kap q bank-7. Resp - sanju12

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A 65-year-old man, his wife, and 38-year-old son have been your clinic patients for the last 15 years. In the evaluation of some mild hemoptysis of the 65-year-old man, a chest x-ray reveals a 4 cm right sided lung mass, hilar and mediastinal adenopathy, and several lytic lesions in his ribs and humerus. None of these findings were present on an x-ray performed 4 years earlier. He has a 50-pack year smoking history. When he returns to your office, you inform him that he likely has stage IV lung cancer and that you would like to refer him to an oncologist for further evaluation. He states that he wants no therapy whatsoever, and that he wants to keep this a secret from his family. The most appropriate response would be to A. call his son as soon as he leaves the office
B. inform him that treatment will likely be curative and that he should really reconsider his decision
C. investigate what it is that makes him feel uncomfortable in telling his family and provide counseling
D. realize that he will likely "come to his senses" and give him a referral to the oncologist anyway
E. tell him that he is probably just in denial and try to persuade him to tell his wife when he gets home
Explanation: The correct answer is C. Patient confidentiality is one of the most important medical ethical issues facing physicians, and it certainly can pose dilemmas at times. This patient has just received horrible news and is likely just reacting without really thinking about the ramifications of his decision. However, there may be very important personal, social, or cultural reasons for his decision. It is important for you, as a physician, to explore these with him.Calling his son (choice A) is inappropriate because it breaks confidentiality.Although you will likely try to get the patient to reconsider his decision (choice B) telling him that therapy will likely be curative for stage IV lung cancer is not true. There is very little chance at a cure and palliative therapy is a much more reasonable expectation.Giving him a referral to the oncologist because he is will "come to his senses" (choice D) is inappropriate. He obviously needs counseling, and the feelings as to why he does not want treatment and why he does not want his family to know, should be explored.Although the patient may be in denial (choice E), patient confidentiality precludes you from unilaterally deciding to tell his wife. It is appropriate to try to understand the reasons why he does not want to tell his family, as opposed to trying to persuade him to tell his wife when he gets home.


A 24-year-old woman comes to the office because of a cough with "yellowish sputum production" for the past 2 days. She states that the cough has been keeping her up at night and it is bothering her co-workers. They insisted that she "go get medicine" so that she does not "infect the entire office." She has no history of respiratory disease. Her temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is 70/min, and respirations are 18/min. Physical examination is normal. The most appropriate next step in management is to A. admit her to the hospital for medical management
B. obtain a sputum culture
C. order a chest x-ray
D. prescribe erythromycin, orally
E. send her home with no medications
Explanation: The correct answer is E. This patient most likely has acute bronchitis. Acute bronchitis in a healthy patient with no other medical conditions is often due to viral infection that is usually self-limited. Given that this patient has only had 2 days of symptoms, an antibiotic is not necessary and is inappropriate. If the symptoms persist for longer than 1 week, a macrolide antibiotic may be given. A chest x-ray and a sputum culture are not indicated.Admission to the hospital for medical management (choice A) is inappropriate for a healthy patient with acute bronchitis.A sputum culture (choice B) is used to identify organisms, but should only be used in an elderly patients with chronic disease that fail antibiotic therapy. This patient's acute bronchitis is most likely due to a self-limited viral infection.A chest x-ray (choice C) has no role in the diagnosis of acute bronchitis in a healthy patient.Send the patient home with antibiotic therapy (choice D) is appropriate management for acute bronchitis in an elderly patient with chronic disease. A macrolide (erythromycin, azithromycin, clarithromycin) is the treatment of choice. It is not part of the initial treatment in a previously healthy patient.



A 45-year-old woman with severe reflux disease secondary to a hiatal hernia is admitted to the hospital with flank pain from a kidney stone. An abdominal CT shows multiple stones in the right ureter and renal pelvis. On the floor, she is given intramuscular meperidine every 4 hours for pain control. Early in the morning the patient is found to be obtunded in moderate respiratory distress with some evidence of vomitus on her lips and bed shirt. She had been given 3 additional doses of meperidine for pain control in the past 5 hours. A chest radiograph will most likely show a A. diffuse bilateral airspace disease
B. diffuse bilateral interstitial infiltrates
C. right lower lobe opacification
D. right pleural effusion
E. widened mediastinum
Explanation: The correct answer is C. Aspiration of gastric contents causes severe lung inflammation. The traditional dogma that the acidic nature of the aspirate is critical has recently been reevaluated and it is now clear that large volumes of gastric contents of any pH are dangerous to the lung. Patients with severe reflux often regurgitate frequently throughout the day and at night will have small aspiration events, which will wake them from sleep by coughing. Once sedated, these people develop depressed cough reflexes and therefore are more likely to be unable to protect their airway during such regurgitations. This is most certainly what has occurred with this patient. The most common radiological finding is right lower lobe opacification (alveolar filling) or collapse. Diffuse bilateral airspace disease (choice A) is characteristic of acute respiratory distress syndrome (ARDS) or very late stage aspiration which can lead to ARDS.Diffuse bilateral interstitial infiltrates (choice B) are characteristic of pulmonary edema. This may be a late manifestation (a few days) of severe aspiration, but not an early one. Pleural effusions (choice D) are not present in aspirations. A unilateral effusion can be found in cases of liver abscess or right sided diaphragmatic irritation or with Meigs syndrome (ovarian cancer and ipsilateral pleural effusion). A widened mediastinum (choice E) is characteristic of an aortic arch dissection or of a pulmonary disease such as sarcoid.


A 78-year-old man who lives alone is brought to the emergency department by ambulance because of respiratory distress. According to the brief history obtained by the paramedics, he is having abdominal pain since the morning and reports a history of congestive heart failure, insulin dependent diabetes mellitus, hypertension, and peripheral vascular disease. On arrival to the hospital, he is very drowsy and his temperature is 36.7 C (98.0 F), pulse is 110/min and irregular, blood pressure is 90/54 mm Hg, respirations are 24/min, and oxygen saturation is 84%. He appears to be in great distress from his abdominal pain. Laboratory studies show: After starting an intravenous catheter and administering a diuretic, you are getting ready to intubate the patient. The emergency department nurse conveys a message from the patient's daughter in Florida that there is a living will written by the patient which mandates that under no circumstances should he be intubated, resuscitated by CPR or dependent on artificial ventilation or feeding. The nurse reports that the daughter was very emotional and adamant that the patient should just be made comfortable, and that she would sue if he was intubated or if CPR carried out. During that emotional conversation she forgot to leave her phone number. The most appropriate next step in management is to A. call a hospital administrator to make a decision
B. call a hospital lawyer for advice
C. intubate the patient
D. respect the daughter's wishes and keep the patient comfortable without intubation
E. try and trace the daughter's phone number and request a fax of the living will
Explanation: The correct answer is C. The patient is in respiratory distress and needs intubation for airway control, better oxygenation, hemodynamic resuscitation, and to feel comfortable. Although every attempt should be made to respect the patient's wishes and the family's requests, in an emergency situation there is limited opportunity to check the validity of telephone messages and faxed documents. Medical emergency mandates appropriate action prior to legal concerns.Calling the hospital administrator (choice A) and lawyer (choice B) are not advisable in an emergency situation for the reasons explained above.A living will mandating œdo not resuscitate or do not intubate needs to be checked and certified by a hospital social worker or legal department for authenticity before implementation. In an emergency situation this is not practical. Even if this patient is intubated, once a valid living will is obtained the ventilator can be switched off. Hence, to respect the daughter's wishes and keep the patient comfortable without intubation (choice D) is incorrect.To try and trace the daughter's phone number and request a fax of the living will (choice E) is not practical in an emergency situation, and the validity of the documents is questionable without being checked by hospital authorities.


