Pulm and Critical Care III

Question 1

What bacteria is the most common cause of community-acquired pneumonia?

Answer 1

Streptococcus pneumoniae

Question 2

What chest imaging finding is virtually pathognomonic for asbestosis?

Answer 2

Pleural plaques

Question 3

What CXR finding is characteristic of epiglottitis?

Answer 3

“Thumbprint sign” (enlarged epiglottis)

Question 4

What fungal infection typically occurs in patients exposed to soil contaminated by bird or bat droppings (e.g. caves)?

Answer 4

Histoplasma capsulatum

may manifest as subacute fever, malaise, dry cough; hilar lymphadenopathy seen on CXR (often mimics sarcoidosis) and granulomas with narrow-based budding yeast seen on biopsy

Question 5

What imaging modality is typically used to diagnose pneumonia?

Answer 5

Chest X-ray

diagnosis requires presence of lobar, interstitial, or cavitary infiltrate on imaging; CXR should be acquired before administering empiric antibiotics

Question 6

What is the best initial step in management for a stabilized patient with likely PE (modified Wells criteria) who has no absolute contraindications to anticoagulation?

Answer 6

Begin anticoagulation (e.g. IV heparin)

if there is no contraindication to anticoagulation, it should precede diagnostic imaging in patients with likely PE, especially when in moderate distress

Question 7

What is the best initial step in management for a stabilized patient with suspected PE who has absolute contraindications to anticoagulation?

Answer 7

Obtain diagnostic test (e.g. CT angiography)

if CTA is positive, patients should receive appropriate treatment (e.g. IVC filter)

Question 8

What is the best initial step in management for a stabilized patient with unlikely PE (modified Wells criteria) who has no absolute contraindications to anticoagulation?

Answer 8

Obtain diagnostic test (e.g. D-dimer assay)

Question 9

What is the best test to differentiate asthma from COPD?

Answer 9

Spirometry before and after an inhaled bronchodilator

reversal of airway obstruction suggests asthma; partial or non-reversal suggests COPD

Question 10

What is the best treatment for hypersensitivity pneumonitis?

Answer 10

Avoidance of the responsible antigen

Question 11

What is the best treatment to minimize the development of life-threatening complications in patients with anaphylaxis (e.g. hypotension, upper airway edema)?

Answer 11

Intramuscular epinephrine

IV epinephrine is indicated for patients with anaphylaxis who do not respond to initial IM epinephrine

Question 12

What is the diagnostic test for obstructive sleep apnea?

Answer 12

Nocturnal polysomnography

Question 13

What is the first-line therapy for obesity hypoventilation syndrome?

Answer 13

Nocturnal positive-pressure ventilation

Question 14

What is the first-line treatment for patients with exercise-induced bronchoconstriction who exercise a few times per week?

Answer 14

Short-acting β-agonists 10-20 minutes before exercise

use inhaled corticosteroids or anti-leukotriene if exercising daily

Question 15

What is the first-line treatment for patients with exercise-induced bronchoconstriction who exercise daily?

Answer 15

Inhaled corticosteroids or anti-leukotriene agents 10-20 minutes before exercise

use short-acting β-agonists if only needed a few times per week

Question 16

What is the general treatment for complicated parapneumonic effusion?

Answer 16

Antibiotics and drainage (e.g. chest tube)

Question 17

What is the general treatment for uncomplicated parapneumonic effusion?

Answer 17

Antibiotics

Question 18

What is the initial management for patients with non-allergic rhinitis?

Answer 18

intranasal antihistamine and/or glucocorticoids

Question 19

What is the initial treatment for a child with severe respiratory distress and signs of epiglottitis?

Answer 19

Endotracheal intubation

broad-spectrum antibiotics should be administered after the patient is stabilized

Question 20

What is the initial treatment of choice in asymptomatic or mildly symptomatic patients with SIADH?

Answer 20

Fluid restriction +/- salt tablets

Question 21

What is the likely cause of dyspnea in patients with ankylosing spondylitis?

Answer 21

Limited chest and spinal mobility

causes a restrictive pattern on PFTs with an normal or increased FRC (due to fixation of rib cage in an inspiratory position)

Question 22

What is the likely cause of leukocytosis with neutrophilic predominance in a patient being treated for asthma exacerbation?

Answer 22

Glucocorticoid side effect

glucocorticoids cause mobilization of marginated neutrophils, while decreasing the number of other circulating lymphocytes

Question 23

What is the likely diagnosis given the flow-volume loop below?

Answer 23

Fixed upper airway obstruction (e.g. laryngeal edema)

Question 24

What is the likely diagnosis in a euvolemic patient with low serum osmolality and high urine osmolality?

Answer 24

SIADH

commonly precipitated by pulmonary pathologies; hyponatremia may worsen with saline infusion

Question 25

What is the likely diagnosis in a euvolemic patient with low serum osmolality and low urine osmolality?

Answer 25

Primary polydipsia especially common in psychiatric patients; this presentation may also occur with beer potomania

Question 26

What is the likely diagnosis in a patient on a ventilator who develops hypotension, tachycardia, and unilateral absence of breath sounds?

