aspirating on ozzy

D. Smoking Emphysema is most commonly caused by smoking, which often results in centriacinar (also called centrilobular) emphysematous destruction of lung tissue. It appears as focal lucencies (emphysematous spaces) which measure up to 1cm in diameter.

A 72-year-old woman comes to the office because of progressive dyspnea for a year. She states that she now struggles to walk to her letterbox because of shortness of breath. She denies fevers or recent weight loss. Pulmonary examination shows prolonged expiration with pursed lips and an increased anterior-posterior diameter of the chest. A CT-scan is obtained and the patient is subsequently diagnosed with centri-acinar emphysema. Which of the following is the most likely underlying cause for this pathology? A. Asbestos exposure B. Silicone exposure C. Alpha-1-Antitrypsin Deficiency D. Smoking E. Metastatic disease

A 40-year-old man is brought to the emergency department because of severe epigastric pain. He says that the pain radiates to his back and that he has experienced nausea and vomiting. His past medical history is significant for chronic alcoholism and obesity. A CT scan is obtained and confirms the diagnosis of acute pancreatitis. Two days later he develops shortness of breath and hypoxemia. Patient is intubated and placed on mechanical ventilation. His temperature is 37.5°C (99.5°F), pulse is 115/min, respirations are 28/min, and blood pressure is 115/65 mm Hg. Laboratory test shows a brain natriuretic peptide (BNP) level of 90 pg/mL. Which of the following is the most likely diagnosis? A. Acute respiratory distress syndrome (ARDS) B. Cardiac contusion C. Fat emboli D. Hemothorax E. Tension pneumothorax

A. Acute respiratory distress syndrome (ARDS) Acute respiratory distress syndrome (ARDS) is a medical condition that occurs in critically ill patients and is characterized by widespread inflammation in the lungs and is triggered by trauma, pneumonia, and sepsis

A 45-year-old man is admitted to the hospital with shortness of breath and found to have a pleural effusion on chest X-ray. Thoracentesis is performed and the fluid is sent for laboratory testing. Results of the fluid analysis are: pleural protein 8.0, serum protein 6.5, pleural LDH 500, serum LDH 100. Based on these findings, which of the following is the most likely etiology of the pleural effusion? A. Bacterial B. Congestive heart failure (CHF) C. Cirrhosis D. Nephrotic syndrome E. Pulmonary embolism

A. bacterial Pleural effusions are collections of fluid in the lungs. Exudative effusions are characterized by a fluid protein to serum ratio >0.5, fluid LDH to serum LDH ratio >0.6, and LDH >2/3 the normal serum upper limit.

A 14-year-old girl with hereditary spherocytosis comes to the emergency department following a fall from a horse. Her injuries consisted of three fractured ribs, a punctured right lung, and a ruptured spleen that required surgical removal.Three months later the patient comes to the office because of fatigue, cough, and shortness of breath. Physical examination shows dullness to percussion and decreased breath sounds in the right lower lobe. A chest radiograph is obtained and shows a right lower lobe infiltrate with patchy opacity. The patient is started on antibiotic therapy. Which of the following organisms is the most likely causative organism in this patient? A. Streptococcus pneumoniae B. Neisseria meningitidis C. Escherichia coli D. Staphylococcus aureus E. Klebsiella pneumoniae

A.Streptococcus pneumoniae Asplenic patients are at risk of infection of encapsulated organisms. Patients in this group should receive the pneumococcal vaccine, haemophilus influenza type b vaccine, meningococcal conjugate vaccine, and annual Influenza vaccine Her history of splenectomy following her injury is particularly relevant as asplenic patients have an increased susceptibility to encapsulated organisms.

A healthy couple comes to their primary care provider's office for genetic counseling. Previously, they conceived a child who died at 7 months of age due to severe pneumonia and failure to thrive. Testing done at birth showed the child having cystic fibrosis. What is the probability that another child conceived by this couple will have the same disease? A. 0% B. 25% C. 50% D. 75% E. 100%

B. 25% Cystic fibrosis is an autosomal recessive condition. Two parents who are carriers will pass this disease to their offspring at a 25% rate.

A 68-year-old woman comes to the office for a routine examination. At this visit, she is diagnosed with mild hypertension and her physician elects to start treatment with a beta-blocker. The patients medical history includes asthma, for which she takes an albuterol inhaler as necessary, though she has not used it in over three years. Which of the following beta blockers is most likely to cause an exacerbation of her asthma? A. Atenolol B. Esmolol C. Metoprolol D. Nevibolol E. Propranolol

E. Propanolol Propranolol is a nonselective B-blocker (antagonising both beta-1 and beta-2 receptors). Asthmatics should not be prescribed anything that blocks beta-2 receptors

A. Alpha-1-Antitrypsin (A1AT) deficiency associated with panacinar emphysema, most often seen in the lower lung lobes. Think of A1AT deficiency when a young, non-smoker has signs indicative of emphysema

A 30-year-old woman comes to the office because of dyspnea and cough for 7 months. She says that she has not had any fevers, and only minimal cough. Abdominal examination shows an enlarged liver. Pulmonary examination shows prolonged expiration through pursed lips and an increased anterior-posterior diameter of the chest. Laboratory investigations show an elevated alpha fetoprotein (AFP) level. A CT-scan of the lungs is obtained, and the radiology report diagnoses panacinar emphysema. Which of the following is the most likely underlying cause? A. Alpha-1-Antitrypsin Deficiency B. Lung malignancy C. Smoking D. Streptococcus pneumoniae E. Alpha-L iduronidase deficiency

D. Emphysema may be caused by alpha-1 anti-trypsin deficiency in young patients without a history of smoking. Pulmonary symptoms in a non-smoker along with liver pathology is pathognomonic for this condition which causes panlobular emphysema in the lung tissues.

A 39-year-old woman comes to the office because of worsening shortness of breath for 5 months. She states she used to be very fit and cycled everywhere, but has been progressively finding this more difficult. She is a non-smoker, but was diagnosed with hepatocellular carcinoma a month ago. Pulmonary examination shows that her chest is hyper-resonant to percussion. Her breath sounds are distant to auscultation and she has a prolonged expiratory phase. Which of the following is the most likely diagnosis? A. Asthma B. Bronchiectasis C. Chronic bronchitis D. Emphysema E. Lung malignancy

A. Alpha 1-antitrypsin deficiency Patients with emphysema without risk factors or recurrent spontaneous pneumothorax (caused by the rupture of bullae) should be investigated for alpha 1-antitrypsin.

A 45-year-old woman comes to the office because of shortness of breath and chest tightness on exertion, which she noticed for the past two months. Examination shows mildly jaundiced conjunctivae, several spider nevi on her upper torso, and a barrel chested appearance. She was diagnosed with asthma a month ago, but says that asthma medication has not improved her breathing. She does not smoke and works as a hotel manager. A chest X-ray is obtained. Which of the following is the most likely diagnosis? A. Alpha 1-antitrypsin deficiency B. Bilateral pneumothorax C. Kartagener syndrome D. Pneumomediastinum E. Pulmonary hypertension

A. Pulmonary function testing in chronic obstructive pulmonary disease is characterized by a decreased FEV1, decreased FEV1/FVC ratio, and increased TLC, and a decreased DLCO.

A 65-year-old woman comes to the office because of a 3-month history of worsening shortness of breath and fatigue. She has also had a morning cough productive of a small amount of white sputum almost daily for the past two years. She has a 50 pack-year smoking history. Pulmonary function testing, including tests of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), total lung capacity (TLC), and diffusion capacity (DLCO) are ordered and a diagnosis is made. Which of the following best describes the most likely results of her pulmonary function testing?

A 46-year-old man comes to the emergency department after three days of difficulty breathing. He has a cough productive of yellow phlegm and his dyspnea worsens with minimal exertion. He has experienced no fever, chills or chest pain. He is otherwise generally well except from a morning cough that brings up white sputum which he has had for many years. He has a 40-pack-year smoking history and has not been vaccinated for pneumonia or influenza. On examination he has an oxygen saturation of 88% on room air, no cyanosis, a prolonged expiratory phase and auscultation elicits expiratory wheezes bilaterally. What is the most likely diagnosis? A. Acute exacerbation of chronic obstructive pulmonary disease B. Bronchial pneumonia C. Bronchiectasis D. Congestive heart failure E. Viral pneumonia

A. Acute exacerbation of chronic obstructive pulmonary disease This patient is presenting with an exacerbation of chronic obstructive pulmonary disease (COPD) of the the chronic bronchitis subtype which can be either viral or bacterial. Patients commonly produce white phlegm with their chronic cough which may increase and change color during an exacerbation. Treatment consists of corticosteroids, oxygen, and bronchodilators. If symptoms are severe, continuous positive airway pressure or endotracheal intubation may be required.

