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Section 1

Question 1: A 67-year-old female presents to her primary care clinician for a routine
wellness check. She is a known smoker with a 39 pack-year history and so of chronic
obstructive pulmonary disease. She states that over the past several weeks she has had
increasing cough secondary to a "cold." The patient states that she also has noticed a
lump on the left side of her abdomen which presented after one of her coughing spells.
She denies any pain associated, but states that sometimes increases in size. On physical
exam, the clinician is unable to appreciate any masses with the patient in the supine or
standing position but thinks that she does have some fullness lateral to her rectus muscle.
What is the next best step to evaluate this possible left-sided fullness?

Choices:

1. Expectant management and observation

2. MRI of the abdomen
3. CT scan of the abdomen with oral and IV contrast
4. CT scan of the abdomen with IV contrast only

Answer: 3 - CT scan of the abdomen with oral and IV contrast

Explanations:

This patient is at risk for a ventral hernia due to the smoking history leading to chronic
obstructive pulmonary disease and her recent coughing spell.
Elevated intra-abdominal pressure can lead to hernias in the anterior abdominal wall,
including Spigelian hernias.
CT scan with oral contrast is necessary to evaluate for any possible bowel contents
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 which may be incarcerated or obstructed secondary to herniation.
Physical exam findings for strangulated Spigelian hernia included significant pain
and erythema overlying the hernia site. The patients may also exhibit signs of bowel
obstruction with nausea, vomiting, and absence of flatus or bowel movements.

Research Concepts:

Spigelian Hernia

Question 2: A 65-year-old female presents to her healthcare provider with the complaint
of a cough for six weeks. She describes the cough as dry and pronounced, especially at
night. This cough is accompanied by hoarseness and a sore throat. On further
questioning, she reports a sensation of burning in her chest and "indigestion" that is
worse when she lies down. Her current medications include lisinopril, metformin, and
atorvastatin, all of which she has been using for several months. She states she had been
a smoker for 15 years but quit recently. She denies any history of allergies, rhinorrhea,
wheezing, or difficulty breathing. What is the most likely cause of her symptoms?

Choices:

1. Acute pharyngitis
2. Upper airway cough syndrome
3. Gastroesophageal reflux disease (GERD)
4. Medication side effect

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 Answer: 3 - Gastroesophageal reflux disease (GERD)
Explanations:

Gastroesophageal reflux disease (GERD) is a condition of the incompetence of the

lower esophageal sphincter muscle causing the reflux of stomach contents into the
esophagus.
Patients with GERD often report symptoms of chest pain, heartburn, sudden sour
taste in the mouth, and a sense of a lump in the throat. These symptoms are often
accompanied by sore throat, laryngitis, chronic cough, and disturbed sleep.
Risk factors for this condition include delayed stomach emptying, pregnancy,
obesity, hiatal hernia, and connective tissue diseases while factors that may
aggravate this disorder include smoking, large late-night meals, fried food, aspirin,
etc. Upper airway cough syndrome is characterized by a chronic cough of greater
than or equal to eight weeks duration along with the sense of something stuck in
the throat. Angiotensin- converting enzyme inhibitors (ACEIs) induced cough is a
chronic, dry cough that occurs due to the accumulation of bradykinin and
substance P in the body. Since the patient has been taking the medication lisinopril
or several months with acute symptom onset, GERD is more likely the cause of
cough in this case.

Research Concepts:
Nocturnal Cough

Question 3: A 31-year old female presents for the third time with a pneumothorax on the
left side. Previously she was treated with a chest tube. She has been having exertional
dyspnea for many months and has been treated for chronic obstructive lung disease. She
denies she is a smoker, does not use drugs, and has no allergies. For the past 3 months,
she has developed constant fatigue, cough, and chest pain. A chest CT scan was done this
morning reveal numerous thin-walled cystic changes in the lung.
After the chest tube is inserted in her, there is discharge (See image). What other
comorbid condition is often present in people with this disorder?

