3.2 Block Exam Set 32112

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Block B1 - Chest Problems


Exam[edit]

1[edit]

"amphoric breath sound: an abnormal, resonant, hollow, blowing sound heard with a stethoscope over the thorax. It indicates a cavity opening into a bronchus or a pneumothorax." - Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.


2[edit]

"The apical lordotic can be performed in the first instance if the suspected or known pathology is associated with the lung apices- eg tuberculosis." - WikiRadiography.

"A posterior-anterior (PA) chest X-ray is the standard view used; other views (lateral or lordotic) or CT scans may be necessary." - Wikipedia: Tuberculosis radiology

3[edit]

The five elements of DOTS:

  1. Political commitment with increased and sustained financing
  2. Case detection through quality-assured bacteriology
  3. Standardized treatment, with supervision and patient support
  4. An effective drug supply and management system
  5. Monitoring and evaluation system, and impact measurement

- WHO.


4[edit]

All answers in the test-paper are incorrect.

"Millennium Development Goal: to have halted by 2015 and begun to reverse the incidence of TB." - WHO

"To have ceased and started reversal of the incidence of malaria and other major diseases by 2015" - MDG Monitor

"Current projections suggest that the Stop TB Partnership target of halving 1990 death rates by 2015 can be achieved at the global level and in several regions." - MDG Report of 2012, WHO

5[edit]

D, Streptococcus pneumonia (aka pneumococcus). - PubMed.

6[edit]

"M. tuberculosis can survive in sputum on carpet (19 days) and wood (over 88 days), moist and dry soil (4 weeks), and in the environment for more than 74 days if protected from light (possibly longer if in feces)." - PHAC.

"It was found that 28 percent of the tuberculosis bacteria remains alive in a room after nine hours. Tuberculosis can live up to 45 days on clothing, 70 days in carpet, 90 to 120 days in dust, approximately 105 days on a paper book, and approximately six to eight months in sputum. " - eHow.

"Once coughed out by a person with TB, they can survive up to six months outside the body if they are protected from direct sunlight." - TBOnline

"showed a half life for M. tuberculosis of about 6 hours." - GHD.

7[edit]

B - ASM.

  • Streptococcus pneumoniae – the most common cause of bacterial pneumonia in children;
  • Haemophilus influenzae type b (Hib) – the second most common cause of bacterial pneumonia;
  • Respiratory syncytial virus is the most common viral cause of pneumonia.

- WHO

8[edit]

C (or maybe B, but most likely C).

"Ghon's complex is a lesion seen in the lung that is caused by tuberculosis. The lesions consist of a calcified focus of infection and an associated lymph node. These lesions are particularly common in children and can retain viable bacteria, so are sources of long-term infection and may be involved in reactivation of the disease in later life. As sensitization develops, a 1- to 1.5-cm area of gray-white inflammation with consolidation emerges, known as the Ghon focus. In most cases, the center of this focus undergoes caseous necrosis. Tubercle bacilli, either free or within phagocytes, drain to the regional nodes, which also often caseate. This combination of parenchymal lung lesion and nodal involvement is referred to as the Ghon complex." - Wikipedia

"A Ghon focus is a primary lesion usually subpleural, often in the mid to lower zones, caused by mycobacterium bacilli (tuberculosis) developed in the lung of a nonimmune host (usually a child)." - Wikipedia

9[edit]

B.

"Generally, the right middle and lower lung lobes are the most common sites of infiltrate formation due to the larger caliber and more vertical orientation of the right mainstem bronchus. " - Wikipedia

"The usual site for an aspiration pneumonia is the apical and posterior segments of the lower lobe of the right lung." - Patient.info.


10[edit]

E. (aka pneumococcus).

  • Streptococcus pneumoniae – the most common cause of bacterial pneumonia in children;
  • Haemophilus influenzae type b (Hib) – the second most common cause of bacterial pneumonia;
  • Respiratory syncytial virus is the most common viral cause of pneumonia

- WHO

11[edit]

C.

Bronchiectasis is the buildup of mucus in the airway and shortness of breath is usually expected as one of the complaints. This scenario doesn't mention shortness of breath. However, chronic productive cough is mentioned that hints towards mucus buildup in the airway. The mucus buildup is a good place for bacterial infections to take root. Prolonged cough or an infection can cause bloody cough.

