pneumonia Flashcards
A 68-year-old man presents with acute onset fever, productive cough, and pleuritic chest pain. On physical exam, his lung auscultation reveals bronchial breath sounds with increased tactile fremitus and dull percussion over the right lower lobe. Which stage of pneumonia does his presentation most likely represent?
A) Initial Stage
B) Red Hepatization
C) Gray Hepatization
D) Resolution
Answer: B) Red Hepatization
Rationale: The red hepatization stage is marked by consolidation due to proteinaceous exudate and red blood cells entering the alveoli, which correlates with the physical exam findings of increased tactile fremitus and dull percussion.
A patient develops pneumonia 72 hours after being admitted to the hospital and while on mechanical ventilation. What is the most likely classification of his pneumonia?
A) Community-Acquired Pneumonia (CAP)
B) Hospital-Acquired Pneumonia (HAP)
C) Ventilator-Associated Pneumonia (VAP)
D) Aspiration Pneumonia
Answer: C) Ventilator-Associated Pneumonia (VAP)
Rationale: Pneumonia that develops in a patient on mechanical ventilation is classified as VAP.
A 52-year-old woman presents with signs of pneumonia. Her laboratory studies show elevated CRP and procalcitonin levels. To identify the specific bacterial pathogen, which diagnostic test should be performed next?
A) Sputum Gram stain & culture
B) PCR testing
C) Blood culture
D) CT scan
Answer: A) Sputum Gram stain & culture
Rationale: Sputum Gram stain and culture are standard for isolating the pathogen responsible for pneumonia, especially in a bacterial etiology.
A 60-year-old patient with a history of chronic obstructive pulmonary disease (COPD) presents with community-acquired pneumonia. Given his comorbidities and increased risk for antibiotic resistance, which initial outpatient antibiotic regimen is most appropriate?
A) Amoxicillin alone
B) A macrolide alone
C) Amoxicillin-clavulanate plus a macrolide
D) Respiratory fluoroquinolone alone
Answer: C) Amoxicillin-clavulanate plus a macrolide
Rationale: In patients with risk factors for antibiotic resistance (e.g., COPD), combining a beta-lactam (like amoxicillin-clavulanate) with a macrolide is recommended.
A patient with pneumonia experiences severe hypoxemia that does not improve with supplemental oxygen. Which pathophysiological mechanism is most likely responsible for this finding?
A) Dead space ventilation
B) Intrapulmonary shunting
C) Bronchospasm
D) Increased secretions
Answer: B) Intrapulmonary shunting
Rationale: Intrapulmonary shunting occurs when blood passes through non-ventilated areas of the lung, leading to hypoxemia that is refractory to oxygen supplementation.
During the resolution stage of pneumonia, which of the following processes predominates?
A) Neutrophilic infiltration
B) Macrophage-mediated clearance of debris
C) Red blood cell accumulation
D) Fibroblast proliferation
Answer: B) Macrophage-mediated clearance of debris
Rationale: In the resolution stage, macrophages clean up cellular debris and exudates, allowing recovery from the inflammatory process.
Which of the following best explains the decreased lung compliance seen in pneumonia?
A) Excessive alveolar ventilation
B) Accumulation of proteinaceous exudate in the alveoli
C) Increased surfactant production
D) Hyperinflation of alveolar spaces
Answer: B) Accumulation of proteinaceous exudate in the alveoli
Rationale: The presence of exudate in the alveoli reduces lung compliance by stiffening the lung parenchyma.
A hospitalized patient with pneumonia does not improve after initial treatment with a beta-lactam plus macrolide regimen. His condition suggests possible infection with resistant organisms. Which additional coverage is most appropriate at this point?
A) Add coverage for atypical pathogens
B) Add MRSA and Pseudomonas coverage
C) Increase the dose of the beta-lactam
D) Switch to doxycycline monotherapy
Answer: B) Add MRSA and Pseudomonas coverage
Rationale: In severe cases or when there is a lack of improvement, it is essential to cover for resistant organisms such as MRSA and Pseudomonas
On physical examination, a patient with pneumonia has dullness on percussion over a lobe of the lung. What does this finding most likely indicate?
A) Air trapping
B) Lung consolidation
C) Normal lung tissue
D) Pneumothorax
Answer: B) Lung consolidation
Rationale: Dullness on percussion typically indicates consolidation, which is common in pneumonia
A 40-year-old previously healthy patient is diagnosed with community-acquired pneumonia without any risk factors for antibiotic resistance. What is the most appropriate outpatient treatment?
A) Amoxicillin
B) Vancomycin
C) Cefepime
D) Piperacillin-tazobactam
Answer: A) Amoxicillin
Rationale: For a patient without comorbidities or risk factors for resistant pathogens, amoxicillin is an appropriate first-line therapy.
A 55-year-old patient develops fever, increased sputum production, and dyspnea on day 4 of hospitalization. His chest X-ray now shows a new infiltrate. Which classification best fits his pneumonia?
A) Community-Acquired Pneumonia (CAP)
B) Hospital-Acquired Pneumonia (HAP)
C) Ventilator-Associated Pneumonia (VAP)
D) Atypical pneumonia
Answer: B) Hospital-Acquired Pneumonia (HAP)
Rationale: Pneumonia developing ≥48 hours after admission is classified as HAP
In a patient with pneumonia, which laboratory markers are most useful to assess the inflammatory response?
A) D-dimer and troponin
B) CRP and procalcitonin
C) BNP and lactate
D) ESR and ALT
Answer: B) CRP and procalcitonin
Rationale: CRP and procalcitonin are key markers that reflect the severity of inflammation in pneumonia.
A 70-year-old patient with CAP is treated as an outpatient. He has no significant comorbidities. Which regimen is most appropriate?
A) Respiratory fluoroquinolone alone
B) Amoxicillin alone
C) Amoxicillin-clavulanate plus macrolide
D) Beta-lactam plus vancomycin
Answer: B) Amoxicillin alone
Rationale: In otherwise healthy patients with CAP, amoxicillin is a suitable first-line agent.
Which pathophysiological process in pneumonia contributes to severe hypoxemia that does not improve with supplemental oxygen?
A) Increased alveolar ventilation
B) Intrapulmonary shunting
C) Bronchospasm
D) Enhanced surfactant production
Answer: B) Intrapulmonary shunting
Rationale: In shunting, blood bypasses ventilated alveoli, leading to refractory hypoxemia.
During which stage of pneumonia is neutrophil predominance and fibrin deposition most prominent?
A) Initial Stage
B) Red Hepatization
C) Gray Hepatization
D) Resolution
Answer: C) Gray Hepatization
Rationale: Gray hepatization is characterized by neutrophils predominating and the deposition of fibrin in the alveoli.
A 42-year-old patient with suspected CAP undergoes diagnostic workup. Which imaging modality is the most appropriate initial test to confirm the diagnosis?
A) Chest CT scan
B) Chest X-ray
C) Ultrasound of the thorax
D) MRI of the chest
Answer: B) Chest X-ray
Rationale: Chest X-ray is the gold standard initial imaging test for diagnosing pneumonia.
In pneumonia, decreased lung compliance is primarily due to:
A) Excessive mucus production
B) Accumulation of proteinaceous exudate
C) Bronchospasm
D) Airway hyperresponsiveness
Answer: B) Accumulation of proteinaceous exudate
Rationale: The exudate in the alveoli stiffens the lung, reducing compliance.
