Case Ico-delete Highlights
A newborn infant is delivered at 30 weeks since the last menstrual period. At birth, the infant weighs 1,500gm, but otherwise appears normal. Soon after birth, the infant becomes cyanotic and breathes with a grunting noise. Ches
Correct answer:
Respiratory distress syndrome
Explanation
The leading cause of death among premature infants is respiratory distress syndrome. A fetus 30 weeks from the last menstrual period is actually 28 weeks old. At 28 weeks, type II pneumocytes first
Case Ico-delete Highlights
A 76-year-old Caucasian man with a 90 pack per year smoking history presents with progressive fatigue, tachypnea, exertional dyspnea, cough, and lower extremity edema. Inspection of his chest and abdomen reveals an increased che
Correct answer:
Distended neck veins with prominent a or v waves
Explanation
The correct response is distended neck veins with prominent a or v waves.
This patient's diagnosis is chronic cor pulmonale. Cor pulmonale is a change in the structure and functi
Case
A 53-year-old man with a 40 pack-year smoking history presents with a 10-month history of an intermittent cough with productive sputum. He admits to progressive exertional shortness of breath, which recently has limited his activity to climbing 1 fli
Correct answer:
Behavioral modification - smoking cessation
Explanation
This patient's diagnosis is most consistent with chronic obstructive pulmonary disease. Only 3 interventions: smoking cessation, oxygen therapy in chronically hypoxemic patients, and
Case Ico-delete Highlights
An immigrant worker presents with a chronic cough, blood-stained sputum, and night sweats. Physical examination reveals a wasted middle-aged man with bronchial breathings on the right upper lobe. His sputum examination under mic
Correct answer:
Ethambutol
Explanation
The correct response is ethambutol.
Important side effects of TB drugs are:
Ethambutol: optic neuritis and difficulty distinguishing blue from green
Isoniazid: hepatitis, and peripheral neuropathy (pyridoxine is the
Case Ico-delete Highlights
A 3-year-old girl presents with her mother for an acute visit. The mother states that the chief issue is a persistent cough. About 4 weeks ago, she had a low-grade fever with rhinorrhea and cough for several days. The rhinorrhea
Correct answer:
Begin daily montelukast.
Explanation
This girl's symptoms and history of allergic rhinitis are consistent with cough-variant asthma. Respiratory symptoms are characteristically worse at night and often triggered by respiratory (likely vira
Question Ico-delete Highlights
A 7-year-old boy presents with a 1-week history of wheezing and dyspnea on any exertion (with productive cough). On physical examination, bilateral rhonchi are heard. After a few days of treatment, spirometry is done on the
Correct answer:
Asthma
Explanation
The spirometry result in this patient shows reduction in both forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1), but FEV1 is more affected than FVC. Therefore, there is a decrease in the FEV1/FV
Question
Spirometry is conducted preoperatively on a 50-year-old woman about to undergo a cholecystectomy. The patient is a chronic smoker with a history of recent respiratory infection. What spirometry findings pose an increased risk for respiratory fail
Correct answer:
FVC<50% and FEV1 <50%
Explanation
Patients with history of chronic smoking have increased chances of developing respiratory failure with FEV1<50% and FVC<50%. A pulmonary function test is one of the important tests in a person undergoing a
Case Ico-delete Highlights
A 69-year-old man presents with shortness of breath associated with a nonproductive cough. He notes stabbing chest pain that increases with inspiration. On exam, there is dullness to percussion over the left side. EKG and cardia
Correct answer:
Congestive heart failure
Explanation
Congestive heart failure is the most common cause of transudative pleural effusion. In transudative pleural effusion, pleural fluid function is increased, but the patient has normal capillaries, causing
Case
A 63-year-old man with a past medical history of hyperlipidemia presents with an 8-month history of intermittent flushing and warmth sensation to his face and neck areas, alternating watery, frothy, and bulky stools associated with steatorrhea, weigh
Correct answer:
Sandostatin (Octreotide)
Explanation
This patient's diagnosis is consistent with carcinoid tumor. Carcinoid tumors are of neuroendocrine origin and derived from primitive stem cells in the gut wall, but they can be seen in other organs, in
Case
A 72-year-old man presents with longstanding but increasing dyspnea, and a 3-day history of shortness of breath, coughing, unilateral sharp chest pain and mild temperature elevation. Pain is worse when he takes a deep inspiration and when he coughs.
Correct answer:
Pleural effusion
Explanation
This patient's signs and symptoms are consistent with pleural effusion. The key finding is blunting of the costophrenic angle on chest X-ray. Fluid in the pleural space pushes the lung upward resulting in a blu
Question
During your well newborn morning nursery rounds, a nurse tells you about an abnormal finding on an antenatal ultrasound that was done. The rest of the maternal history is unremarkable. The infant was born last night. She was born at term and with
Correct answer:
Echogenic bowel
Explanation
Echogenic bowel, which is sometimes seen on antenatal ultrasound (US) that is done during the 2nd trimester, may be a marker for aneuploidy, congenital infections such as toxoplasmosis and cytomegalovirus, rare
Case Ico-delete Highlights
A 32-year-old man presents due to occasional shortness of breath and associated cough, especially when he is working outside. He has associated chest tightness that resolves within minutes when he sits down and rests. These symp
Correct answer:
Inhaled short-acting beta agonist
Explanation
This patient has intermittent asthma, which is defined as symptoms ?2 days per week, nighttime awakenings ?2 times a month, and no interference of normal activities with a normal FEV1 between e
Question
A 16-year-old boy presents with a dry cough of 1 week duration, pharyngitis, and malaise. Examination shows a low-grade fever (38.5� C), and chest auscultation reveals sibilant rhonchi. Chest films show a patchy bronchopneumonia. What is the best
Correct answer:
Erythromycin
Explanation
The correct response is erythromycin.
A clinical syndrome that includes low-grade fever, malaise, and nonproductive cough is characteristicof atypical pneumonia. The highest prevalence of infection is in the young,
Case Ico-delete Highlights
A 22-year-old woman presents with frequent sinus infections, a persistent cough productive of discolored purulent sputum, and progressive dyspnea on exertion. She also reports recurrent episodes of pneumonia, and she has been in
Correct answer:
Skin sweat test
Explanation
The criterion standard for diagnosing cystic fibrosis (CF) is the skin sweat test. An elevation of the sweat chloride >60 mmol/L is typical of CF, but the diagnosis requires positive results on 2 separate occasi
Case
A 6-week-old male infant presents with a 4-day history of cough and nasal congestion. According to his mother, he occasionally has a bluish tint around his lips while sleeping. There is no history of fever. His older siblings have an upper respirator
Correct answer:
Supplemental oxygen and supportive therapy
Explanation
Respiratory syncytial virus (RSV) is the most important etiology of viral lower respiratory disease in infants and children; bronchiolitis is the most common manifestation. Infection i
Case
A 38-year-old man presents with pneumonia. He is a construction worker who is otherwise healthy and has no allergies. His temperature is elevated, he has a nonproductive cough, and he states he "feels bad" and lacks energy.
