Pulmonary Case Questions
A 65 year-old with COPD receiving their first pneumococcal conjugate vaccination should be revaccinated in A 1 year. B 3 years. C 5 years D 10 years.
5 years
An O2 saturation of 90% corresponds to what PO2 value? A 90 mmHg B 80 mmHg C 70 mmHg D 60 mmHg
60 mmHg
Which of the following best describes the pathophysiology of emphysema? A Interstitial inflammation and fibrosis B Alveolar enlargement and loss of septa C Mucosal edema and inflammatory response D Excessive mucus secretion and chronic cough
Alveolar enlargement and loss of septa -Emphysema results from alveolar enlargement with loss of septal wall integrity without any evidence of fibrosis.
A 69 year-old male presents with complaint of increasing dyspnea over the past 6-8 months. The patient denies cough, chest pain or smoking history. Physical examination reveals inspiratory crackles at the bases and clubbing of the nails. Chest x-ray reveals interstitial fibrosis of the lower lungs, thickened pleura and calcified pleural plaques of the lateral chest wall. Pulmonary function testing shows a restrictive pattern with a decreased diffusing capacity. What information is most likely noted in this patient's history? A Coal mining B Silica exposure C Textile work D Asbestos exposure
Asbestos exposure
Which of the following is an independent risk factor for development of a mesothelioma? A Cigarette smoking B Asbestos exposure C Radon gas exposure D Chronic obstructive lung disease
Asbestos exposure
Which of the following is generally recognized as the most significant symptom of COPD? A Productive cough B Pulmonary hypertension C Cor pulmonale D Breathlessness
Breathlessness
Which of the following is independently associated with an increased risk for all-cause mortality in patients with COPD? A Asthma B Bronchiectasis C Underweight status D Depression
Bronchiectasis
Patients with COPD have the symptoms of chronic bronchitis and emphysema. Which of the following morphologic patterns of emphysema is typically most severe in the upper lobes? A Centriacinar emphysema B Panacinar emphysema C Distal acinar emphysema D Paraseptal emphysema
Centriacinar emphysema -Centriacinar emphysema is characterized by focal destruction limited to the respiratory bronchioles and the central portions of the acini. This form of emphysema is associated with cigarette smoking and is typically most severe in the upper lobes.
A solitary pulmonary nodule is found on a pre-employment screening chest x-ray in a 34 year-old nonsmoking male. There are no old chest x-rays to compare. Which of the following is the most appropriate next step in the evaluation? A CT scan of the chest B Needle biopsy of the lesion C Positron emission tomography of the chest D Fiberoptic bronchoscopy
CT of chest
A 42 year-old male smoker presents for further evaluation of a 4 cm solitary pulmonary nodule discovered on a recent chest x-ray. Which of the following diagnostic tests is indicated next? A Bone scan B Thoracotomy C Mediastinoscopy D CT scan of chest
CT scan of chest
Which of the following is an indication for a pediatric patient to receive Pneumovax? A Children at any age with a history of asthma B All children at 2,4,6 and 12-18 months of age C All children at 12-23 months of age in a two dose series D Children age 24-59 months at high risk for invasive pneumococcal disease
Children age 24-59 months at high risk for invasive pneumococcal disease -Pneumovax is licensed for use in children over the age of 23 months and is indicated for all pediatric patients at increased risk for pneumococcal disease.
A 62 year-old male presents with a right hilar mass. Needle-biopsy of the mass reveals the presence of small-cell carcinoma and a bone scan reveals the presence of scattered hot spots throughout the skeleton. Which of the following is the most appropriate treatment? A Lobectomy B Pneumonectomy C Thoracic radiation therapy D Combination chemotherapy
Combination chemotherapy
Which of the following chest x-ray abnormalities would most likely be seen in a patient with hypersensitivity pneumonitis? A Lobar consolidation B Apical infiltration C Granulomatous inflammation D Diffuse nodular densities
Diffuse nodular densities
Which of the following physical exam findings is consistent with moderate emphysema? A Increased tactile fremitus B Dullness to percussion C Distant heart sounds D Deviated trachea
Distant heart sounds
What is the diagnostic study of choice for pulmonary hypertension? A right heart catheterization B spirometry C chest X-ray D echocardiography
right heart catheterization
Inspiratory stridor if high in the airway, will have wheezing and decreased breath sounds if low in the airway
Foreign body aspiration
Which of the following pathophysiological processes is associated with chronic bronchitis A Destruction of the lung parenchyma B Mucous gland enlargement and goblet cell hyperplasia C Smooth muscle hypertrophy in the large airways D Increased mucus adhesion secondary to reduction in the salt and water content of the mucus
Mucous gland enlargement and goblet cell hyperplasia
A post-op patient has signs and symptoms highly suggestive of a pulmonary embolism. The results of the CT scan of the lung is nondiagnostic. What is the most appropriate next step in the evaluation? A Ventilation perfusion (V/Q) scan B Ultrasound of the legs C Echocardiography D D-dimer
Echocardiography -In a patient with a high likelihood of pulmonary embolism or an inpatient, as in this case, ultrasound of the legs would be the next diagnostic step after a nondiagnostic CT.
