B2E2 Study Cases/Questions

The mood in the examination room turns a shade bluer as your patient wonders whether, at age 60 and with an 86-pack-year history, there is even any reason to quit. "It's too late for me," she laments. How long does it take to reduce the risk of myocardial infarction by 50% after one stops smoking?

1 Year

A 50-year-old salesman was admitted to the hospital with acute appendicitis. He has no significant medical history, takes no medications, does not smoke cigarettes, and has an alcoholic beverage "once in a while with the boys." He underwent an uncomplicated appendectomy. On the second hospital day, you find him to be quite agitated and sweaty. His temperature, heart rate, and blood pressure are elevated. A short time later he has a grand mal seizure. What do you suspect the diagnosis is?

Alcohol Withdrawal

You see a 38-year-old female in follow-up for a recent episode of sinusitis. The illness has been present for about 6 weeks and has not responded to 2 weeks of appropriate antibiotics. She continues to have intermittent nosebleeds, fatigue, arthralgias, low-grade fevers, and night sweats. Two new complaints have surfaced: she has a cough productive of white sputum and she occasionally expectorates quarter-sized clots of blood. She has pleuritic chest pain, but denies dyspnea, tobacco use, and cardiac or pulmonary disease. She is afebrile with a respiratory rate of 16, blood pressure 120/74 mm Hg, and pulse rate 92 bpm. Her oxygen saturation is 98% on room air. There is dried blood in the nares, but the oropharynx is clear. Cardiac and pulmonary examinations are unremarkable. You obtain the following laboratory results: CBC: Leukocytosis, thrombocytosis, and normochromic, normocytic anemia ESR: 70 mm/hr Urine dipstick: Positive for protein, heme, and red cells What test will best assist in the diagnosis of this patient?

ANCA

A 28-year-old man presents with fever, pleuritic pain, cough, weight loss, and dyspnea for the last week. He states he has worked in a stone quarry for the last 6 months and rarely wears his personal protective equipment. His chest radiograph shows bilateral, lower-lobe predominant hazy opacities in an alveolar-filling pattern, in addition to a small apical pneumothorax on the right. What is the most likely diagnosis?

Acute Silicosis

A 62-year-old man presents to your office for an acute visit because of coughing and shortness of breath. He is well known to you because of multiple office visits in the past few years for similar reasons. He has a chronic "smoker's cough" but reports that in the past 2 days his cough has increased, his sputum has changed from white to green in color, and he has had to increase the frequency with which he uses his albuterol inhaler. He denies having a fever, chest pain, peripheral edema, or other symptoms. His medical history is significant for hypertension, peripheral vascular disease, and two hospitalizations for pneumonia in the past 5 years. He has a 60 pack-year history of smoking and continues to smoke two packs of cigarettes a day. On examination, he is in moderate respiratory distress. His temperature is 98.4 °F, his blood pressure is 152/95 mm Hg, his pulse is 98 beats/min, his respiratory rate is 24 breaths/min, and he has an oxygen saturation of 94% on room air. His lung examination is significant for diffuse expiratory wheezing and a prolonged expiratory phase of respiration. There are no signs of cyanosis. The remainder of his examination is normal. A chest x-ray done in your office shows an increased anteroposterior (AP) diameter and flattened diaphragm, but otherwise he has clear lung fields. What is the most likely cause of this patient's dyspnea?

Acute exacerbation of chronic obstructive pulmonary disease (COPD)

Twelve hours after a surgical admission for a broken arm, a 42-year-old woman begins to complain of feeling jittery and shaky. Six hours later, she tells staff members that she is hearing the voice of a dead relative shouting at her, although on admission she denied ever having heard voices previously. She complains of an upset stomach, irritability, and sweatiness. Her vital signs are BP 150/95 mm Hg, pulse 120 beats per minute (bpm), respirations 20 breaths per minute, and temperature 100 °F (37.8 °C). The patient reports no prior significant medical problems and says that she takes no medications. She has not had prior complications due to general anesthesia. What is the most likely diagnosis?

Alcohol Withdrawal

A 33-year-old woman is being seen in the office for a dry cough that has persisted for 3 months. She has lost 30 lb without intention over the past 3 months. On examination, she is noted to be cachectic. Examination shows clear lung fields. A chest x-ray shows a 3-cm lung mass. Bronchoscopic biopsy is performed. What is the most likely lung cancer diagnosis?

Adenocarcinoma

A 48-year-old man is admitted to a hospital because of pneumonia. Two days after the hospitalization, the patient becomes agitated and restless with tachycardia and hypertension. On physical examination, the patient is noted to be alert, but anxious, tremulous, and disoriented to place and time. And these findings differ from those on examination at admission. His alcohol history is significant (eg, drinking 3 or more vodkas a day for years; most recent alcohol intake occurred 2 days before coming to the hospital), but no history of liver diseases or alcohol withdrawal is evident. Subsequent physical examinations reveal no specific changes from the admission assessment except disorientation and anxiety. His respiratory status appears stable, and repeated CXR does not show any progression compared with the admission assessment. Routine laboratory workups including CBC, CMP, EKG, and blood glucose are stable. What diagnosis are you considering?

Alcohol Withdrawal

A 70-year-old female is brought into the clinic by her daughter due to concerns about her mother's sleeplessness, isolation, weight loss, falls, and anxiety over the past year. In addition, since the patient has been staying at her daughter's home the past 3 days, she began vomiting, hallucinating, perspiring profusely, and wanting to return to her own home. The patient has no history of medical problems. She is disheveled, confused, diaphoretic, and tremulous. Her blood pressure is 162/110 mm Hg, pulse is 120 bpm, and temperature is 38.5°C. She blames her symptoms on being unable to have a cigarette. She also blames her daughter's nagging. When asked about alcohol use, the patient says she has had a cocktail every evening since she retired from her job last year, and that this helps her to sleep. What best describes the patient's current clinical condition?

Alcohol withdrawal

A 38-year-old woman presents with progressively worsening dyspnea and cough. She has never smoked cigarettes, has no known passive smoke exposure, and does not have any occupational exposure to chemicals. She has a family history of cirrhosis. Pulmonary function testing shows obstructive lung disease that does not respond to bronchodilators, and a complete metabolic panel demonstrates elevation of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). What is the most likely etiology?

Alpha-1 antitrypsin deficiency (A1AD)

A 57-year-old man with a history of diabetes mellitus type 2 (HbA1c 6.9%), hypertension, gout, and osteoarthritis presents for evaluation for an abnormal chest radiograph. The patient was involved in a car accident with airbags deployed, and during his trauma evaluation, an abnormality was identified on the patient's CXR. The patient reports no actual chest trauma during the accident. The patient was asymptomatic before this event, with no dyspnea, orthopnea, fevers, chills, sweats, weight loss, pleuritic chest pain, or cough. The patient works in a factory that produces brake pads for large vehicles and aircraft. He has worked there for the past 36 years. He lives in a condominium with no evidence of water damage. He does woodworking as a hobby but uses appropriate personal protective equipment. He does not smoke or use illicit drugs. His vital signs are T 36.7°C, HR 65, BP 104/55, RR 12, and O2 saturation 100% on room air. His examination is notable for decreased breath sounds and dullness to percussion in the left lower lung field. He has some trace pedal edema. The patient undergoes a thoracentesis, and serosanguinous fluid is found. There is an increased eosinophil count (25% total cell count). The laboratory studies show an exudative effusion with elevated lactate dehydrogenase (LDH) and protein levels and a normal glucose level. The culture data are negative, and the cytology is normal as well. The patient reports that he has never had any chest trauma or falls. What occupational exposure may explain the abnormalities?

