Lange Q&A Pulmonology Flashcards
A 19yo male college student presents with a 4-day history of fever, headache, sore throat, myalgia, malaise, and a non-productive cough. On exam, you note an erythematous pharynx without exudate. The lung exam is unimpressive. A CXR reveals a right-sided lower lobe patchy infiltrate. Which of the following is the most likely cause?
a) Mycoplasma pneumoniae
b) Klebsiella pneumoniae
c) Streptococcus pneumoniae
d) Staphylococcus aureus
a: Mycoplasma pneumonia often presents after days of constitutional symptoms and a nonproductive cough. Generally, the exam reveals little more than a reddened throat and rarely, bullous myringitis. Dx is made on clinical grounds. Cold agglutinins are a common confirmatory test*
A 40yo woman presents with sudden onset of cough productive of blood-speckled sputum, chest pain with cough, shaking chills, high fever, and myalgia for the last 12 hours. On exam, she appears acutely ill, is tachypneic, and is coughing. Auscultation of the chest reveals rales and CXR reveals unilateral lobar consolidation consistent with pneumonia. Which of the following is the most likely cause?
a) Mycoplasma pneumoniae
b) Streptococcus pneumoniae
c) Chlamydia pneumoniae
d) aspiration pneumonia
b: Pneumococcal pneumonia is the most common cause of pneumonia. Classically it presents with abrupt onset of fever, cough (productive of rusty sputum), and pleuritic CP. CXR usually reveals lobar consolidation.
A 3yo pt presents with sudden onset of coughing and wheezing, which began at the dinner table this evening. Vital signs are pulse 120, respirations 26, and temp 98.6F. The most likely dx is a partial obstruction secondary to tracheal foreign body. What is the next step in the management of this pt?
a) chest physiotherapy
b) intubation
c) tracheostomy
d) bronchoscopy
d: pts with obstruction of the trachea typically present with cough, wheezing, dyspnea, and/or cyanosis. In most cases, the definitive dx is made by endoscopy, and tx can be accomplished at the same time by removal of the object.
An otherwise healthy 30yo pt presents with a 3 week hx of cough and malaise. The hx reveals that prior to this episode had a URI that was tx with acetaminophen, bedrest, and fluids. The physical exam reveals a normal lung exam and no fever. The pt is coughing while in the office. The CXR is normal. What is the most effect tx for this pt?
a) clarithromycin
b) albuterol HFA
c) Flumadine
d) fluticasone
b: in pts with acute bronchitis, bronchodilators may give symptomatic relief. Studies show that bronchodilator therapy may lead to quicker resolution of cough and return to normal functioning. Antibiotics have not been shown to be effective in pts with acute bronchitis. Corticosteroid therapy and antiviral therapy are NOT appropriate for acute bronchitis.
A 32yo pt with a 3 week hx of fever, malaise, weight loss, joint pain, and dry cough presents in your office. The CXR reveals bilateral hilar adenopathy with no parenchymal abnormalities. You suspect and would like to rule out sarcoidosis. How can the definitive dx be made?
a) biopsy of the mediastinal nodes
b) perform a bronchoalveolar lavage
c) administer an intradermal purified protein derivative
d) measure serum angiotensin-converting enzyme
a: Dx is confirmed by finding well formed noncaseating granulomas in affected tissues. Because the lung is involved so commonly, the routine CXR is almost always abnormal but cannot be used as the sole criteria
What is the most common mode of transmission of the Mycobacterium tuberculosis bacteria?
a) aerosolized droplets
b) blood borne
c) transplacental
d) transdermal
a: Mycobacterium tuberculosis is most commonly transmitted from a patient with infectious pulmonary tuberculosis to other persons by droplet nuclei, which are aerosolized by coughing, sneezing, or speaking. Crowding in poorly ventilated rooms is one of the most important factors in the transmission of tubercle bacilli, since it increases the intensity of a contact with a case.
A 65yo alcoholic male pt presents with the acute onset of fever, cough productive of purulent sputum, hemoptysis, CP, and SOB. On exam, he is noted to be confused and hypotensive. CXR shows bilateral infiltrates and cavitations. Sputum smear reveals gram-neg rods. Which of the following is the most likely cause of this pneumonia?
a) Pneumocytstis jiroveci
b) Mycoplasma pneumoniae
c) Chamydia pneumoniae
d) Klebsiella pneumoniae
d: Klebsiella pneumoniae is the most likely cause. It is common, along with other gram-neg bacilli, in alcoholic and in debilitated pts. It typically causes the acute onset of cough, CP, and SOB. Cavitation are likely to be seen in pneumonias caused by Klebsiella.
