Pulm Exam 3 PPT questions and exam master
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? A Acute bronchitis B Bronchiectasis C Pneumonia DTuberculosis
B. bronchiectasis
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? A Persistent asthma B Chronic obstructive pulmonary disease C Idiopathic fibrosing interstitial pneumonia D Sarcoidosis
B. chronic obstructive pulmonary disease
Which of the following is essential to make a diagnosis of cystic fibrosis? A Positive family history B Elevated sweat chloride C Recurrent respiratory infections DElevated trypsinogen levels
B. elevated sweat chloride
Which of the following physical exam findings is consistent with moderate emphysema? A Increased tactile fremitus B Dullness to percussion C Distant heart sounds D Deviated trachea
C. distant heart sounds
A 3 year-old male with cystic fibrosis develops pneumonia. Which of the following is the most likely etiology of the pneumonia? A Escherichia coli B Staphylococcus epidermidis C Pseudomonas aeruginosa D Streptococcus pneumoniae
C. pseudomonas aeruginosa
A 4-year-old girl has always been below 3% for her height and weight. Her mother says she eats three meals a day with healthy snacks. The family tries to maintain a low-fat high-fiber diet. Her parents and sisters are of above average height and average weight. Other than occasional upper respiratory infections and one episode of pneumonia last winter, the girl has been fairly healthy. Her failure to thrive workup is normal, other than a sweat test, which reveals a high chloride concentration. Question What is an important modification to her diet as a result of the most likely diagnosis? Answer Choices 1 Fat-soluble vitamin supplements 2 Low-protein foods 3 Low-fat foods
Fat soluble vitamin supplementation
A 66-year-old man presents with vomiting. He has lung cancer, but he has declined treatment. His father died of lung cancer at the age of 65. On examination, he is confused and dehydrated with a BP of 100/50 mm Hg and HR of 100 beats/minute. Laboratory analysis reveals a calcium level of 16 mg/dL. His renal function tests are normal. Question What is the most appropriate initial therapy in the management of this patient? Answer Choices 1 Normal saline 2 Prednisone 3 Denosumab 4 Hemodialysis 5 Plicamycin
Normal saline
Which of the following is a common presenting clinical manifestation of a patient with interstitial lung disease? A Early inspiratory crackles B Progressive dyspnea on exertion C Productive cough with copious sputum D Decreased breath sounds with hyperresonant percussion
Progressive dyspnea on exertion
A 62-year-old African American woman presents with a persistent cough and shortness of breath. Bronchoscopy is performed and the report includes the following description: "2 x 2 cm non-necrotizing granuloma in the left upper lung field and a 1 x 1 cm non-necrotizing granuloma in the right middle lung field." Question What is the most likely diagnosis? Answer Choices 1 Hypersensitivity pneumonitis 2 Lung cancer 3 Mononucleosis 4 Sarcoidosis 5 Sickle cell disease
Sarcoidosis
Which of the following is the most likely reason for this patient's acute exacerbation of asthma? A Viral upper respiratory infection (URI) B Sinusitis C Noncompliance with inhaled albuterol D Sensitivity to aspirin E Noncompliance with nasal steroids
sensitivity to aspirin
A 57-year-old Caucasian man presents with worsening shortness of breath. While obtaining his history, you uncover that he has noted increasing shortness of breath with minor exertional activity and a persistent but non-productive cough. The patient admits to being a former smoker with a 34 pack-year history, admitting to cessation at age 50. He denies any known caustic occupational exposures and states he worked in an office his whole life. He admits to an uncle having some kind of breathing issues, although he is unsure of a definite diagnosis. Patient denies weight loss, fever, or significant recent illness. Physical examination is pertinent for significant clubbing of the fingers, inspiratory squeaks auscultated during the pulmonary exam, and a right-sided gallop found during the cardiac exam. Question What is the most likely diagnosis? Answer Choices 1 Sarcoidosis 2 Idiopathic pulmonary fibrosis 3 silicosis 4 cryptogenic organizing pneumonia 5 lung cancer
2. Idiopathic pulmonary fibrosis
A 64-year-old man presents with progressive dyspnea, fatigue, chronic dry cough, and exercise intolerance. His symptoms have worsened over the past year. Pulmonary function testing reveals an FEV1/FVC ratio >0.7, decreased total lung capacity, and decreased residual volume. Question What is the most likely diagnosis? Answer Choices 1 Anemia 2 Asthma 3 Chronic obstructive pulmonary disease 4 Pulmonary embolism 5 Idiopathic pulmonary fibrosis
5 idiopathic pulmonary fibrosis
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? A Bronchiectasis B Tuberculosis C Adenocarcinoma DPulmonary fibrosis
