Pulmonary

Question 1

A 58-year-old female with coronary artery disease and alcohol use disorder presents with progressive shortness of breath over the past 3 weeks. A chest radiograph demonstrates bilateral pleural effusions that are greater on the right side. Laboratory studies, including pleural fluid analysis, show the following:

Serum protein……………………..5.5 g/dL (N 6.0–8.0)
Serum LDH…………………………..305 IU/L (N 105–333)
Plasma glucose…………………..88 mg/dL (N 70–100)
Pleural fluid protein…………..2.9 g/dL
Pleural fluid LDH………………..295 IU/L
Pleural fluid glucose………….51 mg/Dl

Which one of the following is the most likely cause of the effusion? (check one)
-Cirrhosis of the liver
-Congestive heart failure
-COPD
-Malignancy | Pulmonary embolism
-Pulmonary embolism

Answer 1

Malignancy | ?Infection

The modified Light’s criteria are used to determine whether pleural effusions are transudative or exudative. This fluid is exudative as defined by a pleural fluid protein to serum protein ratio >0.5, a pleural fluid LDH to serum LDH ratio >0.6, and a pleural fluid LDH greater than two-thirds the upper limit of normal for serum. Lung malignancy is a cause of exudative pleural effusions. Cirrhosis and congestive heart failure cause transudative rather than exudative effusions. COPD does not cause pleural effusions. This fluid also has low glucose, which suggests malignancy or infection rather than pulmonary embolism.

Question 2

An anxious 30-year-old white female comes to the emergency department with shortness of breath, circumoral paresthesia, and carpopedal spasms. Which one of the following sets of blood gas values is most consistent with this clinical picture? (check one)
pH 7.25 (N 7.35–7.45), pCO2 25 mm Hg (N 35–45), pO2 100 mm Hg (N 80–100)
pH 7.25, pCO2 50 mm Hg, pO2 80 mm Hg
pH 7.50, pCO2 25 mm Hg, pO2 100 mm Hg
pH 7.55, pCO2 50 mm Hg, pO2 80 mm Hg

Answer 2

pH 7.50, pCO2 25 mm Hg, pO2 100 mm Hg

Anxiety, shortness of breath, paresthesia, and carpopedal spasm are characteristic of hyperventilation. Respiratory alkalosis secondary to hyperventilation is diagnosed when arterial pH is elevated and pCO2 is depressed. Low pH is characteristic of acidosis, either respiratory or metabolic, and elevated pH with elevated pCO2 is characteristic of metabolic alkalosis with respiratory compensation.

Question 3

A 66-year-old 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? (check one)
Reduce oxygen use to nighttime only
Stop oxygen when his course of antibiotics and corticosteroids is completed
Reassess the need for oxygen within 3 months
Stop oxygen within 6 months
Continue oxygen indefinitely

Answer 3

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 without assessing the patient for ongoing hypoxemia (SOR C). The rationale for this recommendation is that hypoxemia often resolves after recovery from an acute illness. The guidelines recommend that a plan be established to reassess the patient no later than 90 days after discharge and that Medicare guidelines and evidence-based criteria should be followed to determine whether the patient meets the criteria for supplemental oxygen.

Continuous oxygen therapy is indicated in patients with COPD and severe hypoxemia. There is good evidence that the addition of home long-term continuous oxygen therapy for COPD increases survival rates in patients with severe hypoxemia, defined as an oxygen saturation <90% or a PaO2 <8 kPa (60 mm Hg), but not in patients with moderate hypoxemia or nocturnal desaturation.

Continuous supplemental oxygen should be used to improve exercise performance and survival in patients with moderate to severe COPD who have severe daytime hypoxemia. The Centers for Medicare and Medicaid Services (CMS) provides guidelines for supplemental oxygen therapy and sets the standard for nearly all adult oxygen prescriptions. According to these standards, oxygen therapy is covered for patients with a documented PaO2 :55 mm Hg or an oxygen saturation :88% on room air at rest.

Question 4

While making rounds on the rehabilitation floor of your hospital, you see a 62-year-old female who was recently transferred from the acute-care section of the hospital where she was admitted for urosepsis. She is a liver-transplant recipient and her specialist has been tapering her immunosuppressive drug regimen for the last 2 months. According to the nursing staff the patient became hypoxic suddenly and had a low-grade fever and cough. You note that she looks ill and uncomfortable, and has an increased respiratory rate. A chest radiograph reveals diffuse bilateral interstitial infiltrates.

Which one of the following is the most likely diagnosis? (check one)
Pneumococcal pneumonia
Staphylococcal pneumonia
Pneumocystis pneumonia
Pulmonary tuberculosis
Pneumothorax

Answer 4

Pneumocystis pneumonia

The most likely diagnosis is Pneumocystis pneumonia. Initially named Pneumocystis carinii, the causative organism has been reclassified and renamed Pneumocystis jiroveci. It causes disease in immunocompromised patients. In non–HIV-infected patients, the most significant risk factors are defects in cell-mediated immunity, glucocorticoid therapy, use of immunosuppressive agents (especially when dosages are being lowered), hematopoietic stem cell or solid organ transplant, cancer, primary immunodeficiencies, and severe malnutrition.

The clinical presentation in patients without HIV/AIDS is typically an acute onset of hypoxia and respiratory failure, associated with a dry cough and fever. Characteristic radiographic findings include diffuse bilateral interstitial infiltrates.

Pneumococcal pneumonia typically presents with fever, chills, cough, and pleuritic chest pain. A sudden onset of severe hypoxia is less common. Radiologic findings typically include lobar infiltrates or bronchopneumonia (with a segmental pattern of infiltrate), whereas diffuse bilateral infiltrates are much less common. Staphylococcal pneumonia usually has radiologic findings of focal, multiple infiltrates or cavitary lesions.

Pulmonary tuberculosis presents most commonly with pleuritic or retrosternal chest pain. Fever is present in about 25% of patients. Cough is actually less common, and a sudden onset of acute hypoxia would be a very rare presentation. Radiographs typically reveal hilar adenopathy and pleural effusion. Diffuse bilateral interstitial infiltrates would be a very rare finding.

Spontaneous pneumothorax does present with an acute onset of hypoxia, tachypnea, and respiratory distress. However, fever would be unlikely and the radiologic findings in this patient are not consistent with pneumothorax.

Question 5

An 18-month-old 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 management of this patient?
(check one)
Tracheal suction to clear the lower airways
Nasal suction to clear the upper airway
Chest physiotherapy
Corticosteroids
Azithromycin (Zithromax)

Answer 5

Nasal suction to clear the upper airway

Recommendations for the treatment of hospitalized infants with bronchiolitis include nasal suctioning via
bulb or neosucker to clear the upper airway. Deep suction (beyond the nasopharynx) is not recommended.
Oxygen is recommended for infants with a persistent oxygen saturation <90%. Bronchodilators should
not be used routinely in the management of bronchiolitis, and corticosteroids, antibiotics, nasal
decongestants, and chest physiotherapy are not recommended. A single trial of inhaled epinephrine or
albuterol for respiratory distress may be considered, but only if there is a history of asthma, atopy, or
allergy.

Question 6

An otherwise healthy 55-year-old male who is visiting from Arizona presents to your office with a 4-week history of intermittent fevers, night sweats, dry cough, weight loss, and myalgia. The patient has no other recent history of travel.

Of the following, the most likely cause of his symptoms is (check one)
blastomycosis
coccidioidomycosis
cryptococcosis
histoplasmosis
mucormycosis

Answer 6

coccidioidomycosis

Knowledge of endemic fungi capable of causing infection in otherwise healthy patients can be very helpful
in ensuring an appropriate evaluation. Coccidioidomycosis is a common infection in the southwestern
United States. In addition to the symptoms in this patient, coccidioidomycosis can also present with a rash
such as erythema nodosum. Histoplasmosis is most common in the Midwest and with low-level exposure
symptoms are usually mild or absent. Blastomycosis is also present in the Midwest, as well as in the
Atlantic and southeastern states. Symptoms include an abrupt onset of fever, chills, pleuritic chest pain,
arthralgias, and myalgias. The cough is initially nonproductive but frequently becomes purulent.
Cryptococcosis and mucormycosis are more opportunistic infections occurring in immunocompromised
hosts.

Question 7

A 40-year-old male respiratory therapist presents for a health examination prior to hospital
employment. His history indicates that as a child he lived on a farm in Iowa. His examination
is unremarkable, but a chest radiograph shows that both lung fields have BB-sized calcifications
in a miliary pattern. No other findings are noted. A PPD skin test is negative.

The findings in this patient are most likely a result of (check one)
HIV infection
histoplasmosis
coccidioidomycosis
tuberculosis
cryptococcosis

Answer 7

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 United
States. Exposure to bird or bat excrement is a common cause, and treatment is usually not needed. This
pattern is not characteristic of the other infections listed, although miliary tuberculosis is a remote
possibility despite the negative PPD skin test.