A 45-year-old woman is brought to the emergency department because of upper abdominal pain. She has nausea, vomiting, and anorexia. Medical history is contributory for gallstones. Patient's BMI is 39 kg/m2. Her temperature is 38°C (100.4°F), pulse is 107/min, respirations are 31/min, and blood pressure is 85/65 mm Hg. Physical examination shows an ecchymotic discoloration over the flanks. Alkaline phosphatase and serum lipase are both elevated. Which of the following is most likely an associated complication of this patient's condition? A. Acute respiratory distress syndrome B. Cardiac contusion C. Fat embolism D. Hemothorax E. Tension pneumothorax

A. Acute respiratory distress syndrome Acute respiratory distress syndrome (ARDS), pseudocyst formation, abscess formation, hypocalcemia, and acute renal failure are all sequelae of acute pancreatitis

A 23-year-old man is brought to the emergency department because of a head-on motor vehicle collision. Patient is breathing well with normal vital signs. Physical examination shows multiple bruises on his chest and areas of point tenderness. Four hours later he begins with dyspnea. His temperature is 37.8°C (100°F), pulse is 110/min, respirations are 28/min, and blood pressure is 140/82 mm Hg. Physical examination shows JVP of 3 cm and oxygen saturation of 85%. Supplemental oxygen has little effect. Patient is intubated and placed on mechanical ventilation (60% oxygen, PEEP of 5 cm H2O). Arterial blood gases reveal a PaO2 of 72. Chest x-ray is shown below. Which of the following is the most likely diagnosis? A. Acute respiratory distress syndrome B. Cardiac contusion C. Fat embolism D. Hemothorax E. Tension pneumothorax

A. Acute respiratory distress syndrome CXR shows generalized infiltrates or opacities in both lungs

A 16-year-old boy comes to the emergency department because of shortness of breath for an hour. His medical history includes asthma, and his symptoms have not been improved by home nebulizer treatments. He is only able to respond to questions in one-word answers due to his difficulty breathing. Respiratory examination shows elevated respiratory rate. Pulmonary auscultation shows bilateral wheezes. He is given supplemental oxygen, albuterol and ipratropium nebulizer treatments, methylprednisolone, and magnesium. After his third nebulizer treatment, his breathing becomes easier. His respirations decrease to 16/min, but his pulse is now 116/min. Which of the following is most likely responsible for the increase in pulse? A. Albuterol B. Ipratropium C. Magnesium D. Methylprednisolone E. Oxygen

A. Albuterol Beta-agonist that acts mainly on beta-2-receptors to relax bronchial smooth muscle, it does have cross-reactivity and can cause tachycardia. .

A 30-year-old woman comes to the office because of dyspnea and cough for 7 months. She says that she has not had any fevers, and only minimal cough. Abdominal examination shows an enlarged liver. Pulmonary examination shows prolonged expiration through pursed lips and an increased anterior-posterior diameter of the chest. Laboratory investigations show an elevated alpha fetoprotein (AFP) level. A CT-scan of the lungs is obtained, and the radiology report diagnoses panacinar emphysema. Which of the following is the most likely underlying cause? A. Alpha-1-Antitrypsin Deficiency B. Lung malignancy C. Smoking D. Streptococcus pneumoniae E. Alpha-L iduronidase deficiency

A. Alpha-1-Antitrypsin Deficiency Alpha-1-Antitrypsin (A1AT) deficiency is associated with panacinar emphysema, most often seen in the lower lung lobes. Think of A1AT deficiency when a young, non-smoker has signs indicative of emphysema.

A 50-year-old man comes to the office because of frequent coughing with "cups" of mucus for two months. He says he has experienced similar episodes in the preceding two years, which lasted for 3-5 months each time. Examination shows a BMI of 31, central cyanosis, and coarse rhonchi and wheezing are heard on pulmonary auscultation. Oxygen saturation measured by pulse oximetry is 90%. He has a 30 pack-year history of cigarette smoking and his Reid index was calculated to be 55%. Which of the following is the most likely diagnosis? A. Chronic Bronchitis B. Asthma C. Emphysema D. Congestive heart failure E. Sarcoidosis

A. Chronic Bronchitis Chronic bronchitis is a form of chronic obstructive pulmonary disease (COPD), along with emphysema. It is caused by hypertrophy of mucus-secreting glands in the bronchi, known as goblet cells. This is often associated with a Reid index (thickness of gland layer divided by the total thickness of the bronchial wall) of 50% or more. Common symptoms and signs include wheezing, rhonchi, central cyanosis, and dyspnea. Chronic bronchitis is defined as a productive cough for > 3 months per year (not necessarily consecutive) for > 2 years.

A 35-year-old woman develops dyspnea 4 days after thoracic surgery. Patient starts coughing with a yellowish sputum. Chest x-ray shows pleural effusion and contralateral mediastinal shift. Thoracentesis drains a milky white fluid with no odor and a triglyceride level of 115 mg/dL. Which of the following is the most likely cause of this patient's pleural effusion? A. Chylothorax B. Congestive heart failure C. Empyema D. Hemothorax E. Pneumonia

A. Chylothorax Chylothorax (or chyle leak) is a type of pleural effusion. It results from lymph formed in the digestive system (chyle) accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct. Chylothorax is related with malignancy and recent thoracic surgery.

A 67-year-old man with a history of cigarette smoking presents to his family doctor with progressive shortness of breath and cough. He came in three months ago with similar symptoms and was started on treatment with bronchodilators for a presumed diagnosis of chronic obstructive pulmonary disease (COPD). His past medical history is only significant for rheumatoid arthritis, for which he takes methotrexate. On examination, there are bibasilar crackles and finger clubbing. The patient's pulmonary function tests from 30-years-ago are shown below: Which of the following pulmonary function test findings is now most likely? A. Decreased FVC, decreased FEV1, normal FEV1/FVC ratio, and decreased DLCO B. Decreased FVC, normal FEV1, increased FEV1/FVC ratio, and decreased DLCO C. Increased FVC, decreased FEV1, decreased FEV1/FVC ratio, and decreased DLCO D. Normal FVC, decreased FEV1, decreased FEV1/FVC ratio, and normal DLCO E. Normal FVC, normal FEV1, normal FEV1/FVC ratio, and increased DLCO

A. Decreased FVC, decreased FEV1, normal FEV1/FVC ratio, and decreased DLCO This patient has interstitial lung disease as evidenced by the three classical symptoms of: cough, fine crackles (often described as "velcro-like crackles"), and digit clubbing. Other clues to this patient's diagnosis are his unresponsiveness to bronchodilators, and his long history of rheumatoid arthritis. Common causes of interstitial lung disease are idiopathic, environmental (e.g. asbestosis/silicosis), hypersensitivity (e.g. bird fancier's lung), autoimmune (e.g. rheumatoid arthritis, lupus), and drug induced (e.g. amiodarone). The disease is characterised by fibrosis of the lung parenchyma. This results in volume restriction (decreased FVC), and impaired gas diffusion in the lung (decreased DLCO).

A 20-year-old man comes to the emergency department because of shortness of breath and cough for two weeks' duration. Past medical history includes recurrent respiratory infections and cystic fibrosis. Physical examination reveals decreased lung sounds in the right lower lung field. A chest radiograph is obtained and reveals a right lower lobe consolidation. A sputum sample reveals oxidase-positive, gram-negative rods. Which of the following skin conditions is this patient at risk for developing? A. Ecthyma gangrenosum B. Erysipelas C. Impetigo D. Syphilis E. Uncomplicated cellulitis

A. Ecthyma gangrenosum Pseudomonas aeruginosa is an oxidase-positive, gram-negative rod that commonly causes pneumonia in patients with cystic fibrosis. P. aeruginosa septicemia can result in ecthyma gangrenosum an uncommon cutaneous condition classically associated with P. aeruginosa bacteremia. This dermatology condition is associated with patients who are very ill or immunocompromised. Lesions begin as painless, erythematous macules which then turn into bullous, bloody pustules. Without treatment, they gradually progress to become necrotic. Late lesions often have a black center with an erythematous border. These lesions are most commonly seen on the legs or gluteal region

A 58-year-old female comes to the emergency department because of nasal congestion, cough, purulent nasal discharge, and maxillary tooth discomfort for 2 weeks. In addition, she says that she thinks the pressure in her head is increased. Past medical history is noncontributory. Examination shows facial pain and pressure that is worse when the patient bends forward. Endoscopic examination shows purulent secretions in the middle meatus. Which of the following is the most likely diagnosis? A. Acute sinusitis B. Cystic fibrosis C. Idiopathic intracranial hypertension D. Kartagener syndrome E. Wiskott-Aldrich syndrome

A. acute sinusitis Acute sinusitis is characterized by symptoms of less than four weeks duration, nasal congestion, purulent nasal discharge, and maxillary tooth discomfort.

