USMLE Step 2 CK Medical Subject Review: Internal: Pulmonary Diseases
22-year-old woman presents with shortness of breath. She has a history of intermittent wheezing while exercising. On examination, you find that her pulse rate is increased; there are diffuse wheezes on pulmonary auscultation. Her oxygen saturation is 95%. What would be the most effective therapy in this patient?
Inhaled albuterol
60-year-old Caucasian man with chronic obstructive pulmonary disease (COPD) and severe pneumonia has been intubated and mechanically ventilated for 5 days. Suddenly, he became agitated and diaphoretic; he has a blood pressure of 75/55 mm Hg, a heart rate of 120/min, and a respiratory rate of 42/min. Body temperature is 38.5°C. Physical examination reveals distended neck veins, decreased breath sounds on the left, and the trachea is deviated to the right. What should your next maneuver be?
14-gauge catheter-over-needle device in the left chest
40-year-old woman presents with flu-like symptoms (e.g., headache, fever, dry cough, and breathlessness without wheezing) after attending an office meeting. She experiences these symptoms every time she attends meetings in that particular office. From her symptoms, it can be concluded that she has hypersensitivity pneumonitis. What best represents hypersensitivity pneumonitis?
Farmer's lung
44-year-old man came to the ER after a motor vehicle accident. He has multiple and extensive internal and bone injuries. Exploratory laparotomy was done 2 hours later and splenectomy was performed. The patient also undergoes bone reduction and internal fixation of both femurs. The patient's condition is stabilized after a week. The patient then suddenly complains of shortness of breath and dies. What is the most likely diagnosis?
Fat embolism
25-year-old man presents at the hospital after a car collision. He is intubated and placed on a ventilator. He becomes progressively difficult to oxygenate despite increasing the PEEP and the oxygen supply to 100%. Patient remains afebrile. He dies several days later. At autopsy, the lung shows diffuse hyaline membranes in the alveoli, thickened alveolar walls, and many alveolar macrophages, but few neutrophils. What condition did this patient have?
Acute respiratory distress syndrome
55-year-old man with a 100 pack-year smoking history presents with dyspnea. The patient is cyanotic, restless, and confused. He has tachycardia, tachypnea, as well as peripheral and conjunctival hyperemia. Ophthalmoscopy shows papilledema. ABG shows PaO2 - 54mmHg, PaCO2 57mmHg and SaO2 76%. Chest X-ray shows hyperinflated lungs. What is the most likely diagnosis?
Acute respiratory failure with COPD exacerbtion
27-year-old man with multiple trauma fractures is transferred to the hospital ICU. The patient is intubated and sedated. His vitals are P 125 and BP 80/60 mm Hg. ABG reveals pH of 7.3, PaCO2 30, and PaO2 67 on a ventilator with pressure control. His Chest X-ray reveals dense infiltrate. What change is most likely to improve oxygenation in this patient?
Add PEEP of 5 cm of water
48-year-old man presents with history of breathlessness. The chest X-ray shows diaphragmatic fibrous pleural plaques and interstitial fibrosis. What is the most likely histopathological finding possible in this case?
Ferruginous bodies in the lung
55-year-old man presents with dyspnea that has been increasing over several years. He has a history of exposure to asbestos during construction projects. What is the most likely finding in this case?
Fibrous pleural plaques
60-year-old woman presents with a history of persistent cough. She is confined to her bed; walking over 10 paces causes severe breathlessness. She has no energy to carry out any regular activities. She has never smoked, and she drinks an occasional glass of wine. On physical examination, she is found to have decreased breath sounds and dullness to percussion over her right lower thorax. Further evaluation reveals an irregular mass in the periphery of the right lung base with a right-sided pleural effusion. A needle is inserted into the pleural space and divulges bloodstained fluid. If results prove to be a malignancy, what is the most likely pathology of her mass?
Adenocarcinoma
A thoracocentesis is performed on a 55-year-old woman who has multiple lung masses. The pleural fluid obtained is serosanguinous. What would the cytological examination of the pleural fluid most likely show?
Adenocarcinoma
45-year-old chronic smoker presents with increasing exertional breathlessness. The patient has a productive cough. The patient is diagnosed with panacinar emphysema. He is also found to have cirrhosis of the liver. What underlying disease could relate panacinar pulmonary emphysema to cirrhosis of the liver?
Alpha-1 anti-trypsin deficiency
40-year-old man presents with increasing dyspnea. After thorough examination and investigation it is found that he has panacinar emphysema, ascites, splenomegaly and caput medusae. What do the patient's findings suggest?
Alpha-1 antitrypsin deficiency
26-year-old woman presents with a 12-hour history of wheezing. She was recently diagnosed with asthma by her family physician. Her asthma is not well controlled despite treatment with β2 agonists and prednisolone 60mg/day. She has had 3 - 4 ER visits over the past month since her diagnosis. She is obese, a non-smoker, and is 8 weeks postpartum. Her BP is 160/80; P is 120/min, and T is 99F. Pulse oximetry on room air is 72%. PFR is 36% of predicted. She has staccato speech, and there is mild central cyanosis. She is using her accessory muscles, and she is not agitated. On auscultation, she has a loud S1 and inspiratory wheeze is greater than expiratory wheeze. She has peripheral edema. You suspect a condition for which, in addition to admission, the following treatment is required?
Anticoagulants
25-year-old woman develops symptoms of breathlessness and cough along with fever. The symptoms were acute in onset, developed within a day. A chest X-ray shows diffuse and nodular infiltrates. She has some pet birds at home. Her symptoms disappear when she goes out for a vacation, but they reappear when she comes back home to take care of her birds. What is the most likely cause of the woman's condition?
Antigen-antibody complexes
40-year-old man with chronic alcoholism presents with a cough that produces of large amounts of fetid sputum. He developed the cough about 4 weeks ago, and it has gradually worsened over time. The sputum is now foul-smelling and copious. He has had high intermittent pyrexia for 4 days. His vitals are: T 102°F, PR 98\min, RR 24\min, BP 140\80 mm Hg. HEENT exam shows poor dentition with multiple missing teeth, mild erythema to the nasal muscosa with clear drainage. RRR without a murmur. On lung auscultation, there is pleural rub and diminished air entry on the right side. The chest X-ray shows a large, irregularly shaped, dense opacity on the right side with a fluid level. How should this patient's diagnosis be regarded?