Question 8

Which one of the following therapeutic interventions improves outcomes in adults with acute respiratory distress syndrome (ARDS)? (check one)
Early initiation of antibiotics
Surfactant therapy
Pulmonary artery catheterization
Aggressive intravenous fluid resuscitation
Starting mechanical ventilation with lower tidal volumes

Answer 8

Starting mechanical ventilation with lower tidal volumes

In patients with acute respiratory distress syndrome (ARDS), starting mechanical ventilation with lower tidal volumes of 6 mL/kg is superior to starting with traditional tidal volumes of 10–14 mL/kg (SOR A). Conservative fluid therapy is recommended in patients with ARDS, as this is associated with a decrease in the number of days on the ventilator and in the intensive-care unit (SOR B). Pulmonary artery catheters are not recommended for routine management of ARDS (SOR A). Surfactant therapy does not improve mortality in adults with ARDS (SOR A), and antibiotics are not an effective treatment.

Question 9

A 60-year-old male with recently diagnosed squamous cell lung cancer presents to the emergency department with generalized weakness and altered mental status. He has a temperature of 36.9°C (98.4°F) and a blood pressure of 134/78 mm Hg. His pulse rate is 100 beats/min and regular. A physical examination reveals confusion and dry oral mucosa. An EKG reveals sinus rhythm with first-degree atrioventricular block and a short ST segment. Aside from his known lung mass, imaging studies including head CT and a chest radiograph are normal. Laboratory studies, including a CBC, comprehensive metabolic panel, and lactate level, are normal except for a serum calcium level of 14.0 mg/dL (N 8.0–10.0) and a creatinine level of 1.4 mg/dL (N 0.7–1.3).

Which one of the following is the most important first step to address his hypercalcemia? (check one)
A 2-liter intravenous fluid bolus with normal saline
Furosemide, 40 mg intravenously
Methylprednisolone (Solu-Medrol), 125 mg intravenously
Pamidronate, 90 mg intravenously
Placement of a large bore central venous dialysis catheter

Answer 9

A 2-liter intravenous fluid bolus with normal saline

This patient presents with malignant hypercalcemia, which in this case is most likely due to parathyroid hormone–related peptide (PTHrP) production from his squamous cell lung cancer. The first step in management is to correct the volume depletion that is associated with the hypercalcemia, which commonly occurs due to the combined effects of anorexia, nausea/vomiting, and nephrogenic diabetes insipidus. This often leads to extreme dehydration followed by a decreased glomerular filtration rate, which reduces the kidneys’ ability to excrete calcium, thereby compounding the electrolyte disturbance. An initial 2-liter intravenous fluid bolus in this case would be an appropriate first step. Once the volume status has been addressed and renal function is stabilized, additional treatment options may include loop diuretics such as furosemide, corticosteroids such as prednisone or methylprednisolone, and/or bisphosphonates such as pamidronate, depending on the clinical circumstances. In patients with severe chronic kidney disease or acute, life-threatening hypercalcemia, calcium may be removed via dialysis, although preparing for imminent dialysis would not be appropriate for this patient.

Question 10

A 45-year-old female presents to an urgent care center complaining of left-sided chest pain for the past 2 days. The pain is nonradiating and sharp in character, and increases with deep inspiration. She has no associated shortness of breath, cough, nausea, diaphoresis, or dizziness. She has no significant past medical history or recent travel history.

On examination she is afebrile, with a pulse rate of 102 beats/min, a blood pressure of 116/72 mm Hg, and a respiratory rate of 22/min. Her lungs are clear and her heartbeat is regular with no murmurs. Her lower extremities have no edema, tenderness, or varicosities.

Which one of the following is the most appropriate next step in her evaluation? (check one)
A high-sensitivity D-dimer test
A troponin I level
An antinuclear antibody level
Ultrasound examination of the veins of the lower extremities
Multidetector helical CT of the chest

Answer 10

A high-sensitivity D-dimer test

This patient has a low pretest probability of pulmonary embolism based on the Wells criteria. She would be a good candidate for a high-sensitivity D-dimer test, with a negative test indicating a low probability of venous thromboembolism. In patients with a low pretest probability of venous thromboembolism, ultrasonography or helical CT would not be the recommended initial evaluation. Neither troponin I nor an ANA level would be part of the recommended initial evaluation.

Question 11

A 32-year-old male presents to an urgent care center with a 2-day history of left calf pain and swelling, which started gradually a few hours after he played tennis. He remembers that he “tweaked” his calf on a serve late in the match but was able to continue playing. He has no history of prior medical problems, and no recent surgery or immobilization.

On examination his left calf appears slightly erythematous and swollen from the mid-calf to the ankle, with 1+ pitting over the lower leg. There is no venous distention. The left calf is 3 cm greater in circumference than the right calf. He has pain with dorsiflexion, and there is an area of tenderness in the medial calf.

Which one of the following is the most appropriate next step in ruling out deep vein thrombosis in this patient? (check one)
D-dimer
Ultrasonography
Venography
Impedance plethysmography

Answer 11

D-dimer

A number of pretest probability scoring systems are available for assessing venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism. Although the Wells clinical prediction rule is widely used, other tools such as the Hamilton score and the AMUSE (Amsterdam Maastricht Utrecht Study on thromboEmbolism) score are also available. The Wells rule divides patients suspected of having a DVT into low, intermediate, and high-risk categories, with a 5%, 17%, and 53% prevalence of DVT, respectively. This patient has a Wells score of 0 (+1 for calf circumference increase >3 cm, +1 for pitting edema, –2 for a likely alternative diagnosis of gastrocnemius strain) and is therefore at low risk. A negative D-dimer assay has a high negative predictive value for DVT, so the diagnosis can be ruled out in a patient who has a low pretest probability and a negative D-dimer result. A negative D-dimer assay does not rule out DVT in a patient with a moderate to high pretest probability (SOR C).

Question 12

A 44-year-old male in the intensive-care unit develops acute respiratory distress syndrome (ARDS). Which one of the following has been shown to improve outcomes in this situation? (check one)
Surfactant
Lower positive end-expiratory pressure (PEEP) settings
Lower tidal volumes
Aggressive fluid therapy
Pulmonary artery catheters

Answer 12

Lower tidal volumes

Acute respiratory distress syndrome (ARDS) may be caused by pulmonary sepsis or sepsis from another source, or it may be due to acute pulmonary injury, including inhalation of smoke or other toxins. Inflammatory mediators are released in response to the pulmonary infection or injury. The syndrome has an acute onset and is manifested by rapidly developing profound hypoxia with bilateral pulmonary infiltrates. The mortality rate in patients with ARDS may be as high as 55%.
Early recognition and prompt treatment with intubation and mechanical ventilation is necessary to improve chances for survival. Patients with ARDS should be started at lower tidal volumes (6 mL/kg) instead of the traditional volumes (10–15 mL/kg) (SOR A). These patients also often require higher positive end-expiratory pressure settings (SOR B).
Fluid management should be conservative to allow for optimal cardiorespiratory and renal function and to avoid fluid overload. However, the routine use of central venous or pulmonary artery pressure catheters is not recommended due to the potential complications associated with their use (SOR A). While surfactant is commonly used in children with ARDS, it does not improve mortality in adults (SOR A).

Question 13

A 70-year-old male without underlying lung disease presents with a 36-hour 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 examination the patient has a temperature of 38.8°C (101.8°F), a blood pressure of 90/50 mm Hg, a heart rate of 110 beats/min, and an 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 to the laboratory. A chest radiograph shows a large lobar pneumonia.

You hospitalize the patient and initiate? (check one)
ceftriaxone (Rocephin) and azithromycin (Zithromax)
levofloxacin (Levaquin)
oseltamivir (Tamiflu)
oseltamivir, ceftriaxone, and azithromycin
oseltamivir, ceftriaxone, azithromycin, and vancomycin (Vancocin)

Answer 13

oseltamivir, ceftriaxone, azithromycin, and vancomycin (Vancocin)

This patient has pneumonia, sepsis, and suspected coinfection with influenza. Although the rapid antigen-based nasal swab was negative, false-negative rates may be as high as 70% and this test should not be relied upon to rule out influenza. Treatment should include both antiviral and antibacterial agents that include coverage against methicillin-resistant Staphylococcus aureus (MRSA), the most common bacterial pathogen isolated from critically ill patients with coinfection. Oseltamivir, ceftriaxone, azithromycin, and vancomycin should be initiated empirically for the pneumonia and sepsis. The criteria for sepsis are satisfied by a temperature >38.3°C, a WBC count >12,000/mm3, a respiratory rate >20/min, and a source of probable infection.

Question 14

A 67-year-old female hospitalized with pneumonia develops the rapid onset of dyspnea, pleuritic chest pain, tachypnea, and hypoxemia not responding to oxygen and requiring intubation. A physical examination is notable for rales throughout both lung fields with no peripheral edema noted. A chest radiograph shows bilateral pulmonary infiltrates. Her BNP level is 90 ng/L.

