PULM
A 32 year-old African American female presents with complaints of a gradual worsening of exertional dyspnea associated with a mild dry cough. She has tried various cough preparations on her own without any significant relief. Her examination is essentially unremarkable. A chest x-ray reveals the presence of bilateral hilar adenopathy. Which of the following is the most likely diagnosis?
sarcoidosis
A 64 year-old with COPD receiving their first 23-valent pneumococcal polysaccharide vaccine (PPSV23) should be revaccinated in
5 years.
An O2 saturation of 90% corresponds to what PO2 value?
60 mmHg
Which of the following best describes the pathophysiology of emphysema?
Alveoli enlargement and loss of septa
Which of the following classes of medications is most likely to cause a persistent cough?
Angiotensin converting enzyme inhibitors
Which of the following is essential to make a diagnosis of cystic fibrosis?
Elevated sweat chloride
Which of the following findings confirm the adequacy of a sputum specimen for Gram stain and culture?
Increased polymorphonuclear leukocytes
A 33 year-old HIV-positive woman develops an 8mm area of induration following the administration of a purified protein derivative (PPD) test. Her chest radiograph shows no evidence of active tuberculosis (TB) infection. Which of the following is the most appropriate clinical intervention?
Isoniazid with Rifampin
Which of the following is a physical examination finding that is consistent with a diagnosis of lobar pneumonia?
Late inspiratory crackles
Which of the following causes of pneumonia is most likely to be complicated by diarrhea?
Legionella
A 28 year-old man presents to the emergency department complaining of sudden onset of shortness of breath associated with sharp right-sided chest pain increased with breathing. On physical examination, respirations are 20 per minute and blood pressure is 120/76 mm Hg. Auscultation of the chest reveals absent breath sounds over the right apex with normal heart sounds. Percussion of the right apex is noted to be hyperresonant. Which of the following is the most likely diagnosis?
Pneumothorax
Which of the following is the most common radiographic presentation of lung abscess?
cavitation
Which of the following describes the pathophysiological changes of pulmonary sarcoidosis?
granulomas and inflammation of alveoli, small bronchi and small blood vessels
Which of the following clinical manifestations is most commonly seen in viral croup?
inspiratory stridor
The finding of egophony is most consistent with
lobar pneumonia.
Which of the following forms of lung cancer is associated with the poorest prognosis?
small cell
On a shift in the emergency department, several arterial blood gasses are drawn from different patients at approximately the same time. When preparing the tubes for transport to the labs the samples are mixed up. One such sample had the following values: pH 7.3, PCO2 50, HCO3 25. Which of the following patients most likely had this result?
17-year-old with an acute asthma attack
A 29-year-old female presents to clinic for an evaluation of her asthma. She was given a prescription by her previous physician for an albuterol inhaler which she has been using. She reports symptoms on average three days per week. Last month she was awakened by her asthma on three nights. She is able to participate in light jogging but high intensity aerobic exercise often triggers her symptoms. Which of the following is the best next step in management?
Add an inhaled corticosteroid
An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient?
Admit to the hospital (CAP)
Which of the following has been found to be an important reservoir in the transmission of pertussis?
Adult humans
Which of the following is the major pathogenetic mechanism that causes asthma?
Airway inflammation
A patient presents with occasional wheezing and chest tightness that occurs approximately once a week and at night only about once a month. Peak expiratory flow is 85% of predicted. Which of the following is the most appropriate initial treatment?
Albuterol (Proventil) inhaler
A 17 year-old male who is trying out for the track team notes excessive coughing with chest tightness when running. Which of the following is the most appropriate preventive agent for this patient?
Albuterol inhaler (Proventil)
A 55 year-old man with a history of chronic bronchitis presents with two days of increased dyspnea and cough with worsening purulent sputum production. He is currently using inhaled albuterol as needed. In addition to systemic corticosteroids, what pharmacologic agent is warranted at this time for treatment of this patient?
Antibiotic
A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient?
