Rosh Pulmonolgy
Ethambutol
A 46-year-old man presents with right eye pain and a change in his vision. He was recently diagnosed with tuberculosis and started on a 4-drug regimen. Based on his history and physical exam findings, you are concerned for optic neuritis. Which of the following medications is likely responsible for his symptoms? A. Ethambutol B. Isoniazid C. Pyrazinamide D. Rifampin
Isoniazid
A 47-year-old woman with diabetes mellitus is found to have latent tuberculosis during a routine employee health purified protein derivative (PPD) test. She should receive supplementation with pyridoxine (vitamin B6) if her drug regimen contains which of the following medications? A. Ethambutol B. Isoniazid C. Pyrazinamide D. Rifampin
Oseltamivir
A 68-year-old woman presents with abrupt onset of fever, malaise, body aches, headache, and sore throat. Rapid strep test is negative and nasal swab is positive for influenza B. Which of the following is the most appropriate therapy? A. Acyclovir B. Amantadine C. Azithromycin D. Oseltamivir
Computed tomography angiography
A patient presents with acute dyspnea and pleuritic chest pain. You suspect pulmonary embolism. Which of the following is the most appropriate test to confirm the diagnosis of a pulmonary embolus? A. Computed tomography angiography B. D-dimer assay C. Echocardiography D. Ventilation-perfusion scan
Elevated amylase concentrations
A patient with acute pancreatitis is noted to have a pleural effusion on chest radiography. Which of the following findings would you expect to find on pleural fluid analysis? A. Elevated amylase concentrations B. Elevated triglyceride concentrations C. Low glucose concentrations D. Low pH of pleural fluid
V/Q scan
A 46-year-old woman with a past history of a DVT was recently diagnosed with Burkitt's lymphoma. Recent blood work revealed a creatinine of 2.3. She is currently hospitalized to receive chemotherapy when she suddenly develops tachycardia to a rate of 130 and oxygen saturation of 91%. Which of the following is the most appropriate test to confirm the diagnosis of pulmonary embolism? A. Chest X-ray B. CT angiogram of the chest with intravenous contrast C. D-dimer D. V/Q scan
Carcinoid tumor
A 47-year-old woman presents with several months of a persistent cough that recently resulted in hemoptysis. A review of system also confirms episodes of diarrhea, rash, and flushing. Physical exam is normal with the exception of focal wheezing over the right upper lobe. Which of the following is the most likely diagnosis? A. Alpha-1-antitrypsin deficiency B. Carcinoid tumor C. Pulmonary hypertension D. Pulmonary tuberculosis
Oxygen saturation < 92%
Which of the following findings has the highest odds ratio when diagnosing pneumonia in children? A. Crackles B. Oxygen saturation < 92% C. Retractions D. Temperature > 38°C
Elevated serum lactate dehydrogenase
Which of the following findings is most suggestive of Pneumocystis jirovecii pneumonia in a patient with suspected HIV infection and shortness of breath? A. Bradycardia despite relative volume depletion B. Elevated serum lactate dehydrogenase C. Hyponatremia D. Unilateral lobar consolidation on chest radiograph
Pulmonary rehabilitation
Which of the following is most appropriate in the treatment plan for a patient with idiopathic pulmonary fibrosis? A. Albuterol B. Azathioprine C. Bosentan D. Pulmonary rehabilitation
Pulmonary embolism
Which of the following is most closely associated with the development of acute cor pulmonale? A. Acute bronchitis B. Heart failure C. Hospital-acquired pneumonia D. Pulmonary embolism
Isoniazid plus rifampin
Which of the following is the first-line preferred treatment for a latent tuberculosis infection? A. Doxycycline B. Isoniazid plus rifampin C. Lamivudine plus zidovudine D. Penicillin
Heart failure
Which of the following is the most common cause of a pleural effusion in developed countries? A. Bacterial pneumonia B. Heart failure C. Malignancy D. Tuberculosis
Chronic obstructive pulmonary disease
Which of the following is the most common cause of cor pulmonale? A. Chronic obstructive pulmonary disease B. Connective tissue disorders C. Left-sided cardiac disease D. Right ventricular hypertrophy
Sinus tachycardia
Which of the following is the most common electrocardiogram finding in an acute pulmonary embolism? A. Right bundle branch block B. S wave in lead I, Q wave in III, inverted T wave in III (S1Q3T3) C. Sinus tachycardia D. T wave inversions in leads V1-V4
Right main bronchus
Which of the following is the most common location of aspirated foreign bodies in children? A. Left lower bronchus B. Left main bronchus C. Right main bronchus D. Trachea
Pneumocystis jiroveci
Which of the following is the most common opportunistic respiratory infection in patients with acquired immunodeficiency syndrome? A. Cytomegalovirus B. Mycobacterium tuberculosis C. Pneumocystis jiroveci D. Streptococcus pneumoniae
Tachypnea
Which of the following is the most common sign seen in patients presenting with a pulmonary embolism? A. Hemoptysis B. Hypoxia C. Swollen calf D. Tachypnea
It may have varied appearance on chest X-ray
Which of the following is true regarding active tuberculosis? A. A cavitary lesion on CT of the chest is pathognomonic B. Isoniazid treatment for six months is adequate therapy C. It may have varied appearance on chest X-ray D. Patients with active tuberculosis need droplet precautions
Infectivity is greatest in the catarrhal stage
Which of the following is true regarding pertussis? A. Childhood vaccination and clinical disease provide lifelong immunity B. Infectivity is greatest in the catarrhal stage C. Lobar consolidations are commonly seen on chest radiography D. The treatment of choice is oral amoxicillin
Streptococcus pneumoniae
Which of the following organisms is most associated with pneumonia and bullous myringitis? A. Bordetella pertussis B. Haemophilus influenzae C. Streptococcus bovis D. Streptococcus pneumoniae
Egophony
Which of the following physical exam findings can aid in differentiating the cause of crackles or rales, heard on lung auscultation? A. Clubbing B. Egophony C. Percussion D. Respiratory rate
Increased tidal volumes
Which of the following physiologic responses would occur after application of noninvasive positive pressure ventilation in a patient presenting with an acute exacerbation of chronic obstructive pulmonary disease? A. Increased alveolar dead space B. Increased LV afterload C. Increased tidal volumes D. Increased venous return
It is caused by an inflammatory chemical injury
Which of the following statements is true concerning aspiration pneumonitis? A. Antibiotics should be administered early in the course B. Corticosteroid administration decreases the incidence of associated lung injury C. It is caused by an inflammatory chemical injury D. The ABG is diagnostic
Prednisone
Which of the following treatments is most appropriate for a patient with acutely symptomatic sarcoidosis? A. Lung transplantation B. Prednisone C. Theophylline D. Tiotropium
Adenocarcinoma
Which of the following types of lung cancers is less likely associated with smoking? A. Adenocarcinoma B. Large cell carcinoma C. Small cell carcinoma D. Squamous cell carcinoma
Nasopharyngeal swab
A 33-year-old man presents to the clinic with a sudden onset of dry cough, fever, myalgias, nasal congestion, and headache. He has a benign past medical history. His physical exam is remarkable for a temperature of 38.4°C, pharyngeal injection, conjunctival injection, and clear rhinorrhea. His lung sounds are clear to auscultation and there are no adventitious sounds heard. Which of the following diagnostic tests would be most useful at this time? A. Chest X-ray B. Nasopharyngeal swab C. Sputum culture D. Sputum cytology
Pulmonary hypertension
