MedPath E3 Case Studies

A 70 y/o man with a history of COPD presents complaining of worsening shortness of breath for the last several days. He is coughing large amounts of yellow-colored sputum and he is receiving no relief from his B-2-agonist and ipratropium aerosolized pumps. On PE, the patient's RR 40/min, HR is 110/min. BP is 150/85 mm Hg. The patient is afebrile. He is using his accessory muscles of respiration to assist in breathing. Lung examination reveals inspiratory and expiratory diffuse wheezing. Which of the following is the most likely diagnosis? A. Acute exacerbation of COPD B. Chronic bronchitis D. Exacerbation of asthma E. Pneumonia

A. Acute exacerbation of COPD

A 70 y/o white man with advanced COPD presents to you in the ER with pneumonia and an exacerbation of COPD. He is awake and alert, with acceptable work of breathing, and a ABG reveals a pH of 7.30, a PCO2 of 50 mm Hg, and a PO2 of 48 mm Hg. He is visiting relatives, and his PA 300 miles away tells you he has advanced disease and should not be intubated. He and his family state that they wish mechanical ventilation if it has a chance of helping him. Aggressive bronchodilator therapy and antibiotics are initiated. Which of the following is the most appropriate therapeutic plan? A. Begin oxygen at 1 liter per minute by nasal cannula and follow O2 sats B. Intubate the patient C. Begin oxygen 40% by face mask D. Administer sodium bicarbonate

A. Begin oxygen at 1 liter per minute by nasal cannula and follow O2 sats

A 54-year-old obese woman presents with the chief complaint of hemoptysis. She states that over the last day she has coughed up approximately 10 cc of blood-streaked sputum. She denies any fever, chills, chest pain, or shortness of breath. She does admit to a recent upper respiratory tract infection with cough and a copious amount of sputum production. She remembers similar episodes of cough with bloody sputum occurring after colds for the last several years. She has smoked 1 pack of cigarettes per day since high school. Examination of the pharynx and lungs are normal. Which of the following is the most likely diagnosis? A. Chronic bronchitis B. Tuberculosis C. Adenocarcinoma of the lung D. Congestive heart failure E. Pulmonary Infarction

A. Chronic bronchitis

Which of the following treatment modalities is only minimally effective in the management of emphysema? A. Corticosteroids B. Smoking cessation C. Diuretics if cor pulmonale present D. Oxygen supplement if partial pressure of oxygen > 55 mm Hg at rest, exercise, or nocturnally E. Pulmonary rehabilitation

A. Corticosteroids

Which of the following represents an obstructive pattern of impairment during spirometry? A. Decreased FEV1/FVC ratio, a reduced FEF, an FEV1 less than 80% of predictive value, reduced FVC B. Normal FEV1/FVC ratio, decreased RV, TLC, vital capacity and functional residual capacity C. Increased FVC, decreased FEV, decreased TLC and RV D. Increased FVC, FEV1, RV, and TLC

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

A 54 y/o male stonecutter presents with a chronic cough & dyspnea with exertion. He denies any other symptom such as hemoptysis, chest pain or fever. PMH is unremarkable He smokes 1 pack of cigarettes daily. CXR: Eggshell calcification of nodes, Diagnosis? A. Silicosis B. Sarcoidosis C. Asbestosis D. Idiopathic Pulmonary Fibrosis E. Hypersensitivity pneumonitis

A. Silicosis

RX Clindamycin or B-lactam/B-lactamase inhibitor Treatment for what group of organisms?

Anaerobes

How should you confirm the diagnosis of sarcoidosis? A. Liver biopsy B. Bronchoscopy and Transbronchial lung biopsy C. Scalene nerve biopsy D. Serum angiotensin converting enzyme (ACE) level

B. Bronchoscopy and Transbronchial lung biopsy

A 22-year-old female presents to the emergency department with extreme shortness of breath after jogging. No past medical history is immediately available. VS are pulse 120, RR 32,T 98.7 F, and BP 130/84. PE reveals a lethargic and confused patient; there are diffuse expiratory wheezes and a prolonged expiratory phase. Hyperresonance to percussion is noted. The most likely diagnosis is: A. Pneumothorax B. Exercise induced asthma C. Pulmonary edema D. Pneumonia E. Bronchiolitis