A 29-year-old man is admitted to the hospital with fever and cough. The symptoms began roughly 1-month prior and have been intermittent. He states that his cough is often productive of thick secretions and that, despite normal food intake, he has lost about 10 pounds in the past month. He is a volunteer at a local hospital and has received no special health care personnel vaccinations or screening tests. On examination, the patient appears somewhat thin, tired, and is coughing intermittently. His temperature is 38.0 C (100.4 F) and respirations are 16/min. He has patchy bilateral rhonchi over all lung fields. Prior to initiating therapy for this condition, the laboratory test required to confirm the suspected diagnosis is a A. chest radiograph
B. sputum acid-fast stain
C. sputum culture
D. sputum Gram stain
E. tuberculin skin test
Explanation: The correct answer is B. The patient likely has tuberculosis. Virtually all M. tuberculosis is transmitted by airborne particles that are 1 to 5 µm in diameter. The symptoms of tuberculosis are protean and nonspecific and can be classified as either systemic or organ-specific. Classic systemic symptoms include fever, night sweats, anorexia, weight loss, and weakness. However, since tuberculosis is associated with other illnesses that have similar symptoms, this lack of specificity can result in a delayed diagnosis or even a misdiagnosis. Organ-specific symptoms of pulmonary tuberculosis include cough, pleuritic pain, and hemoptysis. The requirement for diagnosis is the presence of the organism that appears by acid-fast staining in a sputum sample. In patients with primary tuberculosis, chest radiographs (choice A) often show infiltrates in the middle or lower lung zones, with ipsilateral hilar adenopathy. These findings are non-specific and are not used for confirmation of the diagnosis. A sputum culture (choice C) is not useful in this case since the organism responsible for TB is fastidious and is difficult to culture, and certainly does not grow rapidly. The organism responsible for TB does not stain with traditional Gram stain dyes (choice D) and therefore requires special staining such as acid-fast in order to detect it. Although it is imperfect, the gold standard for diagnosing latent tuberculosis infection remains the intradermal injection (choice E) of purified protein derivative (5 TU) into the volar or dorsal surface of the forearm (Mantoux method). The test has no role in the diagnosis of active infection.


A 56-year-old man comes to the clinic for a pre-employment physical examination. He feels well and denies any health problems. Past medical history is negative except for an appendectomy about 20 years ago. The patient drinks several alcoholic beverages per day and smokes "a lot" of cigarettes. A "screening" chest x-ray, which you ordered because it is asked for on the employment forms, is shown below and demonstrates a left hilar mass and emphysema. In considering the most appropriate next step in management, the most relevant question to ask this patient at this time is: A. "Are your affairs in order?"
B. "Do you have any allergies?"
C. "How many packs of cigarettes do you smoke per day?"
D. "What are your thoughts on end of life care?"
E. "Would you consent to a lung biopsy?"
F. "Would you consider chemotherapy or radiation treatment for cancer?"
Explanation: The correct answer is B. The chest x-ray demonstrates a right mid-lung nodule and emphysema. There is a lung nodule that is likely to be cancer in this patient with a smoking history and radiographic emphysema. The next step is a CT scan of the thorax with contrast, and before administering iodinated contrast, an allergy history must be elicited. Prior allergies to iodinated contrast material or shellfish will require further questioning. If the allergy is minor such as mild hives, pruritus, or flushing, a pre-medication regimen of prednisone and diphenhydramine is necessary. More serious allergies such as anaphylaxis preclude the administration of intravenous contrast.Questions about death (choice A and D) are premature. This nodule may be an artifact, pneumonia, a granuloma, or cancer. Moreover, a localized cancer may be curable.While quantification of the patient's smoking (choice C) is necessary for a complete history, it does not change the management of this patient.A lung biopsy (choice E) is premature. A CT scan and possibly PET scan are necessary to evaluate this lesion noninvasively before an invasive procedure is carried out.Even though this nodule is likely to be cancer, questions about cancer treatment (choice F) are premature.


A 53-year-old widowed woman comes to the office for a health maintenance examination. She is a new patient who recently moved to your city after her husband died in an office fire 6 months ago. She says that she has no complaints, except for a cough that she began to notice 4 months ago. She denies nasal discharge, "a tickle in the throat," frequent throat clearing, heartburn and the sensation of regurgitation, fever, sputum production, cigarette smoking, illegal drug use, sexual activity, occupational exposures, and any other symptoms associated with a respiratory infection. She says that the cough is not seasonal or associated with wheezing. Her temperature is 37.0 C (98.6 F), blood pressure is 135/90 mm Hg, pulse is 70/min, and respirations are 14/min. Physical examination is unremarkable. The most appropriate next step is to A. order an electrocardiogram
B. order an x-ray of the chest
C. question her about medications
D. refer her for fiberoptic bronchoscopy
E. schedule her for pulmonary function tests
Explanation: The correct answer is C. This patient has a chronic cough, which is usually considered chronic because it is lasting more than 3 weeks. It may be due to a variety of things. However, the important lesson in this question is that before you turn to diagnostic studies you need, to make sure that you have obtained a detailed history. The case history will provide the answer to almost every question that you will need to ask her, except what medications she takes. Since she is a new patient, you will need to find out if she is taking an ACE inhibitor, such as captopril or enalapril, which is a frequent cause of a chronic cough in hypertensive patients. They cause a cough in up to 20% of people taking them. The exact mechanism is unknown, but it is thought to somehow be related to bradykinin and substance P. The treatment for the cough is the discontinuation of the ACE inhibitor.An electrocardiogram (choice A) is unnecessary at this time in this patient, complaining of a chronic cough. She is not complaining of chest pain and there is nothing in her history that suggests an arrhythmia. The most important next step, is to take a detailed history before you order diagnostic tests.An x-ray of the chest (choice B) may be appropriate in the near future, but it is not the next step at this time. Before you order diagnostic studies, you need to make sure that you ask her any questions that might help you figure out the etiology of her cough. Asking her about medications is very important because ACE inhibitors cause a chronic cough in up to 20% of patients taking this medication.A fiberoptic bronchoscopy (choice D) is used to obtain histologic and cytologic specimens and to visualize an endobronchial tumor. Before you turn to such a specialized study, you need to first obtain a detailed history. If the patient is not taking an ACE inhibitor, a chest x-ray should usually be performed, and if this is abnormal, sputum cytology, a high resolution CT scan, and fiberoptic bronchoscopy should be considered.Pulmonary function tests (choice E) are used to assess airway hyperresponsiveness for patients in which you suspect asthma, and lung volumes and diffusion capacity in patients in which you suspect a diffuse interstitial lung disease. A detailed history is necessary before using any of these studies.