Asbestos

A 66-year-old man presents to your clinic for worsening dyspnea on exertion over the past several years. The patient first noted some mild dyspnea on exertion approximately 3 years ago but believed this was due to some weight gain and inactivity. However, over the next 24 months, despite attempts to exercise more frequently, he feels as though his exercise tolerance has only continued to decrease. Over the last few months, he has begun to feel short of breath with some of his normal daily activities, including walking from the car to the front door. He presented to an urgent care facility a few days ago and had a chest radiograph that was described as abnormal. The patient was noted to be saturating 92% O2 on room air at rest and desaturated to 86% with activity and was thus prescribed 2 L/min supplemental O2 with activity. The patient has a history of diabetes mellitus (DM) type 2, gastroesophageal reflux disease (GERD), and hypertension. He smokes two to four cigarettes a day and has a 45-pack-year smoking history. He drinks one to two alcoholic beverages a day but has no history of alcohol dependence or withdrawal. He served in the Navy from 1959 to 1963 in a shipyard. After retiring from the Navy, he worked as an automotive mechanic for 10 years before opening his own auto repair shop, at which time he transitioned to working in an office. He has no known environmental exposure. What is the most likely diagnosis?

Asbestosis

A 37-year-old man presents to your office with a complaint of cough. The cough began approximately 3 months prior to this appointment, and it has become progressively more annoying to the patient. The cough is nonproductive and worse at night and after exercise. The patient has had a sedentary lifestyle but recently started an exercise program, including jogging, and he says he is having a much harder time with exertion. He "runs out of breath" earlier than he did previously and "coughs a lot". He has not had any fever, blood-tinged sputum, or weight loss. He denies nasal congestion and headaches. He does not smoke and has no significant medical history. His examination is notable for a blood pressure of 134/78 mm Hg and lung findings of occasional expiratory wheezes on forced expiration. A chest radiograph is read as normal. What is the most likely diagnosis?

Asthma

A 10-year-old boy in respiratory distress arrives to the emergency department (ED) with his mother. She reports that the patient developed nasal congestion and a sore throat 24 hours prior and then a cough a few hours previously. Over the past 2 hours, he has complained of chest pain and has been breathing rapidly. His mother administered a unit dose of albuterol via the nebulizer and then a second dose 5 minutes later. He showed no improvement. She reports that he has had two similar episodes in the past year. Your examination reveals an afebrile boy with a respiratory rate of 40 breaths per minute, oxygen saturation of 88%, and a heart rate of 130 beats per minute. You note that his radial pulse becomes weak in amplitude with inspiration. His blood pressure is normal, but his capillary refill is sluggish at 4 to 6 seconds. He appears drowsy and is using accessory chest muscles to breathe. You hear faint inspiratory wheezes and no breath sounds during expiration. What is the most likely diagnosis?

Asthma Exacerbation

B.B. is a 46-year-old female who presents to primary care clinic for the first time for an annual physical. While taking a social history, you ask about drug and alcohol use. B.B. does not smoke or use illicit drugs, she drinks 3 to 4 glasses of wine 4 to 5 times per week and occasionally will have 5 to 6 drinks if going to a social event. She is a lawyer and works full time. She is married and has a teenage daughter. Her blood pressure today is 146/82 mm Hg, pulse is 86 bpm, and body mass index (BMI) is 27 kg/m2. She is not on any medications. How would you classify B.B.'s alcohol use?

At-Risk Drinking

B.B. is a 46-year-old female who presents to primary care clinic for the first time for an annual physical. While taking a social history, you ask about drug and alcohol use. B.B. does not smoke or use illicit drugs, she drinks 3 to 4 glasses of wine 4 to 5 times per week and occasionally will have 5 to 6 drinks if going to a social event. She is a lawyer and works full time. She is married and has a teenage daughter. Her blood pressure today is 146/82 mm Hg, pulse is 86 bpm, and body mass index (BMI) is 27 kg/m2. She is not on any medications. How would you define her drinking risk?

At-risk drinking

A 67-year-old white male with underlying chronic obstructive pulmonary disease (COPD) presents to primary care clinic with cough, fever to 103°F for the past 24 hours, and shortness of breath with exertion and rest. Cough is productive of blood-tinged sputum. Exam reveals respiratory rate of 28 bpm, Sao2 of 93% on room air, and blood pressure 100/58 mm Hg. He has egophony changes in right lower lobe with crackles. There is no dullness to percussion. White blood cell (WBC) count is 22 000. Chest x-ray shows a dense consolidation in the right lower lobe and a questionable infiltrate in the right middle lobe. No known allergies. What is the best initial treatment?

Augmentin + Azithromycin

Which class of drugs would you choose to treat the symptoms of alcohol withdrawal?

Benzodiazepines

A 34-year-old man is brought to the emergency department by his friends for "freaking out." They state that he is usually in good health and has had no head trauma or injuries but that he does drink a lot of alcohol each day. He is noted to have marked tremors of his extremities and states that he is seeing large scorpions skittering across the walls of the room and hearing the scorpions talking to him. What is the best initial treatment?

Benzodiazepines

A 55-year-old man presents to the office reporting progressive dyspnea. He has a history of HTN and gout. He notes that the onset of symptoms was perhaps 2 years ago, but it was rather insidious, so he cannot be sure. At first, he noticed only dyspnea with heavy exertion, which he attributed to his age, but over the past year, this has progressed to include dyspnea with mild activity such as walking to his car on level ground. He is a never-smoker. He has no family history of pulmonary disease, rheumatologist disease, or malignancy. The patient's occupational history shows that he worked as a machinist for a company that has been manufacturing fluorescent light bulbs for the last 30 years. He denies any lower extremity edema, chest pain, or diaphoresis. He has noticed a mild nonproductive cough. On examination, his body mass index (BMI) is 27 kg/m2. His vitals are HR 95, BP 110/80, RR 12, O2 saturation 94% on room air. His ambulatory O2 saturation is 92% after 1000 feet, with an HR of 133. What is the most likely diagnosis?

Berylliosis

A 32-year-old married woman presents with a history of panic disorder and posttraumatic stress disorder resulting from sexual trauma. She began using opioids when a friend gave her oxycodone to help her to "relax." Currently, she uses opioids daily "just to function." Despite ongoing use, she has been able to continue working as a receptionist. She says that she has a support system, although few people are aware of her use. She has begun individual therapy and started taking citalopram after meeting with her psychiatrist. She attempted non-medication-assisted detox last year but had horrible withdrawal symptoms. She relapsed soon after detox was completed. She is interested in medication to help with her OUD. She cannot take much time off work, and she is currently on long-term birth control. What option would be the best choice for this patient's medical condition?

Buprenorphine/naloxone

"I tried those things, Doc, and nicotine didn't work and varenicline made me shoot my boyfriend in the leg—but he had it coming. Isn't there something else?" What medication might you also prescribe to aid this patient in smoking cessation?

Bupropion

This is the radiograph of a 67-year-old chronic smoker with a sudden onset of right-sided chest pain. He notices a "crunchy" feeling on the right side of the chest, the onset of which is coincidental with the onset of pain. He has mild shortness of breath but is in no distress.

COPD and a simple pneumothorax

A 72-year-old man is complaining of the acute onset of dyspnea and pleuritic chest pain. He had a right hip replacement surgery 4 days ago. He has osteoarthritis and well-controlled hypertension. His respiratory rate is 28 breaths per minute, HR is 100 beats per minute, and BP is 130/80 mm Hg. His pulse oximetry oxygen saturation is 91% on room air. What study would be most useful in confirming the diagnosis?

