Pulmonary Exam Master
You are performing a physical examination on a patient with long-standing COPD. Significant findings appreciated include wheezing respirations, cyanosis, and distended neck veins; a left parasternal lift and a tender liver are both noted upon palpation. Question: What is most likely causing the patient's symptoms? Answer Choices: A Constrictive pericarditis B Cor pulmonale C Rheumatic fever D Dilated cardiomyopathy E Congestive heart failure
B Cor pulmonale
A 3-year-old boy presents with difficulty in breathing and a cough that sounds like a seal. On examination, the child has fever, a harsh barking cough, a respiratory rate of 38/minute, and minimal stridor on agitation. On lung auscultation, there are no rales or wheezing. On cardiac auscultation, there is tachycardia. Radiological examination reveals the so-called 'steeple sign'. What is the most likely diagnosis? Answer Choices: A Bronchiolitis B Croup C Epiglottitis D Foreign body aspiration E Pneumonia
B Croup
Routine physical examination of a 55-year-old man demonstrates marked finger clubbing. Radiography of the hand shows new bone formation beneath the periosteum. With what disorder is this finding most strongly associated? Answer Choices: A Chronic renal failure B Colon cancer C Endocrine adenomas D Intrathoracic cancer E Profound anemia
D Intrathoracic cancer
A 46-year-old man is hospitalized due to pneumonia. Over the course of 24 hours, he develops a very bad headache and stiff neck followed by a seizure. On physical examination, he is febrile with signs of meningeal irritation. A lumbar puncture results are as follows: TEST RESULTS REFERENCE RANGE CSF pressure 250 mm H2O 70-80 mm H2O CSF leukocytes 8,700 cu mm 0-10 cu mm CSF glucose 22 mg/dL 45-80 mg/dL CSF protein 233 mg/dL 15-45 mg/dL CSF gram stain pending What organism is the most likely cause of his meningitis? Answer Choices: A Streptococcus pneumoniae B Streptococcus agalactiae C Cryptococcus neoformans D Staphylococcus epidermidis E Staphylococcus aureus
A Streptococcus pneumoniae
A 52-year-old man presents after coughing up blood. He has a 60-pack/year history of smoking, and he recently developed a persistent cough. An extensive work-up is done, and he is found to have small cell carcinoma of the lung. What is most likely to be secreted by the tumor? Answer Choices: A ADH B HCG C CA 125 D Alpha-fetoprotein E Calcitonin
A ADH
A 60-year-old man gives a characteristic history of carcinoma of the lung. The patient is a non-smoker. Because the patient a non-smoker, what cancer does he probably have? Answer Choices: A Adenocarcinoma of the lung B Squamous cell carcinoma of the lung C Squamous cell carcinoma of the larynx D Mesothelioma of the pleura E Small cell anaplastic carcinoma of the lung
A Adenocarcinoma of the lung
A 23-year-old man presents with a fever (T max of 103°F), cough, and shortness of breath that has been going on for approximately three weeks now. He originally came in to see your colleague and was prescribed trimethoprim-sulfamethoxazole. This has not alleviated his symptoms and now he is experiencing chest pain due to coughing so much. He remembers that he had a sore throat 4 weeks ago, just prior to all of these symptoms beginning. He currently works as a sales officer. He is married and denies any extramarital affairs. He has not traveled abroad recently and denies using any illicit drugs. He has no known drug allergies. Question: Given the likely diagnosis, what antibiotic is most appropriate first line therapy? Answer Choices: A Azithromycin B Ciprofloxacin C A second course of trimethoprim-sulfamethoxazole D Amoxicillin E Ceftriaxone
A Azithromycin
An 87-year-old woman presents with progressive shortness of breath. She has been in a wheelchair for 15 years due to paralysis of her lower extremities from unknown causes. At this time, she is unable to transfer from the chair to her wheelchair without having dyspnea. She is extremely tired, but denies chest pain, palpitations, cough, hemoptysis, dysphagia, hoarseness, or sick exposures. She has never smoked. Her past medical history is positive for hypertension (treated with enalapril), heart failure, chronic kidney disease, hepatitis C, breast cancer, s/p lumpectomy, and radiation treatment 10 years ago. You order a chest X-ray. What in her medical history would lead you to suspect an exudative pleural effusion? Answer Choices: A Breast cancer B Chronic kidney disease C Cirrhosis D Heart failure E Hypertension
A Breast cancer
A 25-year-old man presents with fever, cough, and shortness of breath. He is experiencing chest pain and had a sore throat 2 weeks ago. He is working as a sales officer. He is married and denies any extramarital affairs. He has not traveled abroad in the recent past and denies using any illicit drugs. Question: What is the most likely cause of his symptoms? Answer Choices: A Chlamydophila pneumoniae B Legionella pneumophila C Streptococcus pyogenes D Klebsiella pneumoniae E Pneumocystis jiroveci
A Chlamydophila pneumoniae
A 34-year-old man presents with a 3-day history of fever, cough, and dyspnea. The chest X-ray shows bilateral perihilar infiltrates. The bronchoalveolar lavage reveals cysts of Pneumocystis carinii. What laboratory test finding is most likely to be present in this patient? Answer Choices: A Decreased CD4 lymphocyte count B 4+ urine ketones C Serum gamma-globulin of 0.4g/dL D Cryptococcal antigen in CSF E Positive hepatitis B surface antigen
A Decreased CD4 lymphocyte count
A 76-year-old Caucasian man with a 90 pack per year smoking history presents with progressive fatigue, tachypnea, exertional dyspnea, cough, and lower extremity edema. Inspection of his chest and abdomen reveals an increased chest diameter, labored respiratory efforts with retractions and cyanosis, left parasternal and subxiphoid heaves, hepatojugular reflux, and a pulsatile liver. Additionally, there is scattered wheezes and crackles in his lungs and bilateral lower extremity edema. Question: What physical exam findings would be most consistent with the underlying diagnosis? Answer Choices: A Distended neck veins with prominent a or v waves B Dullness to percussion and increased tactile fremitus of the lungs C Pericardial friction rub D Laterally displaced and enlarged point of maximal impulse E A systolic ejection murmur located at the aortic valve area
A Distended neck veins with prominent a or v waves
Spirometry is conducted preoperatively on a 50-year-old woman about to undergo a cholecystectomy. The patient is a chronic smoker with a history of recent respiratory infection. What spirometry findings pose an increased risk for respiratory failure? Answer Choices: A FVC<50% and FEV1 <50% B Only FVC<50% C Pulmonary function test is irrelevant D Asthma E Pneumonia
A FVC<50% and FEV1 <50%
A 57-year-old man presents with worsening shortness of breath with exercise. He also describes a persistent cough, which is often productive of whitish-gray sputum. He denies chest pain, orthopnea, fever, or chills. He is still able to walk 5 miles a day, but he avoids inclines. Past medical history is noncontributory. Social history reveals significant tobacco use; he has been smoking approximately 1.5 packs-per-day for the past 40 years. Physical exam is unremarkable. Vital signs are as follows: BMI 26 kg/m2, BP 128/70 mmHg, HR 90 bpm, SpO2 97% on room air. His physician orders pulmonary function testing (PFTs) and a chest X-ray (CXR). Question: What chest X-ray finding is most consistent with the diagnosis of chronic obstructive pulmonary disease (COPD)? Answer Choices: A Hyperinflation, bronchial thickening B Perihilar fluffy infiltrates C Pleural effusion, Kerley B lines D Diffuse nodular opacities E Ground glass shadowing
A Hyperinflation, bronchial thickening
A 50-year-old woman presents with right-sided pleural effusion. Thoracentesis shows the presence of exudative serosanguineous pleural fluid and positive cytology. For what condition is this finding most typical? Answer Choices: A Metastatic infiltrating ductal carcinoma B Cor pulmonale C Systemic lupus erythematosus D Staphylococcus aureus septicemia E Pulmonary infarction
A Metastatic infiltrating ductal carcinoma
A 45-year-old man is on chemotherapy. He starts to notice that he is short of breath and has developed a nonproductive cough. Bronchial lavage confirms that he has an infection. What is the most likely pathogen? Answer Choices: A Pneumocystis jiroveci B Giardia lamblia C Babesia microti D Trichophyton tonsurans E Trypanosoma cruzi
A Pneumocystis jiroveci
A 6-year-old boy presents with fever and cough. He has history of several episodes of pneumonia. A sweat test reveals an increased amount of chloride, indicating that he has cystic fibrosis. He is coughing up thick, greenish sputum. Temperature is 37.6° C. A Gram stain of the sputum reveals Gram-negative rods and a culture grows a Gram-negative rod that is oxidase-positive and produces a blue-green pigment. What is the most likely cause of the infection? Answer Choices: A Pseudomonas aeruginosa B Haemophilus influenzae C Bordetella pertussis D Legionella pneumophila E Streptococcus pneumoniae
A Pseudomonas aeruginosa
A 44-year-old healthy man, who is a non-smoker, has a 3-cm coin lesion in the right upper lobe. The lesion was revealed on his chest radiograph. The patient did not have any clinical symptoms. The fine-needle aspiration did not reveal any cells. What is the most likely tumor in this case? Answer Choices: A Pulmonary hamartoma B Bronchial carcinoid C Mesothelioma D Metastatic adenocarcinoma E Large cell undifferentiated carcinoma
