smartyPANCE (PULM case studies and quizzes)

A 65-year-old with COPD having received their first PPSV23 vaccination at age 63 should be revaccinated with PPSV23 in A. 1 year B. 3 years C. 5 years D. 10 years

5 years

An O2 saturation of 90% corresponds to what PO2 value? A. 90 mmHg B. 80 mmHg C. 70 mmHg D. 60 mmHg

60 mmHg

Of the following, which is considered the more significant risk factor for pulmonary embolism? A. Hypercystinuria B. Mild bradycardia C. Hemolytic anemia D. Hypolipidemia

Hemolytic anemia

Which of the following is not considered an indication for hospitalization in an infant diagnosed with bronchiolitis? A. < 95% by pulse ox on RA B. Age < 3 months C. Temperature > 100.5 D. Respiratory rate > 70 breaths per minute E. Atelectasis on chest radiograph

< 95% by pulse ox on RA

Pt presents as a 23-year-old female with a one-week history of cough productive of whitish sputum. This was preceded one week prior by a URI. She denies chills, night sweats, shortness of breath, or wheezing. Her temperature is 99.9°F. What is your dx?

Acute bronchitis

A patient brought to the emergency room with acute onset of dyspnea and tachypnea. He has a long history of alcoholism and was involved in a motor vehicle accident two days ago. He is hypoxic with crackles auscultated bilaterally and frothy pink sputum. Chest radiography reveals diffuse bilateral infiltrates which spare the costophrenic angle and air bronchograms, there is no cardiomegaly or pleural effusion noted. Oxygen saturation is 70%

Acute respiratory distress syndrome

Pt presents as a non-smoker, with an incidental finding, with a small peripheral lesion what is your dx

Adenocarcinoma

An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient? A. Administer nebulized corticosteroids B. Admit to the hospital C. Oral antimicrobial therapy D. Endotracheal intubation

Admit to the hospital

Which of the following has been found to be an important reservoir in the transmission of pertussis? A. Mosquitoes B. Adult humans C. Dogs and cats D. White-tailed deer

Adult humans

Which of the following is the major pathogenetic mechanism that causes asthma? A. Airway inflammation B. Increased pulmonary secretions C. Presence of Ghon complexes D. Irreversible fibrosis

Airway inflammation

A patient presents with occasional wheezing and chest tightness that occurs approximately once a week and at night only about once a month. Peak expiratory flow is 85% of predicted. Which of the following is the most appropriate initial treatment? A. Albuterol (Proventil) inhaler B. Montelukast (Singulair) C. Salmeterol (Serevent) inhaler D. Sustained release theophylline

Albuterol (Proventil) inhaler

A 17 year-old male who is trying out for the track team notes excessive coughing with chest tightness when running. Which of the following is the most appropriate preventive agent for this patient? A. Albuterol inhaler (Proventil) B. Inhaled corticosteroids C. Aminophylline (Theo-Dur) D. Ipratropium (Atrovent)

Albuterol inhaler (Proventil)

Which of the following best describes the pathophysiology of emphysema? A. Interstitial inflammation and fibrosis B. Alveolar enlargement and loss of septa C. Mucosal edema and inflammatory response D. Excessive mucus secretion and chronic cough

Alveolar enlargement and loss of septa

The treatment of choice for cryptococcal meningeal infection is A. Amphotericin B and flucytosine B. Metronidazole C. Acyclovir D Amantadine E. Penicillin G

Amphotericin B and flucytosine

A 55 year-old man with a history of chronic bronchitis presents with two days of increased dyspnea and cough with worsening purulent sputum production. He is currently using inhaled albuterol as needed. In addition to systemic corticosteroids, what pharmacologic agent is warranted at this time for treatment of this patient? A. Antibiotic B. Inhaled corticosteroid C. Long acting beta-agonist D. Theophylline

Antibiotic

A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient? A. Anticoagulation B. Embolectomy C. Thrombolysis D Inferior vena cava filter

Anticoagulation

Which of the following studies provides the best clues to the acuteness and severity of disease exacerbation? A. Serum chemistry evaluation B. Alpha1-antitrypsin measurement C. Arterial blood gas (ABG) analysis D. Sputum evaluation

Arterial blood gas (ABG) analysis

A 69 year-old male presents with complaint of increasing dyspnea over the past 6-8 months. The patient denies cough, chest pain or smoking history. Physical examination reveals inspiratory crackles at the bases and clubbing of the nails. Chest x-ray reveals interstitial fibrosis of the lower lungs, thickened pleura and calcified pleural plaques of the lateral chest wall. Pulmonary function testing shows a restrictive pattern with a decreased diffusing capacity. What information is most likely noted in this patient's history? A. Coal mining B. Silica exposure C. Textile work D. Asbestos exposure

Asbestos exposure

Which of the following is an independent risk factor for development of a mesothelioma? A. Cigarette smoking B. Asbestos exposure C. Radon gas exposure D. Chronic obstructive lung disease

Asbestos exposure

A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future? A. Asthma B. Tinea pedis C. Squamous carcinoma D. Systemic lupus erythematosus (SLE)

Asthma

A 42 year-old male with unremarkable past medical history is admitted to the general medical ward with community-acquired pneumonia. He has a 20 pack-year history of cigarette smoking. He is empirically started on ceftriaxone (Rocephin). Which of the following antibiotics would be most appropriate to add to his empiric treatment regimen? A. Piperacillin B. Vancomycin C. Clindamycin D. Azithromycin

Azithromycin

A 4-month-old infant is brought to the clinic by his mother with complaints of a cough for the past 3 weeks. Initially, symptoms included running nose, sneezing and an irritating cough. Over the past week the cough has changed to persistent staccato, paroxysmal forceful coughs ending with a loud inspiration. WBC is 20,0000/mcl with 72% lymphocytes. Which of the following is the drug of choice for managing this patient? A. Azithromycin (Zithromax) B. Ceftriaxone (Rocephin) C. Ampicillin (Unasyn) D. Gentamicin (Garamycin)

Azithromycin (Zithromax)

Pt presents as a 71-year-old male who was admitted to the acute care hospital two days following a massive CVA with a possible brainstem infarct. Because he was also experiencing secondary respiratory failure, he was intubated and placed on mechanical ventilation. He was subsequently transferred to the neurointensive care unit where he was stabilized. His present vital signs are: respiratory rate 14 (ventilator rate), temperature 100.4 F. His SpO2 is 95%. His rating on the Glasgow Coma Scale is 5. What is your dx

Bacterial pneumonia

A 22 year-old female with a history of asthma presents with complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals > 85% predicted value. Which of the following is the most appropriate intervention at this time? A. Oral prednisone B. Oral theophylline C. Salmeterol inhaler D. Beclomethasone inhaler

Beclomethasone inhaler

Which of the following is generally recognized as the most significant symptom of COPD? A. Productive cough B. Pulmonary hypertension C. Cor pulmonale D. Breathlessness

Breathlessness

A 60 year-old patient with COPD characteristic of emphysema presents with a cough and increased sputum production. The following information is noted: Temperature 100°F (37.8°C); Respiratory rate 20/min; Heart rate 88 beats/min; pH 7.44; PaO2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable for increased AP diameter, diminished breath sounds without wheezes, rhonchi, or other signs of respiratory distress. Which of the following would be an appropriate treatment for this patient? A. Broad-spectrum antibiotic B. Admission to the hospital C. Oxygen at 6 L/min by nasal cannula D. Brief course of oral theophylline

Broad-spectrum antibiotic

A 5 year-old male presents with a history of recurrent episodes of acute bronchitis, characterized by fever and productive cough. He has no known significant past medical history. His pulmonary examination reveals crackles in the bilateral lower lobes. The remainder of his physical examination is normal. Chest x-ray demonstrates platelike atelectasis and dilated, thickened airways in the middle and lower lungs. Which of the following is the most likely diagnosis? A. Acute bronchitis B. Bronchiectasis C. Pneumonia D. Tuberculosis

