mm Hg, heart rate is 80/min, and oxygen saturation is 89% with the patient breathing oxygen, 2 L/min, by nasal cannula. There are decreased breath sounds and dullness to percussion at the left lower lung base. Cardiac examination reveals no murmurs or extra sounds.
Chest radiograph shows a pleural effusion that occupies one third of the left lung. A lateral decubitus chest radiograph shows a 1.5-cm layer of pleural fluid.
Community Acquired Pneumonia
300
A patient presents with severe COPD symptoms. She states that her pulmonologist told her 20% of her lungs have been destroyed secondary to emphysema. She asks you," Can you just cut out the bad lung?"
Yes
In Lung volume reduction surgery small wedges of damaged tissue, usually 20 to 30 percent of each lung, are removed, which helps the remaining tissue function better. Following surgery, people often have less shortness of breath and are able to exercise better.
300
What is the most common EKG finding seen in patients with COPD?
RVH: Increased pulmonary pressure causes the RV to begin to enlarge
300
Why do I have to stop smoking?
COPD is almost always caused by smoking. Over time, breathing tobacco smoke irritates the airways and destroys the stretchy fibers in the lungs
300
You begin the morning by visiting Mr. Gonzalez. Your census states he is a 35 yr old that has been admitted overnight for CP R/O ACS, Syncope, and TIA. After interviewing the patient he states his abdominal pain was relieved by his PRN Lactulose, and denies ever having any other complaints. Which of his 3 diagnoses is the pt likely to never have experienced?
CP R/O ACS, Syncope, and TIA. (Any of the 3 will be excepted)
400
COPD
400
A 76-year-old woman is evaluated in the office after an acute exacerbation of chronic obstructive pulmonary disease 10 days ago that was treated with ampicillin. She is now doing well. She does not currently smoke. She is on the appropriate medications. She also uses oxygen, 2 L/min by nasal cannula, at home. Her most recent pneumococcal vaccination was 12 years ago; her most recent influenza vaccination was 1 year ago. Physical exam is normal, except for occasional end-expiratory wheezing.
What is the most appropriate management for this patient at this time?
Administer Influenza and pneumococcal vaccines.
Influenza and pneumococcal vaccines have been shown to reduce all-cause pneumonia and cardiac hospitalizations in the elderly by 30% to 40%.
400
THE DAILY DOUBLE:
Who is known as the Father of Western Medicine?
Hippocrates
FYI: Epocrates is not a real person.. its an app
400
Why do I need a pneumococcal vaccine again? I'm 66 and I got one on my 60th birthday?
Immunity likely wanes 5 or more years after initial vaccination, and a single booster dose is recommended for patients continually at risk and those vaccinated before age 65 years.
400
EXCELLENT!!!!
Dr. Cohen
500
According to the GOLD criteria, what is the definition of COPD Stage 1 or "mild COPD"?
FEV1/FVC < 0.7 and FEV1 ≥80% predicted
500
On physical examination, the temperature is 38.9 °C (102 °F), blood pressure is 96/60 mm Hg, heart rate is 120/min, and respiration rate is 26/min. Oxygen saturation is 85% with the patient breathing oxygen, 2 L/min, by nasal cannula. He has poor oral hygiene. There is decreased respiratory excursion on the right side with decreased breath sounds and egophony. Tubular bronchial breathing is heard in the right mid-chest posteriorly.
Chest radiograph shows a moderate-sized right pleural effusion. A right lateral decubitus film shows the effusion to be large (>3 cm from the chest wall to the lung margin), free flowing, and associated with a right lower lobe infiltrate. Thoracentesis is performed, and 1 L of foul-smelling turbid fluid is aspirated. Gram stain reveals gram-positive cocci and gram-negative rods. Pleural fluid analysis is as follows:
Cell Count: 80% Neutrophils
LDH: 3200
pH: 6.95
In addition to broad spectrum antibiotics, what is the next best step in this patient's management?
Chest tube drainage (tube thoracostomy) of a parapneumonic effusion should be instituted if pus or gram-positive pleural fluid is detected or if the pleural fluid pH is <7.0.
500
A 67-year-old woman with emphysema is evaluated in the office for worsening dyspnea. She also has increased ankle edema and is less responsive to a regimen of long-acting bronchodilators, inhaled corticosteroids, and theophylline along with continuous supplemental oxygen. She has difficulty managing her activities of daily living because of dyspnea.
On physical examination, Vital signs are normal except for a respiration rate of 16/min. There is no JVD, and heart sounds are distant. Breath sounds are distant without wheezes or crackles.
Chest radiograph shows hyperinflation with decreased pulmonary markings. CT scan of the chest shows widespread homogeneous emphysema. The FEV1 is 0.6 L (approximately 19% of predicted). ABG shows pH of 7.40, PCO2 of 42 mm Hg, and PO2 of 62 mm Hg.
What treatment will improve this patient's overall quality of life?
(It's not a medication and don't you dare say OMT!)
Pulmonary Rehabilitation
Pulmonary rehabilitation does not increase survival in patients with chronic obstructive pulmonary disease but does improve symptoms, exercise endurance, and quality of life and would therefore be indicated in this patient. Consider pulmonary rehabilitation in patients who experience anxiety with activity, breathlessness and limitations with exercise, and loss of independence and who are willing to undergo an intensive education and exercise program.
500
Why do I have to stay in the hospital? What causes my "COPD Exacerbations? I take my medicines just like you told me.
COPD exacerbation is a period in the natural course of the disease that is characterized by a worsening of a patient's baseline symptoms -- such as dyspnea, cough and/or sputum production.
The two primary causes of COPD exacerbation are lung infections and air pollution.
500
A completely oriented, non-combative ER patient begins to complain to his nurse that he has not been seen by an ER physician in a expeditious manner. Shortly thereafter, the patient becomes angry and begins to yell. <2 minutes later, the patient is now Baker Acted, restrained, and has been tranquilized with a "B52 shot".
What is in a B52 shot?
IM Benadryl + Haldol + Ativan