A Bronchiectasis
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? A pH = 7.27 pCO2 = 46 pO2 = 56 B pH = 7.60, pCO2 = 18 pO2 = 80 C pH = 7.44, pCO2 = 38 pO2 = 90 D pH = 7.52, pCO2 = 28, pO2 = 80
A pH = 7.27 pCO2 = 46 pO2 = 56
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? A Albuterol (Proventil) inhaler B Montelukast (Singulair) C Salmeterol (Serevent) inhaler D Sustained release theophylline
A. 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? A Albuterol inhaler (Proventil) B Inhaled corticosteroids C Aminophylline (Theo-Dur) D Ipratropium (Atrovent)
A. Albuterol 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? A Broad-spectrum antibiotic B Admission to the hospital C Oxygen at 6 L/min by nasal cannula D Brief course of oral theophylline
A. broad spectrum antibiotic
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? A Emphysema B Pulmonary fibrosis C Ventricular septal defect D Congestive heart failure
A. emphysema
Your patient goes on to develop more frequent recurrent symptoms, such that she is using her albuterol inhaler more than three times per week, although her nighttime symptoms are rare. Which medication is the most appropriate next step in treating this patient's asthma? A Inhaled triamcinolone B Inhaled salmeterol C Inhaled cromolyn sodium D Inhaled ipratropium EOral montelukast
A. inhaled triamcinolone
Six months after you discuss her findings and prescribe inhaled beta-agonist therapy, she returns with complaints of continued wheezing and difficulty breathing. Her symptoms are brought on by cold weather and exercise and she uses her inhaler two times per week or less. She woke up two nights over the last 6 months with shortness of breath and coughing. Her albuterol still works for these symptoms, but she finds them bothersome and asks, "Why haven't I gotten over this?" How would you categorize this patient's respiratory state? A Intermittent asthma B Mild persistent asthma C Moderate persistent asthma D Severe persistent asthma E Recurrent lower respiratory tract infections
A. intermittent asthma
This patient is found to have only pulmonary sarcoidosis with some mild systemic symptoms. Which of the following is the best initial choice for management? A Observation B Oral corticosteroids C Oral antibiotics D Inhaled corticosteroids E Methotrexate
A. observation
A 60-year-old woman presents with a history of persistent cough. She is confined to her bed; walking over 10 paces causes severe breathlessness. She has no energy to carry out any regular activities. She has never smoked, and she drinks an occasional glass of wine. On physical examination, she is found to have decreased breath sounds and dullness to percussion over her right lower thorax. Further evaluation reveals an irregular mass in the periphery of the right lung base with a right-sided pleural effusion. A needle is inserted into the pleural space and divulges bloodstained fluid. Question If results prove to be a malignancy, what is the most likely pathology of her mass? Answer Choices 1 Small cell carcinoma 2 Large cell carcinoma 3 Adenocarcinoma 4 mesothelioma 5 SCC
Adenocarcinoma
A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future? A. Asthma B Tinea pedis C Squamous carcinoma D Systemic lupus erythematosus (SLE)
Asthma
A 7-year-old boy presents with his mother with a 1-week history of wheezing and dyspnea on any exertion (with productive cough). On physical examination, bilateral rhonchi are heard. After a few days of treatment, spirometry is done on the patient. Total lung capacity (TLC) is 111% on spirometry. Pre-bronchodilators Post-bronchodilators FVC% 49 63 FEV1% 41 46 FEV1/FVC 49 55 Question What is the most likely diagnosis? Answer Choices 1 Asthma 2 Pneumonia 3 Pleural effusion 4 Kyphoscoliosis 5 Tuberculosis
Asthma
A 33-year-old man presents with shortness of breath, wheezing, mild fever, and fatigue. He has had several similar episodes in the past, and each previous episode began after a cold that moved into his chest. Over the past several weeks, he has had a productive cough most mornings. He has no other symptoms or exam findings. He smokes on a social basis. His CXR is normal and most recent pulmonary function tests reveal a reversible airflow limitation. Question What is the most likely diagnosis? Answer Choices 1 Chronic emphysema 2 Chronic bronchitis 3 Cor pulmonale 4 Asthmatic bronchitis 5 Bronchiectasis
Asthmatic bronchitis
A 35-year-old woman presents with 5-hour history of progressive shortness of breath, cough, and wheezing. This morning she felt that she was "catching a cold" because of sore throat and thin purulent rhinorrhea, for which she took aspirin. Her past medical history is significant for persistent rhinitis resistant to therapy. Question What should your patient do to prevent future asthma attacks? Answer Choices 1 Avoid aspirin. 2 Take antihistamine. 3 Inhale cromolyn. 4 Take albuterol. 5 Get influenza vaccine.
