Respiratory

Cough

100

A 62-year-old male presents with bright red hemoptysis. While not severe, it is recurrent and has persisted for several weeks. He is otherwise asymptomatic.
A thorough history and physical examination does not provide any additional clues. Gastrointestinal and ear, nose, and throat etiologies are considered and are not thought to be the cause. Posteroanterior and lateral chest radiographs are normal.
Which one of the following would be the most appropriate next step in diagnosis?
A) Antineutrophil cytoplasmic antibody (ANCA) testing
B) A sputum smear for acid-fast bacillus
C) Sputum cytology
D) CT of the chest
E) Bronchoscopy

ANSWER: D
A chest radiograph is appropriate in the initial evaluation of hemoptysis (SOR C). If the chest radiograph does not indicate a cause, then CT or CT angiography with intravenous contrast should be performed (SOR C). CT has become the preferred modality over bronchoscopy because it is more effective in determining the etiology. If CT does not identify the cause, bronchoscopy would be the next step. In addition, other tests including a sputum Gram stain, acid-fast bacillus smear, or sputum cytology can be useful depending upon the clinical situation.
If there are concerns about the possibility of immunologic, rheumatologic, or vasculitic disease, testing for immunologic antibodies such as antineutrophil cytoplasmic antibody (ANCA) can be ordered.

200

A 46-year-old male presents with a persistent cough that has been present for several months
and was not preceded by an upper respiratory infection. He does not have a history of
asthma, does not smoke, and takes no medications. His symptoms consist of short bursts of
coughing that produce a small amount of mucoid sputum during the day. He does not have
emesis or nausea. The cough sometimes wakes him at night but does not seem to be specific
to any particular posture. He does not have a fever, shortness of breath, wheezing,
heartburn, or nasal symptoms. A thorough physical examination is normal and a chest
radiograph appears normal.
Which one of the following would be the most appropriate next step in the management of
this patient?
A) Amoxicillin/clavulanate (Augmentin)
B) An empiric trial of a proton pump inhibitor
C) CT of the chest
D) CT of the sinuses
E) Referral for bronchoscopy

ANSWER: B
Chronic cough is defined as a cough lasting at least 8 weeks. If a thorough history (with attention to ACE
inhibitor use), a physical examination, and a plain-film chest radiograph do not suggest an obvious cause
for the cough, experts suggest that the three most common etiologies are gastroesophageal reflux,
persistent postnasal drip, and unrecognized asthma. Treating a chronic cough empirically with a high-dose
proton pump inhibitor for 2-3 months is considered a reasonable choice before further investigations are
attempted. Ordering an esophageal pH probe or esophagogastroduodenoscopy would also be considered
appropriate. Postnasal drip is often due to allergic rhinitis or another noninfectious condition and some
guidelines recommend empiric nasal corticosteroid sprays and/or first-generation oral antihistamine use.
CT of the chest and bronchoscopy may become necessary if the evaluation and treatment for these three
common conditions does not improve the patient's symptoms. Since there are no symptoms of bacterial
sinusitis, the use of a broad-spectrum antibiotic is not justified.

300

25. A 60-year-old male presents with a several-month history of a dry cough and progressive
shortness of breath with exertion. On examination he has tachypnea and bibasilar
end-inspiratory dry crackles, and a chest radiograph reveals interstitial opacities. Which one of the following patient occupations would most likely support a diagnosis of
silicosis?
A) Baker
B) Firefighter
C) Stone cutter
D) Goat dairy farmer
E) High-tech electronics fabricator

ANSWER: C
Family physicians should be aware of the environmental exposures associated with pulmonary disease. Stone cutting, sand blasting, mining, and quarrying expose patients to silica, which is an inorganic dust that causes pulmonary fibrosis (silicosis). Occupational exposure to beryllium, which is also an inorganic
dust, occurs in the high-tech electronics manufacturing industry and results in chronic beryllium lung disease. Exposure to organic agricultural dusts (fungal spores, vegetable products, insect fragments, animal
dander, animal feces, microorganisms, and pollens) can result in "farmer's lung," a hypersensitivity pneumonitis. Other organic dust exposures, such as exposures to grain dust in bakers, can lead to asthma, chronic bronchitis, and COPD. Firefighters are at risk of smoke inhalation and are exposed to toxic
chemicals that can cause many acute and chronic respiratory symptoms.