B. Exercise induced asthma

Which of the following is a known consequence of asbestos exposure? A. The same increased risk of mesothelioma as cigarette use B. Pleural effusions, often initially benign C. Pleural mesothelioma but not peritoneal mesothelioma D. An obstructive pattern, typically revealed by PFT

B. Pleural effusions, often initially benign

39 y/o F, fatigue, no energy. DOE, fever, denies occupational exposures.- Recent visual deterioration, skin rash on face, fingers, legs- Diffuse lymphadenopathy noted- Lung exam revealed scattered expiratory wheezes and scattered rales- Hepatomegaly, elevated LFTs- Gallium scan was consistent with diffuse interstitial pneumonitis- Lymphadenopathy noted on CXR and CT Diagnosis? A. TB B. Sarcoidosis C. Pneumoconiosis D. Metastatic cancer E. Histoplasmosis

B. Sarcoidosis

A 22-year-old male comes to your office for assessment of a chronic cough. He has moved into a bachelor apartment in the basement of a house. As soon as he moved in, he noticed a chronic, nonproductive cough associated with shortness of breath. He has never had these symptoms before, and he has no known allergies. When he leaves for school for the day, the symptoms disappear. The symptoms are worse at night. His landlady has three cats. He didn't think he was allergic to cats, but now thinks that might be the case On PE, RR 16 breaths/min and regular. He is in no distress at the present time. There are a few expiratory rhonchi heard in all lobes. His BP is 120/70 mm Hg, and his pulse is 72 bpm and regular. What is the most likely diagnosis in this patient? A. Paroxysmal nocturnal cough syndrome B. Chronic Bronchitis C. Cough variant asthma D. Emphysema

C. Cough variant asthma

Which of the following pulmonary function tests is the most useful for the diagnosis of asthma? A. Decreased forced vital capacity (FVC) B. Increased residual volume C. Reduced FEV1/FVC D. Increased functional residual capacity E. Increased total lung capacity

C. Reduced FEV1/FVC

A 59-year-old man with a long-standing smoking history presents with persistent dyspnea. His FEV1 is 1.0 L/min, arterial blood gas reveals PO2 of 50 mmHg, PCO2 of 40 mmHg, pH 7.45, and O2 saturation of 90%. He has hyperlucent lungs on chest x-ray and decreased breath sounds on physical examination. The patient's current medical regimen consists of theophylline (300 mg twice daily) and inhaled isoproterenol. The most important addition to the patient's therapy would be: A. trimethoprim-sulfamethoxazole B. substitution of albuterol for isoproterenol C. oxygen therapy for emphysema D. prednisone E. addition of inhaled beclomethasone

C. oxygen therapy for emphysema

Cor pulmonale: Peaked P waves. Prominent R wave in V1. Right axis deviation. Atrial arrhythmias especially multifocal atrial tachycardia(MAT) Common comorbidity in what condition?

COPD

What other condition is also a/w Cor pulmonale with increased bronchovascular markings and cardiomegaly?

Chronic bronchitis

- 65 y/o M: right-sided chest pain over several months. - Liifelong smoker and worked most of his life as a shipbuilder - Dyspneic at rest. Lung auscultation reveals scattered rhonchi anteriorly and posteriorly - Clubbing noted - CXR reveals the lungs to have a "ground glass" appearance and bilateral pleural plaques Diagnosis? A. Byssinosis B. Berylliosis C. Silicosis D. Asbestosis E. Farmers Lung

D. Asbestosis

In emphysema, the single most important factor in slowing the inevitable decline in forced expiratory volume in 1 second (FEV1) and improving life expectancy and quality of life is: A. The long-term use of oral or inhaled corticosteroids B. The use of continuous or nocturnal oxygen therapy C. Bronchodilator therapy with theophyllines and/or beta-agonists D. Smoking cessation E. Giving pneumococcal vaccine and yearly influenza vaccination

D. Smoking cessation

What is the best test for definitively making the diagnosis in the previous patient ? A. Pulmonary function testing B. High-Resolution CT Scan C. Bronchoscopy with transbronchial biopsy D. Surgical open lung biopsy E. Pulmonary angiogram