A 65-year-old patient with pneumonia presents with tachypnea, accessory muscle use, and a tripod positioning. These signs primarily indicate:
A) Reduced lung compliance
B) Severe hypoxemia and increased work of breathing
C) Pulmonary embolism
D) Cardiac failure
Answer: B) Severe hypoxemia and increased work of breathing
Rationale: Accessory muscle use and tripod positioning are compensatory mechanisms in response to severe hypoxemia.
A patient on mechanical ventilation develops pneumonia. Which organism is most likely implicated if the patient has been ventilated for more than 48 hours?
A) Streptococcus pneumoniae
B) Pseudomonas aeruginosa
C) Mycoplasma pneumoniae
D) Chlamydophila pneumoniae
Answer: B) Pseudomonas aeruginosa
Rationale: VAP is often associated with resistant gram-negative bacteria like Pseudomonas, especially after prolonged ventilation.
For a patient with CAP and risk factors for antibiotic resistance, which alternative antibiotic regimen is recommended?
A) Amoxicillin alone
B) Macrolide monotherapy
C) Amoxicillin-clavulanate or a cephalosporin plus a macrolide
D) Doxycycline alone
Answer: C) Amoxicillin-clavulanate or a cephalosporin plus a macrolide
Rationale: This combination provides broader coverage for resistant pathogens in patients with risk factors.
A patient with HAP does not respond to initial therapy with a beta-lactam plus a macrolide. What additional antimicrobial coverage should be considered?
A) Increased beta-lactam dosage
B) Add MRSA and Pseudomonas coverage
C) Switch to doxycycline
D) Add an antifungal agent
Answer: B) Add MRSA and Pseudomonas coverage
Rationale: In nonresponsive HAP cases, resistant organisms such as MRSA and Pseudomonas must be covered.
Which physical exam finding is most indicative of lung consolidation in a patient with pneumonia?
A) Hyper-resonant percussion
B) Dullness to percussion
C) Wheezing
D) Stridor
Answer: B) Dullness to percussion
Rationale: Dull or flat percussion indicates the presence of consolidation.
In the resolution stage of pneumonia, which cell type is most responsible for clearing debris?
A) Neutrophils
B) Lymphocytes
C) Macrophages
D) Eosinophils
Answer: C) Macrophages
Rationale: Macrophages are essential for phagocytizing debris and resolving inflammation.
A patient with CAP presents with pleuritic chest pain and cough productive of purulent sputum. Which diagnostic test is least likely to contribute to identifying the etiology of his pneumonia?
A) Sputum Gram stain
B) Blood culture
C) PCR testing for viral pathogens
D) Echocardiography
Answer: D) Echocardiography
Rationale: Echocardiography is not typically used to diagnose pneumonia.
Which of the following best describes the role of micro-aspiration in the development of pneumonia?
A) It increases lung compliance
B) It introduces pathogens into the alveoli
C) It promotes the formation of surfactant
D) It decreases the inflammatory response
Answer: B) It introduces pathogens into the alveoli
Rationale: Micro-aspiration allows bacteria from the oropharynx to enter the lungs, leading to infection.
A 58-year-old patient with pneumonia shows tachycardia and increased respiratory drive. What underlying mechanism is most responsible for these signs?
A) Hypercarbia due to alveolar hypoventilation
B) Increased secretion of surfactant
C) Severe hypoxemia triggering compensatory responses
D) Bronchospasm causing airway obstruction
Answer: C) Severe hypoxemia triggering compensatory responses
Rationale: Hypoxemia increases respiratory drive and heart rate as the body attempts to improve oxygen delivery.
Which of the following is a primary function of the lung microbiota in preventing pneumonia?
A) Directly producing antibiotics
B) Inhibiting colonization of pathogenic bacteria
C) Increasing lung compliance
D) Promoting alveolar fluid accumulation
Answer: B) Inhibiting colonization of pathogenic bacteria
Rationale: A healthy lung microbiota competes with potential pathogens, reducing the risk of infection.
In a patient with pneumonia, which finding on physical examination suggests the presence of a pleural effusion?
A) Increased tactile fremitus
B) Dullness to percussion with decreased breath sounds
C) Hyperresonance
D) Bronchial breath sounds
Answer: B) Dullness to percussion with decreased breath sounds
Rationale: A pleural effusion produces dullness on percussion and diminished breath sounds.
Which of the following best explains why pneumonia can lead to decreased lung volumes?
A) Hyperinflation of the alveoli
B) Compression of lung tissue by inflammatory exudate
C) Excessive alveolar ventilation
D) Increased lung elasticity
Answer: B) Compression of lung tissue by inflammatory exudate
Rationale: Inflammatory exudate fills the alveoli, reducing the effective lung volume and compliance.
A patient with CAP presents with shortness of breath and cough. His exam reveals crackles and a pleural friction rub. Which complication might these findings suggest?
A) Pulmonary embolism
B) Complicated pleural effusion
C) Asthma exacerbation
D) Myocardial infarction
Answer: B) Complicated pleural effusion
Rationale: Crackles with a pleural friction rub can indicate involvement of the pleura, possibly from a complicated effusion.
- A 68-year-old patient with cough, fever, and productive sputum is diagnosed with community-acquired pneumonia. Which organism is most common?
A. Staphylococcus aureus
B. Streptococcus pneumoniae
C. Mycoplasma pneumoniae
D. Legionella pneumophila
o Answer: B
o Rationale: Streptococcus pneumoniae is the most common cause of community-acquired pneumonia in adults.
- Which complication of pneumonia “will kill your patient” if not recognized early?
A. Pleural effusion
B. Lung abscess
C. Empyema leading to sepsis
D. Bronchitis
o Answer: C
o Rationale: Empyema with sepsis can rapidly progress to shock and death if not promptly treated.
- A patient with pneumonia develops sudden chest pain and hypotension. What complication should be immediately considered?
A. Acute bronchitis
B. Pulmonary embolism
C. Cardiac tamponade
D. Empyema
o Answer: B
o Rationale: Pneumonia increases VTE risk; a pulmonary embolism can be fatal if not managed quickly.
- Which finding is “really common” on chest X-ray in bacterial pneumonia?
A. Diffuse interstitial infiltrates
B. Focal lobar consolidation
C. Cavitary lesions in every case
D. Hyperlucent fields
o Answer: B
o Rationale: Lobar consolidation is a classic finding in bacterial pneumonia.
- In pneumonia management, what is an essential nonpharmacologic intervention?
A. Bed rest with complete immobilization
B. Chest physiotherapy
C. Aggressive fluid restriction
D. Immediate intubation for all patients
o Answer: B
o Rationale: Chest physiotherapy can help mobilize secretions, improving ventilation.
A 72-year-old patient presents with confusion, hypotension, and a productive cough. Which complication must be recognized early to prevent rapid deterioration?
A. Lung abscess
B. Parapneumonic effusion leading to empyema
C. Mild bronchitis
D. Simple atelectasis
Answer: B. Parapneumonic effusion leading to empyema
Rationale: In elderly patients, a parapneumonic effusion can quickly progress to an empyema, causing sepsis and rapid deterioration.
In community-acquired pneumonia, what is the most likely pitfall if antibiotic therapy is delayed in a patient showing signs of sepsis?
A. Spontaneous resolution
B. Improved lung function
C. Progression to septic shock
D. Transient fever only
Answer: C. Progression to septic shock
Rationale: Delaying antibiotics can allow the infection to progress, potentially leading to septic shock, which significantly increases morbidity and mortality.