A 13-year-old boy comes to his pediatrician's office because of fevers and worsening cough for the past 4 days. His past medical history is significant for cystic fibrosis. A sputum culture is done which grows gram-negative rods which are oxidase positive, catalase positive, and do not ferment lactose. Which of the following is the most likely causative organism? A. Burkholderia cepacia B. Escherichia coli C. Proteus mirabilis D. Stenotrophomonas maltophilia E. Staphylococcal aureus

A. burkholderia cepacia Burkholderia cepacia is a gram-negative rod which is catalase positive and oxidase positive bacterium. B. cepacia does not ferment lactose and is a common pathogen affecting the pulmonary system in patients with cystic fibrosis, chronic granulomatous disease, and sickle cell disease. B. cepacia thrives in damp environments and are able to adhere to medical prosthesis and equipment.

A 65-year-old woman is admitted to the hospital because of severe shortness of breath that suddenly began 1 hour ago. She also has left-sided chest pain that is worse on inspiration. Medical history includes dilated cardiomyopathy and congestive heart failure. She was also recently mechanically ventilated in the intensive care unit for 2 weeks after developing a severe infection following resection of an ischemic portion of small bowel. Her temperature is 36.8°C (98°F), pulse is 119/min, respirations are 27/min, and blood pressure is 91/78 mm Hg. Examination shows that the left side of her chest is hyper-resonant to percussion. Chest X-ray is obtained. Which of the following is most likely a risk factor for her current condition? A. Chronic mechanical ventilation B. Congestive heart failure C. Dilated cardiomyopathy D. Short stature E. Female gender

A. chronic mechanical ventilation complication of long-term mechanical ventilation. The condition requires prompt treatment with decompression catheter placement in the second rib interspace in the midclavicular line.

A 28-year-old man comes to the emergency department because of wheezing and recurrent pain radiating to his back. He was treated for a Pseudomonas aeruginosa infection last week. Chest X-ray shows airway obstruction and quantitative pilocarpine iontophoresis test is positive. Which of the following complications is this patient most likely to suffer from? A. Asthma B. Azoospermia C. Mental retardation D. Mousy odor E. Tuberculosis

B. Azoospermia Classic symptoms of cystic fibrosis are bronchiectasis, pancreatic insufficiency, and cirrhosis. 95% of all males who survive cystic fibrosis to adulthood will have infertility secondary to azoospermia.

A 65-year-old man, who works at the aerospace factory in town, comes to the clinic because of fatigue, weight loss, arthralgias, and a chronic non-productive cough for the past month. Chest X-ray shows mediastinal and hilar lymphadenopathy and reticulonodular infiltrate. Kveim skin test results are negative, and a tissue biopsy from the lung shows noncaseating granulomas. Which of the following is the most likely diagnosis? A. Asbestosis B. Berylliosis C. Coal workers pneumoconiosis D. Sarcoidosis E. Silicosis

B. Berylliosis Berylliosis is a restrictive pneumoconiosis due to exposure to metallic beryllium. Risk of heavy exposure is increased in nuclear and aerospace industries. Mediastinal and hilar lymphadenopathy, as well as reticulonodular infiltrates, are often visible on chest x-ray. Kveim test will be negative. Restrictive pneumoconiosis due to heavy exposure to dust or fumes containing metallic beryllium. Nuclear and aerospace industry workers are at an increased risk. The chronic form of the disease presents with systemic symptoms, much like sarcoidosis, but a Kveim test is negative. On chest X-ray, there are mediastinal and hilar lymphadenopathy and reticulonodular infiltrates. Berylliosis is usually insidious until very late. There is an increased risk for lung cancer.

A 25-year-old man is brought to the emergency department because of a motor vehicle crash at approximately 45mph 25 minutes ago. On admission, he states that he has generalized pain and dyspnea. Examination shows he is alert and tachypneic, with unilaterally decreased breath sounds and dullness to percussion on the left side. His vital signs and the rest of his trauma-specific physical examination are otherwise unremarkable. Which of the following is the most appropriate initial diagnostic test in this patient? A. Diagnostic thoracotomy B. A chest x-ray C. A chest CT D. A diagnostic thoracentesis E. An ultrasound

B. Chest x-ray Upright chest radiography is the ideal primary diagnostic study in the evaluation of hemothorax

A 67-year-old man comes to the emergency department because of fever and shortness of breath for the past 6 days. He has associated chills and a cough productive of multiple tablespoons of thick green sputum each morning. He has a history of diabetes and end-stage renal disease requiring regular dialysis which he gets at a center near his home. He lives at home with his wife, has had no recent travel or sick contacts, and no recent hospitalizations. His temperature is 38.5°C (101.3°F), pulse is 100/min, respirations are 22/min, and blood pressure is 100/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. He can speak in 3-4 word sentences. Physical examination shows bibasilar crackles on auscultation, and diminished breath sounds at the right middle and right lower lung fields. Which of the following is the most likely diagnosis? A. Aspiration pneumonia B. Community-acquired pneumonia C. Healthcare-associated pneumonia D. Hospital-acquired pneumonia E. Ventilator-associated pneumonia

B. Community Acquired Pneumonia Community-acquired pneumonia is defined as any pneumonia occurring outside a hospital settings

A 67-year-old woman comes to the emergency department because of progressive respiratory distress for 12 hours. She says that she also has chest pain, and is very concerned that she is having a heart attack. She has a history of diabetes mellitus type 2, congestive heart failure, and gout. Current medications include metformin, insulin, cilazapril, allopurinol, and metoprolol. Pulmonary auscultation shows decreased breath sounds in the left lower lobe. A chest X-ray is obtained. Which of the following is the most likely diagnosis? (a) Previous chest x-ray, (b) Today's chest x-ray A. Cirrhosis B. Congestive heart failure exacerbation C. Malignant metastases D. Pneumonia E. Pulmonary embolism and infarction

B. Congestive heart failure exacerbation This patient has a left pleural effusion. The costophrenic angle on the left is obscured, as well as the left lower lung field. Considering this patient's past history of congestive heart failure, this is most likely an exacerbation from fluid overload causing a transudative effusion. The accumulation of fluid can cause respiratory distress as it causes compressive atelectasis of the adjacent lung

A 64-year-old man comes to the office because of progressive shortness of breath for 6 months. He states that he first noticed symptoms walking upstairs but now is short of breath even walking on the flat. He has minimal cough and denies expectoration. Examination shows a thin appearing man with a barrel chest. He is breathing through pursed lips and using his accessory respiratory muscles. The chest is hyper-resonant to percussion, and pulmonary auscultation shows distant breath sounds and wheezing. Chest X-ray is obtained. Which of the following is the most likely diagnosis? A. Chronic bronchitis B. Emphysema C. Lobar pneumonia D. Lung cancer E. Sarcoidosis

B. Emphysema Characteristic signs of emphysema on X-ray are over-expanded lungs, a flattened diaphragm, increased retrosternal airspace, and bullae. Emphysema patients are often referred to as "Pink Puffers"

A 55-year-old Caucasian woman comes to the office because of a 1-week history of a productive cough and shortness of breath. Her medical history is relevant for type II diabetes mellitus, high blood pressure, and major depressive disorder. She currently takes metformin, telmisartan, and escitalopram. Upon further interrogation, the patient reports having yellowish sputum whenever she coughs. On physical examination, the patient looks pale and has shaking chills. Auscultatory findings reveal inspiratory crackles on inspiration and increased tactile and vocal fremitus. Her temperature is 39.7°C (102.2°F), pulse is 122/min, respirations are 27/min, blood pressure is 130/61 mmHg, oximetry on room air shows an oxygen saturation of 96%. A conventional chest radiograph is obtained and shown below. Which is likely the best causal organism responsible for this condition? A. Encapsulated, gram positive, diplococci, bacitracin sensitive B. Encapsulated, gram positive, diplococci, optochin sensitive C. Unencapsulated, gram negative, coccobacillary, bacitracin sensitive D. Unencapsulated, gram positive, positive acid-fast stain E. Encapsulated, gram negative, rod, oxidase negative

