PULM Pre test
d. Noncardiogenic pulmonary edema the definition of drowning is death from suffocation after submersion. Freshwater drowning in swimming pools is actually more common than saltwater drowning. The patient described has noncardiogenic pulmonary edema, which is a complication of near drowning (survival after suffocation from submersion)
100. A 22-year-old man is brought to the emergency room after being found unconscious in a swimming pool. The patient is mildly cyanotic. Blood pressure is 80/50 mm Hg, heart rate is 60 beats per minute, and respiratory rate is 26 breaths per minute. His core body temperature is 31.7°C (89°F). Pupils are 4 mm bilaterally and reactive. The patient is moving all extremities and responds appropriately to questions. Crackles are heard bilaterally on lung auscultation. Pulse oximetry reveals a saturation of 94% on 50% oxygen. Chest radiograph reveals bilateral perihilar infiltrates with a normal-sized heart. Which of the following is the most likely diagnosis? a. Partial fracture of the C5 vertebral body b. Subdural frontal hematoma c. Congestive heart failure d. Noncardiogenic pulmonary edema e. Drowning
a. Fat embolism Patients with severe long bone injuries are at risk for developing widespread fat embolism syndrome
101. Forty-eight hours after a motor vehicle accident, a 47-year-old man develops restlessness and hypoxemia. He has retinal and conjunctival hemorrhages, and fat is seen in the retinal vessels. A petechial rash is visible in the upper chest and supraclavicular areas. Lung examination reveals bilateral crackles, and chest radiograph shows interstitial bilateral infiltrates. Fat globules are present in the urine. The patient requires immediate endotracheal intubation. Which of the following is the most likely diagnosis? a. Fat embolism b. Hospital-acquired pneumonia c. Mendelson syndrome d. Cardiac pulmonary edema e. Pneumocystis jiroveci pneumonia
c. Nasal flaring Patients with emphysema or chronic bronchitis at baseline often have a thin body habitus due to caloric expenditure in excess of intake, increased anteroposterior thickness of the thorax (barrel chest), clubbing, productive cough, and often employ pursed-lip breathing to prolong the expiratory phase of respiration and prevent sudden collapse of the small airways.
102. A 60-year-old man with an 80-pack-per-year history of cigarette smoking presents to the emergency room complaining of some dyspnea on exertion. He has an asthenic body habitus and pursed-lip breathing. He has an increased anteroposterior thickness of the thorax. Lung examination reveals decreased fremitus, hyperresonance on percussion, and diminished breath sounds. Which of the following signs most indicates respiratory distress signifying possible need for intubation? a. Pursed-lip breathing b. Prolonged expiratory phase of breathing c. Nasal flaring d. Clubbing e. Productive cough
c. Lung abscess A lung abscess is a thick-walled cavity surrounded by consolidation, usually presenting with an air-fluid level on imaging. Periodontal disease and a history of aspiration, often as a result of loss of consciousness due to seizure, alcoholism, or illicit drug use, predispose to this anaerobic infection.
103. A 45-year-old alcoholic man with a history of blackouts when intoxicated presents with fever, chills, and cough productive of putrid, foul-smelling sputum. On physical examination the patient appears inebriated. He is febrile with a temperature of 39.5°C (103.2°F). Mouth examination reveals numerous dental caries and poor dental hygiene. Which of the following is the most likely diagnosis? a. Spontaneous pneumothorax b. Bronchogenic carcinoma c. Lung abscess d. Pleural effusion e. Community-acquired pneumonia
a. Acute respiratory distress syndrome Acute respiratory distress syndrome (ARDS) is the most severe form of acute lung injury and leads to acute respiratory failure.
104. A 53-year-old woman with diabetes and COPD was initially admitted with pyelonephritis and sepsis. On her second day of admission, she complains of significant shortness of breath. The patient is tachypneic with use of accessory muscles and on lung examination has crackles anteriorly and posteriorly. Her cardiac examination is only significant for tachycardia. Arterial blood gas reveals a PO2 of 50 mm Hg on 100% oxygen. The chest radiograph reveals bilateral whiteout of the lungs, consistent with interstitial and alveolar infiltrates, without cardiomegaly. V/Q scan is read as low probability. Which of the following is the most likely diagnosis? a. Acute respiratory distress syndrome b. Hospital-acquired pneumonia c. Pneumothorax d. Cardiogenic pulmonary edema e. Pulmonary embolism
b. Greater dyspnea and deoxygenation when upright this patient with cirrhosis has developed the hepatopulmonary syndrome, which is a triad of liver disease, intrapulmonary vascular dilations, and increased alveolar-arterial oxygen gradient on room air.
105. A 62-year-old man with a history of cirrhosis presents to the hospital with discomfort due to ascites. While hospitalized he is noted to have an increased alveolar-arterial gradient on room air and upon further discussion admits to baseline shortness of breath over the past few months. What might you expect to find on this patient? a. Greater dyspnea and deoxygenation when supine b. Greater dyspnea and deoxygenation when upright c. Greater dyspnea and deoxygenation when laying on his left side d. Greater dyspnea and deoxygenation when laying on his right side e. Complete improvement of his symptoms with paracentesis of his ascitic fluid
b. Asthma asthma is an airway disease characterized by a hyperreactive tracheobronchial tree that manifests physiologically as narrowing of the airway passages.