You are called to see a 75-year-old man who has metastatic lung cancer because of hypoxia, hypotension, and mental status changes. He has been your patient for many years and he has told you multiple times that he does not want to be placed on a respirator for any reason. On multiple occasions after his wife died, he has explained to you that if he was ever in a situation where mechanical respiration or any heroic measures should become necessary, that he would prefer to simply be made comfortable and be "allowed to go." He has a living will, which states that if he was in a terminal condition he does not want any life sustaining treatments including hemodialysis, intubation, and cardiac resuscitation. Rather, he wants comfort care only. His two daughters and three sons are all present in the room with you. They explain to you that they are very upset by their father's condition and that they want to place him on a ventilator to help him get through this episode. You explain that their father did not want aggressive medical care at the end of life, but the family insists on intervention. They threaten to sue you for malpractice if he dies. His temperature is 37.0 C (98.6 F), blood pressure is 75/40 mm Hg, pulse is 130/min, and respirations are 29/min. Physical examination shows a cachetic man in moderate respiratory distress. He is extremely disoriented and agitated and appears to be in pain. The most appropriate course of action at this time is to A. ask the family to leave and inject a lethal dose of morphine in accordance with the patients wishes
B. do not intubate patient but administer morphine and dopamine together to alleviate his suffering while maintaining his blood pressure
C. do not intubate the patient but administer morphine for comfort even though this might lower his blood pressure and respiratory rate and hasten the patient's demise
D. contact the hospital ethics committee to decide on the proper course of action
E. intubate the patient for now; when the situation is more stable discuss the patient's end of life wishes with the family
Explanation: The correct answer is C. This patient has a living will, which states that if he was in a terminal condition he wants only comfort care. He has also clearly stated his wishes to you in the past. Intubation of this patient is clearly against his wishes. Starting morphine may cause respiratory suppression or worsen his hypotension which might hasten death. The potential to hasten death is an acceptable risk if the primary intention is to decrease patient suffering. Ideally, the patient's wishes should be clearly explained early in his hospital course.Injection of a "lethal dose" of morphine (choice A) is not acceptable management of this patient since its only purpose would be to hasten death. As stated above, it is acceptable to use a drug that may hasten death if the primary intention is to decrease suffering. Asking the family to leave and then injecting a lethal dose of medication is clearly not acceptable management.Any time you start morphine on a patient you need to be aware of the possibility of worsening hypotension. Morphine is a mild vasodilator and therefore acts as a preload reducer. In this patient, hypotension already is prominent prior to starting morphine. Starting dopamine with the morphine (choice B) is not appropriate in this case since most physicians agree that, in this patient, starting vasopressors would constitute "heroic" measures.Contacting the hospital ethics committee (choice D) is not appropriate in this patient. This patient needs immediate medical attention. There is no time for meetings now. Intubation of this patient now (choice E) is clearly against the patient's documented wishes. To ignore a patient living's will and end of life issues is clearly wrong and would make completion of advance directives meaningless.


A 53-year-old woman who is a heavy smoker presents to the emergency department complaining of increasing shortness of breath for the past 3 days. She denies any history of asthma or coronary artery disease. Her temperature is 37.3 C (99.2 F), blood pressure is 150/90 mm Hg, heart rate is 110/min, and respiratory rate is 34/min. On examination, she is awake, alert, and oriented. Diffuse bilateral wheezes are heard on lung auscultation. Pulse oximetry measures 90% oxygen saturation on room air. An arterial blood gas is drawn and the results show: A chest radiograph demonstrates bilateral, hyperinflated lungs with a flattened diaphragm. Sputum Gram stain shows a few polymorphonuclear cells, moderate number of epithelial cells, and a moderate number of Gram-positive cocci. She receives supplemental oxygen, albuterol nebulizer treatments, and steroids. Her symptoms improve and pulse oximetry now reads 93% saturation. The most appropriate next step is to A. add antibiotics to the treatment regimen
B. do diffusion capacity testing by carbon monoxide
C. intubate and begin mechanical ventilation
D. obtain lung spirometry measurements
E. start non-invasive positive pressure ventilation
Explanation: The correct answer is A. The patient is a smoker who presented with progressive shortness of breath. Physical examination found diffuse wheezing and chest X-ray noted emphysema. In addition, she had an elevated pCO2 with acute respiratory acidosis and moderate hypoxia. These findings are consistent with an exacerbation of chronic obstructive lung disease. Such flares are treated with β2-agonists, anticholinergics, and steroids. In addition, antibiotics have also been shown to improve clinical outcome, and so they are part of the treatment regimen for chronic obstructive lung disease flares. Diffusion capacity (choice B) for this patient will likely be low given her emphysema and is an important measurement for diagnosis, but it is not required in the acute management of this condition.The patient has a normal mental status and is able to protect her airway. Her symptoms and oxygenation also improve with treatment. Thus, there is no current indication for intubation (choice C). Intubation is required if the patient has severe CO2 retention and/or hypoxia refractory to medical therapy. Intubation is also indicated if her condition is refractory to non-invasive ventilation, if she has severe acid-base disturbances, or if there is any change in her mental status that would compromise the airway. Lung spirometry (choice D) will aid in the diagnosis of her disease but is not useful in management of her clinical course.Non-invasive positive pressure ventilation (choice E) is indicated in patients with severe chronic obstructive pulmonary disease that is refractory to medical therapy. It is also useful in patients with increasing respiratory fatigue. A patient must be able to initiate breathing and tolerate the breathing mask. This patient has a normal mental status and her symptoms improve with treatment. Thus, she currently does not require any assistance in ventilation.