A 16-year-old boy is taken to his doctor for snoring. His mother reports that his snoring keeps others in the house awake and that sometimes his breathing pauses during sleep with gasping or choking. His teachers report that he falls asleep frequently at school. On exam, he has a body mass index of 31 kg/m² and has enlarged tonsils. His symptoms are concerning for obstructive sleep apnea so the pediatrician refers him for an overnight polysomnography. Which of the following can be a longterm complication of obstructive sleep apnea? A. Epilepsy B. Lung scarring C. Nasal polyps D. Pulmonary hypertension
Inhaled corticosteroid
A 16-year-old boy with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist on an as needed basis. He presently needs to use his short acting beta agonist daily. Which of the following is the most appropriate addition to this patient's medication regimen? A. Inhaled corticosteroid B. Leukotriene inhibitor C. Long acting beta agonist inhaler D. Methylxanthine oxidase inhibitor
Admission to monitored bed for continued supportive care
A 10-week-old boy is brought to the Emergency Department in late December by his mother who reports that he has had difficulty breathing for the past 24 hours. His mother and sister have a history of asthma, and his father has been sick with an upper respiratory tract infection. Vital signs are notable for a respiratory rate of 70 breaths/min and an oxygen saturation of 99 percent on room air. Examination reveals significant rhinorrhea, intercostal retractions, bilateral expiratory wheezes and crackles at the bases. Nasal suctioning is performed with minimal improvement. He has normal urine output. Which of the following is the most appropriate next step in management? A. Administer prednisolone and nebulized albuterol B. Admission to monitored bed for continued supportive care C. Discharge with recommendations for next-day pediatrician follow-up D. Perform a chest X-ray and administer empiric antibiotics
Mycoplasma pneumoniae
A 10-year-old girl presents with fever, sore throat, cough, headache, and general malaise worsening over the past four days. Lung auscultation reveals rales in the lower left lobe. A chest radiograph demonstrates interstitial infiltrates in the lower left lobe. Which of the following is the most likely causative pathogen? A. Klebsiella pneumoniae B. Mycoplasma pneumoniae C. Parainfluenza virus D. Respiratory syncytial virus
Amoxicillin
A 12-year-old girl presents to the clinic with acute onset of productive cough, fever to 102°F, and extreme fatigue. She is awake and alert but appears tired. Her oxygen saturation is 96%, and respiratory rate is 15 breaths per minute. Lung auscultation reveals fine crackles in the left upper lobe. A chest radiograph reveals localized alveolar infiltrates with consolidation. Which of the following is the most appropriate treatment for this patient? A. Amoxicillin B. Azithromycin C. Cefotaxime D. Clindamycin
Coarse crackles
A 13-year-old boy presents to your ED with worsening cough and exercise intolerance. The triage note says he has seen his primary care physician twice over the last month and was given albuterol which has not improved his symptoms. His vital signs show a temperature of 37.2°C, heart rate of 110 beats per minute, respiratory rate of 28 breaths per minute, blood pressure of 110/82 mm Hg, and pulse oximetry of 93% on room air. A chest X-ray obtained from triage is shown above. Which of the following findings do you expect on your physical examination? A. Coarse crackles B. Pleural friction rub C. Rhonchi D. Stridor
Elevated sweat chloride
A 16-month-old boy and his adoptive parents present to your office with a complaint of cough and concern about the patient's weight. The parents indicate that they don't have much information about the patient's birth parents and since adopting him four months ago they have noticed daily shortness of breath, cough and wheezing. He is also a fussy eater and is in the second percentile of weight on the growth chart. Which lab finding is most consistent with the diagnosis? A. Elevated exhaled nitric oxide testing B. Elevated sweat chloride C. Elevated white blood cell count D. Positive skin allergy test
Begin nebulized albuterol
A 16-year old boy with a history of asthma presents to the ED with severe shortness of breath and audible wheezing. He uses an inhaled corticosteroid and a long acting beta-2-agonist at home daily. However, he has had to use his short acting beta-2-agonist roughly every hour for the past day. In the ED, his vital signs are BP 114/72, HR 106, RR 28, oxygen saturation 94% on room air, and temperature 99.0°F. Diffuse wheezing is appreciated and intercostal retractions are observed. After oxygen is initiated, what is the next step in management for this patient? A. Begin nebulized albuterol B. Give epinephrine C. Give systemic corticosteroids D. Prepare for intubation
Intravenous heparin
A 16-year-old girl presents to the ED with difficulty breathing. She has had no fevers, rhinorrhea, or cough and her symptoms began abruptly two days ago while watching television. She is wearing a right shoulder immobilizer for a scapula fracture she sustained two weeks ago. Her only medications include oral contraceptive pills and ibuprofen. Her respiratory rate is 20 breaths/minute, heart rate is 110 beats/minute, and oxygen saturation is 99% on room air. She is alert and her lungs are clear to auscultation. An X-ray reveals a shallow wedge-shaped opacity in the periphery of the lung with its base against the pleural surface. Of the following, which is the next most appropriate step once the likely diagnosis is confirmed? A. Intravenous ampicillin B. Intravenous furosemide C. Intravenous heparin D. Tube thoracostomy placement
Discharge home with close follow-up
A 16-year-old man presents to the ED complaining of three days of rhinorrhea, cough, myalgias, and generalized malaise. After a coughing episode yesterday, he developed pleuritic chest pain radiating to the left neck. His vital signs are BP 130/70 mm Hg, HR 76 bpm, RR 16 breaths/min, T 36.6°C and pulse oximetry 98% on room air. You obtain the chest radiograph seen above. Which of the following is the most appropriate next step in management? A. Discharge home with close follow-up B. Endoscopy C. Needle decompression D. Tube thoracostomy
Add a low dose inhaled glucocorticoid
A 17-year-old girl with a history of asthma presents to your office with complaints of wheezing and shortness of breath. She says that in the past month she has experienced symptoms approximately 3-4 times per week requiring use of her short-acting beta agonist inhaler. She has also woken up at night four times during the month with shortness of breath and occasionally gets dyspneic on her daily walk. Which of the following is the most effective management? A. Add a low dose inhaled glucocorticoid B. Add a low dose inhaled glucocorticoid plus long-acting beta agonist C. Continue use of short-acting beta agonist only D. Start an oral course of glucocorticoids
Dilated, thickened bronchi with "tram-track" marks
A 17-year-old girl with a history of well-managed cystic fibrosis is being evaluated for a steadily worsening chronic cough with shortness of breath and wheezing. She is producing copious purulent malodorous sputum and occasional hemoptysis. Crackles are heard at her bilateral lung bases. Which of the following findings would be most expected on this patient's chest radiograph? A. Dilated, thickened bronchi with "tram-track" marks B. Low lung volumes and ground glass opacities C. Lung hyperinflation with flattening of the diaphragm D. Normal chest radiograph
Narrowing of the subglottic region
A 19-month-old boy is brought into the emergency department by his parents with concern for intermittent cough and fever for the past 3 days. On exam, he has a mild inspiratory stridor and a barking cough. Exam of the posterior oropharynx is unremarkable and his oxygen saturation is 98% on room air. An anteroposterior soft tissue neck X-ray and chest X-ray are obtained. Which of the following findings on imaging is most consistent with the diagnosis? A. Enlarged aryepiglottic folds B. Foreign body C. Narrowing of the subglottic region D. Thickening of the epiglottis
