A
B
C
D
100
A 66-year-old man is evaluated for a 7-month history of gradually progressive shortness of breath and dry cough. Medical history is otherwise unremarkable, and he takes no medications.
On physical examination, vital signs are normal. Oxygen saturation is 93% with the patient breathing ambient air. Auscultation reveals fine end-inspiratory bibasilar crackles. Clubbing is present. There are no rashes or edema. Cardiac examination is unremarkable.
Chest radiograph reveals small lung volumes and bibasilar reticular infiltrates without lymphadenopathy. Spirometry reveals an FEV1/FVC ratio of 0.87, an FVC of 62% of predicted, and a DLCO of 48% of predicted.
Which of the following is the most appropriate diagnostic test to perform next?
High resolution CT chest
Lung biopsy
Exercise test
CT angio
TTE
100
A 45-year-old woman is evaluated for increasing shortness of breath and fatigue for the past 6 weeks and weight loss of 4.5 kg (10 lb) over the past 2 months. She has no other symptoms. She has a history of rheumatoid arthritis. Her only medications are methotrexate and folic acid.
On physical examination, vital signs are normal. Typical chronic changes of rheumatoid arthritis are present in her hands, wrists, and feet in the absence of active synovitis. Chest findings are consistent with bilateral pleural effusions.
Complete blood count is normal. Serum lactate dehydrogenase level is 200 U/L (normal 60-100), and total serum protein level is 6 g/dL (normal 6-7.8).
Pleural fluid studies:
Leukocyte count
600/μL (0.6 × 109/L) (70% lymphocytes)
pH
7.4
Glucose
100 mg/dL (5.5 mmol/L)
Lactate dehydrogenase
85 U/L
Total protein
4.1 gm/dL (41 g/L)
Total cholesterol
120 mg/dL (3.1 mmol/L)
Triglycerides
140 mg/dL (1.58 mmol/L)
Chest radiograph demonstrates bilateral pleural effusions and bulky mediastinal lymphadenopathy. Thoracentesis is performed, and 1100 mL of milky fluid is drained.
Which of the following is the most likely diagnosis?
Chylothorax
Empyema
RA
Cholesterol effusion
100
A 57-year-old woman is evaluated for a 4-month history of progressive exertional dyspnea and occasional chest pain and palpitations. She has limited cutaneous systemic sclerosis with Raynaud phenomenon and gastroesophageal reflux disease. Medications are omeprazole and diltiazem.
On physical examination, blood pressure is 107/74 mm Hg and pulse rate is 90/min. Oxygen saturation is normal at rest. Characteristic skin findings of limited cutaneous systemic sclerosis are present. New cardiac findings include jugular venous distention, persistent splitting of S2, and 2/6 systolic murmur at the left lower sternal border that increases with inspiration. Lungs are clear.
ECG shows a heart rate of 95/min and is otherwise normal. Chest radiograph is normal. Echocardiography performed 12 months ago was normal.
Which of the following is the most appropriate diagnostic test?
ECHO (RHC is what I guessed, too)
CTA chest
Exercise stress test
PFTs
100
A 32-year-old man is evaluated in the emergency department after being found unresponsive at home. Methadone and lorazepam pill bottles were found nearby. At the scene, respiratory rate was 6/min. He was administered supplemental oxygen and intranasal naloxone, followed by intravenous naloxone. Food found in his mouth was cleared.
In the emergency department, intravenous naloxone is repeated. Temperature is 37.2 °C (99.0 °F), blood pressure is 120/68 mm Hg, pulse rate is 80/min, respiratory rate is 10/min, and oxygen saturation is 90% breathing oxygen, 5 L/min by nasal cannula. The patient is unresponsive. Pupillary miosis is present but responsive to light.
The fingerstick blood glucose level is 88 mg/dL (4.9 mmol/L).
Portable chest radiograph shows a right lower lobe infiltrate.
Which of the following is the most appropriate treatment?
