Pulmonology

Question 1

A 58-year-old man presents to the emergency department with shortness of breath, cough, fever, nausea, and diarrhea for three days. He recently installed a hot tub in his home and has been using it quite frequently. Physical exam reveals a soft, mildly tender abdomen, bilateral crackles on chest auscultation, and a pulse oxygen saturation of 91%. Abnormal laboratory values include leukocytosis, hyponatremia, and elevated liver enzymes. Which of the following causes of atypical pneumonia correlates most closely with this patient’s clinical picture?

A. Klebsiella pneumoniae
B. Legionella pneumoniae
C. Mycoplasma pneumoniae
D. Pseudomonas aeruginosa

What antibiotic is the treatment of choice?

Answer 1

Legionella pneumoniae

Legionella pneumoniae is a gram-negative, aerobic organism responsible for both nosocomial and community-acquired pneumonia. The bacteria are present in water and soil, and infection occurs via contaminated aerosolized particles.

Levofloxacin or Doxycicline

Question 2

What is Pontiac fever?

Answer 2

A self-limited, acute febrile illness caused by Legionella pneumoniae that results in gastrointestinal and constitutional symptoms but no respiratory symptoms.

Question 3

Which of the following is consistent with the classic triad of foreign body aspiration in a young child?

A. Choking, coughing, and wheezing
B. Coughing, diminished breath sounds, and wheezing
C. Hemoptysis, retractions, and stridor
D. Mediastinal shift, retractions, and stridor

What is the treatment?

Answer 3

Coughing, diminished breath sounds, and wheezing

Removal via rigid bronchoscopy

Question 4

A 5-year-old boy who is brought to the emergency department by his parents for a cough and shortness of breath. He has a past medical history of eczema and seasonal rhinitis. On physical exam, you note a young boy in respiratory distress taking deep, slow breaths to try and catch his breath. He has diminished breath sounds in all lung fields with prolonged expiratory wheezes.

What is the diagnosis?

Answer 4

Asthma

Question 5

In a young patient whom you suspect asthma, what would be the expected results of pulmonary functioning testing?

Answer 5

In asthma, since there is an obstruction (inflammation), you will have a decreased FEV1 and, therefore, a reduced FEV1 to FVC ratio

Will also likely see an increased RV, TLC, and RV/TLC

Question 6

What are the treatment steps for asthma and their associated symptoms?

Answer 6

Mild Intermittent: Less than 2 times per week or 3-night symptoms per month

Step 1: Short-acting beta2 agonist (SABA) PRN
Mild Persistent: More than 2 times per week or 3-4 night symptoms per month

Step 2: Low-Dose inhaled corticosteroids (ICS) daily
Moderate Persistent: Daily symptoms or more than 1 nightly episode per week

Step 3: Low-Dose ICS + Long-acting beta2 agonist (LABA) daily

Step 4: Medium-Dose ICS +LABA daily
Severe Persistent: Symptoms several times per day and nightly

Step 5: High-Dose ICS +LABA daily

Step 6: High-Dose ICS +LABA +oral steroids daily

Question 7

According to the National Asthma Education and Prevention Program (NAEPP) guidelines, what is the first-line maintenance therapy for asthma in adults?
a. Long-acting beta-agonists (LABAs)
b. Inhaled corticosteroids (ICS)
c. Leukotriene modifiers
d. Short-acting beta-agonists (SABA)

Answer 7

Inhaled corticosteroids (ICS)

Question 8

What is the initial step in the management of an acute asthma exacerbation in the primary care setting?
a. Administering systemic corticosteroids
b. Initiating long-acting beta-agonists (LABAs)
c. Administering a short-acting beta-agonist (SABA)
d. Assessing for oxygen saturation

Answer 8

Administering a SABA

Question 9

What is a recommended controller medication for managing asthma in a 5-year-old child?
a. Oral corticosteroids
b. Montelukast (Singulair)
c. Short-acting beta-agonists (SABA)
d. Long-acting beta-agonists (LABAs)

Answer 9

Montelukast

ICS are also another controller in children but is used off label as not approved for use under the age of 8. Also, children may ineffectively use inhalers making oral medications perferrable if symptoms are not controlled.

