(Test Bank) PAeasy Pulmonary Questions and answers, Test bank, 2022. Rated A+

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Test Bank for PAeasy Pulmonary Questions and answers, Test bank, 2022. Rated A+, The downloadable file consists of 166 pages, and the total size of the file is 0.95 MB. Purchase now only for highly discounted price.

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PAeasy Pulmonary Questions and answers, Test ba nk, 2022. Rated A+ A 30 -year -old female presents with a five day history of a sore throat. She denies cough or nasal congestion. She also denies vomiting or diarrhea. On physical exam, her temperature is 101˚ F, the pharynx is red with tonsillar exudates, and she has tender anterior cervical lymphadenopathy. What is your next step? A Perform culture and sensitivity B Perform rapid strep C Treat symptomatically with antipyretics D Begin oral penicillin E Beg in oral ciprofloxacin - ✔✔Begin Oral PCN The centor criteria include fever, tonsillar exudates, tender anterior lymphadenopathy and lack of cough. These signs and symptoms highly suggest group A beta hemolytic strep. Treatment with penicillin would be the most appropriate step, especially if cost is a concern to the patient. Penicillin v potassium, 250 mg three times per day, or 500 mg twice daily for 10 days, is highly effective. Some studies show a five-day regime to be as effective. A 43 year -old woman is brought to the emergency department in critical care secondary to a traumatic brain injury. Which of the following best describes her Cheyne -Stokes respiratory pattern? A Alternating periods of shallow and deep breathing B Difficu lt or labored breathing C Difficult of labored breathing while supine D Periods of absent breathing E Sudden awakening due to shortness of breath - ✔✔A Cheyne -Stokes respirations are characterized by shallow breaths that increase in rate and depth follo wed by periods of apnea (A). Dyspnea is difficult or labored breathing (B) and if it occurs while supine (C) is termed orthopnea. Apnea is noted periods of absent breathing (D). Sudden awakening due to shortness of breath (E) is paroxysmal nocturnal dyspne a. A 48 year -old male presents to the clinic with a history of productive cough for the past 3 days. Which of the following factors if present best predicts the diagnosis of pneumonia in this patient? A Adenopathy B Double sickening C Dyspnea D Fever E Hoarseness - ✔✔Fever Cough, fever (D) and sputum production are classic symptoms of pneumonia. Adenopathy (A) and hoarseness (E) may coexist in some cases of viral pneumonia. Dyspnea (C) may develop as pneumonia progresses. Double sickening (B) is a cl inical consideration in the differentiation of acute sinusitis from upper respiratory infection that typically occurs after approximately 7 days of illness. A 22 year -old male presents with a 2 -week history of an upper respiratory infection that hasn't improved after taking amoxicillin for 6 days. He notes persistent sore throat, intermittent fever, and a worsening nonproductive cough. Physical examination reveals bilateral diffuse crackles. What is the most likely causative agent of this patient's symptom s? A Streptococcal pneumoniae B Klebsiella pneumoniae C Mycoplasma pneumoniae D Pneumocystis jiroveci E Staphlococcal aureus - ✔✔Mycoplasma pneumoniae C The patient presentation is consistent with atypical pneumonia most commonly caused by viruses, mycoplasma pneumonia (C), chlamydia pneumonia, or legionella. The presentation of streptococcal pneumoniae (A) is more acute with productive cough and fever being early symptoms. Klebsiella pneumoniae (B) also presents with fever and a cough classically not ed to be productive of "currant jelly" sputum. Pneumocystis jiroveci (D) causes pneumonia of insidious onset in immunocompromised patients. Staphlococcal (E) pneumonia also presents more acutely with productive cough. A 22 year -old male presents with a 2 -week history of an upper respiratory infection that hasn't improved after taking amoxicillin for 6 days. He notes persistent sore throat, intermittent fever, and a worsening nonproductive cough. Physical examination reveals bilateral diffuse crackles. What is the most appropriate antibiotic to initiate after discontinuing the amoxicillin? A Amoxicilin and clavulanic Acid B Azithromycin C Cephalexin D Ciprofloxacin E Trimethoprim/Sulfamethoxazole - ✔✔Azithromycin B The patient most likely has atypical pneumonia that responds best to macrolide antibiotics (B). Antibiotics that inhibit cell wall synthesis (A, C) are generally ineffective against these atypical organisms that are either intracellular or lack a cell wa ll. A 76 year -old woman with steroid dependent chronic obstructive pulmonary disease is hospitalized with fever, chills, and a productive cough. The sputum gram stain shows many WBCs and small, pleomorphic gram -negative rods. Which of the following is the most likely causative agent? A Chlamydia pneumoniae B Haemophilus influenzae C Mycoplasma pneumoniae D Staph aureus E Strep pneumoniae - ✔✔Haemophilus influenzae Haemophilus influenzae (B) is a gram -negative pleomorphic coccobacillus. Strep pneumon ia (E) and Staph aureus (D) are gram positive organisms. Mycoplasma pneumonia (C) and Chlamydia pneumoniae (A) aren't visible on gram stain. A 23 year -old male with cystic fibrosis inquires about the availability of treatments that can help improve his lu ng function. Which of the following treatments is most effective at reversing the pulmonary effects of cystic fibrosis? A Albuterol B Azithromycin C Inhaled hypertonic saline D Inhaled levofloxacin E Ivacaftor - ✔✔Ivacaftor Ivacaftor (E) is the only treatment that restores function of the CFTR protein in cystic fibrosis patients with a G551D mutation thereby reversing the effects of the disease, approximately 5% of all cystic fibrosis patients have the G551D mutation. Albuterol (A) and hypertonic sal ine (C) are indicated to improve lung function and mucous clearance. Azithromycin (B) and inhaled levofloxacin (D) are used to treat chronic infection/colonization with pseudomonous. A 23 -year -old male presents to the clinic complaining of left anterior n eck pain that developed over the past week following recovery from an acute upper respiratory infection. On physical exam a tender mass is felt anterior to the left sternocleidomastoid muscle