B. Encapsulated, gram positive, diplococci, optochin sensitive Community-acquired pneumonia (CAP) is a lower tract respiratory infection that is most commonly caused by Streptococcus pneumoniae, an encapsulated, gram positive, diplococci, and optochin sensitive microorganism. right-upper-lobe consolidation in the chest radiograph

A 58-year-old obese man comes to the emergency department after becoming severely short of breath after climbing a flight of stairs. A brief history reveals that his shortness of breath is associated with a severe cough and is productive of green sputum. He has had symptoms like these for at least four months out of the year over the past decade, but they have been consistently present for the past 6 months and seem to be worsening in severity. The patient admits to smoking about a pack of cigarettes a week for the past 20 years. He has never received the flu vaccine. He is worried that this could be related to his family history of cardiac issues. He is afebrile, there is no sign of edema, and heart sounds appear to be normal. Which of the following findings is most likely to be observed on physical examination? A. Diffusely increased breath sounds B. Expiration time much longer than inspiration time C. Hypo-resonance on percussion D. Increased tactile fremitus on palpation E. Pulmonary edema

B. Expiration time much longer than inspiration time Airway resistance is greatly increased in patients with COPD. As such, expiration, a passive process involving collapsing airways, requires a much longer time than does inspiration, an active process of expanding airways. This leads to the phenomenon of 'air trapping', where inspired air is not fully expired, slowly increasing amount of air in the lungs

A 26-year-old male is brought to the emergency department because of a gun shot wound to his left chest 27 minutes ago. His temperature is 35.6°C (96.1°F), pulse is 145/min, respirations are 32/min, blood pressure is 80/48 mm Hg, and and SpO2 is 94% on 15 L/min O2 via a non-rebreather mask. His Glasgow Coma Scale is 8. He is intubated and FAST scan reveals a left hemothorax but is otherwise unremarkable. A left-sided chest tube is placed and rapidly drains 1000 mL of blood. Over the next 45 second the patient rapidly declines and until he is cardiac arrest and has no-detectable blood pressure or carotid pulse. When performing the procedure shown in the picture, where is the initial incision made? A. Right 5th intercostal space B. Left 5th intercostal space C. Left 4th intercostal space D. Right 6th intercostal space E. Left 6th intercostal space

B. Left 5th intercostal space Emergency thoracotomy is a procedure used in extreme circumstances to provide further cardiac resuscitation. A generous thoracotomy incision is performed through the fifth intercostal space; the incision should start at the opposite side of the sternum, and begin curving into the axilla at the level of the ipsilateral nipple.

A 56-year-old woman comes to the emergency room because of wheezing and severe shortness of breath for 2 days. Her past medical history includes breast cancer that was treated with paclitaxel over the past several months. Physical examination shows decreased tactile fremitus over the left lower lobe. A chest radiograph is obtained. Which of the following is the most likely diagnosis? A. Left lung collapse B. Left pleural effusion C. Right lung collapse D. Right pleural effusion E. Right tension pneumothorax

B. Left pleural effusion Radiographs will often show blunting of the costophrenic angles and the presence of a horizontal fluid line, among other signs.

A 60-year-old man comes to the emergency department because of progressive shortness of breath and chest pain for 3 weeks. His medical history includes diabetes mellitus, hyperlipidemia, and a myocardial infarction 6 years ago. He is in moderate respiratory distress. Pulmonary auscultation shows decreased breath sounds throughout both lung fields. A chest x-ray is obtained and confirms a pleural effusion. Cardiac auscultation demonstrates a heart sound occurring after S2. Thoracentesis is performed, and 800 mL of fluid is removed. Which of the following laboratory results is most likely to be found? A. Pleural fluid LDH/serum LDH ratio of 0.85 B. Pleural fluid protein/serum protein ratio of 0.25 C. Pleural fluid protein/serum protein ratio of 1.2 D. Pleural fluid that has an LDH which is 75% of the laboratories upper limit of normal for serum LDH E. Pleural fluid protein/serum protein ratio of 0.55

B. Pleural fluid protein/serum protein ratio of 0.25 Pleural effusion resulting from acute decompensated heart failure is usually transudative, from pulmonary vascular congestion secondary to left heart failure. Transudative effusions do not fulfill any of Light's criteria

A 38-year-old man comes to the office because of a persistent headache that has worsened in the last three days. His temperature is 38.1°C (100.6°F), pulse is 75/min, respirations are 12/min, and blood pressure is 120/75 mm Hg. He requests that the lights be dimmed. Acetaminophen helps with the pain temporarily. He has also been sweating profusely at night and says his muscles ache. Rales are heard on auscultation. He is the owner of a pet store, where he began remodeling the aviary last week. He does not know of any sick contacts. Which of the following is the most likely diagnosis? A. Migraine B. Psittacosis C. Legionnaires' disease D. Chlamydia pneumoniae infection E. Q fever

B. Psittacosis Psittacosis is a disease caused by Chlamydia psittaci, an obligate intracellular bacterium transmitted primarily from birds. This diagnosis should be considered in a patient with fever, headache, dry cough, and systemic symptoms who has exposure to birds.

A 65-year-old man comes to the emergency department with shortness of breath and a yellow sputum when he coughs. He has been smoking cigarettes for the past 30 years, average about two packs a week. He reports he has a cough that is difficult to get rid of greater than 6 months in the year. Physical examination shows a blood pressure of 140/92mmHg, heart rate of 88/min, temperature of 37.2o C (98.9o F), and a respiratory rate of 28/min. His breath sounds are diminished bilaterally, and his lungs are hyper-resonant to percussion. Which of the following arterial blood gas results would be most likely characteristic of the patient's? A. pH (7.30), pCO2 (50mmHg), pO2 (85mm Hg), HCO3 (23mEq/L) B. pH (7.30), pCO2 (60mmHg), pO2 (90mm Hg), HCO3 (30mEq/L) C. pH (7.40), pCO2 (50mmHg), pO2 (90mm Hg), HCO3 (28mEq/L) D. pH (7.45), pCO2 (60mm Hg), pO2 (85mmHg), HCO3 (26mEq/L) E. pH (7.50), pCO2 (60mmHg), pO2 (90mm Hg), HCO3 (22mEq/L)

B. pH (7.30), pCO2 (60mmHg), pO2 (90mm Hg), HCO3 (30mEq/L) With his extensive smoking history and new onset dyspnea, the patient in this scenario is likely experiencing an acute chronic obstructive pulmonary disease (COPD) exacerbation. It results in chronic respiratory acidosis, characterized by low pH and elevated pCO2 and HCO3. His decreased breath sounds suggest emphysema, pursed lips would also support this diagnosis. COPD can lead to respiratory acidosis, which is characterized by a serum pH below 7.4. Chronic hypoventilation eventually results in hypoxia and hypercapnia (pCO2 greater than 40 mmHg). As this is a chronic condition, a compensatory rise in HCO3 will be observed

A 16-year-old girl comes to the emergency department with severe difficulty breathing that began while she was playing basketball with friends 40 minutes ago. She has had nasal congestion for the past week and today has also developed a persistent dry cough and chest tightness. Pulmonary auscultation shows a prolonged expiratory phase and decreased breath sounds throughout. A high-pitched whistling sound that is louder during expiration is appreciated. Which of the following findings is consistent with the most likely diagnosis? A. A negative methacholine challenge B. A normalizing PCO2 in an acute exacerbation indicates respiratory improvement C. A normalizing PCO2 in an acute exacerbation warrants close observation for impending respiratory failure D. Laboratory analysis reveals neutrophilia E. Spirometry shows an increased FEV1/FVC ratio

C. A normalizing PCO2 in an acute exacerbation warrants close observation for impending respiratory failure Initially in an acute episode of asthma the patient's reflexive hyperventilation will cause the PCO2 to drop and the pH to rise, resulting in a respiratory alkalosis. As the patient begins to fatigue the PCO2 will begin to rise again and approach normal values. This is an ominous sign and may precede respiratory failure.