Aspiration is the most common cause
7-year-old boy presents with his mother with a 1-week history of wheezing and dyspnea on any exertion (with productive cough). On physical examination, bilateral rhonchi are heard. After a few days of treatment, spirometry is done on the patient. Total lung capacity (TLC) is 111% on spirometry. Pre-bronchodilators Post-bronchodilators FVC% 49 63 FEV1% 41 46 FEV1/FVC 49 55 What is the most likely diagnosis?
Asthma
33-year-old man presents with shortness of breath, wheezing, mild fever, and fatigue. He has had several similar episodes in the past, and each previous episode began after a cold that moved into his chest. Over the past several weeks, he has had a productive cough most mornings. He has no other symptoms or exam findings. He smokes on a social basis. His CXR is normal and most recent pulmonary function tests reveal a reversible airflow limitation. What is the most likely diagnosis?
Asthmatic bronchitis
35-year-old woman presents with 5-hour history of progressive shortness of breath, cough, and wheezing. This morning she felt that she was "catching a cold" because of sore throat and thin purulent rhinorrhea, for which she took aspirin. Her past medical history is significant for persistent rhinitis resistant to therapy. What should your patient do to prevent future asthma attacks?
Avoid aspirin.
40-year-old man presents with a 5-day history of cough and purulent sputum without fever. The patient has had recurrent attacks of cough with sputum production since childhood. He was born several weeks premature. He does not smoke and works as a computer programmer. He reports no other systemic problems. The patient is afebrile and has grade III finger clubbing. Rales are present all over the chest on auscultation. The chest X-ray shows a characteristic honeycomb appearance. What is the most likely diagnosis?
Bronchiectasis
40-year-old man coughs a large thick mucus plug after an episode of dyspnea with wheezing. The patient also gives a history of similar episodes in the past. These findings are typical for what type of disorder?
Bronchial asthma
50-year-old man presents with a 1-week history of hemoptysis. He is a chronic smoker. A chest X-ray shows a hilar mass. What is the least likely pathologic finding in this setting?
Bronchoalveolar carcinoma
50-year-old family practitioner who has been in good health all his life develops progressive dyspnea over a period of 2 years. He develops cor pulmonale and death ensues. The most probable underlying cause of death is
Idiopathic pulmonary fibrosis
Refer to the table. The findings in the chart are of the findings of spirometry in a 65-year-old woman who is a chronic smoker with a history of breathlessness on any exertion, productive cough, and frequent wheeze. TLC is 103. What is the most likely diagnosis?
COPD
50-year-old male presents to his primary care physician for worsening dyspnea and progressive cough. He is a chronic smoker. On physical examination, he has cyanosis in his fingertips and he is using his accessory muscles to breath. Lung examination reveals course rhonchi throughout his chest wall. Chest X-ray shows increased bronchovascular markings and cardiomegaly. PFT reveals decreased FEV1, decreased FVC and decreased FEV1/FVC ratio, TLC is104. The peak flow rate is 170. What is the most likely diagnosis?
Chronic obstructive pulmonary disease (COPD)
50-year-old man who has smoked 2 packs of cigarettes per day for the past 30 years presents with a lung mass on chest X-ray. He also says that he has recently gained weight. Laboratory examination shows hyponatremia with hyperosmolar urine. What does the patient probably have?
Inappropriate ADH
84-year-old woman presents with a 6-hour history of dyspnea, non-productive cough, hemoptysis, and a "sharp, stabbing" pleuritic chest pain. Her review of systems is negative for any fever, chills, palpitations, wheezing, abdominal pain, nausea, vomiting, diarrhea, and rashes. She has a past medical history of myocardial infarction, congestive heart failure, dyslipidemia, asthma, and lung cancer. Social history is significant for a 50 pack-year smoking history, but she quit 10 years ago. She denies any alcohol or recreational drug use, sick contacts, or recent travel. She also denies any recent hospitalizations or surgeries. On physical exam, skin is warm and dry without rashes. There is abdominal distension, hepatosplenomegaly, supraclavicular lymphadenopathy, and 2+ lower extremity pitting edema (right greater than left) noted. The cardiac exam reveals tachycardia, jugular venous distension of 6 cm, and an S3 gallop. Pulmonary exam reveals tachypnea, diffuse dullness to percussion, decreased tactile fremitus, and absent breath sounds. She undergoes diagnostic thoracentesis. Laboratory findings of pleural fluid are listed below. Appearance Clear Pleural fluid LDH 160 units/liter Pleural-to-serum protein 0.2 Pleural-to-serum LDH 0.3 Pleural fluid glucose Negative Pleural fluid WBCs Negative Pleural fluid pH Within normal limits Pleural fluid RBCs Negative What is the most likely contributory etiology?
Congestive heart failure
62-year-old man presents with a 2-month history of worsening fatigue and shortness of breath. He has a past medical history of emphysema attributable to his 85 pack-year smoking history. The patient complains of nearly passing out while climbing the stairs in his house. He tells you that he feels like his heart races. He reports chronic shortness of breath and cough, but he now he feels like his dyspnea is dramatically worse; he can no longer sleep in his bed. He has been trying to sleep propped up in a chair at night. He is also experiencing fatigue. He has gained about 15 pounds, and he notes that he can no longer lace up his shoes. He denies fever, chills, and chest pain. His cough produces some mucus, but no hemoptysis. His vitals are shown in the table. Weight 212 lb Height 69" Body mass index 31.3 Pulse 108 Blood pressure 140/88 Temperature 98.2°F Pulse oximetry 88% On physical exam, you see a man in mild respiratory distress; he is sitting upright and leaning forward, and he uses accessory respiratory muscles for breathing. The exam is significant for reduced air movement and mild rales bilaterally in the lungs; distended neck veins; mild tachycardia with prominent P2; lower extremity edema; and right upper quadrant abdominal tenderness with hepatomegaly. Based upon this patient's history and physical, what is the most likely diagnosis?
