A
B
C
D
100
An 87-year-old woman was hospitalized 2 days ago for sepsis related to pyelonephritis. Medical history is significant for hypertension and heart failure. She has responded to fluid resuscitation and antibiotic therapy but is intermittently confused. She reports no pain. Attempts have been made not to interrupt her night-time sleep. Nurses provide frequent orientation, and she has been provided with her glasses and hearing aids. Medications are ceftriaxone, acetaminophen, carvedilol, hydrochlorothiazide, and lisinopril.
On physical examination, vital signs are normal. Oxygen saturation is 92% breathing oxygen, 2 L/min by nasal cannula. She is awake and oriented. There are no focal neurologic deficits.
What is the most appropriate measure to prevent delirium?
Early mobilization
Haloperidol
Lorazepam
Melatonin
100
A 53-year-old woman presents for follow-up evaluation of an incidentally found 4-mm solid lung nodule in the right lower lobe on abdominal CT scan. The CT scan showed no other nodules, no lymphadenopathy, and unremarkable lung parenchyma. There are no old scans for comparison. She has no personal or family history of lung cancer.
She is asymptomatic, a lifelong nonsmoker, and has no significant exposure history.
What is the most appropriate management?
No further follow-up
Bronchoscopy with lung biopsy
CT of chest in 12 months
CT-guided lung biopsy
Fluorodeoxyglucose PET
100
A 74-year-old man is evaluated in the ICU for sepsis and hypotension. A central venous catheter has just been inserted into the left internal jugular vein under ultrasound visualization to start vasopressor therapy. As the catheter line is being secured, the patient suddenly becomes more hypotensive. Medications are propofol, piperacillin-tazobactam, and vancomycin.
Temperature is 37.8 °C (100.0 °F), blood pressure is 74/55 mm Hg, pulse rate is 118/min, and respiration rate is 18/min on mechanical ventilation. Oxygen saturation is 91% on FIO2 of 1.00. Breath sounds are diminished bilaterally. Heart sounds are diminished.
What is the most appropriate next management step?
Chest ultrasonography
Chest CT
Needle thoracostomy
Removal of central venous catheter
100
A 40-year-old man is evaluated 10 days after an emergency department visit for a cough, chest tightness, wheezing, and shortness of breath. He was treated with nebulized albuterol and sent home with a 5-day course of prednisone and an albuterol metered-dose inhaler. Since completing the prednisone, he has felt well, with no further symptoms and no need to use the albuterol. He reports a similar episode requiring an emergency department visit 1 year ago.
On physical examination, vital signs are normal. Oxygen saturation is 97% with the patient breathing ambient air. Cardiopulmonary examination is normal.
Spirometry is normal.
What is the most appropriate management?
Methacholine challenge testing
Budesonide-salmeterol
Fluticasone
Measurement of exhaled nitric oxide
200
A 42-year-old man is evaluated at a follow-up appointment. He underwent polysomnography 6 weeks ago because of suspected obstructive sleep apnea. The study showed moderate obstructive sleep apnea (apnea-hypopnea index 20) that was controlled with continuous positive airway pressure (CPAP). Although daytime alertness has improved with CPAP, the apparatus is cumbersome to transport on his frequent business trips. At his last visit, the physical examination was normal except for a BMI of 34.
The patient is enrolled in a supervised weight loss program and has started to exercise.
What is the most appropriate treatment?
Oral appliance
Hypoglossal nerve stimulator
Maxillomandibular advancement surgery
Uvulopalatopharyngoplasty
200
A 59-year-old man is seen in a follow-up visit for a 6-month history of progressively worsening chronic cough productive of small amounts of thin clear sputum and dyspnea on exertion. He has shortness of breath when he walks quickly and when he walks uphill. He has a 45-pack-year smoking history but quit 2 years ago. He has been using albuterol as needed since his diagnosis of COPD 3 months ago, but he remains symptomatic.