400

You see a 50-year-old male in your office with a 2-week history of cough that began as mild and intermittent, but now occurs as paroxysms that frequently cause him to vomit. He feels very tired after these coughing fits. He also reports rhinorrhea throughout the course of his symptoms. He has been feeling overheated but does not report documented fevers. He notes that he does not typically receive routine vaccinations. His vital signs include a temperature of 37.4°C (99.3°F), a pulse rate of 85 beats/min, a respiratory rate of 20/min, and an oxygen saturation of 93% on room air. He has no medication allergies. A test for COVID-19 is negative. Of the following treatments, which one would be the most beneficial for this patient's most likely condition?

A) Continued supportive care only
B) Tdap vaccination
C) Azithromycin (Zithromax)
D) Doxycycline
E) Oseltamivir (Tamiflu)

ANSWER: C
The duration and characterization of this patient's cough are most suggestive of pertussis. Of the options listed, azithromycin is the most appropriate for management of pertussis. Azithromycin is most effective for treatment and minimizing spread of the disease within 21 days of symptom onset.

Sulfamethoxazole/trimethoprim and other macrolides, such as erythromycin and clarithromycin, are also acceptable options.

Continued supportive care only does not provide the advantages of cure and minimization of community spread that are accomplished by initiating azithromycin. Symptomatic treatment with over-the-counter medication is appropriate but such supportive care does not replace the therapeutic advantages of azithromycin.

This patient's objection to routine vaccination should be explored as priorities allow. He should be vaccinated against pertussis with Tdap as soon as feasible, but the vaccination would not provide immediate treatment of his current episode of pertussis.

Doxycycline has shown benefit in other bacterial infections but does not provide effective treatment of pertussis. Based upon the duration of symptoms, quality of his cough, and lack of documented fevers, this patient is not likely to have influenza, so oseltamivir would not be appropriate.

500

Chronic cough in an adult is defined as a cough that has been present for longer than 8 weeks. Which one of the following is the most common cause of chronic cough in an adult?

A) Asthma
B) Laryngopharyngeal reflux disease
C) Nonasthmatic eosinophilic bronchitis
D) Protracted bacterial bronchitis
E) Upper airway cough syndrome

ANSWER: E
Chronic cough in adults is a common presenting symptom for primary care visits. The four most common causes of chronic cough in adults include upper airway cough syndrome (UACS), asthma, nonasthmatic eosinophilic bronchitis, and reflux-related disorders. UACS, previously referred to as postnasal drip syndrome, is the most common cause of chronic cough in adults. This syndrome can have multiple etiologies, including chronic rhinosinusitis, allergic rhinitis, and nonallergic rhinitis. The diagnosis may be suggested by symptoms of rhinorrhea such as nasal stuffiness, sneezing, and postnasal drainage, but the absence of these symptoms does not rule out the diagnosis. The most common causes of chronic cough in children 6-14 years of age are asthma, protracted bacterial bronchitis, and UACS.

You take my breath away

100

A 51-year-old patient asks about recommended lung cancer screenings. The U.S. Preventive Services Task Force recommends annual lung cancer screening with low-dose CT for individuals starting at what age and how many pack year smoking history?