Bronchiectasis

A 69 year-old male with a history of chronic lymphocytic leukemia presents to the clinic complaining of cough, dyspnea and production of copious amounts of foul smelling sputum. Physical examination reveals crackles at the lung bases. Chest x-ray shows dilated and thickened bronchi that appear as ring-like markings. Which of the following is the most likely diagnosis? A. Bronchiectasis B. Tuberculosis C. Adenocarcinoma D. Pulmonary fibrosis

Bronchiectasis

Pt presents as a 25-year-old cystic fibrosis patient complaining of chronic, frequent coughing productive of yellow and green sputum. She recently recovered from a Pseudomonas spp. pneumonia requiring hospitalization. On physical examination, you notice foul breath, purulent sputum, and hemoptysis along with a CXR demonstrating dilated and thickened airways with "plate-like" atelectasis (scarring)

Bronchiectasis

Which of the following is independently associated with an increased risk for all-cause mortality in patients with COPD? A. Asthma B. Bronchiectasis C. Underweight status D. Depression

Bronchiectasis

A 42 year-old male smoker presents for further evaluation of a 4 cm solitary pulmonary nodule discovered on a recent chest x-ray. Which of the following diagnostic tests is indicated next? A. Bone scan B. Thoracotomy C. Mediastinoscopy D. CT scan of chest

CT scan of chest

A solitary pulmonary nodule is found on a pre-employment screening chest x-ray in a 34 year-old nonsmoking male. There are no old chest x-rays to compare. Which of the following is the most appropriate next step in the evaluation? A. CT scan of the chest B. Needle biopsy of the lesion C. Positron emission tomography of the chest D. Fiberoptic bronchoscopy

CT scan of the chest

Pt presents as a 43-year-old man who comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent "v" wave of the jugular vein and a 1/6 holosystolic murmur best heard on the left lower sternal border. Abdominal examination shows hyperactive bowel sounds

Carcinoid tumors

A 32-year-old male with sarcoidosis presents to the clinic complaining of shortness of breath, fatigue, and palpitations for a few months. His in-office EKG reveals QRS prolongation and some premature ventricular beats. A chest radiograph shows cephalization of the pulmonary vessels and cardiomegaly. Which of the following is the most likely diagnosis? A. Cryptogenic organizing pneumonia B. Hypertensive encephalopathy C. Cardiac sarcoidosis D. Acute coronary syndrome E. Pneumoconiosis

Cardiac sarcoidosis

A 62 year-old homeless patient presents complaining of fever, weight loss, anorexia, night sweats and a chronic cough that recently became productive of purulent sputum that is blood streaked. On physical examination, the patient appears chronically ill and malnourished. Which of the following chest x-ray findings supports your suspected diagnosis? A. Hyperinflation and flat diaphragms B. interstitial fibrosis and pleural thickening C. Cavitary lesions involving the upper lobes D. "Eggshell" calcification of hilar lymph nodes

Cavitary lesions involving the upper lobes

A 40 year-old alcoholic male presents with sudden onset of severe chills, fever, dyspnea and cough productive of red mucoid sticky sputum. He appears ill looking with cyanosis. Examination reveals vital signs: Temp - 102 degrees F; Pulse - 120 /minute and regular; 89 RR - 28/min; BP 90/62 mm Hg. Lungs reveal minimal rales and dullness in the right upper lobe with decreased breath sounds. Chest x-ray reveals right upper lobe consolidation with a bulging fissure. Gram stain reveals many white blood cells and many gram- negative rods. Which of the following is the most appropriate drug of choice? A. Ticarcillin B. Cefotaxime C. Doxycycline D. Clindamycin

Cefotaxime

Patients with COPD have the symptoms of chronic bronchitis and emphysema. Which of the following morphologic patterns of emphysema is typically most severe in the upper lobes? A. Centriacinar emphysema B. Panacinar emphysema C. Distal acinar emphysema D. Paraseptal emphysema

Centriacinar emphysema

A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears non- toxic with a respiratory rate of 42 breaths per minute. What is the next step in the evaluation of this patient? A. Lateral soft tissue x-ray of the neck B. Indirect laryngoscopy C. Finger sweep D. Chest x-ray

Chest x-ray

Which of the following is an indication for a pediatric patient to receive the 23-valent polysaccharide vaccine (Pneumovax)? A. Children at any age with a history of asthma B. All children at 2,4,6 and 12-18 months of age C. All children at 12-23 months of age in a two dose series D. Children age 24-59 months at high risk for invasive pneumococcal disease

Children age 24-59 months at high risk for invasive pneumococcal disease

A 45 year-old male presents with complaints of a chronic cough productive of mucopurulent sputum. The cough has been present for the past 3 years, but he attributed it to a "smoker's cough". He has been coughing up a lot of sputum lasting all winter long for the past 2 years. He denies any hemoptysis, weight loss or chest pain. Physical examination reveals a moderately obese male in no acute respiratory distress. Lung fields reveal presence of scattered rhonchi and wheezes. There is 1+ peripheral edema. Which of the following is the most likely diagnosis? A. Lung cancer B. Bronchiectasis C. Chronic bronchitis D. Interstitial lung disease

Chronic bronchitis

A 56 year-old female with a 35 pack year smoking history presents to the clinic with shortness of breath and cough. On examination, she is thin with no recent weight loss. She appears uncomfortable, breath sounds are diminished without adventitious sounds. Pulmonary function tests show a marked increase in total lung capacity (TLC) and a decreased FEV1. What is the most likely diagnosis for this patient? A. Persistent asthma B. Chronic obstructive pulmonary disease C. Idiopathic fibrosing interstitial pneumonia D. Sarcoidosis

Chronic obstructive pulmonary disease

Which of the following conditions will produce a transudative pleural effusion? A. Kaposi's sarcoma B. Pneumonia C. Cirrhosis D. Mesothelioma

Cirrhosis

Pt presents as a 65-year-old man comes to the office due to 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate chronic obstructive pulmonary disease. His medical history is relevant for a 40 pack-year smoking history, type II diabetes mellitus, hyperlipidemia, and coronary artery stenting 2 years ago. Physical exam shows barrel shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), the pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86% what is your dx

Cor pulmonale

Which of the following physical examination findings would be most consistent with a pleural effusion? A. Hyperresonance to percussion B. Increased tactile fremitus C. Unilateral lag on chest expansion D. Egophony

Unilateral lag on chest expansion

Which of the following is the greatest risk factor for the development of drug resistance in the treatment of tuberculosis? A. A child with cystic fibrosis B. An elderly patient in a nursing home C. Non-adherence to prescribed drug regimen D. Patients with a history of diabetes mellitus

Non-adherence to prescribed drug regimen

Upon auscultation of a patient's lungs, there are harsh, hollow breath sounds which have a long inspiratory component in the region of the suprasternal notch. Throughout the periphery of the lung fields, softer breath sounds are heard. Which of the following best describes these findings? A. Normal B. Asthmatic C. Atelectasis D. Foreign body Explanations

Normal

A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis? A. Croupy cough and drooling B. Thick gray, adherent exudate C. Beefy red uvula, palatal petechiae, white exudate D. Inflammation and medial protrusion of one tonsil

Croupy cough and drooling

An elderly nursing home resident is admitted with methicillin-resistant Staphylococcus aureus pneumonia. Which of the following is the most appropriate treatment to initiate? A. Nafcillin B. Vancomycin C. Clindamycin D. Doxycycline

Vancomycin

Pt presents as a 3-year-old girl with growth retardation who has a long history of recurrent pneumonia and chronic diarrhea. Her mother states that he has 6-8 foul-smelling stools per day. Physical exam reveals a low-grade fever, scattered rhonchi over both lung fields, crepitant rales at the left lung base, and dullness to percussion. Other findings include mild hepatomegaly and slight pitting edema of the lower extremities. CXR reveals hyperinflation, mucus plugging, and focal atelectasis. Labs reveal an elevated quantitative sweat chloride test.