Question
What is the best
Correct answer:
You obtain a specimen for a Gram-stain and sputum cultures and prescribe erythromycin 500mg PO q6h for 14 to 21 days for an empiric therapy against Mycoplasma pneumoniae.
Explanation
The patient presents with symptoms of community-acquired
Question
A 5-month-old infant presents with severe respiratory symptoms that include apnea and asphyxia; she is admitted to the hospital. 3 days before her admission, she developed rhinitis and a cough with wheezing. The mother became concerned when the c
orrect answer:
Respiratory syncytial virus
Explanation
Respiratory syncytial virus (RSV) is the major cause of lower respiratory tract illness (i.e., pneumonia, bronchiolitis, and tracheobronchitis) in young children. The virus belongs to the Paramyxoviri
Case
A 40-year-old man presents in January with a 4-day history of fevers, chills, myalgias, headache, productive cough, and mild sinus congestion. He has no significant past medical history.
His physical examination reveals a temperature of 101.7�F, puls
Correct answer:
Recommend bed rest, analgesics, and nasal decongestants.
Explanation
The best course of treatment is supportive and symptomatic care with hydration, analgesics, and decongestants.
This patient presents with classic symptoms of an influenza
Case
A 40-year-old man, a chronic alcoholic, presents with a cough that is productive of large amounts of fetid sputum. He developed the cough about 2 weeks ago, and it has gradually worsened over time. The sputum is now foul-smelling and copious. He has
Correct answer:
Aspiration is the most common cause
Explanation
A lung abscess is the result of a microbial infection causing cavities containing necrotic pulmonary tissue to develop in the lung. Aspiration of oropharyngeal material is the most common cau
Case
A 45-year-old man presents with a fever accompanied by a productive cough. He has had the symptoms for several weeks. His temperature rises in the evenings, and he has experienced weight loss. The chest X-ray shows upper lobe cavitary lesions.
Questi
Correct answer:
Secondary tuberculosis
Explanation
An upper lobe cavitary lesion in an adult person is classical of secondary tuberculosis. The granulomas of secondary tuberculosis are mostly present in the upper lobe, and they tend to cavitate when large
Case
You are evaluating a 12-year-old boy with cystic fibrosis (CF) at a periodic evaluation visit. Weight gain has been stable, but he has had 3 pulmonary exacerbations in the past year. His participation in physical activity has decreased during that ti
Correct answer:
Long-term, regular exercise training should be initiated.
Explanation
It is now generally accepted that regular physical activity should be an integral component of the treatment plan for individuals with cystic fibrosis (CF). Benefits inc
Case
A 69-year-old man presents with dyspnea on exertion that has been slowly progressive over the course of the last year. He notes impairment in climbing stairs and walking short distances. His review of systems is positive for fatigue, palpitations, in
Correct answer:
Cor pulmonale
Explanation
The most appropriate diagnosis in this scenario is cor pulmonale, often referred to as pulmonary heart disease. It occurs due to right ventricle structure and/or function alteration due to chronic lung disease, an
Case
A 30-year-old woman presents because she recently had a PPD skin test; the transverse diameter of the induration was 14mm. The patient denies ever having tuberculosis and she is asymptomatic now. However, she expresses some anxiety about the result o
Correct answer:
Chest X-ray
Explanation
Any PPD skin test should be performed and interpreted only in healthy, asymptomatic individuals, with a negative chest X-ray for active tuberculosis (TB). A positive result is considered if the transverse diameter o
Case
A 59-year-old man presents with a 3-month history of progressive exertional dyspnea. He also complains of dry cough, but he denies any history of fever, chest pain, or weight loss. You discover that he works in the ceramic industry at the outskirts o
Correct answer:
Silicosis
Explanation
Silicosis is the chronic fibrosing disease of the lungs produced by the prolonged and extensive exposure to free crystalline silica dust. It is the most prevalent occupational disease in the world. It requires years o
Question
A 4-year-old boy presents with a recurrent cough. The boy is small for his age, but his mother insists that he eats well. She also mentions that he frequently passes stool that is oily and foul smelling. He has had pneumonia several times, and th
Correct answer:
Cystic fibrosis
Explanation
Cystic fibrosis is one of the most common genetic disorders in the Caucasian population, with a carrier rate of approximately 1 in 28 Caucasians (1 in 31 Americans). It is inherited in an autosomal recessive fas
Case
A 75-year-old man is recovering from a pneumonia caused by Streptococcus pneumoniae; his condition suddenly deteriorates. He presents after developing a persistent fever, chills, cough, and diaphoresis. A CBC reveals leukocytosis with a left-shift. A
Correct answer:
Staphylococcus aureus
Explanation
The clinical picture is suggestive of a pleural empyema. Of the organisms listed, empyemas are commonly caused by Staphylococcus aureus, S. pneumoniae, S. pyogenes, and H. influenza in the adult patient.
T
Case
A 42-year-old man presents to the Emergency Department with a 3-day a history of fever with chills, cough with greenish-yellow sputum, and chest pain. He finds himself short of breath after walking 1 block. He has body aches, headache, and lack of ap
Correct answer:
Ceftriaxone 1 g IV Q24H and azithromycin 500 mg IV Q24H
Explanation
The correct response is ceftriaxone 1 g IC Q24H and azithromycin 500 mg IC Q24H.
The patient is possibly suffering from community-acquired pneumonia (CAP). He was admitted
Case
A 23-year-old woman presents with an anaphylactic reaction after being stung by several bees. She complains of wheezing and shortness of breath. On examination, the patient is in acute distress. BP is 98/56 mm Hg, PR 110/min, RR 28/min, and temperatu
Correct answer:
Epinephrine
Explanation
The correct answer is epinephrine, as this is the drug of choice in anaphylactic reactions. The definite indications are hypotension, bronchospasm, and urticaria. Epinephrine has significant beta-agonistic effects t
Case
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 has to 'catch' her breath because of pain on inspiration and when coughing. She has no known pas
Correct answer:
NSAIDs (non-steroidal anti-inflammatory drugs)
Explanation
The patient has pleuritis without effusion. Pleuritis is inflammation of the pleura; it may occur with or without effusion and is characterized by a sharp pain worsened by cough an
Case
A 2-week-old neonate has been reported to have an elevated Immunoreactive Trypsinogen (IRT) level on her newborn screening sample that was sent from the newborn nursery after birth. The state newborn screening lab also ran additional tests to screen
Correct answer:
Sweat chloride test
Explanation
The patient in this vignette is being evaluated for Cystic Fibrosis. Since there are more than 1,900 mutations that are known to cause CF, the absence of 40 of the most common mutations does not completely r
Case
A 68-year-old man with a history of cirrhosis presents due to weight gain, increased girth, and shortness of breath. He denies fever or chills, cough, melena, hematemesis, hemoptysis, and confusion. He takes furosemide on a daily basis, and he has no
Correct answer:
Reduced intravascular oncotic pressure
Explanation
Pleural effusion, an abnormal collection of fluid in the pleural space, is related to an underlying pathology causing excess fluid production or decreased absorption. Effusions are classif
Question
A 3-year-old girl presents with a rapid onset of high fever and noisy breathing that developed in the last 8 hours. The patient has missed standard immunizations. The child denies having a sore throat, but she tells you that she cannot eat or dri
Correct answer:
Immediate intubation
Explanation
Epiglottitis, an infection most commonly caused by Haemophilus influenzae, is characterized by inflammation and rapidly progressive edema of epiglottis and contiguous tissue. Children of ages 2 to 7 years w
Case
A 40-year-old woman undergoing chemotherapy develops fevers and respiratory symptoms. A chest radiograph is ordered, and it reveals bilateral fluffy pulmonary infiltrates. A bronchoscopy with biopsy is performed, and the specimen is found to contain
Correct answer:
Voriconazole
Explanation
The patient's symptoms are most indicative of a pneumonia-like infection, most likely stemming from the fungus Aspergillus fumigatus.
