Rosh Pulmonology

A 27-year-old man with a history of asthma presents to your office for his annual exam. He reports that in the past month he has experienced wheezing and shortness of breath about once per week which resulted in using his rescue inhaler. He woke up once because of coughing. He has a peak flow meter and home readings have been 85-90% of his personal best. Which of the following best describes the classification of his asthma? AMild intermittent BMild persistent CModerate persistent DSevere persistent

A

What is the most appropriate therapy for carcinoid syndrome? AOctreotide BOlanzapine COmeprazole DOxaliplatin

A

A 16-year-old boy with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist on an as needed basis. He presently needs to use his short acting beta agonist daily. Which of the following is the most appropriate addition to this patient's medication regimen? AInhaled corticosteroid BLeukotriene inhibitor CLong acting beta agonist inhaler DMethylxanthine oxidase inhibitor

A Program, inhaled corticosteroids are indicated for mild to moderate persistent asthma. For most patients twice-daily dosing provides adequate control of asthma symptoms. Short acting beta agonists are helpful with controlling acute exacerbations by acting as bronchodilators; however they are not helpful in the long term management in patients with persistent asthma. Using an inhalation chamber, also known as a spacer, along with rinsing of the mouth after inhaled corticosteroid use decreases local side effects and systemic absorption. In addition, guidelines issued in 2019 by the Global Initiative for Asthma recommend that an inhaled low-dose corticosteroid be used whenever the short acting beta agonist is used, in adults as well as in children ages 6 years and older, due to increased effectiveness and decreased risk of exacerbations. Long acting beta agonist inhalers (C) should not be used in place of anti-inflammatory therapy. Salmeterol and formoterol are the two long acting beta-2 agonists available for asthma. They are indicated for long-term prevention of asthma symptoms, nocturnal symptoms, and for the prevention of exercised-induced bronchospasms. Leukotriene inhibitors (B) are less desirable alternatives to inhaled corticosteroids. They are used to control smooth muscle airway contraction, increase vascular permeability, and reduce mucous secretion. Methylxanthine oxidase inhibitor (D) preparations (e.g., theophylline) may have beneficial effects in some patients, but their value is limited due to a narrow therapeutic window and modest efficacy.

A 17-year-old girl with a history of asthma presents to your office with complaints of wheezing and shortness of breath. She says that in the past month she has experienced symptoms approximately 3-4 times per week requiring use of her short-acting beta agonist inhaler. She has also woken up at night four times during the month with shortness of breath and occasionally gets dyspneic on her daily walk. Which of the following is the most effective management? AAdd a low dose inhaled glucocorticoid BAdd a low dose inhaled glucocorticoid plus long-acting beta agonist CContinue use of short-acting beta agonist only DStart an oral course of glucocorticoids

A mild persistent asthma is defined as having symptoms more than twice per week but less than daily, 3-4 nocturnal awakenings per month Mild persistent asthma requires daily use of a long-term controlling medication, the most preferred option being a low dose inhaled glucocorticoid.

A previously healthy 27-year-old man presents to your office with a complaint of cold symptoms. He says that initially he had sinus congestion and a sore throat, which have since resolved, but he has also had a productive cough for approximately 10 days that is keeping him up at night. Physical exam reveals a temperature of 98.6°F and mild, diffuse wheezing on auscultation of the lungs. Which of the following is the most appropriate therapy? AAlbuterol BAzithromycin COseltamivir DPrednisone

A Acute bronchitis is a common condition involving inflammation of the bronchi caused by upper airway infection. It is a self-limited condition that is almost always caused by a virus. Acute bronchitis presents as a cough, which may be productive and can last from 1-3 weeks. Diagnosis is based on clinical presentation. Care must be taken to differentiate acute bronchitis from pneumonia, which presents with a combination of fever, cough with sputum production and constitutional symptoms requiring treatment with antibiotics. Treatment of acute bronchitis is symptomatic with initial interventions including non-steroidal anti-inflammatory agents, acetaminophen, or aspirin. Patients with wheezing may benefit from a trial of inhaled beta-agonists, such as albuterol. Patients should be reassured of the course of viral illness and that antibiotics are not indicated in the treatment of acute bronchitis.

