A 65-year-old man, his wife, and 38-year-old son have been your clinic patients
for the last 15 years. In the evaluation of some mild hemoptysis of the 65-yearold man, a chest x-ray reveals a 4 cm right sided lung mass, hilar and
mediastinal adenopathy, and several lytic lesions in his ribs and humerus. None
of these findings were present on an x-ray performed 4 years earlier. He has a
50-pack year smoking history. When he returns to your office, you inform him
that he likely has stage IV lung cancer and that you would like to refer him to an
oncologist for further evaluation. He states that he wants no therapy whatsoever,
and that he wants to keep this a secret from his family. The most appropriate
response would be to
A. call his son as soon as he leaves the office
B. inform him that treatment will likely be curative and that he should
really reconsider his decision
C. investigate what it is that makes him feel uncomfortable in telling his
family and provide counseling
D. realize that he will likely "come to his senses" and give him a referral to
the oncologist anyway
E. tell him that he is probably just in denial and try to persuade him to tell
his wife when he gets home
Explanation:
The correct answer is C. Patient confidentiality is one of the most important
medical ethical issues facing physicians, and it certainly can pose dilemmas at
times. This patient has just received horrible news and is likely just reacting
without really thinking about the ramifications of his decision. However, there
may be very important personal, social, or cultural reasons for his decision. It is
important for you, as a physician, to explore these with him.
Calling his son (choice A) is inappropriate because it breaks confidentiality.
Although you will likely try to get the patient to reconsider his decision (choice B)
telling him that therapy will likely be curative for stage IV lung cancer is not true.
There is very little chance at a cure and palliative therapy is a much more
reasonable expectation.
Giving him a referral to the oncologist because he is will "come to his senses"
(choice D) is inappropriate. He obviously needs counseling, and the feelings as
to why he does not want treatment and why he does not want his family to
know, should be explored.
Although the patient may be in denial (choice E), patient confidentiality
precludes you from unilaterally deciding to tell his wife. It is appropriate to try to
understand the reasons why he does not want to tell his family, as opposed to
trying to persuade him to tell his wife when he gets home.
A 24-year-old woman comes to the office because of a cough with "yellowish
sputum production" for the past 2 days. She states that the cough has been
keeping her up at night and it is bothering her co-workers. They insisted that she
"go get medicine" so that she does not "infect the entire office." She has no
1
history of respiratory disease. Her temperature is 37 C (98.6 F), blood pressure is
110/80 mm Hg, pulse is 70/min, and respirations are 18/min. Physical
examination is normal. The most appropriate next step in management is to
A. admit her to the hospital for medical management
B. obtain a sputum culture
C. order a chest x-ray
D. prescribe erythromycin, orally
E. send her home with no medications
Explanation:
The correct answer is E. This patient most likely has acute bronchitis. Acute
bronchitis in a healthy patient with no other medical conditions is often due to
viral infection that is usually self-limited. Given that this patient has only had 2
days of symptoms, an antibiotic is not necessary and is inappropriate. If the
symptoms persist for longer than 1 week, a macrolide antibiotic may be given. A
chest x-ray and a sputum culture are not indicated.
Admission to the hospital for medical management (choice A) is inappropriate
for a healthy patient with acute bronchitis.
A sputum culture (choice B) is used to identify organisms, but should only be
used in an elderly patients with chronic disease that fail antibiotic therapy. This
patient's acute bronchitis is most likely due to a self-limited viral infection.
A chest x-ray (choice C) has no role in the diagnosis of acute bronchitis in a
healthy patient.
Send the patient home with antibiotic therapy (choice D) is appropriate
management for acute bronchitis in an elderly patient with chronic disease. A
macrolide (erythromycin, azithromycin, clarithromycin) is the treatment of
choice. It is not part of the initial treatment in a previously healthy patient.
A 45-year-old woman with severe reflux disease secondary to a hiatal hernia is
admitted to the hospital with flank pain from a kidney stone. An abdominal CT
shows multiple stones in the right ureter and renal pelvis. On the floor, she is
given intramuscular meperidine every 4 hours for pain control. Early in the
morning the patient is found to be obtunded in moderate respiratory distress with
some evidence of vomitus on her lips and bed shirt. She had been given 3
additional doses of meperidine for pain control in the past 5 hours. A chest
radiograph will most likely show a
A. diffuse bilateral airspace disease
B. diffuse bilateral interstitial infiltrates
C. right lower lobe opacification
2
D. right pleural effusion
E. widened mediastinum
Explanation:
The correct answer is C. Aspiration of gastric contents causes severe lung
inflammation. The traditional dogma that the acidic nature of the aspirate is
critical has recently been reevaluated and it is now clear that large volumes of
gastric contents of any pH are dangerous to the lung. Patients with severe reflux
often regurgitate frequently throughout the day and at night will have small
aspiration events, which will wake them from sleep by coughing. Once sedated,
these people develop depressed cough reflexes and therefore are more likely to
be unable to protect their airway during such regurgitations. This is most
certainly what has occurred with this patient. The most common radiological
finding is right lower lobe opacification (alveolar filling) or collapse.
Diffuse bilateral airspace disease (choice A) is characteristic of acute respiratory
distress syndrome (ARDS) or very late stage aspiration which can lead to
ARDS.
Diffuse bilateral interstitial infiltrates (choice B) are characteristic of pulmonary
edema. This may be a late manifestation (a few days) of severe aspiration, but
not an early one.
Pleural effusions (choice D) are not present in aspirations. A unilateral effusion
can be found in cases of liver abscess or right sided diaphragmatic irritation or
with Meigs syndrome (ovarian cancer and ipsilateral pleural effusion).
A widened mediastinum (choice E) is characteristic of an aortic arch dissection
or of a pulmonary disease such as sarcoid.
A 78-year-old man who lives alone is brought to the emergency department by
ambulance because of respiratory distress. According to the brief history
obtained by the paramedics, he is having abdominal pain since the morning and
reports a history of congestive heart failure, insulin dependent diabetes mellitus,
hypertension, and peripheral vascular disease. On arrival to the hospital, he is
very drowsy and his temperature is 36.7 C (98.0 F), pulse is 110/min and
irregular, blood pressure is 90/54 mm Hg, respirations are 24/min, and oxygen
saturation is 84%. He appears to be in great distress from his abdominal pain.
Laboratory studies show:
After starting an intravenous catheter and administering a diuretic, you are
getting ready to intubate the patient. The emergency department nurse conveys
a message from the patient's daughter in Florida that there is a living will written
by the patient which mandates that under no circumstances should he be
3
intubated, resuscitated by CPR or dependent on artificial ventilation or feeding.
The nurse reports that the daughter was very emotional and adamant that the
patient should just be made comfortable, and that she would sue if he was
intubated or if CPR carried out. During that emotional conversation she forgot to
leave her phone number. The most appropriate next step in management is to
A. call a hospital administrator to make a decision
B. call a hospital lawyer for advice
C. intubate the patient
D. respect the daughter's wishes and keep the patient comfortable
without intubation
E. try and trace the daughter's phone number and request a fax of the
living will
Explanation:
The correct answer is C. The patient is in respiratory distress and needs
intubation for airway control, better oxygenation, hemodynamic resuscitation,
and to feel comfortable. Although every attempt should be made to respect the
patient's wishes and the family's requests, in an emergency situation there is
limited opportunity to check the validity of telephone messages and faxed
documents. Medical emergency mandates appropriate action prior to legal
concerns.
Calling the hospital administrator (choice A) and lawyer (choice B) are not
advisable in an emergency situation for the reasons explained above.
A living will mandating “do not resuscitate or do not intubate” needs to be
checked and certified by a hospital social worker or legal department for
authenticity before implementation. In an emergency situation this is not
practical. Even if this patient is intubated, once a valid living will is obtained the
ventilator can be switched off. Hence, to respect the daughter's wishes and
keep the patient comfortable without intubation (choice D) is incorrect.
To try and trace the daughter's phone number and request a fax of the living will
(choice E) is not practical in an emergency situation, and the validity of the
documents is questionable without being checked by hospital authorities.
A 29-year-old man is admitted to the hospital with fever and cough. The
symptoms began roughly 1-month prior and have been intermittent. He states
that his cough is often productive of thick secretions and that, despite normal
food intake, he has lost about 10 pounds in the past month. He is a volunteer at a
local hospital and has received no special health care personnel vaccinations or
screening tests. On examination, the patient appears somewhat thin, tired, and is
coughing intermittently. His temperature is 38.0 C (100.4 F) and respirations are
16/min. He has patchy bilateral rhonchi over all lung fields. Prior to initiating
therapy for this condition, the laboratory test required to confirm the suspected
diagnosis is a
A. chest radiograph
4
B. sputum acid-fast stain
C. sputum culture
D. sputum Gram stain
E. tuberculin skin test
Explanation:
The correct answer is B. The patient likely has tuberculosis. Virtually all M.
tuberculosis is transmitted by airborne particles that are 1 to 5 µm in diameter.
The symptoms of tuberculosis are protean and nonspecific and can be classified
as either systemic or organ-specific. Classic systemic symptoms include fever,
night sweats, anorexia, weight loss, and weakness. However, since tuberculosis
is associated with other illnesses that have similar symptoms, this lack of
specificity can result in a delayed diagnosis or even a misdiagnosis. Organspecific symptoms of pulmonary tuberculosis include cough, pleuritic pain, and
hemoptysis. The requirement for diagnosis is the presence of the organism that
appears by acid-fast staining in a sputum sample.
In patients with primary tuberculosis, chest radiographs (choice A) often show
infiltrates in the middle or lower lung zones, with ipsilateral hilar adenopathy.
These findings are non-specific and are not used for confirmation of the
diagnosis.
A sputum culture (choice C) is not useful in this case since the organism
responsible for TB is fastidious and is difficult to culture, and certainly does not
grow rapidly.
The organism responsible for TB does not stain with traditional Gram stain dyes
(choice D) and therefore requires special staining such as acid-fast in order to
detect it.
Although it is imperfect, the gold standard for diagnosing latent tuberculosis
infection remains the intradermal injection (choice E) of purified protein
derivative (5 TU) into the volar or dorsal surface of the forearm (Mantoux
method). The test has no role in the diagnosis of active infection.
A 56-year-old man comes to the clinic for a pre-employment physical
examination. He feels well and denies any health problems. Past medical history
is negative except for an appendectomy about 20 years ago. The patient drinks
several alcoholic beverages per day and smokes "a lot" of cigarettes. A
"screening" chest x-ray, which you ordered because it is asked for on the
employment forms, is shown below and demonstrates a left hilar mass and
emphysema.
5
In considering the most appropriate next step in management, the most relevant
question to ask this patient at this time is:
A. "Are your affairs in order?"
B. "Do you have any allergies?"
C. "How many packs of cigarettes do you smoke per day?"
D. "What are your thoughts on end of life care?"
E. "Would you consent to a lung biopsy?"
F. "Would you consider chemotherapy or radiation treatment for cancer?"
Explanation:
The correct answer is B. The chest x-ray demonstrates a right mid-lung nodule
and emphysema. There is a lung nodule that is likely to be cancer in this patient
with a smoking history and radiographic emphysema. The next step is a CT
scan of the thorax with contrast, and before administering iodinated contrast, an
allergy history must be elicited. Prior allergies to iodinated contrast material or
shellfish will require further questioning. If the allergy is minor such as mild
hives, pruritus, or flushing, a pre-medication regimen of prednisone and
diphenhydramine is necessary. More serious allergies such as anaphylaxis
preclude the administration of intravenous contrast.
Questions about death (choice A and D) are premature. This nodule may be an
artifact, pneumonia, a granuloma, or cancer. Moreover, a localized cancer may
be curable.
While quantification of the patient's smoking (choice C) is necessary for a
6
complete history, it does not change the management of this patient.
A lung biopsy (choice E) is premature. A CT scan and possibly PET scan are
necessary to evaluate this lesion noninvasively before an invasive procedure is
carried out.
Even though this nodule is likely to be cancer, questions about cancer treatment
(choice F) are premature.
A 53-year-old widowed woman comes to the office for a health maintenance
examination. She is a new patient who recently moved to your city after her
husband died in an office fire 6 months ago. She says that she has no
complaints, except for a cough that she began to notice 4 months ago. She
denies nasal discharge, "a tickle in the throat," frequent throat clearing, heartburn
and the sensation of regurgitation, fever, sputum production, cigarette smoking,
illegal drug use, sexual activity, occupational exposures, and any other
symptoms associated with a respiratory infection. She says that the cough is not
seasonal or associated with wheezing. Her temperature is 37.0 C (98.6 F), blood
pressure is 135/90 mm Hg, pulse is 70/min, and respirations are 14/min. Physical
examination is unremarkable. The most appropriate next step is to
A. order an electrocardiogram
B. order an x-ray of the chest
C. question her about medications
D. refer her for fiberoptic bronchoscopy
E. schedule her for pulmonary function tests
Explanation:
The correct answer is C. This patient has a chronic cough, which is usually
considered chronic because it is lasting more than 3 weeks. It may be due to a
variety of things. However, the important lesson in this question is that before
you turn to diagnostic studies you need, to make sure that you have obtained a
detailed history. The case history will provide the answer to almost every
question that you will need to ask her, except what medications she takes.
Since she is a new patient, you will need to find out if she is taking an ACE
inhibitor, such as captopril or enalapril, which is a frequent cause of a chronic
cough in hypertensive patients. They cause a cough in up to 20% of people
taking them. The exact mechanism is unknown, but it is thought to somehow be
related to bradykinin and substance P. The treatment for the cough is the
discontinuation of the ACE inhibitor.
An electrocardiogram (choice A) is unnecessary at this time in this patient,
complaining of a chronic cough. She is not complaining of chest pain and there
is nothing in her history that suggests an arrhythmia. The most important next
step, is to take a detailed history before you order diagnostic tests.
An x-ray of the chest (choice B) may be appropriate in the near future, but it is
not the next step at this time. Before you order diagnostic studies, you need to
make sure that you ask her any questions that might help you figure out the
7
etiology of her cough. Asking her about medications is very important because
ACE inhibitors cause a chronic cough in up to 20% of patients taking this
medication.
A fiberoptic bronchoscopy (choice D) is used to obtain histologic and cytologic
specimens and to visualize an endobronchial tumor. Before you turn to such a
specialized study, you need to first obtain a detailed history. If the patient is not
taking an ACE inhibitor, a chest x-ray should usually be performed, and if this is
abnormal, sputum cytology, a high resolution CT scan, and fiberoptic
bronchoscopy should be considered.
Pulmonary function tests (choice E) are used to assess airway
hyperresponsiveness for patients in which you suspect asthma, and lung
volumes and diffusion capacity in patients in which you suspect a diffuse
interstitial lung disease. A detailed history is necessary before using any of
these studies.
You are called to see a 75-year-old man who has metastatic lung cancer
because of hypoxia, hypotension, and mental status changes. He has been your
patient for many years and he has told you multiple times that he does not want
to be placed on a respirator for any reason. On multiple occasions after his wife
died, he has explained to you that if he was ever in a situation where mechanical
respiration or any heroic measures should become necessary, that he would
prefer to simply be made comfortable and be "allowed to go." He has a living will,
which states that if he was in a terminal condition he does not want any life
sustaining treatments including hemodialysis, intubation, and cardiac
resuscitation. Rather, he wants comfort care only. His two daughters and three
sons are all present in the room with you. They explain to you that they are very
upset by their father's condition and that they want to place him on a ventilator to
help him get through this episode. You explain that their father did not want
aggressive medical care at the end of life, but the family insists on intervention.
They threaten to sue you for malpractice if he dies. His temperature is 37.0 C
(98.6 F), blood pressure is 75/40 mm Hg, pulse is 130/min, and respirations are
29/min. Physical examination shows a cachetic man in moderate respiratory
distress. He is extremely disoriented and agitated and appears to be in pain. The
most appropriate course of action at this time is to
A. ask the family to leave and inject a lethal dose of morphine in
accordance with the patients wishes
B. do not intubate patient but administer morphine and dopamine together
to alleviate his suffering while maintaining his blood pressure
C. do not intubate the patient but administer morphine for comfort even
though this might lower his blood pressure and respiratory rate and hasten
the patient's demise
D. contact the hospital ethics committee to decide on the proper course of
action
E. intubate the patient for now; when the situation is more stable discuss
the patient's end of life wishes with the family
Explanation:
The correct answer is C. This patient has a living will, which states that if he was
8
in a terminal condition he wants only comfort care. He has also clearly stated his
wishes to you in the past. Intubation of this patient is clearly against his wishes.
Starting morphine may cause respiratory suppression or worsen his hypotension
which might hasten death. The potential to hasten death is an acceptable risk if
the primary intention is to decrease patient suffering. Ideally, the patient's
wishes should be clearly explained early in his hospital course.
Injection of a "lethal dose" of morphine (choice A) is not acceptable
management of this patient since its only purpose would be to hasten death. As
stated above, it is acceptable to use a drug that may hasten death if the primary
intention is to decrease suffering. Asking the family to leave and then injecting a
lethal dose of medication is clearly not acceptable management.
Any time you start morphine on a patient you need to be aware of the possibility
of worsening hypotension. Morphine is a mild vasodilator and therefore acts as
a preload reducer. In this patient, hypotension already is prominent prior to
starting morphine. Starting dopamine with the morphine (choice B) is not
appropriate in this case since most physicians agree that, in this patient, starting
vasopressors would constitute "heroic" measures.
Contacting the hospital ethics committee (choice D) is not appropriate in this
patient. This patient needs immediate medical attention. There is no time for
meetings now.
Intubation of this patient now (choice E) is clearly against the patient's
documented wishes. To ignore a patient living's will and end of life issues is
clearly wrong and would make completion of advance directives meaningless.
A 53-year-old woman who is a heavy smoker presents to the emergency
department complaining of increasing shortness of breath for the past 3 days.
She denies any history of asthma or coronary artery disease. Her temperature is
37.3 C (99.2 F), blood pressure is 150/90 mm Hg, heart rate is 110/min, and
respiratory rate is 34/min. On examination, she is awake, alert, and oriented.
Diffuse bilateral wheezes are heard on lung auscultation. Pulse oximetry
measures 90% oxygen saturation on room air. An arterial blood gas is drawn and
the results show:
A chest radiograph demonstrates bilateral, hyperinflated lungs with a flattened
diaphragm. Sputum Gram stain shows a few polymorphonuclear cells, moderate
number of epithelial cells, and a moderate number of Gram-positive cocci. She
receives supplemental oxygen, albuterol nebulizer treatments, and steroids. Her
symptoms improve and pulse oximetry now reads 93% saturation. The most
appropriate next step is to
A. add antibiotics to the treatment regimen
B. do diffusion capacity testing by carbon monoxide
9
C. intubate and begin mechanical ventilation
D. obtain lung spirometry measurements
E. start non-invasive positive pressure ventilation
Explanation:
The correct answer is A. The patient is a smoker who presented with
progressive shortness of breath. Physical examination found diffuse wheezing
and chest X-ray noted emphysema. In addition, she had an elevated pCO2 with
acute respiratory acidosis and moderate hypoxia. These findings are consistent
with an exacerbation of chronic obstructive lung disease. Such flares are treated
with β2-agonists, anticholinergics, and steroids. In addition, antibiotics have also
been shown to improve clinical outcome, and so they are part of the treatment
regimen for chronic obstructive lung disease flares.
Diffusion capacity (choice B) for this patient will likely be low given her
emphysema and is an important measurement for diagnosis, but it is not
required in the acute management of this condition.
The patient has a normal mental status and is able to protect her airway. Her
symptoms and oxygenation also improve with treatment. Thus, there is no
current indication for intubation (choice C). Intubation is required if the patient
has severe CO2 retention and/or hypoxia refractory to medical therapy.
Intubation is also indicated if her condition is refractory to non-invasive
ventilation, if she has severe acid-base disturbances, or if there is any change in
her mental status that would compromise the airway.
Lung spirometry (choice D) will aid in the diagnosis of her disease but is not
useful in management of her clinical course.
Non-invasive positive pressure ventilation (choice E) is indicated in patients with
severe chronic obstructive pulmonary disease that is refractory to medical
therapy. It is also useful in patients with increasing respiratory fatigue. A patient
must be able to initiate breathing and tolerate the breathing mask. This patient
has a normal mental status and her symptoms improve with treatment. Thus,
she currently does not require any assistance in ventilation.
An 8-year-old boy is brought to the office by his mother because of recurrent
episodes of "shortness of breath" and wheezing. These episodes typically occur
when he is playing in the park with friends or when he is in the house at night.
The symptoms are worst in the springtime and when he is watching television
with his mother's boyfriend. The mother's boyfriend, who happens to smoke
cigarettes, has been spending more and more time at the house, trying to bond
with the patient. Pulmonary function tests show that the peak expiratory flow and
forced respiratory volume per second are reduced during an attack and are
normal during symptom-free intervals. Skin testing shows that he is allergic to
grass and tree pollen, dust mites, animal dander, and a variety of other allergens.
Laboratory studies show:
10
The most appropriate next step is to
A. administer immunotherapy against identified allergens
B. advise him to avoid all exercise
C. advise him to try to avoid respiratory irritants, especially cigarette
smoke
D. advise the patient's mother to use a humidifier and air cleaners at
home
E. prescribe inhaled sodium cromoglycate, oral corticosteroids, and oral
theophylline
Explanation:
The correct answer is C. This patient has asthma, and the most crucial step in
the management of asthma is avoidance of the triggering factors, e.g.,
allergens. Unfortunately, it is difficult to avoid specific types of allergens, such as
pollens. Specific measures to eliminate or reduce exposure to dust mites and
animal dander at home lead to a reduced frequency of attacks and
hospitalization rates. Regardless of the allergens involved, elimination of
respiratory irritants, especially cigarette smoke, is of crucial importance. The
bronchial tree of asthmatic patients is highly reactive to any form of chemical or
physical irritation. Thus the avoidance of passive smoke is important. The
mother should ask her boyfriend to go smoke outside alone if he needs to, but
he should not be allowed to smoke in the house.
It is not practical to administer immunotherapy against identified allergens
(choice A) in this case because he is allergic to multiple airborne allergens, and
it seems like he is especially responsive to cigarette smoke. Immunotherapy is
of some benefit when a single allergen is identified. The most important step is
to try to reduce exposure to avoidable allergens (smoke).
Avoidance of all exercise (choice B) is not appropriate because even though
exercise triggers asthmatic attacks in some patients, this does not seem to be
his main trigger.
Humidifiers and air cleaners (choice D) at home is not the appropriate
management. Humidifiers favor the growth of dust mites, and air cleaners have
not been shown to be uniformly effective in getting rid of dust mites.
It is inappropriate to prescribe inhaled sodium cromoglycate, oral
corticosteroids, and oral theophylline (choice E) for this patient because the
fewest number of drugs at the lowest effective doses should be used. Typically,
a one drug regimen (a bronchodilator or an inhaled corticosteroid) for mild to
11
moderate asthma or two drugs for more severe cases is sufficient to control
asthma exacerbations. Oral corticosteroids are indicated in cases of severe
asthma and are therefore, not for this patient.
A previously healthy 21-year-old college student comes to the clinic because of a
headache, sore throat, muscle aches, and a constant, irritating, dry cough for six
days. He says that he is "never sick" and has only been to this clinic for his
"immunizations". He exercises regularly, does not smoke cigarettes, and has an
"occasional beer on the weekends with buddies." His temperature is 38.8 C
(101.8 F), blood pressure is 120/80 mm Hg, pulse is 68/min, and respirations are
16/min. Scattered rhonchi are heard in the left lower lobe. A chest x-ray shows
diffuse interstitial infiltrates in the left lower lobe. A single dose of erythromycin
therapy is given in the clinic. The most appropriate next step in management is to
A. admit him to the hospital and begin administration of erythromycin,
intravenously
B. admit him to the hospital and begin administration of trimethoprimsulfamethoxazole, intravenously
C. admit him to the hospital for a cold agglutinin test
D. give him a prescription for erythromycin and send him home
E. recommend aspirin, fluids, and rest at home
Explanation:
The correct answer is D. This patient most likely has Mycoplasma pneumonia,
which is a common cause of pneumonia in young adults and is typically treated
with oral erythromycin as an outpatient. It is characterized by a dry cough,
headache, myalgia, malaise, and fever. Physical examination is usually
unremarkable except for diffuse rhonchi or fine rales. A chest x-ray shows
diffuse interstitial or reticulonodular infiltrates, typically in the lower lobes. Given
the patient's age, history, physical examination, and chest x-ray findings, it is
reasonable to assume that he has a community-acquired pneumonia. This is
most likely due to Mycoplasma pneumoniae and empiric antimicrobial therapy
with erythromycin should be prescribed. In these patients, a microbial diagnosis
(with a sputum culture, transtracheal aspiration, bronchoscopy, or a blood
culture) is often impractical and unnecessary. A cold agglutinin response is often
associated with Mycoplasma pneumoniae. However, it is nonspecific and
detected in less than 50% of cases.
Admitting him to the hospital and beginning administration of erythromycin,
intravenously (choice A) is incorrect because a patient with Mycoplasma
pneumonia, which is what this patient most likely has, is usually treated as an
outpatient. The criteria for hospitalization of patients with pneumonia are ages
>65, significant comorbidity, leukopenia, pneumonia due to Staphylococcus
aureus, Gram-negative bacilli or anaerobes, suppurative complications, failure
of outpatient management, inability to take oral medication, respirations
>30/min, heart rate >140/min, hypotension, hypoxia, or acute alteration of
mental status. The patient in this case does not meet any of these criteria.
Admitting him to the hospital and beginning administration of trimethoprim-
12
sulfamethoxazole intravenously (choice B) is the management for patients with
severe Pneumocystis carinii pneumonia (PCP), which is characterized by
shortness of breath, a dry cough, fever, night sweats, rales or rhonchi, and
bilateral patchy alveolar infiltrates. This is a common cause of pneumonia in
immunocompromised patients, especially those with HIV and AIDS. The patient
in this case does not appear to be immunocompromised, and he is not short of
breath, which makes the diagnosis of PCP unlikely.
Admitting him to the hospital for a cold agglutinin test (choice C) is inappropriate
because even though this patient most likely has Mycoplasma pneumonia, it can
be treated with erythromycin as an outpatient, and a cold agglutinin test can be
performed as an outpatient. A cold agglutinin response is often associated with
Mycoplasma pneumoniae. However, it is nonspecific and detected in less than
50% of cases.
Recommending aspirin, fluids, and rest at home (choice E) is inappropriate
treatment for this patient who most likely has Mycoplasma pneumonia, which
needs to be treated with an antibiotic such as erythromycin.
A 23-year-old man with a childhood history of eczema presents to your office for
the first time complaining of a non-productive cough that started 4 months ago
after a respiratory tract infection during the winter. He generally has the cough
roughly once or twice a week, usually after strenuous exercise. He has not had
any fevers at home and denies any hemoptysis. He smokes socially, roughly 1
pack a week, and binge drinks on the weekends. He denies any intravenous drug
use, but has had several unprotected heterosexual relationships this past year.
His temperature is 37.0 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is
65/min, and respirations are 15/min. His physical examination is remarkable only
for end expiratory wheezes on bilateral lower lung fields. At this time the most
correct statement about his condition is:
A. Bronchoscopy should be performed to rule out opportunistic infection
B. A chest x-ray is necessary prior to starting any empiric therapy
C. Inhaled steroids are an appropriate first line agent
D. Pulmonary function tests would reveal a reduction in the FEV1/FVC
ratio
E. A trial of antibiotics against atypical pathogens such as mycoplasma or
chlamydia would relieve this patient's cough
Explanation:
The correct answer is D. This patient has a classic history for cough variant
asthma. The diagnosis of asthma is helped by the history of atopy/eczema. His
cough is predominant after exercising, but other allergens (e.g., cigarette
smoke, dust, pollen) or cold weather could also induce asthma in many patients.
Pulmonary function tests would reveal a decrease in the FEV1/FVC ratio,
pathognomonic for obstructive lung disease.
There is no need for bronchoscopy (choice A) since in this patient there is low
suspicion for an infectious process. His history of unprotected sexual intercourse
13
does raise the suspicion for HIV, yet opportunistic pulmonary infections such as
Pneumocystis Carinii pneumonia would be a late finding when the CD4 counts
are less than 200.
A chest x-ray (choice B) would probably be unremarkable, since we have low
suspicion for any pulmonic infection. Other causes of pulmonary wheezing and
cough could include a foreign body, hypersensitivity pneumonitis, or
intrathoracic lung mass. However, these are rarer etiologies and asthma is still
primarily a clinical diagnosis.
