Pulmonology

Question 1

Which of the following statements is true regarding emphysema?

A. Associated with mucopurulent sputum and chronic cough

B. Characterized by submucosal and peribronchiolar fibrosis

C. Structural changes occur distal to the terminal bronchioles

D. There is airflow obstruction that is reversible with treatment

Answer 1

Structural changes occur distal to the terminal bronchioles

Question 2

A 58-year-old man presents to the emergency department with shortness of breath, cough, fever, nausea, and diarrhea for three days. He recently installed a hot tub in his home and has been using it quite frequently. Physical exam reveals a soft, mildly tender abdomen, bilateral crackles on chest auscultation, and a pulse oxygen saturation of 91%. Abnormal laboratory values include leukocytosis, hyponatremia, and elevated liver enzymes. Which of the following causes of atypical pneumonia correlates most closely with this patient’s clinical picture?

A. Klebsiella pneumoniae
B. Legionella pneumoniae
C. Mycoplasma pneumoniae
D. Pseudomonas aeruginosa

What antibiotic is the treatment of choice?

Answer 2

Legionella pneumoniae

Legionella pneumoniae is a gram-negative, aerobic organism responsible for both nosocomial and community-acquired pneumonia. The bacteria are present in water and soil, and infection occurs via contaminated aerosolized particles.

Levofloxacin or Doxycicline

Question 3

What is Pontiac fever?

Answer 3

A self-limited, acute febrile illness caused by Legionella pneumoniae that results in gastrointestinal and constitutional symptoms but no respiratory symptoms.

Question 4

In a young patient whom you suspect asthma, what would be the expected results of pulmonary functioning testing?

Answer 4

In asthma, since there is an obstruction (inflammation), you will have a decreased FEV1 and, therefore, a reduced FEV1 to FVC ratio

Will also likely see an increased RV, TLC, and RV/TLC

Question 5

What are the treatment steps for asthma and their associated symptoms?

Answer 5

Mild Intermittent: Less than 2 times per week or 3-night symptoms per month

Step 1: Short-acting beta2 agonist (SABA) PRN
Mild Persistent: More than 2 times per week or 3-4 night symptoms per month

Step 2: Low-Dose inhaled corticosteroids (ICS) daily
Moderate Persistent: Daily symptoms or more than 1 nightly episode per week

Step 3: Low-Dose ICS + Long-acting beta2 agonist (LABA) daily

Step 4: Medium-Dose ICS +LABA daily
Severe Persistent: Symptoms several times per day and nightly

Step 5: High-Dose ICS +LABA daily

Step 6: High-Dose ICS +LABA +oral steroids daily

Question 6

According to the National Asthma Education and Prevention Program (NAEPP) guidelines, what is the first-line maintenance therapy for asthma in adults?
a. Long-acting beta-agonists (LABAs)
b. Inhaled corticosteroids (ICS)
c. Leukotriene modifiers
d. Short-acting beta-agonists (SABA)

Answer 6

Inhaled corticosteroids (ICS)

Question 7

What is the initial step in the management of an acute asthma exacerbation in the primary care setting?
a. Administering systemic corticosteroids
b. Initiating long-acting beta-agonists (LABAs)
c. Administering a short-acting beta-agonist (SABA)
d. Assessing for oxygen saturation

Answer 7

Administering a SABA

Question 8

What parameter should be regularly monitored during follow-up visits for a patient with asthma?

Answer 8

Peak flow or spirometry measurements

Question 9

What is the recommended treatment for acute bronchitis?

Answer 9

Antibiotics not recommended—mostly viral

Symptomatic-based treatment NSAIDs, ASA, Tylenol, and/or ipratropium
Cough suppressants—codeine-containing cough meds
Bronchodilators (albuterol)

Question 10

A 65-year-old male complaining of fatigue and shortness of breath with exertion. The patient reports minimal cough. On physical exam, you note a thin, barrel-chested man with decreased heart and breath sounds, pursed-lip breathing, end-expiratory wheezing, and scattered rhonchi. What is the most likely diagnosis and what will the work-up show?

Answer 10

Emphysema

Chest X-ray will show a flattened diaphragm, hyperinflation, and a small, thin-appearing heart.

PFTs will show a decreased FEV1/FVC ratio.

Question 11

What are the findings on CXR for emphysema?

Answer 11

flattened diaphragm, hyperinflation, and small, thin appearing heart
parenchymal bullae (subpleural blebs) are pathognomonic

Question 12

What is the criteria for initiating supplemental home oxygen for patients with COPD?