A Pulmonary hamartoma
A 5-month-old infant presents with severe respiratory symptoms that include apnea and asphyxia; she is admitted to the hospital. 3 days before her admission, she developed rhinitis and a cough with wheezing. The mother became concerned when the child became lethargic. The physical examination reveals an agitated child with a persistent cough. She has a body temperature of 39°C, pulse of 190 BPM with a noted tachycardia, respirations of 76/min, and a blood pressure of 89/58 mm Hg. Her throat is clear, and auscultations of her lungs are significant for expiratory wheezing and rhonchi. Chest radiographs are positive for interstitial infiltrates and hyperexpansion. Blood gases reveal a relative hypoxemia and acidosis. The child is placed in isolation and subsequently intubated. A nasopharyngeal aspirate is sent to the laboratory for a stat rapid diagnostic test; it is positive. The child is treated with ribavirin. Based on the clinical presentation and treatment, what is the most likely diagnosis? Answer Choices: A Respiratory syncytial virus B Bordetella pertussis C Haemophilus influenzae Type b D Streptococcus pyogenes E Corynebacterium diphtheriae
A Respiratory syncytial virus
Early in the morning on a cold winter day, a 5-month-old infant presents with a 2-day history of severe cough, fast breathing, and fever. According to its mother, the infant is gradually getting worse and has been in close contact with other children in the neighborhood. Some of the neighborhood children were coughing when they visited the patient. The mother does not describe any paroxysmal cough. The infant's immunizations are up to date. On examination, the infant is pyrexial, tachypneic, dehydrated, and he has nasal flaring with wheezing. You admit the infant for oxygen therapy and do some blood tests to help your diagnosis. Blood test results are as follows: • Leukocyte count: 6,500/mm3 • Differential count: • Segmented neutrophils 2 • Lymphocytes 68% • Eosinophils 1% • Basophilic 1% • Hemoglobin, blood 13.0g/dl What is the most likely causative agent? Answer Choices: A Respiratory syncytial virus B Bordetella pertussis C Haemophilus influenzae D Parainfluenza viruses E Rhinovirus F Influenza virus type A
A Respiratory syncytial virus
A 65-year-old man presents with a 25-pound unexplained weight loss. He also has noticed a change in his usual cough. He sees his family doctor. Upon questioning for the medical history, the doctor discovers that he has a 60-pack/year history of smoking as well as dyspnea. On physical examination, he appears to have Cushing's syndrome. X-rays show a central lesion with no cavitation. A hilar mass is seen on chest X-ray. What is the most likely diagnosis? Answer Choices: A Small cell carcinoma B Adenocarcinoma C Metastatic Wilms tumor D Large cell carcinoma E Squamous cell carcinoma
A Small cell carcinoma
A 3-year-old girl presents for a respiratory check due to her 3rd episode of pneumonia this year. She has moderate crackles in the lower right lung base, but she is afebrile and breathing comfortably. 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 2 days ago. Question: What test should be considered once she has recovered completely from pneumonia? Answer Choices: A Sweat chloride test B Karyotype C Pulmonary function tests D Abdominal ultrasound E CT of the chest
A Sweat chloride test
A 55-year-old man is found on routine X-ray to have a growing lesion in the right middle lung field. He is a heavy smoker. The physical examination is within normal limits. Tuberculin test is negative. What is the management of choice? Answer Choices: A Thoracotomy B Antibiotics C Reassurance D Observation E Chemotherapy
A Thoracotomy
A 20-year-old woman presents with breathlessness with severe wheeze. She has had similar episodes since childhood. They commonly occur when she visits her grandmother who lives on a farm. From this, it can be concluded that the patient has extrinsic asthma. What hypersensitivity reaction is classical for her extrinsic asthma? Answer Choices: A Type I hypersensitivity reaction B Type II hypersensitivity reaction C Type III hypersensitivity reaction D Type IV hypersensitivity reaction E Neutrophilic reaction
A Type I hypersensitivity reaction
A 31-year-old HIV-positive woman presents for ongoing care. She was diagnosed with HIV 2 years ago, and she began antiretroviral therapy. Her CD4 T cell count is 400 cells/mL, and she has a history of oral candidiasis. As part of evaluation, her physician decides to perform a tuberculin skin test (TST) using 5 TU of purified protein derivative (PPD). The test site is examined 48 hours later and the skin reaction is measured. What is the minimum diameter of induration at which this test result should be considered positive in this patient? Answer Choices: A 2 mm B 5 mm C 10 mm D 15 mm E 20 mm
B 5 mm
During a routine X-ray examination for employment insurance purposes, the radiologist notices a lesion on the right upper lobe of the pulmonary X-ray of a middle-aged man. The patient was treated for pulmonary cavitary tuberculosis (TB) 2 years ago; he has completed treatment, and he has not had any problems since. Refer to the image. What late complication of TB is seen in this patient? Answer Choices: A Fibrothorax B Aspergilloma C Broncholithiasis D Reactivation of TB E Bronchiectasis
B Aspergilloma
A 73-year-old woman presents to you for the first time for an initial history and physical. She states that over the past year she has been hospitalized twice for pneumonia that required mechanical ventilation for 2-3 weeks each episode and bacteremia requiring several weeks of antibiotics. Which of the following nail abnormalities would you most likely expect to see? A Paronychia B Beau's lines C Pitting D Onycholysis E Splinter hemorrhages
B Beau's lines
A 72-year-old man presents to the outpatient clinic in follow-up for his dyspnea and cough. He reports shortness of breath, especially with activity, and a cough, which is non-productive. Symptoms have been present for 1 year, and they are getting worse. He initially went to the cardiologist for heart concerns, but no cardiovascular disease was found. A chest X-ray was ordered, and the patient reports it showed no masses in his chest. The patient denies any other symptoms, including fever, chills, night sweats, chest pain, and weight loss. The patient is a retired salesman; he fishes as a hobby. He lives at home with his wife; he denies use of tobacco, alcohol, and drugs. He denies any out of the country travel. On physical exam, the patient sits comfortably with normal respiratory effort. Auscultation of his lungs reveals fine crackles in both bases. A dry cough is noted a few times. Cardiovascular exam, including heart and extremities, is normal, except for clubbing of the fingers bilaterally. Question: What test is the next most appropriate in evaluation of this patient's condition? Answer Choices: A Echocardiogram B High-resolution computed tomography (CT) C Mantoux test or purified protein derivative (PPD) D Ultrasound of the thorax E Ventilation-perfusion (VQ) scan
B CT
A 4-year-old boy presents with a 1-month history of weight loss, fevers, cough, and night sweats. He and his family moved to the United States from Africa 3 months ago. He is a thin, pale boy in no acute distress. His heart rate and rhythm are regular; his lungs are clear to auscultation, and he has no organomegaly. Question: What initial tests would most likely have the most value? Answer Choices: A Chest X-ray and test for Hepatitis B surface antigen B Chest X-ray and tuberculin skin test C Chest X-ray and blood culture D Rapid plasma regain (RPR) and blood culture E Stool ova & parasites and Schistosoma serologic testing
B Chest X-ray and tuberculin skin test
A 25-year-old man presents with acute onset shortness of breath associated with right-sided chest pain. The pain is unaffected by position and is worse with inspiration. He was grocery shopping when it started. He denies chest trauma. He had an upper respiratory infection earlier in the month that had resolved without incident. He smokes 1 pack of cigarettes per day, and he has no significant past medical history. On examination, he is afebrile and BP is138/80; pulse is 124, respiratory rate is 24, and pulse oximetry is 94% on room air with mild respiratory distress. Trachea is midline. He has increased resonance to percussion with no breath sounds on the right anterior apex; the other lung fields are clear to auscultation. Heart is tachycardic with normal S1 and S2; no murmur, rubs, or gallops are present. Question: What is the imaging of choice to make the diagnosis? Answer Choices: A Chest computed tomography (CT) B Chest radiograph C Chest ultrasound D Electrocardiogram (ECG) E Spiral chest computed tomography (CT)
B Chest radiograph
A 45-year-old man presents for a certification of disability. The man works in a nursery. He gives history of occasional breathlessness for which no medical record is present. Examination shows tachypnea, and scattered rhonchi are heard all over the chest. In what way is spirometry helpful in this case? Answer Choices: A Done alone B Done once and repeated again with bronchodilator therapy C Done only with bronchodilator therapy D Spirometry is not important E Spirometry conducted alone or with bronchodilator therapy, does not matter
B Done once and repeated again with bronchodilator therapy