from the mandible inferiorly to the level of the cricoid cartila ge. Which of the following is the most likely diagnosis? A Branchial cleft cyst B Dermoid cyst C Peritonsillar abcess D Salivary gland tumor E Thryoglossal duct cyst - ✔✔Branchial cleft cyst The development of a neck mass in a young adult following URI is consistent with branchial cleft cyst (A) and thyroglossal duct cyst (E). The location of this mass away from the midline and anterior to the SCM is most consistent with branchial cleft cyst ( A). The location of the mass and history are inconsistent with dermoid cysts (B), which are typically midline, peritonsillar abcesses (C), which would be located in the retropharyngeal space, and salivary gland tumors (D), which would be located in the par otid, submandibular, or submental salivary regions. A 26 year -old man presents to the clinic after developing a severe productive cough, fever, chills, night sweats and weight loss. Which is the most definitive diagnostic test for determining the presence of Mycobacterium tuberculosis as the causative agent of his active pulmonary tuberculosis and yields results in less than 24 hours? A Acid -fast bacilli smear of sputum B Blood culture C Mycobacterial culture of sputum D Nucleic acid amplification of sputum E Tuberculin skin test - ✔✔Nucleic acid amplification of sputum The most definitive diagnostic tests for confirmation of tuberculosis are mycobacterial culture (C) which requires at least 2 weeks to grow mycobacterium, and nucleic acid amplificati on (D) of a respiratory specimen that can be completed in a matter of hours. AFB smear (A) has a sensitivity of only 40 -60%, but positive results help establish a presumptive diagnosis. Tuberculin skin testing (D) is effective in screening patients for lat ent TB. Routine blood cultures (B) are ineffective in diagnosing TB. A 2-year -old male presents with a 10 -day history of fever, cough, and decreased appetite and fluid intake. He is normally healthy. On examination, the child appears ill, has a temperatur e of 102.2 0 F, a pulse rate of 122, and a respiratory rate of 36. On auscultation of the lungs there are rhonchi heard on the right lung fields, as well as a small amount of wheeze. A chest x -ray is ordered, which reveals the presence of pneumatoceles. Ba sed on these findings, what is the most likely pathogen causing this patient's infection? A Streptococcus pneumoniae B Hemophilus influenza C Staphylococcal aureus D Pseudomonas aeurginosa E Chlamydia pneumoniae - ✔✔Staph Aureus Pneumatoceles, pyopne umothorax, and empyemas are frequently encountered in pediatric Staphylococcal aureus pneumonias. A 1-year -old female is having a 2 -day history of fever (102 0 F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daugh ter has been less active, and her fluid intake has decreased for her age. On exam, the child is non -toxic appearing, has a rectal temperature of 100.2 0 F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minima l wheeze heard bilaterally. Her chest x -ray has no specific findings. Based on these findings, what is the initial ancillary test to confirm the diagnosis? A Acid fast bath test B Viral nasal washings C Sputum culture and sensitivity D Blood cultures E Throat culture - ✔✔Viral Nasal Washings B Viral nasal washings are the best choice for determining RSV infection that causes bronchiolitis. Sputum and blood cultures do not grow the agents that would typically cause the infection to occur, and you are obtaining a sample from a different part of the respiratory tract and blood. A 15 -year -old male presents complaining of a sore throat, headache, and mild cough that started 8 days ago and has progressed to include a worsening cough and increasing fatigue. His chest x -ray reveals bilateral hilar inf iltrates and a CBC is normal. Which of the following diagnostic tests will most likely confirm the suspected diagnosis? A Acid -fast bacilli smear and culture B Blood culture C PCR testing of sputum D Sputum culture E Sputum gram stain - ✔✔PCR Testing of the sputum The patient most likely has atypical pneumonia secondary to mycoplasma pneumoniae which is best confirmed by PCR testing of sputum (C), oropharyngeal or nasal secretions and isn't detected through standard cultures (B, D) or staining techniq ues (A, E). A 1-year -old female is having a 2 -day history of fever (102 0 F oral), rhinorrhea, and dry cough, with a decreased appetite. The mother states that her daughter has been less active, and her fluid intake has decreased for her age. On exam, the child is non -toxic appearing, has a rectal temperature of 100.2 0 F, and has nasal flaring and a respiratory rate of 45, rhinorrhea, moist mucous membranes, and a minimal wheeze heard bilaterally. Her chest x -ray has no specific findings. What is the init ial treatment of choice for this patient with these symptoms? A Antibiotics B Oxygen therapy C Supportive care D Antiviral medications E Plasmaphoresis - ✔✔Supportive care The choice for treatment of acute bronchiolitis is supportive care. Oxygen the rapy is only reserved for those patients who are hypoxic, and antiviral medications have not proven to be effective in shortening or eradicating the infection. A 17 year -old male notes acute onset of dyspnea, excessive non -productive coughing, "wheezing" and upper chest tightness when running. Symptoms usually resolve in a few minutes and he is able to resume running. He is prescribed albuterol with no improvement. Which of the following is the most likely diagnosis in the patient? A Angioedema B Bronch iectasis C Cystic fibrosis D GERD E Vocal Cord Dysfunction - ✔✔Vocal Cord Dysfunction E Vocal cord dysfunction (E) is commonly misdiagnosed as asthma or is a comorbidity in patients with asthma. The history of acute onset and rapid disappearance of symp toms is consistent with vocal cord dysfunction, and not typical of cystic fibrosis (C), or GERD (D). The presence of urticarial or swelling of the face or lips would support the life -threatening diagnosis of angioedema (A). Bronchiectasis (B) typically pre sents with a chronic productive cough and additional pulmonary symptoms based on the underlying cause and severity. A 78 -year -old male presents to the office due to increasing exertional dyspnea and cough for the past week. Physical exam reveals an S3 gallop, mild JVD, and 2+ pitting edema of the