Answer 12

• Pao2 55 mm Hg
• O2 saturation < 88% (pulse oximetry) either at rest or during exercise
• Pao2 55 59 mm Hg + polycythemia or cor pulmonale

Question 13

What are the benefits to treatment with a LAMA in COPD?

What is the LAMA available for the treatment of COPD?

What are the side-effects?

Answer 13

Improves lung function, decreases hyperinflation, improves quality of life for patients with COPD

Slightly more efficacious than LABAs

Tiotropium

Anticholinergic: dry mouth, thirst, blurred vision, urinary retention, difficulty swallowing

Question 14

What inahler class of medications can be used as needed to relieve intermittent dyspnea?

Answer 14

SAMA (Ipratropium) or SABA (albuterol)

Question 15

What is the USPSTFs recommendation for lung cancer screening?

Answer 15

• The USPSTF recommends annual low-dose CT screening for those 55-80 years of age who have no symptoms of lung cancer and a 30+ PPY smoking history who currently smoke
• Screening should be discontinued once a person has not smoked for 15 years

Question 16

What antibiotic classes are used to treat pneumonia?

What is the outpatient empiric treatment of community acquired pneumonia

Answer 16

Macrolides (Azithromycin, Clarithromycin) or respiratory Fluoroquinolones (Levofloxacin, Moxifloxacin, and gemifloxacin)

Macrolide or Doxycicline

Fluoroquinalones only used if comorbid conditions are present or recent abx treatment

Question 17

A 55-year-old man presents with shortness of breath and a productive cough with yellow phlegm for 2 days; he has had blood-tinged sputum for the last 3 hours. He has smoked 2 packs of cigarettes for the past 35 years. He has a temperature of 102°, and rhonchi, wheeze, and crepitations are heard over the right hemithorax. A chest X-ray shows a dense lobar infiltrate in the right hemithorax. What is the diagnosis?

What is the proper outpatient treatment?

Answer 17

Lobar Pneumonia

Macrolide (Azithromycin) or Doxycicline

Question 18

At what age should all patients receive the pnumonia vaccine?

Answer 18

Pneumonia vaccine should start at age 65 for all patients

Question 19

What is the best test to rule out a pulmonary embolism?

Answer 19

CT Angiography

Question 20

What groups are at an increased risk of Klebselia Pneumonia?

Answer 20

Alcoholics and Nursing Home Patients

Question 21

A 50-year-old female patient presents for follow-up for breathing problems. She has a 40 pack-year smoking history. She states that the shortness of breath is getting slightly worse, and she has lost about 5 pounds in recent months without trying. Exam reveals tachypnea. Chest x-ray shows lung hyperinflation and flattening of the diaphragm. What is the most likely diagnosis and what would expect to find on PFTs?

Answer 21

Emphysema

This presentation is consistent with a diagnosis of emphysema: a condition caused by loss of lung elastic recoil, which leads to airflow obstruction, specifically expiration. A characteristic finding is elevated total lung capacity.

Question 22

What pulmonary infections most commonly cause granulomas in the lungs?

Answer 22

Histoplasmosis, Coccidioidomycosis, Mycobacterium tuberculosis, and nontuberculous species

Question 23

A 26-year-old pregnant woman diagnosed with primary tuberculosis and wants to discuss treatment options. Initial labs come back with mild anemia, positive HCG, and elevated cholesterol. All other labs are within normal range.

What drug should be avoided in this patient?

Answer 23

Streptomycin and Pyrizinomide

Initial treatment for TB in pregnant women should include Rifampin, Isonizid, and Ethembutal only. Pyrizinomide can be added if needed. Streptomycin is considered class X.

Question 24

A 52-year-old woman living a non-sedentary lifestyle presents with a 5-day history of low-grade fever, flu-like syndrome, sore throat, and malaise. She is mostly bothered by the fact that she has to “catch” her breath because of pain on inspiration and when coughing. She has no known past medical or surgical history; she is not on any medication, and she has no pertinent family history. She denies any medication use, including over-the-counter medicines. On physical examination, her vitals are: Temperature 100.6 F, pulse 86/min, BP133/75 mm Hg, and RR 20cycles/min. She has shallow breathing, resonant percussion notes, fair air entry with vesicular breath sounds, and friction rub. Her blood gas on room air is: pH 7.36, PCO2 44 mmHg, PO2 100 mmHg, HCO3 26 mEq\L, O2 saturation 99.8%. Her chest X-ray (CXR) is normal and the D-dimer assay is also normal. What is the most appropriate management modality for this patient?

