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Lung Story Short: Clearing the Air About Those Pulmonology Step 1 Questions

It’s your first day on the wards, and after months of studying for Step 1, you have no idea how to actually treat a patient. You have the knowledge, but how do you apply it?

This post is the first of many to help you succeed on the wards.  It will be your most commonly “pimped” questions for each common chief complaint in case format. And while this post will focus strictly on pulmonary complaints, we hope to get through each system by the end of this series.  I will present each case in its bare bones and I will try to anticipate what the most commonly pimped questions would be for each.  

Most commonly “pimped” questions for your Patients with Shortness of Breath:

Your patient is a 40 year old female with no significant PMH who presents with sudden onset shortness of breath. She is on birth control, is a two ppd smoker, and just finished a long road trip.

What is the most likely diagnosis?

Pulmonary embolism.   

What predisposes this patient to a PE?

This patient has many risk factors for a pulmonary embolism including her smoking, road trip, and birth control.  

Name the triad that predisposes patients to the formation of blood clots.

Virchow’s triad, and it is composed of venous stasis (i.e. long car ride, flight), endothelial injury (i.e. hypertension), and hypercoagulability (i.e. cancer, nephrotic syndrome, blood disorders).  

What risk scoring system do we use to stratify risk of pulmonary embolism?

Well’s criteria. Your attendings will be pleasantly surprised if you have calculated your patient’s risk before rounds. You can use MdCalc to calculate a score for each patient with shortness of breath. See for yourself here.

What is the most common EKG finding in PE?

Sinus tachycardia. (This may be the most commonly pimped question on the wards, period.)

What is the most specific EKG finding in PE?

S1q3t3. This is simply a deep S wave in lead one, a pathologic Q wave in lead three, as well as an inverted T wave in lead three. This is a great fact to know, but maybe even more important is what it indicates: right heart strain. With a large enough PE in the pulmonary vasculature, the right ventricle is forced to pump against increased resistance and this puts it under strain.

What is the most common chest x-ray finding?  

Normal chest X ray! Usually there are no radiographic changes associated with acute PEs. These clots are really only well visualized on CT scans with contrast.  

Are there any possible chest x-ray findings for PE?

Yes! And you will definitely be asked about this one on the wards and boards. A Hampton’s hump is a wedge shaped portion of infarcted tissue which can be seen on chest x-ray in a large enough PE.

Now, what if the patient instead was a 65 year old female with shortness of breath, a fever, and had a productive cough with sputum.  

What is the most likely diagnosis?

Pneumonia. However, you will be asked for more than that on your rotations, and you must know how to specify this diagnosis.

If the patient is coming from home and does not have close contact with a healthcare facility, then the diagnosis is community-acquired pneumonia (CAP). If the patient does have close contact with a healthcare facility, they are deemed to have health care associated pneumonia (HCAP). The definition of CAP vs. HCAP is currently in flux, so stay tuned for the newest updates on that front…

What is the most common bacteria and best treatment for CAP?  

Strep pneumoniae is the most common pathogen. Common antibiotic choices to cover strep pneumo include macrolides, doxycycline, or fluoroquinolones.  

What bugs do you have to worry about for HCAP and what is the treatment?

Consider pseudomonas as well as MRSA. These bugs inhabit hospitals and nursing facilities and frequently cause hospital acquired infections. Treatment includes coverage of pseudomonas such as with piperacillin-tazobactam, cefepime and coverage of MRSA with vancomycin or linezolid.

Now, what if the patient was a 66-year old male who presents with shortness of breath, wheezing, and a productive cough.  He is a two ppd smoker for the past 40 years.

What is the most likely diagnosis?

COPD exacerbation.  In an older smoker presenting with shortness of breath, COPD should always be in the differential.

What is the treatment for an acute COPD exacerbation?

The key is to dilate the bronchioles that have collapsed, reduce the inflammation, and increase oxygenation.  With that in mind, these patients get oxygen, beta agonists, anticholinergics, and steroids.  

Do you give antibiotics for COPD exacerbations?

Good luck with this one –— many attendings differ on the use of antibiotics for COPD exacerbations. In general, azithromycin (and other macrolides) have been shown to be helpful in some studies, some argue due to its potential anti-inflammatory effect rather than its effect against atypical bacterial organisms. It is a safe bet to recommend a short course of azithromycin as long as you are willing to support your position.

What can you do to prevent future COPD exacerbations?

For all patients with COPD, smoking cessation counseling and pneumococcal and influenza vaccines are key for preventative care.

What does the PaO2 and O2 sat need to be to start O2 and why?

PaO2 <55 and SaO2 <88%. Patients with COPD retain CO2, and after having the disease chronically they do not hyperventilate in response to high CO2. Therefore, they depend on O2 as a marker of inadequate ventilation. Low O2 means they need to breathe more. If the goal O2 saturation for these patients were 100%, they could lose their drive to breathe. There are a few other explanations not to keep the O2 saturation high in COPD patients, but this is the most commonly tested and asked one.


This wraps up the most commonly “pimped” pulmonology questions. You’ll be sure to wow your team with your knowledge next time a patient comes in with a chief pulmonology complaint!