Pulmonary Midterm
in the inpatient setting, which antibiotic regimens are recc for empiric tx of CAP w/o risk factors for MRSA and pseudomonas?
ampicillin + sulbactam PLUS macrolide or monotherapy with fluoroquinolone
in the inpatient setting, should adults with CAP and risk factors for MRSA or pseudomonas be treated with extended spectrum antibiotic therapy instead of standard CAP regimens?
if locally validated risk factors for either pathogen are present
in the outpt setting, which antibiotic are recc for empiric tx of CAP in adults? w/o comorbidities
amoxicillin OR doxycycline OR macrolide - not recc alone bc increased resistance
This same patient is taken to the ICU for continuous monitoring and hourly neurological examinations. What is the best test to screen for DVT? A D-dimers B Platelets C CT scan D Ultrasound E Coagulation profile
d
should a clinical prediction rule for prognosis plus clinical judgement versus clinical judgment alone be used to determine inpt general medicine vs higher level (ICU) for adults with CAP?
direct admission to ICU for pts with hypotension requiring vasopressors or resp failure requiring ventilation
in adults with CAP, should gram stain and culture of lower respiratory secretions be obtained at the time of dx?
no, only if in hospital setting as severe CAP
in the inpatient setting, should adults with CAP be treated with steroids?
not for non-severe
should a clinical prediction rule for prognosis plus clinical judgment versus clinical judgement alone be used to determine inpt vs outpt tx location for adults with CAP?
use clinical judgement and PSI
Which of the following statements regarding DVT is most accurate? A A patient with thrombosis of the superficial femoral vein is never at risk for PE. B Venography is the definitive test for the diagnosis of DVT. C Thrombosis of the vena cava, subclavian veins, and right atrium are frequent sources of PE. D Venous duplex ultrasonography is most useful in diagnosing DVT in the pelvic veins. E Cancer successfully treated 5 years ago is associated with a higher risk for DVT.
b
A 52-year-old healthy man presents with a 3-day history of a pleuritic chest pain and SOB. He has normal vital signs and physical examination. Which test is most useful in ruling out pulmonary emboli in this patient? A Electrocardiogram (ECG) B Chest x-ray C Arterial blood gas (ABG) D d-dimer level E Oxygen saturation
d
A 3-month-old infant is admitted to the hospital with her third episode of lobar pneumonia and wheezing. Findings that would increase your suspicions for CF and prompt sweat chloride testing include all of the following EXCEPT: A Hyponatremia, hypochloremia, and metabolic alkalosis B Failure to thrive C Lymphocytosis D Digital clubbing E Oily appearing stools
c
A 47-year-old obese woman presents complaining of excessive daytime sleepiness, snoring, and frequent awakenings from sleep. She is having difficulty concentrating, and her sleepiness is affecting personal and professional relationships. She smokes a pack of cigarettes per day, averages two glasses of wine per night, and has hypertension and hyperlipidemia. You perform a comprehensive sleep history and physical examination. You suspect OSA. Which of the following physical examination findings is most suggestive of OSA? A Mallampati score of 2 B Obesity C Acanthosis nigricans D Peripheral edema E Elevated blood pressure
B
in adults with CAP, should blood cultures be obtained at time of dx?
no
in the outpatient and inpatient adults with CAP who are improving, what is the appropriate duration of antibiotic therapy?
no less than 5 days
A 10-year-old Caucasian boy has a history of recurrent sinusitis and multiple episodes of pneumonia. You suspect CF and order a sweat chloride test. The sweat electrolyte test result is within the normal range. What is your next step in management? A Perform DNA testing for CFTR (cystic fibrosis transmembrane conductance regulator) gene mutations. B Perform a pH probe test for gastroesophageal reflux. C Referral to pulmonologist. D Reassure parents that he does not have CF. E Place him on a high-calorie, high-protein diet.
