AAFP Board Review - Lung
Which one of the following is recommended in all patients with croup, including those with mild disease? (check one) A. Humidification therapy B. Oral dexamethasone as a single dose C. Oral diphenhydramine (Benadryl) every 6 hours until improvement D. Subcutaneous epinephrine as a single dose E. Intramuscular ceftriaxone (Rocephin) as a single dose
B. Oral dexamethasone as a single dose - 0.15-0.60 mg/kg
A 14-year-old female with a history of asthma is having daytime symptoms about once a week and symptoms that awaken her at night about once a month. Her asthma does not interfere with normal activity, and her FEV1 is >80% of predicted. Which one of the following is the most appropriate treatment plan for this patient? (check one) A. A short-acting inhaled β-agonist as needed B. Low-dose inhaled corticosteroids daily C. A leukotriene receptor antagonist daily D. Medium-dose inhaled corticosteroids daily E. Low-dose inhaled corticosteroids plus a long-acting inhaled β-agonist daily
A. A short-acting inhaled β-agonist as needed - intermittent asthma.
A 48-year-old male who weighs 159 kg (351 lb) is admitted to the hospital with a left leg deep vein thrombosis and pulmonary embolism. Treatment is begun with enoxaparin (Lovenox). Which one of the following would be most appropriate for monitoring the adequacy of anticoagulation in this patient? (check one) A. Anti-factor Xa levels B. Activated partial thromboplastin time (aPTT) C. Daily INRs D. Daily factor VIII levelsA
A. Anti-factor Xa - In severely obese patients (>330 lb) and those with renal failure, low molecular weight heparin therapy should be monitored with anti-factor Xa levels obtained 4 hours after injection. Not INR - for warfarin Not activated partial thromboplastin time (aPTT) - for unfractionated heparin. Not Factor VIII - not used for any therapy
A 52-year-old female with a 60-pack-year history of cigarette smoking and known COPD presents with a 1-week history of increasing purulent sputum production and shortness of breath on exertion. Which one of the following is true regarding the management of this problem? (check one) A. Antibiotics should be prescribed B. Intravenous corticosteroids are superior to oral corticosteroids C. Inhaled corticosteroids should be started or the dosage increased D. Levalbuterol (Xopenex) is superior to albuterol E. Acetylcysteine should be given if the patient is hospitalized
A. Antibiotics should be prescribed - Brief courses of systemic corticosteroids shorten hospital stays and decrease treatment failures - Studies have not shown a difference between oral and intravenous corticosteroids - Inhaled corticosteroids are not helpful - Levalbuterol and albuterol have similar benefits and adverse effect - Acetylcysteine, a mucolytic agent, not helpful
A 58-year-old male presents with a several-day history of shortness of breath with exertion, along with pleuritic chest pain. His symptoms started soon after he returned from a vacation in South America. He has a history of deep-vein thrombosis (DVT) in his right leg after surgery several years ago, and also has a previous history of prostate cancer. You suspect pulmonary embolism (PE.). Which one of the following is true regarding the evaluation of this patient? (check one) A. CT angiography would reliably either confirm or rule out PE B. Compression ultrasonography of the lower extremities will reveal a DVT in the majority of patients with PE C. No further testing is needed if a ventilation-perfusion lung scan shows a low probability of PE D. No further testing is needed if a D-dimer level is normal E. An elevated D-dimer level would confirm the diagnosis of PE
A. CT angiography would reliably either confirm or rule out PE
A healthy 48-year-old bookkeeper who works in a medical office has a positive PPD on routine yearly screening. Which one of the following would be most appropriate at this point? (check one) A. A chest radiograph B. A repeat PPD C. Treatment with isoniazid and one other antituberculous drug for 12 months D. Anergy testing
A. CXR - Clinical evaluation and a chest radiograph are recommended in asymptomatic patients with a positive PPD (SOR C). - Asymptomatic patients with a positive PPD and an abnormal chest film should have a sputum culture for TB. - Persons with a PPD conversion should be encouraged to take INH for 9 months with proper medical supervision. A two-step PPD - for those at high risk whose initial test is negative Anergy testing - Patients with a negative PPD who are still at high risk for TB, especially HIV-positive patients
A 54-year-old white male presents with drooping of his right eyelid for 3 weeks. On examination, he has ptosis of the right upper lid, miosis of the right pupil, and decreased sweating on the right side of his face. Extraocular muscle movements are intact. In addition to a complete history and physical examination, which one of the following would be most appropriate at this point? (check one) A. A chest radiograph B. MRI of the brain and orbits C. 131I thyroid scanning D. A fasting blood glucose level E. An acetylcholine receptor antibody level
A. CXR - Horner's syndrome - ipsilateral ptosis, miosis, and decreased facial sweating - suggests decreased sympathetic innervation due to involvement of the stellate ganglion, a complication of Pancoast's superior sulcus tumors of the lung - Radiographs or MRI of the pulmonary apices and paracervical area is indicated. - Horner's syndrome may accompany intracranial pathology, such as the lateral medullary syndrome (Wallenbergs syndrome), but is associated with multiple other neurologic symptoms, so MRI of the brain is not indicated at this point.