106. A 6-year-old boy who had a mild respiratory tract infection for 2 days awakens in the middle of the night with shortness of breath and difficulty breathing, and his parents bring him to the emergency room. His respiratory rate is 36 breaths per minute and his heart rate is 150 beats per minute. He has a prolonged expiratory phase when breathing. He is afebrile. Lung auscultation reveals high-pitched, squeaky, musical breath sounds in all lung fields during inspiration and expiration. Which of the following is the most likely diagnosis? a. Epiglottitis b. Asthma c. Croup d. Tonsillitis e. Pneumonia
c. She should receive isoniazid chemoprophylaxis. Health-care workers with a positive (≥ 10 mm) PPD require chemoprophylaxis, optimally with isoniazid for 9 months.
107. A 26-year-old incoming medical resident develops a positive PPD skin test. The area of induration is 12 cm in diameter at 48 hours. A previous PPD skin test was negative. The patient has no past medical history and does not know of any contact with patients with tuberculosis. She has not received the BCG (extract of Mycobacterium bovis) vaccine. She has no fever, chills, night sweats, weight loss, or respiratory symptoms. Her chest x-ray is negative. Which of the following statements is the next best step? a. She does not have tuberculosis and therefore needs no therapy. b. She requires a booster purified protein derivative (PPD). c. She should receive isoniazid chemoprophylaxis. d. She should have anergy testing. e. This is likely a false-positive test.
g. Pheochromocytoma The posterior mediastinum is the likely area for neurogenic tumors, lymphomas, pheochromocytomas, myelomas, meningoceles, meningomyeloceles, gastroenteric cysts, and diverticula. The area between the pleural sacs—the mediastinum—is divided anatomically into the anterior mediastinum, middle mediastinum, and posterior mediastinum. The most common masses found in the anterior mediastinum are the four Ts = Thymomas, Teratomas, Thyroid masses, and para Thyroid masses.
108. A 36-year-old woman complains of frequent headaches accompanied by abdominal pain, nausea, weakness, and palpitations. A mass located in the posterior mediastinum is seen on chest radiograph. Which of the following masses is most likely to be found in this compartment of the mediastinum? a. Thymoma b. Teratoma c. Thyroid adenoma d. Parathyroid adenoma e. Bronchogenic cyst f. Pericardial cyst g. Pheochromocytoma
b. Early septic shock the early phase of septic shock is characterized by vasodilation resulting in a warm, flushed patient with a normal or elevated cardiac output.
109. A 59-year-old patient presents with fever and agitation. On physical examination, his temperature is 39.5°C (103.2°F). His respirations are 26 breaths per minute, pulse is 126 beats per minute, and blood pressure is 100/70 mm Hg. He appears warm and flushed. A Swan-Ganz catheter is inserted that demonstrates increased cardiac output, decreased peripheral vascular resistance, and normal pulmonary capillary wedge pressure (PCWP). The patient's urine Gram stain reveals pyuria and gram-negative rods. Which of the following is the most likely diagnosis? a. Late septic shock b. Early septic shock c. Cardiogenic shock d. Hypovolemic shock e. Neurogenic shock
d. The patient has severe sepsis. Bacteremia is the presence of bacteria in blood culture bottles. SIRS is not a diagnosis but a response to a variety of clinical situations
110. A 45-year-old woman presents to the emergency room with altered mental status. On physical examination, her temperature is 38.9°C (102°F), pulse is 120 beats per minute, and respirations are 24 breaths per minute. She has increased fremitus and bronchial breath sounds at the left base. Neurologic examination reveals no focal deficits, but the patient is disoriented to place and time. Chest radiograph confirms the diagnosis of pneumonia. The patient's PaCO2 is 30 mm Hg. Which of the following best categorizes this patient's illness? a. The patient has bacteremia. b. The patient has systemic inflammatory response syndrome (SIRS). c. The patient has multiple-organ dysfunction syndrome (MODS). d. The patient has severe sepsis. e. The patient has septic shock.
b. Opiate overdose accidental overdose of opiates may occur in drug addicted patients; they present with pinpoint pupils (miosis), hypothermia, bradycardia, hypotension, and shallow breathing.
111. A 28-year-old woman is brought to the emergency room in a coma. Her respiratory rate is 6 breaths per minute and shallow. Blood pressure is 90/60 mm Hg, heart rate is 50 beats per minute, and temperature is 35.5°C (96°F). Her pupils are pinpoint but reactive to light and accommodation. She has no focal neurologic deficits. Which of the following is the most likely diagnosis? a. Carbon monoxide poisoning b. Opiate overdose c. Ethylene glycol poisoning d. Methanol poisoning e. Cocaine abuse
e. Anaphylaxis Anaphylaxis may occur several minutes after the introduction of a specific antigen; presenting symptoms may include pruritus, urticaria, angioedema, abdominal pain, nausea, vomiting, diarrhea, respiratory distress, and shock.
