Pulm

Which of the following therapeutic agents would be the best treatment for a 24 year-old female with a history of intermittent wheezing and dyspnea while exercising 3-4 times a month?

Inhaled albuterol

A 22-year-old female patient is having an acute asthma exacerbation in your office. Which of the following is the most appropriate intervention?

Inhaled beta-2 agonist

A 8 y/o boy presents with intense coughing productive of yellow sputum & posttussive vomiting. He did not receive many childhood vaccinations as his parents feared that autism and sudden infant death syndrome could be side effects of the vaccines. What is recommended for all close and household contacts of this patient?

14 day course of Erythromycin regardless of age or immunization status

An O2 saturation of 90% corresponds to what PO2 value?

60mmHg

A 20 y/o female with asthma presents with symptoms requiring use of albuterol three times a week, but less than once a day. The next appropriate medication to add to this patient's regimen is

Inhaled flunisolide (Aerobid)

Which of the following best describes the pathophysiology of hypersensitivity pneumonitis?

A cell-mediated immune reaction to inhaled antigens in susceptible persons

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 (right pneumo). All of the following should be done as part of the PRIMARY survey EXCEPT:

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

Following a motor vehicle accident with blood loss leading to prolonged, severe hypotension, a 30 y/o male is intubated and placed on a mechanical ventilator. He has progressively decreasing oxygen saturations despite increasing PEEP and FI02 of 100%. He remains afebrile. He dies 3 days later. At autopsy, the distal lungs show pink hyaline membranes, thickened interstitium, and many macrophages but few neutrophils. Which of the following pulmonary diseases most likely complicated his course?

Acute Respiratory Distress Syndrome

The most common cause of hemoptysis seen in non hospitalized patients is:

Acute & chronic bronchitis

A 70-year-old man with a history of COPD presents c/o worsening shortness of breath for the last several days. He is coughing large amounts of yellow-colored sputum and he is receiving no relief from his B-2 agonist and ipratropium aerosolized pumps. On physical examination, the patient's respiratory rate is 40/min and his heart rate is 110/min. His BP is 150/85 mm Hg. The patient is afebrile. He is using his accessory muscles of respiration to assist in breathing. Lung examinaiton reveals diffuse inspiratory and expiratory wheezing. His CXR appears below. Which of the following is the most likely diagnosis?

Acute exacerbation of COPD

A 65-year-old female is admitted to the ER with a 3-hour history of cyanosis, SOB, and substernal chest pain. She was discharged 5 days earlier after having a total hip replacement for severe osteoarthritis. The hip surgery was uneventful. On PE , the patient is in obvious respirtory distress. Her respiratory rate is 40 breaths/minute and her breathing is labored. Her BP is 100/70 mm Hg. Cyanosis is present. There appears to be decreased breath sounds in the lower lobe of the right lung as well as adventitious breath sounds in all lobes. Based on the information provided, what is the most likley diagnosis in this patient?

Acute pulmonary embolism

A 24 year-old female with asthma presents to the clinic reporting for the past month she has increased her albuterol inhaler use to 3 times a week and has awoken at night 3 times in the past month with shortness of breath. Which of the following is the next best step in the management of this patient?

Adding fluticasone (Flovent) Inhaler

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. Which of the following lung cancers is the most likley cell type this woman has?

Adenocarcinoma

A 75-year-old patient is 48 hours status post lumbar laminectomy and develops a fever, cough with purulent sputum, and leukocytosis. Chest x-ray demonstrates right lower lobe consolidation with air bronchograms. Which of the following is the most appropriate treatment?

Administer antibiotics.

One week after a right total hip replacement a 65-year-old woman develops the sudden onset of shortness of breath. A workup reveals normotension, a prominent second heart sound, hypoxemia, sinus tachycardia with new right axis deviation on the electrocardiogram, and a normal chest x-ray. Oxygen is administered. Impedance plethysmography is consistent with a large proximal clot in the left leg. Which of the following would be the most reasonable next step?

Administration of heparin and ordering a imaging study to R/O pulmonary emboli

Which of the following should be screened for in a 35 year-old, non-smoker diagnosed with emphysema?

Alpha-1 antitrypsin deficiency

A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Which of the following is the next step in the management of this patient?

Anticoagulation

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 60 year-old man presents with severe right-sided chest pain over several months. He has been a life long smoker and worked most of his life as a ship builder. On physical examination, the patient appears to be dyspneic at rest. Lung auscultation reveals scattered rhonchi anteriorly and posteriorly. The patient has clubbing. Pulmonary function studies reveal a restrictive pattern. Chest radiograph is seen below (deviated trachea, enlarged aortic notch, bilateral lower lobe shadowing). Which of the following is the most likely diagnosis?

Asbestosis

A 85-year-old nursing home resident has dementia, requiring that she have assistance in all activities of daily living. She has a 3-day history of fever and productive cough. Chest x-ray is seen below. Which of the following is the most likely description of the mechanism of infection?

Aspiration of oral flora

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

Which of the following is characterized by reversible airway obstruction, inflammation and bronchial hyperreactivity?

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

Which of the following is the treatment of choice for pulmonary Legionellosis?

Azithromycin (Zithromax)

All of the following conditions produce a transudative pleural effusion EXCEPT:

Bacterial infection of the pleural space

Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)?

Barking cough

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 70-year-old white man with advanced COPD presents to you in the ER with pneumonia and an exacerbation of COPD. He is awake and alert, with acceptable work of breathing, and a ABG reveals a pH of 7.30, a PCO2 of 65 mm Hg, and a PO2 of 48 mm Hg. He is visiting relatives, and his private physician near his hometown 300 miles away tells you he has advanced disease and should not be intubated. He and his family state that they wish mechanical ventilation if it has a chance of helping him. Aggressive bronchodilator therapy and antibiotics are initiated. Which of the following is the most appropriate therapeutic plan?