Which one of the following is the most likely reason for her worsening clinical situation?
(check one)
Heart failure
Hypersensitivity pneumonitis
Acute respiratory distress syndrome
Pulmonary embolus
Pneumothorax

Answer 14

Acute respiratory distress syndrome

This patient demonstrates classic findings for acute respiratory distress syndrome (ARDS). In many cases ARDS must be differentiated from heart failure. Heart failure is characterized by fluid overload (edema), jugular venous distention, a third heart sound, an elevated BNP level, and a salutary response to diuretics. A BNP level <100 pg/mL can help rule out heart failure (SOR A). In addition, a patient with ARDS would not have signs of left atrial hypertension and overt volume overload.
Hypersensitivity pneumonitis is usually preceded by exposure to an inciting organic antigen such as bird feathers, mold, or dust. Pulmonary embolus, while certainly in the differential, is unlikely to cause such dramatic radiographic findings. Pneumothorax would be seen on the chest radiograph.

Question 15

An 80-year-old male nonsmoker with Parkinson’s disease is treated for community-acquired pneumonia with azithromycin (Zithromax), 500 mg/day for 10 days. On follow-up the patient feels better but still has a productive cough. A repeat chest radiograph reveals a single thin-walled cavity lesion in the left lower lobe.

It would be most appropriate to replace this patient’s azithromycin with?
(check one)
Doxycycline
Clindamycin (Cleocin)
Metronidazole (Flagyl)
Trimethoprim/sulfamethoxazole (Bactrim, Septra)

Answer 15

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 β-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 involved in pulmonary infections, and is therefore associated with a high failure rate when used to treat lung abscesses. Doxycycline does not cover anaerobes. Trimethoprim/sulfamethoxazole is also not considered a good anaerobic antibiotic.

Question 16

A 55-year-old male with a 10-pack-year history of smoking as a young adult sees you for follow-up after a recent hospitalization for community-acquired right lower lobe pneumonia. His symptoms resolved after standard antibiotic treatment.

Which one of the following should you recommend regarding follow-up radiography?
(check one)
No follow-up chest imaging
A standard chest radiograph 2 weeks after treatment
A standard chest radiograph 6 weeks after treatment
Standard chest CT 6 weeks after treatment
Low-dose chest CT 12 weeks after treatment and again in 1 year

Answer 16

No follow-up chest imaging

For most patients with community-acquired pneumonia and resolution in 7 days, a follow-up chest radiograph is not recommended. Exceptions would include suspicion of a possible mass or lymphadenopathy. Although this patient is over 50 years of age, he does not meet the criteria for low-dose CT screening for lung cancer, which is recommended in adults ages 50–80 who have a ³20-pack-year smoking history, and who currently smoke or have quit within the past 15 years.

Question 17

An 85-year-old 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 chest radiograph shows pleural plaques. He has a 20-pack-year smoking history, but quit at the age of 39.

You suspect his problem is due to occupational exposure to which one of the following?
(check one)
Asbestos
Beryllium
Iron oxide
Silica
Uranium

Answer 17

Asbestos

The inhalation of asbestos fibers may lead to a number of respiratory diseases, including lung cancer, asbestosis, pleural plaques, benign pleural effusion, 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. The occupational history helps to guide clinical suspicion in these high-risk populations. This patient is a retired U.S. Navy veteran who spent his entire career in ship maintenance and repair.

The patient history is not consistent with berylliosis, silicosis, or uranium exposure. Berylliosis is an occupational disease related to mining and manufacturing. Silicosis is seen in sandblasters, miners, persons who have worked with abrasives, and several other occupations. Uranium exposure occurs after nuclear reactor leaks or blasts. Uranium compounds are also used in photography and as dyes or fixatures. The chemical toxicity involves nonmalignant damage to alveolar cells. Iron oxide exposure is not known to be related to lung disease.

Question 18

Which one of the following is best for preventing acute mountain sickness?

(check one)
Acetazolamide (Diamox Sequels) started the day before arriving at altitude
Prednisone started the day before arriving at altitude
Moderate alcohol consumption on the first day at altitude
Ascending quickly, then resting to acclimatize before beginning planned activities

Answer 18

Acetazolamide (Diamox Sequels) started the day before arriving at altitude

Acute mountain sickness is common in people traveling to altitudes higher than 8200 ft. Symptoms include headache and at least one of the following: nausea or vomiting, anorexia, dizziness or lightheadedness, fatigue or weakness, and difficulty sleeping. Slow ascent is the most effective way to prevent acute mountain sickness. Acetazolamide or dexamethasone can be used for both prevention and treatment. Ataxia and altered mental status are signs of cerebral edema and occur with end-stage acute mountain sickness. This can progress to coma and death and requires prompt treatment and descent. High-altitude pulmonary edema can occur without acute mountain sickness. Alcohol consumption on the first day at altitude can exacerbate acute mountain sickness.

Question 19

A previously healthy 74-year-old male presents to the emergency department with a fever and altered mental status. His illness began 2 days ago with symptoms of fever, malaise, body aches, reduced appetite, nausea, and diarrhea. His temperature is 39.6°C (103.3°F) in the emergency department and his examination is nonfocal. Initial laboratory studies include a sodium level of 131 mEq/L (N 135–145) and a WBC count of 14,200/mm3 (N 4500–11,000) with a neutrophilic predominance. Blood and urine cultures are obtained and he is admitted to the hospital for observation.

The next morning he develops a productive cough and shortness of breath. You order a chest radiograph, which shows patchy consolidation of the bilateral bases.

Which one of the following is the most likely cause of this patient’s condition?
(check one)
Chlamydophila pneumoniae
Legionella pneumophila
Mycoplasma pneumoniae
Streptococcus pneumoniae

Answer 19

Legionella pneumophila

Pneumonia caused by Legionella pneumophila is commonly preceded by nonspecific systemic symptoms that may lead a clinician to consider other diagnoses. Symptoms may include high-grade fever, malaise, myalgias, anorexia, and headache. Gastrointestinal and neurologic symptoms are also common and include nausea, vomiting, abdominal pain, diarrhea, and confusion. Focal neurologic signs are less common, but have been reported. Localizing respiratory symptoms will typically develop later, most often a dry cough and dyspnea. From this point on the illness resembles a typical pneumonia with fever, productive cough, pleuritic pain, and breathlessness.

Question 20

You see a 55-year-old female for the first time. She has a 2-year history of chronic daily cough; thick, malodorous sputum; and occasional hemoptysis. She has been treated with antibiotics for recurrent respiratory infections, but is frustrated with her continued symptoms. She has never smoked. Her FEV1/FVC ratio is 60% and CT shows bronchial wall thickening and luminal dilation.

The most likely diagnosis is?
(check one)
Emphysema
Bronchiectasis
Chronic bronchitis
Bronchiolitis
Asthma

Answer 20

Bronchiectasis

Bronchiectasis is an illness of the bronchi and bronchioles involving obstructive and infectious processes that injure airways and cause luminal dilation. In addition to daily viscid, often purulent sputum production with occasional hemoptysis, wheezing and dyspnea occur in 75% of patients. 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 secondary to respiratory syncytial virus infection in young children. Asthma is not characterized by the sputum and CT findings seen in this patient.

Question 21

A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea,
cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note
conjunctivitis, and a chest examination reveals tachypnea and crackles. A chest film shows
hyperinflation and diffuse interstitial infiltrates and a WBC count reveals eosinophilia.
What is the most likely etiologic agent? (check one)
Staphylococcus species
Chlamydia trachomatis
Respiratory syncytial virus
Parainfluenza virus

Answer 21

Chlamydia trachomatis

Chlamydial pneumonia is usually seen in infants 3–16 weeks of age, and these patients frequently have
been sick for several weeks. The infant appears nontoxic and is afebrile, but is tachypneic with a prominent
cough. The physical examination will reveal diffuse crackles with few wheezes, and conjunctivitis is
present in about 50% of cases. A chest film will show hyperinflation and diffuse interstitial or patchy
infiltrates.
Staphylococcal pneumonia has a sudden onset. The infant appears very ill and has a fever, and initially
may have an expiratory wheeze simulating bronchiolitis. Signs of abdominal distress, tachypnea, dyspnea,
and localized or diffuse bronchopneumonia or lobar disease may be present. The WBC count will show
a prominent leukocytosis.
Respiratory syncytial virus infections start with rhinorrhea and pharyngitis, followed in 1–3 days by a
cough and wheezing. Auscultation of the lungs will reveal diffuse rhonchi, fine crackles, and wheezes, but
the chest film is often normal. If the illness progresses, coughing and wheezing increase, air hunger and
intercostal retractions develop, and evidence of hyperexpansion of the chest is seen. In some infants the
course of the illness may be similar to that of pneumonia. Rash or conjunctivitis may occur occasionally,
and fever is an inconsistent sign. The WBC count will be normal or elevated, and the differential may be
normal or shifted either to the right or left. Chlamydial infections can be differentiated from respiratory
syncytial virus infections by a history of conjunctivitis, the subacute onset and absence of fever, and the
mild wheezing. There may also be eosinophilia.
Parainfluenza virus infection presents with typical cold symptoms. Eight percent of infections affect the
upper respiratory tract. In children hospitalized for severe respiratory illness, parainfluenza viruses account
for about 50% of the cases of laryngotracheitis and about 15% each of the cases of bronchitis,
bronchiolitis, and pneumonia.

Question 22

A 40-year-old white male was seen 4 weeks ago for a sudden onset of cough and shortness of breath. At that visit his O2 saturation was 92%, but his examination and a chest radiograph were normal. You prescribed azithromycin (Zithromax) and an albuterol inhaler (Proventil, Ventolin). Ten days later he was feeling well and his oxygen saturation was 97%. Today he returns to the office with a dry cough and shortness of breath.