bilateral lower extremities. The patient has had mild congestive heart fai lure in the past. A chest x -ray reveals prominent pulmonary vasculature without any additional complications. The patient's current medications are aspirin and simvastatin daily. He has no drug allergies. Which of the following is the most appropriate init ial management for this patient? A Angiotensin II receptor blocker B β blocker C Calcium channel blocker D Nitrate E Thiazide diuretic plus ACE inhibitor - ✔✔Thiazide diuretic plus ACE -I ACE inhibitors are recommended, as first line treatment for sym ptomatic congestive heart failure, based upon clinical trials, reveal an approximately 20% reduction in CHF mortality in symptomatic heart failure patients. Diuretics provide CHF symptom improvement and promote water and sodium excretion to decrease intrav ascular volume. blockers and Angiotensin II receptor blockers are also beneficial for CHF patients. Nitrates are usually reserved for acute or decompensating patients. Calcium channel blockers may accelerate CHF progression and should be used with caution. A premature infant is born with the inability to produce adequate amounts of pulmonary surfactant. Which of the following is the primary function of pulmonary surfactant? A increase the solubility of carbon dioxide in the alveoli B increase the solubi lity of oxygen in the alveoli C prevent infectious organisms from infiltrating the alveoli D prevent the collapse of small lung alveoli E stimulate the unloading of carbon dioxide from hemoglobin - ✔✔Prevent the collapse of lung alveoli Because of their small size, many lung alveoli are prone to collapse. Pulmonary surfactant contains a high concentration of amphipathic phospholipid molecules, which lowers the surface tension of alveoli. According to the law of Laplace, a reduction of surface tension red uces the collapsing pressure on small alveoli and allows them to remain open. Pulmonary surfactant production does not typically begin until the 24th week of gestation; hence, an infant born before this time is at great risk for having collapsed alveoli. A 42 year -old woman presents complaining of shortness of breath, three days of fever as high as 103F, and has a cough productive of green sputum. On physical examination, you hear crackles in her lungs. A chest radiograph reveals a consolidation in the lef t lower lobe. What do you expect to hear when you percuss this patient's left lower thorax? A Dull B Flat C Hyperresonant D Resonant E Tympanic - ✔✔Dullness Consolidation leads to dullness (A) to percussion. Flat sounds (B) are noted with organ percu ssion (i.e., hepatic flatness), hyperresonant (C) sounds are noted in pneumothorax, normal lung parenchyma results in resonance (D), and percussion of the gastric air bubble leads to tympanic sounds. A 28 -week -premature infant is noted to have increasing tachypnea and difficulty breathing, with diffusely decreased breath sounds on exam shortly after delivery. A chest x -ray reveals diffuse, bilateral atelectasis and air bronchograms. Which of the following is the most likely diagnosis? A Acute asthma exacerbation B Hyaline membrane disease C Meconium aspiration D Pleural effusion E Spontaneous pneumothorax - ✔✔Hyaline membrane disease Premature infants, due to a lack of surfactant, develop marked atelectasis and decreased lung compli ance, with acute respiratory distress. This is termed hyaline membrane disease and is the most common cause of respiratory distress in preterm infants. Meconium aspiration is more likely in full -term or near -term infants who experience fetal distress, and the x -ray may demonstrate hyperexpansion and irregular infiltrates. Spontaneous pneumothorax can occur at birth. Exam findings will include decreased breath sounds on the affected side, and x -ray findings should indicate the pneumothorax or pneumomediastin um. Pleural effusion may be present in hydropic infants, or it may be due to an underlying disorder or chylothorax. The x -ray would reveal opacity of the affected side, with blunting of the costophrenic recess. Asthma exacerbation should involve airway hyp erresponsiveness in relation to a trigger exposure, and would demonstrate bilateral hyperinflation with diaphragm flattening on x -ray. A 56 year -old woman develops a fever of 102.1 F on her first post -operative surgery day following cholecystectomy. Which of the following is the most likely diagnosis? A Atelectasis B Catheter -related phlebitis C Drug reaction D Urinary tract infection E Wound infection - ✔✔Atelectasis Post -operative fever that occurs in the first 24 hours is most likely caused by ate lectasis (A). Catheter - related phlebitis (B), drug reactions (C) and urinary tract infection (D) typically present between post - operative days 2 and 4, while wound infection (E) typically presents on or after post -operative day 5. A 4 year -old girl presen ts to the clinic due to severe allergic rhinitis and recurrent asthma exacerbations. Which of the following leukotriene pathway inhibitors is indicated for use in this child? A Beclomethasone B Montelukast C Salmeterol D Zafirlukast E Zileuton - ✔✔Montelukast Montelukast (B) is indicated for use in children 1 year of age or older, zafirlukast (D) is indicated for children > 5 years of age, and zileuton (E) is indicated for children > 12 years of age. Beclomethasone (A) is an inhaled corticosteroid and salmeterol (C) is an inhaled long -acting beta -2 agonist. A couple presents to the office seeking genetic counseling advice regarding their child's potential risk of being born with Cystic Fibrosis. Both parents are identified as carriers for the cystic f ibrosis gene mutation. Which of the following genetic inheritance patterns should be used to predict the probability of their child being affected by Cystic Fibrosis? A Autosomal dominant B Autosomal recessive C Mitochondrial inherited D X-linked dominant E X-linked recessive - ✔✔Autosomal recessive Cystic fibrosis has an autosomal recessive (B) genetic inheritance pattern. In this case their children have a 25% chance of being affected, 50% chance of being a carrier, and 25% chance of lacking inheritance of the genetic trait. A neonate presents with meconium ileus that is successfully unobstructed. The infant returns at her 4 - month appointment with signs of failure to thrive. Which of the following is the most