Inhaled steroids (choice C) may be an appropriate treatment for mild or
moderate persistent asthma. However, this patient only coughs roughly once or
twice a week, and therefore would be considered to have mild intermittent
asthma. An intermittent beta agonist would be the appropriate first line treatment
for mild intermittent asthma.
There is no reason to suspect atypical pneumonia (choice E) in this afebrile
patient with cough variant asthma.
A 56-year-old man is admitted to the intensive care unit for acute respiratory
distress syndrome (ARDS). The patient was transferred from an outside hospital
today after a 2-week hospitalization for pneumonia. During that time, the patient's
pulmonary status continued to deteriorate. One week ago he was intubated and
placed on mechanical ventilation and over the past week, his oxygenation has
worsened with a PaO2 of 66 on an inspired concentration of 100% oxygen. The
patient has no other medical history except for rheumatoid arthritis. On transfer to
the ICU, the patient is intubated and sedated on a mechanical ventilator. His
chest radiograph shows patchy, bilateral, diffuse interstitial infiltrates. The most
important intervention that will most benefit this patient is to
A. keep the patient in a prone position during mechanical ventilation
B. keep tidal volumes greater than 15 cc/kg
C. limit peak inspiratory pressure to 45 cm H2O or less
D. limit PEEP levels to less than 10 cm H2O
E. limit tidal volumes to 6cc/kg
Explanation:
The correct answer is E. Although once limited to very specialized care units,
patients with ARDS are becoming more prevalent in general medical ICU
settings, in part due to the increasing incidence and recognition of the disorder.
ARDS is an inflammatory condition of the lungs of unknown etiology but is
associated with many conditions such as pneumonia, trauma, sepsis, and blood
transfusions. The common denominator of all ARDS is profound hypoxia defined
as a PaO2/FiO2 ratio of less than 200. Because of the profound hypoxia, the
patients require mechanical ventilation for improvement. Ironically, many of the
strategies employed over the years have actually contributed to or significantly
worsened the injury of ARDS. The only effective intervention to date was
recently shown in an NIH clinical trial. The mortality benefit conferred from this
14
maneuver is substantial. The limitation of tidal volume to 6cc/kg or less is now
standard of care and is required knowledge of any physician caring for critically
ill patients.
Although there have been case reports that prone positioning during mechanical
ventilation (choice A) is useful for these patients, the randomized trials indicate
that there is no mortality benefit associated with this intervention.
The traditional teaching of keeping tidal volumes greater than 15 cc/kg (choice
B) and of limiting peak inspiratory pressure to 45 cm H2O or less (choice C) is
now incorrect and in fact, has been shown to be very detrimental to these
patients. Experimental data have shown that ventilatory strategies that
overdistend parts of the lung or allow the lung to cycle repeatedly between a
collapsed state and an open state can lead to injuryXso-called ventilatorinduced lung injury. PIPs should be limited to 35 cm H2O or less.
Limiting PEEP levels to less than 10 cm H2O (choice D) is opposite of what is
required to manage these patients. PEEP values often exceed 10 cm H2O so
that repeated cycling between a collapsed state and an open state is prevented.
This is the so-called "open-lung" approach to ARDS management.
A 60-year-old man comes to the emergency department because of shortness of breath. He
complains of a dry cough, but denies any fever, chills, or sweats. His past medical history is
significant for a history of chronic obstructive pulmonary disease (COPD), hypertension, and
alcoholism. His medications include an albuterol inhaler and furosemide. He appears to be in
moderate respiratory distress. His temperature is 37.0 C (98.6 F), blood pressure is 146/98
mm Hg, pulse is 120/min, and respiratory rate is 36/min. His oxygen saturation on room air is
89%. His breath sounds are diminished bilaterally and he has diffuse wheezes. The
remainder of the physical examination is unremarkable. A chest radiograph shows
hyperexpanded lungs. An electrocardiogram shows sinus tachycardia. The most appropriate
next diagnostic study is
A. arterial blood gas analysis
B. chest CT scan
C. echocardiogram
D. venous blood gas analysis
E. ventilation-perfusion scan
Explanation:
The correct answer is A. In a patient with a history of chronic obstructive pulmonary disease
(COPD), the constellation of described historical and physical findings with a chest
radiograph showing no acute pathology indicates a COPD exacerbation. An arterial blood
gas analysis, especially in the setting of a room air oxygen saturation of 89%, will more
clearly define the patient's oxygenation and ventilation status and assist in better
management and triage.
A chest CT scan (choice B) in the setting of a chronic obstructive pulmonary disease
exacerbation associated with a negative chest radiograph cannot be expected to provide
additional useful information.
15
An echocardiogram (choice C) will offer no useful information since the patient's respiratory
distress, based upon the available history and physical exam, is due to an exacerbation of
his chronic obstructive pulmonary disease.
A venous blood gas analysis (choice D) cannot provide any information regarding systemic
oxygenation. It's utility in this setting, therefore, is minimal.
Since there is no reason to suspect a pulmonary embolus, a ventilation-perfusion scan
(choice E) will not provide any useful information in this instance.
A previously healthy 31-year-old woman comes to your office complaining of 1-day history of
a cough and a fever. She reports that she was celebrating a job promotion 3 days prior and
drank quite a bit of alcohol at a local bar. She had 2 episodes of vomiting that evening. She
takes no regular medications and has only been using acetaminophen for fever suppression.
Her temperature is 38.2 C (100.8 F). Her lungs have decreased breath sounds in the left
base and right upper lobe. She has a cough that is productive of foul-smelling sputum. The
remainder of her examination is unremarkable. The most appropriate management is to
A. admit the patient to the hospital for clindamycin therapy
B. admit the patient to the hospital for penicillin therapy
C. admit the patient to the intensive care unit for levofloxacin therapy
D. begin outpatient cefuroxime therapy
E. begin outpatient erythromycin therapy
Explanation:
The correct answer is A. This is a patient who likely has pneumonia in the setting of likely
aspiration. Since most pneumonia never have the etiologic agent identified, the treatment is
empirical based upon patient locale at time of infection and presumed organisms based upon
epidemiology. In this case, the presumed aspiration indicates that coverage for Gramnegative and anaerobic organisms is required. Clindamycin is a macrolide derivative that has
activity against these agents. It is effective and is well-tolerated orally. Uncomplicated
pneumonia such as community acquired or atypical infections rarely require hospitalization.
For this patient with a likely anaerobic, purulent infection, a more monitored setting for
therapy is required.
Penicillin (choice B) is an excellent choice for community acuquired pneumonia with the
caveat that an increasing number of isolates of S. pneumonia are resistant. In some centers,
this number is as high as 20%. However, penicillin has no activity against Gram-negative or
anaerobic organisms.
Levofloxacin (choice C) is a fluoroquinolone that has broad activity against Gram-positive,
Gram-negative, and some anaerobes. However, it does not have adequate coverage of
anaerobic organisms to provide effective coverage for presumed aspiration. This patient has
no objective findings that would warrant an ICU admission. Hemodynamic instability or
respiratory distress requiring intubation would be classical reasons why patients with severe
pneumonia may require an ICU stay.
Outpatient cefuroxime (choice D) is a second-generation cephalosporin that is standard
outpatient therapy for community acquired pneumonia. It does not have the required broad
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Gram-negative (although it has some) coverage and it has no anaerobic coverage. This
patient should however be hospitalized for observation during initial therapy.
Erythromycin (choice E) is a macrolide antibiotic that is also effective for both typical and
atypical community acquired pneumonia but is only minimally useful in cases of aspiration
pneumonia.
A 24-year-old African American woman comes to the clinic with a 2-week history
of painful red "lumps" on her shins. She denies fevers, night sweats, cough, or
sputum production. Her only past history was a broken arm when she was 10,
and she does not take any medications. Her temperature is 37 C (98.6 F), blood
pressure is 120/72 mm Hg, pulse is 68/min, and respirations are 16/min. Her
lungs are clear and cardiac examination is normal. She has multiple bilateral,
large, red, nodular lesions on her anterior tibial regions, which are painful to
palpation. There is no purulent discharge. Laboratory studies show: leukocyte
count 8,200/mm3, platelets 300,000/mm3, hematocrit 42%, BUN 16 mEq/L, and
creatinine 0.9 mEq/L. A chest x-ray shows bilateral hilar adenopathy. Appropriate
treatment for this patient should include
A. antifungal therapy
B. antituberculous therapy
C. corticosteroids
D. systemic chemotherapy
E. systemic intravenous antibiotics
Explanation:
The correct answer is C. This patient has erythema nodosum in the setting of
bilateral hilar adenopathy. Given the fact that she has no other underlying
symptoms of infection, and is a young African American female, the erythema
nodosum is most likely in the setting of sarcoidosis. The treatment in this case
will often involve the use of corticosteroids.
Erythema nodosum can also be associated with several other disease
processes such as streptococcal infections, upper respiratory infections, and
inflammatory bowel diseases. The less common associations include
tuberculosis, histoplasmosis, coccidioidomycosis, and drugs such as oral
contraceptives and sulfonamides. She is on none of these drugs and has no
symptoms of tuberculosis (choice B), a systemic or regional fungal
infection(choice A), or systemic bacterial infection (choice E).
Hilar adenopathy is always a concern for a malignancy (choice D). However,
this clinical scenario is much more classic for sarcoidosis. Biopsy proof should
nevertheless be obtained. Therefore, chemotherapy is not indicated at this time.
A 68-year-old woman comes to the office for a health maintenance examination. She has
had 5-7 episodes of "expectorated blood" in the past month that she describes as a "bit
concerning." She denies any other symptoms. She has been a patient of yours for 20 years
17
and you have treated her for various "colds and flus" in the past, but she does not have any
chronic medical conditions. She is a retired schoolteacher, gets regular exercise, and
smokes a pack of cigarettes a day. She and her husband have become "world travelers"
since both of their retirements. Her last mammogram, Pap smear, and colonoscopy were 1
year ago, and were normal, as they have always been. Her temperature is 37.0 C (98.6 F),
blood pressure is 130/80 mm Hg, pulse is 65/min, and respirations are 16/min. Physical
examination is unremarkable. The most appropriate next step is to
A. obtain a sputum sample by transtracheal aspiration for cytology
B. order a chest x-ray
C. schedule fiberoptic bronchoscopy
D. schedule a high-resolution CT scan
E. reassure her that it is most likely nothing but to come back if she continues to have
"expectorated blood"
Explanation:
The correct answer is B. This patient comes in for a routine examination but tells you
something that could possibly be serious—that she has nonmassive (less than 100mL)
hemoptysis ("expectorated blood"). Since she is a smoker and travels very frequently, you
should not ignore this symptom. Since it is likely that the blood-streaked sputum is from the
respiratory tract, a chest x-ray is the first diagnostic procedure that should be ordered.
Obtaining a sputum sample (choice A) by transtracheal aspiration is not indicated at this time
because it is too invasive. Expectorated sputum should first try to be obtained. Blood in the
sputum may occur in cases of bronchitis, pneumonia, bronchiectasis, a lung abscess, or an
endobronchial tumor. Gram, fungal, and acid-fast stains will help diagnose an infectious
cause, while cytology may be helpful to diagnose a tumor.
Fiberoptic bronchoscopy (choice C) is part of the evaluation of a patient with hemoptysis, but
it is typically performed after a chest x-ray. It is the next step if a chest x-ray shows a mass, if
the chest x-ray is normal and there are major risk factors for cancer, or if the chest x-ray is
normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after
weeks to months of observation.
A high-resolution CT scan (choice D) is usually only indicated after a chest x-ray is
performed. If the chest x-ray shows a mass and a bronchoscopy fails to suggest a specific
diagnosis, a HRCT is ordered. Also, if a chest x-ray shows parenchymal disease, a HRCT
may be indicated for further evaluation.
It is inappropriate to reassure her that it is most likely nothing but to come back if she
continues to have blood-streaked sputum (choice E) because hemoptysis can be the sign of
serious disease, especially because she is a smoker and a "world traveler." Even though she
came to the office for a routine physical examination, a chest x-ray should be ordered at this
time. Keep in mind that a chest x-ray is not part of a routine physical examination of an
asymptomatic smoker.
A 31-year-old woman with primary pulmonary hypertension is admitted to the hospital
because of increasing shortness of breath, dyspnea on exertion, and increasing home
oxygen requirements. The agent that will selectively decrease her pulmonary arterial
pressures is
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A. hydralazine
B. nifedipine
C. nitrous oxide
D. prostacyclin I
E. sodium nitroprusside
Explanation:
The correct answer is C. Nitrous oxide is a gas that is usually given in low doses, 20-80 ppm
via inhalation. It then acts via cGMP to mediate vasodilation of the pulmonary vasculature
without any systemic hemodynamic effects.
Hydralazine (choice A) is a potent generalized arterial dilator.
Nifedipine (choice B) is a calcium channel antagonist. In some persons with pulmonary
hypertension, a therapeutic dose of this agent can be given without producing dramatic
systemic hypotension. The majority of patients receiving this therapy have significant
peripheral vasodilation as well.
Prostacyclin I (choice D) is used via direct pulmonary artery infusion to produce pulmonary
vasodilation. However, it has moderate to severe side effects including increased GI motility
and peripheral vasodilation.
Sodium nitroprusside (choice E) is a generalized arterial and venous vasodilator.
A 23-year-old woman comes to the emergency department because of a "severe asthma
flare." She reports that over the past hour, she has had progressively more difficulty
breathing and that her medications at home have not helped her. She has a 7-year history of
asthma with multiple hospitalizations. She was last hospitalized 3 years ago for a severe
flare that required inpatient therapy with corticosteroids. Her current medications include
albuterol 4 times daily, oral leukotriene inhibitors, cromolyn sodium, and theophylline. Her
temperature is 37.0 C (98.6 F), blood pressure is 160/80 mm Hg, pulse is 90/min, and
respirations are 32/min. Her breath sounds are scant with a prolonged expiratory phase. She
appears to be moving minimal air. Albuterol and ipratropium nebulizers are initiated. An
arterial blood gas is drawn and is most likely to show
A. PaCO2 14 mm Hg, pH 7.22, PaO2 90 mm Hg
B. PaCO2 14 mm Hg, pH 7.56, PaO2 86 mm Hg
C. PaCO2 35 mm Hg, pH 7.22, PaO2 60 mm Hg
D. PaCO2 35 mm Hg, pH 7.39, PaO2 98 mm Hg
E. PaCO2 65 mm Hg, pH 7.24, PaO22 60 mm Hg
Explanation:
The correct answer is B. This patient has a severe asthma flare which caused her to
hyperventilate to relieve her dyspnea. When looking at arterial blood gases, examine the pH
to identify the acid-base disturbance, and then determine whether the acid-base disturbance
is respiratory (change in CO2) or metabolic. The relationship between PaCO2 and pH
19
determines whether the condition is acute or chronic. Chronic conditions have a pH closer to
7.4 than would be predicted based upon PCO2 because of compensation. For this patient,
she is hyperventilating, but with no current inability to oxygenate. She should be alkalotic
with a low PCO2 and her oxygenation should be nearly normal: PaCO2 14 mmHg, pH 7.56,
PaO2 86 mm Hg.
A PaCO2 of 14 mm Hg, pH 7.22, PaO2 90 mm Hg (choice A) represents an acidosis that is
likely metabolic since the PaCO2 is low. Oxygenation is normal. This is typical for a diabetic
in ketoacidosis where they hyperventilate (Kussmaul breathing) to compensate for their
systemic acidosis.
A PaCO2 of 35 mm Hg, pH 7.22, PaO2 60 mm Hg (choice C) reflects acidosis, likely
metabolic since PCO2 is normal, with profound hypoxemia. This is typical for lactic acidosis
of sepsis.
A PaCO2 of 35 mm Hg, pH 7.39, PaO2 98 mm Hg (choice D) represents a completely normal
blood gas.
A PaCO2 of 65 mm Hg, pH 7.24, PaO2 60 mm Hg (choice E) reflects very late asthma. At
this stage, PaCO2 has risen secondary to the inability to ventilate from severe
bronchoconstriction, pH has fallen because of a respiratory induced acidosis, and
oxygenation fails. When PaCO2 normalizes or becomes high in asthmatics, they have an
impending respiratory failure in their near future.
A 37-year-old man with a history of allergic rhinitis comes to the office with a 3-day history of
fever and cough. He was in his usual state of health until 3 days ago when he developed a
cough productive of yellow-green sputum and fevers to 38.3 C (101.8 F). The fevers have
been accompanied by drenching sweats. He has been experiencing right sided pleuritic
chest pain. He denies shortness of breath, abdominal pain, weakness, or numbness. He has
not had any sick contacts and has no recent travel outside of the United States. He has a 15pack year history of smoking but denies any alcohol use or injection drug use. His
temperature is 38.5 C (101.3 F), blood pressure is 132/74 mm/Hg, pulse is 82/min,
respirations are 14/min, and oxygen saturation is 96%. Physical examination shows crackles
at the right base A complete blood count and biochemical profile are all within normal limits.
A chest x-ray shows a right lower lobe infiltrate. The most appropriate next step in the
management of this patient is to
A. admit the patient to the hospital for intravenous ceftriaxone therapy
B. obtain a CT scan of the chest
C. request a pulmonary consultation for bronchoscopy
D. treat the patient as an outpatient with oral azithromycin therapy
E. treat the patient as an outpatient with oral ciprofloxacin therapy
Explanation:
The correct answer is D. The patient's history, exam, and x-ray are all consistent with a
diagnosis of community acquired pneumonia (CAP). CAP can be safely treated as an
outpatient in most circumstances. Exceptions to this rule are when the patient has an
underlying medical condition (cardiac disease, pulmonary disease, diabetes, HIV, cirrhosis,
renal disease, or malignancy), advanced age, or presents with a severe pneumonia
20
manifested by unstable vital signs or bilobar pneumonia. The appropriate treatment for this
patient is either a macrolide antibiotic or an extended spectrum fluoroquinolone as they will
cover typical and atypical organisms.
As discussed previously this patient does not require intravenous therapy or hospital
admission (choice A) unless his condition deteriorates. In addition ceftriaxone would not be
adequate coverage as it does not cover the atypical organisms.
In the management of routine cases of CAP, a CT scan (choice B) is not necessary. A CT
scan might be appropriate in situations where there is a concern for malignancy, underlying
pulmonary disease, or non-resolving pneumonia. None of these conditions are present in this
case.
This patient does not require a bronchoscopy (choice C). Potential indications for
bronchoscopy are when there is a concern for an obstructive lesion on imaging studies,
recurrent lobar pneumonia, or significant hemoptysis.
Ciprofloxacin (choice E) is not the antibiotic of choice for CAP. It does not provide adequate
coverage against streptococcal pneumonia, which is the most common cause of CAP.
A 68-year-old man comes to the clinic because of progressive dyspnea on exertion (DOE)
and shortness of breath over the last 7 months. He denies chest pain, orthopnea, or
paroxysmal nocturnal dyspnea. His past medical history is significant only for mild
osteoarthritis and an episode of pneumonia 20 years ago. His temperature is 37 C (98.6 F),
blood pressure is 128/76 mm Hg, pulse is 98/min, respirations are 18/min, and oxygen
saturation is 98%. His lungs are clear to auscultation and his heart is slightly tachycardic with
no murmurs, rubs, or gallops. His abdomen is soft, nontender, with normal bowel sounds.
His extremities have no edema. Rectal examination shows brown guaiac-positive stool. An
electrocardiogram shows sinus tachycardia with a single PVC. Chest x-ray shows minimal
scarring in the right lower lobe. Laboratory studies show a hematocrit of 27%, hemoglobin of
9.1 g/dL, platelets of 298,000mm3 , MCV 78 mm3, sodium of 139 mEq/l, potassium of 4.1
mEq/l, blood urea nitrogen of 16 mg/dL, and creatinine 0.9 mg/dL. The most appropriate next
step in the patient's management is a
A. cardiac stress test to rule out 3 vessel coronary artery disease
B. colonoscopy to rule out colon cancer
C. high resolution CT scan (HRCT) to rule out pulmonary fibrosis
D. iron pills and follow up in 3 months
E. ventilation-perfusion (V/Q) lung scan to rule out chronic pulmonary emboli
Explanation:
The correct answer is B. It is important to remember that anemia can present with dyspnea
on exertion and a complete blood count should always be part of this work up. This elderly
patient has an iron deficiency anemia with hemoccult positive stool. A GI malignancy needs
to be ruled out and colon cancer is the most likely etiology in this patient population.
Therefore, a colonaoscopy is imperative.
Although ischemic cardiomyopathy or silent ischemia can certainly present with progressive
dyspnea on exertion, there are other things in the patient's history to suggest the cause of
21
his symptoms. A cardiac workup (choice A) at this time is not the most pressing issue.
HRCT (choice C) is a very good test to evaluate for pulmonary fibrosis. It is likely that the
CXR would show more abnormalities. The minimal scarring mentioned at the right lower lobe
is likely from his prior pneumonia mentioned in the past medical history, and is not causing
the patient any symptoms.
The patient is presenting with a microcytic anemia. The most likely cause is iron deficiency.
However, it must always be remembered that the finding of a microcytic anemia should
always prompt the immediate search for an underlying cause. So although the patient will
likely require iron supplementation (choice D), follow up in 3 months with no other diagnostic
test is not appropriate.
A V/Q scan (choice E) can rule out chronic pulmonary emboli, which is certainly a cause of
progressive DOE, but as mentioned previously, there are other things in the patient's history
to suggest the cause of his symptoms.
A 31-year-old woman comes to the office for a follow-up visit. Two weeks ago,
the patient underwent an echocardiogram for the evaluation of a systolic murmur.
Her valves appeared normal but the echocardiogram disclosed elevated right
ventricular systolic and diastolic pressures consistent with pulmonary
hypertension. She has no primary lung disease and reports no symptoms of
dyspnea or tachypnea. Her other past medical history is unremarkable and she
takes only oral contraceptive pills for medications. The most appropriate next
step in the management of this patient is to
A. prescribe calcium channel blockers, orally
B. prescribe nitric oxide, inhaled
C. prescribe prostaglandin, intravenously
D. refer the patient for oxygen diffusion capacity testing
E. refer the patient for vasodilator response testing
Explanation:
The correct answer is E. The management of patients with pulmonary
hypertension focuses on three issues: is the disease secondary to primary
pulmonary disease (secondary pulmonary hypertension), is the patient
responsive to vasodilator therapy, and, can the pulmonary pressures be made
normal with medication. For this patient, the assumption is, given her age and
lack of medical history, that her pulmonary hypertension is primary. In addition
to pulmonary function testing to help verify this assumption, vasodilator testing
to determine whether the pulmonary vasculature is responsive or not is the first
step in the management of such patients.
Calcium channel blockers (choice A), inhaled nitric oxide (choice B) or
intravenous prostaglandin (choice C) are all agents used in the management of
primary pulmonary hypertension. The choice of these agents depends on
whether the patient is vasodilator responsive and the side effect profile.
Systemic agents such as calcium antagonists and prostaglandins are
associated with often profound systemic hypotension which limits their utility is
22
normalizing pulmonary pressures.
Referring the patient for oxygen diffusion capacity testing (choice D) is not
necessary. Standard spirometry as part of a full battery of pulmonary function
tests are indicated to assess whether the hypertension is primary or secondary,
but diffusion testing is only useful in cases where hypoxemia coexists with
existing pulmonary disease.
A 72-year-old smoker is admitted to the hospital for COPD exacerbation. Admission vitals
are respirations 18/min, with a blood pressure of 180/100 mm Hg, and an oxygen saturation
of 91%. He is started on nebulized albuterol and ipratropium bromide, as well as
prednisolone intravenously. Admission chest radiograph reveals flattened hemidiaphragms,
increased retrosternal clear space, and hyperlucent lungs. Given a suspicion of pulmonary
embolus, a ventilation perfusion scan is performed demonstrating nonsegmental perfusion
defects of the left upper lobe, with a small left lung and a complete absence of perfusion and
ventilation of the entire right lung. The patient becomes acutely short of breath in the nuclear
medicine department. His respirations are 30/min with otherwise normal vital signs. After
supplemental oxygen (4 L/min by nasal cannula) and nebulizers are administered, the
respirations become 29/min, with a blood pressure of 80/40 mmHg, and an oxygen
saturation of 82%. A repeat chest radiograph is pending. The most appropriate management
is to
A. administer heparin, intravenously
B. insert a chest tube on the left side
C. insert a chest tube on the right side
D. obtain a surgical consult for emergent lung volume reduction surgery
E. send him for coronary artery catheterization
Explanation:
The correct answer is C. The patient is exhibiting clinical signs of a tension pneumothorax,
including pulmonary and cardiac failure. The ventilation perfusion scan demonstrates lack of
ventilation and perfusion of the right lung, which is consistent with a pneumothorax. A
tension pneumothorax must be suspected given the diminished size of the left lung. A
tension pneumothorax is a unilateral pneumothorax that becomes loculated by a one-way
valve mechanism and compromises the contralateral lung and the venous return to the
chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary
collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the
pressure in the right hemithorax.
The ventilation perfusion scan is consistent with a pneumothorax of the right lung with signs
of tension, given the small left lung. The ventilation perfusion mismatches of the left lung
apex are consistent with bullous disease, which is common in patients with COPD. A
pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion
scan. Heparin would be an appropriate treatment if the ventilation perfusion scan was
positive for pulmonary embolus (choice A).
The chest tube must be ipsilateral to the tension pneumothorax, not on the left side (choice
B).
23
Volume reduction surgery (choice D) is a controversial method for reducing lung volumes in
patients with emphysema. It is an elective procedure and is inappropriate for the
management of tension pneumothorax.
The patient's low blood pressure is due to the effect of the tension pneumothorax on preload,
not due to intrinsic coronary artery disease as seen in a cardiac catheterization (choice E).
A 13-year-old boy is brought to the emergency department because of shortness of breath.
He has a medical history significant for asthma and he has been admitted to the hospital
several times in the past, most recently 3 months ago when he needed to be intubated for
extreme respiratory distress. He lives at home with his mother and 2 cats. His medications
include albuterol, ipatroprium, and steroid inhalers. As you approach him you notice that he
is using all accessory muscles of respiration and you hear audible wheezing. His
temperature is 37.0 C (98.6 F), blood pressure is 122/68 mmHg, pulse is 102/min, and his
respiratory rate is 34/min. His oxygen saturation on room air is 94%. Physical examination is
significant for diffuse expiratory wheezes. The factor in this patient's history that constitutes a
predictor of poor outcome with respect to his risk for morbidity from his asthma is
A. age
B. history of having a pet
C. history of living in a single parent household
D. history of previous intubation
E. sex
Explanation:
The correct answer is D. A history of intubation related to an asthma exacerbation has been
found to be a predictor of adverse outcome with respect to asthma. Other historical factors
indicating poor outcome in this patient's history are a recent hospitalization related to asthma
and steroid use.
The patient's age (choice A), while leaving hope that the patient will be able to "outgrow" his
asthma as his airways increase in diameter with increasing age, is not a predictor of poor
outcome.
The patient's history of having a pet (choice B), while leaving open the possibility of providing
a possible trigger for an asthma exacerbation, is not a predictor of adverse outcome.
The patient's history of living in a single family household (choice C) is not a predictor of
adverse outcome.
The patient's sex (choice E) is not a predictor of adverse outcome.
An 80-year-old male is admitted to your inpatient medical service with a presumed aspiration
pneumonia. He has a medical history significant for chronic renal failure, hypertension,
aspiration pneumonias, and Alzheimer's disease. His medications include furosemide,
thiamine, and folate. He has a history of alcohol abuse in the past and currently is a nursing
home resident. He is a cachectic old man who is confused, which you are told is his baseline
mental status. He has a nasogastric tube in place, which has been used for tube feeds. His
24
temperature is 37.8 C (100 F), blood pressure is 122/67 mm Hg, heart rate is 98/min,
respiratory rate is 23/min, and his room air oxygen saturation is 97%. He has decreased
breath sounds in his right lower lung field and his cardiac examination is unremarkable. A
chest radiograph shows a right lower lobe consolidation, consistent with pneumonia. While
reviewing his medical records, you notice that this patient has been admitted for aspiration 4
times over the past 12 months. The intervention that could be instituted to reduce his risk of
aspiration pneumonia in the future is to
A. change his nasogastric tube to a feeding tube placed via a nasogastric route
B. change his nasogastric tube to a percutaneous gastrostomy tube
C. change his nasogastric tube to a percutaneous jejunostomy tube
D. change his nasogastric tube to an open (surgically placed) gastrostomy tube
E. elevate the head of his bed
Explanation:
The correct answer is E. Of all the methods that are available to decrease the risk of
aspiration pneumonias in chronically ill patients, the one that works best is the adherence to
strict aspiration precautions. These precautions include elevating the head of the bed to limit
passive reflux, strict monitoring during all oral intake, and choice of food that will decrease
the risk of aspiration (thickened liquids etc.). Since this patient already has a nasogastric
tube in place, the best intervention is to elevate the head of his bed. This will reduce the risk
of pooling of oropharyngeal secretions and their subsequent aspiration.