On examination he has rare inspiratory rales that clear with deep breaths, and he has an O2 saturation of 86%. A chest film and a D-dimer test are normal. Pulmonary function tests show significant restriction that improves only minimally with albuterol. He has not been exposed to anyone with a similar illness, has no history of asthma, and has no smoking history or occupational exposure. However, he reports that 2 months ago his home was flooded after a heavy rain, and he has been tearing out carpeting that was ruined by the flood.

Which one of the following is the most likely diagnosis?
(check one)
Persistent asthma with acute exacerbations
Legionnaires’ disease
Pulmonary embolism
Hypersensitivity pneumonitis

Answer 22

Hypersensitivity pneumonitis

Hypersensitivity pneumonitis can present in acute, subacute, or chronic forms. The case described includes two episodes of the acute form. The patient was exposed to mold antigens in his flooded home. Within 4–8 hours of exposure, chills, cough, and shortness of breath will be noted, and at times will be dramatic. A chest film can be normal, even with significant hypoxia. Pulmonary function tests will show restrictive changes, as compared to the reversible obstructive changes of acute asthma. Blood tests often show an elevated erythrocyte sedimentation rate. Serum IgG tests for the probable antigen confirm the diagnosis.

Symptoms of acute hypersensitivity pneumonitis resolve over several days, but will suddenly and violently recur with repeated exposure to the offending antigen. The subacute form begins gradually over weeks or months, causing a cough and increasing shortness of breath. The chronic form develops over years of exposure, causing fibrotic changes to the lungs that will be evident on radiographs, as well as chronic crackles on auscultation.

Asthma would be an unlikely diagnosis in this case, with the pulmonary function tests showing restrictive changes rather than obstructive changes, and little improvement with albuterol. Also, the lack of a previous history of asthma makes it less likely. Legionnaires’ disease is always possible, but is unlikely in this case given the sudden onset, quick recovery over several days, and sudden recurrence. Pulmonary embolism is ruled out by the negative D-dimer test.

Question 23

Which one of the following medications is most appropriate for treating moderate to severe shortness of breath in a hospice patient with lung cancer? (check one)
Dexamethasone
Haloperidol
Scopolamine
Morphine

Answer 23

Morphine

Morphine effectively decreases the feeling of shortness of breath in hospice patients. Randomized, controlled trials have shown significant improvements in symptoms without a significant change in oxygen saturation. Haloperidol can be used for nausea and vomiting (SOR B) and delirium, but is not helpful in the treatment of shortness of breath. Scopolamine is used to decrease the production of secretions but is not helpful for treating dyspnea. Corticosteroids will not manage the sensation of shortness of breath in a dying patient.

Question 24

Which one of the following comorbid conditions increases the risk that latent tuberculosis
infection will progress to active disease? (check one)
Hypertension
Lung Cancer
Obesity
Hyperlipidemia

Answer 24

Lung Cancer

Risk factors for progression from latent to active tuberculosis include lung cancer, diabetes mellitus,
alcoholism, recent contact with a person who has an active tuberculosis infection, any condition treated
with immunosuppressive therapy, and lung parenchymal diseases such as COPD, silicosis, or lung cancer.
The medically underserved and those in low-income groups are also more at risk of progression, as well
as children under age 5 and individuals weighing less than 90% of their ideal minimum body weight.

Question 25

A 54-year-old white male presents with drooping of his right eyelid for 3 weeks. On examination, he has ptosis of the right upper lid, miosis of the right pupil, and decreased sweating on the right side of his face. Extraocular muscle movements are intact. In addition to a complete history and physical examination, which one of the following would be most appropriate at this point? (check one)
A chest radiograph
MRI of the brain and orbits
131I thyroid scanning
A fasting blood glucose level
An acetylcholine receptor antibody level

Answer 25

A chest radiograph

The clinical triad of Horner’s syndrome-ipsilateral ptosis, miosis, and decreased facial sweating-suggests decreased sympathetic innervation due to involvement of the stellate ganglion, a complication of Pancoast’s superior sulcus tumors of the lung. Radiographs or MRI of the pulmonary apices and paracervical area is indicated. Horner’s syndrome may accompany intracranial pathology, such as the lateral medullary syndrome (Wallenbergs syndrome), but is associated with multiple other neurologic symptoms, so MRI of the brain is not indicated at this point. The acetylcholine receptor antibody level is a test for myasthenia gravis, which can also present with ptosis, but not with full-blown Horner’s syndrome. Diabetes mellitus and thyroid disease do not commonly present with Horner’s syndrome.

Question 26

A 71-year-old male who resides at sea level travels to Colorado for a vacation. He spends the first night in a resort at 2700 m (8858 ft) above sea level. He notes a headache and sleeps poorly. The next morning he is somewhat nauseated and lightheaded, but feels well enough to proceed with his plans and ascends to his campsite at 4000 m (13,123 ft). During the first evening at the campsite, friends note that he is confused and having difficulty with his balance.

Which one of the following diagnoses best explains his symptoms at the campsite? (check one)
Acute mountain sickness
High-altitude cerebral edema
High-altitude headache
High altitude–induced central sleep apnea
High-altitude pulmonary edema

Answer 26

High-altitude cerebral edema

This patient likely had a high-altitude headache on arrival, central sleep apnea during his first night in the hotel, and acute mountain sickness by the next morning. None of these conditions are life-threatening, and proper acclimatization would have been helpful. The addition of ataxia and confusion to his symptom list points to high-altitude cerebral edema, which can progress to coma and death. Immediate descent is indicated. Symptoms of high-altitude pulmonary edema include cough with pinkish sputum, respiratory distress, and cyanosis.

Question 27

A 57-year-old male presents to the emergency department complaining of dyspnea, cough, and
pleuritic chest pain. A chest radiograph 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?
(check one)
Cirrhosis
Heart Failure
Nephrotic syndrome
Pulmonary embolism
Superior vena cava obstruction

Answer 27

Pulmonary embolism

The protein and lactate dehydrogenase (LDH) levels in pleural fluid can help differentiate between
transudative and exudative effusions. 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%–96% of cases. Of the listed pleural effusion etiologies, only pulmonary
embolism is exudative. The remainder are all transudative.

Question 28

A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea, cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note conjunctivitis, and a chest examination reveals tachypnea and rales. A chest film shows hyperinflation and diffuse interstitial infiltrates. A WBC count reveals eosinophilia.
What is the most likely etiologic agent?
(check one)
Staphylococcus species
Chlamydia trachomatis
Respiratory syncytial virus
Parainfluenza virus

Answer 28

Chlamydia trachomatis

Chlamydial pneumonia is usually seen in infants 3–16 weeks of age, and they frequently have been sick for several weeks. The infant appears nontoxic and is afebrile, but is tachypneic with a prominent cough. Physical examination reveals diffuse rales with few wheezes. Conjunctivitis is present in about 50% of cases. The chest film shows hyperinflation and diffuse interstitial or patchy infiltrates.
Staphylococcal pneumonia has a sudden onset. The infant appears very ill and has a fever. At the time of onset there may be an expiratory wheeze simulating bronchiolitis. Signs of abdominal distress, tachypnea, dyspnea, and localized or diffuse bronchopneumonia or lobar disease may be present. The WBC count shows a prominent leukocytosis.

Respiratory syncytial infections start with rhinorrhea and pharyngitis, followed in 1–3 days by cough and wheezing. Auscultation reveals diffuse rhonchi, fine rales, and wheezes. The chest film is often normal. If the illness progresses, cough and wheezing increase, air hunger and intercostal retractions develop, and evidence of hyperexpansion of the chest is seen. In some infants, the course of the illness may be similar to that of pneumonia. Rash or conjunctivitis may occur occasionally, and fever is an inconsistent sign. The WBC count is normal or elevated, and the differential may be normal or shifted either to the right or left. Chlamydial infections may be differentiated from respiratory syncytial infections by a history of
conjunctivitis and a subacute onset. Coughing is prominent, but wheezing is not. There may also be
eosinophilia. Fever is usually absent.

Parainfluenza virus infection presents with typical cold symptoms. Eight percent of infections affect the upper respiratory tract. In children hospitalized for severe respiratory illness, parainfluenza viruses account for about 50% of the cases of laryngotracheitis and about 15% each of the cases of bronchitis, bronchiolitis, and pneumonia.

Question 29

A patient’s office spirometry results reveal a normal FEV1/FVC ratio and a decreased FVC. Which one of the following is the most likely explanation for these findings? (check one)
A normal pattern
A mixed pattern
A restrictive pattern
A reversible obstructive pattern
An irreversible obstructive pattern

Answer 29

A restrictive pattern

Forced vital capacity (FVC) is the total amount of air that can be expelled from full lungs. A decreased FVC on spirometry indicates a restrictive pattern. FEV1 is the volume of air (in liters) that is exhaled in the first second during forced exhalation after maximal inspiration. A normal FEV1/FVC ratio and normal FVC would indicate a normal pattern. A decreased FEV1/FVC ratio with a decreased FVC is consistent with a mixed pattern. A reduced FEV1/FVC ratio indicates an obstructive pattern. A bronchodilator is then utilized to determine whether the obstructive pattern is reversible or irreversible.