D. Surgical open lung biopsy

A 59-year-old woman presents complaining of a cough producing sputum for nearly 10 years. Her cough occurs during the day, and she produces sputum daily. The woman states that as a child she had several episodes of pneumonia requiring hospital admissions and antibiotics. Several times a year, her sputum becomes purulent, and she requires antibiotic therapy. She denies smoking cigarettes and has worked as a seamstress all of her life. On physical examination the lungs are clear without wheezes, rhonchi, or crackles. Which of the following is the most likely diagnosis? A. Asthma B. Cystic fibrosis C. Chronic bronchitis D. Emphysema E. Bronchiectasis

E. Bronchiectasis

- 34 y/o F, new work environment with animals. Reports progressive cough & DOE worsening over the last 3 months with fever- O2 saturation of 95% RA, desaturates to 91% with ambulation. T is 99.8 - Normal CXR. Chest CT scan shows diffuse ground-glass infiltrates in the lower lobes with the presence of centrilobular nodules Most likely diagnosis?

HP

56 y/o M, presents with progressive dyspnea and fatigue. Worsens with exercise. - 94% on RA, with walking, it declines to 83% - No pmh, hx of smoking - PE: fine dry crackles are heard bilaterally at the bases, clubbing noted - CT of the chest reveal a bibasilar reticular nodular pattern in the lung field. Diagnosis?

IPF

Exposure to a contaminated source like AC, hospital, work exposure Atypical Symptoms such as neurologic, GI Bradycardia and hyponatremia may be present Special testing with Urine antigen will be required for diagnosis

Legionella

Most commonly seen in younger patients (<40 y/o) "Atypical" organism May have accompanying systemic symptoms: headache, rash, cardiac, hemolytic anemia, etc Special serology testing is needed to confirm the diagnosis

Mycoplasma pneumoniae

RX Antipseudomonal B-lactam + and aminoglycoside OR Ciprofloxacin (Cipro) + an aminoglycoside What condition does this treat?

Pseudomonas

A 50-year-old man presents with sudden onset of breathlessness for 1 hour. He has had chronic bronchitis for 2 years, and he has been a chronic smoker for 20 years. Temperature is 99.8°F, pulse 96/min, respirations 24/min, blood pressure 128/88 mm Hg. Physical examination shows absence of breath sounds in the left lower lung zone. Abdominal examination is normal, and there is no pedal edema. Further analysis shows pleural effusion on the left side. What is the most likely cause? a. Atelectasis b. Bacterial pneumonia c. Pulmonary embolism d. COPD

a. Atelectasis

What is the normal respiratory stimulus in people without obstructive disease? a. CO2 b. Hypoxia c. Tachycadia d. Dyspnea

a. CO2

A 67-year-old woman presents with shortness of breath and chest pain. She admits to getting home yesterday from a 2-day car ride after visiting her grandchildren. Heart rate 110 beats/minute, respirations 22/minute, blood pressure 125/85 mm Hg, oxygen saturation 89% on room air, temperature 98.9°F. ECG is unremarkable. What is the most appropriate imaging test for this patient? a. CT pulmonary angio b. CT chest w/ constrast c. Echocardiogram d. V/Q scan

a. CT pulm angio

A 36-year-old African American woman presents with a nonproductive cough, malaise, mild fever, and mild dyspnea. She also indicates that she has some lesions around her nose. Upon physical exam, you note red-brown dermal papules around her nares. A chest X-ray demonstrates a right hilar mass. A pulmonologist is consulted and performs a biopsy during bronchoscopy. The report reveals that the mass is a non-caseating granuloma. What initial therapy should be prescribed? a. Corticosteroids b. Inhaled beta agonist c. Methotrexate d. Cyclosporine

a. Corticosteroids (dx: sarcoidosis)