What is the most common cause of minor hemoptysis in the emergency department? AAcute bronchitis BPneumonia CPulmonary embolism DTuberculosis

Acute bronchitis is MC however the other are true but just less common

A 37-year-old man presents with cough and shortness of breath. Vital signs are T 102°F, BP 110/76, HR 108, RR 20, and oxygen saturation of 92% on room air. His chest X-ray is shown above. Which of the following helps determine the causative organism? AExposure to white powder BHistory of smoking CRecent influenza infection DResidence in Connecticut

After a recent influenza infection, patients may develop a Staph aureus pneumonia. Of particular concern is community-associated methicillin-resistant Staph aureus (CA-MRSA) after influenza especially in a rapidly progressive pneumonia in younger, healthy patients. Staph aureus pneumonia often have necrotizing features creating the cavitation and may also lead to the development of pneumatoceles.

Which of the following organisms is most associated with pneumonia and bullous myringitis? ABordetella pertussis BHaemophilus influenzae CStreptococcus bovis DStreptococcus pneumoniae

Although bullous myringitis is described as a classic finding in Mycoplasma. pneumoniae infections, it is not specific for mycoplasmal infection and is present in only a few cases. S. pneumoniae infection is most likely the cause of bullous myringitis in the setting of pneumonia. S. pneumoniae is a common cause of community acquired pneumonia. Bullous myringitis is an inflammation of the eardrum in which painful, fluid filled vesicles form. Patients with S. pneumoniae will present with typical signs of pneumonia. The presence of otalgia should prompt evaluation for bullous myringitis. Bullous myringitis will resolve with antibiotics directed at the S. pneumoniae pneumonia.

A 12-year-old girl presents to the clinic with acute onset of productive cough, fever to 102°F, and extreme fatigue. She is awake and alert but appears tired. Her oxygen saturation is 96%, and respiratory rate is 15 breaths per minute. Lung auscultation reveals fine crackles in the left upper lobe. A chest radiograph reveals localized alveolar infiltrates with consolidation. Which of the following is the most appropriate treatment for this patient? AAmoxicillin BAzithromycin CCefotaxime DClindamycin

Amoxicillin (this was a hard one only 23% got right) - Patient's constellation of symptoms are concerning for community-acquired pneumonia. - The onset of symptoms was acute and severe, the cough is productive, and the lung findings are focal, which is suggestive of a typical bacterial etiology. - S. pneumoniae is the most frequent cause of "typical" bacterial pneumonia in children of all ages. - Amoxicillin is the recommended first-line treatment for outpatient pediatric pneumonia thought to be secondary to S. pneumoniae. - Macrolide antibiotics, such as azithromycin (B), are the treatment of choice for community-acquired pneumonia due to atypical pathogens.

A 26-year-old gravida 3 para 2 at 12 weeks gestation presents with fever, myalgias, headache, and malaise. There have been multiple cases of influenza in the community and her influenza swab is positive. Which one of the following is recommended by the Centers for Disease Control and Prevention in this situation? AAcyclovir BOseltamivir CRimantadine DSupportive therapy only

B

A 68-year-old woman presents with cough that has been present for the past several months. She describes it as a dry, hacking cough that she attributed to her cigarette smoking. A chest X-ray is completed that shows a 2.5 cm mass in the peripheral right lower lobe. Sputum cytology is performed and is negative for malignant cells. What is the next best step in managing this patient? AOrder bronchoscopy BRefer for transthoracic needle aspiration CRepeat chest X-ray in six months DSmoking cessation and reassurance

B

A 30-year old woman presents with shortness of breath. She has a history of asthma since childhood. She says that she uses her rescue inhaler 3 days each week. On average, she wakes up in the middle of the night with symptoms approximately three times a month. Her vital signs are BP 120/76, HR 112, RR 26, and oxygen saturation 92% on room air. The patient appears to be in mild distress with intercostal retractions present, and respiratory exam is remarkable for diffuse wheezing. This patient is diagnosed with an acute asthma exacerbation. Which of the following best classifies this patient's asthma? AIntermittent BMild persistent CModerate persistent DSevere persistent

B What drugs are commonly associated with an asthma exacerbation? Answer: Aspirin and beta-blockers

Asbestosis exposure increases the risk of developing which of the following types of malignancies the greatest? ALarge cell carcinoma BMesothelioma CSmall cell carcinoma DSquamous cell carcinoma