Begin oxygen at 1 liter per minute by nasal cannula

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; Pa O2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable forincreased 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 65-year-old man presents with progressive shortness of breath. Other than a history of heavy tobacco abuse, the patient has a benign past medical history. Breath sounds are absent two-thirds of the way up on the left side of the chest. Percussion of the left chest reveals less resonance than normal. While you place your hand on the left side of the chest and have the patient say "ninety-nine," no tingling is appreciated in the hand. The trachea appears to be deviated toward the left. Which of the following diagnoses is most likely?

Bronchial obstruction

A 59-year-old woman presents complaining of a cough productive of sputum for 10 years. Her cough occurs during the days and she produces sputum daily. The woman states as a child she had several episodes of pneumonia requiring hospital admissions and antibiotics. Several times a year, her sputum becomes purulent and she requires antibiotic therapy. She denies smoking cigarettes and has worked as a seamstress all her life. On physical examination the lungs are clear without wheezes, rhonchi, or crackles. Her CXR is seen below. Which of the following is the most likley diagnosis?

Bronchiectasis

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 (spots by cardiac silloutte). Which of the following diagnosis is most consistent with the given history?

Bronchogenic Carcinoma

Which of the following physical exam findings is consistent with moderate emphysema?

Distant heart sounds

A 66-year-old man with advanced COPD presents to the ER with 2 days of increasing dyspnea. Diffuse end-expiratory wheezing is noted. The CXR is clear; ABG's reveal a pH of 7.33, a PCO2 of 55 mm Hg, and a PO2 of 49 mm Hg. Aggressive bronchodilators are institute and oxygen 1 liter per minute by nasal cannula is administered. A blood gas 30 minutes later reveals a pH of 7.30, a PCO2 of 62 mm Hg, and a PO2 of 61 mm Hg. Which of the following is the most appropriate intervention?

Continue oxygen at 1 liter per minute

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?

CAP

Respiratory Acidosis may be seen in a patient with

COPD

A 74 y/o male with a history of congestive heart failure, chronic kidney disease stage III, & colon cancer is hospitalized for community acquired pneumonia. While awaiting culture results, which of the following medications would be the best initial treatment option in this patient?

Ceftriaxone + Azithromycin (Rocephin + Zithromax)

A 75 year-old alcoholic with a history of CHF is admitted to the hospital suffering fever, SOB, CP, and cough productive of purulent sputum and blood. PE: T 39 C RR 28. Bronchial breath sounds in the RUL CXR RUL pneumonia, with a small cavitary lesion. What is the treatment of choice for this patient?

Ceftriaxone and azithromycin

A 48 year-old man with bullous emphysema presents with sudden onset of dyspnea and chest pain. Vital signs: BP 136/80, HR 96, RR 24. Physical exam reveals flat neck veins, midline trachea, decreased breath sounds on the right with associated hyper-resonance to percussion. A CXR reveals a right visceral pleural line with the absence of vascular marking beyond the pleural line. Which of the following is the best intervention?

Chest tube placement

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 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?

Chest x-ray

In which of the following populations is the pneumococcal conjugate vaccine (Pneumovax) indicated for a patient younger than 65 years of age?

Chronic alcohol abusers

Physical exam of a 60-year-old male reveals perioral cyanosis with a normal respiratory rate and no use of accessory muscles. Chest percussion is resonant; auscultation demonstrates wheezes & coarse rhonchi that change in location & intensity after a cough. What is the most likely diagnosis?

Chronic bronchitis

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 68 y/o male is diagnosed with small cell lung cancer. Which of the following treatment options could be considered in this patient?

Combination chemotherapy

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 65 year-old male presents with a transudative pleural effusion. This patient most likely has a history of which of the following

Congestive heart failure

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 42 year old female with systemic sclerosis, with recognized interstitial lung disease, has a 3-week history of peripheral edema, nausea, and anorexia. Exam shows elevated JVP and 2+/4 bilateral ankle edema. The liver is enlarged, smooth, and tender. Which of the following is the most likely diagnosis?

Cor pulmonale

A 72-year-old man with a long history of tobacco use presents to the emergency room with shortness of breath. He is mildly cyanotic and hypotensive.On exam he has poor air movement bilaterally and has evidence of an elevated jugular venous pressure.A Swan-Ganz is placed revealing RA pressures of 15 mmHg (normal range 0-5), a PA pressure of 70/28 (normal range 12-28/3-13), and a PCWP of 10 (normal range 3-11). Which of the following is most consistent with this clinical picture?

Cor pulmonale

The therapeutic mainstay for interstitial lung disease includes which of the following?

Corticosteriod therapy

A two-year-old female was brought to the ER by her parents because she has developed wheezing and a low-grade fever. She is also horse and has a barking cough. History reveals that the patient is recovering from an upper respiratory infection. Lung auscultation reveals as inspiratory and expiratory stridor. Neck radiographs revealed subglottic narrowing. What is the most likely diagnosis?

Croup

Clubbing of the fingers is associated with which of the following?

Cystic fibrosis

Parents bring their 1 year old female toddler into your office. They have noticed that their daughter has had delayed growth, poor weight gain, clay colored stools, and frequent episodes of pneumonia. You order a sweat chloride test. If the result is positive, what is the most likely diagnosis?

Cystic fibrosis

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

Which of the following most accurately describes the preferred pharmacologic treatment of moderate persistent asthma in adults?

Daily-inhaled corticosteroids and long-acting, inhaled Beta2-agonists, if needed

Which of the following is most consistent with an obstructive lung disease on spirometry?

Decreased FEV1/FVC ratio

Which of the following represents an obstructive pattern of impairment during spirometry?

Decreased FEV1/FVC ratio, a reduced FEF, an FEV1 less than 80% of predictive value, reduced FVC

In emphysema, the disease process is characterized by

Destruction of alveolar walls

Which of the following is most likely to cause a false negative PPD?