likely diagnosis for this patient? A cystic fibrosis B Wilson disease C intussusception D volvulus - ✔✔cystic fibrosis Cystic fibrosis (CF) is a major cause of gastrointestinal and pulmonary morbidity in children due to mutations in the CF genes. The mutations lead to a defic iency in cystic fibrosis transmembrane conductance regulator protein that controls movement of salt and water into and out of epithelial cells and results in production of abnormally thick mucus. About 15% of patients with CF present with meconium ileus at birth. This is typically treated with enema for disimpaction and rarely surgery. Approximately half of the infants with CF will present with failure to thrive, which is diagnosed by lack of growth for 2 consecutive months in patients younger than 6 months of age. They may also present with respiratory compromise. However, not all patients present in childhood. Diagnosis of CF is confirmed by a sweat chloride level above 60 meq/L or with genetic testing. Treatment for patients with CF is mainly symptomatic therapy for obstructions of the digestive and respiratory tract. In addition, there is pancreatic enzyme supplementation to aid in digestion and vitamin and calorie supplementation for deficiencies in the diet. Gene therapy is now being looked at for futur e treatment. Intussusception (telescoping of the small intestine) typically presents in an infant with paroxysmal abdominal pain, vomiting, and diarrhea that may progress into bloody stools. Volvulus is normally the result of intestinal malrotation that ca uses occlusion of the superior mesenteric artery and eventual bowel necrosis. Infants typically present within 3 weeks of life with bile -stained vomiting and bowel obstruction. Wilson's disease is the defect in the ability to excrete copper in the bile tha t results in accumulation of copper in the liver. A 25 -year -old asymptomatic, non -smoking male presents with a 9mm solitary pulmonary nodule, with dense central calcification on routine chest x -ray. The nodule's appearance is smooth and calcified with a well-defined edge. This same lesion was present on a work physical x -ray two years ago. Which of the following is the most appropriate management step for this patient? A Positron emission tomograph to rule out malignancy B Resection of the pulmonary nod ule C Thoracic magnetic resonance imaging (MRI) D Watchful waiting with serial imaging E Pulmonary function tests - ✔✔watchful waiting with serial imaging Solitary pulmonary nodules are categorized based upon the probability of malignancy. This patient is under the age of 30, with previous documentation of the lesion and without evidence of growth or change, which decreases the probability of malignancy. In this case, watchful waiting is indicated. Risk factors, such as advanced age, smoking, lesion grow th or appearance change, and history of prior malignancy increase malignancy probability, and indicate a need for more defined evaluation. A 62 year -old woman with a 40 pack year smoking history presents with a history of progressive dyspnea of several mo nths duration. She denies hemoptysis, cough, fever, or orthopnea. Sputum production is positive. On physical exam, she shows evidence of accessory muscle use when breathing, sits in a slightly bent forward position, uses pursed lips, and you notice she is very thin. Auscultation reveals decreased vesicular breath sounds with prolonged expiration. Which of the following is the most likely diagnosis? A CHF B COPD C Lung cancer D Pulmonary emboli E Pulmonary fibrosis - ✔✔COPD The patient scenario is consistent with COPD (B) based on the history of progressive dyspnea and physical exam findings of obstructive lung disease (i.e., pursed lip breathing and decreased breath sounds with prolonger expiratory phase. The patient lacks p hysical exam findings of pulmonary edema due to CHF (A). She is at increased risk of lung cancer (C), but lacks red flag symptoms at this time. Pulmonary embolism (D) typically occurs in patients with venous stasis, hyper coagulable state, and vascular wal l injury. Pulmonary fibrosis (E) would present with sign of restrictive lung disease (e.g., shallow breaths with rapid expiration) A 43 -year -old male farmer from the Southwest United States has been working in a very contaminated barn with rodent feces fo r the last week. He presents to your office with complaints of fever, non - productive cough, malaise, and decreased appetite. His physical exam reveals a temperature of 102 0 F, pulse rate of 98, blood pressure of 98/62, and O 2 saturation of 93%. Lung soun ds have diffuse crackles throughout, and the rest of the exam is unremarkable. Based on the history and exam findings, what is the most likely pathogen for this type of illness? A Influenza pneumonia B Varicella pneumonia C Hantavirus pneumonia D Stre ptococcal pneumoniae E Cytomegalovirus - ✔✔Hantavirus The history of the patient being exposed to the rodent feces is a typical presentation of a pneumonia caused by the hantavirus. There is no treatment for this type of pneumonia, only supportive care. A 45 -year -old male with asthma and diabetes is diagnosed with influenza B by nasal swab. He has been ill for one and a half days. Which of the following is indicated for treating this patient? A Acyclovir B Amantadine C Nevirapine D Oseltamivir E Zan amivir - ✔✔Oseltamavir The neuraminidase inhibitors, including oseltamivir and zanamivir, are associated with a reduction in duration of illness, and secondary complications for both influenza A and B viral strains. However, zanamivir, due to the oral inha lation delivery route, is relatively contraindicated in this patient, due to his history of asthma and an associated increased risk of bronchospasm. Amantadine is inactive against influenza B, as well as certain influenza A strains. Nevirapine is an antire troviral agent used in the treatment regimen for HIV. Acyclovir is an antiviral agent, but is not indicated for influenza. A 34 -year -old male has a one and one -half day history of fever, chills, a non -productive cough, and malaise. He is otherwise healthy with no long -standing medical history, and is taking no chronic medications. On examination, the patient has a temperature of 101.3 0 F, BP 123/63, P 78, R 18. His HEENT reveals mild rhinorrhea, moist mucous membranes, clear lung sounds, and a regular rat e and