AAFP: Respiratory

Question 1

Which one of the following therapeutic interventions improves outcomes in adults with ARDS?

a. Early initiation of abx
b. Surfactant therapy
c. Pulmonary artery catheterization
d. Aggressive IV fluid resuscitation
e. Starting mechanical ventilation with lower tidal volumes

Answer 1

e. Starting mechanical ventilation with lower tidal volumes

Starting mechanical ventilation with lower tidal volumes of 6 mL/kg is superior to starting with traditional tidal volumes of 10-14 mL/kg.

Question 2

A 15 y/o male has a 1 week history of nonproductive cough, a low-grade fever, a sore throat, and hoarseness. His RR is 22/min but unlabored, his temperature is 100.6 F and his O2 saturation is 94% on room air. A CXR reveals bilateral interstitial infiltrates. Which one of the following treatments would be most appropriate for this pt?

a. Ceftriaxone (Rocephin)
b. Amoxicillin
c. Cefdinir
d. Linezolid (Zyvox)
e. Azithromycin (Zithromax)

Answer 2

e. Azithromycin (Zithromax)

CAP in children over age of 5 is most commonly due to Mycoplasma pneumoniae, Chlamydia pneumonia, and Strep pneumo.

Less common bacterial infections include H. influenzae, S. aureus, and group A Strep.

Children age 5-16 years who can be treated as outpatients are usually treated with oral azithromycin. For patients requiring inpatient mgmt, IV cefuroxime + IV erythromycin or azithromycin is recommended.

Question 3

A 3 yo female is brought to your office with coughing and a tactile fever. Her only other symptom is mild rhinorrhea. She has a temperature of 100.8 F and is mildly tachypneic. Her vital signs are otherwise normal and she appears to be well and in no respiratory distress. Her exam is unremarkable except for decreased breath sounds and crackles in the RLL field. She has no allergies to meds. Which one of the following would be the most appropriate tx?

a. Amoxicillin
b. Azithromycin (Zithromax)
c. Cefdinir
d. Moxifloxacin (Avelox)
e. Ceftriaxone (Rocephin)

Answer 3

a. Amoxicillin

Recommended first-line tx for previously healthy infants and school-age children with mild to moderate CAP.

Most prominent bacterial pathogen in CAP in this age group is Strep pneumo and amoxicillin provides coverage.

Azithromycin would be appropriate choice in an older child b/c Mycoplasma pneumoniae would be more common.

Moxifloxacin should NOT be used in children.

Cefdinir and ceftriaxone can both be used to treat CAP, but they are broader spectrum abx and would not be a first-line choice in this age group.

Question 4

A 68 y/o white male with severe COPD has diminished symmetric breath sounds, +1 ankle edema, a regular heart rhythm, a loud pulmonic component of the second heart sound, and a R parasternal heave. Which one of the following interventions is most likely to be therapeutic?

a. alpha-blocker therapy
b. ACEI therapy
c. CCB therapy
d. Digoxin therapy
e. Long-term O2 therapy

Answer 4

e. Long-term O2 therapy

This patient has cor pulmonale. Patients should be assessed for chronic oxygen therapy, which has been shown to reduce hospitalization rates and mortality. Cautious diuretic therapy may be useful for symptomatic edema.

Question 5

A 67 yo male with moderate to severe COPD has had several exacerbations in the past year, one requiring hospitalization. Regular use of which one of the following long-term tx would be expected to reduce his risk for another COPD exacerbation?

a. Oral theophylline
b. Inhaled short-acting beta2 agonists
c. Inhaled long-acting beta2 agonists
d. Inhaled short-acting ipratropium bromide (Atrovent)
e. Nasal oxygen

Answer 5

c. Inhaled long-acting beta2 agonists

Regular use of inhaled, long-acting beta2 agonists, inhaled long-acting anticholinergic agents, or inhaled corticosteroids has been shown to reduce the risk of COPD exacerbations, with combinations of these agents producing additional benefit compared with monoterapy.

The other agents listed are helpful for relief of symptoms of COPD but do not reduce the incidence of exacerbations.

Question 6

A 26 y/o female has had a severe anaphylactic rxn to eggs in the past. Which one of the following influenza vaccines would be safest for her?

a. Live attenuated trivalent influenza vaccine
b. Recombinant trivalent influenza vaccine
c. Inactivated trivalent influenza vaccine
d. Inactivated quadrivalent influenza vaccine

Answer 6

b. Recombinant trivalent influenza vaccine

This is formulated w/o eggs. Live attenuated influenza vaccine comes only in a trivalent formulation. The other vaccines listed are all prepared using eggs.

Question 7

An 18 mo white female is brought to your office by her father, who states that 8 days ago, the child developed a temperature of 100 F with a mild sore throat, a runny nose, and loss of her voice. She is still symptomatic and the father is concerned about the longevity of this illness and requests abx therapy. On exam, the pt is afebrile with normal TMs, moderate mucopurulent posterior pharyngeal drainage, and a normal cardiopulmonary exam. She appears alert and active in the office, with no signs of acute distress. Which one of the following is the most appropriate mgmt at this time?

a. Reassurance and supportive care
b. Diphenhydramine (Benadryl)
c. Amoxicillin
d. Azithromycin (Zithromax)
e. Cefdinir

Answer 7

a. Reassurance and supportive care

This pt has laryngitis (a viral infection causing inflammation of the vocal cords lasting less than 3 weeks). Symptoms of laryngitis can include loss/muffling of the voice, as well as other classic sx of URI infection.