On physical examination, oxygen saturation is 95% with the patient breathing ambient air. Scattered expiratory wheezing is heard. Cardiac examination is normal.
Chest radiograph from 3 months ago shows flattened diaphragm but no infiltrate.
Spirometry at the time of diagnosis showed reduced postbronchodilator FEV1/FVC ratio and FEV1 of 69% of predicted.
What is the most appropriate pharmacologic treatment?
Inhaled tiotropium bromide
Inhaled fluticasone propionate–salmeterol
Prednisone
Roflumilast
200
A 35-year-old woman is evaluated for a cough and wheezing occurring several times during the week, unrelated to exercise. She has a history of asthma that was previously well controlled with a budesonide inhaler. She is also taking albuterol five times weekly with good response. Her symptoms have woken her once in the past month. She reports no additional symptoms and no environmental triggers. She is a nonsmoker. Inhaler technique is good.
On physical examination, vital signs are normal. Oxygen saturation is 96% with the patient breathing ambient air. Expiratory wheezing is noted.
What treatments should be started?
Add formoterol
Azithromycin
Prednisone
Tiotropium
200
A 49-year-old man is transferred from a psychiatric hospital to the emergency department because of a change in vital signs and encephalopathy. He has schizophrenia and depression. He was hospitalized 3 days ago for acute psychosis and attempted suicide. In the psychiatric hospital, he was treated with risperidone and fluoxetine. He subsequently developed nausea and vomiting and was prescribed promethazine.
On physical examination, temperature is 39.5 °C (103.1 °F), blood pressure is 173/112 mm Hg, pulse rate is 132/min, respiration rate is 26/min, and oxygen saturation is 99% with the patient breathing ambient air. He is diaphoretic and tachypneic, with clear lungs. He has tachycardia without murmur, gallops, or rubs. Muscles are rigid. Deep tendon reflexes are normal.
Promethazine is discontinued.
What is the most appropriate initial treatment?
Discontinue risperidone
Discontinue fluoxetine
Start cyproheptadine
Start dantrolene
300
A 25-year-old man is evaluated in the emergency department for worsening shortness of breath and right-side pleuritic chest pain, which developed 1 hour ago. He has an 8-pack-year history of smoking cigarettes. His medical history is otherwise unremarkable, including the absence of lung disease. He is a professional scuba diver.
On physical examination, blood pressure is 150/70 mm Hg, pulse rate is 105/min, and respiration rate is 30/min. Oxygen saturation is 92% with the patient breathing ambient air. There are decreased breath sounds, reduced expansion, and hyperresonance to percussion on the right side.
Chest radiograph reveals a large right pneumothorax and no signs of tension.
Smoking cessation counseling and an offer of varenicline are planned at the time of discharge.
What is the most appropriate additional pneumothorax management?
Catheter thoracostomy followed by pleurodesis
Needle aspiration
Observation
Supplemental oxygen and observation
300
A 35-year-old man is evaluated in the emergency department 4 hours after being rescued from his burning home by firefighters. He initially refused transportation to the hospital but now desires an evaluation. He reports tracheal irritation with breathing, sore throat, and a change in his voice.
On physical examination, he is alert and in moderate pain. Temperature is 37.5 °C (99.5 °F), blood pressure is 144/90 mm Hg, pulse rate is 100/min, and respiration rate is 26/min. Oxygen saturation is 96% with the patient breathing ambient air. He has dysphonia. There is no soot in the nares or the oral pharynx or burns on his face, neck, or thorax. Nonobstructing edema of the oropharynx is noted. Cardiac examination reveals a regular rhythm. Chest is clear to auscultation; there is no stridor.
Arterial blood gas studies:
pH 7.45
PCO2 35 mm Hg (4.7 kPa)
PO2 95 mm Hg (12.6 kPa)
A chest radiograph shows no infiltrates.
What is the most appropriate management?