Cor pulmonale
69-year-old man presents with dyspnea on exertion (climbing stairs and walking short distances) that has slowly progressed over the last year. He has fatigue, palpitations, intermittent retrosternal chest pain, lower extremity swelling, dizziness, and "feeling faint." Associated symptoms occur upon exertion. He denies fever, chills, weight changes, cough, abdominal pain, early satiety, nausea, vomiting, diarrhea, changes in urine color/odor, flank pain, hematuria, or dysuria. No cigarette, alcohol, or drug use. Cardiac exam shows increased pulmonic component of the second heart sound (P2), wide inspiratory splitting of S2 over the cardiac apex, right-sided S3 and S4 gallops, left parasternal lift, loud diastolic murmur increasing with inspiration and diminishing with Valsalva maneuver, prominent "A" waves in jugular venous pulsations, and increased JVD. Enlarged liver with hepatojugular reflux, peripheral edema, and ascites. EKG reveals peaked P waves, rightward axis deviation, and prominent R waves in the early V leads. What is the most likely diagnosis?
Cor pulmonale
65-year-old man presents with fatigue, shortness of breath, chest pain, and weight loss. Physical exam findings include diminished breath sounds on auscultation, and there is dullness to percussion. You order a CXR and it reveals a pleural thickening and unilateral pleural effusion. Based on the CXR, which of the following cancers is highest on the differential diagnosis?
Mesothelioma
50-year-old woman presents with right-sided pleural effusion. Thoracentesis shows the presence of exudative serosanguineous pleural fluid and positive cytology. This finding is most typical for what condition?
Metastatic infiltrating ductal carcinoma
50-year-old man who has smoked 1 pack-a-day of cigarettes since age 23 presents with a history of cough and dyspnea on exertion that has progressively worsened over the past several months. Chest x-ray reveals flattening of the diaphragms but no consolidations. Spirometry was performed, and the results are as follows: FEV1 60% predicted FVC 84% predicted FEV1/FVC 69% predicted Based on these findings, what is the most likely diagnosis?
Obstructive lung disease
22-year-old couple presents for the evaluation of primary infertility. The woman has no symptoms; her family and gynecological history are not relevant. Her spouse regularly takes pancreatic enzymes, albuterol, and vitamins; he also frequently takes antibiotics because of the presence of recurrent respiratory tract infections, bronchiectasis, and bronchiolectasis; there is also exocrine pancreatic insufficiency and intestinal dysfunction. What is the next step in the evaluation of their inability to conceive?
Semen analysis
75-year-old man is recovering from a pneumonia caused by Streptococcus pneumoniae; his condition suddenly deteriorates. He presents after developing a persistent fever, chills, cough, and diaphoresis. A CBC reveals leukocytosis with a left-shift. A chest X-ray demonstrates an air-fluid level in the pleural space, which is suggestive of an abscess. What organism caused the patient's deterioration?
Staphylococcus aureus
45-year-old man suffering from viral hepatitis requires being started on antitubercular therapy for pulmonary tuberculosis. He has icterus with hepatomegaly, and his liver function tests are moderately deranged. What antitubercular drug combination is safest for this patient?
Streptomycin + Ethambutol
55-year-old man presents with a 2-day history of hemoptysis; he has a chronic cough that he attributes to his 40 pack-year history of cigarette smoking. He also reports that he has been bruising easily. On examination, he has moon facies and truncal obesity with wasting of his shoulder muscles. He has several red-purple striae over his anterior abdominal wall. The lungs are clear to auscultation. Laboratory results are as follows: hemoglobin 12 g/dL, white blood cell count 8 x 103/mm3, platelets 160 x 103/mm3, sodium 138 mmol/L, and potassium 3.0 mmol/L. Tuberculin skin test is negative. Sputum cytology is positive for carcinoma. What syndrome commonly associated with lung cancer is the most likely diagnosis?
Cushing syndrome
60-year-old man, a cigarette smoker for 40 years, presents with a 2-week history of several episodes of hemoptysis. He has had a chronic cough for years, which has worsened in the last month. The patient has no history of diabetes mellitus or hypertension. General physical examination reveals pigmentation, abdominal striae, and central obesity. Vitals are as follows: temperature 98.6° F, pulse 82/min, and BP 160/100 mm Hg. A chest X-ray shows an ill-defined hilar mass; a transbronchial biopsy shows small cell lung cancer. Laboratory examination reveals persistent hypokalemia, metabolic alkalosis, and hyperglycemia. This patient's clinical presentation, along with lab findings, is suggestive of what paraneoplastic syndrome?
Cushing's syndrome
10-year-old girl presents with recurrent bronchitis. Her past history is significant for polypectomy, nasal polyps, failure to thrive, and repeated attacks of bronchitis. Examination reveals clubbing and diffuse rhonchi on respiratory auscultation. Investigations reveal subnormal lung function, decreased exercise tolerance, and a sweat chloride concentration of 62 mEq/L (normal: <40 mEq/L). What is the most likely diagnosis?
Cystic fibrosis
30-year-old man receives a bone marrow transplant (BMT) for treatment of acute myeloid leukemia (AML). He develops increasing respiratory failure 3 weeks later. A bronchoalveolar lavage yields cells that are enlarged and have prominent intranuclear inclusions. What is the most likely diagnosis?
Cytomegalovirus infection
40-year-old female presents with shortness of breath on exertion that has been worsening over the past few months. She also has lost 10 pounds unintentionally in the past month. She works on a farm and notices her shortness of breath is worse while working. She denies any other symptoms. Her physical examination is normal except for a few scattered inspiratory crepitations. It is suspected that she has restrictive lung disease. What will her spirometry findings be if this diagnosis is correct?
Decreased FEV1, decreased FVC and normal or increased FEV1/FVC ratio
25-year-old man is brought to the hospital after a vehicular accident. He is intubated and placed on a ventilator. He becomes progressively difficult to oxygenate despite increasing the PEEP and the oxygen supply to 100%. The appearance of hyaline membrane with type II pneumocytes proliferation in this patient is most consistent with what?
Diffuse alveolar damage
52-year-old man presents with a 2-year history of worsening dyspnea and a 1-month history of dry cough. The patient gives no history of fever, chills, chest pain, or wheezing. History is significant for smoking (25 cigarettes/day for more than 22 years). Pulmonary function tests (PFT) reveal a decrease in forced expiratory volume in 1 second (FEV1) along with reduction of FEV1/FVC (forced vital capacity) ratio. The patient's chest X-ray is below. Refer to the image. These findings are characteristic of what condition?
