Random Pulm Q's

+ PPD in a patient with HIV

< 5 mm

During a wilderness emergency medicine training course conducted in a remote location, a member of the group begins choking on a piece of food. The patient has lost the ability to cough and seems unable to breathe. What is the next best step in management?

initiate Heimlich maneuver

On physical exam you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. What is the most likely cause?

pleural effusion

Patients with______will have (+) egophony

pneumonia

productive cough an increased respiratory rate; chest percussion may be dull

pneumonia

An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. What is the interpretation of this test result?

positive (≥5mm is positive in HIV pts)

What is more likely to occur in emphysema-predominant COPD compared to chronic bronchitis-predominant COPD?

weight loss

Consolidation would increase the transmission of vocal vibrations and manifest as_______

(+) tactile hremitus

treatment for Coccidioides (Valley Fever) ____or____

-fluconazole -itraconazole

treatment for Pulmonary aspergillosis _____or_____

-fluconazole -itraconazole

+ PPD in a patient from rural Mexico

< 10 mm

histoplasmosis treatment

Amphotericin B

treatment of Cryptococcus

Amphotericin B

treat (and prophylax) Pneumocystis jiroveci with______

Bactrim

1st episode of cough and wheezing in a 4 month old

Bronchiolitis

A 10 year old AA male with a history of chronic dry cough presents to clinic for evaluation. You strongly suspect asthma as etiology. His exam today is normal. You order spirometry, which is normal, without evidence of small airways obstruction. The next step in his workup is:

Bronchoprovocation test

hallmark of________= -Cutaneous flushing, diarrhea, wheezing, ↓BP (GI tract cancers that have metastasized to the lungs) -chest XR=pedunculated sessile growth in the central bronchi

Carcinoid syndrome

A 33 year old obese female with a history of oral contraception use who smokes 1-2 packs of cigarettes per day presents to clinic with 2 month history of right calf pain. She developed a cough a week ago that has progressed to shortness of breath and substernal chest pain. On exam she appears nervous/anxious. RR is 30, SpO2 is 88%. She has diminished breath sounds throughout on the L. You activate EMS so she can be transported to the ER for further evaluation and management of her condition. The BEST imaging test to diagnose this problem is:

CT angiogram (Suspected DVT that's now a PE)

Look for_____in a patient with non-remitting cough/bronchitis non-responsive to conventional treatments; Caused by fungal inhalation in western states.

Coccidioides (Valley Fever)

-currant jelly sputum -drinkers -aspiration

Klebsiella

-found in soil can disseminate and can cause meningitis -Immunocompromised patients are usually symptomatic -Lumbar puncture for meningitis

Cryptococcus

_____can cause: -low NA+ (hyponatremia) -GI symptoms (diarrhea) -high fever

Legionella

A 7-year-old male presents with a history of frequent respiratory infections with recurrent pulmonary infiltrates and failure to thrive. His cough is persistent and productive of thick, green sputum. A recent sputum culture was positive for Haemophilus influenzae and Staphylococcus aureus. Which laboratory results is pathognomonic for his condition?

Elevated sweat chloride values (cystic fibrosis)

which medication causes optic neuritis (red-green vision loss)

Ethambutol (EMB)

Can be obvious: sudden onset of choking in toddler But can look like...asthma, bronchiolitis, croup, pneumonia Not just toddlers: drug overdose, intellectual disability, neuromuscular disease, edentulous

Foreign body aspiration

-bird or bat droppings (caves, zoo) -Mississippi or Ohio river valley, -mediastinal or hilar lymphadenopathy (looks like sarcoid)

Histoplasma capsulatum

-Young people living in dorms -(+) cold agglutinins -bullous myringitis

Mycoplasma

(+) cold agglutinins

Mycoplasma Pneumonia

A 6-year-old presents with intermittent episodes of wheezing. Exam reveals expiratory wheezing but no rales or rhonchi. She is cooperative with the exam. She responds well to an albuterol treatment. What is the most effective method to monitor symptoms at home?