Intubate
IV naloxone infusion
Flumazenil
O2 via nonrebreather
200
A 24-year-old woman is evaluated in the emergency department for acute onset of dyspnea and pleuritic chest pain. She is 10 weeks pregnant. She is otherwise well, and her only medication is folic acid.
On physical examination, temperature is 37.7 °C (99.9 °F), blood pressure is 140/78 mm Hg, pulse rate is 90/min, respiration rate is 24/min, and oxygen saturation is 95% with the patient breathing ambient air. Cardiopulmonary examination is normal. There is no evidence of deep venous thrombosis.
A chest radiograph is normal. A ventilation/perfusion lung scan is interpreted as high probability for pulmonary embolism.
Which of the following is the most appropriate treatment?
LMWH
Dabigatran
Fondaparinux
Rivaroxaban
Unfractionated heparin followed by warfarin
200
A 66-year-old man is evaluated for gradually progressive dyspnea and dry cough over the past 6 months. He has a 30-pack-year history of smoking; he stopped 10 years ago. Medical history is otherwise unremarkable.
On physical examination, respiration rate is 22/min. Oxygen saturation is 93% with the patient breathing ambient air. Auscultation of the lungs reveals fine end-inspiratory Velcro-like crackles at both lung bases. Clubbing is present.
Spirometry shows an FVC of 55% of predicted, an FEV1/FVC ratio of 0.91, and a DLCO of 42% of predicted.
A high-resolution CT scan of the chest is shown.
Which of the following is the most likely diagnosis?
Idiopathic Pulm Fibrosis
Cryptogenic organizing pneumonia
Nonspecific interstitial pneumonia
Respiratory bronchiolitis-associated interstitial lung disease
200
A 52-year-old man is evaluated following a diagnosis of severe obstructive sleep apnea 8 weeks ago. He was prescribed auto-adjusting positive airway pressure therapy. He uses a nasal mask with heated humidification. He still feels drowsy during the day.
Which of the following is the most appropriate management?
Assess adherence
Bipap
Eszoplicone
Modafinil
200
A 23-year-old man is evaluated for cough, rhinorrhea, and wheezing of 3 weeks' duration. He has no fevers, chills, or chest pain and no history of asthma or allergies. He is a pastry chef and notes that his symptoms improve on nonworking weekends.
On physical examination, vital signs are normal. Oxygen saturation is 94% with the patient breathing ambient air. Expiratory wheezing is noted.
Laboratory studies show a normal Aspergillus-specific IgE level.
Spirometry reveals moderate airflow obstruction that improves after inhaled albuterol.
Chest radiograph is normal.
Which of the following is the most likely diagnosis?
Occupational asthma
Acute bronchitis
Acute hypersensitivity pneumonitis
ABPA
300
A 77-year-old man is evaluated for acute agitation with worsening of oxygenation, hypotension, and tachycardia over the last 30 minutes. He was hospitalized 2 days ago with pneumonia and hypoxemic respiratory failure requiring mechanical ventilation. Medical history is also significant for COPD and heart failure. Medications are cefotaxime, levofloxacin, propofol, furosemide, albuterol, and low-molecular-weight heparin.
On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 102/55 mm Hg, pulse rate is 122/min, and respiration rate is 30/min. Oxygen saturation is 87% with a tidal volume of 420 mL, a positive end-expiratory pressure of 8 cm H2O, and FIO2 of 0.50. Trachea is midline. Pulmonary examination reveals decreased breath sounds bilaterally. The jugular vein is difficult to visualize; an S3 is present.
Which of the following is the most appropriate management?
Bedside thoracic ultrasonography
CT of the chest
Infusion of cisatracurium
Needle thoracostomy
300
A 37-year-old woman is evaluated in the emergency department for headache, dyspnea, and cough. Two days ago she traveled from her home at 300 meters (984 feet) above sea level to a mountain ski resort where the slopes are as high as 3914 meters (12,841 feet). She developed the headache yesterday, and today it is worse and she has shortness of breath and a cough.