rhythm. The rapid nasal viral test for influenza B is positive. Based on this information, what is the medication treatment for this patient? A Amantadine B Oseltamavir C Ramantadine D Famciclovir E Azithromycin - ✔✔Oseltamavir Oseltamivir is t he best antiviral medication for the treatment of acute influenza. This medication is ideally started within the first onset of illness, usually within the first 24 to 36 hours. Amantadine and Ramantidine have been shown to not be effective, and there is g rowing resistance to the medication. Which of the following is the causative agent in patients with Fifth disease? A herpesvirus 6 (HHV -6) B human parvovirus B19 C paramyxovirus D varicella -zoster virus (VZV) E none of the above - ✔✔Human parvovirus B19 The disease is caused by parvovirus B19. It appears sporadically, but often in epidemics in communities. Children are infectious during the prodromal stage, which is unapparent or mild and usually indistinguisha ble from an upper respiratory infection. The rash is an immune -mediated phenomenon that occurs after the infection, so children with the rash are not infectious and should not be restricted from school or other activities. Aka slapped cheeks disease What is the most common cause of treatment failure in tuberculosis? A Drug resistance B Noncompliance to therapy C Inappropriate selection of medication D Sepsis - ✔✔Noncompliance to therapy The usual reason for failure is simply due to the patient not co ntinuning their treatment plan, regardless of the severity of the disease. Drug resistence, while present in some cases does not preclude the patient from treatment failure. Ongoing sepsis is not a reason to have treatment failure. A 25 year -old HIV posit ive white male presents with dyspnea and a nonproductive cough. The patient's temperature is 103.5 degrees F, respirations 40, and pulse 140. Physical exam reveals a thin, dyspneic male, height 5'10" and weight 150 pounds, in moderate respiratory distress with minimal bibasilar crackles and peripheral cyanosis. CXR reveals a diffuse interstitial infiltrate and his LDH is elevated. Your most likely diagnosis is: A Streptococcal pneumoniae B Klebsiella pneumoniae C Mycoplasma pneumoniae D Pneumocystis ji roveci E Staphlococal aureus - ✔✔Pneumocystitis jiroveci D The insidious onset of atypical pneumonia symptoms in a patient with HIV is consistent with pneumocystis jiroveci (D). Streptococcal pneumoniae (A), Klebsiella pneumonia (B), and Staphlococal aure us (E) present as "typical" pneumonia with the acute onset of fever and productive cough. Which agent is most responsible for croup infections? A Parvovirus B Adenovirus C Parainfluenza D Bocavirus E Streptococcus - ✔✔Parainfluenza Laryngotracheobronchitis, or croup, is mostly caused by the parainfluenza virus. Other agents that can cause this are respiratory syncytial virus (RSV), human metapneumovirus, influenza virus, rubeola virus, adenovirus, and Mycoplasma pneumoniae. Croup, a lso known as laryngotracheobronchitis, is associated with upper tracheal narrowing and edema, which is visible on an anteroposterior soft tissue neck x -ray. This is termed the "steeple sign." Epiglottitis is associated with a thickened epiglottis on a late ral soft -tissue neck x -ray, termed the "thumb" sign. Foreign body aspiration and tracheal carcinoma may have x -ray findings based on the location, size, and components present. Peritonsillitis is best visualized on physical exam. If assessing for a potenti al peritonsillar abscess, a contrasted CT is recommended. A 62 -year -old male diabetic patient presents to your family practice office with a fever and cough, and after a physical examination you perform a chest x -ray, which reveals a right middle lobe pne umonia. You prescribe levofloxacin 750 mg PO for five days and give the patient his first dose in the office prior to sending him home. Within five minutes, he develops generalized urticaria, shortness of breath with a pronounced wheeze, and becomes hypote nsive. While your staff calls 911, what is the most important agent to administer first? A cimetidine B dipenhydramine C epinephrine D methylprednisolone E none of the above - ✔✔epinephrine Early recognition of an anaphylactic reaction is mandatory, since death occurs within minutes to hours after the first symptoms. Mild symptoms such as pruritus and urticaria can be controlled by administration of 0.3 to 0.5 mL of 1:1000 (1.0 mg/mL) epinephrine SC or IM, with repeated doses as required at 5 - to 20 -minute intervals for a severe reaction. An aspirated peanut that is causing a partial obstruction of the trachea in a child is most likely to cause which of the following physical exam findings? A Aphonia B Inability to cough C Stridor D Progressive c yanosis E Rhonchi - ✔✔Stridor Incomplete airway obstruction due to a foreign body will cause turbulent air flow in the airway and an inspiratory wheeze sound, known as stridor. Attempts should be made to remove the foreign body, leaving the patient with a partial obstruction to utilize the cough reflex to remove the foreign body. If unsuccessful, or if findings such as aphonia, an inability to cough, progressive cyanosis, or unconsciousness occur, a complete obstruction is present and definitive interventi on must convene. Age appropriate measures, utilizing back blows and chest compressions in infants younger than the age of one and abdominal thrusts in children over the age of one, should be attempted. A 6-year -old male child presents to the clinic for a cough that occurs only after he has been running, according to his mother. She says she first noticed this about 6 months ago, after he had had one of his usual winter colds, and his cough persisted for about a week. On the basis of this history, what is t he most likely diagnosis? A airway foreign body B asthma C cystic fibrosis D laryngomalacia - ✔✔Asthma Asthma, in this case exercise -induced, is the most likely cause of this problem. The symptoms commonly associated with acute exacerbations of asthma include wheezing, cough, dyspnea, and chest pain. Some symptoms that might be suggestive of asthma include exercise -induced cough, nighttime cough, cough after cold air exposure, and cough after laughing. Airway foreign bodies, though not common, are an acute problem that may present as sudden cough, choking, and wheezing. Cystic fibrosis (CF) is