Changing a nasogastric tube to a feeding tube via a nasogastric route (choice A) does not
decrease the risk of aspiration. The narrower caliber of these tubes do, however, make it
more comfortable for the patient.
Changing a nasogastric tube to a percutaneous gastrostomy tube (choice B) in chronically ill
patients has not been shown to reduce the risk of aspiration pneumonias if they already have
nasogastric tubes in place. This procedure, however, is used for patients who will need longterm enteral nutrition via a feeding tube since it is more comfortable.
Changing a nasogastric tube to a percutaneous jejunostomy tube (choice C) has not been
shown to reduce the risk of aspiration in chronically ill patients who have nasogastric tubes in
place. This procedure, however, is used for patients who will need long-term enteral nutrition
via a feeding tube since it is more comfortable.
Changing a nasogastric tube to a surgically placed gastrostomy tube (choice D) has not
been shown to reduce the risk of aspiration pneumonias in chronically ill patients who have
nasogastric tubes in place. This procedure is recommended for patients who will need longterm enteral tube feedings (for comfort) who have contraindications to a percutaneous
approach.
A 32-year-old African American woman returns to the clinic for a follow-up visit.
She was seen 2 weeks prior with complaints of dyspnea, dry cough, chest pain,
and tightness of the chest. An electrocardiogram was within normal limits. A
chest x-ray was performed a week later which showed bilateral hilar
lymphadenopathy with pulmonary infiltrate. While in clinic now, she points out a
rash on her nasal tip that has been present for a number of months. There is a 4
25
x 2 cm violaceous, indurated plaque involving the nasal tip extending to the
bilateral ala. There are a few tiny button-like papules in the center of the plaque.
In addition, there are waxy, translucent lesions with flat tops on the face, lids,
around the orbits, and in the nasolabial folds. The most appropriate next step in
evaluation is to
A. determine serum angiotensin-converting enzyme and serum calcium
levels
B. determine serum CEA marker level
C. order a complete blood count
D. refer her for a bronchoscopy
E. send her for a lung biopsy
Explanation:
The correct answer is A. Determining serum angiotensin-converting enzyme
(ACE) and serum calcium is the correct management for this patient with
suspected sarcoidosis. Although a bronchoscopy (choice D) and a lung biopsy
(choice E) will also help with diagnosis of sarcoidosis, serum ACE and calcium
levels are less invasive tests to obtain for diagnosis. Sarcoidosis involves
multisystems including lungs, eyes, peripheral lymph nodes, spleen,
gastrointestinal tract, hearing, and musculoskeletal systems. Hypercalcemia
may occur in any stage of sarcoidosis. Corticosteroids lower the raised calcium
level to normal by inhibiting the peripheral action of 1,25(OH)2D3 and by
metabolizing the compound to an inactive metabolite. The serum ACE level is
also raised in 60% of patients. ACE activity is higher in patients with hilar
adenopathy and pulmonary infiltration.
A complete blood count (choice C) is incorrect, because hemolytic anemia is
rare in sarcoid and leukopenia alone is too non-specific for diagnosis of sarcoid.
Serum CEA level (choice B) is incorrect, because this is a non-specific tumor
marker used to monitor for colon carcinoma recurrence, as well as some lung
adenocarcinoma responses to chemotherapy.
A 73-year-old woman comes to the office complaining of a 6-month history of
progressive shortness of breath. She has a 30-pack year smoking history but quit
25 years ago. She has no other significant medical history. She tells you that her
exercise tolerance has been slowly decreasing over the last 6 months and now
she gets tired walking 1-2 blocks. One year ago, she was able to walk a mile
without symptoms. She reports a cough but denies sputum production, fevers, or
chills. Her temperature is 37.0 C (98.6 F), blood pressure is 135/90 mm Hg, pulse
is 90/min, and respirations are 22/min. Physical examination shows late
inspiratory crackles. There is no significant lower extremity edema. A chest x-ray
reveals a diffuse ground glass appearance. Pulmonary function tests are
obtained. You would expect the study to show:
FVC
FEV1
FEV1/FVC RV
TLC
Diffusion
Bronchodilator
response
26
Dec
Decreased Decreased Increased Increased Normal
Positive
Dec
Decreased Normal
Negative
Dec
Decreased Increased Decreased Decreased Decreased Negative
Dec
Decreased Decreased Increased Increased Decreased Negative
A.
Decreased Decreased Normal
B.
C.
D.
Normal Normal
Normal
Normal
Normal
Normal
Negative
E.
Explanation:
The correct answer is C. This patient has interstitial fibrosis. Clues to the
diagnosis include a history of mildly progressive shortness of breath with a nonproductive cough. Physical exam findings of late crackles with inspiration, and
the lack of signs of CHF or reactive airway disease such as wheezing suggest
interstitial fibrosis. A chest x-ray revealing a ground glass pattern or a reticular
nodular pattern also suggests the diagnosis. Pulmonary function tests reveal
decreased lung volume with decreased forced vital capacity and FEV1. The ratio
of FEV1/FVC might be normal or increased. Diffusion capacity should be
decreased.
Patients with asthma have a similar PFT pattern to patients with other obstructive
lung disease such as emphysema or bronchitis (choice A) but should have a
good bronchodilator response since the pathology of asthma involves
bronchospasm. Patients with COPD with bronchospasm will have similar PFTs.
Patients with restriction secondary to obesity or kyphosis have PFTs which show
a restrictive pattern (choice B) similar to a patient with interstitial lung disease.
The two etiologies can be differentiated by either history or physical exam
findings or by examination of the diffusion capacity. In obesity/kyphosis, the
diffusion capacity is normal while in interstitial lung disease, the diffusion capacity
is decreased.
Emphysema (choice D) patterns on PFT look identical to other obstructive
patterns (e.g., asthma, chronic bronchitis) with two exceptions. First, the diffusion
capacity in emphysema is decreased. Second, there should not be a significant
bronchodilator response in pure emphysema. The caveat of this is that very often
chronic bronchitis and emphysema coexist so that some bronchodilator response
is possible.
This patient does have underlying lung disease so it would be unlikely for her to
have normal PFTs (choice E).
You are the physician-on-call and are asked to see a 57-year-old woman who has been
complaining of progressive shortness of breath over the past 2 days. The woman was
admitted to the medical service 6 days ago after a fall and has been on bed rest for a
27
nondisplaced pubic ramus fracture. She has been on deep vein thrombosis prophylaxis with
subcutaneous heparin. Her past medical history is significant for type-II diabetes and
dialysis-dependent renal failure secondary to diabetic nephropathy. She makes no urine at
baseline. Her last dialysis run was 4 days ago, though she is usually dialyzed 3 times per
week. She is complaining of shortness of breath but no chest pain. She is anxiousappearing, has a blood pressure of 160/105 mm Hg, respiratory rate of 30/min, and heart
rate of 110/min. She has an oxygen saturation of 80% on room air and appears cyanotic.
Physical examination reveals a jugular venous pressure of 10 cm and inspiratory crackles
half way up from the bases upon auscultation of the lungs. An electrocardiogram shows a
rate-related right bundle branch block but no ischemic changes. Chest x-ray obtained
yesterday revealed interstitial edema and vascular redistribution to the apices. The patient's
husband has arrived from home and is very concerned about the recent events. In particular,
he asks what has caused the current problem with her breathing. You suspect that a
scheduling error may have delayed her last dialysis run and caused volume overload, but
you are not completely sure. The most appropriate initial approach to take with the husband
given that you have just met the patient for the first time is to
A. acknowledge sympathetically that a mistake may have been made but will not likely
cause permanent harm
B. ask him to kindly wait until the hospital lawyer can be present before speaking to
him about the matter
C. explain that hospitals are complex institutions, making scheduling a difficult process
at times
D. explain that you are the physician on-call tonight and are not privy to all of the
scheduling details, but that you will explore in detail whether a mistake has been made
and that you will communicate these findings in a timely manner to both him and the
patient
E. speculate on how recent health maintenance organization's cuts in reimbursement
may have made it necessary to decrease the number of dialysis runs for each
hospitalized patient
Explanation:
The correct answer is D. When you suspect a mistake has been made in the hospital, the
first approach should always be to make an earnest effort to get all of the facts. This
approach will immediately build a rapport with the husband as you become an advocate for
the truth, readily demonstrate your interest in the patient's specific case, and help identify
process errors in the hospital.
While acknowledging that a mistake has been made (choice A) is often an important step, it
usually does not go far enough because patients and their families are interested in why
mistakes happen and whether they will happen again. It is simply unprofessional to not go
further and explore all of the details of the mistake regardless of whether an injury actually
occurs.
While seeking legal advice (choice B) may be an important step in dealing with this issue, the
initial approach again should focus on a thorough investigation of the facts by the physician
and relevant administration.
Philosophical approaches (choice C) are unsatisfactory because they seek to diminish any
individual responsibility for a mistake happening and are unlikely to result in correcting a
serious process error.
Speculating on cuts in insurance reimbursement (choice E) is inappropriate and
28
unprofessional. The job of physicians is to care for their patients and be their advocates. This
must occur regardless of the practice environment one finds themself in. Specifically,
whether the patient population is wealthy and cash paying or whether they depend on
insurance, medical decisions are based upon medical need and not insurance mandates. To
acknowledge any differently is to commit medical malpractice.
A 102-year-old man is brought to the clinic from his apartment by a neighbor
because of a cough productive of green sputum. He has a past medical history of
a stroke 10 years ago with residual left arm weakness. The patient is widowed
and lives alone. He takes no medications. Vital signs are: temperature 38.8 C
(101.8 F), blood pressure 100/50 mm Hg, pulse 110/min. On physical
examination, the patient has rhonchi in the right lower lung field. A chest x-ray
reveals an infiltrate in the right lower and middle lobes. The patient has a score of
30/30 on a mini mental status examination. The patient states that he has "lived a
good life and now wants to go home". He refuses any intravenous medications
and will only take pills. After discussing that the pneumonia could potentially be
fatal without intravenous antibiotic treatment, the patient continues to ask to be
sent home. The neighbor insists that the patient should be admitted to the
hospital. The next step in the care of this patient is to
A. admit the patient to hospital care with intravenous antibiotics
B. admit the patient to hospital care without intravenous antibiotics
C. admit the patient to psychiatric ward with antibiotics
D. discharge the patient home with oral antibiotics
E. discuss the case with the hospital attorney
F. initiate antidepressant therapy and administer intravenous antibiotics
Explanation:
The correct answer is D. The principle of individual autonomy is central to
medicine. The only exceptions are if the patient has no clearly expressed wishes
documented and is unable to make a decision or if the patient is deemed
incompetent to make a decision. This patient is clearly competent to refuse
treatment despite the wishes of his physician or neighbor. It is important to make
the consequences of his decision clear to the patient before discharge and to
tell him that he should return immediately should he change his mind.
Hospital care with or without intravenous antibiotics (choices A and B) is
inappropriate as this patient is refusing hospital care.
This patient is clearly competent to refuse treatment, so he should not be
admitted to the psychiatry ward (choice C) or given antidepressant therapy
(choice F).
Consultation with an attorney (choice E) is not necessary as the patient is
clearly competent to refuse medical care.
A 2-year old boy is brought to the emergency department at 2:00 a.m. because
29
of episodic coughing "fits". He was well until one day earlier when he developed
rhinorrhea and a temperature of 38.3 C (101 F). He has no prior history of
respiratory illnesses, and no one else in the family is ill. On arrival to the hospital,
he is coughing in a rapid, "barking" fashion, but appears otherwise well. His
temperature is 38.2 C (100.8 F), heart rate is 120/min, respiratory rate is 50/min,
and oxygen saturation is 96% on room air with coughing. Physical examination
shows clear lungs, a normal cardiac and abdominal examination, and no rash.
He continues to have repeated, episodic coughing with inspiratory stridor at rest.
A frontal radiograph of the chest at this time is most likely to reveal
A. cardiomegaly with pulmonary venous congestion
B. left lower lobe infiltrate
C. pneumothorax
D. subglottic swelling
E. thumb-shaped epiglottis
Explanation:
The correct answer is D. This child's clinical picture is most consistent with
infectious croup (laryngotracheobronchitis), commonly caused by parainfluenza
viruses. The prodrome of upper respiratory illness with fever followed by a
spasmodic, barking cough, is typical of this diagnosis. The classic sign on chest
x-ray is the subglottic swelling ( "steeple sign,"), which is the result of viralinduced swelling of the subglottic tissue. This swelling can cause an incomplete
airway obstruction, leading to stridor either at rest or during crying. Stridor at rest
is an indication for treatment with steroids to decrease inflammation.
Dyspnea in a child can be the result of congenital heart disease and resulting
congestive heart failure, manifested as cardiomegaly and pulmonary venous
congestion on x-ray (choice A), but given the absence of prior symptoms, the
normal oxygen saturation, and the lack of rales on lung examination, this is
unlikely.
Fever and cough in a child also raises the possibility of pneumonia as a
diagnosis. A lobar pneumonia (choice B) would be a surprising x-ray finding in
this case given the child's clear lung fields on examination and the presence of
stridor, which indicates upper airway involvement.
Pneumothorax (choice C) can be a cause of sudden dyspnea in a child,
especially in tall, male adolescents who may be predisposed to spontaneous
pneumothoraces. This child's prodrome and stridor on examination make this
diagnosis unlikely.
Prior to the introduction of the vaccine against Haemophilus influenzae type b,
epiglottitis was a common and much-feared diagnosis in pediatrics. Infection of
the epiglottis by this organism led to rapidly progressive airway obstruction and
potentially death. A lateral neck radiograph would demonstrate a thumb-shaped
epiglottis (choice E) in these cases. This sign is not seen on frontal views of the
chest.
30
A 67-year-old man comes to the clinic for an initial visit. He and his wife have just
moved to the area from out of the state. He brought along his medical records
which show that he has hypertension, mild peripheral vascular disease, and that
he carries the diagnosis of emphysema. He tells you that he smokes 1 pack of
cigarettes per day but refrains from all but social alcohol. His medications include
thiazide, captopril, quinine, and albuterol inhalers as needed. He has never had
pulmonary function testing. His temperature is 37.0 C (98.6 F), blood pressure is
135/85 mm Hg, pulse is 72/min, and respirations are 14/min. He has diffuse
bilateral expiratory wheezes with a mildly prolonged expiratory time. His
abdomen is obese, but non-tender and there is no fluid wave. The most
appropriate intervention for this patient is to
A. change captopril to lisinopril
B. encourage him to quit smoking immediately
C. increase his thiazide diuretic dose
D. initiate home oxygen therapy
E. obtain pulmonary function testing
Explanation:
The correct answer is B. The two interventions that have been shown to affect
mortality, smoking cessation and oxygen therapy, should be foremost in the
minds of all caregivers who manage patients with COPD. At any stage of the
disease, smoking cessation is the most important intervention that can be taken
to improve lifestyle and longevity. Other management strategies such as
medications, rehabilitation, and even surgery are less effective, sometimes
ineffective, when smoking is still practiced.
Changing ACE inhibitors from captopril to lisinopril, a 3 times per day drug to a
once daily drug (choice A) is not required for this patient. Since this is a
compliance/lifestyle issue, it should not take priority of a critical medical
intervention. There is no difference in efficacy between the two drugs.
This patient has reasonably controlled blood pressure so that increasing his
thiazide diuretic dose (choice C) may improve his blood pressure slightly, but its
benefits are minimal when compared to those obtained with smoking cessation.
The decision to initiate home oxygen therapy (choice D) is based upon arterial
oxygen pressures of less than 55 mm Hg (saturations less than 88%) and
therefore a resting arterial blood gas is required before a decision to initiate
long-term oxygen therapy is made.
Pulmonary function testing (choice E) is an important tool to stratify patients with
COPD and to determine if they have an element of reversible
bronchoconstriction. Since they are not therapeutic however, they do not take
precedence over immediate medical interventions that have life-prolonging
consequences.
A 72-year-old woman with a 6-month history of non-small cell lung cancer comes to the
office because of neck and facial swelling. She denies any shortness of breath or
31
hemoptysis. Physical examination shows dilated neck veins and edema of the face and right
arm. A CT scan of the chest shows a right paratracheal mass with diminished opacification of
the central venous structures. The most appropriate next step in the management of this
patient is to
A. administer dexamethasone every 6 hours
B. begin chemotherapy
C. biopsy the mass
D. give her intravenous morphine
E. recommend radiation therapy
Explanation:
The correct answer is E. The patient has a classic case of superior vena cava syndrome
(SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of
SVCS are caused by malignancies, with lung cancer being the most common. The most
feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment
of choice for most patients with SVCS.
Corticosteroids, such as dexamethasone, (choice A) are not the primary treatment of SVCS.
In some malignancies which are steroid responsive or if there is significant inflammation,
steroids can be started as an adjunct to radiation therapy.
Chemotherapy (choice B) is not the initial treatment of choice for patients with non-small lung
cancer who present with SVCS. After the patient has been started on radiation, a
chemotherapeutic regimen can be offered to the patient if it is appropriate.
In patients with known lung cancer, a biopsy of the mass (choice C) causing the SVCS is
usually not necessary and treatment can commence once the clinical diagnosis is made. In
patients without a history of cancer, every effort should be made to obtain a diagnosis before
starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement,
thrombosis).
Narcotics (choice D) are not direct therapy for SVCS. Of course if the patient has any
significant pain due to their cancer then narcotics should be prescribed to help alleviate it.
This patient is not complaining of any pain by history but like any cancer patient she should
be asked directly whether she is experiencing any pain or discomfort.
A 34-year-old airline pilot is admitted to the hospital with a first episode of a spontaneous
pneumothorax. The pneumothorax resolved after 2 days of pleural decompression by a
chest tube. A chest x-ray shows complete resolution of the pneumothorax, and a CT scan of
the chest shows an apical bulla in the right lung. While discussing further management of his
condition, it is appropriate to advise the patient to
A. avoid flying until after bullectomy
B. carry oxygen with him during the flight
C. change his career
D. quit smoking
32
E. resume his duties after 1 week of rest
Explanation:
The correct answer is A. A spontaneous pneumothorax can recur especially if associated
with bulla. In patients with high risk due to the possibility of recurrence, a first episode of a
pneumothorax deserves definitive treatment. Airline pilots and patients living away from
hospital facilities are at risk for morbidity and mortality from recurrence of a pneumothorax
when they are far from treatment facilities. Hence, this patient needs to be advised to
undergo definitive treatment for resection of the bulla before resumption of duties.
Oxygen is helpful in treating a pneumothorax when it is of small percentage and
asymptomatic. A sudden high percentage of a pneumothorax cannot be cured by oxygen
(choice B).
A pneumothorax from a bulla can be treated and recurrence can be avoided by bullectomy
and pleurodesis. Hence, changing careers is not essential (choice C).
Quitting smoking (choice D) has no association with avoiding the recurrence of a
pneumothorax.
After appropriate treatment of pneumothorax, the recurrence risk is small and duties can be
resumed as soon as possible. Taking rest has no association with avoiding recurrence of a
pneumothorax (choice E).
A 45-year-old man with a history of recurrent deep venous thrombosis and known to have
the factor V Leiden mutation comes to the emergency department because of an abrupt
onset of severe dyspnea that started while he was walking to work. He also complains of
sharp chest pain on inspiration and says that he has coughed up small amounts of blood. He
is not currently taking any medications and he has no known drug allergies. His temperature
is 37.8 C (100.1 F), his blood pressure is 100/60 mm Hg, pulse is 110/min, respirations are
30/min, and his oxygen saturation is 91% on room air. He appears mildly anxious and is
clearly tachypneic, but he is able to speak in full sentences. Cardiac examination reveals a
prominent P2. His lungs are clear. His right lower extremity has 2+ pretibial edema and his
left lower extremity has no edema. A chest x-ray is unremarkable. A ventilation/ perfusion
lung scan is consistent with a high probability for bilateral pulmonary emboli. The next most
appropriate step in management is to
A. administer intravenous unfractionated heparin and warfarin; discontinue the heparin
as soon as the INR is therapeutic
B. administer intravenous unfractionated heparin and warfarin; discontinue the heparin
2 days after a therapeutic INR is achieved
C. begin therapy with subcutaneous low molecular weight heparin and warfarin and
send the patient home to follow up in anticoagulation clinic in 1 week
D. obtain an ultrasound of his right lower extremity to rule out deep venous thrombosis
E. perform a CT angiogram to confirm the diagnosis of pulmonary embolism
Explanation:
The correct answer is B. In the setting of a high pretest probability for pulmonary embolism
(as in this case with a patient who is known to be hypercoagulable and presents with classic
symptoms), a high probability ventilation/perfusion scan is sufficient to make the diagnosis.
33
Ventilation/perfusion scans may be read as negative, but are otherwise described in terms of
the probabilities (low, intermediate, or high) of pulmonary embolism. The patient should be
immediately anticoagulated with heparin to prevent further progression of thrombosis.
Studies have demonstrated that low molecular weight heparin and unfractionated heparin
have similar efficacies in this setting. Given the severity of his symptoms and abnormal vital
signs, the patient should not be sent home until he has been monitored in the hospital and
his condition stabilizes. This patient should be started on intravenous unfractionated heparin
and warfarin and the heparin should be discontinued 2 days after a therapeutic INR is
achieved.
Start intravenous unfractionated heparin and warfarin; discontinue the heparin as soon as
the INR is therapeutic (choice A) is incorrect because the heparin must overlap with the
warfarin for at least 2 days after the INR is therapeutic. Warfarin inhibits the synthesis of
factors II, VII, IX, and X. The initial increase in INR seen with warfarin is due to inhibition of
the factor with the shortest half-life, factor VII (the half life is approximately 7 hours). The
antithrombotic effect of warfarin is thought to rely mainly on inhibition of factor II. Due to its
longer half life, it can take up to 2 days for factor II levels to sufficiently decline. Therefore, if
the heparin is discontinued as soon as the INR is therapeutic, the patient will be left
essentially un-anticoagulated for 1-2 days.
Beginning subcutaneous low molecular weight heparin and warfarin and sending the patient
home to follow up in anticoagulation clinic in 1 week (choice C) is incorrect due to the
reasons described above. While low molecular weight heparin has similar efficacy to
unfractionated heparin in this setting, there is no data to suggest nor any consensus that
patients with pulmonary embolism can safely be treated as outpatients. This patient's
tachycardia, low blood pressure, high respiratory rate, and low oxygen saturation warrants
cardiac monitoring and an inpatient stay.
Obtaining an ultrasound of his right lower extremity to rule out deep venous thrombosis
(choice D) is incorrect. The patient already has a known history of deep venous thrombosis.
While the physical finding of asymmetric lower extremity edema is strongly suggestive of a
deep venous thrombosis in the right lower extremity, knowing this for certain would not
change management. The patient will receive anticoagulation for his pulmonary embolism
regardless of any findings on lower extremity ultrasound.
Performing a CT angiogram to confirm the diagnosis of pulmonary embolism (choice E) is
incorrect because a CT angiogram is neither more sensitive nor more specific than
ventilation/perfusion lung scan. Pulmonary angiogram (via fluoroscopy, not computed
tomography) is the gold standard to make the diagnosis of pulmonary embolism. As noted
above, a high probability scan is sufficient to make the diagnosis of pulmonary embolism in
this setting. The PIOPED study provides data on ventilation/perfusion lung scanning for the
diagnosis of pulmonary embolism, validating its use. While a CT angiogram is commonly
used in practice, its routine use has not yet been validated in large trials.
A 67-year-old man presents to your office complaining of severe shortness of
breath and a cough. The man is a long-time patient who you have been treating
for chronic obstructive pulmonary disease (COPD). He has a 120 pack-year
smoking history. He was recently hospitalized for a flare of his COPD and he has
been intubated in the past for respiratory distress. His other medical history is
notable for diabetes mellitus and hypercholesterolemia. He reports to you that for
the past 3 days he has increasing dyspnea and a fever. He has gradually
developed a cough. On examination, he is moderately dyspneic at rest and has
34
marked dyspnea on exertion. His blood pressure is 130/80 mm Hg, heart rate is
78 /min, and respirations are 20 /min. The patient does not appear cyanotic. His
lung exam demonstrates a markedly prolonged expiratory time and diffusely
diminished breath sounds. The most appropriate intervention at this time is to
A. admit the patient to the hospital
B. obtain a chest radiograph and prescribe antibiotics if an infiltrate is
present
C. prescribe oral cefuroxime and oral steroids
D. prescribe oral cefuroxime and see the patient in seven days
E. refer the patient to the local emergency department
Explanation:
The correct answer is A. This patient has long-standing pulmonary disease and
is suffering from some acute respiratory event, either infection or a COPD flare.
His past medical history is enlightening because it can be appreciated that this
patient has required ventilatory support for his pulmonary disease in the past. In
the office, he is clearly in some distress. With his history and known lung
disease, this patient should be admitted to the hospital for further care and
observation.
Similar reasoning holds for obtaining a chest radiograph and prescribing
antibiotics if an infiltrate is present (choice B). Knowing that his distress is due to
pneumonia does not alter the fact that he needs to be treated in the hospital.
Prescribing oral cefuroxime and oral steroids (choice C), although a reasonable
regimen for a COPD flare, fails to address how this patient's acute respiratory
compromise will be addressed. He has been intubated in the past for flares such
as this and discharging the patient out of your care could result in serious harm
or even death to this patient.
Prescribing oral cefuroxime and see the patient in seven days (choice D) is
clearly inappropriate since the patient is presently in mild to moderate distress
and the cause for this is unknown. Even if he does have an infection, the
antibiotics will take days to be of any assistance.
It would be inappropriate to refer the patient to a local emergency department
(choice E) where he may sit unobserved in triage or may be discharged home if
another physician had a different impression of the patient.
A 71-year-old retired clerk comes to the clinic because of hoarseness. He says that he had a
“chest cold” 4 weeks ago with congestion and a sore throat. He attributed the hoarseness of
his voice to the cold, but has been worried for the last 2 weeks because the hoarseness has
been persistent. He is a diabetic taking insulin twice a day. He smokes 1-2 packs of
cigarettes a day and stopped drinking alcohol about 2 years ago. His only other medication is
an aspirin a day. He has had no prior surgeries and no other medical problems.
Laryngoscopy performed in the office demonstrates paralysis of the left vocal cord but no
evidence of masses or inflammation in the larynx. The most likely etiology of this patient's
vocal cord paralysis is
35
A. diabetic neuropathy
B. laryngeal carcinoma
C. lung carcinoma
D. pneumonia
E. stroke
Explanation:
The correct answer is C. Hoarseness of the voice is a symptom of vocal cord paralysis.
Vocal cord paralysis is a result of injury to the ipsilateral recurrent laryngeal nerve, which is a
branch of the vagus nerve supplying all the intrinsic muscles of the larynx. Unilateral vocal
cord paralysis is much more common than bilateral disease by a factor of 3 to 1 and the left
side is more commonly affected than the right side due to the longer course of the left
recurrent laryngeal nerve. The most common cause of unilateral vocal cord paralysis is lung
cancer. This patient's history of smoking puts him at high risk for developing lung cancer.
Laryngeal carcinoma (choice A) can also present very early with symptoms of hoarseness.
The most common laryngeal cancer is a glottic tumor arising from the true vocal cords. 90%
of these tumors are squamous cell carcinomas. This is not a likely cause of this patient's
hoarseness because the laryngoscopy did not demonstrate a laryngeal mass or lesion.
Laryngoscopy very readily detects lesions and is a good means for obtaining biopsies for
further cytologic studies.
Diabetic neuropathy (choice B) is not the cause of this patient's symptoms. Most diabetics
over time will develop some neurologic involvement due to peripheral vascular disease.
Classic signs and symptoms of diabetic neuropathy include numbness and loss of sensation
in the distal extremities, particularly in the feet. Diabetic neuropathy is not known to cause
damage to the recurrent laryngeal nerve and is thus not a cause of vocal cord paralysis.
Pneumonia (choice D) is not a cause of vocal cord paralysis. Primary lung cancers that occur
in the lung apices are the most common cause of injury to the recurrent laryngeal nerve and
thus vocal cord paralysis. Pneumonia is an infectious process that does not cause mass
effect or damage to the nerve.
Stroke (choice E) can be a cause of vocal cord paralysis when an infarct occurs in the
nucleus ambiguus of the medulla. The nucleus ambiguus is the origin of the vagus nerve in
the brain. However, if a stroke were to occur in the medulla, there would be many more
deficits than a focal vocal cord injury. This patient is presenting with isolated unilateral vocal
cord paralysis which means the injury occurred somewhere after the left recurrent laryngeal
nerve branched off the vagus nerve.