A 64-year-old man comes to the primary care physician's office because of diarrhea, a rash on his arms and legs, and severe flushing of the skin of his upper thorax and head. His wife talks about his history of congestive heart disease and cancer of the small intestine six years ago, for which he received radiation therapy. Urinalysis shows a significantly decreased concentration of N-methylnicotinamide. A diagnosis of pellagra is made. Which of the following is most likely the primary cause of niacin deficiency in this patient? A. Adverse effect of digoxin therapy B. Adverse effect of statin therapy C. Carcinoid syndrome D. Celiac disease E. Decreased absorption due to a complication of radiation therapy

C. Carcinoid syndrome Carcinoid syndrome is a complication of carcinoid cancer, and it is characterized by niacin deficiency in some patients. It occurs secondary to carcinoid tumors

A 60-year-old man comes to the office because of worsening dyspnea upon exertion over the past 6 months. The patient has a dry cough. On auscultation, crackles are heard bilaterally at the base of each lung. His chest X-ray is shown below: In addition to reduced forced expiratory volume in 1 second (FEV1), which of the following results for his forced vital capacity (FVC), FEV1/FVC ratio, and total lung capacity (TLC) are most likely to be expected in his pulmonary function testing? A. Decreased FVC, decreased FEV1/FVC ratio, decreased TLC B. Decreased FVC, decreased FEV1/FVC ratio, normal TLC C. Decreased FVC, increased FEV1/FVC ratio, decreased TLC D. Normal FVC, decreased FEV1/FVC ratio, normal TLC E. Normal FVC, normal FEV1/FVC ratio, increased TLC

C. Decreased FVC, increased FEV1/FVC ratio, decreased TLC Restrictive lung disease examples include pulmonary fibrosis and pneumothorax, which impair inspiration. When conducting pulmonary function testing, decreases in FVC and FEV1 are observed in both defects.

A 6-year-old boy is brought to his pediatrician's office for a well-child check. His past medical history is significant for meconium ileus at birth. He has since developed a chronic productive cough. His mom reports that he has frequent bulky and fatty stools. Which of the following is this patient most at risk for? A. Wet beriberi B. Pellagra C. Rickets D. Scurvy E. Vitamin B12 deficiency

C. Rickets abnormal cystic fibrosis transmembrane conductance regulator protein in cystic fibrosis results in viscous secretions which plugs the pancreatic ducts. Hence, these patients will have pancreatic insufficiency leading to diarrhea, malabsorption, and fatty stools. In addition, there is malabsorption of fat-soluble vitamins (vitamin K, A, D, and E). These patients are at an increased risk for rickets or vitamin D deficiency. Patients with rickets will have myopathy, increased fractures, genu varum, genu valgum, hypocalcemia, and widening of the wrists. These deformities can easily be visualized on radiograph imaging.

A 34-year-old male is brought to the emergency department because of a gun shot wound to his left chest 27 minutes ago. His temperature is 35.6°C (96.1°F), pulse is 138/min, respirations are 32/min, blood pressure is 74/48 mm Hg, and and SpO2 is 92% on 15 L/min O2 via a non-rebreather mask. His Glasgow Coma Scale is 8. He is intubated and a trauma ultrasound scan shows a hemothorax. During the course of the resuscitation, the pictured procedure is preformed. Which of the following answer choices is most likely an indication for the pictured procedure? A. Hemoglobin level of 95g/L B. Oxygen saturation dropped below 85% C. Systolic BP <70 mmHg despite vigorous resuscitation D. The patient's chest tube rapidly drained 1100mL of blood E. Trauma ultrasound scan revealing blood in pericardial sac, without tamponade

C. Systolic BP <70 mmHg despite vigorous resuscitation Emergency thoracotomy is a highly invasive procedure which can be used in extreme circumstances following blunt force or penetrating trauma to alleviate life threatening complications.

A 75-year-old woman presents to the emergency room for progressive shortness of breath. History is positive for a recent bout of pneumonia for which she had been prescribed appropriate antibiotics. The patient admits that she has been mostly non-compliant with taking the medication. A chest X-ray is performed and is displayed below. Which of the following interventions would most likely give you the etiology of the patient's pathology? A. CT of the chest B. Pericardiocentesis C. Thoracentesis D. CBC E. PET

C. Thoracentesis Pleural effusions are locations of fluid build-up within the lungs. Thoracentesis can diagnose the underlying causes of the pleural effusion and should be performed. (also therapeutic)

A 3-day-old female newborn comes to the office for her first well child visit. Her mother wants to learn about the warning signs of poor growth, because a distant family member's baby was diagnosed with cystic fibrosis after showing poor growth as an infant. The patient was born at full term, weighing 3.3 kg (7.3 lb). Which of the following changes would most likely indicate an underlying pathology in the patient? A. Failure to recover to birth weight at 5 days of life B. Weight less than the 25th percentile by age at 1 month of age C. Weight loss nadir of 12% of birth weight D. Weight loss nadir of 8% of birth weight E. Weight less than the 50th percentile for age at 1 month of age

C. Weight loss nadir of 12% of birth weight Failure to thrive, which is described as a weight loss that is greater than 12% of birth weight within the first few days of life and does not return to birth weight by 10 days of life.

A 27-year-old man comes to the emergency department because of muscle weakness for 3 hours. He was treated in hospital 2 days ago for an asthma exacerbation. He was not admitted, but received numerous albuterol nebulizers. He also used 5 nebulized albuterol treatments at home before coming to the emergency department. Today, he is not wheezing and does not appear to be in respiratory distress. He endorses muscle weakness and significant cramping in his thighs, but no chest pains. An ECG is obtained. Which of the following is the most likely diagnosis? A. Cardiac ischemia B. Hyperkalemia C. Hypokalemia D. Pulmonary embolism E. Rhabdomyolysis

C. hypokalemia Beta-2 agonist therapy for asthma can result in hypokalemia. In fact, albuterol can be used to treat emergent hyperkalemia. Hypokalemia presents with muscle weakness, cramps and pain. With more severe hypokalemia, flaccid paralysis can occur. ECG changes often occur in hypokalemia <2.7 mg/dL. Hypokalemia causes Increased amplitude and width of the P-wave, prolongation of the PR interval, T-wave flattening and inversion, ST-depression, and Prominent U-waves.

A 54-year-old man comes to the emergency department because of shortness of breath. Chest X-ray shows signs of a lesion causing central airway obstruction. A biopsy is obtained and subsequent histology shows a neoplasm with a distinctly neuroendocrine pattern of differentiation and small, round cells in nests surrounded by capillaries. Which of the following is the most likely diagnosis? A. Adenocarcinoma B. Large cell carcinoma C. Pulmonary carcinoid D. Small cell carcinoma E. Squamous cell carcinoma

C. pulmonary carcinoid Pulmonary carcinoid is a neoplasm that is usually found centrally in larger airways, often characterized by bronchial obstruction. While the gastrointestinal tract tends to be the most common site of carcinoid, the lungs are the second most common site.

An 82-year-old Caucasian man comes to the emergency department because of a 1-week history of fever and pleuritic pain. His medical history is relevant for type II diabetes mellitus, systemic sclerosis, and a recent hospitalization due to community-acquired pneumonia. On physical examination the patient has lateral chest wall swelling and tenderness. Auscultatory findings reveal decreased respiratory sounds and increased right-side vocal fremitus. His temperature is 39.7°C (103.4°F), pulse is 100/min, respirations are 70/min, blood pressure is 130/80 mmHg, and pulse oximetry on room air shows an oxygen saturation of 93%. A chest radiograph shows a unilateral, biconvex, and encapsulated fluid collection on the right chest wall. A pleural drainage is performed and shown below. Which of the following is the most likely cause of this patient's current condition? A. Aspergilloma B. Mesothelioma C. Pleural effusion D. Empyema E. Lung adenocarcinoma

D. Empyema a pleural cavity bacterial infection predominantly caused as a complication of pneumonia that results in the accumulation and collection of pus. The mainstay therapy is to treat the underlying infection and pleural drainage of the collection. fever, pleuritic pain, and chest wall swelling, in addition to an encapsulated fluid collection with a yellowish pleural drainage is consistent with pleural empyema. Pleural empyema (also known as, pyothorax or purulent pleuritis

A 66 year-old woman comes to the emergency department because of worsening confusion for the past day. Past medical history is significant for Parkinson disease and diabetes mellitus type 2. She is admitted for observation and returns to baseline mentation after 3 days, but on the third day she begins complaining of worsening shortness of breath and cough productive of white sputum. The cough is also associated with chest pain during deep inhalation. Associated symptoms include sinus congestion and headache. Her temperature is 38.3°C (101.3°F), pulse is 92/min, respirations are 22/min, blood pressure is 140/90 mm Hg, and oxygen saturation is 94% on 2L O2 via nasal cannula. Labs and imaging are pending. At this time, which of the following is the most likely diagnosis? A. Atypical pneumonia B. Community-acquired pneumonia C. Healthcare-associated pneumonia D. Hospital-acquired pneumonia E. Lobar pneumonia

D. Hospital Acquired Pneumonia Hospital-acquired pneumonia is categorically defined as pneumonia contracted after 48 hours following hospital admission.