A 27 year-old woman presents with one week of worsening productive cough, dyspnea, fever and malaise. Which of the following physical examination findings would support the diagnosis of lobar pneumonia? A Decreased tactile fremitus B Egophony C Hyperresonance to percussion D Wheeze
Egophony
A 68 year-old male with history of COPD is brought to the emergency department following a motor vehicle collision. On physical examination there is evidence of head trauma. The left side of the chest wall appears to move inward with inspiration and outward with expiration. A chest x-ray reveals multiple rib fractures on the left. Which of the following is the most appropriate intervention? A Surgical fixation of the fractured ribs B Application of elastic binders and adhesive tape C Endotracheal intubation and mechanical ventilation D Chest physiotherapy that encourages frequent coughing
Endotracheal intubation and mechanical ventilation
A 2 month-old infant has been diagnosed with pneumonia due to Chlamydia trachomatis. Which of the following is the treatment of choice? A Ceftriaxone (Rocephin B Doxycycline C Levofloxacin (Levaquin) D Erythromycin
Erythromycin
A 73 year-old obese female with a 20 pack year smoking history presents complaining of chronic productive cough. She states that it has been occurring over the past 3 years more frequently November through February. Which of the following pulmonary function test values would you expect to find decreased? A tidal volume B FEV1/FCV C residual volume D total lung capacity
FEV1/FCV
A 67 year-old man presents complaining of gradually worsening fatigue and shortness of breath. He is a previous smoker with an 80 pack-year smoking history. He denies chest pain, night sweats, or hemoptysis. On physical examination, you note a very thin male who appears older than his stated age. Lung and heart sounds are barely audible to auscultation. Which of the following interventions is likely to alter the disease course? A Inhaled bronchodilator therapy B Inhaled steroid therapy C Home oxygen D Theophylline
Home oxygen -Home oxygen therapy has been shown to prolong life in patients with COPD and alter the natural history of the disease.
A 24 year-old male presents in respiratory distress and appears quite ill. A Gram stain and culture of the sputum reveals gram-positive cocci in clumps and a chest x-ray reveals multiple patchy infiltrates with some cavitations. Which of the following is most likely to also be found in his medical history? A IV drug abuse B Alcohol abuse C Poor dental hygiene D HIV positive patient
IV drug abuse - This patient has pneumonia caused by Staphylococcus aureus which is commonly associated with a history of intravenous drug use, influenza epidemics and the hospital setting.
You are evaluating a patient whom you suspect has asthma. You perform spirometry before and after administration of an inhaled short-acting bronchodilator. After administration of the bronchodilator, which of the following spirometry results would suggest reversibility? A Decrease In FEV1 B Increase in FEV1 C Decrease in FVC D Increase in FVC
Increase in FEV1
A 33 year-old HIV-positive woman develops an 8mm area of induration following the administration of a purified protein derivative (PPD) test. Her chest radiograph shows no evidence of active tuberculosis (TB) infection. Which of the following is the most appropriate clinical intervention? A Four-drug regimen for 4 months B Isoniazid with Rifampin C Observation only D Repeat PPD and chest radiograph in 3 months
Isoniazid with Rifampin -isoniazid with Rifampin is recommended in HIV positive patients with a positive PPD and a negative chest x- ray.
Which of the following is a major contraindication to curative surgical resection of a lung tumor? A Liver metastases B Vagus nerve involvement C Non-malignant pleural effusion D Chest wall invasion of the tumor
Liver metastases -Distant metastases, except for solitary brain and adrenal metastases are an absolute contraindication for pulmonary resection. Other absolute contraindications include MI within past 3 months, SVC syndrome due to metastatic tumor, bilateral endobronchial tumor, contralateral lymph node metastases and malignant pleural effusion.
