Primary Care Review: Pulmonary

A 15 year-old female recently diagnosed with asthma is placed on mometasone 220 mcg inhaled daily and albuterol 90 mcg/spray MDI 2 puffs Q6H prn. Which of the following is most useful to monitor her treatment? CXR 6 minute walk test peak expiratory flow rate pulse oximetry

peak expiratory flow rate

A 22 year old male is stabbed multiple times by an unknown assailant. He arrives in the ED with a BP of 60 by palpation, pulse of 150, and rapid respiratory rate. He is complaining that he cannot breathe. His chest xray is shown (tension Pneumothorax with mediastinum shifted to the left). All of the following should be done as part of the *PRIMARY survey EXCEPT: (CT should NOT be on what side of chest)*

A chest tube should be placed on the left side of the chest.

A 55-year-old male with a 60-pack/year history of smoking and documented COPD comes to your office with a high fever, chills, a productive cough (yellowish green sputum), and SOB PE- decreased breath sounds in the RML and RLL CXR confirms right middle lobe and right lower lobe pneumonia. A gram stain reveals gram-negative rods in abundance. Based on his 60-pack/year history of smoking, the Gram stain results, and his history of chronic bronchitis, what is the most likely organism in this patient? A. Moraxella catarrhalis B. M. pneumoniae C. H. influenzae D. A or B E. A or C

A or C In a patient with a pneumoniae complicating chronic bronchitis, likely organisms include H. influenzae and M.catarrhalis

A 33-year-old woman who is not a smoker has lost 30 lbs of weight and has a cough. She is noted to have a lung mass on CXR. Her CT Scan of the chest is seen below (peripheral right lung mass). Which of the following lung cancers is the most likley cell type this woman has? Adenocarcinoma Large Cell Small Cell A. Squamous cell

Adenocarcinoma

A 30-year-old athlete with asthma is also a cigarette smoker. Which of the following is characteristic of asthma but not other obstructive lung diseases?

Airway obstruction is reversible

A 42-year-old woman is being treated with corticosteroids for an exacerbation of her colitis. After several days of IV steroid therapy, she develops a cough, fever, and night sweats. A PPD is +. You suspect TB. *Which of the following is the most common site for a Mycobacterium Tuberculosis infection*

Apical aspect of the lung

A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future? Squamous carcinoma Systemic lupus erythematosus (SLE) Asthma Tinea pedis

Asthma Up to 50% of patients with atopic dermatitis develop asthma and/or allergic rhinitis in the future.

A 42 year-old male with unremarkable past medical history is admitted to the general medical ward with community-acquired pneumonia. He has a 20 pack-year history of cigarette smoking. He is empirically started on ceftriaxone (Rocephin). Which of the following antibiotics would be most appropriate to add to his empiric treatment regimen?

Azithromycin Patients with community-acquired pneumonia who require hospitalization on the general medical ward are treated with an extended-spectrum beta-lactam antibiotic, such as ceftriaxone, with a macrolide, such as azithromycin. Addition of a macrolide is also recommended due to the patient's smoking history and possible involvement of iHemophilus influenzae/i.

A *4 month-old infant* is brought to the clinic by his mother with complaints of a cough for the past 3 weeks. Initially,symptoms included running nose, sneezing and an irritating cough. Over the past week the *cough has changed to persistent staccato, paroxysmal forceful coughs ending with a loud inspiration.* WBC is 20,0000/mcl with 72% lymphocytes. *Which of the following is the drug of choice for managing this patient?*

Azithromycin (Zithromax) Azithromycin terminates respiratory tract carriage of Bordetella pertussis.

A 34 year-old female with a history of asthma presents with *complaints of increasing asthma attacks. *The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler *3-4 times a week* and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. *Which of the following is the most appropriate intervention at this time?*

Beclomethasone (Qvar)inhale

A 22 year-old female with a history of asthma presents with complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals > 85% predicted value. Which of the following is the most appropriate intervention at this time? Oral prednisone Oral theophylline Beclomethasone inhaler Salmeterol inhaler

Beclomethasone inhaler

A 34-year old black female presents to your office with symptom of cough, dyspnea, and lymphadenopathy. Physical exam shows cervical adenopathy and hepatomegaly. Her CXR is shown below (perihilar lymphadenopathy). How should you pursue the diagnosis? Liver biopsy Bronchoscopy and Transbronchial lung biopsy Serum angiotension converting enzyme (ACE) level Open lung biopsy Scalene nerve biopsy

Bronchoscopy and Transbronchial lung biopsy

A 30 year-old patient presents with a* three year history of episodic of wheezing, dyspnea and dry to minimally productive cough. *These episodes are typically worse at night and during the fall and spring seasons. The patient admits to a long history of allergies and tobacco use. Exam reveals numerous nasal polyps, xerotic skin and expiratory wheezes in bilateral lung fields. There is no cyanosis or abnormal heart sounds noted. His pulmonary function test reveals a *low FEV1/FVC ratio. Which of the following class of medications would be best to treat an acute exacerbation of this disorder?*

Beta agonists

A 50-year-old male presents with a history of persistent cough, hemoptysis, and weight loss. He stares that he has had several lung infections over the past 3-4 months. The patient is a 30 pack per year smoker, and also complains of right shoulder and chest pain. The patient is afebrile, pale and dyspneic with exertion.The CXR is seen below (large mass beginning in the perihilar region and extending peripherally). Which of the following diagnosis is most consistent with the given history? Idiopathic Pulmonary Fibrosis Bronchiectasis Emphysema Bronchogenic Carcinoma Chronic Bronchitis

Bronchogenic Carcinoma

A 3 year-old playing on the floor develops acute dyspnea and is found to have wheezing over the right mid lung. A Neck and CXR in the ED are negative. The child is afebrile and vital signs are stable. Which of the following is the next best step? Chest CT IV Rocephin Bronchoscopy Inhaled albuterol