CT angiography (CTA)

A 51-year-old man with 22 years of experience as a coal miner presents with worsening dyspnea. He has an intermittently productive cough with black-tinged sputum for years. He does not smoke. He was diagnosed with rheumatoid arthritis 2 years ago with predominantly joint symptoms, including his hands and knees. He has been on immunosuppressive therapy. He denies any fevers, chills, sweats, or weight loss. His chest imaging shows bilateral nodular opacities, predominantly in the periphery. Several of the lesions are calcified, and one shows evidence of cavitation. What is the most likely diagnosis?

Caplan syndrome

A 50-year-old male who is a heavy drinker with a history of squamous cell carcinoma of the neck presents to your office complaining of abdominal pain. He has been coughing and expectorating bloody sputum and notes a low-grade fever, chills, and mild dyspnea starting about 1 week ago. He denies nausea, emesis, and chest pain. His squamous cell carcinoma was treated with external beam radiation several years ago. Examination reveals an afebrile male in mild distress. His vital signs are normal, and his lungs sound clear. The abdominal examination reveals only mild epigastric tenderness. Chest XR reveals a cavitary lesion in the right upper lobe. What is the best next step in the diagnosis of this process?

Chest CT

A 68-year-old woman is brought to the emergency center after coughing up several tablespoons of bright red blood. For the previous 3 to 4 months, she has had a chronic nonproductive cough but no fevers. More recently, she has noticed some scant blood-streaked sputum. She also 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 drinks two martinis every day and has smoked one pack of cigarettes per day for the past 35 years. Other than alcohol and tobacco use, she has not had any additional medical issues. She worked in a library for 35 years and has no history of occupational exposures. She does not take any medication except for one low-dose aspirin per day. The patient is a mildly anxious appearing, thin woman who is alert and oriented. Her blood pressure is 150/90 mm Hg, heart rate is 88 beats per minute (bpm), respiratory rate is 16 breaths/min, and temperature is 99.2 °F. Neck examination reveals no lymphadenopathy, thyromegaly, or carotid bruit. The chest has scattered rhonchi bilaterally, with no wheezes or crackles. Cardiovascular examination reveals a regular rate and rhythm, without rubs, gallops, or murmurs. The abdomen is benign with no hepatosplenomegaly. Examination of her extremities reveals no cyanosis; there is finger clubbing. Neurologic examination is normal. What is your next step?

Chest Imaging (XR/CT)

A 68-year-old woman is brought to the emergency center after coughing up several tablespoons of bright red blood. For the previous 3 to 4 months, she has had a chronic nonproductive cough but no fevers. More recently, she has noticed some scant blood-streaked sputum. She also 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 drinks two martinis every day and has smoked one pack of cigarettes per day for the past 35 years. The patient is a mildly anxious appearing, thin woman who is alert and oriented. Her BP is 150/90 mm Hg, HR is 88bpm, RR is 16 breaths/min, and temperature is 99.2 °F. The chest has scattered rhonchi bilaterally, with no wheezes or crackles. Examination of her extremities reveals no cyanosis; there is finger clubbing. What is your next step in evaluation?

Chest XR

A 67-year-old man presents to your office with worsening cough, sputum production, and shortness of breath. He has been a cigarette smoker for the past 50 years, smoking approximately 1 pack a day. He has a chronic AM cough productive of some yellow sputum but generally feels okay during the day. He was in his usual state of health until two weeks ago when he developed a cold. Since then, he has had a hacking cough and increased thick sputum production. He also has had difficulty walking more than a block without stopping due to shortness of breath. Physical examination reveals prolonged expiration, audible wheezing, and diffuse rhonchi throughout both lung fields. Chest x-ray shows hyperinflation of both lungs with a flattened diaphragm. What is the most likely diagnosis?

Chronic Bronchitis (COPD)

A 50-year-old homeless man is brought to the emergency department by the police for disruptive behavior. On mental status examination, he has an elevated affect, but he also has psychomotor agitation and paranoia; he says he "feels fantastic" but is wary of answering any questions, quickly becoming irritated. On physical examination, the patient exhibits a moderately elevated blood pressure and pulse rate. He is most likely intoxicated with which substance?

Cocaine (Stimulant)

A 61-year-old woman presents to the emergency department complaining of a cough for 2 weeks. The cough is productive with green sputum and is associated with sweating, shaking chills, and fever up to 102 °F (38.8 °C). She was exposed to her grandchildren, who were told that they had upper respiratory infections 2 weeks ago but now are fine. Her past medical history is significant for diabetes for 10 years, which is under good control using oral hypoglycemics. She denies tobacco, alcohol, or drug use. On examination, she looks ill and in distress, with continuous coughing and chills. Currently, her blood pressure is 100/80 mm Hg, pulse is 110 beats/min, temperature is 101 °F (38.3 °C), respirations are 24 breaths/min, and oxygen saturation is 97% on room air. Examination of the head and neck is unremarkable. Her lungs have rhonchi and decreased breath sounds, with dullness to percussion in bilateral bases. Her heart is tachycardic but regular. Her extremities are without signs of cyanosis or edema. The remainder of her examination is normal. A complete blood count (CBC) shows a high white blood cell count of 17,000 cells/mm3, with a differential of 85% neutrophils and 20% lymphocytes. Her blood sugar is 120 mg/dL. What is the most likely diagnosis?

Community-acquired pneumonia (CAP)

A 29-year-old man with past medical history significant for heroin use is evaluated in the emergency department for stupor. On arrival, he was minimally responsive with miotic and sluggish pupils. He had needle tracks on his arms. His respiration rate was 8 breaths/min, but 5 minutes after administration of two doses of intravenous naloxone, his respiration rate is 16 breaths/min, and he is alert but not completely oriented. He does not remember what happened before the admission but is able to answer some questions. His vital signs have normalized. What is the best next step?

Continue to observe for several hours

A 38-year-old man with acute onset of shortness of breath is being evaluated in the emergency department. Your differential diagnosis is pleural effusion versus pneumothorax. What physical finding will help differentiate between the two dx?

Dullness to percussion over the affected hemithorax

Which medication would be the best choice for DT in a patient who is vomiting profusely and who has no IV access?

Lorazepam (Ativan)

A 2½-year-old boy comes to your clinic for the first time with a history of fever and increasing "wet" cough for 8 days. His mother reports that he has been diagnosed with asthma and has an albuterol inhaler to use for wheezing or cough. Since 6 months of age, he has had several similar episodes of "wet" cough and fever, which were diagnosed as bronchitis or pneumonia, and each time, he improved when treated with antibiotics and albuterol. However, over the past year, these episodes have become more frequent and the cough now occurs almost daily. Sometimes the mother sees him expectorate the sputum, which is thick and purulent. He has daily nasal congestion, for which she uses saline and bulb suction. She is able to remove some thick yellow discharge, but the symptoms mainly improve when he is treated with antibiotics. He is not in daycare and has no tobacco exposure. She is concerned that his frequent illnesses are causing him to be "small for his age." The mother notes his stools are malodorous, and since initiating potty training, she has observed that his stools float and sometimes appear to have drops of oil on them. On physical examination, the patient is a moderately ill-appearing child whose height and weight are at the third percentile for his age. His temperature is 101 °F (38.3 °C), and respiratory rate is 32 breaths per minute and oxygen saturation of 96%. He is breathing with his mouth open. Over the upper lung fields, he has crackles and rhonchi, along with a few expiratory wheezes over all lung fields. He has no heart murmur; S1 and S2 are normal. His fingers show clubbing. You obtain a chest radiograph, which shows linear opacities in a parallel tram-track configuration in the upper lobes with some ring-shaped opacities; the radiologist interprets the findings as bronchiectasis. What is the most likely diagnosis?