Anticoagulation (PE)
A 42-year-old male with no significant medical history presents to the ED with complaints of headache, nausea, and dizziness. He states that he was at home working on his automobile in his closed garage, and started to develop the symptoms suddenly. He denies recent trauma and sick contacts, although recalls that he had a cold 2 weeks ago which had resolved. Vital signs are T 98.4, HR 80 bpm, BP 125/80, RR 16/min, SpO2 99% on room air. Physical exam is unremarkable. In addition to placing the patient on supplemental oxygen, which of the following is the next best step in management?
Arterial blood gas sample (Carbon monoxide poisoning)
A 69 year-old male presents with complaint of increasing dyspnea over the past 6-8 months. The patient denies cough, chest pain or smoking history. Physical examination reveals inspiratory crackles at the bases and clubbing of the nails. Chest x-ray reveals interstitial fibrosis of the lower lungs, thickened pleura and calcified pleural plaques of the lateral chest wall. Pulmonary function testing shows a restrictive pattern with a decreased diffusing capacity. What information is most likely noted in this patient's history?
Asbestos exposure
Which of the following is an independent risk factor for development of a mesothelioma?
Asbestos exposure
A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future?
Asthma
A 4 year-old patient presents with episodic wheezing and a non-productive cough for the last 4 weeks. His symptoms are worse at night. Past medical history reveals a history of atopic dermatitis. Physical examination at this time is unremarkable. Which of the following is the most likely diagnosis?
Asthma
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
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) (pertussis)
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?
Beclomethasone inhaler
A 60 year-old patient with COPD characteristic of emphysema presents with a cough and increased sputum production. The following information is noted: Temperature 100°F (37.8°C); Respiratory rate 20/min; Heart rate 88 beats/min; pH 7.44; PaO2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable for increased AP diameter, diminished breath sounds without wheezes, rhonchi, or other signs of respiratory distress. Which of the following would be an appropriate treatment for this patient?
Broad-spectrum antibiotic
A 5 year-old male presents with a history of recurrent episodes of acute bronchitis, characterized by fever and productive cough. He has no known significant past medical history. His pulmonary examination reveals crackles in the bilateral lower lobes. The remainder of his physical examination is normal. Chest x-ray demonstrates platelike atelectasis and dilated, thickened airways in the middle and lower lungs. Which of the following is the most likely diagnosis?
Bronchiectasis
A 69 year-old male with a history of chronic lymphocytic leukemia presents to the clinic complaining of cough, dyspnea and production of copious amounts of foul smelling sputum. Physical examination reveals crackles at the lung bases. Chest x-ray shows dilated and thickened bronchi that appear as ring-like markings. Which of the following is the most likely diagnosis?
Bronchiectasis
A 42 year-old male smoker presents for further evaluation of a 4 cm solitary pulmonary nodule discovered on a recent chest x-ray. Which of the following diagnostic tests is indicated next?
CT scan of chest
A solitary pulmonary nodule is found on a pre-employment screening chest x-ray in a 34 year-old nonsmoking male. There are no old chest x-rays to compare. Which of the following is the most appropriate next step in the evaluation?
CT scan of the chest
A 62 year-old homeless patient presents complaining of fever, weight loss, anorexia, night sweats and a chronic cough that recently became productive of purulent sputum that is blood streaked. On physical examination, the patient appears chronically ill and malnourished. Which of the following chest x-ray findings supports your suspected diagnosis?
Cavitary lesions involving the upper lobes (TB)
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; 89 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 rods. Which of the following is the most appropriate drug of choice?
Cefotaxime (pneumonia caused by klebsiella)
A 2 year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears non- toxic with a respiratory rate of 42 breaths per minute. What is the next step in the evaluation of this patient?
Chest x-ray
Which of the following is an indication for a pediatric patient to receive the 23-valent polysaccharide vaccine (Pneumovax)?
Children age 24-59 months at high risk for invasive pneumococcal disease
A 45 year-old male presents with complaints of a chronic cough productive of mucopurulent sputum. The cough has been present for the past 3 years, but he attributed it to a "smoker's cough". He has been coughing up a lot of sputum lasting all winter long for the past 2 years. He denies any hemoptysis, weight loss or chest pain. Physical examination reveals a moderately obese male in no acute respiratory distress. Lung fields reveal presence of scattered rhonchi and wheezes. There is 1+ peripheral edema. Which of the following is the most likely diagnosis?
