Pulmonology cases

A 17 year-old girl presents with a chronic cough productive of copious, foul-smelling, purulent sputum. The patient is afebrile and the lung examination reveal crackles at the lung bases bilaterally. 1. What is the most likely diagnosis? A. Bronchiolitis B. Bronchiectasis C. Pneumonitis D. Pulmonary Fibrosis 2. What other diagnosis is likely in this patient's history or should you be suspicious of? A. Asthma B. Muscular Dystrophy C. Renal Failure D. Cystic Fibrosis

1. Bronchiectasis 2. CF

A 59 year-old woman presents to the clinic complaining of a daily productive cough for the last 3 years which is worse in the winter months. She has some occasional dyspnea with exertion. She denies any fever or weight changes. She is a current 1 pack per day smoker and has a 39 pack-year history of smoking. Physical examination is currently normal. 1. What is the most likely diagnosis? A. Asthma B. Bronchiectasis C. Chronic Bronchitis D. Tuberculosis E. Pneumonitis 2. What evaluations other than chest radiography should most likely be undertaken. A. Spirometry B. CT Scan of the Chest C. Sputum Culture D. Bronchoscopy

1. C-Chronic bronchitis 2. A.-Spirometry

A 42 year-old nurse with a medical history inclusive of only hypertension presents for interpretation of his tuberculin skin test done as part of his yearly employment screening. He denies any symptoms and is in his usual state of health. Test shows 7 mm of induration. 1. What is the most appropriate next step in management? A. Interferon Gamma Release Assay B. Chest X-Ray C. Re-screen in 1 year D. Start 6 month course of daily Isoniazid 2. The next day the patient calls back, concerned because he remembered taking care of a patient with tuberculosis 2 weeks ago. Chest x-ray in performed and is normal. What is the most appropriate next step in management? A. Interferon gamma release assay B. Chest CT Scan C. Start Isoniazind, Pyrazinamide, ethambutol, and rifampin D. Start Isoniazid [not active dz so no other confirmation to do; latent TB so just 1 drug] 3. What is the most common form of transmission of Mycobacterium tuberculosis? A. Aerosolized droplets B. Blood borne C. Transdermal D. Airborne

1. C.-Rescreen 1 year 2. D.-Start Isonazid 3. A.-Aerosolized droplets

A 72 year-old retired pharmacist presents to the ED with a complaint of fever for the last 2 days and a several month history of worsening dyspnea. He has occasional dry cough. On his intial presentation his oxygen saturation was 88% but this improved with oxygen administration His medical history is significant for atrial fibrillation and hypertension. His medications include ASA and diltiazem. He was previously prescribed amiodarone for atrial fibrillation but only took this for a month before it was discontinued. Physical exam is significant for bibasilar crackles and digital clubbing. 1. What is the most definitive method of establishing a diagnosis in this patient? A. High-Resolution CT Scan B. MRI C. Pulmonary Function Testing D. Surgical Lung Biopsy E. Ventilation Perfusion Scan 2. What is the most commonly prescribed next step in treatment for this patient? A. Colchicine + Broad Spectrum Antibiotics B. Corticosteroids + Immunosuppressive agents C. Hospitalization + Mechanical ventilation D. Lung Transplantation E. Methotrexate and Low Dose Corticosteroids

1. D. Surgical Lung Biopsy [for definitive dx; we will still do A though] 2. B. Corticosteroids + Immunosuppressive agents

A 39 year-old man presents to the emergency department with acute onset of shortness of breath, hemoptysis, and left -sided pleuritic chest pain. His past medical history includes medication-controlled asthma, PUD, and a recent onset of idiopathic nephrotic syndrome (severe proteinurea). Physical Exam • VS HR 110 BP 180/110 RR 28 Tc 99 F • Cardiac examination demonstrates tachycardia and 2+ lower extremity edema • Pulmonary examination is normal • Laboratory tests show an elevated creatinine and are otherwise unremarkable. CXR is normal EKG is shown: Shows S1-Q1-T3 pattern 1. What is the most likely diagnosis? A. Aortic Dissection B. Esophageal Spasm C. Myocardial Infarction D. Pulmonary Embolism 2. What is the most appropriate test to confirm the diagnosis? A. Cardiac Catheterization B. CTA PE Protocol C. Ventilation/Perfusion Scanning [bc kidney issues so no contrast] D. Serum troponin level 3. Prior to the interpretation of testing the patient suddenly becomes unresponsive and his blood pressure is now 63/32. What is the next best step in management? A. Anticoagulation with heparin B. Antiembolization stockings C. Insertion of and IVC filter D. Thrombolysis with t-PA E. Anticoagulation with LMWH