A) 45 with a 15-pack-year smoking history
B) 50 with a 20-pack-year smoking history
C) 55 with a 30-pack-year smoking history
D) 60 with a 35-pack-year smoking history
E) 65 with a 40-pack-year smoking history

ANSWER: B
Lung cancer is the second most common cancer in both women and men, after breast cancer for women and prostate cancer for men. It is the leading cause of cancer deaths in the United States, making it important for primary care providers to screen for this disease process. The primary risk factor for lung cancer is tobacco smoking, which accounts for 90% of all lung cancer cases. Lung cancer has a relatively poor prognosis, but early-stage lung cancer is more amenable to treatment and has a better prognosis. Low-dose CT has a reasonable specificity and high sensitivity for lung cancer in patients at high risk. The eligibility criteria were recently updated by the U.S. Preventive Services Task Force (March 2021) due to evidence of mortality benefit, with a recommendation for screening to begin at age 50 for patients with a 20-pack-year smoking history who are current smokers or have quit within the past 15 years.

200

A 4-year-old male is brought to your office by his parents because of a 2-day history of cough and a runny nose, but no fever. The child's symptoms are not progressing. The patient has a history of wheezing when he has mild respiratory infections. The only findings on examination are yellow nasal discharge and mild wheezing. The appropriate management with the LEAST amount of risk would be treatment for 10 days with:

A) amoxicillin
B) montelukast (Singulair)
C) an antihistamine decongestant
D) an inhaled corticosteroid
E) an oral corticosteroid

ANSWER: D
For children up to 4 years of age who only have wheezing with respiratory infections, using an inhaled corticosteroid (IC) daily when a respiratory infection develops reduces exacerbations and the use of systemic corticosteroid therapy. It is uncertain if ICs affect growth, but they would be less likely to do so than systemic corticosteroids.

Antibiotic therapy should be reserved for bacterial infections. Montelukast is indicated for the prevention of asthma and allergic rhinitis. The use of antihistamine decongestant preparations in children is not recommended due to potential side effects and minimal benefit.

300

A 57-year-old male who uses tobacco presents with cough and dyspnea. His symptoms were previously controlled with an albuterol (Proventil, Ventolin) inhaler once or twice a month. After a 3-week trial of a tiotropium (Spiriva) inhaler his symptoms are better, but he is still having frequent episodes of coughing and dyspnea. He has been smoking 1-2 packs of cigarettes a day since age 13 and is not interested in quitting. On examination he is afebrile, his vital signs are stable, and his oxygen saturation is 95% on room air. His lung sounds are diminished, and the remainder of the examination is unremarkable. His in-office peak flow is 300 L/min. You suspect he has moderate COPD and recommend pulmonary function tests but he declines. In addition to continuing tiotropium, which one of the following medications would you recommend adding to his current regimen?

A) An oral antibiotic
B) An oral corticosteroid
C) An inhaled corticosteroid
D) An inhaled long-acting β-agonist
E) A nebulized short-acting β-agonis

ANSWER: D
Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Initiative for Health and Care Excellence, and the American College of Chest Physicians all recommend that in addition to smoking cessation, COPD should be treated initially with either a long-acting beta-agonist (LABA) or a long-acting muscarinic antagonist (LAMA). If symptoms persist with either of those inhaled medications then combination therapy should be initiated.

An inhaled corticosteroid (ICS) can be added to the LABA/LAMA regimen for triple therapy if symptoms continue. Long-term use of an ICS as monotherapy is not recommended due to a slight increase in the incidence of pneumonia.

400

A 60-year-old male with moderate COPD presents to your office with shortness of breath and a cough with increased sputum volume. After appropriate evaluation, you diagnose an acute COPD exacerbation. According to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, which one of the following additional factors would provide the strongest indication for treatment with antibiotics?

A) A decline in oxygen saturation from baseline
B) Diffuse wheezing on lung auscultation
C) A fever
D) Increased sputum purulence
E) Leukocytosis

ANSWER: D
COPD exacerbations, when caused by an infectious agent, may be bacterial or viral. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines support the use of antibiotics in patients with an acute COPD exacerbation with the three cardinal symptoms of increased dyspnea, increased sputum volume, and increased sputum purulence; in patients with increased sputum purulence and one of the other cardinal symptoms; and in patients who require invasive or noninvasive mechanical ventilation.