Voriconazole is considered a first-line treatment for invasive aspergillosis. It
Case
A 58-year-old woman with a past medical history of hypertension, hyperlipidemia, and breast cancer is being evaluated in the emergency room after presenting with a 2-hour history of acute-onset severe left-sided pleuritic chest pain. The pain is asso
Correct answer:
Order a CT angiography of the chest
Explanation
This patient's presentation suggests a pulmonary embolism. EKG findings include an S1Q3T3 pattern, sinus tachycardia, T wave inversion in leads V1 - V3, Right Bundle Branch Block, and low amp
Case
A 72-year-old man presents with an 8-month history of progressive dyspnea, accompanied by a dry and persistent hacking cough. While the dyspnea now occurs at rest, he denies fever, chills, palpitations, chest pain, or peripheral edema. He states that
Correct answer:
Prednisone
Explanation
This patient most likely has hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis. This is an inflammatory disorder of the lung involving alveolar walls and terminal airways that is induced
A 45-year-old woman presents with insidious onset of increasing dyspnea. A chest X-ray revealed nodular infiltrates and marked hilar lymphadenopathy. The transbronchial biopsy demonstrated non-necrotizing granulomas.
Question
What is the most likely diagn
Correct answer:
Sarcoidosis
Explanation
Sarcoidosis is a multisystem granulomatous disease. Histologically, it is characterized by the presence of non-necrotizing granulomas and hilar lymph node involvement occurs in 100% of the cases. Any infection has t
Case
A 50-year-old man presents with a 2-week history of not being able to see well. He is not on any medications. He has been smoking 2 packs of cigarettes a day for the past 30 years. On examination of his right eye, there is ptosis and miosis. A chest
Correct answer:
Horner syndrome
Explanation
Horner syndrome is due to a bronchogenic carcinoma tumor mass extending to the sympathetic chain. Horner syndrome is comprised of miosis, ptosis, enophthalmos, and hemianhidrosis. In addition, the patients may a
Case
A 3-year-old child presents with sudden onset of high-grade fever, sore throat, pain during swallowing, and drooling of saliva. There is no history of a cough. The child appears toxic and is dyspneic with inspiratory stridor. The child is sitting upr
Correct answer:
Epiglottitis
Explanation
The most likely diagnosis is acute epiglottitis, as the child has presented with sudden high fever, sore throat, dysphagia, drooling, and dyspnea. Cough is usually absent in epiglottitis. The diagnosis is further s
Case
A 44-year-old healthy man, who is a non-smoker, has a 3-cm coin lesion in the right upper lobe. The lesion was revealed on his chest radiograph. The patient did not have any clinical symptoms. The fine-needle aspiration did not reveal any cells.
Ques
Correct answer:
Pulmonary hamartoma
Explanation
A peripheral 'coin lesion' could be a granuloma, carcinoma, or a hamartoma.
The most likely malignancy in a non-smoker would be adenocarcinoma.
Pulmonary hamartoma is the most common benign lung tumor, altho
Case
A 28-year-old man presents with a 2-hour history of chest tightness, coughing, and wheezing. The history determines that he has had many such attacks in recent years, usually brought on by emotional factors or exertion; the attacks are generally trea
Correct answer:
Decreased FEV1
Explanation
The correct response is decreased FEV1.
The patient suffers from extrinsic asthma, which is an obstructive lung disease. There is, therefore, reduction of both the vital capacity and the FEV1; there is more reduc
Case
A 23-month-old boy is brought in by his distraught mother. Both are crying. It seems that while crawling on the floor, the child found a penny and put it in his mouth. Before the mother could get to him, he swallowed it. She put her finger in the bab
Correct answer:
Repeat an abdominal X-ray in an hour.
Explanation
The critical issue in treating and managing swallowed foreign bodies is their size and their ability to pass through the pylorus. There are 5 areas of natural constriction in the pediatric
Question
A woman is diagnosed with primary tuberculosis. She is 5 months pregnant. What drug should be avoided in this patient?
Correct answer:
Streptomycin
Explanation
The correct response is streptomycin.
Tuberculosis in pregnancy is treated with an initial regimen of isoniazid, rifampin, and ethambutol. Because the teratogenicity of pyrazinamide is not determined, pyrazinamide
Case
A 45-year-old man presents with significant weight loss (10 pounds in 4 months), cough with hemoptysis, and pleuritic chest pain. The chest X-ray shows ill-defined opacities in both the lungs; the opacities have a reticulonodular pattern. A transbron
Correct answer:
Tuberculosis
Explanation
The epithelioid cells suggest that it is a granuloma; the hemoptysis suggests that the granuloma has eroded enough parenchyma and involved a bronchus. A granulomatous infection, along with hemoptysis, is typical fo
Question
A New Orleans resident invites his friend to partake in a Mardi Gras tradition: the King cake. Baked into the sweet cake is a small trinket, which is shaped like a baby. The tradition is as follows: whoever gets the piece of cake with the baby in
Correct answer:
Right main bronchus
Explanation
The trachea has a diameter of approximately 2 cm. The right main bronchi is more vertical and wider (and shorter) than the left main bronchi, so things are more likely to lodge there. When children swallow t
Case
A 69-year-old man with a 50 pack-year smoking history, COPD for 12 years, and a myocardial infarction 2 years ago has been experiencing increased exertional dyspnea for 4 months. There is associated easy fatigability, exertional chest discomfort, and
Correct answer:
Right axis deviation, R wave greater than S wave in V1, and peaked p-waves on EKG
Explanation
This patient's presentation is consistent with secondary pulmonary arterial hypertension. Common ECG findings include right axis deviation, R > S
A 55-year-old woman presents with dyspnea, cough, and a feeling of fullness in her head. Clinical examination shows facial and neck swelling, dilated venous channels over the upper part of her body, facial flushing, and cyanosis. She was recently diagnose
Correct answer:
Compressive
Explanation
The correct response is compressive.
This patient has a clinical picture consistent with superior vena cava compression, which is not uncommon in the presence of a right upper lobe tumor.
Because the superior vena c
Case
A term infant is apneic at birth. After providing warmth and positioning and clearing the airway, the infant is still apneic and has central cyanosis; his heart rate is 80 beats per minute.