A 57-year-old man presents with a 6-month history of a daily productive cough. The patient is a non-smoker, and he has worked in a local coal mine for the past 39 years. He very rarely comes in to see a healthcare provider. When asked if he is up to date with his vaccinations, he does not recall the last ones he received; he also does not recall when these may have been given. Given the most likely diagnosis, what pair of vaccinations would be recommended to help decrease any significant morbidity and mortality in this patient? a. Influenzae and pneumococci b. Influenzae and zoster c. Pneumococci and varicella d. Pneumococci and zoster e. Varicella and zoster

a. Influenzae and pneumococci

A 32-year-old man presents due to occasional shortness of breath and associated cough, especially when he is working outside. He has associated chest tightness that resolves within minutes when he sits down and rests. These symptoms occur 1-2 days a month. He is otherwise healthy and does not smoke. Blood pressure is 128/74 mm Hg, pulse is 76, respirations are 14, pulse oximetry is 100% on room air. FEV1 is 96%. What is the treatment of choice when this patient is experiencing symptoms? a. Inhaled short-acting beta-agonist b. Oral steroids c. Inhaled anticholinergic plus inhaled short-acting beta-agonist d. Oral beta-agonist

a. Inhaled short-acting beta-agonist

What is the drug class of choice for empiric antibiotics in children ages 5-16 years old? a. Macrolides b. Beta lactams c. Fluroquinolones d. Tetracyclines

a. Macrolides

A 9-year-old boy presents with a productive cough for the past few days. The patient also has been having fevers of 101°F. The patient has had recurrent bouts of pneumonia. His neonatal course was complicated by meconium ileus. A sweat chloride test is positive and sputum examination reveals gram-negative rods that are oxidase-positive. The culture has a greenish tint. Based on the patient's underlying condition and laboratory findings, this infection is most likely caused by what organism? a. Pseudomonas aeruginosa b. Staphylococcus aureus c. Streptococcus pneumoniae d. Haemophilus influenzae e. Listeria monocytogenes

a. Pseudomonas aeruginosa Positive sweat test indicates CF- common to have p. aeruginosa in CF patients

A 64-year-old man presents with progressive dyspnea, fatigue, chronic dry cough, and exercise intolerance. His symptoms have worsened over the past year. Pulmonary function testing reveals an FEV1/FVC ratio >0.7, decreased total lung capacity, and decreased residual volume. What is the most likely diagnosis? a. Pulmonary fibrosis b. Asthma c. COPD d. Pulmonary embolism

a. Pulmonary fibrosis

A 52-year-old man has a past medical history of smoking 40 packs of cigarettes per year; he presents for a follow-up. He notes that, over the past week, he has developed increased nonproductive cough and shortness of breath. He has had a chronically-progressive cough and shortness of breath upon exertion over the past year. His occupational history reveals coal mining for 25 years. He denies any alcohol consumption, travel history, or sick contacts. He also denies fever, chills, sore throat, otalgia, chest or abdominal pain, peripheral edema, rashes, and pruritus. A chest radiograph is performed, which reveals diffuse bilateral ground-glass opacities and eggshell calcification of hilar lymph nodes. Based on the most likely diagnosis, what preventive medicine factor is true? a. Smoking cessation strategies are encouraged. b. Influenza and pneumococcal pneumonia immunizations are contraindicated. c. A 15-mm induration upon PPD testing indicates a positive test result. d. Low-level occupational exposure may be safely tolerated at this time.

a. Smoking cessation strategies are encouraged.

Gram positive cocci in clumps More common in nursing home & hospital acquired pneumonias, IVDA patients, post influenzae Worry about methicillin-resistant strains a. Staphylococcus aureus b. Pseudomonas aeruginosa c. Streptococcus pneumoniae d. Pneumocystis pneumoniae

a. Staphylococcus aureus

A 43-year-old man without any significant PMHx presents with acute onset of a productive cough, shortness of breath, pleuritic chest pain, and fever. His sputum is described as "thick, brown-colored, and mucoid" but without blood. He also notes associated fatigue and night sweats. He denies chills, changes in weight, a history of travel, sick or confined contacts, exposure to animals, cigarette smoking, otalgia, sore throat, swollen glands, abdominal pain, diarrhea, rashes, myalgias, and arthralgias. His physical exam is remarkable for fever, tachycardia, and tachypnea. The lung exam is noteworthy for right lower lung field increased tactile fremitus, dullness to percussion, inspiratory crackles, and bronchial breath sounds. What is the most likely etiologic agent responsible for this patient's presentation? a. Streptococcus pneumoniae b. Histoplasma capsulatum c. Chlamydia psittaci d. Pseudomonas aeruginosa e. Mycobacterium tuberculosis