Diagnosis of AIDS

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 place an IVC filter

Which of the following is the most effective outpatient treatment for Mycoplasma pneumonia?

Doxycycline (Doryx)

A 43-year-old male patient presents with fever, productive cough with brown sputum, rigors, and lethargy for seven days. Chest x-ray reveals a right middle lobe infiltrate with a pleural effusion. He perform a thoracentesis to obtain plueral fluid for examination. The results you have a pH of 7.1 and a glucose of 32 mg/dL and a positive Gram stain. Which of the following is the most appropriate next treatment in management?

Drainage of pleural effusion

Which of the following radiologic findings is suggestive of chronic silicosis?

Eggshell calcification of enlarged hilar lymph nodes

A 60-year-old man presents to your office with an 80-pack-year history of cigarette smoking. He complains of some dyspnea on exertion. He has an asthenic body habitus and pursed-lip-breathing. He has an increased anteriorposterior diameter in the thorax. Lung examination reveals decreased fremitus, hyperresonance on percussion, and diminished breath sounds. Which of the following is the most likely diagnosis?

Emphysema

A 4 year-old male patient is brought to the emergency room by his father because of a sudden onset of fever at 102.5°. He also has a muffled voice and difficulty breathing. The child has no cough but is drooling. Upon inspection, the child is sitting in the tripod position and leaning forward. What should be immediately done for this child?

Endotracheal intubation

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 reveals 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 mother brings her unvaccinated child to the ER with a deep whooping cough. The child is diagnosed with pertussis. Which medication can you prescribe to the mother to help prevent her child from spreading the illness to others?

Erythromycin

Which of the following diagnostic test is most useful in assessing a patient with chronic obstructive pulmonary disease?

FEV1/FVC ratio

Which of the following is the best measure of airflow obstruction?

Forced expiratory volume in 1 second/forced vital capacity ratio(FEV1/FVC)

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?

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?

Glucocorticoids and nebulized epinephrine

A man is stabbed and arrives to the ED within 30 minutes. you notice that the trachea is deviated away from the side of the chest with the puncture. The most likely lung findings on physical examination of the traumatized side is which of the following?

Hyperresonant percussion

A 44 y/o male who takes care of pigeons presents with a chronic cough & dyspnea with exertion. CXR shows a diffuse nodular lung pattern. Labs reveal an elevated erythrocyte sedimentation rate and C-related peptide. What is the most likely diagnosis?

Hypersensitivity pneumonitis

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 68 year-old male presents to your office complaining of increasing shortness of breath over the past 8-9 months and is now short of breath at rest. Physical exam is significant for clubbing on the upper extremity digits and bibasilar crackles (rales). The patient is sent for pulmonary function tests (PFTs) and spirometry reveals a FEV1/FVC ratio of 111%, a FEV1 of 1.19 L (38% predicted), and a FVC of 1.24 L (34% predicted). A CT scan is performed (see below). Which of the following is the most likely diagnosis?

Idiopathic pulmonary fibrosis

A 34 year-old male driver of an automobile arrives in the ED after a head-on collision. The patient is unresponsive, vitals: R 10 and shallow, HR 140 with weak, thready pulses, BP 105/60, monitor shows sinus tachycardia. You note absence of lung sounds on the left side with tracheal deviation to the right.The most appropriate management in this patient is...

Immediate placement of large bore needle with a catheter in the Left 2nd ICS MCL

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?

Mycoplasma pneumoniae

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 proteinuria and CKD

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 tacticle fremitus

Which examination finding is not consistent with emphysema?

Increased tacticle fremitus

A 49 year old male suffers a crash injury to the right chest complicated by development of a tension pneumothorax. Which of the following is the preferred initial therapy?

Insert needle in right 2nd intercostal space in midclavicular line

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 mm Hg 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 mm Hg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment?

Intubate the patient

A 68 year-old male w/ a 40 pack year smoking history presents with chronic dyspnea with exertion. Pulmonary function tests reveal an FEV1/FVC of 69% pred, FEV1 68% pred, FVC 98% predicted with no bronchodilator response. Which of the following treatment options would be best indicated for the management of this patient's chronic dyspnea?

Ipratroprium (Atrovent)

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 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 corticosteroids

A 14-year-old male presents for his asthma follow up. He states that he has symptoms three to four days per week and awakens from sleep three times a month, requiring the use of his inhaler. He occasionally has to sit out of gym class due to his symptoms, but overall he functions well. He currently uses a short-acting Beta 2-agonist as needed. What is the preferred pharmacologic agent to add to this patient's regimen?

Low-dose inhaled corticosteroid

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?

Lung abscess

A 6-year-old male presents to the ED with a 3-day history of productive cough and fever. Arterial blood gas results are:PH 7.24 PCO2 36 mm Hg PO2 100 mm Hg HCO3 16 mEq/L. The principal acid-base derangement is

Metabolic acidosis

You are evaluating a 10 year old child with asthma exacerbation. His mother says this is the worst he has ever been. Medications include an inhaler and theophylline. He has a normal respiratory rate and you really cannot hear much in terms of wheezes. His oral cavity is dry and he looks lethargic. ABG's: pO2 70 pCO2 40 pH 7.30 Your mangement includes all EXCEPT

Morphine (to relax him and make his breathing easier)

Which of the following pathophysiological processes is associated with chronic bronchitis?

Mucous gland enlargement and goblet cell hyperplasia

A 24 year old female has asthma attacks that are precipitated by ingestion of aspirin. Which of the following is most likely to be noted upon physical examination?