Question
What is the next appropriate step for resuscitation
Correct answer:
Begin positive pressure ventilation
Explanation
The initial steps like providing warmth, positioning, clearing the airway, drying, removing wet linen, and evaluating the infant takes about 30 seconds. If the infant is still apneic and the
Case
A 9-year-old boy presents with a productive cough for the past few days. The patient also has been having fevers of 101�F. The patient has had recurrent bouts of pneumonia. The patient's neonatal course was complicated by meconium ileus. A sweat chlo
Correct answer:
Pseudomonas aeruginosa
Explanation
This child who has recurrent bouts of pneumonia, a history of meconium ileus, and a positive sweat chloride test most likely has cystic fibrosis. Cystic fibrosis is an autosomal recessive disorder affecti
Case
A 72-year-old man is evaluated at the bedside following hospital admission for a 1-year history of progressive dyspnea, weight loss, low-grade fevers, fatigue, and myalgias. His past medical history is remarkable for atrial fibrillation, for which he
Correct answer:
Physical exam findings of pulmonary hypertension commonly occur.
Explanation
This patient's most likely diagnosis is idiopathic pulmonary fibrosis. It is critical to obtain a complete history, including medication history, social history,
Case
A 45-year-old man presents with progressive dyspnea and chest discomfort. He is 2 days status post total hip arthroplasty, which was uncomplicated. He denies any trauma to the chest. On exam, his pulse is 110 BPM; respirations are 40/min. The chest r
Correct answer:
Pulmonary embolism
Explanation
Pulmonary embolism pain is often abrupt in onset and pleuritic in nature. It can last several minutes to a few hours. Cough and hemoptysis may also be present. There may be predisposing factors such as deep v
Case
You have just taken over the management of a 55-year-old man with COPD who was admitted 3 days earlier for community-acquired pneumonia. He currently feels somewhat better, and he has been afebrile for the last 24 hours.
Leukocytes count 5,600/?L ser
Correct answer:
Home oxygen
Explanation
The only therapy that has been shown to decrease mortality and morbidity in COPD patients with chronic hypoxemia is oxygen therapy. It is indicated in patients with COPD with PO2 <55 or O2 saturation <88% or PO2 56-
Case
A 22-year-old man presents with a sudden onset of shortness of breath and right-sided chest pain. Symptoms began yesterday, and he felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He is a 1 pack-p
Correct answer:
Pneumothorax
Explanation
This patient is presenting with a spontaneous primary pneumothorax. A finding of a pleural line on chest x-ray (CXR) is diagnostic for this condition. A pneumothorax is a condition in which air is introduced into t
Case
A 3-year-old boy has been on antibiotics for 3 days for pneumonia. In the past 24 hours, he has developed dyspnea, fever, chills, and left-sided chest pain. On exam, he has diminished breath sounds and dullness to percussion on the left. A chest X-ra
Correct answer:
Empyema
Explanation
A patient with a pleural effusion and signs of worsening pneumonia is at high risk of having an empyema. Patients with empyema often appear ill with fever, tachycardia, dyspnea, and pleuritic chest pain.
Empyema is an i
You receive notice that one of your patients, a 2-month-old boy, was found dead in his parents' bed. He was just seen for his 2-month well-baby check and seemed healthy and thriving, although he was recovering from a mild upper respiratory infection. His
Correct answer:
Maternal smoking during pregnancy
Explanation
Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant under the age of 1 that is unexplained by thorough case investigation, autopsy, and review of case history. The o
Case
You receive notice that one of your patients, a 2-month-old boy, was found dead in his parents' bed. He was just seen for his 2-month well-baby check and seemed healthy and thriving, although he was recovering from a mild upper respiratory infection.
Correct answer:
Maternal smoking during pregnancy
Explanation
Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant under the age of 1 that is unexplained by thorough case investigation, autopsy, and review of case history. The o
Case
A 72-year-old man is evaluated at bedside following hospital admission for a 1-year history of progressive dyspnea, weight loss, low-grade fevers, fatigue, and myalgias. He has a past medical history of coronary artery disease, COPD, obstructive slee
Correct answer:
Evaluation by a pulmonologist and lung transplantation specialists should be made.
Explanation
Any patient suspected of having idiopathic pulmonary fibrosis, interstitial lung disease, or any another idiopathic interstitial pneumonia shoul
Case
A 50-year-old woman presents with right-sided pleural effusion. Thoracentesis shows the presence of exudative serosanguineous pleural fluid and positive cytology.
Question
For what condition is this finding most typical?
Correct answer:
Metastatic infiltrating ductal carcinoma
Explanation
Metastatic infiltrating ductal carcinoma is the correct response.
A blood-tinged effusion in anyone past the age of 40 should put neoplasia into the differential diagnosis. Neoplastic pl
Case
A 69-year-old man with a past medical history of obstructive sleep apnea, hypertension, and COPD presents to his local medical office with dyspnea on exertion that has been slowly progressive over the course of the last year. He notes impairment in c
Correct answer:
Spironolactone
Explanation
This patient has a presentation most consistent with cor pulmonale secondary to chronic obstructive pulmonary disease (COPD). The electrocardiogram demonstrates right axis deviation, right ventricular hypertrophy
Case
A 58-year-old man presents to the emergency department for a 4-hour history of chest pain and shortness of breath. He is a long-haul truck driver and noted the symptoms started while he was driving. He admits a mild cough, with some blood in his sput
Correct answer:
Anticoagulation
Explanation
This patient is presenting with a likely pulmonary embolism (PE). Acute dyspnea, cough (with or without hemoptysis), chest pain, and tachycardia/tachypnea are common presenting signs/symptoms of a PE. If further
Case
A 12-year-old boy presents with sudden onset of dyspnea with wheezing. The patient had a similar appearance a month ago. An arterial blood gas shows hypoxemia, hypercapnia, and acidosis. The chest x-ray shows clear lung fields. He is afebrile.
Questi
Correct answer:
Numerous sputum eosinophils
Explanation
The characteristic dyspnea with wheezing suggests that it is an acute attack of asthma. In children, exposure to an allergen is often the inciting event for extrinsic asthma. This form of obstructive
Case Ico-delete Highlights
You are evaluating a 78-year-old man who lives in a nursing home due to moderate Parkinsonism. The patient does not have any specific complaints, but nursing home staff have noticed that he does not seem as alert as usual and is
Correct answer:
Complete blood count
Explanation
This patient is presenting with altered mental status, fatigue, weight loss, and fever, which are concerning for the presence of an underlying infection. The correct response is complete blood count.
Many c
Case Ico-delete Highlights
A 57-year-old man, who is well known to your practice, presents with a 6-month history of a daily productive cough. The patient is a nonsmoker, and he has worked in a local coal mine for the past 39 years. He very rarely comes i
Correct answer:
Influenzae and pneumococci
Explanation
The correct response is influenzae and pneumococci.