Cochrane study has shown that abx therapy does not decrease duration of laryngitis sx or hasten return of vocal patency.

Question 8

An otherwise healthy 1 yo male is brought to your office because of increased respiratory effort, wheezing, and rhinorrhea. He has no fever. On exam, he is found to have an increased RR and mild retractions. A chest film shows no foreign body or infiltrates. His O2 saturation is 94%. Mgmt should include which one of the following?

a. A trial of nebulized albuterol (AccuNeb)
b. Nebulized epinephrine (Asthmanefrin)
c. Oxygen
d. Abx
e. Corticosteroids

Answer 8

a. A trial of nebulized albuterol (AccuNeb)

This presentation is consistent with bronchiolitis, which is a response to a viral respiratory infection. AAP guidelines for bronchiolitis mgmt do NOT recommend routine use of any tx, recommending instead that the choice be based on specific needs of the child.

If the child responds to a trial of albuterol, then tx can be continued; otherwise, evidence shows no benefit.

Abx are indicated for signs of bacterial infection. Oxygen is indicated if O2 saturation is <90%. Corticosteroids have not been shown to be of benefit.

Question 9

Which one of the following immunizations is indicated for all pregnant women at any stage of pregnancy?

a. MMR
b. Varicella
c. Influenza
d. HPV

Answer 9

c. Influenza

Women are advised to avoid pregnancy for 28 days after receiving MMR or varicella vaccine. HPV vaccine is not recommended during pregnancy.

Question 10

A 54 yo male presents to your office with a 10 day hx of increasing cough. A physical exam reveals coarse crackles in the LLL. You make a dx of pneumonia. The patient’s only current medication is simvastatin (Zocor). Which one of the following is CONTRAINDICATED in this pt?

a. Amoxicillin/clavulanate (Augmentin)
b. Azithromycin (Zithromax)
c. Clarithromycin (Biaxin)
d. Doxycycline
e. Levofloxacin (Levaquin)

Answer 10

c. Clarithromycin (Biaxin)

In older adults, coprescription of clarithromycin or erythromycin with a statin that is metabolized by CYP 3A4 (atorvastatin, simvastatin, lovastatin) increases the risk of statin toxicity. The other abx listed do not interact with statins.

Question 11

According to national and international guidelines, which one of the following is the next step for adults with asthma who require therapy with inhaled beta-agonists more than 3x a week?

a. Inhaled glucocorticoids
b. Inhaled salmeterol (Serevent)
c. Sustained-release oral beta-agonists
d. Sustained-release oral theophylline

Answer 11

a. Inhaled glucocorticoids

Patients who require inhalation therapy with beta2-adrenergic-receptor agonists more than twice weekly but not daily have mild persistent asthma. Long-term control with inhaled corticosteroids is recommended for adults with persistent asthma.

Question 12

You are treating an 18 yo college freshman for allergic rhinitis. It is September, and he tells you that he has severe symptoms every autumn that impair his academic performance. He has a strongly positive family hx of atopic dermatitis. Which one of the following intranasal medications is considered optimal tx for this condition?

a. Glucocorticoids
b. Cromolyn sodium
c. Decongestants
d. Antihistamines

Answer 12

a. Glucocorticoids

Topical intranasal glucocorticoids are currently believed to be the most effacious medications for treatment of allergic rhinitis. They are far superior to oral preparations in terms of safety.

Question 13

A 32 y/o male smoker presents with a 4 day history of progressive hoarseness. He is almost unable to speak, and associated symptoms include a cough slightly productive of yellow sputum, as well as tenderness over the ethmoid sinuses. He is afebrile and has normal ear and lung examinations. His oropharynx is slightly red with no exudate, and examination of his nasal passages reveals mucosal congestion. Which one of the following would be the most appropriate treatment?

a. Amoxicillin for 10 days
b. Omeprazole (Prilosec), 40 mg daily
c. Azithromycin (Zithromax) for 5 days
d. Symptomatic tx only

Answer 13

d. Symptomatic tx only

Acute laryngitis most often is a viral etiology and symptomatic tx is therefore most appropriate. A Cochrane review concluded that abx appear to have no benefit in treating acute laryngitis.

Question 14

A heroin overdose is most likely to cause acute

a. renal failure
b. hepatic necrosis
c. MI
d. pulmonary edema
e. pelvic thrombophlebitis

Answer 14

d. pulmonary edema

Overdose is manifested by CNS depression and hypoventilation. Clinical clues include pupillary miosis and a decreasing RR in the presence of a semi-wakeful state. In addition to hypoventilation, a multifactorial acute lung injury occurs within 2-4 hours of the overdose and is associated with hypoxemia and a HSN rxn, resulting in noncardiogenic pulmonary edema. Findings include hypoxia, crackles on lung auscultation, and pink, frothy sputum.

Treatment must include respiratory support with intubation, mechanical ventilation, and oxygen, as well as opiate reversal with naloxone.

Question 15

A 52 yo white male presents for a health maintenance visit. The patient has mild osteoarthritis but is otherwise healthy. He lives at home with his wife. He drinks approximately 2 beers a week and does not smoke. He takes a multivitamin, but no other medications. What is the recommendation for immunizing this pt with pneumococcal polyvalent-23 vaccine (Pneumovax)?

Answer 15

One dose after 65

For a healthy nonsmoker with no chronic disease who is not in a high-risk group, pneumococcal vaccine is recommended once at age 65, or as soon afterward as possible.