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Choices:

1. Lymphoma
2. Sjogren disease
3. Tuberous sclerosis
4. Leiomyosarcoma

Answer: 3 - Tuberous sclerosis

Explanations:

Lymphangioleiomyomatosis (LAM) is a rare disorder that results due to the

proliferation of lymphatics in the lung, axilla, and kidney. It is the abnormal smooth
muscle-like cells that have a neural crest origin and show some features of
neoplasia.
There is usually extensive cystic damage to the lung parenchyma, which results in
repeated pneumothoraces, chylous ascites, and chylothorax. LAM is most
common in premenopausal women, indicating that perhaps the female sex
hormones play a role in the pathology.
Women who develop LAM are also known to have a high frequency of tuberous
sclerosis. It is estimated that tuberous sclerosis occurs in at least one-third of LAM
patients.
Survival for this condition is poor, most women are dead within 10 years from
respiratory failure. Recent data indicate that early diagnosis and better treatment
may extend survival.

Research Concepts:
Lymphangioleiomyomatosis

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Question 4: A 55-year-old female presents with sudden shortness of breath, tachycardia,
and tachypnea 2 days after surgery. An arterial blood gas reveals a pH of 7.38, PCO2 35,
PO2 72, and bicarbonate 23 mEq/L. Lower extremity duplex ultrasonography shows a
large clot in the iliofemoral veins. The diagnosis of pulmonary embolism is made. What
would a chest x-ray most likely show?

Choices:

1. No abnormality
2. Hampton hump; a cone-shaped area of opacification
3. Westermark sign; a dilated pulmonary artery with distal oligemia
4. Pleural effusion

Answer: 1 - No abnormality

Explanations:

The vast majority of patients with acute and hyperacute thromboembolic disease
lack definite radiographic findings. Hampton hump is related to a wedge-shaped
peripheral opacity near the costophrenic angle that points toward the hilum with
the base against the pleura. This represents a pulmonary infarction.
The Westermark sign is dilatation of proximal pulmonary vessels and distal focal
oligemia. It is seen in less than 4% of patients with pulmonary embolism.
After 48 hours, at least 30% will show focal opacities related to developing
infarctions or atelectasis. The presence of new pleural effusion favors infarct over
atelectasis.

Research Concepts:

Acute Pulmonary Embolism

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Question 5: A 21-year-old male trauma patient with complex, bleeding intraoral and facial
lacerations as well as spinal, craniofacial, and thoracic fractures was transferred from the
emergency department to the intensive care unit (ICU). In the ICU, the nurse and
respiratory therapist are having trouble ventilating the patient because the pilot balloon
has been cut off the endotracheal tube, causing a massive air leak, despite the tube being
in a good position within the trachea. The patient's oxygen saturation is falling. What is the
next best step in securing this patient's airway?

Choices:

1. Place a 20 gauge intravenous angiocatheter into the pilot tube and reinflate the
balloon.
2. Remove the endotracheal tube and begin mask ventilation.
3. Remove the endotracheal tube and replace it with a new one using
videolaryngoscopy.
4. Remove the endotracheal tube and perform nasotracheal intubation.

Answer: 1 - Place a 20 gauge intravenous angiocatheter into the pilot tube and reinflate the
balloon.
Explanations:

The pilot tube and balloon are designed to provide a seal against the inner wall of
the trachea and, when inflated, permit positive pressure ventilation. Without a
good seal, positive pressure ventilation is not possible or, at best, not very effective.
Because of this patient's extensive bleeding lacerations, he most likely has a
difficult airway, and removal of an endotracheal tube in good position should be
avoided if at all possible, at least until the patient is stable and the factors making
the airway difficult have been addressed.
This patient is best managed by using a 20 gauge angiocatheter as a temporary
solution to reinflate the endotracheal tube cuff and allow time to plan a re-
intubation, which may require more help or equipment brought to the patient's
room.
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 While mask ventilation may work, it will not prevent significant aspiration of blood
from the patient's lacerations and may very well force blood into the trachea and
lungs. Similarly, because of the blood in the airway, the use of videolaryngoscopy is
likely to be unsuccessful - the view through the scope is liable to be obscured by the
blood. Lastly, the use of nasotracheal intubation in an urgent or emergent situation
is limited to awake patients who can maintain their airway protective reflexes,
which this paralyzed patient cannot. Additionally, the presence of craniofacial
fractures also makes nasotracheal intubation risky because of the potential to pass
the endotracheal tube through a skull base defect and into the brain.