Which of the following is the greatest risk factor for the development of drug resistance in the treatment of tuberculosis? A A child with cystic fibrosis B An elderly patient in a nursing home C Non-adherence to prescribed drug regimen D Patients with a history of diabetes mellitus
Non-adherence to prescribed drug regimen
An 85 year-old nursing home resident presents with abrupt onset of cough, sore throat, headache, myalgias, and malaise. On examination the patient's temperature is 102 degrees F; the rest of the exam is unremarkable. Nasal smear is positive for Influenza B. Which of the following is the treatment of choice in this patient? A Amantadine (Symmetrel) B Oseltamivir (Tamiflu) C Acyclovir (Zovirax) D Nevirapine (Viramune)
Oseltamivir (Tamiflu)
A 60 year-old female with a 30 pack year smoking history complains of new onset shortness of breath. On physical examination, dullness is noted on percussion with dimished breath sounds over her left base. Chest x-ray shows a new left pleural effusion. Which of the following is the next step in the management of this patient? A Repeat chest x-ray in two months B Perform diagnostic thoracentesis C Order MRI of the chest D Treat with antibiotic
Perform diagnostic thoracentesis -Diagnostic thoracentesis should be performed whenever there is a new pleural effusion and no clinically apparent cause.
A 28 year-old man presents to the emergency department complaining of sudden onset of shortness of breath associated with sharp right-sided chest pain increased with breathing. On physical examination, respirations are 20 per minute and blood pressure is 120/76 mm Hg. Auscultation of the chest reveals absent breath sounds over the right apex with normal heart sounds. Percussion of the right apex is noted to be hyperresonant. Which of the following is the most likely diagnosis? A Hemothorax B Pneumothorax C Pulmonary embolus D Foreign body aspiration
Pneumothorax
Patients with long-term exposure to silica, coal dust, and asbestos may develop which of the following as complications? A Airway Hyperreactivity B Epithelial hyperplasia C Pulmonary fibrosis D Upper airway obstruction
Pulmonary fibrosis
A 62 year-old male presents with a history of dyspnea on exertion and chronic cough worse with arising in the mornings. He has a 40-year-pack history of cigarette use. On examination there is increased AP diameter and decreased breath sounds with a prolonged expiratory phase. Pulse oximetry reveals an oxygen saturation of 93% on room air. In addition to smoking cessation, which of the following is an appropriate intervention at this time? A Home oxygen therapy B Maintenance oral steroids C Prophylactic antibiotic therapy D Recommend influenza and pneumococcal vaccines
Recommend influenza and pneumococcal vaccines
Which of the following mechanisms leads to a primary pneumothorax? A Penetrating or blunt trauma forces B Underlying lung cancer C Pressure of air in the pleural space exceeds room air pressure D Rupture of subpleural apical blebs due to high negative intrapleural pressures
Rupture of subpleural apical blebs due to high negative intrapleural pressures
Which histologic type of lung cancer is typically centrally located? A Adenocarcinoma B Bronchoalveolar C Large cell D Squamous cell
Squamous cell
Which of the following is the most likely presentation of an acute pulmonary embolism (PE) in a patient without preexisting cardiac or pulmonary disease? A Anginal chest pain B Cough C Tachypnea D Palpitations
Tachypnea -tachypnea is the most common symptom in acute PE
A patient is brought to the emergency room with acute onset of dyspnea and tachypnea. He has a long history of alcoholism and was involved in a motor vehicle accident two days ago. He is hypoxic with crackles auscultated bilaterally. Chest radiography reveals diffuse bilateral infiltrates which spare the costophrenic angle and air bronchograms, there was no cardiomegaly or pleural effusion noted. Oxygen saturation is 70%. Which of the following is the most important initial treatment? A Tracheal intubation B Bilateral chest tube insertion C Type-specific packed cells D Colloid solutions
Tracheal intubation -Tracheal intubation with lowest level of PEEP is required to maintain the PaO2 above 60 mmHg or SaO2 above 90% in a patient with ARDS.
An elderly nursing home resident is admitted with methicillin-resistant Staphylococcus aureus pneumonia. Which of the following is the most appropriate treatment to initiate? A Nafcillin B Vancomycin C Clindamycin D Doxycycline
Vancomycin
What is the most common cause of acute bronchitis? A. H. influenzae B. Viral infection C. Fungal infection D. Allergic reaction
Viral
Which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms? A call the health care provider regularly B keep a diary of symptoms C monitor peak flow D ask a family member to monitor symptoms
monitor peak flow
On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause? A asthma B consolidation C pneumothorax D pleural effusion
pleural effusion
Which of the following forms of lung cancer is associated with the poorest prognosis? A squamous cell B adenocarcinoma C large cell D small cell
small cell
A 40 year-old male nonsmoker in good health undergoes a routine chest x-ray for an insurance physical. Results show an isolated, well-defined, coin lesion 1 cm in size. Which of the following is the next step in the evaluation of this problem? A Review old radiographs B Order chest CT C Schedule lung biopsy D Prepare for surgical lung resection
Review old radiographs
A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future? A Asthma B Tinea pedis C Squamous carcinoma D Systemic lupus erythematosus (SLE)
Asthma
Rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event. Physical exam will show tachypnea, frothy pink or red sputum and diffuse crackles
ARDS
What is the Dx? Looks like CHF on chest X-ray but pulmonary wedge pressure in normal.