It is very likely that the patient described above has an occupation pulmonary disease process, most likely coal worker's pneumoconiosis, or black l
Case Ico-delete Highlights
A 57-year-old man presents with progressive dyspnea on exertion and left lumbar colic. He has a history of hypertension as well as a 40 pack-year history of smoking. He denies cough, orthopnea, and paroxysmal nocturnal dyspnea.
Correct answer:
Cirrhosis
Explanation
Pleural effusion occurs because of the accumulation of excess fluid in the pleural space. Effusions may be transudative or exudative. Transudates have fluid protein less than 50% of the serum protein and LDH less than
Case Ico-delete Highlights
A 22-year-old man presents with a 3-day history of sharp, localized, intermittent back pain on the right side. The patient denies any physical trauma to the area. He states the pain intensifies with deep breathing, sneezing, and
Correct answer:
Indomethacin 25mg twice daily with a cough suppressant for 1 week
Explanation
Based on the symptomatology and physical exam findings, the most likely diagnosis is pleuritis. Pleurisy is characterized by an irritation of the parietal pleura
Case Ico-delete Highlights
A 15-year-old girl with a history of mild asthma has had worsening episodes of cough, wheezing, and increasing bloody sputum over the past 5 months. She denies any weight loss, decreased appetite, lethargy, or unusual travel. Sh
Correct answer:
Bronchial carcinoid tumor
Explanation
Bronchial carcinoid tumors, though rare in children, are the most common primary malignant lung tumor in children. They tend to arise in the perihilar region. Carcinoid tumors are rare neuroendocrine t
Case Ico-delete Highlights
A 30-year-old African American man presents with a 2-month history of coughing and a 2-day history of coughing blood. He also mentions that he is losing weight and sweating at night. On physical examination, the patient is waste
Correct answer:
Left upper lobe cavitations and infiltrations
Explanation
This patient is presenting with typical pulmonary tuberculosis; symptoms include long-term cough, weight loss, night sweats, and sometimes hemoptysis. Physical examination also show
Case Ico-delete Highlights
A 72-year-old man presents due to worsening shortness of breath, orthopnea, and chest pain; symptoms have been occurring for the past few weeks. The patient admits to some chronic heart problems as well as fatigue, dyspnea, and
Correct answer:
Control of his heart failure to prevent pulmonary complications
Explanation
Preventive medicine is often classified into primary, secondary, and tertiary methods. Primary methods are meant to prevent disease occurrence altogether. Secondar
Case Ico-delete Highlights
A 4-year-old boy presents with a 3-day history of fever with chills, cough, and fast breathing. His parents report decreased oral intake and increased difficulty breathing with retractions over the last 24 hours. His initial vit
Correct answer:
Ventilation/Perfusion mismatch
Explanation
Of all the causes of hypoxemia in children, ventilation perfusion mismatch is the most common cause in most clinical situations. In a child with pneumonia, the middle and lower lobes of the right
Case Ico-delete Highlights
A 2-year-old girl presents with cough, fever, decreased oral intake, and irritability for a few days. Prior to presentation, she had a 1-week history of an upper respiratory infection. On exam, she is febrile to 102�, has a resp
Correct answer:
Pneumonia
Explanation
Fever and cough combined with the abnormal lung exam make pneumonia the most likely diagnosis.
Foreign body aspiration may occur in this age group but is less likely to be associated with fever and global changes on l
Case Ico-delete Highlights
An 18-year-old man has been diagnosed with asthma since he was 12 years old. The patient states he has been controlled using his rescue inhaler but for some reason his allergies this year are really acting up. You ask him how ma
Correct answer:
Mometasone furoate
Explanation
Momemtasone furoate is an inhaled low-dose corticosteroid, which is the preferred treatment for mild persistent asthma. This is a daily maintenance treatment that can be used up to twice a day to help control
Case Ico-delete Highlights
A 52-year-old woman with a history of tobacco use was diagnosed with non-small cell bronchogenic carcinoma after a biopsy of a palpable supraclavicular lymph node. She was proceeding with her work up, but she now presents after
Correct answer:
Radiation therapy
Explanation
The patient is presenting with signs and symptoms of superior vena cava (SVC) syndrome, caused by obstruction of blood flow through the SVC due to compression, thrombosis, or infiltration from a right upper hi
Case
A 76-year-old man with hypertension, coronary artery disease, and poorly-controlled left ventricular congestive heart failure presents with a 3-day history of insidious chest pain. Pain is made worse when he takes a deep breath in and when he coughs.
Correct answer:
Pleural fluid N-terminal pro-brain natriuretic peptide levels greater than 1500 pg/mL
Explanation
This patient's presentation is most consistent with a pleural effusion. This patient is demonstrating pleuritis, which is caused by damage an
Case Ico-delete Highlights
A 54-year-old Caucasian man presents with sudden severe shortness of breath. The patient is well known to you due to a 5-year history of severe emphysema. He states that he has been a basketball player all his life; he was pract
Correct answer:
Talc sclerotherapy
Explanation
The correct response is Talc sclerotherapy.
The clinical scenario is highly suggestive of a (recurrent) secondary pneumothorax. Components that lead to this diagnosis include unilateral, sudden chest pain wit
Case Ico-delete Highlights
A 17-year-old boy presents with intermittent bouts of shortness of breath, coughing, and chest tightness. The symptoms most often occur during football practice; sometimes, however, they also occur when he is just standing outdo
Correct answer:
Normal chest X-ray
Explanation
Asthma is a chronic condition that affects pulmonary function. The pathophysiologic process underlying asthma is inflammation. In response to specific triggers, an immune-mediated cascade occurs that leads to
Case
A 69-year-old woman presents with shortness of breath. She states it has been worsening over the last 3 - 4 days; she also is experiencing increased fatigue. The patient is not on any daily medications other than over-the-counter multivitamins, and s
Correct answer:
Pleural effusion
Explanation
The correct response is pleural effusion.
The key findings are absent breath sounds, specifically in the lower lung field during auscultation, percussion that produces a dull note in the same area, and tactile
Case Ico-delete Highlights
A 50-year-old man presents with a 4-day history of increasing exertional dyspnea. He has had a chronic cough for the past 3 years and attributes it to cigarette smoking. The cough had been productive of watery sputum, but it has
Correct answer:
Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis
Explanation
Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis are the most predominant pathogens involved in the acute exacerbation of chroni
Case Ico-delete Highlights
A 70-year-old man with type II diabetes mellitus, hyperlipidemia, homocysteinemia, and metabolic syndrome presents with a 5-month history of excessive daytime sleepiness, a lack of refreshing sleep, a depressed mood, and an inab
Correct answer:
Reduced inspiratory patency of the upper airway due to relaxation of the airway muscles
Explanation
This patient's history and physical exam are remarkable for obstructive sleep apnea/hypopnea syndrome (OSAHS), which is caused by the airwa
Case
A 3-year-old boy presents with a 4-hour history of respiratory distress, dysphagia, and fever. On examination, temperature is 104.3�F, pulse 150, and respirations 32 and shallow. Marked inspiratory stridor with an open-mouth appearance and sialorrhea
Correct answer:
Securing the airway
Explanation
The above description is characteristic of acute upper airway obstruction due to an infection, with epiglottitis being the most likely cause. All diagnostic and therapeutic measures must be held in abeyance
Case
A 58-year-old woman with a past medical history of hypertension, hyperlipidemia, breast cancer, hip fractures, and coronary artery disease is being evaluated for acute-onset, severe left-sided pleuritic chest pain over the course of the last 2 hours.