Which one of the following has been shown to reduce the croup score in children and lead to shorter hospital stays? (check one) A. Dexamethasone (Decadron), 0.6 mg/kg in a single oral dose B. Amoxicillin, 45 mg/kg/day divided into two doses, for 10 days C. Azithromycin (Zithromax), 10 mg/kg the first day, then 5 mg/kg daily for 4 days D. Albuterol (Ventolin), 0.63 mg by aerosol every 4 hours E. Ceftriaxone (Rocephin), 50 mg/kg intramuscularly in a single dose
A. Dexamethasone (Decadron), 0.6 mg/kg in a single oral dose - Oral or intramuscular dexamethasone, 0.6 mg/kg as a single dose, and nebulized budesonide have been shown to reduce croup scores and shorten hospital stays. Not Racemic epinephrine - may be used acutely, but rebound can occur. Not Albuterol - useless
A 17-year-old male presents to the urgent care clinic 15 minutes after being stung by a wasp. He feels weak, his voice is hoarse, and he is beginning to have trouble breathing. Which one of the following should be administered first? (check one) A. Epinephrine IM B. An oral leukotriene-receptor antagonist C. Intranasal antihistamines D. Intranasal corticosteroids E. Oral antihistamine
A. Epinephrine IM
A 12-year-old male uses a short-acting bronchodilator three times per week to control his asthma. Lately he has been waking up about twice a week because of his symptoms. Which one of the following medications would be most appropriate? A. Inhaled medium-dose corticosteroids B. A scheduled short-acting bronchodilator C. A scheduled long-acting bronchodilator D. A leukotriene inhibitor E. Ordering a free T 4
A. Inhaled medium-dose corticosteroids - moderate persistent asthma. - although many parents are concerned about corticosteroid use in children with open growth plates, inhaled corticosteroids have not been proven to prematurely close growth plates and are the most effective treatment with the least side effects. - Scheduled use of a SABA or LABA has been shown to cause tachyphylaxis, and is not recommended. - Leukotriene use may be beneficial, but compared to those using inhaled corticosteroids, patients using leukotrienes are 65% more likely to have an exacerbation requiring systemic corticosteroids.
You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September, and he tells you that he has severe symptoms every autumn that impair his academic performance. He has a strongly positive family history of atopic dermatitis. Which one of the following medications is considered optimal treatment for this condition? (check one) A. Intranasal glucocorticoids B. Intranasal cromolyn sodium C. Intranasal decongestants D. Intranasal antihistamines
A. Intranasal glucocorticoids - best medications for the treatment of allergic rhinitis. Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effecti00.-*lmlll\]=,p-;]8ve if started prior to the season of peak symptoms.
Which one of the following treatment regimens is most appropriate for an HIV-positive 42-year old who has latent tuberculosis infection? (check one) A. Isoniazid daily for 9 months B. Rifampin (Rifadin) daily for 4 months C. Rifampin plus pyrazinamide daily for 2 months D. Combination therapy with isoniazid, rifampin, pyrazinamide, and ethambutol (Myambutol) for 2 months
A. Isoniazid daily for 9 months Latent tuberculosis infection carries a risk of progression to active disease, especially among patients who are immunosuppressed. Isoniazid monotherapy is the treatment of choice for most patients with latent tuberculosis infection. Rifampin is not recommended as monotherapy in patients with HIV infection because of increased rates of resistance and drug interactions with many antiretrovirals. Rifampin plus pyrazinamide is no longer recommended for treatment of latent tuberculosis infection because cases of significant hepatotoxicity have occurred with preventive therapy. Combination drug therapy is reserved for treatment of active tuberculosis in order to prevent drug resistance.
Which one of the following is the most likely cause of chronic unilateral nasal obstruction in an adult? (check one) A. Nasal septal deviation B. Foreign-body impaction C. Allergic rhinitis D. Adenoidal hypertrophy
A. Nasal septal deviation - most common cause of nasal obstruction in all age groups is the common cold aka mucosal disease (bilateral) - Anatomic abnormalities 1. septal deviation most common 2. adenoidal hypertrophy (most common nasal tumor) 3. nasal polyps - Foreign-body impaction infrequent cause of unilateral obstruction and purulent rhinorrhea..
A 40-year-old nurse presents with a 1-year history of rhinitis, and a more recent onset of episodic wheezing and dyspnea. Her symptoms seem to improve when she is on vacation. She does not smoke, although she says that her husband does. Her FEV1 improves 20% with inhaled β-agonists. Which one of the following is the most likely diagnosis? (check one) A. Occupational asthma B. Sarcoidosis C. COPD D. Anxiety E. Vocal cord dysfunction
A. Occupational asthma - consider this with new adult asthma or recurrence of childhood asthma after a significant asymptomatic period (SOR C). - often preceded by the development of rhinitis in the workplace and should be considered in patients whose symptoms improve away from work Not COPD - reversed by β-agonist Not Cystic fibrosis - Pt is too old Not sarcoidosis - this is reversible airway obstruction & intermittent
A 22-year-old female in her second trimester of pregnancy presents with a 48-hour history of a sore throat. She has also had coryza and a nonproductive cough. A physical examination reveals a temperature of 37.3°C (99.2°F) and a blood pressure of 110/70 mm Hg. A HEENT examination reveals tonsillar and pharyngeal erythema with no exudate. There is no adenopathy. Her chest is clear. Which one of the following would be most appropriate for this patient? (check one) A. Reassurance and symptomatic treatment only B. A routine throat culture C. A rapid antigen detection test for Streptococcus D. Azithromycin (Zithromax) for 5 days E. Penicillin V for 10 days
A. Reassurance and symptomatic treatment only pharyngitis - mostly viral
A 50-year-old male has a pre-employment chest radiograph showing a pulmonary nodule. There are no previous studies available. Which one of the following would raise the most suspicion that this is a malignant lesion if found on the radiograph? . (check one) A. The absence of calcification B. Location above the midline of the lung C. A diameter of 4 mm D. A solid appearance
A. The absence of calcification benign nodules include - diameter <5 mm - smooth border - solid appearance, concentric calcification, and a doubling time of less than 1 month or more than 1 year. Features of malignant nodules - a size >10 mm, an irregular border - "ground glass" appearance - no calcification or an eccentric calcification, and - a doubling time of 1 month to 1 year
Which one of the following is true concerning the use of dexamethasone to treat acute laryngotracheitis (croup)? (check one) A. A single dose is adequate for treatment B. It commonly leads to a secondary bacterial infection due to immunosuppression C. It increases the need for hospitalization D. It is indicated only for patients with severe croup
A. a single dose is adequate - A single dose of dexamethasone, either orally or intramuscularly, is appropriate. - Prolonged courses of corticosteroids provide no additional benefit and may lead to secondary bacterial or fungal infections. - Secondary infections rarely occur with single-dose treatment. - Corticosteroid therapy shortens emergency department stays and decreases the need for return visits and hospitalizations. It is indicated for patients with croup of any severity.