ARDS
An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient? A Administer nebulized corticosteroids B Admit to the hospital C Oral antimicrobial therapy D Endotracheal intubation
Admit to the hospital
Which of the following is the major pathogenetic mechanism that causes asthma? A Airway inflammation B Increased pulmonary secretions C Presence of Ghon complexes D Irreversible fibrosis
Airway inflammation
A patient presents with occasional wheezing and chest tightness that occurs approximately once a week and at night only about once a month. Peak expiratory flow is 85% of predicted. Which of the following is the most appropriate initial treatment? A Albuterol (Proventil) inhaler B Montelukast (Singulair) C Salmeterol (Serevent) inhaler D Sustained release theophylline
Albuterol (Proventil) inhaler
A 17 year-old male who is trying out for the track team notes excessive coughing with chest tightness when running. Which of the following is the most appropriate preventive agent for this patient? A Albuterol inhaler (Proventil) B Inhaled corticosteroids C Aminophylline (Theo-Dur) D Ipratropium (Atrovent)
Albuterol inhaler (Proventil)
A 55 year-old man with a history of chronic bronchitis presents with two days of increased dyspnea and cough with worsening purulent sputum production. He is currently using inhaled albuterol as needed. In addition to systemic corticosteroids, what pharmacologic agent is warranted at this time for treatment of this patient? A Antibiotic B Inhaled corticosteroid C Long acting beta-agonist D Theophylline
Antibiotic -Empiric antibiotic treatment is indicated in the treatment of acute exacerbations of COPD if there are sputum changes suggestive of bacterial infection, such as increased quantity and purulence.
A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient? A Anticoagulation B Embolectomy C Thrombolysis D Inferior vena cava filter
Anticoagulation
Which of the following studies provides the best clues to the acuteness and severity of disease exacerbation? A Serum chemistry evaluation B Alpha1-antitrypsin measurement C Arterial blood gas (ABG) analysis D Sputum evaluation
Arterial blood gas (ABG) analysis
A 42 year-old male with unremarkable past medical history is admitted to the general medical ward with community-acquired pneumonia. He has a 20 pack-year history of cigarette smoking. He is empirically started on ceftriaxone (Rocephin). Which of the following antibiotics would be most appropriate to add to his empiric treatment regimen? A Piperacillin B Vancomycin C Clindamycin D Azithromycin
Azithromycin -Patients with community-acquired pneumonia who require hospitalization on the general medical ward are treated with an extended-spectrum beta-lactam antibiotic, such as ceftriaxone, with a macrolide, such as azithromycin. Addition of a macrolide is also recommended due to the patient's smoking history and possible involvement of Haemophilus influenzae.
A 5 year-old male presents with a history of recurrent episodes of acute bronchitis, characterized by fever and productive cough. He has no known significant past medical history. His pulmonary examination reveals crackles in the bilateral lower lobes. The remainder of his physical examination is normal. Chest x-ray demonstrates platelike atelectasis and dilated, thickened airways in the middle and lower lungs. Which of the following is the most likely diagnosis? A Acute bronchitis B Bronchiectasis C Pneumonia D Tuberculosis
Bronchiectasis
A 22 year-old female with a history of asthma presents with complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals > 85% predicted value. Which of the following is the most appropriate intervention at this time? A Oral prednisone B Oral theophylline C Salmeterol inhaler D Beclomethasone inhaler
Beclomethasone inhaler
A 60 year-old patient with COPD characteristic of emphysema presents with a cough and increased sputum production. The following information is noted: Temperature 100°F (37.8°C); Respiratory rate 20/min; Heart rate 88 beats/min; pH 7.44; PaO2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable for increased AP diameter, diminished breath sounds without wheezes, rhonchi, or other signs of respiratory distress. Which of the following would be an appropriate treatment for this patient? A Broad-spectrum antibiotic B Admission to the hospital C Oxygen at 6 L/min by nasal cannula D Brief course of oral theophylline
Broad-spectrum antibiotic -Sputum production is extremely variable from patient to patient, but any increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly.