Bronchoscopy

A 54 y/o alcoholic male presents with fever, chills, and cough with purulent sputum production for 3 days. On PE, Temp is 101.5F, RR 20, BP 128/80, P 82, and O2 sat 100% on RA. *The left lower lung base reveals inspiratory crackles with auscultation and associated + egophony, + bronchophony.Which of the following outpatient treatment options would be best indicated in this patient?*

Ceftriaxone + Azithromycin (Rocephin + Zithromax)

A 40 year-old alcoholic male presents with sudden onset of severe chills, fever, dyspnea and cough productive of red mucoid sticky sputum. He appears ill looking with cyanosis. Examination reveals vital signs: Temp - 102 degrees F; Pulse - 120 /minute and regular; RR - 28/min; BP 90/62 mm Hg. Lungs reveal minimal rales and dullness in the right upper lobe with decreased breath sounds. Chest x-ray reveals right upper lobe consolidation with a bulging fissure. Gram stain reveals many white blood cells and many gram negative organisms. Which of the following is the best treatment? Cefotaxime Clindamycin Doxycycline Ticarcillin

Cefotaxime This patient most likely has pneumonia caused by Klebsiella. A third generation cephalosporin, such as cefotaxime, is the preferred antimicrobial therapy against iKlebsiella pneumoniae. Alternative antibiotic choices may include a carbapenem, beta-lactam/betalactamase inhibitor or a fluoroquinolone

A 24 year-old PA student had a negative 2 step PPD before entering school. However, 2 years later returns from clinical rotations and has a repeat PPD that is 15mm indurated. She is completely asymptomatic. Which of the following is the next best step in the evaluation of this patient? Sputum for acid fast bacilli Repeat the PPD in 3 months CXR Skin punch biopsy

CXR

A 2 year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears nontoxic with a respiratory rate of 42 breaths per minute. What is the next step in the evaluation of this patient?

Chest x-ray

A 44-year-old man presents with the sudden onset of shaking chills, fever, and a productive cough. He was in his usual state of good health until 1 week ago when he developed mild nasal congestion and achiness.He otherwise felt well until last night, when he became fatigued, feverish, and developed a cough associated with right side-pleuritic chest pain. His past medical history is remarkable only for a 15 pack-year history of smoking. In your office, his vital signs are normal except for a temperature of 102 F. His oxygen saturation on RA is 100%. He is comfortable, except when he coughs. His exam is unremarkable except for bronchial breath sounds and end inspiratory crackles in the right lower lung field. What is the most likely diagnosis? Lung cancer Bronchiectasis Tuberculosis Community acquired pneumonia(CAP) Pulmonary embolism

Community acquired pneumonia(CAP)

A 32 year-old female on coumadin for a *history of PE presents to the clinic follow-up.* She is taking Warfarin 2.5mg x 3 days (M, W, F) & 5mg x 4 days (S, S, T, Th,). *Her INR today is 2.2.* She has no bleeding symptoms and denies any changes to her diet and medications. *Which of the following actions is most appropriate for this patient?*

Continue the current dose

A 36-year-old school teacher presents with an acute onset of fever, chills, malaise, headache & congestion. She is coughing & sneezing, conjunctivae are injected, pharyngeal mucosa is edematous & injected. What is expected on examination of lungs? clear lung fields with good air exchange dullness & rhonci at the bases diffuse expiratory wheezes scattered crackles & inspiratory wheezes

clear lung fields with good air exchange

A 48 year-old African-American female who works as a PA has had increasing dyspnea for 7 years which now greatly restricts her physical activity. She has painful nodules on her lower legs that are suspected to be *erythema nodosum.* A chest radiograph reveals *bilateral hilar lymphadenopathy.* Laboratory results are significant for *elevated calcium and elevated liver function tests.* *An angiotensin converting enzyme level is elevated as well.* Which of the following treatment options would be indicated in this patient?

Corticosteroids

A 21-year-old-college student with no prior medical problems begins working as a laboratory technician. He subsequently presents because of several recent episodes of shortness of breath, cough, fever, chills and malaise. Each episode last several days. The patient is seen during the recovery phase of an episode of this type; findings at physical examination are normal. Chest-x-ray reveals several ill-defined, diffuse patchy infiltrates. The laboratory evaluation is positive only for an increased ESR.Pulmonary function studies display reduced lung volumes. On further questioning, it is learned that these episodes begin on days when the patient is required to tend to experiments involving laboratory rats at the animal facility. What is the best treatment for this condition? Inhaled beclomethasone Inhaled cromolyn sodium Discontinuation of visits to the animal facility Prednisone

Discontinuation of visits to the animal facility

A 54-year-old woman diagnosed with a venous thromboembolism last month is currently taking warfarin (coumadin) and develops a massive bleeding complication on this medication. Which of the following would be the most appropriate in this patient? Discontinue coumadin and start rivaroxaban (Xarelto) Discontinue coumadin and place an IVC filter Discontinue coumadin and start fondaparinux (Arixtra) Discontinue coumadin and schedule the patient for a surgical embolectomy

Discontinue coumadin and place an IVC filter

A 18 month-old male presents with his parents who report symptoms of a barking cough and intermittent stridor that has worsened over the past 12 hours. They note improvement in symptoms when he was taken outdoors to the cool night air. Which of the following is the most likely organism causing this patient's symptoms? Rubeola virus Influenza virus Adenovirus Para-influenza virus

Para-influenza virus Croup is most often caused by para-influenza virus

A 24 year-old male presents complaining of a* 9 month history of increasing shortness of breath, dyspnea on exertion, and a cough productive of white sputum, mostly in the mornings.* He denies orthopnea, PND, peripheral edema, fever, chills, night sweats, recent changes in weight, palpitations, chest pain, food intolerances, or other complaints. Patient has a history of recurrent lung infections. He states that *his father had chronic pulmonary problems and died at age 42 from unknown lung disease.* The patient denies smoking, alcohol or illicit drug use. On physical examination, the respiratory rate is 22 per minute, pulse of 98 bpm, temperature of 98.7 degrees. Pulmonary exam reveals end-expiratory wheezes bilaterally and hyperresonance to percussion. His cardiac exam is normal. Chest Xray shows decreased lung markings. ECG is normal.* Pulmonary function tests show an FEV1 63% of expected* and residual capacity is 123% of expected. *Which of the following is the most likely diagnosis?*

Emphysema This person has an obstructive lung disease based on PFTs. Emphysema is the most likely diagnosis, and may be related to alpha-1 antitrypsin deficiency based on family history and lack of smoking history and young age.