Intravenous antibiotics and admission
A 19-year-old man presents with a sore throat and difficulty swallowing. He has had four days of worsening sore throat and fever but today he was unable to swallow any liquids. Physical examination reveals a muffled voice, difficulty tolerating saliva, and minimal pharyngeal erythema with a midline uvula. He also has tenderness over the hyoid bone. Which of the following is the best management of this patient? A. Inhaled racemic epinephrine and discharge home B. Intravenous antibiotics and admission C. Intravenous corticosteroids and discharge home D. Needle aspiration of peritonsilar area
Staccato cough
A 2-month-old boy presents with a low fever and cough. Which of the following is suggestive of Chlamydia pneumonia in this infant? A. Bullous myringitis B. Diarrhea C. Rusty-colored sputum D. Staccato cough
Croup
A 2-year-old girl presents to clinic with a gradual onset of nasal congestion, hoarseness, and a barking cough. Stridor is auscultated and the patient is sitting upright and does not appear to be in acute respiratory distress. Which of the following is the most likely diagnosis? A. Croup B. Epiglottitis C. Foreign body aspiration D. Peritonsillar abscess
Beta-2-agonists promote bronchodilation by increasing cyclic adenosine monophosphate
A 22-year-old man presents with an asthma exacerbation. Which of the following is true regarding treatment modalities? Anticholinergic agents promote bronchodilation by decreasing cyclic adenosine monophosphate Beta-2-agonists promote bronchodilation by increasing cyclic adenosine monophosphate The onset of action for beta-2-agonists is 10 minutes The peak effect of corticosteroids occurs within 3-5 hours
Hypokalemia
A 22-year-old woman presents with dyspnea. She has a history of asthma and noted increased difficulty breathing starting yesterday. She says she has been using her albuterol inhaler every 15 minutes for the last four hours without relief. What laboratory abnormality is likely to be found in this patient? A. Hypocalcemia B. Hypoglycemia C. Hypokalemia D. Hyponatremia
X-ray
A 23-year-old man presents to the emergency room with acute onset of shortness of breath and chest pain that started 2 hours ago and has progressively worsened. He denies any sick contacts, systemic symptoms, past medical history and he does not take any medications. His vital signs are HR 130, RR 24, BP 124/72, and oxygen sat 92% on 3 L NC. On physical exam he appears to be in mild distress. Diminished breath sounds are heard in the right lung field. Which of the following imaging studies is considered first-line? A. Computed tomography angiography B. Contrast-enhanced esophagography C. V/Q Scan D. X-ray
Doxycycline
A 23-year-old woman presents with a dry cough, malaise, sore throat, and subjective fever for the last two weeks. She was seen at an urgent care four days ago and was prescribed a cough syrup. Physical examination reveals diffuse crackles. Vital signs are within normal limits. Which of the following is the most appropriate empiric treatment? A. Cephalexin B. Clindamycin C. Doxycycline D. Levofloxacin
Lung abscess
A 33-year-old man presents to the ED with several weeks of cough, pleuritic chest pain, weight loss, and night sweats. The patient drinks a six-pack of beer daily. Vital signs are BP 145/75 mm Hg, HR 88 bpm, RR 18 breaths/min, and T 37.7°C. Pulmonary exam reveals crackles and decreased breath sounds on auscultation. You obtain the radiograph seen above. Which one of the following is the most likely diagnosis? A. Lung abscess B. Neoplasm C. Septic pulmonary emboli D. Tuberculosis
Gram positive cocci in clusters
A 25-year-old man presents for evaluation of fever and cough. He reports last week that he was diagnosed with influenza. In the last two days he developed a worsening cough productive of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR 18, and 95% oxygen saturation on room air. His chest X-ray demonstrates a lobar infiltrate in the left lower lobe. Which of the following would you most likely expect to see on the patient's Gram stain? A. Gram negative bacilli B. Gram negative diplococci C. Gram positive bacilli D. Gram positive cocci in clusters
Oseltamivir
A 26-year-old gravida 3 para 2 at 12 weeks gestation presents with fever, myalgias, headache, and malaise. There have been multiple cases of influenza in the community and her influenza swab is positive. Which one of the following is recommended by the Centers for Disease Control and Prevention in this situation? A. Acyclovir B. Oseltamivir C. Rimantadine D. Supportive therapy only
Trimethoprim-sulfamethoxazole
A 26-year-old man presents with a 2-week history of fever and a cough. He was diagnosed with HIV four months ago and is not on any antiretroviral medications. His vital signs are BP 122/76, HR 78, RR 16, oxygen saturation 92% on room air, and temperature 99.2°F. Chest X-ray is shown above. Given his presentation, which of the following antibiotics should be used to treat this patient? A. Azithromycin B. Clindamycin C. Penicillin D. Trimethoprim-sulfamethoxazole
Infant respiratory distress syndrome
A 27-gestational-week-old infant is delivered in the emergency department. The neonate is cyanotic, tachypneic and shows chest wall retractions. An emergent chest radiograph reveals a diffuse ground-glass appearance. Meconium aspiration is not suspected. Which of the following is the most likely diagnosis? A. Erythroblastosis fetalis B. Hydrops fetalis C. Infant respiratory distress syndrome D. Persistent pulmonary hypertension of the newborn
Mild intermittent
A 27-year-old man with a history of asthma presents to your office for his annual exam. He reports that in the past month he has experienced wheezing and shortness of breath about once per week which resulted in using his rescue inhaler. He woke up once because of coughing. He has a peak flow meter and home readings have been 85-90% of his personal best. Which of the following best describes the classification of his asthma? A. Mild intermittent B. Mild persistent C. Moderate persistent D. Severe persistent
Pneumothorax
A 28-year-old man presents to the Emergency Department with dyspnea. On an anterior-posterior chest X-ray, you notice a visceral pleural line with a radiolucent area devoid of vascular and pulmonary markings on the right side only. What is the most likely diagnosis? A. Adenocarcinoma B. Pneumonia C. Pneumothorax D. Pulmonary embolism
Spread is by the hematogenous route
A 29-year-old man with a history of HIV presents with shortness of breath and fever. He has a productive cough but denies hemoptysis. You obtain the chest radiograph seen above. Which of the following is true regarding the patient's diagnosis? A. Elevated LDH is common B. Spread is by the hematogenous route C. Steroids should be administered prior to antibiotics if the PaO2 is < 80 D. Trimethoprim-sulfamethoxazole is the treatment
Supportive care
A 29-year-old woman presents to the ED complaining of pain on inspiration. Over the previous three days, she has experienced a low-grade fever, sore throat, and body aches. Auscultation of her lungs reveals normal breath sounds. Her upright chest radiograph is seen above. Which of the following is the most appropriate next step in management? A. D-dimer B. Doxycycline C. Inspiratory and expiratory radiographic views D. Supportive care
Mild persistent
A 30-year old woman presents with shortness of breath. She has a history of asthma since childhood. She says that she uses her rescue inhaler 3 days each week. On average, she wakes up in the middle of the night with symptoms approximately three times a month. Her vital signs are BP 120/76, HR 112, RR 26, and oxygen saturation 92% on room air. The patient appears to be in mild distress with intercostal retractions present, and respiratory exam is remarkable for diffuse wheezing. This patient is diagnosed with an acute asthma exacerbation. Which of the following best classifies this patient's asthma? A. Intermittent B. Mild persistent C. Moderate persistent D. Severe persistent
