A
A 29-year-old woman was hospitalized 24 hours ago with hypoxemic respiratory failure due to influenza pneumonia. She was intubated and placed on mechanical ventilation. Treatment includes lactated Ringer solution, intravenous peramivir, propofol, fentanyl, and norepinephrine.
On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 109/59 mm Hg, pulse rate is 90/min, and respiration rate is 24/min. The arterial PO2 is 60 mm Hg on FIO2 of 0.65, and positive end-expiratory pressure is 10 cm H2O. Tidal volume is 6 mL/kg ideal body weight, and plateau pressure is 27 cm H2O. The patient is sedated but wakes to touch and is calm. Pulmonary rhonchi are present bilaterally.
Chest radiograph shows bilateral opacities. Echocardiogram reveals normal cardiac function and chamber size.
Which of the following is the most appropriate intervention to improve oxygenation?
Prone positioning
Perform recruitment maneuver
Diuresis
Increase sedation
A 57-year-old woman is evaluated for progressive dyspnea of 1 year's duration. She has otherwise been well and takes no medications.
On physical examination, blood pressure is 121/82 mm Hg. Oxygen saturation is 94% with the patient breathing ambient air. There is a grade 2/6 systolic murmur at the left lower sternal border that increases with inspiration and persistent splitting of S2. Central venous pressure is elevated. There is a prominent venous a wave.
ECG shows right atrial enlargement. Chest radiograph shows prominence of the pulmonary artery. Echocardiogram reveals a right ventricular systolic pressure of 64 mm Hg and an estimated right atrial pressure of 15 mm Hg. Left ventricular function is normal. Pulmonary function tests show decreased DLCO but are otherwise normal. Ventilation/perfusion scan is low probability for pulmonary embolism.
Which of the following is the most appropriate management?
Right heart cath
Sildenafil
Enalapril
Coronary angiogram
A 32-year-old woman is evaluated in the hospital for a 3-week history of progressive shortness of breath, arthralgia, and fatigue. Her only medication is pantoprazole for gastroesophageal reflux disease. Medical history is significant for Raynaud phenomenon treated with cold avoidance. She works in an accounting firm and has no unusual environmental exposures.
On physical examination, blood pressure is 140/90 mm Hg, pulse rate is 98/min, and respiration rate is 24/min. Oxygen saturation is 90% breathing oxygen, 2 L/min by nasal cannula. Auscultation reveals crackles at both lung bases. She has puffy-appearing fingers. The remainder of the examination is normal.
Laboratory studies:
Hemoglobin 11 g/dL
C-reactive protein 4 mg/dL
Antinuclear antibody Positive
Antitopoisomerase I (anti-Scl-70) antibody Positive
Chest radiograph shows bilaterally increased markings with a basilar predominance without lymphadenopathy.
Which of the following is the most likely diagnosis?
Hypersensitivity pneumonitis
Idiopathic pulm fibrosis
Sarcoidosis
A 62-year-old man is evaluated during a follow-up visit for COPD. He continues to smoke one pack daily and has a 40-pack-year history. He can walk rapidly on a level surface but has breathlessness walking up a slight hill. He has not been hospitalized or seen urgently for an exacerbation. Medications are salmeterol and tiotropium.
On physical examination, vital signs are normal. Oxygen saturation is 92% with the patient breathing ambient air. Faint expiratory wheezing is present.
Spirometry shows an FEV1/FVC ratio of 0.58, and FEV1 is 62% of predicted.
Which of the following is the most appropriate additional therapy?
Smoking cessation
Prednisone
Chronic azithro
Pulm rehab
A 55-year-old woman is hospitalized for increased daytime sleepiness that has progressed since discharge from the hospital 2 days ago. She had right knee arthroplasty for osteoarthritis-related severe knee pain. She has a history of obesity, hypertension, and type 2 diabetes mellitus. Medications are lisinopril, metformin, and liraglutide. In addition, she was discharged on oxycodone and enoxaparin.