Research Concepts:

Endotracheal Tube

Question 6: A 65-year-old male was referred to the pulmonary clinic for evaluation of left
diaphragmatic palsy which was diagnosed on a low dose computed tomography (CT) scan
done for screening for lung cancer by his primary care provider. The patient is a chronic
smoker with a history of a coronary artery bypass graft (CABG) surgery two years back. He
denies any respiratory or cardiac problem. In fact, after his cardiac surgery, he can do 20
minutes of brisk walking on the treadmill every day. What is the next step in management
for this patient?

Choices:

1. Referral to thoracic surgery for surgery of repair of the left diaphragmatic

palsy
2. Referral to an interventional radiologist for phrenic nerve pacing
3. Treatment with bilevel positive airway pressure (BIPAP) for diaphragmatic
palsy
4. Advise no treatment is needed as the patient is not having symptoms right
now

Answer: 4 - Advise no treatment is needed as the patient is not having symptoms right now
Explanations:

The patient is likely to have left diaphragmatic palsy secondary to cardiac bypass
surgery. As the contralateral hemidiaphragm compensate for the ventilatory
functions, most patients are asymptomatic and need no treatment.
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 Non-Invasive positive pressure ventilator is also used in patients with diaphragmatic
palsy who are symptomatic and are not a candidate for surgery. Most unilateral
diaphragmatic palsy patients asymptomatic.
Diaphragmatic pacing can be done in a patient with high cervical cord injury leading
to bilateral diaphragmatic palsy and who are in persistent respiratory failure. This
treatment is not tried in patients with unilateral diaphragmatic palsy.
Surgical treatment should be only considered in symptomatic patients that are
attributable to diaphragmatic palsy. Surgical plication of the affected
hemidiaphragm has provided excellent results in carefully selected patients. This
operation is performed using an open, thoracoscopic, or laparoscopic approach and
involves creating folds in the diaphragm and suturing them in place to reduce the
mobility of the paralyzed hemidiaphragm.
Plication usually results in an improvement in lung function, exercise endurance, and
dyspnea.

Research Concepts: Diaphragm Disorders

Question 7: A 16-year-old male with a past medical history of cystic fibrosis presents for a
routine visit. He reports that he is at his baseline health and denies any polyuria or
polydipsia. His hemoglobin A1c level is 6.3%, and a 2-hr 75 g oral glucose tolerance test
plasma glucose level is 210 mg/dL. What is the most appropriate next step in the
management of this patient?

Choices:

1. Start therapy with metformin

2. Start therapy with sulfonylurea
3. Start therapy with insulin
4. Obtain autoantibodies for islet cell antibody (ICA) and glutamic acid
decarboxylase antibody (GAD65)
Answer: 3 - Start therapy with insulin

Explanations:

The patient meets diagnostic criteria for cystic fibrosis-related diabetes and should
start insulin therapy to initiate treatment. At baseline health, the diagnosis of cystic
fibrosis-related diabetes is be made with a 2-hour oral glucose tolerance plasma
glucose level of 200 mg/dL, fasting plasma glucose of 126mg/dL, HgbA1c level 6.5%,
and/or random glucose 200 mg/dL with clinical symptoms.
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 Insulin is the only recommended treatment option for cystic fibrosis-related
diabetes. Initiation of early insulin therapy has been shown to improve glycemic
control, improve weight gain, improve pulmonary function, and decrease mortality
associated with cystic fibrosis-related diabetes.
There is currently insufficient data to recommend non-insulin injectables or oral
hypoglycemics agents in CFRD.
A low hemoglobin A1c does not rule out cystic fibrosis-related diabetes.
Hemoglobin A1c levels can be falsely low in individuals with cystic fibrosis and
have a low sensitivity to detect cystic fibrosis-related diabetes. Hemoglobin A1c
levels are not an effective tool to screen for CFRD but can be reliably used to
monitor response to treatment after establishing a diagnosis.

