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Question 1

Which of the following physical exam findings can confirm the diagnosis of community-acquired pneumonia?

A.Crackles on chest auscultation
B.Egophony
C.Tachypnea
D.None of the above

Answer 1

Answer: D. None of the above

A posteroanterior and lateral chest x-ray is used for diagnosis in a patient suspected of having community-acquired pneumonia. Diagnosis is established by the presence of opacity on chest imaging in a patient with associated symptoms (e.g., fever, dyspnea, cough, sputum production). Rarely is the diagnosis of community-acquired pneumonia based on clinical features alone (e.g., tachycardia, tachypnea, crackles, tactile fremitus, egophony) due to their limited (and relatively nonspecific) diagnostic accuracy.

Question 2

What is egophony

Answer 2

Ask the pt to say eee while listening
Normal : will hear eee clearly instead of bahh

Abnormal: will hear bahh when egophony is present. This finding suggests the presence of consolidation or fluid in the lungs

Question 3

Tactile tremitus

Answer 3

Say 99 or blue moon

Use finger pads to palpate lungs and feel vibrations

Normal: stronger vibrations are palpable on the upper lobes and softer vibrations on lower lobes

abnormal: findings are reversed. May palpate stronger vibrations on one lower lobe (where consolidation is), asymmetric findings are always abnormal

Question 4

Whispered pectoriloquy

Answer 4

Advise pt to whisper 99 or blue moon

Normal: the whispered voice will be distant and muffled

Abnormal: if there is consolidation, the whispered words are clearly heard on the lower lobes of the lung

Question 5

you percuss a patients lungs and they are hyperresonance. What is it

Answer 5

Very loud sound, low in pitch and longer in duration. Occurs with COPD, emphysema (overinflating)

Question 6

Tympanic percussion sounds means what. What is normal?

Answer 6

Normal : resonance is heard over lung tissue

Tympanic: loud and high pitched drum like sound. Normal when percussed across the abdomen. Abnormal when found in the chest wall (suggest pneumothorax)

Question 7

What is dull sound heard on percussion ?

Answer 7

Bacterial pneumonia with consolidation, pleural effusion

A solid organ such as liver sounds dull

Question 8

When do you hospitalize for pneumonia

Answer 8

CRB 65

C- confusion
R- resp > 30
B - low blood pressure <90/60
65-> 65

Score:
>3 = admit urgently
2= same day assessment in secondary care
0-1= treatment at home

Question 9

AECOPD first line treatment for simple “. What is simple

Answer 9

Simple is FEV1 >50% predicted, have 3 or fewer exacerbations per year and no significant cardiac disease

First line:
Amoxicillin 500mg BID
Doxycycline 100mg BID first day then 100mg once daily
TMP/SMX 1 DS tab BID

Duration x 5 days

Question 10

what are the symptoms of AECOPD

Answer 10

1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence

Usually only 1 of these may not require antibiotics

Question 11

What is AECOPD complicated (high risk patient first line antibiotics

Answer 11

Amox/ clav 875mg BID
Duration: 7-10 days

High risk = FEV1 <50%, demonstrate significant cardiac disease ( isxhemic heart , CHF) and/or 4 or more exacerbations a year.
May also use supplemental oxygen, chronic use of oral steroids or antibiotics in the last 3 months

Question 12

Step by step for COPD management

Answer 12

SABA

LAMA or LABA
Lama= Spiriva
LABA = formeterol, salmeterol, indacaterol

LAMA + LABA
Inspiolto
Ultibro

LAMA + LABA + ICS

Question 13

During the physical exam, the nurse practitioner (NP) asks the patient to whisper a short phrase while auscultating the peripheral lung fields. The nurse practitioner notes that the whispered voice sounds clear and loud. This finding is suggestive of which of the following?

A.Considered a normal finding
B.Area of consolidation in the lung suggestive of pneumonia
C.Possible air in the lungs suggestive of pneumothorax
D.Tumor causing bronchial obstruction

Answer 13

Answer: B. Area of consolidation in the lung suggestive of pneumonia

Whispered pectoriloquy is used as an auscultation technique during the respiratory component of the physical exam. The patient whispers a few numbers or a short phrase while auscultating. A normal finding is to hear distant and muffled whispered voices. However, if there is consolidation in an area of lung, the whispered voice will sound clear and loud because sound transmits better through dense consolidation than through air. Tachypnea, crackles (rales), decreased bronchial breath sounds, bronchophony, whispered pectoriloquy, increased tactile fremitus, and/or dullness to percussion are suggestive of pneumonia. Decreased tactile fremitus is seen with pneumothorax and a tumor causing bronchial obstruction.