Question:
Which organism is the most frequent cause of lobar pneumonia requiring hospitalization in adults?
A. Staphylococcus aureus
B. Streptococcus pneumoniae
C. Mycoplasma pneumoniae
D. Klebsiella pneumoniae
Answer: B. Streptococcus pneumoniae
Rationale: Streptococcus pneumoniae is the most common cause of bacterial pneumonia in adults, especially those requiring hospital care
A patient with pneumonia develops confusion and tachypnea, meeting criteria for severe disease. What nonpharmacologic measure is commonly implemented alongside IV antibiotics?
A. Bed rest without respiratory exercises
B. Chest physiotherapy and incentive spirometry
C. Oral diuretics
D. Immediate intubation for all patients
Answer: B. Chest physiotherapy and incentive spirometry
Rationale: These measures help mobilize secretions and improve ventilation, complementing antibiotic therapy in severe pneumonia.
A 67-year-old patient presents with community-acquired pneumonia. Their vitals are as follows: BP 82/52, HR 97, O2 97% on 2LNC. Symptoms include confusion, and you note an effusion. What is your plan of care?
A. Discharge home with PO antibiotics and primary care follow-up.
B. Admit for 23-hour observation with PO antibiotics.
C. Admit to a medical floor with IV antibiotics and fluids.
D. Admit to critical care with IV antibiotics and fluids.
D. Admit to critical care with IV antibiotics and fluids.
Which antibiotic regimen is recommended for the treatment of community-acquired pneumonia (CAP) when the patient does not have comorbidities or risk factors for antibiotic resistance?
A. Penicillin VK plus vancomycin
B. Cephalosporin plus macrolide
C. Amoxicillin plus macrolide or doxycycline
D. Respiratory fluoroquinolone
C. Amoxicillin plus macrolide or doxycycline
alveolar ventilation and pulmonary capillary blood flow are not properly balanced.
V/Q mismatch
Perfect ratio: Ideal 1:1 (ventilation = perfusion), but in reality, it is approximately 0.8 due to physiological variations.
Shunting
(V/Q Ratio = 0)
shunting when ratio is Zero
Occurs when there is no ventilation in a perfused lung unit, leading to an absence of gas exchange at the alveolar-capillary interface.
Key characteristic: Does not improve with supplemental oxygen because the affected alveoli are not ventilated. Common causes: Conditions such as pneumonia, pulmonary edema, or atelectasis, where alveoli are filled with fluid or collapsed.
Dead Space Ventilation (V/Q Ratio = ∞)
Represents the volume of ventilated air that does not participate in gas exchange due to lack of perfusion.
This occurs when a portion of the lung receives air but has no corresponding blood flow to facilitate gas exchange.
Potential causes: Pulmonary embolism, severe hypotension, or conditions that obstruct pulmonary blood flow.
Key takeaway: Affected lung areas are ventilated but not perfused, leading to ineffective oxygenation
What is one of the primary mechanisms involved in the pathophysiology of pneumonia?
A. Decreased production of alveolar surfactant
B. Proliferation of pathogens at the alveolar level and the host’s response
C. Increased synthesis of lung collagen fibers
D. Direct destruction of bronchi by toxins
Correct Answer: B
Explanation: Pneumonia involves the proliferation of pathogens in the alveoli along with the host’s immune response, leading to inflammation and other changes.
Stages of Pneumonia – Initial Stage
Which of the following best describes the initial stage of pneumonia?
A. Intra-alveolar accumulation of neutrophils and fibrin deposits
B. Proteinaceous exudate formation and bacterial accumulation in the alveoli
C. Infiltration of red blood cells into the alveoli with rapid progression
D. Dominance of macrophages cleaning up debris
Correct Answer: B
Explanation: The initial stage is characterized by the formation of a proteinaceous exudate and bacterial accumulation within the alveoli.
Red and Gray Hepatization
Which statement correctly differentiates red hepatization from gray hepatization?
A. Red hepatization is characterized by the presence of neutrophils and fibrin deposits, whereas gray hepatization involves new red blood cells entering the alveoli.
B. Red hepatization occurs when there is no new red blood cell influx, while gray hepatization involves rapid red blood cell accumulation.
C. Red hepatization involves the entry of red blood cells into the alveoli with an exudate, and gray hepatization is marked by containment of the infection with neutrophils and fibrin deposits without new red blood cells.
D. Both stages are identical in presentation and do not differ significantly.
Correct Answer: C
Explanation: Red hepatization is marked by the rapid influx of red blood cells into the alveoli along with an exudate, while gray hepatization occurs later with no new red blood cell entry, and the infection becomes contained with neutrophils and fibrin deposits.
Types of Pneumonia
Which of the following is correctly paired with its definition?
A. Community-Acquired Pneumonia (CAP) – develops ≥48 hours after hospital admission
B. Hospital-Acquired Pneumonia (HAP) – associated with mechanical ventilation
C. Ventilator-Associated Pneumonia (VAP) – occurs in patients receiving mechanical ventilation
D. Community-Acquired Pneumonia (CAP) – only affects individuals in long-term care facilities
Correct Answer: C
Explanation: Ventilator-Associated Pneumonia (VAP) is the type of pneumonia associated with mechanical ventilation. Hospital-Acquired Pneumonia (HAP) develops ≥48 hours after hospital admission, while Community-Acquired Pneumonia (CAP) occurs in the community setting.
Pneumonia
Which of the following is NOT a typical consequence of pneumonia?
A. Decreased lung compliance and lung volume
B. Severe hypoxemia
C. Increased respiratory drive and secretions
D. Increased lung compliance
Correct Answer: D
Explanation: Pneumonia leads to decreased lung compliance and lung volume along with severe hypoxemia and increased respiratory drive and secretions. Increased lung compliance is not typically observed.
During the initial stage of pneumonia, which of the following processes predominates?
A. Macrophage-mediated cleanup of debris
B. Influx of red blood cells into the alveoli
C. Formation of a proteinaceous exudate with bacterial accumulation
D. Deposition of fibrin and neutrophils in the alveoli
Correct Answer: C
Explanation: In the initial stage, a proteinaceous exudate forms along with bacterial accumulation within the alveoli, setting the stage for subsequent inflammatory responses.
What is the key characteristic of the red hepatization stage in pneumonia?
A. Absence of red blood cells and predominance of neutrophils
B. Entry of red blood cells into the alveoli, leading to a red appearance
C. Complete resolution of the inflammatory process
D. Predominance of macrophages cleaning up debris
Correct Answer: B
Explanation: Red hepatization is marked by the entry of red blood cells into the alveoli along with a proteinaceous exudate, giving the lung tissue a reddish appearance
What best describes the resolution stage in the progression of pneumonia?
A. Worsening of hypoxemia and bronchospasm
B. Continuous accumulation of red blood cells and exudate
C. Dominance of macrophages that remove debris and cessation of the inflammatory process
D. Rapid influx of additional bacteria leading to an acute inflammatory response
Correct Answer: C
Explanation: During the resolution stage, macrophages become dominant and work to clear debris, signaling the end of active inflammation and the beginning of lung recovery.
Which event best signifies the transition from red to gray hepatization in pneumonia?
A. A surge in alveolar macrophage activity
B. The cessation of new red blood cell influx and appearance of fibrin deposits with neutrophils
C. The development of a proteinaceous exudate
D. An increase in alveolar air volume and lung compliance
Correct Answer: B
Explanation: Gray hepatization is characterized by no further red blood cell influx, with the alveolar spaces now filled with neutrophils and fibrin deposits, indicating that the infection is becoming contained.