Question 30

A 6-year-old male presents with a cough and a fever. His vital signs include a temperature of 38.0°C (100.4°F), a heart rate of 120 beats/min, a respiratory rate of 22/min, a blood pressure of 90/52 mm Hg, and an oxygen saturation of 94% on room air. An examination reveals a child who is occasionally coughing but is in no acute distress. The mucous membranes are moist and capillary refill time is 2 seconds. There are no retractions, nasal flaring, use of accessory muscles of respiration, or any other signs of respiratory distress. The heart is mildly tachycardic without murmur and the lungs have rhonchi in the left lung base. Rapid tests for influenza and COVID-19 are negative. You suspect typical community-acquired pneumonia.

Which one of the following would be the most appropriate next step in the management of this patient’s condition? (check one)
Oral amoxicillin
Oral doxycycline
Intramuscular ceftriaxone
Withholding antibiotics until the diagnosis is confirmed with radiography
Hospitalization for intravenous antibiotics

Answer 30

Oral amoxicillin

This child presents with symptoms and signs consistent with community-acquired pneumonia. Since the child is well hydrated and in no distress, outpatient therapy with oral antibiotics is most appropriate. The preferred first-line antibiotic is amoxicillin. In patients older than 7 years of age, doxycycline is an alternative option when an atypical bacterial cause is presumed likely. Intramuscular ceftriaxone, withholding antibiotics until the diagnosis is confirmed with radiography, and hospitalization for intravenous antibiotics would not be appropriate in this case.

Question 31

You are reviewing the home health care progress report of a 68-year-old female who was hospitalized with pneumonia 2 months ago. The patient moved to the area to live with her daughter following treatment for breast cancer 5 years earlier. Before the hospitalization her only medical needs had been for preventive services, treatment for hypertension, and surveillance for problems related to her chemotherapy and for return of her cancer. During the recent hospitalization oxygen supplementation was required to maintain healthy oxygen saturation levels, and after failing several attempts at weaning, home oxygen service was arranged.

You ask the home health nurse to test the patient’s oxygen saturation after 1 hour on room air and the nurse reports that the patient’s oxygen saturation is now consistently above 90% on room air. The care plan provided by the home health service includes a recommendation for the continuation of supplemental oxygen.

Which one of the following would be most appropriate for this patient? (check one)
Order arterial blood gas studies to confirm her oxygenation status
Discontinue oxygen supplementation
Discontinue daytime use of oxygen and continue nighttime oxygen
Continue oxygen use, but only as needed when short of breath
Continue oxygen use to obtain a saturation >92% on room air

Answer 31

Discontinue oxygen supplementation

Hypoxemia following an acute illness is often short-lived and as many as half the patients prescribed home oxygen on discharge from the hospital will not meet criteria supporting continuation after 3 months. For this group of patients there is no apparent benefit derived from supplemental oxygen once their oxygen saturation is 88% or greater on room air. Potential harmful effects of continuing unnecessary home oxygen include decreased mobility, falls, house fires, and mucosal irritation, and oxygen toxicity must be considered as well. Continuing home oxygen beyond what is needed also results in a misallocation of resources. According to the American Thoracic Society and the American College of Chest Physicians, prescriptions for supplemental home oxygen should not be renewed for patients who have recently been hospitalized for acute illnesses without assessing them for ongoing hypoxemia.

Question 32

A previously healthy 57-year-old patient who smokes is hospitalized and treated with a fluoroquinolone for community-acquired pneumonia. Which one of the following could be expected with a 5-day course of antibiotics compared to a longer course in patients such as this? (check one)
Slower clinical improvement
Higher hospital readmission rates
Higher mortality rates
Slower resumption of normal activity
No difference in clinical outcome

Answer 32

No difference in clinical outcome

A 5-day course of antibiotics for community-acquired pneumonia produces the same clinical success rates as longer treatment programs. There is no difference in the rate of clinical improvement, hospital readmissions, or mortality between longer or shorter treatment courses. Patients are often discharged from the hospital before significant clinical improvement occurs, leading both patients and physicians to believe that longer antibiotic courses must be prescribed. Physicians must educate their patients about the benefit of shorter antibiotic courses, including fewer adverse effects, lower cost, and lower rates of bacterial resistance.

Question 33

A 46-year-old male with a 30-pack-year smoking history has had multiple episodes of coughing up blood that he describes as a “quarter size” amount. This has happened over the last couple of days. He has not had any chronic cough and has not been ill. A chest radiograph is negative.

Which one of the following would be the most appropriate management at this point? (check one)
Observation with no further workup unless the cough persists for >1 month or the quantity of hemoptysis increases
CT of the chest
Referral for bronchoscopy
Referral for nasolaryngoscopy

Answer 33

CT of the chest

While a plain chest radiograph should come first in the workup for hemoptysis, patients with normal radiographs who have a higher risk of malignancy (age 40 and a smoking history of 30 years) should undergo CT, usually with contrast. If CT is negative, pulmonary consultation and possible bronchoscopy should be pursued. Nasolaryngoscopy is not indicated if the initial history and examination do not indicate an upper airway source. Observation alone is not appropriate in patients with risk factors for malignancy.

Question 34

A 67-year-old female sees you because of a cough she has had for the past few days and
a fever that started today. She is short of breath and generally does not feel well. She has no history of lung disease and is a nonsmoker. Her medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus, all of which are well managed with medications and diet.
A physical examination reveals a mildly ill-appearing female with a temperature of 38.2°C (100.8°F), a pulse rate of 90 beats/min, a respiratory rate of 21/min, a blood pressure of 110/60 mm Hg, and an oxygen saturation of 98% on room air. Her heart has a regular rhythm and her respirations appear unlabored. She has rhonchi in the left lower lung field but has good air movement overall. A chest radiograph reveals a left lower lobe infiltrate.

Which one of the following is the most appropriate setting for the management of this patient’s pneumonia? (check one)
Home with close monitoring
An inpatient medical bed without telemetry monitoring
An inpatient medical bed with telemetry monitoring
An inpatient intensive care bed

Answer 34

Home with close monitoring

For community-acquired pneumonia, an important decision point is the severity of illness that indicates the need for inpatient care. There are multiple tools for evaluation of pneumonia severity, including SMART-COP (predicts the likelihood of the need for invasive ventilation or vasopressor support), the Pneumonia Severity Index (predicts the risk of 30-day mortality and the need for admission to the intensive-care unit), and CURB-65 or CRB-65. In an outpatient setting, CURB-65 and CRB-65 are easy to use, although they have weaker predictive values for 30-day mortality. In addition, clinical judgment should always be used. In this scenario, the patient does not clinically appear markedly ill, and her vital signs and physical examination do not fit any criteria for increased risk in any of the scoring systems. Her only risk factor is age 65 years, and those with zero or one criteria for CURB-65 or CRB-65 can be managed as outpatients.

Question 35

A 48-year-old male with a history of type 2 diabetes, obesity, and tobacco use disorder presents to your office for evaluation of a 4-day history of fever, malaise, and a productive cough. He smokes a half-pack of cigarettes per day but does not use recreational drugs or drink alcohol in excess. He has no known medication allergies.

Aside from a temperature of 38.2°C (100.8°F) and a BMI of 32 kg/m2, his vital signs, including oxygen saturation, are normal. On physical examination he appears mildly ill although well hydrated and is breathing comfortably. Lung auscultation reveals focal right-sided crackles and decreased breath sounds.

Which one of the following oral treatment options would be best in this situation? (check one)
Amoxicillin
Cefuroxime
Doxycycline
Amoxicillin/clavulanate (Augmentin) plus azithromycin (Zithromax)
Cephalexin plus sulfamethoxazole/trimethoprim (Bactrim)

Answer 35

Amoxicillin/clavulanate (Augmentin) plus azithromycin (Zithromax)

This patient presents with symptoms and examination findings that are consistent with community-acquired pneumonia (CAP) with significant medical comorbidity, and he is stable for outpatient treatment. Medical comorbidities in this context include chronic heart, lung, liver, or kidney disease; diabetes mellitus; alcohol use disorder; cancer; or asplenia. One option for treatment in this situation is monotherapy with a respiratory fluoroquinolone, such as levofloxacin or moxifloxacin. Other options for outpatient treatment of CAP in adults with comorbidities include either the β-lactam amoxicillin/clavulanate or a cephalosporin (specifically cefpodoxime, a third-generation cephalosporin, or cefuroxime, a second-generation cephalosporin), in combination with either doxycycline or a macrolide (SOR A). Of the available choices, only amoxicillin/clavulanate plus azithromycin would provide the appropriate spectrum of antimicrobial coverage.§Amoxicillin or doxycycline monotherapy would be appropriate outpatient CAP treatment for an adult without a significant medical comorbidity. Another option in such a case is a macrolide such as azithromycin if the local pneumococcal resistance rate to macrolides is known to be less than 25% (SOR B). Oral cefuroxime would be appropriate in combination with either doxycycline or azithromycin in this scenario, but it would not provide broad enough coverage as monotherapy. Sulfamethoxazole/trimethoprim has encountered increasing pneumococcal resistance over the past several decades and therefore does not factor into current management for CAP, either alone or in combination with cephalexin, a first-generation cephalosporin that provides coverage against skin flora but not against typical CAP pathogens.