Cystic Fibrosis

Which of the following medications would be indicated to prevent delirium tremens (DT) in a patient with hepatic impairment?

Lorazepam (Ativan)

A 42-year-old diabetic woman complains of soreness of the left leg. She is moderately obese and has been recovering from surgical removal of her gallbladder (cholecystectomy) performed 2 weeks ago. On examination, she has obvious swelling in the left lower leg and some tenderness of the calf that increases when the calf is gently squeezed. There is no redness of the leg, and she is afebrile (without fever). What is the most likely diagnosis?

Deep Vein Thrombosis

A 49-year-old man with diabetes underwent laparoscopic colectomy 5 days ago. He now complains of right calf and thigh swelling and pain. His blood pressure (BP) is 120/70 mm Hg, heart rate (HR) is 80 beats per minute, respiratory rate is 14 breaths per minute, and temperature is afebrile. His oxygen saturation is 96% on room air. What is high on your differential?

Deep Vein Thrombus (DVT)

A 42-year-old man was admitted for vomiting blood. On admission, his examinations including vital signs were unremarkable. Initial laboratory tests showed mild macrocytic anemia on CBC, normal LFT, and a negative alcohol level. The next day, he started to see "spiders hanging from the ceiling." Examination revealed temperature 97.8°F, heart rate 74/min, respiratory rate 12/min, and blood pressure 130/80 mm Hg. There was mild tremulousness. His past medical history was significant for alcohol abuse. What is the most likely diagnosis?

Delirium Tremens - Alcohol Withdrawal

A 57-year-old man was admitted to the hospital 2 days ago following a motor vehicle accident. He suffered multiple contusions and a femur fracture that was surgically repaired 24 hours ago. His hospital course has been uncomplicated, and he currently is taking morphine as needed for pain and subcutaneous enoxaparin for prophylaxis of deep venous thrombosis. This evening he has been agitated and combative and pulled out his intravenous (IV) line. He is cursing at the nurses and is trying to get out of bed to leave the hospital. When you see him, he is febrile with a temperature of 100.8 °F, heart rate of 122 beats per minute, blood pressure of 168/110 mm Hg, respiratory rate of 28 breaths per minute, and oxygen saturations of 98% on room air. He is awake and fidgety, staring around the room nervously. He is disoriented to place and time; he seems to be having auditory hallucinations and is brushing off unseen objects from his arms. On examination, his forehead wound is bandaged, his pupils are dilated but reactive, and he is mildly diaphoretic. You are able to contact family members by phone. They confirm that prior to his car accident, the patient had no medical problems, and was employed as an attorney. They report that he took no medications at home, did not smoke or use illicit drugs, and drank three to four mixed drinks every day after work, sometimes more on the weekends. What is the most likely diagnosis?

Delirium Tremens-Alcohol Withdrawal

A 48-year-old man has a community-acquired pneumonia. He is prescribed an oral penicillin product. Within 15 minutes of taking the first dose, he develops tightness in his chest, and numbness and swelling of his lips. His wife calls emergency services; he is treated in his home and transported to the hospital. How will you treat his CAP now?

Doxy or Azithro

A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had the symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month. She notes that the symptoms are worse during the spring months. She has no exercise-induced or nocturnal symptoms. The family history is notable for a father with asthma. She is single and works as an administrative assistant in a high-tech firm. She lives with a roommate, who moved in approximately 2 months ago. The roommate has a cat. The patient smokes occasionally when out with friends and drinks socially, but has no history of illicit drug use. Examination is notable for mild end-expiratory wheezing. The history and physical examination are consistent with a diagnosis of asthma. Pulmonary function tests are ordered to confirm the diagnosis. What might you expect the results of her pulmonary function tests to be during an exacerbation?

During an attack, all indices of expiratory airflow may be reduced, including FEV1, FEV1/FVC, and peak expiratory flow rate.

A 62-year-old man presents to clinic with 3 weeks of coughing up streaks of blood. He denies any fevers or chills, but says his energy level is low and he has lost about 8 pounds in the past month unintentionally. He smoked 1 pack daily for 40 years but quit 5 years ago after being diagnosed with coronary artery disease. His medications include aspirin, lisinopril, simvastatin, and metoprolol. His hematocrit is 33% (two years ago, it was 42%), and a CXR shows no obvious abnormalities. What would further testing likely show?

Lung Cancer (Neoplasm)

A 36-year-old single man who works in an office arrives at your office to establish care. He has a 3-year history of low back pain and is requesting a refill of medications. The pain started 3 years ago with a motor vehicle accident in which he broke ribs and developed disabling low back pain. The patient has been on naproxen and oxycodone regularly since then. He also takes cyclobenzaprine at night as needed for sleep and muscle relaxation. He brings old medical records, which include a report of magnetic resonance imaging (MRI) of the lumbar spine without noted pathology, a copy of a pain contract, and a problem list that shows a history of tobacco use disorder and a family history of alcohol use disorder. On intake, the patient completed a screening, brief intervention, referral for treatment (SBIRT) evaluation, showing a nine-question Patient Health Questionnaire (PHQ9) score of 15 (indicating moderate-to-severe depression) and ASSIST (Alcohol, Smoking, Substance Involvement Screening Test) score of 32 for use of prescription opiates obtained from friends. He states he finds himself looking forward to taking the oxycodone and doubling his dose more often recently. He admits that he was given the option of leaving or being fired from his previous job due to sleepiness at work and poor performance. On reviewing the SBIRT screen results with the patient, he admits that he feels out of control and that he tried to cut back on his oxycodone recently but felt empty, isolated, and unable to sleep without the medication. He would like to stop using the medication but does not know how. How do you address the increasing desire for opioids?

Express understanding and present the patient with options for medication-assisted therapy (MAT) for stabilization versus outpatient detoxification.

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. Is this Exudative or Transudative effusion?

Exudative

A 65-year-old female with chronic obstructive pulmonary disease (COPD) who is a current smoker (30 pack-year history) presented to your clinic for evaluation of worsening cough. She denies fever, chills, weight loss, worsening shortness of breath, hemoptysis, or night sweats. You order a chest x-ray (CXR) which shows a 14-mm single pulmonary nodule (SPN) in the left upper lobe. You are able to obtain two prior CXRs. The first is from 3 years ago and shows emphysema with no pulmonary nodules visible. The most recent is from 18 months ago and shows possible increased density in the left upper lobe, but no discrete nodule is identifiable. You obtain a chest CT that reveals a 16 mm, noncalcified, solid, irregularly shaped nodule. What would be your next course of action?

FDG-PET Scan

A 45-year-old man presents with shortness of breath, cough, and nonmassive hemoptysis. He requires 50% FIO2 via a heated, high-flow nasal cannula. His urinalysis is positive for 3+ hematuria and trace protein, no glucose, and less than 5 WBCs per high-powered field. The nephrology team centrifuged the patient's urine and identified cellular casts. The patient denies any constitutional symptoms and rather feels like he has gained 3 to 5 lb of water weight recently. The patient's creatinine level is 5.4 mg/dL, from a baseline of 1.1 mg/dL 6 months ago. He has no medical history aside from stage 1 essential hypertension. The patient undergoes a kidney biopsy that returns with linear deposition of IgG antibodies along the capillaries. What is the most likely diagnosis?