Peak expiratory flow rate

Common in HIV-infected patients with a low CD4 count of less than 200

Pneumocystis jiroveci (PJP)

Tuberculosis of the spine

Potts disease

-Ventilator associated pneumonia patients -become sick fast, treat with two antibiotics

Pseudomonas

The majority of_________cases occur in people with underlying illnesses such as tuberculosis or chronic obstructive pulmonary disease (COPD), but with otherwise healthy immune systems

Pulmonary aspergillosis

which medication causes orange discoloration of body fluids

Rifampin (RIF)

-Rust-colored sputum -common in patients with splenectomy

S. Pneumoniae

A child who resides with someone who has been newly diagnosed with active tuberculosis has a negative initial skin test. What is the most appropriate next step in the management of this child?

Start the child on isoniazid therapy

Upper (apical) cavitary lesions

Tuberculosis

Patients on Isoniazid (INH) should take what supplement? (daily, to prevent neuropathy)

Vitamin B6 (Pyridoxine)

An 8-month-old male infant has had rhinorrhea, sneezing, cough, and low-grade fever for 2 days. On exam, there is nasal flaring, tachypnea, retractions, and wheezes. Chest radiography reveals air trapping and peribronchial thickening. What is the most likely diagnosis?

acute bronchiolitis

A 22 yr-old female with hx of asthma presents c/o increasing "asthma" attacks. pt states she has been well controlled on albuterol inhaler until 1 month ago. Since that time she notices that she has had to use her inhaler 3-4x/week and also has had increasing nighttime use averaging about 3 episodes in the past month. Spirometry reveals >85% predicted value. What is the most appropriate intervention at this time?

add an Inhaled corticosteroid

A 12-year-old presents with acute onset of dyspnea and wheezing. He reports similar episodes over the past few months. He is not on any medications. Physical exam reveals a respiratory rate of 30, normal blood pressure, no rash, clear throat, and diffuse expiratory wheezing. What is the most likely diagnosis?

asthma

A 62 yr-old male presents with hx of dyspnea on exertion and chronic cough worse with waking in the mornings. He has a 40-year-pack hx of cigarette use. On exam there is increased AP diameter and decreased breath sounds with a prolonged expiratory phase. Pulse ox is 93% on room air. In addition to smoking cessation, what is an appropriate recommendation?

influenza and pneumococcal vaccines (COPD)

A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. on physical exam, a spoken "ee" is heard as "ay" (egophony). what is the most likely dx?

bacterial pneumonia with consolidation

What is the MC symptom associated with laryngotracheobronchitis (viral croup)?

barking cough

A 19 year old, previously healthy male is being evaluated in the ER for acute onset of cough 3-4 days ago, productive for thick, yellow mucus. Cough is associated with pleuritic chest pain. He has had fevers, chills and loss of appetite. On exam he is tachypneic with a RR of 24. He has mild hypoxemia with SpO2 of 93%. You hear crackles in the RLL on auscultation. CBC reveals elevated WBC of 20,000. You suspect pneumonia; To confirm, you order:

chest XR

A tall, thin 26-year-old male complains of sudden left-sided chest pain and dyspnea. He is tachycardic and there are decreased breath sounds on the left. What is the initial diagnostic study of choice?

chest XR

wheezes and coarse rhonchi that change in location and intensity after a cough.

chronic bronchitis- predominant COPD

A 66-year-old male presents with productive cough and shortness of breath. While he has had a cough for "years," he notes that his shortness of breath is worsening, particularly when he lifts things above his head. He is able to tolerate walking on a treadmill if he uses the armrests. He has had four respiratory infections in the past 6 months. He has smoked 1-2 packs of cigarettes per day since the age of 16; he works in a cotton textile mill and lives in a large urban area. Exam reveals an overweight gentleman with nicotine-stained fingernails. He is using his accessory muscles of respiration; there is an expiratory wheeze diffusely over the chest. What is the biggest contributor in the pathogenesis of this condition?

cigarette smoking

A 36-year-old school teacher presents with an acute onset of fever, chills, malaise, headache, and congestion. She is coughing and sneezing. Conjunctivae are injected; pharyngeal mucosa is edematous and injected. What is expected on examination of the lungs?