12[edit]

D.

"Most people who are exposed to TB bacteria do not develop TB disease. Sometimes, your immune system can kill the TB germs, but when this does not happen, the bacteria can remain alive but inactive in your body. This is called latent TB infection (also known as LTBI)" - HealthyCanadians.

13[edit]

C. TB-Anak-Indonesia.

14[edit]

C. NHS.

15[edit]

A.

16[edit]

E. PathologyAtlas.

17[edit]

02-injection.gif

D, because the tuberculin skin test is affected by BCG vaccine. It is not A because the tuberculin skin test is performed intradermally not intracutaneously.

"In some people, BCG may cause a positive skin test when they are not infected with TB bacteria." - CDC.

"The TST is an intradermal injection." - CDC.

18[edit]

19[edit]

B. The TST > 10mm,no symptoms, and normal xrays means latent TB infection. The answers are confusing because a "contact child" can mean somebody who came in contact but then did not get infected (not even latent) and "No TB disease" can mean latent TB infection depending on what is considered a "disease". Also since there is no sign of active infection, the child is otherwise healthy. So the answer can be either B, C, or D.

20[edit]

A.

"BCG, or bacille Calmette-Guerin, is a vaccine for tuberculosis (TB) disease." - CDC

21[edit]

D. Because anti-TB drugs are known most commonly for causing hepatotoxicity.

22[edit]

B.

23[edit]

All answers incorrect. - WHO.

24[edit]

B.

"Pulmonary emphysema is defined as the abnormal permanent enlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of the alveolar wall and without obvious fibrosis. Emphysema is one of the entities grouped together as chronic obstructive pulmonary disease. Patients typically report dyspnoea without significant sputum production. Signs include hyper-resonant to percussion." - Radiopaedia.


25[edit]

A.

"Bronchial hyperresponsiveness is currently defined as an increase in sensitivity to a wide variety of airway narrowing stimuli. Most patients with asthma and chronic obstructive pulmonary disease (COPD) exhibit such an enhanced sensitivity. In asthma, in particular, this hypersensitivity is accompanied by excessive degrees of airway narrowing." - PubMed

"Bronchoconstriction: The condition has a number of causes, the most common being emphysema as well as asthma." Wikipedia

26[edit]

D. "Have you noticed that a sudden change in weather can trigger your asthma symptoms? If so you're not the only one. In a recent survey, 75 per cent of people said that cold air can trigger asthma symptoms." - Asthma.org.uk.


27[edit]

E.

"Auscultation of the chest reveals moderate wheezing, which is often end expiratory. Rapid forced expiration may elicit wheezing that is otherwise inaudible" - Medscape.

28[edit]

B.

29[edit]

C.

"Asthma is characterized by functional and structural alterations of the bronchial epithelium, chronic airway inflammation and remodeling of the normal bronchial architecture. Bronchial myofibroblasts are thought to play a crucial role in the pathogenesis of subepithelial fibrosis, a prominent aspect of the remodeling process. The results of the studies reviewed in this report indicate that circulating fibrocytes contribute to the bronchial myofibroblast population and may be responsible for the excessive collagen deposition below the epithelial basement membrane in asthma." - NCBI.

30[edit]

E.

http://radiopaedia.org/articles/bronchial-wall-thickening

31[edit]

32[edit]

33[edit]

C.

TLC
Total lung capacity: the inspiratory capacity plus the functional residual capacity; the volume of air contained in the lungs at the end of a maximal inspiration; also equals vital capacity plus residual volume.
FVC
Forced vital capacity: the determination of the vital capacity from a maximally forced expiratory effort.
Anatomical dead space
portion of the airways (such as the mouth and trachea to the bronchioles) which conducts gas to the alveoli. No gas exchange is possible in these spaces.
Alveolar dead space
sum of the volumes of those alveoli which have little or no blood flowing through their adjacent pulmonary capillaries, i.e., alveoli that are ventilated but not perfused, and where, as a result, no gas exchange can occur.
Physiologic dead space
the sum of the anatomic and alveolar dead spaces.

34[edit]

D.