Goodpasture Syndrome/Disease

A 30-year-old woman presents with recurrent nose bleeds, sinus infections, a cough, often productive of blood, fever, weight loss, and fatigue for the last 5-6 months. She has had some stridor and wheezing for the last week, which has not been responsive to bronchodilators. She has had no exposures to infectious diseases that she is aware of and has not traveled. She takes no medications. Initial lab testing is positive for ANCA. What is the most likely diagnosis?

Granulomatosis with Polyangiitis

A 26-year-old graduate student is brought to the emergency department after becoming physically aggressive with his best friend. The patient has not been sleeping or eating well, resulting in a weight loss of approximately 10 lb, and has been "studying like a fiend" for his exams. The patient has no medical or psychiatric history. The patient's physical examination shows hypertension and tachycardia, as well as dilated pupils, diaphoresis, and a fine bilateral tremor in his hands. In the emergency department, he is oriented but belligerent and uncooperative. He states that his mood is fine, although he appears angry and tries to elope from the hospital. Several staff members are needed to control the patient, who is psychotic and extremely agitated, requiring placement in four-point restraints. What pharmacologic interventions is the most appropriate?

Haloperidol (Antispychotic)

A 56-year-old man presents with several acute episodes of dyspnea over the last few weeks. He has a history of HTN and GERD. He takes an angiotensin-converting enzyme (ACE) inhibitor and omeprazole. He has never smoked. He exercises three to four times a week, though he has not been able to recently because of fatigue. He has no family history of cardiac, pulmonary, or rheumatologic history and no history of malignancy. He works as a consultant for an engineering firm. He initially experienced intermittent episodes of fever, myalgia, dyspnea, and dry cough, which started in the middle of the night about 3 weeks ago. This coincided with starting a new project at work, to help design a new manufacturing plant that had flooded recently and is being demolished soon because of mold. After 2 days of these symptoms, the patient presented to the ED because of some lightheadedness and tachycardia. What is the most likely diagnosis?

Hypersensitivity Pneumonitis

A 68-year-old man presents to the clinic with a complaint of shortness of breath. He states that he has become progressively more short of breath over the last 2 months, such that he is now short of breath with walking one block. In addition, he has noted a nonproductive cough. He denies fever, chills, night sweats, chest pain, orthopnea, and paroxysmal nocturnal dyspnea. He has noted no lower extremity edema. The medical history is unremarkable. Physical examination reveals a respiratory rate of 19/min and fine, dry inspiratory crackles heard throughout both lung fields. Digital clubbing is present. What is the most likely diagnosis?

Idiopathic Pulmonary Fibrosis

You are urgently called to the recovery room because a 5-year-old boy is hypotensive. He just underwent rigid bronchoscopy for removal of a foreign body (metal part of a toy car) from a left main bronchus 30 minutes earlier. The procedure required some time because the metal part had embedded in the bronchus, but the area was hemostatic following the procedure. He underwent general anesthesia, and intubation and extubation were unremarkable. The child's past medical history is unremarkable, and he takes no medications. On physical examination, the child appears anxious and complains of chest pain. His temperature is normal, heart rate is 160 beats per minute, blood pressure is 60/40 mm Hg, and oxygen saturation is 91% on 80% FiO2 by face mask. Jugular venous distention is noted. The pulmonary examination reveals diminished breath sounds on the left and normal breath sounds on the right. The cardiac examination demonstrates tachycardia and no murmurs or gallops. The trachea appears to be deviated to the right side. What is your next step?

Immediate Needle Decompression

What lab test results are you most likely to find in a patient going through alcohol withdrawal?

Increased gamma-glutamyltransferase (GGT)

A 15-year-old male is brought into the ED by his neighbor who found the boy passed out in his backyard with multiple tubes of glue nearby. He had difficulty rousing the boy. Currently, the patient is lethargic with slurred speech and difficulty walking. When his parents arrive, they are shocked, as their son has been a "good kid." What best describes the patient's current clinical condition?

Inhalation intoxication

A 25-year-old woman is seen in the clinic because her father, who recently emigrated from South America, was diagnosed with and has been treated for TB. She denies a cough, and her chest radiograph is normal. A PPD test shows 10 mm of induration. Her only medication is an oral contraceptive. How would you treat this patient?

Isoniazid + Rifapentine

A 62-year-old man is admitted to the ICU after a motor vehicle accident. The patient was previously healthy per his girlfriend of 3 days, whom he met online. Per his girlfriend, they were at a party prior to the motor vehicle accident. A psychiatrist is called because the patient has become confused, agitated, and diaphoretic and screams that the nurses are trying to euthanize him. He begins pulling out his IV lines and other tubes. He is visibly tremulous, flushed, and diaphoretic. His blood pressure is 168/93 mm Hg, heart rate is 125 bpm, respiratory rate is 20 breaths per minute, and oxygen saturation is 98% on room air. The results of his physical examination are unremarkable, but his laboratory tests show low serum albumin and low protein levels, as well as an elevated prothrombin time/partial prothrombin time. What medications would be most appropriate in treating this patient?

Lorazepam

What disease should be ruled out in a patient with significant history for asbestos exposure and asbestosis?

Mesothelioma

An 8-year-old boy presents to primary care clinic with nighttime cough. On further questioning, his mother did notice this at times when he was younger, but it seemed to go away within a day or two. It now wakes him from sleep at least once a week. He sometimes has difficulty breathing when he runs, but this has been attributed to his being a little overweight in the past. On physical exam, his lungs are clear, and he is in no distress. His BMI is 21 kg/m2. Nasal mucosa is hyperemic and bluish. Chest x-ray reveals slightly hyperinflated lungs. Spirometry shows FEV1 of 85% and FEV/FVC of 85%, which improves with short-acting bronchodilator treatment. How severe is his asthma?

Moderate persistent asthma (though lung function is in Mild)

A 21-year-old woman is brought into the emergency department by her college roommate. The patient has been unconscious for at least 30 minutes. The patient's roommate is unaware of any health condition but states that the patient has attended several college parties over the last weeks, and though she is uncertain of this fact, she believes her roommate "has been doing drugs." On examination, the patient is somewhat pale. Her mucous membranes are dry. Her temperature is 98 °F, heart rate is 80 beats per minute (bpm), respiratory rate is 8 breaths per minute, and blood pressure is 90/60 mm Hg. The skin has no lesions suggestive of intravenous injections. Her heart and lung examinations are unremarkable. The abdominal examination reveals hypoactive bowel sounds, and the abdomen is nontender. The patient barely opens her eyes upon painful stimulus. There is no evident focal deficit. Pupils are miotic and sluggish. What medication will you treat with?

Naloxone

A 35-year-old intoxicated female presents to your office requesting to be started on disulfiram (Antabuse). She is otherwise healthy and recently has begun to drink alcohol daily in response to the death of her sister. She wants to decrease her use but has been unsuccessful, has noticed she is needing to drink more to achieve the same effect, has missed a few family functions due to her alcohol use, and has experienced the need to drink in the morning to avoid "feeling bad." Before this, she was a teetotaler (i.e., a nondrinker). As the patient meets criteria for an alcohol use disorder and is still drinking (as indicated by her intoxicated appearance in clinic today), you suggest an FDA-approved alternative to disulfiram. You recommend:

Naltrexone

If the patient consumes alcohol while taking disulfiram, what is most likely to occur?