Persons that should be immunized before age 65 include patients with chronic lung disease, cardiovascular disease, DM, chronic liver disease, CSF leaks, cochlear implants, immunocompromising conditions, or asplenia, and residents of nursing homes and long-term care facilities.

Question 16

Which one of the following is true regarding the live attenuated intranasal influenza vaccine?

a. It is preferred in all children >6 mo of age
b. It is more effective in children age 2-6 years than the inactivated vaccine
c. It is more effective in children >6 years of age than in younger children
d. It is the vaccine of choice for pregnant women

Answer 16

b. It is more effective in children age 2-6 years than the inactivated vaccine

The live attenuated intranasal influenza vaccine is recommended for healthy nonpregnant persons 2-49 years of age

The live intranasal vaccine is contraindicated in pregnancy and in patients with asthma or COPD

Patients older than 49 years should receive the inactivated vaccine

Question 17

Which one of the following is an indication for a second dose of pneumococcal polysaccharide vaccine in children?

a. a CSF leak
b. Cyanotic CHD
c. Type 1 DM
d. Sickle cell disease
e. Chronic bronchopulmonary dysplasia

Answer 17

d. Sickle cell disease

Patients with chronic illness, DM, CSF leaks, chronic bronchopulmonary dysplasia, cyanotic congenital heart disease, or cochlear implants should receive one dose of pneumococcal polysaccharide vaccine after 2 years of age, and at least 2 months after the last dose of pneumococcal conjugate vaccine. Revaccination with polysaccharide vaccine is not recommended for these patients.

Individuals with SCD, those with asplenia, immunocompromised persons with renal failure or leukemia, and HIV-infected persons should receive polysaccharide vaccine on this same schedule AND should also be revaccinated at least 3 years after the first dose.

Question 18

Which one of the following is associated with treatment of COPD with inhaled corticosteroids?

a. An increased risk of monilial vaginitis
b. An increased risk of bruising
c. Consistent improvement in FEV1
d. A decreased risk of pneumonia
e. Decreased mortality

Answer 18

b. An increased risk of bruising

Inhaled corticosteroids increase the risk of bruising, candidal infection of the oropharynx, and pneumonia. They also have the potential for increasing bone loss and fractures.

They decrease the risk of COPD exacerbations but have no benefit on mortality and do not improve FEV1 on a consistent basis.

Question 19

A 66 y/o male with known GOLD stage 3 COPD is admitted to the hospital with pneumonia. His pneumonia improves and he is discharged with home oxygen because of hypoxemia. He did not require home oxygen before this. Which one of the following would be most appropriate regarding his future use of home oxygen?

a. Reduce oxygen use to nighttime only
b. Stop oxygen when his course of abx and corticosteroids is completed
c. Reassess the need for oxygen within 3 months
d. Stop oxygen within 6 mo.
e. Continue oxygen indefinitely

Answer 19

c. Reassess the need for oxygen within 3 months

The American College of Chest Physicians and the American Thoracic Society recommend that for patients discharged on supplemental home oxygen following hospitalization for an acute illness, the prescription for home oxygen should not be renewed w/o assessing the patient for ongoing hypoxemia.

The rationale for this recommendation is that hypoxemia often resolves after recovery from an acute illness.

Question 20

A 25 y/o male presents with a 3 day history of cough, chills, and fever. The patient was previously healthy and has no chronic medical problems. He has no known drug allergies. On exam, he is alert and oriented, and has a temperature of 101.1 F, a pulse rate of 88 bpm, BP of 120/70 and RR of 16/min. O2 saturation is 98%. Auscultation of the lungs reveals no wheezing and the presence of R basilar crackles. CXR shows RLL infiltrate. There is a low rate of macrolide-resistant pneumococcus in the community. Which one of the following is the most appropriate initial mgmt of this pt?

a. Outpatient treatment with azithromycin (Zithromax)
b. Outpatient treatment with cefuroxime (Ceftin)
c. Inpatient treatment with ceftriazone (Rocephin) + azithromycin
d. Inpatient treatment with piperacillin/tazobactam (Zosyn) + levofloxacin
e. Inpatient treatment in ICU with ceftriaxone, levoflaxacin, and vancomycin

Answer 20

a. Outpatient treatment with azithromycin (Zithromax)

Pts with mild symptoms can be treated with azithromycin on outpatient basis of there is a low level of macrolide resistance in the community.

If high level of resistance, if pt has comorbidities such as DM or COPD, or there is a hx of immunosuppressing drug use, pt can still be treated as outpatient but should be treated with levofloxacin.

Pts with more severe sx, such as elevated pulse rate or RR, should be treated on inpatient basis with ceftriaxone or azithromycin.

Pts who have more severe sx along with bronchiectasis should be treated with Zosyn + levofloxacin.

Question 21

A 58 yo male with COPD presents with 5 day hx of increased dyspnea and purulent sputum production. He is afebrile. His RR is 24/min, HR 90 bpm, BP 140/80, and oxygen saturation 90% on room air. Breath sounds are equal, and diffuse bilateral rhonchi are note. He is currently using albuterol/ipratropium by metered-dose inhaler 3x a day. In addition to abx, which one of the following would be most appropriate for treating this exacerbation?

a. Single dose IM dexamethasone
b. Oral prednisone for 5 days
c. Daily inhaled fluticasone (Flovent)
d. Hospital admission for IV methylprednisolone sodium succinate (Solu-Medrol)
e. No corticosteroids at this time

Answer 21

b. Oral prednisone for 5 days

His vital signs do not indicate a serious condition at this time, so he can be treated as an outpatient. Since he is already on a reasonable dose of an inhaled bronchodilator/anticholinergic combo, he should be treated with an oral abx and oral corticosteroid. Short courses of oral corticosteroids (5-7 days) are as effective as longer ones.