Which sequence correctly represents the progression of stages in pneumonia?
A. Red Hepatization → Initial Stage → Gray Hepatization → Resolution
B. Initial Stage → Gray Hepatization → Red Hepatization → Resolution
C. Resolution → Initial Stage → Red Hepatization → Gray Hepatization
D. Initial Stage → Red Hepatization → Gray Hepatization → Resolution
Correct Answer: D
Explanation: The proper progression of pneumonia stages is the Initial Stage, followed by Red Hepatization, then Gray Hepatization, and finally Resolution.
- General: Fever, chills, diaphoresis, myalgia, fatigue, headache.
- Respiratory:
o Tachypnea, tachycardia
o Cough (with/without sputum, possible hemoptysis)
o Shortness of breath, pleuritic chest pain
o Accessory muscle use, tripod positioning
Clinical Manifestations of pneumonia
o Tactile fremitus ↑
o Dull/flat percussion (indicates consolidation)
o Crackles, bronchial breath sounds, pleural friction rub
o Sepsis Risk → Multi-organ involvement
- Assessment Findings of pneumonia
Tactile Fremitus in Pneumonia
An increase in tactile fremitus is most likely indicative of which of the following?
A. Air trapping in the alveoli
B. Presence of pleural effusion only
C. Consolidation in the lung tissue
D. Normal lung function
Correct Answer: C
Explanation: Increased tactile fremitus typically indicates that lung tissue has become consolidated, allowing for enhanced transmission of sound vibrations through the lungs.
Percussion Findings in Consolidation
Dull or flat percussion over a lung field during assessment most commonly suggests:
A. Hyperinflation of the lungs
B. Normal lung resonance
C. Consolidation due to pneumonia
D. Excessive air in the pleural cavity
Correct Answer: C
Explanation: Dull or flat percussion is associated with consolidation, which is a hallmark of pneumonia due to the filling of alveoli with fluid and exudate
Which of the following sets of auscultation findings is most consistent with pneumonia?
A. Wheezes and prolonged expiration
B. Crackles, bronchial breath sounds, and pleural friction rub
C. Diminished breath sounds with a hyper-resonant percussion note
D. Stridor and inspiratory retraction
Correct Answer: B
Explanation: Crackles, bronchial breath sounds, and a pleural friction rub are common findings in pneumonia, reflecting inflammation and consolidation of the lung tissue.
In the context of pneumonia, a high risk of sepsis is particularly concerning because it may lead to:
A. Isolated lung infection with no systemic effects
B. Only mild fever and local inflammation
C. Multi-organ involvement and systemic complications
D. Hyper-resonance on percussion
Correct Answer: C
Explanation: The risk of sepsis in pneumonia is significant because it can progress to involve multiple organs, leading to systemic complications and a higher morbidity risk.
Which of the following combinations best represents the diagnostic approach for Community-Acquired Pneumonia (CAP)?
A. History, physical exam, and pulmonary function tests
B. History, symptoms (cough, fever, dyspnea), and a new lung infiltrate on CXR
C. History, sputum culture only, and blood gas analysis
D. History, cardiac stress test, and lung volume measurement
Correct Answer: B
Explanation: The diagnostic approach for CAP involves taking a thorough history, assessing symptoms such as cough, fever, and dyspnea, and confirming the diagnosis with a chest x-ray showing a new lung infiltrate.
For a patient with suspected severe CAP, which of the following diagnostic tests is most appropriate to include?
A. Sputum gram stain and culture, blood cultures, and PCR testing (if viral etiology is suspected)
B. Lung biopsy and MRI
C. Only chest CT scan
D. Spirometry and peak flow measurement
Correct Answer: A
Explanation: Severe CAP is often evaluated with sputum gram stain and culture, blood cultures to assess for bacteremia, and PCR testing when a viral etiology is suspected. These tests help tailor treatment appropriately
Question 3: Management of CAP Without Comorbidities
What is the recommended first-line treatment for a patient with CAP who has no comorbidities or risk factors for antibiotic resistance?
A. Intravenous vancomycin
B. Amoxicillin or a macrolide (azithromycin or clarithromycin) or doxycycline
C. Piperacillin-tazobactam
D. High-dose corticosteroids
Correct Answer: B
Explanation: For patients with CAP and no comorbidities, first-line treatment options include amoxicillin, a macrolide, or doxycycline, as these agents are effective in targeting the common pathogens associated with CAP.
Question 4: Management of CAP with Comorbidities
In a patient with CAP who has comorbidities or risk factors for antibiotic resistance, which treatment strategy is recommended?
A. Amoxicillin alone
B. Amoxicillin-clavulanate or cephalosporin plus a macrolide or doxycycline, with a respiratory fluoroquinolone as an alternative option
C. Only a respiratory fluoroquinolone
D. Supportive care without antibiotics
Correct Answer: B
Explanation: Patients with comorbidities or risk factors for antibiotic resistance should be managed with a combination therapy—amoxicillin-clavulanate or cephalosporin plus either a macrolide or doxycycline. A respiratory fluoroquinolone may be used as an alternative option.
For a patient diagnosed with Hospital-Acquired Pneumonia (HAP) who has no risk factors for multidrug-resistant (MDR) pathogens, which antibiotic regimen is most appropriate?
A. Beta-lactam plus macrolide or a respiratory fluoroquinolone
B. Monotherapy with doxycycline
C. High-dose amoxicillin
D. Only vancomycin
Correct Answer: A
Explanation: Mild HAP cases without risk factors for MDR pathogens are typically managed with a beta-lactam plus a macrolide, or alternatively, a respiratory fluoroquinolone.
Question 6: HAP Management in Severe Cases
Which of the following best describes the management approach for severe HAP or cases with prior respiratory isolation?
A. Use of a macrolide alone
B. Broad-spectrum coverage including agents for MRSA and Pseudomonas, such as vancomycin or linezolid plus agents like zosyn, cefepime, or meropenem
C. Supportive care with oxygen therapy only
D. Immediate surgical intervention
Correct Answer: B
Explanation: In severe HAP or cases with prior respiratory isolation, there is a concern for MDR pathogens. Therefore, broad-spectrum antibiotics covering MRSA (vancomycin or linezolid) and Pseudomonas (e.g., zosyn, cefepime, or meropenem) are indicated.
For Ventilator-Associated Pneumonia (VAP) in patients without risk factors for multidrug-resistant pathogens, which antibiotic is among the recommended options?
A. Piperacillin-tazobactam
B. Amoxicillin-clavulanate
C. Azithromycin
D. Doxycycline
Correct Answer: A
Explanation: In VAP patients without risk factors for MDR pathogens, piperacillin-tazobactam is one of the recommended antibiotic options along with other agents like cefepime, levofloxacin, imipenem, or meropenem.
Which of the following is NOT typically considered a complication of pneumonia?
A. Respiratory failure requiring mechanical ventilation
B. Sepsis with multi-organ dysfunction
C. Lung abscess or complicated pleural effusion
D. Enhanced lung compliance leading to improved oxygenation
Correct Answer: D
Explanation: Complications of pneumonia include respiratory failure, sepsis with multi-organ dysfunction, lung abscesses, and complicated pleural effusions. Enhanced lung compliance is not a complication of pneumonia—in fact, pneumonia typically leads to decreased lung compliance.