A 45-year-old woman is planning a trip from the United States to Hong Kong on a
direct flight. She comes to the office inquiring about advice for any travel
precautions that she should take. She has fibrocystic disease of the breast and
takes oral contraceptive pills. Physical examination is unremarkable. Her
estimated flying time is 18 hours and the total mileage is greater than 10,000.
Concerning her risks associated specifically with this flight and her history, the
most correct statement is:
A. She is at increased risk for middle ear damage
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B. She is at increased risk for myocardial infarction
C. She is at increased risk for tuberculosis
D. She is at no increased risk for a pulmonary embolism
E. She is at significantly increased risk for a pulmonary embolism
Explanation:
The correct answer is E. Based upon the classic Virchow triad of stasis,
hypercoagulability, and endothelial damage, it had been widely speculated that
prolonged air travel can be associated with an increased incidence of deep
venous thrombosis and pulmonary embolism. Infact, this risk increases with
increasing duration of the flight and for a flight this long, the relative risk is 4.7
fold. In general, any trip longer than 5,000 miles confers at least a 2-fold greater
risk. The risk is not increased for trips less than 3,500 miles (choice D).
The pressurization of the cabin, which is required for modern-day air flight can
cause damage to the middle ear if people fail to equalize the ambient pressure
with the middle ear pressure. However, since this patient has no evidence of a
middle ear infection that would cause her eustachian tubes to fail to offer this
equalization (choice A), she has no increased risk.
At altitude, airliners routinely have ambient PaO2 of much less than sea level
since cabins are not pressurized to one atmosphere. For this reason, arterial
PaO2 is around 70 mm Hg. In persons with known coronary disease(choice B),
this decrease in supply cannot be met with an increased flow and myocardial
ischemia can occur.
Although the ambient air in airliners is recirculated and therefore exposes
passengers to "common" pathogens, there is no epidemiological evidence that
states that the risk of acquiring tuberculosis (choice C) is any greater than
breathing ground level, non-recirculated air.
A 79-year-old man who lives in a retirement community is admitted to the hospital with chest
pain, shortness of breath, and lethargy. His past medical history is significant for a right
upper lobe resection for small cell lung cancer and a stroke many years ago. Since his stroke
he has been relatively inactive and is minimally mobile in his wheelchair. His only
medications include aspirin and a stool softener. His temperature is 37.0 C (98.6 F), pulse is
120/min, blood pressure is 100/60 mm Hg, and respirations are 24/min. The patient appears
to be in moderate distress. Physical examination reveals lungs clear to auscultation,
tachycardia without murmurs, and 1+ pitting edema in both lower extremities. He denies any
pain in his legs. An electrocardiogram shows sinus tachycardia and a right bundle branch
block. Chest x-ray shows mild cardiomegaly, volume loss in the right upper lung field, and
bibasilar atelectasis. Arterial blood gas values while breathing room air are:
The most appropriate next step in the evaluation of this patient is
37
A. bronchoscopy
B. contrast venography
C. pulmonary angiography
D. ultrasound of both lower extremities
E. ventilation/perfusion (V/Q) lung scan
Explanation:
The correct answer is E. This patient is presenting with signs and symptoms of pulmonary
embolism (PE). His risk factors for PE include prior history of cancer and immobility. A
ventilation/perfusion scan is a nuclear medicine study that is most often used for the
diagnosis of PE. The demonstration of segments of lung that are ventilated, but not
perfused is called a "V/Q" mismatch (V stands for ventilation and Q stands for perfusion).
This is highly specific for PE. A ventilation/perfusion scan is the most appropriate diagnostic
step in this patient particularly since he has a non-diagnostic chest x-ray. Patients with
infiltrates or other parenchymal abnormalities are not ideal candidates for this type of
imaging because these abnormalities can limit interpretation of the scan. Helical CT
pulmonary angiography is a relatively new diagnostic study which is now commonly used
for patients suspected of PE and have abnormal chest x-rays.
Bronchoscopy (choice A) is used for the evaluation of airways. Common indications for
bronchoscopy include hemoptysis, chronic cough, and evaluation of central lung lesions
identified on chest x-ray or CT of the chest. Bronchoscopy has no role in the evaluation of
the pulmonary arteries.
Contrast venography (choice B) is an invasive method of evaluating the veins for
thrombosis. This examination has been largely replaced by ultrasonography.
Pulmonary angiography (choice C) is the gold standard in the diagnosis of pulmonary
embolism. The most common indication is a patient with an indeterminate or intermediate
probability ventilation/perfusion (V/Q) scan who requires a definitive diagnosis. Due to the
risks and complications associated with angiography, it is not a study that is performed in
the initial work up. It is usually only performed when a definitive diagnosis is not achieved by
either V/Q lung scan or helical CT pulmonary angiography.
Ultrasound of the lower extremities (choice D) is an indirect way of evaluating for pulmonary
embolism. 90% of PE arise from deep vein thrombosis (DVT) in the lower extremities. Since
the treatment of PE and proximal DVT is the same, many clinicians feel that the diagnosis
of DVT is an adequate endpoint to decide on treatment. An important criterion in deciding
whether or not to perform a lung scan or ultrasound depends on the stability of the patient.
This patient is hypotensive, tachycardic, and will benefit from a ventilation/perfusion scan
which may show a lack of perfusion to one or both lungs. In the case of a saddle embolus,
anticoagulation is not adequate therapy and further intervention with possible thrombectomy
is indicated. Ultrasound can be used when a ventilation/perfusion scan is intermediate or
indeterminate probability.
An 86-year-old woman is brought to the emergency department by her daughter
because of a 3-day history of increasing shortness of breath, a cough, and fever.
She has had a copious amount of rust-brown sputum, nearly 3 tablespoons per
38
day. She has also had decreased food and water intake over the past few weeks.
A chest x-ray shows a right lower lobe pneumonia and laboratory studies show
mild hyponatremia most likely from dehydration. She is admitted to the hospital
for antibiotic therapy. You are called to examine her because of severe shortness
of breath. Her temperature is 39.0 C (101.2 F), blood pressure is 105/70 mm Hg,
pulse is 88/min, and respirations are 36/min. She appears to be in respiratory
distress. According to the daughter, the patient had just eaten her dinner about
30 minutes ago. You decide that endotracheal intubation is indicated at this time.
The most important adjunct maneuver during endotracheal intubation of this
patient is
A. aggressive oral suctioning during laryngoscopy
B. application of cricoid pressure by an assistant
C. beginning oral anti-acid therapy prior to intubation
D. placement of a nasogastric tube for evacuation of the stomach
E. placement of an orogastric tube for evacuation of the stomach
Explanation:
The correct answer is B. Any patient that has eaten solids or liquids within 8
hours prior to an intubation, or is a trauma patient that has eaten within 12
hours, is considered a high risk patient for aspiration. These patients require, in
addition to any other intervention, cricoid pressure to minimize the risk of
aspiration. The cricoid pressure must be applied by an assistant since the
operator has no free hands with which to perform the maneuver.
Aggressive oral suctioning during laryngoscopy (choice A) is important to assist
with visualization of the pharyngeal and laryngeal structures but in fact does little
to minimize the risk of aspiration of gastric contents.
For a patient such as this, giving the patient oral anti-acid therapy prior to
intubation (choice C) is not practical since she is in distress and will be unable to
take oral medications without likely aspirating those.
Placement of a nasogastric tube (choice D) or orogastric tube (choice E) for
evacuation of the stomach is a reasonable choice in non-emergent situations.
For this patient, having her cooperate in order to place either one of these tubes
is not going to be possible and would delay an urgent, if not emergent,
intubation. These tubes are often used in the operating room by
anesthesiologists to evacuate the stomach once the patient has been sedated.
A 29-year-old man is brought to the emergency department because of a severe asthma
attack. Two hours ago, he began to wheeze and it has progressively worsened to the point
where he is unable to move air. He has suffered from asthma since the age of 7 and has
been hospitalized multiple times for asthma flares. His home medications include albuterol
MDI, ipratropium bromide MDI, inhaled steroids, and oral theophylline. His temperature is
37.0 (98.6 F), blood pressure is 185/105 mm Hg, pulse is 90/min, and respirations are
90/min. Arterial blood gas on 100% oxygen is PaO2 56 mm Hg, PaCO2 48 mm Hg, pH 7.26.
The decision is made to intubate the patient. After laryngoscopy, intubation, cuff inflation,
39
and end-tidal carbon dioxide confirmation, the next step in confirming placement of the tube
is to
A. auscultate for breath sounds
B. auscultate the stomach
C. ask the patient to speak
D. get a chest radiograph
E. none is required, the tube is appropriately placed
Explanation:
The correct answer is A. The appropriate placement of an endotracheal tube in the trachea is
of obvious importance. The recognition however of an inappropriately placed tube is very
difficult. For this reason, multiple checks are in place such that all of them combined serve as
a nearly 100% sensitive indicator for correct placement. After cuff inflation, most institutions
will now check for end-tidal carbon dioxide. Once this is done, since that test is not
completely sensitive, auscultation for BILATERAL breath sounds is crucial. This confirms not
only tracheal placement, but also evaluates for a possible main stem placement.
Although auscultation of the stomach (choice B) is reasonable, it actually is not required in
confirmation of tube placement. Most persons will listen for stomach air, but only after they
listen for breath sounds since, if none are present, listening to the stomach would delay
reintubation attempts.
Asking the patient to speak (choice C) is not a method to ensure tube placement through the
cords. Most patients are either sedated from the intubation attempt or are acutely ill and not
able to speak.
A chest radiograph (choice D) is useful to confirm tracheal placement of the tube that is
sufficiently proximal to the carina to avoid patient coughing. It is however not a method to
ensure tube placement since it requires minutes to perform, develop, and interpret.
Thinking that none is required, the tube is appropriately placed (choice E) is incorrect.
Because the end-tidal carbon dioxide is confirmed, this does not guarantee appropriate tube
placement. It is the most sensitive indicator of tube placement, but it does have a common
false positive, which occurs when air insufflated into the stomach turns the color indicator.
You need to auscultate for breath sounds.
A 22-year-old man with a history of asthma controlled with albuterol metered dose inhaler
(MDI) alone complains of worsening symptoms of shortness of breath. Over the last 10 years
he rarely needed his inhaler more than 2 times a month. However, over the last 4 months he
reports requiring rescue inhaler treatment 4-5 times a week. A canister of albuterol, which
used to last 2-3 months, is now being replaced every 3 weeks. He denies any other
symptoms. The most appropriate pharmacotherapy at this time is
A. cromolyn MDI
B. ipratropium bromide MDI
C. montelukast
40
D. salmeterol MDI
E. triamcinolone MDI
Explanation:
The correct answer is E. This patient has worsening of his asthma. Patients should not need
albuterol rescue treatments more than 2 times each week. Patients should not wake up at
night more than 2 times each month with asthma symptoms, and patients should not need 2
canisters of albuterol in any given month. If your patient fits any of the above criteria, his
asthma is poorly controlled. The next treatment is steroid MDI such as triamcinolone.
Remember: Asthma is inflammation and steroids decrease inflammation.
Cromolyn (choice A) is a mast-cell stabilizer. It is commonly used in children, but its role in
adult asthma is not as well studied as steroids. It is not typically a first- or second-line
treatment in asthma of the adult.
Ipratropium bromide (choice B) is an anticholinergic agent which is used for acute treatment
of asthma and is helpful in bronchospasm associated with COPD. It is an effective agent in
the acute setting of asthma but it takes about 45 minutes to have any effect. It is not the
proper drug to be added if rescue inhalers are not providing adequate control of symptoms.
Montelukast (choice C) is a relatively new therapy for asthma. It is a leukotriene inhibitor and
is useful in selective patients with asthma such as those with aspirin sensitivity or those that
are unable to use MDI properly. Its use should be initiated in select patients on inhaled
steroids who continue to have poor control of their asthma symptoms.
Salmeterol (choice D) is a long-acting beta agonist. It is a useful medication to be added to
patients who are already on inhaled steroids but continue to have symptoms of asthma.
Remember, regular use of short-acting beta agonist is a sign of poor asthma control.
A 52-year-old woman is admitted to the hospital with shortness of breath, a
productive cough with "yellowish sputum," fevers, and chills. She has a medical
history significant for non-insulin dependent diabetes and depression for which
she takes glyburide and sertraline. She has an allergy to penicillin, to which she
gets severe hives. Her temperature is 38 C (100.4 F), blood pressure is 123/67
mmHg, pulse is 102/min, and respirations are 25/min. Her oxygen saturation on
room air is 96%. Physical examination shows decreased breath sounds over the
lower right lung field with dullness to percussion. A chest radiograph shows
consolidation in her right lower lobe. The most appropriate next step is to
A. obtain a sputum sample for Gram stain and culture
B. obtain a surgery consult for an open lung biopsy
C. order a CT scan of the chest
D. order a ventilation-perfusion scan
E. send her for bronchoalveolar lavage
Explanation:
The correct answer is A. By history, exam, and chest radiography, this patient
41
has pneumonia. In someone with a pneumonic process, it is advisable to send
sputum for Gram stain and culture prior to the initiation of antibiotics in order to
ensure that the choice of antibiotic agent will be appropriate. Empiric antibiotics
are often started anyway, but it is good to know if the organism that is present is
covered by the chosen antibiotic.
An open lung biopsy (choice B) is not used in the routine diagnosis of a lobar
pneumonia. It is instead used in the diagnosis of more complex pulmonary
pathologies such as the idiopathic interstitial pneumonias that are not amenable
to diagnosis using routine methods.
A chest CT (choice C) will not add any additional information at this juncture
since a chest radiograph is sufficient to confirm the presence of pneumonia in
this patient.
A ventilation-perfusion scan (choice D) is used to diagnose the presence of a
pulmonary embolus, which is not a part of the differential diagnosis with this
patient. This type of scan is often uninterpretable in the setting of a lobar
pneumonia.
A bronchoalveolar lavage (choice E) is not used in the diagnosis of a lobar
pneumonia associated with a productive cough.
An 83-year-old female nursing home patient is brought to the emergency department after
she is found down on her bedroom floor next to her walker. The nursing home staff reports
that she appeared confused and disoriented. The patient suffered an embolic stroke 2 years
ago, leaving her with residual dysarthria. The patient appears mildly dyspneic and cannot
appropriately follow commands. Her temperature is 39.8 C (103.6 F), blood pressure is
110/70 mm Hg, and pulse is 70/min. Laboratory studies show a leukocyte count of
17,000/mm3. A chest x-ray shows a right lower lobe infiltrate. Gram stain of a sputum sample
shows many neutrophils and Gram-negative rods. The most appropriate pharmacotherapy is
A. cefuroxime
B. clindamycin
C. erythromycin
D. levofloxacin
E. penicillin G
Explanation:
The correct answer is D. The patient is a nursing home resident with a residual neurologic
deficit from a stroke that affects her speech. She is found with an altered mental status by
the nursing home staff. On evaluation, she has a temperature, elevated WBC, and obvious
infiltrate on CXR. She probably an aspiration pneumonia. She is predisposed to aspiration
pneumonia due to her stroke, which has affected her speech and likely her ability to swallow.
In addition, the CXR infiltrate is in the right lower lobe, which is the likely place for aspirated
contents to fall due to anatomy of the bronchi. Finally, she has Gram-negative rods in her
sputum. Elderly individuals in long-term care facilities tend to have colonization of the
oropharynx with Gram-negative rod bacteria. Levofloxacin has excellent coverage of most
pathogens causing aspiration pneumonia and is a preferred antibiotic treatment. If the patient
42
had known Pseudomonas colonization, a ceftazidime or piperacillin may have been better
alternative choices.
Cefuroxime (choice A) is the drug of choice for community-acquired pneumonia, but does not
have enough Gram-negative coverage in regards to aspiration pneumonias.
Clindamycin (choice B) is another traditional choice for aspiration pneumonia to cover
anaerobic organisms. However, without evidence of anaerobic infection such as lung
abscess on CXR, necrotizing pneumonia, severe periodontal disease, or putrid sputum,
clindamycin is not indicated.
Erythromycin (choice C) covers atypical organisms, not commonly associated with aspiration
pneumonia.
Penicillin G (choice E) was the traditional choice for aspiration pneumonia to cover Grampositive organisms, but recent findings show that Gram-negative organisms predominate in
elderly nursing home patients, making this an incorrect choice.
A 30-year-old man is brought to the emergency department because of shortness of breath.
He had been diagnosed with asthma the previous month, but had not required medication.
He has no other medical history, is on no medications, and has no allergies to any
medications. He smokes a pack of cigarettes a day and drinks 6 cans of beer a week. He is
anxious and is using his accessory muscles of respirations. His blood pressure is 135/88 mm
Hg, pulse is 102/min, respiratory rate is 36/min, and room air oxygen saturation is 93%. His
pulmonary examination is significant for diffuse expiratory wheezes and a markedly
prolonged expiratory phase. He is already receiving supplemental oxygen by face mask. The
most appropriate next step is to administer
A. albuterol by nebulizer
B. cromolyn, orally
C. epinephrine, intravenously
D. montelukast, orally
E. magnesium, intravenously
Explanation:
The correct answer is A. Inhaled beta agonists such as albuterol constitute the first line of
treatment of an asthma exacerbation. Both nebulizer and meter dose inhalations of beta
agonists have been shown to work well during an asthma exacerbation.
Cromolyn (choice B), a mast cell stabilizer, is useful in the chronic setting in preventing
asthma exacerbations, but has no use in the setting of an asthma exacerbation.
Epinephrine (choice C) is reserved for those cases when bronchospasm is refractory to beta
agonists. Given the risk for hypertension and tachyarrythmias, epinephrine is not used as a
first-line agent.
Montelukast (choice D), a leukotiene antagonist, as with cromolyn is used in the chronic
setting to prevent asthma exacerbations, but has no role in the management of an acute
exacerbation.
43
Magnesium (choice E), presumably through its smooth muscle relaxing properties, has been
proposed as an alternative agent in the management of an asthma exacerbation. Studies
have, however, found no role for it during an asthma exacerbation.
A 49-year-old man comes to the office for a health maintenance examination. He
has had 5-7 episodes of blood-tinged sputum in the past month that he is very
concerned about. He denies any other symptoms. He has been a patient of yours
for 15 years and has been generally healthy. He does not have any chronic
medical conditions. He is a superintendent of a large apartment building, gets
regular exercise, eats a low-fat diet, and smokes 2 packs of cigarettes a day for
the past 30 years. His temperature is 37.0 C (98.6 F), blood pressure is 130/80
mm Hg, pulse is 65/min, and respirations are 16/min. Physical examination is
unremarkable. You order a chest x-ray, a complete blood count and coagulation
profile, electrolytes, BUN and creatinine, a urinalysis, and send sputum samples
for Gram, fungal, and acid-fast stains, cytology and schedule a follow-up visit in 2
weeks. He arrives for the appointment and you review the results with him, all
which came back normal. He tells you that he has had increasing episodes of
"blood in the sputum" and has even coughed up about 10mL blood over the past
2 weeks. Physical examination and vital signs are unchanged since the last visit.
The most appropriate next step is to
A. admit him to the hospital for immediate thoracic surgery
B. order a chest x-ray
C. schedule a bronchoscopy
D. schedule a high-resolution CT scan
E. reassure him that all of the tests were normal
Explanation:
The correct answer is C. This patient has non-massive hemoptysis, which is
defined as less that 100 mL of expectorated blood over 24 hours. The work-up
begins with history and physical examination. A chest x-ray and laboratory
studies should be ordered initially. If the chest x-ray is normal and the patient
has risk factors for cancer, like smoking 2 pack of cigarettes a day for the past
30 years, a bronchoscopy should be ordered to localize the bleeding site and
look for an endobronchial mass. If none is found, a high resolution CT scan
should be considered. If a mass is found on a study, referral to a thoracic
surgeon is necessary.
It is inappropriate to admit him to the hospital for immediate thoracic surgery
(choice A) at this time. He has non-massive hemoptysis and needs a
bronchoscopy to be ordered to localize the bleeding site and look for an
endobronchial mass. Surgery may be indicated in the future, but now, since he
is hemodynamically stable, he needs further evaluation for his hemoptysis.
It is unnecessary to order another chest x-ray (choice B) at this time. Since his
physical examination has not changed, it is unlikely that a chest x ray would
have changed in 2 weeks. He has no symptoms that suggest pneumonia which
may appear on a later x-ray. He requires a bronchoscopy to look for a mass that
44
cannot be visualized on the x-ray.
A high-resolution CT scan (choice D) is usually only indicated after a chest x-ray
and a bronchoscopy. An exception is when the chest x-ray suggests
parenchymal disease, then the HCRT is usually performed before the
bronchoscopy.
In this patient with hemoptysis and a significant smoking history, reassuring him
that all of the tests were normal (choice E) is inappropriate. You need to find the
cause of his symptoms by continuing with the diagnostic evaluation. A
bronchoscopy is indicated at this time.
A 49-year-old woman comes to the office because of difficulty breathing, fevers reaching 40
C (104 F), and a productive cough with blood tinged sputum. She was recently diagnosed
with ductal carcinoma of the breast and underwent a radical mastectomy with four rounds of
adjuvant chemotherapy with vinblastine and doxorubicin. Her last infusion of chemotherapy
was 5 days ago. A chest radiograph shows focal infiltrates in both lungs. Laboratory studies
show:
You admit her to the hospital and start her on vancomycin and ceftazidime. Over the next 3
days, her clinical status continues to worsen. Blood cultures are negative. A bronchoscopy is
performed and biopsy samples are obtained. The biopsy specimen shows septated,
branching hyphae that are locally invading tissue. The most appropriate pharmacotherapy at
this time is
A. amphotericin B, intravenously
B. fluconazole, intravenously
C. fluconazole, orally
D. itraconazole, intravenously
E. rifampin plus isoniazid, orally
Explanation:
The correct answer is A. This is a case of pulmonary aspergillosis in a neutropenic patient
after she underwent chemotherapy. The treatment of choice in neutropenic or
immunosuppressed patients is amphotericin B intravenously.
Fluconazole (choices B and C) and itraconazole (choice D) are antifungal agents that have
limited activity or no activity against aspergillus infections. Also, she should get intravenous
therapy at this time.
Rifampin plus isoniazid (choice E) is a combination used to treat mycobacterial infections.
45
A 4-year-old girl with a history of asthma is brought to the emergency department
by her mother because of "difficulty breathing." She has had an upper respiratory
infection for several days with low-grade fevers and began coughing last night.
Her guardian did not refill the medication that you prescribed 3 months ago,
when she had her last "asthma attack," so your patient has not received any
medication with the onset of these symptoms. As you observe your patient and
ask her questions as to how she is feeling, you notice that she is unable to finish
sentences without becoming short of breath. Her temperature is 38.3 C (101.0
F), pulse is 34/min, and oxygen saturation on room air of 92%. Physical
examination shows nasal flaring and subcostal retractions, decreased air entry
bilaterally with scattered inspiratory and expiratory wheezing, and a prolonged
expiratory phase. The first priority in caring for this patient is to
A. administer albuterol via metered dose inhaler
B. administer prednisolone
C. provide oxygen via face mask
D. obtain a chest x-ray
E. prepare to do an arterial blood gas
Explanation:
The correct answer is C. This patient appears to be in moderate respiratory
distress and is hypoxic. As part of a pediatric advanced life support protocol, the
most important initial interventions should pertain to airway, breathing, and
circulation, the "ABCs". The first intervention for this patient should be to provide
oxygen because her room air saturation is below 95%.
As you are providing oxygen, you may prepare to give the patient albuterol, a
beta-2 agonist, via nebulizer for early management of her bronchospasm.
Albuterol via metered dose inhaler (choice A) is not appropriate in this patient
because of the child's age. Four-year-olds do not have the skill to master a
metered dose inhaler in a way that will administer the medication correctly.
Prednisolone (choice B) is a steroid commonly used to treat reactive airway
disease. It helps to decrease inflammation. Children having a significant asthma
attack should be started on prednisolone early in the course of their
management, but not prior to being started on oxygen if hypoxemic.
Obtaining a chest x-ray (choice D) is important in the evaluation of a child with
cough and fever. This patient may have a pneumonia, which is exacerbating her
reactive airway disease. Classic chest x-ray findings in children with asthma
include hyperinflation and peribronchial cuffing. However, a chest x-ray is not an
immediate priority in the patient in this vignette.
Preparing to do an arterial blood gas (choice E) is not appropriate in the initial
management of the patient in the vignette. This patient is in moderate
respiratory distress but has not received any medications or interventions to
improve her bronchoconstriction. If this patient does not improve, or begins to
become tired, she may require an arterial blood gas to evaluate her pCO2, which
looks for carbon dioxide retention.
46
You are called to see a patient in the intensive care unit who was admitted with pneumonia
and intubated for hypoxemia and acidosis. You learn that he is a 57-year-old man with
severe asthma for which he was being treated with chronic steroids along with multiple
inhalers. He has no other medical problems. Currently his temperature is 39 C (102 F), blood
pressure is 75/40 mm Hg, pulse is 140/min, and respirations are 17/min. His physical
examination is significant for bilateral wheezes with decreased breath sound at the right
base. Despite aggressive hydration with normal saline, his blood pressure remains low. You
suspect he is septic. You decide to place a Swan Ganz catheter to clarify his volume status
and better understand his hemodynamic picture. The most likely finding to support your
suspicion that he is septic would be
CI
SVR
PAWP
A. Decreased Increased Normal
B. Decreased Increased Decreased
C. Increased Decreased Normal
D. Decreased Normal
Normal
E. Increased Increased Decreased
Explanation:
The correct answer is C. This patient has septic shock. Septic shock is characterized by
decreased blood pressure despite euvolemia and is often seen with severe infection,
especially with Gram-negative organisms. Release of inflammatory mediators is responsible
for decreasing SVR. Patients are thought to be in a hyperdynamic state with increased
cardiac output. Volume status is reflected by PAWP and is classically normal but can be
normal, low, or high depending on the aggressiveness of hydration.
Decreased CI, increased SVR, and normal PAWP (choice A) is an example of cardiogenic
shock. This is common with cardiac tamponade or myocardial infarction. It should be thought
of as pump failure. The cardiac index is low because the heart is not pumping well. The SVR
is increased in an effort to maintain blood pressure. The PAWP is normal in these patients
since volume is typically not the primary problem.
Hypovolemic shock (choice B) is demonstrated by a low cardiac index, an increased SVR,
and a decreased PAWP. Simply, CI and PAWP are low because there isn't enough blood
volume to be pumped by the heart (low volume = low pre-load). SVR is elevated to attempt
to increase blood pressure.
Obstructive shock, characterized decreased CI and normal SVR and PAWP (choice D), is
typically caused by massive pulmonary embolus. Supportive care with IV fluids and
vasoconstrictors along with possible embolectomy is indicated. Note: The only indication for
embolectomy is hemodynamic instability.
Increased CI and SVR, and decreased PAWP (choice E) is not likely to be seen since
Starling principles would suggest that it would be difficult to increase your cardiac output
against a high pressure system (increased SVR) and a low intravascular volume (decreased
SVR).
47
A 67-year-old man comes to the office complaining of a 12–month history of
shortness of breath at rest and with mild exertion. He also reports wheezing on
occasion that seems to correspond to the times when he is most short of breath.
He has a cough that is persistent most of the year and is occasionally productive
of scant sputum. He has a long smoking history of over 100 packs/ year, but has
recently quit. His only other medical history is hypertension and hyperlipidemia
for which he takes atenolol and simvastatin. A chest radiograph shows
hyperinflation but clear lung fields and no evidence of a parenchymal or
mediastinal mass. The most appropriate next step in management is to
A. obtain spirometry
B. order a chest CT scan
C. prescribe albuterol inhalers
D. prescribe corticosteroids
E. prescribe home oxygen
Explanation:
The correct answer is A. This patient likely has COPD based upon his social
history and symptoms. All patients who present complaining of shortness of
breath, are over the age of 40, and have a smoking history or environmental
exposure history to asbestos, beryllium, or dust, should have screening
spirometry. Spirometry measures forced inspiratory and expiratory effort. The
hallmark of COPD is decreased forced expiratory effort. The tests are
noninvasive and can be performed in fully clothed patients.
A chest CT scan (choice B) is of minimal value in this case since the chest
radiograph revealed no evidence of any abnormality except hyperinflation, which
is to be expected in a case of COPD.