Question 22

The mother of a 2 yo calls you for advice because her child has an acute cough that is keeping him awake at night. Which one of the following has been shown in a double-blind, randomized, placebo-controlled study to decrease nighttime cough and improve sleep in children with this problem?

a. Sugar water
b. Cinnamon
c. Turmeric
d. Ginger
e. Honey

Answer 22

e. Honey

A teaspoon of honey has been shown to reduce severity and frequency of coughing.

Question 23

A 19 yo female presents with a 2 week hx of sore throat and mild adenopathy. She denies fever, congestion, and cough. Her ROS is negative. Rapid tests for streptococcal infection and mononucleosis are negative. A throat swab shows Neisseria. Which one of the following is recommended for this patient?

a. Pelvic exam
b. Cervical culture or urine nucleic acid amplification testing
c. Cotreatment for Chlamydia infection
d. Test of cure in 1 month

Answer 23

c. Cotreatment for Chlamydia infection

Patients diagnosed with pharyngeal gonorrhea may be asymptomatic, or they may have oropharyngeal erythema and exudate, along with cervical lymphadenopathy. Gonorrheal pharyngitis can coexist with cervical gonorrhea. First-line tx for gonorrheal pharyngitis is ceftriaxone, 250 mg IM once.

Question 24

The preferred site for an emergency airway is:

a. Thyrohyoid membrane
b. Cricothyroid membrane
c. Immediately below the cricoid cartilage
d. Through the first and second tracheal rings

Answer 24

b. Cricothyroid membrane

Question 25

An 85 yo navy veteran presents to your office with a complaint of cough and dyspnea with exertion. He spent his entire career in ship maintenance and repair, and retired from the navy at the age of 45. His CXR shows pleural plaques. He has a 20-pack-year smoking hx, but quit at age of 39. You suspect his problem is due to occupational exposure to which one of the following?

a. Asbestos
b. Beryllium
c. Iron oxide
d. Silica
e. Uranium

Answer 25

a. Asbestos

The inhalation of asbestos fibers may lead to a number of respiratory diseases, including lung cancer, asbestosis, pleural plaques, and malignant mesothelioma. High-risk populations for asbestos exposure include individuals who worked in construction trades or as boilermakers, shipyard workers, or railroad workers, as well as U.S. Navy veterans.

Berylliosis is an occupational disease related to mining and manufacturing. Silicosis is seen in sandblasters, miners, persons who have worked with abrasives. Uranium exposure occurs after nuclear reactor leaks or blasts. Uranium compounds are also used in photography and as dyes or fixatures.

Question 26

For which one of the following respiratory infections should abx therapy be initiated immediately upon dx?

a. Bronchitis
b. Epiglottitis
c. Laryngitis
d. Rhinosinusitis
e. Tracheitis

Answer 26

b. Epiglottitis

Epiglottitis (Haemophilus influenzae type b) can produce a rapidly worsening, potentially fatal airway compromise. When epiglottitis is suspected based on findings such as hoarseness, dysphagia, stridor, drooling, fever, chills, and respiratory distress, IV abx treatment should be instituted immediately, ideally with a beta-lactam drug that exhibits activity against MRSA.

Question 27

A 2 yo female is brought to the urgent care center with fever and cough. Her symptoms started suddenly a few hours ago with a runny nose and fever to 101 F. On exam, the child is crying and has a persistent barking cough but has no stridor or significant respiratory distress. Her hungs are clear to auscultation. Her skin is warm, pink, and well perfused, and her oxygen saturation is 99% on room air. CXR is normal. Which one of the following treatments has been shown to improve outcomes for this problem?

a. Humidified air
b. Nebulized albuterol (Proventil, Ventolin)
c. Oral azithromycin (Zithromax)
d. Oral dexamethasone
e. Oxygen therapy

Answer 27

d. Oral dexamethasone

This patient presents with a typical case of mild to moderate croup. This is a viral infection that results in swelling in the larynx. The condition is usually benign and self-limiting, with the worst symptoms occurring at night. Studies have confirmed the benefits of treating croup with a single dose of either an oral or IM corticosteroid. Specifically, dexamethasone is recommended due to its 72-hour length of effect. Inhaled racemic epi has been shown to reduce the need for intubation in cases of moderate to severe croup.

Question 28

You attend the cesarean delivery of a full-term male infant with no prenatal risk factors other than breech position. The infant was received from the operating team crying and vigorous, with Apgar scores of 8 at 1 minute and 9 at 5 minutes. An hour later, the infant becomes ashen-blue in color with an O2 saturation of 82%. He is alert and tachypneic, with a HR of 140 bpm, and a normal temperature. You order supplemental oxygen. Which one of the following is the most appropriate next step in managing this pt?

a. Bag-mask ventilation with 100% oxygen
b. Endotracheal intubation
c. Prostaglandin E1 infusion
d. EKG
e. CXR and laboratory studies

Answer 28

e. CXR and laboratory studies

Cyanosis and tachypnea may be a sign of TTN, or may be the first signs of a more serious health condition. Many of the severe conditions may be ruled out through history (hyaline membrane disease is unlikely in this full-term infant) and physical exam (choanal atresia may be ruled out at the bedside). After these initial steps are taken, CXR and laboratory studies will help r/o many urgent and life-threatening conditions, such as pneumothorax, pneumonia, severe anemia, sepsis, etc.