In what stage of pneumonia do red blood cells break down, neutrophils predominate, and fibrin deposits increase?
A. Red hepatization stage
B. Initial stage
C. Resolution stage
D. Grey hepatization stage
D. Grey hepatization stage
A 72-year-old male presents with fever, productive cough, and dyspnea for 3 days. His vitals include BP 100/60 mmHg, HR 110 bpm, RR 28, and SpO₂ 88% on room air. He has a history of COPD and diabetes. Chest X-ray shows right lower lobe consolidation. Based on his presentation, what is the best initial management?
A) Outpatient treatment with doxycycline
B) Hospital admission with IV ceftriaxone and azithromycin
C) ICU admission with IV piperacillin-tazobactam and vancomycin
D) Start nebulized albuterol and discharge with a macrolide
Answer: B) This patient meets CURB-65 criteria (age >65, tachypnea, hypotension) and has hypoxia (SpO₂ 88%), indicating inpatient treatment with a beta-lactam + macrolide regimen.
A 64-year-old woman with recent hospitalization 2 months ago for heart failure presents with fever, cough, and shortness of breath. She was treated with IV antibiotics during that admission. What is the most likely pathogen to cover empirically?
A) Streptococcus pneumoniae
B) Mycoplasma pneumoniae
C) Pseudomonas aeruginosa
D) Legionella pneumophila
Answer: C) Prior hospitalization + IV antibiotics within 90 days increases the risk for multidrug-resistant (MDR) organisms like Pseudomonas aeruginosa
A 56-year-old man is intubated in the ICU for respiratory failure due to pneumonia. On day 5, he develops worsening hypoxia and fever. Sputum cultures grow Acinetobacter baumannii. What is the most appropriate next step?
A) Start azithromycin and doxycycline
B) Continue current antibiotics and reassess in 48 hours
C) Initiate broad-spectrum coverage including carbapenems
D) Perform a CT chest before changing therapy
Answer: C) Ventilator-associated pneumonia (VAP) with MDR organisms (Acinetobacter) requires broad-spectrum coverage, often with a carbapenem (e.g., meropenem or imipenem).
A 60-year-old man with a history of alcoholism presents with fever, foul-smelling sputum, and right lower lobe pneumonia with cavitation on CXR. What is the most appropriate initial antibiotic regimen?
A) Levofloxacin
B) Ceftriaxone and azithromycin
C) Clindamycin or ampicillin-sulbactam
D) Vancomycin and piperacillin-tazobactam
Answer: C) This is aspiration pneumonia with lung abscess (anaerobes suspected), requiring clindamycin or ampicillin-sulbactam for anaerobic coverage
A 30-year-old previously healthy woman presents with a persistent dry cough, low-grade fever, and fatigue for two weeks. Chest X-ray shows diffuse interstitial infiltrates. What is the most appropriate treatment?
A) Ceftriaxone
B) Azithromycin
C) Vancomycin
D) Piperacillin-tazobactam
Answer: B) Atypical pneumonia (walking pneumonia) due to Mycoplasma pneumoniae presents with a dry cough and interstitial infiltrates and is treated with macrolides (azithromycin) or doxycycline.
A 50-year-old man is diagnosed with community-acquired pneumonia and started on levofloxacin. Two days later, he develops worsening confusion, diarrhea, and leukocytosis. What is the most likely complication?
A) Sepsis
B) Clostridioides difficile infection
C) Acute respiratory distress syndrome (ARDS)
D) Legionella pneumonia
Answer: B) Fluoroquinolones (levofloxacin) increase the risk of C. difficile infection, leading to diarrhea and leukocytosis.
A 70-year-old nursing home resident presents with altered mental status, fever, and productive cough. His SpO₂ is 85% on room air. Chest X-ray shows bilateral infiltrates. What is the best next step?
A) Obtain sputum culture and start azithromycin
B) Start cefepime + vancomycin and admit to ICU
C) Discharge with a 5-day course of doxycycline
D) Give albuterol nebulizer and reassess
Answer: B) Nursing home residents are high risk for multidrug-resistant (MDR) pneumonia, requiring broad-spectrum IV antibiotics and ICU admission due to hypoxia (SpO₂ 85%).
A 65-year-old patient with diabetes and chronic kidney disease is diagnosed with pneumonia and needs an outpatient antibiotic. Which regimen is most appropriate?
A) Doxycycline alone
B) Azithromycin alone
C) Amoxicillin-clavulanate + azithromycin
D) Levofloxacin monotherapy
Answer: C) Patients with comorbidities require broader coverage: Beta-lactam (amoxicillin-clavulanate) + macrolide (azithromycin) or respiratory fluoroquinolone alone (levofloxacin), but fluoroquinolones should be used cautiously in CKD.
A 42-year-old man with flu-like symptoms develops worsening dyspnea and productive cough. Chest X-ray shows diffuse bilateral infiltrates. Gram stain of sputum shows no organisms. What is the most likely etiology?
A) Streptococcus pneumoniae
B) Legionella pneumophila
C) Klebsiella pneumoniae
D) Haemophilus influenzae
Answer: B) Legionella causes atypical pneumonia with no organisms on Gram stain, as it is intracellular. Associated with flu-like symptoms, diarrhea, and hyponatremia.
A 77-year-old man with COPD presents with fever, purulent sputum, and dyspnea for 4 days. His oxygen requirement has increased, and a chest X-ray shows a right lower lobe infiltrate. He has not been recently hospitalized. Which of the following is the most appropriate antibiotic regimen?
A) Azithromycin alone
B) Levofloxacin alone
C) Ceftriaxone + Azithromycin
D) Piperacillin-tazobactam + Vancomycin
Answer: C) This patient has community-acquired pneumonia (CAP) with COPD, a high-risk factor requiring dual therapy: a beta-lactam (ceftriaxone) + macrolide (azithromycin) or a respiratory fluoroquinolone.
A 67-year-old woman with advanced Parkinson’s disease and recurrent aspiration pneumonia presents with fever, hypoxia, and a new right middle lobe infiltrate. Which of the following is the best empiric antibiotic choice?
A) Amoxicillin
B) Ceftriaxone + Azithromycin
C) Piperacillin-tazobactam + Metronidazole
D) Vancomycin + Cefepime
Answer: C) This is aspiration pneumonia due to oropharyngeal anaerobes. Piperacillin-tazobactam (broad spectrum including anaerobes) is preferred over ceftriaxone. Metronidazole covers additional anaerobes.
A 70-year-old patient with heart failure is admitted with pneumonia and started on ceftriaxone and azithromycin. Three days later, his respiratory status worsens, and a repeat chest X-ray shows a new left pleural effusion. What is the next best step?
A) Continue current antibiotics and monitor
B) Perform a thoracentesis
C) Start broad-spectrum antibiotics for sepsis
D) Order a CT scan of the chest
Answer: B) New pleural effusion in pneumonia raises concern for parapneumonic effusion or empyema, which requires thoracentesis for evaluation
A 48-year-old construction worker presents with fever, cough, and confusion. He recently cleaned an old air conditioning system. Chest X-ray reveals bilateral patchy infiltrates. Urine antigen testing is positive for the suspected pathogen. What is the most appropriate treatment?
A) Doxycycline
B) Ceftriaxone + Azithromycin
C) Levofloxacin
D) Amoxicillin
Answer: C) This is Legionnaires’ disease (Legionella pneumophila), commonly associated with contaminated water sources. Fluoroquinolones (levofloxacin) or macrolides (azithromycin) are first-line.