On physical examination, respiration rate is 12/min; the remainder of the vital signs are normal. BMI is 44. Oxygen saturation is 94% breathing oxygen, 5 L/min by nasal cannula. She is sleepy but easily aroused and cooperative. Lung sounds are distant. A healing surgical wound is present. The remainder of the examination is unremarkable.
Laboratory studies:
Bicarbonate 33 mEq/L (22-28)
Arterial blood gases:
pH 7.25
PCO2 78 mm Hg (35-45)
PO2 66 mm Hg (80-100)
Pulmonary function tests performed 1 month ago demonstrated a restrictive pattern.
Chest radiograph shows small lung fields.
Which of the following is the most appropriate treatment?
BiPap
CPAP
Acetazolamide
Intubation w/mechanical ventilation
A 22-year-old man is evaluated in the emergency department (ED) after being pulled from a partially frozen lake. Immersion time is estimated to be 2 hours. He was found by emergency medical services and was unresponsive and pulseless. He was intubated, and advanced life support was initiated. On arrival at the ED, pulse had returned and cardiopulmonary resuscitation was stopped. Mechanical ventilation was initiated, and intravenous fluids were administered. Wet clothes were removed.
On physical examination, blood pressure is 92/60 mm Hg. Temperature by an esophageal probe is 27.6 °C (81.7 °F). There are no signs of trauma.
Laboratory studies:
Glucose 88 mg/dL
Potassium 5.4 mEq/L
Arterial blood gas studies:
pH7.28
Pco2 36 mm Hg (35-45)
PO2 110 mm Hg (80-100)
Which of the following is the most appropriate warming technique?
Active internal rewarming
Passive rewarming
Hemodialysis
Cardiopulmonary bypass warming
A 66-year-old woman is evaluated for stress ulcer prophylaxis. She has been in the ICU on mechanical ventilation for 72 hours for respiratory failure due to community-acquired pneumonia. She has required vasopressors and glucocorticoids to maintain her blood pressure. She has acute kidney injury. Medications are ceftaroline, levofloxacin, norepinephrine, dexamethasone, and low-molecular-weight heparin. She is receiving enteral nutrition through a feeding tube.
The decision is made to initiate stress ulcer prophylaxis with an oral proton pump inhibitor.
A reduction in which of the following outcomes is most likely with this preventive strategy?
GIB
Mortality
Hospital stay
ICU stay
A 22-year-old man is evaluated for a 6-week history of shortness of breath and cough. He is otherwise healthy and takes no medications. He works from home as a software developer. Two months ago, he acquired a pet parakeet.
On physical examination, other than a respiratory rate of 25/min, vital signs are normal. Oxygen saturation is 93% with the patient breathing ambient air. Auscultation demonstrates inspiratory crackles over both lung fields. The remainder of the physical examination is normal.
Chest CT shows micronodular opacities in the mid- to upper-lung zones.
Which of the following is the most appropriate management?
Get rid of the parakeet
Lung transplant
Nintedanib
Surgical lung biopsy
A 64-year-old man is treated in the emergency department for a COPD exacerbation characterized by worsened dyspnea, cough, and increased purulent sputum. Home medications are inhaled fluticasone-vilanterol and tiotropium.
On physical examination, temperature is 36.9 °C (98.4 °F), blood pressure is 128/71 mm Hg, pulse rate is 96/min, respiration rate is 18/min, and oxygen saturation is 92% breathing oxygen, 2 L/min by nasal cannula. Lung examination reveals expiratory wheezing and mildly labored respirations. The remainder of the physical examination is normal.
Chest radiograph shows a flattened diaphragm but no infiltrates or pleural effusions.
Treatment is initiated with prednisone and nebulized albuterol-ipratropium.
Which of the following is the most appropriate additional treatment?
Azithro
IV theophylline
IV pip-tazo
BiPap
A 54-year-old man is evaluated during a follow-up visit for asthma. He has a 5-year history of persistent asthma. He has had one exacerbation within the last year, which was treated with glucocorticoids. He reports no wheezing but notes an intermittent nonproductive cough. His Asthma Control Test score is 24, indicating well-controlled asthma. He reports adherence to his maintenance inhaler and demonstrates good inhaler technique. He describes symptoms of epigastric burning following meals. He has no other gastrointestinal symptoms. He does not smoke, and he exercises daily without limitation. Medications are fluticasone-salmeterol 100/50 μg and an albuterol inhaler.