In a patient with a severe anaphylactic reaction to peanuts, the most appropriate route for epinephrine is: (check one) A. intramuscular B. intravenous C. oral D. subcutaneous E. sublingual
A. intramuscular
A 70-year-old male with widespread metastatic prostate cancer is being cared for through a local hospice. Surgery, radiation, and hormonal therapy have failed to stop the cancer, and the goal of his care is now symptom relief. Over the past few days he has been experiencing respiratory distress. His oxygen saturation is 94% on room air and his lungs are clear to auscultation. His respiratory rate is 16/min. Which one of the following would be best at this point? A. Morphine B. Oxygen C. Albuterol (Proventil, Ventolin) D. Haloperidol
A. morphine Dyspnea is a frequent and distressing symptom in terminally ill patients. In the absence of hypoxia, oxygen is not likely to be helpful. Opiates are the mainstay of symptomatic treatment
A 24-year-old female with a 2-year history of dyspnea on exertion has been diagnosed with exercise-induced asthma by another physician. Which one of the following findings on pulmonary function testing would raise concerns that she actually has vocal cord dysfunction? (check one) A. A good response to an inhaled β-agonist B. Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase C. Flattening of the expiratory portion of the flow-volume loop, but a normal inspiratory phase D. Flattening of both the inspiratory and expiratory portion of the flow-volume loop E. A decreased FEV1 and a normal FVC
B. Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase Pulmonary function testing with a flow-volume loop typically shows a normal expiratory portion but a flattened inspiratory phase (SOR C).
A 47-year-old male who lives at sea level attempts to climb Mt. Rainier. On the first day he ascends to 3400 m (11,000 ft). The next morning he complains of headache, nausea, dizziness, and fatigue, but as he continues the climb to the summit he becomes ataxic and confused. Which one of the following is the treatment of choice? (check one) A. Administration of oxygen and immediate descent B. Dexamethasone, 8 mg intramuscularly C. Acetazolamide (Diamox), 250 mg twice a day D. Nifedipine (Procardia), 10 mg immediately, followed by 30 mg in 12 hours E. Helicopter delivery of a portable hyperbaric chamber
A. oxygen and immediate descent - acute mountain sickness. - headache in an unacclimatized person who recently arrived at an elevation >2500 m (8200 ft), - plus the presence of one or more of the following: anorexia, nausea, vomiting, insomnia, dizziness, or fatigue. - pt already deteriorated to high-altitude cerebral edema i.e. ataxia and/or altered consciousness in someone - management of choice is a combination of descent and supplemental oxygen - Often, a descent of only 500-1000 m (1600-3300 ft) will lead to resolution of acute mountain sickness. - Simulated descent with a portable hyperbaric chamber also is effective, but descent should not be delayed while awaiting helicopter delivery. - if descent and/or administration of oxygen is not possible, medical therapy with *dexamethasone* and/or *acetazolamide* may reduce the severity of symptoms. - Nifedipine has also been shown to be helpful in cases of high-altitude pulmonary edema where descent and/or supplemental oxygen is unavailable.
An 80-year-old female is being started on warfarin (Coumadin) for atrial fibrillation. According to the American College of Chest Physicians guidelines, the initial dose in this patient should NOT exceed: (check one) A. 2.5 mg B. 5 mg C. 7.5 mg D. 10 mg E. 12.5 mg
B. 5 mg starting warfarin dosage of ≤5 mg/day in elderly patients, or in patients who have conditions such as heart failure, liver disease, or a history of recent surgery. The INR should be used to guide adjustments in the dosage.
A 42-year-old female presents with a cough productive of blood-streaked sputum for the past 3 days. Her hemoptysis was preceded by several days of rhinorrhea, congestion, and subjective fever. She estimates the total amount of blood loss to be approximately 1 tablespoon. She is a nonsmoker and her past medical history is unremarkable. Vital signs are within normal limits, and other than an intermittent cough there are no abnormal findings on the physical examination. Which one of the following would be the most appropriate next step? (check one) A. Observation B. A chest radiograph C. Chest CT D. Bronchoscopy E. Antibiotics
B. A chest radiograph The first step in the evaluation of nonmassive hemoptysis is to obtain a chest radiograph. If this is normal and there is a high risk of malignancy (patient age 40 years or older with at least a 30-pack year smoking history), chest CT should be ordered. Bronchoscopy should also be considered in the workup of high-risk patients. If a chest radiograph shows an infiltrate, treatment with antibiotics is warranted. If the chest radiograph is normal the patient is at low risk for malignancy, and if the history does not suggest lower respiratory infection and hemoptysis does not recur, observation can be considered.
A 20-year-old male with a history of exercise-induced bronchoconstriction presents to your office with a complaint of cough and decreasing performance when he runs. He is training for a marathon and is currently running 30 miles/week, but has noted that his times have been worsening and that he is using his albuterol inhaler (Proventil, Ventolin) as needed for symptom relief 5 days a week. Which one of the following is the best regimen for treatment of this condition? (check one) A. Inhaled albuterol before he runs B. A daily low-dose inhaled corticosteroid C. A daily inhaled long-acting $2-agonist D. A daily low-dose oral corticosteroid E. Immunotherapy
B. A daily low-dose inhaled corticosteroid - daily use of short-acting beta 2-agonists can lead to overuse and tolerance. - Long-acting beta 2-agonists should not be used without the concomitant use of an inhaled corticosteroid. - Chronic oral corticosteroids are not indicated in this situation, and may require a therapeutic use exemption by the sports authority overseeing athletic competitions. - Immunotherapy is useless with asthma
A 20-year-old nonsmoker presents to your office with a sudden onset of chest pain. You order a chest radiograph, which shows a small (<15%) pneumothorax. He is in no respiratory distress and vital signs are normal. Pulse oximetry shows a saturation of 98% on room air. which one of the following would be most appropriate initially? (check one) A. CT of the affected lung B. Analgesics and a follow-up visit in 48 hours C. Chest tube insertion D. Hospital admission and a repeat chest film in 24 hours
B. Analgesics and a follow-up in 48 hours - patient without apparent lung disease who develops a spontaneous "small" pneumothorax (<15% of lung volume) can be managed as an outpatient with analgesics and follow-up within 72 hours. - CT of the lung is needed in complicated cases, including patients with known lung disease or recurrent pneumothoraces. - A chest tube is required only when the pneumothorax involves >15% of lung volume.