Cystic fibrosis

Which of the following tests is generally the next step after clinical prediction rule results indicate that a patient has a low or moderate pretest probability of pulmonary embolism? A. D-dimer measurement B. Troponin level measurement C. Brain natriuretic peptide (BNP) measurement D. Activated partial thromboplastin time (aPTT) measurement

D-dimer measurement

Which of the following infectious agents is most likely to be found in a rural Kentucky farmer or in someone who is responsible for clearing bats out of the local caverns before the tourist season begins? A. cryptococcosis B. histoplasmosis C. psittacosis D. Candidal species

histoplasmosis

A 39-year-old man comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent "v" wave of the jugular vein and a 1/6 holosystolic murmur best heard on the left lower sternal border. Abdominal examination shows hyperactive bowel sounds. Which other clinical findings is likely to be present? A. Cheilosis and stomatitis B. Confusion, ophthalmoplegia, and ataxia C. Swollen gums, bruising, and hemarthrosis D. Dermatitis and mental status change E. Ptosis, anhydrosis, and miosis

Dermatitis and mental status change

Which of the following chest x-ray abnormalities would most likely be seen in a patient with hypersensitivity pneumonitis? A. Lobar consolidation B. Apical infiltration C. Granulomatous inflammation D. Diffuse nodular densities

Diffuse nodular densities

Which of the following physical exam findings is consistent with moderate emphysema? A. Increased tactile fremitus B. Dullness to percussion C. Distant heart sounds D. Deviated trachea

Distant heart sounds

Pt presents as a 5-year-old with sudden onset of fever, chills, malaise, sore throat, headache, and coryza. The child is also complaining of myalgia, especially in her back and legs. On physical exam, the patient appears lethargic, has a temperature of 102.5 F, and palpable cervical lymph nodes. Breath sounds are distant with faint end-expiratory wheezes. What is your dx

Influenza

A 27 year-old woman presents with one week of worsening productive cough, dyspnea, fever and malaise. Which of the following physical examination findings would support the diagnosis of lobar pneumonia? A. Decreased tactile fremitus B. Egophony C. Hyperresonance to percussion D. Wheeze

Egophony

Which of the following is essential to make a diagnosis of cystic fibrosis? A. Positive family history B. Elevated sweat chloride C. Recurrent respiratory infections D. Elevated trypsinogen levels

Elevated sweat chloride

A 23-month-old male presents to the office with his father who reports the patient has had an acute onset of severe pharyngitis, fever of 103.5 degrees F and what sounds like harsh, high-pitched breath sounds. His dad states the child has started drooling and seems to be worsening. The child is not presently crying but has muffled voice sounds. The child has not been immunized due to religious reasons. What is the most appropriate next step? A. Administer ceftriaxone (Rocephin) B. Emergent transfer C. Administer racemic epinephrine D. Obtain intravenous access

Emergent transfer

A 24 year-old male presents complaining of a 9 month history of increasing shortness of breath, dyspnea on exertion, and a cough productive of white sputum, mostly in the mornings. He denies orthopnea, PND, peripheral edema, fever, chills, night sweats, recent changes in weight, palpitations, chest pain, food intolerances, or other complaints. Patient has a history of recurrent lung infections. He states that his father had chronic pulmonary problems and died at age 42 from unknown lung disease. The patient denies smoking, alcohol or illicit drug use. On physical examination, the respiratory rate is 22 per minute, pulse of 98 bpm, temperature of 98.7 degrees. Pulmonary exam reveals end-expiratory wheezes bilaterally and hyperresonance to percussion. His cardiac exam is normal. Chest x- ray shows decreased lung markings. ECG is normal. Pulmonary function tests show an FEV1 63% of expected and residual capacity is 123% of expected. Which of the following is the most likely diagnosis? A. Emphysema B. Pulmonary fibrosis C. Ventricular septal defect D. Congestive heart failure

Emphysema

Pt presents as a 65-year-old male complaining of fatigue and shortness of breath with exertion. The patient reports minimal cough. On physical exam, you note a thin, barrel-chested man with decreased heart and breath sounds, pursed-lip breathing, end-expiratory wheezing, and scattered rhonchi. Chest X-ray reveals a flattened diaphragm, hyperinflation and a small, thin appearing heart. PFTs show a decreased FEV1 / FVC ratio. What is your dx?

Emphysema

A 68 year-old male with history of COPD is brought to the emergency department following a motor vehicle collision. On physical examination there is evidence of head trauma. The left side of the chest wall appears to move inward with inspiration and outward with expiration. A chest x-ray reveals multiple rib fractures on the left. Which of the following is the most appropriate intervention? A. Surgical fixation of the fractured ribs B. Application of elastic binders and adhesive tape C. Endotracheal intubation and mechanical ventilation D. Chest physiotherapy that encourages frequent coughing

Endotracheal intubation and mechanical ventilation

A 35 year-old patient presents with a sudden onset of fever, dysphonia, drooling, and difficulty drinking a few hours ago. Physical examination reveals a temperature of 102 degrees F. The patient appears ill and is sitting forward. Inspiratory retractions are noted and there is a soft stridor. Which of the following is the most likely diagnosis? A. Angioedema B. Foreign body aspiration C. Epiglottitis D. Bacterial pharyngitis

Epiglottitis

Pt presents as a 3-year-old boy who is brought to the ER with a sudden onset of fever (104.0 F), respiratory distress, and stridor. On examination, the boy appears acutely ill. He is sitting, leaning forward with his mouth open, he has a muffled voice and is drooling. When asked the parents report "we don't believe in vaccinations." What is your dx

Epiglottitis

A 2 month-old infant has been diagnosed with pneumonia due to Chlamydia trachomatis. Which of the following is the treatment of choice? A Ceftriaxone (Rocephin B. Doxycycline C. Levofloxacin (Levaquin) D. Erythromycin

Erythromycin

Which of the following can be considered an effective prophylaxis for acute bronchitis? A. Oseltamivir 75 mg on day two of symptoms B. Influenza vaccine C. Inhaled corticosteroids D. Nystatin

Influenza vaccine

Pt presents as a 32-year-old male with dyspnea and a nonproductive cough. He is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia and his LDH is elevated. What is your dx?

HIV-related pneumonia

A 30 year-old male presents with sudden onset of chills, fever, chest pain and a cough productive of greenish-brown sputum. On examination his temperature is 102 degrees F. He appears acutely ill and his respirations are shallow. Chest x-ray demonstrates left lower lobe consolidation. Which of the following findings would most likely be present on examination of his left lower lung? A. Hyperresonance B. Vesicular breath sounds C. Increased tactile fremitus D. Wheezing

Increased tactile fremitus

The drug of choice for treatment of severe coccidioidomycosis (" valley fever") is A. Ceftriaxone B. Tetracyline C Ciprofloxacin D. Mefloquin E. Fluconazole

Fluconazole

Which of the following is accurate regarding the imaging studies of foreign bodies in soft tissue injuries? A Radiography is the recommended imaging study in all foreign body soft tissue injuries B. Fluoroscopy allows for real-time visualization and allows precise location of the foreign body using skin markers C. Ultrasonography use is generally discouraged in foreign body soft tissue injuries D. MRI is commonly used for foreign body detection upon initial presentation and is less valuable in nonacute presentations

Fluoroscopy allows for real-time visualization and allows precise location of the foreign body using skin markers

Pt presents as a 2-year-old male child who is brought to the emergency department by his mother with a sudden onset of choking, gagging, coughing, and wheezing. Vital signs are temperature 37 ° C; pulse 120/ min; and respirations 28/min. The physical examination reveals decreased breath sounds over the right lower lobe with inspiratory rhonchi and localized expiratory wheezing. The chest X-ray reveals normal inspiratory views but expiratory views show localized hyperinflation with a mediastinal shift to the left.