On physical examination, vital signs are normal, and no wheezing is noted. Spirometry is normal. Fractional exhaled nitric oxide level is normal.
Which of the following is the most appropriate management?
Omeprazole
Increase fluticasone-salmeteroldose
Switch fluticasone-salmeterol to fluticasone 250
Upper endoscopy
A 34-year-old man is evaluated at a routine follow-up examination. He has a history of spirometry-confirmed asthma. He reports feeling well and denies sinus symptoms, gastroesophageal reflux disease, and tobacco use. He demonstrates excellent inhaler technique. Medications are inhaled budesonide and albuterol.
On physical examination, vital signs are normal, and the remainder of the examination is unremarkable.
Which of the following is the most appropriate next step in evaluation?
Perform Asthma Control Test
Measure FENO
Obtain CXR
Perform 6 min walk test
A 34-year-old man is evaluated in the emergency department after being found unresponsive in a homeless shelter with two empty bottles of hand sanitizer. The pertinent listed ingredients of the hand sanitizer are ethanol and isopropyl alcohol. The patient has a history of chronic alcoholism.
On physical examination, temperature is normal, blood pressure is 112/68 mm Hg, pulse rate is 94/min, respiration rate is 14/min, and oxygen saturation is 96% breathing oxygen, 2 L/min by nasal cannula. He arouses to painful stimuli. His speech is slurred, and he shows psychomotor slowing. Neurologic examination is otherwise normal.
The calculated anion gap is normal; the osmolal gap is elevated.
Which of the following is the most appropriate management?
Supportive care
Ethanol
Flumazenil
Hemodialysis
A 55-year-old woman is evaluated for progressive anemia during her 12-day hospital stay. She was hospitalized for pneumonia that progressed to acute respiratory distress syndrome requiring intubation and mechanical ventilation. Since intubation, daily routine laboratory evaluation has detected a slow decline in hemoglobin level from 12.5 g/dL (125 g/L) to the current level of 9.0 g/dL (90 g/L). There is no evidence of bleeding. Medications are propofol infusion, fentanyl infusions, and cefotaxime and levofloxacin.
Laboratory studies document normal platelet and leukocyte counts. The reticulocyte count is elevated, and the peripheral blood smear, other than documenting reticulocytosis, is normal. The direct antiglobulin test is negative, and there is no laboratory evidence of hemolysis.
Which of the following is the most appropriate management?
Discontinue routine blood tests
EPO
Transfusion
Iron studies
A 67-year-old woman is evaluated for a 6-month history of dull right chest pain, persistent cough, and dyspnea on exertion. During this time she lost 9.1 kg (20 lb) and had night sweats. She is a retired ship refitter. She has a 25-pack-year smoking history and quit smoking 20 years ago.
On physical examination, vital signs are normal. There are diminished breath sounds and dullness to percussion over the right lower hemithorax. Cardiac examination is normal.
Chest radiograph demonstrates a large pleural effusion on the right side as well as pleural plaques. Chest CT scan shows basilar fibrosis and moderate to large right-sided pleural effusion with associated pleural thickening and nodularity.
Thoracentesis yields 1200 mL of serosanguinous fluid; chemical analysis is compatible with an exudative effusion. Interferon-γ release assay is negative. Cytology findings are negative for malignancy.
Which of the following is the most appropriate diagnostic test to perform next?
thorascopic pleural plaque biopsy
PET
repeat thora
closed pleural biopsy
A 66-year-old woman is evaluated in the ICU for management of acute hypoxic respiratory failure due to viral pneumonia. She has no other medical problems and takes no medications.
On physical examination, the patient is calm, alert, and interactive. Temperature is 37.6 °C (99.7 °F), blood pressure is 140/90 mm Hg, pulse rate is 100/min, and respiration rate is 32/min. Oxygen saturation is 89% breathing oxygen, 3 L/min by nasal cannula. Lung examination reveals bilateral rhonchi and tachypnea. Cardiac examination is normal.