Research Concepts:

Cystic Fibrosis Related Diabetes

Question 8: A patient who is debilitated presents to the emergency department with

fevers and general malaise. A two-view chest x-ray shows a mass in the periphery of the
right lung with an air-fluid level. The patient is started on intravenous antibiotics. Over
the next 2 days, the patient looks more toxic and shows signs of sepsis. The lung mass
appears to have increased and the patient is not improving. What is the most
appropriate next step in management?

Choices:

1. Thoracotomy
2. Video-assisted thoracoscopic surgery
3. Percutaneous decompression
4. Infiltration of the mass with antibiotics
Answer: 3 - Percutaneous decompression

Explanations:

Percutaneous tube drainage has been used for drainage in patients with an
expanding lung abscess, signs of unremitting sepsis, abscess under tension, failure
to wean from mechanical ventilation, and if there has been contamination of the
contralateral lung.
In such a case, percutaneous decompression is the best procedure.
Studies have shown that the incidence of empyema after percutaneous drainage is
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 low and that patients improve significantly after decompression.
When these patients need surgery, a double lumen tube should be used to prevent
contamination of the unprotected lung.

Research Concepts:

Lung Abscess

Question 9: A 64-year-old white woman presents with increasing dyspnea on exertion

and dry cough for past 8 months. Symptoms have not improved despite antibiotics or
steroid burst. Pulmonary function tests reveal restrictive defect with impaired diffusing
capacity of the lungs for carbon monoxide (DLCO). High-resolution CT of the chest
reveals upper and mid zone predominant ground- glass opacities and areas of
reticulation and honeycombing.
Expiratory images reveal mosaic attenuation. Lung biopsy was performed to assist in
diagnosis. What is the most likely pathologic appearance of this patient's disease process?

Choices:

1. Well-formed non-caseating granulomas with negative stains for organisms

2. Airway-centered loosely formed granulomas with interstitial inflammation
and areas of fibrosis
3. Marked subpleural fibrosis with honeycombing and distortion of pulmonary
architecture
4. Submucosal lymphocytic inflammation of small airways and granulation tissue
formation resulting in complete obstruction of small airways.

Answer: 2 - Airway-centered loosely formed granulomas with interstitial inflammation and

areas of fibrosis

Explanations:

Classic pathology in chronic hypersensitivity pneumonitis (CHP) is bronchiolocentric

interstitial inflammation and areas of fibrosis.
The challenge in CHP is differentiating it from usual interstitial pneumonia (UIP).
Subpleural fibrosis, microscopic honeycombing and distortion of pulmonary
architecture are uncommon in CHP and favors a diagnosis of UIP.
Diagnosis of CHP can be challenging in cases of advanced fibrosis
necessitating a lung biopsy. Diagnosis is made after considering clinical,
radiological, laboratory and pathological data. No single diagnostic test exists.
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 Research Concepts:
Hypersensitivity Pneumonitis

Question 10: A 3-year-old male presents with recent-onset episodic coughing and fever.
The mother states that he has been coughing for two weeks since returning from a
birthday party at a local restaurant, but only recently developed a fever. The cough is non-
productive and fairly constant throughout the day and night. On examination, the child
appears comfortable but had mild audible wheezing without stridor. Auscultation reveals
rales over the right lower lung fields and wheezing in all right lung fields. His vital signs are
blood pressure 107/60 mmHg, pulse rate 110 beats per minute, respiratory rate 23
breaths per minute, and temperature 38.5 C (101 F). The chest X-ray demonstrates mild
consolidation of the right lower lobe. What is the next best step along with a 10-day
course of antibiotic therapy in management?