A 55-year-old homeless man with alcoholism presents with high fever, productive cough, and currant jelly sputum. Chest X-ray reveals a dense right upper lobe consolidation with cavitation. What is the most likely causative pathogen?
A) Streptococcus pneumoniae
B) Klebsiella pneumoniae
C) Legionella pneumophila
D) Mycoplasma pneumoniae
Answer: B) Klebsiella pneumoniae is associated with alcoholism, currant jelly sputum, and cavitary upper lobe infiltrates
A 23-year-old college student presents with persistent dry cough, low-grade fever, and sore throat for one week. Physical exam reveals no significant findings, and a chest X-ray shows diffuse interstitial infiltrates. Which pathogen is most likely?
A) Streptococcus pneumoniae
B) Mycoplasma pneumoniae
C) Haemophilus influenzae
D) Pseudomonas aeruginosa
Answer: B) Mycoplasma pneumoniae causes atypical pneumonia (“walking pneumonia”), common in young adults, with diffuse interstitial infiltrates.
A 68-year-old man with diabetes is diagnosed with CAP and treated with ceftriaxone and azithromycin. After 72 hours, he remains febrile with worsening leukocytosis. A repeat chest X-ray shows worsening consolidation. What is the most appropriate next step?
A) Continue current treatment and reassess in 48 hours
B) Perform a sputum culture and consider changing antibiotics
C) Switch to a fluoroquinolone alone
D) Start steroids to control inflammation
Answer: B) Persistent fever and worsening pneumonia despite antibiotics suggest resistant organisms or incorrect coverage. Sputum cultures help guide therapy adjustments.
A 52-year-old man is admitted with severe CAP requiring ICU admission. His urine antigen test is positive for Legionella pneumophila. What additional supportive care should be considered?
A) Nebulized corticosteroids
B) High-dose vitamin C
C) IV fluids and electrolyte replacement
D) Antifungal therapy
Answer: C) Legionella causes severe pneumonia with hyponatremia, so IV fluids and electrolyte correction are essential.
A 60-year-old immunocompromised patient presents with cough, fever, and progressive dyspnea. Chest X-ray shows bilateral infiltrates with ground-glass opacities. His lactate dehydrogenase (LDH) is elevated. What is the most likely cause?
A) Pneumocystis jirovecii
B) Streptococcus pneumoniae
C) Haemophilus influenzae
D) Chlamydia pneumoniae
Answer: A) Pneumocystis jirovecii pneumonia (PJP) presents with bilateral ground-glass opacities and elevated LDH, common in immunocompromised patients.
- Aspiration pneumonia → Anaerobes,
treat with piperacillin-tazobactam or clindamycin
- Pleural effusion after pneumonia →
Thoracentesis to assess for empyema
A 72-year-old woman with a history of hypertension and diabetes presents with fever, productive cough, and dyspnea. Her vitals are BP 92/60 mmHg, HR 120 bpm, RR 30, SpO₂ 86% on room air. Chest X-ray shows right lower lobe consolidation. What is the most immediate intervention?
A) Administer IV fluids and broad-spectrum antibiotics
B) Order blood cultures and start inhaled bronchodilators
C) Admit to ICU and start IV vasopressors
D) Initiate supplemental oxygen and broad-spectrum antibiotics
Answer: D) This patient has severe pneumonia with hypoxia (SpO₂ 86%) and possible sepsis. Oxygen therapy is the immediate priority, followed by broad-spectrum IV antibiotics.
A 65-year-old man with COPD presents with worsening dyspnea and fever. He was treated with azithromycin for pneumonia 3 days ago but is now deteriorating. Chest X-ray shows new bilateral infiltrates. What is the next best step?
A) Continue azithromycin and reassess in 48 hours
B) Perform a sputum culture and switch to levofloxacin
C) Admit for IV cefepime + vancomycin
D) Start inhaled steroids and bronchodilators
Answer: C) Worsening pneumonia on outpatient therapy suggests treatment failure or a resistant organism. Hospitalization with broad-spectrum IV antibiotics (cefepime for Pseudomonas, vancomycin for MRSA) is necessary
A 55-year-old man presents with pneumonia symptoms. His history includes alcohol use disorder. Chest X-ray shows right upper lobe cavitary consolidation. What is the most appropriate initial antibiotic regimen?
A) Ceftriaxone + Azithromycin
B) Piperacillin-Tazobactam + Metronidazole
C) Levofloxacin alone
D) Linezolid + Clindamycin
Answer: B) This is likely aspiration pneumonia with anaerobic infection. Piperacillin-tazobactam + Metronidazole covers anaerobes commonly seen in aspiration pneumonia.
A 45-year-old woman with no significant history presents with dry cough, low-grade fever, and fatigue for two weeks. Chest X-ray shows bilateral interstitial infiltrates. What is the best treatment?
A) Ceftriaxone + Azithromycin
B) Amoxicillin-clavulanate
C) Doxycycline
D) Piperacillin-Tazobactam
Answer: C) This presentation is consistent with atypical pneumonia (likely Mycoplasma pneumoniae), which is treated with doxycycline or azithromycin
A 68-year-old man presents with pneumonia requiring ICU admission. Sputum culture is positive for MRSA. What is the most appropriate antibiotic regimen?
A) Cefepime + Azithromycin
B) Linezolid or Vancomycin
C) Meropenem + Tobramycin
D) Amoxicillin + Doxycycline
Answer: B) MRSA pneumonia requires Vancomycin or Linezolid for targeted treatment
A 60-year-old man is diagnosed with hospital-acquired pneumonia (HAP) and started on cefepime + vancomycin. His respiratory status worsens on day 3. What is the most appropriate next step?
A) Switch to amoxicillin-clavulanate
B) Add metronidazole for anaerobic coverage
C) Evaluate for empyema with thoracentesis
D) Start corticosteroids to reduce inflammation
Answer: C) Worsening pneumonia despite antibiotics suggests complications like empyema or abscess, requiring thoracentesis for evaluation
A 72-year-old man on a ventilator for 5 days develops fever, worsening oxygenation, and purulent sputum. What is the best next step?
A) Start vancomycin and cefepime
B) Discontinue ventilator support and monitor
C) Order a sputum culture and wait for results before starting antibiotics
D) Continue current therapy and reassess in 24 hours
Answer: A) Ventilator-associated pneumonia (VAP) requires empiric broad-spectrum antibiotics, including coverage for MRSA and Pseudomonas.
A 50-year-old woman presents with pneumonia symptoms and a SpO₂ of 80% on room air. Chest X-ray shows bilateral ground-glass opacities. She recently returned from an area with high COVID-19 prevalence. What is the most appropriate management?
A) Start ceftriaxone + azithromycin
B) Administer remdesivir and dexamethasone
C) Discharge with a 5-day course of doxycycline
D) Start oseltamivir and bronchodilators
Answer: B) COVID-19 pneumonia with hypoxia (SpO₂ 80%) is managed with remdesivir + dexamethasone.
A 67-year-old woman with advanced COPD and chronic steroid use is admitted with pneumonia. She is started on cefepime + azithromycin but remains febrile and dyspneic after 4 days. What is the best next step?