Question 36

A 25-year-old female was involved in a motor vehicle accident 2 weeks ago. A chest radiograph to assess for rib fractures revealed bilateral hilar lymphadenopathy. She thinks that her mother had a similar finding when she was younger. Records from the emergency department reveal that a CBC, comprehensive metabolic panel, and urinalysis were all normal.

The patient has never been sexually active, does not take any medications, and does not smoke or use any illicit drugs. Her rib pain has since resolved and she has no other symptoms. She does not have a cough, dyspnea, weight loss, or skin lesions. Spirometry in the office today is normal.

Which one of the following would be the most appropriate next step? (check one)
A follow-up visit and a repeat chest radiograph in 6 months
Oral prednisone, 40 mg daily for 4 weeks
CT of the chest, abdomen, and pelvis
Formal pulmonary function tests
Referral for bronchoscopy with a biopsy

Answer 36

A follow-up visit and a repeat chest radiograph in 6 months

Given this patient’s age, lack of symptoms, and possible family history, the presence of asymptomatic
bilateral hilar lymphadenopathy most likely represents stage 1 pulmonary sarcoidosis. Because the patient
does not have any symptoms and stage 1 sarcoidosis resolves in most cases, the most prudent course is to
reevaluate her in 6 months with a careful history, a physical examination, and a chest radiograph. Given
the normal spirometry results, pulmonary function tests are not needed at this time. Neither CT nor a lung
biopsy would change management at this time. Treatment is not indicated in stage 1 sarcoidosis but would
be merited if she developed increasing pulmonary symptoms or any extrapulmonary symptoms.

Question 37

A 60-year-old male presents with a several-month history of a dry cough and progressive shortness of breath with exertion. On examination he has tachypnea and bibasilar end-inspiratory dry crackles, and a chest radiograph reveals interstitial opacities.

Which one of the following patient occupations would most likely support a diagnosis of silicosis? (check one)
Baker
Firefighter
Stone cutter
Goat dairy farmer
High-tech electronics fabricator

Answer 37

Stone cutter

Family physicians should be aware of the environmental exposures associated with pulmonary disease. Stone cutting, sand blasting, mining, and quarrying expose patients to silica, which is an inorganic dust that causes pulmonary fibrosis (silicosis). Occupational exposure to beryllium, which is also an inorganic dust, occurs in the high-tech electronics manufacturing industry and results in chronic beryllium lung disease. Exposure to organic agricultural dusts (fungal spores, vegetable products, insect fragments, animal dander, animal feces, microorganisms, and pollens) can result in “farmer’s lung,” a hypersensitivity pneumonitis. Other organic dust exposures, such as exposures to grain dust in bakers, can lead to asthma, chronic bronchitis, and COPD. Firefighters are at risk of smoke inhalation and are exposed to toxic chemicals that can cause many acute and chronic respiratory symptoms.

Question 38

A 68-year-old male presents to your office with a 2-day history of headache, muscle aches, and chills. His wife adds that his temperature has been up to 104.1°F and he seems confused sometimes. His symptoms have not improved with usual care, including ibuprofen and increased fluid intake. He and his wife returned from a cruise 10 days ago but don’t recall anyone having a similar illness on the ship. This morning he started to cough and his wife was concerned because she saw some blood in his sputum. He also states that he experiences intermittent shortness of breath and feels nauseated. His blood pressure is 100/70 mm Hg, heart rate 98/min, temperature 39.4°C (102.9°F), and oxygen saturation 95% on room air.

Which one of the following would be the preferred method to confirm your suspected diagnosis of Legionnaires’ disease? (check one)
Initiating azithromycin (Zithromax) to see if symptoms improve
A chest radiograph
Legionella polymerase chain reaction (PCR) testing
A sputum culture for Legionella
Urine testing for Legionella pneumophila antigen

Answer 38

Urine testing for Legionella pneumophila antigen

A urine test for Legionella pneumophila antigen is the preferred method to confirm Legionnaires’ disease. This test is rapid and will only detect Legionella pneumophila antigen. A sputum culture is the gold standard for the diagnosis of Legionnaires’ disease but it requires 48–72 hours. A chest radiograph does not confirm the diagnosis but may show the extent of disease. Responding to antibiotic treatment does not confirm a specific diagnosis.

Question 39

A 56-year-old male presents with a 2-day history of a fever and productive cough. He has mild dyspnea with exertion and has pain in his right side when he takes a deep breath. On examination his temperature is 38.4°C (101.1°F), his respiratory rate is 24/min, his pulse rate is 92 beats/min, and his oxygen saturation is 92% on room air. He has crackles in the right lower lung posteriorly. The remainder of the examination is normal.

The most likely diagnosis is (check one)
upper respiratory infection
community-acquired pneumonia
heart failure
pulmonary embolus
acute leukemia

Answer 39

community-acquired pneumonia

This patient has pneumonia based on the clinical presentation and the physical findings of fever, cough, and abnormal lung findings. A fever would not be a typical finding in pulmonary embolus or heart failure. An upper respiratory infection is unlikely given the abnormal lung findings that suggest a lower respiratory tract infection. This would not be a typical presentation for acute leukemia.

Question 40

A 2-year-old female is brought to your office with a 3-day history of rhinorrhea, fever, cough, and increasing dyspnea. Her past medical history is unremarkable and she is up to date on her immunizations. She has a respiratory rate of 40/min, a pulse rate of 120 beats/min, a temperature of 37.8°C (100.0°F), and an oxygen saturation of 93% on room air. She is alert and irritable, and has clear rhinorrhea and expiratory wheezing, but good airflow overall. The remainder of the examination is normal.

Which one of the following would be most appropriate at this time? (check one)
Supportive treatment only
Nebulized racemic epinephrine (Asthmanefrin)
Nebulized albuterol
A single dose of dexamethasone
A 5-day course of methylprednisolone (Medrol)

Answer 40

Supportive treatment only

No pharmacologic treatment shortens the course of viral bronchiolitis in a young child. Supplemental oxygen is indicated if the oxygen saturation falls below 90%, but otherwise the most effective treatment is simply supportive care (fluids, antipyretics, nasal bulb suction, etc.). None of the pharmacologic options listed are recommended in the treatment of bronchiolitis in this scenario.

Question 41

You see a 4-month-old male in your office with a 2-day history of cough, runny nose, fever, poor feeding, and difficulty breathing. He was born at 38 weeks gestation via a normal spontaneous vaginal delivery after an uncomplicated pregnancy. He did well after birth and went home with his mother after a 48-hour hospital stay. He is breastfed and had been doing well until now. He has breastfed much less than usual today and has had no wet diapers in the last 8 hours.

On examination you note a temperature of 38.9°C (102.0°F), a pulse rate of 176 beats/min, a respiratory rate of 66/min, and an oxygen saturation of 92% on room air. The patient generally appears tachypneic and clingy, is fussy during the examination, and has notable subcostal retractions and nasal flaring. A nasal examination reveals crusted mucus at the nares bilaterally. Examination of the mouth reveals no oral lesions. A cardiovascular examination reveals tachycardia with a regular rhythm and no murmur. Auscultation of the lungs reveals diffuse crackles and wheezes without focal findings. His extremities are warm, with a capillary refill time of <3 sec.

In addition to oral or intravenous rehydration, which one of the following treatment plans is most appropriate for this patient at this time? (check one)
Send the child home and follow up tomorrow
Admit to the hospital for supportive care only
Admit to the hospital for inhaled bronchodilators
Admit to the hospital for inhaled bronchodilators and oral dexamethasone
Admit to the hospital for inhaled bronchodilators, oral dexamethasone, and intravenous antibiotics

Answer 41

Admit to the hospital for supportive care only

This patient has classic signs and symptoms of viral bronchiolitis, likely due to respiratory syncytial virus (RSV). A chest radiograph is not indicated in a patient with a classic presentation and no focal findings on examination. Most concerning is his history of low urine output, suggesting inadequate oral intake. This is often related to a high respiratory rate and copious nasal secretions. The patient requires hospitalization for monitoring of his respiratory status and supportive care, including intravenous or nasogastric rehydration. At this time the infant does not require supplemental oxygen, as his oxygen saturation is above 90%. Many medications have been studied for the treatment of bronchiolitis in children and most have been found to not provide benefit with regard to the need for hospitalization, length of hospitalization, or disease resolution. Medications that are NOT recommended include inhaled bronchodilators, inhaled epinephrine, inhaled or systemic corticosteroids, and antibiotics.

Question 42

A 62-year-old male presents with bright red hemoptysis. While not severe, it is recurrent and has persisted for several weeks. He is otherwise asymptomatic.

