Master the board step 3

Pulmonology
Specific Associations
Presentation
Recent viral syndrome
Alcoholics
Gastrointestinal symptoms, confusion
Young, healthy patients
Persons present at the birth of an
animal
Arizona construction workers
HIV with < 200 CD4 cells
Cause
Staphylococcus
Klebsiella
Legionella
Mycoplasma
Coxiella burnetii
Coccidioidomycosis
Pneumocystis (PCP)
An HIV-positive man comes to the emergency department with shortness of
breath and a dry cough. His LDH is elevated and the chest x-ray shows bilateral
interstitial infiltrates. His pO 2 is 65. What is the next best step in management?
a. Sputum induction
b. Respiratory isolation
c. Trimethoprim/sulfamethoxazole and prednisone
d. Pentamidine
e. Bronchoalveolar lavage
VAP is:
••
Fever
••
Hypoxia
••
New infiltrate
••
Increasing secretions
Answer: C. PCP is best managed with trimethoprim/sulfamethoxazole. This has better
efficacy than pentamidine. Bronchoalveolar lavage needs to be done and is the most
accurate test, but it is more important to start specific therapy. Steroids are indicated if
the pO 2 < 70 or the A-a gradient > 35. Sputum induction is not as important as starting
treatment. Also, it is only positive in 50–70 percent of patients.
Tuberculosis (TB)
TB occurs in specific risk groups, such as immigrants, HIV-positive patients,
homeless patients, prisoners, and alcoholics. TB presents with fever, cough,
sputum, weight loss, and night sweats.
Diagnostic Testing
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Best initial test: Chest x-ray
··
Sputum acid-fast stain and culture should be done to confirm the presence
of TB.
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