Chronic bronchitis
A 56 year-old female with a 35 pack year smoking history presents to the clinic with shortness of breath and cough. On examination, she is thin with no recent weight loss. She appears uncomfortable, breath sounds are diminished without adventitious sounds. Pulmonary function tests show a marked increase in total lung capacity (TLC) and a decreased FEV1. What is the most likely diagnosis for this patient?
Chronic obstructive pulmonary disease
Which of the following will result in decreased serum theophylline levels in a patient with COPD?
Cigarette smoking
A 62 year-old male presents with a right hilar mass. Needle-biopsy of the mass reveals the presence of small-cell carcinoma and a bone scan reveals the presence of scattered hot spots throughout the skeleton. Which of the following is the most appropriate treatment?
Combination chemotherapy
A 32 year-old male with a history of Tetralogy of Fallot with poor right ventricular function presents for evaluation of sleep apnea. There is no evidence of deviated septum. Polysomnography reveals apneic episodes of 60 seconds in duration. Oxygen saturation falls to low levels. Which of the following is the first-line treatment in the management of this patient?
Continuous positive airway pressure
A 6-hour-old male has failed to pass stool and is vomiting greenish fluid. An abdominal radiograph is shown here. What is the most likely diagnosis?
Cystic fibrosis- meconium ileus
Which of the following chest x-ray abnormalities would most likely be seen in a patient with hypersensitivity pneumonitis?
Diffuse nodular densities
Which of the following physical exam findings is consistent with moderate emphysema?
Distant heart sounds
A 30-year-old previously healthy woman with no significant past medical history presents to your office with gradually worsening shortness of breath of one year's duration. The patient reports worsening dyspnea on exertion, fatigue, shortness of breath, and occasional exertional chest pain. On exam, the patient is noted to have an increased intensity of the P2 heart sound. Chest radiograph is seen here. What diagnostic test is most likely to lead to a diagnosis?
Echocardiogram (pulmonary HTN)
A 27 year-old woman presents with one week of worsening productive cough, dyspnea, fever and malaise. Which of the following physical examination findings would support the diagnosis of lobar pneumonia?
Egophony
A 63-year-old female with a known diagnosis of metastatic breast cancer presents to the emergency department after decompensating while at the chemotherapy suite. On arrival, vitals are pulse 124 bpm, blood pressure 92/64 mmHg, temperature 98.5 F, respiration 24/min and shallow. The patient is diaphoretic and disoriented, but able to complain about excruciating chest pain. Labs are drawn, and the patient is quickly worked up with an EKG (seen here) and helical CT (seen here). The patient is started on a heparin drip. Which of the following results confers a poor prognosis for the patient?
Elevated troponin (PE)
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 x- ray 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
A 68 year-old male with history of COPD is brought to the emergency department following a motor vehicle collision. On physical examination there is evidence of head trauma. The left side of the chest wall appears to move inward with inspiration and outward with expiration. A chest x-ray reveals multiple rib fractures on the left. Which of the following is the most appropriate intervention?
Endotracheal intubation and mechanical ventilation
A 36 year-old male developed a sore throat and was treated with IM penicillin. Within 20 minutes, he felt faint, became dyspneic, and had diarrhea. Upon entry to the emergency department, he was pale and apprehensive. He had a thready pulse, and systolic blood pressure was 40 mmHg. Which of the following is the most appropriate initial agent to use?
Epinephrine
A 2 month-old infant has been diagnosed with pneumonia due to Chlamydia trachomatis. Which of the following is the treatment of choice?
Erythromycin
Which of the following types of pleural effusion result from increased production of fluid due to underlying inflammatory conditions?
Exudate
A 67 year-old man presents complaining of gradually worsening fatigue and shortness of breath. He is a previous smoker with an 80 pack-year smoking history. He denies chest pain, night sweats, or hemoptysis. On physical examination, you note a very thin male who appears older than his stated age. Lung and heart sounds are barely audible to auscultation. Which of the following interventions is likely to alter the disease course?