A 69 year-old male with a history of chronic lymphocytic leukemia presents to the clinic complaining of cough, dyspnea and production of copious amounts of foul smelling sputum. Physical examination reveals crackles at the lung bases. Chest x-ray shows dilated and thickened bronchi that appear as ring-like markings. Which of the following is the most likely diagnosis? A Bronchiectasis B Tuberculosis C Adenocarcinoma D Pulmonary fibrosis
Bronchiectasis -This patient has signs and symptoms consistent with bronchiectasis including CXR findings of dilated and thickened bronchi that may appear as tram-tracks or as ring-like markings.
A 62 year-old homeless patient presents complaining of fever, weight loss, anorexia, night sweats and a chronic cough that recently became productive of purulent sputum that is blood streaked. On physical examination, the patient appears chronically ill and malnourished. Which of the following chest x-ray findings supports your suspected diagnosis? A Hyperinflation and flat diaphragms B Interstitial fibrosis and pleural thickening C Cavitary lesions involving the upper lobes D "Eggshell" calcification of hilar lymph nodes
Cavitary lesions involving the upper lobes
A 40 year-old alcoholic male presents with sudden onset of severe chills, fever, dyspnea and cough productive of red mucoid sticky sputum. He appears ill looking with cyanosis. Examination reveals vital signs: Temp - 102 degrees F; Pulse - 120 /minute and regular; 89 RR - 28/min; BP 90/62 mm Hg. Lungs reveal minimal rales and dullness in the right upper lobe with decreased breath sounds. Chest x-ray reveals right upper lobe consolidation with a bulging fissure. Gram stain reveals many white blood cells and many gram- negative rods. Which of the following is the most appropriate drug of choice? A Ticarcillin B Cefotaxime C Doxycycline D Clindamycin
Cefotaxime -This patient most likely has pneumonia caused by Klebsiella. A third generation cephalosporin, such as cefotaxime, is the preferred antimicrobial therapy against Klebsiella pneumoniae. Alternative antibiotic choices may include a carbapenem, beta-lactam/beta- lactamase inhibitor or a fluoroquinolone.
A recent Haitian immigrant presents to the clinic for an employment physical examination before starting work at a local hospital. The patient has a history of receiving bacilli Calmette-Guerin (BCG) vaccination. Screening for tuberculosis for this employee should include which of the following tests? A Sputum induction B PPD skin test C Chest x-ray D No screening needed
Chest x-ray
A 45 year-old male presents with complaints of a chronic cough productive of mucopurulent sputum. The cough has been present for the past 3 years, but he attributed it to a "smoker's cough". He has been coughing up a lot of sputum lasting all winter long for the past 2 years. He denies any hemoptysis, weight loss or chest pain. Physical examination reveals a moderately obese male in no acute respiratory distress. Lung fields reveal presence of scattered rhonchi and wheezes. There is 1+ peripheral edema. Which of the following is the most likely diagnosis? A Lung cancer B Bronchiectasis C Chronic bronchitis D Interstitial lung disease
Chronic bronchitis
A 56 year-old female with a 35 pack year smoking history presents to the clinic with shortness of breath and cough. On examination, she is thin with no recent weight loss. She appears uncomfortable, breath sounds are diminished without adventitious sounds. Pulmonary function tests show a marked increase in total lung capacity (TLC) and a decreased FEV1. What is the most likely diagnosis for this patient? A Persistent asthma B Chronic obstructive pulmonary disease C Idiopathic fibrosing interstitial pneumonia D Sarcoidosis
Chronic obstructive pulmonary disease -Lung volume measurements in COPD reveal a marked increase in residual volume indicative of air trapping.
Which of the following conditions will produce a transudative pleural effusion? A Kaposi's sarcoma B Pneumonia C Cirrhosis D Mesothelioma
Cirrhosis -Transudative pleural effusions result from alteration in the formation of pleural fluid, the absorption of pleural fluid, or both, by systemic factors. Local factors affecting pleural fluid absorption and/or formation produce
In patients with COPD, which of the following has been shown to decrease rate of malignancy and cardiovascular disease and improve survival? A bronchodilator therapy B pulmonary rehabilitation C oral glucocorticosteroids D smoking cessation
smoking cessation
A 24 year-old male presents complaining of a 9 month history of increasing shortness of breath, dyspnea on exertion, and a cough productive of white sputum, mostly in the mornings. He denies orthopnea, PND, peripheral edema, fever, chills, night sweats, recent changes in weight, palpitations, chest pain, food intolerances, or other complaints. Patient has a history of recurrent lung infections. He states that his father had chronic pulmonary problems and died at age 42 from unknown lung disease. The patient denies smoking, alcohol or illicit drug use. On physical examination, the respiratory rate is 22 per minute, pulse of 98 bpm, temperature of 98.7 degrees. Pulmonary exam reveals end-expiratory wheezes bilaterally and hyperresonance to percussion. His cardiac exam is normal. Chest x- ray shows decreased lung markings. ECG is normal. Pulmonary function tests show an FEV1 63% of expected and residual capacity is 123% of expected. Which of the following is the most likely diagnosis? A Emphysema B Pulmonary fibrosis C Ventricular septal defect D Congestive heart failure
Emphysema -This person has an obstructive lung disease based on PFTs. Emphysema is the most likely diagnosis, and may be related to alpha-1 antitrypsin deficiency based on family history and lack of smoking history and young age.