A thorough history and physical examination does not provide any additional clues. Gastrointestinal and ear, nose, and throat etiologies are considered and are not thought to be the cause. Posteroanterior and lateral chest radiographs are normal.
Which one of the following would be the most appropriate next step in diagnosis? (check one)
Antineutrophil cytoplasmic antibody (ANCA) testing
A sputum smear for acid-fast bacillus
Sputum cytology
CT of the chest
Bronchoscopy

Answer 42

CT of the chest

A chest radiograph is appropriate in the initial evaluation of hemoptysis (SOR C). If the chest radiograph does not indicate a cause, then CT or CT angiography with intravenous contrast should be performed (SOR C). CT has become the preferred modality over bronchoscopy because it is more effective in determining the etiology. If CT does not identify the cause, bronchoscopy would be the next step. In addition, other tests including a sputum Gram stain, acid-fast bacillus smear, or sputum cytology can be useful depending upon the clinical situation.

If there are concerns about the possibility of immunologic, rheumatologic, or vasculitic disease, testing for immunologic antibodies such as antineutrophil cytoplasmic antibody (ANCA) can be ordered.

Question 43

A 54-year-old male presents to your office with a 2-day history of mild right anterior chest pain with deep breathing. He reports that it has been sharp and constant and is preventing him from sleeping. He also describes shortness of breath and a cough productive of white sputum. He reports that prior to this episode he had been in good health, and he has not experienced these symptoms in the past.

On examination his blood pressure is 140/88 mm Hg, his temperature is 37.1°C (98.8°F), his pulse rate is 88 beats/min, and his oxygen saturation is 95% on room air. Heart auscultation reveals a regular rhythm with no murmur. His lungs are clear. Examination of the lower extremities reveals no edema or tenderness. A chest radiograph is normal. An EKG reveals right bundle branch block.

Which one of the following would you order next? (check one)
A D-dimer level
Compression ultrasonography
Echocardiography
A ventilation-perfusion scan of the lungs
CT angiography of the lungs

Answer 43

A D-dimer level

Validated clinical prediction rules can be used to estimate the pretest probability of deep vein thrombosis (DVT) and pulmonary embolism in a patient with dyspnea and chest pain, and to guide further evaluation (SOR C). Factors used for calculating the pretest probability include elevated heart rate without hemoptysis, a diagnosis of cancer, recent surgery/immobilization, previous thromboembolism, and signs and symptoms of DVT. Based on these rules the patient described in the scenario has a low score and therefore a low probability of pulmonary embolism.

A D-dimer level is the next most appropriate test for this low-probability scenario. Compression ultrasonography would be the next test for a patient with an intermediate or high pretest probability for DVT. CT angiography would be the next test for a clinically stable patient with an intermediate or high pretest probability of pulmonary embolism. A ventilation-perfusion scan would be the next test if a CT angiogram were indicated in a patient with a contraindication such as contrast allergy, renal disease, or pregnancy. Echocardiography would be the next test for a critically ill patient with a high pretest probability of pulmonary embolism.

Question 44

A 30-year-old male is taking a motorcycle trip in 6 weeks to Colorado, including a ride to the top of Pikes Peak (elevation 14,100 ft). He has never been above 5000 ft prior to this trip and is concerned about developing acute mountain sickness (AMS). He is generally healthy and takes no medications, but smokes 1 pack of cigarettes per day. He is allergic to penicillin.

Which one of the following is the best option for this patient to reduce his risk of developing AMS? (check one)
An intensive aerobic fitness program
Varenicline (Chantix) for smoking cessation
Prophylaxis with acetazolamide
Prophylaxis with Ginkgo biloba

Answer 44

Prophylaxis with acetazolamide

Acute mountain sickness (AMS) occurs in at least 25% of persons traveling to destinations over 8000 feet above sea level. Risk factors include rapid ascent, living at low altitudes (<2000 ft), a prior history of altitude illness, and strenuous physical exertion during the ascent. AMS is most often manifested by headache, fatigue, lightheadedness, and/or nausea. The best way to prevent AMS is gradual ascent, but medications may also be effective in prophylaxis, especially if a rapid ascent such as in motorcycling, driving, or flying to altitude is planned.

The drug of first choice in preventing AMS is acetazolamide, a carbonic anhydrase inhibitor, starting the day before ascent. It is, however, contraindicated in patients with sulfa allergy. The second-line drug for prevention is dexamethasone, which should be used for prophylaxis in sulfa-allergic patients. It is also used in the treatment of AMS and high-altitude cerebral or pulmonary edema, but immediate descent of at least 2000 feet is imperative if either of those more serious complications develop. While advocated as a prophylactic and treatment option for AMS, the results for ginkgo are mixed and it is therefore not recommended for use in this situation. Smoking cessation and physical conditioning are both good ideas for this patient, but neither will reduce his risk for developing AMS.

Question 45

A 34-year-old female with systemic sclerosis sees you for a follow-up visit. She is afebrile, with a blood pressure of 132/76 mm Hg, a heart rate of 82 beats/min, and an oxygen saturation of 94% on room air. On examination you note that the patient is thin and has fibrotic skin changes proximal to the elbows and knees, and facial tightening. She does not have increasing shortness of breath but does have ongoing chronic musculoskeletal pain. She is currently taking cyclophosphamide prescribed by her rheumatologist. Pulmonary function tests reveal an FVC <50%, consistent with restrictive lung disease. CT of the chest shows ground-glass opacities and honeycombing of the lower lobes of the lungs.

Which one of the following do these findings suggest? (check one)
Emphysema
Idiopathic pulmonary fibrosis
Interstitial lung disease
Pulmonary edema
Sarcoidosis

Answer 45

Interstitial lung disease

Patients with systemic sclerosis (SS) in its final stages often develop a restrictive lung disease (SOR C). Interstitial lung disease and pulmonary artery hypertension are common. While the restrictive pattern is similar to idiopathic pulmonary fibrosis, this condition is characteristic of SS and is not idiopathic. Emphysema presents with an obstructive pattern on pulmonary function tests. Pulmonary edema can develop from cardiac malfunction and heart failure, but it is not present in this patient. Sarcoidosis is not related to SS. There is a 10-year mortality of 42% in patients with SS who have an FVC <50%. Cyclophosphamide may be helpful in some cases to improve lung function, decrease dyspnea, and improve the patient’s quality of life (SOR B).

Question 46

A 62-year-old male sees you the day after returning from a 4-day cruise. He says he developed a fever and a productive cough on the day before the ship returned to Los Angeles following a trip down the coast of Baja California. He tells you that several other passengers had similar symptoms. The examination is remarkable for tachypnea and you hear crackles in both lungs.

This patient’s history should raise concerns about infection with which one of the following pathogens? (check one)
Asian avian influenza A virus
Coxiella burnetii
Hantavirus
Histoplasma capsulatum
Leginella species

Answer 46

Leginella species

Legionella should be considered as a pathogen for community-acquired pneumonia when the patient has a history of a hotel stay or cruise ship travel within the past couple of weeks. Travel to or residence in Southeast Asia or East Asia is a risk factor for avian influenza, exposure to farm animals or parturient cats is a risk factor for Coxiella burnetii infection, exposure to bird or bat droppings is a risk factor for Histoplasma capsulatum infection, and travel to or residence in desert Southwest states with deer mouse exposure is a risk factor for Hantavirus infection.

Question 47

A 30-year-old female presents to your office for evaluation of a 5-mm pulmonary nodule noted on CT of the chest performed after a motor vehicle accident 2 weeks ago. She has had no symptoms and she is not a smoker. A physical examination is unremarkable.

Which one of the following would be most appropriate at this point? (check one)
Noncontrast chest CT in 1 year
A PET scan
Referral for a needle biopsy
Referral for bronchoscopy
Referral for wedge resection

Answer 47

Noncontrast chest CT in 1 year

By definition, a pulmonary nodule is a circumscribed, round lesion that may measure up to 3 cm in size and is surrounded by aerated lung. Management is based on the size of the nodule and the probability of malignancy. Risk factors for lung cancer include a previous malignancy, a positive smoking history, and age ≥65. Only 1% of nodules between 2 mm and 5 mm in size are malignant.

Nodules <8 mm are difficult to biopsy, and a PET scan is not reliable. The risk of surgery outweighs the benefits in nodules of this size. For a low-risk patient with a nodule 4 mm to <8 mm in size, a repeat noncontrast CT at 12 months is recommended. If it is unchanged, no further follow-up is needed.

Question 48

A 48-year-old female presents to the emergency department with chest pain. The evaluation, including CT angiography, reveals a pulmonary embolus.

Which one of the following initial findings would be the strongest indication for thrombolytic therapy? (check one)
Elevated troponin
Hypotension
Hypoxia
Bilateral pulmonary emboli
Right ventricular dysfunction on echocardiography

Answer 48

Hypotension

Recent guidelines have suggested that hypotension (a systolic blood pressure <90 mm Hg or a diastolic blood pressure <60 mm Hg, for 15 minutes or longer) should be treated with thrombolysis in patients who are not at high risk for bleeding. Patients who have other indicators of cardiopulmonary impairment without signs of hypotension should be given anticoagulation therapy and aggressive supportive care, but should not be treated with thrombolytic therapy. If the patient’s condition continues to deteriorate as evidenced by the development of hypotension or other clinical indicators of cardiopulmonary compromise, thrombolysis may be considered.