The answer can be either B or D as they're both suited to infants and young children, however nebulizers take much longer (up to an hour) to deliver the medication by pMDI+spacer+facemask will only take seconds. They're both similarly efficacious.

"Nebulizers are particularly effective in delivering asthma medications to infants and small children and to anyone who has difficulty using an asthma inhaler." - AsthaAllergyClinic.in.

"Younger children may need to use a spacer with a mask, because they may not follow instructions to seal their lips together when using a mouthpiece." - AboutKidsHealth.ca

35[edit]

Medications for asthma-2.jpg

D. Theophylline does but it isn't the recommended agent for asthma control. Salbutamol isn't a controller, but rather a reliever.

"Inhaled corticosteroids are the preferred agents for long-term control of persistent asthma according to expert panel recommendations. Currently available controller medications: inhaled corticosteroids (ICSs), Long-Acting Beta-2 Agonists (LABAs), leukotriene modifiers, anti-IgE medications, and combination products." - PubMed.

"Though traditionally classified as a bronchodilator, the ability of theophylline to control chronic asthma appears disproportionately greater than is explainable by its modest degree of bronchodilator activity alone" - UpToDate

"Theophylline is an alternative, but not preferred, therapy for persistent asthma." - GetAsthmaHelp

"While relievers help you treat the symptoms of asthma, controller medications help to treat the underlying inflammation of the airways in a person with asthma. By controlling the inflammation, asthma symptoms will diminish and attacks prevented. Remember, controllers do not immediately relieve wheezing, coughing or chest tightness, and should not be used to treat a severe asthma attack." - Asthma.ca


36[edit]

C.

"The majority of side effects have been dependent on the serum concentration. Generally, serum concentrations of theophylline ranging from 10 to 20 mcg/mL are considered therapeutic, and serum concentrations greater than 20 mcg/mL are associated with greater toxicity." - Drugs.com.

37[edit]

D.

"Beta2-agonists are considered first-line therapy for the treatment of stable chronic obstructive pulmonary disease (COPD) with symptoms that come and go (intermittent symptoms). They are used for both short- and long-term relief of symptoms. Beta2-agonists also may be used before exercise to reduce breathing difficulties. Arformoterol, formoterol, or salmeterol may be taken to prevent shortness of breath or coughing that may keep you from exercising." - WebMD

"Long-acting beta-agonists (LABAs): Salmeterol and formoterol are bronchodilators that have a duration of bronchodilation of at least 12 hours after a single dose. In the opinion of the Expert Panel, the use of LABA for the treatment of acute symptoms or exacerbations is not currently recommended." - GetAsthmaHelp.

"Fenoterol is a short-acting sympathomimetic agent with bronchodilator activity. Fenoterol stimulates beta-2-adrenergic receptors in the lungs" - PubChem.

"Salbutamol (aka albuterol) is a short-acting beta2-agonist" - WebMD


38[edit]

All answers are wrong, so just answer with A.

"Right-sided heart failure is often caused by pulmonary heart disease (cor pulmonale). Cor pulmonale is the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance (such as from pulmonic stenosis) or high blood pressure in the lungs." - Wikipedia.

39[edit]

40[edit]

41[edit]

"When the pericardium (the sac around your heart) is inflamed, the amount of fluid between its two layers of tissue increases. As part of the exam, your doctor will look for signs of excess fluid in your chest.A common sign is the pericardial rub. This is the sound of the pericardium rubbing against the outer layer of your heart. Your doctor will place a stethoscope on your chest to listen for this sound." - NHLBI

42[edit]

C

Chf-guidelines-2013seminar-6-638.jpg

43[edit]

D

44[edit]

45[edit]

"Causes of Kerley B lines include; pulmonary edema, lymphangitis carcinomatosa and malignant lymphoma, viral and mycoplasmal pneumonia, interstitial pulmonary fibrosis, pneumoconiosis, sarcoidosis. They can be an evanescent sign on the CXR of a patient in and out of heart failure." - Wikipedia: Kerley Lines.