the most commo n, lethal, genetic disease affecting the Caucasian population. Up to 50% of patients with CF are diagnosed in infancy, but others may not be diagnosed until adolescence or adulthood. Chronic or recurrent cough should be an indicator for consideration of CF as a differential diagnosis. Laryngomalacia is the most common cause of stridor in infants. It is the incomplete development of the cartilaginous support of the laryngoglottic structures. This congenital condition is usually self -limiting and occurs most commonly in infants at or just after birth. The inspiratory collapse of the epiglottis or arytenoid cartilages is heard as stridor. During the physical exam of a patient with a suspected pleural effusion, you ask the patient to make the sound "eee." You n ote on auscultation that the transmission is auscultated as "ay," suggestive of resonance through fluid. What is the name of this exam technique? A Bronchophony B Diaphragmatic excursion C Egophony D Tactile fremitus E Whispered pectoriloquy - ✔✔Egop hony Normal lungs transmit spoken sounds faintly and with indistinct syllables, except over main bronchi. An area of fluid, such as a pleural effusion, consolidation or atelectasis, and areas of fibrosis will increase sound transmission and alter the disti nction of the sound. This occurs for both whispered and spoken sounds. The utilization of the spoken sound "eee," auscultating for a change to "ay" due to fluid within the lung fields, is termed egophony. The use of whispered sounds and generally spoken so unds to determine lung changes are termed whispered pectoriloquy and bronchophony respectively. Diaphragmatic excursion is performed to determine the thoracic diaphragmatic movement during respiration. Tactile fremitus assesses chest vibration during vocal ization, with changes being noted in the presence of consolidation (increases fremitus) and pleural effusion (decreased or absent fremitus). Which of the following is the most prevalent fatal cancer in the United States? A Cervical B Colon C Esophagea l D Liver E Lung - ✔✔Lung Lung cancer continues to lead as the major cause of cancer deaths in both men and women in the United States, with cigarette smoking causing greater than 90% of cases. Despite educational campaigns highlighting the risks of smok ing, lung cancer continues to kill more individuals that colorectal, breast, and prostate cancers combined. What is the most common pathogen in pediatric bronchiolitis? A Mycoplasma B Chlamydia C Parainfluenza D Respiratory syncytial virus (RSV) E Streptococcus - ✔✔RSV Viruses are by far the most common reasons for bronchiolitis to occur. RSV is the clear leader in causative agents. A 15 -year -old male presents complaining of a sore throat, headache, and mild cough that started 8 days ago and has progressed to include a worsening cough and increasing fatigue. His chest x -ray reveals bilateral hilar infiltrates, CBC is normal and a nasal secretions test positive for mycoplasma pneumoniae by PCR. What is the most appropriate therapy? A Amoxicillin B Cefuroxime C Clindamycin D Ciprofloxacin E Doxycycline - ✔✔Doxycycline Mycoplasma pneumoniae is commonly treated with macrolides, doxycycline (E), or respiratory fluoroquinolones. Mycoplasma pneumonia doesn't respond to beta -lactam antibiotics (A, B) or non - respiratory fluoroquinolones (D). Following emergent appendectomy, a 58 -year -old obese male develops a temperature of 102.4˚F, 18 hours postoperatively. His respiratory rate is 26 and his pulse is 116bpm. A physical exam reveals scattered fine ral es. What is the most likely diagnosis? A Atelectasis B Aspiration pneumonitis C Pleural effusion D Pneumonia E Pulmonary embolus - ✔✔Atelectasis A Pulmonary alveoli collapse, also known as atelectasis, occurs during operative procedures for a variety of reasons, including decreased clearance of secretions and decreased intra -alveolar pressure. Postoperatively, often due to pain, patients may not mobilize secretions appropriately, also contributing to atelectasis. Atelectasis is the most common postope rative pulmonary complication, and is often associated with emergent and prolonged surgeries, especially those of the thorax and abdomen. Atelectasis is associated with fever, an increased respiratory rate, an increased pulse, and lung exam findings rangin g from normal to rales and decreased breath sounds. Symptoms usually present within the first 48 hours postoperatively. Pulmonary aspiration pneumonitis, although possible, is less likely due to appropriate preoperative and intraoperative measures being utilized to decrease risk. Pneumonia is also a common postoperative complication, due to the same contributing factors as atelectasis. Physical exam findings may also be similar. However, postoperative pneumonia is likely to become evident between 24 and 9 6 hours postoperatively. A postoperative pleural effusion may form, due to free peritoneal fluid as well as a complication of atelectasis, but has a lower incidence of occurrence than atelectasis alone. Patient symptoms will be based upon the size of the e ffusion, associated inflammation, and whether or not the effusion is infectious. Consideration must be given to pulmonary emboli for any post -surgical patient with tachypnea, tachycardia, and dyspnea. Pulmonary emboli may occur at any point postoperatively , but atelectasis remains a more common cause of postoperative fever and respiratory changes. A 1 day -old boy develops progressing abdominal distension, bilious vomiting and failure to pass a meconium stool. Abdominal radiographs show dilated loops of sma ll bowel. Which of the following is the most likely diagnosis in this patient? A Cystic Fibrosis B Hypothyroidism C Imperforate anus D Intussusception E Pyloric Stenosis - ✔✔Cystic Fibrosis The patient presents with a meconium ileus consistent with a diagnosis of cystic fibrosis (A). Pyloric stenosis (E) typically presents between 3 and 6 months of age, while intussusception (D) presents later (6 to 24 months). Imperforate anus (C) presents a t birth, but infants typically lack acute abdominal distention and bilious vomit. Other common causes of intestinal obstruction in a newborn include meconium plug syndrome, Hirschsprung Disease, Intestinal Atresia, and Midgut Volvulus. A 43 year -old woman with a past medical history of HIV infection presents to the clinic