A 50-year-old male is brought to the emergency department with shortness of breath, chest tightness, tremulousness, and diaphoresis. Aside from tachypnea, the physical examination is normal. Arterial blood gases on room air show a pO2 of 98 mm Hg (N 80-100), a pCO2 of 24 mm Hg (N 35-45), and a pH of 7.57 (N 7.38-7.44). The most likely cause of the patient's blood gas abnormalities is: (check one) A. carbon monoxide poisoning B. anxiety disorder with hyperventilation C. an acute exacerbation of asthma D. pulmonary embolus E. pneumothorax
B. Anxiety with hyperventilation - resp alkalosis Pulmonary embolism - pO2 and pCO2 are decreased, while the pH is elevated (acute resp alkalosis) Carbon monoxide poisoning - vitals will be normal Asthma exacerbation - prominent cough and wheezing, and possibly other abnormalities. Tension pneumothorax - significant physical findings including tachycardia, hypotension, and decreased mental activity.
For which one of the following respiratory infections should antibiotic therapy be initiated immediately upon diagnosis? A. Bronchitis B. Epiglottitis C. Laryngitis D. Rhinosinusitis E. Tracheitis
B. Epiglottitis Many infections of the respiratory tract are viral Epiglottitis is one exception - Haemophilus influenzae type b - rapidly worsening, potentially fatal airway - hoarseness, dysphagia, stridor, drooling, fever, chills, and respiratory distress - IV antibiotic: beta-lactam against methicillin-resistant Staphylococcus aureus.
A 45-year-old male presents with a 3-month history of hoarseness. He denies any other complaints and has not been ill recently. He is not on any medication, has no history of chronic medical problems, and does not smoke cigarettes or drink alcohol. Which one of the following would be the most appropriate management of this patient? (check one) A. Voice rest for 1 month B. Laryngoscopy C. A trial of a proton pump inhibitor D. A trial of inhaled corticosteroids E. Oral corticosteroids
B. Laryngoscopy should be performed to visualize the larynx and evaluate for vocal cord pathology in a patient whose hoarseness does not resolve within 3 months (SOR C).
A 58-year-old male with COPD presents with a 5-day history of increased dyspnea and purulent sputum production. He is afebrile. His respiratory rate is 24/min, heart rate 90 beats/min, blood pressure 140/80 mm Hg, and oxygen saturation 90% on room air. Breath sounds are equal, and diffuse bilateral rhonchi are noted. He is currently using albuterol/ipratropium by metered-dose inhaler three times daily. In addition to antibiotics, which one of the following would be most appropriate for treating this exacerbation? (check one) A. A single dose of intramuscular dexamethasone B. Oral prednisone for 5 days C. Daily inhaled fluticasone (Flovent) D. Hospital admission for intravenous methylprednisolone sodium succinate (Solu-Medrol) E. No corticosteroids at this time
B. Oral prednisone for 5 days
When treating acute adult asthma in the emergency department, using a metered-dose inhaler (MDI) with a spacer has been shown to result in which one of the following, compared to use of a nebulizer? (check one) A. Higher hospitalization rates B. Shorter stays in the emergency department C. Higher relapse rates D. Less improvement in peak-flow rates E. Increases in the total dose of albuterol
B. Shorter stays in the emergency department - lower pulse rates - better peak-flow rates - greater improvement in arterial blood gases - decrease required albuterol doses - lower costs
A patient with chronic atrial fibrillation treated with dabigatran (Pradaxa) sees you for follow-up. She says she can no longer afford the dabigatran and would like to switch to warfarin (Coumadin). She has normal renal function. Which one of the following would be the most appropriate approach? (check one) A. Start warfarin and stop dabigatran when her INR is 2.0-3.0 B. Start warfarin now and stop dabigatran in 3 days C. Stop dabigatran, start warfarin, and start low molecular weight heparin and enoxaparin (Lovenox) every 12 hr until her INR is 2.0-3.0 D. Stop dabigatran for 24 hr and then start warfarin E. Hospitalize the patient, stop dabigatran, start warfarin, and treat with heparin until her INR is 2.0-3.0
B. Start warfarin now and stop dabigatran in 3 days - Bridging with a parenteral agent is not necessary. - Dabigatran is known to increase the INR, so the INR will not reflect warfarin's effect until dabigatran has been withheld for at least 2 days.
A 60-year-old female with moderate COPD presents with ongoing dyspnea in spite of treatment with both an inhaled long-acting β-agonist and a long-acting anticholinergic agent. Your evaluation reveals an oxygen saturation of 88% and a PaO2 of 55%. Echocardiography reveals a normal ejection fraction but moderate pulmonary hypertension. Which one of the following would be most appropriate at this time? (check one) A. No changes in the current medical regimen B. Supplemental oxygen C. Low-dose sildenafil (Revatio) D. Nifedipine (Procardia) E. Low-dose prednisone
B. Supplemental oxygen - moderate COPD and moderate nonpulmonary arterial hypertension pulmonary hypertension is hypoxic - meets the criteria for use of supplemental oxygen (SOR A). - Low-dose prednisone may be a future option.
The preferred site for an emergency airway is: (check one) A. the thyrohyoid membrane B. the cricothyroid membrane C. immediately below the cricoid cartilage D. through the first and second tracheal rings E. at the level of the thyroid isthmus
B. cricothyroid membrane - directly above the cricoid cartilage, through the cricothyroid membrane. - Strictly speaking, this is not a tracheotomy, because it is actually above the trachea - However, it is below the vocal cords and bypasses any laryngeal obstruction Not thyrohyoid membrane - above the vocal cords, impractical site Not area directly below the cricoid cartilage - i.e. second, third, and fourth tracheal rings, as well as the thyroid isthmus - preferred tracheotomy site under controlled circumstances - excessive bleeding and difficulty finding the trachea may significantly impede the procedure in an emergency.