Answer 24

NSAID’s

This patient has pleuricy without an effusion; no imaging modalities are required because XR and D-dimer are negative. Treat with NSAIDs and supportive care.

Question 25

A 57-year-old man who works as a quartz miner presents to the clinic with shortness of breath and dry cough for 9 months. His medical history includes essential hypertension and benign prostatic hyperplasia. Current vital signs are heart rate 86 bpm, blood pressure 130/88 mm Hg, respiratory rate 18/minute, oxygen saturation 95% on room air, and temperature 98.7°F. Physical examination reveals regular rate and rhythm, soft and nontender abdomen, no respiratory distress, crackles over bilateral lower lung fields, no wheezing, and no stridor. Pulmonary function testing reveals an FEV1/FVC of 85%, FVC of 65%, and total lung capacity of 70%. What is the most likely diagnosis?

Answer 25

Interstitial Lung Disease

Question 26

What drugs are associated with the development of interstitial lung disease?

Answer 26

* amiodarone * bleomycin * methotrexate * opiates * nitrofurantoin

Question 27

A 57-year-old male had an abdominal CT in the ED for an acute work-up of gastrointestinal pain. A lung nodule, measuring, 5mm was found incidentally. What should be done about the lung nodule?

Answer 27

Nothing, the patient should be reassured. Incidental findings of lung masses < 30mm do not require follow-up. If greater than 30 mm then a chest CT without contrast should be ordered.

Question 28

A 28-year-old woman presents to the clinic with 2 months of fatigue, dry cough, blurred vision, rash, and weight loss. She has no significant medical or surgical history. She was adopted and does not know her family history. Vital signs today are heart rate 82 bpm, blood pressure 116/78 mm Hg, respiratory rate 18/minute, oxygen saturation 97% on room air, and temperature 98.4°F. On physical examination, the patient has erythema surrounding the cornea, cervical lymphadenopathy, regular rate and rhythm, clear lungs to auscultation bilaterally, soft and nontender abdomen, and tender nodules on the bilateral lower legs. Chest X-ray is shown above. Additional diagnostic studies are performed. What diagnostic finding is most consistent with the suspected diagnosis?

Answer 28

Noncaseating granulomas on lung biopsy Sarcoidosis

Question 29

What medication is used to treat seizures caused by isoniazid toxicity?

Answer 29

Vitamin B6 (pyridoxacine) | Vitamin B6 should be given with Isoniazid to reduce risk of toxicity

Question 30

What are some common causes of a chronic cough?

Answer 30

* Post nasal drip syndrome * COPD or Asthma * GERD * ACE inhibitor use

Question 31

What is an adverse side effect of inhaled steroids and what patient education should be completed to reduce the risk?

Answer 31

Thrush (oral candidiasis) Patients should be instructed to rinse their mouth or drink water after ICS use

Question 32

What is a serious side effect of Ethambutal? | What test should be done prior to initiating treatment for TB?

Answer 32

Optic neuritis, which can lead to loss of red-green color discrimination and decreased visual acuity. | Opthamology Testing (red-green color testing)

Question 33

What is the most common cause of acute bronchitis? | What is the treatment?

Answer 33

Viral Infection | Supportive, abx not indicated

Question 34

Name one key clinical feature that differentiates chronic bronchitis from acute bronchitis | What lung disease is chronic bronchitis most commonly associated with?

Answer 34

Chronic productive cough lasting for at least 3 months in two consecutive years | COPD

Question 35

Which type of sputum production is more indicative of bacterial infection in acute bronchitis?

Answer 35

Purulent (green or yellow) phlegm

Question 36

What is the most common long-term complication of chronic bronchitis?

Answer 36

Pulmonary hypertension leading to cor pulmonale

Question 37

A 35-year-old woman presents to the clinic with a persistent cough that started two weeks ago. She describes the cough as dry initially, but it has recently become productive with clear sputum. She denies fever, chills, or shortness of breath. On physical examination, her lungs are clear to auscultation, and she has no wheezing or rales. She has no significant past medical history and is a non-smoker. What is the most likely diagnosis? A) Community-acquired pneumonia B) Acute bronchitis C) Asthma exacerbation D) Chronic bronchitis

Answer 37

Acute Bronchitis ## Footnote Acute Bronchitis = cough > 5 days, can last 2-3 weeks in duration

Question 38

A 60-year-old male with a 40-pack-year smoking history presents with a chronic productive cough that has persisted for the past two years. He reports that the cough is worse in the mornings and is associated with frequent sputum production. He denies any weight loss, hemoptysis, or fever. Pulmonary function tests reveal an FEV1/FVC ratio of 0.65. What is the most appropriate diagnosis? A) Asthma B) Chronic bronchitis C) Tuberculosis D) Lung cancer | An FV1/FVC ration less than what value indicates COPD?