due to a 3 -month history of dry, non -productive cough and progressive dyspnea. The patient is subsequently prescribed trimethoprim -sulfamethazole. What is the mechanism of action of this sulfamethazole? A Binds to the 30S ribosomal subunit to inhibit protein synthesis B Binds to the 50S ribosomal subunit to inhibit protein synthesis C Inhibits dihydropteroate synthase and folate production D Inhibits DNA replication by binding to DNA gyrase and topoisomerase IV E Inhibits the transpeptidation reaction - ✔✔Inhibits dihydropteroate synthase and folate production Sulfamethoxazole inhibits dihydropteroate synthase and folate production (C). Tetracycline binds to the 30S ribosomal subuni t to inhibit protein synthesis (A). Macrolide antibiotics bind to the 50S ribosomal subunit to inhibit protein synthesis (B). Ciprofloxacin inhibits DNA replication by binding to DNA gyrase and topoisomerase IV (D). Beta lactam antibiotics inhibit the tran speptidation reaction leading to cell wall destruction (E). A 4-year -old male has been experiencing a significant cough for the last 12 to 14 days, and initial episodes of coughing are characterized as frequent outbursts of 5 to 10 spastic coughs in a row . The patient does not report any fever, but does note that the coughing is worse at night. On examination, the patient is alert, awake, and oriented. His temperature is 97.7 0 F, pulse rate is 89, respiratory rate is 25, and blood pressure is 110/56. The HEENT is unremarkable, and lung sounds are clear to auscultation. You suspect that the patient may have an acute case of pertussis. Based on the history and physical exam findings, which is the test of choice for confirming a diagnosis of pertussis? A Co mplete blood count (CBC) B Throat culture C Chest x -ray D Nasopharyngeal culture E Sputum gram stain and culture - ✔✔Nasopharyngeal culture A special medium culture plate (such as a Bordet -Gengou agar) is required for the nasopharyngeal swab for the di agnosis of pertussis. Throat culture, chest x -rays, and complete blood counts are helpful in ruling out other disease patterns. A 17 year -old male is training for an Ironman triathlon and notes excessive coughing, chest tightness and wheezing when running . Which of the following is the most appropriate treatments for this patient? A Albuterol B Cromolyn C Fluticasone D Ipratropium bromide E Salmeterol - ✔✔Salmeterol The mainstay of treatment for exercise -induced asthma are beta -2 agonists. Due to the duration of physical activity this patient should be treated with a long -acting beta -2 agonist, salmeterol (E) instead of albuterol (A). If his symptoms are persistent th en addition of a daily inhaled corticosteroid (C) is required, and daily ICS should be added if his use of salmeterol is frequent to avoid asthma -related death associated with the lone use of long -acting beta -agonists. Cromolyn (B) is an additional treatme nt options for exercise -induced bronchospasm, but is less commonly used compared to beta -2 agonists. A 62 -year -old woman with a long -standing history of hypertension presents with severe headache; it started this morning and is rapidly worsening. During t he interview, she suddenly collapses. Your brief examination shows that she responds with extensor posturing on external stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that her breathing has a peculiar pattern : deep inspiration with a pause at full inspiration, followed by a brief insufficient release and the end-inspiration pause. Question How do you best describe her respiratory pattern? Answer Choices 1 Cheyne -Stokes 2 Apneusis 3 Ataxic 4 Cluster 5 Cent ral neurogenic hyperventilation - ✔✔Apneusis In the hypertensive patient with sudden loss of consciousness and decerebrate response (extensor posturing), you should consider brain stem hemorrhage. Abnormal breathing patterns can be observed in both pontine and medullary lesions; they sometimes can be prognostic. Her breathing pattern is apneustic. Apneustic breathing pattern characterizes deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release and the end -inspira tion pause before expiration. Lesion in the pons or upper medulla causes the removal of input from the vagus nerve and the pneumotaxic center. Normally, apneustic center of the lower pons promotes inspiration by stimulation of the dorsal respiratory center in the medulla to delay the 'switch off' signal of the inspiratory ramp provided by the pneumotaxic center of pons. Therefore, athe pneustic center controls the intensity of breathing. Apneusis is an ominous sign, with a generally poor prognosis. Cheyne -Stokes respiration is an abnormal pattern of breathing characterized by repetitive progressively deeper and sometimes faster breathing, followed by a gradual decrease in breathing that results in temporary apnea. Cycles usually take 30 seconds to 2 minutes . Increased CO2 during the period of apnea causes compensatory hyperventilation. Hyperventilation in turn causes the decrease in CO2, which causes apnea and the cycle to restart. Causes include CNS dysfunction, cardiac failure with low cardiac output, slee p, hypoxia, or profound hypocapnia. Ataxic breathing (Biot's respiration) is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. It is generally a poor prognostic sign. Biot's respiration is caused by the medullary lesion due to strokes or trauma or by pressure on the medulla due to uncal or tentorial herniation. Kussmaul breathing is a deep, labored, and gasping breathing pattern seen often in severe metabolic acidosis (diabetic ketoacidosis, renal failure). In metabolic acidosis, breathing is first rapid and shallow, but later on, as acidosis worsens, breathing gradually becomes Kussmaul breathing. Central neurogenic hyperventilation is a very deep and rapid pattern o f breathing, usually seen in the lesions of the midbrain and upper pons. Respirations are generally regular, and the PACO2 decrease due to the hyperventilation. Cluster breathing is irregular breathing with periods of apnea that occurs at irregular interv als. It is generally seen in lesions in the low pons or upper medulla. It differs from Cheyne -Stokes pattern because there is no increasing and decreasing depth of respirations. A 72 -year -old man presents due to worsening shortness of breath, orthopnea, and chest pain; symptoms have been occurring for the past