A 22 year-old college student presents with a* one-day history of left-sided, sharp and non-radiating chest pain. He describes a recent cold with dry cough, *sore throat and rhinitis starting five days ago but all of the symptoms are now much improved. He denies fever, palpitations or dyspnea. Examination reveals normal heart sounds, clear lung fields and no rash or palpable areas of tenderness to the chest wall. *A chest radiograph is normal. Which of the following is the most likely diagnosis?*

Pleuritis

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 has been able to continue working with her symptoms. She is febrile but does not appear acutely ill. 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 likley diagnosis?*

Right middle lobe pneumonia

A 30-year-old woman is admitted to the hospital with fever and back pain. Laboratory tests reveal a profound leukocytosis(elevated WBC count). The urine contains leukocytes and gram-negative rods. A presumptive diagnosis of pyelopneprhtis is made. She is admitted to the hospital and broad-spectrum antibiotics are institiuted. Eight hours after admission, her BP falls to 70 mm Hg systolic and the urine output falls to 10 ml perhour. Resuscitative efforts are successful at stabilizing her BP. Howvever, she develops progressive dyspnea and hypotension and requires endotracheal intubation. *After review of all clinical and laboratory data, you make a diagnosis of acute respiratory distress syndrome(ARDS). Which is the appropriate basis for making his diagnosis?*

Hypoxia, diffuse pulmonary infiltrates, absence of another etiology

A 46- year-old male presents with several months of dyspnea and a nonproductive cough.Physical examination reveals dry crackles at both lung bases. Spirometry reveals reduction in total lung capacity, vital capacity, and residual volume. CXR seen below CT of the chest reveal a bibasilar reticular nodular pattern in the lung field. ABG pO2 55 Transbronchial biopsy results reveal an increase in inflammatory cells as well as diffuse intraalveolar fibrosis. The most likely diagnosis is Asthma Chronic Bronchitis Emphysema Idiopathic Pulmonary Fibrosis Bronchiectasis

Idiopathic Pulmonary Fibrosis

A 45 year-old female presents with complaint of lower extremity discomfort. The patient admits to dull aching of the left lower extremity. The discomfort is worse after standing for long periods of time. Examination reveals *dilated, tortuous and elongated veins* on the medial aspect of the left leg. Pedal pulses are +2/4 bilaterally. There are no skin changes or lower extremity edema noted. *Which of the following is the most appropriate initial treatment of choice in this patient?*

compression stockings

A 53-y/o male is accompanied by his wife to your office and complains of cough. The cough began 6 weeks ago and has been especially bothersome several nights over the past month. He does not produce any sputum and denies shortness of breath, chest pain, or wheezing. He does not smoke. He denies any significant medical history and only takes 1 aspirin a day. He specifically denies any history related to cardiac disorders. He has not recently lost weight nor has had any cold symptoms, fevers, or night sweats. His wife reports that he snores at night, and she adds. "He's always hacking and clearing his throat. In order to sleep better, he has recently started to have a shot of whisky before going to bed. What is the most likely cause for his cough? Aspirin use Gastroesophageal reflux Lung Cancer Alcohol abuse Congestive heart failure

Gastroesophageal reflux

A 3 y/o boy who was recently sick with an upper respiratory infection presents to the ER with stridor and a cough that awoke him last night. Which of the following treatment options could be considered in this patient if he developed severe respiratory symptoms? Cool mist Glucocorticoids and nebulized epinephrine An expectorant An antihistamine

Glucocorticoids and nebulized epinephrine

A 21 year-old college student presents with a 3 week history of slowly worsening dry cough, generalized fatigue and most recently low-grade fevers. He denies nasal congestion, sore throat and nausea and has no past history of pulmonary disease or tobacco use. He does note that many other dorm residents have had similar symptoms over the past two months. Examination reveals mild inspiratory crackles but is otherwise normal. Chest radiograph is clear and CBC is normal. Which of the following is the most likely causative organism? Klebsiella Pseudomonas Mycoplasma Staphylococcus

Mycoplasma

A 50-y/o male with emphysema and a chest x-ray that has shown apical blebs develops the sudden onset of shortness of breath and pleuritic chest pain. Pneumothorax is suspected. Physical exam findings that would confirm the diagnosis are Increased tactile fremitus on the left side Decreased breath sounds on the left side with deviation of the trachea to the left Hyperresonance of the left chest with decreased breath sounds Localized wheezes at the left base

Hyperresonance of the left chest with decreased breath sounds

A 21-year-old college student with no prior medical problems begins working as a laboratory technician. He subsequently presents because of several recent episodes of shortness of breath, cough, fever, chills and malaise. Each episode last several days. The patient is seen during the recovery phase of an episode of this type; findings at physical examination are normal. Chest x-ray reveals several ill-defined diffuse patchy infiltrates. The laboratory evaluation is positive only for an increased ESR(marker of inflammation). Pulmonary function studies display reduced lung volumes. On further questioning, it is learned that these episodes begin on days when the patient is required to tend to experiments involving laboratory rats at the animal facility. The most likely diagnosis is Heart failure Sarccoidosis Asthma Hypersensitvity pneumonitis Bronchiectasis