A 65-year-old man comes to the office for a routine visit. He states that he has recently retired from working in the coal industry in Pennsylvania, where he worked his way from coal tender to superintendent of his mine. Spirometry shows that his FEV1/FVC ratio is 0.75, slightly above predicted levels for his age and height. Chest X-ray shows many round opacities ranging in diameter from 2-10 mm, especially in the upper zones. Which of the following best explains the progression of pulmonary dysfunction associated with this patient's condition at this time? A. Loss of pulmonary function secondary to lung carcinoma and/or mesothelioma B. Loss of pulmonary function secondary to tuberculosis C. Loss of pulmonary function from anthracosis, leading to pulmonary hypertension and cor pulmonale with peripheral edema D. Little to no change in pulmonary function E. Progressive development of a productive cough associated with chronic bronchitis

D. Little to no change in pulmonary function Coalworker's pneumoconiosis is a common dust disease in patients that have worked in underground coal mines. It results from inhalation of coal dust particles (1-3 μm in diameter) over 15-20 years. These are ingested by macrophages which die, releasing their enzymes and causing fibrosis. Characteristically coal worker's pneumoconiosis is asymptomatic, and the management involves avoiding further exposure to coal dust and treating any concurrent chronic bronchitis. It may progress to pulmonary fibrosis and more severe restrictive lung disease

A 40-year-old man comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent "v" wave of the jugular vein and a 1/6 holosystolic murmur best heard at left lower sternal border. Abdominal examination shows hyperactive bowel sounds. Which of the following is the most likely diagnosis? A. Catecholamine secreting adrenal tumor B. Chronic obstructive pulmonary disease C. Community-acquired pneumonia D. Neuroendocrine tumor metastatisis to the liver E. Serotonin-secreting tumor isolated to the gastrointestinal tract

D. Neuroendocrine tumor metastatisis to the liver Symptoms of carcinoid syndrome can be memorized using the mnemonic FDR (flushing, diarrhea, and right-sided heart valves) Patients with a carcinoid syndrome usually remain asymptomatic until the tumor metastasizes to the liver, allowing its vasoactive products to bypass hepatic metabolism

A 32-year-old woman comes to the emergency department because of shortness of breath. She has a body mass index of 36 kg/m2. She denies use of narcotics and has no history of lung disease or neuromuscular disease. Her arterial carbon dioxide concentrations are measured to be 49 mm Hg. Spirometry is performed and shows a restrictive pattern. Which of the following is the most likely diagnosis? A. Central hypoventilation syndrome B. Extreme hypothyroidism C. Kyphoscoliosis D. Obesity hypoventilation syndrome E. Obstructive sleep apnea

D. Obesity hypoventilation syndrome condition that affects severely overweight people causing failure to breathe rapidly enough or deeply enough. This results in low blood oxygen levels and high blood carbon dioxide levels. Obesity hypoventilation syndrome is defined by the combination of obesity (BMI >30 kg/m2), hypoxemia during sleep, and hypercapnia during the day.

A 25-year-old woman comes to her primary care provider's office because progressively worsening dyspnea, productive cough, and wheezing for the past 2 months. Physical examination shows decreased breath sounds bilaterally, distant heart sounds, and wheezing. A chest radiograph is done and shows the following image: Laboratory tests show elevated alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin. Which of the following is the most likely diagnosis? A. Status asthmaticus B. Alcoholic cirrhosis C. Bronchiectasis D. Panacinar emphysema E. Viral hepatitis

D. Panacinar emphysema Alpha-1 antitrypsin deficiency is a hereditary condition causing liver cirrhosis and panacinar emphysema. Suspect this diagnosis in a patient with early-onset chronic obstructive pulmonary disease and a negative history for smoking. Pulmonary function testing will show an obstructive lung disease pattern.

A 5-day-old newborn in the neonatal unit has been crying constantly since birth. He had an uncomplicated delivery but has not passed any stool. Physical examination shows a distended abdomen. An abdominal x-ray is taken and shows the following image: Which of the following complications is this patient most likely to develop? A. Abetalipoproteinemia B. Whipple disease C. Celiac disease D. Pancreatic insufficiency E. Lactase deficiency

D. Pancreatic insufficiency Failure to pass meconium is commonly the first appearing symptom of cystic fibrosis.

A 34-year-old man comes to the emergency department via ambulance because of a motor vehicle collision in which he was not wearing a seatbelt. On the way to the hospital he developed shortness of breath and tachycardia. He is in obvious discomfort, and his pulse is 120/min, respirations are 32/min, and a blood pressure is 80/50 mm Hg. He opens his eyes spontaneously, he can move all four extremities, and obeys commands. His neck veins are distended. Breathing sounds are absent on the right side. In which of the following structures is pressure most likely increased? A. Aorta B. Left atrium C. Left ventricle D. Pulmonary artery E. Pulmonary veins

D. Pulmonary artery This collapse 2/2 pneumothorax creates an obstruction that increases resistance (and therefore pressure) proximally along the path of flow, and decreases volume (and therefore pressure) distally. The increased resistance impedes normal right-sided flow, and causes blood to back up into the systemic circulation, resulting in a dilation of the neck veins

A 40-year-old man comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent "v" wave of the jugular vein and a 1/6 holosystolic murmur best heard on the left lower sternal border. Abdominal examination shows hyperactive bowel sounds. Which other clinical findings is likely to be present? A. Cheilosis and stomatitis B. Confusion, ophthalmoplegia, and ataxia C. Swollen gums, bruising, and hemarthrosis D. Dermatitis and mental status change E. Ptosis, anhydrosis, and miosis

D. dermatitis and mental status change Serotonin is a derivative of tryptophan. Because of the excessive amount of serotonin produced in carcinoid syndrome, there may be a deficiency of other products which are also tryptophan derivatives. Niacin is one of those products. Therefore, some patients with carcinoid syndrome may be characterized by niacin deficiency, also known as pellagra. Pellagra is defined by the classic triad of dermatitis, dementia, and diarrhea (The 3 D's of pellagra)

A 73-year-old woman comes to the emergency department because she sustained multiple stab wounds from a knife to the chest during a mugging 20 minutes ago. She says the pain is worse on inspiration and that she feels shortness in her breath. Her temperature is 36.8°C (98°F), pulse is 104/min, respirations are 26/min, and blood pressure is 95/78 mm Hg. Chest X-ray is obtained and is shown below. Which of the following is the deepest layer of tissue that the offending weapon penetrated? A. Dermis B. Epidermis C. Intercostal muscle D. Parietal pleura E. Pectoral muscle

D. parietal pleura the pleural space was penetrated by the knife which allowed air to enter but not to exit. The resulting build up of air has caused pressure to build up in the pleural space resulting in a collapsed lung and mediastinal shift

A 23-year-old college student comes to the student health offices because of a non-productive cough, subjective tactile fevers, and "feeling sick" for 2 days. She says she has a final exam tomorrow and wants some medicine so she feels better during the test. Her temperature is 37.2°C (99°F), pulse is 87/min, respirations are 18/min, and blood pressure is 117/78 mm Hg. Examination shows clear lung sounds bilaterally in all fields. There is no cervical lymphadenopathy. She has some pharyngeal erythema with neither exudates nor vesicles. Which of the following is the most appropriate next step in the management of this patient? A. Admit for IV antibiotic therapy B. Chest X-ray C. Outpatient antibiotic therapy D. Reassure and discharge E. Respiratory viral panel by PCR

D. reassure and discharge Upper respiratory tract infections can be diagnosed solely on the basis of history and exam findings and do not require further work-up or treatment. For cases which are less clear, the modified Centor score can be used to triage patients to a combination of further testing and/or empiric antibiotic treatment.