Answer 26

Pneumothorax due to positive pressure ventilation; hypotension and tachycardia result from impaired right ventricular filling secondary to compression of the IVC

Question 27

What is the likely diagnosis in a patient on high-doses of β2 agonists who develops muscle weakness?

Answer 27

Hypokalemia β-agonists drive potassium into cells, causing hypokalemia; other potential side effects include tremor, palpitations, and headache

Question 28

What is the likely diagnosis in a patient who develops respiratory failure, hypotension, and DIC immediately post-partum?

Answer 28

Amniotic fluid embolism

Question 29

What is the likely diagnosis in a patient who smokes and has coronary artery disease that presents with shortness of breath, bibasilar crackles, low CO2 and respiratory alkalosis?

Answer 29

CHF exacerbation low CO2 and respiratory alkalosis help differentiate from COPD exacerbation, which causes high CO2 and respiratory acidosis

Question 30

What is the likely diagnosis in a patient with a recent URI and a persistent productive cough without fever or significant CXR findings?

Answer 30

Acute bronchitis may be associated with purulent and/or blood-tinged sputum production in up to half of patients

Question 31

What is the likely diagnosis in a patient with an extensive smoking history who presents with digital clubbing and sudden-onset arthropathy of the hand/wrist?

Answer 31

Hypertrophic osteoarthropathy often associated with lung cancer, therefore CXR is indicated to rule out malignancy or other lung pathology

Question 32

What is the likely diagnosis in a patient with bronchospasm and nasal congestion following aspirin ingestion?

Answer 32

Aspirin-exacerbated respiratory disease most often seen in patients with a history of asthma or chronic rhinosinusitis with nasal polyposis

Question 33

What is the likely diagnosis in a patient with COPD who develops sudden-onset dyspnea and chest pain with unilaterally decreased breath sounds (no tracheal deviation)?

Answer 33

Secondary spontaneous pneumothorax chronic destruction of alveolar sacs leads to formation of large alveolar blebs, which can eventually rupture

Question 34

What is the likely diagnosis in a patient with COPD who presents with JVD, hepatomegaly, and pitting edema?

Answer 34

Cor pulmonale i.e. RHF from pulmonary hypertension

Question 35

What is the likely diagnosis in a patient with mild hypoxemia, tachypnea, and CXR infiltrates hours after an episode of aspiration?

Answer 35

Aspiration pneumonitis gastric acid induces a chemical burn with a consequent inflammatory response; resolves with supportive management

Question 36

What is the likely diagnosis in a patient with PMHx of Hodgkin lymphoma status-post chemotherapy/radiation who presents with cough, dyspnea, and chest pain (imaging below)?

Answer 36

Secondary malignancy there is an 18.5-fold increased risk for developing a second cancer in HL patients compared to the general population (likely related to chemo- and/or radiation therapy at a young age); most common sites are lung, breast, thyroid, bone, and GI

Question 37

What is the likely diagnosis in a patient with pneumonia that presents with continued symptoms despite adequate antibiotic coverage and loculation on CXR?

Answer 37

Complicated parapneumonic effusion

Question 38

What is the likely diagnosis in a patient with previous TB infection who presents with months of weight loss, fatigue, and hemoptysis without night sweats, fever, or chest pain (imaging below)?

Answer 38

Chronic pulmonary aspergillosis

Question 39

What is the likely diagnosis in a patient with recurrent episodes of bacterial infection, purulent sputum, hemoptysis, and digital clubbing?

Answer 39

Bronchiectasis may present similarly to chronic bronchitis, but bronchiectasis has more prominent sputum production and exacerbations are typically bacterial (viral in chronic bronchitis)

Question 40

What is the likely diagnosis in a patient with recurrent sinusitis, bronchiectasis, and dextrocardia?

Answer 40

Kartagener syndrome (primary ciliary dyskinesia)

Question 41

What is the likely diagnosis in a patient with repeated episodes of fever, dyspnea, and cough after exposure to environmental antigens (e.g. bird droppings, molds)?

Answer 41

Hypersensitivity pneumonitis

Question 42

What is the likely diagnosis in a patient with respiratory distress, hypoxemia, and diffuse, bilateral alveolar infiltrates not due to CHF/fluid overload?

Answer 42

Acute respiratory distress syndrome

Question 43

What is the likely diagnosis in a patient with significant smoking history that presents with shortness of breath, bilateral wheezing, high CO2 and respiratory acidosis?

Answer 43

COPD exacerbation high CO2 and respiratory acidosis help differentiate from CHF exacerbation, which causes low CO2 and respiratory alkalosis

Question 44

What is the likely diagnosis in a patient with significant smoking history who presents with shoulder pain, weight loss, and the imaging findings below?

Answer 44

Pancoast (superior sulcus) tumor

Question 45

What is the likely diagnosis in a patient with sinusitis, lung nodules/cavitations, and elevated creatinine?

Answer 45

Granulomatosis with polyangiitis (formerly Wegener's) necrotizing vasculitis involving the upper and lower respiratory tract and kidneys; cutaneous manifestations are also common