Hypersensitvity pneumonitis

A 42-year-old female presents to your office for evaluation of shortness of breath. She has had a fever as high as 103 F for the last 3 days and has had a cough productive of green sputum. On physical examination, you hear crackles in her lungs. A chest radiograph reveals a consolidation of the left lower lobe. You diagnose her with *lobar pneumonia. When you perform tactile fremitus of the left lower thorax, you would expect fremitus to be:*

Increased

A 19 year-old college student presents to the emergency room for sudden onset of dyspnea. The general survey reveals that she is 6'2" tall and weighs 135 pounds. She denies fever, chills, cough, or sore throat. She is a non-smoker. You suspect that she has a* pneumothorax What findings would you expect with percussion of the thorax*

Increased resonance (hyperresonance)

A 54-year-old male presents to your office complaining of sleepiness. He states that he invariably naps after dinner and normally is in bed for 8 to 10 hours nightly. He does report, however, that he feels that his sleep is fragmented. When the patient awakens in the morning, he rarely feels refreshed. His wife has complianed for years of his snoring to the extent that she now sleeps in a different room. The patient notes that he frequently has difficulty staying awake during the late afternoon at work. He is seeking evaluation now because his job performance has been impaired and he has been put on probation at work. Past medical hisotry is significant for hypertension since age 38 that has recently worsened despite medication. Body mass index is increased at 36 kg/m2. He is noted to have central obesity and a thick neck. *You suspect obstructive sleep apnea(OSA) All of the following are long-term consequences of untreated OSA except:* Increased risk of motor vehicle accidents Increased risk of systemic hypertension Worsening of congestive heart failure Increased risk of proteinuria and chronic kidney disease Personality disturbance

Increased risk of proteinuria and chronic kidney disease

A 30 year-old male presents with sudden onset of chills, fever, chest pain and a cough productive of greenish-brown sputum. On examination his temperature is 102 degrees F. He appears acutely ill and his respirations are shallow. Chest x-ray demonstrates left lower lobe consolidation. Which of the following findings would most likely be present on examination of his left lower lung? Vesicular breath sounds Wheezing Increased tactile fremitus Hyperresonance

Increased tactile fremitus Increased tactile fremitus occurs in the presence of fluid or a lung consolidation such as lobar pneumonia

A 28 year-old male presents with history of a recent upper respiratory tract infection. He complains of chest *pain aggravated by deep breathing and movement.* The patient is afebrile and lungs are clear to auscultation bilaterally. *Which of the following is the most appropriate first line therapy for this patient's chest pain?*

Indomethacin

A 34 year old man was recently diagnosed with exercise induced asthma as a part of the first-line therapy Advise that symptoms will likely subside with increased conditioning Start oral prednisone Initiate theophylline daily as prophylaxis Discontinued exercise indefinitely Initiate a B2-Agonist approximately 20 minutes before exercise.

Initiate a B2-Agonist approximately 20 minutes before exercise.

A 50-year-old obese man with history of asthma returns with complaints of occasional dyspepsia and cough. He wakes up in the morning with a *sour taste in his mouth.* His current medications include inhaled corticosteroid and a short acting B2 agonist. *What should be your next step?*

Initiation of omeprazole

A 42 y/o female was initially seen in the ED where she was diagnosed with influenza and discharged with a cough suppressant. She presented back four days later for severe SOB and hypoxemia. CXR showed bilateral interstitial infiltrates and patient's SaO2 was below 80% on ~100% NRB. What is the most appropriate next step?

Intubation and mechanical ventilation

A 55 year old male with a long history of smoking has a squamous cell carcinoma of the respiratory tract. This is most likely to present as a(an): Pneumonia-like consolidation In situ lesion Peripheral nodule Large hilar mass Carinal mass

Large hilar mass

A 19 year-old male presents to the ED complaining of a sudden onset of dyspnea and left sided chest pain. He denies fever, chills, cough or sore throat. General survey shows that he is 6 feet 2 inches tall and weighs 135 lbs. Vital signs are BP 86/60 mmHg, HR 130 bpm, RR 28, temp. 98.6 degrees F. Which of the following would you likely find on examination of his thorax? Increased anterior/posterior diameter Increased tactile fremitus of left base Scattered rales throughout Left-sided hyperresonance

Left-sided hyperresonance

A 55 year-old female presents to the emergency department with complaints of dyspnea, chest pain and coughing with hemoptysis. Past medical history includes breast cancer 5 years ago, currently in remission. Vital signs are Temp. 98.6 degrees F, BP 150/90 mmHg, P 110 bpm, RR 20. Physical examination shows her right leg swollen with pain on palpation of deep veins. Which of the patient's history or examination findings is most suggestive of a pulmonary embolus (PE)? Hemoptysis Heart rate > 100 Leg swelling and pain with palpation of deep veins Past history of cancer

Leg swelling and pain with palpation of deep veins

A 35-year old-male patient has chronic renal failure. He had a *renal transplant 6 months ago *and is being treated with corticosteroids and cyclosporine.He came to the ER 4 days ago with *fever, dyspnea, and 2 days of diarrhea. *He has failed to respond to ceftriaxone and continues with a fever and a cough. Today he is lethargic and confused CXR showed bilateral pulmonary infiltrates *What is the most likely organism causing his pneumonia?*

Legionella pneumoniae

A 52 year-old male who is post-op day 3 for a right total hip arthroplasty has acute onset of shortness of breath when ambulating to the restroom. Vital signs are as follows: BP 136/80 mm Hg, Pulse of 104, Respiration Rate of 22, and O2 Sat of 93%. On physical exam, he appears somewhat anxious, heart is tachy with a regular rhythm, lungs are clear to ausculation, and the left lower extremity is swollen and tender with dorsiflexion of the foot. Studies confirm your diagnosis. Which of the following treatment options are most appropriate in this patient now? Greenfield Filter Placement Vitamin K Antagonist Thrombolytics Low Molecular Weight Heparin