Question 10

What parameter should be regularly monitored during follow-up visits for a patient with asthma?

Answer 10

Peak flow or spirometry measurements

Question 11

What is the recommended treatment for acute bronchitis?

Answer 11

Antibiotics not recommended—mostly viral

Symptomatic-based treatment NSAIDs, ASA, Tylenol, and/or ipratropium
Cough suppressants—codeine-containing cough meds
Bronchodilators (albuterol)

Question 12

A 65-year-old male complaining of fatigue and shortness of breath with exertion. The patient reports minimal cough. On physical exam, you note a thin, barrel-chested man with decreased heart and breath sounds, pursed-lip breathing, end-expiratory wheezing, and scattered rhonchi. What is the most likely diagnosis and what will the work-up show?

Answer 12

Emphysema

Chest X-ray will show a flattened diaphragm, hyperinflation, and a small, thin-appearing heart.

PFTs will show a decreased FEV1/FVC ratio.

Question 13

What are the findings on CXR for emphysema?

Answer 13

flattened diaphragm, hyperinflation, and small, thin appearing heart
parenchymal bullae (subpleural blebs) are pathognomonic

Question 14

What is the criteria for initiating supplemental home oxygen for patients with COPD?

Answer 14

• Pao2 55 mm Hg
• O2 saturation < 88% (pulse oximetry) either at rest or during exercise
• Pao2 55 59 mm Hg + polycythemia or cor pulmonale

Question 15

What are the benefits to treatment with a LAMA in COPD?

What is the LAMA available for the treatment of COPD?

What are the side-effects?

Answer 15

Improves lung function, decreases hyperinflation, improves quality of life for patients with COPD

Slightly more efficacious than LABAs

Tiotropium

Anticholinergic: dry mouth, thirst, blurred vision, urinary retention, difficulty swallowing

Question 16

What inahler class of medications can be used as needed to relieve intermittent dyspnea?

Answer 16

SAMA (Ipratropium) or SABA (albuterol)

Question 17

A 65-year-old woman with a 40 pack-year history of smoking presents with a 7 kg weight loss over the last 3 months and recent onset of streaks of blood in the sputum. PE reveals a thin, afebrile woman with clubbing of the fingers, an increased anteroposterior diameter, scattered and coarse rhonchi and wheezes over both lung fields, and distant heart sounds. What is the most likely diagnosis?

What else would expect to find in the patients history?

Answer 17

Small-cell lung cancer

Recurrant pneumonia

Question 18

What is the USPSTFs recommendation for lung cancer screening?

Answer 18

• The USPSTF recommends annual low-dose CT screening for those 55-80 years of age who have no symptoms of lung cancer and a 30+ PPY smoking history who currently smoke
• Screening should be discontinued once a person has not smoked for 15 years

Question 19

What is the most common bacterial etiology of community acquired pneumonia?

What is the classic presentation?

Answer 19

S. pneumoniae

Chills, rigors, fever, productive cough with blood-tinged (rusty) sputum

Question 20

What antibiotic classes are used to treat pneumonia?

What is the outpatient empiric treatment of community acquired pneumonia

Answer 20

Macrolides (Azithromycin, Clarithromycin) or respiratory Fluoroquinolones (Levofloxacin, Moxifloxacin, and gemifloxacin)

Macrolide or Doxycicline

Fluoroquinalones only used if comorbid conditions are present or recent abx treatment

Question 21

Is Ciprofloxacin a respiratory Flouroquinalone?

Answer 21

No, it can be used to treat pseudomonas or Legionella

Question 22

What is the most common treatment approach for lung abscesses?

What is the most common cause of lung abscesses?

Answer 22

Emperic Antibiotic Treatment with ampicillin-sulbactam or a carbapenium (imepenium or meropeneum)

Aspiration (ETOH abuse, drug abuse, anesthesia, etc.)

Question 23

A 55-year-old man presents with shortness of breath and a productive cough with yellow phlegm for 2 days; he has had blood-tinged sputum for the last 3 hours. He has smoked 2 packs of cigarettes for the past 35 years. He has a temperature of 102°, and rhonchi, wheeze, and crepitations are heard over the right hemithorax. A chest X-ray shows a dense lobar infiltrate in the right hemithorax. What is the diagnosis?