Infusion of prostaglandin E1 should be started only if the condition is determined to be ductal dependent.

Question 29

A 6 yo male is diagnosed with acute bacterial sinusitis. He has a previous history of a rash 5 days after beginning penicillin treatment. Which one of the following medications is most appropriate for this patient?

a. Amoxicillin/clavulanate (Augmentin)
b. Trimethoprim/sulfamethoxazole (Bactrim)
c. Cefuroxime (Ceftin)
d. Doxycycline
e. Azithromycin (Zithromax)

Answer 29

c. Cefuroxime (Ceftin)

2nd or 3rd gen cephalosporin used in patients with penicillin allergy

Question 30

You see a 55 yo female for the first time. She has a 2 year hx of chronic daily cough; thick, malodorous sputum; and occasional hemoptysis. She has been treated with abx for recurrent respiratory infections, but is frustrated with her continued sx. She has never smoked. Her FEV1/FVC ratio is 60% and CT shows bronchial wall thickening and luminal dilation. The most likely dx is:

a. Emphysema
b. Bronchiectasis
c. Chronic bronchitis
d. Bronchiolitis
e. Asthma

Answer 30

b. Bronchiectasis

Bronchiectasis is an illness of the bronchi and bronchioles involving obstructive and infectious processes that injure airways and cause luminal dilation. Emphysema and chronic bronchitis, forms of COPD, also cause a decreased FEV1/FVC ratio, but the sputum is generally mucoid and luminal dilation of bronchi is not characteristically present.

Bronchiolitis is usually 2/2 RSV infection in young children.

Question 31

A 50 yo female presents to your office for evaluation of a 2 month hx of dyspnea on exertion and a nonproductive cough. She has a previous history of HTN, overactive bladder, GERD, and recurrent UTIs. Vital signs are unremarkable and she has an oxygen saturation of 94%. She has inspiratory crackles in the posterior lung bases that do not clear with coughing. Office spirometry shows that the FVC is only 80% of normal, but the FEV1/FVC ratio is 0.85. Which one of the patient’s current medications is most likely to be the cause of her problem?

a. Lisinopril (Prinivil, Zestril)
b. Omeprazole (Prilosec)
c. Solifenacin (Vesicare)
d. Nitrofurantoin (Macrodantin)

Answer 31

d. Nitrofurantoin (Macrodantin)

Interstitial lung disease is a consideration in patients with chronic dyspnea. It is often accompanied by a chronic nonproductive cough. IF the FVC is decreased and the FEV1 is normal or decreased, the ratio would be >0.7, indicating a restrictive impairment. Common offenders of medications that induce interstitial lung disease are amiodarone and nitrofurantoin, which can induce a pneumonitis.

In this patient, lisinopril might explain the cough but not the dyspnea, crackles, or abnormal spirometry.

Question 32

An 18 mo male with hx of prematurity at 36 weeks gestation but no baseline lung disease is brought to the ER with fever of 100.9 F, rhinorrhea, cough, wheezing, mild tachypnea, and an oxygen saturation of 88%. CXR reveals perihilar infiltrates, and a nasal swab is positive for RSV antigen. Which one of the following mgmt options has evidence of benefit for this pt?

a. Aerosolized ribavirin
b. Supplemental oxygen
c. IV corticosteroids
d. Macrolide abx

Answer 32

b. Supplemental oxygen

Bronchodilators, corticosteroids, and antiviral agents do not have a significant impact on symptoms or the disease course. Ribavirin is not recommended for routine use due to its expense, and potential toxicity to exposed health care workers.

Question 33

An asymptomatic 60 yo male sees you for a health maintenance visit. His PMH is significant for HTN and hyperlipidemia. His medications include chlorthalidone and atorvastatin. He smoked 2 packs of cigarettes a day for 20 years but quit 5 years ago. The physical exam is normal. Laboratory findings include a normal BMP, cholesterol level of 210, HDL level of 34, LDL level of 150, and triglyceride level of 200. Which one of the following screening tests is recommended by the USPSTF for this patient?

a. PSA
b. Bone density
c. Abdominal U/S
d. Low-dose chest CT
e. Carotid U/S

Answer 33

d. Low-dose chest CT

USPSTF recommends screening smokers for lung cancer with low-dose CT. Patients should be age 55-80 and healthy. They should be current smokers or have quit within the past 15 years, and have a 30-pack-year hx of smoking.

USPSTF recommends against PSA testing (D recommendation) for prostate cancer, as well as screening for carotid artery stenosis.

Question 34

A 70 yo male without underlying lung disease presents with a 36 hr history of fever, body aches, cough, and dyspnea. He did not receive influenza vaccine this year, and was recently exposed to his grandson who had influenza. On exam, the patient has temperature of 101.8 F, BP of 90/50 mm Hg, HR of 110 bpm, and O2 saturation of 87% on room air. A nasal swab rapid antigen test is negative, and his WBC count is 15,000/mm3 (N 4300-10,800). A viral culture is sent out. A CXR shows a large lobar pneumonia. You hospitalize the patient and initiate:

a. Ceftriaxone (Rocephin) and azithromycin (Zithromax)
b. Levofloxacin (Levaquin)
c. Oseltamivir, ceftriaxone, and azithromycin
d. Oseltamivir, ceftriaxone, azithromycin, and vacomycin (Vancocin)

Answer 34

d. Oseltamivir, ceftriaxone, azithromycin, and vacomycin (Vancocin)

This patient has pneumonia, sepsis, and suspected coinfection with influenza. Treatment should include both antiviral and antibacterial agents that include coverage against MRSA, the most common bacterial pathogen isolated from critically ill pts with coinfection.