112. A 41-year-old man presents to the emergency room complaining of itchiness and difficulty breathing. He states that his symptoms started after attending a party where he ate some fish and peanuts. On physical examination, the patient is anxious, tachypneic, and tachycardic. He has urticaria over his chest, neck, and extremities. Lung examination reveals inspiratory and expiratory wheezes. Heart examination is normal. Which of the following is the most likely diagnosis? a. Angioedema b. Exacerbation of asthma c. Pulmonary embolus d. Toxic shock syndrome e. Anaphylaxis
a. Familial C1 inhibitor deficiency Hereditary angioedema is an autosomal dominant disease due to a deficiency of C1 inhibitor (C1INH). The family history and the lack of urticaria suggest the diagnosis.
113. A 16-year-old student has recurrent episodes of facial swelling without urticaria. Family history reveals that two siblings and both parents have similar symptoms. Which of the following is the most likely diagnosis? a. Familial C1 inhibitor deficiency b. Cystic fibrosis c. Exacerbation of asthma d. Acquired C1 inhibitor deficiency e. Serum sickness
b. Latex anaphylaxis latex anaphylaxis may occur in patients, like this young girl, who have spina bifida or congenital urologic defects and have undergone repetitive surgeries.
114. A 6-year-old girl with spina bifida is admitted to the intensive care unit because of rapidly progressive swelling of her lips, wheezing, and stridor. She had been playing with balloons at a birthday party. Which of the following is the most likely diagnosis? a. Food anaphylaxis b. Latex anaphylaxis c. Severe drug allergy d. Exercise-related anaphylaxis e. Idiopathic anaphylaxis
b. Acute mountain sickness High-altitude sickness can occur at altitudes greater than 9500 ft, and mountain climbers at extreme altitudes (over 18,000 ft) are susceptible to hypoxemia and physiologic deterioration.
115. A 22-year-old man develops shortness of breath and difficulty breathing while mountain climbing at an altitude of 12,000 ft. His temperature is 36.1°C (97°F). He has a blood pressure of 120/80 mm Hg, respirations of 24 breaths per minute, and a heart rate of 114 beats per minute. He has retinal hemorrhages on funduscopy examination. He has no heart murmur. Bilateral crackles are audible on lung examination. Which of the following is the most likely diagnosis? a. Carbon monoxide poisoning b. Acute mountain sickness c. Hypothermia d. Exhaustion e. Dehydration
b. Carbon monoxide poisoning Gasoline engines, paint removers, and the incomplete combustion of wood, coal, or natural gas produce carbon monoxide (CO), which binds preferentially to hemoglobin and decreases the release of oxygen to tissues.
116. Paramedics bring a 41-year-old man to the emergency room. He is complaining of headache, dizziness, nausea, and abdominal pain. The paramedics state that the patient's apartment has a coal furnace. His blood pressure is 110/70 mm Hg, respirations are 20 breaths per minute, and pulse is 100 beats per minute. The patient has a cherry-red appearance most noticeable around the lips and nail beds. Neurologic examination reveals a disoriented and confused man without focal deficits. Oxygen saturation by pulse oximetry is normal. Which of the following is the most likely diagnosis? a. Drug overdose b. Carbon monoxide poisoning c. Alcohol intoxication d. Methemoglobinemia e. Dysbarism
c. Obstructive sleep apnea syndrome The patient with obstructive sleep apnea syndrome (OSAS) presents complaining of disruptive snoring and daytime hypersomnolence.
119. A 35-year-old man complains of daytime sleepiness and disruptive snoring. He admits to falling asleep several times a day while at work. He does not smoke. He is 72 in tall and weighs approximately 210 lb. a. Narcolepsy b. Depression c. Obstructive sleep apnea syndrome d. Obesity hypoventilation syndrome e. Cataplexy f. Somnambulism
d. Obesity hypoventilation syndrome Patients with obesity hypoventilation syndrome, or pickwickian syndrome, demonstrate a decrease in central respiratory drive (no respiratory effort), especially during sleep (sleep-induced hypoventilation), since vital capacity is further reduced in the recumbent position.
120. A morbidly obese woman is admitted to the intensive care unit after being found in bed with lethargy, cyanosis, and hypoxemia. a. Narcolepsy b. Depression c. Obstructive sleep apnea syndrome d. Obesity hypoventilation syndrome e. Cataplexy f. Somnambulism
b. Cyanide poisoning yanide poisoning is associated with a bitter almond odor elevated venous oxygen saturation because tissues fail to take up arterial oxygen.
121. A 30-year-old man presents to the emergency room with headache, dizziness, abdominal pain, nausea, vomiting, and confusion. The odor of bitter almonds is detected on his breath. Venous oxygen saturation is more than 90%. a. Diabetic ketoacidosis b. Cyanide poisoning c. Marijuana use d. Mercaptan poisoning e. Arsenic poisoning f. Naphthalene ingestion
a. Diabetic ketoacidosis Patients in diabetic ketoacidosis (DKA) often have a fruity breath odor. Hyperpnea refers to respiration, which is deep (increase in tidal volume) as well as rapid (Kussmaul breathing).