Choices:

1. Inhaled corticosteroids
2. Chest computed tomography if still symptomatic
3. Bronchoscopy if still symptomatic
4. Pulmonary function testing if still symptomatic

Answer: 3 - Bronchoscopy if still symptomatic

Explanations: This child has a history consistent with several potential causes for persistent
cough and new fever, but it is important to remember distal infection of the respiratory tract is
common with aspirated objects, and many aspirated objects are radiolucent. This patient is
worsening with new fevers after two weeks of symptoms that are potentially infectious in
nature (particularly after a known potential exposure at a birthday party), so a trial of
antibiotics is warranted. If the patient is still symptomatic after appropriate treatment,
reassessment could include imaging or direct examination. A foreign body must be in the
differential, and if present, is radiolucent based on prior examination. Bronchoscopy is,
therefore, both diagnostic and therapeutic, allowing for retrieval of a foreign body if present, or
for directed aspiration and culture if a pure infectious etiology is encountered. Go to the next
page if you knew the correct answer, or click the link image(s) below to further research the
concepts in this question (if desired).

Research Concepts: Airway Foreign Bodies

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Question 11: A 25-year-old male is admitted to the medical intensive care unit after
presenting to the hospital with acute shortness of breath due to multifocal pneumonia.
The patient has a medical history of asthma and anxiety disorder, for which he is
chronically on inhaled corticosteroids and clonazepam therapy. He is in severe respiratory
distress with oxygen saturation 84% despite several nebulized bronchodilator therapies
and 100% oxygen supplementation. Etomidate and rocuronium are given for rapid
sequence intubation. Postintubation, his oxygen saturation improves to 95%. A chest x-ray
confirms adequate positioning of the endotracheal tube. Twenty minutes later, the
patient is tachycardic and hypertensive, with high pressures alarming on the ventilator.
Oxygen saturation remains 95%. What is the next step in the management of this patient?

Choices:

1. Start nicardipine
2. Start fentanyl
3. Start propofol
4. Start metoprolol

Answer: 3 - Start propofol

Explanations:

This patient is still most likely paralyzed from the rocuronium but without sedation
as the etomidate has most likely worn off by now.
Analgesia and sedation are paramount in the intubated patient. It ensures
ventilator synchrony, reduces patient agitation and improves outcomes.
Analgesia-first sedation should be provided. Fentanyl is a great first choice for the
mechanically ventilated patient due to its hemodynamic profile.
If analgesia sedation is insufficient then propofol or dexmedetomidine should be
added. Benzodiazepines should be avoided in most cases. However in patients
chronically on benzodiazepine therapy fentanyl would not prevent benzodiazepine
withdrawal. Propofol would be a better choice for this patient.

Research Concepts:

Mechanical Ventilation

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Question 12: A 58-year-old female with the past medical history of very severe chronic
obstructive pulmonary disease (FEV1 0.9L less than 30% predicted) and chronic carbon
dioxide retention presents to the hospital complaining of worsening shortness of breath
and cough productive of greenish-yellow phlegm without blood. Her oxygen saturation is
72% on room air. There is bilateral wheezing on the physical examination, and she is using
accessory muscles to breath. She is alert awake oriented. Before she is placed on
supplemental oxygen, a room air arterial blood gas is drawn which reveals pH 7.26, PCO2
68, PO2 48, and HCO3- 32. The chest x-ray is normal. EKG is normal. She is given
corticosteroids, antibiotics, and ipratropium bromide/albuterol via nebulizer. What acid-
base disorder does she have and what is the next step in treatment?

Choices:

1. Respiratory alkalosis and intubate the patient

2. Metabolic acidosis and place the patient on high flow nasal cannula
3. Chronic respiratory acidosis with metabolic compensation and place the patient
on BI-PAP
4. Respiratory acidosis and metabolic acidosis and intubate the patient.

Answer: 3 - Chronic respiratory acidosis with metabolic compensation and place the patient
on BI-PAP

Explanations:

