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米国にて内科修行中。何ができるか模索している過程を記録していく

Pulmonary and Critical care medicine (memo from NEJM knowledge plus and MKSAP)

・Tx for idiopathic pulmonary arterial hypertension

 require long-term anticoagulation 

 

・management of acute pulmonary embolism in patient with h/o HIT

argatroban (parenteral direct thrombin inhibitor) or others

 

・duration of ABX for ventilator-associated pneumonia caused by Pseudomonas aeruginosa

   15 days

 

・management of patient with provoked DVT on warfarin for 6 months, who was found to have residual nonocclusive thrombus by US

discontinue warfarin

(follow-up US not necessary, residual thrombi are present  in 60% at 6 months, 30% at 2 years, using D-dimer to gauge the duration of anticoagulation is not appropriate for provoked DVT)

 

・management of patient with repeated exacerbation of asthma who present with respiratory distress, inspiratory and expiratory wheezing heard predominantly in central lung fields, no improvement with repeated bronchodilator nebs and systemic corticosteroid IV

laryngoscopy (for possible misdiagnosis, evaluate vocal cord dysfunction)

 

・first-line treatment of central sleep apnea secondary to heart failure

medical opitimaztion of cardica function (diuresis, )

 

・managment of patient with h/o unprovoked pulmonary embolism and elevation of follow-up D-dimer after 3 months duration of anticoagulation

restart anticoagulation for indefinite period

 

・next step for patient with significant smoking history who presents with cough, weight loss, CXR and CT show right upper lobe mass and moderate amount of right pleural effusion, diagnostic thoracentesis negative for cytology

repeat thoracentesis and pleural effusion cytology

(sensitivity of pleural effusion cytology: 60% for initial sampling, additional 27% on second sampling, and 5% on third sampling)

 

・one of the risk factors of pulmonary artery hypertension

symptomatic hemoglobinopathy (thalassemia, sickle cell disease) 

 

・benign pattern of calcification in lung nodule

central (granuloma), popcorn, lamellar (concentric ring), diffuse

 

・plateau pressure in ARDS management 

less than 30, TV initially set at 6ml/kg of ideal body weight, sebsequently reduced by 1ml/kg if necessary to maintain plateau pressure < 30

 

・diagnostic test for chronic thromboembolic pulmonary hypertension 

ventilation / perfusion scan

 

・first line treatment of hemodynamically unstable massive pulmonary embolism

intravenous tPA (catheter-based thrombus removal not first-line, catheter-directed thrombolysis: no data of improved outcome so far)

 

・military veteran deployed to Iraq during Operation Iraq Freedam p/w dyspnea, centrilobular nodules and airway thickening in CT   

   constrictive bronchiolitis

 

・common cause of COPD in nonsmoker from developing countries

    biomass fuel exposure (wood, crop, residues, and animal dung)

 

・most well-described cause of occupational asthma

   diisocyanate

 

・most common extrapulmonary site of disseminated nocardiosis

   central nervous system (-> focal sign)

 

・two most common cause of secondary pneumothorax

   pneumocystis jirovecii infection and COPD

 

・second major cause of lung cancer

   residential radon 

 

・ABX for UTI causing interstitial lung disease

   nitrofurantoin

 

・Tx of amiodarone-induced lung toxicity 

   discontinuation and prednisone

 

・diagnosis of tuberculosis pleural effusion 

    pleural biopsy

   

・test of pleural effusion when tuberculosis is suspected

adenosine deaminase (>70: highly specific, < 40: almost exclude)

(acid-fast stain positive only 5% in non-HIV, TB culture positive in 24%)

 

・prevention of high altitude pulmonary edema 

   nifedipine

 

・patient from New Mexico p/w flu-like symptom, pulmonary edema, peripheral immunoblast, cardiac collapse 

   aerosolized rodent excreta (hantavirus)

 

・primary ciliary dyskinesia:

   involvement of upper and lower respiratory tract,  infertility

 

・treatment of patient who found unconscious, Cre 1.9, severe AG acidosis, osmolal gap 109, negative ETOH and toxic screen, envelope-shaped crystal in urine

IV fomepizole and hemodialysis for ethylene glycol toxication 

 

・initial step of evaluation for patient with excessive daytime sleepiness and no obvious sign of sleep disorder

sleep diary

 

・pulmonary nodule less than 4mm

no further evaluation if no risk, follow up CT in 12 months if risk factor

 

・upper lobe predominance diffuse infiltrate witn normal or minimally abnormal pulmonary function test

sarcoidosis 

 

・management of 9mm ground-glass nodule in lung, followed by CT, no change in the past 2 years

follow up in 1 year (ground-glass nodule requires more than 2 years follow up, for possible slow-growing adenocarcinoma in situ) 

 

・management of patient with OSA who doesn't tolerate CPAP due to nasal congestion

add heated humidification to CPAP circuit

 

・explanation to patient who is concerned about radiation of CT scan of chest

5-7 mSv

comparable to the amount of radiation a person receives from ambient solar radiation over 1 year

 

・diagnosis of childbearing-age female without smoking history who has dyspnea on exertion, dry cough, hyperinflation in CXR, diffuse, thin-walled, small cyst in CT

lymphangioleiomyomatosis

 

・Dx of coal miner with productive cough, dyspnea on exertion 

obstructive lung disease

 

・assessment of risk of respiratory failure for patient with exacerbation of myasthenia gravis

serial vital capacity and maximum negative inspiratory force

 

・next step for patient who present with cough, hemoptysis, weight loss, sputum cytology positive for squamous cell carcinoma, CXR and CT show mass in right lower lobe, PET-CT show mass in R lung and increased activity in mediastinal lymph nodes

mediastinal lymph node sampling

 

・management of agitation for patient with neuroleptic malignant syndrome

benzodiazepine (lorazepam)

 

・management of patient who present with fever, polyarthralgia, erythema nodosum, CXR show bilateral hilar lymphadenopathy

observation :  more than 80% of patient with sarcoidosis who present with Lofgren syndrome have spontaneous resolution