Answer 38

Chronic Bronchitis | < 70% (0.7)

Question 39

A 45-year-old male presents to the emergency department with a severe cough, shortness of breath, and wheezing that started five days ago. He reports that he has had similar symptoms in the past, especially during winter months. He is a current smoker with a history of chronic bronchitis. His oxygen saturation is 92% on room air, and he has diffuse wheezing on lung auscultation. What is the best initial treatment for his condition? A) Antibiotics and expectorants B) Inhaled bronchodilators and corticosteroids C) Oral corticosteroids and oxygen therapy D) Immediate intubation and mechanical ventilation

Answer 39

Inahled bronchodilators and corticosteroids

Question 40

A 28-year-old female presents with a persistent cough that has been ongoing for 10 days. She initially had cold-like symptoms, which have since improved, but her cough has lingered. She denies any significant medical history, is a non-smoker, and has no recent travel history. Physical examination is unremarkable, and her vital signs are within normal limits. What is the most appropriate management for this patient? A) Prescribe antibiotics and cough suppressants B) Order a chest X-ray to rule out pneumonia C) Reassure the patient and provide symptomatic treatment D) Refer for a pulmonology evaluation

Answer 40

Reassure the patient and provide symptomatic treatment

Question 41

A 50-year-old man with a long history of smoking presents with worsening shortness of breath and a productive cough. He has been diagnosed with chronic bronchitis and has had multiple exacerbations over the past year. He currently uses a short-acting bronchodilator as needed. What additional long-term therapy should be considered to manage his chronic bronchitis and reduce exacerbations? A) Long-term antibiotic therapy B) Long-acting bronchodilator (LABA) C) Oral corticosteroids D) Leukotriene receptor antagonist

Answer 41

LABA

Question 42

What antirhythmic medication is notorious for causing interstitial lung disease? | What classic radiology finding is seen in interstitial lung disease?

Answer 42

Amiodorone | Reticular pattern on CXR

Question 43

What is Pickwickian syndrome?

Answer 43

Hypoventilation due to obesity

Question 44

Which of the following types of lung cancers is less likely associated with smoking? A. Adenocarcinoma B. Large cell carcinoma C. Small cell carcinoma D. Squamous cell carcinoma

Answer 44

Adenocarcinoma

Question 45

A 21 year old male presents for a physical. Physical examination is significant for expiratory wheezes. Pulmonary function and bronchodilator response tests are ordered. The patient’s baseline forced expiratory volume in 1 second is 75% of the predicted value, and his forced vital capacity is 3.5 L. Which of the following bronchodilator responses is most consistent with asthma? A. A decrease in both forced expiratory volume and forced vital capacity B. A decrease in forced expiratory volume and an increase in forced vital capacity C. An increase in both forced expiratory volume and forced vital capacity D. No change in forced expiratory volume or forced vital capacity

Answer 45

An increase in both forced expiratory volume and forced vital capacity

Question 46

A 63-year-old man with recently diagnosed chronic obstructive pulmonary disease presents to the office for his 2-month follow-up. At his last visit in July, he received a tetanus-diphtheria-acellular pertussis vaccination. He does not recall receiving the pneumococcal vaccine in the past. Which of the following should this patient receive today? A. Influenza vaccine B. Influenza vaccine and 20-valent pneumococcal conjugate vaccine C. Influenza vaccine and 23-valent pneumococcal polysaccharide vaccine D. Influenza vaccine and second dose of tetanus-diphtheria-acellular pertussis

Answer 46

Influenza vaccine and 20-valent pneumococcal conjugate vaccine ## Footnote 23-valent pneumococal is given to patients already vaccinated with 15-valent pneumococcal vaccine

Question 47

A 51-year-old man with a 35 pack-year smoking history presents to the office for his annual physical. He has a history of a lung nodule on a prior chest X-ray. The patient is now reporting right shoulder pain and hand weakness. On physical examination, atrophy of the intrinsic muscles of the right hand is noted. What other physical examination finding would be characteristic of his suspected diagnosis? A. Heliotrope rash B. Hyperreflexia of bilateral upper extremities C. Ipsilateral ptosis and miosis D. Palpable adrenal mass

Answer 47

Ipsilateral ptosis and miosis | Classic presentation of Pancoast Syndrome

Question 48

What is the primary cause of cor pulmonale? | Which lung disease is most commonly associated with cor pulmonale

Answer 48

Pulmonary Hypertension | COPD

Question 49

What is the most common presenting symptom of cor pulmonale? | What diagnostic test is most useful in confirming the diagnosis?