Hypoxemia and fever, although often seen in the setting of COPD exacerbations, do not provide as strong an indication for treatment with antibiotics. Diffuse wheezing is a hallmark examination finding that is present in most COPD exacerbations, regardless of the underlying cause. Leukocytosis is a relatively nonspecific marker for acute inflammation and may be seen with either viral or bacterial etiologies. Serum biomarkers such as C-reactive protein and procalcitonin have yielded controversial and conflicting evidence in guiding antibiotic therapy

500

 A 48-year-old female presents with dyspnea with exertion. She has never smoked. A
physical examination is normal, including vital signs and pulse oximetry. A chest radiograph
reveals mild hyperexpansion of the chest, and pulmonary function testing reveals an
FEV1/FVC ratio of 0.67, unchanged after bronchodilator use. An EKG and stress
echocardiogram are normal. You suspect COPD.
Which one of the following is the most likely underlying cause of this patient's pulmonary
disease?
A) Allergic bronchopulmonary aspergillosis
B) 1-Antitrypsin deficiency
C) Hemochromatosis
D) Primary pulmonary hypertension
E) Hypertrophic obstructive cardiomyopathy

ANSWER: B
This patient is a nonsmoker but has typical symptoms and findings of COPD. 1-Antitrypsin deficiency
should be considered in patients with very premature COPD or in patients without risk factors for COPD
such as smoking, secondhand smoke exposure, or other smoke exposure. Dyspnea would be present and
lung function would be normal in patients with primary pulmonary hypertension or hypertrophic
obstructive cardiomyopathy. Hemochromatosis may cause liver function abnormalities but not abnormal
lung function. Allergic bronchopulmonary aspergillosis is associated with asthma, not COPD.

Interventions

100

A 55-year-old female with a BMI of 50 kg/m2 and recently diagnosed severe obstructive sleep apnea (OSA) presents for follow-up after a sleep study. She was unable to tolerate positive pressure therapy. Her OSA could be most effectively addressed by which one of the following interventions?

A) Use of a nasal dilator device
B) A positional sleep alarm to avoid the supine position
C) Clonidine, 0.1 mg orally before bedtime
D) Uvulopalatopharyngoplasty
E) Bariatric surgery

ANSWER: E
Obstructive sleep apnea (OSA) is a common disorder that, if left untreated, can be associated with other serious health conditions such as atrial fibrillation, depression, heart failure, and stroke. Positive pressure therapy is effective and considered the first-line treatment for OSA, although some patients are unable to tolerate this therapy.

In obese patients with OSA, bariatric surgery has been shown to reliably result in improvement in >75% of patients and result in remission in 40% of patients after 2 years.

Nasal dilator devices and pharmacologic interventions such as clonidine have not been shown to improve symptoms or to be effective for treatment.

Positional therapy is not recommended as a long-term solution for severe OSA due to poor long-term compliance.

Currently there is insufficient evidence to support oral procedures such as uvulopalatopharyngoplasty as primary interventions for OSA.

200

A 2-year-old male is brought to the urgent care clinic by his parents in February with a low-grade fever that started the night before. His mother awoke early in the morning when she heard his barking cough. He recently started attending preschool and the mother does not know of any sick contacts. On initial examination the patient is in mild respiratory distress and appears nontoxic. He does not have any rhinorrhea or congestion. He has a temperature of 38.2°C (100.8°F), a respiratory rate of 40/min, a heart rate of 145 beats/min, and an oxygen saturation of 96% on room air. No rashes or petechiae are present. The most appropriate next step in management would be

A) humidified air
B) albuterol via nebulizer
C) oral dexamethasone
D) a viral culture
E) a chest radiograph

ANSWER: C
This patient has a classic presentation of croup, which peaks in the fall and winter months. There may not be any particular history of sick contacts and it does not present with a prodrome, in contrast to respiratory syncytial virus. The diagnosis of croup is purely clinical and does not require laboratory studies, viral cultures, or imaging (SOR C). The treatment of croup includes corticosteroids such as dexamethasone in mild cases (SOR A) and the addition of epinephrine in moderate to severe cases (SOR A).