CT pulmonary angiography
A 30-year-old woman who recently returned home from a six hour road trip presents to the ED complaining of shortness of breath and chest pain associated with deep breaths. Past medical history significant for GERD. Medication list includes omeprazole and an oral contraceptive which she started taking one month prior. Physical exam reveals diaphoresis. Vital signs are temperature 37°C, heart rate 110 beats per minute, respiratory rate 20 breaths per minute, blood pressure 100/70 mm Hg, and pulse oximetry 89% on room air. Auscultation reveals a split S2 and lungs are clear bilaterally. ECG shows sinus tachycardia. Chest X-ray is normal. Based on the most likely diagnosis, which of the following is the most appropriate diagnostic test? A. CT pulmonary angiography B. CT thorax with IV contrast C. Echocardiogram D. Emergent left heart catheterization
CT pulmonary angiography
A 30-year-old woman who recently returned home from a six-hour road trip presents to the ED complaining of shortness of breath and chest pain associated with deep breaths. Past medical history significant for GERD. Medication list includes omeprazole and an oral contraceptive which she started taking one month prior. Physical exam reveals diaphoresis. Vital signs are temperature 37°C, heart rate 110 beats per minute, respiratory rate 20 breaths per minute, blood pressure 100/70 mm Hg, and pulse oximetry 89% on room air. Auscultation reveals a split S2 and lungs are clear bilaterally. ECG shows sinus tachycardia. Chest X-ray is normal. Based on the most likely diagnosis, which of the following is the most appropriate diagnostic test? A. CT pulmonary angiography B. CT thorax with IV contrast C. Echocardiogram D. Emergent left heart catheterization
Symptomatic treatment
A 32-year-old woman presents to your office with a complaint of productive cough that started 6 days ago. She reports occasional wheezing, chest wall tenderness, and has been afebrile since the onset of symptoms. Her husband had similar symptoms and was prescribed azithromycin by his primary care provider. Which of the following is the most appropriate next step in management? A. Order a chest X-ray B. Prescribe a course of azithromycin C. Send a sputum sample for culture D. Symptomatic treatment
Pneumocystis jiroveci
A 33-year-old man presents with five days of gradual onset nonproductive cough, fatigue, and fever. He also notes a 15 pound weight loss over the last month. He is tachypneic with a heart rate of 105 beats/minute, temperature of 38.2°C, and an oxygen saturation of 89% on room air. On examination, white plaques are noted on his tongue and his lungs are clear on auscultation. His chest X-ray is shown above. Which of the following is the most likely causative agent? A. Influenza A B. Klebsiella pneumoniae C. Pneumocystis jiroveci D. Streptococcus pneumoniae
Sarcoidosis
A 33-year-old woman comes to the clinic complaining of blurred vision, cough, and fatigue. Her blood pressure is 135/90 mm Hg and temperature is 38.6°C (101.5°F). She has no past medical history. Physical examination shows several subcutaneous nodules on both lower extremities. Ophthalmologic examination shows uveitis. Chest X-ray shows bilateral hilar adenopathy and reticular opacities. Laboratory studies show leukopenia, eosinophilia, and an elevated erythrocyte sedimentation rate. Which of the following is the most likely diagnosis? A. Asbestosis B. Cystic fibrosis C. Sarcoidosis D. Tuberculosis
Supportive care
A 33-year-old woman with no past medical history presents with a cough and fever for one week. Her cough is productive of green sputum. Auscultation of the chest is normal. Vital signs are: T 100.2°F, BP 120/72, HR 88, RR 12, and 100% saturation on room air. She is otherwise well-appearing. What is the most appropriate plan? A. Azithromycin B. Prednisone C. Sputum cultures D. Supportive care
No further follow-up
A 35-year-old woman presents to her primary care physician for follow up of an incidental finding on chest CT found during a workup for possible pulmonary embolism. She is a non-smoker and has a negative family history for lung cancer. A solid, solitary pulmonary nodule of 4 mm was seen on chest CT. The scan was otherwise unremarkable. Which of the following is the next best step? A. CT scan at 12 months B. Needle biopsy C. No further follow-up D. Serial CT surveillance
Oral prednisone
A 35-year-old woman with a history of asthma presents to the emergency department with an asthma exacerbation. Treatment with an inhaled bronchodilator and ipratropium does not lead to significant improvement, and she is admitted to the hospital for ongoing management. On examination she is afebrile, her respiratory rate is 26/min, her pulse rate is 98 beats/min, and oxygen saturation is 94% on room air. She has diffuse bilateral inspiratory and expiratory wheezes with mild intercostal retractions. Which one of the following should be administered in the acute management of this patient? A. Chest physical therapy B. Inhaled fluticasone/salmeterol C. Oral azithromycin D. Oral prednisone
Doxycycline
A 36-year-old veterinarian presents with myalgias, dry cough, and severe headache. His vital signs include blood pressure 138/74 mm Hg, heart rate 82 beats/minute, temperature 39°C, and oxygen saturation 94% on room air. He has hepatosplenomegaly on abdominal exam. His chest X-ray shows patchy perihilar infiltrates. What of the following is the most appropriate antibiotic for this patient? A. Amoxicillin-clavulanate B. Doxycycline C. Levofloxacin D. Trimethoprim-sulfamethoxazole
Recent influenza infection
A 37-year-old man presents with cough and shortness of breath. Vital signs are T 102°F, BP 110/76, HR 108, RR 20, and oxygen saturation of 92% on room air. His chest X-ray is shown above. Which of the following helps determine the causative organism? A. Exposure to white powder B. History of smoking C. Recent influenza infection D. Residence in Connecticut
Sarcoidosis
A 38-year-old man presents with fever, fatigue, cough, and increasing dyspnea. The patient denies chills or night sweats. On physical exam, lungs are clear to auscultation bilaterally. Hepatosplenomegaly is noted on abdominal exam. Chest X-ray findings include bilateral hilar adenopathy and diffuse reticular infiltrates. Labs reveal leukocytopenia, hypercalcemia, and elevated erythrocyte sedimentation rate. What is the most likely diagnosis in this patient? A. Histoplasmosis B. Mycoplasma pneumoniae C. Pulmonary tuberculosis D. Sarcoidosis
Silicosis
A 39-year-old stonemason presents with dyspnea that has been present for several months. A chest X-ray shows an eggshell calcification of the hilar lymph nodes and multiple small 1-2 mm nodules throughout the lung. Which of the following is the most likely diagnosis? A. Asbestosis B. Byssinosis C. Siderosis D. Silicosis
Azithromycin
A 43-year old man presents complaining of a two-week history of gradually worsening dry cough, fatigue and occasional shortness of breath. He has "felt warm" but has not checked his temperature. Review of systems is notable for mild diarrhea and decreased appetite, though he is drinking fluids well. He denies chronic medical problems and takes no medications. He does not smoke. His temperature is 100.6°F; pulse 112; BP 122/78; RR 24; pulse oximetry is 92% on room air. He appears tired, though is not ill-appearing. Lung-fields sound clear on auscultation, though a chest X-ray is obtained which demonstrates diffuse infiltrates. What is the most appropriate treatment for his condition? A. Azithromycin B. Metronidazole C. Olsetamivir D. Piperacillin and Tazobactam
Oral corticosteroid is indicated