Avoid aspirin
Which of the following is true about ACE levels in sarcoidosis? A An elevated ACE level is specific for sarcoidosis B ACE levels often correlate with disease severity in sarcoidosis C ACE inhibitors are effective in the treatment of sarcoidosis D All of the above
B ACE levels often correlate with disease severity in sarcoidosis
Which of the following best describes the pathophysiology of emphysema? A Interstitial inflammation and fibrosis B Alveolar enlargement and loss of septa C Mucosal edema and inflammatory response DExcessive mucus secretion and chronic cough
B Alveolar enlargement and loss of septa
Which of the following is an independent risk factor for development of a mesothelioma? A Cigarette smoking B Asbestos exposure C Radon gas exposure DChronic obstructive lung disease
B Asbestos exposure
After a brief hospitalization, your patient recovers nicely. Prior to this incident involving aspirin, she had been free of exacerbations for about a month. In addition to a short course of oral steroids, which of the following medication regimens do you prescribe for this patient with aspirin sensitive asthma at discharge? A Inhaled triamcinolone and inhaled albuterol as a "rescue" B Inhaled triamcinolone, oral montelukast, and inhaled albuterol as a "rescue" C Oral montelukast and inhaled albuterol as a "rescue" D Inhaled albuterol as a "rescue" EInhaled salmeterol and inhaled triamcinolone
B Inhaled triamcinolone, oral montelukast, and inhaled albuterol as a "rescue"
Which of the following is NOT found as a part of sarcoidosis? A Erythema nodosum B Myocardial infarction C Cardiac arrhythmias D Elevated liver enzymes E Vision loss
B Myocardial infarction
A 35-year-old African-American female presents with dyspnea worsening over the last 2 months. She also complains of cough, generalized fatigue, and intermittent low-grade fevers. She does not smoke. Chest x-ray shows hilar adenopathy and small bilateral pleural effusions. Spirometry is consistent with a restrictive pattern. Of the following, which is the most likely diagnosis? A Granulomatosis with polyangiitis B Sarcoidosis C Bronchogenic carcinoma D Pneumonia EMicroscopic polyangiitis
B Sarcoidosis
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? A hyperinflation and flat diaphragms B interstitial fibrosis and pleural thickening C cavitary lesions involving the upper lobes D "eggshell" calcification of hilar lymph nodes
B interstitial fibrosis and pleural thickening
Which of the following pathophysiological processes is associated with chronic bronchitis? A Destruction of the lung parenchyma B Mucous gland enlargement and goblet cell hyperplasia C Smooth muscle hypertrophy in the large airways D Increased mucus adhesion secondary to reduction in the salt and water content of the mucus
B. Mucous gland enlargement and goblet cell hyperplasia-
Your patient's office spirometry shows the following: ◦Normal FVC ◦FEV1 82% predicted ◦FEV1/FVC 0.68 These findings are most consistent with which of the following? A Normal spirometry B Obstructive lung disease C End-stage emphysema D Interstitial fibrosis E Obesity-hypoventilation syndrome
B. Obstructive lung disease
Which of the following medications, when used alone as maintenance therapy in persistent asthma, is associated with an increased risk of asthma-related mortality? A Inhaled fluticasone B Inhaled salmeterol C Oral zafirlukast DOral prednisone
B. inhaled salmeterol
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? A Diabetic ketoacidosis B Pulmonary infection C Intestinal obstruction DAcute respiratory failure
B. pulm infection
A 15-year-old girl with a history of mild asthma has had worsening episodes of cough, wheezing, and increasing bloody sputum over the past 5 months. She denies weight loss, decreased appetite, lethargy, or travel. She has increased her bronchodilator use, but she had not sought further care. Her mother has noted facial flushing with sweating that sometimes appears when she feels stressed—brief at first but lasting longer now. On exam, her respiratory rate is 32 breaths/min, temperature is 98.6°F, heart rate 84 bpm, BP 114/76 mm Hg, oxygen saturation is 94%. Her throat is clear, RRR without murmur; on auscultation, breath sounds over the left hemithorax are diminished without retractions or wheezes; there are few fine crackles at the base. Right side is clear. Remainder of the exam is normal. Chest X-ray reveals a round area of increased opacification near the right hilar region. CBC shows normal white count and differential. Question What diagnosis would most easily explain the patient's symptoms? Answer Choices 1 Pulmonary embolism 2 Bacterial pneumonia 3 Bronchial carcinoid tumor 4 Pulmonary hemosiderosis 5 Vascular malformation
Bronchial carcinoid tumor
If this patient has mild asthma, which of the following pulmonary function test results would you expect to find? A Forced vital capacity (FVC) 50% of predicted B Forced expiratory volume in 1 second (FEV1) 100% of predicted C FEV1/FVC ratio <0.7 D Total lung capacity (TLC) 50% of predicted E FEV1/TLC <0.7
C FEV1/FVC ratio <0.7
Patients with long-term exposure to silica, coal dust, and asbestos may develop which of the following as complications? A Airway Hyperreactivity B Epithelial hyperplasia C Pulmonary fibrosis DUpper airway obstruction
C Pulmonary fibrosis
What is the mechanism of action of salmeterol (Serevent) in the treatment of asthma? A Anti-inflammatory B Immunotherapy for specific allergens C Relaxing of bronchial smooth muscle DReduction of leukotriene production
C Relaxing of bronchial smooth muscle
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? A Building demolitionist B Coal miners C Sandblasters D Farmers
C Sandblasters
