Case Studies/Practice Questions
A 33-year-old woman who is a nonsmoker has lost 30 lb and has a cough. She is noted to have a lung mass on CXR. Which of the following lung cancers is the most likely cell type? A. Squamous cell B. Adenocarcinoma C. Small cell D. Large cell
B. Adenocarcinoma
Which of the following is not a clinical characteristic of bronchogenic carcinoma ? A. Long term treatment is to prevent smoking B. Amendable to early detection due to hemoptysis C. Definitive diagnosis requires histological exam of tissue D. Small cell treated by chemotherapy
B. Amendable to early detection due to hemoptysis
A -53-year-old man with a 20 pack-year smoking history presents with a 2-week history of a productive cough. The CXR reveals a right middle lobe infiltrate. Which of the following is the most appropriate management of this patient? A. CT scan of the chest, PFT's, and thoracoscopic wedge resection of the right middle lobe B. Antibiotic therapy for 2 weeks followed by repeat CXR. If the infiltrate persists, obtain CT of chest and bronchoscopy C. CT scan with CT-guided biopsy D. Right thoracotomy and RML resection D. Bronchoscopy and brushing and biopsy
B. Antibiotic therapy for 2 weeks followed by repeat CXR. If the infiltrate persists, obtain CT of chest and bronchoscopy
In terms of prevention of bronchogenic carcinoma, the single most important factor is A. Adherence to a low-fat diet B. Cessation of cigarette smoking C. Avoidance of asbestos exposure D. Avoidance of air pollution
B. Cessation of cigarette smoking
A 64-year-old woman comes to your office c/o hoarse voice for 4 months. She has not had fever, sore throat, or a cough. On examination she has expiratory wheezes in her left mid-lung fields. Which of the following is the best next step? A. Prescribe antibiotics for bronchitis B. Order a CXR C. Advise gargling with saltwater solution D. Prescribe an albuterol inhaler
B. Order a CXR
A 61-year-old women presents to the ER with headache, dyspnea on exertion and facial swelling for nearly 2 weeks. She has smoked 3 packs of cigarettes per day for nearly 40 years. Her blood pressure is 120/88, pulse is 90/min, respirations are 16/minute, and she is afebrile. Heart and lung examinations are normal. She has dilated veins in the neck and upper chest area. Which of the following is the most likely diagnosis? A. Tumor lysis syndrome B. Superior vena cava syndrome C. Hypercalcemia D. Pericardial tamponade E. Cord compression
B. Superior vena cava syndrome
- 68-year-old woman in the ED after coughing up red blood. For the last 3-4 months, she has had a chronic non-productive cough, is afebrile. - Recently noticed blood-streaked sputum. On ROS, she reports increased fatigue, decreased appetite, and a 25-lb weight loss in the past 3 months. She denies chest pain, fever, chills, or night sweats. - The patient has smoked one pack of cigarettes per day for the past 35 years. - Physical exam reveals fingernail clubbing. The most likely diagnosis is: A. Tuberculosis B. Chronic bronchitis C. Bronchogenic carcinoma D. Emphysema E. Bronchiectasis
C. Bronchogenic carcinoma
A 45-year-old non-smoker is noted to have a 2-cm soft tissue mass in the left lung field. Which of the following is the most appropriate next step? A. Perform a CT-guided biopsy of the mass B. Obtain sputum samples C. Evaluate all prior CXR's D. Obtain a repeat CXR in 6 months E. Perform a video-assisted thoracic resection
C. Evaluate all prior CXR's
A 56-year-old man presents with dyspnea, and CXR shows a hilar mass with ipsilateral pleural effusion. Which of the following is the best next step? A. CT scan of the chest, head and abdomen for cancer staging B. PFT to evaluate pulmonary reserve to evaluate for pneumonectomy C. Obtain a specific tissue diagnosis by biopsy of the hilar mass D. Initiate palliative radiation because the patient is not a candidate for curative resection
C. Obtain a specific tissue diagnosis by biopsy of the hilar mass
A 45-year-old man with a persistent cough is noted to have a suspicious lesion on CXR. The physician orders a CT scan of the chest. Which of the following describes the main purpose of CT imaging for a patient with a suspicious lung mass? A. Discern between exudative pleural effusion and transudative effusion B. Differentiate between malignant and benign lesions C. Determine if the mass is infectious in origin D. Differentiate between primary and metastatic disease E. Determine anatomic location of the mass