Therapeutic interventions such as albuterol inhalers (choice C), steroids (choice
D), or home oxygen (choice E) are options to be considered once a diagnosis of
COPD is established and its severity is quantified. Inhalers are excellent firstline drugs for patients that have reversible airflow obstruction demonstrated by
full pulmonary function testing. Home oxygen is usually given for late-stage
COPD in patients who have room air arterial oxygen pressures of less than 60
mm Hg. Steroids are very useful agents in acute exacerbations of COPD.
You are called to see a 67-year-old woman with severe COPD who was
intubated on the medicine floor 30 minutes earlier because of respiratory
distress. Her temperature is 37.0 C (98.6 F), blood pressure is 90/60 mm Hg,
pulse is 133/min and regular, and respiratory rate is 24/min. Her ABG reveals the
following: pH 7.21, PaCO2 80 mm Hg, PaO2 69 mm Hg, and her oxygen
saturation is 91%. Her current ventilator settings are assist control (AC),
respiratory rate (RR) of 12/min, tidal volume (TV) of 500 ml, fraction of inspired
oxygen (FiO2) is 50%, positive end expiratory pressures (PEEP) of 5 mm/Hg. The
most appropriate intervention at this time is to
A. decrease set respiratory rate
48
B. increase the fraction of inspired oxygen
C. increase PEEP
D. increase tidal volume
E. make no adjustments at this time
Explanation:
The correct answer is D. The key to this question is to recognize that this patient
remains acidotic and hypercarbic despite intubation. In order to "blow off" more
carbon dioxide and normalize the blood pH, you must increase minute
ventilation (MV). If you remember that MV=TV X RR, you can quickly recognize
that the two ways to decrease carbon dioxide is to increase the RR or increase
the TV.
Decreasing RR (choice A) will increase carbon dioxide because we are
decreasing minute ventilation as described above. This will result in worsening
acidosis. In addition, our set respiratory rate is lower than the patient's actual
rate. If we decreased the respiratory rate, our patient would continue to breathe
at a high rate and receive the same tidal volume (thereby not even changing the
MV).
Increasing FiO2 (choice B) will not be beneficial. First, the patient already has a
paO2 of greater than 60 mm Hg. If you remember the hemoglobin binding curve,
you should remember oxygen saturations remain above 90% for paO2>60 mm
Hg. Therefore, our goal is to keep paO2>60 mm Hg for most patients. Second,
maintaining patients on greater than 60% oxygen may have some associated
lung toxicity. Therefore, if possible, keeping the inspired oxygen less than 60%
is an important part of management. Of course, if high levels of inspired oxygen
are necessary, you should not hesitate to use them. Please remember that
patients on ventilators need not (and should not) have oxygen saturations of
100% or paO2 much greater than 60 mm Hg.
PEEP (choice C) is the use of positive airway pressures at the end of expiration.
PEEP is useful in hypoxic respiratory failure such as ARDS or cardiogenic
pulmonary edema. Low levels of PEEP can be used in COPD to keep airways
open. Our patient's oxygenation is acceptable so increasing PEEP would not be
beneficial now. In addition, our patients blood pressure is only borderline
acceptable. Increasing PEEP will decrease venous return to the heart and might
lead to further reductions in blood pressures. High levels of PEEP might also
predispose patients to barotrauma which is a form of ventilator induced lung
damage.
Making no adjustments (choice E) is not acceptable. This patient is severely
acidotic and hypercarbic and should not be left in this state.
A 23-year-old man with a childhood history of eczema presents to your office for
the first time complaining of a non-productive coughthat started 4 months ago
after a respiratory tract infection during the winter. He generally has the cough
roughly once or twice a week, usually after strenuous exercise. He has not had
any fevers at home and denies any hemoptysis. He smokes socially, roughly 1
49
pack a week, and binge drinks on the weekends. He denies any intravenous drug
use, but has had several unprotected heterosexual relationships this past year.
His temperature is 37.0 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is
65/min, and respirations are 15/min. His physical examination is remarkable only
for end expiratory wheezes on bilateral lower lung fields. At this time the most
correct statement about his condition is:
A. Bronchoscopy should be performed to rule out opportunistic infection
B. A chest x-ray is necessary prior to starting any empiric therapy
C. Inhaled steroids are an appropriate first line agent
D. Pulmonary function tests would reveal a reduction in the FEV1/FVC
ratio
E. A trial of antibiotics against atypical pathogens such as mycoplasma or
chlamydia would relieve this patient's cough
Explanation:
The correct answer is D. This patient has a classic history for cough variant
asthma. The diagnosis of asthma is helped by the history of atopy/eczema. His
cough is predominant after exercising, but other allergens (e.g., cigarette
smoke, dust, pollen) or cold weather could also induce asthma in many patients.
Pulmonary function tests would reveal a decrease in the FEV1/FVC ratio,
pathognomonic for obstructive lung disease.
There is no need for bronchoscopy (choice A) since in this patient there is low
suspicion for an infectious process. His history of unprotected sexual intercourse
does raise the suspicion for HIV, yet opportunistic pulmonary infections such as
Pneumocystis Carinii pneumonia would be a late finding when the CD4 counts
are less than 200.
A chest x-ray (choice B) would probably be unremarkable, since we have low
suspicion for any pulmonic infection. Other causes of pulmonary wheezing and
cough could include a foreign body, hypersensitivity pneumonitis, or
intrathoracic lung mass. However, these are rarer etiologies and asthma is still
primarily a clinical diagnosis.
Inhaled steroids (choice C) may be an appropriate treatment for mild or
moderate persistent asthma. However, this patient only coughs roughly once or
twice a week, and therefore would be considered to have mild intermittent
asthma. An intermittent beta agonist would be the appropriate first line treatment
for mild intermittent asthma.
There is no reason to suspect atypical pneumonia (choice E) in this afebrile
patient with cough variant asthma.
You are called emergently to the medical floor where a 66-year-old man was
found to be minimally responsive. His past medical history is unclear but his arm
band lists allergies to penicillin and sulfa medications. On arrival, chest
compressions are being performed and 2 operators are mask ventilating the
patient. Evaluation with an electrocardiogram reveals sinus tachycardia and the
diagnosis of pulseless electrical activity is made. Volume is infused and
50
compressions are continued. The patient remains apneic, so mask ventilation
continues. During masking, the patient appears to regurgitate large volumes of
gastric contents. The most appropriate immediate next step in the management
of this patient is to
A. cease mask ventilation and suction the mouth
B. continue masking the patient
C. insert a nasogastric tube
D. intubate the trachea and suction the airway
E. intubate the trachea and ventilate
Explanation:
The correct answer is D. Aspiration of gastric contents causes severe lung
inflammation. The traditional dogma that the acidic nature of the aspirate is
critical has recently been reevaluated and it is now clear that large volumes of
gastric contents of any pH are dangerous to the lung. A witnessed aspiration
event has the best chances for airway lavage so in these cases an endotracheal
tube should be placed, ventilation should be held for a moment, and a flexible
suction catheter should be passed so that the airway can be evacuated of
gastric contents. By ventilating (choice E) with a tube in the trachea, a 100%
effective mechanism for dispersion and aerosolizing the material to the distal
airways is occurring. This is to be avoided.
To cease mask ventilation and suction the mouth (choice A) would not address
the material that is distal to the larynx that would become aerosolized to the
distal airways upon resumption of mask ventilation.
To continue masking the patient (choice B) is the least desirable course of
action to take with this patient. Continuing to bellow the material on the pharynx
into the larynx and lungs will almost certainly result in severe aspiration disease
and death for this patient.
The insertion of a nasogastric tube (choice C) has no role in the management of
acute aspiration. The goals are securing the airway and evacuation of the
material from the airway prior to any delivery of the aspirate to the distal
airways.
You are called to intubate a patient on the surgical floor. The patient is postoperative day
number 2 after a lumbar disc removal for sciatica. She had an uneventful postoperative
course but has a past medical history significant for severe ischemic congestive heart failure.
Four hours ago, she began to complain of shortness of breath and has progressively
worsened despite diuretic therapy and supplemental oxygen. On arrival to the bedside, her
temperature is 37.0 C (98.6 F), blood pressure is 170/105 mm Hg, pulse is 102/min, and
respirations are 38/min. Oxygen saturation is 82% on 100% nonrebreathing mask. The
patient is somnolent and minimally responsive. After laryngoscopy and insertion of the
endotracheal tube, the next most appropriate step is to
A. auscultate for air in the stomach
51
B. auscultate for breath sounds
C. check for end-tidal carbon dioxide
D. deliver 100% inspired oxygen and initiate mechanical ventilation
E. inflate the balloon on the endotracheal tube
Explanation:
The correct answer is E. Although the task of performing laryngoscopy and intubation of the
trachea is a skill that requires practice to perfect, the steps immediately after placement of
the tube are in fact more critical to the success of the procedure. Once a tube is placed,
unless in an infant or small child where cuffless tubes are used, the balloon on the tube
must be inflated with at least 3-4cc of air. This completes the protection of the airway from
aspiration and seals the airway so that delivered tidal volumes do not "leak" around the
tube.
Auscultation for air in the stomach (choice A) or breath sounds (choice B) are appropriate
interventions once the cuff is inflated. Ensuring no air is heard in the stomach during
delivery of tidal volume (first place to auscultate), followed by bilateral breath sounds, is
standard procedure for tube placement verification.
At many institutions, checking for end-tidal carbon dioxide (choice C) with a portable
monitor that is placed inline with the ambu-bag is now standard. These detect the presence
of carbon dioxide by a color change. These devices are now packaged as part of standard
emergency airway trays at many hospitals. However, the tube must be inflated first to seal
the airway.
Once the tube is secured and determined to be in the trachea, delivery of 100% inspired
oxygen and initiation of mechanical ventilation (choice D) is appropriate.
You are present during the intubation of an 87-year-old man who was found
unconscious by his nurse. The patient was admitted to the hospital that morning
after a syncopal episode. He has a past medical history of coronary artery
disease and is status-post a Q-wave myocardial infarction and a 3-vessel bypass
procedure 7 months ago. This morning, he had a syncopal episode that was
preceded by palpitations and chest pressure. About 10 minutes ago, his nurse
heard a fall and came to the room to find the patient on the floor, pulseless and
apneic. A senior medicine attending places the endotracheal tube via direct
laryngoscopy. The most sensitive method for the detection of an appropriately
placed tube is
A. absence of air heard in the stomach
B. bilateral breath sounds
C. detection of end-tidal carbon dioxide
D. restoration of 100% saturation by pulse oximetry
E. rise and fall of the chest with positive pressure respirations
Explanation:
52
The correct answer is C. Placement of an endotracheal tube via laryngoscopy
can be a life-saving intervention. Ensuring proper placement of the tube
however is critical to the success of the intervention. The most sensitive method
of ensuring appropriate placement is colorimetric detection of end-tidal carbon
dioxide. These devices are now packaged as part of standard emergency
airway trays at many hospitals. A false-positive result can be obtained if a
significant amount of air has been insufflated into the stomach and a false
negative if the patient has no circulation (no delivery of carbon dioxide to the
lungs) or has suffered a massive pulmonary embolism (large dead space).
The absence of air heard in the stomach (choice A) is reassuring, but
auscultation is wholly unreliable in ascertaining whether a tube is placed in the
esophagus. This is especially true in obese persons.
The presence of bilateral breath sounds (choice B) is reassuring as well, but
transmitted breath sounds across the midline are a common cause for a falsepositive result.
The restoration of 100% saturation by pulse oximetry (choice D) in no way offers
any insight into appropriate placement of an endotracheal tube. If a patient has
a large shunt, as for example with a large pneumonia, then the saturation of
oxygen may not approach 100%, even with endotracheal intubation and
mechanical ventilation. Also, patients can maintain 100% saturations via apneic
oxygenation.
The rise and fall of the chest with positive pressure respirations (choice E) is not
a good indicator of placement since patients with restrictive disorders of the lung
or chest wall or with poor pulmonary compliance may not manifest any chest
wall changes during ventilation.
A 45-year-old woman is planning a trip from the United States to Hong Kong on a direct
flight. She comes to the office inquiring about advice for any travel precautions that she
should take. She has fibrocystic disease of the breast and takes oral contraceptive pills.
Physical examination is unremarkable. Her estimated flying time is 18 hours and the total
mileage is greater than 10,000. Concerning her risks associated specifically with this flight
and her history, the most correct statement is:
A. She is at increased risk for middle ear damage
B. She is at increased risk for myocardial infarction
C. She is at increased risk for tuberculosis
D. She is at no increased risk for a pulmonary embolism
E. She is at significantly increased risk for a pulmonary embolism
Explanation:
The correct answer is E. Based upon the classic Virchow triad of stasis, hypercoagulability,
and endothelial damage, it had been widely speculated that prolonged air travel can be
associated with an increased incidence of deep venous thrombosis and pulmonary
embolism. Infact, this risk increases with increasing duration of the flight and for a flight this
long, the relative risk is 4.7 fold. In general, any trip longer than 5,000 miles confers at least a
53
2-fold greater risk. The risk is not increased for trips less than 3,500 miles (choice D).
The pressurization of the cabin, which is required for modern-day air flight can cause
damage to the middle ear if people fail to equalize the ambient pressure with the middle ear
pressure. However, since this patient has no evidence of a middle ear infection that would
cause her eustachian tubes to fail to offer this equalization (choice A), she has no increased
risk.
At altitude, airliners routinely have ambient PaO2 of much less than sea level since cabins
are not pressurized to one atmosphere. For this reason, arterial PaO2 is around 70 mm Hg.
In persons with known coronary disease(choice B), this decrease in supply cannot be met
with an increased flow and myocardial ischemia can occur.
Although the ambient air in airliners is recirculated and therefore exposes passengers to
"common" pathogens, there is no epidemiological evidence that states that the risk of
acquiring tuberculosis (choice C) is any greater than breathing ground level, non-recirculated
air.
A 60-year-old man comes to the emergency department because of shortness of breath. He
complains of a dry cough, but denies any fever, chills, or sweats. His past medical history is
significant for a history of chronic obstructive pulmonary disease (COPD), hypertension, and
alcoholism. His medications include an albuterol inhaler and furosemide. He appears to be in
moderate respiratory distress. His temperature is 37.0 C (98.6 F), blood pressure is 146/98
mm Hg, pulse is 120/min, and respiratory rate is 36/min. His oxygen saturation on room air is
89%. His breath sounds are diminished bilaterally and he has diffuse wheezes. The
remainder of the physical examination is unremarkable. A chest radiograph shows
hyperexpanded lungs. An electrocardiogram shows sinus tachycardia. The most appropriate
next diagnostic study is
A. arterial blood gas analysis
B. chest CT scan
C. echocardiogram
D. venous blood gas analysis
E. ventilation-perfusion scan
Explanation:
The correct answer is A. In a patient with a history of chronic obstructive pulmonary disease
(COPD), the constellation of described historical and physical findings with a chest
radiograph showing no acute pathology indicates a COPD exacerbation. An arterial blood
gas analysis, especially in the setting of a room air oxygen saturation of 89%, will more
clearly define the patient's oxygenation and ventilation status and assist in better
management and triage.
A chest CT scan (choice B) in the setting of a chronic obstructive pulmonary disease
exacerbation associated with a negative chest radiograph cannot be expected to provide
additional useful information.
An echocardiogram (choice C) will offer no useful information since the patient's respiratory
distress, based upon the available history and physical exam, is due to an exacerbation of
54
his chronic obstructive pulmonary disease.
A venous blood gas analysis (choice D) cannot provide any information regarding systemic
oxygenation. It's utility in this setting, therefore, is minimal.
Since there is no reason to suspect a pulmonary embolus, a ventilation-perfusion scan
(choice E) will not provide any useful information in this instance.
A 32-year-old African American woman returns to the clinic for a follow-up visit.
She was seen 2 weeks prior with complaints of dyspnea, dry cough, chest pain,
and tightness of the chest. An electrocardiogram was within normal limits. A
chest x-ray was performed a week later which showed bilateral hilar
lymphadenopathy with pulmonary infiltrate. While in clinic now, she points out a
rash on her nasal tip that has been present for a number of months. There is a 4
x 2 cm violaceous, indurated plaque involving the nasal tip extending to the
bilateral ala. There are a few tiny button-like papules in the center of the plaque.
In addition, there are waxy, translucent lesions with flat tops on the face, lids,
around the orbits, and in the nasolabial folds. The most appropriate next step in
evaluation is to
A. determine serum angiotensin-converting enzyme and serum calcium
levels
B. determine serum CEA marker level
C. order a complete blood count
D. refer her for a bronchoscopy
E. send her for a lung biopsy
Explanation:
The correct answer is A. Determining serum angiotensin-converting enzyme
(ACE) and serum calcium is the correct management for this patient with
suspected sarcoidosis. Although a bronchoscopy (choice D) and a lung biopsy
(choice E) will also help with diagnosis of sarcoidosis, serum ACE and calcium
levels are less invasive tests to obtain for diagnosis. Sarcoidosis involves
multisystems including lungs, eyes, peripheral lymph nodes, spleen,
gastrointestinal tract, hearing, and musculoskeletal systems. Hypercalcemia
may occur in any stage of sarcoidosis. Corticosteroids lower the raised calcium
level to normal by inhibiting the peripheral action of 1,25(OH)2D3 and by
metabolizing the compound to an inactive metabolite. The serum ACE level is
also raised in 60% of patients. ACE activity is higher in patients with hilar
adenopathy and pulmonary infiltration.
A complete blood count (choice C) is incorrect, because hemolytic anemia is
rare in sarcoid and leukopenia alone is too non-specific for diagnosis of sarcoid.
Serum CEA level (choice B) is incorrect, because this is a non-specific tumor
marker used to monitor for colon carcinoma recurrence, as well as some lung
adenocarcinoma responses to chemotherapy.
55
A 21-year-old college student comes to the emergency department because of a
30-minute history of difficulty in breathing, and a sharp left-sided chest pain that
came on suddenly when he was walking back to his dormitory after biology class.
He says that he is generally very healthy and has never experienced anything
like this in the past. He is 188 cm (6 ft 2 in) tall and weighs 70 kg (154 lb). His
temperature is 37.0 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 75/min,
and respirations are 22/min. Physical examination shows decreased breath
sounds, decreased tactile fremitus, and increased resonance to percussion on
the left side. The cardiac examination is normal. You order a chest x-ray and go
to see the next patient. You hear a radiology technician call for help as you finally
get to sit down to write your notes. You run over to the patient and find that it is
your "shortness of breath and chest pain" patient and that he has not had the
chest x-ray yet. He is now cyanotic and has severe dyspnea. Examination shows
tracheal deviation and distended neck veins. The most appropriate immediate
management is
A. draw an arterial blood gas
B. endotracheal intubation
C. insert a chest tube on the left side
D. insert a needle into the left 2nd intercostal space
E. obtain a chest x-ray at the bedside
Explanation:
The correct answer is D. This patient has developed a tension pneumothorax,
which is an emergency that requires immediate intervention with a needle on the
side of the pneumothorax. He presented with a spontaneous pneumothorax,
that progressed to a tension pneumothorax, and decompression to relieve the
increased intrathoracic pressure is the first step in management. Young, thin
men are at an increased risk for developing a spontaneous pneumothorax, and
the exact cause is unknown.
Blood gases (choice A) are not the most important next step in management of
this case. He requires a needle into the left 2nd intercostal space, which is a lifesaving intervention in a patient with a tension pneumothorax. Blood gases may
be drawn later on, after the needle and then the chest tube are inserted.
Endotracheal intubation (choice B) is the treatment for a flail chest, which
presents with paradoxical chest wall motion, splinting, and crepitus of rib
fragments. The patient in this case has a tension pneumothorax, not a flail
chest.
A chest tube (choice C) is inserted after the needle is placed into the left 2nd
intercostal space. By the time all of the required chest tube equipment is put
together, a patient with a tension pneumothorax may die. Therefore, a needle
insertion is the quickest life-saving procedure for this patient.
A chest x-ray (choice E) is not required to make the diagnosis of a tension
pneumothorax. The diagnosis is clinical and a chest x-ray will only waste
precious time.
56
A 45-year-old woman with severe reflux disease secondary to a hiatal hernia is admitted to
the hospital with flank pain from a kidney stone. An abdominal CT shows multiple stones in
the right ureter and renal pelvis. On the floor, she is given intramuscular meperidine every 4
hours for pain control. Early in the morning the patient is found to be obtunded in moderate
respiratory distress with some evidence of vomitus on her lips and bed shirt. She had been
given 3 additional doses of meperidine for pain control in the past 5 hours. A chest
radiograph will most likely show a
A. diffuse bilateral airspace disease
B. diffuse bilateral interstitial infiltrates
C. right lower lobe opacification
D. right pleural effusion
E. widened mediastinum
Explanation:
The correct answer is C. Aspiration of gastric contents causes severe lung inflammation. The
traditional dogma that the acidic nature of the aspirate is critical has recently been
reevaluated and it is now clear that large volumes of gastric contents of any pH are
dangerous to the lung. Patients with severe reflux often regurgitate frequently throughout the
day and at night will have small aspiration events, which will wake them from sleep by
coughing. Once sedated, these people develop depressed cough reflexes and therefore are
more likely to be unable to protect their airway during such regurgitations. This is most
certainly what has occurred with this patient. The most common radiological finding is right
lower lobe opacification (alveolar filling) or collapse.
Diffuse bilateral airspace disease (choice A) is characteristic of acute respiratory distress
syndrome (ARDS) or very late stage aspiration which can lead to ARDS.
Diffuse bilateral interstitial infiltrates (choice B) are characteristic of pulmonary edema. This
may be a late manifestation (a few days) of severe aspiration, but not an early one.
Pleural effusions (choice D) are not present in aspirations. A unilateral effusion can be found
in cases of liver abscess or right sided diaphragmatic irritation or with Meigs syndrome
(ovarian cancer and ipsilateral pleural effusion).
A widened mediastinum (choice E) is characteristic of an aortic arch dissection or of a
pulmonary disease such as sarcoid.
A 45-year-old man with a history of recurrent deep venous thrombosis and
known to have the factor V Leiden mutation comes to the emergency department
because of an abrupt onset of severe dyspnea that started while he was walking
to work. He also complains of sharp chest pain on inspiration and says that he
has coughed up small amounts of blood. He is not currently taking any
medications and he has no known drug allergies. His temperature is 37.8 C
(100.1 F), his blood pressure is 100/60 mm Hg, pulse is 110/min, respirations are
30/min, and his oxygen saturation is 91% on room air. He appears mildly anxious
and is clearly tachypneic, but he is able to speak in full sentences. Cardiac
examination reveals a prominent P2. His lungs are clear. His right lower
57
extremity has 2+ pretibial edema and his left lower extremity has no edema. A
chest x-ray is unremarkable. A ventilation/ perfusion lung scan is consistent with
a high probability for bilateral pulmonary emboli. The next most appropriate step
in management is to
A. administer intravenous unfractionated heparin and warfarin;
discontinue the heparin as soon as the INR is therapeutic
B. administer intravenous unfractionated heparin and warfarin;
discontinue the heparin 2 days after a therapeutic INR is achieved
C. begin therapy with subcutaneous low molecular weight heparin and
warfarin and send the patient home to follow up in anticoagulation clinic in 1
week
D. obtain an ultrasound of his right lower extremity to rule out deep
venous thrombosis
E. perform a CT angiogram to confirm the diagnosis of pulmonary
embolism
Explanation:
The correct answer is B. In the setting of a high pretest probability for pulmonary
embolism (as in this case with a patient who is known to be hypercoagulable
and presents with classic symptoms), a high probability ventilation/perfusion
scan is sufficient to make the diagnosis. Ventilation/perfusion scans may be
read as negative, but are otherwise described in terms of the probabilities (low,
intermediate, or high) of pulmonary embolism. The patient should be
immediately anticoagulated with heparin to prevent further progression of
thrombosis. Studies have demonstrated that low molecular weight heparin and
unfractionated heparin have similar efficacies in this setting. Given the severity
of his symptoms and abnormal vital signs, the patient should not be sent home
until he has been monitored in the hospital and his condition stabilizes. This
patient should be started on intravenous unfractionated heparin and warfarin
and the heparin should be discontinued 2 days after a therapeutic INR is
achieved.
Start intravenous unfractionated heparin and warfarin; discontinue the heparin
as soon as the INR is therapeutic (choice A) is incorrect because the heparin
must overlap with the warfarin for at least 2 days after the INR is therapeutic.
Warfarin inhibits the synthesis of factors II, VII, IX, and X. The initial increase in
INR seen with warfarin is due to inhibition of the factor with the shortest half-life,
factor VII (the half life is approximately 7 hours). The antithrombotic effect of
warfarin is thought to rely mainly on inhibition of factor II. Due to its longer half
life, it can take up to 2 days for factor II levels to sufficiently decline. Therefore, if
the heparin is discontinued as soon as the INR is therapeutic, the patient will be
left essentially un-anticoagulated for 1-2 days.
Beginning subcutaneous low molecular weight heparin and warfarin and
sending the patient home to follow up in anticoagulation clinic in 1 week (choice
C) is incorrect due to the reasons described above. While low molecular weight
heparin has similar efficacy to unfractionated heparin in this setting, there is no
data to suggest nor any consensus that patients with pulmonary embolism can
safely be treated as outpatients. This patient's tachycardia, low blood pressure,
high respiratory rate, and low oxygen saturation warrants cardiac monitoring and
an inpatient stay.
58
Obtaining an ultrasound of his right lower extremity to rule out deep venous
thrombosis (choice D) is incorrect. The patient already has a known history of
deep venous thrombosis. While the physical finding of asymmetric lower
extremity edema is strongly suggestive of a deep venous thrombosis in the right
lower extremity, knowing this for certain would not change management. The
patient will receive anticoagulation for his pulmonary embolism regardless of
any findings on lower extremity ultrasound.
Performing a CT angiogram to confirm the diagnosis of pulmonary embolism
(choice E) is incorrect because a CT angiogram is neither more sensitive nor
more specific than ventilation/perfusion lung scan. Pulmonary angiogram (via
fluoroscopy, not computed tomography) is the gold standard to make the
diagnosis of pulmonary embolism. As noted above, a high probability scan is
sufficient to make the diagnosis of pulmonary embolism in this setting. The
PIOPED study provides data on ventilation/perfusion lung scanning for the
diagnosis of pulmonary embolism, validating its use. While a CT angiogram is
commonly used in practice, its routine use has not yet been validated in large
trials.
A 72-year-old smoker is admitted to the hospital for COPD exacerbation. Admission vitals
are respirations 18/min, with a blood pressure of 180/100 mm Hg, and an oxygen saturation
of 91%. He is started on nebulized albuterol and ipratropium bromide, as well as
prednisolone intravenously. Admission chest radiograph reveals flattened hemidiaphragms,
increased retrosternal clear space, and hyperlucent lungs. Given a suspicion of pulmonary
embolus, a ventilation perfusion scan is performed demonstrating nonsegmental perfusion
defects of the left upper lobe, with a small left lung and a complete absence of perfusion and
ventilation of the entire right lung. The patient becomes acutely short of breath in the nuclear
medicine department. His respirations are 30/min with otherwise normal vital signs. After
supplemental oxygen (4 L/min by nasal cannula) and nebulizers are administered, the
respirations become 29/min, with a blood pressure of 80/40 mmHg, and an oxygen
saturation of 82%. A repeat chest radiograph is pending. The most appropriate management
is to
A. administer heparin, intravenously
B. insert a chest tube on the left side
C. insert a chest tube on the right side
D. obtain a surgical consult for emergent lung volume reduction surgery
E. send him for coronary artery catheterization
Explanation:
The correct answer is C. The patient is exhibiting clinical signs of a tension pneumothorax,
including pulmonary and cardiac failure. The ventilation perfusion scan demonstrates lack of
ventilation and perfusion of the right lung, which is consistent with a pneumothorax. A
tension pneumothorax must be suspected given the diminished size of the left lung. A
tension pneumothorax is a unilateral pneumothorax that becomes loculated by a one-way
valve mechanism and compromises the contralateral lung and the venous return to the
chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary
59
collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the
pressure in the right hemithorax.
The ventilation perfusion scan is consistent with a pneumothorax of the right lung with signs
of tension, given the small left lung. The ventilation perfusion mismatches of the left lung
apex are consistent with bullous disease, which is common in patients with COPD. A
pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion
scan. Heparin would be an appropriate treatment if the ventilation perfusion scan was
positive for pulmonary embolus (choice A).
The chest tube must be ipsilateral to the tension pneumothorax, not on the left side (choice
B).
Volume reduction surgery (choice D) is a controversial method for reducing lung volumes in
patients with emphysema. It is an elective procedure and is inappropriate for the
management of tension pneumothorax.
The patient's low blood pressure is due to the effect of the tension pneumothorax on preload,
not due to intrinsic coronary artery disease as seen in a cardiac catheterization (choice E).