122. A 19-year-old college student is brought to the emergency room by ambulance. She has no past medical history and takes no medications. She does not smoke cigarettes, drink alcohol, or use illicit drugs. She is unresponsive and hyperpneic. Her breath has a fruity odor. a. Diabetic ketoacidosis b. Cyanide poisoning c. Marijuana use d. Mercaptan poisoning e. Arsenic poisoning f. Naphthalene ingestion
e. Arsenic poisoning Arsenic ingestion and parathion poisoning are associated with a garlic odor.
123. A 44-year-old factory worker presents with a 12-hour history of abdominal pain, vomiting, watery diarrhea, and muscle cramps. An odor of garlic is detected on his breath. He has diminished vibration sensation of the lower extremities. a. Diabetic ketoacidosis b. Cyanide poisoning c. Marijuana use d. Mercaptan poisoning e. Arsenic poisoning f. Naphthalene ingestion
d. Primary pulmonary hypertension Primary pulmonary hypertension (PPH) is of unknown etiology and primarily affects women in their thirties or forties.
81. A 30-year-old woman presents with the chief complaint of shortness of breath with minimal activity. In retrospect, she feels she has been dyspneic for at least 1 year but has now progressed to the point where she has difficulty climbing stairs and walking short distances. She denies fever, cough, or chest pain. On physical examination, the patient has jugular venous distension (JVD) and a palpable right ventricular lift. On heart auscultation, there is a loud S2 and a systolic murmur that increases with inspiration. Lungs are clear. There is no clubbing. Which of the following is the most likely diagnosis? a. Sarcoidosis b. Coronary heart disease c. Idiopathic pulmonary fibrosis d. Primary pulmonary hypertension e. Systemic lupus erythematosus
a. Acute bronchitis Massive life-threatening hemoptysis is more than 200 mL of blood in 24 hours. The most common cause for nonmassive hemoptysis (< 30 mL/d) in smokers and nonsmoking patients with a normal chest radiograph is acute or chronic bronchitis.
82. A 44-year-old obese woman presents with the chief complaint of hemoptysis. She states that over the last day she has coughed up approximately 10 mL of blood- streaked sputum. She denies fever, chills, chest pain, or shortness of breath. She had a recent upper respiratory tract infection with cough and a copious amount of sputum production. She has smoked one pack of cigarettes per day since high school. Examinations of the pharynx and lungs are normal. Which of the following is the most likely diagnosis? a. Acute bronchitis b. Tuberculosis c. Adenocarcinoma of the lung d. Congestive heart failure e. Pulmonary infarction
e. Bronchiectasis Bronchiectasis is an acquired disease that causes abnormal dilatation of the bronchi leading to pooling of secretions in the airways and recurrent infections.
72. A 59-year-old woman presents complaining of a cough productive of sputum for nearly 10 years. Her cough occurs during the day, and she produces sputum daily. The woman states that as a child, she had several episodes of pneumonia requiring hospital admissions and antibiotics. Several times a year, her sputum becomes purulent and she requires antibiotic therapy. She has never smoked cigarettes and has worked as a seamstress all of her life. On physical examination, the lungs are clear without wheezes, rhonchi, or crackles. A chest radiograph reveals tram-track markings at the bases. Which of the following is the most likely diagnosis? a. Asthma b. Cystic fibrosis c. Chronic bronchitis d. Emphysema e. Bronchiectasis
a. Pseudomonas aeruginosa The patient has been in the hospital for more than 48 hours and has developed a hospital-acquired pneumonia. Patients develop fever, leukocytosis, cough productive of purulent sputum, and a new or progressive infiltrate on chest radiograph.
73. A 71-year-old woman has been in the hospital for 4 days after suffering a stroke in the distribution of the middle cerebral artery. She is not ambulating but is able to eat a pureed diet with assistance from hospital personnel. On the fifth hospital day, she develops a fever and a cough productive of purulent sputum. Lung examination reveals increased fremitus and crackles at the right base. Chest radiograph reveals a right lower-lobe patchy infiltrate. Which of the following is the most likely causal organism? a. Pseudomonas aeruginosa b. Chlamydia pneumoniae c. Atypical Mycobacterium d. Influenza virus e. Parainfluenza virus f. Moraxella catarrhalis
d. D-dimer 74. The answer is d. (Simel, pp 561-575.) Pulmonary embolism (PE) occurs in 1 to 2 persons per 1000 annually in the United States. Most patients who have a PE present with risk factors for hypercoagulability (pregnancy, use of oral contraceptives, family or personal history of clotting, prolonged immobility), pleuritic chest pain, dyspnea, and occasionally hemoptysis.
74. A 33-year-old woman comes to the emergency department complaining of sharp, pleuritic chest pain on the right, 3 days following the onset of an upper respiratory infection which includes nasal drainage and nonproductive cough. She has no significant past medical history and takes no medication except an oral contraceptive. She does smoke occasionally and has not traveled recently. She has no family history of venous thromboembolism. On physical examination she is not in respiratory distress, with no tachypnea or tachycardia, though she is preventing full inspiratory effort due to pain. Her legs are not swollen. A pregnancy test is negative. Which is the appropriate first step in ruling out a pulmonary embolism in this patient? a. Ventilation-perfusion scan (V/Q scan) b. Doppler ultrasound of the lower extremities c. Spiral computed tomography (CT) of the chest d. D-dimer e. Chest x-ray
a. Cryptogenic organizing pneumonitis This patient has cryptogenic organizing pneumonitis, also known as idiopathic bronchiolitis obliterans with organizing pneumonia (BOOP).