Question 49

A 64-year-old male presents with increasing dyspnea on exertion. He feels well otherwise and has no chronic medical problems. A physical examination is normal. Pulmonary function testing reveals normal spirometry, with no evidence of an obstructive or restrictive pattern. However, his lung carbon monoxide diffusing capacity (DLCO) is low.

Based on these results, which one of the following is the most likely diagnosis? (check one)
Asthma
Bronchiectasis
Chronic pulmonary emboli
COPD
Pulmonary fibrosis

Answer 49

Chronic pulmonary emboli

Low diffusing capacity of the lungs for carbon monoxide (DLCO) with normal spirometry indicates a disease process that disrupts gas transfer in the lungs without causing lung restriction or airflow obstruction. Common causes include chronic pulmonary emboli, heart failure, connective tissue disease with pulmonary involvement, and primary pulmonary hypertension. Asthma, bronchiectasis, COPD, and pulmonary fibrosis are associated with abnormalities on spirometry.

Question 50

A 72-year-old male with a past history of hypertension, COPD, and pulmonary embolism presents with nonspecific symptoms including fatigue and syncope. You suspect he has pulmonary hypertension.

Which one of the following would be the most appropriate initial test? (check one)
Pulmonary function tests
Chest CT with contrast
Echocardiography
A coronary calcium scan
Right heart catheterization

Answer 50

Echocardiography

According to national guidelines echocardiography is the preferred initial noninvasive testing modality
when pulmonary hypertension is suspected (SOR C). Pulmonary function tests provide helpful information
in regard to pulmonary capacity but are not necessarily diagnostic of pulmonary hypertension. CT of the
chest with contrast will not provide pulmonary pressures but may assist in the detection of pulmonary
emboli. A coronary calcium scan may be indicated to evaluate for coronary artery disease but it is not a
diagnostic test for pulmonary hypertension. Although right heart catheterization would provide pulmonary
pressure values it is considered more invasive than echocardiography and is not always necessary for
making the diagnosis.

Question 51

A 42-year-old bricklayer was diagnosed with acute bronchitis at an urgent care center 6–7 weeks ago. A chest radiograph was negative for pneumonia but revealed a solitary pulmonary nodule. No previous chest radiograph was available, so a follow-up chest radiograph was ordered for 4–6 weeks after the initial one. He is following up with you today to review those results.

The patient’s bronchitis has since resolved, and he feels well. He has no significant past medical history and does not take any medications. He has no constitutional symptoms and a physical examination today is within normal limits. He has a 10-pack-year cigarette smoking history and quit 15 years ago.

If a lesion is noted on the chest radiograph, which one of the following characteristics would be most suspicious for malignancy? (check one)
A diameter of 5 mm
Concentric calcifications
Doubling in size in less than 1 month
A nonsolid “ground glass” appearance
Smooth borders

Answer 51

A nonsolid “ground glass” appearance

Characteristics that are more commonly associated with malignant lesions include a nonsolid “ground
glass” appearance, a size >6 mm, noncalcified lesions, a lesion size or volume doubling time between 1
month and 1 year, and irregular or spiculated borders. Findings on a chest radiograph that are more
commonly associated with benign lesions include a lesion size <6 mm, concentric or “popcorn-like”
calcifications, doubling times of <1 month or >2–4 years, dense solid-appearing lesions, and lesions with
smooth regular borders. Other diagnostic imaging modalities are also utilized, including CT and PET, and
a biopsy is sometimes necessary to establish the diagnosis. Chest radiographs are still useful for monitoring
patients with multiple findings that correlate most often with benign lesions. Informed decision making by
the patient and family physician can sensibly guide the follow-up of patients with solitary pulmonary
nodules without automatically referring them to specialists or ordering the most sophisticated imaging.

Question 52

A 67-year-old male is admitted to the hospital for community-acquired pneumonia. An examination reveals a temperature of 40.0°C (104.0°F), a respiratory rate of 50/min, a pulse rate of 110 beats/min, a blood pressure of 90/50 mm Hg, and an oxygen saturation of 88% on room air. The patient is confused and requires aggressive fluid resuscitation for hypotension and he is transferred to the intensive-care unit. He has no known additional risk factors or exposures.

In addition to treatment with ceftriaxone and azithromycin (Zithromax), which one of the following medications is most likely to result in improved outcomes? (check one)
Clindamycin (Cleocin)
Levofloxacin (Levaquin)
Methylprednisolone (Medrol)
Oseltamivir (Tamiflu)

Answer 52

Methylprednisolone (Medrol)

This patient has severe community-acquired pneumonia based on clinical criteria, including an elevated
respiratory rate, confusion, and hypotension requiring aggressive fluid resuscitation. Corticosteroids such
as methylprednisolone have been shown to improve clinical outcomes such as length of stay, duration of
antibiotic treatment, and the risk of developing adult respiratory distress syndrome. The preferred choice
of antibiotic treatment for patients in the intensive-care unit is a -lactam antibiotic (ceftriaxone,
cefotaxime) or ampicillin/sulbactam, plus a macrolide alone or a macrolide and a respiratory
fluoroquinolone. The addition of levofloxacin is not necessarily preferred over just ceftriaxone and
azithromycin. Clindamycin is not indicated in the absence of risk factors for anaerobic infection such as
aspiration or alcoholism. Oseltamivir is not indicated in the absence of known or suspected influenza
infection.

Question 53

A 64-year-old male is hospitalized with anorexia, intractable abdominal pain, and dehydration due to locally advanced pancreatic cancer. He is started on intravenous fluids and morphine, along with a prophylactic dose of subcutaneous heparin. Shortly after admission he develops right-sided chest pain and shortness of breath. His vital signs are normal, except for a respiratory rate of 24/min. An abdominal examination reveals tenderness in the epigastric area. An examination of the heart and lungs is normal. There is no calf tenderness or leg edema. An EKG shows new right bundle branch block.

Which one of the following tests should you order next? (check one)
A D-dimer level
A troponin level
Doppler ultrasonography of the lower extremities
A ventilation-perfusion (V/Q) scan
Computed tomography pulmonary angiography (CTPA)

Answer 53

Computed tomography pulmonary angiography (CTPA)

This patient’s pretest probability for pulmonary embolism is high given his multiple risk factors, signs, and symptoms. The presence of a new onset of right bundle branch block in a patient presenting with a sudden onset of shortness of breath and chest pain, especially in the setting of active cancer, should raise suspicion of pulmonary embolism. Other EKG abnormalities include tachycardia or bradycardia, an S1Q3T3 pattern, atrial fibrillation, and T-wave inversions in the anterior leads. Patients with cancers of the pancreas and stomach have the highest risk of developing venous thromboembolism (VTE) and should receive pharmacologic VTE prophylaxis during hospitalizations.

In the absence of renal failure, a computed tomography pulmonary angiogram (CTPA) is the most appropriate diagnostic study and would be preferred over a ventilation-perfusion (V/Q) scan. A D-dimer level has a high negative predictive value in the diagnosis of pulmonary embolism; however, it has low specificity, and therefore a high rate of false positives, in patients with active cancer. An elevated troponin level can occur in the setting of pulmonary embolism and is nondiagnostic. Their principal value is in the diagnosis of acute myocardial infarction (SOR A). Doppler ultrasonography of the lower extremities helps identify and locate peripheral deep vein thrombosis and helps support but not confirm the diagnosis of pulmonary embolism. A V/Q scan is a reasonable option when CTPA is contraindicated.

Question 54

A 36-year-old male went skiing last year for the first time and when he made it to the top of the mountain he developed a headache, nausea, and dizziness, but no respiratory difficulty. That night he had difficulty sleeping. He asks for your recommendation on preventing a recurrence of the problem when he goes skiing again this year.

Which one of the following medications would you recommend he start the day before his ascent and continue until his descent is complete? (check one)
Acetazolamide (Diamox Sequels)
Aspirin
Dexamethasone (Decadron)
Tadalafil (Adcirca)
Zolpidem (Ambien)

Answer 54

Acetazolamide (Diamox Sequels)

Acetazolamide is the preferred agent for preventing acute mountain sickness (AMS). Multiple trials have
demonstrated its efficacy in preventing AMS. Dexamethasone is a first-line treatment for acute mountain
sickness of any severity but is a second-line drug for prevention because of its side-effect profile. Tadalafil
is advised as a second-line treatment after nifedipine for the prevention and treatment of high-altitude
pulmonary edema. Zolpidem may help with sleep but not AMS, and aspirin is not recommended for
prevention of AMS.

Question 55

In asymptomatic patients with sarcoidosis, which one of the following organ systems should be examined yearly to detect extrapulmonary manifestations of the disease? (check one)
Cardiac
Neurologic
Ocular
Integumentary

Answer 55

Ocular

Sarcoidosis has numerous extrapulmonary manifestations. Because inflammation of the eye can result in
permanent impairment and is often asymptomatic, patients require yearly eye examinations as well as
additional monitoring with disease flares. Although skin involvement is common it is usually readily
apparent and rarely has serious sequelae. Cardiac sarcoidosis can potentially lead to progressive heart
failure and sudden death, but evaluation is needed only in patients who are symptomatic. Similarly,
evaluation for neurologic involvement is needed only in patients who are symptomatic.