A 43-year-old man with asthma presents with wheezing. After 6 inhaled albuterol treatments he feels better and his lungs are clear. Which of the following is true regarding further management? A. Intravenous corticosteroid is indicated B. Intravenous magnesium sulfate is indicated C. Oral corticosteroid is indicated D. Oral respiratory antibiotic is indicated
Administer pneumococcus and annual influenza vaccines
A 45-year-old patient with newly diagnosed diabetes mellitus type 2 presents to your office for her annual exam. She has had her hepatitis B vaccination, but wants to know if she needs any additional vaccinations because of her new diagnosis. Which of the following is the most appropriate next step in her management? A. Administer annual influenza vaccine only B. Administer pneumococcus and annual influenza vaccines C. Administer pneumonia prophylaxis with trimethoprim-sulfamethoxazole D. The patient does not need any additional vaccines since she is up to date
Legionella pneumophila
A 45-year-old woman presents to the Emergency Department with a fever, productive cough, and diarrhea. Her chest X-ray shows a patchy unilobar infiltrate and her sodium is 127 mmol/L. Which of the following organisms is most likely to be responsible for these symptoms? A. Legionella pneumophila B. Pseudomonas aeruginosa C. Staphylococcus aureus D. Streptococcus pneumoniae
Discharge home with oral antibiotics and follow-up
A 47-year-old woman with no significant past medical history and no hospitalizations, presents with cough, green sputum, and fever. Her vitals are T 100.7°F, HR 94 bpm, BP 123/76 mm Hg, RR 18/min, and oxygen saturation 97%. She is well appearing, and her blood work (CBC and BMP) is unremarkable. A chest X-ray shows a left lower lobe infiltrate. Which one of the following answer choices represents the best management for this patient? A. Discharge home with oral antibiotics and follow-up B. Draw blood cultures and discharge home on oral antibiotics C. Order a chest CT scan D. Start IV antibiotics, draw blood cultures, and admit
Ground glass opacification
A 48-year-old man with a history of HIV presents to your office with complaints of fever, cough and shortness of breath. Laboratory testing reveals a CD4 count of 130 cells/microL. Which of the following findings is most likely to be seen on chest X-ray? A. Ground glass opacification B. Hampton's hump C. Honeycombing D. Kerley B lines
Bordetella pertussis
A 5-year-old girl presents to clinic with a gradual onset of generalized malaise and severe vigorous coughing fits but without a fever. Which of the following bacteria are you likely to find on a posterior nasopharynx culture? A. Bordetella pertussis B. Haemophilus influenzae C. Mycoplasma pneumoniae D. Streptococcus pyogenes
Ventilation/perfusion scan
A 50-year-old man with a history of hypertension, diabetes and stage IV chronic kidney disease with a GFR of 25, presents to the emergency department complaining of shortness of breath and stabbing chest pain for the past hour. Vital signs are BP 145/70, RR 36, HR 115, and pulse oximetry 89% on room air. An ECG reveals sinus tachycardia. Two days ago he returned to Los Angeles on a business trip from China. Which of the following is the most appropriate diagnostic test for this patient? A. Chest CT pulmonary angiography B. Chest radiography C. Pulmonary angiography D. Ventilation/perfusion scan
Acute bronchitis
A 53-year-old man comes to the emergency department complaining of a 5-day history of a cough and shortness of breath. His temperature is 37.6°C (99.8°F). Auscultation of the lungs shows rhonchi and wheezing. Chest X-ray shows thickening of the bronchial walls in both lower lobes. Laboratory studies show a slightly elevated white blood count. Which of the following is the most likely diagnosis? A. Acute bronchitis B. Asthma C. Influenza D. Pneumonia
Pulmonary embolism
A 55-year-old business executive comes to the emergency department with a 6-hour history of shortness of breath, cough, and chest pain. He smokes 1 to 2 packs of cigarettes daily and drinks 2 to 3 alcoholic beverages every night. He occasionally uses cocaine for recreational purposes. Physical examination reveals an erythematous and edematous right calf and a palpable cord. Auscultation of the lungs reveals rales and decreased breath sounds on the right side. Which of the following is the most likely diagnosis? A. Acute myocardial infarction B. Gastroesophageal reflux disease C. Pulmonary embolism D. Venous thrombosis
Chest X-ray
A 55-year-old man presents complaining of a 2-day history of cough, fatigue and fever which came on suddenly. He denies chronic medical problems and takes no medications. He does not smoke. He is ill-appearing, though in no distress. His temperature is 101.6°F; pulse 112; BP 122/78; RR 24; and pulse oximetry 92% on room air. Physical exam is remarkable for rales along the right side of his lung fields. What is the most appropriate next step in evaluating his condition? A. Acid-fast bacillus smear B. Chest X-ray C. Complete blood count D. Sputum Gram stain and culture
Pulmonary arterial hypertension
A 55-year-old man presents to his pulmonologist with progressive shortness of breath over the past year. He was previously healthy and now can barely make it up the stairs in his home. A chest radiograph shows enlargement of the pulmonary arteries with a normal sized cardiac shadow and normal-appearing lung fields. An echocardiogram is performed showing a normal-shaped left ventricle and thickened myocardium in the right ventricle. Which diagnosis is most likely in this patient? A. Chronic obstructive pulmonary disease B. Hypertrophic cardiomyopathy C. Idiopathic pulmonary fibrosis D. Pulmonary arterial hypertension
A large neck circumference
A 55-year-old obese man presents to the clinic complaining of fatigue and poor concentration for the past six months. His wife reports that he snores nightly and often sounds like he gasping for air. Which of the following would most likely be found on physical exam? A. A large neck circumference B. Coarsening of facial features C. Increased skin pigmentation D. Moon facies
Lung cancer
A 55-year-old smoker presents to the ED with hemoptysis and dyspnea for four weeks. His vital signs are T 37°C, BP 146/76 mm Hg, HR 85 bpm, RR 20 per minute, and oxygen saturation 96% on RA. His lung exam reveals distant breath sounds on the left side. His chest X-ray is shown above. What is the most likely cause of his hemoptysis? A. Bronchitis B. Lung cancer C. Pneumonia D. Pulmonary embolism
Dextromethorphan
A 56-year-old man comes to the clinic complaining of a six-day history of a mucopurulent cough and worsening shortness of breath. His temperature is 37.6°C (99.8°F). Auscultation of the lungs reveals rhonchi and wheezing throughout. Chest X-ray shows thickening of the bronchial walls in both lower lobes. Laboratory studies show a slightly elevated white blood count. Which of the following medications is most appropriate to administer for this patient's cough? A. Aspirin B. Dextromethorphan C. Penicillin D. Prednisone
Pulmonary function testing
A 56-year-old, overweight man presents for bronchitis. He tells you that every winter he gets bronchitis that makes him short of breath and productive of "tons" of mucus for two to three months. Further questioning reveals that he has smoked heavily for 35 years but is trying to cut back. A physical exam is normal except for a BMI of 31, and a lung exam that shows rhonchi bilaterally. Which of the following tests would be most useful in initially guiding diagnosis and management of his condition? A. Arterial blood gas analysis B. Chest CT scan C. Chest radiograph D. Pulmonary function testing
Low dose chest CT scan
A 68-year-old man presents for a wellness visit. He is a former smoker, having quit 3 years ago. He has a 35 pack-year history of smoking. He has no other comorbidities and is feeling well at the time of his visit. What screening needs to be performed with regard to lung cancer? A. Chest X-ray B. Low dose chest CT scan C. No screening is indicated D. Pulmonary function tests