You are called to see a patient in the intensive care unit who was admitted with
pneumonia and intubated for hypoxemia and acidosis. You learn that he is a 57year-old man with severe asthma for which he was being treated with chronic
steroids along with multiple inhalers. He has no other medical problems.
Currently his temperature is 39 C (102 F), blood pressure is 75/40 mm Hg, pulse
is 140/min, and respirations are 17/min. His physical examination is significant for
bilateral wheezes with decreased breath sound at the right base. Despite
aggressive hydration with normal saline, his blood pressure remains low. You
suspect he is septic. You decide to place a Swan Ganz catheter to clarify his
volume status and better understand his hemodynamic picture. The most likely
finding to support your suspicion that he is septic would be
CI
SVR
PAWP
A. Decreased Increased Normal
B. Decreased Increased Decreased
C. Increased Decreased Normal
D. Decreased Normal
Normal
E. Increased Increased Decreased
Explanation:
The correct answer is C. This patient has septic shock. Septic shock is
characterized by decreased blood pressure despite euvolemia and is often seen
with severe infection, especially with Gram-negative organisms. Release of
inflammatory mediators is responsible for decreasing SVR. Patients are thought
to be in a hyperdynamic state with increased cardiac output. Volume status is
reflected by PAWP and is classically normal but can be normal, low, or high
depending on the aggressiveness of hydration.
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Decreased CI, increased SVR, and normal PAWP (choice A) is an example of
cardiogenic shock. This is common with cardiac tamponade or myocardial
infarction. It should be thought of as pump failure. The cardiac index is low
because the heart is not pumping well. The SVR is increased in an effort to
maintain blood pressure. The PAWP is normal in these patients since volume is
typically not the primary problem.
Hypovolemic shock (choice B) is demonstrated by a low cardiac index, an
increased SVR, and a decreased PAWP. Simply, CI and PAWP are low
because there isn't enough blood volume to be pumped by the heart (low
volume = low pre-load). SVR is elevated to attempt to increase blood pressure.
Obstructive shock, characterized decreased CI and normal SVR and PAWP
(choice D), is typically caused by massive pulmonary embolus. Supportive care
with IV fluids and vasoconstrictors along with possible embolectomy is indicated.
Note: The only indication for embolectomy is hemodynamic instability.
Increased CI and SVR, and decreased PAWP (choice E) is not likely to be seen
since Starling principles would suggest that it would be difficult to increase your
cardiac output against a high pressure system (increased SVR) and a low
intravascular volume (decreased SVR).
A 72-year-old woman with a 6-month history of non-small cell lung cancer comes to the
office because of neck and facial swelling. She denies any shortness of breath or
hemoptysis. Physical examination shows dilated neck veins and edema of the face and right
arm. A CT scan of the chest shows a right paratracheal mass with diminished opacification of
the central venous structures. The most appropriate next step in the management of this
patient is to
A. administer dexamethasone every 6 hours
B. begin chemotherapy
C. biopsy the mass
D. give her intravenous morphine
E. recommend radiation therapy
Explanation:
The correct answer is E. The patient has a classic case of superior vena cava syndrome
(SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of
SVCS are caused by malignancies, with lung cancer being the most common. The most
feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment
of choice for most patients with SVCS.
Corticosteroids, such as dexamethasone, (choice A) are not the primary treatment of SVCS.
In some malignancies which are steroid responsive or if there is significant inflammation,
steroids can be started as an adjunct to radiation therapy.
Chemotherapy (choice B) is not the initial treatment of choice for patients with non-small
lung cancer who present with SVCS. After the patient has been started on radiation, a
61
chemotherapeutic regimen can be offered to the patient if it is appropriate.
In patients with known lung cancer, a biopsy of the mass (choice C) causing the SVCS is
usually not necessary and treatment can commence once the clinical diagnosis is made. In
patients without a history of cancer, every effort should be made to obtain a diagnosis
before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement,
thrombosis).
Narcotics (choice D) are not direct therapy for SVCS. Of course if the patient has any
significant pain due to their cancer then narcotics should be prescribed to help alleviate it.
This patient is not complaining of any pain by history but like any cancer patient she should
be asked directly whether she is experiencing any pain or discomfort.
A 67-year-old man comes to the clinic for an initial visit. He and his wife have just moved to
the area from out of the state. He brought along his medical records which show that he has
hypertension, mild peripheral vascular disease, and that he carries the diagnosis of
emphysema. He tells you that he smokes 1 pack of cigarettes per day but refrains from all
but social alcohol. His medications include thiazide, captopril, quinine, and albuterol inhalers
as needed. He has never had pulmonary function testing. His temperature is 37.0 C (98.6 F),
blood pressure is 135/85 mm Hg, pulse is 72/min, and respirations are 14/min. He has
diffuse bilateral expiratory wheezes with a mildly prolonged expiratory time. His abdomen is
obese, but non-tender and there is no fluid wave. The most appropriate intervention for this
patient is to
A. change captopril to lisinopril
B. encourage him to quit smoking immediately
C. increase his thiazide diuretic dose
D. initiate home oxygen therapy
E. obtain pulmonary function testing
Explanation:
The correct answer is B. The two interventions that have been shown to affect mortality,
smoking cessation and oxygen therapy, should be foremost in the minds of all caregivers
who manage patients with COPD. At any stage of the disease, smoking cessation is the
most important intervention that can be taken to improve lifestyle and longevity. Other
management strategies such as medications, rehabilitation, and even surgery are less
effective, sometimes ineffective, when smoking is still practiced.
Changing ACE inhibitors from captopril to lisinopril, a 3 times per day drug to a once daily
drug (choice A) is not required for this patient. Since this is a compliance/lifestyle issue, it
should not take priority of a critical medical intervention. There is no difference in efficacy
between the two drugs.
This patient has reasonably controlled blood pressure so that increasing his thiazide diuretic
dose (choice C) may improve his blood pressure slightly, but its benefits are minimal when
compared to those obtained with smoking cessation.
The decision to initiate home oxygen therapy (choice D) is based upon arterial oxygen
pressures of less than 55 mm Hg (saturations less than 88%) and therefore a resting arterial
62
blood gas is required before a decision to initiate long-term oxygen therapy is made.
Pulmonary function testing (choice E) is an important tool to stratify patients with COPD and
to determine if they have an element of reversible bronchoconstriction. Since they are not
therapeutic however, they do not take precedence over immediate medical interventions that
have life-prolonging consequences.
A 31-year-old woman comes to the office for a follow-up visit. Two weeks ago, the patient
underwent an echocardiogram for the evaluation of a systolic murmur. Her valves appeared
normal but the echocardiogram disclosed elevated right ventricular systolic and diastolic
pressures consistent with pulmonary hypertension. She has no primary lung disease and
reports no symptoms of dyspnea or tachypnea. Her other past medical history is
unremarkable and she takes only oral contraceptive pills for medications. The most
appropriate next step in the management of this patient is to
A. prescribe calcium channel blockers, orally
B. prescribe nitric oxide, inhaled
C. prescribe prostaglandin, intravenously
D. refer the patient for oxygen diffusion capacity testing
E. refer the patient for vasodilator response testing
Explanation:
The correct answer is E. The management of patients with pulmonary hypertension focuses
on three issues: is the disease secondary to primary pulmonary disease (secondary
pulmonary hypertension), is the patient responsive to vasodilator therapy, and, can the
pulmonary pressures be made normal with medication. For this patient, the assumption is,
given her age and lack of medical history, that her pulmonary hypertension is primary. In
addition to pulmonary function testing to help verify this assumption, vasodilator testing to
determine whether the pulmonary vasculature is responsive or not is the first step in the
management of such patients.
Calcium channel blockers (choice A), inhaled nitric oxide (choice B) or intravenous
prostaglandin (choice C) are all agents used in the management of primary pulmonary
hypertension. The choice of these agents depends on whether the patient is vasodilator
responsive and the side effect profile. Systemic agents such as calcium antagonists and
prostaglandins are associated with often profound systemic hypotension which limits their
utility is normalizing pulmonary pressures.
Referring the patient for oxygen diffusion capacity testing (choice D) is not necessary.
Standard spirometry as part of a full battery of pulmonary function tests are indicated to
assess whether the hypertension is primary or secondary, but diffusion testing is only useful
in cases where hypoxemia coexists with existing pulmonary disease.
A 30-year-old man is brought to the emergency department because of shortness of breath.
He had been diagnosed with asthma the previous month, but had not required medication.
He has no other medical history, is on no medications, and has no allergies to any
medications. He smokes a pack of cigarettes a day and drinks 6 cans of beer a week. He is
anxious and is using his accessory muscles of respirations. His blood pressure is 135/88 mm
63
Hg, pulse is 102/min, respiratory rate is 36/min, and room air oxygen saturation is 93%. His
pulmonary examination is significant for diffuse expiratory wheezes and a markedly
prolonged expiratory phase. He is already receiving supplemental oxygen by face mask. The
most appropriate next step is to administer
A. albuterol by nebulizer
B. cromolyn, orally
C. epinephrine, intravenously
D. montelukast, orally
E. magnesium, intravenously
Explanation:
The correct answer is A. Inhaled beta agonists such as albuterol constitute the first line of
treatment of an asthma exacerbation. Both nebulizer and meter dose inhalations of beta
agonists have been shown to work well during an asthma exacerbation.
Cromolyn (choice B), a mast cell stabilizer, is useful in the chronic setting in preventing
asthma exacerbations, but has no use in the setting of an asthma exacerbation.
Epinephrine (choice C) is reserved for those cases when bronchospasm is refractory to beta
agonists. Given the risk for hypertension and tachyarrythmias, epinephrine is not used as a
first-line agent.
Montelukast (choice D), a leukotiene antagonist, as with cromolyn is used in the chronic
setting to prevent asthma exacerbations, but has no role in the management of an acute
exacerbation.
Magnesium (choice E), presumably through its smooth muscle relaxing properties, has been
proposed as an alternative agent in the management of an asthma exacerbation. Studies
have, however, found no role for it during an asthma exacerbation.
A 53-year-old man is admitted to the hospital because of rapid onset of shortness of breath.
He reports that a little less than 2 weeks ago he noticed that he was short of breath and
since that time it has progressed to the point where at rest, he is barely able to breath, and
he is unable to walk without "nearly passing out." He denies chest pain, pressure, any
altered mental status, cough, or fever. His past medical history is remarkable only for
hypertension treated with atenolol. The patient denies any recent travel, occupational
exposures, or sick contacts. On arrival to the emergency department, the patient is mildly
cyanotic and breathing at 24-28/min. He is conversant and appropriate, but visibly short of
breath. There are no obvious signs of accessory muscle engagement. His room air oxygen
saturation is 82%. The most appropriate management of this patient at this time is to
A. administer heliox
B. administer high flow oxygen via non-rebreathing mask
C. administer 3 liters/min oxygen via nasal prongs
D. administer 3 liters/min oxygen via simple face mask
64
E. perform endotracheal intubation
Explanation:
The correct answer is B. This patient has severe hypoxia of unknown etiology. The nature of
his illness and rapid course suggests a disease such as interstitial pulmonary fibrosis. Most
rapid cases such as this are idiopathic (Hammond-Rich syndrome). Regardless of the cause,
immediate management is the same, provide adequate oxygen to determine if the hypoxia
can be corrected. High flow oxygen delivered via NRB mask offers about 82-86% inspired
oxygen concentration. If the shunt fraction is less than 50%, inspired oxygen of this amount
will be able to correct the hypoxia. The patient can then continue on oxygen until he can no
longer protect his airway, his work of breathing becomes too great, or he begins to
desaturate.
Heliox (choice A) is a mixture of helium and oxygen that is used in patients with severe
bronchoconstriction. The combination gas is more laminar with its' flow and allows better
delivery of oxygen to the distal airways. It has no role in the correction of hypoxia since it is a
low oxygen concentration mixture.
Oxygen via nasal prongs (choice C) is inadequate for this patient. 3 L/min offered in this
manner is essentially 26-28% inspired oxygen concentration. With this marginal escalation
over ambient tensions, the patient will improve minimally, or more likely, not at all.
In order to use a simple face mask for oxygen delivery (choice D) the flows need to be
greater than 6 L/min in order to effectively evacuate the expired carbon dioxide from the
mask and prevent rebreathing.
There is no indication to place an endotracheal tube at this time (choice E). Although the
patient is exerting tremendous effort to breathe, he is not in distress, has no accessory
muscle use, and is not discoordinate. The first attempt at management should be to
determine if oxygen, delivered via external devices, can augment his oxygenation. If this is
successful, his respiratory rate will decline and his work of breathing will decrease
substantially.
A 4-year-old girl is brought to the emergency department because of a sudden episode of
drooling and coughing that began when the babysitter left the patient alone in the kitchen for
1-2 minutes. She is generally very healthy and all of her vaccinations and routine preventive
care measures are current. Vital signs are temperature 37.2 C (99 F), pulse 90/min, blood
pressure 100/50 mm Hg, and respirations 16/min. The physical examination reveals a welldeveloped girl in mild respiratory distress with mild stridor. Notably, there is nothing in the
mouth and the lungs are clear on auscultation. A chest x-ray is normal. Twenty minutes later
the patient is still in mild respiratory distress but is improving. The oxygen saturation on room
air is 97%. The next step would be to
A. begin amoxicillin therapy
B. begin levofloxacin therapy
C. order a C reactive protein laboratory test
D. order a lateral x-ray of the neck
E. perform endotracheal intubation
65
Explanation:
The correct answer is D. When young children have acute onset of drooling and coughing, a
foreign body aspiration must be suspected. Alternative diagnoses of croup or epiglottitis
should also be considered. In this case a coin was found in the posterior oropharynx.
Radiographic evaluation of the neck, chest, and abdomen is necessary to exclude a foreign
body. Some objects such as hard food may not be radiopaque, so endoscopy is sometimes
necessary.
Antibiotic therapy (choice A and B) should not be pursued, as there are no clinical signs of
infection at this time. A lateral x-ray of the neck is necessary first to evaluate for epiglottitis.
C reactive protein (choice C) is a nonspecific indicator of inflammation and would not be
helpful in this case. Foreign body aspiration must be suspected and alternative diagnoses of
croup or epiglottitis must also be considered.
Endotracheal intubation (choice E) may be undertaken in the case of respiratory failure or to
protect the airway. This patient is not symptomatic of respiratory failure, but is certainly at
risk of losing the airway. Preparation for intubation must be made, but is not necessary at
this time. Foreign body aspiration must be suspected and alternative diagnoses of croup or
epiglottitis must also be considered.
An 83-year-old female nursing home patient is brought to the emergency department after
she is found down on her bedroom floor next to her walker. The nursing home staff reports
that she appeared confused and disoriented. The patient suffered an embolic stroke 2 years
ago, leaving her with residual dysarthria. The patient appears mildly dyspneic and cannot
appropriately follow commands. Her temperature is 39.8 C (103.6 F), blood pressure is
110/70 mm Hg, and pulse is 70/min. Laboratory studies show a leukocyte count of
17,000/mm3. A chest x-ray shows a right lower lobe infiltrate. Gram stain of a sputum sample
shows many neutrophils and Gram-negative rods. The most appropriate pharmacotherapy is
A. cefuroxime
B. clindamycin
C. erythromycin
D. levofloxacin
E. penicillin G
Explanation:
The correct answer is D. The patient is a nursing home resident with a residual neurologic
deficit from a stroke that affects her speech. She is found with an altered mental status by
the nursing home staff. On evaluation, she has a temperature, elevated WBC, and obvious
infiltrate on CXR. She probably an aspiration pneumonia. She is predisposed to aspiration
pneumonia due to her stroke, which has affected her speech and likely her ability to swallow.
In addition, the CXR infiltrate is in the right lower lobe, which is the likely place for aspirated
contents to fall due to anatomy of the bronchi. Finally, she has Gram-negative rods in her
sputum. Elderly individuals in long-term care facilities tend to have colonization of the
oropharynx with Gram-negative rod bacteria. Levofloxacin has excellent coverage of most
pathogens causing aspiration pneumonia and is a preferred antibiotic treatment. If the patient
had known Pseudomonas colonization, a ceftazidime or piperacillin may have been better
66
alternative choices.
Cefuroxime (choice A) is the drug of choice for community-acquired pneumonia, but does not
have enough Gram-negative coverage in regards to aspiration pneumonias.
Clindamycin (choice B) is another traditional choice for aspiration pneumonia to cover
anaerobic organisms. However, without evidence of anaerobic infection such as lung
abscess on CXR, necrotizing pneumonia, severe periodontal disease, or putrid sputum,
clindamycin is not indicated.
Erythromycin (choice C) covers atypical organisms, not commonly associated with aspiration
pneumonia.
Penicillin G (choice E) was the traditional choice for aspiration pneumonia to cover Grampositive organisms, but recent findings show that Gram-negative organisms predominate in
elderly nursing home patients, making this an incorrect choice.
An 83-year-old female nursing home patient is brought to the emergency department after
she is found down on her bedroom floor next to her walker. The nursing home staff reports
that she appeared confused and disoriented. The patient suffered an embolic stroke 2 years
ago, leaving her with residual dysarthria. The patient appears mildly dyspneic and cannot
appropriately follow commands. Her temperature is 39.8 C (103.6 F), blood pressure is
110/70 mm Hg, and pulse is 70/min. Laboratory studies show a leukocyte count of
17,000/mm3. A chest x-ray shows a right lower lobe infiltrate. Gram stain of a sputum sample
shows many neutrophils and Gram-negative rods. The most appropriate pharmacotherapy is
A. cefuroxime
B. clindamycin
C. erythromycin
D. levofloxacin
E. penicillin G
Explanation:
The correct answer is D. The patient is a nursing home resident with a residual neurologic
deficit from a stroke that affects her speech. She is found with an altered mental status by
the nursing home staff. On evaluation, she has a temperature, elevated WBC, and obvious
infiltrate on CXR. She probably an aspiration pneumonia. She is predisposed to aspiration
pneumonia due to her stroke, which has affected her speech and likely her ability to swallow.
In addition, the CXR infiltrate is in the right lower lobe, which is the likely place for aspirated
contents to fall due to anatomy of the bronchi. Finally, she has Gram-negative rods in her
sputum. Elderly individuals in long-term care facilities tend to have colonization of the
oropharynx with Gram-negative rod bacteria. Levofloxacin has excellent coverage of most
pathogens causing aspiration pneumonia and is a preferred antibiotic treatment. If the patient
had known Pseudomonas colonization, a ceftazidime or piperacillin may have been better
alternative choices.
Cefuroxime (choice A) is the drug of choice for community-acquired pneumonia, but does not
have enough Gram-negative coverage in regards to aspiration pneumonias.
Clindamycin (choice B) is another traditional choice for aspiration pneumonia to cover
67
anaerobic organisms. However, without evidence of anaerobic infection such as lung
abscess on CXR, necrotizing pneumonia, severe periodontal disease, or putrid sputum,
clindamycin is not indicated.
Erythromycin (choice C) covers atypical organisms, not commonly associated with aspiration
pneumonia.
Penicillin G (choice E) was the traditional choice for aspiration pneumonia to cover Grampositive organisms, but recent findings show that Gram-negative organisms predominate in
elderly nursing home patients, making this an incorrect choice.
A 53-year-old widowed woman comes to the office for a health maintenance examination.
She is a new patient who recently moved to your city after her husband died in an office fire
6 months ago. She says that she has no complaints, except for a cough that she began to
notice 4 months ago. She denies nasal discharge, "a tickle in the throat," frequent throat
clearing, heartburn and the sensation of regurgitation, fever, sputum production, cigarette
smoking, illegal drug use, sexual activity, occupational exposures, and any other symptoms
associated with a respiratory infection. She says that the cough is not seasonal or associated
with wheezing. Her temperature is 37.0 C (98.6 F), blood pressure is 135/90 mm Hg, pulse is
70/min, and respirations are 14/min. Physical examination is unremarkable. The most
appropriate next step is to
A. order an electrocardiogram
B. order an x-ray of the chest
C. question her about medications
D. refer her for fiberoptic bronchoscopy
E. schedule her for pulmonary function tests
Explanation:
The correct answer is C. This patient has a chronic cough, which is usually considered
chronic because it is lasting more than 3 weeks. It may be due to a variety of things.
However, the important lesson in this question is that before you turn to diagnostic studies
you need, to make sure that you have obtained a detailed history. The case history will
provide the answer to almost every question that you will need to ask her, except what
medications she takes. Since she is a new patient, you will need to find out if she is taking an
ACE inhibitor, such as captopril or enalapril, which is a frequent cause of a chronic cough in
hypertensive patients. They cause a cough in up to 20% of people taking them. The exact
mechanism is unknown, but it is thought to somehow be related to bradykinin and substance
P. The treatment for the cough is the discontinuation of the ACE inhibitor.
An electrocardiogram (choice A) is unnecessary at this time in this patient, complaining of a
chronic cough. She is not complaining of chest pain and there is nothing in her history that
suggests an arrhythmia. The most important next step, is to take a detailed history before
you order diagnostic tests.
An x-ray of the chest (choice B) may be appropriate in the near future, but it is not the next
step at this time. Before you order diagnostic studies, you need to make sure that you ask
her any questions that might help you figure out the etiology of her cough. Asking her about
medications is very important because ACE inhibitors cause a chronic cough in up to 20% of
68
patients taking this medication.
A fiberoptic bronchoscopy (choice D) is used to obtain histologic and cytologic specimens
and to visualize an endobronchial tumor. Before you turn to such a specialized study, you
need to first obtain a detailed history. If the patient is not taking an ACE inhibitor, a chest xray should usually be performed, and if this is abnormal, sputum cytology, a high resolution
CT scan, and fiberoptic bronchoscopy should be considered.
Pulmonary function tests (choice E) are used to assess airway hyperresponsiveness for
patients in which you suspect asthma, and lung volumes and diffusion capacity in patients in
which you suspect a diffuse interstitial lung disease. A detailed history is necessary before
using any of these studies.
A 36-year-old man is brought to the emergency department because of shortness of breath
and stridor. His shortness of breath has been progressive for the past few months but has
worsened significantly in the past week. He was in a serious motor vehicle accident 14
months ago after which he was intubated and ventilated for nearly 3 months. His intensive
care unit stay was complicated by ventilator-associated pneumonia. He was eventually
weaned from the ventilator and extubated 7 months ago. Since that time, he has been
convalescing well but his shortness of breath has become increasingly troublesome. In the
last 2 or 3 days his wife has noticed the stridor. His temperature is 37.0 C (98.6F), blood
pressure is 140/75 mm Hg, pulse is 72/min, and respirations are 24/min. His lungs are clear
bilaterally, but inspiratory stridor is appreciated. A chest CT scan shows a tracheal stenosis
of 7mm at the level of C6 vertebral body. The most appropriate management at this time is to
A. admit the patient for observation
B. give the patient bronchodilator therapy
C. initiate antiinflammatory therapy
D. intubate the patient immediately
E. obtain a thoracic surgical consult
Explanation:
The correct answer is E. This patient has tracheal stenosis secondary to long-term
intubation. This is a common complication of long-term intubation and is one of the main
reasons that tracheostomy tubes are placed in patients that are in need of long-term
mechanical ventilation. Stridor is caused by the inflow of air across a narrow obstruction in
the airway. It signifies that some part of the trachea or main stem bronchi are quite narrow
and portends an airway disaster if the disease process is allowed to progress. The CT scan
demonstrates tracheal stenosis of moderate degree (3-8 mm is moderate) that will require
surgical correction in the near term.
Simply admitting the patient for observation (choice A) fails to address management of a
clearly abnormal airway. It is critical to act in cases such as this and triage the patient to the
appropriate management as soon as possible.
The trachea is not responsive to bronchodilator therapy (choice B), only the distal
bronchioles.
The inflammation and fibrosis that are responsible for the stenosis have already occurred
69
and therefore, antiinflammatory therapy (choice C) will offer little benefit at this time.
There is no need to intubate the patient immediately (choice D). His ventilation and
oxygenation are adequate and he does not appear to be in respiratory distress. His airway
can in fact become much more narrow (1-2 mm) before any major respiratory distress is
appreciated. In addition, since his stenosis is at the level of the cricoid cartilage (C6), an
endotracheal tube will not be able to pass.
A 67-year-old man comes to the office complaining of a 12–month history of
shortness of breath at rest and with mild exertion. He also reports wheezing on
occasion that seems to correspond to the times when he is most short of breath.
He has a cough that is persistent most of the year and is occasionally productive
of scant sputum. He has a long smoking history of over 100 packs/ year, but has
recently quit. His only other medical history is hypertension and hyperlipidemia
for which he takes atenolol and simvastatin. A chest radiograph shows
hyperinflation but clear lung fields and no evidence of a parenchymal or
mediastinal mass. The most appropriate next step in management is to
A. obtain spirometry
B. order a chest CT scan
C. prescribe albuterol inhalers
D. prescribe corticosteroids
E. prescribe home oxygen
Explanation:
The correct answer is A. This patient likely has COPD based upon his social
history and symptoms. All patients who present complaining of shortness of
breath, are over the age of 40, and have a smoking history or environmental
exposure history to asbestos, beryllium, or dust, should have screening
spirometry. Spirometry measures forced inspiratory and expiratory effort. The
hallmark of COPD is decreased forced expiratory effort. The tests are
noninvasive and can be performed in fully clothed patients.
A chest CT scan (choice B) is of minimal value in this case since the chest
radiograph revealed no evidence of any abnormality except hyperinflation, which
is to be expected in a case of COPD.
Therapeutic interventions such as albuterol inhalers (choice C), steroids (choice
D), or home oxygen (choice E) are options to be considered once a diagnosis of
COPD is established and its severity is quantified. Inhalers are excellent firstline drugs for patients that have reversible airflow obstruction demonstrated by
full pulmonary function testing. Home oxygen is usually given for late-stage
COPD in patients who have room air arterial oxygen pressures of less than 60
mm Hg. Steroids are very useful agents in acute exacerbations of COPD.
A 54-year-old African American woman comes to the office because of fatigue, anorexia,
weight loss, and fever. The patient reports that over the past few months, these symptoms,
which were new, have progressively worsened. She has a past medical history significant
70
only for temporal arteritis for which she takes low-dose prednisone daily. Her physical
examination is remarkable for a temperature of 37 C (98.6 F), blood pressure is 130/85 mm
Hg, pulse is 80/min, and respirations are 20/min. Her lungs are clear, there are no murmurs
and no cyanosis or clubbing of the digits. A chest radiograph discloses bilateral hilar
lymphadenopathy. After obtaining a thorough occupational, environmental, and medicationuse history, the most appropriate diagnostic step is to
A. obtain the ratio of CD4/CD8 T-lymphocytes
B. order serum ACE levels
C. perform the Kveim-Siltzbach skin test
D. schedule a mediastinal lymph node biopsy to obtain evidence of noncaseating
granulomas
E. schedule a skin biopsy to obtain evidence of noncaseating granulomas
Explanation:
The correct answer is E. The clinical manifestations of sarcoidosis can be widespread or
may involve only one organ system at a time. Sarcoidosis is a systemic disorder of unknown
cause that is characterized by its pathological hallmark, the noncaseating granuloma.
Because the lungs and thoracic lymph nodes are almost always involved, most patients
report acute or insidious respiratory problems, variably accompanied by symptoms affecting
the skin, eyes, or other organs. Once the diagnosis is suspected by evidence on chest
radiography, the diagnosis should be confirmed by biopsy to exclude infection or malignant
conditions. In most centers, skin and transbronchial lung biopsies have supplanted biopsy of
mediastinal lymph nodes (choice D) and the liver because of their high yield, greater
specificity, and low morbidity.
There are no definitive diagnostic blood, skin, or radiologic imaging tests specific for the
disorder. Therefore, a ratio of CD4/CD8 T-lymphocytes (choice A), or serum ACE levels
(choice B), although often used, are not of diagnostic value because of their very low
specificity.
The Kveim-Siltzbach skin test (choice C) in which spleen or lymph node homogenate from a
patient with suspected disease is injected intradermally and later subjected to biopsy, is not
widely available, not well standardized, and not approved for general use by the FDA.
A 73-year-old woman is found apneic and pulseless on the medical floor. She
had been admitted to the hospital 2 days prior for management of her
hypothyroidism. She was diagnosed with severe hypothyroidism and started on
intravenous thyroid hormone replacement. Her nurse found the patient
unresponsive in the bathroom. The patient was lying on the floor, blue, and
without a palpable pulse. An emergency was called. The patient was unable to
be intubated by either an anesthesiologist or a medical house officer present at
the emergency. By the time you arrive, you are told that there were at least three
attempts to secure the airway by laryngoscopy, none of which were successful.