Bronchoscopy
Methylprednisolone
Nebulized epinephrine
Noninvasive positive pressure ventilation
300
A 57-year-old woman is evaluated at a follow-up visit after discharge from the hospital for a COPD exacerbation. This was her third hospitalization for a COPD exacerbation in the past 6 months. She no longer smokes cigarettes. Medications are fluticasone-umeclidinium-vilanterol and albuterol inhalers. She has been adherent with her medication, has excellent inhaler technique, and continues to use home oxygen. Between exacerbations she has a cough productive of thin, colorless sputum.
On physical examination, vital signs are normal. Oxygen saturation is 93% breathing oxygen, 2 L/min by nasal cannula. Scattered expiratory wheezing is heard. Cardiac examination is normal.
Spirometry shows postbronchodilator reduced FEV1/FVC ratio and an FEV1 of 45% of predicted.
Influenza, COVID-19, and pneumococcal pneumonia vaccinations are brought up to date. The patient is enrolled in a pulmonary rehabilitation program. α1-Antitrypsin level is normal.
What additional long-term treatments is most appropriate?
Azithromycin
α1-Antitrypsin augmentation therapy
Metoprolol
Oral N-acetylcysteine
300
A 38-year-old man is evaluated for shortness of breath and a dry cough for the past 3 months. He has a 20-pack-year smoking history and continues to smoke.
On physical examination, vital signs are normal. Oxygen saturation is 92% with the patient breathing ambient air. Auscultation of the lungs reveals coarse bibasilar inspiratory crackles. The cardiac examination and remainder of the physical examination are normal.
Chest radiograph demonstrates bilateral reticular infiltrates. High-resolution chest CT demonstrates patchy ground-glass infiltrates with lower-lobe predominance. Pulmonary function testing shows an FVC of 65% of predicted, an FEV1/FVC ratio of 0.81, and a DLCO of 56% of predicted.
What is the most appropriate treatment?
Smoking cessation
Glucocorticoids
Methotrexate
Pirfenidone
400
A 72-year-old man is evaluated in the emergency department for decreasing responsiveness after he spent the day at the zoo. The outside temperature was 38.9 °C (102.0 °F). He also has hypertension. Medications are hydrochlorothiazide and lisinopril.
On physical examination, temperature is 40.5 °C (104.9 °F), blood pressure is 97/54 mm Hg, pulse rate is 117/min, respiration rate is 22/min, and oxygen saturation is 96% with the patient breathing ambient air. He is somnolent. His skin is flushed, warm, and dry. Other than tachycardia, cardiac and pulmonary examinations are normal.
Laboratory results are pending.
What is the most appropriate treatment?
Evaporative cooling
Acetaminophen
Dantrolene
Immersion in ice water
400
A 42-year-old man is evaluated for fatigue, dyspnea, and lightheadedness. He was diagnosed with a provoked pulmonary embolism 5 months ago and has been taking apixaban since then. Initially, his dyspnea and tachycardia improved, but over the past 2 months, he has had progressive exertional dyspnea.
On physical examination, vital signs are normal. BMI is 28. Cardiopulmonary examination is normal.
An echocardiogram reveals right atrial enlargement and right ventricular hypertrophy and an elevated mean pulmonary artery pressure.
What is the most appropriate diagnostic test?
Ventilation/perfusion scan
CT angiography of the chest
D-dimer assay
Right heart catheterization and pulmonary angiography
400
A 63-year-old man is evaluated for dyspnea. The patient has newly diagnosed stage IV lung adenocarcinoma with a right malignant pleural effusion. A thoracentesis removed 1200 mL of bloody fluid 5 days ago with relief of dyspnea. Follow-up chest radiograph documented incomplete expansion of the right lung, with air replacing the removed pleural fluid. He has returned to the emergency department today with increasing dyspnea.
On physical examination, vital signs are normal. Respiration rate is 18/min. Oxygen saturation is 93% with the patient breathing ambient air. Lung examination is consistent with a large right pleural effusion.
Repeat chest radiograph shows a large right-sided pleural effusion with loculations.
What is the most appropriate management?