few weeks. The patient admits to some chronic heart problems as well as fatigue, dyspnea, and a non -productive cough; howe ver, he feels like symptoms have worsened recently. He denies fever, chills, and a productive cough. On physical exam, the man has mildly increased respiratory effort, but he does not appear in distress. He is barrel -chested. His breath sounds are diminis hed bilaterally, with dullness to percussion over the right and left lower lungs. No pleural friction rub is noted. On cardiovascular exam, an S3 gallop and mild tachycardia (110 bpm) are noted. Clubbing of the fingers, dependent edema in the lower extremi ties, and jugular venous distention are also noted. His cardiac enzymes and electrocardiogram demonstrate no acute cardiac pathology. Pleural fluid and cardiomegaly are found on the chest X -ray, and a thoracentesis is performed. The pleural fluid is gener ally clear in color, testing negative for chylomicrons and triglycerides. It has low levels of red blood cells, white blood cells, protein, and lactate dehydrogenase (LDH). Question What is the likely underlying mechanism for the pleural effusion in th is patient? Answer Choices 1 Chylothorax from disruption of the thoracic duct 2 Empyema from infection in the pleural space 3 Exudates from local inflammation in capillary beds 4 Hemothorax 5 Transudates from increased hydrostatic pressure or decreased on cotic pressure - ✔✔All of the listed choices are possible mechanisms for pleural effusions. According to this patient's history and physical exam, as well as the characteristics of the pleural fluid, it should be apparent that his pleural effusion stems fr om transudates from increased hydrostatic pressure or decreased oncotic pressure. He presents with typical chronic congestive heart failure symptoms. The pleural effusion occurs not from diseased pleura, but from the underlying illness. Transudative pleura l effusions are the most common type, and heart failure is the most common underlying cause of pleural effusions. Chylothorax from disruption of the thoracic duct is relatively uncommon. The primary distinguishing characteristics are seen in the milky app earance of pleural fluid, with a large amount of chylomicrons and triglycerides. Empyema from infection in the pleural space might have been a cause if this patient had pneumonia or other severe pulmonary infection. This patient's clinical history is not suggestive of infection. The pleural fluid of empyema may be grossly purulent or milky white. If the milky white fluid is centrifuged, showing clear supernatant with a pellet of white cells below, empyema should be considered. Exudates from local inflamma tion in capillary beds is a mechanism for pleural effusions secondary to pulmonary embolism, malignancy, as well as some infections, such as pneumonia. Exudates can be distinguished from transudates by a combination of history, appearance, and characterist ics of the pleural fluid (using Light's criteria). Simplified, the pleural fluid with exudates may be cloudy in appearance, with relatively high levels of protein and LDH. Hemothorax is blood in the pleural space. It can occur with trauma to the chest wal l or other structures of the thorax. Typically, there would be a history of trauma. Hemothorax is unlikely to be bilateral, except in cases of significant trauma. Additionally, the pleural fluid may appear grossly bloody and demonstrate high numbers of red blood cells on analysis. A 58 -year -old woman with a past medical history of hypertension, hyperlipidemia, breast cancer, hip fractures, and coronary artery disease is being evaluated for acute -onset, severe left -sided pleuritic chest pain over the course of the last 2 hours. The pain is associated with feelings of anxiety, hemoptysis, shortness of breath, and nausea. She "feels warm" but denies chills, palpitations, wheezing, cough, edema, vomiting, abdominal pain, abnormal bowel habits, or dietary intole rances. She endorses a 30 pack/year smoking history, but denies drug or alcohol use. Upon physical exam, she is found to be febrile, hypotensive, tachycardic, tachypnic, diaphoretic, and in acute painful distress. There is perioral cyanosis and a pleural f riction rub to the left lung fields; the remainder of the exam is normal. Question What is the most appropriate therapeutic intervention for this patient at this time? Answer Choices 1 Indomethacin 2 Doxycycline 3 Heparin 4 Prednisolone 5 Albuterol - ✔✔Heparin This patient's presentation is significant for a pulmonary embolism. Predisposing underlying conditions are almost always present; venous thrombosis may result from a generalized hypercoagulable state, venous endothelial injury, or local stasis (Virchow triad). Most commonly, the initial manifestations of pulmonary embolism include an abrupt dyspnea and chest pain. Tachycardia and hypoxia are the most common clinical signs. Associated manifestations include fever, hypotension, cyanos is, pleural friction rub, and findings consistent with pulmonary consolidation. Anticoagulation is the foundation for successful treatment of DVT and PE. Unfractionated heparin, low -molecular -weight heparin, or fondaparinux all achieve effective anticoagul ation immediately. An 8 -month -old infant presents with shortness of breath, wheezing, intercostal retractions, and respiratory rate of 50. What would further suggest a diagnosis of bronchiolitis? Answer Choices 1 Wheezing improved after nebulizer 2 Peak flow 300 prior to treatment 3 Liver and spleen palpable 4 Clubbing of the finger - ✔✔Liver and spleen palpable Enlargement of the liver and spleen occurs due to hyperinflation of the lungs with bronchiolitis. With this diagnosis, a nebulizer that improves wheezing is not a specific criterion, but it is more so with asthma. A peak flow of 300 is good; therefore, it would likely be lower with bronchiolitis. Clubbing of the fingers is seen with prolonged COPD in adults, not in the pediatric population. A 53 -year-old woman presents with a 2 -year history of chronic cough. The cough produces large volumes of grossly purulent sputum. She has a history of recurrent respiratory infections; they resulted in 5 hospitalizations in the past year. She also had similar co mplaints during the previous year.. Shortness of breath limits her daily activity considerably. Upon pulmonary examination, bilateral breath