On physical examination, temperature is 38.0 °C (100.4 °F), blood pressure is 124/72 mm Hg, pulse rate is 115/min, and respiration rate is 28/min. Oxygen saturation is 82% with the patient breathing ambient air. Inspiratory crackles are present bilaterally.
Chest radiograph demonstrates patchy alveolar infiltrates.
High-flow supplemental oxygen by nasal cannula is initiated.
Which of the following is the most appropriate additional treatment?
Descend to lower altitude
Acetazolamide
Furosemide
Dexamethasone
300
An 81-year-old man is evaluated in the hospital for pneumonia.
On physical examination, temperature is 38.0 °C (100.4 °F), blood pressure is 119/65 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. Oxygen saturation is 88% with the patient breathing ambient air. There are coarse rhonchi and decreased breath sounds and dullness to percussion over the left lower half of the chest.
CT scan of the chest shows left lower lobe consolidation and loculated left pleural effusion. A thoracentesis is performed.
Which of the following pleural fluid tests is most appropriate in directing therapy?
pH
LDH
total protein
procal
300
A 62-year-old man is evaluated in follow-up examination for COPD. Despite smoking cessation, adherence to his medical regimen, good inhaler technique, and participation in pulmonary rehabilitation, he continues to experience breathlessness with mild exertion and has diminished quality of life. He has a minimal dry cough, and he has never required treatment for an acute exacerbation of COPD. Medications are fluticasone-umeclidinium-vilanterol and albuterol inhalers as needed. Immunizations are up to date.
On physical examination, vital signs are normal. Oxygen saturation is 93% with the patient breathing ambient air. There are diminished breath sounds.
A 6-minute walk test shows a minimum oxygen saturation of 90% with the patient breathing ambient air. Spirometry shows an FEV1 of 35% of predicted and a DLCO of 42% of predicted.
Chest imaging shows upper-lobe-predominant emphysema.
Which of the following is the most appropriate treatment?
Lung volume reduction surgery
Longterm/Lifelong azithromycin
Supplemental oxygen
Roflumilast
400
A 62-year-old woman is evaluated in the emergency department for fatigue, headaches, confusion, and weakness that have progressed over the past 6 weeks. She has an 11.3 kg (25 lb) unintentional weight loss over the past month. She has an 85-pack-year history of smoking and quit smoking 3 months ago.
On physical examination, blood pressure is 125/75 mm Hg, pulse rate is 92/min, respiration rate is 21/min, and oxygen saturation is 89% with the patient breathing ambient air. BMI is 17. An expiratory wheeze is noted on the left side. The remainder of the examination is normal.
Laboratory evaluation reveals a serum sodium level of 123 mEq/L (123 mmol/L).
CT scan of the chest shows a 4-cm mediastinal mass compressing the left upper lobe bronchus with associated bulky mediastinal lymphadenopathy.
Which of the following is the most likely diagnosis?
Small cell lung cancer
Fibrosing mediastinitis
Adenocarcinoma of lung
Large cell lung cancer
400
An 84-year-old man living in a nursing home is evaluated in the emergency department for recent onset of unresponsiveness and fever. He has Alzheimer dementia.
On physical examination, temperature is 39.3 °C (102.7 °F), blood pressure is 88/50 mm Hg, pulse rate is 106/min, and respiration rate is 18/min. Oxygen saturation is 95% with the patient breathing ambient air. The patient is responsive only to physical stimuli. Cardiopulmonary examination reveals normal heart and lung sounds. Abdominal examination is normal. A 6 × 6 cm necrotic sacral decubitus wound is present.
Laboratory data are pending. Blood cultures are obtained.
What type of fluids are the most appropriate resuscitative treatment?