Emphysema
68-year-old African American woman with past medical history of obstructive sleep apnea, hypertension, and COPD presents with chronic progressive dyspnea. The dyspnea initially occurred upon exertion, now noted at rest for the past 8 months. She is maintained on home oxygen for COPD. There is associated fatigue, substernal exertional chest pain, and 2 episodes of exertional syncope. She denies other symptoms. Physical exam reveals oxygen saturation of 90%, left parasternal lift, narrow splitting of the second heart sound, accentuation of the pulmonary component of the second heart sound, an early systolic ejection click, and an S4 gallop. No murmurs are identifiable. +1 pitting edema bilaterally to the lower extremities to the mid-calf level. EKG shows right axis deviation and incomplete right bundle branch block. Chest x-ray shows right ventricular enlargement with prominent right pulmonary artery. What treatment is most beneficial in the symptomatic management of this patient?
Furosemide
40-year-old woman presents with a history of increasing dyspnea associated with weight loss. The patient was treated with mastectomy with chemotherapy 2 years ago for an infiltrating ductal carcinoma of the left breast. What might be the cause of her increasing dyspnea?
Hemorrhagic effusion
38-year-old woman presents with acute onset of shortness of breath. She has never experienced anything like this before. Her husband states they were returning home after visiting relatives out of state. They were in the car together for 6 hours, and he denies any noxious exposures. Her past medical history is significant for hypertension and obesity. She takes hydrochlorothiazide and an oral contraceptive pill. She denies smoking cigarettes, and she drinks 1-2 glasses of wine per week. Family history shows that her mother has diabetes and hypertension, and her sister has von Willebrand's disease. On physical exam, her BP is 100/60 mm Hg; pulse 120/min; respirations 40/min; and O2 saturation is 90% on 100% oxygen via non-rebreather mask. What treatment improves mortality in a patient with this condition and should be started immediately?
Heparin
50-year-old obese woman undergoes a cholecystectomy and T-tube drainage of the common bile duct. On postoperative day 7, she develops sudden epigastric and left-sided chest pain. She is short of breath and is sweating profusely. Her temperature has been between 99-100°F for the past 2 days. The patient's vitals are: pulse 90/min, BP 110/60 mm Hg, and RR 24/min. The ECG reading shows tachycardia, and the ventilation-perfusion lung scan shows a VQ mismatch. Based on the most likely diagnosis, what should be the initial management of this patient?
Heparinization
72-year-old man presents to the outpatient clinic in follow-up for his dyspnea and cough. He reports shortness of breath, especially with activity, and a cough, which is non-productive. Symptoms have been present for 1 year, and they are getting worse. He initially went to the cardiologist for heart concerns, but no cardiovascular disease was found. A chest X-ray was ordered, and the patient reports it showed no masses in his chest. The patient denies any other symptoms, including fever, chills, night sweats, chest pain, and weight loss. The patient is a retired salesman; he fishes as a hobby. He lives at home with his wife; he denies use of tobacco, alcohol, and drugs. He denies any out of the country travel. On physical exam, the patient sits comfortably with normal respiratory effort. Auscultation of his lungs reveals fine crackles in both bases. A dry cough is noted a few times. Cardiovascular exam, including heart and extremities, is normal, except for clubbing of the fingers bilaterally. What test is most appropriate in evaluation of this patient's condition?
High-resolution computed tomography (CT)
72-year-old man is evaluated at his bedside following hospital admission for a 1-year history of progressive dyspnea, nonproductive cough, weight loss, low-grade fevers, fatigue, and myalgias. Past medical history is remarkable for atrial fibrillation (for which he takes amiodarone), hypercholesterolemia, and recurrent urinary tract infections. He is currently on nitrofurantoin on a chronic prophylactic basis. He denies cigarette use. He denies chills, fatigue, rhinitis, otalgia, chest pain, wheezing, hemoptysis, syncope, abdominal pain, rashes, peripheral edema, diaphoresis, arthralgias, vomiting, and urinary complaints. A bedside echocardiogram and electrocardiograms are unremarkable for abnormalities. A chest x-ray reveals peripheral reticular opacities at the lung bases and a generalized honeycombing pattern. What is the next step in the diagnosis of this patient?
High-resolution computed tomography (HRCT)
45-year-old man presents with shortness of breath on exertion. The patient also notes an occasional dry cough. The spirometry findings reveal a normal FEV1/FVC ratio, decreased FVC and decreased TLC. What is the pathologic finding most likely to be present in this setting?
Honeycomb fibrosis
50-year-old man presents with a 2-week history of not being able to see well. He is not on any medications. He has been smoking 2 packs of cigarettes a day for the past 30 years (60 pack-years). On physical examination, the right eye demonstrates ptosis and miosis, and the right side of the face is unusually dry compared to the left. No weakness is noted on the musculoskeletal exam. A chest radiograph reveals a rounded opacity in the right lung field. What is the most likely diagnosis?
Horner syndrome
50-year-old woman presents for follow-up due to emphysema. She has a 40 pack-year history of smoking. She states that her dyspnea is getting slightly worse and she has lost about 5 pounds in recent months without trying. She is sent for a chest radiograph, PFTs, and a V/Q scan. What would be expected to be seen on these test results?
Hyperinflation of the lungs, reduced DLCO, and high dead space ventilation
28-year-old man presents with acute onset of dyspnea and left-sided chest pain. He denies any trauma or previous similar problems. Chest X-ray demonstrates a visceral pleural line just under the left hilum. What left-sided finding would you expect on physical exam?
Hyperresonance to percussion
34-year-old secretary working temporarily in an office building presents with acute onset of fever, cough and dyspnea. Over the past 6 months, she has had the same problem every time she works in the office building. She is hospitalized for respiratory distress, and a transbronchial biopsy is performed. The histological findings include focal peribronchial mononuclear interstitial infiltrates with some macrophages. What condition is she most likely infected with?