A 52-year-old man is seen for fevers and weight loss. A chest radiograph shows mediastinal lymphadenopathy. Laboratory findings show hypercalcemia, elevated alkaline phosphatase, and an elevated level of ACE. The most likely diagnosis is: A Small cell carcinoma of the lung B Pulmonary tuberculosis C Sarcoidosis D Histoplasmosis E Asbestosis
C Sarcoidosis
A 65-year-old with COPD having received their first PPSV23 vaccination at age 63 should be revaccinated with PPSV23 in ___________. A 1 year B 3 years C 5 years D10 years
C. 5 years
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? A chest x-ray B sputum gram stain C peak flow D ventilation - perfusion scan
C. Peak flow
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? A Decrease the oxygen flow rate. B Administer oral corticosteroids. C Intubate the patient. DAdminister salmeterol (Serevent)
C. intubate the pt
A 29-year-old man presents with a chronic respiratory infection; he is seeking the advice of an ear, nose, and throat specialist. He reports a history of recurrent respiratory infections. A biopsy of his respiratory epithelium reveals an alteration in certain epithelial structures. Question What is most likely to be abnormal? Answer Choices 1 Cilia 2 Desmosomes 3 Hemidesmosomes 4 Microvilli 5 Stereocilia
Cilia
Which of the following is most appropriate for this patient given that she has intermittent asthma? A Add theophylline B Add montelukast C Continue albuterol as needed D Schedule albuterol every 4 hours E Prednisone 5 mg daily
Continue albuterol prn
A 36-year-old African American woman presents with a nonproductive cough, malaise, mild fever, and mild dyspnea. She also indicates that she has some lesions around her nose. Upon physical exam, you note red-brown dermal papules around her nares. A chest X-ray demonstrates a right hilar mass. A pulmonologist is consulted and performs a biopsy during bronchoscopy. The report reveals that the mass is a non-caseating granuloma. Question What initial therapy should be prescribed? Answer Choices 1 Corticosteroids 2 Inhaled beta agonists 3 Methotrexate 4 Amphotericin B 5 Cyclosporine
Corticosteroids
A 10-year-old girl presents with recurrent bronchitis. Her past history is significant for polypectomy, nasal polyps, failure to thrive, and repeated attacks of bronchitis. Examination reveals clubbing and diffuse rhonchi on respiratory auscultation. Investigations reveal subnormal lung function, decreased exercise tolerance, and a sweat chloride concentration of 62 mEq/L (normal: <40 mEq/L). Question What is the most likely diagnosis? Answer Choices 1 Pulmonary aspergilloma 2 Bronchial asthma 3 Pulmonary tuberculosis 4 Cystic fibrosis 5 Primary ciliary dyskinesia
Cystic fibrosis
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? A Coal mining B Silica exposure C Textile work DAsbestos exposure
D Asbestos exposure
Which of the following is NOT commonly associated with sarcoidosis? A Hypercalcemia B Elevated ACE levels C Reduced diffusion capacity D Hypothyroidism E Facial or peripheral nerve palsy
D Hypothyroidism
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? A Home oxygen therapy B Maintenance oral steroids C Prophylactic antibiotic therapy D Recommend influenza and pneumococcal vaccines
D Recommend influenza and pneumococcal vaccines
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? A Oral prednisone B Oral theophylline C Salmeterol inhaler DBeclomethasone inhaler
D. Beclomethasone inhaler
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? A methylxanthine oxidase inhibitor B long acting beta agonist inhaler C leukotriene inhibitor Dinhaled corticosteroid
D. inhaled cocticosteroids
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? A Mast cell stabilizer B Long-acting beta agonist C Leukotriene receptor antagonist DLow dose inhaled corticosteroid
D. low dose inhaled corticosteroids
A 55-year-old woman presents with a slight cough she has had for about a week. She is a nonsmoker, and she does not remember having a fever or feeling sick. The patient currently works as a third-grade teacher and has done this for 30 years. She has no past medical history of significant pulmonary diagnoses. Auscultation of the chest reveals clear lung fields. A chest X-ray shows a subpleural "coin lesion" in the right upper lobe. Question What is the most likely diagnosis? Answer Choices 1 Small cell anaplastic carcinoma 2 Bronchiectasis 3 Silicosis 4 Granuloma 5 Exogenous lipid pneumonia
Granuloma
A 72-year-old man is evaluated at his bedside following hospital admission for a 1-year history of progressive dyspnea, nonproductive cough, weight loss, low-grade fevers, fatigue, and myalgias. Past medical history is remarkable for atrial fibrillation (for which he takes amiodarone), hypercholesterolemia, and recurrent urinary tract infections. He is currently on nitrofurantoin on a chronic prophylactic basis. He denies cigarette use. He denies chills, fatigue, rhinitis, otalgia, chest pain, wheezing, hemoptysis, syncope, abdominal pain, rashes, peripheral edema, diaphoresis, arthralgias, vomiting, and urinary complaints. A bedside echocardiogram and electrocardiograms are unremarkable for abnormalities. A chest x-ray reveals peripheral reticular opacities at the lung bases and a generalized honeycombing pattern. Question What is the next step in the diagnosis of this patient? Answer Choices 1 High-resolution computed tomography (HRCT) 2 Surgical lung biopsy by video-assisted thoracoscopic surgery (VATS) 3 C-reactive protein levels and an erythrocyte sedimentation rate 4 Polymerase chain reaction (PCR) testing for common respiratory viruses 5 Upper endoscopy to assess for the presence of esophageal reflux
HRCT