E. Determine anatomic location of the mass
A 72-year-old man is sent to the interventional radiology department by his primary care doctor to undergo a thoracentesis after a chest radiograph revealed a moderate left-sided pleural effusion. Analysis reveals a pleural fluid/serum protein ratio > 0.9 and a pleural fluid/serum LDH ratio > 0.8. Based on these findings, what is the most likely cause of this effusion? a. Cirrhosis with ascites b. Heart failure c. Hypoalbuminemia d. Malignancy e. Nephrotic syndrome
d. Malignancy
A 27-year-old man with no reported prior medical history presents to the emergency department via EMS after a gunshot to the right side of his chest. His vitals are heart rate 151 bpm, respiratory rate 32 breaths per minute, and blood pressure 88/57 mm Hg. There is noted to be decreased chest wall movement to the affected side, hyper-resonant chest percussion, and minimal to no breath sounds are heard to the right lung. What is the most appropriate initial management for this patient's condition? a. Complete a bedside thoracoscopy b. Observe the patient and administer supplemental oxygen c. Order chest radiograph d. Perform needle thoracostomy/decompression e. Perform thoracentesis
d. Perform needle thoracostomy/decompression Indicated for suspected traumatic tension pneumothorax
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. What is the most likely diagnosis? a. Asthma b. COPD c. Early left-sided heart failure d. Pleural effusion e. Pneumothorax
d. Pleural effusion
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 of 2 packs/day for 40 years (80 pack-years). The patient has other co-morbidities, including CAD, COPD, CHF, hypertension, and dyslipidemia. He denies recent travel, sick contacts, 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. What is the most likely diagnosis? a. Pneumothorax b. Pulmonary thromboembolism c. Pulmonary fibrosis d. Pleural effusion e. Bronchiectasis
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 (CXR)
A 55-year-old man presents to his pulmonologist with progressive shortness of breath over the past year. He was previously healthy and now can barely make it up the stairs in his home. A chest radiograph shows enlargement of the pulmonary arteries with a normal sized cardiac shadow and normal-appearing lung fields. An echocardiogram is performed showing a normal-shaped left ventricle and thickened myocardium in the right ventricle. Which diagnosis is most likely in this patient? a. Chronic obstructive pulmonary disease b. Hypertrophic cardiomyopathy c. Idiopathic pulmonary fibrosis d. Pulmonary arterial hypertension
d. Pulmonary arterial hypertension
An obese 34-year-old woman is brought to the emergency department with respiratory distress. Two months ago, she was in the hospital for knee surgery. Paramedics report an acute onset of dyspnea and pleuritic chest pain. She also complains of a tender thigh on the same side of her knee surgery. She is tachycardic and tachypneic, and mildly hypotensive. Examination reveals decreased breath sounds but no hyperresonance. An emergent chest radiograph is relatively normal except for some mild atelectasis. Which of the following is the most likely diagnosis? a. Acute bronchitis b. Pleural effusion c. Pneumothorax d. Pulmonary embolism
d. Pulmonary embolism
Which of the following is most closely associated with the development of acute cor pulmonale? a. Acute bronchitis b. Hospital-acquired pneumonia c. Left-sided heart failure d. Pulmonary embolism
d. Pulmonary embolism
Which of the following diagnoses should be considered when an unexplained isolated pleural effusion is found on chest radiograph? a. Bacterial pneumonia b. Heart failure c. Pneumothorax d. Pulmonary embolism
d. Pulmonary embolism That was a "WHALE" of a PE W= Westermark Sign H =Hampton's Hump A = Atelectasis L = Lovely (Meaning perfectly normal) E = Effusions
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? a. Epilepsy b. Lung scarring c. Nasal polyps d. Pulmonary hypertension
d. Pulmonary hypertension
Carcinoid tumors commonly secrete which of the following substances? a. Acetylcholine b. Calcium c. Melatonin d. Serotonin
d. Serotonin
Which of the following is the most common ECG finding associated with the diagnosis of pulmonary embolism? a. Atrial fibrillation b. Atrioventricular nodal reentrant tachycardia c. Multifocal atrial tachycardia d. Sinus tachycardia
d. Sinus tachycardia