Nasal polyps

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 reveals the following: LDH 100 u/L, glucose 150 mg/dl, and amylase 90 U/L. Cell count reveals 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:

Needle biopsy of pleura

A 62 year-old female who is intubated on mechanical ventilation in the ICU undergoes a CT guided biopsy for a right lung mass. After the biopsy, the patient is transferred back to the ICU. Several hours later the patient codes, has no pulse, but the cardiac monitor shows a rhythm (Pulseless Electrical Activity). There is obvious tracheal deviation to the left, absent right breath sounds, and hyperresonance to percussion on the right. The patient is given Epinepherine 1mg IV push and chest compressions are initiated. What should be done immediately?

Needle decompression

A patient presents with increasing shortness of breath. On examination there are decreased breath sounds on the right with hyperresonance to percussion. There is tracheal deviation to the left. Of the following which intervention is indicated?

Needle decompression

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?

Obtain a specific tissue diagnosis by biopsy of the hilar mass

A 63-year-old male with a 100 pack year smoking history who quit 2 years ago comes to see you for a 4-month history of progressive dyspnea on exertion. The symptoms have been indolent, with no recent worsening. He denies fever, chest pain, or hemoptysis. The patient says he has not seen a physician for over 10 years. Physical examination is notable for normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated jugular venous pulsation, and moderate pedal edema. Hematocrit is 49%. PO2 54mmHg. You send the patient for a CXR and pulmonary function tests and place him on tiotropirum (Spiriva) Inh, formoterol/budesonide (Symbicort) Inh, & prn Albuterol Inh. Which of the following below therapies is most likely to prolong his survival?

O2

A 59-year-old man with a long-standing smoking history presents with persistent dyspnea. His FEV1 is 1.0 L/min, arterial blood gas reveals PO2 of 55 mm Hg, PCO2 of 40 mm Hg, pH 7.45, and O2 saturation of 90%. He has hyperlucent lungs on chest x-ray and decreased breath sounds on physical examination. The patient's current medical regimen consists of theophylline (300 mg twice daily) and inhaled isoproterenol. The most important addition to the patient's therapy would be

Oxygen therapy

Interpret the following spirometry results in this patient with chronic dyspnea:Forced Expiratory Volume in 1 second/Forced Vital Capacity ratio: 66% predicted Forced Expiratory Volume in 1 second: (1.04 L) 63% predicted Forced Vital Capacity:(1.58L)84% predicted

Obstructive Pattern

A 72-year-old female with severe osteoporosis presents for evaluation of shortness of breath. She is a lifetime nonsmoker and has had no exposures. On physical examination you note marked kyphoscoliosis. All the following pulmonary abnormalities are expected except

Obstructive lung disease

A patient is suspected to have a PTE. Results of a ventilation-perfusion lung scan indicate intermediate probability. What is the most appropriate next step,

Obtain a lower extremity venous ultrasound

A 66 year old man presents to your office with complaints of productive cough and low grade fever for past two days. He denies any sick contacts. On physical examination, his temperature is 100F, breath sounds are reduced in left lower lobe. A chest x-ray reveals left lower lobe infiltrate. Laboratory investigations reveal WBC count of 12,ooo/µl with 80% neutrophils. He received a Flu vaccine about one month ago but never received a pneumococcal vaccine. The next important step in managing this patient is

Oral doxycycline

A 60 y/o male with 100 pack year smoking history presents with dyspnea on exertion and a chronic dry cough. PFTs show a post bronchodilator FEV1/FVC ratio of 50% (predicted), FEV1 47% (predicted) & FVC 94% (predicted). DLCO is decreased. Which of the following medications would NOT be appropriate in the daily management of this patient?

Oral prednisone

A 75-year-old male patient with mild dementia chokes and coughs as he eats. His wife says the problem is worse with liquids them with solids. On examination, patient begins coughing immediately after drinking water. The quality of his voice is then altered. Which of the following is the most likely diagnosis?

Oropharyngeal dysphagia

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)

In patients with COPD, the respiratory drive is most sensitive to

Oxygen

Which of the following is the only therapy that is documented to alter the natural history of COPD?

Oxygen

A 15-year-old male patient is experiencing a severe asthma attack. Although he is using accessory muscles to breathe, the auscultation of his chest reveals no audible wheezing. His heart rate is 160 bpm and respirations are 52 per minute. Which of the following arterial blood gas results represent the worst prognosis for this patient?

PH is 7.35; PCO2 is 62, PO2 is 60

The patient has respiratory acidosis. Which of the following blood gas findings matches the patients condition?

PH level is 7.30; PCO2 level is 50, HCO3 level is 25

Which of the following patient would benefit most from the pneumococcal vaccine?

Patient with sickle cell anemia

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

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

Treatment of empyema involves:

Placement of a chest tube to drain the infection or open surgical drainage and debridement.

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

On a frontal chest radiograph view, you notice a visceral pleural line with a radiolucent area devoid of vascular and pulmonary markings on the right side only. Which of the following is the most likely diagnosis?

Pneumothorax

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 (vascular congestion near cardiac sillouette). Which of the following is the most likely diagnosis?

Primary pulmonary hypertension(PPH)

What is the most effective prophylaxis against respiratory syncytial virus (RSV) infection in the general pediatric population?

Proper hand-washing techniques

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?

Pseudomonas aeruginosa

A 58 year-old with a 20 pack-year history of tobacco use presents to the emergency department with sudden onset of severe, progressive right-sided chest pain and shortness of breath. She denies fever, nausea and productive cough but reports returning from a mission trip to South Africa yesterday. Her exam reveals tachycardia, tachypnea, clear lung fields and 3+ edema and erythema of the left leg. Her chest radiograph is normal. Which of the following is the most likely diagnosis?