75. A healthy 50-year-old man presents with a 1-month history of low-grade fever, exertional dyspnea, and cough productive of clear phlegm. He denies hemoptysis and hematuria. He has been taking two antibiotics for the symptoms without relief. He does not smoke cigarettes and works as an accountant. On physical examination, his temperature is 38.3°C (101.0°F) and his lung examination reveals inspiratory crackles. A chest radiograph reveals bibasilar fibrosis and air-space densities in the lower lobes. Which of the following is the most likely diagnosis? a. Cryptogenic organizing pneumonitis b. Sarcoidosis c. Allergic bronchopulmonary aspergillosis d. Wegener granulomatosis e. Goodpasture syndrome
e. Head tilt-chin lift maneuver The tongue may fall posteriorly to obstruct the oropharynx and is the major cause of airway obstruction. This may occur in patients with a decreased level of consciousness and may be corrected by utilizing the head tilt-chin lift maneuver.
76. A 39-year-old man has a seizure in your clinic. On physical examination he is unresponsive and cyanotic. Vital signs reveal a temperature of 38°C (100.5°F), heart rate of 110 beats per minute, and blood pressure of 150/85 mm Hg. Lung examination reveals decreased breath sounds bilaterally. Heart examination is normal and he has a gag reflex. Pulse oximetry reveals a hemoglobin saturation of 80% on 100% oxygen. Which of the following is the most appropriate first step in management? a. Chest tube placement b. Endotracheal intubation c. Arterial blood gas analysis d. Stat portable chest radiograph e. Head tilt-chin lift maneuver
d. Helical CT This patient has several symptoms (shortness of breath and pleuritic chest pain, in the setting of cancer) and signs (tachypnea, tachycardia, lower extremity edema, increased alveolar-arterial gradient, loud S2) suspicious for pulmonary embolus (PE).
77. A 65-year-old woman being treated for lung cancer presents with the sudden onset of pleuritic chest pain and shortness of breath. She has been doing well until 3 days ago, when she noticed some swelling of her left lower extremity. She is not a smoker and denies any recent trauma. On physical examination, she is afebrile but has a respiratory rate of 32 breaths per minute. Her heart rate is 120 beats per minute and her blood pressure is normal. An accentuated (loud) S2 is heard on heart auscultation. The left lower extremity is swollen, tender to palpation, and erythematous. Lung examination and chest radiograph are normal. Arterial blood analysis on room air shows a PCO2 of 30 mm Hg and a PO2 of 58 mm Hg. Which of the following is the most appropriate next diagnostic step? a. Transesophageal echocardiogram b. Transthoracic echocardiogram c. Cardiac catheterization d. Helical CT e. D-dimer assay
e. Increased tactile fremitus on the left The patient described most likely has community-acquired pneumonia (CAP) due to Streptococcus pneumoniae. Other pathogens responsible for CAP include M pneumoniae, viruses, and C pneumoniae.
78. A thin 35-year-old woman presents with a 2-day history of cough. She complains of some mild dyspnea and left-sided pleuritic chest pain. On physical examination, her temperature is 38.5°C (101.4°F) and her respiratory rate is 26 breaths per minute. Her blood pressure is 110/65 mm Hg and her heart rate is 125 beats per minute. Which of the following physical examination findings would most likely be found if she has an uncomplicated left-sided pneumonia? a. Inspiratory stridor b. Vesicular breath sounds on the left c. Absence of egophony on the left d. Decreased tactile fremitus on the left e. Increased tactile fremitus on the left
d. Right middle-lobe pneumonia The best areas to listen for right middle lobe findings would be (1) the right anterior midclavicular line between the fifth and sixth ribs and (2) the right midaxillary line between the fourth and sixth ribs.
79. A 34-year-old nursing student is referred to your office because of the onset of a recent cough productive of dark-colored sputum. She is febrile but does not appear ill. She has been able to continue working with her symptoms. Examination of the posterior thorax is normal, but there is dullness at the anterior right hemithorax below the fifth rib. Crackles, as well as localized pectoriloquy, are audible over the same area. Which of the following is the most likely diagnosis? a. Right lower-lobe pneumonia b. Left lower-lobe pneumonia c. Right lower-lobe atelectasis d. Right middle-lobe pneumonia e. Right upper-lobe pneumonia
b. Kartagener syndrome This patient has Kartagener's syndrome, due to a defect that causes the cilia within the respiratory tract epithelium to become immotile, thereby predisposing patients to frequent pneumonias.
80. A 14-year-old adolescent presents with a history of chronic sinusitis and frequent pneumonias. He was born at 38 weeks and had an uneventful delivery. On physical examination, the patient has normal vital signs and is afebrile. He has mild frontal and maxillary sinus tenderness with palpation. Transillumination of the sinuses is normal. Heart sounds are best heard on the right side of the chest. The boy is coughing copious amounts of yellowish sputum. Which of the following is the most likely diagnosis? a. Cystic fibrosis b. Kartagener syndrome c. Bronchopulmonary dysplasia d. Tuberculosis e. Pulmonary hypertension
a. Acute exacerbation of chronic obstructive pulmonary disease (COPD) This patient has an exacerbation of chronic obstructive pulmonary disease (COPD), a condition in which there is chronic obstruction to airflow due to chronic bronchitis or emphysema.