Low Molecular Weight Heparin

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 103.2 F. Mouth examination reveals numerous dental caries and poor dental hygiene. Lung examination reveals normal fremitus, dullness, and auscultation. Which of the following is the most likely diagnosis? Bronchogenic carcinoma Lung abscess Empyema Pleural effusion

Lung abscess

A 22-year-old male presents with a 2 week history of an URTI. He has been taking amoxicillin for 6 days. He is still c/o malaise, sore throat, subjective fever, and a nonproductive cough. Physical exam reveals diffuse crackles. What is the MOST appropriate class of antimicrobials. Cephalosporin Macrolide Sulfonamide Fluroquinolone

Macrolide

A 35-year-old man seeks medical attention for dyspnea on exertion. He has never smoked cigarettes and has not been coughing. One sibling died of respiratory failure at 40 years of age. His three children are healthy. Physical examination reveals him to be tachypneic and he exhales through pursed lips. His chest is hyperresonant to percussion, and breath sounds are poorly heard on auscultation. CXR is seen below (shows hyperexpansion). Which of the following would be the most reasonable next step in the assessment of the patient? Measurement of sweat chloride concentration(test to R/O cystic fibrosis) Measurement of alpha 1 anti-trypsin levels High resolution CT scan Perfusion/Ventillation lung scan

Measurement of alpha 1 anti-trypsin levels

A 51 year-old man develops pancreatitis associated with the passage of a gallstone. His treamtent includes analgesics and inreavenous normal saline. Two days later, he becomes anxious, tachypneic, and short of breath. An emergency CXR demonstrates diffuse, bilateral interstitial and alveolar infiltrates(see below). A year ago, he suffered a myocardial infarction but since then he has had no evidence of congestive heart failure. In this case,* adult respiratory distress syndrome(ARDS) can be distinguished by cardiogenic pulmonary edema by *

Measurement of pulmonary artery wedge pressure

A 48-year-old HIV+ female presents with a productive cough of purulent sputum. CXR reveals an apical infiltrate and a small right pleural effusion. Gram stain of the sputum reveals normal flora. Acid-fast stain of the sputum reveals the presence of acid fast bacilli. The most likely diagnosis at this point is: Staphylococcus aureus abscess Streptococcus pneumoniae bronchitis Mycobacterium tuberculosis infection Mycoplasma pneumoniae infection

Mycobacterium tuberculosis infection

A 22 year-old previously healthy female had a worsening non-productive cough for the past 4 days. On physical examination her temperature was 100.9 F. A chest radiograph showed patchy infiltrates and diffuse interstitial markings. Laboratory studies showed a sputum gram stain with mixed flora. Her Hgb was 12.9 g/dL, platelet count 229,450/microliter, and WBC count 5,815/microliter. Her cold agglutinin titer was elevated. Following a course of erythromycin therapy, she improved, with no complications. Which of the following infectious agents was most likely in this patient? Klebsiella pneumoniae Mycobacterium tuberculosis Mycoplasma pneumoniae Pneumocystis jiroveci

Mycoplasma pneumoniae

A 24-year-old university student comes to the Student Health Service with a 3-day history of a dry hacking cough that was initially nonproductive but has become productive of scant, white sputum. Also c/o of malaise, headache, fever, muscle aches, and pains. She had no other upper respiratory tract symptoms before this illness Her roommate developed the same symptoms 2 days ago. On examination, the patient has a temperature of 39 C. You hear a few scattered crackles in the left lung base. No other abnormalities are found. What is the most likely diagnosis in this patient? Mycoplasma pneumoniae pneumonia Klebsiella pneumoniae pneumonia Viral Pneumonia No pneumonias of any kind; a case of simple acute bronc Streptococcus pneumoniae pneumonia

Mycoplasma pneumoniae pneumonia

A 45 year-old male presents to the clinic complaining of morning sluggishness, daytime fatigue, headaches. He admits to drinking two cocktails each evening. His bed partner reports his loud cyclical snoring, breath cessation and thrashing movements of his extremities during sleep. BMI is 40. Heart examination reveals regular rate and rhythm without S3, S4, or murmur and lungs are clear to auscultation. Polysomnography shows apneic episodes lasting as long as 60 seconds. Which of the following clinical interventions would most likely provide for the acute cessation of apneic episodes? Supplemental oxygen Nasal continuous positive airway pressure Avoidance of alcohol Weight loss

Nasal continuous positive airway pressure

A 48-year-old Hatian male presents with dyspna. CXR reveals a right pleural effusion extending about halfway up the chest. The patient has no other known medical problems and is on no medications. The PE reveals dullness and decreased lung sounds at the right base. The rest of the PE is unremarkable. Diagnostic thoracentesis reveasl the following: LDH 100 u/L, glucose 150 mg/dl, and amylase 90 U/L. Cell count reveasl 1000 RBC's per microliter, and 1000 white cells per microliter(50% polys, 25% lymphocytes, and 25% monocytes. Imaging studies show no evidence of pulmonary emboli. The most appropriate next step would be: Chest CT scan Needle biopsy of pleura Abdominal CT scan Pulmonary arteriogram Administration of INH and ethambutol

Needle biopsy of pleura

A 22-year-old man is brought to the ED after being *found unconscious in a swimming pool.* The patient is mildly cyanotic. The BP is 80/50 mm Hg, HR is 60/min, and RR is 26/min. His core body temperature is 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% O2. CXR reveals *bilateral perihilar infiltrates with a normal sized heart. Which of the following is the most likely diagnosis?*

Noncardiogenic pulmonary edema

A 52-year-old man presents with dyspnea and chest x-ray shows a hilar mass with an ipsilateal pleural effusion. What is the best next step? Initiate palliative radiation because the patient is not a candidate for curative resection PFT'S to evaluate pulmonary reserve to evaluate for pneumonectomy Obtain a specific tissue diagnosis by biopsy of the hilar mass CT scan of the chest, head, and abdomen for cancer staging None of the above