Pulmonary Embolism

A very anxious patient who is hyperventilating would expected to have a ABG result consistent with:

Respiratory alkalosis

Which of the following is the most common cause of pneumonia and Bronchiolitis in children < 1 year of age

Respiratory syncytial virus

A 62-year-old female presents to your office complaining of progressive dyspnea with exertion for the past 1-2 years. Interpret the spirometry results: FVC 1.6L (44% predicted) FEV1 1.5L (54% predicted) FEV1/FVC 94%

Restrictive pattern

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 35 year old male has a 2 day history of fever, chills, and productive cough with brown sputum. Exam reveals flat percussion noted in left lower posterior chest, increaded tactile fremitus, and bronchial breath sounds. Which of the following is the most likely infecting organism?

S. Pneumoniae

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 (RUL opaque haziness). Which of the following medications would be indicated in this patient?

Rifampin, Pyranzinamide, Ethambutol, and Isoniazide

Which of the following treatments regimens would be acceptable in the initial treatment of a patient diagnosed with pulmonary tuberculosis?

Rifampin, Pyranzinamide, Ethambutol, and Isoniazide

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 lower lobe pneumonia

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

Which of the following is the most likely organism to cause a lung abscess?

S. Aureus

Which of the following pathogens more frequently cause nosocomial pneumonia then community-acquired pneumonia?

S. Aureus

A 70-year-old woman at an extended care facility for the past two years has increasing inability to perform activities of daily living. She can no longer recognize family members. She is lethargic and spends most of her days in a wheelchair or in bed. She develops an acute febrile illness and is noted to be coughing up increasing quantities of yellowish sputum. Her temperature is 38°C. A chest x-ray shows infiltrates involving the left lower lobe. A sputum sample shows numerous neutrophils and gram-positive diplococci. Which of the following infectious agents is most likely to cause her pulmonary disease?

S. Pneumoniae

A 44-year-old African-American female presents with a history of night sweats, weight loss, cough, and shortness of breath progressing over the past six weeks. Her laboratory results revealed an elevated alkaline phosphatase and an elevated angiotensin - converting enzyme level. Bronchoscopy with biopsy reveals noncaseating granuloma. Most likely diagnosis for this patient is this?

Sarcoidosis

A 50-year-old African American male presents with increasing shortness of breath for the past 4 months. He denies any tobacco use history. On physical examination his temperature is 98.6 F. There are fine rales auscultated in all lung fields. CXR 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?

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?

Sarcoidosis

What is the most common disorder associated with the development of ARDS?

Sepsis

A 12 y/o male presents with a history of reactive airway disease since he was 6 y/o. He wheezes throughout the day and requires a short and long-acting beta 2-agonist daily. At night he complains of waking up frequently with cough and wheezing. He is currently taking a high-dose-inhaled steroid, a leukotriene inhibitor, and has just completed a 2-week oral steroid burst. His last PEF was < 60% of predicted. How would you classify his asthma?

Severe persistent

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

She will probably develop empyema

A 58 y/o male presents with a 2 month history of a 20 lb unintentional weight loss and hemoptysis. CXR reveals a 6cm mass near the left hilum. Sputum cytology is positive for malignancy. Which of the following is the most likely predisposing factor to the development of this disease?

Smoking

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?

Smoking cessation

In emphysema, the single most important factor in slowing the inevitable decline in forced expiratory volume in 1 second (FEV1) and improving life expectancy and quality of life is:

Smoking cessation

A 39-year-old woman presents with the sudden onset of pleuritic chest pain and shortness of breath. She has been in good health until 3 days ago, when she noticed some swelling of the left lower extremity. She is not a smoker and denies any recent trauma. On physical examination, she is afebrile but has a respiratory rate of 32.min. Her heart rate is 120/min and her blood pressure is normal.An accentuated S2 is heard. The left lower extremity is swollen, tender to palpation, and erythematous. Dorsiflexion of the left foot (Homan's sign) causes severe calf discomfort. Lung examination and chest radiograph are normal. Arterial blood analysis on room air shows a PCO2 of 30 mm Hg and a PO2 of 58 mm Hg. Which of the following is the most appropriate next diagnostic step?

Spiral CT scan or Ventilation/perfusion lung scan

A 70-year-old female with a history of type two diabetes mellitus and chronic renal insufficiency, and hypertension presents with moderate dyspnea and right-sided pleuritic chest pain. She denies fevers, cough, or chills. Her temperature is 100.6° the pressure is 130/70, pulse is one 23 bpm and respirations are 32. Physical examination shows a swollen and tender right calf. Lung examination is noted to be normal. Chest x-ray reveals no active disease. EKG shows sinus tachycardia with nonspecific ST segment and T wave activity. At this time, which of the following is the initial diagnostic test of choice for this patient?

Spiral chest CT scan

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?

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 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?

Steroids

A previously healthy 30-year-old African American woman has fatigue, arthralgia, and a nodular rash over the trunk and upper extremities for three weeks. There are twelve .3-.8 cm, pale, indurated plaques over the chest, back, and upper extremities. The liver is palpable 2 cm below the right costal margin with a percussion span of 14 cm, and the spleen tip is palpable 3 cm below the left costal margin. There is no pain or limitation of any of the joints. An CXR shows bilateral hilar lymphadenopathy. Which of the following is the next best management of this patient if she fails conservative treatment or develops severe symptoms?

Steroids

A premature male infact at birth has tachypnea, nasal flaring, gruting subxiphoid retractions, and cyanosis. Lung sounds are generally decreased. Which of the following is the most likely etiology?

Surfactant deficiency

"

Surfactant replacement

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

What is the preferred treatment of choice for most patients with non-small cell carcinoma?

Surgical resection

A 7 year-old white male presents with a life-long history of frequent, and commonly complicated, bouts of bronchiectasis and other respiratory tract infections. His past history includes poor weight gain, low exercise endurance and pancreatitis. Examination reveals a barrel chest and hyperresonance to percussion while a mixed obstructive-restrictive pattern is seen on pulmonary function testing. Peribronchial cuffing and increased interstitial markings are noted on chest radiograph. Which of the following tests would confirm the diagnosis?