What is the proper outpatient treatment?

Answer 23

Lobar Pneumonia

Macrolide (Azithromycin) or Doxycicline

Question 24

At what age should all patients receive the pnumonia vaccine?

Answer 24

Pneumonia vaccine should start at age 65 for all patients

Question 25

What is the best test to rule out a pulmonary embolism?

Answer 25

CT Angiography

Question 26

What groups are at an increased risk of Klebselia Pneumonia?

Answer 26

Alcoholics and Nursing Home Patients

Question 27

A 50-year-old female patient presents for follow-up for breathing problems. She has a 40 pack-year smoking history. She states that the shortness of breath is getting slightly worse, and she has lost about 5 pounds in recent months without trying. Exam reveals tachypnea. Chest x-ray shows lung hyperinflation and flattening of the diaphragm. What is the most likely diagnosis and what would expect to find on PFTs?

Answer 27

Emphysema

This presentation is consistent with a diagnosis of emphysema: a condition caused by loss of lung elastic recoil, which leads to airflow obstruction, specifically expiration. A characteristic finding is elevated total lung capacity.

Question 28

What pulmonary infections most commonly cause granulomas in the lungs?

Answer 28

Histoplasmosis, Coccidioidomycosis, Mycobacterium tuberculosis, and nontuberculous species

Question 29

A 26-year-old pregnant woman diagnosed with primary tuberculosis and wants to discuss treatment options. Initial labs come back with mild anemia, positive HCG, and elevated cholesterol. All other labs are within normal range.

What drug should be avoided in this patient?

Answer 29

Streptomycin and Pyrizinomide

Initial treatment for TB in pregnant women should include Rifampin, Isonizid, and Ethembutal only. Pyrizinomide can be added if needed. Streptomycin is considered class X.

Question 30

A 62-year-old woman with a long-standing history of hypertension presents with a severe headache; it started this morning and is rapidly worsening. During the interview, she suddenly collapses. Your brief examination shows that she responds with extensor posturing on external stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that her breathing has a peculiar pattern: deep inspiration with a pause at full inspiration, followed by a brief insufficient release and the end-inspiration pause. How do you best describe her respiratory pattern?

Describe Kussmaul’s Breathing Pattern?

Answer 30

Apneusis

Kussmaul breathing is a deep, labored, and gasping breathing pattern seen often in severe metabolic acidosis (diabetic ketoacidosis, renal failure). In metabolic acidosis, breathing is first rapid and shallow, but later on, as acidosis worsens, breathing gradually becomes Kussmaul breathing.

Question 31

A 52-year-old woman living a non-sedentary lifestyle presents with a 5-day history of low-grade fever, flu-like syndrome, sore throat, and malaise. She is mostly bothered by the fact that she has to “catch” her breath because of pain on inspiration and when coughing. She has no known past medical or surgical history; she is not on any medication, and she has no pertinent family history. She denies any medication use, including over-the-counter medicines. On physical examination, her vitals are: Temperature 100.6 F, pulse 86/min, BP133/75 mm Hg, and RR 20cycles/min. She has shallow breathing, resonant percussion notes, fair air entry with vesicular breath sounds, and friction rub. Her blood gas on room air is: pH 7.36, PCO2 44 mmHg, PO2 100 mmHg, HCO3 26 mEq\L, O2 saturation 99.8%. Her chest X-ray (CXR) is normal and the D-dimer assay is also normal. What is the most appropriate management modality for this patient?

Answer 31

NSAID’s

This patient has pleuricy without an effusion; no imaging modalities are required because XR and D-dimer are negative. Treat with NSAIDs and supportive care.

Question 32

A 57-year-old man who works as a quartz miner presents to the clinic with shortness of breath and dry cough for 9 months. His medical history includes essential hypertension and benign prostatic hyperplasia. Current vital signs are heart rate 86 bpm, blood pressure 130/88 mm Hg, respiratory rate 18/minute, oxygen saturation 95% on room air, and temperature 98.7°F. Physical examination reveals regular rate and rhythm, soft and nontender abdomen, no respiratory distress, crackles over bilateral lower lung fields, no wheezing, and no stridor. Pulmonary function testing reveals an FEV1/FVC of 85%, FVC of 65%, and total lung capacity of 70%. What is the most likely diagnosis?