Which one of the following causes rhinitis medicamentosa with prolonged use in the treatment of rhinitis? (check one) A. Intranasal antihistamines B. Intranasal decongestants C. Intranasal anticholinergics D. Intranasal mast cell stabilizers E. Leukotriene antagonists
B. intranasal decongestants - Intranasal decongestants such as phenylephrine should not be used for more than 3 days, as they cause rebound congestion on drug withdrawal. - When used for several months or more, these agents can cause a form of rhinitis, rhinitis medicamentosa, that can be extremely difficult to treat. (rhinitis medicamentosa = rebound nasal dripping)
Which one of the following comorbid conditions increases the risk that latent tuberculosis infection will progress to active disease? (check one) A. Hypertension B. Lung cancer C. Obesity D. Coronary artery disease E. Hyperlipidemia
B. lung cancer Risk factors for progression from latent to active tuberculosis include 1. diabetes mellitus, alcoholism, recent contact w(0.15-0.60 mg/kgith a person who has an active tuberculosis infection 2. immunosuppressive therapy 3. lung parenchymal diseases such as COPD, silicosis, or lung cancer 4. under 5 y/o 5. weighing less than 90% of ideal body weight
You see a 9-year-old female for evaluation of her asthma. She and her mother report that she has shortness of breath and wheezing 3-4 times per week, which improves with use of her albuterol inhaler. She does not awaken at night due to symptoms, and as long as she has her albuterol inhaler with her she does not feel her activities are limited by her symptoms. About once per year she requires prednisone for an exacerbation, often triggered by a viral infection. Based on this information you classify her asthma severity as: (check one) A. intermittent B. mild persistent C. moderate persistent D. severe persistent
B. mild persistent her symptoms occurring more than 2 days per week, but not daily, and use of her albuterol inhaler more than 2 days per week, but not daily.
A 12-year-old white male asthmatic has an acute episode of wheezing. You diagnose an acute asthma attack and prescribe an inhaled β2-adrenergic agonist. After 2 hours of treatment, he continues to experience wheezing and shortness of breath. Which one of the following is the most appropriate addition to acute outpatient management? (check one) A. Oral theophylline (Theo-Dur) B. Oral corticosteroids C. An oral β-adrenergic agonist D. Inhaled cromolyn (Intal) E. Inhaled corticosteroids
B. oral corticosteroids - 1st: β2-adrenergic agonist such as albuterol, terbutaline, or pirbuterol. - if ineffective: systemic corticosteroids. Theophylline - useless in acute attacks - less potent bronchodilator - adverse effects such as nausea and central nervous system stimulation in patients Cromolyn - can decrease airway hyperreactivity - no bronchodilating activity - only useful as prophylaxis. Inhaled corticosteroids - should be used to suppress the symptoms of chronic persistent asthma. Oral β2-selective agonists - less effective and have a slower onset of action than the same drugs given by inhalation.
A 40-year-old white female presents with pain on inspiration and dyspnea since this morning. She has no chronic medical problems, takes no medications, has not traveled, and has no history of trauma. On examination the patient is afebrile, has a heart rate of 90 beats/min and a respiratory rate of 20/min, and her lungs are clear to auscultation. The pain is worse in the supine position. Which one of the following would you do initially? (check one) A. Order a CBC with differential B. Order a chest film and EKG C. Prescribe ibuprofen D. Prescribe omeprazole (Prilosec) E. Prescribe a bronchodilator
B. order a CXR and CKG - pleuritic chest pain, and - worse when supine and is accompanied by dyspnea creates additional concern. - Supine pain could be due to pericarditis (EKG) - Dyspnea increases suspicion for pneumonia, pulmonary embolism, pneumothorax, and myocardial infarction (EKG/CXR) - Once these problems have been ruled out, a diagnosis of pleurisy would be reasonable and can be treated with an NSAID. Not CBC - for infection or anemia is the cause of the problem Not Omeprazole or a bronchodilator - inappropriate treatment, as asthma and reflux are not likely in this patient.
Which one of the following is the recommended duration of thromboprophylaxis following total hip arthroplasty, starting from the day of surgery and including outpatient prophylaxis? (check one) A. 7 days B. 14 days C. 35 days D. 60 days E. 90 days
B. outpatient thromboprophylaxis for a duration of up to 35 days. - Older recommendations for 10-14 days of prophylaxis were based on studies performed when this was the usual hospital stay. - This is still recommended as the minimum length for prophylaxis, but a longer period of time is preferred.
A patient presenting with severe carbon monoxide poisoning should be treated with: (check one) A. inhaled helium B. supplemental oxygen C. intravenous calcium gluconate D. intravenous iron E. intravenous magnesium
B. supplemental oxygen
A 25-year-old white male who has a poorly controlled major seizure disorder and a 6-week history of recurrent fever, anorexia, and persistent, productive coughing visits your office. On physical examination he is noted to have a temperature of 38.3°C (101.0°F), a respiratory rate of 16/min, gingival hyperplasia, and a fetid odor to his breath. Auscultation of the lungs reveals rales in the mid-portion of the right lung posteriorly. Which one of the following is most likely to be found on a chest radiograph? (check one) A. Sarcoidosis B. Miliary calcifications C. A lung abscess D. A right hilar mass E. A right pleural effusion
C. A lung abscess - anaerobic lung abscess Physical examination usually reveals - poor dental hygiene - a fetid odor to the breath and sputum - rales, and pulmonary findings consistent with consolidation Sarcoidosis - no productive cough and have bilateral physical findings Disseminated TB (miliary calcification) - A persistent productive cough is not a striking finding Right hilum mass or Right pleural effusion - The clinical presentation and physical findings are not consistent
A 2-year-old Hispanic male with a 3-day history of nasal congestion presents with a barking cough and hoarseness. He is afebrile. The examination reveals tachypnea, inspiratory and expiratory stridor, noticeable intercostal retractions, and good color. Which one of the following is indicated? (check one) A. Albuterol syrup and the use of a humidifier B. Inhaled albuterol (Proventil, Ventolin) C. Aerosolized epinephrine and intramuscular dexamethasone D. Visualization of the epiglottis, and ceftriaxone (Rocephin)
C. Aerosolized epinephrine and intramuscular dexamethasone - laryngotracheobronchitis, or croup - In rare instances, this illness can be complicated by critical upper airway obstruction. - Humidification of inspired air is sometimes beneficial, but the child should not be sent home until improvement is demonstrated - Because this child has stridor and intercostal retractions, aerosolized epinephrine is indicated, along with intramuscular dexamethasone, and hospitalization may be required for observation and continued treatment - Antibiotics do not have a role in the treatment of viral croup - Attempted visualization of the epiglottis is not indicated since it will increase the child's anxiety and worsen the symptoms.