Hypersensitivity pneumonitis
62-year-old man presents with a 2-month history of worsening fatigue and shortness of breath. PMH features emphysema attributable to smoking 85 packs of cigarettes per year. He reports nearly passing out while climbing stairs. He feels like his heart races. He reports chronic shortness of breath and cough, but now he feels like his dyspnea is dramatically worse; he can no longer sleep in bed. He has tried to sleep propped up in a chair. He is also experiencing fatigue. He has gained about 15 lb and notes that he can no longer lace up his shoes. He denies fever, chills, and chest pain. His cough produces some mucus, but no hemoptysis. He is in mild respiratory distress, sitting upright and leaning forward, and he uses accessory respiratory muscles to breathe. The exam is significant for reduced air movement and mild rales bilaterally in the lungs, distended neck veins, mild tachycardia with prominent P2, lower extremity edema, and right upper quadrant abdominal tenderness with hepatomegaly. Weight 212 lb Height 69" Body mass index 31.3 Pulse 108 Blood pressure 140/88 Temperature 98.2°F Pulse oximetry 88% What intervention is the most appropriate next step?
Initiate oxygen.
60-year-old man presents with a 1-month history of weakness, an inability to climb stairs, and erectile dysfunction. He is not on any medications and has no prior admissions. He has smoked 2 packs of cigarettes a day for the past 45 years. Noted abnormalities on examination include strength in his shoulder as well as in his pelvic girdle muscles at only a 2/5. All deep tendon reflexes are significantly decreased. What is the most likely diagnosis?
Lambert-Eaton myasthenic syndrome
47-year-old man presents with persistent chills following a recent upper respiratory tract infection. The patient reports cough with the production of yellowish sputum and myalgia. The patient is febrile (37.9C) with a HR of 94 bpm and a respiratory rate of 24/min. Knowing that the patient has had a prolonged exposure to the air-conditioned space in a large office building, what may be the causative microbial agent in this case?
Legionella pneumophila
A 40-year-old man presents with a cough with productive sputum. A chest X-ray reveals a 4 cm mass lesion with air fluid levels in the middle lobe of the right lung. On the basis of the radiological findings, what is the most likely diagnosis?
Lung abscess
69-year-old man presents with a 7 - 10 day history of increasing dyspnea and inspiratory chest pain. He has a 2-pack-per-day smoking history and abuses alcohol. He has hypertension, diabetes, coronary artery disease, and chronic kidney disease. He was discharged from the hospital 2-1/2 weeks ago; he was diagnosed with congestive heart failure after presenting with similar symptoms. The patient's breathing appears labored; there are diminished breath sounds on auscultation and dullness to percussion in the lower 1/2 of the lung fields, bilaterally. A chest X-ray reveals bilateral moderate pleural effusions. Thoracentesis reveals pleural fluid with the following characteristics: (1) turbid in appearance; (2) 2500 white blood cells/microliter; (3) glucose equal to serum levels; (4) ratio of pleural fluid protein to serum protein of 0.75; and (5) ratio of pleural fluid LDH to serum LDH of 0.72. Based on the information above, what is the most likely etiology of the pleural effusions?
Malignancy
50-year-old man presents with dyspnea. The chest radiograph shows a large right pleural effusion. A thoracentesis is performed; 700 cc of chylous (milky white) fluid is obtained. What is the most probable cause of this finding?
Mediastinal malignant lymphoma
72-year-old man is noted as having a 9-pound weight loss over the past few weeks. His past medical history is significant for oat cell carcinoma of the lung, without known metastases, for which he is currently undergoing treatment. The patient states that even though his wife is preparing his favorite meals, he is not hungry. What would be the best treatment option to improve his eating habits?
Megestrol acetate
40-year-old woman develops an acute renal failure, and a renal biopsy reveals crescentic glomerulonephritis. She has an antineutrophilic cytoplasmic autoantibody test that is positive. A chest X-ray shows bilateral nodular infiltrates. What pulmonary pathology is likely to be present?
Necrotizing vasculitis
55-year-old cardiac transplant recipient has recently been treated with increasing doses of immunosuppressive medications because an endomyocardial biopsy showed moderate acute rejection. Patient then developed fever and cough with left lingular consolidation seen by chest radiograph. This persists for about 6 weeks and a bronchoalveolar fistula develops. Patient's course was then complicated by headaches. CT scan of the brain revealed the presence of several brain abscesses. What organism is the most probable cause of these findings?
Nocardia asteroides
51-year-old man with a cardiac transplantation 20 days ago starts having fever for the past 5 days. He has developed an extensive pneumonia (abscess) involving the left lower lobe. A sputum Gram stain reveals normal respiratory tract flora. If he does not respond to antibiotic therapy over next 5 months, what is the most likely causative organism?
Nocardia brasiliensis
A 12-year-old boy presents with sudden onset of dyspnea with wheezing. The patient had a similar appearance a month ago. An arterial blood gas shows hypoxemia, hypercapnia, and acidosis. The chest x-ray shows clear lung fields. He is afebrile. What is the most likely accompanying laboratory finding in this case?
Numerous sputum eosinophils
Refer to the table. The findings in the chart are of a pulmonary function test in a 40-year-old woman with no significant clinical findings. She is a non-smoker. Spirometry was done and then repeated following bronchodilator (albuterol sulfate). The TLC is 83%. ABG showed PaO2 - 63mmHg, PaCO2 - 40mmHg, pH 7.36 & SaO2 92%. From the above findings, it can be concluded that the patient suffers from what condition?
Obstructive combined with restrictive lung disease
72-year-old man is evaluated at the bedside following hospital admission for a 1-year history of progressive dyspnea, non-productive cough, weight loss, low-grade fevers, fatigue, and myalgias. Past medical history is remarkable for atrial fibrillation (for which he takes amiodarone), hypercholesterolemia, and recurrent urinary tract infections (for which his urologist prescribed nitrofurantoin on a chronic prophylactic basis). He denies any cigarette use, history of murmurs or coronary artery disease, chills, fatigue, rhinitis, otalgia, chest pain, wheezing, hemoptysis, syncope, abdominal pain, rashes, peripheral edema, diaphoresis, arthralgias, vomiting, or urinary issues. Arterial blood gas analysis demonstrates PaO2 50 mm Hg and pulse oximetry SpO2 of 87%; bedside echocardiogram and electrocardiograms are unremarkable for abnormalities; chest x-ray reveals peripheral reticular opacities at the lung bases and a generalized honeycombing pattern. What treatment is the most beneficial in the management of this patient?