Question 35

A 25 yo clinically healthy AA female is involved in a minor MVC. CXR reveal bilateral hilar lymphadenopathy. She has no hx of environmental exposures and has no sx. A physical exam is completely normal. Your initial workup includes a normal comprehensive metabolic panel, CBC, and urinalysis; negative TB skin test; normal EKG; normal PFTs. A transbronchial lung biopsy specimen reveals a noncaseating epithelioid granuloma. Which one of the following would be the most appropriate tx at this time?

a. Long-term high-dose systemic corticosteroids
b. Pulsed doses of systemic corticosteroids
c. Inhaled corticosteroids
d. Oral MTX weekly
e. Observation only

Answer 35

e. Observation only

Sarcoidosis is a disease of unknown cause characterized by the presence of noncaseating epithelioid granulomas; it involves many different organ systems. The lungs are commonly involved; bilateral hilar lymphadenopathy is often present and pulmonary infiltrates and fibrosis somewhat typical. When the disease is limited to asymptomatic hilar adenopathy, it is termed stage I and no tx has been shown to be beneficial. The most approrpriate mgmt of stage I patients is routine follow up.

Question 36

A 67 yo male is admitted for week-long acute exacerbation of COPD. He also has hypertension and type 2 DM. After 24 hours of IV fluids, and IV methylprednisolone, he is now tolerating oral intake. Which one of the following corticosteroid regimens is best for this patient at this time?

a. Continue IV methylprednisolone until his COPD is back to baseline, then switch to oral methylprednisolon for a 14 day total course of tx
b. Switch to oral prednisone for 14 day total course of tx, including the initial 24 hour IV tx
c. Switch to oral prednisone for 4 more days of tx
d. Use only inhaled corticosteroids by nebulizer
e. Discontinue corticosteroid tx altogether after 24 hrs

Answer 36

c. Switch to oral prednisone for 4 more days of tx

Oral therapy has been shown to be as effective as IV route in patients who can tolerate oral intake.

Question 37

An 18 mo previously healthy infant is admitted to the hospital with bronchiolitis. Pulse oximetry on admission is 92% on room air. Which one of the following should be included in the mgmt of this patient?

a. Tracheal suction to clear the lower airways
b. Nasal suction to clear the upper airway
c. Chest physiotherapy
d. Corticosteroids
e. Azithromycin (Zithromax)

Answer 37

b. Nasal suction to clear the upper airway

Oxygen is recommended for infants with a persistent oxygen saturation <90%.

Question 38

A 67 yo male presents with persistent, intermittent cough. He says that his exercise tolerance has decreased, nothing that he becomes short of breath more easily while playing tennis. He smoked briefly while in college but has not smoked for over 45 years, and reports no history of known pulmonary disease. You obtain pulmonary function testing in the office to help you diagnose and manage his respiratory symptoms. His FVC and FEV1/FVC are both less than the lower limit of normal. Repeat testing following administration of a bronchodilator does not correct these values. Which one of the following would be most appropriate at this time?

a. Methacholine challenge test
b. Mannitol inhalation challenge test
c. Exercise pulmonary function testing
d. Testing for diffusing capacity of the lung for CO (DLCO)

Answer 38

d. Testing for diffusing capacity of the lung for CO (DLCO)

An FVC that falls below LLN is consistent with restrictive pattern. FEV1/FVC less than LLN is consistent with obstructive defect. A mixed pattern exists when both values are below the LLN, as in this case. The patient should now be referred for full pulmonary function testing, including DLCO which is a quantitative measure of gas transfer in the lungs. Diseases that decrease blood flow to the lungs or that damage alevoli will lead to less efficient gas exchange and result in a lower DLCO value.

Bronchoprovocation (methacholine challenge, mannitol inhalation challenge, or exercise testing) should be performed if pulmonary function test results are normal but exercise- or allergen-induced asthma is suspected.

Question 39

A healthy 24 yo male presents with a sore throat of 2 days’ duration. He reports mild congestion and a dry cough. On exam, his temperature is 99 F. His pharynx is red without exudates, and there are no anterior cervical nodes. His TMs are normal, and his chest is clear. Which one of the following would be most appropriate at this point?

a. Analgesics and supportive care only
b. Rapid strep test
c. Throat culture and empiric tx with penicillin
d. Azithromycin (Zithromax)

Answer 39

a. Analgesics and supportive care only

The most reliable clinical predictors of streptococcal pharyngitis = Centor criteria

Tonsillar exudates

Tender anterior cervical lymphadenopathy

Absence of cough

Hx of fever > 100.4

The presence of 3-4 of these criteria has a PPV 40%-60%, and the absecne of 3-4 criteria has a negative predictive value of 80%.

Patients with 4 positive criteria should be treated with abx, those with 3 positive criteria should be tested and treated if positive, and those with 0-1 positive criteria should be treated with analgesics and supportive care only.

Question 40

A 7 yo male presents with a 3 day hx of sore throat, hoarseness, fever to 100 F, and cough. Your exam reveals injection of his tonsils, no exudates, shotty lymphadenopathy, and normal breath sounds. Which one of the following would be most appropriate?

a. Symptomatic tx only
b. Empiric tx for streptococcal pharyngitis
c. Rapid antigen test for streptococcal pharyngitis
d. Throat culture for streptococcal pharyngitis
e. Office test for mononucleosis

Answer 40

a. Symptomatic tx only

Pharyngitis is a common complaint, and usually has a viral cause. The key factors in diagnosing streptococcal pharyngitis are a fever over 100.4 F, tonsillar exudates, anterior cervical lymphadenopathy, and absence of cough. The scenario described is consistent with a viral infection, with no risk factors to make streptococcal infection likely; therefore, this patient should be offered symptomatic tx only.