B Mesothelioma is most commonly caused by exposure to asbestos Asbestosis Patient with a history of working in shipping, roofing, or plumbing Complaining of SOB, nonproductive cough, chronic hypoxia CXR will show "ivory white" calcified pleural plaques Biopsy will show ferruginous bodies Comments: Associated with mesothelioma

A 19-year-old man presents with a sore throat and difficulty swallowing. He has had four days of worsening sore throat and fever but today he was unable to swallow any liquids. Physical examination reveals a muffled voice, difficulty tolerating saliva, and minimal pharyngeal erythema with a midline uvula. He also has tenderness over the hyoid bone. Which of the following is the best management of this patient? AInhaled racemic epinephrine and discharge home BIntravenous antibiotics and admission CIntravenous corticosteroids and discharge home DNeedle aspiration of peritonsilar area

B Epiglottitis is a localized cellulitis This patient presents with symptoms and signs concerning for epiglottitis and should have antibiotics started and admission for further monitoring.

A 36-year-old veterinarian presents with myalgias, dry cough, and severe headache. His vital signs include blood pressure 138/74 mm Hg, heart rate 82 beats/minute, temperature 39°C, and oxygen saturation 94% on room air. He has hepatosplenomegaly on abdominal exam. His chest X-ray shows patchy perihilar infiltrates. What of the following is the most appropriate antibiotic for this patient? AAmoxicillin-clavulanate BDoxycycline CLevofloxacin DTrimethoprim-sulfamethoxazole

B It is harbored in avian species making bird owners, veterinarians, and pet-shop employees particularly susceptible to infection. Patients present with high fevers, severe headache, myalgias, nonproductive cough, and hepatosplenomegaly treatment of choice is a 7-10 day course of doxycycline

A 22-year-old woman presents with dyspnea. She has a history of asthma and noted increased difficulty breathing starting yesterday. She says she has been using her albuterol inhaler every 15 minutes for the last four hours without relief. What laboratory abnormality is likely to be found in this patient? AHypocalcemia BHypoglycemia CHypokalemia DHyponatremia

C

A 65-year-old man with a body mass index of 35 kg/m2 presents with a complaint of restlessness at night and daytime drowsiness. His wife says that his snoring keeps her up at night and he occasionally will stop breathing. What is his most likely diagnosis? ACentral sleep apnea BObesity hypoventilation syndrome CObstructive sleep apnea DRestless legs syndrome

C Central sleep apnea (A) is associated with Cheyne-Stokes breathing, drug use, or central nervous system disorders and is characterized by the repetitive cessation of ventilation during sleep.

Which of the following physiologic responses would occur after application of noninvasive positive pressure ventilation in a patient presenting with an acute exacerbation of chronic obstructive pulmonary disease? AIncreased alveolar dead space BIncreased LV afterload CIncreased tidal volumes DIncreased venous return

C Noninvasive positive pressure ventilation applies a consistently positive airway pressure to increase laminar flow. This leads to airway stenting, elimination of dead space through alveolar recruitment, and an increase in tidal volumes and minute ventilation. The beneficial effects of positive pressure ventilation are not only realized in the pulmonary system but also in the cardiovascular system. Patients with pulmonary edema from decompensated heart failure benefit from the increased intrathoracic pressure which decreases venous return and increases left heart output and thus decreases afterload. What is a physiologic complication of noninvasive positive pressure ventilation? Answer: Barotrauma including pneumothorax.

Which of the following is the most common opportunistic respiratory infection in patients with acquired immunodeficiency syndrome? ACytomegalovirus BMycobacterium tuberculosis CPneumocystis jiroveci DStreptococcus pneumoniae

C. PCP pneumonia Pneumocystis jiroveci is classified as a fungus.

Which of the following is true regarding active tuberculosis? AA cavitary lesion on CT of the chest is pathognomonic BIsoniazid treatment for six months is adequate therapy CIt may have varied appearance on chest X-ray DPatients with active tuberculosis need droplet precautions

CXR varied appearance - The classic X-ray finding on chest radiograph is a cavitary lesion in the upper lobe of the lung. - However, tuberculosis can cause varied abnormalites on the X-rayincluding infiltrate in any portion of the lung. - Isoniazid treatment for six months (B) is the recommended treatment for someone with evidence of a primary infection identified through a PPD test.