a
After placement of a pelvic binder and rapid splinting of the left femur fracture, the above patient went to the CT scanner and was found to have a 4 cm cerebral contusion in the right frontal lobe, three right-sided rib fractures, a grade II splenic laceration, and an extra-peritoneal pelvic hematoma with no active extravasation. Which of the following thrombosis prophylaxis measures should be avoided in this patient? A Bilateral sequential compression devices B Immediately start prophylactic SC UFH upon arrival in the ICU C Graduated compression stockings D Start SC UFH after 48 hours in the ICU if there is no enlargement of the cerebral contusion
b
What is the next step in management of the patient in Questions 57.1 and 57.2? A Dobutamine stress echocardiogram B Treatment with PAP C Referral for uvulopalatoplasty D Pulmonary function testing E Dental evaluation for oral appliance
b
A 7-year-old girl is admitted to the hospital in respiratory distress due to pneumonia. This is her third admission in the past 6 months. At this time you are suspecting cystic fibrosis (CF) and order a sputum culture. Which organism would be most consistent with a diagnosis of cystic fibrosis? A Streptococcus pneumoniae B Mycobacterium tuberculosis C Pseudomonas aeruginosa D Bacillus cereus E Haemophilus influenzae
c
An 18-month-old girl is seen in the clinic for cough and fever. Her weight is in the third percentile. The mother reports she is concerned her daughter is around "toxic mold" because she has had five to six prior episodes of bronchitis since they moved to a new apartment at 6 months of age. She states that albuterol and an antibiotic are always given for treatment, and symptoms resolve in 2 weeks. A chest radiograph is obtained. What finding on the radiograph would prompt you to perform a sweat chloride test? A An enlarged cardiac silhouette B Absent thymus C Bronchiectasis D Dextrocardia E Hilar lymphadenopathy
c
By hospital day 4 the patient has been started on LMWH and her pelvis and femur fractures stabilized with external fixation devices. She has been hemodynamically stable. She has now developed swelling and pain in her right thigh and calf. What is the best diagnostic approach for her at this time? A CT angiography B CT venography C Duplex ultrasonography D Echocardiography E Venography
c
A 39-year-old man is noted to have a DVT without any known risk factors. He notes that his brother also developed a PE at age 45, and his mother developed a "clot in the leg" when she was in her 30s. Which of the following is the most likely inherited disorder in this patient? A Protein S deficiency B Antithrombin III deficiency C Factor V Leiden mutation D Antiphospholipid antibody syndrome E Familial malignancy syndrome
C
A 24-year-old woman is brought in by ambulance to the emergency department as a Level I trauma after crashing into a tree at 75 kmph. The paramedics found the patient ejected from the automobile, semi-conscious with an open left femur fracture. The patient's initial systolic blood pressure in the ED was 80 mm Hg. After a blood transfusion, the patient's mental status improved, and her blood pressure increased to 96/40 mm Hg. Upon reviewing the pelvic film, you notice a diastasis of the right sacroiliac joint and pubic symphysis. The patient gives no history of prior medical conditions. She is currently taking oral contraceptive pills. All of the following are risk factors for venous thromboembolism in this patient EXCEPT: A Age B Lower extremity fracture C Hypotension D Pelvic fractures E Oral contraceptive pills
a
in the outpt setting, which antibiotic are recc for empiric tx of CAP in adults? w/o comorbidities
augmentin OR cephalosporin PLUS macrolife OR doxycycline or monotherapy with fluoroquinolone (levofloxacin)
A 55-year-old man with HF presents to the emergency department with a 1-week history of dyspnea on exertion and swelling in both ankles. He has had no fever or cough. Chest radiography shows bilateral pleural effusions. Which of the following is the most likely pleural fluid characteristic if thoracentesis is performed? A Pleural fluid LDH 39, LDH ratio 0.2, protein ratio 0.7 B Pleural fluid LDH 39, LDH ratio 0.2, protein ratio 0.1 C Pleural fluid LDH 599, LDH ratio 0.9, protein ratio 0.1 D Pleural fluid LDH 599, LDH ratio 0.9, protein ratio 0.7
b
A 69-year-old man is being seen in the emergency center for gradually worsening dyspnea and a nagging cough over the past 3 months. He denied feeling warm or having fever. The chest radiograph shows a right-sided pleural effusion. A diagnostic thoracentesis reveals gross blood in the fluid. Which of the following is the most likely diagnosis? A Parapneumonic effusion B Malignancy in the pleural space C Rupture of aortic dissection into the pleural space D Pulmonary embolism with pulmonary infarction
b
Which of the following patients with shortness of breath has the lowest clinical probability for PE? A A 67-year-old man who underwent bilateral total knee replacements 2 weeks ago. B A 38-year-old man who underwent an uncomplicated open appendectomy 3 weeks ago. C A 35-year-old woman undergoing treatment for ovarian cancer. D A 35-year-old man with a history of a DVT 15 years ago, which occurred after an accident. E A 26-year-old woman who had an uncomplicated vaginal delivery 10 days ago.