Correct answer:
Heparin
Explanation
This patient's presentation is significant for a pulmonary embolism. Predisposing underlying conditions are almost always present; venous thrombosis may result from a generalized hypercoagulable state, venous endothelia
Question
A 66-year-old man with moderately well-controlled type II diabetes mellitus presents for the management of community-acquired pneumonia. He is currently being treated with intravenous levofloxacin. He is afebrile; pulse is 93, blood pressure is 1
Correct answer:
Streptococcus pneumoniae
Explanation
The correct response is Streptococcus pneumoniae.
Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality worldwide, particularly among patients age 65 and older. The pathogens as
Case
A 54-year-old man presents with a 1-year history of pneumonia, visceral Kaposi's sarcoma that is unresponsive to therapy, and chronic persistent diarrhea. He says that he uses heroin on and off because he is tired of visiting doctors all the time. He
Correct answer:
Hospice care with the diagnosis of end stage HIV/AIDS disease
Explanation
This patient has end-stage HIV/AIDS, and hospice care is appropriate for him. Patients with HIV/AIDS should meet the following criteria to be eligible for hospice se
Case
A 69-year-old man presents with a 7 - 10 day history of increasing dyspnea and inspiratory chest pain. He has a 2-pack-per-day smoking history and abuses alcohol. He has hypertension, diabetes, coronary artery disease, and chronic kidney disease. He
Correct answer:
Malignancy
Explanation
The correct response is malignancy.
A pleural effusion is an abnormal accumulation of fluid in the pleural space. Patients with pleural effusions most often report dyspnea, cough, and pleuritic chest pain. Large pleu
Question
A 40-year-old man presents with a 3-month history of a productive cough; the cough produces a scant amount of yellow sputum. He has also had an evening temperature rise (101 F) for the past 3 months. On occasion, the sputum was blood-streaked. He
Correct answer:
Tuberculosis
Explanation
The classical clinical presentation is of tuberculosis. Chest X-ray confirms the diagnosis. As tuberculosis is a common disease in developing countries,
the patient being an immigrant from a developing country stre
Case
A 28-year-old woman of Norwegian descent presents with cough, dyspnea, joint pain, fever, fatigue, and weakness. Her history is negative for occupational and environmental exposure. A previous tuberculin skin test was negative. Chest X-ray shows inte
Correct answer:
Erythema nodosum
Explanation
This patient presents with classical findings of sarcoidosis. Erythema nodosum (EN) may occur in up to 39% of sarcoidosis cases, characterized by tender erythematous nodules most commonly located on the anterio
Case
A 33-year-old African American woman with no significant past medical history, who is in her 38th week of a normal pregnancy, presents with a 1-hour history of shortness of breath. She does not recall any precipitating activities or events that may h
Correct answer:
Pulmonary embolism
Explanation
This patient has a presentation most consistent with pulmonary embolism. Nearly all PEs arise from deep venous thrombosis (DVT) in the lower extremity or pelvic veins. Risk factors for DVT and PE are similar
Case
A 43-year-old man without any significant PMHx presents with acute onset of a productive cough, shortness of breath, pleuritic chest pain, and fever. His sputum is described as "thick, brown-colored, and mucoid" but without blood. He also notes assoc
Correct answer:
Streptococcus pneumoniae
Explanation
This patient is demonstrating signs and symptoms representative of bacterial pneumonia. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia and classically causes rust-colo
Case Ico-delete Highlights
A 52-year-old man has a past medical history of smoking 40 packs of cigarettes per year; he presents for a follow-up. He notes that, over the past week, he has developed increased nonproductive cough and shortness of breath. He
Correct answer:
Smoking cessation strategies should be strongly encouraged
Explanation
This patient's most likely diagnosis is silicosis. Patients should be strongly advised to quit smoking; they should be assisted in their smoking cessation efforts. Furt
Case
A 22-year-old man presents with a 1-week history of fever, chills, dry or mildly productive cough, and chest wall discomfort. He is on no medications, but he has a history of mild asthma for which he does not need chronic therapy. He states that he h
Correct answer:
Azithromycin 500 mg first dose, then 25 0mg daily for 4 days
Explanation
The correct response is azithromycin 500 mg first dose, then 250 mg daily for 4 days.
Azithromycin is a macrolide that is effective against almost all causes of commu
Case
A 45-year-old man presents with a 2-year history of worsening dyspnea and a 1-month history of dry cough. The patient gives no history of fever, chills, chest pain, or wheezing. History is significant for smoking (25 cigarettes/day for more than 22 y
Correct answer:
Emphysema
Explanation
The findings described suggest that the patient is suffering from emphysema. Emphysema is a chronic obstructive airway disease; it is characterized by abnormal, permanent enlargement of the airways distal to the termi
Case
A 5-year-old girl has paroxysms of cough that increase in severity and duration. Some coughing episodes are followed by a whoop-like, high-pitched inspiratory noise, and vomiting has also occurred after paroxysms.
Question
What laboratory test could
Correct answer:
Polymerase chain reaction assay and antigen detection
Explanation
The correct response is polymerase chain reaction assay and antigen detection.
The characteristics presented by this child suggest B. pertussis or parapertussis infection. T
Case
A 3-year-old boy presents with a loud cough. Two days ago, the boy developed a runny nose and irritability; the next day, he began to cough loudly and felt warm. His mother tells you that the cough sounded like a wounded animal or a dog barking. The
Correct answer:
Parainfluenza virus
Explanation
The correct answer is parainfluenza virus, the most common cause of croup. Croup is more formally known as acute laryngotracheobronchitis. It occurs most often in children 2 to 3 years of age, and it has a d
Case
A 62-year-old man presents with a 2-month history of worsening fatigue and shortness of breath. He has a past medical history of emphysema attributable to his 85 pack-year cigarette smoking history. The patient complains of nearly passing out while c
Correct answer:
Pneumococcal polysaccharide vaccination
Explanation
Normally recommended for all individuals 65 and over, the pneumococcal polysaccharide vaccination is recommended for younger patients who have chronic lung diseases, such as this patient.