A 50-year-old man presents with a 4-day history of increasing exertional dyspnea. He has had a chronic cough for the past 3 years and attributes it to cigarette smoking. The cough had been productive of watery sputum, but it has changed to a yellowish color over the past week. He has no known allergies and reports no family history of asthma. On general appearance, he is wheezing. His temperature is 101°F, P 105/min, BP 136/86 mm Hg, and RR 30/min. Respiratory system examination reveals decreased chest wall excursion. Auscultation reveals a prolonged expiratory phase with crepitations and generalized rhonchi. Chest X-ray reveals irregular bronchovascular markings. Laboratory results reveal Hb 15 g/dL, WBC 12,000/uL, and platelets 300 x 109/L. Question What group of pathogens is most commonly associated with acute exacerbation of the patient's most likely diagnosis? Answer Choices 1 Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis 2 Pseudomonas aeruginosa, Moraxella catarrhalis, Chlamydia pneumoniae 3 Legionella pneumophila, Chlamydia pneumoniae, Mycoplasma pneumoniae 4 Mycoplasma pneumoniae, Legionella pneumophila, Pseudomonas aeruginosa 5 Legionella pneumophila, Streptococcus pneumoniae, Haemophilus influenzae
Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis
You have just taken over the management of a 55-year-old man with COPD who was admitted 3 days earlier for community-acquired pneumonia. He currently feels somewhat better, and he has been afebrile for the last 24 hours. Leukocytes count 5,600/μL Serum glucose 106 mg/dL Segmented neutrophils 75% Sodium 138 mmol/L Hemoglobin 19g/dL Chloride 102 mmol/L Platelets 245,000/μL Potassium 4.2 mmol/L Arterial blood gas PH 7.25 Bicarbonate 29 mmol/L PCO2 55 BUN 18 mmol/L PO2 57 Creatinine 1.0 mmol/L HCO3 29 O2 sat 88% Question What has been shown to improve life expectancy in a patient like this? Answer Choices 1 Antibiotics 2 Bronchodilator therapy 3 Home oxygen 4 Inhaled steroids 5 Acetazolamide
Home oxygen
A 50-year-old man presents with a 2-week history of not being able to see well. He is not on any medications. He has been smoking 2 packs of cigarettes a day for the past 30 years (60 pack-years). On physical examination, the right eye demonstrates ptosis and miosis, and the right side of the face is unusually dry compared to the left. No weakness is noted on the musculoskeletal exam. A chest radiograph reveals a rounded opacity in the right lung field. Question What is the most likely diagnosis? Answer Choices 1 Lambert-Eaton syndrome 2 Superior vena cava syndrome 3 Horner syndrome 4 Cushing syndrome 5 Syndrome of inappropriate antidiuretic hormone secretion
Horner syndrome
A 57-year-old man presents with a 6-month history of a daily productive cough. The patient is a non-smoker, and he has worked in a local coal mine for the past 39 years. He very rarely comes in to see a healthcare provider. When asked if he is up to date with his vaccinations, he does not recall the last ones he received; he also does not recall when these may have been given. Question Given the most likely diagnosis, what pair of vaccinations would be recommended to help decrease any significant morbidity and mortality in this patient? Answer Choices 1 Influenzae and pneumococci 2 Influenzae and zoster 3 Pneumococci and varicella 4 Pneumococci and zoster 5 Varicella and zoster
Influenzae and pneumococci
A 14-year-old boy presents with two episodes per week of shortness of breath exacerbated by playing soccer. His mother has given him her albuterol inhaler on several occasions, and his cough and shortness of breath improve significantly. He also wakes up 1-2 times per month with coughing episodes. He has a strong family history of asthma. He denies fever, chills, and chest pain and has no known drug allergies. Question In addition to his own albuterol inhaler, what medication should be prescribed for this patient? Answer Choices 1 Oral steroids 2 Oral antihistamine 3 Inhaled corticosteroids 4 Oral leukotriene modifier 5 Subcutaneous injections of omalizumab
Inhaled corticosteroid
A 32-year-old man presents due to occasional shortness of breath and associated cough, especially when he is working outside. He has associated chest tightness that resolves within minutes when he sits down and rests. These symptoms occur 1-2 days a month. He is otherwise healthy and does not smoke. Blood pressure is 128/74 mm Hg, pulse is 76, respirations are 14, pulse oximetry is 100% on room air. FEV1 is 96%. Question What is the treatment of choice when this patient is experiencing symptoms? Answer Choices 1 Leukotriene modifiers 2 Inhaled short-acting beta-agonist 3 Oral steroids 4 Inhaled anticholinergic plus inhaled short-acting beta-agonist 5 Oral beta-agonist
Inhaled short acting beta agonist
Routine physical examination of a 55-year-old man demonstrates marked finger clubbing. Radiography of the hand shows new bone formation beneath the periosteum. Question This finding is most strongly associated with what disorder? Answer Choices 1 Chronic renal failure 2 Colon cancer 3 Endocrine adenomas 4 Intrathoracic cancer 5 Profound anemia
Intrathoracic cancer
A 12-year-old boy with cystic fibrosis (CF) presents for a periodic evaluation visit. Weight gain has been stable, but he has had three pulmonary exacerbations in the past year. His participation in physical activity has decreased during that time because his parents believe that exercise will be detrimental to him in his weakened condition. He has many friends who participate in athletics and physical activity, however, and he would like to join them. Past medical history is otherwise unremarkable except for occasional episodes of sinusitis. Vital signs reveal a respiratory rate of 20 at rest, with scattered crackles and wheezes at both lung bases. Pulse oximetry is 93% at rest. Question What advice would you give? Answer Choices 1 Cystic fibrosis is a contraindication to competitive sports. 2. Exercise training is of little benefit in cystic fibrosis. 3 Activity should be minimal in patients with frequent exacerbations. 4 Long-term regular exercise training should be initiated. 5 Parents should remain neutral on the issue of exercise.