Nausea and vomiting

60-year-old female presents to your office and is determined to stop smoking. She has a history of schizophrenia treated with clozapine (Clozaril) and a 43-year history of smoking up to two packs of cigarettes per day. She asks you what is available to help her stop. You tell her that nicotine replacement therapy (NRT), bupropion (Zyban), and varenicline (Chantix) are currently approved to aid patients who want to stop smoking. If you want to offer NRT that is easy to use, has few side effects, and provides steady blood levels of nicotine over the whole day, which do you choose?

Nicotine patch

A 52-year-old man with a history of hypertension presents to primary care clinic because he just hasn't been feeling like himself over the last year. He has trouble concentrating, does not have the energy he used to have, and is having trouble sleeping. His wife says he snores excessively and has "fitful" sleep. Physical exam reveals a man with body mass index (BMI) of 32 kg/m2, BP 145/90 mm Hg, 2+ tonsils, mild crowding of the oropharynx, and truncal obesity. He has no thyromegaly, murmurs, abnormal lung fields, or abdominal masses or tenderness. Neurologic exam is normal. What is the likely diagnosis?

Obstructive Sleep Apnea

A 45-year-old male presents to your clinic to establish care for his chronic back and leg pain. He denies any other medical conditions. He reports being injured at work approximately 5 years ago, at which time he was started on oxycodone. He reports being on a stable dose for the past few years. He appears slightly drowsy during the appointment, has small pupils, and is having moderate difficulty describing his injury and previous treatments. He reports his mood as okay but becomes irritable when you begin to ask specifics about his injury. He has not been able to keep a job for the last year because "everyone fires me." He states that he needs the oxycodone to function and that he ran out of his medication one week ago. He does report occasional alcohol use, although he states that he knows not to mix alcohol with his oxycodone. What is the most likely explanation for the patient's presentation?

Opioid intoxication

You do not prescribe opiods to a patient seeking a refill for low back pain, instead offering alternatives. He says he has tried them all and none of them work (ever heard that before?). When not offered an opioid, he gets upset and walks out of your office. Two days later, while you are covering an emergency department (ED) shift, the same male presents to the ED for severe, uncontrolled pain. He is vomiting, complains of muscle aches and diarrhea, his pupils are dilated, and he is febrile. What is the most likely explanation for the patient's current presentation?

Opioid withdrawal

A 64-year-old man is brought to the emergency room by his family for evaluation of mental status changes. They noticed that he was becoming somewhat confused the day before presentation, describing him as "just not acting like his usual self." That morning, he was barely arousable and even more confused. He had previously been feeling a bit tired but was otherwise without complaint except for a nagging cough. He had had no falls or head trauma. He had a greater than 50-pack-year smoking history and currently smokes one pack per day. A chest x-ray shows a 3 cm mass in his right upper lung field. Blood chemistries show a serum calcium level of 14 mg/dL. A computed tomography scan of the head is normal. What is this patient likely suffering from?

Paraneoplastic Syndrome

A 14-year-old boy has ataxia. He is brought to the local emergency department, where he appears euphoric, emotionally labile, and a bit disoriented. He has nystagmus and hypersalivation. Many notice his abusive language and aggression toward caregivers. What agent is most likely responsible for his condition?

Phencyclidine (PCP)

Following the placement of a left subclavian vein catheter in the radiology suite, a 45-year-old man develops shortness of breath and chest pain. His breath sounds are diminished on the left, and percussion of the left hemithorax reveals hyperresonance. His oxygen saturation by pulse oximetry drops from 97% to 88%. What is the best treatment for this patient?

Placement of a left chest tube

A 32-year-old woman presents to the emergency center complaining of a productive cough, fever, and chest pain for 4 days. She was seen 2 days ago in her primary care provider's clinic with the same complaints; she was diagnosed clinically with pneumonia and was sent home with oral azithromycin. Since then, her cough has diminished in quantity. However, the fever has not abated, and she still experiences left-sided chest pain, which is worse when she coughs or takes a deep breath. In addition, she has started to feel short of breath when she walks around the house. She has no other medical history. On physical examination, her temperature is 103.4 °F, heart rate is 116 beats per minute (bpm), blood pressure is 128/69 mm Hg, and respiratory rate is 24 breaths/min and shallow. Her pulse oximetry is 94% saturation on room air. Physical examination is significant for decreased breath sounds in the lower half of the left lung fields posteriorly, with dullness to percussion between the fifth and eighth intercostal spaces at the midclavicular line. There are a few inspiratory crackles in the midlung fields, and her right lung is clear to auscultation. She has sinus tachycardia with no murmurs. She has no cyanosis. What is the most likely diagnosis?

Pleural Effusion

For patients with either CWP or silicosis, what is the most important intervention?

Prevention of exposure

At 3 am the paramedics call to inform you that they are en route to the emergency department with a 33-year-old woman with a history of asthma. As she is brought in, you identify she is in severe respiratory distress. Sweat pours from her face and body as her neck and chest heave in an attempt to inhale another breath. Her efforts are ultimately futile as her consciousness slips away and she becomes apneic. What is your initial priority in the management of this patient?

Protect Airway - Intubate

A 34-year-old man presents to the emergency department (ED) complaining of shortness of breath and right-sided chest pain that increases with deep breathing. He states it started suddenly when he woke up and was worse with activity. He denies fever, chills, nausea, vomiting, or cough. He has a recent history of multiple gunshot wounds, resulting in ongoing pain in his upper back and T-10 paraplegia. One week ago, he was discharged from the hospital to a rehabilitation facility. He is currently taking acetaminophen/hydrocodone and ibuprofen for his pain, which has increased with his physical therapy and occupational therapy. He is also taking hydrochlorothiazide and lisinopril for hypertension and fluoxetine for depression. He recently quit smoking tobacco since he was hospitalized and denies any alcohol or illicit drug use. On physical examination, he is an otherwise fit young man who appears slightly short of breath and uncomfortable. His heart rate is 101 beats per minute, his blood pressure is 110/78 mm Hg, and his respiratory rate is 26 breaths per minute. His pulse oximetry is 96% on 2 L of O2 by nasal canula. His lungs are clear to auscultation. There is mild swelling of his left calf. He has no sensation in his lower extremities. Laboratory studies reveal a white blood cell (WBC) count of 10,000/mm3. Hemoglobin, hematocrit, electrolytes, and renal function are all within normal limits. A 12-lead electrocardiogram (ECG) reveals a sinus rhythm at a rate of 103 beats per minute. His chest radiograph reveals minimal bibasilar atelectasis but no evidence of infiltrates or effusions. What is the most likely diagnosis?

Pulmonary Embolism

A 48-year-old woman is brought to the emergency center complaining of a sudden onset of dyspnea. She reports that she was standing in the kitchen making dinner when she suddenly felt as if she could not get enough air. Also, her heart started racing, she became light-headed, and she felt as if she would faint. She denies chest pain or cough. Her medical history is significant only for a cholecystectomy performed 2 weeks earlier for gallstones. The procedure was complicated by a wound infection, requiring her to stay in the hospital for 8 days. She takes no medications regularly and only takes acetaminophen as needed for pain at her abdominal incision site. On examination, she is tachypneic with a respiratory rate of 28 breaths/min, oxygen saturation of 84% on room air, heart rate of 124 beats per minute (bpm), and blood pressure of 118/89 mm Hg. She appears uncomfortable, diaphoretic, and frightened. Her oral mucosa is slightly cyanotic, her jugular venous pressure is elevated, and her chest is clear to auscultation. Her heart rhythm is tachycardic but regular with a loud second sound in the left second intercostal space, without gallop or murmurs. Her abdominal examination is benign, with a clean incision site without signs of infection. Her right leg is moderately swollen from her midthigh to her foot, and her thigh and calf are mildly tender to palpation. Laboratory studies, including cardiac enzymes, are normal; her electrocardiogram (ECG) reveals only sinus tachycardia, and her chest x-ray is interpreted as normal. What is the most likely diagnosis?