a. Streptococcus pneumoniae

A 66-year-old man with moderately well-controlled type 2 diabetes mellitus presents to his primary care provider for the management of pneumonia. His influenza test was negative. He is currently being treated with levofloxacin. He is afebrile; pulse is 93, blood pressure is 130/90 mm Hg, respirations are 18/min, and oxygen saturation is 92% on room air. What is the most common bacterial cause of this patient's pneumonia? a. Streptococcus pneumoniae b. Haemophilus influenzae c. Staphylococcus aureus d. Pseudomonas aeruginosa e. Moraxella catarrhalis

a. Streptococcus pneumoniae

Which is best for an acute COPD exacerbation? a. Systemic glucocorticoids b. Inhaled glucocorticoids c. Combination inhaled β-Agonists + anticholinergic drugs d. Lung transplant

a. Systemic glucocorticoids: inhaled is better for chronic

If a COPD patient has an pO2 of less than ____mmHg per ABG, give them oxygen: a. 90mmHg b. 55mmHg c. 50mmHg d. 70mmHg

b. 55mmHg

A 40-year-old man with chronic alcoholism presents with a cough that produces of large amounts of fetid sputum. The sputum is now foul-smelling and copious. His vitals are: T 102°F, PR 98\min, RR 24\min, BP 140\80 mm Hg. Exam shows poor dentition with multiple missing teeth, mild erythema to the nasal muscosa with clear drainage. RRR without a murmur. On lung auscultation, there is pleural rub and diminished air entry on the right side. The chest X-ray shows a large, irregularly shaped, dense opacity on the right side with a fluid level. How should this patient's diagnosis be regarded? a. Only anaerobic organisms are responsible for this condition. b. Aspiration is the most common cause. c. Sputum culture is the best investigation. d. CT has no role as an investigation in this condition. e. Treatment is with antibiotics for 3 days.

b. Aspiration is the most common cause.

A 7-year-old boy presents with his mother with a 1-week history of wheezing and dyspnea on any exertion (with productive cough). On physical examination, bilateral rhonchi are heard. After a few days of treatment, spirometry is done on the patient. Total lung capacity (TLC) is 111% on spirometry. FVC% pre-bronchodilator: 49% FVC% post-bronchodilator: 63% Most likely diagnosis? a. Pneumonia b. Asthma c. Pleural effusion d. TB

b. Asthma

Within the United States, infection is most common in the Midwestern states located in the Ohio and Mississippi River valleys. Found in soil contaminated with bird or bat droppings. a. Coccidioidomycosis b. Histoplasmosis c. Anaerobic organisms d. PCP

b. Histoplasmosis

What becomes the respiratory stimulus in obstructive pulmonary conditions? a. CO2 b. Hypoxia c. Tachycadia d. Dyspnea

b. Hypoxia

A 57-year-old Caucasian man presents with worsening shortness of breath. While obtaining his history, you uncover that he has noted increasing shortness of breath with minor exertional activity and a persistent but non-productive cough. The patient admits to being a former smoker with a 34 pack-year history, admitting to cessation at age 50. He denies any known caustic occupational exposures and states he worked in an office his whole life. He admits to an uncle having some kind of breathing issues, although he is unsure of a definite diagnosis. Patient denies weight loss, fever, or significant recent illness. Physical examination is pertinent for significant clubbing of the fingers, inspiratory squeaks auscultated during the pulmonary exam Most likely diagnosis? a. Sarcoidosis b. Idiopathic pulmonary fibrosis c. Silicosis d. Lung cancer

b. Idiopathic pulmonary fibrosis

A 27-year-old male accident victim with a head injury is admitted to the ICU and kept on mechanical ventilatory support. On the seventh day after admission, he is clinically diagnosed with pneumonia. Blood samples and lower respiratory secretions are submitted to the laboratory for culture; empiric antimicrobial therapy is started. What is the most likely etiologic agent of pneumonia in this patient? a. Streptococcus pneumoniae b. Klebsiella pneumoniae c. Mycoplasma pneumoniae d. Moraxella catarrhalis e. Haemophilus influenzae