Sweat chloride test

In addition to severe respiratory distress, which of the following findings may be indicative of a pneumothorax with mediastinal shift?

Tracheal deviation away from midline position

Which of the following is considered the definitive treatment of severe obstructive sleep apnea?

Tracheostomy

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?

Unfractionated heparin or low molecular weight heparin during pregnancy

Which of the following physical examination findings would be consistent with a pleural effusion?

Unilateral lag on chest expansion

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 66 year-old male has had increasing dyspnea for the past year. He is a smoker and is retired from the construction business. There are some rales auscultated in both lungs on physical examination. A chest radiograph reveals bilateral diaphragmatic pleural plaques with focal calcification as well as diffuse interstitial lung disease. A sputum cytology shows no atypical cells. Pulmonary function studies reveal a low FVC and a normal FEV1/FVC ratio. These findings are most likely to suggest prior exposure to which of the following environmental agents?

asbestos crystals

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 20,000 with 72% lymphocytes. Which of the following is the drug of choice for managing this patient?

azithromycin

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

Increased wheezing in an asthmatic patient that you are treating indicates:

improved air exchange

Which of the following is a general health maintenance recommendation for elderly patients?

influenza vaccine annually each fall

You are making rounds in the hospital and you observe a post-op patient with Kussmaul breathing. Stat arterial blood gases obtained show the following: pH 7.20 HCO3 13 pCO2 30 K 3.2.Na 138; Cl 103. The most likely diagnosis based on these findings is

metabolic acidosis

98) A 66 y/o female presents with a non-productive cough with malaise for the past week. Her temperature increases to 102F. A CXR reveals diffuse bilateral pulmonary interstitial infiltrates in all lung fields. A sputum gram stain reveals normal flora and few neutrophils. She recovers over the next two weeks without sequelae. Infection with which of the following organisms most likely caused her illness

mycoplasma pneumoniae

Which pulmonary function test (PFT) result is NOT found in COPD patients:

normal FEV1

A 55 y/o male presents with a 3 day history of fever, chills, and cough productive of purulent sputum. CXR reveals a left lower lobe patchy infiltrate. Which of the following is most likely found on physical exam over the area of consolidation?

positive egophany

Kussmaul breathing is characterized by

rapid, deep labored breathing

A 68-year-old male with a 100 pack/year smoking history develops truncal obesity, easy bruisability, and osteoporosis. Which of the following pulmonary diseases do you most strongly suspect as the cause for these findings:

small cell carcinoma

First-line treatment in the management of sleep apnea includes which of the following?

weight loss and alcohol avoidance

In HIV infected persons, a tuberculin skin test reaction is considered positive if it is

An induration greater or equal to 5mm

Which of the following mechanisms is most likely responsible for pneumonia in a stroke patient with dysphagia?

Aspiration

The therapeutic mainstay for interstital lung disease includes which of the following?

Corticosteriod therapy

Which of the following is most consistent with a restrictive lung disease on spirometry?

Decreased FVC

A 15-year-old girl presents with a two day history of cough that is productive of small quantities of white yellow phlegm. Her blood pressure is 114/78 and her pulse is 84 bpm, respirations are 16, and temperature is 99.7°. Normal pulse O2 sat reading is noted. Her lungs are clear bilaterally. Which of the following is the most appropriate therapeutic recommendation?

Fluids, rest, and acetaminophen as needed

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

The following is used to treat hypoxemia in COPD patients?

Oxygen

Which of the following is the recommended treatment of a large volume hemothorax?

Remove blood

A 56 year-old male presents with shortness of breath with exertion for the past week. Auscultation of the lungs reveals decreased breath sounds in the right lower lung field. There is also associated dullness to percussion and decreased tactile fremitus to the right lower lung field. There is limited movement of the right side during thoracic expansion. A CXR is performed. Which of the following is the best next step?

Thoracentesis

What is the initial diagnostic step in a patient with a large pleural effusion?

Thoracentesis

Which of the following patients with community aquired pneumonia (CAP) would you admit to the hospital?

A 48 year-old with an O2 Sat of 85% on room air

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) inhaler

A 44-year-old female complains of nonproductive cough for the past 6 months. She denies rhinorrhea, wheezing, dyspnea, chest pain, or hemoptysis. Her medical problems include hypertension. Medications include benazepril 10 mg QD, Amlodipine 5 mg QD, and HCTZ 25 mg QD. She is a nonsmoker and denies any foreign travel. The following CXR PA/LAT is taken. What is the most likely cause of her cough?

Benazepril

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 11-year-old female patient has been known to have cystic fibrosis since age 3. A chest x-ray film demonstrates tubular, air filled structures that extend near the edges of the lung fields. The intervening lung tissue appears normal. Which of the following is most likely diagnosis?

Bronchiectasis

Which of the following is most appropriate for a child with suspected foreign body aspiration?

Bronchoscopy

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. How should you pursue the diagnosis?

Bronchoscopy and Transbronchial lung biopsy

Which of the following is the most likely complication of a pneumonia caused by Mycoplasma pneumoniae?

Bullous myringitis

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?

COPD

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 15 mm indurated. She is completely asymptomatic. Which of the following is the next best step in the evaluation of this patient?

CXR

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

Which of the following describes periods of deep breathing alternating with periods of no the breathing and can be caused by heart failure?

Cheyne-Stokes respiration

Which of the following conditions is likely to present with cor pulmonale, severe hypoxia, and edema of the legs?

Chronic bronchitis

A 61-year-old male presents with acute onset dyspnea, cough with thick, blood tinged sputum, and fever. He is a known, longstanding alcoholic and has Type II Diabetes, for which he takes no medication. A chest x-ray reveals a right upper lobe infiltrate with early fibrotic changes. Which of the following is an appropriate first-line medication(s) for the most likely etiologic organism?