Pulmonary Embolism

A 52-year-old woman presents to the emergency department complaining of sudden-onset right chest pain and shortness of breath of 2 hours' duration. Six days ago, she underwent an uncomplicated laparoscopic left colectomy for adenocarcinoma of the descending colon; she was discharged 3 days after surgery and was doing well at home. The patient appears anxious and complains that she cannot "catch her breath." Her temperature is 37.9 °C (100.3 °F), heart rate is 105 beats per minute, blood pressure is 138/80 mm Hg, and respiratory rate is 32 breaths per minute. Her oxygen (O2) saturation is 96% on 2 L/min O2 by nasal cannula. There is no jugular venous distention. Her lungs are clear with slightly diminished breath sounds at both bases. Her legs are mildly edematous bilaterally, and her left calf is mildly tender to palpation. Laboratory studies reveal a white blood cell (WBC) count of 10,000 cells/mm3 with a normal differential and normal hemoglobin, hematocrit, and platelet count. The serum electrolytes are normal. An arterial blood gas reveals pH of 7.45, PO2 of 73 mm Hg, PCO2 of 34 mm Hg, and HCO3 of 24 mEq/L. A twelve-lead electrocardiogram (ECG) reveals sinus tachycardia. A portable chest radiograph (CXR) demonstrates no infiltrates, no effusion, and minimal atelectasis in both lower lung fields. What is the most likely diagnosis?

Pulmonary Embolism

A 55-year-old man presents with 2 days of significantly worsening dyspnea. He has a history of hypertension, for which he takes amlodipine and carvedilol. He has a 20-pack-year smoking history but quit smoking 5 years ago. He reports the onset of dyspnea immediately when he awoke 2 days ago, and it has progressively worsened since that time, to the point that he is now short of breath with minimal activity. He denies any chest pain, but he does have an intermittent dry cough. He denies any fevers, chills, sweats, weight loss, changes in appetite, or hemoptysis. He denies any abdominal or joint symptoms. He works as a mechanical engineer and is in an office setting most of the time. He recently had an injury on the job and was not working for the last 2 weeks while recovering from a severe right knee sprain. He has been more sedentary over the last several weeks. He does endorse some swelling in his right lower extremity but states his leg has been swollen since the time of the injury. His vital signs are T 99.7°F, HR 110, BP 105/60, RR 24, and O2 saturation 84% on room air, improved to 92% on 4 L NC. His creatine is 1.2 mg/dL. His WBC count is 11,800/μL, and his platelet count and hemoglobin are normal. His other coagulation studies and liver function panel are also normal. EKG shows sinus tachycardia. What is the most likely diagnosis?

Pulmonary Embolism

Ms. Cava is a 23-year-old female who presents to the emergency department with shortness of breath. She has had shortness of breath for about 6 hours. She states that the shortness of breath came on suddenly at rest. She states it is now worse with exertion and incompletely relieved with rest. She also reports some sharp left-sided chest pain. She denies extremity pain or swelling. She has had no similar prior pain. Past medical history is negative for PE, DVT, cancer, asthma, and heart disease. She takes only a birth control pill. She has had no prior surgeries. The patient denies smoking. She reports a recent 5-hour car trip. Her vitals are temperature 37.1°C (98.8°F), blood pressure 129/76 mm Hg, pulse 108 beats/min, respiratory rate 22 breaths/min, and oxygen saturation of 93% on room air. On examination, you note mildly increased respiratory effort, and clear lungs. Heart examination reveals tachycardia, but is otherwise normal. She has some mild tenderness to palpation of the left chest wall. Her left lower extremity is mildly swollen. Her extremities have normal perfusion and neurological function. What is the most likely Diagnosis?

Pulmonary Embolism

A 28-year-old woman with no significant past medical history presents to clinic with complaints of progressive shortness of breath; she becomes dyspneic with less activity compared to 1 year ago. If she exerts herself beyond a brisk walk, she becomes lightheaded, pre-syncopal, and feels tightness in her chest. She also notes generalized fatigue. Your examination discloses a heart rate of 105 bpm and normal blood pressure. Resting transcutaneous oximetry is 92% on room air. BMI is 24 kg/m2. She has JVD but clear lungs. What is the most likely diagnosis?

Pulmonary Hypertension

A 44-year-old woman is scheduled for a vaginal hysterectomy for dysmenorrhea that has failed medical therapy. Although she had been otherwise healthy, over the past year, she has increasingly noticed exertional dyspnea, particularly when shopping in large stores. These symptoms have worsened, to the point that she sometimes felt as though she was about to "pass out." What is the likely diagnosis?

Pulmonary Hypertension

A 62-year-old man is brought to the clinic for a 3-month history of unintentional weight loss (12 lb). His appetite has diminished, but he reports no vomiting or diarrhea. He does report some depressive symptoms since the death of his wife a year ago, at which time he moved from Cambodia to the United States to live with his daughter. He denies a smoking history. He complains of a 3-month history of productive cough with greenish sputum. He has not felt feverish. He takes no medications regularly. On examination, his temperature is 100.4 °F and respiratory rate is 16 breaths per minute. His neck examination shows a normal thyroid gland and no cervical or supraclavicular lymphadenopathy. His chest has scattered crackles in the left midlung fields and a faint expiratory wheeze on the right. His heart rhythm is regular with no gallops or murmurs. His abdominal examination is benign, his rectal examination shows no masses, and his stool is negative for occult blood. What is the most likely diagnosis?

Pulmonary Tuberculosis

A 57-year-old man undergoes total knee replacement for severe degenerative joint disease. Four days after surgery, he develops an acute onset of shortness of breath and right-sided pleuritic chest pain. He is now in moderate respiratory distress with a respiratory rate of 28/min, heart rate of 120 bpm, and blood pressure of 110/70 mm Hg. Oxygen saturation is 90% on room air. Lung examination is normal. Cardiac examination reveals tachycardia but is otherwise unremarkable. The right lower extremity is postsurgical, healing well, with 2+ pitting edema, calf tenderness, erythema, and warmth; the left leg is normal. He has a positive Homan sign on the right. What is the most likely diagnosis?

Pulmonary embolism

A 64-year-old female with a history of COPD and obstructive sleep apnea was admitted to the hospital for suspected methicillin-resistant Staphylococcus aureus cellulitis. The patient was started on intravenous vancomycin. She refused to use the hospital CPAP machine during the night. At 6:00 AM the phlebotomist found the patient unresponsive, and the rapid response team was called. The patient had a Glasgow coma score of 5. Her vital signs were normal except for an O2 saturation of 85% on room air. ABG showed: pH of 7.01, PO2 of 55, PCO2 of 90, and HCO3 of 30. What is the patient's acid-base disorder?

Respiratory Acidosis - non-compensated

A 62-year-old woman with chronic obstructive pulmonary disease (COPD) presents to primary care clinic for an acute visit. She normally uses 3 to 5 liters per minute (LPM) of oxygen continuously. She has had one week of increased cough and sputum production and has had to increase her oxygen to 7 LPM at rest. On exam she has equal breath sounds, bilateral inspiratory and expiratory wheezes, and distant heart sounds. She is using accessory muscles to breathe and has supraclavicular retractions. She reports that the last 3 days she has had fever to 102°F. She has not had any shaking chills. Her vitals are: pulse 103 bpm, BP 90/60 mm Hg, respiratory rate 23 bpm, temperature 101.6°F. Pulse oximetry is 91% on 7 LPM O2. Because of her respiratory distress, you start an albuterol/ipratropium treatment in clinic. Na: 142 (135-145) Cl: 98 (96-106) pH: 7.2 (7.35-7.45) PCO2: 75 (35-45) HCO3: 27 (20-29) What is the patient's acid-base disorder?