b. Klebsiella pneumoniae

A 24-year-old man undergoes a routine medical check-up to become a volunteer in the ER. PPD skin test shows an induration diameter of 9 mm. Sputum and chest X-ray are done; they are negative for tuberculosis. He is otherwise healthy and has no fever, cough, or other symptoms of Mycobacterium tuberculosis infection. What is the most appropriate explanation for the doubtful tuberculin test in this patient? a. Incorrect CXR and sputum report b. Previous BCG vaccination c. Active TB infection d. Testing performed incorrectly

b. Previous BCG vaccination

Gram negative rods May be seen in patients with Cystic fibrosis, bronchiectasis, or hospital-acquired a. Klebsiella pneumoniae b. Pseudomonas aeruginosa c. Streptococcus pneumoniae d. Pneumocystis pneumoniae

b. Pseduomonas aeruginosa

A 4-year-old boy presents with a 3-day history of fever with chills, cough, and fast breathing. His parents report decreased oral intake and increased difficulty breathing with retractions over the last 24 hours. His initial vital signs are heart rate 144 bpm; respiratory rate 32/min; temperature 101.3°F (38.5°C); oxyhemoglobin saturation 89% on room air. He is immediately started on supplemental oxygen, and his oxyhemoglobin saturation improves to 95%. Subsequent evaluation, including a chest X-ray, is suggestive of right middle and lower lobe pneumonia. What is the mechanism for the low oxyhemoglobin saturation in this patient? a. Hypoventilation b. Ventilation-perfusion mismatch c. Diffusion block d. Shunt e. Increased dead space in lungs

b. Ventilation-perfusion mismatch

What drug is used as a first-line agent for children under the age of five with uncomplicated community-acquired pneumonia: a. Cipro b. Doxy c. Amoxicillin d. Clindamycin

c. Amoxicillin (high dose)

Patients who have poor dental hygiene or aspiration risk factors (ie - seizure patients, stroke patients, neurologically impaired patients) May progress to pulmonary abscess Group of organisms? a. Coccidioidomycosis b. Mycoplasma pneumoniae c. Anaerobic organisms d. PCP

c. Anaerobes

A 72-year-old man presents with progressive shortness of breath over the years. He denies chest pain or a history of smoking. The patient was in the construction business for many years, and before that he worked as a shipbuilder. Chest X-ray reveals marked interstitial fibrosis and calcified pleural plaques on the lateral chest wall. Most likely diagnosis? a. Sarcoidosis b. Silicosis c. Asbestosis d. Byssinosis

c. Asbestosis

Which condition increases risk of TB, atypical mycobacterial infections and fungal infections? a. Byssinosis b. Simple silicosis c. Complicated silicosis d. Asbestosis

c. Complicated silicosis

What is the most common indication for a lung transplant? a. IPF b. Asthma c. Emphysema in COPD d. PCP

c. Emphysema in COPD patients

You have just taken over the management of a 55-year-old man with COPD who was admitted 3 days earlier for community-acquired pneumonia. He currently feels somewhat better, and he has been afebrile for the last 24 hours. What has been shown to improve life expectancy in a patient like this? a. Antibiotics b. Bronchodilator therapy c. Home oxygen d. Inhaled steroids e. Acetazolamide

c. Home oxygen

A 14-year-old male patient presents with two episodes per week of shortness of breath exacerbated by playing soccer. His mother has given him her albuterol inhaler on several occasions, and his cough and shortness of breath improve significantly. He wakes up 1-2 times per month with coughing episodes. He has a strong family history of asthma. He denies fever, chills, and chest pain and has no known drug allergies. In addition to his own albuterol inhaler, what medication should be prescribed for this patient? a. Oral steroids b. Oral antihistamine c. Inhaled corticosteroids d. Oral leukotriene modifier