An 8-year-old boy is brought to the office by his mother because of recurrent episodes of "shortness of breath" and wheezing. These episodes typically occur when he is playing in the park with friends or when he is in the house at night. The symptoms are worst in the springtime and when he is watching television with his mother's boyfriend. The mother's boyfriend, who happens to smoke cigarettes, has been spending more and more time at the house, trying to bond with the patient. Pulmonary function tests show that the peak expiratory flow and forced respiratory volume per second are reduced during an attack and are normal during symptom-free intervals. Skin testing shows that he is allergic to grass and tree pollen, dust mites, animal dander, and a variety of other allergens. Laboratory studies show: The most appropriate next step is to A. administer immunotherapy against identified allergens
B. advise him to avoid all exercise
C. advise him to try to avoid respiratory irritants, especially cigarette smoke
D. advise the patient's mother to use a humidifier and air cleaners at home
E. prescribe inhaled sodium cromoglycate, oral corticosteroids, and oral theophylline
Explanation: The correct answer is C. This patient has asthma, and the most crucial step in the management of asthma is avoidance of the triggering factors, e.g., allergens. Unfortunately, it is difficult to avoid specific types of allergens, such as pollens. Specific measures to eliminate or reduce exposure to dust mites and animal dander at home lead to a reduced frequency of attacks and hospitalization rates. Regardless of the allergens involved, elimination of respiratory irritants, especially cigarette smoke, is of crucial importance. The bronchial tree of asthmatic patients is highly reactive to any form of chemical or physical irritation. Thus the avoidance of passive smoke is important. The mother should ask her boyfriend to go smoke outside alone if he needs to, but he should not be allowed to smoke in the house.It is not practical to administer immunotherapy against identified allergens (choice A) in this case because he is allergic to multiple airborne allergens, and it seems like he is especially responsive to cigarette smoke. Immunotherapy is of some benefit when a single allergen is identified. The most important step is to try to reduce exposure to avoidable allergens (smoke).Avoidance of all exercise (choice B) is not appropriate because even though exercise triggers asthmatic attacks in some patients, this does not seem to be his main trigger. Humidifiers and air cleaners (choice D) at home is not the appropriate management. Humidifiers favor the growth of dust mites, and air cleaners have not been shown to be uniformly effective in getting rid of dust mites.It is inappropriate to prescribe inhaled sodium cromoglycate, oral corticosteroids, and oral theophylline (choice E) for this patient because the fewest number of drugs at the lowest effective doses should be used. Typically, a one drug regimen (a bronchodilator or an inhaled corticosteroid) for mild to moderate asthma or two drugs for more severe cases is sufficient to control asthma exacerbations. Oral corticosteroids are indicated in cases of severe asthma and are therefore, not for this patient.


A previously healthy 21-year-old college student comes to the clinic because of a headache, sore throat, muscle aches, and a constant, irritating, dry cough for six days. He says that he is "never sick" and has only been to this clinic for his "immunizations". He exercises regularly, does not smoke cigarettes, and has an "occasional beer on the weekends with buddies." His temperature is 38.8 C (101.8 F), blood pressure is 120/80 mm Hg, pulse is 68/min, and respirations are 16/min. Scattered rhonchi are heard in the left lower lobe. A chest x-ray shows diffuse interstitial infiltrates in the left lower lobe. A single dose of erythromycin therapy is given in the clinic. The most appropriate next step in management is to A. admit him to the hospital and begin administration of erythromycin, intravenously
B. admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
C. admit him to the hospital for a cold agglutinin test
D. give him a prescription for erythromycin and send him home
E. recommend aspirin, fluids, and rest at home
Explanation: The correct answer is D. This patient most likely has Mycoplasma pneumonia, which is a common cause of pneumonia in young adults and is typically treated with oral erythromycin as an outpatient. It is characterized by a dry cough, headache, myalgia, malaise, and fever. Physical examination is usually unremarkable except for diffuse rhonchi or fine rales. A chest x-ray shows diffuse interstitial or reticulonodular infiltrates, typically in the lower lobes. Given the patient's age, history, physical examination, and chest x-ray findings, it is reasonable to assume that he has a community-acquired pneumonia. This is most likely due to Mycoplasma pneumoniae and empiric antimicrobial therapy with erythromycin should be prescribed. In these patients, a microbial diagnosis (with a sputum culture, transtracheal aspiration, bronchoscopy, or a blood culture) is often impractical and unnecessary. A cold agglutinin response is often associated with Mycoplasma pneumoniae. However, it is nonspecific and detected in less than 50% of cases. Admitting him to the hospital and beginning administration of erythromycin, intravenously (choice A) is incorrect because a patient with Mycoplasma pneumonia, which is what this patient most likely has, is usually treated as an outpatient. The criteria for hospitalization of patients with pneumonia are ages >65, significant comorbidity, leukopenia, pneumonia due to Staphylococcus aureus, Gram-negative bacilli or anaerobes, suppurative complications, failure of outpatient management, inability to take oral medication, respirations >30/min, heart rate >140/min, hypotension, hypoxia, or acute alteration of mental status. The patient in this case does not meet any of these criteria.Admitting him to the hospital and beginning administration of trimethoprim-sulfamethoxazole intravenously (choice B) is the management for patients with severe Pneumocystis carinii pneumonia (PCP), which is characterized by shortness of breath, a dry cough, fever, night sweats, rales or rhonchi, and bilateral patchy alveolar infiltrates. This is a common cause of pneumonia in immunocompromised patients, especially those with HIV and AIDS. The patient in this case does not appear to be immunocompromised, and he is not short of breath, which makes the diagnosis of PCP unlikely.Admitting him to the hospital for a cold agglutinin test (choice C) is inappropriate because even though this patient most likely has Mycoplasma pneumonia, it can be treated with erythromycin as an outpatient, and a cold agglutinin test can be performed as an outpatient. A cold agglutinin response is often associated with Mycoplasma pneumoniae. However, it is nonspecific and detected in less than 50% of cases. Recommending aspirin, fluids, and rest at home (choice E) is inappropriate treatment for this patient who most likely has Mycoplasma pneumonia, which needs to be treated with an antibiotic such as erythromycin.