A 7-year-old boy is brought by his mother to the clinic because of coughing. For the past week, he has had a nonproductive cough. On physical examination, vital signs are normal, with erythematous posterior pharynx, and clear breath sounds. Complete blood count is normal. Chest radiograph reveals perihilar infiltrates. Polymerase chain reaction from the boy's nasopharyngeal specimen comes back positive for Mycoplasma pneumoniae. Which of the following is the most appropriate therapy? AAmoxicillin BClarithromycin CLevofloxacin DOseltamivir

Clarithromycin this is an atypical pneumonia in a child, first line I Azythromycin but that wasn't an answer choice so clarithromycin is just fine :) Amoxicillin is for CAP that is typical NOT atypical

A 16-year-old boy is taken to his doctor for snoring. His mother reports that his snoring keeps others in the house awake and that sometimes his breathing pauses during sleep with gasping or choking. His teachers report that he falls asleep frequently at school. On exam, he has a body mass index of 31 kg/m² and has enlarged tonsils. His symptoms are concerning for obstructive sleep apnea so the pediatrician refers him for an overnight polysomnography. Which of the following can be a longterm complication of obstructive sleep apnea? AEpilepsy BLung scarring CNasal polyps DPulmonary hypertension

D

A 64-year-old man presents with a headache and cough for the last one week. Physical exam shows facial edema, facial plethora, and prominent venous distention of the chest. History is significant for lung cancer. What is the most likely diagnosis? ACarcinoid syndrome BHorner syndrome CPancoast tumor DSuperior vena cava syndrome

D

Which of the following is the initial treatment of choice in an overweight patient with moderate obstructive sleep apnea? AAlbuterol nebulizer 30 minutes prior to sleep BOral appliances CTracheostomy DWeight loss and continuous positive airway pressure

D

What is the most common form of lung cancer?

adenocarcinoma

Which of the following HIV-positive patients suspected of having Pneumocystis pneumonia should receive prednisone before treatment with trimethoprim/sulfamethoxazole? AA 10-year-old with a normal chest X-ray and a PaO2 of 65 mm Hg BA 15-year-old with diffuse interstitial infiltrates on chest X-ray, a pulse oximetry of 92%, and PaO2 of 80 mm Hg CA 20-year-old with diffuse interstitial infiltrates on chest X-ray and an A-a gradient of 25 mm Hg DAn 18-year-old with diffuse interstitial infiltrates on chest X-ray, a pulse oximetry of 94% on room air, PaO2 of 75 mm Hg, and an A-a gradient of 10 mm Hg

Corticosteroids are used as adjunct therapy in HIV-positive patients with moderate to severe Pneumocystis jiroveci pneumonia, defined by a room air arterial oxygen partial pressure (PaO2) of less than 70 mm Hg or an alveolar-arterial oxygen gradient that exceeds 35 mm Hg . steroids should be given before trimethoprim/sulfamethoxazole because microbial degradation and clearance caused by antibiotics may trigger a severe inflammatory response. Corticosteroid therapy can blunt this inflammatory response, improve oxygenation, and reduce the incidence of respiratory failure.

A 35-year-old woman with a history of asthma presents to the emergency department with an asthma exacerbation. Treatment with an inhaled bronchodilator and ipratropium has not led to significant improvement, and she is admitted to the hospital for ongoing management. On examination the patient is afebrile, respiratory rate is 26/min, heart rate is 98 beats/min, and oxygen saturation is 94% on room air. She has diffuse bilateral inspiratory and expiratory wheezes with mild intercostal retractions. Which one of the following should be administered in the acute management of this patient? AChest physical therapy BInhaled fluticasone/salmeterol COral azithromycin DOral prednisone

D Oral prednisone is recommended for all patients admitted to the hospital with an asthma exacerbation, except for those with impending or actual respiratory arrest in which an intravenous corticosteroid is preferred. Prednisone helps to reduce inflammation of the small airways. Corticosteroids have been shown to reduce the time frame of the acute exacerbation and prevent early recurrence. The length of treatment with corticosteroids can be different depending on the individual and severity of the symptoms. The most common dispensed form is oral prednisolone for 3 to 5 days or a dose pack which is tapered over 7 days.