c. Inhaled corticosteroids

A 75-year-old man presents with a 4-month history of dyspnea on exertion and a productive cough. He also unintentionally lost 10 lb in 2 months. His past medical history is significant for coronary artery disease and myocardial infarction (MI). He has smoked the occasional cigar over the last few years. He has been retired for 12 years, but he worked odd jobs in construction for 30 years. He also helped his father in the family's auto shop. Vital signs are normal. Physical exam is remarkable for decreased breath sounds in left lower lung fields and dullness to percussion. A chest radiograph shows a left-sided pleural effusion. What is the most likely diagnosis? a. Sarcoidosis b. Congestive heart failure c. Malignant mesothelioma d. Pneumonia e. Recurrent postmyocardial infarction pericarditis

c. Malignant mesothelioma

A 72-year-old man presents with longstanding and increasing dyspnea and a 3-day history of shortness of breath, coughing, and unilateral sharp chest pain. Pain is worse when he takes a deep inspiration and when he coughs. PMH is significant for a smoking history. Denies occupational exposure, and drug or alcohol use. Vital signs are BP 150/90, HR 96, RR 26, O2 94% on room air. Chest examination of the left posterior chest reveals a dull percussion note, inaudible bronchovesicular breath sounds, decreased tactile fremitus, a pleural friction rub on inspiration and diminished voice sounds below the sixth intercostal space. Significant bilateral lower extremity edema is also noted. A chest X-ray reveals blunting of the costophrenic angle. Most likely diagnosis? a. Pneumothorax b. Pulmonary fibrosis c. Pleural effusion d. Bronchiectasis

c. Pleural effusion

A 50-year-old man is evaluated for non-productive cough and shortness of breath. He reports a progressive cough that has worsened over the past year. Over the last 2 weeks, he has increasing cough, chest pain, and low-grade fever. His occupational history reveals coal mining for 25 years. He denies any smoking, alcohol consumption, travel history, or sick contacts. He also denies sore throat, otalgia, abdominal pain, peripheral edema, rashes, or pruritus. Best treatment? a. Oseltamivir b. Amoxicillin-clavulanate c. Prednisone d. Acyclovir

c. Prednisone

A 75-year-old man is recovering from a pneumonia caused by Streptococcus pneumoniae; his condition suddenly deteriorates. He presents after developing a persistent fever, chills, cough, and diaphoresis. A CBC reveals leukocytosis with a left-shift. A chest X-ray demonstrates an air-fluid level in the pleural space, which is suggestive of an abscess. What organism caused the sudden deterioration? a. Pseudomonas aeruginosa b. Chlamydia trachomatis c. Staphylococcus aureus d. Legionella pneumophila

c. Staphylococcus aureus

Gram positive diplococci Most common community acquired pneumonia "Typical" organism Textbook presentation of fever, chills, cough with "rusty brown sputum" a. Mycoplasma pneumoniae b. Viral pneumonia c. Streptococcus pneumoniae d. Pneumocystis pneumoniae

c. Streptococcus pneumoniae

A 33-year-old man presents with shortness of breath, wheezing, mild fever, and fatigue. He has had several similar episodes in the past, and each previous episode began after a cold that moved into his chest. Over the past several weeks, he has had a productive cough most mornings. He has no other symptoms or exam findings. He smokes on a social basis. His CXR is normal and most recent pulmonary function tests reveal a reversible airflow limitation. What is the most likely diagnosis? a. Chronic emphysema b. Chronic bronchitis c. Cor pulmonale d. Asthmatic bronchitis e. Bronchiectasis

d. Asthmatic bronchitis

A 50-year-old man presents with bilateral pneumonia. He recently traveled from a work conference last week and presented with fever, cough, and malaise 4 days ago. He was given a BSA and progressively became worse over the course of the antibiotic treatment. On exam, his body temperature is 40°C, RR is 35/min, and HR is 100/min. CXR shows patchy infiltrates without evidence of consolidation. A sputum culture is performed and is significant for the presence of WBC in the Gram stain, but there are no organisms present. The culture result is negative. Based on your suspected diagnosis, what is the drug of choice in treating this patient? a. Vancomycin b. Prednisone c. Metronidazole d. Azithromycin

d. Azithromycin for suspected legionella from hotel AC

If you're wanting a greater gram negative drug coverage for Klebsiella pneumoniae, what can be used? a. Macrolides b. Tetracyclines c. Bactrim d. Fluroquinolone