Foreign body aspiration

Pt presents as a 21-year-old male presents with a cough and mild shortness of breath for three days. The cough is occasionally productive of yellowish mucus. He reports a low-grade fever with this episode but says that he has otherwise been healthy. He has spent the last month working in bat caves. He denies tobacco or alcohol use. (Histoplasmosis) What is your dx

Fungal pneumonia

A 67 year-old man presents complaining of gradually worsening fatigue and shortness of breath. He is a previous smoker with an 80 pack-year smoking history. He denies chest pain, night sweats, or hemoptysis. On physical examination, you note a very thin male who appears older than his stated age. Lung and heart sounds are barely audible to auscultation. Which of the following interventions is likely to alter the disease course? A. Inhaled bronchodilator therapy B. Inhaled steroid therapy C. Home oxygen D. Theophylline

Home oxygen

Pt presents as a premature infant who is born at 32 weeks and after several hours develops rapid shallow respirations at 60/ min, grunting retractions, and duskiness of the skin. The chest X-ray reveals diffuse bilateral atelectasis, ground glass appearance, and air bronchograms

Hyaline membrane disease

A 24 year-old male presents in respiratory distress and appears quite ill. A Gram stain and culture of the sputum reveals gram-positive cocci in clumps and a chest x-ray reveals multiple patchy infiltrates with some cavitations. Which of the following is most likely to also be found in his medical history? A. IV drug abuse B. Alcohol abuse C. Poor dental hygiene D. HIV positive patient

IV drug abuse

Pt presents as a 55-year-old female who is a current smoker presents with a 9-month history of respiratory symptoms, including dyspnea on exertion, thoracic pain, and dry cough, which were preceded by a pulmonary infection. On auscultation, you hear inspiratory crackles. Pulmonary function tests (PFTs) show a decrease in total lung capacity, decreased forced vital capacity (FVC), and decreased forced expiratory volume in 1 second (FEV1). Chest CT demonstrates diffuse patchy fibrosis with pleural-based honeycombing. What is your dx

Idiopathic pulmonary fibrosis

Which of the following is accurate about the presentation of GI foreign bodies? A. Direct examination typically provides better information than indirect laryngoscopy B. The most common cause of GI foreign bodies in adults involves accidental swallowing of small objects like toothpicks C. In children, tracheal compression and stridor suggest a large foreign body at the upper esophageal sphincter D. In adults, dysphagia is associated with foreign bodies in the oropharynx but not in the esophageal regions

In children, tracheal compression and stridor suggest a large foreign body at the upper esophageal sphincter

You are evaluating a patient whom you suspect has asthma. You perform spirometry before and after administration of an inhaled short-acting bronchodilator. After administration of the bronchodilator, which of the following spirometry results would suggest reversibility? A. Decrease In FEV1 B. Increase in FEV1 C. Decrease in FVC D. Increase in FVC

Increase in FEV1

A 63-year-old male, heavy smoker, presents to your office with a low-grade fever and sudden onset of dry cough for the past 6 days. You diagnose him with acute bronchitis. What is the most appropriate management at this time? A. Amoxicillin/clavulanic acid 875 mg two times per day for 10 days B. Doxycycline 100 mg PO two times per day for 14 days C Increased fluids and ibuprofen D. Give the patient an albuterol inhaler

Increased fluids and ibuprofen

Which of the following findings confirm the adequacy of a sputum specimen for Gram stain and culture? A. Decreased red blood cells B. Decreased bronchial epithelial cells C. Increased Gram positive cocci D Increased polymorphonuclear leukocytes

Increased polymorphonuclear leukocytes

A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment? A. Decrease the oxygen flow rate. B. Administer oral corticosteroids. C. Intubate the patient. D. Administer salmeterol (Serevent)

Intubate the patient.

A 33 year-old HIV-positive woman develops an 8mm area of induration following the administration of a purified protein derivative (PPD) test. Her chest radiograph shows no evidence of active tuberculosis (TB) infection. Which of the following is the most appropriate clinical intervention? A. Four-drug regimen for 4 months B. Isoniazid with Rifampin C. Observation only D. Repeat PPD and chest radiograph in 3 months

Isoniazid with Rifampin

Which of the following is a physical examination finding that is consistent with a diagnosis of lobar pneumonia? A. Resonant to percussion B. Late inspiratory crackles C Decreased tactile fremitus D. Tracheal shift toward uninvolved side

Late inspiratory crackles

A 55 year-old female presents to the emergency department with complaints of dyspnea, chest pain and coughing with hemoptysis. Past medical history includes breast cancer 5 years ago, currently in remission. Vital signs are Temp. 98.6 degrees F, BP 150/90 mmHg, P 110 bpm, RR 20. Physical examination shows her right leg swollen with pain on palpation of deep veins. Which of the patient's history or examination findings is most suggestive of a pulmonary embolus (PE)? A. Leg swelling and pain with palpation of deep veins B. Heart rate > 100 C. Hemoptysis D. Past history of cancer

Leg swelling and pain with palpation of deep veins

Which of the following causes of pneumonia is most likely to be complicated by diarrhea? A. Legionella B. Chlamydophila C. Mycoplasma D Pneumococcal

Legionella

A 4-year-old boy is sent home from day care for a severe cough following one week of cold symptoms, including sneezing, conjunctivitis, and nocturnal cough. He presents with paroxysms of cough followed by a deep inspiration, and occasional post-tussive emesis. During severe paroxysms, he exhibits transient cyanosis. What is the most appropriate treatment for exposed contacts at his day care center? A. Macrolide prophylaxis B. Isolation C. Observation and treatment only if symptomatic D. Supportive care only

Macrolide prophylaxis

Which of the following is a major contraindication to curative surgical resection of a lung tumor? A. Liver metastases B. Vagus nerve involvement C. Non-malignant pleural effusion D. Chest wall invasion of the tumor

Liver metastases

Which of the following is accurate regarding the treatment of patients with COPD? A. Pneumococcal vaccines are contraindicated in patients with COPD B. Intravenous alpha1-antitrypsin levels should be kept at 8-10 mmol/L C. Long-term oxygen therapy is recommended for patients with a partial pressure of oxygen in arterial blood <55 mm Hg or oxygen saturation <90% D. Because cardiovascular disease is common in patients with COPD, beta-blockers are indicated in all patients

Long-term oxygen therapy is recommended for patients with a partial pressure of oxygen in arterial blood <55 mm Hg or oxygen saturation <90%

A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. Which of the following would be the most appropriate treatment for this patient? A. Mast cell stabilizer B. Long acting beta agonist C. Leukotriene receptor antagonist D. Low dose inhaled corticosteroid

Low dose inhaled corticosteroid

Pt presents as a 65-year-old woman with a 40 pack-year history of smoking presents with a 7kg weight loss over the last 3 months and recent onset of streaks of blood in the sputum. PE reveals a thin, afebrile woman with clubbing of the fingers, an increased anteroposterior diameter, scattered and coarse rhonchi and wheezes over both lung fields, and distant heart sounds.