46[edit]

Heart sounds

"Aortic insufficiency (AI), also known as aortic regurgitation (AR), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. There may also be an Austin Flint murmur, a soft mid-diastolic rumble heard at the apical area. It appears when regurgitant jet from the severe aortic insufficiency renders partial closure of the anterior mitral leaflet." - Wikipedia

47[edit]

A.

"Classically, it is described as being the result of mitral valve leaftlet displacement and turbulent mixing of antegrade mitral flow and retrograde aortic flow" - Wikipedia: Austin Flint murmur


48[edit]

E.

Prazosin: "When these two medicines are taken together, the amount of potassium in your blood may decrease. This may cause the effects of your digitalis glycoside medicine to increase." - WebMD

49[edit]

Heart medications

"Lisinopril is a drug of the angiotensin-converting enzyme (ACE) inhibitor class used primarily in treatment of high blood pressure, heart failure, and after heart attacks. " - Wikipedia

50[edit]

D.

"Digoxin is occasionally used in the treatment of various heart conditions, namely atrial fibrillation, atrial flutter and sometimes heart failure that cannot be controlled by other medication." - Wikipedia

51[edit]

Duke's criteria for endocarditis

63[edit]

C.


68[edit]

69[edit]

70[edit]

D.

"The Trendelenburg Test or Brodie-Trendelenburg test is a test which can be carried out as part of a physical examination to determine the competency of the valves in the superficial and deep veins of the legs in patients with varicose veins." - Wikipedia

71[edit]

B.

72[edit]

81[edit]

82[edit]

83[edit]

84[edit]

85[edit]

86[edit]

87[edit]

A.

"If you are being treated for high blood pressure, the usual target is to reduce blood pressure in someone who has had an MI to below 130/80 mm Hg." - Patient.info

88[edit]

C.

89[edit]

Cardiac markers after MI

90[edit]

Patient lab test result : low homocysteine, increased protein C, normal C-reactive protein (CRP), increased HbA1c, and normal LDL-cholesterol. Which is related to Acute Coronary Syndrome risk? : (B) HbA1C

  • Homocysteine :
    • A type of amino acid NOT obtained from diet. It is instead made from methionine - amino acid found in meat, fish, and dairy product.
    • ELEVATED homocysteine is associated with cardiovascular risk.
    • Test for homocysteine is only done if other risk factors for cardiovascular disease is ruled out - the test is still relatively expensive.
  • Protein C
    • A zymogen (inactive substance that is converted in an enzyme when activated by another enzyme) that prevents blood clotting. Also known as autoprothrombin IIA and blood coagulation factor XIV - a vitamin-K dependent glycoprotein synthesized in the liver.
    • Activated by binding to Thrombin, to become aPC (activated Protein C), which plays its role in anticoagulation by inactivating coagulation factors V(a) and VII(a).
    • Other role of aPC : anti-inflammatory, cytoprotective functions.
    • DEFICIENCY of aPC is associated with venous thrombosis (excess clotting).
    • Deficiency of aPC can be inherited, or develop with conditions such as: chemotherapy, liver disease, long-term antibiotic use, warfarin use.
  • C-reactive protein (CRP)
    • Protein made by the liver in acute phase (within few hours after tissue injury, start of an infection, or inflammation).
    • Test for CRP is usually done to determine presence of inflammation in the patient (low CRP does not always mean no inflammation present, and CRP level may NOT increase in Lupus and Rheumatoid Arthritis patient).
    • High-sensitive C-Reactive Protein (hs-CRP) assay can determine risk for heart disease where LOW risk is value <1.o mg/L, AVERAGE risk for 1.0 - 3.0 mg/L, and HIGH risk when level of hs-CRP is >3.0 mg/L.
  • HbA1c
    • A glycated haemoglobin - a form of Hb measured to identify average plasma glucose over longer period.
    • Normal HbA1c value is > 6%
    • HIGHER hbA1c increase risk of developing diabetes-related complications e.g. Cardiovascular disease.
  • LDL Cholesterol
    • Low-density lipoprotein, the Bad cholesterol.
    • HIGH LDL increase risk of cardiovascular disease as it contributes to plaque (thick, hard deposit that can clog arteries and reduce arteries' flexibility).
    • For patient with no other risk factors, Optimal level is <100mg/dL, near optimal at 100-129 mg/dL, and borderline HIGH at 130-159mg/dL.