A 64-year-old man with hypertension, coronary artery disease, and poorly-controlled left ventricular congestive heart failure presents with a 3-day history of insidious chest pain. Pain is made worse when he takes a deep breath in and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, abdominal pain, nausea, vomiting, diarrhea, or peripheral edema. His physical exam reveals a widespread friction rub upon inspiration, absent lung fremitus, and reduced lung sounds over the thoracic cavity. Q: What additional physical exam finding would be most likely expected in this patient? Answer Choices: A Vesicular breath sounds B Dullness to percussion C Tracheal shift to the affected side D Chest wall tenderness E Increased anteroposterior diameter
B Dullness to percussion
A 40-year-old Asian-American man presents with a 3-day history of nausea and vomiting. He notes his health is good. He was started on a new medication 1 month ago for a positive PPD. What is a true statement regarding this patient? Answer Choices: A His kidney functions would be abnormal B His AST and ALT would be elevated C His GGT would be normal D He should be getting blood work at 3 and 9-month intervals for possible drug toxicity E He is suffering from gastroparesis from a drug-induced neuropathy
B His AST and ALT would be elevated
A 56-year-old man presents for a routine follow-up regarding his positive HIV status. He is compliant with his medications and has been feeling well. In addition to his antivirals, he takes daily trimethoprim/sulfamethoxazole for Pneumocystis jiroveci pneumonia (PCP) prophylaxis. Question: What detail of his history would warrant the prophylaxis? Answer Choices: A CD4 cell count <400 B History of previous PCP infection C CD4 cell count >200 D History of any previous pneumonia infection E HIV viral load >100,000 copies/mL
B History of previous PCP infection
Your patient is a 57-year-old Caucasian man who presents with worsening shortness of breath. While obtaining his history, you uncover that he has noted increasing shortness of breath with minor exertional activity, as well as a persistent yet nonproductive cough. The patient admits to being a former smoker with a 34 pack/year history, admitting to cessation at the age of 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 this patient's most likely diagnosis? Answer Choices: A Sarcoidosis B Idiopathic pulmonary fibrosis C Silicosis D Cryptogenic organizing pneumonia E Lung cancer
B Idiopathic pulmonary fibrosis
On Thanksgiving day, a 5-month-old infant presents with wheezing, rapid respirations (>45 breaths/min), and chest retractions. The patient has a 2-day history of rhinorrhea and low-grade fever. Breath sounds are normal, and there is no cyanosis. What test can confirm the most likely diagnosis? Answer Choices: A Chest X-ray B Immunofluorescence of nasal secretion C Gram stain of the sputum D Blood gas analysis E White blood cell count and differential
B Immunofluorescence of nasal secretion
A 30-year-old man presents with a 15-day history of fever and worsening dry cough, headache, and scratchy sore throat. The general appearance is non-toxic. On examination, he has a erythematous tympanic membrane, mild pharyngeal erythema with no exudates, and no cervical lymphadenopathy. Chest auscultation reveals rhonchi and rales scattered over the chest wall. A chest X-ray shows plate-like atelectasis and nodular infiltrate. What is the most likely diagnosis? Answer Choices: A Viral pneumonia B Mycoplasma pneumoniae C COPD D Bronchiectasis E Tuberculosis
B Mycoplasma pneumoniae
A 12-year-old boy presents with sudden onset of dyspnea with wheezing. The patient had a similar appearance a month ago. An arterial blood gas shows hypoxemia, hypercapnia, and acidosis. The chest X-ray shows clear lung fields. What is the most likely accompanying laboratory finding in this case? Answer Choices: A Elevated sweat chloride B Numerous sputum eosinophils C Decrease CD4 lymphocyte count D Increased serum alkaline phosphatase E Positive tuberculin skin test
B Numerous sputum eosinophils
A 76-year-old man with hypertension, coronary artery disease, and poorly-controlled left ventricular congestive heart failure presents with a 3-day history of insidious chest pain. Pain is made worse when he takes a deep breath in and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, abdominal pain, nausea, vomiting, diarrhea, or peripheral edema. His physical exam reveals a widespread friction rub upon inspiration, absent lung fremitus, and reduced lung sounds over the thoracic cavity. Question: What finding would be anticipated upon further diagnostic testing? Answer Choices: A Serum glucose to pleural ratio of greater than 1.0 on pleural fluid analysis B Pleural fluid N-terminal pro-brain natriuretic peptide levels greater than 1500 pg/mL C Lobar consolidations with air bronchograms on chest radiography D Hyperinflation, hyperluceny, and depressed diaphragms on chest x-ray E Pleural to serum LDH ratio of greater than 0.6
B Pleural fluid N-terminal pro-brain natriuretic peptide levels greater than 1500 pg/mL
A 2-week-old 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 also ran additional tests to screen for the 40 most common mutations that are known to cause Cystic Fibrosis (CF). The result from that mutation screening was negative. Question: What should be the next step in the evaluation of this positive newborn screening result for Cystic Fibrosis? Answer Choices: A Nasal epithelial potential difference measurement B Sweat chloride test C Sweat conductivity testing D Fecal Elastase level E Throat swab
B Sweat chloride test
A 22-year-old man presents with a 3-day history of sharp, localized, intermittent back pain on the right side. He denies any physical trauma to the area. He states the pain intensifies with deep breathing, sneezing, and coughing. He is also experiencing a concurrent viral respiratory illness for which he has not sought treatment. He denies any PMH other than typical childhood illnesses. His vitals are: BP: 125/76 mm Hg, pulse: 85/min,Temp: 97.8 F. Respirations: 16/min Height: 67, Weight: 170 lbs. Lung exam reveals occasional coarse rhonchi throughout all lung fields without wheezes or rales. There is no increase or decrease in tactile fremitus in any lung fields, egophony is not present, and diaphragmatic excursion is equal bilaterally. Localized tenderness in the right back at the level of ribs 7, 8, 9 is present with deep breaths and coughing, but tenderness is not elicited with palpation of the area. A skin exam reveals no rashes or other abnormal findings. The remainder of the physical examination does not demonstrate any other abnormal findings. Question: What is the most likely diagnosis? Answer Choices: A Pneumonia B Pleuritis C Pneumothorax D Varicella zoster E Costochondritis
B Pleuritis
A 45-year-old man presents with a 2-day history of sharp left-sided chest pain. It is aggravated by taking a deep breath. He denies any trauma to the chest. On examination, he is febrile, dyspneic, and has rales on auscultation. Question: What is the most likely cause of his chest pain? Answer Choices: A Esophageal reflux B Pneumonia C Aortic dissection D Pulmonary embolism E Unstable angina
B Pneumonia
A 57-year-old man presents with worsening shortness of breath with exercise. He also describes a persistent cough, often productive of whitish-gray sputum. He denies chest pain, orthopnea, fever, or chills. He is still able to walk 5 miles a day, but he avoids inclines. Past medical history is noncontributory. Social history reveals significant cigarette use; he has been smoking approximately 1.5 packs-per-day for the past 40 years. Physical exam is unremarkable, aside from faint expiratory wheezes that clear with coughing. Vital signs are as follows: BMI 26 kg/m2, BP 128/70 mmHg, HR 90 bpm, SpO2 97% on room air. His physician orders pulmonary function testing (PFTs) and a chest X-ray (CXR). Question: What set of PFT results is most consistent with the diagnosis of moderate chronic obstructive pulmonary disease (COPD)? Answer Choices: A Reduced forced expiratory volume in 1 minute (FEV1), reduced FEV1/Forced vital capacity (FVC) ratio, and Reduced Residual Volume (RV) B Reduced FEV1, Reduced FEV1/FVC ratio, and Increased RV C Reduced FEV1, Increased FEV1/FVC ratio, and Increased RV D Reduced FEV1, Increased FEV1/FVC ratio, and Reduced RV E Increased FEV1, Increased FEV1/FVC ratio, and Reduced RV
B Reduced FEV1, Reduced FEV1/FVC ratio, and Increased RV
A 58-year-old woman presents with a 2-hour history of acute-onset severe left-sided pleuritic chest pain. Her past medical history is significant for hypertension, hyperlipidemia, and breast cancer. The pain is associated with feelings of anxiety, hemoptysis, shortness of breath, and nausea. She "feels warm", but she denies chills, palpitations, wheezing, cough, edema, vomiting, abdominal pain, abnormal bowel habits, and dietary intolerances. She admits to a 30 pack-year smoking history, but she denies drug or alcohol use. Upon physical exam, she is found to be febrile, hypotensive, tachypneic, diaphoretic, and in acute painful distress. There is perioral cyanosis and a pleural friction rub to the left lung fields; the remainder of the exam is normal. Question: What is an expected diagnostic test result for this patient? Answer Choices: A Reduced plasma D-dimer levels B Respiratory alkalosis on arterial blood gas analysis C Sinus bradycardia on the electrocardiogram D Ventilation-perfusion matching pattern upon V/Q scanning E Kerley B-lines, engorged hila and cardiomegaly on the chest X-ray