A 67-year-old male post office worker presents with a 3-week history of increasing shortness of breath; it occurs even while he is at rest. The patient was diagnosed with congestive heart failure in the past year and he has been well controlled on oral medication. He has no history of tobacco use. He has gained 10 pounds since his last exam 2 months prior to presentation. On physical exam, there are diminished breath sounds and decreased tactile fremitus bilaterally at the base of the lungs. Dullness to percussion is also noted in the same area. He has 3+ bilateral pitting lower extremity edema. What is the most likely diagnosis? a. Lung malignancy b. Tuberculosis c. Empyema d. Spontaneous pneumothorax e. Pleural effusion
d. Spontaneous pneumothorax
Which of the following is the most common sign seen in patients presenting with a pulmonary embolism? a. Hemoptysis b. Hypoxia c. Swollen calf d. Tachypnea
d. Tachypnea
A 1-month-old premature male infant with bronchopulmonary dysplasia (BPD) remains intubated and monitored in the NICU. He has been doing relatively well and is being gradually weaned from the respirator. Suddenly, his O2 saturations and heart rate plummet, and he becomes very dusky. On quick exam, there are decreased breath sounds on the right with an asymmetric chest rise. What is the most likely explanation for his sudden respiratory and clinical change? a. Inadequate tidal volume b. Large leak around the tracheal tube c. Displacement of the tracheal tube d. Tension pneumothorax
d. Tension pneumothorax
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? a. Abdominal computed tomography scan b. Abdominal magnetic resonance imaging c. Erythrocyte sedimentation rate d. Twenty four hour urine excretion of 5-hydroxyindoleacetic acid
d. Twenty four hour urine excretion of 5-hydroxyindoleacetic acid
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%. Based on the patients history and labs, 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
d. V/Q scan IV contrast is contraindicated in patients w/ elevated creatinine
A 23-year-old man presents to the emergency room with acute onset of shortness of breath and chest pain that started 2 hours ago and has progressively worsened. He denies any sick contacts, systemic symptoms, past medical history and he does not take any medications. His vital signs are HR 130, RR 24, BP 124/72, and oxygen sat 92% on 3 L NC. On physical exam he appears to be in mild distress. Diminished breath sounds are heard in the right lung field. Which of the following imaging studies is considered first-line? a. Computed tomography angiography b. Contrast-enhanced esophagography c. V/Q Scan d. X-ray
d. X-ray Diminished breath sounds aren't heard for PE so not CTA
58y/o M admitted to the hospital for an infected diabetic foot ulcer suddenly develops SOB and AMS. PMH includes insulin-dependent DM, HTN,, and dyslipidemia. He is currently receiving IV ABX for the foot wound, insulin, oral antihypertensives, and an oral statin. He became febrile but had a negative chest X-ray. BP is 90/60 mm Hg, pulse is 120 bpm, RR are 22, temperature is 101.9°F, O2 is 80% on room air, and blood glucose level is 190 mmol/L. Physical exam reveals a purulent foot wound, an obtunded patient, decreased breath sounds with crackles bilaterally, weak pulses, cool extremities, and perioral cyanosis. A complete blood count is normal except for leukocytosis. Which condition most likely led to this patient's clinical presentation? a. Accumulation of fluid in the alveolar spaces b. Bacterial infiltrate in the interstitium c. Diffuse alveolar hemorrhage d. Eosinophilic proliferation in the interstitium e. Malignant cells in the endobronchial tissue
a. Accumulation of fluid in the alveolar spaces Infection leading to ARDS/noncardiogenic shock
62 year-old female with severe COPD presents to the emergency department with shortness of breath, she is in acute respiratory distress using accessory muscles, appears fatigued, and has perioral cyanosis. She is given IV solumedrol, and a combivent nebulizer treatment and place on 6L NRB. ABG on 6L of O2 is pH 7.25, pCO2 72, pO2 55, SO2 88% What NIV would be recommended for this patient? a. BiPAP b. CPAP c. NRB d. High flow nasal cannula
a. BiPAP Type II Resp failure: give BiPAP
An eight-year-old boy comes in your clinic for follow-up. Two days ago, he was diagnosed with pneumonia and started on amoxicillin-clavulanic acid. However, fever and cough persisted and is accompanied by decreased appetite, chest pain, and difficulty breathing. You suspect a complicated pneumonia. Which of the following physical exam findings is consistent with pleural effusion? a. Dullness to percussion b. Early inspiratory crackles c. Trachea deviates away from affected side d. Vesicular breath sounds