Home oxygen (COPD)
A 24 year-old male presents in respiratory distress and appears quite ill. A Gram stain and culture of the sputum reveals gram-positive cocci in clumps and a chest x-ray reveals multiple patchy infiltrates with some cavitations. Which of the following is most likely to also be found in his medical history?
IV drug abuse (pneumonia caused by Staphylococcus aureus)
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?
Increased tactile fremitus (lobar pneumonia)
You are evaluating a patient whom you suspect has asthma. You perform spirometry before and after administration of an inhaled short-acting bronchodilator. After administration of the bronchodilator, which of the following spirometry results would suggest reversibility?
IncreaseinFEV1
A 25-year-old female is brought to the emergency department with an acute asthma exacerbation. The patient takes combination fluticasone propionate and salmeterol for long-term management of severe asthma. Her symptoms are well-controlled while on medication, but for the past few days she has not taken her medication after she left her inhaler at her tennis club. Her pulse is 100/min and respirations are 26/min. On physical examination, she is using accessory muscles of respiration. Rhonchi and wheezing are present in both lung fields. Oxygen saturation is 85% on room air. The patient is started on 2L/min nasal cannula oxygen. Which of the following is the most appropriate next step in management?
Inhaled albuterol
A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment?
Intubate the patient. (increasing respiratory failure as indicated by the raising PaCO2 levels)
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?
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)?
Leg swelling and pain with palpation of deep veins
Which of the following is a major contraindication to curative surgical resection of a lung tumor?
Liver metastases
You are seeing 62 year-old African American male for health maintenance. He is a former cigarette smoker with a 40 pack-year history. He quit smoking 10 years ago. He denies cough, hemoptysis, shortness of breath, chest pain, weight loss, or night sweats. What method of screening for lung cancer is appropriate in this patient?
Low dose computed tomography
A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. Which of the following would be the most appropriate treatment for this patient?
Low dose inhaled corticosteroid
A 76-year-old man with chronic obstructive pulmonary disease (COPD) presents complaining of 3 weeks of cough and progressive dyspnea on exertion in the setting of a 20 pound weight loss. He is a 60 pack-year smoker, worked as a shipbuilder 30 years ago, and recently traveled to Ohio to visit family. Chest radiograph shows increased bronchovascular markings, reticular parenchymal opacities, and multiple pleural plaques. Labs are unremarkable except for a slight anemia. Which of the following is the most likely finding on this patient's chest CT?
Lower lobe cavitary mass (bronchogenic carcinoma-->squamous cell)
A 4 year-old boy is sent home from day care for a severe cough following one week of cold symptoms, including sneezing, conjunctivitis, and nocturnal cough. He presents with paroxysms of cough followed by a deep inspiration, and occasional post-tussive emesis. During severe paroxysms, he exhibits transient cyanosis. What is the most appropriate treatment for exposed contacts at his day care center?
Macrolide prophylaxis (pertussis)
Which of the following pathophysiological processes is associated with chronic bronchitis?
Mucous gland enlargement and goblet cell hyperplasia
A 20 year-old male presents with 3 weeks of constitutional and upper respiratory symptoms, including malaise, sore throat, dry cough, and fever. Lung auscultation demonstrates diffuse crackles bilaterally. What is the most likely infectious agent involved?
Mycoplasma pneumoniae
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?
Nasal continuous positive airway pressure
A 2 year-old presents to the emergency department in acute respiratory distress. The parents relate a history of a recent upper respiratory illness that was followed by a sudden onset of barking cough during the night, but this morning they noted increased difficulty breathing. The child is noted to have stridor at rest, but has no evidence of cyanosis. Which of the following is the most appropriate initial intervention?
Nebulized racemic epinephrine
Which of the following is the greatest risk factor for the development of drug resistance in the treatment of tuberculosis?
Non-adherence to prescribed drug regimen
Upon auscultation of a patient's lungs, there are harsh, hollow breath sounds which have a long inspiratory component in the region of the suprasternal notch. Throughout the periphery of the lung fields, softer breath sounds are heard. Which of the following best describes these findings?