83. A 70-year-old man with a history of smoking since age 14 complains of worsening shortness of breath for the last several days. At baseline he has a dry cough and wheezes daily, but now he is coughing large amounts of yellow-colored sputum and is receiving no relief from his β2-agonist and ipratropium aerosolized pumps. On physical examination, the patient's respiratory rate is 40 breaths per minute and his heart rate is 110 beats per minute. His blood pressure is 150/85 mm Hg. The patient is afebrile. He is using his accessory muscles of respiration (sternocleidomastoids and inter-costals) to assist in breathing. Lung examination reveals diffuse inspiratory and expiratory wheezing with a prolonged expiratory phase. Which of the following is the most likely diagnosis? a. Acute exacerbation of chronic obstructive pulmonary disease (COPD) b. α1-Antitrypsin deficiency c. Chronic bronchitis d. Exacerbation of asthma e. Pneumonia
c. Fiberoptic bronchoscopy Carcinoid and bronchial gland tumors are called bronchial adenomas but are actually low-grade malignant neoplasms. They are resistant to radiation and chemotherapy.
84. A 53-year-old woman presents with a 4-month history of cough productive of bloody sputum. She denies fever, chills, and night sweats but has occasional flushing that she feels is secondary to menopause. She has had two pneumonias over the last 3 years that required short-term hospitalization. Physical examination reveals wheezing localized to the left midlung field. Chest radiograph is normal. Which of the following is the most appropriate next diagnostic step? a. Pulmonary function tests b. Pulmonary angiography c. Fiberoptic bronchoscopy d. Ventilation-perfusion scan e. Video-assisted thoracoscopy
d. Hyperresonant percussion The patient has a tension pneumothorax, as evidenced by the trachea deviating away from the side of the traumatized lung. This occurs secondary to trauma or during mechanical ventilation.
85. A man is stabbed and arrives at the emergency room within 30 minutes. You notice that the trachea is deviated away from the side of the chest with the puncture. The most likely lung finding on physical examination of the traumatized side is which of the following? a. Increased fremitus b. Increased breath sounds c. Dullness to percussion d. Hyperresonant percussion e. Wheezing f. Stridor
b. Secondary pneumothorax The patient most likely has a secondary spontaneous pneumothorax, likely due to ruptured blebs resulting from his emphysema. Patients with COPD, cystic fibrosis, Pneumocystis jiroveci pneumonia (PCP), and tuberculosis may have blebs and are at risk for secondary pneumothoraxes.
86. A 65-year-old man with longstanding emphysema presents with the sudden onset of sharp right-sided chest pain associated with shortness of breath. He denies any history of trauma. On physical examination, the patient is afebrile with a respiratory rate of 28 breaths per minute. His blood pressure is 100/70 mm Hg and his heart rate is 120 beats per minute. Neck examination reveals no tracheal deviation. On lung auscultation, the patient has decreased fremitus, hyperresonance, and diminished breath sounds over the right posterior hemithorax. Which of the following is the most likely diagnosis? a. Tension pneumothorax b. Secondary pneumothorax c. Pulmonary embolus d. Primary pneumothorax e. Pneumonia
e. Cholesterol crystals the pleural effusion of rheumatoid arthritis is exudative with a high lactate dehydrogenase, low complement level, low glucose level, high rheumatoid factor, and characteristic cholesterol crystals.
87. A 41-year-old woman with a past medical history significant for rheumatoid arthritis presents with shortness of breath and dyspnea on exertion. She has right- sided chest pain that worsens with cough and deep breath. Her cough is nonproductive; she denies fever, chills, and night sweats. Physical examination reveals diminished breath sounds halfway down the right posterior hemithorax with an audible pleural rub. Chest radiograph reveals a right-sided pleural effusion. Which of the following is most likely to be seen on thoracentesis? a. High amylase level b. High glucose level c. Bloody fluid d. High complement levels e. Cholesterol crystals
b. Legionnaires disease the clinical presentation of pulmonary and gastrointestinal complaints is most consistent with legionnaires disease (Legionella pneumonia).
88. A 66-year-old man presents with a scanty cough and pleuritic chest pain. He also complains of fever and watery diarrhea. He smokes one pack of cigarettes per day and lives in an apartment building that is undergoing plumbing renovation. He has no past medical history and takes no medications. Physical examination reveals a toxic-appearing man with a temperature of 40°C (104°F). His heart rate is 60 beats per minute. Chest auscultation reveals bilateral scattered crackles. Abdominal examination reveals diffuse tenderness. Laboratory results reveal hyponatremia, hypophosphatemia, elevated liver function tests, and thrombocytopenia. A chest radiograph reveals patchy bilateral infiltrates. Which of the following is the most likely diagnosis in this patient? a. Pontiac fever b. Legionnaires disease c. Influenza d. Tuberculosis e. Psittacosis
d. Tracheal stenosis Tracheal stenosis may occur days to months after intubation and is a sequela of the balloon cuff of the tracheal tube pressing against the tracheal wall, causing necrosis and scar tissue formation.