Case
A 72-year-old man presents with progressive shortness of breath over the years. He denies chest pain or a history of smoking. The patient was in the construction business for many years, and before that he worked as a shipbuilder. Chest X-ray reveals
Correct answer:
Asbestosis
Explanation
The correct answer is asbestosis. Asbestosis is an interstitial fibrosis that occurs from lung irritation caused by exposure to asbestos; it is often seen in patients who have an extensive work history of shipbuildin
Case
A 65-year-old man presents with dry mouth and difficulties rising from a chair, climbing stairs, and walking. His symptoms started about 1 year ago, are worse in the morning, and improve with exercise. He is a heavy smoker and was recently diagnosed
Correct answer:
Paraneoplastic
Explanation
Paraneoplastic syndrome (Lambert-Eaton syndrome), resembling myasthenia gravis, occurs in some people with small cell carcinoma of the lungs. It usually manifests as progressive weakness in the large muscles. Lam
Case Ico-delete Highlights
A 47-year-old Caucasian woman, previously healthy, presents for evaluation of a 4-week history of dyspnea. Her symptoms started approximately 1 month ago when on vacation in Colorado. She initially attributed these symptoms to t
Correct answer:
Pulmonary hypertension
Explanation
The correct answer is pulmonary hypertension. The reduced oxygen concentration present at high altitudes can trigger (or worsen) the development of pulmonary hypertension in patients who were previously a
Case
A 24-year-old man undergoes a routine medical check-up to become a volunteer in the ER. PPD skin test shows an induration diameter of 9 mm. Sputum and chest X-ray are done; they are negative for tuberculosis. He is otherwise healthy and has no fever,
Correct answer:
He was given BCG vaccination earlier in life.
Explanation
The patient was given BCG vaccination earlier in life.
The Mantoux tuberculin skin test (TST) is performed to determine whether the person is infected with Mycobacterium tuberculosi
Case Ico-delete Highlights
A 65-year-old retired man worked for 30 years at a mineral plant that processes diatomaceous earth. The area surrounding the plant is pretty; however, the residents have long complained that the plant produces a white dust that
Correct answer:
Silicosis
Explanation
Workers in the mining industry, because of exposure to silica dust, can develop silicosis. Diatomaceous earth is primarily crystalline silica. Eggshellcalcificationin the hilar lymph nodespoints towards a diagnosis of
Case
A 46-year-old man is a known asthmatic and has been on a carefully titrated dose of theophylline for 14 years without any complications. Recently, he sought medical attention for malaise, persistent cough, and weight loss. He was diagnosed with tuber
Correct answer:
Cimetidine
Explanation
Theophylline is metabolized via the cytochrome P450 oxidative drug metabolizing system.
Cimetidine is the most likely cause of the theophylline toxicity because it inhibits cytochrome P450. Theophylline's metabolism
Case
A 25-year-old male basketball player presents with acute onset shortness of breath associated with right-sided chest pain. The pain is unaffected by position and is worse with inspiration. He was grocery shopping when it started. He denies chest trau
Correct answer:
Spontaneous pneumothorax
Explanation
The patient has a primary spontaneous pneumothorax (PSP). There is a higher incidence in male patients and it usually occurs in age 20-40. PSP is heavily associated with smoking. Patient presentation an
Case Ico-delete Highlights
A middle-aged man is an immigrant to the United States; he presents with a chronic cough, blood-stained sputum, and night sweats. Physical examination reveals a cachectic man with bronchial breathing in the right upper lobe. His
Correct answer:
Start isoniazid+rifampicin+pyrazinamide+ethambutol immediately and reassess the patient's treatment after the culture result.
Explanation
The choice for tuberculosis treatment is always multiple drug therapy to prevent resistance during th
Case Ico-delete Highlights
A 35-year-old woman presents with a progressive 5-hour history of shortness of breath, cough, and wheezing. This morning she felt that she was 'catching a cold' because of fever, sore throat, and thin, purulent rhinorrhea for wh
Correct answer:
Nasal polyposis
Explanation
Your patient most probably has aspirin-exacerbated respiratory disease, also called aspirin triad, or Samter's triad. It is characterized by nasal polyposis, nonallergic induced asthma, and aspirin sensitivity.
Case Ico-delete Highlights
A 3-year-old boy presents for his annual well-child check. He and his family moved to the United States from Africa 4 months ago. He is a thin boy in no acute distress. His heart rate and rhythm are regular. His lungs are clear,
Correct answer:
Normal well-child care
Explanation
For a child who has immigrated from a high-prevalence area of the world but has no close contacts with tuberculosis disease, is not immunocompromised, and has no signs or symptoms of the disease, the indu
Case
A 33-year-old man presents with shortness of breath, wheezing, mild fever, and fatigue. He has had several similar episodes in the past, and each previous episode began after a cold that moved into his chest. Over the past several weeks, he has had a
Correct answer:
Acute asthmatic bronchitis
Explanation
The clinical picture is suggestive of acute asthmatic bronchitis. Typical symptoms include a persistent cough with mucus that can become thicker and more profuse, as well as dyspnea, mild fever, and c
Case
A 53-year-old woman presents with a 2-year history of chronic cough. The cough produces large volumes of grossly purulent sputum. She has a history of recurrent respiratory infections; they resulted in 5 hospitalizations in the past year. She also ha
Correct answer:
Chronic bronchitis
Explanation
The clinical picture is suggestive of chronic bronchitis. Chronic bronchitis is defined by a clinical history of productive cough for 3 months of the year for 2 consecutive years. Smoking is the leading cause
Case
A 72-year-old man is evaluated at the bedside following hospital admission for a 1-year history of progressive dyspnea, nonproductive cough, weight loss, low-grade fevers, fatigue, and myalgias. His past medical history is remarkable for atrial fibri
Correct answer:
Oxygen
Explanation
This patient's most likely diagnosis is idiopathic pulmonary fibrosis (IPF). It is defined as a specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause, primarily occurring in older adults
Case Ico-delete Highlights
An 18-month-old boy presents with a 2-day history of runny nose, slight cough, and low-grade fever. Over the last 24 hours, however, his condition has worsened; the child is tachypneic on exam. He is wheezing, and his breaths ar
Correct answer:
Respiratory syncytial virus
Explanation
This child presents with bronchiolitis. In approximately 70% of cases of bronchiolitis in children under the age of 2 years, respiratory syncytial virus (RSV) is the causative agent.
The remaining ca
Case Ico-delete Highlights
A 55-year-old woman presents with a slight cough she has had for about a week. She is a nonsmoker, and she does not remember having a fever or feeling sick. The patient currently works as a third-grade teacher and has done this
Correct answer:
Granuloma
Explanation
The most likely diagnosis is granuloma.
The differential diagnosis of a solitary coin lesion includes:
Lung carcinoma (most commonly an adenocarcinoma)
Granuloma
Hamartoma
A small cell carcinoma (or oat cell carcinoma
Case Ico-delete Highlights
A 45-year-old man presents with a 2-day history of sharp left-sided chest pain. It is aggravated by taking a deep breath. He denies any trauma to the chest. On examination, he is febrile, dyspneic, and has rales on auscultation.