A 23-year-old man with a childhood history of eczema presents to your office for the first time complaining of a non-productive coughthat started 4 months ago after a respiratory tract infection during the winter. He generally has the cough roughly once or twice a week, usually after strenuous exercise. He has not had any fevers at home and denies any hemoptysis. He smokes socially, roughly 1 pack a week, and binge drinks on the weekends. He denies any intravenous drug use, but has had several unprotected heterosexual relationships this past year. His temperature is 37.0 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is 65/min, and respirations are 15/min. His physical examination is remarkable only for end expiratory wheezes on bilateral lower lung fields. At this time the most correct statement about his condition is: A. Bronchoscopy should be performed to rule out opportunistic infection
B. A chest x-ray is necessary prior to starting any empiric therapy
C. Inhaled steroids are an appropriate first line agent
D. Pulmonary function tests would reveal a reduction in the FEV1/FVC ratio
E. A trial of antibiotics against atypical pathogens such as mycoplasma or chlamydia would relieve this patient's cough
Explanation: The correct answer is D. This patient has a classic history for cough variant asthma. The diagnosis of asthma is helped by the history of atopy/eczema. His cough is predominant after exercising, but other allergens (e.g., cigarette smoke, dust, pollen) or cold weather could also induce asthma in many patients. Pulmonary function tests would reveal a decrease in the FEV1/FVC ratio, pathognomonic for obstructive lung disease. There is no need for bronchoscopy (choice A) since in this patient there is low suspicion for an infectious process. His history of unprotected sexual intercourse does raise the suspicion for HIV, yet opportunistic pulmonary infections such as Pneumocystis Carinii pneumonia would be a late finding when the CD4 counts are less than 200.A chest x-ray (choice B) would probably be unremarkable, since we have low suspicion for any pulmonic infection. Other causes of pulmonary wheezing and cough could include a foreign body, hypersensitivity pneumonitis, or intrathoracic lung mass. However, these are rarer etiologies and asthma is still primarily a clinical diagnosis. Inhaled steroids (choice C) may be an appropriate treatment for mild or moderate persistent asthma. However, this patient only coughs roughly once or twice a week, and therefore would be considered to have mild intermittent asthma. An intermittent beta agonist would be the appropriate first line treatment for mild intermittent asthma.There is no reason to suspect atypical pneumonia (choice E) in this afebrile patient with cough variant asthma.


A 56-year-old man is admitted to the intensive care unit for acute respiratory distress syndrome (ARDS). The patient was transferred from an outside hospital today after a 2-week hospitalization for pneumonia. During that time, the patient's pulmonary status continued to deteriorate. One week ago he was intubated and placed on mechanical ventilation and over the past week, his oxygenation has worsened with a PaO2 of 66 on an inspired concentration of 100% oxygen. The patient has no other medical history except for rheumatoid arthritis. On transfer to the ICU, the patient is intubated and sedated on a mechanical ventilator. His chest radiograph shows patchy, bilateral, diffuse interstitial infiltrates. The most important intervention that will most benefit this patient is to A. keep the patient in a prone position during mechanical ventilation
B. keep tidal volumes greater than 15 cc/kg
C. limit peak inspiratory pressure to 45 cm H2O or less
D. limit PEEP levels to less than 10 cm H2O
E. limit tidal volumes to 6cc/kg
Explanation: The correct answer is E. Although once limited to very specialized care units, patients with ARDS are becoming more prevalent in general medical ICU settings, in part due to the increasing incidence and recognition of the disorder. ARDS is an inflammatory condition of the lungs of unknown etiology but is associated with many conditions such as pneumonia, trauma, sepsis, and blood transfusions. The common denominator of all ARDS is profound hypoxia defined as a PaO2/FiO2 ratio of less than 200. Because of the profound hypoxia, the patients require mechanical ventilation for improvement. Ironically, many of the strategies employed over the years have actually contributed to or significantly worsened the injury of ARDS. The only effective intervention to date was recently shown in an NIH clinical trial. The mortality benefit conferred from this maneuver is substantial. The limitation of tidal volume to 6cc/kg or less is now standard of care and is required knowledge of any physician caring for critically ill patients. Although there have been case reports that prone positioning during mechanical ventilation (choice A) is useful for these patients, the randomized trials indicate that there is no mortality benefit associated with this intervention. The traditional teaching of keeping tidal volumes greater than 15 cc/kg (choice B) and of limiting peak inspiratory pressure to 45 cm H2O or less (choice C) is now incorrect and in fact, has been shown to be very detrimental to these patients. Experimental data have shown that ventilatory strategies that overdistend parts of the lung or allow the lung to cycle repeatedly between a collapsed state and an open state can lead to injuryXso-called ventilator-induced lung injury. PIPs should be limited to 35 cm H2O or less. Limiting PEEP levels to less than 10 cm H2O (choice D) is opposite of what is required to manage these patients. PEEP values often exceed 10 cm H2O so that repeated cycling between a collapsed state and an open state is prevented. This is the so-called "open-lung" approach to ARDS management.


A 60-year-old man comes to the emergency department because of shortness of breath. He complains of a dry cough, but denies any fever, chills, or sweats. His past medical history is significant for a history of chronic obstructive pulmonary disease (COPD), hypertension, and alcoholism. His medications include an albuterol inhaler and furosemide. He appears to be in moderate respiratory distress. His temperature is 37.0 C (98.6 F), blood pressure is 146/98 mm Hg, pulse is 120/min, and respiratory rate is 36/min. His oxygen saturation on room air is 89%. His breath sounds are diminished bilaterally and he has diffuse wheezes. The remainder of the physical examination is unremarkable. A chest radiograph shows hyperexpanded lungs. An electrocardiogram shows sinus tachycardia. The most appropriate next diagnostic study is
A. arterial blood gas analysis
B. chest CT scan
C. echocardiogram
D. venous blood gas analysis
E. ventilation-perfusion scan
Explanation: The correct answer is A. In a patient with a history of chronic obstructive pulmonary disease (COPD), the constellation of described historical and physical findings with a chest radiograph showing no acute pathology indicates a COPD exacerbation. An arterial blood gas analysis, especially in the setting of a room air oxygen saturation of 89%, will more clearly define the patient's oxygenation and ventilation status and assist in better management and triage.A chest CT scan (choice B) in the setting of a chronic obstructive pulmonary disease exacerbation associated with a negative chest radiograph cannot be expected to provide additional useful information.An echocardiogram (choice C) will offer no useful information since the patient's respiratory distress, based upon the available history and physical exam, is due to an exacerbation of his chronic obstructive pulmonary disease. A venous blood gas analysis (choice D) cannot provide any information regarding systemic oxygenation. It's utility in this setting, therefore, is minimal. Since there is no reason to suspect a pulmonary embolus, a ventilation-perfusion scan (choice E) will not provide any useful information in this instance.