A patient should be tested for tuberculosis prior to being treated with A etanercept (Enbrel). B cyclosporine (Neoral). C methotrexate (Rheumatrex). D prednisone (Deltasone).
Enbrel Etanercept is an anti-cytokine agent used in the treatment of rheumatoid arthritis and has as a side effect the potential for serious infections. One of these side effects includes reactivation of dormant tuberculosis.
Which of the following findings confirm the adequacy of a sputum specimen for Gram stain and culture? A Decreased red blood cells B Decreased bronchial epithelial cells C Increased Gram positive cocci D Increased polymorphonuclear leukocytes
Increased polymorphonuclear leukocytes -The presence of increased polymorphonuclear leukocytes and the absence of squamous epithelial cells are the criteria utilized to evaluate the adequacy of a sputum sample.
A 30 year-old male presents with sudden onset of chills, fever, chest pain and a cough productive of greenish-brown sputum. On examination his temperature is 102 degrees F. He appears acutely ill and his respirations are shallow. Chest x-ray demonstrates left lower lobe consolidation. Which of the following findings would most likely be present on examination of his left lower lung? A Hyperresonance B Vesicular breath sounds C Increased tactile fremitus D Wheezing
Increased tactile fremitus -Increased tactile fremitus occurs in the presence of fluid or a lung consolidation such as lobar pneumonia.
A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient? A spoken "ee" heard as "ay" B hyperresonant percussion note C wheezes over the involved area D vesicular breath sounds over involved area
spoken "ee" heard as "ay"
A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment? A Decrease the oxygen flow rate. B Administer oral corticosteroids. C Intubate the patient. D Administer salmeterol (Serevent)
Intubate the patient. -high PaCO2 is an indication of respiratory failure
Which of the following is a physical examination finding that is consistent with a diagnosis of lobar pneumonia? A Resonant to percussion B Late inspiratory crackles C Decreased tactile fremitus D Tracheal shift toward uninvolved side
Late inspiratory crackles
A 55 year-old female presents to the emergency department with complaints of dyspnea, chest pain and coughing with hemoptysis. Past medical history includes breast cancer 5 years ago, currently in remission. Vital signs are Temp. 98.6 degrees F, BP 150/90 mmHg, P 110 bpm, RR 20. Physical examination shows her right leg swollen with pain on palpation of deep veins. Which of the patient's history or examination findings is most suggestive of a pulmonary embolus (PE)? A Leg swelling and pain with palpation of deep veins B Heart rate > 100 C Hemoptysis D Past history of cancer
Leg swelling and pain with palpation of deep veins
Which of the following causes of pneumonia is most likely to be complicated by diarrhea? A Legionella B Chlamydophila C Mycoplasma D Pneumococcal
Legionella
Which of the following is accurate regarding the treatment of patients with COPD? A Pneumococcal vaccines are contraindicated in COPD B Intravenous alpha1-antitrypsin levels should be kept at 8-10 mmol/L C Long-term O2 therapy is recommended for patients with a paO2 in arterial blood <55 mm Hg or O2 <90% D Because cardiovascular disease with COPD, beta-blockers are indicated in all patients
Long-term O2 therapy is recommended for patients with a paO2 in arterial blood <55 mm Hg or O2 <90%
A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. Which of the following would be the most appropriate treatment for this patient? A Mast cell stabilizer B Long acting beta agonist C Leukotriene receptor antagonist D Low dose inhaled corticosteroid
Low dose inhaled corticosteroid
A 20 year-old male presents with 3 weeks of constitutional and upper respiratory symptoms, including malaise, sore throat, dry cough, and fever. Lung auscultation demonstrates diffuse crackles bilaterally. What is the most likely infectious agent involved? A Respiratory syncytial virus B Influenza virus C Mycoplasma pneumoniae D Streptococcus pneumoniae
Mycoplasma pneumoniae
You are seeing 62 year-old African American male for health maintenance. He is a former cigarette smoker with a 40 pack-year history. He quit smoking 10 years ago. He denies cough, hemoptysis, shortness of breath, chest pain, weight loss, or night sweats. What method of screening for lung cancer is appropriate in this patient? A Chest radiograph B Spiral CT of the chest C Sputum cytology D No screening is recommended
No screening is recommended
What is the mechanism of action of salmeterol (Serevent) in the treatment of asthma? A Anti-inflammatory B Immunotherapy for specific allergens C Relaxing of bronchial smooth muscle D Reduction of leukotriene production
Relaxing of bronchial smooth muscle