b
A 28-year-old African American woman presents with nonspecific symptoms, including malaise and mild subjective fever. A chest x-ray reveals bilateral enlarged hilar lymph nodes ("potato nodes") with mottling of the lungs. Laboratory evaluation finds elevated serum levels of calcium and ACE. No organisms are found with any cultured material. A biopsy from her enlarged lymph nodes most likely would reveal the presence of which of the following abnormalities? A Caseating granulomas B Infiltrating malignant cells C Noncaseating granulomas D Stellate abscesses E Sterile microabscesses
c
A 35-year-old woman presents with calf tenderness and acute dyspnea. The arterial blood gas reveals a partial pressure of oxygen (Po2) of 76 mm Hg. Which of the following is the most common physical examination finding of PE? A Wheezing B Increased pulmonary component of the second heart sound C Tachypnea D Calf swelling E Pulmonary rales
c
A 39-year-old man develops a moderate free-flowing pleural effusion following a left lower lobe pneumonia. Thoracentesis reveals straw-colored fluid with gram-positive diplococci on Gram stain, pH 6.9, glucose 32 mg/dL, and LDH 1890. Which of the following is the best next step? A Send the fluid for culture. B Continue treatment with antibiotics for pneumococcal infection. C Drain the effusion via tube thoracostomy. D Schedule a follow-up chest x-ray in 2 weeks to document resolution of the effusion.
c
In the absence of contraindications for anticoagulation, the most appropriate therapy for femoral DVT with associated PE is: A Inferior vena caval filter B SC UFH upon arrival in the ICU C SC LMWH 150 to 200 units/d followed by transition to warfarin D Unmonitored IV UFH drip followed by transition to warfarin E Aspirin 325 mg PO daily
c
You decide to perform an overnight PSG study to confirm the diagnosis for the patient in Question 57.1. The study is converted into a split-night study because her AHI was found to be over 40 (normal < 5) in the first 2 hours of the study. What is the most likely diagnosis? A Mild OSA B Moderate OSA C Severe OSA D Positional OSA E Central apnea
c
A 57-year-old man presents to the ED complaining of sudden onset of shortness of breath with pleuritic chest pain. He was recently released from the hospital after being diagnosed with lymphoma. He had an indwelling catheter placed in his left subclavian vein the day before for chemotherapy administration. He was previously healthy without significant medical history. His vital signs are heart rate of 105 beats per minute, blood pressure of 126/86 mm Hg, respiratory rate of 28 breaths per minute, and O2 saturation of 100% on room air. The breath sounds are clear bilaterally. His heart sounds are normal without an S3 or S4 gallop. His left arm is mildly edematous but otherwise painless, with a normal pulse examination. There is no swelling of his lower extremities, and he has no pain with palpation of his calves. His catheter incision site is clean and intact. Which of the following studies is inappropriate for this patient? A Chest x-ray B ECG C Contrast CT scan of the chest D d-dimer assay E Duplex ultrasonography of the deep veins of the upper and lower extremities
d
A 54-year-old man comes to your clinic for a follow-up for OSA. He has been using PAP with a nasal mask for the last 3 years since he was diagnosed. He has recently purchased a CPAP machine and tells you he has been unable to use it because of facial discomfort and nasal congestion. You check the machine and all the parts are in good condition. What is the next most appropriate step in the management of this patient? A Decrease the airway pressure B Refer for surgery C Refer for an oral appliance D Change the mask E Add heated humidification
e
A 54-year-old woman is being evaluated in the emergency center with shortness of breath of 12 hours' duration. She also has significant vaginal bleeding of 1 month's duration. On examination, she is found to have significant pallor of her sclera and skin. Speculum examination showed a large necrotic and exophytic mass of the cervix. The hemoglobin level is 7 g/dL. Her left leg is swollen and markedly different from her right leg. Doppler investigation reveals a DVT of the left leg. Which of the following is the best treatment for the thrombus? A Intravenous unfractionated heparin B Fractionated subcutaneous heparin C Subcutaneous unfractionated heparin D Oral warfarin (Coumadin) E Vena cava filter
e
in adults with CAP, should serum procalcitonin plus clinical judgement alone be used to withhold initiation of antibiotic tx?
empiric tx should be initiated
in the inpt setting, should pts with suspected aspiration pneumonia receive addition anaerobic coverage beyond standard empiric tx for CAP?
not unless lung abscess or empyema is suspected
in adults with CAP, should Legionella and pneumococcal urinary antigen testing be performed at time of dx?
not unless they have risk factors
In Adults with CAP, Should a Respiratory Sample Be Tested for Influenza Virus at the Time of Diagnosis?
when it is flu season
in adults with CAP who test positive for influenza, should the treatment regimen include antibacterial therapy?
yes
in adults with CAP who test positive for influenza, should the treatment regimen include antiviral therapy?
yes such as tamiflu independent of duration of illness before dx
