Pulmonary ABIM Certification Exam Review Course Relative Value?

75 Pages·2009·2.49 MB·English

PPuullmmoonnaarryy
AABBIIMM  CCeerrttiiffiiccaattiioonn  
EExxaamm  RReevviieeww  CCoouurrssee
Robert M. Jasmer, M.D.
Associate Clinical Professor of Medicine,
UCSF
Leslie Zimmerman, MD
Professor of Clinical Medicine, UCSF
ICU Director, SFVAMC
RReellaattiivvee  VVaalluuee??
Medical Content
(cid:132)
CV 14%
•
Pulmonary 10%
•
ID 9%; GI 9%
•
Cross Content
(cid:132)
Critical Care 10%
•
Geriatrics 10%
•
Prevention 6%; Women’s Health 6%
•
RReellaattiivvee  VVaalluuee??
Pulmonary: ½ is
(cid:132)
Obstructive disease
•
Occupational and Environmental
•
Restrictive & Interstitial
•
Pulmonary vascular disease
•
LLeeccttuurree  OOuuttlliinnee
PFTs
(cid:132)
Cough
(cid:132)
Asthma
(cid:132)
Solitary Pulmonary Nodule
(cid:132)
PVD
(cid:132)
ILDs
(cid:132)
TB
(cid:132)
Etc.
(cid:132)
QQuueessttiioonn  11
A 65 year-old woman with known
COPD has spirometry. Which values
can be obtained from the following
graph?
QQuueessttiioonn  11
4
Liters 3
2
1
1 2 3 4 5 6
Seconds
A. FEV1
B. FEV1/FVC
C. FEF 25%-75%
D. Maximal flow rate at 25% of FVC
E. Maximal flow rate at 50% of FVC
SSppiirroommeettrryy
FEV1
All you need to
know is:
FEV1 (F)VC
TLC
FEV1/FVC
(FEV1%)
TLC
(and DLCO) RV
Time
SSppiirroommeettrryy
(F)VC
Obstructive disease
TLC
Restrictive disease
RV
Time
QQuueessttiioonn  22
Which of the following diseases typically has a normal
DLCO?
A. Asthma
B. Emphysema
C. Idiopathic pulmonary arterial
hypertension
D. Idiopathic pulmonary fibrosis
E. Pneumocystis jiroveci pneumonia
DDLLCCOO
Destroy alveoli or
capillaries (cid:198) CO DLCO: integrity
Low DLCO of the alveolar–
capillary
membrane
CO
CO
DDLLCCOO
Just narrow
airways (cid:198) CO DLCO: integrity
Normal DLCO of the alveolar–
capillary
membrane
CO
CO
QQuueessttiioonn  22
Which of the following diseases typically has a
normal DLCO?
A. Asthma
B. Emphysema
Air “sac”
C. Idiopathic pulmonary arterial
problem
hypertension
D. Idiopathic pulmonary fibrosis
E. Pneumocystis jiroveci pneumonia
Capillary problem
PPFFTTss
Obstructive Disease: Low FEV1%
- normal DLCO: asthma and chronic
bronchitis
- low DLCO: emphysema
Restrictive Disease: Low TLC
- normal or mildly decreased DLCO:
obesity
- low DLCO: ILD
QQuueessttiioonn  33
A 72 year-old man with 5 years of
progressive DOE has the following CXR
QQuueessttiioonn  33
And has the following PFTs:
FVC 2.4L (52%)
FEV1 1.02L (38%)
FEV1/FVC 41%
TLC 5.0L (77%)
RV 2.6L (120%)
DLCO 12 (48%)
QQuueessttiioonn  33
You should order which of the following?
A. Body box plethysmography
B. CT Angiogram
C. HRCT
D. Negative inspiratory pressure
E. Pulmonary exercise testing
PPuullmmoonnaarryy  FFuunnccttiioonn  TTeessttss
Spirometry
(cid:132)
Diagnose obstruction if
FEV1/FVC < 70%
Flow-volume loop
(cid:132)
Diagnose restriction if
Lung volumes
(cid:132)
TLC < 80%
Diffusing capacity
(cid:132)
Non-specific, but sensitive for
alveolar capillary wall integrity
Low in emphysema, ILDs, PVD
TTLLCC  mmeeaassuurreemmeennttss  iinn  CCOOPPDD  
CCaann  bbee  uunnddeerreessttiimmaatteedd  bbyy  ggaass  ddiilluuttiioonn  tteecchhnniiqquuee
Body box
plethysmography
estimates entire
Standard thoracic cage
C1V1= C2(V1+V2)
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ddiiddnn’’tt mmaakkee sseennssee tthhaatt TTLLCC
wwaass llooww..
Large blebs don’t equilibrate
22000044::  WWoorrllddwwiiddee  LLeeaaddiinngg  CCaauusseess  ooff  DDeeaatthh
10
9
Affects 9% of
8 World
Population
7
By 2020, will
s move to 3rd
n 6
o leading
Milli 5 cause of
death
4
3
2
1
0
Heart Disease CVA Pneumonia COPD Diarrhea
http://www.who.int/mediacentre/factsheets/fs310_2008.pdf
In US, only common disease with RISING mortality
In US, the
increase
in COPD
deaths is
driven by
very large
increase
in deaths
by women