A 52-year-old man is seen for fevers and weight loss. A chest radiograph shows mediastinal lymphadenopathy. Laboratory findings show hypercalcemia, elevated alkaline phosphatase, and an elevated level of ACE. The most likely diagnosis is A Small cell carcinoma of the lung B Pulmonary tuberculosis C Sarcoidosis D Histoplasmosis E Asbestosis
Sarcoidosis
A 61-year-old male presents to your office with the chief complaint of "coughing up blood and weakness" for the past 3 weeks. He reports at least five to six episodes every 2 to 3 days of coughing of bright red blood, approximately one to two tablespoons each time. The patient denies any chest pain, fevers, chills, or recent travel. He has mild dyspnea at baseline. He has recently developed lower extremity muscle cramps and he has difficulty rising from a chair. Past medical history is significant for COPD diagnosed 5 years ago and HTN. He has a 40-pack-year smoking history and currently smokes 1 pack per day. Examination is notable for end-expiratory wheezing and a prolonged expiratory phase on lung auscultation. He has 3/5 hip flexion and decreased deep tendon reflexes bilaterally in lower extremities. Laboratory tests are normal including electrolytes. CXR reveals typical changes seen in COPD (flattened diaphragms, hyperinflation) and a perihilar mass. What is the most likely diagnosis? A Bronchial carcinoid B Adenocarcinoma C Large cell carcinoma D Squamous cell carcinoma E Small cell carcinoma
Small cell carcinoma
The most common pathogen identified in community acquired pneumonia (CAP) is A Mycoplasma pneumoniae. B Staphylococcus aureus. C Legionella pneumophila. D Streptococcus pneumoniae.
Streptococcus pneumoniae.
You advise your patient with acute bronchitis to take antipyretic drugs and get some rest. He returns to your office 12 days later feeling worse and now has a fever with a cough productive of purulent sputum. What is the most appropriate next step in the management of this patient? A. Treat with a macrolide antibiotic B. Administer penicillin intramuscularly C. Influenza titers D. Pulmonary function tests
Treat with a macrolide antibiotic -A purulent, productive cough may be bacterial in origin (although purulent sputum is not the definite sign of bacterial infection). Given the length of this patient's symptoms > 12 days and fever (fever is unusual in bronchitis) it would be reasonable to treat with antibiotics empirically. (beta-lactam, macrolide first line)
A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. Which of the following is the next most appropriate intervention? A Thoracotomy B Needle aspiration C Close observation D Tube thoracostomy
Tube thoracostomy -This patient has a hemothorax. Drainage of a hemothorax is best obtained through insertion of a chest tube (tube thoracostomy).
A 62 year-old female is admitted to a nursing home during an outbreak of influenza. In review of her records, you note that she did not receive the flu vaccine this year. Which of the following is the most appropriate drug of choice for influenza prophylaxis in this patient? A Ciprofloxacin (Cipro) B Zanamivir (Relenza) C Clarithromycin (Biaxin) D Alpha-2b interferon (Avonex)
Zanamivir (Relenza)
Which of the following can be considered an effective prophylaxis for acute bronchitis? A. Oseltamivir B. influenza vaccine C. Inhaled steroids D. Nystatin
vaccine
A 56 year-old male with a 40 pack-year smoking history presents complaining of progressive shortness of breath. Spirometry reveals an FEV1 of 2 L (40% of predicted), an FVC of 4 L (80% of predicted) and an FEV1/FVC of 50%. These findings are most consistent with A sarcoidosis. B chronic bronchitis. C interstitial lung disease. D congestive heart failure.
chronic bronchitis.
A 75 year-old man with a long history of COPD presents with acute onset of worsening dyspnea, increased productive cough, and marked agitation. While in the emergency department he becomes lethargic and obtunded. His ABG's reveal a PaO2 40 mmHg, PaCO2 65 mmHg, and arterial pH 7.25. Which of the following is the most appropriate management at this point? A oxygen supplementation with a 100% non-rebreather mask B noninvasive positive pressure ventilation (NIPPV) C endotracheal intubation and mechanical ventilation D emergency tracheostomy
endotracheal intubation and mechanical ventilation
A 63-year-old male, heavy smoker, presents to your office with a low-grade fever and sudden onset of dry cough for the past 6 days. You diagnose him with acute bronchitis. What is the most appropriate management at this time? A. Amoxicillin/clavulanic acid 875 mg 2x per day for 10 days B. Doxycycline 100 mg PO two times per day for 14 days C. Increased fluids and ibuprofen D. Give the patient an albuterol inhaler
increase fluids and ibuprofen -Acute bronchitis is defined by a cough which persists for more than five days. The most common cause of acute bronchitis is a viral infection (90% of cases). Therefore, supportive therapy such as increased fluids (cough results in increased fluid loss) and ibuprofen (antipyretic) is the most appropriate approach.