Normal
A 57 year-old man is being evaluated for shortness of breath. The following spirometric data are obtained: VC 4.90 L (predicted), 5.15 L (observed) 105% predicted FRC 3.99 L (predicted), 4.37 L (observed) 110% predicted RV 2.47 L (predicted), 3.17 L (observed) 128% predicted FEV1 3.50 L (predicted), 2.35 L (observed) 67% predicted These findings are consistent with which of the following?
Obstructive lung disease
A mother of a newborn infant presents to the office concerned about reducing the risk of sudden infant death syndrome (SIDS). The infant was delivered at 39 weeks gestation weighing 7 pounds 9 ounces. There is no family history of SIDS and this is her first child. Which of the following is appropriate advice to reduce the risk of SIDS?
Offer a pacifier at nap and bedtimes
A 22 month-old male infant presents with one day of barking cough preceded by three days of cold symptoms. On physical examination, his axillary temperature is 100.4°F and he has no stridor at rest. Inspiratory stridor is evident when he becomes agitated during the examination. There are no signs of respiratory distress or cyanosis. Which of the following is the most appropriate treatment for this patient?
Oral dexamethasone (croup)
A 43-year-old woman presents to her primary care physician with complaints of mild shortness of breath and right-sided chest pain for three days. She reports that lately she has had a nagging nonproductive cough and low-grade fevers. On examination, her vital signs are: temperature 99.1 deg F (37.3 deg C), blood pressure is 115/70 mmHg, pulse is 91/min, respirations are 17/min, and oxygen saturation 97% on room air. She is well-appearing, with normal work of breathing, and no leg swelling. She is otherwise healthy, with no prior medical or surgical history, currently taking no medications. You have a low suspicion for the most concerning diagnosis and would like to exclude it with a very sensitive though non-specific test. Which of the following should you order?
Order a D-dimer
An 85 year-old nursing home resident presents with abrupt onset of cough, sore throat, headache, myalgias, and malaise. On examination the patient's temperature is 102 degrees F; the rest of the exam is unremarkable. Nasal smear is positive for Influenza B. Which of the following is the treatment of choice in this patient?
Oseltamivir (Tamiflu)
A previously healthy 8 month-old boy is hospitalized for acute bronchiolitis. He has no known significant past medical or family history. On admission, he exhibits nasal flaring and retractions with a respiratory rate of 68, axillary temperature of 102.0 degrees F and O2 saturation of 86%. Which of the following medications is indicated?
Oxygen
A recent Haitian immigrant presents to the clinic for an employment physical examination before starting work at a local hospital. The patient has a history of receiving bacilli Calmette-Guerin (BCG) vaccination. Screening for tuberculosis for this employee should include which of the following tests?
PPD skin test
An 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?
Para-influenza virus (croup)
A 60 year-old female with a 30 pack year smoking history complains of new onset shortness of breath. On physical examination, dullness is noted on percussion with dimished breath sounds over her left base. Chest x-ray shows a new left pleural effusion. Which of the following is the next step in the management of this patient?
Perform diagnostic thoracentesis
Which of the following is a common presenting clinical manifestation of a patient with interstitial lung disease?
Progressive dyspnea on exertion
What is the most effective prophylaxis against respiratory syncytial virus (RSV) infection in the general pediatric population?
Proper hand-washing techniques
A 58-year-old female is recovering from a total knee replacement performed 3 days previously. She develops sudden onset shortness of breath and is complaining of a sharp pain in her chest with inspiration. A D-dimer test returns as positive, and a chest radiograph is performed and appears normal. Spiral CT scan is indeterminate for the presence of a pulmonary embolism. Homan's sign is absent bilaterally. Venous ultrasound is then performed to attempt to identify a deep venous thrombosis. Where is the venous ultrasound most likely to demonstrate the source of the pulmonary embolus in this patient?
Proximal femoral veins
A 3 year-old male with cystic fibrosis develops pneumonia. Which of the following is the most likely etiology of the pneumonia?