A 29-year-old female comes to the office because of a cough and "feeling sick" for 2 days. Her medical history is noncontributory and she says she took some acetaminophen for this illness before coming in. Her temperature is 37.2°C (99°F), pulse is 87/min, respirations are 18/min, and blood pressure is 117/78 mm Hg. Examination shows mild nasal congestion, rhinorrhea, and a non-productive cough. She has some pharyngeal erythema with neither exudates nor vesicles. Which of the following is the most accurate test in the diagnosis of this illness? A. Chest X-ray B. Rapid streptococcus antigen detection C. Sputum bacterial culture D. Sputum viral culture E. Sputum viral panel by PCR

D. sputum viral culture This patient is afebrile, with a non-productive cough and normal respiratory examination findings, all of which point to a viral upper respiratory tract infection (URTI). A sputum viral culture is the gold standard in diagnosis of viral URTI.

A 42-year-old man presents to the office because of a productive cough for the last 2 years. He admits to multiple hospitalizations due to pneumonia with the most recent being 4 months ago. The patient's medical history includes common variable immunodeficiency and hypothyroidism. Physical examination shows a man of stated age. Crepitations and expiratory rhonchi are heard on auscultation of the lungs. CT of the chest is obtained and is shown below. Which of the following is the most likely cause of the patient's pulmonary complaints? A. Tobacco abuse B. Allergic bronchopulmonary aspergillosis C. Cystic fibrosis D. Alpha-1 antitrypsin deficiency E. Bronchiectasis

E. Bronchiectasis the chronic, irreversible dilation of the major airways, and is characterized by recurrent pulmonary infections, copious sputum production, and hemoptysis. CT imaging shows an increased broncho-arterial ratio.

A 1-year-old previously healthy male infant is brought the emergency department because of a 4-day history of fever, poor feeding, and respiratory distress. His medical history is noncontributory. Physical exam shows mild peripheral cyanosis, inspiratory crackles, sibilant rhonchi, and nasal flaring. His temperature is 39.7°C (103.4°F), pulse is 160/min, respirations are 60/min, blood pressure is 100/50 mmHg, and pulse oximetry on room air shows an oxygen saturation of 90%. Upon hospital admission, the patient's clinical condition deteriorates despite optimal treatment. A chest radiograph is obtained and shown below Which of the following is the most likely cause of this patient's condition? A. Congenital lobar emphysema B. Bronchomalacia C. Bronchopulmonary dysplasia D. Bronchiolitis E. Bronchopneumonia

E. Bronchopneumonia Bronchopneumonia (or lobular pneumonia) is a suppurative peribronchiolar inflammation most commonly caused by an underlying bacterial pneumonia. Pediatric patients often present with fever, tachypnea, and respiratory distress. A chest radiograph usually reveals the presence of patchy lobar consolidations or an "air-bronchogram pattern."

A 2-day-old infant is brought to the emergency department because of bilious vomiting, abdominal distention, and failure to pass meconium. An abdominal X-ray shows a "soap bubble" appearance in the right lower quadrant. A contrast enema shows an obstructed terminal ileum distended with stool. Both parents are Caucasian without any significant past medical history. A soluble contrast is successfully employed to wash out the stool and the infant's obstruction resolves. This patient is most likely to develop which of the following future complications? A. Panacinar emphysema B. Zollinger-Ellison syndrome C. Hirschsprung disease D. Psuedomonas aeruginosa sepsis E. Cirrhosis

E. Cirrhosis Patients with cystic fibrosis typically have thickened mucus secretions in the lung and pancreas, which are responsible for the chronic cough, frequent lung infections, difficulty digesting food, and increased risk of developing diabetes. Liver failure is the second most common cause of death for sufferers of CF

A 70-year-man comes to the emergency department with dyspnea and a dry cough that have been getting slowly worse over several months. He says that he was in good shape from working in a shipyard for 25 years, but now is short of breath because he just doesn't do as much physical work as he used to. He also has a 20 pack-year smoking history. A chest radiograph is obtained and is shown below. Which of the following is consistent with the most likely diagnosis? A. He has an increased risk of developing tuberculosis B. Smoking has no effect on his risk for developing malignancy C. Lung biopsy will reveal diffuse alveolar damage D. He is likely to have distant metastases E. Lung biopsy will indicate fibrosis and ferruginous bodies

E. Lung biopsy will indicate fibrosis and ferruginous bodies The most likely diagnosis is asbestosis caused by inhalation of asbestos fibers. There is a strong correlation between certain jobs and asbestos exposure, including shipyard work, exposure to insulation, and demolition work. Symptoms of asbestosis appear at least 20 years after the exposure and the duration of latency is inversely proportional to the degree of exposure. Asbestosis affects mainly the lower lobes of the lungs and the pleura of the mid-zones bilaterally though upper zones may be affected in advanced disease. Pleural involvement is significant especially because of it's absence in other interstitial lung diseases. Plaques form on the parietal pleural and may form adhesions with the adjacent lung leading to atelectasis. Asbestosis can lead to pulmonary hypertension, cor pulmonale, respiratory failure and malignancy. The most common cause of malignant mesothelioma is asbestos exposure but the most common type of lung cancer in people exposed to asbestos is bronchogenic carcinoma

A 66-year-old man comes to the emergency department because of a 2-day history of a productive cough with yellow sputum, chest tightness, fatigue, chills, and fever. He has smoked cigarettes since the age of 25. Vital signs show his temperature is 38.8°C (102°F), pulse is 80/min, respirations are 22/min, and blood pressure is 140/90 mm Hg. Auscultation of his lungs shows rhonchi over the lower 2/3 of the left lung and bilateral crackles at the bases. The patient is told to pronounce the long-E vowel sound while you auscultate the lungs, the E sounds like an A over the L lung. Tactile fremitus is increased in this area and the percussion note is dull. Which of the following is the most likely diagnosis? A. Lung cancer B. Tuberculosis C. Atelectasis D. Bronchitis E. Pneumonia

E. Pneumonia Characteristic examination findings over the involved lung segment are an increase in tactile fremitus, dullness to percussion, course crepitations, increased vocal resonance, and egophony (an E-to-A change over consolidated lung

A 52-year-old female comes to the office because of a 5-year history of a slowly progressive productive cough and mild dyspnea on exertion. Medical history is unremarkable the patient takes no medications. The patient has never smoked and has worked as a sandblaster for the past 15 years. Temperature is 37.2°C (98.96°F), pulse is 72/min, respirations are 18/min, and blood pressure is 135/80 mm Hg. Physical examination shows dry rales, especially the bilateral upper and middle lung fields. Leukocyte count showed 6,000/mm3. The chest x-ray is shown below. Which of the following is the most likely diagnosis? A. Asbestosis B. Asthma C. Gastroesophageal reflux disease D. Legionella pneumonia E. Silicosis

E. Silicosis Silicosis should be suspected in a patient with progressive respiratory complaints combined with a history of exposure to particulate matter and eggshell calcifications of the lymph nodes on chest X-ray. Silicosis is a pneumoconiosis caused by inhalation of tiny particles of crystalline silica. Exposure to silica dust is common in miners, foundry workers, and sandblasters. Inhalation of these particles can cause inflammation and fibrosis and may impair phagolysosomes and macrophages. Acute silicosis may develop from weeks to years after exposure. Chronic silicosis or "classic" silicosis is much more common and develops 10-30 years after first time exposure. Typical imaging findings in classic silicosis are multiple small rounded opacities in upper lung zones on chest X-ray and CT, as well as hilar lymphadenopathy and "eggshell calcification" of lymph nodes (as demonstrated in the image of this patient). Patients with classic silicosis are often asymptomatic but may develop a chronic cough with sputum production and dyspnea on exertion. Silicosis is associated with increased risk of tuberculosis and bronchogenic carcinoma

A 52-year-old man comes to the clinic because of progressive breathing trouble for the past year. He has been coughing more than usual each time he takes a cigarette break and can not seem to catch his breath after walking up one flight of stairs. He has worked as a sandblaster in a local mine for the past 20 years. His medical history includes a 30-pack-year smoking history. His temperature is 37.0°C (98.6°F), pulse is 82/min, respirations are 18/min, and blood pressure is 138/84 mm Hg. Physical examination shows bilateral rhonchi and a prolonged expiratory phase on auscultation of the lungs. A chest radiograph (shown below) shows "eggshell" calcifications of the hilar lymph nodes and scattered small nodules throughout the upper lung lobes. Which of the following is the most likely diagnosis? A. Asbestosis B. Berylliosis C. Coal workers' pneumoconiosis D. Sarcoidosis E. Silicosis

E. Silicosis Silicosis typically affects the upper lung lobes of those who work in sandblasting and mining. When the silica particles are inhaled, they are engulfed by macrophages that release fibrogenic cytokines in response, causing scarring of the lung parenchyma. Because the macrophages are left with impaired function, these patients are at an increased risk for tuberculosis. On imaging of the lungs, it is said that the hilar lymph nodes appear to have "eggshell" calcifications, which means that the periphery of the lymph node appears to be calcified.