The inhalation of humidified air does not improve outcomes (SOR B) nor does nebulized albuterol.

300

A 30-year-old gravida 2 para 1 at 20 weeks gestation presents with a 1-day history of a fever, cough, headache, and myalgias. A nasal swab confirms influenza B. Which one of the following is the preferred antiviral treatment for this patient?

A) No treatment because of her pregnancy
B) No treatment because antiviral medication is indicated for influenza A but not influenza B
C) Baloxavir marboxil (Xofluza)
D) Oseltamivir (Tamiflu)
E) Peramivir (Rapivab)

ANSWER: D
Antiviral medications are recommended for the treatment of influenza only within 48 hours of symptom onset (SOR A). However, in high-risk patient populations and in severe cases of disease, antiviral medications should be provided regardless of the duration of symptoms (SOR B). According to the CDC, oseltamivir remains the drug of choice for the treatment of influenza A and B during pregnancy because it has good safety data.

Baloxavir marboxil is indicated for patients >12 years of age but should be avoided during pregnancy. There is less safety data for peramivir and zanamivir.

400

Montelukast (Singulair) has an FDA boxed warning related to an increased risk of:
A) delirium
B) myocardial infarction
C) suicidality
D) venous thromboembolism

ANSWER: C
In March 2020, the FDA upgraded its warning label for montelukast to a boxed warning (black box warning) based on the trends for all neuropsychiatric adverse events, including suicidality, associated with montelukast use reported in the FDA Adverse Event Reporting System database from the date of FDA approval in February 1998 through May 2019 (SOR B).

The boxed warning does not indicate an increased risk of delirium, myocardial infarction, or venous thromboembolism

500

 42-year-old male presents with a fever, cough, and chest pain. A rapid influenza test is
positive.
Which one of the following would be most appropriate for the management of this patient's
pleuritic chest pain?
A) Colchicine (Colcrys)
B) Hydrocodone
C) Ibuprofen
D) Prednisone
E) Tramadol (Ultram)

ANSWER: C
NSAIDs such as ibuprofen should be used as first-line treatment for the control of pleuritic pain (SOR B).
While NSAIDs do not have the analgesic potency of narcotics, they do not cause respiratory suppression
or change the patient's sensorium. Corticosteroids should be reserved for patients who cannot take
NSAIDs.

Misc

100

This chest radiograph is consistent with a large right pneumothorax and complete lung collapse. In addition, there is a leftward mediastinal shift that raises the concern for a tension pneumothorax. The chest radiograph is not consistent with aspiration pneumonia or community-acquired pneumonia. While a non-ST-elevation myocardial infarction or pulmonary embolus could have a similar presentation, this abnormal chest radiograph points to pneumothorax as the most likely diagnosis

200

The results of a meta-analysis of lung cancer screening using low-dose CT were as follows: the pooled lung cancer-specific mortality rate in the control group was 2.12%, the estimated lung cancer-specific mortality rate in the screened population was 1.72%, and the absolute risk reduction for lung cancer mortality was 0.4% (2.12% minus 1.72%). What is the number needed to screen to prevent one death due to lung cancer?

ANSWER: E
The absolute risk reduction (ARR) in this meta-analysis was 0.4%. The number needed to screen is the reciprocal of the ARR. The number needed to screen would equal 1 divided by the ARR (1/ARR), or 1/0.004, which equals 250. Based upon this meta-analysis, 250 individuals would need to be screened to prevent one lung cancer death.

300

In adolescents and adults, what proportion of cases of uncomplicated, acute bronchitis are caused by atypical organisms such as Mycoplasma pneumoniae and Chlamydia pneumoniae?