B Respiratory alkalosis on arterial blood gas analysis
A 69-year-old man with a 50-pack/year smoking history, COPD for 12 years, and a myocardial infarction 2 years ago has been experiencing increased exertional dyspnea for 4 months. There is associated easy fatigability, exertional chest discomfort, and lightheadedness. He denied fever, chills, palpitations, cough, wheezing, abdominal pain, nausea, vomiting, and diarrhea. Physical exam findings were remarkable for a right ventricular heave, widely split S2 with an accentuated pulmonic component, a pulmonary ejection click, an S3 and 1+ pitting edema to the bilateral lower extremities. There was also evidence of a 5 cm jugular vein distention. Question: What diagnostic test results would be expected in this patient? Answer Choices: A Underdevelopment of central pulmonary arteries and hyperemic lung field on chest x-ray B Right axis deviation, R wave greater than S wave in V1, and peaked p-waves on EKG C A normal FEV1 to FVC ratio on pulmonary function testing D Increased thickness of the left atrium on echocardiography E Pulmonary arterial pressure of 15 mmHg on pulmonary artery catherization
B Right axis deviation, R wave greater than S wave in V1, and peaked p-waves on EKG
A 45-year-old man presents with a fever accompanied by a productive cough. He has had the symptoms for several weeks. His temperature rises in the evenings, and he has experienced weight loss. The chest X-ray shows upper lobe cavitary lesions. What is the most likely diagnosis? Answer Choices: A Goodpasture's syndrome B Secondary tuberculosis C Pneumocystis carinii pneumonia D Asbestosis E Cor pulmonale
B Secondary tuberculosis
A 56-year-old man presents with fatigue, fever, chills, and a productive cough. Symptoms began 3 days ago. The patient is drenched in sweat and has shaking chills. The patient has a 2 pack/day smoking habit. He has dyspnea (respiratory rate of 23/min) and pleuritic chest pain to his left side. Crackles are heard over the right middle, left middle, and left lower lung fields. X-rays are significant for right lower lobe, left lingular, and left lower lobe infiltrates. The patient has an elevated body temperature of 40.0° C. Sputum is collected for culture and Gram stain that is brown-green in color. A CBC and blood cultures are also ordered. The CBC results are significant for an elevated WBC of 14.0 x 109/L with a neutrophilic left shift on the differential. The sputum Gram stain contains >25 WBCs per lower-power field with no epithelial cells and many Gram-positive diplococci (refer to the image). The next day, the culture grows 4+ of an alpha hemolytic organism that is catalase negative and bile salt soluble. Blood cultures also turn positive that next day for Gram-positive diplococci. What is causing the pneumonia with septic complications? Answer Choices: A Haemophilus influenzae B Streptococcus pneumoniae C Chlamydia pneumoniae (TWAR) D Candida albicans E Moraxella catarrhalis
B Streptococcus pneumoniae
A 40-year-old man presents with a 3-month history of a productive cough; the cough produces a scant amount of yellow sputum. He has also had an evening temperature rise (101 F) for the past 3 months. On occasion, the sputum was blood-streaked. He has lost a significant amount of weight during this period. Patient is a non-smoker. He immigrated from India 5 years ago, and his medical records are not available. Coarse upper lobe crackles and rhonchi are heard bilaterally. X-ray shows multiple bilateral upper lobe cavities with surrounding infiltrate. What is the probable diagnosis? Answer Choices: A Lobar pneumonia B Tuberculosis C Asthma D Emphysema E Bronchitis
B Tuberculosis
A 37-year-old man with an unremarkable past medical history presents during a cold winter's day with a 10-day history of acute onset of productive cough with a moderate amount of yellow sputum. There is associated fever, shortness of breath, and malaise. He denies recent travel, sick contacts, occupational exposure, and a history of smoking or alcohol use. He denies arthralgias, chills, wheezing, abdominal pain, nausea, vomiting, diarrhea, edema, or rashes. His physical exam is remarkable for fever, tachypnea, reduced fremitus, dullness to percussion, and basilar crackles in the right lower lung field. Q: What additional presentation finding would be most likely in this patient? Answer Choices: A Chest pain precipitated by exertion and an S4 gallop B Unilateral, sharp inspiratory chest pain and thoracic friction rub C Chest pain relieved by antacids and provoked by food intake D A vesicular rash on the thorax preceded by paresthesias E Hemoptysis, tachypnea, unilateral lower extremity edema
B Unilateral, sharp inspiratory chest pain and thoracic friction rub
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 any weight loss, decreased appetite, lethargy, or unusual travel. She has increased her bronchodilator use, but she has not sought further care until now. Her mother has also noted occasional facial flushing with sweating that sometimes appears when she feels stressed, but not always. They were of brief duration at first, but seem to be lasting longer now. On exam, her respiratory rate is 32 breaths/min. with obvious respiratory distress, temperature is 98.6, heart rate 84 bpm and BP 114/76, oxygen saturation is 94%. Her throat is clear and 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. The remainder of the exam is normal. Chest X-ray reveals a round area of increased opacification near the right hilar region. Complete blood count shows a normal white count and differential. Based on this information, what is the most likely diagnosis? Answer Choices: A Pulmonary embolism B Bacterial pneumonia C Bronchial carcinoid tumor D Pulmonary hemosiderosis E Unrecognized vascular malformation
C Bronchial carcinoid tumor
A medical student suffering with chronic respiratory infection seeks the advice of an ear, nose, and throat specialist. A biopsy of the student's respiratory epithelium reveals alteration in certain epithelial structures. What is most likely to be abnormal? Answer Choices: A Microvilli B Desmosomes C Cilia D Hemidesmosomes E Stereocilia
C Cilia
A 45-year-old man presents with a 2-year history of worsening dyspnea and a 1-month history of dry cough. Patient gives no history of fever, chills, chest pain, or wheeze. History is significant for smoking (25 cigarettes / day for more than 22 years). A chest X-ray shows hyperinflated lungs with bullae, tubular heart, flattened diaphragm, and no areas of consolidation. Pulmonary function tests (PFT) reveal a decrease in forced expiratory volume in 1 second (FEV1) along with reduction of FEV1/FVC (forced vital capacity) ratio. These findings are characteristic of what condition? Answer Choices: A Congestive cardiac failure B Chronic bronchitis C Emphysema D Bronchiectasis E Diffuse alveolar damage
C Emphysema
A 28-year-old woman of Norwegian descent presents with cough, dyspnea, joint pain, fever, fatigue, and weakness. Her history is negative for occupational and environmental exposure. A previous tuberculin skin test was negative. Chest X-ray shows interstitial infiltrate and bilateral hilar lymphadenopathy. Ophthalmological investigation (slit lamp) reveals a clinically silent uveitis. Blood tests show hypercalcemia, and transbronchial biopsy shows non-caseating granulomas. Therapy with systemic corticosteroids is initiated. Question: What skin lesions would be most likely revealed in this patient's legs upon physical examination? Answer Choices: A Lupus pernio B Erythematous patches and plaques C Erythema nodosum D Pretibial myxedema E Erythema multiforme
C Erythema nodosum
A 29-year old patient presents with a 9-month history of recurrent hemoptysis. The patient suffered from cavitary tuberculous infection 5 years ago and was effectively treated with antituberculous drugs. A thin-walled cavity was seen over the right upper lobe when first diagnosed. At a later date, a progressive opacification of tuberculous cavity was seen. What organism is most likely responsible for such radiologic changes of a tuberculous cavity? Answer Choices: A Secondary growth of staphylococci B Growth of Candida albicans might have filled the cavity C Growth of Aspergillus fumigatus might have filled the cavity D The cavity filled with granulation tissue and subsequent fibrosis E The cavity filled with desquamated epithelial cells of alveoli
C Growth of Aspergillus fumigatus might have filled the cavity
A 24-year-old man undergoes a routine medical check-up to become a volunteer in the ER. PPD skin test shows a diameter of 9 mm. Sputum and chest X-ray were negative for tuberculosis. He is otherwise healthy and shows no systemic effect of Mycobacterium tuberculosis infection. What is the most appropriate explanation for the doubtful tuberculin test in this patient? Answer Choices: A Sputum and chest X-ray report could be wrong B Adequate sputum samples were not supplied C He was given BCG vaccination earlier in life D He may suffer from chronic cavitary lesion in the lung E He has an active tubercular infection
C He was given BCG vaccination earlier in life