Second generation cephalosporin

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 103.1F

A 21 y/o male presents with a five day history of an upper respiratory tract infection and a two day history of progressive shortness of breath. He has a five year history of allergic rhinitis. His father has asthma. On physical exam, he appears anxious. His temperature is 37.8°C (100°F), pulse is 115/min, respirations are 24/min and labored, and blood pressure is 140/90 mm Hg. Diffuse wheezes are heard throughout all lung fields. Examination shows no other abnormalities. CXR shows hyperinflation. Pulse oximetry on room air shows an oxygen saturation of 94%.Which of the following is the most appropriate management of this patient?

Corticosteroid therapy and inhaled β2-adrenergic agonist therapy

A patient undergoes an ultrasound-guided thoracentesis after he is found to have a large loculated pleural effusion on decubitus chest x-ray. The fluid is amber and cloudy with a pH of 7.3, LDH 800IU/L, glucose 65 mg/dl, total protein 5.5 g/dl, WBC 1,300/mm3. Serum studies done the same day includea LDH of 155 IU/L, glucose 99 mg/dl, and total protein 7.0 g/dl. Cytology, gram stain, and culture of the pleural fluid are pending. Which of the following is the most accurate statement regarding the pleural fluid analysis?

The fluid is an exudate

In a patient with a low probability of pulmonary embolism (PE) based on the Wells criteria, which of the following lab studies is most helpful in ruling out a PE?

D dimer assay

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?

Discontinuation of visits to the animal facility

48-year-old female presents to your clinic with a history of sudden onset of fever and productive cough for the last 48 hours. She had recovered from influenza about 10 days prior to the onset of fever. She has right pleuritic chest pain. Her pulse is 120, respiratory is 20, temperature is 102.4°, pulse ox is 90% on room air, and blood pressure is 120/70 mmHg. Physical examination of her lungs, should reveal which physical findings?

Dullness to percussion, bronchial breath sounds, and egophony on the right

Which of the following is essential to make a diagnosis of cystic fibrosis?

Elevated sweat chloride

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 intolerance's, 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

A 62-y/o patient presents with a history of exertional dyspnea and chronic cough that is worse in the morning. On exam, you notice decreased breath and heart sounds, an expiratory wheeze, and increased anterior-posterior chest diameter. The patient has a 42 pack year history of smoking, and a CXR shows hyperinflation of the lungs and flattened diaphragms. Which of the following is the most likely diagnosis?

Emphysema

An ambulance crew that has been giving him oxygen by mask brings a 60-year old man with emphysema and bronchitis to an emergency room. Three days ago, he noted that his sputum had changed color and increased in amount. His wife called the ambulance when he became suddenly short of breath and confused. On arrival at the hospital he is somnolent. Mid-inspiratory crackles and diffuse expiratory wheezes are audible on examination of the chest, and he has marked peripheral edema and ascites. Hemoglobin is 18 g/dL. Arterial blood gases are pH 7.08, P O2 148 mm Hg, and PCO2 106 mm Hg The most appropriate immediate therapy for the man described above would be

Endotracheal intubation and assisted ventilation

Which of the following medications can be given as long-term treatment to a pregnant female with a pulmonary embolism?

Enoxaparin (Lovenox)

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

Have the patient breathe into a paper bag.

A 26-year-old male patient presents with fever, dry cough, and pleuritic chest pain upon return from a hiking trip in the Ohio River region. Physical examination is remarkable for cervical adenopathy and decreased breath sounds at both lung bases. Further history reveals that he was exposed to bat droppings while exploring caves during his trip. What is the most likely organism?

Histoplasma capsulatum

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 COPD patient in acute respiratory distress presents with a decreased level of consciousness, which can be best explained by:

Hypercarbia and hypoxia

A 66-year-old male patient presents to the clinic with a history of productive cough for three months. He has a 60 pack year smoking history. Which of the following chest x-ray findings is most consistent with chronic obstructive pulmonary disease?

Hyperinflation of the lung

A 50-y/o male with emphysema and a chest x-ray that has shown apical blebs in the left lung develops the sudden onset of shortness of breath and pleuritic chest pain. Pneumothorax is suspected. Physical exam findings that would confirm the diagnosis are

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

Hypersensitivity pneumonitis

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 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

A 70-year-old patient with chronic obstructive lung disease requires 2 L of nasal O2 to treat his hypoxia, which is sometimes associated with angina. While receiving nasal O2, the patient develops pleuritic chest pain, fever, and purulent sputum. He becomes stuporous and develops a respiratory acidosis with CO2 retention and worsening hypoxia. The treatment of choice is

Intubate the trachea and begin mechanical ventilation

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 29 year old PA has been exposed to a patient with cavitary pulmonary tuberculosis 1 month ago. He denies any symptoms. His physical examination is normal. A tuberculin skin test reaction is positive now at 5mm. His skin test one year ago was negative. A chest X-ray is within normal limits and chemistry panel is normal. The most appropriate management option for this patient is:

Isoniazide

58-year-old chronic alcohol male patient is found wondering on the street and brought to the emergency department by paramedics. The patient has a high fever, cough productive of red current sputum, and difficulty breathing. Examination of the chest reveals wheezes and rales over the left lower zone and a chest x-ray film confirms pneumonia. Gram stain of the sputum reveals rather large gram-negative bacteria and many white blood cells. Which of the following is the most likely pathogen?

Klebsiella pneumoniae

An intoxicated patient is brought to the ED with a two day history of acute onset of severe fever, chills and chest pain with frequent cough and dyspnea. His past history is significant for a 30 pack year history of tobacco use, alcoholism for the past 20 years and hypertension. A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most likely causative organism?

Klebsiella pneumoniae

A 55-year-old man with a 50 pack year history of smoking cigarettes has recently experienced an episode of hemoptysis along with his usual cough. On physical examination he has no abnormal findings. A sputum for cytology on microscopic examination shows atypical cells with hyperchromatic nuclei and orange-pink cytoplasm. Labortory studies show an elevated serum calcium of 11.3 mg/dL, with phosphorus 2.1 mg/dL. Which of the following chest radiographic findings is this man most likely to have?