A) Start antifungal coverage for possible fungal pneumonia
B) Switch to piperacillin-tazobactam + vancomycin
C) Perform bronchoscopy with lavage for pathogen identification
D) Start high-dose steroids
Answer: C) Persistent pneumonia despite antibiotics in an immunocompromised host suggests atypical pathogens, requiring further bronchoscopy and culture
A 62-year-old man with sepsis due to pneumonia has been receiving broad-spectrum IV antibiotics for 72 hours. He is hemodynamically stable but still febrile. Blood and sputum cultures remain negative. What is the most appropriate next step?
A) Continue current antibiotic regimen for 7 more days
B) De-escalate antibiotics based on clinical response
C) Switch to a different antibiotic class
D) Perform lung biopsy to evaluate for malignancy
Answer: B) Antibiotic stewardship principles dictate de-escalation based on clinical improvement if cultures are negative.
A 75-year-old nursing home resident presents with altered mental status, fever, and productive cough. Chest X-ray reveals right lower lobe consolidation. His SpO₂ is 88% on room air. What is the best next step?
A) Admit for IV ceftriaxone + azithromycin
B) Prescribe amoxicillin-clavulanate and discharge
C) Order a chest CT before deciding on management
D) Give albuterol nebulizer and reassess
Answer: A) Nursing home residents are at high risk for multidrug-resistant (MDR) pneumonia and poor prognosis due to comorbidities. Hospitalization with IV antibiotics is necessary.
A 60-year-old man with diabetes and chronic kidney disease presents with fever, productive cough, and pleuritic chest pain. His vitals are BP 90/55, HR 120, RR 32, SpO₂ 85% on room air. What is the next best step?
A) Start IV fluids and ceftriaxone + azithromycin
B) Discharge with levofloxacin and follow up in 48 hours
C) Order a CT pulmonary angiogram for pulmonary embolism
D) Start high-dose steroids for inflammation
Answer: A) This patient has severe pneumonia with sepsis (hypotension, tachycardia, tachypnea, hypoxia) and requires IV antibiotics and fluid resuscitation
A 50-year-old man with COPD is diagnosed with community-acquired pneumonia. He was treated with levofloxacin two months ago for a similar infection. What is the best antibiotic choice?
A) Levofloxacin again
B) Ceftriaxone + Azithromycin
C) Doxycycline alone
D) Amoxicillin
Answer: B) Recent fluoroquinolone use increases resistance risk. Dual therapy with ceftriaxone + azithromycin is preferred.
A 68-year-old man with heart failure and diabetes presents with fever and cough. His chest X-ray shows a new left pleural effusion. What is the best next step?
A) Continue current antibiotics and monitor
B) Perform a thoracentesis
C) Start broad-spectrum antibiotics for sepsis
D) Order a CT scan of the chest
Answer: B) New pleural effusion in pneumonia suggests parapneumonic effusion or empyema, requiring thoracentesis for evaluation
A 30-year-old woman presents with low-grade fever, dry cough, and fatigue for two weeks. Chest X-ray reveals diffuse interstitial infiltrates. What is the most likely pathogen?
A) Streptococcus pneumoniae
B) Mycoplasma pneumoniae
C) Haemophilus influenzae
D) Pseudomonas aeruginosa
Answer: B) Mycoplasma pneumoniae causes atypical pneumonia with prolonged symptoms and interstitial infiltrates.
. A 55-year-old man with alcoholism presents with fever, cough, and currant jelly sputum. Chest X-ray shows right upper lobe consolidation with cavitation. What is the most likely causative pathogen?
A) Streptococcus pneumoniae
B) Klebsiella pneumoniae
C) Legionella pneumophila
D) Mycoplasma pneumoniae
Answer: B) Klebsiella pneumoniae is associated with alcoholism, currant jelly sputum, and cavitary upper lobe pneumonia.
A 73-year-old man in the ICU on mechanical ventilation develops worsening fever and purulent secretions. What is the next best step?
A) Start vancomycin and cefepime
B) Discontinue ventilator support and monitor
C) Order a sputum culture and wait before starting antibiotics
D) Continue current therapy and reassess in 24 hours
Answer: A) Ventilator-associated pneumonia (VAP) requires empiric broad-spectrum antibiotics, including coverage for MRSA and Pseudomonas.
A 45-year-old man presents with pneumonia and new-onset confusion. Blood pressure is 80/50 mmHg. What is the most appropriate immediate management?
A) Administer IV fluids and broad-spectrum antibiotics
B) Start inhaled steroids and bronchodilators
C) Order a chest CT before starting antibiotics
D) Prescribe azithromycin and discharge
Answer: A) This patient has septic shock due to pneumonia, requiring IV fluids and broad-spectrum antibiotics
. A 65-year-old woman with pneumonia and septic shock has been on broad-spectrum IV antibiotics for 72 hours. She remains febrile and hypotensive. What is the next step?
A) Continue current antibiotic regimen
B) Add antifungal coverage for possible fungal pneumonia
C) Perform a bronchoscopy for further evaluation
D) Start high-dose steroids
Answer: C) Persistent pneumonia despite antibiotics in a critically ill patient suggests atypical or resistant pathogens, requiring bronchoscopy and culture
A 68-year-old woman with pneumonia is started on broad-spectrum antibiotics. She develops profuse watery diarrhea and leukocytosis. What is the most likely complication?
A) Clostridioides difficile infection
B) Sepsis
C) Acute respiratory distress syndrome (ARDS)
D) Legionella pneumonia
Answer: A) Broad-spectrum antibiotics increase the risk of C. difficile infection
A 58-year-old man with a recent influenza infection presents with fever, cough, and hemoptysis. Chest X-ray shows bilateral cavitary infiltrates. What is the most likely pathogen?
A) Streptococcus pneumoniae
B) Staphylococcus aureus (MRSA)
C) Mycoplasma pneumoniae
D) Chlamydia pneumoniae
Answer: B) Post-influenza necrotizing pneumonia is often caused by MRSA.
A 50-year-old patient with ventilator-associated pneumonia (VAP) remains febrile despite 7 days of antibiotics. What is the next step?
A) Stop antibiotics and monitor
B) Perform a repeat sputum culture
C) Switch to corticosteroids
D) Discontinue ventilator support
Answer: B) Persistent fever in VAP warrants repeat culture to guide therapy.
A 65-year-old man with chronic kidney disease is diagnosed with pneumonia. Which outpatient antibiotic regimen is most appropriate?
A) Doxycycline alone
B) Azithromycin alone
C) Amoxicillin-clavulanate + azithromycin
D) Levofloxacin monotherapy
Answer: C) Patients with comorbidities require broader coverage: Beta-lactam + macrolide.
A 75-year-old man with pneumonia on mechanical ventilation develops hypotension and lactic acidosis. What is the best next step?
A) Increase ventilator support
B) Start vasopressors
C) Give IV fluids and broad-spectrum antibiotics
D) Start steroids
Answer: C) Septic shock requires IV fluids and broad-spectrum antibiotics.
A 78-year-old man with a history of chronic heart failure and COPD presents with fever, productive cough, and increasing dyspnea over 2 days. His vitals show BP 88/60 mmHg, HR 115 bpm, RR 28, and SpO₂ 84% on room air.
What is the most immediate management step?
A) Start oral azithromycin and discharge home
B) Initiate supplemental oxygen and begin IV fluids and broad-spectrum antibiotics
C) Order a CT scan of the chest for further evaluation
D) Begin nebulized bronchodilators only
Answer: B)
Rationale: This patient’s low blood pressure, tachycardia, tachypnea, and hypoxia indicate possible septic shock. Immediate stabilization with oxygen, IV fluids, and empiric IV antibiotics is essential.