Question 41

A 55 yo male has a 3 mo hx of chronic SOB and dyspnea on exertion. His physical exam is unremarkable except for 1+ ankle edema bilaterally and a soft systolic murmur. A stress echo is normal. Pulmonary function tests are normal except for a low diffusing capacity of the lung for CO (DLCO). Which one of the following conditions should be considered in this patient?

a. Chronic pulmonary thromboembolism
b. Emphysema
c. Interstitial lung disease
d. Asthma
e. Hypersensitivity pneumonitis

Answer 41

a. Chronic pulmonary thromboembolism

Reduced DLCO values are seen with severe interstitial fibrosis or when the capillary surface has been compromised by vascular obstruction (pulmonary embolism) or is destroyed by emphysema.

• Interstitial lung disease and hypersensitivity pneumonitis cause low DLCO and restrictive pattern​ on PFTs.
• Chronic PE causes low DLCO w/ normal PFTs.
• Emphysema causes low DLCO and obstructive pattern on PFTs.
• Patients with asthma may have an increased DLCO with an obstructive​ pattern, that is reversible after bronchodilator administration.
  *

Question 42

Which one of the following has been shown to have a beneficial effect for symptoms of the common cold in an adult?

a. Diphenhydramine (Benadryl)
b. Ipratropium (Atrovent) nasal spray
c. Intranasal zinc
d. Intranasal corticosteroids
e. Systemic corticosteroids

Answer 42

b. Ipratropium (Atrovent) nasal spray

Ipratropium is the only nasally inhaled anticholinergic recommended by the American College of Chest Physicians for a cough caused by the common cold.

Antihistamine monotherapy (either sedating or nonsedating) such as Benadryl was no more effective than placebo.

Question 43

An obese 10 yo male with tonsillar hypertrophy is brought to your office because of snoring. There is no history of recent or past visits for tonsillitis. Polysomnography shows moderate obstructive sleep apnea syndrome. Which one of the following is the treatment of choice for this patient?

a. Continuous positive airway pressure (CPAP)
b. Intranasal corticosteroids
c. Extended antibiotic therapy
d. Adenotonsillectomy

Answer 43

d. Adenotonsillectomy

Childhood obstructive sleep apnea syndrome has a prevalence rate of 5.7%. It is associated with growth, CV, and neurobehavioral abnormalities. Adenotonsillectomy = treatment of choice. Although CPAP can be effective, compliance is poor and it is therefore not a first-line treatment. Intranasal corticosteroids may also be helpful, but the benefit appears small.

Question 44

A 12 yo female is brought to the ED with an asthma exacerbation. Which one of the following indicates that her exacerbation may be life threatening?

a. A past need for systemic corticosteroids
b. Inspiratory and expiratory wheezing in both lung fields
c. Paradoxical chest movement
d. A PaCO2 < 35 mm Hg
e. An FEV1 that is 60% of expected after initial tx in the ED

Answer 44

c. Paradoxical chest movement

Signs that an asthma exacerbation may be life threatening include altered mental status, absence of wheezing, and paradoxical chest or abdominal movement.

A PaCO2 > 42 mm Hg may indicate impending respiratory failure; levels < 40 mm Hg would be expected with hyperventilation of any cause. An FEV1 < 40% expected, especially after initial treatment in the ED, is an indication for admission. Systemic corticosteroids are frequently used for even moderate asthma exacerbations.

Question 45

What are the three basic categories of restrictive lung disease?

Answer 45

Intrinsic lung disease, chest wall deformities, and neuromuscular disorders

Question 46

A 22 yo female kindergarten teacher comes to your office for evaluation of a cough she has had for 2 weeks. The preceding week, she had symptoms of rhinorrhea, mild malaise, low-grade fever, and lacrimation. She reports that episodes of coughing are so severe that vomiting is induced. She was evaluated at a walk-in clinic 1 week ago and was diagnosed with bronchitis. Treatment with hydrocodone cough syrup and amoxicillin has not helped. On exam, she has mild rhinorrhea and injected conjunctivae, but her lungs are clear. CXR is normal and her laboratory results reveal a mild lymphocytosis. Which one of the following is the most appropriate next step in the mgmt of this patient?

a. Corticosteroid therapy
b. Sputum culture
c. Nasopharyngeal culture and PCR testing
d. Direct fluorescent antibody testing
e. Serologic testing

Answer 46

c. Nasopharyngeal culture and PCR testing

Whooping cough has reemerged over the past few years. The initial catarrhal stage is manifested by nonspecific symptoms similar to those of a viral upper respiratory illness. This stage is usually 1-2 weeks in duration, and the patient is highly contagious. The paroxysmal stage is manifested by severe coughing spells that occur in paroxysms and may be followed by the inspiratory whoop (much more likely in children). Post-tussive emesis is another classic sign.

The CDC recommends both a nasopharyngeal culture and PCR testing to confirm the diagnosis.