A 42-year-old female presents to the emergency department with pleuritic chest pain. Her probability of pulmonary embolism is determined to be low. Which one of the following should be ordered to further evaluate this patient? (check one) A. Brain natriuretic peptide (BNP) B. CT pulmonary angiography C. ELISA-based D-dimer D. A cardiac troponin level E. A ventilation-perfusion lung scan
C. ELISA-based D-dimer Patients who have a low or moderate pretest probability of pulmonary embolism should have d-dimer testing as the next step in establishing a diagnosis.
A 53-year-old male presents to your office with a several-day history of hiccups. They are not severe, but have been interrupting his sleep, and he is becoming exasperated. What should be the primary focus of treatment in this individual? (check one) A. Drug treatment to prevent recurrent episodes B. Decreasing the intensity of the muscle contractions in the diaphragm C. Finding the underlying pathology causing the hiccups D. Improving the patient's quality of sleep E. Suppressing the current hiccup symptoms
C. Finding the pathology of hiccup - respiratory reflex that originates from the phrenic and vagus nerves, as well as the thoracic sympathetic chain. - Hiccups lasting hours: self-limiting - treatment: interrupting the reflex loop of the hiccup e.g. mechanical means (e.g., stimulating the pharynx with a tongue depressor) or medical treatment w/ chlorpromazine i - Hiccups lasting over 2 days: may be an underlying pathology causing the hiccups - must treat pathology
A 35-year-old male consults you about a vague chest pain he developed while sitting at his desk earlier in the day. The pain is right-sided and was sharp for a brief time when it began, but it rapidly subsided. There was no hemoptysis and the pain does not seem pleuritic. His physical examination, EKG, and oxygen saturation are unremarkable. A chest film shows a 10% right pneumothorax. Which one of the following is true in this situation? (check one) A. He is likely to be an overweight smoker with a chronic cough B. Rupture of subpleural bullae would be an unlikely cause of his problem C. Outpatient observation with a repeat chest radiograph in 24 hours is indicated D. A chest tube should be placed expeditiously E. After treatment his probability of recurrence is less than 15%
C. Outpatient observation with a repeat chest radiograph in 24 hours is indicated - spontaneous pneumothorax - tall, thin individuals under 40 years of age - no clinically apparent lung disease, and the chest pain is sometimes minimal at onset and may resolve within 24 hours even if untreated - may have a normal physical examination, although tachycardia is occasionally noted. - Dx: chest radiographs - 30% of patients will have a recurrence within 6 months to 2 years. - The treatment of an initial pneumothorax of less than 20% may be monitored; f/u 24-48 hours. - Indications for treatment include progression, delayed expansion, or the development of symptoms. T - perhaps almost all of them, will have subcutaneous bullae on a CT scan.
A 23-year-old female presents with recurrent unprovoked epistaxis. The patient's mother is known to have hereditary hemorrhagic telangiectasia. Contrast echocardiography is recommended to screen for which one of the following frequently associated conditions? (check one) A. Atrioseptal defect B. Ventricular septal defect C. Pulmonary arteriovenous malformations E. Myocardial perfusion defects
C. Pulmonary arteriovenous malformations
A 24-year-old African-American male presents with a history of several weeks of dyspnea, cough productive of bloody streaks, and malaise. His examination is normal except for bilateral facial nerve palsy. A CBC and urinalysis are normal. A chest radiograph reveals bilateral lymph node enlargement.This presentation is most consistent with: (check one) A. polyarteritis nodosa B. Goodpasture's syndrome C. sarcoidosis D. pulmonary embolus .
C. Sarcoidosis - young to middle-age adults (predominantly 20-29 years old) esp. African-Americans. - asymptomatic in 30%-50% of patients - diagnosed on a routine chest film. - 1/3 will present with fever, malaise, weight loss, cough, and dyspnea - pulmonary system is the main organ system affected: bilateral hilar lymphadenopathy and discrete, noncaseating epithelial granulomas. *Facial nerve palsy* - <5% of patients, and usually late in the process. - Before Lyme disease was recognized, bilateral facial nerve palsy was almost always due to sarcoidosis *Hemoptysis* - late in the course of sarcoidosis - usually related to Aspergillus infection or cavitation. *Renal* - rarely results in significant proteinuria or hematuria Not Polyarteritis nodosa - may involve the lungs - chest radiograph is more likely to reveal granulomatous lesions rather than patchy infiltrates Not Goodpasture's syndrome - pulmonary hemorrhage, glomerulonephritis, and antiglomerular basement membrane antibodies - Hemoptysis, pulmonary alveolar infiltrates, dyspnea, and iron-deficiency anemia are frequent presenting features - Within days or weeks, the pulmonary findings are generally followed by hematuria, proteinuria, and the rapid loss of renal function Not Pulmonary embolus - acute event - dyspnea and possibly hemoptysis, but not hilar lymphadenopathy
A 67-year-old male is admitted to your inpatient service with a week-long acute exacerbation of COPD. He also has hypertension and type 2 diabetes mellitus. After 24 hours of intravenous fluids and intravenous methylprednisolone, he is now tolerating oral intake. Which one of the following corticosteroid regimens is best for this patient at this time? (check one) A. Continue intravenous methylprednisolone until his COPD is back to baseline, then switch to oral methylprednisolone for a 14-day total course of treatment B. Switch to oral prednisone for a 14-day total course of treatment, including the initial 24-hour intravenous treatment C. Switch to oral prednisone for 4 more days of treatment D. Use only inhaled corticosteroids by nebulizer E. Discontinue corticosteroid treatment altogether after 24 hours
C. Switch to oral prednisone for 4 more days of treatment - randomized, controlled trial has demonstrated that 5-day courses of systemic corticosteroid therapy are at least as effective as 14-day courses (SOR A)
A 42-year-old white male develops respiratory distress 12 hours after he sustained a closed head injury and a femur fracture. A physical examination reveals a respiratory rate of 40/min. He has a pO2 of 45 mm Hg (N 75-100), a pCO2 of 25 mm Hg (N 35-45), and a blood pH of 7.46 (N 2 2 7.35-7.45). His hematocrit is 30.0% (N 37.0-49.0). Of the following, the most likely diagnosis is: (check one) A. respiratory depression due to central nervous system damage B. heart failure C. adult respiratory distress syndrome (ARDS) D. hypovolemic shock E. tension pneumothorax
C. adult respiratory distress syndrome (ARDS) - acute resp failure s/p trauma - injury at the alveolar-capillary interface, with resulting leakage of proteinaceous fluid from the intravascular space into the interstitium and subsequently into alveolar spaces - It has become acceptable to describe this entire spectrum of acute diffuse injury as adult respiratory distress syndrome (ARDS). - The syndrome of ARDS can occur under a variety of circumstances and produces a spectrum of clinical severity from mild dysfunction to progressive, eventually fatal, pulmonary failure.