A previously healthy 31-year-old woman comes to your office complaining of 1-day history of a cough and a fever. She reports that she was celebrating a job promotion 3 days prior and drank quite a bit of alcohol at a local bar. She had 2 episodes of vomiting that evening. She takes no regular medications and has only been using acetaminophen for fever suppression. Her temperature is 38.2 C (100.8 F). Her lungs have decreased breath sounds in the left base and right upper lobe. She has a cough that is productive of foul-smelling sputum. The remainder of her examination is unremarkable. The most appropriate management is to
A. admit the patient to the hospital for clindamycin therapy
B. admit the patient to the hospital for penicillin therapy
C. admit the patient to the intensive care unit for levofloxacin therapy
D. begin outpatient cefuroxime therapy
E. begin outpatient erythromycin therapy
Explanation: The correct answer is A. This is a patient who likely has pneumonia in the setting of likely aspiration. Since most pneumonia never have the etiologic agent identified, the treatment is empirical based upon patient locale at time of infection and presumed organisms based upon epidemiology. In this case, the presumed aspiration indicates that coverage for Gram-negative and anaerobic organisms is required. Clindamycin is a macrolide derivative that has activity against these agents. It is effective and is well-tolerated orally. Uncomplicated pneumonia such as community acquired or atypical infections rarely require hospitalization. For this patient with a likely anaerobic, purulent infection, a more monitored setting for therapy is required. Penicillin (choice B) is an excellent choice for community acuquired pneumonia with the caveat that an increasing number of isolates of S. pneumonia are resistant. In some centers, this number is as high as 20%. However, penicillin has no activity against Gram-negative or anaerobic organisms. Levofloxacin (choice C) is a fluoroquinolone that has broad activity against Gram-positive, Gram-negative, and some anaerobes. However, it does not have adequate coverage of anaerobic organisms to provide effective coverage for presumed aspiration. This patient has no objective findings that would warrant an ICU admission. Hemodynamic instability or respiratory distress requiring intubation would be classical reasons why patients with severe pneumonia may require an ICU stay. Outpatient cefuroxime (choice D) is a second-generation cephalosporin that is standard outpatient therapy for community acquired pneumonia. It does not have the required broad Gram-negative (although it has some) coverage and it has no anaerobic coverage. This patient should however be hospitalized for observation during initial therapy. Erythromycin (choice E) is a macrolide antibiotic that is also effective for both typical and atypical community acquired pneumonia but is only minimally useful in cases of aspiration pneumonia.

A 24-year-old African American woman comes to the clinic with a 2-week history of painful red "lumps" on her shins. She denies fevers, night sweats, cough, or sputum production. Her only past history was a broken arm when she was 10, and she does not take any medications. Her temperature is 37 C (98.6 F), blood pressure is 120/72 mm Hg, pulse is 68/min, and respirations are 16/min. Her lungs are clear and cardiac examination is normal. She has multiple bilateral, large, red, nodular lesions on her anterior tibial regions, which are painful to palpation. There is no purulent discharge. Laboratory studies show: leukocyte count 8,200/mm3, platelets 300,000/mm3, hematocrit 42%, BUN 16 mEq/L, and creatinine 0.9 mEq/L. A chest x-ray shows bilateral hilar adenopathy. Appropriate treatment for this patient should include A. antifungal therapy
B. antituberculous therapy
C. corticosteroids
D. systemic chemotherapy
E. systemic intravenous antibiotics
Explanation: The correct answer is C. This patient has erythema nodosum in the setting of bilateral hilar adenopathy. Given the fact that she has no other underlying symptoms of infection, and is a young African American female, the erythema nodosum is most likely in the setting of sarcoidosis. The treatment in this case will often involve the use of corticosteroids.Erythema nodosum can also be associated with several other disease processes such as streptococcal infections, upper respiratory infections, and inflammatory bowel diseases. The less common associations include tuberculosis, histoplasmosis, coccidioidomycosis, and drugs such as oral contraceptives and sulfonamides. She is on none of these drugs and has no symptoms of tuberculosis (choice B), a systemic or regional fungal infection(choice A), or systemic bacterial infection (choice E).Hilar adenopathy is always a concern for a malignancy (choice D). However, this clinical scenario is much more classic for sarcoidosis. Biopsy proof should nevertheless be obtained. Therefore, chemotherapy is not indicated at this time.



A 68-year-old woman comes to the office for a health maintenance examination. She has had 5-7 episodes of "expectorated blood" in the past month that she describes as a "bit concerning." She denies any other symptoms. She has been a patient of yours for 20 years and you have treated her for various "colds and flus" in the past, but she does not have any chronic medical conditions. She is a retired schoolteacher, gets regular exercise, and smokes a pack of cigarettes a day. She and her husband have become "world travelers" since both of their retirements. Her last mammogram, Pap smear, and colonoscopy were 1 year ago, and were normal, as they have always been. Her temperature is 37.0 C (98.6 F), blood pressure is 130/80 mm Hg, pulse is 65/min, and respirations are 16/min. Physical examination is unremarkable. The most appropriate next step is to
A. obtain a sputum sample by transtracheal aspiration for cytology
B. order a chest x-ray
C. schedule fiberoptic bronchoscopy
D. schedule a high-resolution CT scan
E. reassure her that it is most likely nothing but to come back if she continues to have "expectorated blood"
Explanation: The correct answer is B. This patient comes in for a routine examination but tells you something that could possibly be serious”that she has nonmassive (less than 100mL) hemoptysis ("expectorated blood"). Since she is a smoker and travels very frequently, you should not ignore this symptom. Since it is likely that the blood-streaked sputum is from the respiratory tract, a chest x-ray is the first diagnostic procedure that should be ordered. Obtaining a sputum sample (choice A) by transtracheal aspiration is not indicated at this time because it is too invasive. Expectorated sputum should first try to be obtained. Blood in the sputum may occur in cases of bronchitis, pneumonia, bronchiectasis, a lung abscess, or an endobronchial tumor. Gram, fungal, and acid-fast stains will help diagnose an infectious cause, while cytology may be helpful to diagnose a tumor.Fiberoptic bronchoscopy (choice C) is part of the evaluation of a patient with hemoptysis, but it is typically performed after a chest x-ray. It is the next step if a chest x-ray shows a mass, if the chest x-ray is normal and there are major risk factors for cancer, or if the chest x-ray is normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after weeks to months of observation.A high-resolution CT scan (choice D) is usually only indicated after a chest x-ray is performed. If the chest x-ray shows a mass and a bronchoscopy fails to suggest a specific diagnosis, a HRCT is ordered. Also, if a chest x-ray shows parenchymal disease, a HRCT may be indicated for further evaluation.It is inappropriate to reassure her that it is most likely nothing but to come back if she continues to have blood-streaked sputum (choice E) because hemoptysis can be the sign of serious disease, especially because she is a smoker and a "world traveler." Even though she came to the office for a routine physical examination, a chest x-ray should be ordered at this time. Keep in mind that a chest x-ray is not part of a routine physical examination of an asymptomatic smoker.

A 31-year-old woman with primary pulmonary hypertension is admitted to the hospital because of increasing shortness of breath, dyspnea on exertion, and increasing home oxygen requirements. The agent that will selectively decrease her pulmonary arterial pressures is
A. hydralazine
B. nifedipine
C. nitrous oxide
D. prostacyclin I
E. sodium nitroprusside
Explanation: The correct answer is C. Nitrous oxide is a gas that is usually given in low doses, 20-80 ppm via inhalation. It then acts via cGMP to mediate vasodilation of the pulmonary vasculature without any systemic hemodynamic effects. Hydralazine (choice A) is a potent generalized arterial dilator. Nifedipine (choice B) is a calcium channel antagonist. In some persons with pulmonary hypertension, a therapeutic dose of this agent can be given without producing dramatic systemic hypotension. The majority of patients receiving this therapy have significant peripheral vasodilation as well.Prostacyclin I (choice D) is used via direct pulmonary artery infusion to produce pulmonary vasodilation. However, it has moderate to severe side effects including increased GI motility and peripheral vasodilation. Sodium nitroprusside (choice E) is a generalized arterial and venous vasodilator.