Long-term regular exercise training should be initiated.
A 54-year-old man with emphysema presents with a blood pressure of 157/101 mm Hg. Over the next several months, he is prescribed angiotensin-converting enzyme inhibitors, diuretics, and calcium channel blockers, but the patient has to discontinue each agent because of undesirable side effects. He is prescribed a beta antagonist instead. Question What beta antagonist would be most appropriate for this patient? Answer Choices 1 Metoprolol 2 Nadolol 3 Propranolol 4 Sotalol 5 Timolol
Metoprolol
A 17-year-old boy presents with intermittent bouts of shortness of breath, coughing, and chest tightness. The symptoms most often occur during football practice, sometimes when he is just standing outdoors in cold weather. He denies palpitations, fever, and chills. Past medical history is non-contributory. He is a non-smoker. Physical exam is unremarkable. Vital signs are as follows: BMI 19 kg/m2, BP 116/70 mm Hg, HR 80 bpm, SpO2 99% on room air. His physician orders pulmonary function testing (PFT) and a chest X-ray (CXR). Question Based on the most likely diagnosis, what chest X-ray finding is most likely? Answer Choices 1 Hyperinflation 2 Ground glass shadowing 3 Bronchial wall thickening 4 Perihilar fluffy infiltrates 5 Normal chest X-ray
Normal CXR
A 63-year-old man with a past medical history of hyperlipidemia presents with an 8-month history of intermittent flushing and warmth sensation to his face and neck areas; alternating watery, frothy, and bulky stools associated with steatorrhea; weight loss; and wheezing. His urine demonstrates increased 5-hydroxyindoleacetic acid (HIAA) levels. Scintigraphy reveals innumerable foci of intense activity scattered throughout the liver. Question What agent is highly effective at reducing symptoms? Answer Choices 1 Octreotide 2 Danazol 3 Cytarabine 4 Imatinib 5 Gemcitabine
Octreotide
A 50-year-old man is evaluated for non-productive cough and shortness of breath. He reports a progressive cough that has worsened over the past year. Over the last 2 weeks, he has increasing cough, chest pain, and low-grade fever. His occupational history reveals coal mining for 25 years. He denies any smoking, alcohol consumption, travel history, or sick contacts. He also denies sore throat, otalgia, abdominal pain, peripheral edema, rashes, or pruritus. A chest radiograph was performed. Refer to the image. Question What treatment would be most beneficial? Answer Choices 1 Trexall 2 Oseltamivir 3 Amoxicillin-clavulanate 4 Prednisone 5 Acyclovir
Prednisone
A 9-year-old boy presents with a productive cough for the past few days. The patient also has been having fevers of 101°F. The patient has had recurrent bouts of pneumonia. His neonatal course was complicated by meconium ileus. A sweat chloride test is positive and sputum examination reveals gram-negative rods that are oxidase-positive. The culture has a greenish tint. Question Based on the patient's underlying condition and laboratory findings, this infection is most likely caused by what organism? Answer Choices 1 Pseudomonas aeruginosa 2 Staphylococcus aureus 3 Streptococcus pneumoniae 4 Haemophilus influenzae 5 listeria monocytogenes
Pseudomonas aeruginosa
A 3-day-old male neonate is seen in the nursery due to failure to pass meconium and two episodes of vomiting. Prenatal and perinatal histories are unremarkable. Family history reveals a brother and sister with severe asthma. Examination reveals a moderately distended abdomen without signs of tenderness. A barium enema reveals meconium ileus with distal narrowing and proximal dilatation of the colon. Meconium is passed during the procedure, relieving the distention. Question What should be ordered? Answer Choices 1 Chest radiograph, CT, MRI 2 Chromosome analysis of peripheral blood lymphocytes 3 Qualitative stool fat, colonoscopy, ova, parasites 4 Rectal manometry, rectal biopsy, sweat chloride 5 Urine electrolytes, CBC, TSH