A 33-year-old woman with no past medical history presents with a cough and fever for one week. Her cough is productive of green sputum. Auscultation of the chest is normal. Vital signs are: T 100.2°F, BP 120/72, HR 88, RR 12, and 100% saturation on room air. She is otherwise well-appearing. What is the most appropriate plan? AAzithromycin BPrednisone CSputum cultures DSupportive care

D Bronchitis Patient will be complaining of a mucopurulent cough for more than 5 days PE will show wheezing and rhonchi CXR will show thickening of the bronchial walls in the lower lobes Most commonly caused by viruses Treatment is symptomatic relief This patient has acute bronchitis, one of the most common reasons that patients seek medical attention. During acute bronchitis, the bronchial tissue and mucous membranes along the upper respiratory tract become inflamed. Ciliary function is impaired and the airway becomes clogged with secretions. This causes transmitted sounds of rhonchi and sometimes wheezing on auscultation of the chest. The most common symptom of bronchitis is a cough, frequently associated with sputum production of any color. Other upper respiratory symptoms may be present including sore throat, rhinorrhea and nasal congestion. Low grade fever is not uncommon although higher temperatures, tachypnea, findings of focal consolidation on auscultation and hypoxia are more concerning for pneumonia. The respiratory viruses are the most common cause of acute bronchitis including coronavirus, respiratory syncytial virus, parainfluenza and influenza. Treatment of bronchitis is initially supportive. The goals of management are to alleviate the patient's symptoms. Options for treatment include antitussive agents, non-steroidal anti-inflammatories, mucolytics, and possibly short-acting beta-agonists if the patient is experiencing bronchial inflammation causing wheezing or excessive coughing Azithromycin (A) is a macrolide antibiotic frequently prescribed to patients with acute bronchitis. However, trials have not demonstrated a benefit to antibiotic therapy in patients with acute bronchitis and treatment is supportive. Prednisone (B) is not standard in the management of a patient with acute bronchitis. In patients with underlying asthma who may have an exacerbation in the setting of the acute illness, a course of steroids is an acceptable treatment. Given that viral causes are most common, sputum cultures (C) are neither indicated nor recommended in the evaluation of a patient with acute bronchitis.

Carcinoid tumors commonly secrete which of the following substances? AAcetylcholine BCalcium CMelatonin DSerotonin

D Carcinoid Syndrome Patient will be complaining of skin flushing, wheezing, and diarrhea Diagnosis is made by 24-hour excretion of 5-hydroxyindoleacetic acid (5-HIAA) in the patient's urine Most commonly caused by carcinoid tumors (neuroendocrine tumors that secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides)

A 63-year-old man presents to your office complaining of episodic diarrhea and wheezing. His wife also mentions that his skin will occasionally look flushed. You suspect carcinoid syndrome. What initial diagnostic study is most appropriate to confirm this condition? AAbdominal computed tomography scan BAbdominal magnetic resonance imaging CErythrocyte sedimentation rate DTwenty four hour urine excretion of 5-hydroxyindoleacetic acid

D While imaging such as abdominal computed tomography (CT) scan (A) or magnetic resonance imagine (MRI) ( B) may be helpful in detecting and locating masses in this patient, it is not specific enough to confirm carcinoid syndrome.

A 74-year-old woman presents with complaints of fever, productive cough with bloody sputum, shortness of breath, and headache. These symptoms developed and worsened drastically over the past 3 days. She recently recovered from an influenza infection 1 week ago. Her medical history otherwise includes only well-controlled hypertension. Vital signs on presentation are as follows: T 39°C, HR 106, BP 110/75, RR 30, oxygen sat 95% RA. A chest radiograph is obtained and a subsequent CT scan of the chest demonstrates multiple cavitary lung lesions. Which of the following organisms is most likely responsible for this patient's presentation? AClostridum perfringens BEscherichia coli CMycobacterium tuberculosis DStaphylococcus aureus

D. staph aureus This patient's presentation of pneumonia with multiple cavitary lesions on imaging is consistent with a post-viral secondary necrotizing pneumonia. The most common organism in necrotizing pneumonia, particularly after a viral upper respiratory infection, is S. aureus. Necrotizing pneumonia is known to be caused by a specific S. aureus strain that produces Panton-Valentine Leukocidin (PVL).