89. A 37-year-old woman was recently extubated after requiring a ventilator for 10 days for an exacerbation of her asthma. After the uncomplicated extubation, the patient complains of hoarseness and dyspnea. On physical examination, her lungs are clear, with normal fremitus and dullness. There is no tracheal deviation, and heart examination is normal. The patient's chest radiograph is normal. Which of the following is the most likely diagnosis? a. Oxygen toxicity b. Premature extubation c. Hospital-acquired pneumonia d. Tracheal stenosis e. Aspiration pneumonia
e. No other therapy is needed The patient most likely has Mendelson syndrome (acute aspiration of gastric contents), which leads to a chemical pneumonitis and potentially acute respiratory distress syndrome (ARDS) due to extensive desquamation of the bronchial epithelium with subsequent pulmonary edema.
90. A 41-year-old woman presents to the emergency room after being given naloxone by paramedics for a probable heroin overdose. The paramedics state that the patient began to vomit excessively, and they fear she may have aspirated gastric contents. Physical examination reveals a respiratory rate of 32 breaths per minute, and pulse oximetry reveals a saturation of 82%. The patient appears cyanotic. Lung examination is significant for bilateral crackles. There is no S3 gallop. Chest radiograph reveals bilateral basilar alveolar infiltrates. The patient is immediately intubated and stabilized. Which of the following is the most appropriate next step in management ? a. High-dose steroids b. Broad-spectrum antibiotics c. β-Agonist therapy d. Intravenous theophylline e. No other therapy is needed
c. Posterior segment of the right upper lobe The right main stem bronchus is wider, shorter, and vertically placed, and therefore, if the patient aspirates while supine, the posterior segment of the right upper lobe as well as the superior segments of both lower lobes are anatomically susceptible to aspiration.
91. A 23-year-old college student presents to the emergency room unresponsive. He has been depressed at school and may have ingested 20 phenobarbital pills his roommate had for a seizure disorder. Paramedics report that the patient was found in the supine position. Vital signs reveal a blood pressure of 90/50 mm Hg, a heart rate of 54 beats per minute, and a respiratory rate of 10 breaths per minute. Pupils are equally dilated and constrict to light. Lung examination reveals right-sided crackles. Neurologic examination is significant for decreased muscle tone and hyporeflexia. Gag reflex is not tested. You suspect that the patient has aspirated. Which of the following is the most likely lung segment to be affected? a. Medial segment of the right middle lobe b. Lateral segment of the right middle lobe c. Posterior segment of the right upper lobe d. Apical segment of the right upper lobe e. Anterior segment of the right upper lobe
d. Asbestosis Persons in certain occupations, such as asbestos mining, shipbuilding, construction, insulation, pipe fitting, plumbing, electrical repair, and railroad engine repair are at risk for asbestos exposure.
92. A 65-year-old man presents with severe right-sided chest pain over several months. He has been a lifelong smoker and worked most of his life as a shipbuilder. On physical examination, the patient appears to be dyspneic at rest. Lung auscultation reveals scattered rhonchi anteriorly and posteriorly. The patient has clubbing. Chest radiograph reveals the lungs to have a ground-glass appearance, and bilateral pleural plaques with some areas of calcification and pleural thickening are evident. Which of the following is the most likely diagnosis? a. Byssinosis b. Bagassosis c. Silicosis d. Asbestosis e. Farmer's lung
a. Polysomnography This obese patient with daytime somnolence and witnessed snoring and apneic episodes has obstructive sleep apnea. Large neck circumference has specifically been linked to this disorder in which the pharynx collapses during inspiration in sleep.
93. A 45-year-old obese man with a history of hypertension presents with his wife complaining of daytime sleepiness, to the extent that he falls asleep if he sits still for any length of time. His wife reports that he snores very loudly and occasionally even stops breathing for a few seconds, eventually snorting and then resuming his normal breathing pattern. On examination, he has a large neck and centripetal obesity with an elevated blood pressure. He has a pendulous uvula but his heart, lung, and abdominal examinations are normal. What is the most appropriate first step in diagnosing his complaint? a. Polysomnography b. Pulmonary function tests c. Chest radiograph d. Pulse oximetry e. Arterial blood gas analysis
b. Sarcoidosis
94. A 21-year-old college student who lives in an apartment off campus presents with a 2-month history of anterior and posterior cervical lymphadenopathy. He denies recent illness, weight loss, fever, and night sweats. His physical examination reveals scattered nontender 1-cm cervical nodes bilaterally. Lung, heart, and abdominal examinations are normal. His chest radiograph shows bulky hilar lymph nodes with no parenchymal abnormality. Which of the following is the most likely diagnosis? a. Pneumonia b. Sarcoidosis c. Tuberculosis d. Berylliosis e. Idiopathic fibrosing interstitial pneumonia
d. Postnasal drip The most common causes of chronic, noninfectious cough in adults are postnasal drip due to sinusitis or rhinitis (allergic, vasomotor, irritant, perennial nonallergic), asthma, and gastroesophageal reflux disease (GERD).