This patient has chronic respiratory acidosis with metabolic compensation. The patient
should be placed on BI-PAP.
The first step in solving acid-base problems is to evaluate the pH. This blood gas
shows acidosis. The second step is to determine if it is metabolic or respiratory
acidosis. In this case, there is hypercarbia and elevation of bicarbonate.
Hypercarbia causes acidosis and bicarbonate alkalosis. An acute change of 10
mmHg of carbon dioxide (CO2) changes the bicarbonate by 1 mmol/L, and chronic
VO2 elevation changes it by 4. This is most likely chronic CO2 retention with acute
exacerbation.
There is chronic respiratory acidosis with inappropriate compensated metabolic
alkalosis.
BI-PAP should be tried first as the patient is alert awake oriented. Arterial blood gas
should be repeated in 45 minutes to 1 hour and if patients condition worsens
consider intubation with mechanical ventilation.
Chronic respiratory acidosis may be caused by COPD where there is a decreased
responsiveness of the reflexes to states of hypoxia and hypercapnia. Other
individuals who develop chronic respiratory acidosis have the fatigue of the
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 diaphragm resulting from a muscular disorder. It can also be seen in obesity
hypoventilation syndrome, also known as Pickwickian syndrome, amyotrophic
lateral sclerosis, and in patients with severe thoracic skeletal defects. In patients
with chronic compensated respiratory disease and acidosis, an acute insult such as
pneumonia or disease exacerbation can lead to ventilation/perfusion mismatch.

Research Concepts:

Respiratory Acidosis

Question 13: A patient with cryptogenic organizing pneumonia (COP) returns for a
follow-up visit. He was on high dose prednisone for 2 months and now has started a
taper. He notes significant improvement in symptoms and currently has no respiratory
complaints. He is worried about disease recurrence and worsening lung function. What is
known about disease relapse after the tapering of steroids and long-term outcomes in
COP?

Choices:

1. Relapses do not occur in COP

2. Relapses are common in COP but do not affect long-term morbidity or
mortality
3. Relapses are common in COP and result in higher mortality
4. Relapses are rare and indicate worse long-term outcomes

Answer: 2 - Relapses are common in COP but do not affect long- term morbidity or mortality

Explanations:

Relapses are common in COP when tapering steroids but do not affect long-term
outcomes in terms of morbidity and mortality.
Delayed onset of initial treatment and elevated markers of cholestasis are associated
with multiple relapses.
COP has excellent long-term outcomes when treated. Patients demonstrate a
rapid symptomatic response to treatment and up to 80% achieve complete
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 cure.

Research Concepts:

Cryptogenic Organizing Pneumonia

Question 14: A 52-year-old female is referred for evaluation of opacities on a chest x-ray.
She was diagnosed with neuropathy of her left femoral nerve six months ago by her
neurologist. She reports a chronic cough for the last four months but reports it is dry, mild
in intensity, and rarely bothers her. She does not have any dyspnea on exertion but does
admit to having paroxysmal nocturnal dyspnea at times. She has a past medical history of
hypertension, for which she is on amlodipine. On examination, her heart rate is 84 bpm,
blood pressure is 145/82 mmHg, respiratory rate of 18/minute, and pulse oximetry of
95% on room air. Her lungs are clear to auscultation. S1, S2, and S4 are heard with no
murmurs, and the abdomen is soft with no tenderness or organomegaly. She is noted to
have a contiguous macular rash on her lower extremities which does not blanch.
Computed tomography (CT) scan of the chest without contrast shows ground-glass
opacities scattered mainly in the right upper lobe and the left lower lobe. No lobar
consolidation, septal thickening, or honeycombing is seen. CBC with differential shows a
WBC count of 8.9 x 10^9/L with a total eosinophil count of 1.4 x 10^9/L. The IgE level is
within normal limits, and Aspergillus-specific antibodies are negative. Her stool for ova
and parasites is negative. On further investigations, her P-ANCA came back positive.
What would be the best next step?

Choices:

1. Bronchoscopy with bronchoalveolar lavage

2. Biopsy of the left femoral nerve
3. Transthoracic echocardiogram
4. Stop amlodipin

Answer: 2 - Biopsy of the left femoral nerve

Explanations:

Eosinophilic granulomatosis with polyangiitis (EGPA) or Churg Strauss syndrome is a

rare multisystem disorder with chronic rhinosinusitis, asthma, and peripheral
eosinophilia.
It is characterized by eosinophilic necrotizing vasculitis of the small and medium-
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 sized vessels with associated interstitial and extra-vascular granulomas.
Lungs are the most commonly affected organs, although any organ may be
affected, including the heart, central nervous system, skin, renal and
gastrointestinal tract. A biopsy is desirable for making a diagnosis and is taken
from the most accessible site, like skin, kidney, or peripheral nerve.
Treatment involves systemic glucocorticoids along with or without
cyclophosphamide. Cyclophosphamide is generally added with cardiac, renal, or
gastrointestinal involvement.