A 23-year-old woman comes to the emergency department because of a "severe asthma flare." She reports that over the past hour, she has had progressively more difficulty breathing and that her medications at home have not helped her. She has a 7-year history of asthma with multiple hospitalizations. She was last hospitalized 3 years ago for a severe flare that required inpatient therapy with corticosteroids. Her current medications include albuterol 4 times daily, oral leukotriene inhibitors, cromolyn sodium, and theophylline. Her temperature is 37.0 C (98.6 F), blood pressure is 160/80 mm Hg, pulse is 90/min, and respirations are 32/min. Her breath sounds are scant with a prolonged expiratory phase. She appears to be moving minimal air. Albuterol and ipratropium nebulizers are initiated. An arterial blood gas is drawn and is most likely to show
A. PaCO2 14 mm Hg, pH 7.22, PaO2 90 mm Hg
B. PaCO2 14 mm Hg, pH 7.56, PaO2 86 mm Hg
C. PaCO2 35 mm Hg, pH 7.22, PaO2 60 mm Hg
D. PaCO2 35 mm Hg, pH 7.39, PaO2 98 mm Hg
E. PaCO2 65 mm Hg, pH 7.24, PaO22 60 mm Hg
Explanation: The correct answer is B. This patient has a severe asthma flare which caused her to hyperventilate to relieve her dyspnea. When looking at arterial blood gases, examine the pH to identify the acid-base disturbance, and then determine whether the acid-base disturbance is respiratory (change in CO2) or metabolic. The relationship between PaCO2 and pH determines whether the condition is acute or chronic. Chronic conditions have a pH closer to 7.4 than would be predicted based upon PCO2 because of compensation. For this patient, she is hyperventilating, but with no current inability to oxygenate. She should be alkalotic with a low PCO2 and her oxygenation should be nearly normal: PaCO2 14 mmHg, pH 7.56, PaO2 86 mm Hg.A PaCO2 of 14 mm Hg, pH 7.22, PaO2 90 mm Hg (choice A) represents an acidosis that is likely metabolic since the PaCO2 is low. Oxygenation is normal. This is typical for a diabetic in ketoacidosis where they hyperventilate (Kussmaul breathing) to compensate for their systemic acidosis. A PaCO2 of 35 mm Hg, pH 7.22, PaO2 60 mm Hg (choice C) reflects acidosis, likely metabolic since PCO2 is normal, with profound hypoxemia. This is typical for lactic acidosis of sepsis. A PaCO2 of 35 mm Hg, pH 7.39, PaO2 98 mm Hg (choice D) represents a completely normal blood gas. A PaCO2 of 65 mm Hg, pH 7.24, PaO2 60 mm Hg (choice E) reflects very late asthma. At this stage, PaCO2 has risen secondary to the inability to ventilate from severe bronchoconstriction, pH has fallen because of a respiratory induced acidosis, and oxygenation fails. When PaCO2 normalizes or becomes high in asthmatics, they have an impending respiratory failure in their near future.

A 37-year-old man with a history of allergic rhinitis comes to the office with a 3-day history of fever and cough. He was in his usual state of health until 3 days ago when he developed a cough productive of yellow-green sputum and fevers to 38.3 C (101.8 F). The fevers have been accompanied by drenching sweats. He has been experiencing right sided pleuritic chest pain. He denies shortness of breath, abdominal pain, weakness, or numbness. He has not had any sick contacts and has no recent travel outside of the United States. He has a 15-pack year history of smoking but denies any alcohol use or injection drug use. His temperature is 38.5 C (101.3 F), blood pressure is 132/74 mm/Hg, pulse is 82/min, respirations are 14/min, and oxygen saturation is 96%. Physical examination shows crackles at the right base A complete blood count and biochemical profile are all within normal limits. A chest x-ray shows a right lower lobe infiltrate. The most appropriate next step in the management of this patient is to
A. admit the patient to the hospital for intravenous ceftriaxone therapy
B. obtain a CT scan of the chest
C. request a pulmonary consultation for bronchoscopy
D. treat the patient as an outpatient with oral azithromycin therapy
E. treat the patient as an outpatient with oral ciprofloxacin therapy
Explanation: The correct answer is D. The patient's history, exam, and x-ray are all consistent with a diagnosis of community acquired pneumonia (CAP). CAP can be safely treated as an outpatient in most circumstances. Exceptions to this rule are when the patient has an underlying medical condition (cardiac disease, pulmonary disease, diabetes, HIV, cirrhosis, renal disease, or malignancy), advanced age, or presents with a severe pneumonia manifested by unstable vital signs or bilobar pneumonia. The appropriate treatment for this patient is either a macrolide antibiotic or an extended spectrum fluoroquinolone as they will cover typical and atypical organisms.As discussed previously this patient does not require intravenous therapy or hospital admission (choice A) unless his condition deteriorates. In addition ceftriaxone would not be adequate coverage as it does not cover the atypical organisms.In the management of routine cases of CAP, a CT scan (choice B) is not necessary. A CT scan might be appropriate in situations where there is a concern for malignancy, underlying pulmonary disease, or non-resolving pneumonia. None of these conditions are present in this case.This patient does not require a bronchoscopy (choice C). Potential indications for bronchoscopy are when there is a concern for an obstructive lesion on imaging studies, recurrent lobar pneumonia, or significant hemoptysis.Ciprofloxacin (choice E) is not the antibiotic of choice for CAP. It does not provide adequate coverage against streptococcal pneumonia, which is the most common cause of CAP.