A 55-year-old male presents to your office for evaluation of increasing dyspnea with exertion over the past 2 weeks. He has smoked 2 packs of cigarettes per day since the age of 20. He has had a chronic cough for years, along with daily sputum production. He was given an albuterol inhaler for wheezing in the past, which he uses intermittently. On examination he has a severe decrease in breath sounds, no evidence of jugular venous distention, no cardiac murmur, and no peripheral edema. A chest film shows hyperinflation, but no infiltrates or pleural effusion. Office spirometry shows that his FEV1 is only 55% of the predicted value. You consider using inhaled corticosteroids as part of the treatment regimen for this patient. This has been shown to: (check one) A. increase cataract formation B. increase the incidence of fracture C. increase the risk of pneumonia D. slow the progression of the disease E. improve overall mortality from the disease
C. increase the risk of pneumonia Inhaled corticosteroids - will not reduce mortality or affect long-term progression of COPD. - reduce the number of exacerbations and the rate of decline in the quality of life - no increase in cataract formation or rate of fracture - side effects: candidal infection of the oropharynx, hoarseness, and an increased risk of developing pneumonia.
A 30-year-old female presents to your office for an initial visit. She reports a long history of asthma that currently awakens her three times per month, necessitating the use of an albuterol inhaler (Proventil, Ventolin). According to current guidelines, which one of the following would be optimal treatment? (check one) A. Continued use of a short-acting β-agonist only as needed B. Adding a long-acting β-agonist C. Adding a leukotriene receptor antagonist D. Adding a low-dose inhaled corticosteroid E. Adding theophylline
D. Adding a low-dose inhaled corticosteroid - mild persistent asthma - Inhaled corticosteroids improve asthma control more effectively in children and adults than any other single long-term controller medication (SOR A).
A 62-year-old female undergoes elective surgery and is discharged on postoperative day 3. A week later she is hospitalized again with pneumonia. A CBC shows that her platelet count has dropped to 150,000/mm3 (N 150,000-300,000) from 350,000 /mm3 a week ago. She received prophylactic heparin postoperatively during her first hospitalization. The patient is started on intravenous antibiotics for the pneumonia and subcutaneous heparin for deep-vein thrombosis prophylaxis. On hospital day 2, she has an acute onset of severe dyspnea and hypoxia; CT of the chest reveals bilateral pulmonary emboli. Her platelet count is now 80,000/mm3 . Which one of the following would be most appropriate at this point? (check one) A. Continue subcutaneous heparin B. Discontinue subcutaneous heparin and start a continuous intravenous heparin drip C. Discontinue heparin and give a platelet transfusion D. Discontinue heparin and start a non-heparin anticoagulant such as argatroban or desirudin (Iprivask) E. Discontinue unfractionated heparin and start a low molecular weight heparin such as enoxaparin (Lovenox)
D. Discontinue heparin and start a non-heparin anticoagulant such as argatroban or desirudin (Iprivask) - Heparin-induced thrombocytopenia HIT - within 1-2 weeks of heparin administration - will have HIT antibodies in the serum - unexplained 30%-50% decrease in the platelet count - may have arterial or venous thrombosis, anaphylactoid reactions immediately following heparin administration, or skin lesions at the site of heparin injections - Postop patients receiving subcutaneous unfractionated heparin prophylaxis are at highest risk for HIT
A previously healthy 24-year-old female presents with a 10-day history of facial pain and fever. On examination she has tenderness over the maxillary sinus on the left. Which one of the following would be most appropriate for treatment of this patient's condition? (check one) A. Intranasal saline flushes B. Intranasal antihistamines C. Oral antihistamines D. Oral antibiotics E. Reassurance only
D. Oral antibiotics - acute bacterial sinusitis (ABS) - symptoms of at least 10 days without improvement should be treated with antibiotics - Signs and symptoms may include nasal drainage and congestion, facial pressure and/or pain, sinus tenderness, and headache - can be amoxicillin alone; or going directly to amoxicillin/clavulanate - alternatives: "respiratory" quinolone or combination of a third-generation cephalosporin and clindamycin n pt w/ PCN allergy. - Due to the increasing emergence of resistant Strept and H. flu species, neither trimethoprim/sulfamethoxazole nor macrolides are now recommended for empiric treatment of ABS.
A 32-year-old male smoker presents with a 4-day history of progressive hoarseness. He is almost unable to speak, and associated symptoms include a cough slightly productive of yellow sputum, as well as tenderness over the ethmoid sinuses. He is afebrile and has normal ear and lung examinations. His oropharynx is slightly red with no exudate, and examination of his nasal passages reveals mucosal congestion. Which one of the following would be the most appropriate treatment? (check one) A. Amoxicillin for 10 days B. Omeprazole (Prilosec), 40 mg daily C. Azithromycin (Zithromax) for 5 days D. Symptomatic treatment only
D. Symptomatic treatment only Acute laryngitis most often has a viral etiology and symptomatic treatment is therefore most appropriate.