Answer 49

Dyspnea on exertion | ECHO (RV hypertrophy, right arterial enlargement, right axis deviation)

Question 50

Name one treatment option aimed at reducing pulmonary hypertension in cor pulmonale.

Answer 50

Oxygen Therapy

Question 51

A 65-year-old male with a long history of COPD presents to the clinic with worsening shortness of breath and leg swelling. He reports that he has been experiencing increasing fatigue and difficulty performing his daily activities over the past few months. On examination, you note jugular venous distension, peripheral edema, and a loud P2 on auscultation. His ECG shows right axis deviation and right ventricular hypertrophy. Which of the following is the most likely diagnosis? A) Congestive heart failure B) Cor pulmonale C) Acute myocardial infarction D) Pulmonary embolism

Answer 51

Cor pulmonale

Question 52

A 70-year-old woman with a history of interstitial lung disease presents with increasing shortness of breath and fatigue. She is on home oxygen therapy but reports that her symptoms have worsened despite adherence to her oxygen regimen. On physical examination, you observe cyanosis, clubbing of the fingers, and a parasternal heave. What test would be most appropriate to confirm the diagnosis of cor pulmonale?

Answer 52

ECHO

Question 53

A 58-year-old man with a history of sleep apnea and obesity presents with worsening exertional dyspnea and swelling in his legs. He has been non-compliant with his CPAP therapy. On examination, he has a loud S2 and a prominent right ventricular heave. His BNP level is elevated, and his chest X-ray shows enlarged pulmonary arteries. What is the most appropriate initial treatment to manage his cor pulmonale? A) Initiate diuretic therapy B) Increase his oxygen therapy C) Start anticoagulation D) Administer pulmonary vasodilators

Answer 53

Increase his oxygen therapy ## Footnote Improving oxygenation directly addresses the underlying pulmonary hypertension caused by chronic hypoxia. For patients with cor pulmonale secondary to sleep apnea, optimizing oxygen delivery (including CPAP compliance) is essential in managing the condition.

Question 54

What is the most common organism found in aspiration pneumonia?

Answer 54

Klebselia pneumoniae

Question 55

Which type of emphysema is associated with spontaneous pneumothorax and young adults?

Answer 55

Distal acinar emphysema

Question 56

Which substances must be avoided in patients with obesity hypoventilation syndrome?

Answer 56

* Alcohol * Barbiturates * Muscle relaxants * Opiates * Benzodiazepines

Question 57

What is the most commonly affected joint in gout?

Answer 57

The first metatarsophalangeal joint (big toe), also known as podagra

Question 58

Which type of crystals are found in synovial fluid analysis of a gout patient?

Question 59

What is the most common source of Legionella infection? | What populations are at highest risk?

Answer 59

Contaminated water sources, such as air conditioning systems, hot tubs, or cooling towers | Immunocompromised, elderly, smokers, and those w/ chronic lung disease

Question 60

What is a key extrapulmonary feature of Legionella pneumonia?

Answer 60

Gastrointestinal symptoms, such as diarrhea, nausea, and vomiting

Question 61

What laboratory test is often used to diagnose Legionella pneumonia?

Answer 61

Urine antigen test for Legionella pneumophila

Question 62

A 62-year-old man presents with a 5-day history of fever, productive cough, and shortness of breath. He also reports nausea, diarrhea, and muscle aches. His past medical history includes chronic obstructive pulmonary disease (COPD) and a 30-pack-year smoking history. He recently returned from a stay at a hotel where he used the hot tub. Chest X-ray shows patchy consolidation in the right lower lobe. Which of the following is the most likely diagnosis? A) Mycoplasma pneumonia B) Streptococcus pneumonia C) Legionella pneumonia D) Pneumocystis pneumonia

Answer 62

Legionella pneumonia

Question 63

What is the most common type of primary lung cancer? | What is the primary risk factor?

Answer 63

Non-small cell lung cancer (NSCLC), with adenocarcinoma being the most common subtype | Smoking

Question 64

Which type of lung cancer is most strongly associated with paraneoplastic syndromes?