Rectal manometry, rectal biopsy, sweat chloride
A 32-year-old African American woman with no significant past medical history has been referred to a pulmonologist; she presents with a 2-month history of progressive dyspnea. She notes associated low-grade fever, malaise, joint pain, and swollen neck glands. She denies a history of travel, cigarette smoking, drug use, or sexually transmitted diseases (she has not been sexually active in the past year). All other reviews of systems are negative. Her physical exam reveals tender nodular formations on her anterior lower extremities, parotid enlargement, hepatosplenomegaly, and cervical lymphadenopathy. Her vital signs, heart, and lungs are unremarkable. Diagnostic testing reveals leukopenia, increased ESR, hypercalcemia, hypercalciuria, elevations of serum ACE levels, and bilateral hilar adenopathy with diffuse reticular infiltrates. ANCA, ANA, and rheumatoid factor tests are negative. Histological assessment confirms the presence of noncaseating granulomas. Question What is the most likely diagnosis? Answer Choices 1 Sarcoidosis 2 Tuberculosis 3 Wegener's granulomatosis 4 Pneumocystis jirovecii pneumonia 5 Idiopathic pulmonary fibrosis
Sarcoidosis
A 45-year-old woman presents with an insidious onset of increasing dyspnea. A chest X-ray revealed nodular infiltrates and marked hilar lymphadenopathy. The transbronchial biopsy demonstrated non-necrotizing granulomas. Question What is the most likely diagnosis? Answer Choices 1 Asbestosis 2 Idiopathic pulmonary fibrosis 3 Coccidioidomycosis 4 Hypersensitivity pneumonitis 5 Sarcoidosis
Sarcoidosis
A 36-year-old non-smoking man is diagnosed with emphysema. Upon further questioning, he tells you his father was also diagnosed with emphysema when he was in his 30s and never smoked. He states that his father passed away at age 50 of hepatocellular carcinoma. Question What diagnostic study should the patient have done? Answer Choices 1 Interferon-gamma release assay 2 Serum alpha-antitrypsin (AAt) 3 Serum angiotensin-converting enzyme (ACE) 4 Serum brain natriuretic peptide (BNP) 5 Sweat chloride test
Serum alpha-antitrypsin
A 52-year-old man has a past medical history of smoking 40 packs of cigarettes per year; he presents for a follow-up. He notes that, over the past week, he has developed increased nonproductive cough and shortness of breath. He has had a chronically-progressive cough and shortness of breath upon exertion over the past year. His occupational history reveals coal mining for 25 years. He denies any alcohol consumption, travel history, or sick contacts. He also denies fever, chills, sore throat, otalgia, chest or abdominal pain, peripheral edema, rashes, and pruritus. A chest radiograph is performed, which reveals diffuse bilateral ground-glass opacities and eggshell calcification of hilar lymph nodes. Question Based on the most likely diagnosis, what preventive medicine factor is true? Answer Choices 1 Smoking cessation strategies are encouraged. 2 Influenza and pneumococcal pneumonia immunizations are contraindicated. 3 A 15-mm induration upon PPD testing indicates a positive test result. 4 Low-level occupational exposure may be safely tolerated at this time. 5 Dietary and activity restrictions are necessary in disease management.