Lung cancer

Which of the following pathophysiological processes is associated with chronic bronchitis A. Destruction of the lung parenchyma B. Mucous gland enlargement and goblet cell hyperplasia C. Smooth muscle hypertrophy in the large airways D. Increased mucus adhesion secondary to reduction in the salt and water content of the mucus

Mucous gland enlargement and goblet cell hyperplasia

A 20 year-old male presents with 3 weeks of constitutional and upper respiratory symptoms, including malaise, sore throat, dry cough, and fever. Lung auscultation demonstrates diffuse crackles bilaterally. What is the most likely infectious agent involved? A. Respiratory syncytial virus B. Influenza virus C. Mycoplasma pneumoniae D. Streptococcus pneumoniae

Mycoplasma pneumoniae

A 2 year-old presents to the emergency department in acute respiratory distress. The parents relate a history of a recent upper respiratory illness that was followed by a sudden onset of barking cough during the night, but this morning they noted increased difficulty breathing. The child is noted to have stridor at rest, but has no evidence of cyanosis. Which of the following is the most appropriate initial intervention? A. Intravenous antibiotics B. Endotracheal intubation C. Inhaled mucolytic agent D. Nebulized racemic epinephrine

Nebulized racemic epinephrine

A 57-year-old man is being evaluated for shortness of breath. The following spirometric data are obtained: VC 4.90 L (predicted), 5.15 L (observed) 105% predicted FRC 3.99 L (predicted), 4.37 L (observed) 110% predicted RV 2.47 L (predicted), 3.17 L (observed) 128% predicted FEV1 3.50 L (predicted), 2.35 L (observed) 67% predicted These findings are consistent with which of the following? A. No demonstrable abnormality B. Restrictive lung disease C. Obstructive lung disease D. A ventilation/perfusion mismatch

Obstructive lung disease

A 22 month-old male infant presents with one day of barking cough preceded by three days of cold symptoms. On physical examination, his axillary temperature is 100.4°F and he has no stridor at rest. Inspiratory stridor is evident when he becomes agitated during the examination. There are no signs of respiratory distress or cyanosis. Which of the following is the most appropriate treatment for this patient? A. Nebulized albuterol B Nebulized epinephrine C. Oral amoxicillin D. Oral dexamethasone

Oral dexamethasone

A 62 year-old female is admitted to a nursing home during an outbreak of influenza. In review of her records, you note that she did not receive the flu vaccine this year. Which of the following is the most appropriate drug of choice for influenza prophylaxis in this patient? A. Amantadine (Gocovri) B. Oseltamivir (Tamiflu) C. Rimantadine (Flumadine) D. Baloxavir (Xofluza)

Oseltamivir (Tamiflu)

An 85-year-old nursing home resident presents with abrupt onset of cough, sore throat, headache, myalgias, and malaise. On examination the patient's temperature is 102 degrees F; the rest of the exam is unremarkable. Nasal smear is positive for Influenza B. Which of the following is the treatment of choice in this patient? A. Amantadine (Symmetrel) B. Oseltamivir (Tamiflu) C. Acyclovir (Zovirax) D Nevirapine (Viramune)

Oseltamivir (Tamiflu)

A previously healthy 8-month-old boy is hospitalized for acute bronchiolitis. He has no known significant past medical or family history. On admission, he exhibits nasal flaring and retractions with a respiratory rate of 68, axillary temperature of 102.0 degrees F and O2 saturation of 86%. Which of the following medications is indicated? A. Prednisolone B. Oxygen C. Ceftriaxone (Rocephin) D. Palivizumab (Synagis)

Oxygen

An 18-month-old male presents with his parents who report symptoms of a barking cough and intermittent stridor that has worsened over the past 12 hours. They note improvement in symptoms when he was taken outdoors to the cool night air. Which of the following is the most likely organism causing this patient's symptoms A. Rubeola virus B. Adenovirus C. Influenza virus D. Parainfluenza virus

Parainfluenza virus

A 60-year-old female with a 30-pack year smoking history complains of new onset shortness of breath. On physical examination, dullness is noted on percussion with diminished breath sounds over her left base. Chest x-ray shows a new left pleural effusion. Which of the following is the next step in the management of this patient? A. Repeat chest x-ray in two months B. Perform diagnostic thoracentesis C. Order MRI of the chest D. Treat with antibiotic

Perform diagnostic thoracentesis

Which of the following is the most likely to develop into a persistent cough in the adult patient? A. Pertussis B. Allergic rhinitis C. Pharyngitis D. Heart failure

Pertussis

Pt presents as a 24-year-old with an increasing cough for 3 weeks. The cough comes and goes, sometimes lasting for 10 minutes and causing gasping inhalations. The cough was preceded by a mild cough and cold 2 weeks ago. She has no known drug allergies. The patient's immunizations are not up-to-date. What is your dx

Pertussis (Whooping Cough)

Pt presents with a severe paroxysmal cough followed by an inspiratory high-pitched whoop if untreated will develop a chronic cough lasting for weeks What is your dx

Pertussis (Whooping Cough)

Pt presents as a 58-year-old female who returns to the hospital with chest pain and difficulty breathing several weeks after being discharged following a myocardial infarction requiring immediate cardiac catheterization. She has been coughing up frothy sputum for the past three days. The patient complains of a sharp pain that worsens during inspiration. Physical exam reveals decreased tactile fremitus, dullness to percussion, and diminished breath sounds on the left side What is your dx

Pleural effusion

Pt presents as a 53-year-old man presents to the office complaining of progressive dyspnea over the past few years. History reveals that he has worked in construction for the past 20 years demolishing and refurbishing old buildings. He rarely uses any protective breathing equipment. Physical examination demonstrates an afebrile man in mild respiratory distress with inspiratory crackles. The chest x-ray reveals a reticular linear pattern with basilar predominance, opacities, and honeycombing

Pneumoconiosis

A 28 year-old man presents to the emergency department complaining of sudden onset of shortness of breath associated with sharp right-sided chest pain increased with breathing. On physical examination, respirations are 20 per minute and blood pressure is 120/76 mm Hg. Auscultation of the chest reveals absent breath sounds over the right apex with normal heart sounds. Percussion of the right apex is noted to be hyperresonant. Which of the following is the most likely diagnosis? A. Hemothorax B. Pneumothorax C. Pulmonary embolus D. Foreign body aspiration

Pneumothorax

Pt presents as a 19-year-old male transported to the ED following a car crash. Upon arrival, he is alert and anxious and appears to be in respiratory distress. A quick assessment reveals that she sustained trauma to his face, neck, and chest. His left hemithorax appears to be expanding more than the right. He is receiving oxygen via nonrebreathing mask. His vital signs are: respiratory rate 36 and labored. SpO2 is 85%. On physical exam, you notice decreased tactile fremitus, deviated trachea, hyperresonance, and diminished breath sounds. What is your dx

Pneumothorax

Which of the following is a common presenting clinical manifestation of a patient with interstitial lung disease? A. Early inspiratory crackles B. Progressive dyspnea on exertion C. Productive cough with copious sputum D. Decreased breath sounds with hyperresonant percussion

Progressive dyspnea on exertion

A 3 year-old male with cystic fibrosis develops pneumonia. Which of the following is the most likely etiology of the pneumonia? A. Escherichia coli B. Staphylococcus epidermidis C. Pseudomonas aeruginosa D Streptococcus pneumoniae

Pseudomonas aeruginosa

Pt presents as a 68-year-old woman who underwent hip replacement surgery two weeks ago. The postoperative period was complicated by pneumonia, and the patient has been bed-ridden ever since. A nurse calls you to the patient's room due to vital sign abnormalities and complaints of chest pain. The patient's HR is 105 bpm, BP is 90/60 mmHg, RR is 35 rpm, and T is 100.2F. You note jugular venous distension and profound dyspnea. Upon auscultation you notice tachypnea and crackles what is your dx

Pulmonary embolism

A 74-year-old male with a history of coronary artery disease and atrial fibrillation presents to the clinic for follow-up of his shortness of breath. Patient's medications include amiodarone (Cordarone) and metoprolol (Lopressor). His chest x-ray reveals patchy ground-glass infiltrates. Which of the following is the most likely diagnosis? A. COPD B. Tuberculosis C. Bronchiectasis D. Pulmonary fibrosis