Respiratory Acidosis w/ Anion Gap

A 35-year-old African-American female presents with dyspnea worsening over the last 2 months. She also complains of cough, generalized fatigue, and intermittent low-grade fevers. She does not smoke. Chest x-ray shows hilar adenopathy and small bilateral pleural effusions. Spirometry is consistent with a restrictive pattern. What is the most likely diagnosis?

Sarcoidosis

This is the radiograph of a 58-year-old man who complains of progressive shortness of breath. He has a work history significant for years of sandblasting and working in a cement plant. What is the Diagnosis?

Silicosis

A 29-year-old single woman is brought to the emergency department by the police after they picked her up attempting to break into a grocery store. When they apprehended her, they noticed that she "seemed high" and that she was sweating with dilated pupils. The patient admits to "doping" daily for the majority of the past year and losing 30 lb in the past 6 months. She claims that her habit now costs more than $100 per day, although she used to get the "same high" for $20. When intoxicated, she describes her mood as "really good" and that she has "loads" of energy. When she does not use, she craves the drug, becomes very sleepy, feels depressed, and has a large appetite. She has tried to quit on numerous occasions, even entering an inpatient treatment program at one point, but she always quickly begins using again. The patient used to work part-time as a secretary, but she lost her job because she was chronically late and, in fact, stole money in order to pay her dealer. She freely admits that she was trying to rob the grocery store to "pay off my debts." What is the most likely diagnosis?

Stimulant (cocaine) intoxication

A 67-year-old man presents to the office with a 3-day history of headaches and progressive swelling of his face and right arm. He has a 50 pack-year smoking history and was diagnosed with chronic obstructive pulmonary disease 15 years ago. On examination, he is found to have redness and edema of his face and his right arm, which is of recent onset. What is the most likely diagnosis?

Superior vena cava syndrome

A 66-year-old woman presents with progressive dyspnea over the course of the last several years. She first noted symptoms about 4 to 5 years ago, only with strenuous exertion. Over the last 5 years, the symptoms have progressed, and she is experiencing lightheadedness and dizziness in addition to shortness of breath with even minimal exertion. She reports some mild-to-moderate symmetric lower extremity edema as well. Her BP is 104/60, her HR is 105, her O2 Sat is 91% and she is afebrile. What is your first immediate treatment?

Supplemental O2

This is the radiograph of a 25-year-old man who was in a motor vehicle accident. After positive-pressure ventilation he became increasingly difficult to bag with hypoxia and tachycardia. This progressed to hypotension and bradycardia.

Tension Pneumothorax

The need for increasing amounts of alcohol is an example of:

Tolerance

A 24-year-old woman has increased her dosage of hydrocodone to achieve the same analgesic effect. This is a demonstration of:

Tolerence

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. Is this Exudative or Transudative effusion?

Transudative

A 55-year-old man with a 2-month history of fevers, night sweats, increased cough with bloody sputum production, and a 25-lb weight loss was seen in the emergency room. He reported no intravenous drug use or homosexual activity but had multiple sexual encounters in the previous year. He "sips" a pint of gin a day and was jailed 2 years ago in New York City related to a fight with gunshot and stab wounds. His physical examination revealed bilateral anterior cervical and axillary adenopathy and a temperature of 39.4°C. His chest radiograph showed peritracheal adenopathy and bilateral interstitial infiltrates. His laboratory findings showed a positive HIV serology and a low absolute CD4 lymphocyte count. An acid-fast organism grew from the sputum and bronchoalveolar lavage (BAL) fluid from the right middle lobe. What is the most likely diagnosis?

Tuberculosis

This is the radiograph of a 29-year-old recent immigrant from Southeast Asia. He is complaining of fever, chills, and a cough productive of blood-streaked sputum. What is the diagnosis?

Tuberculosis

A 55-year-old female presents for the first time to the outpatient clinic, complaining of a gradual increase in cough and shortness of breath with wheezing for the past month. Her documented past medical history is notable only for seasonal allergic rhinitis. She notes that previously between attacks of her breathing difficulty, described as shortness of breath with wheezing, she would feel pretty normal. For the past year, she feels her breathing "isn't what it used to be," because episodes have become worse, and symptoms do not seem to fully resolve after attacks. She had been prescribed an albuterol inhaler that helps relieve the symptoms, but this has become a daily problem, and she has run out of her last prescription. She is also obese, and has been smoking 2 packs of cigarettes per day since the age of 16. No pets are in the home, and she denies having any prior or recent exposure to industrial chemicals. On examination, she is afebrile, with a heart rate of 83 bpm, blood pressure 117/82 mm Hg, respirations of 18/min, and resting oxygen saturation of 92%. She appears to be slightly uncomfortable, and is able to speak in sentences. Her lung examination is notable for mild wheezing that is worse with forced expiration, and no other adventitious sounds are noted on auscultation. A peak expiratory flow rate (PEFR) done in clinic was noted at 76% predicted. What is the patient's most likely primary diagnosis?

Uncontrolled Asthma

Although your patient does not mind spending $6 to $7 per day on a pack of cigarettes (or more depending on where you live), she does not want to pay a lot for something to help her quit. You decide not to engage in a philosophical discussion about cognitive dissonance. Which smoking cessation aid is the most expensive?

Varenicline (Chantix)

A 65-year-old male presents to your primary care clinic for an annual exam. He has a 60+ pack year history of smoking and currently smokes. He asks whether he should be screened for lung cancer because he recently read an article about it. He denies cough, shortness of breath, fever, chills, chest pain, hemoptysis, weight loss, or night sweats. Should this patient be screened with a LDCT?

Yes

A 46-year-old man presents to the hospital with a 5-day history of worsening cough, high fever, and shortness of breath. On physical examination, he is noted to be tachypneic (respiratory rate of 30 breaths/min), hypoxic with a low oxygen saturation (89%), and febrile (39°C). Chest x-ray film reveals infiltrates in both lower lobes. A complete blood count reveals a high white blood cell count. He is admitted to the hospital. Despite treatment with oxygen and antibiotics, he becomes more hypoxic and requires endotracheal intubation and mechanical ventilation. Blood cultures grow Streptococcus pneumoniae. Despite mechanical ventilation using high oxygen concentrations, his arterial blood oxygen level remains low. His chest x-ray film shows progression of infiltrates throughout both lung fields.

acute respiratory distress syndrome (ARDS)

A 10-month-old girl is brought to primary care clinic for hospital follow-up. She was admitted one week ago for three days with the diagnosis of WARI (wheezing-associated with respiratory infection). She has no additional medical history and was born at term. In addition to her well-child checks, she has been seen on two other occasions for wheezing associated with colds. She received oral steroids at one of those visits. She now appears well and is in no distress. Mom reports that she has not needed to use her albuterol for the last two days. She took her last dose of oral prednisone today. What is her diagnosis?

persistent asthma

A 28-year-old man has been taking the same dose of oxycodone for several weeks as the result of a knee injury. He has not needed to increase his dose of oxycodone to achieve analgesia. He develops irritability and muscle aches upon abruptly stopping his oxycodone. This is a demonstration of:

physical dependence