Oxygen
60-year- male presents to the emergency room for progressive shortness of breath and a productive cough. He has been a heavy smoker for the past 40 years and states his cough is worsening each day with about 1/2 cup of sputum production. He was hospitalized 3 times in the past year for pneumonia. He is currently on 5 mg salbutamol, 250-mcg ipratropium 4 hourly by nebulizer, slow-release theophylline 300-mg b.i.d., and prednisolone 10 mg daily.On examination, the patient appears tired, T 100.5°F, P 100/m, BP 110/70 mm Hg, RR 25/min, SpO2 89% on room air. Chest x-ray shows consolidation and features of chronic bronchitis. Immediate treatment of this patient should include which of the following?
Parenteral antibiotic
The accompanying graphs show expiratory flow-volume loops of a normal subject and 3 patients with different pulmonary dysfunctions. (Assume all data were obtained through identical test methods.) An upper airway obstruction probably exists in what patient?
Patient B
55-year-old woman was diagnosed with small cell cancer of the lung 2 months ago; she now presents with increasing dysphagia, respiratory difficulties, and weakness of the upper limb. Her vital signs are pulse 85/min, BP 120/90 mm Hg, resp. 12/min, and temp. 37.7° C. On examination, she has ptosis of both eyes, and she reports diplopia. Her pupillary responses are normal. The strength in the muscles of her arm on testing is 2/5; on repeated testing, the strength improves to 4/5. Sensation is intact in both upper limbs. Of the following treatments, what would be most effective in treating the patient's symptoms?
Plasmapheresis
65-year-old woman with lung cancer presents with dyspnea. Her dyspnea started 2 days ago and has become gradually worse. She does not have any abnormal acute physical sign. She is having panic attacks, and she has also had episodes of anxiety. What is the most likely cause of her dyspnea?
Pleural effusion
31-year-old HIV positive Caucasian man presents with a 4-month history of nocturnal fever and sweats, pleuritic chest pain, nonproductive cough, and shortness of breath. During this time, he had lost more than 6 kilograms in weight. Symptoms started a couple of days after he was admitted unconsciousness to ED because of heroin overdose, when the attending physician also registered bruises on his face, limbs, and chest and signs of "pocket shot" (attempted intravenous injections in the supraclavicular fossa). Physical examination reveals decreased breath sound in the right hemi-thorax in an underweight patient. A chest X-ray shows right-sided pleural effusion. Routine laboratory findings are normal. Thoracentesis obtained cloudy fluid, specific gravity 1025 (elevated), with 3200 cells per cubic millimeter (80% mononuclear); 6,0 gr/dl proteins and 230 UI/dl LDH (both elevated), with fluid/serum ratio for proteins and LDH both elevated. The adenosine deaminase (ADA) in the pleural fluid is 51 U/L (elevated). What is the most probable diagnosis?
Pleural tuberculosis
19-year-old Caucasian man has come to see you as the last patient of the day. He presents with sudden onset of severe shortness of breath. He states that he has been an avid basketball player all his life and was practicing about 4 hours prior to his visit when he experienced sudden chest pain and immediate shortness of breath that is still bothering him currently. He describes the chest pain in the middle of the chest, more so on the right anterior side. The patient admits to smoking half a pack of cigarettes daily. Physical examination reveals a tall, thin, well-developed man in mild distress. The only other abnormalities discovered are mild tachycardia (120 beats per minute) and diminished breath sounds in the posterior right lower lobe. Based upon the examination so far, what is the most likely diagnosis?
Pneumothorax
30-year-old man is a known COPD patient; he wakes at night with a sudden feeling of tightness on the left side of the chest, which is aggravated on deep breathing. Patient feels breathless and is cyanotic. On examination in the ER, there is expansion of only the right side of the chest. There is decrease in the breath sounds on the affected side. Chest X-ray shows mediastinal shift and deflated lung with translucency between this and the chest wall with no lung markings. What is the most likely diagnosis?
Pneumothorax
77-year-old man presents to the ED with shortness of breath and left-sided chest pain. Medical history is significant for diabetes, GERD, COPD, and hypercholesterolemia. He had been in his usual state of health until about 24 hours ago. He has no history of surgery or trauma, but he was hospitalized overnight 1 year ago with chest pain; his symptoms were determined to be secondary to an esophageal spasm. On examination, the man appears to be tachypneic and extremely weak. He has decreased left-side breath sounds and is tachycardic. Pulse oximetry reveals oxygen saturation 80%. ECG shows no significant findings. He is started on oxygen and admitted. Blood pressure 100/64 mm Hg, pulse 120/min, respiratory rate 20 per minute, temperature 97.6°F. A chest radiograph is significant for a small collection of gas in the left apex. What is the most likely diagnosis?
Pneumothorax
72-year-old man presents with an 8-month history of progressive dyspnea accompanied by a dry and persistent hacking cough. The dyspnea now occurs at rest. He denies fever, chills, palpitations, chest pain, or peripheral edema. He states that he has worked for many years at a local chemical plant. Physical exam is remarkable for digital cyanosis and clubbing. Pulmonary exam reveals diffuse fine dry inspiratory crackles. Cardiac exam is positive for a prominent pulmonary valve closure sound (P2) and an elevated jugular venous pressure of 6 cm. A chest x-ray notes small lung volumes, with increased densities in the lung periphery and a honeycombing pattern; pulmonary function testing measured reductions in TLC, FEV1, and FVC with a preserved FEV1/FVC ratio. What is the best treatment for this patient?
Prednisone
25-year-old male is brought to the hospital after a vehicular accident. He is intubated and placed on a ventilator. He becomes progressively difficult to oxygenate despite increasing the PEEP and the oxygen supply to 100%. Patient remains afebrile. He dies several days later. At autopsy, the lungs show diffuse hyaline membranes in the alveoli, thickened alveolar walls and many alveolar macrophages but few neutrophils. These findings suggest that the patient suffered from diffuse alveolar damage. Which of the following best typifies the second stage of diffuse alveolar damage?