A 68-year-old man comes to the clinic because of progressive dyspnea on exertion (DOE) and shortness of breath over the last 7 months. He denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea. His past medical history is significant only for mild osteoarthritis and an episode of pneumonia 20 years ago. His temperature is 37 C (98.6 F), blood pressure is 128/76 mm Hg, pulse is 98/min, respirations are 18/min, and oxygen saturation is 98%. His lungs are clear to auscultation and his heart is slightly tachycardic with no murmurs, rubs, or gallops. His abdomen is soft, nontender, with normal bowel sounds. His extremities have no edema. Rectal examination shows brown guaiac-positive stool. An electrocardiogram shows sinus tachycardia with a single PVC. Chest x-ray shows minimal scarring in the right lower lobe. Laboratory studies show a hematocrit of 27%, hemoglobin of 9.1 g/dL, platelets of 298,000mm3 , MCV 78 mm3, sodium of 139 mEq/l, potassium of 4.1 mEq/l, blood urea nitrogen of 16 mg/dL, and creatinine 0.9 mg/dL. The most appropriate next step in the patient's management is a
A. cardiac stress test to rule out 3 vessel coronary artery disease
B. colonoscopy to rule out colon cancer
C. high resolution CT scan (HRCT) to rule out pulmonary fibrosis
D. iron pills and follow up in 3 months
E. ventilation-perfusion (V/Q) lung scan to rule out chronic pulmonary emboli
Explanation: The correct answer is B. It is important to remember that anemia can present with dyspnea on exertion and a complete blood count should always be part of this work up. This elderly patient has an iron deficiency anemia with hemoccult positive stool. A GI malignancy needs to be ruled out and colon cancer is the most likely etiology in this patient population. Therefore, a colonaoscopy is imperative.Although ischemic cardiomyopathy or silent ischemia can certainly present with progressive dyspnea on exertion, there are other things in the patient's history to suggest the cause of his symptoms. A cardiac workup (choice A) at this time is not the most pressing issue.HRCT (choice C) is a very good test to evaluate for pulmonary fibrosis. It is likely that the CXR would show more abnormalities. The minimal scarring mentioned at the right lower lobe is likely from his prior pneumonia mentioned in the past medical history, and is not causing the patient any symptoms.The patient is presenting with a microcytic anemia. The most likely cause is iron deficiency. However, it must always be remembered that the finding of a microcytic anemia should always prompt the immediate search for an underlying cause. So although the patient will likely require iron supplementation (choice D), follow up in 3 months with no other diagnostic test is not appropriate.A V/Q scan (choice E) can rule out chronic pulmonary emboli, which is certainly a cause of progressive DOE, but as mentioned previously, there are other things in the patient's history to suggest the cause of his symptoms.

A 31-year-old woman comes to the office for a follow-up visit. Two weeks ago, the patient underwent an echocardiogram for the evaluation of a systolic murmur. Her valves appeared normal but the echocardiogram disclosed elevated right ventricular systolic and diastolic pressures consistent with pulmonary hypertension. She has no primary lung disease and reports no symptoms of dyspnea or tachypnea. Her other past medical history is unremarkable and she takes only oral contraceptive pills for medications. The most appropriate next step in the management of this patient is to A. prescribe calcium channel blockers, orally
B. prescribe nitric oxide, inhaled
C. prescribe prostaglandin, intravenously
D. refer the patient for oxygen diffusion capacity testing
E. refer the patient for vasodilator response testing
Explanation: The correct answer is E. The management of patients with pulmonary hypertension focuses on three issues: is the disease secondary to primary pulmonary disease (secondary pulmonary hypertension), is the patient responsive to vasodilator therapy, and, can the pulmonary pressures be made normal with medication. For this patient, the assumption is, given her age and lack of medical history, that her pulmonary hypertension is primary. In addition to pulmonary function testing to help verify this assumption, vasodilator testing to determine whether the pulmonary vasculature is responsive or not is the first step in the management of such patients. Calcium channel blockers (choice A), inhaled nitric oxide (choice B) or intravenous prostaglandin (choice C) are all agents used in the management of primary pulmonary hypertension. The choice of these agents depends on whether the patient is vasodilator responsive and the side effect profile. Systemic agents such as calcium antagonists and prostaglandins are associated with often profound systemic hypotension which limits their utility is normalizing pulmonary pressures. Referring the patient for oxygen diffusion capacity testing (choice D) is not necessary. Standard spirometry as part of a full battery of pulmonary function tests are indicated to assess whether the hypertension is primary or secondary, but diffusion testing is only useful in cases where hypoxemia coexists with existing pulmonary disease.


A 72-year-old smoker is admitted to the hospital for COPD exacerbation. Admission vitals are respirations 18/min, with a blood pressure of 180/100 mm Hg, and an oxygen saturation of 91%. He is started on nebulized albuterol and ipratropium bromide, as well as prednisolone intravenously. Admission chest radiograph reveals flattened hemidiaphragms, increased retrosternal clear space, and hyperlucent lungs. Given a suspicion of pulmonary embolus, a ventilation perfusion scan is performed demonstrating nonsegmental perfusion defects of the left upper lobe, with a small left lung and a complete absence of perfusion and ventilation of the entire right lung. The patient becomes acutely short of breath in the nuclear medicine department. His respirations are 30/min with otherwise normal vital signs. After supplemental oxygen (4 L/min by nasal cannula) and nebulizers are administered, the respirations become 29/min, with a blood pressure of 80/40 mmHg, and an oxygen saturation of 82%. A repeat chest radiograph is pending. The most appropriate management is to
A. administer heparin, intravenously
B. insert a chest tube on the left side
C. insert a chest tube on the right side
D. obtain a surgical consult for emergent lung volume reduction surgery
E. send him for coronary artery catheterization
Explanation: The correct answer is C. The patient is exhibiting clinical signs of a tension pneumothorax, including pulmonary and cardiac failure. The ventilation perfusion scan demonstrates lack of ventilation and perfusion of the right lung, which is consistent with a pneumothorax. A tension pneumothorax must be suspected given the diminished size of the left lung. A tension pneumothorax is a unilateral pneumothorax that becomes loculated by a one-way valve mechanism and compromises the contralateral lung and the venous return to the chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the pressure in the right hemithorax.The ventilation perfusion scan is consistent with a pneumothorax of the right lung with signs of tension, given the small left lung. The ventilation perfusion mismatches of the left lung apex are consistent with bullous disease, which is common in patients with COPD. A pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion scan. Heparin would be an appropriate treatment if the ventilation perfusion scan was positive for pulmonary embolus (choice A).The chest tube must be ipsilateral to the tension pneumothorax, not on the left side (choice B).Volume reduction surgery (choice D) is a controversial method for reducing lung volumes in patients with emphysema. It is an elective procedure and is inappropriate for the management of tension pneumothorax.The patient's low blood pressure is due to the effect of the tension pneumothorax on preload, not due to intrinsic coronary artery disease as seen in a cardiac catheterization (choice E).

A 13-year-old boy is brought to the emergency department because of shortness of breath. He has a medical history significant for asthma and he has been admitted to the hospital several times in the past, most recently 3 months ago when he needed to be intubated for extreme respiratory distress. He lives at home with his mother and 2 cats. His medications include albuterol, ipatroprium, and steroid inhalers. As you approach him you notice that he is using all accessory muscles of respiration and you hear audible wheezing. His temperature is 37.0 C (98.6 F), blood pressure is 122/68 mmHg, pulse is 102/min, and his respiratory rate is 34/min. His oxygen saturation on room air is 94%. Physical examination is significant for diffuse expiratory wheezes. The factor in this patient's

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