What is the DOC for Mycoplasma pneumonia?
a) penicillins
b) cephalosporins
c) aminoglycosides
d) macrolides
d: Macrolides s/a erythromycin or tetracyclines are the DOC in treating Mycoplasma pneumoniae. GI intolerance is common with erythromycin. Doxycycline, azithromycin, or clarithromycin may be used as alternatives.
What is the empirical drug tx of choice for a known case of community-acquired?
a) gentamycin
b) penicillin
c) clarithromycin
d) vancomycin
c: The pneumococcus is the most common cause of community-acquired pyogenic bacterial pneumonia. The prevalence of penicillin resistant pneumococci is increasing in the U.S.; therefore, macrocodes are the class of choice and may be used in penicillin-allergic patients
A 50yo man presents with a hx of persistent cough, hemoptysis, and weight loss over the past 6 months. He has smoked 2 PPD for 30 years and also complains of shoulder and CP. On exam, he is noted to be pale, febrile, and dyspneic upon exertion. The CXR shows hillier adenopathy. What is the most likely dx?
a) asthma
b) bronchiectasis
c) bronchogenic carcinoma
d) COPD
c: The clinical manifestations of bronchogenic carcinoma can vary and is largely based on the location of the tumor and extent of disease. Anorexia, weight loss, asthenia, and cough are some of the more common clinical manifestations. CXR may demonstrate hilar adenopathy, infiltrates, or single or multiple nodules. Asthma and COPD usually reveal hyperinflation of lungs and flattened diaphragms. The medical hx is not consistent with bronchiectasis where the chest film may demonstrate dilated, thickened bronchi, scattered opacities, and atelectasis.
A 43yo woman with a hx of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal CP. On exam, she has narrow splitting of S1. Radiographic findings demonstrate peripheral “pruning” of the large pulmonary arteries. What is the most likely dx?
a) CHF
b) pericarditis
c) pulmonary embolus
d) pulmonary hypertension
d: Peripheral “pruning” of the large pulmonary arteries is characteristic of pulmonary hypertension in severe emphysema
What radiologic findings is/are most suggestive of chronic silicosis?
a) eggshell calcification of enlarged hilar lymph nodes
b) pneumothorax and atelectasis
c) large nodules that appear primarily in the lower lobes
d) pleural thickening and plaques
a: Eggshell calcification of hilar or mediastinal lymph nodes is characteristic of silicosis. The ds may also be recognized by the presence of SMALL nodules, which appear predominately in the UPPER lobes. Pneumothorax, atelectasis, and pleural thickening and plaques are NOT radiologic features of silicosis.
A 50yo pt presents with a fever of 102F, productive cough, mild CP on deep breathing and coughing, and general malaise for the last 2 days. Prior to the onset of these symptoms, the pt had a “bad cold” for 5 days. What physical finding would be most consistent with this hx?
a) vesicular breath sounds
b) decreased transmitted voice sounds
c) inspiratory crackles
d) diffuse hyperresonance
c: In a pt with pneumonia, inspiratory crackles along with bronchial breath sounds, increase tactile fremitus and transmitted voice sounds (the presence of egophony, bronchophony, and/or whispered pectoriloquy), and dullness to percussion over the involved area would be consistent findings on physical exam.
Which histological type of lung cancer has the LOWEST 5-yr survival rate?
a) bronchioalveolar
b) large cell
c) small cell
d) squamous cell
e) adenocarcinoma
c: the prognosis for each type of lung cancer varies according to the pathologic stage. However, in general, small cell lung carcinoma (SCLC) has the WORST prognosis, with the median survival period of 12-16 months with only 5% to 25% surviving 2 years, whereas pts with extensive disease have a median survival period of only 7-11 months, with only 1% to 3% surviving 2 years.