Atypical organisms such as Mycoplasma pneumoniae and Chlamydia pneumoniae are rare causes and have been found in less than 1% of cases of acute bronchitis.

Acute bronchitis is caused by a viral infection in 90%-99% of cases.

400

Which one of the following is the most common radiologic finding in early pulmonary sarcoidosis?

A) Bilateral hilar adenopathy
B) Caseating granulomas
C) Pleural granulomas
D) Peribronchiolar thickening

ANSWER: A
Sarcoidosis is an inflammatory disease that can affect many organ systems, but 90% of patients have pulmonary involvement. While many patients diagnosed with sarcoidosis are asymptomatic, pulmonary symptoms including dry cough, the gradual onset of dyspnea, and fatigue are nonspecific, and the condition is often not suspected until chest radiography is performed. The most common finding is bilateral hilar adenopathy alone (stage 1). Other findings, which usually develop over time, include infiltrates and, in some patients, ultimately fibrosis. The classic pathologic findings from biopsies are noncaseating granulomas. Caseating granulomas are indicative of tuberculosis. Pleural involvement is not typical in sarcoidosis. Peribronchiolar or peritracheal thickening and interstitial infiltrates may be seen on CT scans, but bilateral hilar adenopathy is the most characteristic finding in earlier pulmonary sarcoidosis and is readily seen on plain chest radiographs.  

500

 A 35-year-old white female presents with recurrent wheezing and coughing over the past few
weeks, and recent production of brown sputum plugs. She is a regular patient of yours and
has a long history of asthma and multiple allergies. She has been treated four times in the
last 3 months for asthma exacerbations and generally feels better the first day she takes her
corticosteroid, but any attempt at tapering leads to a recurrence of symptoms. She previously
had good control of her asthma, although she has required regular use of a high-dose inhaled
corticosteroid and a long-acting -agonist. In spite of just completing a course of
levofloxacin (Levaquin) for suspected pneumonia she returns today with a recurrence of the
same symptoms.
A physical examination is unremarkable with the exception of diffuse expiratory wheezing.
She has no fever or other abnormal vital signs. A chest radiograph shows opacities in the
upper and middle lobes and a CBC is concerning for eosinophilia.
Which one of the following is the most likely diagnosis?
A) Allergic bronchopulmonary aspergillosis
B) Community-acquired pneumonia
C) Pulmonary embolism
D) Medication nonadherence

ANSWER: A
Allergic bronchopulmonary aspergillosis (ABPA) affects 1%-12% of immunocompetent patients with
asthma and is important to consider in patients with recurrent exacerbations because it can cause permanent
lung damage if it is undetected and untreated. The symptoms alone are insufficient for a diagnosis, but this
clinical presentation should prompt consideration of the diagnosis, and some of the symptoms and findings
noted are included in the diagnostic criteria. The major diagnostic criteria include the presence of asthma
or cystic fibrosis and immediate skin reactivity to Aspergillus antigens, peripheral eosinophilia, transient
pulmonary infiltrates or opacities, central bronchiectasis on a chest radiograph or CT, serum precipitating
antibodies to Aspergillus fumigatus , and elevated Aspergillus IgE- and/or IgG-specific antibodies.
Minor criteria that support the diagnosis include production of brownish mucus plugs, identification of
Aspergillus in the sputum, and delayed skin sensitivity to Aspergillus. Pneumonia is unlikely in this case
given recent treatment with a respiratory fluoroquinolone and a lack of common symptoms such as fever,
chills, tachycardia, tachypnea, and pleuritic chest pain, along with a cough productive of mucopurulent
sputum. The most common symptoms of pulmonary embolism include dyspnea, chest pain, syncope,
tachypnea, and a cough. While medication nonadherence may increase asthma exacerbations and wheezing,
it would be unlikely to be related to the new brown mucus production.