A 50-year-old man presents with a 2-week history of not being able to see well. He is a married newspaper editor and is not on any medications. He has been smoking 2 packs of cigarettes a day for the past 30 years. On examination of his right eye, there is ptosis and miosis. A chest radiograph reveals a rounded opacity in the right lung field Question: What is the most likely diagnosis? Answer Choices: A Lambert-Eaton myasthenic syndrome B Hypertrophic pulmonary osteoarthropathy C Horner's syndrome D Ectopic adrenocorticotropic hormone (ACTH) secretion E Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
C Horner's syndrome
A New Orleans resident invites his friend to partake in a Mardi Gras tradition: the King cake. Baked into the sweet cake is a small trinket, which is shaped like a baby. The tradition is as follows: whoever gets the piece of cake with the baby in it has to buy the king cake the following year. Unfortunately, his friend accidentally bites into the trinket and inhales a small fragment of it (about 1 cm x 1 cm) while laughing. Where is the trinket most likely to lodge? Answer Choices: A Trachea B Right main bronchus C Left main bronchus D Bronchioles E Terminal bronchioles
C Left main bronchus
A 47-year-old man presents with persistent chills following a recent upper respiratory tract infection. The patient reports cough with the production of yellowish sputum and myalgia. The patient is febrile (37.9C), with a HR of 94 bmp and a respiratory rate of 24/min. Knowing that the patient has had a prolonged exposure to the air conditioned space in a large office building, what may be the causative microbial agent in this case? Answer Choices: A Klebsiella pneumoniae B Mycoplasma pneumoniae C Legionella pneumophila D Staphylococcus aureus E Pseudomonas aeruginosa
C Legionella pneumophila
An 8-month-old infant presents with shortness of breath, wheezing, intercostal retractions, and respiratory rate of 50. What would further suggest a diagnosis of bronchiolitis? Answer Choices: A Wheezing improved after nebulizer B Peak flow 300 prior to treatment C Liver and spleen palpable D Clubbing of the finger
C Liver and spleen palpable
An 82-year-old man presents with difficulty breathing and chest pain. He admits to poor follow-up with his primary care physician; he has not been seen by his doctor in several years. When last seen, his health issues included hypertension, hyperlipidemia, diabetes mellitus type II, and being grossly overweight. His prescriptions ran out, so he has not been on any treatment for these issues for several years. Chest X-ray done at the bedside reveals significant bilateral effusions that are initially felt to be secondary to congestive heart failure based on various other findings. A pulmonologist is consulted and performs bilateral thoracentesis to help alleviate the patient's symptoms. The right side is significantly more affected than the left, with over 1000mL drained versus about 625mL on the left. Question: During initial testing, what finding was most indicative of these thoracentesis results? Answer Choices: A Bilateral decreased tactile fremitus B Mediastinum shifted to the right C Mediastinum shifted to the left D Pleural friction rub heard throughout E Bilateral inaudible breath sounds
C Mediastinum shifted to the left
A 30-year-old woman presents with a 2-day history of fever, cough with sputum, and chest pain; there is also a 1-day history of frank blood in sputum (75 cc in the last 24 hours). She is a non-smoker and does not give a history of any recent inhalation exposure or illicit drug use. There is no past history of malignancy or autoimmune disease. On examination, pulse is 92/min; BP is 106/70mmHg; and temperature is 101 F. Oxygen saturation is 97%. On auscultation, S1, S2 normal, decreased breath sounds, and increased tactile vocal fremitus are noted on the right middle lobe. There is no pallor, icterus, cyanosis, edema, or lymphadenopathy. Question: What is the next best step in evaluation of her hemoptysis? Answer Choices: A Computed Tomography (CT) scan of chest B Sputum for Gram stain C Plain X-ray of chest D Bronchoscopy E Complete blood count (CBC)
C Plain X-ray of chest
A 66-year-old man presents with a 2-week history of cough, fatigue, and dyspnea. The patient lives alone, is employed on a sheep ranch, and traveled to Arizona 6 months before becoming ill. Examination reveals a temperature of 39° C, rapid pulse, rales, and consolidation. Gram stain of mucopurulent rusty sputum shows numerous polymorphonuclear lymphocytes and Gram-positive cocci in pairs. What is the diagnosis? Answer Choices: A Mycoplasma pneumonia B Coccidioidomycosis C Pneumococcal pneumonia D Respiratory anthrax E Klebsiella pneumonia
C Pneumococcal pneumonia
A 42-year-old woman is noted to have a solitary parenchymal pulmonary nodule in the right upper lobe on a routine plain chest film. This was not evident on a chest film taken 1 year earlier. The patient has a history of invasive ductal carcinoma of the right breast; she underwent a radical mastectomy 6 years ago. At that time, no lymph nodes were involved. 2 years later, she had a chest-wall recurrence and underwent wide local excision followed by radiation therapy. She was disease free for the past 4 years, until the plain chest film confirmed the pulmonary nodule. She had no history or risk factors of HIV or tuberculosis, and there is no history of travel that involved exposure to pulmonary mycosis. The patient smokes 5 cigarettes a day. She denies hemoptysis or other pulmonic or constitutional symptoms. On physical exam, her temperature is 98 degrees Fahrenheit (37 Celsius). She has no lymphadenopathy or abnormal palpable breast masses on the left side. Her complete blood count is normal. A CT scan of the patient's chest revealed only a nodular opacity in the right upper lobe measuring 2 cm x 1.5 cm. Question: What is the most appropriate next step in the patient's evaluation? Answer Choices: A Bone scan B Bronchoscopy C Positron emission tomography (PET) scan D Thoracotomy E Transthoracic needle aspiration biopsy
C Positron emission tomography (PET) scan
An immigrant worker presents with a chronic cough, hemoptysis, and night sweats. Physical exam reveals a wasted, middle-aged man with bronchial breath sounds in the right upper lobe. The patient is asked for 2 sputum samples; 1 is sent for culture, and the other is directly examined under a microscope. What technique will be the best choice for microscopic examination for rapid initial diagnosis? Answer Choices: A Gram stain B Giemsa stain C Ziehl-Neelsen stain D Direct immunofluorescence E Darkfield examination
C Ziehl-Neelsen stain
A 55-year-old woman presents with constant fatigue. She has experienced multiple episodes of falling asleep at work and dozing off while waiting at red lights. Her husband consistently complains about her snoring and snorting while asleep; it wakes him at night. On physical exam, she is 5'2" and 205 lbs. Her blood pressure is 150/90 mm Hg, her pulse is 82 BPM, her respirations are 16/min, and she is afebrile. The rest of her physical exam is unremarkable. Laboratory studies, including thyroid function tests, are within normal limits. After advising her on diet and weight loss, you schedule her for an overnight sleep study. What results do you expect the study to show? Answer Choices: A Long periods of stage IV sleep on electroencephalogram B Mostly episodes of absent airflow with absent respiratory effort C No change in oxygen saturation on pulse oximetry D 5 or more episodes of apnea and/or hypopnea per hour E REM on electro-oculogram 5 minutes after falling asleep
D 5 or more episodes of apnea and/or hypopnea per hour
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 smokes on a social basis. What is the most likely diagnosis? Answer Choices: A Chronic emphysema B Chronic bronchitis C Cor pulmonale D Acute asthmatic bronchitis E Bronchiectasis
D Acute asthmatic bronchitis
A man presents with cough, chest constriction, fever, chills, night sweats, muscle aches, and joint stiffness. Physical exam shows multiple red, non-raised lesions on the anterior aspect of the tibia. The lesions are tender to palpation. The Spherulin test is positive. What is the most likely diagnosis? Answer Choices: A Acute pulmonary eosinophilia B Histoplasmosis C Pulmonary actinomycosis D Acute coccidioidomycosis E Pulmonary asbestosis
D Acute coccidioidomycosis
A 72-year-old man is evaluated at the bedside following hospital admission for a 1-year history of progressive dyspnea, weight loss, low-grade fevers, fatigue, and myalgias. His past medical history is remarkable for atrial fibrillation, for which he takes amiodarone, hypercholesterolemia, and recurrent urinary tract infections, for which his urologist prescribed nitrofurantoin on a chronic, prophylactic basis. He denies any cigarette use, occupational exposure, history of murmurs or coronary artery disease, chest pain, wheezing, hemoptysis, syncope, abdominal pain, rashes, peripheral edema, diaphoresis, or vomiting. His physical exam reveals bilateral basilar crackles and digital clubbing, but is otherwise normal. A chest x-ray revealed peripheral reticular opacities at the lung bases and a generalized honeycombing pattern (refer to image). Question: Which of these is correct regarding additional diagnostic findings in this patient? Answer Choices: A A high C-reactive protein, ESR, and titers of antinuclear antibodies are confirmatory. B Pulmonary function testing is expected to demonstrate an obstructive pattern. C Transbronchial biopsy is required for the diagnosis of this illness. D Bronchoalveolar lavage typically reveals neutrophilia and eosinophilia. E Computed tomography of the chest is an unnecessary diagnostic test.