Answer 64

Small cell lung cancer (SCLC) ## Footnote A paraneoplastic syndrome is a set of symptoms that occur when a cancer causes abnormal immune responses or secretes substances, such as hormones or cytokines, that affect organs and tissues not directly related to the tumor. These syndromes can affect various parts of the body, including the nervous, endocrine, skin, and blood systems. They are most commonly associated with cancers like lung cancer (especially small cell lung cancer), but can occur with other cancers as well. Paraneoplastic syndromes may present before the cancer is diagnosed, offering early clues to its presence, and often improve when the underlying cancer is treated.

Question 65

Which imaging modality is commonly used for initial evaluation of a suspected pulmonary neoplasm?

Answer 65

Chest X-ray, followed by CT scan of the chest for further evaluation

Question 66

A 65-year-old man with a 50-pack-year smoking history presents with a persistent cough, hemoptysis, and unintentional weight loss over the past two months. A chest X-ray reveals a 3 cm right upper lobe mass. CT scan confirms a solitary nodule with spiculated borders. Biopsy reveals malignant glandular cells. What is the most likely diagnosis? A) Squamous cell carcinoma B) Adenocarcinoma C) Small cell lung cancer D) Carcinoid tumor

Answer 66

Adenocarcinoma ## Footnote Adenocarcinoma is the most common type of non-small cell lung cancer (NSCLC) and typically arises in the peripheral lung fields. It is often seen in both smokers and non-smokers.

Question 67

A 55-year-old woman presents with worsening cough, chest pain, and hoarseness. She has a 35-pack-year smoking history. Physical examination reveals decreased breath sounds on the right side. Chest CT shows a 4 cm hilar mass. A biopsy confirms small cell lung cancer (SCLC). Which of the following paraneoplastic syndromes is most likely associated with this diagnosis? A) Hypercalcemia B) Cushing syndrome C) Hypothyroidism D) Hyperglycemia

Answer 67

Cushing Syndrome ## Footnote Small cell lung cancer (SCLC) is commonly associated with paraneoplastic syndromes such as Cushing syndrome due to ectopic production of adrenocorticotropic hormone (ACTH)

Question 68

A 70-year-old man presents with new onset weakness, difficulty climbing stairs, and ptosis. He has a 40-pack-year smoking history and reports recent weight loss. A chest CT scan reveals a 5 cm mediastinal mass, and biopsy confirms small cell lung cancer. Which of the following conditions is the most likely explanation for his neurological symptoms? A) Lambert-Eaton myasthenic syndrome B) Myasthenia gravis C) Guillain-Barré syndrome D) Multiple sclerosis

Answer 68

Lambert-Eaton myasthenic syndrome ## Footnote Lambert-Eaton myasthenic syndrome is a paraneoplastic syndrome commonly associated with small cell lung cancer. It causes proximal muscle weakness and is due to impaired acetylcholine release at the neuromuscular junction

Question 69

A 65-year-old male presents with a persistent cough and recent hemoptysis. He has a significant smoking history. Physical exam reveals decreased breath sounds on the right. Chest X-ray shows a 6 cm mass in the right lower lobe. The patient is diagnosed with squamous cell carcinoma of the lung. Which electrolyte abnormality is commonly associated with this type of cancer? A) Hypokalemia B) Hyponatremia C) Hypercalcemia D) Hypocalcemia

Answer 69

Hypercalcemia ## Footnote Squamous cell carcinoma of the lung is commonly associated with paraneoplastic hypercalcemia due to ectopic production of parathyroid hormone-related protein (PTHrP)

Question 70

A patient is diagnosed with small cell lung cancer. It is noted that this type of cancer is highly aggressive and associated with early metastasis. What is the key histopathological feature of small cell lung cancer? A) Gland formation with mucin production B) Large, pleomorphic cells with prominent nucleoli C) Small, round, blue cells with scant cytoplasm and high mitotic rate D) Keratinization and intercellular bridges

Answer 70

Small, round, blue cells with scant cytoplasm and high mitotic rate Small cell lung cancer is characterized histologically by small, round, blue cells with a high nuclear-to-cytoplasmic ratio, a high mitotic rate, and early metastasis

Question 71

What imaging modality is the preferred initial test for evaluating a solitary pulmonary nodule (SPN)?

Answer 71

Chest CT Scan

Question 72

What is the preferred computed tomographic method for lung nodule evaluation?

Answer 72

Noncontrast, helical computed tomography with contiguous 1 mm sections

Question 73

What size of a solitary pulmonary nodule should be biopsied due to high risk of malignancy in a patient w/no risk factors?

Answer 73

> 30 mm (3 cm)

Question 74

What is the recommended follow-up for a pulmonary nodule < 6 mm in a low-risk patient?