a. Dullness to percussion
- 55y/o M presents to the ED with SOB. EMT's report hx of stable angina and hypertension. He takes metoprolol 200mg QD, and nitroglycerin PRN for chest pain. He just returned from a 200-mile road trip 2 days prior. On exam the patient had a heart rate of 115 beats per minute, bp 125/90 mm Hg, oxygen saturation 96% on room air, and RR of 26. - Physical exam reveals left calf swelling and pain with palpation. Initial lab tests and imaging are ordered based on the suspected diagnosis, but imaging will not be available for another 8 hours. The patient's CBC is normal, and his CMP shows no signs of acute kidney injury. His coagulation factors are also reassuring. D-dimer is pending. What is the initial management based on the patient's suspected diagnosis while awaiting imaging results? a. Empiric anticoagulation therapy with low-molecular-weight heparin b. Empiric anticoagulation therapy with unfractionated heparin c. Inferior vena cava filter d. Surgical embolectomy e. Thrombolytic therapy
a. Empiric anticoagulation therapy with low-molecular-weight heparin
A 50-year-old woman presents with right-sided pleural effusion. Thoracentesis shows the presence of exudative serosanguineous pleural fluid and positive cytology. This finding is most typical for what condition? a. Metastatic infiltrating ductal carcinoma b. Cor pulmonale c. Systemic lupus erythematosus d. Staphylococcus aureus septicemia e. Pulmonary infarction
a. Metastatic infiltrating ductal carcinoma
Which of the following best describes cor pulmonale? a. Altered structure and function of the left ventricle b. Altered structure and function of the right ventricle c. Congenital heart disease d. Right-sided heart disease due to left-sided heart disease
b. Altered structure and function of the right ventricle R sided heart failure d/t pulmonary cause
A 47-year-old woman presents with several months of a persistent cough that recently resulted in hemoptysis. A review of system also confirms episodes of diarrhea, rash, and flushing. Physical exam is normal with the exception of focal wheezing over the right upper lobe. Which of the following is the most likely diagnosis? a. Alpha-1-antitrypsin deficiency b. Carcinoid tumor c. Pulmonary hypertension d. Pulmonary tuberculosis
b. Carcinoid tumor
A 69-year-old man presents with dyspnea on exertion (climbing stairs and walking short distances) that has slowly progressed over the last year. He has fatigue, palpitations, intermittent retrosternal chest pain, lower extremity swelling, dizziness, and "feeling faint." Associated symptoms occur upon exertion. He denies fever, chills, weight changes, cough, abdominal pain, early satiety, nausea, vomiting, diarrhea, changes in urine color/odor, flank pain, hematuria, or dysuria. No cigarette, alcohol, or drug use. Cardiac exam shows increased pulmonic component of the second heart sound (P2), wide inspiratory splitting of S2 over the cardiac apex, right-sided S3 and S4 gallops, left parasternal lift, loud diastolic murmur increasing with inspiration and diminishing with Valsalva maneuver, prominent "A" waves in jugular venous pulsations, and increased JVD. Enlarged liver with hepatojugular reflux, peripheral edema, and ascites. EKG reveals peaked P waves, rightward axis deviation, and prominent R waves in the early V leads. What is the most likely diagnosis? a. Myocardial infarction b. Cor pulmonale c. Primary biliary cirrhosis d. Left ventricular heart failure e. Pulmonary embolism
b. Cor pulmonale
A 24-year-old man with a history of smoking cigarettes presents to the emergency department with abrupt onset of left-sided sharp chest pain and dyspnea for the past 3 hours. The chest pain is worse with inspiration. The patient has no significant medical history. Vital signs include a heart rate of 103 bpm, blood pressure of 120/80 mm Hg, respiratory rate of 24 breaths per minute, pulse oxygenation of 94% on room air, and temperature of 98.6°F. The patient's chest X-ray is shown above. Which of the following would be an expected physical exam finding? a. Crackles on auscultation of the left lung base b. Decreased left-sided tactile fremitus c. Dullness to percussion on the left side d. Tracheal shift to the right side e. Wheezing on auscultation of the left lung base