Answer 32

Interstitial Lung Disease

Question 33

What drugs are associated with the development of interstitial lung disease?

Answer 33

• amiodarone
• bleomycin
• methotrexate
• opiates
• nitrofurantoin

Question 34

What diagnostic tool is used for the definitive diagnosis of pulmonary hypertension?

Answer 34

Right Heart Cath

Question 35

A 57-year-old male had an abdominal CT in the ED for an acute work-up of gastrointestinal pain. A lung nodule, measuring, 5mm was found incidentally. What should be done about the lung nodule?

Answer 35

Nothing, the patient should be reassured. Incidental findings of lung masses < 30mm do not require follow-up. If greater than 30 mm then a chest CT without contrast should be ordered.

Question 36

A 28-year-old woman presents to the clinic with 2 months of fatigue, dry cough, blurred vision, rash, and weight loss. She has no significant medical or surgical history. She was adopted and does not know her family history. Vital signs today are heart rate 82 bpm, blood pressure 116/78 mm Hg, respiratory rate 18/minute, oxygen saturation 97% on room air, and temperature 98.4°F. On physical examination, the patient has erythema surrounding the cornea, cervical lymphadenopathy, regular rate and rhythm, clear lungs to auscultation bilaterally, soft and nontender abdomen, and tender nodules on the bilateral lower legs. Chest X-ray is shown above. Additional diagnostic studies are performed. What diagnostic finding is most consistent with the suspected diagnosis?

Answer 36

Noncaseating granulomas on lung biopsy

Sarcoidosis

Question 37

A 35-year-old man presents to the clinic for occupational tuberculosis screening. The patient is an emergency medicine nurse and reports that he received the Bacille Calmette-Guérin vaccine when he was 5 years old before he started school in South America. He has not had a cough, fever, or shortness of breath recently. Vital signs include HR of 80 bpm, BP of 130/80 mm Hg, RR of 20/minute, oxygen saturation of 97% on room air, and T of 98.2°F. The patient’s lungs are clear to auscultation bilaterally on physical examination. Which of the following is the recommended method of tuberculosis screening in this patient?

What is the treatment of TB?

Answer 37

Interferon-gamma release assay as this patient received the Bacille Calmette-Guerin vaccine

Rifampin, Isonizid, Ethembutal, parysinamide

Question 38

What medication is used to treat seizures caused by isoniazid toxicity?

Answer 38

Vitamin B6 (pyridoxacine)

Vitamin B6 should be given with Isoniazid to reduce risk of toxicity

Question 39

A 45-year-old woman with a medical history of hypothyroidism, for which she takes levothyroxine, presents to the clinic with a cough for the past 2 weeks. The patient reports that she initially had rhinorrhea and nasal congestion but these symptoms resolved with the cough persisting. Vital signs include HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.2°F. On physical examination, her lungs are clear to auscultation bilaterally without rales, rhonchi, or wheezing. She has no erythema or exudate on oropharyngeal exam. What is the most likely diagnosis and associated treatment?

How would the treatment change if this patient had a history of asthma?

Answer 39

Acute Bronchitis and no treatment is required. Patient should be given reassurance and advice to use supportive measures.

Provide a bronchodilator

Question 40

What are some common causes of a chronic cough?

Answer 40

• Post nasal drip syndrome
• COPD or Asthma
• GERD
• ACE inhibitor use

Question 41

You are seeing a 13-year old patient with a known history of asthma. What should be considered when assessing their asthma control?

Answer 41

The category of control is determined by nighttime waking (up to once per month versus twice or more per month), interference with daily activities (yes/no), and frequency of rescue inhaler use (up to twice per week versus more than twice per week).

Question 42

What is an adverse side effect of inhaled steroids and what patient education should be completed to reduce the risk?

Answer 42

Thrush (oral candidiasis)

Patients should be instructed to rinse their mouth or drink water after ICS use

Question 43

What is a serious side effect of Ethambutal?

What test should be done prior to initiating treatment for TB?

Answer 43

Optic neuritis, which can lead to loss of red-green color discrimination and decreased visual acuity.

Opthamology Testing (red-green color testing)