Answer 74

No routine follow-up is needed, although optional CT at 12 months may be considered

Question 75

What are some risk factors that increase the liklihood that a lung nodule is malignant?

Answer 75

* Spiculated nodule, larger than 3cm * Irregular borders * History of smoking * Located in the upper lobe * > 40 years of age * Abnormal PET scan

Question 76

What is the most common benign cause of a solitary pulmonary nodule?

Answer 76

Granulomas, often due to infectious causes like histoplasmosis or tuberculosis

Question 77

A 60-year-old man with a 40-pack-year smoking history undergoes a chest CT for an unrelated reason. The CT scan reveals a 9 mm nodule in the right upper lobe. He is asymptomatic, and there are no previous scans for comparison. What is the next best step in managing this patient? A) Immediate surgical resection B) CT surveillance in 6-12 months C) PET scan for further evaluation D) Bronchoscopy with biopsy

Answer 77

CT surveillance in 6-12 months

Question 78

A 45-year-old woman with no significant smoking history undergoes a chest CT after an episode of pneumonia, revealing a 5 mm solitary pulmonary nodule. She has no prior imaging for comparison. According to current guidelines, what is the appropriate follow-up for this patient? A) No follow-up needed B) Repeat CT scan in 6 months C) Repeat CT scan in 3 months D) Biopsy of the nodule

Answer 78

No follow-up needed ## Footnote For low-risk patients with nodules smaller than 6 mm, no routine follow-up is required. Optional follow-up may be considered at 12 months, but typically no further intervention is needed unless there are new risk factors or clinical changes

Question 79

A 72-year-old male with a history of chronic obstructive pulmonary disease (COPD) and a 45-pack-year smoking history has a 12 mm nodule detected on a recent chest CT. His last CT, performed a year ago, showed no nodules. What is the best next step in managing this patient? A) Surgical resection of the nodule B) PET-CT scan to assess metabolic activity C) Bronchoscopy with biopsy D) Repeat chest CT in 3 months

Answer 79

PET-CT scan to assess metabolic activity ## Footnote A new, relatively large nodule (≥ 8 mm) in a high-risk patient (advanced age, smoking history) warrants further evaluation with PET-CT to assess for metabolic activity and guide decisions about potential biopsy or resection

Question 80

A 65-year-old male with a 40-pack-year smoking history has a 5 mm lung nodule discovered incidentally on CT. Which of the following factors increases the likelihood of malignancy in this nodule? A) Location in the peripheral lung fields B) Patient age C) History of asbestos exposure D) Nodule size less than 6 mm

Answer 80

Patient Age ## Footnote Increased age is a risk factor for malignancy in pulmonary nodules, especially in older patients with a significant smoking history. Nodule size less than 6 mm is generally considered lower risk

Question 81

A 55-year-old man undergoes a routine chest CT, which reveals a 10 mm spiculated nodule in the right upper lobe. He has a 30-pack-year smoking history. What feature of the nodule increases the suspicion for malignancy? A) Smooth borders B) Spiculated margins C) Calcification D) Ground-glass opacity

Answer 81

Spiculated margins ## Footnote Spiculated or irregular margins are concerning for malignancy in pulmonary nodules. Smooth, well-defined margins are more characteristic of benign lesions

Question 82

What imaging modality is most commonly used to diagnose a pleural effusion?

Answer 82

Chest X-ray, typically showing blunting of costophrenic angles

Question 83

What is the key test used to distinguish between transudative and exudative pleural effusion?

Answer 83

Pleural fluid analysis using Light's criteria

Question 84

What is the most common cause of a transudative pleural effusion?

Answer 84

Heart Failure

Question 85

What are common types of exudative pleural effusion?

Answer 85

* Malignancy * Pneumonia * PE

Question 86

What is the procedure called to remove pleural fluid for diagnostic or therapeutic purposes?

Answer 86

Thoracentesis

Question 87

A 67-year-old man with a history of congestive heart failure presents with increasing shortness of breath. Chest X-ray shows a right-sided pleural effusion. Thoracentesis is performed, and the pleural fluid analysis reveals low protein and low lactate dehydrogenase (LDH) levels. According to Light’s criteria, this effusion is classified as: A) Exudative B) Transudative C) Chylous D) Hemorrhagic

Answer 87

Transudative ## Footnote Transudative effusions, commonly due to heart failure, are characterized by low protein and low LDH levels. Light’s criteria distinguish transudates from exudates based on these parameters