Question 47

A 30 yo female presents to your office with a clear nasal discharge, sneezing, nasal congestion, and nasal itching. She notes that these symptoms generally occur in the spring and fall. The most effective drug for treatment and prevention is:

a. Cetirizine (Zyrtec)
b. Cromolyn nasal spray (NasalCrom)
c. Ipratropium nasal spray (Atrovent)
d. Fluticasone nasal spray (Flonase)

Answer 47

d. Fluticasone nasal spray (Flonase)

The initial tx of mild to moderate allergic rhinitis should be an intranasal corticosteroid alone.

Question 48

An 80 yo male nonsmoker with Parkinson’s disease is treated for CAP with azithromycin (Zithromax), 500 mg/day for 10 days. On follow-up, the patient feels better but still has a productive cough. A repeat CXR reveals a single thin-walled cavity lesion in the LLL. It would be most appropriate to replace this patient’s azithromycin with:

a. Doxycycline
b. Clindamycin (Cleocin)
c. Metronidazole (Flagyl)
d. Trimethoprim/sulfamethoxazole (Bactrim, Septra)

Answer 48

b. Clindamycin (Cleocin)

This patient most likely has an anaerobic bacterial infection. Penicillin was used to treat these infections in the past, but because of the emergence of beta-lactamase-producing organisms, clindamycin is now the drug of choice. Clindamycin has broader coverage against both pulmonary anaerobes and facultative aerobes such as Staphylococcus aureus and Klebsiella, which are often seen with lung abscesses.

Metronidazole has anaerobic coverage, but not for the anaerobic species often involve in pulmonary infections, and is therefore associated with a high failure rate when used to treat lung abscesses.

Doxycycline does not cover anaerobes.

TMX/SMP is also not considered a good anaerobic abx.

Question 49

Which one of the following is recommended in all patients with croup, including those with mild disease?

Answer 49

Oral dexamethasone as a single dose (0.15-0.60 mg/kg)

Question 50

A 63 yo female with corticosteroid-dependent COPD has developed pneumonia. Which one of the following pathogens should the abx regimen cover in this patient that would be unlikely in someone with pneumonia and otherwise healthy lungs?

a. S. pneumo
b. Mycoplasma pneumo
c. H. influenza
d. Staph aureus
e. Pseudomonas

Answer 50

e. Pseudomonas

All of the pathogens listed can cause pneumonia in any patient. However, in patients with chronic lung disease who are taking corticosteroids, Pseudomonas is more common that in those with otherwise healthy lungs.

Question 51

A 40 yo male respiratory therapist presents for a health exam prior to hospital employment. His history indicates that as a child, he lived on a farm in Iowa. His exam is unremarkable, but a CXR shows that both lung fields have BB-sized calcifications in a milary pattern. No other findings are noted. A PPD skin test is negative. The findings in this patient are most likely a result of:

a. HIV infection
b. Histoplasmosis
c. Coccidioidomycosis
d. TB
e. Cryptococcosis

Answer 51

b. Histoplasmosis

Asymptomatic patients in excellent health often present with this characteristic chest radiograph pattern, which is usually due to histoplasmosis infection, especially if the patient has been in the midwestern U.S. Exposure to bird or bat excrement is a common cause, and treatment is usually not needed.

Miliary TB is a remote possibility despite negative PPD.

Question 52

A 20 yo male with a history of exercise-induced bronchoconstriction presents to your office with a complaint of cough and decreasing performance when he runs. He is training for a marathon and is currently running 30 miles/week, but has noted that his times have been worsening and that he is using his albuterol inhaler (Proventil, Ventolin) as needed for symptom relief 5 days a week. Which one of the following is the best regimen for treatment of this condition?

a. Inhaled albuterol before he runs
b. A daily low-dose inhaled corticosteroid
c. A daily inhaleed long-acting beta2-agonist
d. A daily low-dose oral corticosteroid

Answer 52

b. A daily low-dose inhaled corticosteroid

An inhaled daily low-dose corticosteroid + occasional use of as-needed inhaled albuterol is the best regimen for the treatment of exercised-induced bronchospasm.

Daily use of SABA can lead to overuse and tolerance.

Question 53

A healthy 68 yo male is seen in December for a routine exam. A review of his immunizations indicates that he received a standard dose of inactivated influenza vaccine at the health clinic in September. He received 23-valent pneumococcal vaccine (Pneumovax 23) at age 65. He should now receive which one of the following?

a. High-dose influenza vaccine
b. 13-valent pneumococcal conjugate vaccine (Prevnar 13)
c. 23-valent pneumococcal vaccine
d. No vaccines at this time

Answer 53

b. 13-valent pneumococcal conjugate vaccine (Prevnar 13)

Advised that the 13-valent pneumococcal vaccine be given in addition to the 23-valent vaccine, preferably before the 23-valent vaccine

Question 54

A 57 yo male presents to the ED complaining of dyspnea, cough, and pleuritic chest pain. A CXR shows a large left-sided pleural effusion. Thoracentesis shows a pleural fluid protein to serum protein ratio of 0.7 and a pleural fluid LDH to serum LDH ratio of 0.8. Which one of the following causes of pleural effusion would be most consistent with these findings?

a. Cirrhosis
b. HF
c. Nephrotic syndrome
d. Pulmonary embolism
e. SVC obstruction

Answer 54

d. Pulmonary embolism

Light’s criteria (pleural fluid protein to serum protein ratio > 0.5, pleural fluid LDH to serum LDH ratio > 0.6 and/or pleural LDH >0.67 times the upper limit of normal for serum LDH) are 99.5% sensitive for diagnosing exudative effusions and differentiate exudative from transudative effusions in 93-95% of cases.

Of the listed pleural effusion etiologies, only PE is exudative. The remainder are all transudative.