A six-month-old boy presents with five days of nasal congestion and discharge that has now progressed to fever, coughing, and wheezing. You suspect acute bronchiolitis. What are you likely to find on physical examination? ACervical lymphadenopathy BExpiratory wheezing CInspiratory stridor DPharyngeal exudate

Expiratory wheezing Expiratory wheezing is one of the physical examination findings of acute bronchiolitis along with tachypnea, chest retractions, prolonged expiratory phase, and rales. Inspiratory stridor is a result of upper respiratory obstruction and can be found in foreign body aspiration, epiglottitis, croup, retropharyngeal abscess, and peritonsillar abscess

PCP pneumonia mc in what demographic

HIV pt with CD4 count <200 prophyaxis with trimethoprin-sulfamethoxazole if CD4 <200

Which of the following conditions requires droplet precautions? AInfluenza BMeasles CTuberculosis DVaricella

Influenza TB is airborne precautions not droplet

PCP pneumonia will have an increase in this lab value

LDH

A 62-year-old man with a history of chronic obstructive pulmonary disease presents with cough, headache, dyspnea, and watery diarrhea that started six days ago. He was seen at a local urgent care four days ago and prescribed amoxicillin-clavulanate without improvement. He is ill-appearing with a fever of 38.7C and inspiratory rales on auscultation. Which of the following results would be most consistent with his diagnosis? ARight upper lobe infiltrate with bulging fissure on chest X-ray BSerum potassium 6 mEq/L CSerum sodium 128 mEq/L DSputum gram stain with gram positive cocci in pairs

Low sodium

A 10-year-old girl presents with fever, sore throat, cough, headache, and general malaise worsening over the past four days. Lung auscultation reveals rales in the lower left lobe. A chest radiograph demonstrates interstitial infiltrates in the lower left lobe. Which of the following is the most likely causative pathogen? AKlebsiella pneumoniae BMycoplasma pneumoniae CParainfluenza virus DRespiratory syncytial virus

Mycoplasma pneumonia

An 8-month-old previously healthy boy presents with fever, cough, and wheezing for the last two days. Physical exam reveals prolonged expiration and mild subcostal retractions. Lung auscultation reveals diffuse expiratory wheezing and tachypnea. His immunizations are up-to-date. Which of the following tests is most likely to confirm the suspected diagnosis? AChest X-ray BComplete blood count CNasopharyngeal swab for fluorescent antibody staining DThroat culture for Streptococcal infection

Nasopharyngeal swab for fluorescent antibody staining A nasopharyngeal swab (NP swab) is used to collect a sample for rapid detection of respiratory syncytial virus (RSV) by fluorescent antibody staining. This test is more than 90 percent sensitive and specific for detecting RSV. A chest X-ray may show patchy infiltrates, hyperinflation, peribronchial thickening or atelectasis but the question asked what can confirm the dx

A two-month-old boy is sent to the emergency department by his pediatrician for cough and an abnormal CBC with lymphocytosis. He is up-to-date with immunizations. His older brother, who is four years old, is not up-to-date since the pediatrician suspended his immunizations due to a developing neurologic condition. The brother has also had a febrile illness and has been coughing for more than three weeks. You observe the two-month-old coughing and see a period of peri-oral cyanosis. What method of confirmatory testing has the best combined sensitivity and specificity for diagnosis? ABlood cultures BDirect fluorescent antibody on nasal swabs CPolymerase chain reaction of nasopharyngeal secretions DSputum cultures

PCR of nasal secretions - The most sensitive and specific testing is via polymerase chain reaction (PCR) of nasopharyngeal secretions - Blood cultures (A) often identify a source in pneumonia but not pertussis. Nasal swabbing with antibody testing (B) is highly specific but less sensitive than PCR. Sputum cultures (D) are also highly specific but not very sensitive as pertussis is highly fastidious and difficult to isolate and grow via culture.

A 2-month-old boy presents with a low fever and cough. Which of the following is suggestive of Chlamydia pneumonia in this infant? ABullous myringitis BDiarrhea CRusty-colored sputum DStaccato cough

Staccato cough Bullous myringitis (A) are blisters (bullae) that are seen on the tympanic membrane during inspection of the middle ear. Bullous myringitis was previously linked to Mycoplasma pneumoniae but it appears, based on middle ear aspirate culture results, that typical acute otitis media pathogens (S. pneumoniae) are the most likely pathogens

What pathogen causes pneumonia that is associated with bullous myringitis?