1. D.-PE 2. C. VQ screening 3. thrombolysis with TPA

A 66 year-old man with a history of chronic back pain presents to the office complaining of 3 days of cough productive of "green" sputum, fever and left-sided sharp chest pain that is worse with deep inspiration. He admits to one episode of shaking chills since the onset of his illness. He denies and nausea or vomiting. His only medication is as needed Tylenol for his back pain. He has a 10 pack-year history of smoking, but quit 25 years ago. Physical Exam: • VS HR 100 BP 160/80 RR26 Tc 104 F • Cardiac and Abd exams are unremarkable • Pulmonary exams shows moist crackles and egophony at the left lung base 1. Which of the following is the most likely pathogen? A. Gram-negative diplococci B. Gram-negative rods C. Gram-positive cocci in clusters D. Gram-positive diplococci in chains E. Gram Positive Rods 2. What is the most appropriate setting for this patient's treatment? A. Home [using CURB-65] B. Inpatient wards C. ICU D. ICU with plan for emergent Mechanical Ventilation 3. Which of the following is the most appropriate antimicrobial regimen for this patient? A. Azithromycin [bc going home] B. Amoxicillin C. Ceftriaxone and Azithromycin D. Piperacillin-Tazobactam and Vancomycin

1. Gram-positive diplococci in chains 2. Home [using CURB 65] 3. Azithromycin

A 47 year old patient with a history of AIDS presents to the ED with fever, tachypnea, shortness of breath, and a non-productive cough. The patient has previously refused HIV treatment and last CD4 count 6 months ago was 70. Patient is a lifelong non-smoker. Physical Exam • VS HR 102 BP 120/75 RR 22 Tc 100.7 F • Patient appears ill. • Cardiac and pulmonary examinations are unremarkable. Notably the patient's serum LDH is elevated CXR shows diffuse reticular infiltrate 1. What is the most likely diagnosis? A. Cryptococcus Infection B. Tuberculosis C. Histoplasmosis D. Pneumocystis Jiroveci Infection 2. What is the most appropriate treatment for this patient condition? A. Amphotericin B B. Trimethoprim-Sulfamethoxazole C. Azithromycin D. Pipercillin-Tazobactam & Vancomycin

1. Pneumocystis jirovecii infection 2. TMP-SMX

1 year later the same patient presents to the ED with a 1 days history of worsening dyspnea, wheezing and cough productive of purulent sputum. He has been adherent to his medication regimen. Exam shows a man in mild respiratory distress with scattered wheezes. Chest X-ray is unchanged from previous and shows no infiltrate. Which of the following should be included in this patient's management? A. Albuterol-Ipratropium Nebulizer Treatments B. Glucocorticoids C. N- Acetyl Cysteine D. Azithromycin E. Ceftriaxone [could use in lieu of azithro but azithro best] F. Tiotropium

A, B, and D

He receives the appropriate treatment. After 1 hour, he reports that he feels much better. He appears tired and is using accessory muscles for breathing. Current VS include: HR 119 and RR 19 ABG on RA now shows • pH 7.38 mm Hg • pCO2 43 mm Hg • pO2 80 mm Hg • HCO3 24 mEq/dL Troubling that he does not have resp alkalosis bc he is about to go under What is the most appropriate management? A. Admit to the general medicine floor B. Admit to the ICU [and continue tx] C. Continue current treatment and reassess in 2 hours D. Discharge home with next day follow-up

B. Admit to ICU [and continue to tx]

A 37 year-old man who recently immigrated to the U.S. presents to urgent care with a complaint of sever paroxysms of cough that have persisted for the last 4 weeks. He describes the cough as severe, causing him to have difficulty catching his breath and making him feel as if he will vomit. He states that before these symptoms he had a "head cold" but has been otherwise well. He is a non-smoker and denies any medical history. Which of the following is the most appropriate treatment choice? A. Ceftriaxone B. Erythromycin C. Isoniazid D. Penicillin E. Trimethoprim-Sulfamethoxazole

B. Erythromycin [bc of post-tussive cough]

A 33 year old woman is seen in the office for follow-up of asthma. She previously has only had mild symptoms and required occasional use of her albuterol rescue inhaler. However she reports that over the past 2 months she has been using her rescue inhaler up to 4 times per week for worsening symptoms. Her physical exam is unremarkable. What is the most appropriate next step in management? A. Continue current treatment B. Start Fluticasone C. Change albuterol to nebulized formulation D. Start Tiotropium (Spiriva) E. Start Advair