Pulmonary fibrosis

Patients with long-term exposure to silica, coal dust, and asbestos may develop which of the following as complications? A. Airway Hyperreactivity B. Epithelial hyperplasia C. Pulmonary fibrosis D. Upper airway obstruction

Pulmonary fibrosis

On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause? A. asthma B. consolidation C. pneumothorax D. pleural effusion

pleural effusion

Pt presents as a 43-year-old woman with a history of COPD presents to your office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has persistent widened splitting of S2. Radiographic findings (seen here) demonstrate peripheral "pruning" of the large pulmonary arteries what is your dx

Pulmonary hypertension

A pediatric patient presents with a history of multiple recurrent respiratory infections associated with failure to thrive. A sweat chloride test is elevated. Which of the following is a common cause of death in patients with this condition? A. Diabetic ketoacidosis B. Pulmonary infection C. Intestinal obstruction D. Acute respiratory failure

Pulmonary infection

A 62 year-old male presents with a history of dyspnea on exertion and chronic cough worse with arising in the mornings. He has a 40-year-pack history of cigarette use. On examination there is increased AP diameter and decreased breath sounds with a prolonged expiratory phase. Pulse oximetry reveals an oxygen saturation of 93% on room air. In addition to smoking cessation, which of the following is an appropriate intervention at this time? A. Home oxygen therapy B. Maintenance oral steroids C. Prophylactic antibiotic therapy D. Recommend influenza and pneumococcal vaccines

Recommend influenza and pneumococcal vaccine

What is the mechanism of action of salmeterol (Serevent) in the treatment of asthma? A. Anti-inflammatory B. Immunotherapy for specific allergens C. Relaxing of bronchial smooth muscle D. Reduction of leukotriene production

Relaxing of bronchial smooth muscle

A 32-week preterm infant has an APGAR score of 9 at 5 minutes. Thirty minutes after delivery, tachypnea, retractions, and expiratory grunting are noted. Cyanosis and dyspnea appear with little response to oxygen. Physical examination reveals poor air movement bilaterally. A chest x-ray reveals air bronchograms and a fine reticular granular pattern. Which of the following conditions should be suspected? A. Atelectasis B. Diaphragmatic hernia C. Respiratory distress syndrome D Pneumothorax

Respiratory distress syndrome

An infant born at 30 weeks' gestation begins to have respiratory difficulty shortly after birth. Examination reveals rapid, shallow respirations at 80 per minute with associated intercostal retractions, nasal flaring and progressive cyanosis. Chest x-ray reveals the presence of air bronchograms and diffuse bilateral atelectasis. Which of the following is the most likely diagnosis? A. Respiratory distress syndrome B. Spontaneous pneumothorax C. Transient tachypnea syndrome D. Meconium aspiration syndrome

Respiratory distress syndrome

Pt presents as a 5-month old infant with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C, and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Nasal flaring, use of accessory muscles, subcostal and intercostal retractions are noted. Expiratory wheezes and a cough are present. What is your dx

Respiratory syncytial virus infection (RSV)

A 40 year-old male nonsmoker in good health undergoes a routine chest x-ray for an insurance physical. Results show an isolated, well-defined, coin lesion 1 cm in size. Which of the following is the next step in the evaluation of this problem? A. Review old radiographs B. Order chest CT C. Schedule lung biopsy D. Prepare for surgical lung resection

Review old radiographs

Which of the following mechanisms leads to a primary pneumothorax? A. Penetrating or blunt trauma forces B. Underlying lung cancer C. Pressure of air in the pleural space exceeds room air pressure D. Rupture of subpleural apical blebs due to high negative intrapleural pressures

Rupture of subpleural apical blebs due to high negative intrapleural pressures

A 52-year-old man is seen for fevers and weight loss. A chest radiograph shows mediastinal lymphadenopathy. Laboratory findings show hypercalcemia, elevated alkaline phosphatase, and an elevated level of ACE. The most likely diagnosis is A. Small cell carcinoma of the lung B. Pulmonary tuberculosis C. Sarcoidosis D. Histoplasmosis E. Asbestosis

Sarcoidosis

Pt presents as a 30-year-old African American female with a cough, fever, and generalized body aches. You order a CXR which shows bilateral hilar adenopathy what is your dx

Sarcoidosis

Pt presents as a 49-year-old man who is brought to your office by his partner, who is concerned about his daytime sleepiness. Last week, the patient fell asleep while stopped at a red light. She says that he snores loudly and sometimes stops breathing for a few seconds while sleeping. His past medical history is significant for hypertension. He has a 20-pack-year history of smoking. His temperature is 98.6 F, heart rate is 86/min, blood pressure is 148/98 mm Hg, respiratory rate is 12/min. On physical exam, he is obese. His lungs are clear and his lower extremity exam is within normal limits.

Sleep Apnea and Obesity Hypoventilation Syndrome

Pt presents as a smoker with hemoptysis and an abnormal chest X-Ray showing a large central solitary tumor. what is your dx?

Squamous cell carcinoma

The most common pathogen identified in community acquired pneumonia (CAP) is A Mycoplasma pneumoniae. B. Staphylococcus aureus. C. Legionella pneumophila. D. Streptococcus pneumoniae

Streptococcus pneumoniae

Which of the following is accurate about complications of pediatric foreign body ingestion? A. The most common site of esophageal impaction is at the lower esophageal sphincter (LES) at the gastroesophageal junction B. Most complications occur once the foreign body reaches a child's stomach C. Migration of a foreign body from the esophagus most often leads to aortoenteric fistula D. Swallowed button batteries may cause substantial mucosal injury within just 2 hours

Swallowed button batteries may cause substantial mucosal injury within just 2 hours

A recent Haitian immigrant presents to the clinic for an employment physical examination before starting work at a local hospital. The patient has a history of receiving bacilli Calmette-Guerin (BCG) vaccination. Screening for tuberculosis for this employee should include which of the following tests? A. Sputum induction B. PPD skin test C. Chest x-ray D. No screening needed E. TB blood test (IGRA)

TB blood test (IGRA)

Which of the following is the most likely presentation of an acute pulmonary embolism (PE) in a patient without preexisting cardiac or pulmonary disease? A. Anginal chest pain B. Cough C. Tachypnea D. Palpitations

Tachypnea

Which of the following statements is accurate about physical examination findings in patients with pulmonary emboli? A. Temperature in excess of 103° F is common in patients with pulmonary emboli B. Tachypnea is among the most common physical signs of pulmonary emboli C. Chest wall tenderness as the sole physical finding indicates a cause other than pulmonary embolism D. Patients with massive pulmonary embolism display signs of systemic hypertension

Tachypnea is among the most common physical signs of pulmonary emboli

Which of the following is accurate regarding treatment of foreign body ingestion? A. Flexible bronchoscopy is generally preferred to rigid bronchoscopy in removing tracheobronchial foreign bodies B. The bougienage method should only be performed if ingestion of a blunt object by a child was witnessed within 24 hours of the procedure C. Foley catheter removal is indicated for patients who have foreign bodies present for longer than 72 hours D. Relaxation of the LES with glucagon is recommended more than watchful waiting for foreign bodies confirmed by imaging studies to be lodged at the LES

The bougienage method should only be performed if ingestion of a blunt object by a child was witnessed within 24 hours of the procedure

Which of the following is accurate about foreign body aspiration? A. The location of an aspirated foreign body inside a patient may depend on the patient's age B. The likelihood of complications decreases after 24-48 hours C. Inflammatory changes are completely reversible D. Foreign body aspiration is more commonly seen in females than in males

The location of an aspirated foreign body inside a patient may depend on the patient's age

Which of the following is accurate about the etiology of pulmonary emboli? A. Most pulmonary emboli originate in the pelvic, renal, or upper extremity veins B. Small thrombi typically travel less distally and are less likely to produce pleuritic chest pain C. Most pulmonary emboli are single D. The lower lobes of the lung are more commonly involved with emboli than the upper lobes