Question 14

Which of the following sounds is typically heard over normal lung tissue?

A.Dullness
B.Tympany
C.Flatness
D.Resonance

Answer 14

Answer: D. Resonance

Resonance is the hollow sound heard over normal lung tissue filled with air. Flatness is normally heard over solid areas such as bones. Tympany is a loud and high-pitched drumlike sound that is normally heard when percussing across the abdomen. It is abnormal when found in the chest wall (suggests pneumothorax). Dullness is heard over a dense area or solid organ (e.g., heart, liver) as a medium-intensity pitch. It is considered abnormal over lung tissue because it is often due to fluid or consolidation (e.g., pneumonia, masses or tumors, pleural effusions, hemothorax, empyema).

Question 15

A middle-aged adult male smoker with chronic obstructive pulmonary disease (COPD) presents to the clinic complaining of several days of fever, loss of appetite, coughing, and chest pain. The cough is productive of purulent sputum. Physical examination reveals a temperature of 102.0°F (39.0°C), pulse of 88, and respiratory rate of 24. The lung exam reveals crackles on the lower right lobe and wheezing in the upper airways. What is the preferred treatment for the patient’s condition?

A.Amoxicillin
B.Doxycyline
C.Amoxicillin-clavulanate (Augmentin) plus a macrolide
D.Azithromycin (Z-Pak) plus a fluoroquinolone

Answer 15

Answer: C. Amoxicillin-clavulanate (Augmentin) plus a macrolide

The patient has community-acquired pneumonia (CAP) with comorbidities (smoker, COPD), which are risk factors for Haemophilus influenzae (gram-negative). Also assume the presence of Streptococcus pneumoniae (gram-positive) because it is the most common bacteria seen in CAP. The preferred treatment for patients with comorbidities who are older than 65 years is combination therapy with beta-lactams (i.e., amoxicillin–clavulanate, cefuroxime, or amoxicillin, cefprozil) plus a macrolide or doxycycline or second line monotherapy with a respiratory fluoroquinolone (i.e., levofloxacin, moxifloxacin, or gemifloxacin).

duration: 7-14 days

Question 16

What are comorbidity / risk factors for CAP

Answer 16

Hospitalize in the past 3 months
Chronic heart, lung, liver or renal disease
Diabetes
Alcoholism
Malignancies
Asplenia
Immunosuppression
Age >65
Antibiotics in the last 3 months

Question 17

Which of the following is a restrictive lung disease?

A.Asthma
B.Chronic obstructive pulmonary disease (COPD)
C.Bronchiectasis
D.Pulmonary fibrosis

Answer 17

Answer: D. Pulmonary fibrosis

Restrictive lung diseases (reduction of lung volume due to decreased lung compliance) include pulmonary fibrosis, pleural disease, and diaphragm obstruction. Obstructive lung diseases (reduction in airflow rates) include asthma, COPD (chronic bronchitis and emphysema), and bronchiectasis.

Question 18

In which situation would a tuberculin skin test reaction be considered positive?

A.≥5 mm in a patient who received a liver transplant
B.≥10 mm in a healthy patient older than 5 years
C.≥5 mm in a patient with diabetes mellitus
D.≥5 mm in a patient who is incarcerated

Answer 18

Answer: A

Question 19

A patient presents with concern for an asthma exacerbation. The patient is tachypneic, heart rate is 125 beats/min, and the patient is using accessory muscles to assist breathing. Which of the following diagnostic tools should be used to assess the severity of the asthma attack?

A.Peak flow meter (or spirometer)
B.Pulse oxygen saturation
C.Arterial blood gas
D.Chest x-ray

Answer 19

Answer: A. Peak flow meter (or spirometer)

The best method to objectively assess the severity of an asthma attack is measurement of maximal expiratory airflow with a peak flow meter (or spirometer). Pulse oxygen saturation testing provides a noninvasive screening test for hypoxemia. Arterial blood gas to assess for hypercapnia is not necessary in most patients. It may be more appropriate in patients who are more critically ill with worsening respiratory status or show signs of hypercapnia (e.g., depressed consciousness). A chest x-ray is not routinely recommended during acute asthma attacks because the findings are often nonspecific.