Research Concepts:

Pulmonary Eosinophilia

Question 15: A 17-year-old male presents with hypothermia, malaise, anorexia, a

semicomatose state, and hypotension. A chest x-ray shows findings consistent with
pneumonia. The blood culture shows gram-negative rods. Which is the presumptive
diagnosis and which cytokines may be involved?

Choices:

1. B-lymphocyte cell growth: Interleukin (IL)-2 and interferon gamma are involved
2. Septic shock: IL-1 and tumor necrosis factor are involved
3. Systemic autoimmune disease: IL-4 and IL-5 are involved
4. AIDS: IL-3 and IL-7 are involved

Answer: 2 - Septic shock: IL-1 and tumor necrosis factor are involved

Explanations:

Septic shock generated by gram-negative bacteria is mediated by cytokines, mainly

tumor necrosis factor (TNF) along with other cytokines including interleukin (IL)-1
and IL-6.
The similarities between IL-1 actions and those of TNF appear surprising at face
value because the cytokines and their receptors are structurally different.
Toxins, including lipopolysaccharide that is present in the outer membrane of the
gram-negative bacterium, are involved in the pathogenesis of the TNF-mediated
septic shock.
IL-1 does not induce the apoptosis. Even at high systemic concentrations, IL-1 by itself
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 it does not cause the pathophysiologic changes of septic shock.

Research Concepts:

Interleukin

Question 16: A 30-year-old female medical student comes to the office due to exertional
dyspnea for past 6 months. She gets short of breath on walking less than a block at her
normal pace now as compared to last year when she could walk 20 blocks without any
symptoms. She denies chest pain, palpitations, syncope, weight loss, cough, or
hemoptysis. She has not used any weight loss supplements or any herbal medications.
She has no other complaints. She had a normal physical exam with no abnormalities 18
months ago on a routine clinic visit. She does not use alcohol, tobacco or illicit drugs. Her
family history includes history of stroke at age 65 in her grandfather, and her mother had
a blood clot in her legs. On heart auscultation, no murmurs or additional sounds are
present. Lungs are clear. Peripheral pulses are normal. No cyanosis or peripheral edema
seen. Prominent pulmonary arteries but no infiltrates are seen on chest x-ray. Normal
sinus rhythm with right axis deviation is seen on electrocardiogram. What is the most
appropriate next step in management of this patient?

Choices:

1. EKG stress test

2. Sleep study
3. Echocardiography
4. Ventilation scan

Answer: 3 - Echocardiography

Explanations:

The most likely diagnosis is pulmonary hypertension and echocardiography should be

ordered next. It is a good screening test for pulmonary hypertension.
Transthoracic echocardiogram is better the transesophageal in estimating the
pulmonary artery pressures.

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 The normal value of blood pressure/ pulmonary pressure has a mean value of 12 to 16
mmHg.
Pulmonary hypertension is present when mean pulmonary artery pressure exceeds
25 mmHg at rest or 30 mmHg with exercise.

Research Concepts:

Idiopathic Pulmonary Artery Hypertension

Question 17: A 36-year-old, small frame female is brought to the emergency department
from the holistic medicine clinic for pleuritic chest pain, diaphoresis, and dyspnea. She
currently smokes 1 pack of cigarettes per day and had a recent upper respiratory tract
infection. She also has chronic thoracic back pain treated by a chiropractor and
acupuncturist. On exam, she has decreased breath sounds in the left lung on auscultation.
What is the most likely cause of her symptoms?