Indwelling pleural catheter
Chemical pleurodesis
Repeat thoracentesis
Surgical decortication
400
A 36-year-old woman is evaluated for respiratory failure requiring invasive mechanical ventilation following a motor vehicle accident.
On physical examination, temperature is 38.0 °C (100.4 °F), blood pressure is 100/65 mm Hg, pulse rate is 100/min, and respiration rate is 26/min. Oxygen saturation is 90% with an FIO2 of 0.50 and positive end-expiratory pressure of 12 cm H2O. There are multiple contusions on her chest. Estimated central venous pressure is normal. Other than tachycardia, cardiac examination is normal. There are diffuse lung crackles.
Arterial blood gas studies:
pH 7.3
PCO2 50 mm Hg (6.6 kPa)
PO2 66 mm Hg (8.8 kPa)
Chest radiograph is shown.
Hemoglobin has remained stable. Echocardiogram reveals a normal ejection fraction and valvular function. ECG shows only sinus tachycardia.
What is the most likely diagnosis?
Acute respiratory distress syndrome
Diffuse alveolar hemorrhage
Pulmonary edema
Pulmonary embolism
500
A 67-year-old man is evaluated for progressive shortness of breath and dry cough over the past 3 months. He has a 40-pack-year history of cigarette smoking. His only medication is an albuterol inhaler.
On physical examination, pulse rate is 90/min and respiration rate is 24/min. Oxygen saturation is 88% with the patient breathing ambient air. Auscultation demonstrates bibasilar crackles. Clubbing is present.
Spirometry shows an FVC of 110% of predicted, an FEV1 of 95% of predicted, an FEV1/FVC ratio of 0.68, and a DLCO of 36% of predicted.
An echocardiogram shows normal left ventricle ejection fraction. Right ventricle systolic pressure is 66 mm Hg.
Representative high-resolution CT chest images are shown.
What is the most likely diagnosis?
Combined pulmonary fibrosis and emphysema
Acute interstitial pneumonia
Desquamative interstitial pneumonia
Idiopathic pulmonary fibrosis
500
A 59-year-old woman was hospitalized for a first COPD exacerbation 5 days ago and is now preparing for discharge. She quit smoking 5 years ago. Immunizations are up to date. Medications are daily tiotropium bromide and albuterol inhalers as needed. Prednisone is to be discontinued today.
On physical examination, vital signs are normal. Oxygen saturation at rest is 87% with the patient breathing ambient air. Breath sounds are distant, without wheezing. Cardiovascular examination is normal.
Complete blood count is normal.
Arterial blood gas studies (at time of discharge):
pH 7.42
PCO2 44 mm Hg (5.8 kPa)
PO2 55 mm Hg (7.3 kPa)
What is the most appropriate additional treatment?
Home oxygen
Aminophylline
Noninvasive positive pressure ventilation
Stop current inhalers; start inhaled fluticasone
500
A 31-year-old man is evaluated following an abnormal finding on a chest radiograph obtained as a part of pre-employment screening. He is a lifelong nonsmoker with no history of dust exposure. His medical history is unremarkable, and he has no known respiratory or constitutional symptoms.
The vital signs and physical examination are normal.
Spirometry is normal.
Chest radiograph reveals bilateral symmetric hilar prominence with clear lung fields.
Interferon-γ release assay is normal.
What is the most appropriate management?
Observation
Bronchoscopic biopsy
Methotrexate
Prednisone
500
A 28-year-old woman is evaluated for sleepiness and difficulty staying awake over the past 6 months. She works as a hospital respiratory therapist. Half of her shifts are from 7:00 PM to 7:00 AM. The sleepiness subsides by the time she drives home, and she then has difficulty falling asleep during the day. Her sleepiness has slowed her cognitive processing during working hours and has resulted in depressed mood.
On physical examination, blood pressure is 118/68 mm Hg and pulse rate is 76/min. BMI is 24.
What is the most appropriate management?
Education and counseling
Home sleep apnea testing
Modafinil
Zolpidem