Question 20

A patient presents complaining of troublesome asthma symptoms on most days. They also report that their asthma symptoms wake them up at night several times each month. Based on the Global Initiative for Asthma (GINA) guidelines, this patient meets the criteria for which step?

A.1
B.2
C.3
D.4

Answer 20

Answer: C. 3

The patient meets criteria for Step 3 according to the GINA guidelines due to occurrence of troublesome symptoms most days and nocturnal awakening more than once per month. Step 1 involves infrequent asthma symptoms (less than 2 × /week); Step 2 involves asthma symptoms or need for reliever inhaler more than 2 × /week; and Step 4 involves severely uncontrolled asthma with three or more of the following: daytime asthma symptoms more than 2 × /week, nocturnal awakening due to asthma, reliever needed for symptoms more than 2 × /week, or activity limitation due to asthma.

Question 21

What are pharm management of Gina step 1,2,3,4

Answer 21

Step 1: infrequent asthma symptoms <2x/wk
SABA PRN
Or
Daily low dose ICS + PRN SABA

Step 2: need reliever >2x/wk
Low dose ICS daily + PRN SABA
-reassess adherence, inhaler technique, environmental control, etc

Step 3: troublesome asthma symptoms most days, nocturnal awakening due to asthma >1 times/ month, risk factors for exacerbations
ICS+ LABA (symbicort, zenhale, advair) 6-11 y
>12y = LAMA + LABA + ICS (Spiriva, trelegy)

Step 4: severely uncontrolled with >3 of daytime asthma symptoms more than 2x/week, nocturnal awakening due to asthma, reliever needed for symptoms more than 2x/ week, or activity limitation due to asthma
Refer to specialist

Question 22

A patient with chronic obstructive pulmonary disease (COPD) and a history of smoking presents with a sudden onset of dyspnea and pleuritic chest pain. Physical exam findings include decreased chest excursion on the left side, diminished breath sounds, decreased tactile fremitus, and tympanic sounds during lung auscultation. The patient’s vital signs are stable on room air. Which of the following is an appropriate diagnostic modality for this patient presentation?

A.Chest x-ray
B.Chest CT scan
C.Pleural ultrasonography
D.Pulmonary function tests

Answer 22

Answer: A. Chest x-ray

The patient is presenting with signs and symptoms concerning for a pneumothorax (gas in the pleural space). It should be suspected in patients with acute dyspnea and pleuritic chest pain, especially in patients with risk factors (e.g., COPD, smoking history). Diagnostic imaging for most stable patients includes a chest radiography. Bedside pleural ultrasonography is indicated in patients who are hemodynamically unstable or in severe respiratory distress. While a chest CT scan is the most accurate diagnostic method, it is recommended when the diagnosis is unclear following chest radiography. Pulmonary function tests are not routinely recommended or performed during diagnosis or treatment.

Question 23

The nurse practitioner performs a physical assessment of a patient. While auscultating over the peripheral lung fields, they hear breath sounds that are of soft intensity and low pitched, with a rustling quality during inspiration and softer sound during expiration. These findings suggest which breath sound?

A.Tracheal
B.Bronchial
C.Bronchovesicular
D.Vesicular

Answer 23

Answer: D. Vesicular

Vesicular breath sounds are soft and low pitched; they are heard bilaterally over most of the peripheral fields. Bronchial breath sounds are louder and higher in pitch and heard over the lower aspect of the trachea and over the manubrium. Bronchovesicular breath sounds are of intermediate intensity and pitch and are heard over major bronchi in the midchest area or between the scapula. Tracheal breath sounds are of the highest and loudest pitch and are heard over the upper aspect of the trachea and anterior aspect of the neck.

Vesicular
Bronchovesicular
Bronchial
Tracheal

Question 24

Isoniazid therapy is associated with possible adverse events. Which of the following events can be minimized or prevented with simultaneous intake of pyridoxine?

A.Hepatic toxicity
B.Peripheral neuropathy
C.Urticaria
D.Nausea and vomiting

Answer 24

Answer: B. Peripheral neuropathy

Isoniazid competes with pyridoxine (vitamin B6) as a cofactor for synthesis of synaptic neurotransmitters, resulting in neurologic adverse effects such as peripheral neuropathy, paresthesias, and ataxia.