Streptococcus pneumoniae. Bullous myringitis was previously linked to Mycoplasma pneumoniae but it appears, based on middle ear aspirate culture results, that typical acute otitis media pathogens are the true cause.

A 26-year-old man presents with a 2-week history of fever and a cough. He was diagnosed with HIV four months ago and is not on any antiretroviral medications. His vital signs are BP 122/76, HR 78, RR 16, oxygen saturation 92% on room air, and temperature 99.2°F. Chest X-ray is shown above. Given his presentation, which of the following antibiotics should be used to treat this patient? AAzithromycin BClindamycin CPenicillin DTrimethoprim-sulfamethoxazole

TMX-SMZ for PCP pneumonia

29-year-old man with a history of HIV presents with shortness of breath and fever. He has a productive cough but denies hemoptysis. You obtain the chest radiograph seen above. Which of the following is true regarding the patient's diagnosis? AElevated LDH is common BSpread is by the hematogenous route CSteroids should be administered prior to antibiotics if the PaO2 is < 80 DTrimethoprim-sulfamethoxazole is the treatment

The chest radiograph demonstrates miliary tuberculosis Spread of the mycobacteria occurs through the hematogenous route, which leads to the multisystem nature of miliary TB

A 68-year-old man presents for a wellness visit. He is a former smoker, having quit 3 years ago. He has a 35 pack-year history of smoking. He has no other comorbidities and is feeling well at the time of his visit. What screening needs to be performed with regard to lung cancer? AChest X-ray BLow dose chest CT scan CNo screening is indicated DPulmonary function tests

This patient needs annual low dose chest CT scans until he has been a non-smoker for 15 years consecutively. United States Preventive Services Task Force (USPSTF) guidelines state patients aged 55-80 years old who are either smokers or former smokers who quit within the past 15 years and have a total of 30 pack-years or more need annual low dose chest CTs until they have been non-smokers for 15 or more years.

If macrolide antibiotics are contraindicated in a patient with suspected pertussis, what is the second line alternative medication?

Trimethoprim/Sulfamethoxazole

A 46-year-old woman with a past history of a DVT was recently diagnosed with Burkitt's lymphoma. Recent blood work revealed a creatinine of 2.3. She is currently hospitalized to receive chemotherapy when she suddenly develops tachycardia to a rate of 130 and oxygen saturation of 91%. Which of the following is the most appropriate test to confirm the diagnosis of pulmonary embolism? A Chest X-ray B CT angiogram of the chest with intravenous contrast C D-dimer D V/Q scan

VQ scan creatinine high so CT angio w/comtrats is CI in this pt cxr has poor sensitivity for PE d-dimer is to r/out PE if negative

A 43-year-old man presents complaining of a 2-week history of gradually worsening dry cough, fatigue, and occasional shortness of breath. He has "felt warm" but has not checked his temperature. Review of systems is notable for mild diarrhea and decreased appetite, though he is drinking fluids well. He reports no chronic medical problems and takes no medications. He does not smoke. His temperature is 100.6°F, pulse 112 bpm, BP 122/78 mm Hg, RR 24 breaths per minute, and pulse oximetry is 92% on room air. He looks tired but not ill. Lung fields sound clear on auscultation, but a chest X-ray is obtained and shows diffuse infiltrates. What is the most appropriate treatment for his condition? ADoxycycline BMetronidazole COseltamivir DPiperacillin-tazobactam

atypical pneumonia treated with doxy, fq or macrolide High-dose amoxicillin, a penicillin, is the most appropriate choice for a patient who has no comorbidities with community-acquired bacterial pneumonia (CAP) if an atypical is not suspected. In this case the patient presents with an insidious onset, low grade temperature, and diffuse infiltrate's therefore doxycycline would be prescribed or a macrolide if local antibiotic resistance is less than 25% to treat an atypical pneumonia

