PULMONOLOGY Flashcards
60-year-old man with a history of alcoholism presents with fever, productive cough, and shortness of breath. Which of the following pathogens is most likely to be associated with his condition?
A. Streptococcus pneumoniae
B. Legionella pneumophila
C. Histoplasma capsulatum
D. Hantavirus
Correct Answer:
A. Streptococcus pneumoniae
Rationale:
Alcoholism is associated with Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter species, and Mycobacterium tuberculosis as potential causes of community-acquired pneumonia.
A patient recently returned from a cruise ship trip with symptoms of cough, fever, and shortness of breath. Which of the following pathogens should be considered most likely?
A. Legionella pneumophila
B. Coxiella burnetii
C. Burkholderia pseudomallei
D. Chlamydia psittaci
Correct Answer:
A. Legionella pneumophila
Rationale:
Staying in a hotel or cruise ship in the previous two weeks is associated with Legionella pneumophila, a common cause of pneumonia in such settings.
A 67-year-old woman presents to the emergency department with fever, productive cough, and shortness of breath for 3 days. She has a history of diabetes mellitus and hypertension. On examination, her vital signs are as follows:
Respiratory rate: 32 breaths/min
Blood pressure: 85/60 mmHg
Oxygen saturation: 88% on room air
Laboratory results show:
Blood urea nitrogen (BUN): 25 mg/dL
White blood cell count: 3,500 cells/µL
Platelet count: 90,000 cells/µL
Chest X-ray reveals multilobar infiltrates.
Question 1: Based on the criteria for severe community-acquired pneumonia (Table 126-3), does this patient meet the criteria for severe pneumonia?
A. No, the patient does not meet any major or minor criteria.
B. Yes, the patient meets both major and minor criteria.
C. Yes, the patient meets at least three minor criteria but no major criteria.
D. No, the patient only meets one minor criterion.
Correct Answer:
B. Yes, the patient meets both major and minor criteria.
Rationale:
This patient meets major criteria due to septic shock requiring vasopressors (hypotension) and respiratory failure (oxygen saturation 88%). She also meets several minor criteria, including a respiratory rate ≥30 breaths/min, uremia (BUN ≥20 mg/dL), leukopenia (WBC <4,000 cells/µL), thrombocytopenia (platelet count <100,000 cells/µL), and multilobar infiltrates.
Question 2: What is the recommended initial treatment strategy for this patient as an outpatient if her condition were less severe and she had comorbidities like diabetes? (Based on Table 126-4)
A. Monotherapy with doxycycline
B. Combination therapy with amoxicillin/clavulanate and a macrolide or doxycycline
C. Monotherapy with a respiratory fluoroquinolone such as levofloxacin
D. Both B and C are correct
Correct Answer:
D. Both B and C are correct
Rationale:
For outpatients with comorbidities or risk factors for antibiotic resistance, the recommended treatment includes:
Combination therapy with amoxicillin/clavulanate or a cephalosporin and a macrolide or doxycycline, OR
Monotherapy with a respiratory fluoroquinolone (e.g., levofloxacin or moxifloxacin).
A 72-year-old man presents to the emergency department with fever, confusion, and productive cough for 3 days. His past medical history includes uncontrolled diabetes mellitus and chronic obstructive pulmonary disease (COPD). On examination, his vital signs are as follows:
Respiratory rate: 32 breaths/min
Pulse: 130 bpm
Blood pressure: 85/60 mmHg
Temperature: 35.5°C
Physical examination reveals altered mental status.
Question: Based on the risk stratification for community-acquired pneumonia (CAP), how would you classify this patient’s risk?
A. Low risk
B. Moderate risk
C. High risk
D. Unable to determine
Correct Answer:
C. High risk
Rationale:
This patient meets the criteria for high risk CAP based on the following findings:
Respiratory rate ≥30/minute
Pulse ≥125 bpm
Systolic blood pressure <90 mmHg
Temperature ≤36°C
Presence of altered mental status
Comorbid conditions, including uncontrolled diabetes mellitus and COPD
These findings indicate significant instability and the need for urgent management.