Proliferation of type II pneumocytes
63-year-old man who is 2 days status post left total hip replacement begins to report chest pain. The pain is worse with deep inspiration, and it is associated with dyspnea. His heart rate and respiratory rate are both elevated. EKG is significant for sinus tachycardia. What method is the gold standard for diagnosing the patient's suspected condition?
Pulmonary angiography
60-year-old man presents with shortness of breath, wheezing, and a feeling of tightness in the chest. He is a non-smoker with no past history of asthma. ECG reveals myocardial ischemia. The patient is anxious and tachypneic. Blood pressure is elevated. Chest sounds reveal rales and rhonchi. There is wheezing and pink frothy sputum. Heart sounds reveal S3 gallop. Chest X-ray shows increased vascularity bilaterally and distended pulmonary artery. On the basis of the above clinical picture, what is the most likely diagnosis?
Pulmonary edema
26-year-old woman presents with a history of asthma; it was diagnosed 1 month ago by her primary care physician. She is obese, a non-smoker, and she is 8 weeks postpartum, She denies any upper respiratory tract infection. She has had 3 - 4 ER visits over the last month. She is on β2 agonists, corticosteroid and prednisolone 60mg/day. Her asthma is not controlled thoroughly. She awakens 3 - 4 times at night to use her inhaler. She has been experiencing wheezing for 12 hours. Her BP is 160/80 mm Hg, P 120/min, and T 99F. Pulse oximetry on room air is 72%. PFR is 36% of predicted. She has staccato speech, mild central cyanosis. She is using her accessory muscles and is not agitated. On auscultation, she has a loud S1, and inspiratory wheeze is greater than expiratory wheeze. She has edema of the feet; it only goes up to the knees. What is the most likely diagnosis?
Pulmonary embolism
33-year-old African American woman with no significant past medical history, who is in her 38th week of a normal pregnancy, presents with a 1-hour history of shortness of breath. She does not recall any precipitating activities or events that may have provoked these symptoms and recalls that she was laying in her bed for several hours since waking when the symptoms developed. She admits to an associated sharp, non-radiating pleuritic chest pain, as well as lower extremity swelling, which she states has been "persistent throughout the course of her pregnancy." She denies palpitations, chest pressure, cough, sputum, fever, chills, changes in weight, rashes, diaphoresis, abdominal pain, nausea, or a history of allergies. Her physical exam is noteworthy for tachypnea and tachycardia, but the rest of the vital signs are normal. Her lungs are clear to auscultation bilaterally, without wheezing, rhonchi, or crackles. Her lower extremities are remarkable for 2+ pitting edema up to the level of her knees; there is no calf tenderness, venous cords, or Homan's sign appreciated. Her skin and mucous membranes were without diaphoresis or cyanosis. A bedside EKG reveals sinus tachycardia at 120 bpm with prominent S waves in lead I and Q waves in lead III. What is the most likely diagnosis?
Pulmonary embolism
60-year-old man is operated on for a nephrectomy for renal cell carcinoma. He had a prolonged postoperative stay in the intensive care unit (ICU) due to postoperative bleeding requiring transfusion and fluid resuscitation. On the tenth postoperative day, the patient ambulates unassisted for the first time and goes to use the bathroom. Upon returning to the bed, he suddenly becomes extremely dyspneic and diaphoretic. What do you suspect has happened?
Pulmonary embolism
A patient recovering from hip surgery begins to ambulate for the first time about 2 hours postoperatively. Suddenly, they experience shortness of breath. The patient becomes tachypneic and tachycardic and experiences pain on inspiration. Prior to getting out of bed, their postoperative course was unremarkable. There is no swelling; there is no palpable thrill at the incision site. What is your initial diagnosis?
Pulmonary embolism
44-year-old healthy man, who is a non-smoker, has a 3-cm coin lesion in the right upper lobe. The lesion was revealed on his chest radiograph. The patient did not have any clinical symptoms. The fine-needle aspiration did not reveal any cells. What is the most likely tumor in this case?
Pulmonary hamartoma
55-year-old woman has a sudden episode of pleuritic chest pain on the left side and dyspnea. The patient has just spent 20 days in the intensive care unit after a laparotomy for a perforated gallbladder complicated by the development of peritonitis. She was just moved to a unit bed. Her past medical history is significant for congestive cardiac failure. Labs reveal an elevated d-dimer. She is afebrile. What is the most likely cause of the patient's symptoms?
Pulmonary infarction
70-year-old man with type 2 diabetes mellitus, hyperlipidemia, homocysteinemia, and metabolic syndrome presents with a 5-month history of excessive daytime sleepiness, a lack of refreshing sleep, a depressed mood, and an inability to focus at work and while driving. Additionally, he has been told by his wife that he snores rather loudly while sleeping. He denies fever, chills, headache, cold intolerance, weight loss, hair changes, hoarseness, dysphagia, chest pain, edema, palpitations, or changes in his bowel habits. On physical exam, he is found to be hypertensive. He has elevated BMI with abdominal obesity, and he has an enlarged neck circumference; no other abnormalities are noted. What pathological mechanism best accounts for this patient's presentation?
Reduced inspiratory patency of the airway due to relaxation of the muscles
45-year-old woman presents with insidious onset of increasing dyspnea. A chest X-ray revealed nodular infiltrates and marked hilar lymphadenopathy. The transbronchial biopsy demonstrated non-necrotizing granulomas. What is the most likely diagnosis?
Sarcoidosis
50-year-old African American woman presents with a history of fever, weight loss, and dyspnea. The chest X-ray shows prominent hilar adenopathy and diffuse pulmonary interstitial disease. The microscopic examination of a lung biopsy does not show bacteria, viral inclusions, or fungi. What is the most likely diagnosis?
Sarcoidosis
70-year-old man presents with a history of dyspnea, productive cough, and occasional wheezing. The patient gives a history of smoking since the age of 19; he smokes about 2 packs/day. An arterial blood gas analysis shows PaO2 63.3 mm Hg, PaCO2 43 mm Hg, pH 7.4, SaO2 92% on room air, CarboxyHb 7.2%. Pulmonary function tests are as follows: FEV1 40% predicted, FEV1/FVC 55% predicted, TLC 130% predicted. There is no response to bronchodilator therapy. Chest x-ray shows lung hyperinflation and flattening of the diaphragm. Pre-bronchodilator Post-bronchodilator FVC 56 59 FEV1 31 30 FEV1/FVC 42 42 What is the most likely diagnosis?