Smoking cessation
A 53-year-old man with a 40 pack-year smoking history presents with a 10-month history of an intermittent cough with productive sputum. He admits to progressive exertional shortness of breath, which recently has limited his activity to climbing 1 flight of stairs or walking 3 city blocks. He denies diaphoresis, fever, chills, chest pain, palpitations, audible wheezing, pleurisy, peripheral edema, hemoptysis, abdominal pain, reflux, regurgitation, diarrhea, melena, or hematochezia. He also denies travel, sick contacts, and drug or alcohol use. His general survey reveals an overweight male with an odor of smoke and nicotine staining of his fingernails. His nails also demonstrate digital clubbing. His pulmonary exam reveals a prolonged expiratory phase, barrel chest, poor diaphragmatic excursion, and wheezing to auscultation. Pulmonary function testing shows airflow obstruction with a reduction in FEV1and FEV1/FVC ratio; increases in total lung capacity, functional residual capacity, and residual volume were noted. Question What intervention has been demonstrated to influence the natural history of this patient's illness? Answer Choices 1 Intravenous diuretics 2 Inhaled anticholinergic agents 3 Smoking cessation 4 Long-acting inhaled agonists and glucocorticoids 5 Antibiotic prophylaxis
Smoking cessation
A 20-year-old woman with no significant past medical history presents with a 2-month history of episodic shortness of breath. These symptoms began with an upper respiratory tract infection. She has fits of coughing and trouble catching her breath with exertion. She states that her breath "sounds like whistles" at times. She tried a friend's albuterol inhaler and an over-the-counter epinephrine inhaler (Primatene...yes, it is back on the market) with some improvement and wonders if she has asthma. On examination, she is breathing comfortably at 16 times per minute and her oxygen saturation is 96% on room air. Her lungs are clear to auscultation, and the remainder of her examination is unremarkable. You want to better categorize this patient's disease. Which of the following tests is most appropriate to order now? A Spirometry B Chest x-ray C Arterial blood gas (ABG) D Methacholine challenge E Chest CT
Spirometry
A 62-year-old man presents for evaluation of facial swelling that feels worse with bending forward. He states he has also experienced headaches, shortness of breath, and visual problems over the past few weeks. He admits that he has a 70 pack-year smoking history. Upon examination, you note swelling of the face and distention of neck and chest veins. You appreciate diminished breath sounds and tactile fremitus in the right upper lobe. Question What is the most likely diagnosis? Answer Choices 1 Interstitial lung disease 2 Spontaneous primary pneumothorax 3 Superior vena cava obstruction 4 Pneumonia 5 Chronic bronchitis
Superior vena cava obstruction
A 2-week-old female neonate has been reported to have an elevated immunoreactive trypsinogen (IRT) level on her newborn screening sample that was sent from the newborn nursery after birth. The state newborn screening lab ran additional tests to screen for the 40 most common mutations known to cause the suspected diagnosis. The result of that mutation screening was negative. Question What test will definitely rule out the diagnosis? Answer Choices 1 Nasal epithelial potential difference measurement 2 Sweat chloride test 3Sweat conductivity testing 4 Fecal elastase level 5 Throat swab
Sweat Chloride test
A 3-year-old Caucasian girl presents with her parents for followup after her third episode of pneumonia this year. Her parents report she has been acting more like herself and appears to be feeling better. On exam, she is afebrile and breathing comfortably. She has moderate crackles in the lower right lung base. Past medical history is significant for a few episodes of pneumonia each winter since birth. She has always been small for her age, but her mother says she has a healthy appetite. Her parents and brother are of medium stature. She takes no medication other than the antibiotic that was prescribed 5 days ago. Question What test should be ordered next? Answer Choices 1 Sweat chloride test 2 DNA analysis 3 Pulmonary function tests 4 Abdominal ultrasound 5 CT of the chest
Sweat chloride test
A 62-year-old man presents with shortness of breath, some chest discomfort, and palpitations. Upon examination, his pulse rate is 200/min; blood pressure is 100/75 mm Hg, and he has an oral temperature of 98.7°F. A 12-lead ECG examination reveals the wave patterns in the figure below (Refer to the image). He has a history of chronic bronchitis. He has been taking drugs to control his condition since he quit smoking 6 months ago. Question What treatment is most likely causing his symptoms? Answer Choices 1 Inhaled corticosteroids 2 Oral steroids 3 Phosphodiesterase-4-inhibitor 4 Theophylline 5 Antibiotics
Theophylline
A 68-year-old non-smoking man presents to your pulmonology practice for long-standing dyspnea and non-productive cough. The patient has had the cough and progressively worsening dyspnea for about 1.5 years with no current exacerbation. He denies fevers, chills, night sweats, and any other symptoms. He denies unusual travel, hobbies, or occupational exposures. He does, however, endorse relatively frequent reflux symptoms. The rest of his review of systems is negative. He has had a workup through his family practice and was then sent to the cardiologist, who ruled out cardiovascular causes of his dyspnea. He has been given trials of various antibiotics, inhalers, and steroids, all without improvement in symptoms, despite good compliance. He currently takes no medications. Several tests have been performed, and results are shown in the table. Blood count, metabolic panel, HIV, and autoimmune markers Normal High-resolution computed tomography (HSCT) scan Few reticular opacities Pulmonary function test (PFT) Restrictive impairment and reduced perfusion of carbon monoxide Physical exam is significant for fine inspiratory bibasilar crackles and clubbing in the fingers. An occasional dry cough is noted. Question What intervention is most likely to prevent complications in this patient? Answer Choices 1 Cisplatin-based chemotherapy 2 Inhaled beta agonist 3 Inhaled corticosteroid 4 Treatment of gastroesophageal reflux disease 5 Avoidance of supplemental oxygen
Treatment of GERD
Which of the following is the major pathogenetic mechanism that causes asthma? A Airway inflammation B Increased pulmonary secretions C Presence of Ghon complexes D Irreversible fibrosis
a. airway inflammation
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? A Decrease In FEV1 B Increase in FEV1 C Decrease in FVC DIncrease in FVC
increase in FEV1
Which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms? A call the health care provider regularly B keep a diary of symptoms C monitor peak flow D ask a family member to monitor symptoms
monitor peak flow
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? A COPD B Tuberculosis C Bronchiectasis DPulmonary fibrosis
pulmonary fibrosis