Correct answer:
Pneumonia
Explanation
Pneumonia often causes a sharp pain that is aggravated by inspiration. Other signs and symptoms of pneumonia (e.g., cough, fever, dyspnea, and rales on auscultation) may also be present. A consolidation on chest X-ray
Question
A 3-year-old boy presents with extreme difficulty in breathing. Recently, the child came to the country with his parents from India. Past medical history reveals a 2-day history of sore throat and mild fever, and he has had some difficulty in swa
Correct answer:
Endotracheal intubation
Explanation
The clinical picture is suggestive of epiglottitis due to H. influenzae type B infection. Hib immunization is not routine in many parts of the world. The illness is characterized by a very sore throat, d
Case
A 55-year-old woman presents with a several-month history of increasing cough and dyspnea. She also has increased serum urea, nitrogen, and serum creatinine. A chest X-ray shows multiple bilateral small nodules. A renal biopsy shows a focal necrotizi
Correct answer:
Hemoptysis
Explanation
The history of upper airway involvement (cough with dyspnea), the nodular pattern on X-ray, and the renal biopsy showing focal necrotizing vasculitis suggests the diagnosis of Wegener's granulomatosis. Pulmonary (as
Case
A 35-year-old African American woman reports to the office with cough and dyspnea that have been bothering the patient for about 6-9 months. The patient denies chest pain, her BP is 138/90 mm Hg, and no obvious edema of extremities has been found. Sh
Correct answer:
Sarcoidosis
Explanation
Increased ACE levels, hypergammaglobulinemia, granulomatosis, and areas of consolidation in the mediastinum seen on MRI in the absence of a reaction to tuberculin are features of sarcoidosis in an African American w
Case
A 22-year-old woman presents with shortness of breath. She has a history of intermittent wheezing while exercising. On examination, you find that her pulse rate is increased; there are diffuse wheezes on pulmonary auscultation. Her oxygen saturation
Correct answer:
Inhaled albuterol
Explanation
In the case of an acute attack, asthmatic patients who lack signs of impending ventilatory collapse should be treated with inhaled aerosolized ?2 agonist (albuterol) every 20 minutes by nebulizer for 3 doses,
Case
A 68-year-old African-American woman with a past medical history of obstructive sleep apnea, hypertension, and COPD presents due to chronic, progressive dyspnea, which initially occurred upon exertion, but over the last 8 months has also been noted a
Correct answer:
Expected complications include syncope, hypoxia, pedal edema, and hepatic congestion.
Explanation
This patient has a presentation most consistent with cor pulmonale. The electrocardiogram demonstrates right axis deviation, right ventricula
Case
A 55-year-old woman was diagnosed with small cell cancer of the lung 2 months ago; she now presents with increasing dysphagia, respiratory difficulties, and weakness of the upper limb. Her vital signs are pulse 85/min, BP 120/90 mm Hg, resp. 12/min,
Correct answer:
Plasmapheresis
Explanation
Lambert-Eaton syndrome is caused by antibodies to the presynaptic calcium channel, which decreases the release of acetylcholine. Repeated stimulation of the nerve ending increases the intracellular calcium concen
Case
A 72-year-old man is evaluated following admission to the hospital for a 1-year history of progressive dyspnea, nonproductive cough, weight loss, low-grade fevers, fatigue, and myalgias. His past medical history is remarkable for atrial fibrillation
Correct answer:
Idiopathic pulmonary fibrosis
Explanation
This patient's most likely diagnosis is idiopathic pulmonary fibrosis. Amiodarone, bleomycin, and nitrofurantoin are notable medications associated with pulmonary fibrosis.
Most patients with idiop
Case
A 14-year-old boy presents with worsening shortness of breath; it most often occurs when he plays soccer. He often awakens in the middle of the night due to 'attacks': he starts to feel anxious because he feels like he cannot breathe, and he experien
Correct answer:
Daily low-dose inhaled budesonide
Explanation
This patient is exhibiting persistent asthma symptoms. Using the stepwise approach to treatment, the 2nd step (after using a short-acting beta-agonist, such as albuterol) is to add a low-dose i
Case
A 22-year-old man presents with sudden onset of shortness of breath and right-sided chest pain. Symptoms began abruptly yesterday. He felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He smokes one
Correct answer:
Pleural line on chest X-ray (CXR)
Explanation
This patient is presenting with a spontaneous primary pneumothorax. A finding of a pleural line on chest x-ray (CXR) is diagnostic for this condition. A pneumothorax is a condition in which air
Case
A 30-year-old immunocompromised patient presents with a 2-week history of breathlessness and a nonproductive dry cough. The patient is afebrile, pulse is 100, and BP is 110/70 mm Hg. On auscultation, scattered rales all over the chest are heard. A ch
Correct answer:
Pneumocystis pneumoniae
Explanation
The patient being immunocompromised narrows the choices to Pneumocystis pneumoniae and tuberculosis; diffuse infiltrate is more common in Pneumocystis infections of the lung. The fungus Pneumocystis jiro
Case
A 3-year-old girl presents with a 2-day history of a sore throat and fever. This morning, she was hoarse and seemed to be having more difficulty breathing. On exam, she appears to be in distress and has an oral temperature of 100.0�F. Tympanic membra
Correct answer:
Admit patient, start humidified oxygen and intermittent racemic epinephrine
Explanation
This child is in acute respiratory distress as depicted by her stridor at rest, nasal flaring, and state of distress.The situation warrants admission,
Question
A 40-year-old Asian-American man presents with a 3-day history of nausea and vomiting. He notes his health is good. He was started on a new medication 1 month ago for a positive PPD. What is a true statement regarding this patient?
Correct answer:
His AST and ALT would be elevated
Explanation
The patient's AST and ALT would be elevated.
Isoniazid (INH) toxicity should be suspected in any patient who is on this medicine and presents with abdominal pain. INH is not metabolized by the
Case
A 30-year-old man presents with a 2-month history of coughing, and a 2-day history of coughing blood. He has been losing weight and sweating at night. On physical examination, the patient appears wasted, tachypneic, has bronchial breath sounds in the
Correct answer:
Ethambutol
Explanation
The correct response is ethambutol .
This patient has all the signs and symptoms of pulmonary tuberculosis (TB). Direct sputum examination by Ziehl-Nielsen stain also helps the diagnosis, but it is still not confirma
Case
A 4-year-old boy presents with a 1-month history of weight loss, fevers, cough, and night sweats. He and his family moved to the United States from Africa 3 months ago. He is a thin, pale boy in no acute distress. His heart rate and rhythm are regula
Correct answer:
Chest X-ray and tuberculin skin test
Explanation
This boy presents with classic symptoms of tuberculosis. Clinical manifestations often appear 1-6 months after infection, which corresponds to the timing of the child's recent immigration fr
Case
A 6-year-old boy with Down's syndrome is brought to the emergency department after a drowning accident in a lake. Submersion time is unknown, although he was missing for some time. He was resuscitated and intubated by emergency medical technicians du
Correct answer:
Active internal warming
Explanation
Active internal warming is the gold standard for warming patients who have cardiac arrest or ongoing cardiovascular instability due to hypothermia, and it is most commonly achieved with cardiopulmonary b
Case
A 31-year-old HIV-positive woman presents for ongoing care. She was diagnosed with HIV 2 years ago, and she began antiretroviral therapy. Her CD4 T cell count is 400 cells/mL, and she has a history of oral candidiasis. As part of her evaluation, a tu
Correct answer:
5 mm
Explanation
The correct response is 5 mm.
Persons with HIV should be tested yearly for tuberculosis using the purified protein derivative (PPD) skin test, also referred to as the Mantoux test. In those with HIV, and in certain other c