Obtain a specific tissue diagnosis by biopsy of the hilar mass

A 40 y/o male presents with shortness of breath, painful skin nodules, blurred vision, and malaise. CXR reveals bilateral hilar adenopathy and right paratracheal node enlargement. Histology of skin and lung reveals the finding of noncaseating granulomas. Which of the following is the best treatment option in this patient? Oral prednisone Montelukast (Singulair) Inhaled salmeterol (Serevent) postural drainage and chest percussion

Oral prednisone

A 48 y/o African American male presents with shortness of breath, painful skin nodules, blurred vision, and malaise. CXR reveals bilateral hilar adenopathy and right paratracheal node enlargement. Histology of skin and lung reveals the finding of *noncaseating granulomas. Which of the following is the best treatment option in this patient?*

Oral prednisone

A 55-year-old male presents with several months of dyspnea and a nonproductive cough. Physical examination reveals dry crackles at both lung bases. Chest radiography and high resolution CT of the chest reveal a bibasilar reticular nodular pattern in the lung field. Spirometry reveals reduction in total lung capacity, vital capacity, and residual volume. The carbon monoxide diffusion capacity is reduced to 35 percent of normal. Resting arterial hypoxemia is demonstrated on arterial blood gas testing. Transbronchial biopsy results reveal an increase in inflammatory cells on the alveolar surface, predominantly macrophages, as well as diffuse intraalveolar fibrosis. The mainstay of therapy at this point would be

Oral prednisone

A 20-year-old college student presents with a 3-mo history of left sided pleuritic chest pain, dyspnea with exertion, and night sweats. He is a nonsmoker and does not use illegal drugs. He is heterosexual. He recalls a negative PPD when he started college 2 years ago. On PE, his temperature is 100.9 F and his respiratory rate is 24/m. 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?*

Pleural effusion

A 30-year-old woman presents with the chief complaint of shortness of breath with minimal activity. In retrospect, she feels she ahs been dyspneci for at least 1 year but has now progrssed 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 ausucultation there is a loud S2 and a systolic murmur that increases with inspiration. Lungs are clear. There is no clubbing. CXR appears below (massively dilated pulmonary artery, bilaterally) Which of the following is the most likely diagnosis? Primary pulmonary hypertension(PPH) Sarcoidosis Systemic lupus erythematosis Idiopathic pulmonary fibrosis Coronary heart disease

Primary pulmonary hypertension(PPH)

A 13 year-old male with known cystic fibrosis presents to the emergency department, accompanied by his parents, with increased coughing, wheezing and low grade fever. Rales are audible on auscultation of the lungs. Treatment should target which of the following organisms? Haemophilus influenza Pseudomonas aeruginosa Mycoplasma pneumoniae Pneumocystis jiroveci

Pseudomonas aeruginosa

A 30-year-old paraplegic male has a long history of *urinary tract infection secondary to an indwelling Foley catheter.* He develops fever and hypotension requiring hospitalization, fluid therapy, and intravenous antibiotics. He improves, but over 1 week becomes increasingly short of breath and tachypneic. He *develops frothy sputum, diffuse rales, and diffuse alveolar infiltrates.* There is no fever, jugular venous distention, S3 gallop, or peripheral or sacral edema. CXR is seen below (diffuse infiltrates in most lung fields). *The best approach to a definitive diagnosis in this patient is *

Pulmonary capillary wedge pressure

A 25-year-old male with a long history of severe asthma presents to the emergency room with shortness of breath. He has previously required admission to the hospital and was once intubated for asthma. Which of the following findings on physical exam would indicate a benign course?

Pulsus paradoxus of 5 mm Hg

A 40 year-old male nonsmoker in good health undergoes a routine chest x-ray for an insurance physical. Results show an isolated, well-defined, coin lesion 1 cm in size. Which of the following is the next step in the evaluation of this problem?

Review old radiographs

A 52 year-old male presents with a 4 week history of fever, chills, night sweats, unintentional weight loss, and cough productive of blood tinged sputum. The following CXR is performed (large apical consolidation). Which of the following medications would be indicated in this patient? Levofloxacin Rifampin, Pyranzinamide, Ethambutol, and Isoniazide Rocephin and Azithromycin Isoniazide

Rifampin, Pyranzinamide, Ethambutol, and Isoniazide

A 21 year-old male presents to the ED with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Examination reveals moderate respiratory distress with absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right. Which of the following is the most appropriate next step? order a chest x-ray insert large bore needle into left 2nd ICS stat order a V/Q scan administer a sclerosing agent

insert large bore needle into left 2nd ICS stat

A 35-year-old woman presents with a 2-day history of cough productive of green-yellow sputum. She complains of fever, chills, and dyspnea.On PE, her T is 102.4 F & her RR is 26/min. Her BP is 110/65 mm Hg and her HR is 125/min. Examination of the lungs reveals increased fremitus and dullness at right posterior base. Crackles and bronchial breath sounds are audible at right base & patient demonstrates egophony & pectoriloquy in the area. Gram stain of the sputum reveals gram-positive cocci and numerous neutrophils. Which of the following is the most likely diagnosis? Right pleural effusion Right lower lobe pneumonia Right lower lobe atelectasis Right middle lobe pneumonia Right upper lobe pneumonia

Right lower lobe pneumonia

A 48 year-old man with a diagnosis of PHTN presents in chronic right heart failure. He has been unable to perform activities of daily living. Currently he is being treated with prostacyclins. What intervention should be considered next? Recommend lung transplantation Begin an exercise program and fluid restriction Schedule a Bronchoscopy None of the above

Recommend lung transplantation

A 21-year-old man presents with a 2 month history of anterior and posterior cervical lympadenopathy. He denies recent illnesses, weight loss, and fever. His physical examination reveals scattered, non tender 1-cm nodes bilaterally. Lung, heart, and abdominal examinations are normal. Chest radiography reveals bilateral hilar adenopathy. Which of the following is the most likely diagnosis? Sarcoidosis Loeffler syndrome Pneumonia Bagassosis Hamman-Rich syndrome

Sarcoidosis

A 36 year-old African American female comes to the clinic for an insurance physical which requires a chest x-ray. She denies any respiratory symptoms. Examination of her chest is negative. X-ray results show marked lymphadenopathy in the right paratracheal region. Angiotensin-converting enzyme (ACE) levels are elevated. Which of the following is the most likely diagnosis?