A 25 year-old male with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist prn. He is presently using his short acting beta agonist on a daily basis. Which of the following is the most appropriate addition to this patient's regimen? A methylxanthine oxidase inhibitor B long acting beta agonist inhaler C leukotriene inhibitor D inhaled corticosteroid
inhaled corticosteroid
A 21 year-old male presents to the ED with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Examination reveals moderate respiratory distress with absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right. Which of the following is the most appropriate next step? A order a V/Q scan B order a chest x-ray C administer a sclerosing agent D insert large bore needle into left 2nd ICS stat
insert large bore needle into left 2nd ICS stat
A patient presents with a history of progressive worsening of dyspnea over the past several years. He gives a history of having worked as a ship builder for over 50 years. He denies any alcohol or tobacco use. On examination you note clubbing and inspiratory crackles. Which of the following chest x-ray findings support your suspected diagnosis? A hyperinflation and flat diaphragms B interstitial fibrosis and pleural thickening C cavitary lesions involving the upper lobes D "eggshell" calcification of hilar lymph nodes
interstitial fibrosis and pleural thickening -This patient most likely has asbestosis, which is supported by his occupation as a ship builder and clinical presentation as noted above. Chest x-ray findings include interstitial fibrosis, pleural thickening and calcified pleural plaques on the diaphragm or lateral chest wall.
A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is A tuberculosis. B mycoplasma pneumonia. C pneumococcal pneumonia. D staphylococcal pneumonia.
mycoplasma pneumonia. -The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely.
A 14 year-old male presents to the ED experiencing a severe asthma attack. His respiratory effort is shallow and he is using accessory muscles to breathe. Auscultation of his chest reveals no audible wheezing. Vital signs include BP 90/60 mmHg, P 160 bpm, RR 52. An arterial blood gas (ABG) is ordered. Normal ABG values at your institution are pH 7.35-7.45, CO2 35-45, pO2 80-95. Which of the following ABG findings suggests the poorest prognosis? A pH = 7.27 pCO2 = 46 pO2 = 56 B pH = 7.60, pCO2 = 18 pO2 = 80 C pH = 7.44, pCO2 = 38 pO2 = 90 D pH = 7.52, pCO2 = 28, pO2 = 80
pH = 7.27 pCO2 = 46 pO2 = 56 -respiratory acidosis
A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A chest x-ray B sputum gram stain C peak flow D ventilation - perfusion scan
peak flow -A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.
An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. Which of the following is the most appropriate interpretation of this test result? A positive B negative C active infection D falsely negative
positive
A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals tachycardia. Which of the following is the most likely diagnosis? A atelectasis B pneumothorax C pulmonary embolism D myocardial infarction
pulmonary embolism
A patient presents with respiratory complaints. Chest x-ray reveals calcification of the hilar nodes with an eggshell pattern. Which of the following occupations is most consistent with these chest x-ray findings? A building demolitioners B coal miners C sandblasters D farmers
sandblasters -Silicosis can occur in sandblasters and produce a CXR appearance of calcification of the hilar nodes with an "eggshell" pattern with long term exposure
A 62 year-old male smoker presents to the clinic with the complaint of a chronic cough, hemoptysis, and weight loss. Chest CT shows a mass obstructing the bronchus with hilar and mediastinal lymph node abnormalities. Bronchoscopy with biopsy is performed. On reviewing pathology results you explain to the patient that his type of lung cancer is prone to early hematogenous spread, is rarely amenable to surgical resection and has a very aggressive course. What type of lung cancer is most likely in this patient? A Squamous cell B Small cell C Large cell D Adenocarcinoma
small cell
Which of the following is the most appropriate therapeutic agent for acute influenza? A azithromycin (Zithromax) B acyclovir (Zovirax) C tetracycline (Sumycin) D zanamivir (Relenza)
zanamivir (Relenza)
Pulmonary hypertension is defined as a mean pulmonary arterial pressure of A ≥ 5 mm Hg B ≥ 10 mm Hg C ≥ 15 mm Hg D ≥ 25 mm Hg
≥ 25 mm Hg