D Bronchoalveolar lavage typically reveals neutrophilia and eosinophilia.
A 3-year-old child presents with sudden onset of high grade fever, sore throat, pain during swallowing, and drooling of saliva. There is no history of cough. The child appears toxic and is dyspneic with inspiratory stridor. The child is sitting upright, leaning forward with chin up and mouth open. Suprasternal and intercostal retractions are present. Chest is clinically clear. Blood count shows polymorphonuclear leukocytosis. Lateral radiograph of upper airway shows 'thumb sign'. Question: What is the most likely diagnosis? Answer Choices: A Acute laryngotracheobronchitis B Bacterial tracheitis C Retropharyngeal abscess D Epiglottitis E Laryngomalacia
D Epiglottitis
A 55-year-old female presents with a several-month history of increasing cough and dyspnea. She also has increased serum urea, nitrogen, and serum creatinine. A chest X-ray shows multiple bilateral small nodules. A renal biopsy shows a focal necrotizing vasculitis; her antineutrophil cytoplasmic autoantibody (ANCA) test is positive at 1:160. What additional finding would be most likely to occur? Answer Choices: A Angina B Hemorrhagic pericarditis C Endocarditis D Hemoptysis E Hemothorax
D Hemoptysis
A 41-year-old woman presents due to worsening symptoms. She was diagnosed with idiopathic pulmonary hypertension about 2 years prior to presentation; she is on home oxygen therapy. She has longstanding fatigue and dyspnea, but she is now experiencing profound dyspnea with exertion; swelling in her ankles; some discomfort in her right, upper abdomen; and the inability to breathe well when lying down. She has always been thin, but her weight has increased by 10 pounds in the last month. She denies fever and chills. She recently had an electrocardiogram (ECG), but she has not seen a healthcare provider to discuss the results. The ECG report indicates peaked p waves, right axis deviation, and tall R wave in V1. Question: Based on this patient's history and test results, what physical exam findings would be expected? Answer Choices: A Abdominal bruit B Absent breath sounds in right lung C Dry mucus membranes and reduced skin turgor D Hepatojugular reflux E Virchow's node enlargement
D Hepatojugular reflux
A 28-year-old man presents to the Accident and Emergency department presenting with acute onset of dyspnoea and left-sided chest pain. He denies any trauma or previous similar complaints in the past. Chest X-ray demonstrates a visceral pleural line just under the left hilum. Question: Which of the following left-sided findings would you expect on physical exam? Answer Choices: A Positive whisper pectoriloquy B Egophony C Increased tactile fremitus D Hyperresonance to percussion E Pleural rub
D Hyperresonance to percussion
A 28-year-old man presents with acute onset of dyspnea and left-sided chest pain. He denies any trauma or previous similar complaints in the past. Chest X-ray demonstrates a visceral pleural line just under the left hilum. Question: What left-sided findings would you expect on physical exam? Answer Choices: A Positive whisper pectoriloquy B Egophony C Increased tactile fremitus D Hyperresonance to percussion E Pleural rub
D Hyperresonance to percussion
A 45-year-old man presents with a 3-day history of fever (T max-103.5°F), chills, anorexia, diarrhea, and a non-productive cough. On general examination, vitals are as follows: Pulse- 98/min, RR- 24/min, BP-120/60mm Hg, and T- 103.5 °F. There are coarse basal crepitations and scattered rhonchi on examination of the lungs. Other systems exam are normal. Chest X-ray (CXR) shows patchy alveolar infiltrates with consolidation in the lower lobe. Complete blood count reveals leukocytosis; sputum Gram stain reveals only a few polymorphonuclear (PMN) leukocytes and no predominant pathogens. Question: What is the most likely diagnosis? Answer Choices: A Tuberculosis B Klebsiella pneumonia C Cryptococcal pneumonia D Legionnaire's disease E Haemophilus influenzae
D Legionnaire's disease
A 66-year-old nonsmoking male presents to the family practice clinic with complaint of a chronic cough. He notes shortness of breath on exertion. On physical exam, an increased respiratory rate with shallow breathing is noted. Dry crackles are auscultated bilaterally over the lungs. No clubbing or cyanosis is noted. The remainder of exam and vitals are normal. This patient has the following test results: Pulse oximetry Slightly hypoxic Chest x-ray Small opacities Pulmonary function tests (PFTs) Restrictive pattern Question: In evaluation of this patient's chronic cough, which of the following aspects of his history are most helpful in distinguishing idiopathic pulmonary fibrosis from the various types of pneumoconioses? Answer Choices: A Character of cough B Duration of cough C Family history of pulmonary disease D Occupational exposure history E Past surgical history
D Occupational exposure history
A 1-year-old boy presents with 'barking' cough and inspiratory stridor. What virus is the probable causative agent of the infant's illness? Answer Choices: A Respiratory Syncytial Virus B Influenza A C Adenovirus D Parainfluenzavirus E Rhinovirus
D Parainfluenzavirus
A 72-year-old man is evaluated at the bedside following hospital admission for a 1-year history of progressive dyspnea, weight loss, low-grade fevers, fatigue, and myalgias. His past medical history is remarkable for atrial fibrillation, for which he takes amiodarone, hypercholesterolemia, and recurrent urinary tract infections, for which his urologist prescribed nitrofurantoin on a chronic, prophylactic basis. He denies any cigarette use, history of murmurs or coronary artery disease, chest pain, wheezing, hemoptysis, syncope, abdominal pain, rashes, peripheral edema, diaphoresis, or vomiting. Bedside echocardiogram and electrocardiograms are unremarkable for abnormalities. A chest x-ray revealed peripheral reticular opacities at the lung bases and a generalized honeycombing pattern (refer to image). Question: Which of these statements regarding the clinical presentation of this patient is correct? Answer Choices: A Acute, severe shortness of breath is the most common presenting symptom. B Most patients are asymptomatic at the time of diagnosis. C The most common symptoms are fever and a productive cough. D Physical exam findings of pulmonary hypertension commonly occur. E The pulmonary exam routinely reveals generalized wheezing and rhonchi.