The patient has no pulse, she is not breathing, and is non-responsive. The most
appropriate immediate intervention is to
A. attempt a surgical airway
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B. attempt to re-intubate the patient with a new laryngoscope
C. begin chest compressions and the ACLS algorithm for ventricular
fibrillation
D. call a surgeon for an emergent cricothyroidotomy
E. deliver 100% oxygen by face mask
Explanation:
The correct answer is D. Although the details of the emergency airway algorithm
are not required for either ACLS or ATLS certification, the basics of airway
management are required for both. The first rule of resuscitation is "A" for
airway. This patient has not had their airway secured so that they can be
ventilated and oxygenated. A surgeon should be called to immediately attempt a
surgical airway.
Trying to attempt a surgical airway (choice A) is not wise in a situation where
there is surgical backup personnel available. These procedures are difficult and,
if not done properly, will result in no chance of survival for a patient with a
difficult airway.
Any attempt to re-intubate the patient with a new laryngoscope (choice B)
should be undertaken only after a surgical airway has been called for. Three
attempts at laryngoscopy by experienced operators is reasonable evidence that
this approach will be unsuccessful at securing the airway rapidly.
To begin chest compressions and the ACLS algorithm for ventricular fibrillation
(choice C) is incorrect for two reasons. First, the "A" airway has not been
secured. Secondly, there is no evidence that this patient is in VF. In order to
determine which ACLS algorithm to follow, a rhythm or must be determined.
To deliver 100% oxygen by face mask (choice E) is incorrect since there is no
way to deliver the oxygen to the lungs without positive-pressure mask
ventilation. Face mask oxygen is only useful for patients who are spontaneously
breathing.
A 37-year-old man with a history of allergic rhinitis comes to the office with a 3day history of fever and cough. He was in his usual state of health until 3 days
ago when he developed a cough productive of yellow-green sputum and fevers
to 38.3 C (101.8 F). The fevers have been accompanied by drenching sweats.
He has been experiencing right sided pleuritic chest pain. He denies shortness of
breath, abdominal pain, weakness, or numbness. He has not had any sick
contacts and has no recent travel outside of the United States. He has a 15-pack
year history of smoking but denies any alcohol use or injection drug use. His
temperature is 38.5 C (101.3 F), blood pressure is 132/74 mm/Hg, pulse is
82/min, respirations are 14/min, and oxygen saturation is 96%. Physical
examination shows crackles at the right base A complete blood count and
biochemical profile are all within normal limits. A chest x-ray shows a right lower
lobe infiltrate. The most appropriate next step in the management of this patient
is to
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A. admit the patient to the hospital for intravenous ceftriaxone therapy
B. obtain a CT scan of the chest
C. request a pulmonary consultation for bronchoscopy
D. treat the patient as an outpatient with oral azithromycin therapy
E. treat the patient as an outpatient with oral ciprofloxacin therapy
Explanation:
The correct answer is D. The patient's history, exam, and x-ray are all consistent
with a diagnosis of community acquired pneumonia (CAP). CAP can be safely
treated as an outpatient in most circumstances. Exceptions to this rule are when
the patient has an underlying medical condition (cardiac disease, pulmonary
disease, diabetes, HIV, cirrhosis, renal disease, or malignancy), advanced age,
or presents with a severe pneumonia manifested by unstable vital signs or
bilobar pneumonia. The appropriate treatment for this patient is either a
macrolide antibiotic or an extended spectrum fluoroquinolone as they will cover
typical and atypical organisms.
As discussed previously this patient does not require intravenous therapy or
hospital admission (choice A) unless his condition deteriorates. In addition
ceftriaxone would not be adequate coverage as it does not cover the atypical
organisms.
In the management of routine cases of CAP, a CT scan (choice B) is not
necessary. A CT scan might be appropriate in situations where there is a
concern for malignancy, underlying pulmonary disease, or non-resolving
pneumonia. None of these conditions are present in this case.
This patient does not require a bronchoscopy (choice C). Potential indications
for bronchoscopy are when there is a concern for an obstructive lesion on
imaging studies, recurrent lobar pneumonia, or significant hemoptysis.
Ciprofloxacin (choice E) is not the antibiotic of choice for CAP. It does not
provide adequate coverage against streptococcal pneumonia, which is the most
common cause of CAP.
A 16-year-old boy is admitted to the hospital for pneumonia. The patient reports that over the
past 3 days he has had an increasing cough, productive of thick, green sputum and pleuritic
chest pain. He has a history of cystic fibrosis and has been hospitalized for pneumonia 9
times in the past 3 years. He has never been intubated, but has required prolonged hospital
stays at times in order to manage his infections. His medications include pancreatic enzymes
and acetylcysteine nebulizers. The most appropriate management of this patient is to
A. begin aggressive chest physiotherapy
B. give him inhaled beta agonists
C. enroll him in gene therapy trials
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D. evaluate him for lung transplantation
E. obtain a sputum culture and await results for directed antibiotic therapy
Explanation:
The correct answer is A. Cystic fibrosis is a pulmonary/gastric disorder caused by mutation
in a protein responsible for maintaining salt and water gradients across cell membranes.
The clinical manifestations of the disease stem from the presence of thick, copious
secretions in the airways and ducts of the pancreas. The pulmonary manifestations are
frequent infection such as pneumonia and eventually bronchiectasis. In addition to
antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is
critical to clearing hyper-acute infections.
Inhaled beta agonists (choice B) offer no benefit for these patients since they have no
element of bronchoconstriction to their disease. All of the airway issues in these patients
relates to the thick mucous plugs that they are unable to clear.
Despite some of the early successes in gene therapy for CF, early enrollment in gene
therapy trials (choice C) is still not considered a standard of care and does not replace in
any way the most basic management principles of caring for patients with CF which is
antibiotics and chest physical therapy.
It is appropriate to begin evaluation for lung transplantation (choice D) at any time during
the course of CF. However, such an evaluation does not in any way assist in managing the
acute infection that the patient is currently suffering.
Most patients with CF have defined pathogenic flora such as pseudomonas. For this
reason, a sputum culture for directed antibiotic therapy (choice E) to direct therapy is not
critical and antibiotic coverage can be initiated prior to any definitive culture data being
returned.
A 65-year-old man, his wife, and 38-year-old son have been your clinic patients
for the last 15 years. In the evaluation of some mild hemoptysis of the 65-yearold man, a chest x-ray reveals a 4 cm right sided lung mass, hilar and
mediastinal adenopathy, and several lytic lesions in his ribs and humerus. None
of these findings were present on an x-ray performed 4 years earlier. He has a
50-pack year smoking history. When he returns to your office, you inform him
that he likely has stage IV lung cancer and that you would like to refer him to an
oncologist for further evaluation. He states that he wants no therapy whatsoever,
and that he wants to keep this a secret from his family. The most appropriate
response would be to
A. call his son as soon as he leaves the office
B. inform him that treatment will likely be curative and that he should
really reconsider his decision
C. investigate what it is that makes him feel uncomfortable in telling his
family and provide counseling
D. realize that he will likely "come to his senses" and give him a referral to
the oncologist anyway
E. tell him that he is probably just in denial and try to persuade him to tell
his wife when he gets home
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Explanation:
The correct answer is C. Patient confidentiality is one of the most important
medical ethical issues facing physicians, and it certainly can pose dilemmas at
times. This patient has just received horrible news and is likely just reacting
without really thinking about the ramifications of his decision. However, there
may be very important personal, social, or cultural reasons for his decision. It is
important for you, as a physician, to explore these with him.
Calling his son (choice A) is inappropriate because it breaks confidentiality.
Although you will likely try to get the patient to reconsider his decision (choice B)
telling him that therapy will likely be curative for stage IV lung cancer is not true.
There is very little chance at a cure and palliative therapy is a much more
reasonable expectation.
Giving him a referral to the oncologist because he is will "come to his senses"
(choice D) is inappropriate. He obviously needs counseling, and the feelings as
to why he does not want treatment and why he does not want his family to
know, should be explored.
Although the patient may be in denial (choice E), patient confidentiality
precludes you from unilaterally deciding to tell his wife. It is appropriate to try to
understand the reasons why he does not want to tell his family, as opposed to
trying to persuade him to tell his wife when he gets home.
An 8-year-old boy is brought to the office by his mother because of recurrent
episodes of "shortness of breath" and wheezing. These episodes typically occur
when he is playing in the park with friends or when he is in the house at night.
The symptoms are worst in the springtime and when he is watching television
with his mother's boyfriend. The mother's boyfriend, who happens to smoke
cigarettes, has been spending more and more time at the house, trying to bond
with the patient. Pulmonary function tests show that the peak expiratory flow and
forced respiratory volume per second are reduced during an attack and are
normal during symptom-free intervals. Skin testing shows that he is allergic to
grass and tree pollen, dust mites, animal dander, and a variety of other allergens.
Laboratory studies show:
The most appropriate next step is to
A. administer immunotherapy against identified allergens
B. advise him to avoid all exercise
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C. advise him to try to avoid respiratory irritants, especially cigarette
smoke
D. advise the patient's mother to use a humidifier and air cleaners at
home
E. prescribe inhaled sodium cromoglycate, oral corticosteroids, and oral
theophylline
Explanation:
The correct answer is C. This patient has asthma, and the most crucial step in
the management of asthma is avoidance of the triggering factors, e.g.,
allergens. Unfortunately, it is difficult to avoid specific types of allergens, such as
pollens. Specific measures to eliminate or reduce exposure to dust mites and
animal dander at home lead to a reduced frequency of attacks and
hospitalization rates. Regardless of the allergens involved, elimination of
respiratory irritants, especially cigarette smoke, is of crucial importance. The
bronchial tree of asthmatic patients is highly reactive to any form of chemical or
physical irritation. Thus the avoidance of passive smoke is important. The
mother should ask her boyfriend to go smoke outside alone if he needs to, but
he should not be allowed to smoke in the house.
It is not practical to administer immunotherapy against identified allergens
(choice A) in this case because he is allergic to multiple airborne allergens, and
it seems like he is especially responsive to cigarette smoke. Immunotherapy is
of some benefit when a single allergen is identified. The most important step is
to try to reduce exposure to avoidable allergens (smoke).
Avoidance of all exercise (choice B) is not appropriate because even though
exercise triggers asthmatic attacks in some patients, this does not seem to be
his main trigger.
Humidifiers and air cleaners (choice D) at home is not the appropriate
management. Humidifiers favor the growth of dust mites, and air cleaners have
not been shown to be uniformly effective in getting rid of dust mites.
It is inappropriate to prescribe inhaled sodium cromoglycate, oral
corticosteroids, and oral theophylline (choice E) for this patient because the
fewest number of drugs at the lowest effective doses should be used. Typically,
a one drug regimen (a bronchodilator or an inhaled corticosteroid) for mild to
moderate asthma or two drugs for more severe cases is sufficient to control
asthma exacerbations. Oral corticosteroids are indicated in cases of severe
asthma and are therefore, not for this patient.
A 49-year-old man comes to the office for a health maintenance examination. He
has had 5-7 episodes of blood-tinged sputum in the past month that he is very
concerned about. He denies any other symptoms. He has been a patient of yours
for 15 years and has been generally healthy. He does not have any chronic
medical conditions. He is a superintendent of a large apartment building, gets
regular exercise, eats a low-fat diet, and smokes 2 packs of cigarettes a day for
the past 30 years. His temperature is 37.0 C (98.6 F), blood pressure is 130/80
mm Hg, pulse is 65/min, and respirations are 16/min. Physical examination is
unremarkable. You order a chest x-ray, a complete blood count and coagulation
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profile, electrolytes, BUN and creatinine, a urinalysis, and send sputum samples
for Gram, fungal, and acid-fast stains, cytology and schedule a follow-up visit in 2
weeks. He arrives for the appointment and you review the results with him, all
which came back normal. He tells you that he has had increasing episodes of
"blood in the sputum" and has even coughed up about 10mL blood over the past
2 weeks. Physical examination and vital signs are unchanged since the last visit.
The most appropriate next step is to
A. admit him to the hospital for immediate thoracic surgery
B. order a chest x-ray
C. schedule a bronchoscopy
D. schedule a high-resolution CT scan
E. reassure him that all of the tests were normal
Explanation:
The correct answer is C. This patient has non-massive hemoptysis, which is
defined as less that 100 mL of expectorated blood over 24 hours. The work-up
begins with history and physical examination. A chest x-ray and laboratory
studies should be ordered initially. If the chest x-ray is normal and the patient
has risk factors for cancer, like smoking 2 pack of cigarettes a day for the past
30 years, a bronchoscopy should be ordered to localize the bleeding site and
look for an endobronchial mass. If none is found, a high resolution CT scan
should be considered. If a mass is found on a study, referral to a thoracic
surgeon is necessary.
It is inappropriate to admit him to the hospital for immediate thoracic surgery
(choice A) at this time. He has non-massive hemoptysis and needs a
bronchoscopy to be ordered to localize the bleeding site and look for an
endobronchial mass. Surgery may be indicated in the future, but now, since he
is hemodynamically stable, he needs further evaluation for his hemoptysis.
It is unnecessary to order another chest x-ray (choice B) at this time. Since his
physical examination has not changed, it is unlikely that a chest x ray would
have changed in 2 weeks. He has no symptoms that suggest pneumonia which
may appear on a later x-ray. He requires a bronchoscopy to look for a mass that
cannot be visualized on the x-ray.
A high-resolution CT scan (choice D) is usually only indicated after a chest x-ray
and a bronchoscopy. An exception is when the chest x-ray suggests
parenchymal disease, then the HCRT is usually performed before the
bronchoscopy.
In this patient with hemoptysis and a significant smoking history, reassuring him
that all of the tests were normal (choice E) is inappropriate. You need to find the
cause of his symptoms by continuing with the diagnostic evaluation. A
bronchoscopy is indicated at this time.
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A 66-year-old man with diabetes mellitus comes to the emergency department because of a
4-day history of a cough with rusty-colored sputum. His wife died from breast cancer 2
months ago and his daughter, who lives 45 minutes away, comes to check on him a couple
of times a week. He says that he normally passes his days watching talk shows on
television, but lately he has felt so "crummy" that he has stayed in bed. His temperature is
38.7 C (101.6 F), blood pressure is 110/70 mm Hg, pulse is 100/min, and respirations are
31/min. His arterial PO2 on room air is 59%. Physical examination shows bronchial breath
sounds, egophony, and dullness to percussion over the right upper lobe and the left lower
lobe. A chest x-ray shows consolidation of the right upper lobe and the left lower lobe. Gram
stain of his sputum sample shows neutrophils and lancet-shaped Gram-positive diplococci.
The sensitivities are still pending. Other patients that you have seen lately have had
penicillin-resistant strains of this disease. The next step should be to
A. admit him to the hospital for intravenous vancomycin therapy
B. have him call his daughter to come pick him up and take care of him
C. order a bronchoscopy with a sampling of respiratory secretions
D. send him home with erythromycin therapy
E. send him home with cefuroxime therapy
Explanation:
The correct answer is A. This patient most likely has community-acquired pneumonia
(Streptococcus pneumoniae), is acutely ill, and requires hospitalization. Criteria for
hospitalization are ages >65, significant comorbidities, leukopenia, pneumonia caused by
Staphylococcus, anaerobes, or Gram-negative bacilli, suppurative complications, failure of
outpatient management, an inability to take oral medication, a respiratory rate >30/min, heart
rate >140/min, hypotension, a PO2 <60 mm Hg, a change in mental status, and a poor
social-support system. Each case needs to be evaluated on an individual basis, however,
this patient has multiple risk factors, and should therefore be hospitalized. Vancomycin is
given empirically in this case before the sensitivities return because he is severely ill, has
diabetes, and there have been cases of penicillin-resistant strains. Therapy can be switched
when the results return.
It is incorrect to have him call his daughter to come pick him up and take care of him (choice
B) because he is very ill and should be hospitalized.
A bronchoscopy with a sampling of respiratory secretions (choice C) is necessary if he fails
initial therapy or if he has a rapidly progressive downhill course. It is not indicated at this
time.
It is inappropriate to send him home with erythromycin therapy (choice D) or cefuroxime
therapy (choice E) because he should not be treated as an outpatient. This patient requires
hospitalization based on his physical findings, comorbidity, and lack of social support (visits 2
times a week by his daughter is not enough).
You are the physician-on-call and are asked to see a 57-year-old woman who has been
complaining of progressive shortness of breath over the past 2 days. The woman was
admitted to the medical service 6 days ago after a fall and has been on bed rest for a
nondisplaced pubic ramus fracture. She has been on deep vein thrombosis prophylaxis with
subcutaneous heparin. Her past medical history is significant for type-II diabetes and
dialysis-dependent renal failure secondary to diabetic nephropathy. She makes no urine at
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baseline. Her last dialysis run was 4 days ago, though she is usually dialyzed 3 times per
week. She is complaining of shortness of breath but no chest pain. She is anxiousappearing, has a blood pressure of 160/105 mm Hg, respiratory rate of 30/min, and heart
rate of 110/min. She has an oxygen saturation of 80% on room air and appears cyanotic.
Physical examination reveals a jugular venous pressure of 10 cm and inspiratory crackles
half way up from the bases upon auscultation of the lungs. An electrocardiogram shows a
rate-related right bundle branch block but no ischemic changes. Chest x-ray obtained
yesterday revealed interstitial edema and vascular redistribution to the apices. The patient's
husband has arrived from home and is very concerned about the recent events. In particular,
he asks what has caused the current problem with her breathing. You suspect that a
scheduling error may have delayed her last dialysis run and caused volume overload, but
you are not completely sure. The most appropriate initial approach to take with the husband
given that you have just met the patient for the first time is to
A. acknowledge sympathetically that a mistake may have been made but will not likely
cause permanent harm
B. ask him to kindly wait until the hospital lawyer can be present before speaking to
him about the matter
C. explain that hospitals are complex institutions, making scheduling a difficult process
at times
D. explain that you are the physician on-call tonight and are not privy to all of the
scheduling details, but that you will explore in detail whether a mistake has been made
and that you will communicate these findings in a timely manner to both him and the
patient
E. speculate on how recent health maintenance organization's cuts in reimbursement
may have made it necessary to decrease the number of dialysis runs for each
hospitalized patient
Explanation:
The correct answer is D. When you suspect a mistake has been made in the hospital, the
first approach should always be to make an earnest effort to get all of the facts. This
approach will immediately build a rapport with the husband as you become an advocate for
the truth, readily demonstrate your interest in the patient's specific case, and help identify
process errors in the hospital.
While acknowledging that a mistake has been made (choice A) is often an important step, it
usually does not go far enough because patients and their families are interested in why
mistakes happen and whether they will happen again. It is simply unprofessional to not go
further and explore all of the details of the mistake regardless of whether an injury actually
occurs.
While seeking legal advice (choice B) may be an important step in dealing with this issue, the
initial approach again should focus on a thorough investigation of the facts by the physician
and relevant administration.
Philosophical approaches (choice C) are unsatisfactory because they seek to diminish any
individual responsibility for a mistake happening and are unlikely to result in correcting a
serious process error.
Speculating on cuts in insurance reimbursement (choice E) is inappropriate and
unprofessional. The job of physicians is to care for their patients and be their advocates. This
must occur regardless of the practice environment one finds themself in. Specifically,
whether the patient population is wealthy and cash paying or whether they depend on
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insurance, medical decisions are based upon medical need and not insurance mandates. To
acknowledge any differently is to commit medical malpractice.
A previously healthy 31-year-old woman comes to your office complaining of 1-day history of
a cough and a fever. She reports that she was celebrating a job promotion 3 days prior and
drank quite a bit of alcohol at a local bar. She had 2 episodes of vomiting that evening. She
takes no regular medications and has only been using acetaminophen for fever suppression.
Her temperature is 38.2 C (100.8 F). Her lungs have decreased breath sounds in the left
base and right upper lobe. She has a cough that is productive of foul-smelling sputum. The
remainder of her examination is unremarkable. The most appropriate management is to
A. admit the patient to the hospital for clindamycin therapy
B. admit the patient to the hospital for penicillin therapy
C. admit the patient to the intensive care unit for levofloxacin therapy
D. begin outpatient cefuroxime therapy
E. begin outpatient erythromycin therapy
Explanation:
The correct answer is A. This is a patient who likely has pneumonia in the setting of likely
aspiration. Since most pneumonia never have the etiologic agent identified, the treatment is
empirical based upon patient locale at time of infection and presumed organisms based upon
epidemiology. In this case, the presumed aspiration indicates that coverage for Gramnegative and anaerobic organisms is required. Clindamycin is a macrolide derivative that has
activity against these agents. It is effective and is well-tolerated orally. Uncomplicated
pneumonia such as community acquired or atypical infections rarely require hospitalization.
For this patient with a likely anaerobic, purulent infection, a more monitored setting for
therapy is required.
Penicillin (choice B) is an excellent choice for community acuquired pneumonia with the
caveat that an increasing number of isolates of S. pneumonia are resistant. In some centers,
this number is as high as 20%. However, penicillin has no activity against Gram-negative or
anaerobic organisms.
Levofloxacin (choice C) is a fluoroquinolone that has broad activity against Gram-positive,
Gram-negative, and some anaerobes. However, it does not have adequate coverage of
anaerobic organisms to provide effective coverage for presumed aspiration. This patient has
no objective findings that would warrant an ICU admission. Hemodynamic instability or
respiratory distress requiring intubation would be classical reasons why patients with severe
pneumonia may require an ICU stay.
Outpatient cefuroxime (choice D) is a second-generation cephalosporin that is standard
outpatient therapy for community acquired pneumonia. It does not have the required broad
Gram-negative (although it has some) coverage and it has no anaerobic coverage. This
patient should however be hospitalized for observation during initial therapy.
Erythromycin (choice E) is a macrolide antibiotic that is also effective for both typical and
atypical community acquired pneumonia but is only minimally useful in cases of aspiration
pneumonia.
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A previously healthy 21-year-old college student comes to the clinic because of a
headache, sore throat, muscle aches, and a constant, irritating, dry cough for six
days. He says that he is "never sick" and has only been to this clinic for his
"immunizations". He exercises regularly, does not smoke cigarettes, and has an
"occasional beer on the weekends with buddies." His temperature is 38.8 C
(101.8 F), blood pressure is 120/80 mm Hg, pulse is 68/min, and respirations are
16/min. Scattered rhonchi are heard in the left lower lobe. A chest x-ray shows
diffuse interstitial infiltrates in the left lower lobe. A single dose of erythromycin
therapy is given in the clinic. The most appropriate next step in management is to
A. admit him to the hospital and begin administration of erythromycin,
intravenously
B. admit him to the hospital and begin administration of trimethoprimsulfamethoxazole, intravenously
C. admit him to the hospital for a cold agglutinin test
D. give him a prescription for erythromycin and send him home
E. recommend aspirin, fluids, and rest at home
Explanation:
The correct answer is D. This patient most likely has Mycoplasma pneumonia,
which is a common cause of pneumonia in young adults and is typically treated
with oral erythromycin as an outpatient. It is characterized by a dry cough,
headache, myalgia, malaise, and fever. Physical examination is usually
unremarkable except for diffuse rhonchi or fine rales. A chest x-ray shows
diffuse interstitial or reticulonodular infiltrates, typically in the lower lobes. Given
the patient's age, history, physical examination, and chest x-ray findings, it is
reasonable to assume that he has a community-acquired pneumonia. This is
most likely due to Mycoplasma pneumoniae and empiric antimicrobial therapy
with erythromycin should be prescribed. In these patients, a microbial diagnosis
(with a sputum culture, transtracheal aspiration, bronchoscopy, or a blood
culture) is often impractical and unnecessary. A cold agglutinin response is often
associated with Mycoplasma pneumoniae. However, it is nonspecific and
detected in less than 50% of cases.
Admitting him to the hospital and beginning administration of erythromycin,
intravenously (choice A) is incorrect because a patient with Mycoplasma
pneumonia, which is what this patient most likely has, is usually treated as an
outpatient. The criteria for hospitalization of patients with pneumonia are ages
>65, significant comorbidity, leukopenia, pneumonia due to Staphylococcus
aureus, Gram-negative bacilli or anaerobes, suppurative complications, failure
of outpatient management, inability to take oral medication, respirations
>30/min, heart rate >140/min, hypotension, hypoxia, or acute alteration of
mental status. The patient in this case does not meet any of these criteria.
Admitting him to the hospital and beginning administration of trimethoprimsulfamethoxazole intravenously (choice B) is the management for patients with
severe Pneumocystis carinii pneumonia (PCP), which is characterized by
shortness of breath, a dry cough, fever, night sweats, rales or rhonchi, and
bilateral patchy alveolar infiltrates. This is a common cause of pneumonia in
immunocompromised patients, especially those with HIV and AIDS. The patient
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in this case does not appear to be immunocompromised, and he is not short of
breath, which makes the diagnosis of PCP unlikely.
Admitting him to the hospital for a cold agglutinin test (choice C) is inappropriate
because even though this patient most likely has Mycoplasma pneumonia, it can
be treated with erythromycin as an outpatient, and a cold agglutinin test can be
performed as an outpatient. A cold agglutinin response is often associated with
Mycoplasma pneumoniae. However, it is nonspecific and detected in less than
50% of cases.
Recommending aspirin, fluids, and rest at home (choice E) is inappropriate
treatment for this patient who most likely has Mycoplasma pneumonia, which
needs to be treated with an antibiotic such as erythromycin.
A 53-year-old woman who is a heavy smoker presents to the emergency
department complaining of increasing shortness of breath for the past 3 days.
She denies any history of asthma or coronary artery disease. Her temperature is
37.3 C (99.2 F), blood pressure is 150/90 mm Hg, heart rate is 110/min, and
respiratory rate is 34/min. On examination, she is awake, alert, and oriented.
Diffuse bilateral wheezes are heard on lung auscultation. Pulse oximetry
measures 90% oxygen saturation on room air. An arterial blood gas is drawn and
the results show:
A chest radiograph demonstrates bilateral, hyperinflated lungs with a flattened
diaphragm. Sputum Gram stain shows a few polymorphonuclear cells, moderate
number of epithelial cells, and a moderate number of Gram-positive cocci. She
receives supplemental oxygen, albuterol nebulizer treatments, and steroids. Her
symptoms improve and pulse oximetry now reads 93% saturation. The most
appropriate next step is to
A. add antibiotics to the treatment regimen
B. do diffusion capacity testing by carbon monoxide
C. intubate and begin mechanical ventilation
D. obtain lung spirometry measurements
E. start non-invasive positive pressure ventilation
Explanation:
The correct answer is A. The patient is a smoker who presented with
progressive shortness of breath. Physical examination found diffuse wheezing
and chest X-ray noted emphysema. In addition, she had an elevated pCO2 with
acute respiratory acidosis and moderate hypoxia. These findings are consistent
with an exacerbation of chronic obstructive lung disease. Such flares are treated
with β2-agonists, anticholinergics, and steroids. In addition, antibiotics have also
been shown to improve clinical outcome, and so they are part of the treatment
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regimen for chronic obstructive lung disease flares.
Diffusion capacity (choice B) for this patient will likely be low given her
emphysema and is an important measurement for diagnosis, but it is not
required in the acute management of this condition.
The patient has a normal mental status and is able to protect her airway. Her
symptoms and oxygenation also improve with treatment. Thus, there is no
current indication for intubation (choice C). Intubation is required if the patient
has severe CO2 retention and/or hypoxia refractory to medical therapy.
Intubation is also indicated if her condition is refractory to non-invasive
ventilation, if she has severe acid-base disturbances, or if there is any change in
her mental status that would compromise the airway.
Lung spirometry (choice D) will aid in the diagnosis of her disease but is not
useful in management of her clinical course.
Non-invasive positive pressure ventilation (choice E) is indicated in patients with
severe chronic obstructive pulmonary disease that is refractory to medical
therapy. It is also useful in patients with increasing respiratory fatigue. A patient
must be able to initiate breathing and tolerate the breathing mask. This patient
has a normal mental status and her symptoms improve with treatment. Thus,
she currently does not require any assistance in ventilation.
A 68-year-old woman comes to the office for a health maintenance examination.