clear lung fields with good air exchange

A 59-year-old male gives a history of chronic productive cough and dyspnea on exertion, which has progressively worsened over the past 3 years. He is obese and continues to smoke1.5 packs per day. Physical exam reveals diffuse rhonchi and wheeze which clear somewhat with coughing. What is the recommended treatment?

combined long-acting Beta-agonist with inhaled corticosteroid

Which of the following is the recommended initial treatment for obstructive sleep apnea in adults?

continuous positive airway pressure (CPAP)

A 30-year-old with asthma reports using levalbuterol(Xopenex) daily. He awakens with wheeze, necessitating use of the inhaler about four nights per month. Exam finds no current wheezing and the patient is not in respiratory distress. He is on no other medications for his asthma. According to current guidelines, what should be initiated at this time?

inhaled steroid plus a long-acting %-agonist

MC chest x-ray finding in pneumoconiosis

diffuse nodular infiltrates

Transmission of vocal sounds through consolidation leads to the changes heard with_____

egophony

A 40-year-old reports close, repeated exposure to a child who tested positive for Bortadella pertussis. Currently the patient is experiencing coryza, lacrimation, low-grade fever, and mild dry cough. Which treatments is warranted at this time?

erythromycin

A 2-year-old boy presents after two hours of paroxysmal coughing. His mother states he had a gagging episode at lunch, just prior to the cough. Stridor is noted on exam, as well as unilateral wheezing. He has no significant past medical history. What is highest on the differential diagnosis?

foreign body

Imaging: Lateral soft tissue neck view; CXR: expiratory view: failure of right lung to deflate on lateral decubitus film indicates______in the right main stem bronchus

foreign body

What is a potential adverse reaction to isoniazid in the treatment of tuberculosis?

hepatitis

Chronic cavitary_______is characterized by pulmonary lesions that are often apical and resemble cavitary TB. Manifestations are worsening cough and dyspnea, progressing eventually to disabling respiratory dysfunction. Dissemination does not occur.

histoplasmosis

22-year-old college student has been experiencing low grade fevers, worsening nonproductive cough, and fatigue for the last 7 to 8 days. Despite his symptoms he has been attending class. The patient reports no significant past medical history. Temperature 100.5"F, BP 110/70, pulse 82, and RR 20 and unlabored. Lung exam is significant for rales and egophony. What is the best management option?

initiate treatment with a macrolide antibiotic and follow-up in 48 hours

A 21 yr-old male presents to ER with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Exam reveals moderate respiratory distress with absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right. What is the most appropriate next step?

insert large bore needle into left 2nd ICS (tension pneumothorax)

pt presents with worsening dyspnea over the past several yrs. He gives hx of work as a ship builder for over 50 yrs. He denies any alcohol/tobacco use. On exam you note clubbing and inspiratory crackles. Which chest XR finding would support your suspected dx?

interstitial fibrosis and pleural thickening (suspected dx=asbestosis)

A screening tuberculin skin test (PPD) is placed on a hospital orderly. Two days later, an area of 10-mm induration is noted. The last PPD, placed 18 months ago, was negative. The patient has_____

latent tuberculosis

A 47-year-old female presents with productive cough and fever. Exam reveals diffuse bronchial breath sounds, rhonchi, and bronchophony in the right middle lobe. What is expected on chest x-ray?

lobar consolidation

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

macrolide

25-year-old female presents with a low-grade fever and nonproductive cough for 5 days. Physical exam reveals a normal chest, mild pharyngeal erythema, and bullous myringitis. What is the most likely diagnosis?

mycoplasma pneumonia

A 4-year-old presents with a 2-day history of a barking cough, runny nose, and fever. Exam reveals a red pharynx with no exudate, a temperature of 100.4"F, and scattered wheezes throughout both lung fields. What is the recommended treatment?

nebulized budesonide (Pulmicort)

A 2-year-old was recently taken to a nursing home to visit a relative. A few days after the visit, the relative was diagnosed with influenza. In the last 24 hours, the child has been experiencing high fever, cough, sore throat, and myalgias. The child did not receive a flu vaccine. What treatment is warranted at this time for the child?