On arterial blood gas analysis with the patient breathing ambient air, pH is 7.40, PCO2 is 37 mm Hg (4.9 kPa), and PO2 is 58 mm Hg (7.7 kPa).
Chest radiograph shows bilateral opacities.
Therapy is initiated.
Which of the following is the most appropriate additional management of the patient's hypoxemia?
High flow humidified NC
NIPPV
Intubation and mechanical vent
No change in treatment
A 63-year-old woman is evaluated for increasing shortness of breath for the past 2 months. She has ischemic cardiomyopathy and a history of breast cancer treated with surgery and irradiation 9 years ago. When she was between 20 and 30 years of age, she worked installing brakes on automobiles. She is on guideline-directed medical therapy for heart failure.
On physical examination, vital signs normal. Cardiac examination reveals an S3, mitral regurgitation, hepatomegaly, possible ascites, and peripheral edema. There is dullness to percussion and absent breath sounds at the left base.
Chest radiograph shows a moderate left-sided pleural effusion but is otherwise normal.
A thoracentesis removes 600 mL of bloody fluid. The pleural fluid lactate dehydrogenase (LDH) level is 208 U/L, and the total protein level is 4.4 g/L. Simultaneous serum lactate dehydrogenase level is 279 U/L, and total protein level is 7.6 g/dL (76 g/L). Pleural fluid cytology is pending.
Which of the following is the most likely diagnosis?
Malignancy
Heart failure
Hepatic hydrothorax
Benign aspestos pleural effusion (BAPE)
A 28-year-old woman is evaluated in the emergency department for severe headache and blurred vision of 8 hours' duration. She is 35 weeks pregnant. She has no history of hypertension. Her only medication is a multivitamin.
On physical examination, blood pressure is 200/110 mm Hg, pulse rate is 90/min, and respiration rate is 20/min. Oxygen saturation is 96% with the patient breathing ambient air. No focal neurologic deficits are noted.
Laboratory studies reveal a hemoglobin level of 12 g/dL (120 g/L), a platelet count of 120,000/μL (120 × 109/L), and a urine protein-creatinine ratio of 600 mg/g. Aminotransferase levels are normal.
Blood pressure is reduced to 180/100 mm Hg with intravenous labetalol.
Which of the following is the most appropriate next step in management?
Delivery
IV betamethasone
IV enalapril
IV nitroprusside
A 67-year-old man is evaluated before airline travel. He is planning a trip to Hawaii next month. He has COPD and becomes dyspneic when walking short distances on level ground. Results of his last pulmonary function test indicated an FEV1 of 40% of predicted. He has not yet required oxygen supplementation. Medications are tiotropium, salmeterol, and fluticasone and albuterol inhalers.
On physical examination, respiration rate is 16/min. Auscultation of the lungs reveals a prolonged expiratory phase with no wheezes.
Which of the following is the most appropriate next step?
Resting pulse ox
No further testing
High altitude stimulation test
Recommend against air travel
A 54-year-old man is evaluated for a 2-year history of chronic productive cough. He has intermittent wheezing, shortness of breath with exertion, and nasal congestion.
On physical examination, vital signs are normal. Bibasilar crackles are present. Cardiac examination is normal.
CT scan of the chest shows cylindrical bronchiectasis of bilateral lower lobes.
Which of the following is the most appropriate diagnostic test to perform next?
immunoglobulin measurement
nasal ciliary biopsy
bronch with BAL
measure IgG to pneumo vacc
A 24-year-old woman is evaluated for intermittent cough, wheezing, and chest tightness of 1 month's duration. She reports worsening symptoms with exercise and with cat exposure.
On physical examination, vital signs are normal. She has end-expiratory wheezing. Cardiac examination is normal.
On spirometry, FEV1 is 75% of predicted and improves significantly following inhaled albuterol.
Which of the following tests will help predict this patient's responsiveness to inhaled glucocorticoids?
FENO
Bronchial challenge testing
DLCO
Pulse ox