b. Decreased left-sided tactile fremitus Common finding for pneumothorax
A 64-year-old man with hypertension, coronary artery disease, and poorly-controlled left ventricular congestive heart failure presents with a 3-day history of insidious chest pain. Pain is made worse when he takes a deep breath in and when he coughs. He denies any relation of pain to position, activity, or food intake. He denies fever, chills, palpitations, sputum production, wheezing, abdominal pain, nausea, vomiting, diarrhea, or peripheral edema. His physical exam reveals a widespread friction rub upon inspiration, absent lung fremitus, and reduced lung sounds over the thoracic cavity. What additional physical exam finding would be most likely expected in this patient? a. Vesicular breath sounds b. Dullness to percussion c. Tracheal shift to the affected side d. Chest wall tenderness e. Increased anteroposterior diameter
b. Dullness to percussion
A 67-year-old obese man with a past medical history of heart failure presents with complaints of daytime sleepiness and morning headaches. He notes that he frequently will doze off in church. His wife complains of his snoring. What is the gold-standard diagnostic study for your suspected diagnosis? a. Home sleep apnea testing b. In-lab polysomnography c. Nocturnal electrocardiogram d. Nocturnal pulse oximetry
b. In-lab polysomnography
Which of the following oxygen delivery methods provides the highest fraction of inspired oxygen? a. Nasal cannula b. Non-rebreather mask c. Simple face mask d. Venturi mask
b. NRB
A 45-year-old man presents with complaints of excessive daytime fatigue. His wife reports that he snores loudly and briefly stops breathing several times during the night. Physical exam reveals a tired-appearing, obese man with a large neck circumference. Which of the following is the strongest risk factor for the development of this condition? a. Male sex b. Obesity c. Smoking d. Upper airway abnormalities
b. Obesity
A 52-year-old patient who is healthy presents to the clinic following a fall down one flight of stairs. Medical history is unremarkable with no prior tobacco or illicit substance use, and the patient reports no current medications. A chest radiograph is ordered to rule out traumatic chest wall injury. While negative for acute trauma, findings indicate a 7 mm well-defined, solid lesion in the upper right lung lobe. The patient reports no pulmonary symptoms, including coughing, wheezing, hemoptysis, dyspnea, or chest pain. Physical examination reveals a well-appearing man in no acute distress with normal breath sounds, respiratory rate, and chest excursion with breathing. Which of the following is the best next step? a. Obtain a tuberculin skin test b. Obtain computed tomography of the chest c. Obtain positron emission tomography d. Provide reassurance and symptomatic treatment e. Repeat chest radiography in 3 months
b. Obtain computed tomography of the chest
A transudative pleural effusion is identified after thoracentesis. Which of the following clinical scenarios is most consistent with this type of effusion? a. 27-year-old female with a lupus flare b. 47-year-old female with alcohol use disorder with an elevated lipase c. 65-year-old male with an ejection fraction of 15% and pulmonary edema d. 72-year-old male recently diagnosed with lung cancer
c. 65-year-old male with an ejection fraction of 15% and pulmonary edema
A 28-year-old man with a history of crack cocaine abuse is rushed in to the emergency room. His mother found him in his apartment; he was cyanotic and severely short of breath. No other history is available. Examination reveals a young man in severe respiratory distress with temperature 99.2°F, pulse 102/min, respiration 40/min, BP 165/95 mm Hg, and pulse oximetry of 66%. He was intubated at his apartment by EMS personnel because of lack of improvement of his pulse oximetry on 100% non-rebreathing mask. His chest X-ray shows bilateral alveolar and interstitial infiltrates. The arterial blood gas on the mechanical ventilation (set at a rate of 12 cycles/min, tidal volume 500 mL) shows the following: PAO2/Fi02 ratio = 100 mm Hg, pH 7.52, PCO2 30, PO2 55, and O2 saturation 88%. What can be done to improve his oxygenation? a. Increase tidal volume. b. Increase respiratory rate. c. Add positive end-expiratory pressure. d. Add positive end-inspiratory pressure. e. Perform emergent thoracentesis
c. Add positive end-expiratory pressure.