Pneumonia caused by anaerobic bacteria
A 57-year-old man presents to your clinic complaining of two days of productive cough, fever, and dyspnea on exertion. He describes his sputum as foul smelling. He denies chest pain. He admits to drinking six to eight alcohol drinks per day and often experiences "blackouts" at night. Vital signs are BP 145/75, HR 114, T 100.8°F, RR 22, and pulse oxygenation 95 percent on room air. On exam, you note poor dentition and right-sided pulmonary rales. A chest X-ray is seen above. Which of the following is the most likely diagnosis? A. Bronchitis caused by influenza A B. Bronchitis caused by rhinovirus C. Pneumonia caused by anaerobic bacteria D. Pneumonia caused by Mycoplasma pneumoniae
Tiotropium
A 58-year-old man presents to your office with complaints of chronic cough and difficulty breathing. He has smoked approximately 2 packs of cigarettes per day since he was 14 years old and has not seen a doctor in many years. You order spirometry testing, which shows airflow limitation (predicted FEV1 45%). Which of the following is the most appropriate therapy? A. Azithromycin B. Guaifenesin C. Prednisone D. Tiotropium
Polysomnography sleep study
A 58-year-old man with a history of obesity presents to your office with a complaint of daytime sleepiness. He says that his wife sleeps in a different room because of his snoring nighttime restlessness and getting up to urinate 2-3 times per night. Which of the following is the most appropriate diagnostic test? A. Polysomnography sleep study B. Post-void residual testing C. Pulmonary function tests D. Upper airway MRI
Chronic bronchitis
A 60-year-old man with a past medical history of tobacco use presents to clinic with a chief complaint of cough. The cough has been present for five months, and he now has difficulty breathing when walking to his mailbox. He also had a "coughing fit" similar to this last year lasting three to four months. What is the most likely diagnosis? A. Acute bronchitis B. Asthma C. Chronic bronchitis D. Emphysema
Serum sodium 128 mEq/L
A 62-year-old man with a history of chronic obstructive pulmonary disease presents with cough, headache, dyspnea, and watery diarrhea that started six days ago. He was seen at a local urgent care four days ago and prescribed amoxicillin-clavulanate without improvement. He is ill-appearing with a fever of 38.7C and inspiratory rales on auscultation. Which of the following results would be most consistent with his diagnosis? A. Right upper lobe infiltrate with bulging fissure on chest X-ray B. Serum potassium 6 mEq/L C. Serum sodium 128 mEq/L D. Sputum gram stain with gram positive cocci in pairs
Twenty four-hour urine excretion of 5-hydroxyindoleacetic acid
A 63-year-old man presents to your clinic complaining of episodic diarrhea and wheezing. His wife also mentions that his skin will occasionally look flushed. You suspect carcinoid syndrome. What diagnostic study is most appropriate to confirm this condition? A. Abdominal computed tomography scan B. Abdominal magnetic resonance imaging C. Erythrocyte sedimentation rate D. Twenty four-hour urine excretion of 5-hydroxyindoleacetic acid
Twenty four hour urine excretion of 5-hydroxyindoleacetic acid
A 63-year-old man presents to your office complaining of episodic diarrhea and wheezing. His wife also mentions that his skin will occasionally look flushed. You suspect carcinoid syndrome. What initial diagnostic study is most appropriate to confirm this condition? A. Abdominal computed tomography scan B. Abdominal magnetic resonance imaging C. Erythrocyte sedimentation rate D. Twenty four hour urine excretion of 5-hydroxyindoleacetic acid
Pleural fluid to serum protein ratio > 0.5
A 64-year-old man presents with a cough and shortness of breath for two weeks. His chest X-ray is shown above. Which of the following tests would indicate an infectious process as the cause of the above finding? A. Pleural fluid to serum LDH ratio < 0.6 B. Pleural fluid to serum protein ratio > 0.5 C. Pleural fluid to serum protein ratio < 0.1 D. Pleural fluid WBC 5,000 cells/mm3
Mesothelioma
A 65-year-old man presents with cough and progressive dyspnea on exertion. He has no significant cardiac disease. He worked as an asbestos remover for thirty years. Examination reveals crackles but no wheezing. Pulmonary imaging reveals multiple basilar round opacities and pleural plaques. This patient is most at risk for developing which of the following diseases? A. Loffler's syndrome B. Lofgren's syndrome C. Mesothelioma D. Multiple myeloma
Idiopathic pulmonary fibrosis
A 65-year-old smoker with no documented cardiac disease presents with several months of worsening cough and exertional dyspnea. He denies exposure to inhalation toxins or dusts. Examination reveals bibasilar inspiratory crackles and fingernail clubbing. Spirometry reveals a restrictive lung pattern. A chest computed tomography scan is read as "honeycombing in the periphery and bases." A bronchoalveolar lavage report is only significant for lymphocytosis and a histological classification of usual interstitial pneumonia. Which of the following is the most likely diagnosis? A. Chronic obstructive pulmonary disease B. Community-acquired pneumonia C. Idiopathic pulmonary fibrosis D. Pneumoconiosis
Klebsiella pneumoniae
A 65-year-old undomiciled man presents to your emergency department with complaints of fever, productive cough, and shortness of breath. He has a 40 pack-year history of smoking and daily alcohol consumption. His chest radiograph demonstrates a right upper lobe lung infiltrate with an air-fluid level. What is the most likely etiology for this finding? A. Klebsiella pneumoniae B. Legionella pneumophilia C. Mycoplasma pneumoniae D. Pseudomonas aeruginosa
Lung abscess
A 66-year-old man with a history of alcoholism and poor dentition presents with 1 week of fever, dyspnea, and cough productive of purulent sputum. Chest radiographs reveal infiltrates in the posterior segments of the upper lobes. If untreated, what is the most likely complication of this disease? A. Hypertrophic cardiomyopathy B. Infective endocarditis C. Lung abscess D. Lung cancer
Recent viral symptoms
A 67-year-old woman presents with shortness of breath and a cough for 3 days. The patient admits to recently having a fever, chills, rhinorrhea, and myalgias for 10 days. She had one episode of diarrhea and has been nauseated. Her past medical history is positive for COPD. She does not smoke but she drinks two cans of beer daily. In the ED, her vital signs are BP 120/76, HR 108, RR 20, oxygen saturation 97% on room air, and temperature 101.2°F. A chest X-ray shows a left lower lobe consolidation. It is suspected that this patient has pneumonia caused by Staphylococcus aureus. Which aspect of this patient's history supports this suspicion? A. Alcohol consumption B. Gastrointestinal symptoms C. History of COPD D. Recent viral symptoms
Refer for transthoracic needle aspiration
A 68-year-old woman presents with cough that has been present for the past several months. She describes it as a dry, hacking cough that she attributed to her cigarette smoking. A chest X-ray is completed that shows a 2.5 cm mass in the peripheral right lower lobe. Sputum cytology is performed and is negative for malignant cells. What is the next best step in managing this patient? A. Order bronchoscopy B. Refer for transthoracic needle aspiration C. Repeat chest X-ray in six months D. Smoking cessation and reassurance
Clarithromycin
A 7-year-old boy is brought by his mother to the clinic because of coughing. For the past week, he has had a nonproductive cough. On physical examination, vital signs are normal, with erythematous posterior pharynx, and clear breath sounds. Complete blood count is normal. Chest radiograph reveals perihilar infiltrates. Polymerase chain reaction from the boy's nasopharyngeal specimen comes back positive for Mycoplasma pneumoniae. Which of the following is the most appropriate therapy? A. Amoxicillin B. Clarithromycin C. Levofloxacin D. Oseltamivir