Lactated ringers
Hydroxyethyl starch
5% albumin
150 mEq bicarb in dextrose 5%
400
A 27-year-old woman is evaluated for a cough and chest tightness that occur during and after exercise. She has been training for her first marathon, but she has been unable to increase her training intensity because of these symptoms. She denies cough or chest tightness at any other time. She reports no stridor, throat tightness, or noisy inspiration during the episodes.
On physical examination, vital signs and pulmonary examination are normal.
Baseline spirometry is normal. Exercise testing demonstrates a significant decrease in FEV1 from baseline.
Which of the following inhaled medications is the most appropriate next step in treatment?
Symbicort before exercise
Ipratropium before exercise
Budesonide daily
Salmeterol daily
400
A 48-year-old man is evaluated in the emergency department for an acute myocardial infarction. Medical history is significant for hyperlipidemia. His only medication is atorvastatin.
On physical examination, pulse rate is 56/min. Other vital signs are normal. Oxygen saturation is 96% with the patient breathing ambient air. Cardiac examination reveals an S4. Lungs are clear.
The initial serum troponin I level is elevated. An ECG shows ST-segment elevations in leads II, III, and aVF. A chest radiograph is normal.
Which of the following is the most appropriate oxygen management?
No additional oxygen
3 L/min by NC
Nonrebreather mask
Venturi mask
500
A 50-year-old woman was admitted to the ICU 24 hours ago for management of acute respiratory distress syndrome due to pneumonia. She is on a mechanical ventilator. She is receiving vasopressors for hypotension. Medications are norepinephrine, fentanyl drip, and propofol drip.
On physical examination, vital signs are stable. Oxygen saturation is 90%, with an FIO2 of 0.60, and positive end-expiratory pressure is 12 cm H2O. The patient is deeply sedated and unresponsive to physical stimulation.
Which of the following is the most appropriate management?
Hold sedation and analgesia
Titrate down sedation and analgesia
Head CT
EEG
500
A 63-year-old woman is evaluated at a follow-up visit for a solitary pulmonary nodule. Six months ago CT angiography (CTA) was performed to evaluate a possible pulmonary embolism. The CTA was negative but demonstrated an 8-mm ground-glass (subsolid) nodule in the left upper lobe. The patient has a 15-pack-year history of cigarette smoking but stopped 6 months ago. Medical history is otherwise unremarkable, and she takes no medications.
On physical examination, vital signs and other examination findings are normal.
A repeat chest CT scan 6 months after the initial scan shows no change in the size or characteristics of the nodule.
Which of the following is the most appropriate management?
CT scan every 2 years for 5 years
CT scan in 12 mos
Surgical resection
PET scan
500
A 27-year-old woman is evaluated in the emergency department for difficulty breathing following a hornet sting to the leg.
On physical examination, blood pressure is 86/54 mm Hg, pulse rate is 130/min, and respiration rate is 20/min. Expiratory wheezing is noted. Her lips are swollen. Urticarial skin lesions are present.
She is administered 1 L of intravenous 0.9% saline, nebulized albuterol, and intramuscular epinephrine. Vital signs normalize, and dyspnea improves. Forty-five minutes later, systolic blood pressure is 90 mm Hg, pulse rate is 128/min, and wheezing has returned.
Which of the following is the most appropriate treatment?
EPI!!
Methylpred
Benadryl
Famotidine
Norepi
500
A 52-year-old man is evaluated after hospital discharge for total knee arthroplasty. In the recovery room following the procedure, he was reintubated because of hypoxemia, which was then completely resolved. The postintubation chest radiograph was normal. Hypoxemia did not return following extubation 24 hours later, and oxygenation was normal at discharge on hospital day 4. He also has hypertension. Medications are lisinopril and short-term apixaban for postarthroplasty venous thromboembolism prophylaxis.
On physical examination, vital signs are normal. BMI is 31. Neck circumference is 42 cm (16.5 in). He has a low-lying soft palate. Lung and heart examinations are normal.
Which of the following is the most likely cause of the hypoxemia?
OSA
PE
pulm edema
aspiration PNA