A 56-year-old man comes to the clinic complaining of a six-day history of a mucopurulent cough and worsening shortness of breath. His temperature is 37.6°C (99.8°F). Auscultation of the lungs reveals rhonchi and wheezing throughout. Chest X-ray shows thickening of the bronchial walls in both lower lobes. Laboratory studies show a slightly elevated white blood count. Which of the following medications is most appropriate to administer for this patient's cough? AAspirin BDextromethorphan CPenicillin DPrednisone

dextromethrophan For the patient's cough, over-the-counter medications such as dextromethorphan or guaifenesin can be offered. Although the benefits of these medications for symptom improvement in patients with acute bronchitis are uncertain, multiple clinical practice guidelines suggest that offering medications for symptom relief may help reduce requests for antibiotics. Based on the constellation of findings, this patient most likely has acute bronchitis. Acute bronchitis is a self-limited inflammation of the bronchi and typically presents with mucopurulent cough for more than five days.

Which of the following physical exam findings can aid in differentiating the cause of crackles or rales, heard on lung auscultation? AClubbing BEgophony CPercussion DRespiratory rate

egophony Egophony is performed by asking the patient to say "EEE" while auscultating. If an "AH" sound is heard instead of "EEE", then this indicated an abnormal finding. This is because the sound being transmitted through an area of consolidated parenchyma. This is present in pneumonia, but not in other conditions of abnormal alveolar filling. This physical exam finding can help differentiate between pneumonia and other lung conditions such as bronchitis or emphysema.

A 25-year-old man presents for evaluation of fever and cough. He reports last week that he was diagnosed with influenza. In the last two days he developed a worsening cough productive of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR 18, and 95% oxygen saturation on room air. His chest X-ray demonstrates a lobar infiltrate in the left lower lobe. Which of the following would you most likely expect to see on the patient's Gram stain? AGram negative bacilli BGram negative diplococci CGram positive bacilli DGram positive cocci in clusters

gram + cocci in clusters - The patient had a recent influenza infection and now presents with a lobar infiltrate. Staphylococcus aureuspneumonia is classically associated with causing post-influenza bacterial pneumonia. On Gram stain this is seen as Gram positive cocci in clusters.

PCP pneumonia CXR

ground glass opacification

Which of the following findings is most suggestive of Pneumocystis jirovecii pneumonia in a patient with suspected HIV infection and shortness of breath? ABradycardia despite relative volume depletion BElevated serum lactate dehydrogenase CHyponatremia DUnilateral lobar consolidation on chest radiograph

high LDH

A 33-year-old man presents to the ED with several weeks of cough, pleuritic chest pain, weight loss, and night sweats. The patient drinks a six-pack of beer daily. Vital signs are BP 145/75 mm Hg, HR 88 bpm, RR 18 breaths/min, and T 37.7°C. Pulmonary exam reveals crackles and decreased breath sounds on auscultation. You obtain the radiograph seen above. Which one of the following is the most likely diagnosis? ALung abscess BNeoplasm CSeptic pulmonary emboli DTuberculosis

lung abscess Tuberculosis may be difficult to distinguish from a lung abscess because they share many of the same radiographic characteristics. However, primary tuberculosis is usually asymptomatic. Reactivation TB is associated with persistent cough, malaise, night sweats, fever, weight loss, and hemoptysis. The chest radiograph in reactivation TB generally shows upper lobe infiltrates with or without cavitation. The patient in this clinical scenario exhibits features more closely related to a lung abscess from aspiration pneumonia

Kerley B line may be seen in

pulmonary edema the thickening of the lung interstitium

A 67-year-old woman presents with shortness of breath and a cough for 3 days. The patient admits to recently having a fever, chills, rhinorrhea, and myalgias for 10 days. She had one episode of diarrhea and has been nauseated. Her past medical history is positive for COPD. She does not smoke but she drinks two cans of beer daily. In the ED, her vital signs are BP 120/76, HR 108, RR 20, oxygen saturation 97% on room air, and temperature 101.2°F. A chest X-ray shows a left lower lobe consolidation. It is suspected that this patient has pneumonia caused by Staphylococcus aureus. Which aspect of this patient's history supports this suspicion? AAlcohol consumption BGastrointestinal symptoms CHistory of COPD DRecent viral symptoms

recent viral symptoms The patient's recent history of fever, chills, rhinorrhea, and myalgias raises suspicion for influenza. Staphylococcus aureus is a common pathogen causing pneumonia in those currently or recently infected with influenza virus.

PCP pneumonia TX

trimethoprin-sulfamethoxazole