A 43yo female pt who is HIV negative is recently dx with pulmonary tuberculosis via a positive purified protein derivative (PPD) and culture. She receives annual PPD testing and prior to this test has been negative. What is the current recommended tx?
a) 3 months of isoniazid (INH), rifampin (RIF), and pyrazinamid (PZA) and ethambutol (EMB)
b) 2 months of INH, RIF, PZA, and streptomycin (SM) followed by 1 month of INH and RIF
c) 6 months of INH and RIF
d) 2 months of INH, RIF, PZA, and EMB followed by 4 months of INH and RIF
- This question is super hard and I doubt they would go in to this depth on our exam, so I figured I’d post it anyways in case anyone cares to know out of curiosity.
d: the CDC currently recommends a minimum of 6 months of INH and RIF with initial 2 months of PZA and SM or EMB for immunocompetent persons
A 35yo man who is HIV positive presents to the ED complaining of high fever, pleuritic CP, and grossly purulent sputum. Hx also reveals that he was recently at a local conference and spend most of the time indoors. The ED has seen three other pts this week with the same complaints. On exam, he is toxic appearing with a temp of 103F. The chest films demonstrate focal patchy infiltrates. What is the tx of choice.
a) doxycylcine
b) erythromycin
c) levofloxacin
d) penicillin
c: The tx of choice for immunocompromised pts with legionella infection is either azithromycin or clarithromycin, or a fluoroquinolone s/a levofloxacin. Erythromycin and doxycycline are acceptable txs for immunocompromised pts with legionella. Penicillin is ineffective against legionella.
A 19yo woman, post motor vehicle accident, is hospitalized with a femur fx. She develops sudden onset of dyspnea, cough, and anxiety with retrosternal CP. On exam, her pulse is 120, respirations 32, and BP 120/80. CXR shows mild bilateral atelectasis. ECG is normal. What is the most likely dx?
a) pulmonary thromboembolism
b) aortic dissection
c) pneumonia
d) pneumothorax
a: PE is most often caused by the embolization of thrombus from the deep veins of the lower extremities. People at risk for PE are those with hypercoagulable states, which may arise from the use of birth control pills, local stasis, immobilization that may be the results of an accident or illness, fx, obesity, CHF. Signs and symptoms often begin abruptly and include dyspnea, cough, and CP (frequently pleuritic in nature). Hemoptysis may occur; tachypnea and tachycardia are common in this illness. A low grade fever, wheezing, rales, or pleural rub are also signs of PE.
What imaging study is the “gold standard” used to confirm the dx of DVT?
a) arteriography
b) contrast venography
c) Doppler ultrasound
d) ventilation-perfusion scan
b: Contrast venography is the imaging study of choice to dx a DVT. Doppler ultrasound can be used for screening. Arteriography and V/Q scans would not be appropriate studies to dx DVT.
A 70yo pt with a long hx of COPD presents to the office for a regular office visit. The pts hx is unchanged and the physical exam is consistent with long-term hx of COPD. One of the findings is distal phalanges that are rounded and bulbous. Upon palpation, the proximal nail folds feel spongy. This finding is consistent with what condition?
a) acute dyspnea
b) chronic hypoxia
c) transient hypercapnia
d) chronic hyponatremia
b: This description is consistent with digital clubbing. It accompanies chronic hypoxia associated with conditions s/a COPD, lung cancer, HD, and cirrhosis.
What is the mainstay bronchodilator treatment for mild intermittent asthma?
a) beta-adrenergic agents
b) theophylline
c) aminophylline
d) antileukotrienes
a: Beta-adrenergic agents are the mainstay bronchodilator tx for mild asthma. Theophylline and aminophylline are bronchodilators of moderate potency and are usually reserved for pts with moderate to severe asthma. Antileukotrienes are controller meds, not bronchodilators.
What is considered the primary therapy for pts with PE who are hemodynamically unstable?
a) anticoagulation with heparin
b) anti-embolization stockings
c) insertion of an inferior vena caval filter
d) thrombolysis with tissue plasminogen activator (tPA)
d: primary therapy consists of clot dissolution with thrombolysis or removal of PE by embolectomy and is reserved for pts at high risk of death from right heart failure and for those pts at risk of recurrent PE despite adequate anticoagulation. Anticoagulation with heparin is useful to prevent further clot developmen, but it does not directly dissolve thrombi or emboli. The use of filters is considered a preventative measure, as is the recommended us of anti embolism stockings.