The lower lobes of the lung are more commonly involved with emboli than the upper lobes

What is (are) the clinical feature(s) associated with Obstructive sleep apnea? A. systemic hypertension B. Inhibited sexual desire C. depression D. all of the above

all of the above

A 75 year-old man with a long history of COPD presents with acute onset of worsening dyspnea, increased productive cough, and marked agitation. While in the emergency department he becomes lethargic and obtunded. His ABG's reveal a PaO2 40 mmHg, PaCO2 65 mmHg, and arterial pH 7.25. Which of the following is the most appropriate management at this point? A. oxygen supplementation with a 100% non-rebreather mask B. noninvasive positive pressure ventilation (NIPPV) C. endotracheal intubation and mechanical ventilation D. emergency tracheostomy

endotracheal intubation and mechanical ventilation

A patient should be tested for tuberculosis prior to being treated with A. etanercept (Enbrel). B. cyclosporine (Neoral). C. methotrexate (Rheumatrex). D. prednisone (Deltasone

etanercept (Enbrel)

A 36-year-old male who is hospitalized because of severe injuries from a motor vehicle accident develops rapid onset of profound dyspnea. Initial chest x-ray shows a normal heart size with diffuse bilateral infiltrates. Follow-up chest xray shows confluent bilateral infiltrates that spare the costophrenic angles. Which of the following is the best clinical intervention for this patient? A. Tracheal intubation B. Bilateral chest tube insertion C. Type-specific packed cells D. Colloid solutions E. Provide supplemental oxygen

Tracheal intubation

You advise your patient from question one to take antipyretic drugs and get some rest. He returns to your office 5 days later feeling worse and now has a fever with a cough productive of purulent sputum. What is the most appropriate next step in the management of this patient? A. Treat with a macrolide antibiotic B. Administer penicillin intramuscularly C. Influenza titers D. Pulmonary function tests

Treat with a macrolide antibiotic

A 47-year-old HIV positive female presents with a complaint of nonproductive cough. She is febrile, tachypneic, and tachycardic. Lung exam reveals bilateral rales. Chest x-ray shows diffuse interstitial infiltrates. What is the recommended treatment for this patient? A. Trimethoprim-Sulfamethoxazole (Bactrim) B. Tetracycline (Sumycin) C. Amantadine (Symmetrel) D. Ticarcillin (Ticar)

Trimethoprim-Sulfamethoxazole (Bactrim)

A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. Which of the following is the next most appropriate intervention? A. Thoracotomy B. Needle aspiration C. Close observation D. Tube thoracostomy

Tube thoracostomy

Pt presents as a 78-year-old man with a 3-month history of weight loss, fever, fatigue, night sweats, and cough. He is a former smoker. A recent HIV test was negative. A chest CT reveals a 3 cm lesion in the upper lobe of the left lung and calcification around the left lung hilus. A sputum smear was positive for acid-fast organisms What is your dx

Tuberculosis

A post-op patient has signs and symptoms highly suggestive of a pulmonary embolism. The results of the CT scan of the lung is nondiagnostic. What is the most appropriate next step in the evaluation? A. Ventilation perfusion (V/Q) scan B. Ultrasound of the legs C. Echocardiography D. D-dimer

Ultrasound of the legs

What is the most common cause of acute bronchitis? A. H. influenzae B. Viral infection C. Fungal infection D. Allergic reaction

Viral infection

Pt presents as a 45-year-old male with a one-week history of hacking non-productive cough, low-grade fever, malaise, and myalgias. The chest x-ray reveals bilateral interstitial infiltrates and a cold agglutinin titer that is negative. Examination reveals scattered rhonchi and rales upon auscultation of the chest. What is your dx?

Viral pneumonia

Which of the following is accurate about the treatment of pulmonary embolism? A. Thrombolytics are the treatment of choice in most children with pulmonary emboli B. When possible, thrombolytic therapy should be used in patients with acute pulmonary embolism associated with hypotension C. Most patients with acute pulmonary embolism should receive IV unfractionated heparin (UFH) instead of low-molecular-weight heparin (LMWH) D. Subcutaneous (SC) UFH is preferred to fondaparinux in patients with acute pulmonary embolism

When possible, thrombolytic therapy should be used in patients with acute pulmonary embolism associated with hypotension

What is (are) the factor(s) predisposing to this condition? A. alcohol intake B. benzodiazepines C. hyperthyroidism D. a and b E. all of the above

a and b

To what is the pathophysiology of obstructive sleep apnea related? A. collapse of the pharyngeal walls repetitively during sleep B. failure of upper airway dilator muscle activity C. sleep-related upper airway obstruction and cessation in ventilation (apneas) D. a, b, and c

a, b, and c

Obstructive sleep apnea is accompanied by which of the following? A. hypoxemia B. hypercarbia C. metabolic acidosis D. respiratory acidosis E. a, b, and d

a, b, and d

Pt presents as a 5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged, expiratory wheezes.

asthma

Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)? A. drooling B. high fever C. "hot potato" voice D. barking cough

barking cough

A 73-year-old obese female with a 20 pack year smoking history presents complaining of chronic productive cough. She states that it has been occurring over the past 3 years more frequently November through February. Which of the following pulmonary function test values would you expect to find decreased? A. tidal volume B. forced expiratory volume in 1 second/forced vital capacity C. residual volume D. total lung capacity

forced expiratory volume in 1 second/forced vital capacity

A 56 year-old male with a 40 pack-year smoking history presents complaining of progressive shortness of breath. Spirometry reveals an FEV1 of 2 L (40% of predicted), an FVC of 4 L (80% of predicted) and an FEV1/FVC of 50%. These findings are most consistent with A. sarcoidosis. B chronic bronchitis. C. interstitial lung disease. D. congestive heart failure.

chronic bronchitis

What is the treatment of first choice for this disorder? A. uvulopalatopharyngoplasty surgery (UPP) B. tracheostomy C. continuous positive airway pressure (CPAP) D. nortriptyline E. alprazolam

continuous positive airway pressure (CPAP)

A 62-year-old woman with pulmonary hypertension called 911 complaining of sweating and difficulty in breathing. Upon arrival to her home the paramedics found her to have pallor, diaphoresis, tachypnea, hypotension, and tachycardia. Her pulse oximetry was 89%, so they gave her oxygen via nonrebreather mask and transported her to the emergency department (ED). She was not complaining of angina. The ED physician assistant noted her to be in acute distress with elevated jugular venous pressure, a medial heave, a tender palpable liver, a systolic murmur of tricuspid regurgitation, and an S4 gallop. ECG demonstrated right axis deviation and right ventricular hypertrophy with no ST-T changes. Her arterial blood gas (ABG) demonstrated a low PaO2 and a low PaCO2. What is her likely diagnosis? A. acute coronary syndrome B. cor pulmonale C. heart failure D. pulmonary embolus

cor pulmonale

A 65-year-old man presents with a chronic productive cough, dyspnea, and wheezing. Examination reveals cyanosis, distended neck veins, and a prominent epigastric pulsation. What is the most likely diagnosis? A. cor pulmonale B. chronic bronchitis C. emphysema D. pneumonia

cor pulmonale

Pt presents as a 2-year-old boy who is brought to you by his father who is concerned about a "barking cough," mild fever, and a hoarse voice. He reports that he had a runny nose last week that has since resolved. Physical exam reveals inspiratory stridor. What is your dx

croup

A 3 month-old male presents with a hoarse cough and thick purulent rhinorrhea for the past 2 days. The mother noted that yesterday he appeared to get worse and seemed to have increasing problems breathing and trouble feeding. Examination reveals a temperature of 100.2 degrees F and respiratory rate of 80/minute with nasal flaring and retractions. Lung examination reveals a prolonged expiratory phase with inspiratory rales. He is tachycardic. Pulse oximetry reveals oxygen saturation of 89%. Chest x-ray reveals hyperinflation with diffuse interstitial infiltrates. Which of the following is the most appropriate intervention?