Large hilar mass

A 60 year old white male is brought to the ED by his wife with complaint of fever and diarrhea. She also states he has coughed up blood. "I'm worried about him; the lights are on but nobody's home", she says, referring to his apparent confusion. PMH is unremarkable. SH is remarkable for chronic ethanol and nicotine abuse. He has a fever of 104F and looks very ill. Chest x-ray demonstrates patchy infiltrates and a small pleural effusion. Gram stain of sputum shows polys but no bacteria. Sed rate and liver function tests are elevated and there are 50 RBCs in the urine sediment. Your patient undoubtedly has pneumonia caused by:

Legionella pneumophilia

A 65-year-old cigarette smoker with a history of hypertension and mild CHF presents to the ED with worsening cough, fever, and dyspnea at rest. The illness began one week ago with fever, muscle aches, abdominal pains, and diarrhea, with the nonproductive cough developing later that week, and rapidly becoming worse. CXR is seen below (bilateral parenchymal infiltrates). Therapy for which atypical organism must be considered in this case?

Legionella pneumophilia

A 69-year-old man with a 50-pack/year history of cigarette smoking presents with a known diagnosis of COPD. Which medication would be LEAST effective in treating this patient

Leukotriene modifier

Which of the following best characterize restrictive ventilatory defects?

Low lung volumes

During a cardiac arrest, a 58 y/o non-smoker male receives cardiopulmonary resuscitation and is brought to the hospital, where he is intubated. During the intubation procedure he suffers aspiration of his dinner gastric contents (rigatoni with mushrooms). Over the next 10 days he develops a non-productive cough along with a fever to 102.2 F. A chest radiograph reveals a 4 cm diameter mass with an air-fluid level in the right lung. Which of the following conditions is he most likely to have?

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.

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 (blunted costophrenic angles). Which of the following would be the most reasonable next step in the assessment of the patient?

Measurement of alpha 1 anti-trypsin levels

Forced vital capacity refers to:

Measurement of the volume of airflow expired with the patient breathing as hard and as fast as possible

Which intervention is the cornerstone of ARDS treatment?

Mechanical ventilation

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:

Mycobacterium tuberculosis infection

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 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

An asymptomatic 60 year-old female with a 30 pack year history of smoking presents to the clinic requesting a chest x-ray to check for lung cancer. Which of the following do you recommend?

No testing and referral for smoking cessation

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

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 55-year-old woman, heavy cigarette smoker presents with complaints of left eye swelling, dry eyes, and left shoulder pain. You notice that the patient's left eyelid is drooping, her conjunctia are dry and her left pupil appears smaller that the right. She also appears to have left sided anhidrosis. She also has severe left shoulder pain with certain movements. Her CXR is seen below (obacity in RUL, shadowing along outer borders of lung fields): Considering these findings you suspect

Pancoast's Syndrome from a Bronchogenic Carcinoma

A child presents with a barking cough and mild stridor after he had a low grade fever and the prodrome of upper respiratory tract symptoms. CXR is below (steeple sign). The most common cause of this condition is:

Parainfluenza virus

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?

Peak expiratory flow rate

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 the most likely chest radiograph presentation of adenocarcinoma of the lung?

Peripheral lesion

You wish to convert a tension pneumothorax to a routine pneumothorax. You can do this by

Placing a 13-gauge needle in the chest over absent breath sounds

While examining a patient's chest you discover an area with absent breath sounds, increased tactile fremitus and egophony. Which of the following conditions do these findings most likely represent?

Pneumonia

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. The best approach to a definitive diagnosis in this patient is

Pulmonary capillary wedge pressure

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

On the 11th postoperative day following a radical prostatectomy for adenocarcinoma, a 70-year-old man is recovering uneventfully. He then ambulates to the bathroom, but upon returning to his bed he suddenly becomes extremely dyspneic and diaphoretic, with chest pain, palpitations, and a feeling of panic. Which of the following post-operative pulmonary complications has he most likely developed?

Pulmonary thromboembolus

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

Which of the following mechanisms leads to a primary pneumothorax?

Rupture of subpleural apical blebs due to high negative intrapleural pressures

What is the most common cause of community acquired pneumonia(CAP)?

S. Pneumonia

19 yr old asthma patient comes to your office with complaints of wheezing symptoms twice per week. What is the next best step in management?

Short acting beta agonist

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

A 66-year-old man with a known history of chronic obstructive pulmonary disease(COPD) presents to the clinic for evaluation of progressive shortness of breath. He had an upper respiratory infection 2 weeks ago, and the symptoms have gotten worse. On physical examination, you find that he is having an acute exacerbation of his COPD. On general survey of this patient, you would expect to see him

Sitting up and leaning forward with arms braced

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

A 60 y/o male who is s/p ORIF of the left hip presents with acute onset of shortness of breath with exertion. On physical exam, he appears anxious and tachypneic. His temperature is 37.8°C (100°F), pulse is 120 beats per minute, respirations are 24/min and labored, and blood pressure is 140/90 mm Hg. Lungs are clear to auscultation bilaterally. Cardiac exam reveals an increased pulmonic component of S2. ECG reveals a S wave in lead I, a Q wave in lead III, and T wave changes in lead III

Spiral CT of the chest

Which of the following signs and symptoms is sufficient to make a diagnosis of chronic bronchitis?

Sputum production for longer than three months of the year and for more than two successive years

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 (large upper mediastinum obacity, no lower lobe vascularity bilaterally). The most likely diagnosis is

Superior Vena Cava Syndrome(SVC obstruction from a mass)

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?

Tachypnea

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?

Tracheal intubation with positive-pressure mechanical ventilation.

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

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 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