Administration of supplemental oxygen, nebulized albuterol and ipratropium, oral prednisone
A 72-year-old man with a 40 pack-year smoking history presents to the emergency department complaining of shortness of breath and cough for two days. He reports difficulty breathing when walking short distances in his home. His cough is nonproductive. His oxygen saturation is 87% on room air. He is alert but has difficulty speaking in complete sentences. On auscultation, there is diffuse expiratory wheezing. Chest radiograph shows hyperexpansion and flattened diaphragms. Which of the following is the most appropriate therapy? A. Administration of supplemental oxygen, intravenous methylprednisolone, theophylline B. Administration of supplemental oxygen, nebulized albuterol and ipratropium, oral prednisone C. Administration of supplemental oxygen, nebulized albuterol, intravenous antibiotics D. Administration of supplemental oxygen, oral prednisone, terbutaline
Emphysema
A 72-year-old man with a history of chronic tobacco use presents to clinic with a complaint of increasing dyspnea while walking to his mailbox. Physical examination reveals decreased breath sounds, hyperresonance to percussion, and a barrel chest. A chest X-ray is obtained that demonstrates hyperinflation with flattened diaphragms. What is the most likely diagnosis? A. Acute bronchitis B. Asthma C. Chronic bronchitis D. Emphysema
Chest X-ray
A 72-year-old woman was hospitalized for atrial fibrillation with rapid ventricular rate. She is being discharged today on amiodarone for long term control of her dysrhythmia. Which of the following diagnostic studies should be followed as an outpatient? A. Chest X-ray B. Coagulation studies C. Complete blood counts D. Renal panels
Staphylococcus aureus
A 74-year-old woman presents with complaints of fever, productive cough with bloody sputum, shortness of breath, and headache. These symptoms developed and worsened drastically over the past 3 days. She recently recovered from an influenza infection 1 week ago. Her medical history otherwise includes only well-controlled hypertension. Vital signs on presentation are as follows: T 39°C, HR 106, BP 110/75, RR 30, oxygen sat 95% RA. A chest radiograph is obtained and a subsequent CT scan of the chest demonstrates multiple cavitary lung lesions. Which of the following organisms is most likely responsible for this patient's presentation? A. Clostridum perfringens B. Escherichia coli C. Mycobacterium tuberculosis D. Staphylococcus aureus
Digital clubbing
A 76-year-old man with a 30-year pack history of smoking tobacco presents with a chief complaint of increasing dyspnea on exertion over the past 7 months. What aspect of his history and physical examination would suggest idiopathic pulmonary fibrosis, rather than another diagnosis, as the source of his dyspnea? A. Chest pain B. Digital clubbing C. Joint pain D. Productive coughing
Begin a course of oseltamivir
A 76-year-old woman with a history of chronic obstructive pulmonary disease presents to your office in December with complaints of fever, muscle aches, headache and malaise that started yesterday. Which of the following is the most appropriate next step in management? A. Advise supportive care measures including acetaminophen B. Begin a course of azithromycin C. Begin a course of oseltamivir D. Begin a course of prednisone
Transient tachypnea of the newborn
A full term male infant is delivered by cesarean section because of dystocia due to macrosomia. Apgar scores are 8 and 10. An hour after delivery he begins to have tachypnea without hypoxemia. A chest radiograph shows diffuse parenchymal infiltrates and fluid in the pulmonary fissures. The symptoms resolve without treatment within 24 hours. What is the most likely diagnosis? A. Laryngomalacia B. Meconium aspiration syndrome C. Respiratory distress syndrome D. Transient tachypnea of the newborn
Betamethasone
A mother who is at 31 weeks gestation is at high risk of preterm delivery. Which of the following is given prenatally to prevent the risk of infant respiratory distress syndrome? A. Albumin B. Betamethasone C. Phosphatidylglycerol D. Sphingomyelin
He is an organ recipient on daily immunosuppressives
A new nursing home employee is being screened for tuberculosis and develops a 6 mm induration on his right volar forearm after injection of a purified protein derivative (PPD). This reading indicates prior tuberculosis exposure if he has had which of the following life circumstances? A. He is a former guard at a correctional facility B. He is a HIV-negative injection drug user C. He is a recent immigrant from Latin America D. He is an organ recipient on daily immunosuppressives
Moderate persistent
A nine-year-old girl is in the clinic for a follow-up. She was diagnosed with asthma a few days ago after an emergency room visit. She would have night awakenings about twice a week. She would also use her inhaled short-acting beta agonists about every day for relief of shortness of breath. On physical examination, you notice occasional wheezing on right and left lung fields. Which of the following is the best classification of her asthma severity? A. Intermittent B. Mild persistent C. Moderate persistent D. Severe
Albuterol
A previously healthy 27-year-old man presents to your office with a complaint of cold symptoms. He says that initially he had sinus congestion and a sore throat, which have since resolved, but he has also had a productive cough for approximately 10 days that is keeping him up at night. Physical exam reveals a temperature of 98.6°F and mild, diffuse wheezing on auscultation of the lungs. Which of the following is the most appropriate therapy? A. Albuterol B. Azithromycin C. Oseltamivir D. Prednisone
Expiratory wheezing
A six-month-old boy presents with five days of nasal congestion and discharge that has now progressed to fever, coughing, and wheezing. You suspect acute bronchiolitis. What are you likely to find on physical examination? A. Cervical lymphadenopathy B. Expiratory wheezing C. Inspiratory stridor D. Pharyngeal exudate
Polymerase chain reaction of nasopharyngeal secretions
A two-month-old boy is sent to the emergency department by his pediatrician for cough and an abnormal CBC with lymphocytosis. He is up-to-date with immunizations. His older brother, who is four years old, is not up-to-date since the pediatrician suspended his immunizations due to a developing neurologic condition. The brother has also had a febrile illness and has been coughing for more than three weeks. You observe the two-month-old coughing and see a period of peri-oral cyanosis. What method of confirmatory testing has the best combined sensitivity and specificity for diagnosis? A. Blood cultures B. Direct fluorescent antibody on nasal swabs C. Polymerase chain reaction of nasopharyngeal secretions D. Sputum cultures
Bordetella pertussis
A two-year-old boy who is new to your practice is brought to the clinic because of coughing. For the past two weeks, he has had rhinorrhea and coughing. However, the coughing has become worse with more frequent coughing fits and episodes of vomiting. You review his previous records and note that the parents have refused immunizations. On physical examination, his temperature is 38 degrees Celsius, respiratory rate is 35, and lungs are clear to auscultation. During the examination, you note that the boy has a long series of coughs followed by a whoop. Which of the following is the most likely etiologic agent causing the illness? A. Bordetella pertussis B. Human metapneumovirus C. Mycoplasma pneumoniae D. Respiratory syncytial virus
Noncaseating granulomas
A young woman with dyspnea on exertion presents for evaluation. She is subsequently diagnosed with sarcoidosis. Which of the following would you expect to appear in her lymph node biopsy report? A. Acid-fast organisms B. Congo red stain birefringence C. Noncaseating granulomas D. Reed-Sternberg cells