95. A 45-year-old woman with no past medical history presents with a 2-year history of nonproductive cough. The cough is not associated with time of day or year, and the patient denies any occupational or environmental exposures. She has never smoked cigarettes. She finds herself clearing her throat frequently during the day and night. She has no nasal discharge, heartburn, or cardiac symptoms. She denies fever, chest pain, or shortness of breath. She takes no medications. On physical examination, her nasopharynx reveals mucopurulent secretions and a cobblestone-appearing mucosa. Lung examination is normal. Chest radiograph is normal. Which of the following is the most likely diagnosis? a. Gastroesophageal reflux disease b. Asthma c. Bronchitis d. Postnasal drip e. Use of angiotensin-converting enzyme (ACE) inhibitors f. Congestive heart failure
c. Pleural effusion This patient has a pleural effusion most likely due to tuberculosis. Chest examination of a pleural effusion reveals distant or absent breath sounds, a pleural friction rub, decreased fremitus, and flatness to percussion.
96. A 30-year-old homeless man presents with a 3-month history of left-sided pleuritic chest pain, shortness of breath with exertion, and night sweats. He admits to a 10-lb weight loss over the last several months. He is a nonsmoker and does not use illicit drugs. He reports being heterosexual. He recalls a negative purified protein derivative (PPD) when he was incarcerated 2 years ago. On physical examination, his temperature is 38.3°C (100.9°F) and his respiratory rate is 24 breaths per minute. Lung examination reveals decreased fremitus, dullness to percussion, and diminished breath sounds over the left posterior lung. A pleural friction rub is audible at the left lung base. Which of the following is the most likely diagnosis? a. Pneumonia b. Pneumothorax c. Pleural effusion d. Lung abscess e. Pulmonary nodule
b. Pneumocystis jiroveci pneumonia based on the patient's risk factors for human immunodeficiency virus (HIV), P jiroveci (formerly P carinii) pneumonia (PCP) is the most likely diagnosis in this patient, but PCP rarely presents with any physical examination findings that distinguish it from other pneumonias.
97. A 26-year-old woman presents complaining of dyspnea on exertion and bilateral pleuritic chest pain with a recent 30-lb weight loss. On social history she reports occasional intravenous drug use and sex with multiple partners since her teens. On physical examination, heart rate is 124 beats per minute, respiratory rate is 28 breaths per minute, blood pressure is 100/70 mm Hg, and temperature is 39.1°C (102.4°F). Pulse oximetry reveals a saturation of 85% on room air. She has thrush in her mouth and lung auscultation reveals scattered bilateral crackles posteriorly. Chest radiograph reveals bilateral interstitial infiltrates and no cardiomegaly. Which of the following is the most likely diagnosis? a. Pulmonary edema b. Pneumocystis jiroveci pneumonia c. Cytomegalovirus pneumonia d. Kaposi sarcoma e. Varicella zoster pneumonia
b. Mycoplasma pneumonia in young, otherwise healthy patients who present with a localized pneumonia (in this case, right middle lobe) of gradual onset accompanied by dry cough and a predominance of extrapulmonary symptoms (ie, malaise, headache, diarrhea), the most likely diagnosis is atypical pneumonia due to C pneumoniae or M pneumoniae.
98. An 18-year-old college student presents with a 2-week history of a dry cough. Her symptoms include sore throat at the start of the illness, headache, low-grade fever, and generalized malaise. She is otherwise healthy and does not drink alcohol or smoke cigarettes. Several of her colleagues at school are ill with a similar illness. Physical examination reveals normal vital signs, and lung examination reveals some crackles at the right midaxillary line. Which of the following is the most likely diagnosis? a. Pneumococcal pneumonia b. Mycoplasma pneumonia c. Aspiration pneumonia d. Primary pulmonary hypertension e. Legionella pneumonia
d. Rapid and shallow breathing In emphysema, there is destruction of alveolar septa and reduced elastic recoil. This causes collapse of the small airways and prolongs the expiratory phase of respiration. During the prolonged expiration, patients will have rapid and shallow breathing and purse their lips to avoid collapse of the small airways (this causes auto-positive end-expiratory pressure [auto-PEEP]).
99. A 55-year-old man with emphysema will have which pattern of breathing? a. Biot respiration b. Apneustic breathing c. Cheyne-Stokes respiration d. Rapid and shallow breathing e. Kussmaul breathing
a. Pectus excavatum Pectus excavatum, or funnel breast, is a congenital, hereditary malformation characterized by depression of the sternum below the clavicular-manubrial junction with symmetric inward bending of the costal cartilages.
A 4-year-old boy has a marked depression of the sternum below the clavicular-manubrial junction. a. Pectus excavatum b. Kyphosis c. Barrel chest d. Pectus carinatum e. Lordosis
d. Pectus carinatum pectus carinatum, or pigeon breast, is a deformity where the sternum protrudes from the narrowed thorax.
A 9-year-old girl has a chest deformity in which the sternum protrudes from the thorax. a. Pectus excavatum b. Kyphosis c. Barrel chest d. Pectus carinatum e. Lordosis