D Physical exam findings of pulmonary hypertension commonly occur.
A 22-year-old man presents with sudden onset of shortness of breath and right-sided chest pain. Symptoms began yesterday, and he felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He is a 1 pack-per-day smoker; otherwise, he has a noncontributory past medical history. On physical exam, the patient is in mild respiratory distress; he has a slightly elevated heart rate, respiratory rate, and blood pressure. He is normotensive. His trachea appears deviated to the left. On pulmonary exam, breath sounds are diminished on the right. Hyperresonance is noted on percussion of the right chest compared to left. Other than tachycardia, his cardiovascular exam is normal. Question: What test finding is most diagnostic for your suspected diagnosis of this patient? Answer Choices: A Blunting of costophrenic angles on chest X-ray (CXR) B Increased pH on arterial blood gas (ABG) C Oxygen saturation less than 90% on pulse oximetry D Pleural line on chest X-ray (CXR) E Sputum smear positive for acid-fast bacilli (AFB)
D Pleural line on chest X-ray (CXR)
An 18-month-old boy presents with a 2-day history of runny nose, slight cough, and low-grade fever. Over the last 24 hours, however, his condition has worsened; the child is tachypneic on exam. He is wheezing, and his breaths are associated with nasal flaring and chest retraction. Question: What is the most common etiology of this patient's condition? Answer Choices: A Adenovirus B Haemophilus influenzae C Influenza virus D Respiratory syncytial virus E Streptococcus pneumoniae
D Respiratory syncytial virus
A woman is diagnosed with primary tuberculosis. She is 5 months pregnant. What drug should be avoided in this patient? Answer Choices: A Isoniazid B Rifampin C Ethambutol D Streptomycin E Pyrazinamide
D Streptomycin
You are evaluating a 78-year-old man who lives in a nursing home due to moderate Parkinsonism. The patient does not have any specific complaints. However, nursing home staff has noticed that he does not seem as alert as usual and is spending more time in his room sleeping. He is also eating less and has dropped 2 lbs in the last 2 weeks. The patient has the following exam: Vital signs: temp 100.8°F; pulse: 100 bpm; respiration: 25/min and bp: 120/70mmHg. On exam, the is aware of the place, but not the exact time or date. His HEENT exam is unremarkable. His heart exam reveals tachycardia, but no other abnormality. His lung sounds are decreased at the bases. Question: Based on this presentation, which of the following should be included as part of the initial workup? A Psychiatric evaluation B CT of the head C Nutritional evaluation D Complete blood count E Erythrocyte sedimentation rate (ESR)
D. CBC
A 57-year-old man presents with progressive dyspnea on exertion and left lumbar colic. He has a history of hypertension as well as a 40-pack/year history of smoking. He denies cough, orthopnea, and paroxysmal nocturnal dyspnea. He has some mild ankle swelling; however, he has no history of congestive heart failure. The only medication he is on is amlodipine. His vital signs are as follows: temperature 99.8° F, pulse 92/min, respiration 22/min and BP 128/88 mm Hg. Of significance on physical examination is the absence of breath sounds in the left lower lung zone. Laboratory data reveals WBC 1000/μL with 70% segmented neutrophils, serum glucose 106 mg/dl, sodium 138mmol/L, chloride 102mmol/L, potassium 4.2mmol/L, bicarbonate 22 mmol/L, BUN 32 mmol/L, creatinine 1.2 mmol/L, protein 8.2g/dL, amylase 56U/dL, and LDH 250 U/mL. Thoracentesis is done and pleural fluid analysis shows: WBC 910/μL, RBC 14/μL, LDH 108U/mL, protein 2.6g/dL, glucose 82mg/dL, and creatinine 1.2 mmol/L. What test will you do to find the cause of the effusion? Answer Choices: A Pleural fluid culture B Chest Computerized tomogram C Sputum AFB D Pleural biopsy E Abdominal sonogram
E Abdominal sonogram
What asbestos-related respiratory disease has a fivefold increased risk in exposed nonsmokers and 60- to 90-fold risk in exposed smokers? Answer Choices: A Asbestosis B Pleural thickening C Benign effusions D Pleural mesothelioma E Bronchogenic carcinoma
E Bronchogenic carcinoma
A family presents in the middle of winter. They live in a low-income housing development. Their gas furnace is broken, and they have been using a kerosene heater at night. For the last 3 days, they have all been experiencing varying degrees of headache, dizziness, nausea, vomiting, and fatigue; symptoms are particularly severe at night. A 4-year-old child has also been very lethargic; occasionally, she seems to black out or fall asleep very soundly. She and her 9-year-old sibling have also had a cough, runny nose and sore throat for the past week. On exam, other than seeming tired, findings are nonspecific. Both children have a runny nose but their lungs and ears are clear. What is the best test to confirm exposure of the most likely diagnosis in this case? Answer Choices: A Hemoglobin level B Pulse oximetry C Blood gas analysis D Urinalysis E Carboxyhemoglobin level
E Carboxyhemoglobin level
An 84-year-old woman with a past medical history of myocardial infarction, congestive heart failure, dyslipidemia, asthma, and lung cancer presents with complaints of a 6-hour history of dyspnea, nonproductive cough, hemoptysis, and a "sharp, stabbing" pleuritic chest pain. She has a 50-pack/year smoking history, but she quit 10 years ago; she denies any alcohol or illicit drug use, sick contacts, or recent travel. She also denies any recent hospitalizations or surgeries. Her review of systems is negative for any fever, chills, palpitations, wheezing, abdominal pain, nausea, vomiting, diarrhea, and rashes. Her physical exam is notable for abdominal distension, hepatosplenomegaly, supraclavicular lymphadenopathy, and right greater than left lower extremity pitting edema. The cardiac exam reveals tachycardia, jugular venous distension of 6 cm, and an S3 gallop; the lung exam is notable for tachypnea, diffuse dullness to percussion, decreased tactile fremitus, and absence of breath sounds. The skin exam does not reveal any abnormalities. Pleural fluid determination from diagnostic thoracentesis notes a clear pleural fluid with an LDH level of 160 units/liter, a pleural-to-serum protein ratio of 0.2, and a pleural-to-serum LDH ratio of 0.3. Pleural fluid glucose, leukocyte, and pH assessments are found to be within the normal range, while no red blood cells were identified. Q: What is the most likely contributory etiology based upon this patient's presentation and diagnostic test result? Answer Choices: A Pulmonary embolization B Lung cancer C Bacterial pneumonia D Cirrhosis E Congestive heart failure
E Congestive heart failure
A 40-year-old man with no significant past medical history presents with a 2-day history of alternating fever and rigors, diaphoresis, fatigue, and a productive cough. He admits to mucoid sputum of moderate quantities. He denies a history of smoking, alcohol use, recent travel, or sick contacts. He further denies chest pain, palpitations, hemoptysis, rashes, abdominal pain, nausea, vomiting, or diarrhea. On physical exam, he is found to be tachypnic and was observed to be intermittently coughing. The pulmonary exam was notable for bronchial breath sounds over the right anterior 4th, 5th, and 6th intercostals spaces. A chest radiograph revealed a right middle lobe consolidation. Question: What additional physical exam findings would be consistent with this patient's most likely diagnosis? Answer Choices: A Cheyne-Stokes respiration B Bradycardia C Decreased fremitus D Decreased whispered pectoriloquy E Dullness to percussion
E Dullness to percussion
On Thanksgiving day, a 5-month-old child presents with wheezing, rapid respirations (>45 breaths/min), and chest retractions. During the last 2 days, the patient had rhinorrhea and a low-grade fever. Breath sounds are normal and there is no cyanosis. What is the treatment of choice for the most likely disease? Answer Choices: A Penicillin B Ribavirin C Erythromycin D Acyclovir E General supporting measures
E General supporting measures
A 25-year-old man presents with fever of 101 degrees F, mildly purulent cough, shortness of breath, and earache. He is a known asthmatic, and he has used his albuterol sulfate aerosol inhaler 3 times an hour with little benefit. He has no known drug allergies. The patient is otherwise stable. What would be appropriate management in this case? Answer Choices: A Ventilatory support B Nebulized albuterol C Prednisolone D Antibiotic E IV aminophylline
E IV aminophylline