A 65-year-old patient with a history of diabetes and recent hospitalization for a urinary tract infection presents with a new onset of fever, cough, and shortness of breath. Chest X-ray reveals a patchy infiltrate in the right lower lobe suggestive of pneumonia.
Question:
Given the patient’s risk factors, which of the following antibiotic regimens would be the most appropriate initial empiric therapy for hospital-acquired pneumonia?
Answer Choices:
Piperacillin-tazobactam 4.5 g IV q6h
Cefepime 2 g IV q8h
Amikacin 15-20 mg/kg IV q24h
Piperacillin-tazobactam 4.5 g IV q6h + Amikacin 15-20 mg/kg IV q24h
Explanation:
The correct answer is 4. Piperacillin-tazobactam 4.5 g IV q6h + Amikacin 15-20 mg/kg IV q24h. The patient has risk factors for resistant gram-negative pathogens due to recent hospitalization and prior antibiotic therapy. Therefore, a combination of two antibiotics active against these pathogens is recommended.
A 10-year-old boy presents to the clinic with complaints of wheezing and coughing at night for the past 2 weeks. His mother reports that he has been using his albuterol inhaler more frequently than usual.
Question:
Based on the GINA asthma control assessment tool in the image, which of the following findings would suggest that the boy’s asthma is not well controlled?
Answer Choices:
a) No nighttime awakenings due to asthma in the past 4 weeks
b) Daytime asthma symptoms less than twice a week
c) No activity limitations due to asthma
d) Use of the albuterol inhaler more than twice a week
Correct Answer:
d) Use of the albuterol inhaler more than twice a week
Explanation:
According to the GINA assessment tool, using a short-acting beta-agonist (SABA) reliever like albuterol more than twice a week is an indicator of not well-controlled asthma.
Rationale for Incorrect Answers:
a) No nighttime awakenings: This would suggest good asthma control.
b) Daytime asthma symptoms less than twice a week: This also suggests good asthma control.
c) No activity limitations: This indicates that asthma is not significantly impacting the child’s daily activities, suggesting good control.
A 68-year-old man presents with a history of smoking and recent weight loss. He complains of shortness of breath and a dry cough. On physical examination, you note dullness to percussion and decreased breath sounds in the left lung base. A chest X-ray reveals a left-sided pleural effusion.
Question 1:
After performing a diagnostic thoracentesis, the pleural fluid analysis reveals the following:
Pleural fluid protein: 4.2 g/dL
Serum protein: 7.0 g/dL
Pleural fluid LDH: 200 IU/L
Serum LDH: 150 IU/L
Based on these results, what type of pleural effusion does this patient most likely have?
a) Exudative effusion
b) Transudative effusion
Correct Answer:
a) Exudative effusion
Explanation:
The Light’s criteria for differentiating exudative from transudative effusions are met in this case:
Pleural fluid protein/serum protein ratio > 0.5 (4.2/7.0 = 0.6)
Pleural fluid LDH/serum LDH ratio > 0.6 (200/150 = 1.33)
Pleural fluid LDH > 2/3 of the upper limit of normal serum LDH (assuming the upper limit of normal serum LDH is around 225 IU/L, then 2/3 of this would be 150 IU/L, and the patient’s pleural fluid LDH is 200 IU/L)
Question 2:
Given the patient’s history and the findings of an exudative effusion, which of the following investigations would be most appropriate to pursue next?
a) Treatment for congestive heart failure
b) Treatment for cirrhosis
c) Measurement of pleural fluid glucose and cytology
d) Treatment for pulmonary embolism
Correct Answer:
c) Measurement of pleural fluid glucose and cytology
Explanation:
In the case of an exudative effusion, further diagnostic procedures are recommended. Measuring pleural fluid glucose, obtaining cytology for malignancy evaluation, and performing a differential cell count are important steps in the workup of an exudative effusion.