Pseudomonas aueroginosa
A 50-year-old male presents to the emergency department with sharp epigastric pain of 7 hours duration. The pain was sudden in onset and radiates to the back. The patient has a history of chronic alcoholism. He does not take any medications. The patient is admitted to the hospital and given 1 liter of normal saline. Several hours later, the patient appears markedly short of breath. Temperature is 36.9 degrees Celsius, blood pressure is 130/75 mmHg, pulse is 110/min, and respiratory rate is 33/min. Physical examination is notable for labored breathing and crackles at both lung bases. Chest X-ray is shown here. Which of the following would help confirm a diagnosis of Acute Respiratory Distress Syndrome (ARDS)
Pulmonary capillary wedge pressure (PCWP) < 18 mmHg
A 74 year-old male with a history of coronary artery disease and atrial fibrillation presents to the clinic for follow-up of his shortness of breath. Patient's medications include amiodarone (Cordarone) and metoprolol (Lopressor). His chest x-ray reveals patchy ground-glass infiltrates. Which of the following is the most likely diagnosis?
Pulmonary fibrosis
A patient taking bleomycin (Blenoxane) should be monitored for which of the following side effects?
Pulmonary fibrosis
Patients with long-term exposure to silica, coal dust, and asbestos may develop which of the following as complications?
Pulmonary fibrosis
A pediatric patient presents with a history of multiple recurrent respiratory infections associated with failure to thrive. A sweat chloride test is elevated. Which of the following is a common cause of death in patients with this condition?
Pulmonary infection (CF)
A 62 year-old male presents with a history of dyspnea on exertion and chronic cough worse with arising in the mornings. He has a 40-year-pack history of cigarette use. On examination there is increased AP diameter and decreased breath sounds with a prolonged expiratory phase. Pulse oximetry reveals an oxygen saturation of 93% on room air. In addition to smoking cessation, which of the following is an appropriate intervention at this time?
Recommend influenza and pneumococcal vaccines
What is the mechanism of action of salmeterol (Serevent) in the treatment of asthma?
Relaxing of bronchial smooth muscle
A 32 week preterm infant has an APGAR score of 9 at 5 minutes. Thirty minutes after delivery, tachypnea, retractions, and expiratory grunting are noted. Cyanosis and dyspnea appear with little response to oxygen. Physical examination reveals poor air movement bilaterally. A chest x-ray reveals air bronchograms and a fine reticular granular pattern. Which of the following conditions should be suspected?
Respiratory distress syndrome
An infant born at 30 weeks' gestation begins to have respiratory difficulty shortly after birth. Examination reveals rapid, shallow respirations at 80 per minute with associated intercostal retractions, nasal flaring and progressive cyanosis. Chest x-ray reveals the presence of air bronchograms and diffuse bilateral atelectasis. Which of the following is the most likely diagnosis?
Respiratory distress syndrome
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
An immunocompromised patient presents with signs and symptoms consistent with Legionella pneumophila who has not responded to initial antibiotic therapy with a macrolide. Which of the following should be added?
Rifampin (Rifadin)
Which of the following mechanisms leads to a primary pneumothorax?
Rupture of subpleural apical blebs due to high negative intrapleural pressures
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 40 year-old woman presents with 3 months of dry cough and intermittent low-grade fever. She is a non-smoker and has no significant family history or past medical history. A purified protein derivative (PPD) test was recently performed at work and was negative. On physical examination she is afebrile with stable vital signs. Lung auscultation reveals crackles in bilateral upper lobes. Chest x-ray shows hilar and mediastinal adenopathy, mild interstitial disease in the upper lung zones, and several small granulomas in both lungs. What is the most likely diagnosis?
Sarcoidosis
A 62 year-old male smoker presents to the clinic with the complaint of a chronic cough, hemoptysis, and weight loss. Chest CT shows a mass obstructing the bronchus with hilar and mediastinal lymph node abnormalities. Bronchoscopy with biopsy is performed. On reviewing pathology results you explain to the patient that his type of lung cancer is prone to early hematogenous spread, is rarely amenable to surgical resection and has a very aggressive course. What type of lung cancer is most likely in this patient?
Small cell
Which histologic type of lung cancer is typically centrally located?
Squamous cell
The most common pathogen identified in community acquired pneumonia (CAP) is
Streptococcus pneumoniae
What is the diagnostic modality of choice to diagnose cystic fibrosis (CF)?