A 65-year-old man presents with fatigue, shortness of breath, chest pain, and weight loss. Physical exam findings include diminished breath sounds on auscultation, and there is dullness to percussion. You order a chest X-ray; it reveals a pleural-based mass. What type of lung cancer is most likely? Answer Choices: A Adenocarcinoma B Squamous cell carcinoma C Small cell carcinoma D Large cell carcinoma E Mesothelioma
E Mesothelioma
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, however, they also occur when he is just standing outdoors in cold weather. He denies palpitations, fever, and chills. Past medical history is noncontributory. He is a nonsmoker. Physical exam is unremarkable. Vital signs are as follows: BMI 19 kg/m2, BP 116/70 mmHg, HR 80 bpm, and SpO2 99% on room air. His physician orders pulmonary function testing (PFTs) and a chest X-ray (CXR). Question: Based on the most likely diagnosis, what chest X-ray finding(s) is most likely? Answer Choices: A Hyperinflation B Ground glass shadowing C Bronchial wall thickening D Perihilar fluffy infiltrates E Normal chest X-ray
E Normal chest X-ray
A 67-year-old man presents with a 3-week history of increasing shortness of breath; it occurs even while he is at rest. The patient was diagnosed with congestive heart failure in the past year, and he has been well controlled on oral medication. He has no history of tobacco use. He has gained 10 pounds since his last exam 2 months prior to presentation. On physical exam, there are diminished breath sounds and decreased tactile fremitus bilaterally at the base of the lungs. Dullness to percussion is also noted in the same area. He has 3+ bilateral pitting lower extremity edema. Q; Based on the patient's physical exam and history, what is the most likely diagnosis? Answer Choices: A Lung malignancy B Tuberculosis C Empyema D Spontaneous pneumothorax E Pleural effusion
E Pleural effusion
A 24-year-old man presents with a 1-week history of shortness of breath and a nonproductive cough. On physical exam, he is tachycardic, tachypneic, and febrile. He has lost weight without a change in dietary habits. Auscultation of this chest reveals bibasilar crackles. A chest X-ray is ordered and demonstrates diffuse interstitial infiltrates. You collect an arterial blood gas, and the results show moderate hypoxemia. A metabolic panel is ordered, and the only abnormality is an isolated elevated lactate dehydrogenase (LDH) enzyme. Question: What is the most likely diagnosis? Answer Choices: A Bowen's disease B Streptococcal pneumoniae C Mycoplasma pneumoniae D Stevens-Johnson syndrome E Pneumocystis jiroveci
E Pneumocystis jiroveci
A 30-year-old immunocompromised patient presents with a 2-week history of breathlessness and a nonproductive, dry cough. The patient is afebrile, pulse is 100, and BP is 110/70 mm Hg. On auscultation, scattered rales all over the chest are heard. A chest X-ray shows diffuse air space and interstitial shadowing in both lungs. The shadowing is more prevalent in the apical region. What is the most likely diagnosis? Answer Choices: A Tuberculosis B Mycoplasma pneumoniae C Viral pneumonia D Bacterial pneumonia E Pneumocystis pneumoniae
E Pneumocystis pneumoniae
A 5-year-old girl has paroxysms of cough that increase in severity and duration. Some coughing episodes are followed by a whooplike, high-pitched inspiratory noise, and vomiting has also occurred after paroxysms. What laboratory test could lead to the earliest confirmation of the likely diagnosis? Answer Choices: A Chest X-ray B Blood cell analysis C Culture D Immunofluorescent antibody staining E Polymerase Chain Reaction assay and antigen detection
E Polymerase Chain Reaction assay and antigen detection
A 49-year-old man presents with chronic fatigue. He states that, despite obtaining 7 - 9 hours of sleep nightly, he wakes up feeling unrested and sometimes with a headache. Occasionally, he falls asleep in the middle of the day. He is not sure if he snores at night, but he has been told that he snores when he is napping. He reports no other changes in general condition. His other medical problems are hypertension and hypercholesterolemia for which he takes metoprolol and simvastatin, respectively. Physical exam reveals a moderately overweight man in no apparent distress. Blood pressure, heart rate, and resting oxygen saturation are within normal limits. Question: Based on the patient's symptoms, what diagnostic studies would be most useful? Answer Choices: A 24-hour Holter monitoring B Echocardiogram C Electrocardiogram D Electroencephalogram E Polysomnography
E Polysomnography
A 63-year-old man who is 2 days status post left total hip replacement begins to complain of chest pain. The pain is worst with deep inspiration, and it is associated with dyspnea. His heart rate and respiratory rate are both elevated. EKG is significant for sinus tachycardia. Question: What method is considered the gold standard for diagnosing the patient's suspected condition? Answer Choices: A Echocardiogram B Chest X-ray C Chest CT D Bronchoscopy E Pulmonary angiography
E Pulmonary angiography
A 40-year-old man presents in January complaining of a 4-day history of fevers, chills, myalgias, headache, productive cough, and mild sinus congestion. He has no significant past medical history. His physical examination reveals a temperature of 102.7° F, pulse 96/min, respiratory rate 20/min, and blood pressure of 128/80. There is mild maxillary sinus tenderness. His oral cavity and oropharynx are clear. His tympanic membranes are pearly gray with normal light reflex. His chest is clear to auscultation; cardiac exam is unremarkable. What is the best course of therapy for this patient? Answer Choices: A Admit to the hospital for antibiotics and intravenous fluids B Treat with oral trimethoprim/sulfamethoxazole for 7 days C Prescribe amantadine D Prescribe zanamivir E Recommend bed rest, analgesics, and topical decongestants only
E Recommend bed rest, analgesics, and topical decongestants only
A 22-year-old woman presents to the office with frequent sinus infections, a persistent cough productive of discolored purulent sputum, and progressive dyspnea on exertion. She also reports recurrent episodes of pneumonia, and she has been increasingly fatigued. These symptoms have evolved over several years. As a child, she had an appendectomy and surgery for bowel obstruction. What is the gold standard for diagnosing the underlying etiology of her primary disease? Answer Choices: A Pulmonary function testing B Chest radiograph C Sputum for culture and sensitivity D Serum α1 Antitrypsin levels E Skin sweat test
E Skin sweat test
You are evaluating a 6-year-old child with a history of recurrent pneumonias. The child has a history of frequent ear infections and often gets sick due to pneumonias, requiring the frequent use of antibiotics. He has a chronic wet cough that is present most of the time, and he also has failure to thrive and poor weight gain. Question: As part of the diagnostic work up, what would be the most useful when differentiating between Cystic Fibrosis (CF) and Primary Ciliary Dyskinesia (PCD) in this patient? Answer Choices: A Absence of situs inversus B Presence of bronchiectasis on chest CT C Low levels of nasal nitric oxide D Failure to thrive and poor weight gain E Sweat chloride level of >60mmol/L
E Sweat chloride level of >60mmol/L
A 45-year-old man presents with significant weight loss (10 pounds in 4 months), cough with hemoptysis, and pleuritic chest pain. The chest X-ray shows ill-defined opacities in both the lungs; the opacities have a reticulonodular pattern. A transbronchial biopsy is performed, and it microscopically shows a few epithelioid cells with necrotic debris. What is the most likely diagnosis? Answer Choices: A Aspergillosis B Squamous cell carcinoma C Pneumocystis carinii pneumonia D Oat cell carcinoma E Tuberculosis
E Tuberculosis
A 9-month-old boy presents with a 3-day history of low grade fever and rhinorrhea, followed by 1 day of barking cough and difficulty breathing. The child's cough has been progressively getting worse. He has had a low-grade fever for 2 days. He is eating poorly, but there is no emesis or diarrhea. There is no significant past medical history and all his vaccinations are up-to-date. No one else in the household is currently ill. The child lives with his mother and a 2-year-old sister, and he attends day care. On physical exam, he has a temperature of 38.5 degrees Celsius, an elevated respiratory rate of 48, and normal heart rate and blood pressure. On lung exam, there are subcostal inspiratory muscle retractions; on auscultation, there is a high-pitched inspiratory stridor. What is causing the patient's symptoms? Answer Choices: A Bacterial infection of the epiglottis B Bacterial infection of the trachea C Tonsillar enlargement from viral infection D Swallowed foreign body E Viral infection of the larynx and trachea
E Viral infection of the larynx and trachea