91[edit]

1575-PB3-R1.png

Most typical (classic) sign on the X-ray thoracic PA projection in patient with pleural effusion: (D) Meniscus sign.

  • Pleural effusion : Abnormal collection of fluid in pleural space (due to overproduction, or malabsorption, or both).
  • Radiographic appearance :
    • CXR (lateral decubitus) : Most sensitive, with patient lying on their side, effusion side down - can visualize even small amounts of fluid dui to costophrenic angle being deepest posteriorly.
    • CXR (erect PA and AP) : Insensitive to small amounts of fluid (as much as 250-600 ml of fluid is required before it becomes evident).
      • Blunting of costophrenic angle
      • Blunting of cardiophrenic angle
      • Fluid within the horizontal or oblique fissures
      • Meniscus
      • With large volume effusions : mediastinal shift occurs away from the effusion (BUT : if coexistent collapse dominates then the mediastinal shift may occur towards the effusion)

92[edit]

Characteristics of Morgagni Hernia: (B) RLD (Right Lateral Decubitus) Thoracic Examination.

  • Morgagni Hernia : a rare type of congenital diaphragmatic hernias.

Herniation through foramen Morgagni (immediately adjacent to xiphoid process of sternum).

  • More rare than Bochdalek hernia (another type CDH).
  • Location : Anterior, more often right-sided (90%), small.
  • Diagnosis : Often before birth and fetal intervention.
    • Early Dx : Right-sided heart, decreased breath sounds, scaphoid abdomen, bowel sound in thorax, respiratory distress. In-utero diagnosis with USG, MRI, or both.
    • Late Dx : Chest mass on chest radiograph, gastric volvulus, splenic volvulus, or large bowel obstruction.
    • CT is the most sensitive in assessing diaphragmatic hernias (gives excellent anatomical detail of hernia's contents and complications e.g. Strangulation), but USG has been shown to be useful.
  • Low risk of prolapse., reduced by surgical intervention.
  • Case studies:

93[edit]

Tachycardia/tachyarrhythmia that is NOT of a supraventricular origin: (E) Ventricular flutter.

Tachyarrhythmia: heart rate (HR) > 100bps. Normal resting heart rates: 60 - 100 bps.

Generally, lower HR at rest means more efficient heart function, better cardiovascular fitness e.g. Athlete may have HR at rest close to 40 bps.

Signs & symptoms: Shock, hypotension, heart failure, shortness of breath, chest pain, acute myocardial infarction (AMI), palpitations, and/or decreased level of consciousness.

Supraventricular tachycardia (SVT): rapid heart rhythm originating at or above Atrioventricular (AV) node (includes sinoatrial and atrial origin).

In contrast, ventricular tachycardia (VT): rapid heart rhythm that starts within the ventricles (considering ventricles are main pumping chambers, this is more dangerous).

(A) Atrial Fibrillation:

  • Heart's electrical signals start at other part of atria or nearby pulmonary veins.
  • Signals don't travel normally. It spreads throughout atria in rapid, disorganized manner - causing atrial fibrillation.
  • The faulty signals flood AV, causing ventricles to also beat faster than normal (but not as fast as atria because: AV node can't send *signal to ventricles as fast as they arrive).

(B) Atrial Flutter:

  • Arrhythmia characterized by atrial rates of 240-400 and some degree of AV node conduction block.
  • Single re-entrant circuit with activation in the right atrium (around tricuspid valve annulus - usually counter-clockwise direction).

(C) Junctional Tachycardia:

  • A form of tachycardia associated with generation of impulse in A-V junction (above region of AV node).
  • Under pathologic condition, A-V junction serve as an ectopic pacemaker, or as a site of re-entry.

(D) Sinus Tachycardia:

  • Elevation of rate of impulse from SA node (> 100 bps).
  • Most often occur when there's an increase in body's demand for oxygen.

(E) Ventricular Flutter:

  • Tachycardia affecting ventricles with a rate over 250-350 bps, due to re-entry.
  • Re-entrant pattern results in chaotic ventricular depolarization.
  • Results in minimal cardiac output, followed by ischemia.
  • Usually continues to Ventricular Fibrillation.