Sweat chloride concentration testing
Which of the following is the most likely presentation of an acute pulmonary embolism (PE) in a patient without preexisting cardiac or pulmonary disease?
Tachypnea
A 22-year-old male is brought to the emergency department following a motor vehicle accident during which he was thrown through the windshield of his vehicle. He is conscious upon arrival and complains of severe right-sided chest pain. His vital signs are stable upon arrival. On auscultation, you note absent breath sounds on the right middle and lower chest. Within 5 minutes of arrival, you notice increased work of breathing and the patient's oxygen saturation begins to fall. Radiographic imaging is shown here. What is the next best step in management?
Thoracostomy tube placement (massive hemothorax)
A patient is brought to the emergency room with acute onset of dyspnea and tachypnea. He has a long history of alcoholism and was involved in a motor vehicle accident two days ago. He is hypoxic with crackles auscultated bilaterally. Chest radiography reveals diffuse bilateral infiltrates which spare the costophrenic angle and air bronchograms, there was no cardiomegaly or pleural effusion noted. Oxygen saturation is 70%. Which of the following is the most important initial treatment?
Tracheal intubation
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 x- ray shows confluent bilateral infiltrates that spare the costophrenic angles. Which of the following is the best clinical intervention for this patient?
Tracheal intubation (ARDS)
A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. Which of the following is the next most appropriate intervention?
Tube thoracostomy
A post-op patient has signs and symptoms highly suggestive of a pulmonary embolism. The results of the CT scan of the lung is nondiagnostic. What is the most appropriate next step in the evaluation?
Ultrasound of the legs
Which of the following physical examination findings would be consistent with a pleural effusion?
Unilateral lag on chest expansion
An elderly nursing home resident is admitted with methicillin-resistant Staphylococcus aureus pneumonia. Which of the following is the most appropriate treatment to initiate?
Vancomycin
A 70 year-old male is admitted to the ICU with fever, leukocytosis and purulent sputum. Sputum culture shows methicillin-resistant gram-positive cocci in clusters. Which of the following medications should be ordered for this patient?
Vancomycin (Vancocin)
A 62 year-old female is admitted to a nursing home during an outbreak of influenza. In review of her records, you note that she did not receive the flu vaccine this year. Which of the following is the most appropriate drug of choice for influenza prophylaxis in this patient?
Zanamivir (Relenza)
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 subcutaneous epinephrine
A 60 year-old patient returned from the recovery room to the floor following a subtotal gastrectomy. At 3 AM the next morning, the patient's temperature is 102° F (39° C) and pulse is 112/min. Which of the following is the most likely cause?
atelectasis
A 79 year-old female presents with productive cough for 2 days. She has associated fever, chills and shortness of breath. On physical exam, RR 30, BP 90/60, T 101.3. There is no JVD. Lungs reveal crackles at the left lower lobe and decreased breath sounds with dullness to percussion. Heart exam reveals RRR with no S3 or S4. No edema is noted. On chest x-ray the patient has a left sided pleural effusion. Examination of the pleural fluid reveals a decreased glucose and an elevated pleural fluid LDH. Pleural fluid cytology reveals squamous epithelial cells. What is the most likely cause of the patient's effusion?
bacterial pneumonia
Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)?
barking cough
A 56 year-old male with a 40 pack-year smoking history presents complaining of progressive shortness of breath. Spirometry reveals an FEV1 of 2 L (40% of predicted), an FVC of 4 L (80% of predicted) and an FEV1/FVC of 50%. These findings are most consistent with
chronic bronchitis.
A 75 year-old man with a long history of COPD presents with acute onset of worsening dyspnea, increased productive cough, and marked agitation. While in the emergency department he becomes lethargic and obtunded. His ABG's reveal a PaO2 40 mmHg, PaCO2 65 mmHg, and arterial pH 7.25. Which of the following is the most appropriate management at this point?
endotracheal intubation and mechanical ventilation
A patient should be tested for tuberculosis prior to being treated with
etanercept (Enbrel)
A 73 year-old obese female with a 20 pack year smoking history presents complaining of chronic productive cough. She states that it has been occurring over the past 3 years more frequently November through February. Which of the following pulmonary function test values would you expect to find decreased?