d. Fluoroquinolone

Classified as a fungus Seen in AIDS patients/immunosupressed patients Patients may be hypoxic and progress to acute respiratory distress syndrome Diffuse, bilateral, symmetrical interstitial infiltrates or may appear normal Treatment is high dose Bactrim Prophylaxis - PO Bactrim in AIDS pt's with CD4 count <200 a. Coccidioidomycosis b. Histoplasmosis c. Anaerobic organisms d. PCP

d. PCP

A 69-year-old woman presents with shortness of breath. She states it has been worsening over the last 3-4 days; she also is experiencing increased fatigue. The patient is not on any daily medications other than over-the-counter multivitamins, and she has no pertinent past medical history. Physical examination is significant for an oral temperature of 101.5°F, and during auscultation, there are absent breath sounds noted in the right lower lung field. Tactile fremitus reveals an absent result in that same lung field, and percussion over that area creates a dull percussion note. Most likely diagnosis? a. Pneumothorax b. COPD c. Asthma d. Pleural effusion

d. Pleural effusion

A 22-year-old man presents with sudden onset of shortness of breath and right-sided chest pain. Symptoms began abruptly yesterday. He felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He smokes one pack per day; he has an otherwise non-contributory past medical history. On physical exam, the patient is in mild respiratory distress. He has a slightly elevated heart rate and respiratory rate. He is normotensive. His trachea appears deviated to the left. On pulmonary exam, breath sounds are diminished on the right. Hyperresonance is noted on percussion of the right chest compared to the left. Other than tachycardia, his cardiovascular exam is normal. What test finding is most diagnostic for your suspected diagnosis of this patient? a. Blunting of costophrenic angles on chest X-ray (CXR) b. Increased pH on arterial blood gas (ABG) c. Oxygen saturation less than 90% on pulse oximetry d. Pleural line on chest X-ray (CXR) e. Sputum smear positive for acid-fast bacilli (AFB)

d. Pleural line on chest X-ray for pneumothorax

A 30-year-old immunocompromised patient presents with a 2-week history of breathlessness and a non-productive dry cough. The patient is afebrile, pulse is 100, and BP is 110/70 mm Hg. On auscultation, scattered rales all over the chest are heard. A chest x-ray shows diffuse air-space and interstitial shadowing in both lungs. Most likely diagnosis? a. Mycoplasma pneumoniae b. Viral pneumonia c. Streptococcus pneumoniae d. Pneumocystis pneumoniae

d. Pneumocystis pneumoniae

A 22-year-old man presents with a sudden onset of shortness of breath and right-sided chest pain. Symptoms began yesterday, and he felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He is a 1 pack-per-day smoker; otherwise, he has a noncontributory past medical history. On physical exam, the patient is in mild respiratory distress, with a slightly elevated heart rate and respiratory rate. He is normotensive. His trachea appears deviated to the left. On pulmonary exam, breath sounds are diminished on the right. Hyperresonance is noted on percussion of the right chest compared to the left. Other than tachycardia, his cardiovascular exam is normal. A chest X-ray is obtained, and a pleural line is visible. What is the most likely diagnosis? a. Bronchiectasis b. Bronchitis c. Asthma d. Pneumonia e. Pneumothorax

e. Pneumothorax- indicated by unilateral diminished breath sounds

A 63-year-old male patient 2 days post left total hip replacement begins to report chest pain. The pain is worse with deep inspiration, and it is associated with dyspnea. Heart rate and respiratory rate are elevated. EKG is significant for sinus tachycardia What test is the gold standard for the patients suspected diagnosis? a. Bronchoscopy b. Chest CT c. Chest x-ray d. Echocardiogram e. Pulmonary angiography

e. Pulmonary angiography for suspected PE

A 45-year-old woman presents with insidious onset of increasing dyspnea. A chest X-ray revealed nodular infiltrates and marked hilar lymphadenopathy. The transbronchial biopsy demonstrated non-necrotizing granulomas. What is the most likely diagnosis? a. Asbestosis b. Idiopathic pulmonary fibrosis c. Coccidioidomycosis d. Hypersensitivity pneumonitis e. Sarcoidosis

e. Sarcoidosis