oseltamivir (Tamiflu)

What is the only intervention documented to improve survival in a patients suffering from chronic obstructive pulmonary disease (COPD)?

oxygen on a continuous basis

25-year-old known asthmatic presents with an exacerbation. Nebulizer treatment with albuterol is begun. Which test would be most useful to evaluate and monitor through treatment?

peak expiratory flow rate

23 yr old female with hx of asthma for the past 5 yrs presents c/o ↑SOB x2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hrs. She is normally very active, however yesterday she did not complete her 30 min exercise routine due to ↑dyspnea. She denies cough, fever, recent surgeries, use of oral contraceptives. On exam, you note prolonged expiration and diffuse wheezing. What is the best initial diagnostic evaluation?

peak flow

A 25-year-old sustained significant blunt force trauma to the chest in a motor vehicle accident. He arrived at the emergency department on supplemental oxygen. An initial evaluation, including chest x-ray, revealed three rib fractures but no other injuries. Suddenly, the patient reports severe shortness of breath. Vital signs at this time are BP 106/66, pulse 20,SaO2 85%.What is the next best step in management of this patient?

perform an immediate needle decompression

What is the most definitive test for the diagnosis of pulmonary embolus?

pulmonary angiography

53 yr-old female status post abd hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. chest XR is unremarkable and EKG reveals tachycardia. What is the most likely diagnosis?

pulmonary embolism

A 55-year-old female presents with sudden onset of dyspnea and chest pain. She is afebrile but is not coughing. She is a smoker with a 30-pack-year history. She returned to the United States from Australia 5 days ago. She is tachycardic. Exam of the heart and lungs is normal. What is the most likely diagnosis?

pulmonary embolus

A 16 yr-old presents to the emergency department with productive cough, hemoptysis, and pleuritic chest pain. Chest XR reveals dilated and thickened bronchi that appear as tram tracks and ring like markings. What is most likely in this patient's history?

recurrent purulent pulmonary infections

A patient with chronic bronchitis-predominant COPD is likely to have specific findings on pulmonary function tests. What is the most typical finding?

reduced FEV1 and low FEV1/FVC ratio combined with increased TLC

32 yr-old African American female presents c/o gradual worsening of exertional dyspnea associated with a mild dry cough. She has tried various cough preparations on her own without any significant relief. Her exam is essentially unremarkable. chest XR reveals the presence of bilateral hilar adenopathy. What is the most likely diagnosis?

sarcoidosis

A 25-year-old African American female presents with dry cough and dyspnea for 4 weeks. She has become increasingly fatigued. She also complains of occasional blurred vision with increased tearing. She has no significant past medical history. A few scattered maculopapular lesions are noted on her trunk. Chest radiography reveals bilateral hilar adenopathy. What is the most likely diagnosis?

sarcoidosis

A 50-year-old female presents with acute onset of dyspnea and pleuritic chest pain. She is recovering from hip replacement surgery performed 3 weeks ago. Heart rate is 106. The right leg is swollen and there is pain with palpation of the deep veins. What diagnostic study is the best next step to secure diagnosis?

spiral CT of the chest

-Salmon colored sputum -MRSA -treat with vancomycin

staph aureus (you can catch salmon with a "staph")

A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical exam finding?

stridor

Which medication is likely to produce wheezing and cough in a patient with a history of asthma?

timolol (Timoptic eye drops) (AVOID beta blockers for asthmatics)

A 22-year-old female was recently diagnosed with HIV. She has a baseline viral load of 230,000 units and a CD4 count of 150 cells/mL. In addition to starting antiretroviral therapy, what is indicated?

trimethoprim

A 15 yr old male presents with a 1 week hx of hacking non-productive cough, low grade fever, malaise, myalgias. Exam is unremarkable except for a few scattered rhonchi and rales on auscultation of chest. chest XR reveals interstitial infiltrates and a cold agglutinin titer was negative. What is the most likely diagnosis?

viral pneumonia