Sarcoidosis

A 50-year-old female has lived in Oslo, Norway all her life and worked as a seamstress. She is a non-smoker, but she has had increasing shortness of breath, fever, and weight loss for the past 4 months. On PE her temperature is 99.6 F. On auscultation, there are diminished breath sounds throughout. A chest radiograph reveals hilar lymphadenopathy and a reticulonodular pattern of small densities in all lung fields. A transbronchial biopsy is performed that microscopically shows numerous small pulmonary interstitial non-caseating granulomas. Which of the following is the most likely diagnosis? Histoplasmosis Sillicosis Berylliosis Sarcoidosis

Sarcoidosis

A 40 year old female c/o sudden onset at 10:03 A.M. of a shaking chill that lasted for several minutes. She now has fever, chest pain and cough. You expect all of the following EXCEPT Her chest xray will probably show lobar consolidation She will probably have rust colored sputum. She will probably have a high WBC. She will probably develop empyema

She will probably develop empyema

A 20 year-old male presents with complaint of difficulty breathing, chest tightness and wheeze during gym class. He denies symptoms at any other times. He denies nighttime cough or shortness of breath. Which of the following is the first line therapy for this patient? Short-acting beta agonist before exercise Leukotriene modifiers daily Immunotherapy Inhaled corticosteroids before exercise

Short-acting beta agonist before exercise

A 46 year-old patient presents with a 4 year history of worsening cough, shortness of breath and dyspnea. He admits to bouts of bronchitis 5-6 times yearly but otherwise denies fevers, weight loss or hemoptysis. He has worked the past 30 years as a sandblaster. His chest radiograph reveals "egg-shell" calcification of the hilar lymph nodes and numerous ground-glass densities throughout both lung fields. Which of the following is the most likely diagnosis? Emphysema Chronic bronchitis Silicosis Asthma

Silicosis

A 44-year-old woman arrives in your clinic complaining of a nonproductive dry cough that has been persistent for the past several months. The patient is also complaining of a 5 to 10% weight loss over the same period. She has low-grade fevers but denies night sweats; she denies any history of hemoptysis. The patient is a long-term smoker. She began smoking at age 13 and currently smokes about 1 to 1½ packs per day. Her physical examination is unremarkable. A chest x-ray shows micronodular interstitial lung infiltrates bilaterally and hyperinflated lungs. No defined mass or cystic cavities are noted. Pulmonary function testing reveals a normal pattern; however, there is a mild reduction in CO diffusing capacity, which is 90% predicted value. The chest radiograph findings are confirmed on high-resolution CT in which 1- to 2-mm cystic and nodular changes are noted, primarily in the upper lung fields. BAL is performed and reveals an increased number of CD1a reactive cells within the lavage. The most appropriate treatment recommendation for this patient would be? Cyclophosphamide chemotherapy Systemic glucocorticoids Smoking cessation Initiation of a Beta-agonist metered dose inhaler Inhaled glucocorticoids

Smoking cessation

A 16-year-old high school student presents with the sudden onset of sharp right-sided chest pain associated with shortness of breath. He denies any history of trauma. On PE, the patient is afebrile with a RR of 28/min. Her BP is 100/70 mm Hg and his HR is 120/min.Neck examination reveals no tracheal deviation. On lung auscultation, the patient has decreased fremitus, hyperresonance, & diminished breath sounds over the right posterior hemithorax CXR is seen below. Which of the following is the most likely diagnosis? Secondary pneumothorax Tension pneumothorax Pulmonary embolus Pneumonia Spontaneous pneumothorax

Spontaneous pneumothorax

A 28 year-old non-smoking black female presents with an 8 week history of dry cough, fatigue and numeroumacular-papular lesions on the face. She denies fever, chills or hemoptysis though she has noticed enlarged,nontender lymph nodes in the neck. Lab tests reveal a normal CBC but her serum ACE level is three times the upperlimit of normal. Her chest radiograph reveals bilateral, hilar adenopathy but is otherwise clear. Which of the following medications is most indicated in this patient?

Steroids

A 24-year-old male presents for evaluation of gradual onset of painless facial swelling, associated with weight loss, anorexia, fatigue, and night sweats. Physical examination revealed in addition to the facial swelling, diffuse lymphadenopathy, and splenomegaly. CXR is seen below. The most likely diagnosis is Tuberculosis Pulmonary Sarcoidois Pancoast Tumor Thoracic Outlet Syndrome Superior Vena Cava Syndrome (SVC obstruction from a mass)

Superior Vena Cava Syndrome (SVC obstruction from a mass)

A 23-year-old female develops onset of premature labor and delivers a boy during the 29th week of pregnancy. Within an hour of delivery, the infant is in severe respiratory distress and requires intubation with mechanical ventilation. Which of the following treatment options would be best indicated in this infant? Surfactant replacement Unfractionated heparin IV furosemide Broad spectrum antibiotics

Surfactant replacement

A 35-year-old woman complains of calf tenderness and acute dyspnea. The ABG reveals a pO2 of 76 mm Hg. Which of the following is the most common physical examination finding of a pulmonary embolism? Wheezing Pulmonary crackles Increased intensity of P2 Calf swelling Tachypnea