hospitalization

A preterm infant is breathing rapidly and grunting. Intercostal retractions, nasal flaring, and cyanosis are noted. Auscultation shows decreased breath sounds and crackles. What is the diagnosis?

hyaline membrane disease

You are called to the nursery to see a male infant, born by uncomplicated vaginal delivery. He weighs 2,600 grams and has one deep crease on the anterior third of each foot. Respirations are 88 breaths/minute with expiratory grunting and intercostals retractions. He is cyanotic on room air and becomes pink when placed in 60% oxygen. Chest x-ray shows atelectasis with air bronchograms. Which of the following is the most likely diagnosis? A. neonatal pneumonia B. congenital heart disease C. hyaline membrane disease D. chronic lung disease of prematurity

hyaline membrane disease

A 25 year-old male with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist prn. He is presently using his short acting beta agonist on a daily basis. Which of the following is the most appropriate addition to this patient's regimen? A. methylxanthine oxidase inhibitor B. long acting beta agonist inhaler C. leukotriene inhibitor D. inhaled corticosteroid

inhaled corticosteroid

A 21 year-old male presents to the ED with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Examination reveals moderate respiratory distress with absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right. Which of the following is the most appropriate next step? A. order a V/Q scan B. order a chest x-ray C. administer a sclerosing agent D. insert large bore needle into left 2nd ICS sta

insert large bore needle into left 2nd ICS stat

A patient presents with a history of progressive worsening of dyspnea over the past several years. He gives a history of having worked as a ship builder for over 50 years. He denies any alcohol or tobacco use. On examination you note clubbing and inspiratory crackles. Which of the following chest x-ray findings support your suspected diagnosis? A. hyperinflation and flat diaphragms B. interstitial fibrosis and pleural thickening C. cavitary lesions involving the upper lobes D. "eggshell" calcification of hilar lymph nodes

interstitial fibrosis and pleural thickening

Which of the following is an indication for hospitalization in a patient who has acute bronchiolitis? A. pulse oximetry of 94% on room air B. Children between 4-6 months of age C. moderate tachypnea with feeding difficulties D. hyperinflation and interstitial infiltrates on chest x-ray

moderate tachypnea with feeding difficulties

Which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms? A. call the health care provider regularly B. keep a diary of symptoms C. monitor peak flow D. ask a family member to monitor symptoms

monitor peak flow

A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is A. tuberculosis. B. mycoplasma pneumonia. C. pneumococcal pneumonia. D. staphylococcal pneumonia

mycoplasma pneumonia

A 48-year-old man comes to your office with his wife. His wife tells you that "he is constantly snoring" and she has put up with all she can. This has been going on for a number of years, but it has been getting worse lately. His wife also tells you that "sometimes he even stops breathing during the night." When you ask the patient directly, he says, "Well, I may snore a bit, but I think my wife is exaggerating." You somehow doubt this statement. There is a history of sleepiness during the day; he has fallen asleep at his desk at work. On examination, the patient weighs 310 pounds. His blood pressure is 200/105 mm Hg (measured with a large cuff). Head, ears, eyes, nose, and throat examination shows boggy nasal mucosa but a normal pharynx. A grade 3/6 systolic murmur is present along the left sternal edge. You believe that there is elevated jugular venous pressure when he lies at a 45-degree angle. Chest is normal to auscultation and percussion. His abdomen is obese, and his extremities are without edema. What is the most likely diagnosis in this patient? A. narcolepsy B. obstructive sleep apnea (OSA) syndrome C. generalized poor physical condition D. central sleep apnea syndrome E. adult-onset adenoid hypertrophy

obstructive sleep apnea (OSA) syndrome

A 14 year-old male presents to the ED experiencing a severe asthma attack. His respiratory effort is shallow and he is using accessory muscles to breathe. Auscultation of his chest reveals no audible wheezing. Vital signs include BP 90/60 mmHg, P 160 bpm, RR 52. An arterial blood gas (ABG) is ordered. Normal ABG values at your institution are pH 7.35-7.45, CO2 35-45, pO2 80-95. Which of the following ABG findings suggests the poorest prognosis? A. pH = 7.27 pCO2 = 46 pO2 = 56 B. pH = 7.60, pCO2 = 18 pO2 = 80 C. pH = 7.44, pCO2 = 38 pO2 = 90 D. pH = 7.52, pCO2 = 28, pO2 = 80

pH = 7.27 pCO2 = 46 pO2 = 56

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A. chest x-ray B. sputum gram stain C. peak flow D. ventilation - perfusion scan

peak flow

An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. Which of the following is the most appropriate interpretation of this test result? A. positive B. negative C. active infection D. falsely negative

positive

A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals tachycardia. Which of the following is the most likely diagnosis? A. atelectasis B. pneumothorax C. pulmonary embolism D. myocardial infarction

pulmonary embolism

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days, but symptoms worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 7 pounds, and maternal group B strep was negative. Immunizations are current. Vital signs include a rectal temperature of 100.8° F, pulse of 120 beats/minute, blood pressure within normal limits, and respiratory rate of 60 breaths/minute. The infant is well hydrated but appears ill. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical examination. Chest radiographs show patchy atelectasis and hyperinflation of the lungs. The most common cause of this condition is: A. human metapneumovirus B. adenovirus C. parainfluenza virus D. respiratory syncytial virus (RSV) E. influenza virus

respiratory syncytial virus (RSV)

Which statement regarding management of Bronchiolitis is true? A. bronchodilators provide a consistent benefit for this illness B. corticosteroids are routinely indicated for initial management C. ribavirin should not be used routinely in this condition D. intravenous fluids are required for infants younger than year E. chest physiotherapy provides proven benefit for this condition

ribavirin should not be used routinely in this condition

What is the diagnostic study of choice for pulmonary hypertension? A. right heart catheterization B. spirometry C. chest X-ray D. echocardiography

right heart catheterization

A patient presents with respiratory complaints. Chest x-ray reveals calcification of the hilar nodes with an eggshell pattern. Which of the following occupations is most consistent with these chest x-ray findings? A. building demolitioners B. coal miners C. sandblasters D. farmers

sandblasters

Peripheral "pruning" of the large pulmonary arteries is characteristic of pulmonary hypertension in

severe emphysema

In patients with COPD, which of the following has been shown to decrease rate of malignancy and cardiovascular disease and improve survival? A. bronchodilator therapy B. pulmonary rehabilitation C. oral glucocorticosteroids D. smoking cessation

smoking cessation

A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient? A. spoken "ee" heard as "ay" B. hyperresonant percussion note C. wheezes over the involved area D. vesicular breath sounds over involved area

spoken "ee" heard as "ay"

A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding? A. stridor B. aphonia C. inability to cough D. progressive cyanosis

stridor

A 15 year-old male presents with a 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. Examination is unremarkable except for a few scattered rhonchi and rales upon auscultation of the chest. The chest x-ray reveals interstitial infiltrates and a cold agglutinin titer was negative. Which of the following is the most likely diagnosis? A. acute bronchitis B. viral pneumonia C. mycoplasma pneumonia D. pneumococcal pneumonia

viral pneumonia

Which of the following is the most appropriate therapeutic agent for acute influenza? A. azithromycin (Zithromax) B acyclovir (Zovirax) C. tetracycline (Sumycin) D. zanamivir (Relenza)

zanamivir (Relenza)

Pulmonary hypertension is defined as a mean pulmonary arterial pressure of A. ≥ 5 mm Hg B. ≥ 10 mm Hg C. ≥ 15 mm Hg D. ≥ 25 mm Hg

≥ 25 mm Hg