Question 88

A 45-year-old woman with a history of rheumatoid arthritis presents with pleuritic chest pain and dyspnea. Chest X-ray reveals a left-sided pleural effusion. Thoracentesis is performed, and the pleural fluid analysis reveals a pleural fluid-to-serum protein ratio of 0.7 and an LDH level greater than two-thirds the upper limit of normal serum LDH. This pleural effusion is most consistent with: A) Transudative effusion B) Exudative effusion C) Empyema D) Hemothorax

Answer 88

Exudative effusion ## Footnote This effusion meets Light’s criteria for an exudative effusion (pleural fluid-to-serum protein ratio > 0.5 and LDH > two-thirds of the upper limit of normal). Rheumatoid arthritis is a common cause of exudative effusion

Question 89

A 60-year-old man presents with dyspnea and a cough. He is a known smoker with a significant weight loss history over the last few months. Chest X-ray reveals a large right-sided pleural effusion. Thoracentesis is performed, and cytology shows malignant cells. What is the most likely cause of his pleural effusion? A) Congestive heart failure B) Pulmonary embolism C) Malignancy D) Cirrhosis

Answer 89

Malignancy ## Footnote Malignant effusions are a common cause of exudative pleural effusion and are typically seen in patients with a history of smoking and significant weight loss. Cytology showing malignant cells confirms the diagnosis

Question 90

A 50-year-old woman with a history of cirrhosis presents with increasing abdominal distension and shortness of breath. Chest X-ray reveals a right-sided pleural effusion. Thoracentesis reveals a low pleural fluid protein concentration and low lactate dehydrogenase (LDH). What is the most likely cause of her pleural effusion? A) Nephrotic syndrome B) Congestive heart failure C) Cirrhosis D) Pneumonia

Answer 90

Cirrhosis ## Footnote Pleural effusion secondary to cirrhosis is usually transudative, due to increased hydrostatic pressure and low protein content, consistent with the findings on pleural fluid analysis

Question 91

A 40-year-old man presents with pleuritic chest pain, fever, and productive cough. Chest X-ray reveals a left-sided pleural effusion. Thoracentesis reveals turbid fluid, and Gram stain is positive for bacteria. What is the next best step in managing this patient? A) Monitor with serial chest X-rays B) Intravenous diuretics C) Chest tube drainage D) Observation and repeat thoracentesis in 48 hours

Answer 91

Chest tube drainage ## Footnote The presence of turbid fluid with bacteria in the pleural fluid suggests an empyema (infected pleural fluid). Immediate chest tube drainage is required to prevent complications like fibrosis and sepsis. You can also give streptokinase to facilitate breakup of loculations.

Question 92

A 55-year-old man with nephrotic syndrome develops shortness of breath. Chest X-ray reveals a moderate pleural effusion. Thoracentesis is performed, and pleural fluid analysis shows a low protein content and a pleural fluid-to-serum protein ratio of 0.3. Which of the following best describes the pathophysiology of his pleural effusion? A) Increased capillary permeability B) Decreased oncotic pressure C) Lymphatic obstruction D) Increased pleural fluid production due to infection

Answer 92

Decreased oncotic pressure ## Footnote Nephrotic syndrome causes hypoalbuminemia, leading to decreased oncotic pressure and transudative pleural effusion with low protein content

Question 93

A 30-year-old man with no significant past medical history presents to the office with a persistent, productive cough for the past week. On examination, his temperature is 99.5°F, and his lungs are clear to auscultation. What is the best treatment for this patient? A) Azithromycin B) Guaifenesin C) Levofloxacin D) Oseltamivir

Answer 93

Guaifenesin ## Footnote This patient has acute bronchitis. No abx or anti-viral treatment is needed.

Question 94

A man presents to the clinic with fever, cough, and shortness of breath. He states his symptoms began after his return from a business trip last week. He has also experienced nausea, vomiting, and diarrhea since returning. Chest radiograph demonstrates patchy unilobar infiltrates. Which of the following results do you expect to see on Gram stain? A) Gram-negative encapsulated bacilli B) Gram-positive cocci in clusters C) Gram-positive diplococciYour Answer D) No bacteria present

Answer 94

No bacteria present ## Footnote The patient's symptoms of fever, cough, shortness of breath, gastrointestinal symptoms (nausea, vomiting, diarrhea), and a history of recent travel, along with the chest radiograph showing patchy unilobar infiltrates, suggest Legionella pneumonia (Legionnaires' disease). Legionella is an intracellular pathogen, which means it does not typically show up on a routine Gram stain because it requires specialized staining methods (e.g., Dieterle silver stain).