A 67-year-old male presents with a persistent, intermittent cough. He says that his exercise tolerance has decreased, noting that he becomes short of breath more easily while playing tennis. He smoked briefly while in college but has not smoked for over 45 years, and reports no history of known pulmonary disease. You obtain pulmonary function testing in the office to help you diagnose and manage his respiratory symptoms. His FVC and FEV1/FVC are both less than the lower limit of normal as defined by the Third National Health and Nutrition Examination Survey. Repeat testing following administration of a bronchodilator does not correct these values. Which one of the following would be most appropriate at this time? (check one) A. A methacholine challenge test B. A mannitol inhalation challenge test C. Exercise pulmonary function testing D. Testing for diffusing capacity of the lung for carbon monoxide (DLCO)
D. Testing for diffusing capacity of the lung for carbon monoxide (DLCO)
You are treating a 53-year-old female for a deep-vein thrombosis in her left leg. The use of compression stockings for this problem has been shown to: (check one) A. increase the risk of pulmonary embolism B. increase the level of pain C. increase complications if used prior to completion of a course of anticoagulation therapy D. decrease the risk of post-thrombotic syndrome
D. decrease the risk of post-thrombotic syndrome - complication of acute deep-vein thrombosis (DVT) - chronic pain, swelling, and skin changes in the affected limb - Within 5 years of experiencing a DVT, one in three patients will develop PTS. - Compression stockings should be applied when anticoagulation therapy is started, not when it has been completed.
A health-care worker has a negative tuberculin skin test (Mantoux method). A second test 10 days later is positive. This result indicates: (check one) A. Previous vaccination with BCG B. A false-positive skin test C. Recent conversion D. Long-standing, latent infection E. Probable immunodeficiency
D. long-standing, latent infection (no explanation)
A 57-year-old male presents to the emergency department complaining of dyspnea, cough, and pleuritic chest pain. A chest radiograph shows a large left-sided pleural effusion. Thoracentesis shows a pleural fluid protein to serum protein ratio of 0.7 and a pleural fluid LDH to serum LDH ratio of 0.8. Which one of the following causes of pleural effusion would be most consistent with these findings? (check one) A. Cirrhosis B. Heart Failure C. Nephrotic syndrome D. Superior vena cava obstruction
D. superior vena cava obstruction i.e. pulmonary embolism The protein and lactate dehydrogenase (LDH) levels in pleural fluid can help differentiate between transudative and exudative effusions. Light's criteria: 1. pleural fluid protein to serum protein ratio >0.5, 2. pleural fluid LDH to serum LDH ratio >0.6, and/or 3. pleural LDH >0.67 times the upper limit of normal for serum LDH i.e. exudative effusions Of the listed pleural effusion etiologies, only pulmonary embolism is exudative. The remainder are all transudative.
Which one of the following hospitalized patients is the most appropriate candidate for thromboembolism prophylaxis with enoxaparin (Lovenox)? (check one) A. An ambulatory 22-year-old obese male admitted for an appendectomy B. A 48-year-old male with atrial fibrillation on chronic therapeutic anticoagulation, admitted for cellulitis C. A 48-year-old male with end-stage liver disease and coagulopathy D. A 52-year-old female on chronic estrogen therapy, admitted with severe thrombocytopenia E. A 67-year-old female with hemiparesis, admitted for community-acquired pneumonia
E. A 67-year-old female with hemiparesis, admitted for community-acquired pneumonia - The patient on chronic anticoagulation, the patient with severe thrombocytopenia, and the patient with coagulopathy are at high risk for bleeding if given anticoagulants
A 45-year-old male presents with shortness of breath and a cough. On pulmonary function testing his FVC is <80% of predicted, his FEV1/FVC is 90% of predicted, and there is no improvement with bronchodilator use. The diffusing capacity of the lung for carbon monoxide (DLCO) is also low. Based on these results, which one of the following is most likely to be the cause of this patient's problem? (check one) A. Asthma B. Bronchiectasis C. COPD D. Cystic Fibrosis E. Idiopathic pulmonary fibrosis
E. Idiopathic pulmonary fibrosis Pulmonary fibrosis is compatible with this pattern. A patient with any of the other listed diagnoses would be expected to have an obstructive pattern on testing.
Which one of the following has been shown to have a beneficial effect for symptoms of the common cold in an adult? (check one) A. Diphenhydramine (Benadryl) B. Ipratropium (Atrovent) nasal spray C. Intranasal zinc D. Intranasal corticosteroids E. Systemic corticosteroids
Ipratropium - nasally inhaled anticholinergic recommended for a cough caused by the common cold. - nasal formulation decreases rhinorrhea and sneezing, - Antihistamine monotherapy (either sedating or nonsedating) such as diphenhydramine was no more effective than placebo (SOR A). - Intranasal zinc should not be used because it may result in the permanent loss of smell.
Which one of the following is true concerning the use of short-acting inhaled β-agonists for asthma? (check one) A. They should be given before any inhaled corticosteroid to facilitate lung delivery B. They are ineffective in patients taking β-blockers C. They are less effective than oral β-agonists D. They are less effective than anticholinergic bronchodilators when given with inhaled corticosteroids E. Their effects begin within 5 minutes and last 4-6 hours
E. Their effects begin within 5 minutes and last 4-6 hours
A 50-year-old female presents to your office for evaluation of a 2-month history of dyspnea on exertion and a nonproductive cough. She has a previous history of hypertension, overactive bladder, gastroesophageal reflux disease, and recurrent urinary tract infections. Vital signs are unremarkable and she has an oxygen saturation of 94%. She has inspiratory crackles in the posterior lung bases that do not clear with coughing. Office spirometry shows that the FVC is only 80% of normal, but the FEV1/FVC ratio is 0.85. Which one of the patient's current medications is most likely to be the cause of her problem? (check one) A. Lisinopril (Prinivil, Zestril) B. Conjugated estrogens (Premarin) C. Omeprazole (Prilosec) D. Solifenacin (Vesicare) E. Nitrofurantoin (Macrodantin)
E. nitrofurantoin - chronic dyspnea d/t interstitial lung disease; w/ chronic non-productive cough Spirometry: - Obstructive: ratio <0.7; FVC is normal or decreased and the FEV1 is decreased - restrictive: ratio >0.7 Diffuse parenchymal lung disease - caused by environmental or occupational exposures. - Many collagen vascular diseases and medications used to treat them can induce interstitial lung disease. - Common offenders for interstitial lung disease: amiodarone and nitrofurantoin which can induce a pneumonitis.