She has had 5-7 episodes of "expectorated blood" in the past month that she
describes as a "bit concerning." She denies any other symptoms. She has been
a patient of yours for 20 years and you have treated her for various "colds and
flus" in the past, but she does not have any chronic medical conditions. She is a
retired schoolteacher, gets regular exercise, and smokes a pack of cigarettes a
day. She and her husband have become "world travelers" since both of their
retirements. Her last mammogram, Pap smear, and colonoscopy were 1 year
ago, and were normal, as they have always been. Her temperature is 37.0 C
(98.6 F), blood pressure is 130/80 mm Hg, pulse is 65/min, and respirations are
16/min. Physical examination is unremarkable. The most appropriate next step is
to
A. obtain a sputum sample by transtracheal aspiration for cytology
B. order a chest x-ray
C. schedule fiberoptic bronchoscopy
D. schedule a high-resolution CT scan
E. reassure her that it is most likely nothing but to come back if she
continues to have "expectorated blood"
Explanation:
The correct answer is B. This patient comes in for a routine examination but tells
you something that could possibly be serious—that she has nonmassive (less
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than 100mL) hemoptysis ("expectorated blood"). Since she is a smoker and
travels very frequently, you should not ignore this symptom. Since it is likely that
the blood-streaked sputum is from the respiratory tract, a chest x-ray is the first
diagnostic procedure that should be ordered.
Obtaining a sputum sample (choice A) by transtracheal aspiration is not
indicated at this time because it is too invasive. Expectorated sputum should
first try to be obtained. Blood in the sputum may occur in cases of bronchitis,
pneumonia, bronchiectasis, a lung abscess, or an endobronchial tumor. Gram,
fungal, and acid-fast stains will help diagnose an infectious cause, while
cytology may be helpful to diagnose a tumor.
Fiberoptic bronchoscopy (choice C) is part of the evaluation of a patient with
hemoptysis, but it is typically performed after a chest x-ray. It is the next step if a
chest x-ray shows a mass, if the chest x-ray is normal and there are major risk
factors for cancer, or if the chest x-ray is normal and there are no risk factors for
cancer, but there is a recurrence of hemoptysis after weeks to months of
observation.
A high-resolution CT scan (choice D) is usually only indicated after a chest x-ray
is performed. If the chest x-ray shows a mass and a bronchoscopy fails to
suggest a specific diagnosis, a HRCT is ordered. Also, if a chest x-ray shows
parenchymal disease, a HRCT may be indicated for further evaluation.
It is inappropriate to reassure her that it is most likely nothing but to come back if
she continues to have blood-streaked sputum (choice E) because hemoptysis
can be the sign of serious disease, especially because she is a smoker and a
"world traveler." Even though she came to the office for a routine physical
examination, a chest x-ray should be ordered at this time. Keep in mind that a
chest x-ray is not part of a routine physical examination of an asymptomatic
smoker.
A 66-year-old woman with a history of small-cell carcinoma presents to the
emergency department with stridor and shortness of breath. She was diagnosed
with cancer 2 years ago and underwent a resection of her left upper lobe 1 year
ago. Six months ago, she presented with a recurrence of her tumor causing rightsided postobstructive pneumonia and bronchial constriction. She underwent
chemotherapy and radiation therapy at that time. Over the past week, she has
had an increasing cough and shortness of breath at rest and, in the last day,
stridor. The most important diagnostic test at this time is a
A. chest radiograph
B. CT scan of the chest
C. flexible bronchoscopy
D. pleural drainage
E. transtracheal biopsy
Explanation:
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The correct answer is B. This patient has a history of aggressive lung cancer
with recurrence that presented with bronchial obstruction. Her symptoms at
present, cough, shortness of breath, and stridor, suggest that again the patient
has a bronchial obstruction. Stridor is caused by the inflow of air across a
narrow obstruction in the airway. It signifies that some part of the trachea or
main stem bronchi are quite narrow and portends an airway disaster if the
disease process is allowed to progress. This patient requires a CT scan to
delineate the extent of her lung malignancy and to assess the extent of her
airway obstruction.
A chest radiograph (choice A) will offer no critical information for management of
this patient. The resolution of the image is such that it will allow visualization of
tumor recurrence and of any infiltration such as a pneumonia, but offers no
details of the airways or mediastinum; the structures likely to be involved in this
disease process.
A flexible bronchoscopy (choice C) is a tool that allows relatively easy
visualization of the airways. It is however not useful for defining the extent to
which an extrinsic mass impinges upon the airway. Flexible bronchoscopy is
often used to ensure that a tumor has not invaded the bronchial structure prior
to performing a lung resection of a patient with cancer of the lung.
Since there is no evidence as of yet, that there is a pleural effusion, pleural
drainage (choice D) is not indicated.
A transtracheal biopsy (choice E) is used as a minimally invasive method to
sample lung parenchyma when a diagnosis of a lung mass is needed. In this
case, the patient has a clear diagnosis so there is no need for a tissue sample.
A 2-year old boy is brought to the emergency department at 2:00 a.m. because
of episodic coughing "fits". He was well until one day earlier when he developed
rhinorrhea and a temperature of 38.3 C (101 F). He has no prior history of
respiratory illnesses, and no one else in the family is ill. On arrival to the hospital,
he is coughing in a rapid, "barking" fashion, but appears otherwise well. His
temperature is 38.2 C (100.8 F), heart rate is 120/min, respiratory rate is 50/min,
and oxygen saturation is 96% on room air with coughing. Physical examination
shows clear lungs, a normal cardiac and abdominal examination, and no rash.
He continues to have repeated, episodic coughing with inspiratory stridor at rest.
A frontal radiograph of the chest at this time is most likely to reveal
A. cardiomegaly with pulmonary venous congestion
B. left lower lobe infiltrate
C. pneumothorax
D. subglottic swelling
E. thumb-shaped epiglottis
Explanation:
The correct answer is D. This child's clinical picture is most consistent with
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infectious croup (laryngotracheobronchitis), commonly caused by parainfluenza
viruses. The prodrome of upper respiratory illness with fever followed by a
spasmodic, barking cough, is typical of this diagnosis. The classic sign on chest
x-ray is the subglottic swelling ( "steeple sign,"), which is the result of viralinduced swelling of the subglottic tissue. This swelling can cause an incomplete
airway obstruction, leading to stridor either at rest or during crying. Stridor at rest
is an indication for treatment with steroids to decrease inflammation.
Dyspnea in a child can be the result of congenital heart disease and resulting
congestive heart failure, manifested as cardiomegaly and pulmonary venous
congestion on x-ray (choice A), but given the absence of prior symptoms, the
normal oxygen saturation, and the lack of rales on lung examination, this is
unlikely.
Fever and cough in a child also raises the possibility of pneumonia as a
diagnosis. A lobar pneumonia (choice B) would be a surprising x-ray finding in
this case given the child's clear lung fields on examination and the presence of
stridor, which indicates upper airway involvement.
Pneumothorax (choice C) can be a cause of sudden dyspnea in a child,
especially in tall, male adolescents who may be predisposed to spontaneous
pneumothoraces. This child's prodrome and stridor on examination make this
diagnosis unlikely.
Prior to the introduction of the vaccine against Haemophilus influenzae type b,
epiglottitis was a common and much-feared diagnosis in pediatrics. Infection of
the epiglottis by this organism led to rapidly progressive airway obstruction and
potentially death. A lateral neck radiograph would demonstrate a thumb-shaped
epiglottis (choice E) in these cases. This sign is not seen on frontal views of the
chest.
A 29-year-old man is admitted to the hospital with fever and cough. The
symptoms began roughly 1-month prior and have been intermittent. He states
that his cough is often productive of thick secretions and that, despite normal
food intake, he has lost about 10 pounds in the past month. He is a volunteer at a
local hospital and has received no special health care personnel vaccinations or
screening tests. On examination, the patient appears somewhat thin, tired, and is
coughing intermittently. His temperature is 38.0 C (100.4 F) and respirations are
16/min. He has patchy bilateral rhonchi over all lung fields. Prior to initiating
therapy for this condition, the laboratory test required to confirm the suspected
diagnosis is a
A. chest radiograph
B. sputum acid-fast stain
C. sputum culture
D. sputum Gram stain
E. tuberculin skin test
Explanation:
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The correct answer is B. The patient likely has tuberculosis. Virtually all M.
tuberculosis is transmitted by airborne particles that are 1 to 5 µm in diameter.
The symptoms of tuberculosis are protean and nonspecific and can be classified
as either systemic or organ-specific. Classic systemic symptoms include fever,
night sweats, anorexia, weight loss, and weakness. However, since tuberculosis
is associated with other illnesses that have similar symptoms, this lack of
specificity can result in a delayed diagnosis or even a misdiagnosis. Organspecific symptoms of pulmonary tuberculosis include cough, pleuritic pain, and
hemoptysis. The requirement for diagnosis is the presence of the organism that
appears by acid-fast staining in a sputum sample.
In patients with primary tuberculosis, chest radiographs (choice A) often show
infiltrates in the middle or lower lung zones, with ipsilateral hilar adenopathy.
These findings are non-specific and are not used for confirmation of the
diagnosis.
A sputum culture (choice C) is not useful in this case since the organism
responsible for TB is fastidious and is difficult to culture, and certainly does not
grow rapidly.
The organism responsible for TB does not stain with traditional Gram stain dyes
(choice D) and therefore requires special staining such as acid-fast in order to
detect it.
Although it is imperfect, the gold standard for diagnosing latent tuberculosis
infection remains the intradermal injection (choice E) of purified protein
derivative (5 TU) into the volar or dorsal surface of the forearm (Mantoux
method). The test has no role in the diagnosis of active infection.
A 68-year-old man comes to the clinic because of progressive dyspnea on
exertion (DOE) and shortness of breath over the last 7 months. He denies chest
pain, orthopnea, or paroxysmal nocturnal dyspnea. His past medical history is
significant only for mild osteoarthritis and an episode of pneumonia 20 years ago.
His temperature is 37 C (98.6 F), blood pressure is 128/76 mm Hg, pulse is
98/min, respirations are 18/min, and oxygen saturation is 98%. His lungs are
clear to auscultation and his heart is slightly tachycardic with no murmurs, rubs,
or gallops. His abdomen is soft, nontender, with normal bowel sounds. His
extremities have no edema. Rectal examination shows brown guaiac-positive
stool. An electrocardiogram shows sinus tachycardia with a single PVC. Chest xray shows minimal scarring in the right lower lobe. Laboratory studies show a
hematocrit of 27%, hemoglobin of 9.1 g/dL, platelets of 298,000mm3 , MCV 78
mm3, sodium of 139 mEq/l, potassium of 4.1 mEq/l, blood urea nitrogen of 16
mg/dL, and creatinine 0.9 mg/dL. The most appropriate next step in the patient's
management is a
A. cardiac stress test to rule out 3 vessel coronary artery disease
B. colonoscopy to rule out colon cancer
C. high resolution CT scan (HRCT) to rule out pulmonary fibrosis
D. iron pills and follow up in 3 months
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E. ventilation-perfusion (V/Q) lung scan to rule out chronic pulmonary
emboli
Explanation:
The correct answer is B. It is important to remember that anemia can present
with dyspnea on exertion and a complete blood count should always be part of
this work up. This elderly patient has an iron deficiency anemia with hemoccult
positive stool. A GI malignancy needs to be ruled out and colon cancer is the
most likely etiology in this patient population. Therefore, a colonaoscopy is
imperative.
Although ischemic cardiomyopathy or silent ischemia can certainly present with
progressive dyspnea on exertion, there are other things in the patient's history to
suggest the cause of his symptoms. A cardiac workup (choice A) at this time is
not the most pressing issue.
HRCT (choice C) is a very good test to evaluate for pulmonary fibrosis. It is
likely that the CXR would show more abnormalities. The minimal scarring
mentioned at the right lower lobe is likely from his prior pneumonia mentioned in
the past medical history, and is not causing the patient any symptoms.
The patient is presenting with a microcytic anemia. The most likely cause is iron
deficiency. However, it must always be remembered that the finding of a
microcytic anemia should always prompt the immediate search for an underlying
cause. So although the patient will likely require iron supplementation (choice
D), follow up in 3 months with no other diagnostic test is not appropriate.
A V/Q scan (choice E) can rule out chronic pulmonary emboli, which is certainly
a cause of progressive DOE, but as mentioned previously, there are other things
in the patient's history to suggest the cause of his symptoms.
A 49-year-old woman comes to the office because of difficulty breathing, fevers
reaching 40 C (104 F), and a productive cough with blood tinged sputum. She
was recently diagnosed with ductal carcinoma of the breast and underwent a
radical mastectomy with four rounds of adjuvant chemotherapy with vinblastine
and doxorubicin. Her last infusion of chemotherapy was 5 days ago. A chest
radiograph shows focal infiltrates in both lungs. Laboratory studies show:
You admit her to the hospital and start her on vancomycin and ceftazidime. Over
the next 3 days, her clinical status continues to worsen. Blood cultures are
negative. A bronchoscopy is performed and biopsy samples are obtained. The
biopsy specimen shows septated, branching hyphae that are locally invading
tissue. The most appropriate pharmacotherapy at this time is
A. amphotericin B, intravenously
B. fluconazole, intravenously
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C. fluconazole, orally
D. itraconazole, intravenously
E. rifampin plus isoniazid, orally
Explanation:
The correct answer is A. This is a case of pulmonary aspergillosis in a
neutropenic patient after she underwent chemotherapy. The treatment of choice
in neutropenic or immunosuppressed patients is amphotericin B intravenously.
Fluconazole (choices B and C) and itraconazole (choice D) are antifungal
agents that have limited activity or no activity against aspergillus infections.
Also, she should get intravenous therapy at this time.
Rifampin plus isoniazid (choice E) is a combination used to treat mycobacterial
infections.
A 52-year-old woman is admitted to the hospital with shortness of breath, a
productive cough with "yellowish sputum," fevers, and chills. She has a medical
history significant for non-insulin dependent diabetes and depression for which
she takes glyburide and sertraline. She has an allergy to penicillin, to which she
gets severe hives. Her temperature is 38 C (100.4 F), blood pressure is 123/67
mmHg, pulse is 102/min, and respirations are 25/min. Her oxygen saturation on
room air is 96%. Physical examination shows decreased breath sounds over the
lower right lung field with dullness to percussion. A chest radiograph shows
consolidation in her right lower lobe. The most appropriate next step is to
A. obtain a sputum sample for Gram stain and culture
B. obtain a surgery consult for an open lung biopsy
C. order a CT scan of the chest
D. order a ventilation-perfusion scan
E. send her for bronchoalveolar lavage
Explanation:
The correct answer is A. By history, exam, and chest radiography, this patient
has pneumonia. In someone with a pneumonic process, it is advisable to send
sputum for Gram stain and culture prior to the initiation of antibiotics in order to
ensure that the choice of antibiotic agent will be appropriate. Empiric antibiotics
are often started anyway, but it is good to know if the organism that is present is
covered by the chosen antibiotic.
An open lung biopsy (choice B) is not used in the routine diagnosis of a lobar
pneumonia. It is instead used in the diagnosis of more complex pulmonary
pathologies such as the idiopathic interstitial pneumonias that are not amenable
to diagnosis using routine methods.
A chest CT (choice C) will not add any additional information at this juncture
since a chest radiograph is sufficient to confirm the presence of pneumonia in
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this patient.
A ventilation-perfusion scan (choice D) is used to diagnose the presence of a
pulmonary embolus, which is not a part of the differential diagnosis with this
patient. This type of scan is often uninterpretable in the setting of a lobar
pneumonia.
A bronchoalveolar lavage (choice E) is not used in the diagnosis of a lobar
pneumonia associated with a productive cough.
A 59-year-old man with diabetes mellitus is admitted to the hospital because of a
4-day history of a cough with yellowish-brown sputum, fever, and chills. He tells
you that he is allergic to penicillin, to which he gets severe urticaria. He reports a
positive sick contact with a friend who was recently admitted with pneumonia. His
temperature is 39 C (102.2 F), blood pressure is 123/67 mm Hg, pulse is
107/min, and respirations are 25/min. His room air oxygen saturation is 96%.
Physical examination shows decreased breath sounds over his left lower lung
field associated with dullness to percussion. A chest radiograph shows
consolidation of the left lower lobe. A sputum Gram stain and culture shows
Gram-positive cocci sensitive to cephalosporins and quinolones. A suitable
treatment regimen given this data is to start the patient on
A. ampicillin-sulbactam, intravenously
B. cefuroxime, intravenously, if a penicillin skin test is negative
C. cefuroxime, intravenously, if a penicillin skin test is positive
D. gentamicin, intravenously
E. vancomycin, orally
Explanation:
The correct answer is B. It is known that patients who are allergic to penicillins
have a higher rate of allergy to cephalosporins. While the true rate of
cephalosporin allergy under these circumstances is controversial, most
authorities believe it is about 7-8%. However, it has been established that if a
patient with a penicillin allergy has a negative penicillin skin test, he/she is at no
increased risk of an allergy to a cephalosporin.
Starting the patient on a regimen of intravenous ampicillin-sulbactam (choice A)
is not appropriate given the patient's history of allergy to penicillin.
Starting the patient on intravenous cefuroxime if a penicillin skin test is positive
(choice C) is inappropriate since a positive skin test to penicillin indicates an
elevated risk of a coexistent allergy to cephalosporins. Under these conditions,
based upon the available data, a quinolone agent would be reasonable.
Starting the patient on intravenous gentamicin (choice D) is not appropriate
since the laboratory data specifies an organism sensitive to cephalosporins.
Starting the patient on oral vancomycin (choice E) is inappropriate since oral
vancomycin has poor systemic absorption and as a rule, it is also best to avoid
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broad- spectrum antibiotics if a more specific agent (such as a cephalosporin
with this patient) is available.
A 24-year-old woman comes to the office because of a cough with "yellowish
sputum production" for the past 2 days. She states that the cough has been
keeping her up at night and it is bothering her co-workers. They insisted that she
"go get medicine" so that she does not "infect the entire office." She has no
history of respiratory disease. Her temperature is 37 C (98.6 F), blood pressure is
110/80 mm Hg, pulse is 70/min, and respirations are 18/min. Physical
examination is normal. The most appropriate next step in management is to
A. admit her to the hospital for medical management
B. obtain a sputum culture
C. order a chest x-ray
D. prescribe erythromycin, orally
E. send her home with no medications
Explanation:
The correct answer is E. This patient most likely has acute bronchitis. Acute
bronchitis in a healthy patient with no other medical conditions is often due to
viral infection that is usually self-limited. Given that this patient has only had 2
days of symptoms, an antibiotic is not necessary and is inappropriate. If the
symptoms persist for longer than 1 week, a macrolide antibiotic may be given. A
chest x-ray and a sputum culture are not indicated.
Admission to the hospital for medical management (choice A) is inappropriate
for a healthy patient with acute bronchitis.
A sputum culture (choice B) is used to identify organisms, but should only be
used in an elderly patients with chronic disease that fail antibiotic therapy. This
patient's acute bronchitis is most likely due to a self-limited viral infection.
A chest x-ray (choice C) has no role in the diagnosis of acute bronchitis in a
healthy patient.
Send the patient home with antibiotic therapy (choice D) is appropriate
management for acute bronchitis in an elderly patient with chronic disease. A
macrolide (erythromycin, azithromycin, clarithromycin) is the treatment of
choice. It is not part of the initial treatment in a previously healthy patient.
A 102-year-old man is brought to the clinic from his apartment by a neighbor
because of a cough productive of green sputum. He has a past medical history of
a stroke 10 years ago with residual left arm weakness. The patient is widowed
and lives alone. He takes no medications. Vital signs are: temperature 38.8 C
(101.8 F), blood pressure 100/50 mm Hg, pulse 110/min. On physical
examination, the patient has rhonchi in the right lower lung field. A chest x-ray
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reveals an infiltrate in the right lower and middle lobes. The patient has a score of
30/30 on a mini mental status examination. The patient states that he has "lived a
good life and now wants to go home". He refuses any intravenous medications
and will only take pills. After discussing that the pneumonia could potentially be
fatal without intravenous antibiotic treatment, the patient continues to ask to be
sent home. The neighbor insists that the patient should be admitted to the
hospital. The next step in the care of this patient is to
A. admit the patient to hospital care with intravenous antibiotics
B. admit the patient to hospital care without intravenous antibiotics
C. admit the patient to psychiatric ward with antibiotics
D. discharge the patient home with oral antibiotics
E. discuss the case with the hospital attorney
F. initiate antidepressant therapy and administer intravenous antibiotics
Explanation:
The correct answer is D. The principle of individual autonomy is central to
medicine. The only exceptions are if the patient has no clearly expressed wishes
documented and is unable to make a decision or if the patient is deemed
incompetent to make a decision. This patient is clearly competent to refuse
treatment despite the wishes of his physician or neighbor. It is important to make
the consequences of his decision clear to the patient before discharge and to
tell him that he should return immediately should he change his mind.
Hospital care with or without intravenous antibiotics (choices A and B) is
inappropriate as this patient is refusing hospital care.
This patient is clearly competent to refuse treatment, so he should not be
admitted to the psychiatry ward (choice C) or given antidepressant therapy
(choice F).
Consultation with an attorney (choice E) is not necessary as the patient is
clearly competent to refuse medical care.
You are called to see a 67-year-old woman with severe COPD who was intubated on the
medicine floor 30 minutes earlier because of respiratory distress. Her temperature is 37.0 C
(98.6 F), blood pressure is 90/60 mm Hg, pulse is 133/min and regular, and respiratory rate
is 24/min. Her ABG reveals the following: pH 7.21, PaCO2 80 mm Hg, PaO2 69 mm Hg, and
her oxygen saturation is 91%. Her current ventilator settings are assist control (AC),
respiratory rate (RR) of 12/min, tidal volume (TV) of 500 ml, fraction of inspired oxygen
(FiO2) is 50%, positive end expiratory pressures (PEEP) of 5 mm/Hg. The most appropriate
intervention at this time is to
A. decrease set respiratory rate
B. increase the fraction of inspired oxygen
C. increase PEEP
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D. increase tidal volume
E. make no adjustments at this time
Explanation:
The correct answer is D. The key to this question is to recognize that this patient remains
acidotic and hypercarbic despite intubation. In order to "blow off" more carbon dioxide and
normalize the blood pH, you must increase minute ventilation (MV). If you remember that
MV=TV X RR, you can quickly recognize that the two ways to decrease carbon dioxide is to
increase the RR or increase the TV.
Decreasing RR (choice A) will increase carbon dioxide because we are decreasing minute
ventilation as described above. This will result in worsening acidosis. In addition, our set
respiratory rate is lower than the patient's actual rate. If we decreased the respiratory rate,
our patient would continue to breathe at a high rate and receive the same tidal volume
(thereby not even changing the MV).
Increasing FiO2 (choice B) will not be beneficial. First, the patient already has a paO2 of
greater than 60 mm Hg. If you remember the hemoglobin binding curve, you should
remember oxygen saturations remain above 90% for paO2>60 mm Hg. Therefore, our goal
is to keep paO2>60 mm Hg for most patients. Second, maintaining patients on greater than
60% oxygen may have some associated lung toxicity. Therefore, if possible, keeping the
inspired oxygen less than 60% is an important part of management. Of course, if high levels
of inspired oxygen are necessary, you should not hesitate to use them. Please remember
that patients on ventilators need not (and should not) have oxygen saturations of 100% or
paO2 much greater than 60 mm Hg.
PEEP (choice C) is the use of positive airway pressures at the end of expiration. PEEP is
useful in hypoxic respiratory failure such as ARDS or cardiogenic pulmonary edema. Low
levels of PEEP can be used in COPD to keep airways open. Our patient's oxygenation is
acceptable so increasing PEEP would not be beneficial now. In addition, our patients blood
pressure is only borderline acceptable. Increasing PEEP will decrease venous return to the
heart and might lead to further reductions in blood pressures. High levels of PEEP might
also predispose patients to barotrauma which is a form of ventilator induced lung damage.
Making no adjustments (choice E) is not acceptable. This patient is severely acidotic and
hypercarbic and should not be left in this state.
A 71-year-old retired clerk comes to the clinic because of hoarseness. He says
that he had a “chest cold” 4 weeks ago with congestion and a sore throat. He
attributed the hoarseness of his voice to the cold, but has been worried for the
last 2 weeks because the hoarseness has been persistent. He is a diabetic
taking insulin twice a day. He smokes 1-2 packs of cigarettes a day and stopped
drinking alcohol about 2 years ago. His only other medication is an aspirin a day.
He has had no prior surgeries and no other medical problems. Laryngoscopy
performed in the office demonstrates paralysis of the left vocal cord but no
evidence of masses or inflammation in the larynx. The most likely etiology of this
patient's vocal cord paralysis is
A. diabetic neuropathy
B. laryngeal carcinoma
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C. lung carcinoma
D. pneumonia
E. stroke
Explanation:
The correct answer is C. Hoarseness of the voice is a symptom of vocal cord
paralysis. Vocal cord paralysis is a result of injury to the ipsilateral recurrent
laryngeal nerve, which is a branch of the vagus nerve supplying all the intrinsic
muscles of the larynx. Unilateral vocal cord paralysis is much more common
than bilateral disease by a factor of 3 to 1 and the left side is more commonly
affected than the right side due to the longer course of the left recurrent
laryngeal nerve. The most common cause of unilateral vocal cord paralysis is
lung cancer. This patient's history of smoking puts him at high risk for
developing lung cancer.
Laryngeal carcinoma (choice A) can also present very early with symptoms of
hoarseness. The most common laryngeal cancer is a glottic tumor arising from
the true vocal cords. 90% of these tumors are squamous cell carcinomas. This
is not a likely cause of this patient's hoarseness because the laryngoscopy did
not demonstrate a laryngeal mass or lesion. Laryngoscopy very readily detects
lesions and is a good means for obtaining biopsies for further cytologic studies.
Diabetic neuropathy (choice B) is not the cause of this patient's symptoms. Most
diabetics over time will develop some neurologic involvement due to peripheral
vascular disease. Classic signs and symptoms of diabetic neuropathy include
numbness and loss of sensation in the distal extremities, particularly in the feet.
Diabetic neuropathy is not known to cause damage to the recurrent laryngeal
nerve and is thus not a cause of vocal cord paralysis.
Pneumonia (choice D) is not a cause of vocal cord paralysis. Primary lung
cancers that occur in the lung apices are the most common cause of injury to
the recurrent laryngeal nerve and thus vocal cord paralysis. Pneumonia is an
infectious process that does not cause mass effect or damage to the nerve.
Stroke (choice E) can be a cause of vocal cord paralysis when an infarct occurs
in the nucleus ambiguus of the medulla. The nucleus ambiguus is the origin of
the vagus nerve in the brain. However, if a stroke were to occur in the medulla,
there would be many more deficits than a focal vocal cord injury. This patient is
presenting with isolated unilateral vocal cord paralysis which means the injury
occurred somewhere after the left recurrent laryngeal nerve branched off the
vagus nerve.
A 69-year-old woman is brought to the emergency department by ambulance
after calling 911 because of severe shortness of breath. By the time the
ambulance arrived, the patient was having pronounced difficulty breathing. She
was placed on 100% oxygen and was brought to the emergency department. Her
medical-alert bracelet disclosed that she is allergic to penicillins and that she has
COPD. Her temperature is 37.0 C (98.6 F), blood pressure is 190/85 mm Hg,
pulse is 112/min, respirations are 34/min, and oxygen saturation on 100%
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oxygen is 82%. She appears to be in moderate to severe respiratory distress.
The decision is made to intubate the patient. The most appropriate management
of this patient after intubation is to
A. allow the patient to breath spontaneously
B. deliver rapid, shallow breaths to increase oxygen delivery
C. deliver slow breaths with 6-10cc/kg tidal volumes
D. deliver slow breaths with 15-20cc/kg tidal volumes
Explanation:
The correct answer is C. This patient has severe COPD and is suffering from a
COPD flare. She is in severe respiratory distress, hypoxic, and almost certainly
hypercarbic. Once her airway is secured, 100% oxygen should be delivered via
slow breaths (8-12 per minute) with smaller tidal volumes than most patients
would receive. Larger tidal volumes are associated with a risk of volu-trauma
such as bursting of a bleb or bulla. Slow breaths minimize the risk of air trapping
and so called "intrinsic-PEEP" or "auto-PEEP."
Allowing the patient to breathe spontaneously (choice A) is inappropriate. She
was unable to ventilate and oxygenate well prior to insertion of the endotracheal
tube. Now, with it present, and the increased resistance to breathing it confers,
there is minimal chance that her success with ventilation would be any greater.
Using rapid, shallow breaths to increase oxygen delivery (choice B) will almost
certainly be harmful. These patients require prolonged expiratory time to exhale
completely. Each rapid breath essentially "stacks" on top of an unfinished
exhalation and therefore augments the end expiratory volume (therefore
pressure) in the lungs. This is known as auto-PEEP and can become so severe
that it impedes venous return to the heart and precipitates in circulatory
collapse.
As discussed above, slow breaths with 15-20cc/kg tidal volumes (choice D) are
associated with a significant risk of volu-trauma in these patients so traditional
tidal volumes are not to be used.
S3 RESP
S3 RESP
95