Severe COPD
The post-mortem examination of lungs of a 50-year-old man shows multiple firm nodules; they are 1 - 8mm in size, and they are scattered throughout, but they are more confluent in the upper lobes. These nodules demonstrate the microscopic appearance of many polarized needle-shaped crystals. What is the most likely cause of the features described?
Silicosis
22-year-old woman presents with frequent sinus infections, a persistent cough productive of discolored purulent sputum, and progressive dyspnea on exertion. She also reports recurrent episodes of pneumonia, and she has been increasingly fatigued. These symptoms have evolved over several years. As a child, she had an appendectomy and surgery for bowel obstruction. What is the criterion standard for diagnosing the underlying etiology of her primary disease?
Skin sweat test
18-year-old woman presents to the Emergency Department with shortness of breath, cough, malaise, and dyspnea on exertion. Her symptoms began abruptly approximately 2 hours ago. She has no history of illness or disease and has been very healthy up until this point. Physical exam revealed a thin, ill-appearing young woman in obvious respiratory distress. Her oxygen saturation was 82%, and she had decreased breath sounds bilaterally. Vital signs are as follows: blood pressure 128/88 mm Hg; pulse 124/min; respiratory rate 26 per minute; temp 97.8 degrees Fahrenheit. What concerning the patient's probable diagnosis is true?
Smoking can increase the chance of developing this condition.
24-year-old man came to the ER presenting with sudden shortness of breath while riding his bicycle. He has never had this before. He is athletic, works as a teacher, walks 10 miles every day, and gave no history of fever or palpitation. He is a smoker, smoking 10 cigarettes per day for the last 5 years. On examination, his heart rate was 120/min, regular rhythm, and no murmurs; breath sounds are heard all over the chest except at the upper left lung where it is hardly heard, and there is a hyperresonant note on percussion. What is the most likely diagnosis?
Spontaneous pneumothorax
A thin 26-year-old woman presents with sudden onset of dyspnea, non-productive cough, and vague chest pain radiating to the left shoulder. She is a soccer player, and her symptoms initially occurred 24 hours ago during her usual 5-mile training run. PMH is unremarkable. EKG shows sinus tachycardia, 105 bpm. Respiratory rate equals 30 breaths per minute. Decreased breath sounds and hyperresonance are noted on the left thorax; otherwise, the physical exam is unremarkable. What is the most likely diagnosis?
Spontaneous pneumothorax
60-year-old man presents with worsening cough for several months; he has also experienced blood-tinged sputum for the past several weeks. He has been a chronic smoker for the past 40 years. Otherwise, he has no major health problems. In order to initiate the management of his disease, what should be done first?
Sputum cytology
60-year-old man presents with a recently experienced episode of hemoptysis and cough. Bronchoscopy reveals a mass lesion involving the left superior segmental bronchus. Cytological examination shows polygonal pink cells with dark angular nuclei and intercellular bridging. What is the most likely diagnosis?
Squamous cell carcinoma of the lung
57-year-old woman presents to the hospital with a 2-week history of feeling weak. She is an artist who has been chain smoking for 30 years. On examination, she is kempt and wasted but not dehydrated. Her BP is 116/70 mm Hg. Laboratory investigations reveal plasma sodium of 122 mEq/L with a high urine osmolality. A chest radiograph reveals a rounded opacity in the right lung field. What is the most likely diagnosis?
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
62-year-old woman presents with right-sided chest pain and shortness of breath. Her symptoms began abruptly about 2 hours ago. Her history is significant for a 30-year smoking history, but she has been relatively healthy otherwise. Examination reveals a thin, frail, ill-appearing woman in respiratory distress. She was tachypnic with decreased breath sounds on the right. A chest radiograph showed a large right-sided pneumothorax. Vital signs are as follows: blood pressure 100/66 mm Hg; pulse 126/min; respiratory rate 24 per minute; and temp 97.2 degrees Fahrenheit. What concerning the most likely diagnosis is true?
There is an increased risk in smokers.
45-year-old male presents to the emergency room with a 1-month history of a progressive cough in addition to feeling short of breath. The patient reports that he has been having blood tinged sputum for the past couple of days. After the completion of the history and physical examination, he undergoes a bedside thoracic procedure in order to determine his diagnosis. Shortly after the bedside procedure, the patient develops shortness of breath and a chest x-ray confirms a pneumothorax. The patient is admitted to the hospital for observation. Which of the following thoracic procedures is most likely the cause of the pneumothorax?
Transthoracic needle aspiration
18-year-old woman presents with chronic fatigue and menorrhagia. Menorrhagia has been present since her first menstrual cycle, but it has recently become worse; she sometimes uses 20 tampons per day. About a year ago, she started using contraceptive pills but is now considering stopping using them because of migraine-like headaches. Her headaches are sometimes so severe that she has to take aspirin or other painkillers several times a day. The rest of her past medical history is unremarkable. Physical examination reveals pale skin and mucosa, pulse rate of 100 beats per minute, and a systolic ejection murmur 1/3 intensity over the precordium. Laboratory findings include white blood count 9 K, hemoglobin 10, platelet count 250 K, normal prothrombin time, slightly prolonged partial thromboplastin time, and normal fibrinogen. Her bleeding time is prolonged. Blood smear shows microcytic hypochromic anemia. What is the most likely diagnosis?
Von Willebrand disease
50-year-old woman presents with decreased exercise tolerance, coughing, and PVCs. She is a light smoker of 10 years. You identify urticaria on the arms and cheeks. Her BP is 155/90 mm Hg, and HR is 65 bpm. CBC reveals increased Hb, lymphocytes and monocytes. PA chest X-ray shows nodules primarily in the mediastinum with some diffuse distribution. Spirometry reports indicate a restrictive pattern. Without auscultation, you are suspicious of sarcoidosis. When making your diagnosis, what other disease should you differentiate against?
Wegner's granulomatosis