A 65-year-old nursing home resident presents with altered mental status, fever, and a productive cough. The chest X-ray reveals right lower lobe consolidation.
Which of the following best describes the next step in management?
A) Outpatient management with oral antibiotics
B) Admission for IV antibiotics with attention to potential multidrug-resistant organisms
C) Order a bronchoscopy before starting any treatment
D) Initiate corticosteroids to reduce lung inflammation
Answer: B)
Rationale: Nursing home residents are at higher risk for MDR pathogens; hospital admission with IV antibiotics is indicated.
A 42-year-old otherwise healthy woman presents with a two-week history of low-grade fever, nonproductive cough, and malaise. Chest X-ray reveals diffuse interstitial infiltrates.
Which management strategy is most appropriate?
A) Initiate treatment with doxycycline
B) Begin high-dose IV ceftriaxone
C) Order an immediate CT scan
D) Treat with oseltamivir
Answer: A)
Rationale: The presentation is most consistent with atypical pneumonia (e.g., Mycoplasma pneumoniae), which is effectively treated with doxycycline or a macrolide.
A 60-year-old man with diabetes and chronic kidney disease is admitted with community-acquired pneumonia. His initial regimen is amoxicillin-clavulanate and azithromycin. Three days later, he remains febrile with persistent hypoxia.
What is the next best step?
A) Continue the same regimen for 7 days
B) Obtain sputum and blood cultures, then consider broadening coverage
C) Switch to oral antibiotics
D) Add inhaled corticosteroids
Answer: B)
Rationale: Persistent symptoms despite appropriate therapy warrant re-evaluation with cultures to assess for resistant organisms or complications and potential adjustment of antibiotic coverage.
A 70-year-old man on mechanical ventilation for severe pneumonia develops a new fever and increased purulent secretions on day 6.
What is the most appropriate next step?
A) Continue current antibiotics and wait for culture results
B) Start empiric therapy with vancomycin and an antipseudomonal agent
C) Immediately extubate the patient
D) Switch to oral antibiotics
Answer: B)
Rationale: Ventilator-associated pneumonia (VAP) is common in this setting, and empiric broad-spectrum coverage (including MRSA and Pseudomonas) is warranted.
A 68-year-old woman with a history of chronic liver disease presents with pneumonia and is started on broad-spectrum IV antibiotics. On day 3, she develops hypotension and tachycardia despite treatment.
What is the most concerning complication, and what should be done?
A) Empyema; order a thoracentesis
B) Septic shock; initiate vasopressors along with further fluid resuscitation
C) Antibiotic allergy; change antibiotics immediately
D) Cardiac arrhythmia; start beta-blockers
Answer: B)
Rationale: The clinical picture suggests septic shock secondary to pneumonia; prompt vasopressor support and additional fluid resuscitation are needed.
A 50-year-old man with pneumonia and recent influenza infection presents with worsening cough and hemoptysis. His chest X-ray now shows bilateral cavitary lesions.
What is the most likely cause?
A) Streptococcus pneumoniae
B) Methicillin-resistant Staphylococcus aureus (MRSA)
C) Legionella pneumophila
D) Mycoplasma pneumoniae
Answer: B)
Rationale: Post-influenza pneumonia complicated by hemoptysis and cavitary lesions is frequently due to MRSA.
A 58-year-old man presents with fever, cough, and shortness of breath. His chest imaging reveals a new left pleural effusion in the context of pneumonia.
Which of the following is the next best step in evaluation?
A) Increase the antibiotic dose
B) Perform thoracentesis to evaluate for empyema
C) Order a lung ultrasound to confirm consolidation
D) Switch to oral antibiotics
Answer: B)
Rationale: A new pleural effusion in pneumonia may represent a parapneumonic effusion or empyema, which should be evaluated with thoracentesis.
A 45-year-old man with pneumonia is admitted and started on IV ceftriaxone and azithromycin. After 72 hours, his clinical status remains unchanged. Which of the following should be considered next?
A) De-escalate antibiotics
B) Obtain bronchoscopy with bronchoalveolar lavage (BAL) for further pathogen identification
C) Add oral antibiotics to the current regimen
D) Stop all antibiotics and monitor
Answer: B)
Rationale: In a patient not improving on initial therapy, further diagnostic workup with bronchoscopy and BAL can help identify atypical or resistant organisms.
A 63-year-old woman with pneumonia and multiple comorbidities is managed as an outpatient with oral antibiotics. Her SpO₂ is 93% on room air, but she has difficulty with oral intake. What is the most appropriate step?
A) Continue outpatient therapy with added IV fluids
B) Transition her to IV antibiotics in the hospital
C) Increase the oral antibiotic dose
D) Add an inhaled bronchodilator and continue home management
Answer: B)
Rationale: Difficulty with oral intake in a patient with pneumonia is a red flag. Hospital admission for IV antibiotics and supportive care is warranted
A 52-year-old man with pneumonia and a history of COPD is started on IV antibiotics. On day 4, he develops severe watery diarrhea and leukocytosis.
What is the most likely complication, and how should it be managed?
A) Worsening pneumonia; broaden antibiotic coverage
B) Clostridioides difficile infection; initiate appropriate treatment and consider antibiotic de-escalation
C) Viral gastroenteritis; provide supportive care only
D) Drug-induced diarrhea; switch to a different antibiotic class
Answer: B)
Rationale: The clinical picture is consistent with C. difficile infection, a known complication of broad-spectrum antibiotic use, which requires specific treatment.
A 70-year-old man with pneumonia in the ICU develops new respiratory distress and worsening oxygenation despite being on mechanical ventilation. A repeat chest X-ray reveals diffuse bilateral infiltrates.
Which complication should be suspected, and what is the next step?
A) Pulmonary embolism; perform a CT pulmonary angiogram
B) Acute respiratory distress syndrome (ARDS); optimize ventilator settings and consider prone positioning
C) Heart failure; start diuretics
D) Empyema; schedule thoracentesis
Answer: B)
Rationale: Diffuse bilateral infiltrates and worsening oxygenation in a ventilated patient suggest ARDS, which requires lung-protective ventilation strategies and possibly prone positioning.
A 60-year-old man with community-acquired pneumonia is being treated with amoxicillin-clavulanate and azithromycin. He is allergic to fluoroquinolones. Which of the following best describes his management plan?
A) Switch to doxycycline monotherapy
B) Continue current therapy, as it covers the typical pathogens
C) Add vancomycin for MRSA coverage
D) Change to a respiratory fluoroquinolone despite the allergy
Answer: B)
Rationale: The combination of amoxicillin-clavulanate and azithromycin provides broad coverage for typical and atypical organisms in CAP, making it a suitable choice when fluoroquinolones are contraindicated.
A 75-year-old patient with pneumonia is admitted to the ICU and is receiving broad-spectrum IV antibiotics. On day 5, he develops sudden hypotension, tachycardia, and increased lactate levels. What is the most likely complication, and how should it be managed?
A) Worsening pneumonia; add another antibiotic
B) Septic shock; initiate vasopressor support along with aggressive fluid resuscitation
C) Drug reaction; discontinue antibiotics
D) Pulmonary embolism; start anticoagulation
Answer: B)
Rationale: Sudden hypotension, tachycardia, and lactic acidosis in a patient with pneumonia are hallmarks of septic shock, requiring immediate hemodynamic support with fluids and vasopressors.