A 20-year-old man presents to the clinic with a chief complaint of dyspnea and chest pain that began spontaneously six hours ago while playing basketball. He has never smoked, takes no medications, and has no family history of cardiovascular or pulmonary diseases. His vital signs are as follows: heart rate 112 beats per minute, respiratory rate 24 breaths per minute, blood pressure 114/68 mm Hg. He is six feet tall and weighs 165 pounds. On a physical exam, the left upper lung field has diminished breath sounds and is hyperresonant to percussion. There are no other abnormalities noted. What is the best initial test to confirm the diagnosis? a. Arterial blood gas b. Chest CT c. Chest X-ray d. Ventilation-perfusion scan
c. CXR
A 67-year-old woman presents with one month of progressive wheezing. On review of systems she also reports recent diarrhea. Which of the following findings on this patient's physical exam is most consistent with the diagnosis of carcinoid tumors? a. Caput medusae b. Erythema nodosum c. Flushed skin d. Paroxysmal cough
c. Flushed skin
A 50-year-old man presents with a 2-week history of not being able to see well. He is not on any medications. He has been smoking 2 packs of cigarettes a day for the past 30 years (60 pack-years). On physical examination, the right eye demonstrates ptosis and miosis, and the right side of the face is unusually dry compared to the left. No weakness is noted on the musculoskeletal exam. A chest radiograph reveals a rounded opacity in the right lung field. What is the most likely diagnosis? a. Lambert-Eaton syndrome b. Superior vena cava syndrome c. Horner syndrome d. Cushing syndrome e. Syndrome of inappropriate antidiuretic hormone secretion
c. Horner syndrome
You evaluate a 65-year-old patient for shortness of breath and note on exam decreased breath sounds at the right lung base. You are suspicious of a small pleural effusion. In which of the following views on the chest radiograph is the small pleural effusion most likely to be detected? a. Lateral b. Lateral decubitus left side down c. Lateral decubitus right side down d. Posteroanterior
c. Lateral decubitus right side down
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
c. Malignant mesothelioma
A 19-year-old Caucasian man has come to see you as the last patient of the day. He presents with sudden onset of severe shortness of breath. He states that he has been an avid basketball player all his life and was practicing about 4 hours prior to his visit when he experienced sudden chest pain and immediate shortness of breath that is still bothering him currently. He describes the chest pain in the middle of the chest, more so on the right anterior side. The patient admits to smoking half a pack of cigarettes daily. Physical examination reveals a tall, thin, well-developed man in mild distress. The only other abnormalities discovered are mild tachycardia (120 beats per minute) and diminished breath sounds in the posterior right lower lobe. Based upon the examination so far, what is the most likely diagnosis? a. Pneumonia b. Pulmonary embolism c. Pneumothorax d. Pleural effusion
c. Pneumothorax
A 70-year-old man with type 2 diabetes mellitus, hyperlipidemia, homocysteinemia, and metabolic syndrome presents with a 5-month history of excessive daytime sleepiness, a lack of refreshing sleep, a depressed mood, and an inability to focus at work and while driving. Additionally, he has been told by his wife that he snores rather loudly while sleeping. He denies fever, chills, headache, cold intolerance, weight loss, hair changes, hoarseness, dysphagia, chest pain, edema, palpitations, or changes in his bowel habits. On physical exam, he is found to be hypertensive. He has elevated BMI with abdominal obesity, and he has an enlarged neck circumference; no other abnormalities are noted. What pathological mechanism best accounts for this patient's presentation? a. Lymphocytic infiltration of the thyroid, causing fibrosis of the thyroid follicles b. Compression of the superior vena cava by an infiltrating mediastinal neoplasm c. Reduced inspiratory patency of the airway due to relaxation of the muscles d. Lower airway inflammation with mucosal thickening and mucus hypersecretion
c. Reduced inspiratory patency of the airway due to relaxation of the muscles
Which of the following is the most common electrocardiographic finding in the setting of a pulmonary embolism? a. A new incomplete right bundle branch block b. P-wave pulmonale c. S1-Q3-T3 pattern d. Sinus tachycardia
c. S1-Q3-T3 pattern