Tachypnea

A 46-year-old woman complains of sudden anxiety and breathlessness. She has been at bed rest for 2 weeks for back pain. She uses oral contraceptives. All of the following would be suggestive of a pulmonary embolism EXCEPT: Temperature of 103.1 F Sinus tachycardia on electrocardiogram Subsegmental atelectasis on CXR Normal findings on examination of the lower extremities PO2 of 60 mm Hg

Temperature of 103.1 F

A 54-year-old woman is noted to have* a cervical cancer *and presents with significant vaginal bleeding with a hemoglobin level of 7 g/dL. Her left leg is swollen, which on Doppler investigation reveals a deep venous thrombosis. *Which of the following is the best treatment for the thrombus?*

Vena cava filter

A 36 year-old male who is hospitalized because of severe injuries from a motor vehicle accident develops rapid onset of profound dyspnea. Initial chest x-ray shows a normal heart size with diffuse bilateral infiltrates. Follow-up chest-xray shows confluent *bilateral infiltrates that spare the costophrenic angles. Which of the following is the best clinical intervention for this patient?*

Tracheal intubation

A 24 year-old near drowning victim has been hospitalized for 24 hours. The patient has now had a rapid decline in her respiratory status and has labored breathing, tachypnea and intercostal retractions. Arterial blood gases reveal a pH 7.28, pO2 60 mm Hg, pCO2 52 mm Hg, and bicarbonate 26 mEq/L. CXR reveals diffuse bilateral infiltrates, normal heart size and no pleural effusions. Which of the following is the most appropriate intervention in this patient? Chest tube placement Systemic corticosteroid therapy. Oxygen via nasal cannula Tracheal intubation with positive-pressure mechanical ventilation.

Tracheal intubation with positive-pressure mechanical ventilation. Treatment of hypoxemia in ARDS requires tracheal intubation and positive-pressure mechanical ventilation.

A 27-y/o male with a history of IV drug abuse presents with fever, chills, cough, hemoptysis, and dyspnea. Physical examination reveals a T of 101.5 F, tachycardia, and tachypnea. Cardiac exam reveals a Gr 3/6-holosystolic murmur which increases with inspiration heard best at the 5th intercostal space left of the sternum. There were no signs of peripheral embolization. *Chest X-ray reveals several small cavitary lesions without pulmonary vascular congestion. His most likley diagnosis is?*

Tricuspid valve endocarditis with septic pulmonary emboli

A 40 y/o pregnant female is diagnosed for the first time with a pulmonary embolism. Which of the following is the best long-term treatment option for this patient during her pregnancy? Coumadin during pregnancy Stop all medications and start Coumadin after labor and delivery Unfractionated heparin or low molecular weight heparin during pregnancy Greenfield filter during pregnancy

Unfractionated heparin or low molecular weight heparin during pregnancy

A 26 year-old man is stung by a bee, and shortly thereafter, a wheal develops at the site of the sting. He soon feels flushed and develops hives, rhinorrhea, and tightness in the chest. He is seen in the urgent care center. Immediate therapy should be to administer oral albuterol transfer him to a local hospital emergency department. apply a cold compress to site of the sting. administer subcutaneous epinephrine.

administer subcutaneous epinephrine Epinephrine hydrochloride 1:1000, 0.2 to 0.5 mL subcutaneously is indicated for the initial treatment of this systemic reaction. Additional injections may be given every 20 to 30 minutes if needed.

A 25-year-old patient complains of lightheadedness and shortness of breath. She appears anxious. Vital signs include temperature 98.6° F, pulse 90/min, and respiratory rate 30/min. Arterial blood gas results reveal a pH of 7.52, a PaO2 of 90 mm Hg, and PaCO2 of 22 mm Hg. The most appropriate initial step is to administer IV diazepam. have the patient breathe into a paper bag. obtain cardiac enzymes. administer heparin.

have the patient breathe into a paper bag.

A 22-year-old woman with a history of intermittent wheezing in response to exercise presents to the emergency room with shortness of breath. Her attack occurred during an aerobics class. At this point she is having obvious difficult breathing and has diffuse wheezes on pulmonary examination. 02 saturation is 95% by pulse oximetry. The most effective treatment at this point would be: Intravenous aminophylline Inhaled cromolyn sodium Intravenous hydrocortisone inhaled albuterol

inhaled albuterol

A 47-year-old female presents with productive cough and fever. Exam reveals diffuse bronchial breath sounds, rhonchi, & bronchophony in the RML. What is expected on CXR? diffuse interstial infiltrates patchy diffuse infiltrates cavitary lesions lobar consolidation

lobar consolidation

A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is: mycoplasma pneumonia. pneumococcal pneumonia. staphylococcal pneumonia. tuberculosis.

mycoplasma pneumonia The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make mycoplasma pneumoniae the most likely.

A 14 year-old male presents to the ED experiencing a severe asthma attack. His respiratory effort is shallow and he is using accessory muscles to breathe. Auscultation of his chest reveals no audible wheezing. Vital signs include BP 90/60 mmHg, P 160 bpm, RR 52. An arterial blood gas (ABG) is ordered. Normal ABG values at your institution are pH 7.35-7.45, CO2 35-45, pO2 80-95. Which of the following ABG findings suggests the poorest prognosis? pH = 7.52, pCO2 = 28, pO2 = 80 pH = 7.27 pCO2 = 46 pO2 = 56 pH = 7.44, pCO2 = 38 pO2 = 90 pH = 7.60, pCO2 = 18 pO2 = 80

pH = 7.27 pCO2 = 46 pO2 = 56

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30 minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment peak flow Ventilation-perfusion scan Chest x-ray Sputum gram stain

peak flow

A 25-year-old sustained significan blunt force trauma to the chest in a MVA. He arrived at the ED on supplimental O2. An initial evaluation, including CXR, revealed three rib fractures but no other injuries. *Suddenly, the patient reports severe dyspnea.* Vital signs at this time are BP 106/66, pulse 20, SaO2 85%. *What is the next best step in management of this patient?*

perform an immediate needle decompression