A 36-year-old woman comes to the emergency department because of coughing, chest pain, severe shortness of breath, and fever for 9 days. She states that this is the sickest she has felt in a long time. Physical examination shows decreased lung sounds on the right side. Pneumonia is suspected, and a CT scan is obtained. A thoracentesis is also attempted, but does not produce significant drainage. Which of the following is the most appropriate next step? A. Chemical pleurodesis B. Culture of thoracentesis samples, followed by tailoring of antibiotic treatment C. Placement of further chest tubes D. Pneumonectomy E. Surgical decortication

E. Surgical decortication Pleural empyemas, which appear as dense pleural effusions on a CT scan, can develop thick rings that inhibit drainage via thoracentesis/chest tube. In these cases, surgical decortication is required.

A 43-year-old man comes to the emergency department because of a stab wound to the right side of his chest 20 minutes ago. He says that in addition to right-sided chest pain, he feels shortness of breath. His temperature is 36.8°C (98°F), pulse is 114/min, respirations are 26/min, and blood pressure is 88/62 mm Hg. He is having trouble finishing his sentences due to his shortness of breath. Pulmonary examination shows right-sided hyperresonance and pulmonary auscultation shows decreased breath sound also on the right-hand side. His neck veins are also distended. Which of the following is the most likely diagnosis? A. Cardiac tamponade B. Flail chest C. Hemothorax D. Pleural effusion E. Tension pneumothorax

E. Tension pneumothorax Tension pneumothorax is characterized by decreased breath sounds and hyperresonance to percussion in the affected hemithorax. It also causes systemic hypotension with distended neck veins, and should be treated promptly.

A 65 year old man presents to the emergency department with shortness of breath and chest pain which has been getting progressively worse over three weeks. His vitals are HR 110, RR 28, BP 130/85, T 98.3, and SpO2 92% on room air. Medical history is significant for diabetes mellitus, hyperlipidemia, and a heart attack 5 years ago. Physical examination shows a patient in moderate respiratory distress. Breath sounds are decreased in the lower half of both lung fields, and there is decreased tactile fremitus in the lower third of both lung fields. Auscultation of the heart reveals a regular rhythm and a protodiastolic gallop. He has jugular venous distention to his earlobe when he reclines to 30°. Which of the following is the most consistent with his presenting symptoms and physical examination? A. Heart failure due to a non-compliant right ventricle B. Tension pneumothorax C. Exudative effusion between visceral and parietal pleura D. Pericardial tamponade E. Transudative effusion between visceral and parietal pleura

E. Transudative effusion between visceral and parietal pleura Pleural effusion can be associated with acute decompensated heart failure. It is usually transudative, secondary to increased capillary hydrostatic pressure. The increase in hydrostatic pressure eventually causes fluid to shift into the pleural space, causing a transudative pleural effusion. The pleural effusion is responsible in part for the patients respiratory distress, chest pain, and physical exam findings. The protodiastolic gallop - a.k.a an S3, or a third-heart sound- is a sign of vascular congestion and fluid overload, as is the patient's elevated JVP.

A 10-year-old boy comes to the emergency room because of falling unconscious. He has respiratory depression on arrival, and is thus intubated. His mother says that he has had severe coughing with blood before he lost consciousness. He has had pneumoniae infections, sinusitis, and intestinal obstruction in the past. The patient is underweight with signs of tachycardia, flushed skin, and muscle twitches. CT scan of his lungs are shown below. Which of the following is the most likely cause of the patient's loss of consciousness? A. Energy exerted by coughing made him hypoglycemic leading to unconsciousness B. He had another case of intestinal obstruction and the pain decreased his level of alertness C. Unconsciousness is a common feature in patients with CFTR gene mutation D. Ventilation perfusion ratio was high due to thick mucus secretion causing respiratory acidosis E. Ventilation perfusion ratio was low leading to hypercapnia

E. Ventilation perfusion ratio was low leading to hypercapnia The patient appears to have cystic fibrosis (defective chloride channels which could lead to recurrent lung infections, sinusitis, meconium ileus and infertility in males), leading to thick mucus plugs that have occluded the bronchi, thus decreasing the rate of gaseous exchange (reduced ventilation perfusion ratio). This leads to hypercapnia (elevated CO2 in blood), causing acidosis as CO2 react with water in the presence of carbonic anhydrase to form carbonic acid.

A 10-year-old boy comes to the clinic for a follow-up visit. The patient has suffered from chronic greasy, bulky diarrhea and recurrent respiratory infections for several years, which cause him to stay indoors. He takes a children's multivitamin. Physical examination shows decreased proprioception and hyporeflexia of the lower extremities. Ophthalmological exam is normal. A complete blood count (CBC) suggests a slight hemolytic anemia. Which of the following conditions is most likely the cause of these findings? A. Niacin deficiency B. Vitamin A deficiency C. Vitamin B12 deficiency D. Vitamin D deficiency E. Vitamin E deficiency

E. Vitamin E. deficiency Vitamin E deficiency is characterized by hemolytic anemia and neurological deficits 2/2 cystic fibrosis induced impaired absorption of fat soluble vitamins

A 2-year-old boy is brought to the pediatrician's office because of a chronic cough present since the first few weeks of life. His parents report that he has had trouble feeding and consistently produces foul and thick bowel movements. A review of his growth charts show a weight and height of less than 10th percentile since birth. Physical examination shows a hyperinflated chest with normal auscultation. Chest radiographs are taken which show mild hyperinflation and bronchial thickening. What is the most likely underlying mechanism for his symptoms? A. Viral infection B. Defect in ciliary activity C. Bronchial hyperresponsiveness D. Hypocalcemia E. Defect in chloride channels

E. defect in chloride channels Cystic fibrosis occurs as a result of a defective chloride ion transporter leading to thick respiratory secretions.

what is the difference between a restrictive and an obstructive pulmonary defect?

Obstructive diseases refers to conditions such as asthma and chronic obstructive pulmonary disease which impair expiration. Restrictive lung disease examples include pulmonary fibrosis and pneumothorax, which impair inspiration. When conducting pulmonary function testing, decreases in FVC and FEV1 are observed in both defects. However, obstructive diseases display decreased FEV1/FVC ratio and normal/increased TLC, whereas restrictive diseases display a normal/increased FEV1/FVC ratio and decreased TLC. Since obstructive diseases are characterized by increased lung compliance and restrictive diseases by decreased compliance, the TLC alone is enough to differentiate the two

________ an inherited disorder that results in early onset panacinar emphysema and cirrhosis of the liver. These patients may or may not have a history of smoking. These patients will have wheezing, dyspnea, progressive shortness of breath, and increased chest diameter in addition to ascites secondary to cirrhosis. Laboratory studies will show elevated alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin. Pulmonary function testing will show an obstructive lung disease pattern. Treatment include injections with ___

alpha-1 antitrypsin deficiency Treatment include injections with human alpha-1 proteinase inhibitor or liver transplantation.

Hereditary Spherocytosis

an autosomal dominant abnormality of erythrocytes. The disorder is caused by mutations in genes relating to membrane proteins that allow for the erythrocytes to change shape. The abnormal erythrocytes are sphere-shaped (spherocytosis) rather than the normal biconcave disk shaped. Dysfunctional membrane proteins interfere with the cell's ability to be flexible to travel from the arteries to the smaller capillaries. This difference in shape also makes the red blood cells more prone to rupture. Cells with these dysfunctional proteins are taken for degradation at the spleen. This shortage of erythrocytes results in hemolytic anemia.