Subglottic narrowing
An 18-month-old boy presents with his father for a cough and difficulty breathing. The father states that the child has had nasal congestion and coryza for the last two days. On exam, he has a barking cough, inspiratory stridor, and a prolonged inspiratory phase. Which of the following would you expect to see on radiographic evaluation? A. Edema of the epiglottis B. Intraluminal membranes of the tracheal wall C. Subglottic narrowing D. Thickening of the retropharyngeal space
Low dose inhaled corticosteroid and short-acting beta-agonist as needed
An 18-year-old woman with a history of asthma presents to her primary care provider for follow-up. Currently she experiences symptoms of coughing, wheezing and shortness of breath 3 days a week and uses her rescue inhaler 3 days a week. She awakens at night with similar symptoms 3 times a month. She reports some minor interference with her daily routine. Which of the following options is an appropriate management plan at this time? A. High dose inhaled corticosteroid and short-acting beta-agonist as needed B. Low dose inhaled corticosteroid and short-acting beta-agonist as needed C. Oral corticosteroid and short-acting beta-agonist as needed D. Short acting beta-agonist as needed
Nasopharyngeal swab for fluorescent antibody staining
An 8-month-old previously healthy boy presents with fever, cough, and wheezing for the last two days. Physical exam reveals prolonged expiration and mild subcostal retractions. Lung auscultation reveals diffuse expiratory wheezing and tachypnea. His immunizations are up-to-date. Which of the following tests is most likely to confirm the suspected diagnosis? A. Chest X-ray B. Complete blood count C. Nasopharyngeal swab for fluorescent antibody staining D. Throat culture for Streptococcal infection
Dullness to percussion
An eight-year-old boy comes in your clinic for follow-up. Two days ago, he was diagnosed with pneumonia and started on amoxicillin-clavulanic acid. However, fever and cough persisted and is accompanied by decreased appetite, chest pain, and difficulty breathing. You suspect a complicated pneumonia. Which of the following physical exam findings is consistent with pleural effusion? A. Dullness to percussion B. Early inspiratory crackles C. Trachea deviates away from affected side D. Vesicular breath sounds
Pulmonary embolism
An obese 34-year-old woman is brought to the Emergency Department with respiratory distress. Two months ago she was in the hospital for knee surgery. Paramedics report an acute onset of dyspnea and pleuritic chest pain. She also complains of a tender thigh on the same side of her knee surgery. She is tachycardic and tachypneic, and mildly hypotensive. Examination reveals decreased breath sounds but no hyperresonance. An emergent chest radiograph is relatively normal except for some mild atelectasis. Which of the following is the most likely diagnosis? A. Acute bronchitis B. Pleural effusion C. Pneumothorax D. Pulmonary embolism
Macrolide antibiotic
An unimmunized 7-year-old boy without any previous medical history presents with fever and cough. The parents report that he has been coughing for two weeks. The patient has sudden fits of coughing followed sometimes by post-tussive emesis. Which of the following is an appropriate plan? A. Albuterol nebulizer B. Corticosteroid therapy C. Macrolide antibiotic D. Respiratory viral panel
Peripheral neuropathy
Which of the following complications can be prevented by simultaneously administering pyridoxine and isoniazid in a patient with tuberculosis exposure? A. Color blindness B. Hepatitis C. Peripheral neuropathy D. Renal failure
Influenza
Which of the following conditions requires droplet precautions? A. Influenza B. Measles C. Tuberculosis D. Varicella
A 10-year-old with a normal chest X-ray and a PaO2 of 65 mm Hg
Which of the following HIV-positive patients suspected of having Pneumocystis pneumonia should receive prednisone before treatment with trimethoprim/sulfamethoxazole? A. A 10-year-old with a normal chest X-ray and a PaO2 of 65 mm Hg B. A 15-year-old with diffuse interstitial infiltrates on chest X-ray, a pulse oximetry of 92%, and PaO2 of 80 mm Hg C. A 20-year-old with diffuse interstitial infiltrates on chest X-ray and an A-a gradient of 25 mm Hg D. An 18-year-old with diffuse interstitial infiltrates on chest X-ray, a pulse oximetry of 94% on room air, PaO2 of 75 mm Hg, and an A-a gradient of 10 mm Hg
Pulmonary embolism
Which of the following diagnoses should be considered when an unexplained isolated pleural effusion is found on chest radiograph? A. Bacterial pneumonia B. Congestive heart failure C. Pulmonary embolism D. Viral pleuritis
Barking cough
Viral croup or laryngotracheitis will most commonly present with which of the following symptoms? A. Barking cough B. Drooling C. Dry cough of a two weeks' duration D. Muffled hot potato voice
Altered structure and function of the right ventricle
Which of the following best describes cor pulmonale? A. Altered structure and function of the left ventricle B. Altered structure and function of the right ventricle C. Congenital heart disease D. Right-sided heart disease due to left-sided heart disease
Systemic lupus erythematosus
Which of the following can cause an exudative pleural effusion? A. Cirrhosis B. Congestive heart failure C. Nephrotic syndrome D. Systemic lupus erythematosus
Honeycombing
What finding on high resolution computed tomographic imaging of the chest is most consistent with idiopathic pulmonary fibrosis? A. Ground glass patches B. Honeycombing C. Non-caseating granulomas D. Solitary nodule
Streptococcus pneumoniae
What is the most common causative organism in community acquired pneumonia? A. Klebsiella pneumoniae B. Mycoplasma pneumoniae C. Staphylococcus aureus D. Streptococcus pneumoniae
Parainfluenza virus
What is the most common cause of croup? A. Adenovirus B. Haemophilus influenzae type b C. Parainfluenza virus D. Streptococcus spp.
Acute bronchitis
What is the most common cause of minor hemoptysis in the emergency department? A. Acute bronchitis B. Pneumonia C. Pulmonary embolism D. Tuberculosis
Cough
What is the most common complaint seen in acute bronchitis? A. Chest pain B. Cough C. Fever D. Sputum
Hypercalcemia
What lab abnormality is commonly seen in sarcoidosis? A. Hypercalcemia B. Hypocalcemia C. Hypophosphatemia D. Neutropenia
Mesothelioma
What type of cancer is classically associated with asbestos exposure? A. Large cell carcinoma B. Mesothelioma C. Small cell carcinoma D. Squamous cell carcinoma
Right heart catheterization
You are seeing an elderly man with new onset of peripheral edema, head fullness and neck venous engorgement. Initial testing shows normal left heart function. You suspect cor pulmonale. Which of the following tests is the most accurate in confirming this diagnosis? A. Cardiac magnetic resonance imaging B. Electrocardiography C. Right heart catheterization D. Ultrafast ECG-gated computed tomography
Pneumoconiosis
You are treating a 50-year-old coal-miner's hypertension with lisinopril. He has been complaining of 3-months of progressive dyspnea. You order a chest radiograph which shows bilateral upper lobe honeycombing. A high resolution computed tomogram shows multiple small, round opacities only in the upper lobes. The lower lobes appear normal. Which of the following is the most likely diagnosis? A. Goodpasture's syndrome B. Granulomatosis with polyangiitis (GPA) C. Pneumoconiosis D. Scleroderma
Lateral decubitus right side down
You evaluate a 65-year-old patient for shortness of breath and note on exam decreased breath sounds at the right lung base. You are suspicious of a small pleural effusion. In which of the following views on the chest radiograph is the small pleural effusion most likely to be detected? A. Lateral B. Lateral decubitus left side down C. Lateral decubitus right side down D. Posteroanterior
