A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure.Which of the following physical examination findings are you most likely to find in this patient?
Answer(s): A
COPD is a group of chronic and progressive pulmonary disorders that cause reduced expiratory flow. Most of the obstruction is fixed, although some reversibility can be found. COPD affects approximately 16 million Americans and smoking is, by far, the greatest risk factor. Onset is typically in the fifth decade and the typical presenting symptoms are dyspnea and cough. Patients often relate these to an acute illness (walking pneumonia in this case) but the decline in pulmonary function has been present for some time prior to the onset of symptoms. The physical examination has poor sensitivity and may, in early disease, only show wheezing on forced expiration and a prolonged expiratory phase of respiration. Clubbing is not typically a manifestation of COPD and its presence should lead to a search for another cause, such as lung cancer. In the setting of pulmonary hypertension, sometimes one can hear a pronounced pulmonic component to the second heart sound, although hyperinflation may obscure this finding. Bilateral pulmonary crackles would be more consistent with pulmonary edema. Supraclavicular adenopathy should lead to a workup to exclude cancer, especially of breast, lung, ovarian, or GI origin. Hyperinflation of the lungs is the most likely CXR finding in this case. This would manifest as flattened diaphragms with elongated lungs and a long, narrow cardiac shadow. Kerley B lines would be more characteristic of pulmonary edema from left-sided heart failure, rather than COPD. A pulmonary mass with adenopathy would be more consistent with lung cancer--certainly a possibility in a long-time smoker, but much less common than COPD. A residual infiltrate from pneumonia a year ago would be highly unlikely.
A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressureWhich of the following is most likely to be found on a CXR?
Answer(s): D
A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressureYou recommend smoking cessation to your patient. She asks why, at this point, she should quit. Which of the following statements is true?
Answer(s): E
A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy.Which of the following is an appropriate medication to use as a preventative measure prior to and during her treatment for leukemia?
Answer(s): C
Tumor lysis syndrome refers to a series of metabolic disturbances resultant from cancer treatment. It generally occurs when a large number of cancer cells are killed rapidly, releasing the contents of those cells into the systemic circulation. These contents include various ions. Tumor lysis syndrome is typically characterized by a combination of hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and lactic acidosis. Besides treatment of electrolyte abnormalities, urine alkalinization and aggressive hydration are frequently included as a part of treatment. Patients with tumor lysis syndrome may also develop oliguric acute renal failure, which arises from the precipitation of uric acid, hypoxanthine, or calcium phosphate within the renal tubules. Acute tubular necrosis is generally not seen in the setting of tumor lysis syndrome. Allopurinol reduces the synthesis of uric acid by blocking the metabolism of xanthine and hypoxanthine to uric acid via xanthine oxidase inhibition. This makes it useful in reducing the risk of hyperuricemia from tumor lysis. Urinary alkalinization and aggressive hydration are also components of treatment. Probenecid and sulfinpyrazone enhance urate excretion by blocking the reabsorption of urate from the proximal tubule. Colchicine is effective in treating acute gout attacks by inhibiting leukocyte migration and phagocytosis. Indomethacin, and other NSAIDs, can be effective in treating acute gout attacks by inhibiting urate crystal phagocytosis. However, low-dose aspirin may actually increase the risk of gout.
A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy.Which of the following is typically seen as a feature of tumor lysis syndrome?
Answer(s): B
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