forced expiratory volume in 1 second/forced vital capacity
A 3 month-old male presents with a hoarse cough and thick purulent rhinorrhea for the past 2 days. The mother noted that yesterday he appeared to get worse and seemed to have increasing problems breathing and trouble feeding. Examination reveals a temperature of 100.2 degrees F and respiratory rate of 80/minute with nasal flaring and retractions. Lung examination reveals a prolonged expiratory phase with inspiratory rales. He is tachycardic. Pulse oximetry reveals oxygen saturation of 89%. Chest x-ray reveals hyperinflation with diffuse interstitial infiltrates. Which of the following is the most appropriate intervention?
hospitalization (bronchiolitis)
You are called to the nursery to see a male infant, born by uncomplicated vaginal delivery. He weighs 2,600 grams and has one deep crease on the anterior third of each foot. Respirations are 88 breaths/minute with expiratory grunting and intercostals retractions. He is cyanotic on room air and becomes pink when placed in 60% oxygen. Chest x-ray shows atelectasis with air bronchograms. Which of the following is the most likely diagnosis?
hyaline membrane disease
A 64 year-old female with a 50 pack year smoking history, presents with worsening dyspnea on exertion, a persistent cough, and increasing oxygen requirement from 2 to 3 liters. She denies any cardiac history. What is the most likely chest x-ray finding in this patient?
hyperinflation with bullae (emphysema)
A patient who appears very anxious enters the office complaining of dizziness with perioral and extremity paresthesias. She vaguely describes some chest discomfort. Physical examination is unremarkable, except for moderate tachypnea with obvious sighing respiration. This clinical picture is most consistent with
hyperventilation syndrome
A 25 year-old male with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist prn. He is presently using his short acting beta agonist on a daily basis. Which of the following is the most appropriate addition to this patient's regimen?
inhaled corticosteroid
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?
insert large bore needle into left 2nd ICS stat (tension pneumothorax)
A patient presents with a history of progressive worsening of dyspnea over the past several years. He gives a history of having worked as a ship builder for over 50 years. He denies any alcohol or tobacco use. On examination you note clubbing and inspiratory crackles. Which of the following chest x-ray findings support your suspected diagnosis?
interstitial fibrosis and pleural thickening (abestosis)
Which of the following is an indication for hospitalization in a patient who has acute bronchiolitis?
moderate tachypnea with feeding difficulties
Which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms?
monitor peak flow
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
A 26 year-old man presents to the emergency room complaining of shortness of breath, palpitations, and tingling of the lips and fingers. He appears anxious and describes a sensation of impending doom. His ECG and plain chest radiograph are normal. Which of the following arterial blood gas findings would you expect in this patient?
pH 7.50 pCO2 23 mm Hg bicarbonate 21 mEq/L
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 = 7.27 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 and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes 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
On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause?
pleural effusion
An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. Which of the following is the most appropriate interpretation of this test result?
positive
A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals tachycardia. Which of the following is the most likely diagnosis?
pulmonary embolism
Kussmaul breathing is characterized by
rapid, deep labored breathing
A patient presents with respiratory complaints. Chest x-ray reveals calcification of the hilar nodes with an eggshell pattern. Which of the following occupations is most consistent with these chest x-ray findings?
sandblasters (scoliosis)
In patients with COPD, which of the following has been shown to decrease rate of malignancy and cardiovascular disease and improve survival?
smoking cessation
A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient?
spoken "ee" heard as "ay" (bacterial pneumonia with consolidation)
A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding?
stridor
A 47 year-old HIV positive female presents with a complaint of a nonproductive cough. She is febrile, tachypneic and tachycardic. Lung exam reveals bilateral rales. Chest x-ray shows diffuse interstitial infiltrates. What is the recommended treatment in this patient?
trimethoprim-Sulfamethoxazole (Bactrim) (pneumocystis)
A 15 year-old male presents with a 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. Examination is unremarkable except for a few scattered rhonchi and rales upon auscultation of the chest. The chest x-ray reveals interstitial infiltrates and a cold agglutinin titer was negative. Which of the following is the most likely diagnosis?
viral pneumonia