A 65-year-old man presents with worsening dyspnea, cough, and respirophasic chest pain. He denies any past medical history. Physical exam shows decreased tactile fremitus, percussive dullness, and decreased breath sounds on the left lower lobe of the lung. Chest radiograph shows blunting of the left costophrenic angle. Which of the following is most likely to confirm the underlying etiology of the suspected diagnosis? a. Chest computed tomography b. Lateral decubitus radiograph c. Thoracentesis d. Ultrasonography e. Ventilation-perfusion scan
c. Thoracentesis
A 67-year-old male patient presents with dyspnea and chest pain 3 days after flying home from Europe. Past medical history is unremarkable. Workup reveals a pulmonary embolism. The patient has required 6 L of O2 to maintain a saturation above 90% and he remains tachycardic. Blood pressure 118/80 mm Hg. Electrocardiogram does not suggest right ventricle dysfunction or myocardial necrosis. What therapy should be initiated now? a. Aspirin plus rivaroxaban b. Warfarin plus clopidogrel c. Clopidogrel plus apixaban d. Low molecular weight heparin plus aspirin e. Low molecular weight heparin plus coumadin
e. Low molecular weight heparin plus coumadin
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. Foreign body in the bronchus d. Pneumonia e. Pneumothorax
e. Pneumothorax
A 24-year-old man presents to the emergency department after experiencing a stab wound to the left thorax. Vital signs include a heart rate of 115 bpm, blood pressure of 120/80 mm Hg, respiratory rate of 22 breaths per minute, pulse oxygenation of 95% on room air, and temperature of 98.6°F. Physical examination reveals decreased breath sounds in the left lower lung fields, and bedside ultrasound reveals fluid between the lung and chest wall on the left side of the chest. You insert a chest tube and there is immediate drainage of 1,600 mL of red fluid. Which of the following is the most appropriate next step for this patient? a. Initiate a norepinephrine drip b. Initiate a vasopressin drip c. Order chest CT angiography d. Perform needle decompression e. Refer for surgical thoracotomy
e. Refer for surgical thoracotomy Need to surgically place larger chest tube for hemothorax
A 63-year-old man presents for routine management of his COPD. He has no other significant medical history and reports his symptoms are well controlled on his daily tiotropium bromide inhaler, which is his only current medication. He has smoked 1.5 packs per day for the past 40 years. His vitals are BP 120/80 mm Hg, RR 13 breaths/minute, pulse 90 bpm, and O2 saturation of 95% on room air. His exam reveals prolonged expiratory wheezes, crackles in the lung bases, and an increased anteroposterior diameter. A CT of the chest shows a 1 cm nodule with ill-defined margins and a lobular appearance. Which of the following is the most appropriate next step in management? a. Pulmonary angiography stat b. Reassurance and follow-up in 3 months c. Repeat chest CT scan in 3 months d. Repeat chest X-ray in 6 months e. Surgical referral for excision
e. Surgical referral for excision Surgical excision is TOC for high probability patients - advanced age - daily smoker
Long but a good one A 72-year-old man presents due to worsening shortness of breath, orthopnea, and chest pain; symptoms have been occurring for the past few weeks. The patient admits to some chronic heart problems, as well as fatigue, dyspnea, and a non-productive cough. He feels like symptoms have worsened recently. He denies fever, chills, and a productive cough. On physical exam, the man has mildly increased respiratory effort, but he does not appear in distress. He is barrel-chested. His breath sounds are diminished bilaterally, with dullness to percussion over the right and left lower lungs. No pleural friction rub is noted. On cardiovascular exam, an S3 gallop and mild tachycardia (110 bpm) are noted. Clubbing of the fingers, dependent edema in the lower extremities, and jugular venous distention are also noted. His cardiac enzymes and electrocardiogram demonstrate no acute cardiac pathology. Pleural fluid and cardiomegaly are found on the chest X-ray, and a thoracentesis is performed. The pleural fluid is generally clear in color, testing negative for chylomicrons and triglycerides. It has low levels of red blood cells, white blood cells, protein, and lactate dehydrogenase (LDH). What is the likely underlying mechanism for the pleural effusion in this patient? a. Chylothorax from disruption of the thoracic duct b. Empyema from infection in the pleural space c. Exudates from local inflammation in capillary beds d. Hemothorax e. Transudates from increased hydrostatic pressure or decreased oncotic pressure
e. Transudates from increased hydrostatic pressure or decreased oncotic pressure