B. Start fluticasone

A 72 year old woman is evaluated in the ICU on her second day of admission. She was admitted in a coma due to an intracerebral hemorrhage. She is currently on mechanical ventilation with the following settings: • RR: 15TV: 400 FiO2 40% PEEP 5 • Her morning ABG shows • pH 7.34 • pCO2 50 • pO2 78 CXR shows bilateral opacities What is the most likely diagnosis? A. Bilateral Ventilator Associated Pneumonia B. Diffuse Alveolar Hemorrhage C. ARDS D. Interstitial Lung Disease

C. ARDS

A 67 year old man is seen in the office for follow-up of COPD. He was diagnosed 1 year ago after presenting with complaints of occasional dyspnea. Spirometry 6 months ago showed: • FEV1/FVc = .60 • FEV1 = 70% He has never had an exacerbation of his symptoms and his symptoms had been well controlled with as needed albuterol. He reports that he now has been having breathlessness on a daily basis. He does report occasional cough with scant sputum production. His examination is normal with the exception of occasional scattered wheezing What is the most appropriate next step in management? A. Prednisone for 5 days B. Start daily Fluticasone C. Start daily tiotropium D. Start daily Roflumilast

C. Start daily tiotropium

A healthy 18 year-old high school student presents to the ED complaining of an acute onset of dyspnea and right sided chest pain that occurred without an inciting event. Physical examination reveals unilateral chest expansion and decreased breath sounds. What is the most likely diagnosis A. Atypical Pneumonia B. Pericarditis C. Pulmonary Embolus D. Spontaneous Pneumothorax E. Vocal Cord Dysfunction

D. Spontaneous pneumothorax

A 32 year-old African-American woman complains of intermittent fevers and fatigue for the past month. She has no medical history and does not take and medications She is a lifelong non-smoker Physical Exam • VS HR 75 BP 115/70 RR 18 Tc 100.6 F • Non-tender, mobile cervical and axillary lymph nodes are noted • Pulmonary auscultation reveals fine crackles bilaterally. CXR: bilateral hilar adenopathy Lymph node biopsy shows non-caseating granulomas. Which of the following is the most appropriate therapy? A. Allopurinol B. ACE Inhibitor C. Cyclosporine D. Glucocorticoids E. Isoniazid, Rifampin, Ethambutol, and Pyrazinamide

D. Glucocorticoids

A 23 year-old man is evaluated in the ED for a worsening asthma exacerbation that began 2 days ago following an upper respiratory infection. He has been using an albuterol inhaler at home without improvement. He has a history of poorly controlled asthma and has been hospitalized once a year for the past 4 years. He required intubation 2 years ago. Medical history is only Asthma. He has never smoked Physical exam • VS HR 124 BP 138/85 RR 20 TC 99.1 F • In moderate discomfort. • Audible wheezing with diffuse wheezing on exam ABG • pH 7.48 • pCO2 30 mmHg • pO2 85 mm Hg • HCO3 24 mEq/dL What is the most appropriate next step in management? A. Azithromycin B. Albuterol C. Prednisone D. Prednisone and Albuterol

D. Prednisone and albuterol

A 62 year old man with history of coronary artery disease, HTN, and HLD, presents to the office in follow-up and complains of a 1 month history of cough. Cough is dry and is non-productive. He denies any fever, chills, or weight changes. He denies ay other recent illness His current medications include: ASA, Atorvastatin, Carvedilol, Lisinopril, and as needed acetaminophen. He medications have not been modified in over a year. He reports occasionally smoking cigars but denies ever smoking on a routine basis. Physical exam in unchanged from previous and is unremarkable. His symptoms are most likely as a result of which of the following? A. GERD B. Cigar Smoking C. Medication Effect [lisinopril; should go away in a week] D. Lung Cancer

Medication effect (lisinopril, should go away in a week)

A 25 year old woman presents to the clinic in January with a complaint of acute onset of fever, malaise, myalgias, and cough. She has been otherwise healthy. She is a life-long non-smoker, and refuses all vaccines. On physical exam: • VS HR 99 BP 110/80 RR 20 Tc 102.0 F • Uncomfortable woman in no distress. • Chest and Pulmonary exam are unremarkable. What is the most appropriate treatment option? A. Acyclovir B. Famciclovir C. Lamivudine D. Oseltamivir E. Amantadine

Oseltamivir for flu