Choices:

1. Cardiac ischemia
2. Spontaneous pneumothorax
3. Pneumonia
4. Iatrogenic pneumothorax

Answer: 4 - Iatrogenic pneumothorax

Explanations:

Iatrogenic pneumothorax is a subset of traumatic pneumothorax that arises secondary

to a procedure or surgery.
An iatrogenic pneumothorax can be suspected rather quickly with the development
of pleuritic chest pain and dyspnea in an awake patient accompanied by occasional
tachypnea and tachycardia. Decreased or absent breath sounds on the affected side
also are characteristic.
Iatrogenic pneumothorax can be caused by any intervention that involves proximity
to the thorax or abdomen, ranging from subclavian central venous catheter
placement to acupuncture.
Although it should be diagnosed clinically, the criterion standard for diagnosing a
pneumothorax is an upright, posteroanterior chest radiography.

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Research Concepts:

Iatrogenic Pneumothorax

Question 18: A 65-year-old male with COPD is in the emergency department with dyspnea,
productive cough, and fatigue. Vital signs show a heart rate of 124/min, blood pressure
158/94 mmHg, respiratory rate 32/min, and SpO2 90% on 6 L nasal cannula.
Physical examination is notable for diminished breath sounds bilaterally with scant end-
expiratory wheezes. He is given non- invasive ventilation via a full face for two hours.
Bronchodilators, antibiotics, and steroids are prescribed. Current ventilator settings are
PSV mode, IPAP 20 cmH2O, EPAP 8 cmH2O, FiO2 50%. Now vital signs are heart rate
130/min, blood pressure 160/96 mmHg, respiratory rate 30/min, and SpO2 94%. He is
alert and answers questions but appears in moderate distress and complains of dyspnea.
Tidal volumes returned to the ventilator measure between 250 and 350 mL. ABG shows
pH 7.25, pCO2 68 mmHg, and pO2 65 mmHg. What is the next best step in the
management of this patient?

Choices:

1. Increase EPAP to 10 cmH2O and FiO2 to 75%; keep IPAP at 20 cmH2O

2. Perform endotracheal intubation and set the ventilator to a volume control mode
3. Perform endotracheal intubation and set the ventilator to a PSV mode
4. Increase IPAP to 28 cmH20 and FiO2 to 75%; keep EPAP at 8 cmH2O
Answer: 2 - Perform endotracheal intubation and set the ventilator to a volume control
mode

Explanations:

PSV is not used as an initial mode of ventilation for intubated patients due to
respiratory depression following sedation given during intubation.
High airway resistance in patients with obstructive lung disease limits peak flow and
can result in small tidal volumes.
Work of breathing and thus oxygen consumption is higher in PSV than in control
modes of ventilation.
Tidal volumes in non-invasive PSV ventilation can be increased by increasing drive
pressure, but this may be limited by high airway resistance, mask leak, or air-
trapping.

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Research Concepts:

Pressure Support Ventilation

Question 19: A 65-year-old patient has been admitted to the intensive care unit (ICU) for
the management of acute respiratory failure needing intubation related to chronic
obstructive pulmonary disease (COPD) exacerbation. The following morning the patient
has been on spontaneous weaning trial for 4 hours since. The patient is getting very
restless and anxious and pointing to his endotracheal tube (ETT) and wants to take it out.
The patient is sitting upright, awake, alert and pointing to his ETT. His vital signs are BP
150/95 mmHg, HR 110 bpm, RR 26/minute, and SpO2 99%. He is on 25% FiO2. His vent
screen showed VT in the range of 500-600, RR 20- 26, PEEP 5 and pressure support of 5.
He has no respiratory distress. The patient has a nasogastric tube with tube feeding has
been running at 65 cc/hour. What is the best strategy for this patient to be removed from
the mechanical ventilator?

Choices:

1. Place back on full support for now. Hold tube feeds at midnight and then consider
extubation if the patient able to pass SBT.
2. Go ahead and extubate patient while tube feeding is going at the current rate.
3. Hold tube feeding now and extubate one hour later.
4. suction all residual gastric contents through NG tube and proceed with extubation.

Answer: 4 - suction all residual gastric contents through NG tube and proceed with
extubation.

Explanations:

The concern about extubation is tube feeding. There is no other contraindication

so delaying extubation for another day will prolong ventilator days and ICU days.
The patient is already very anxious and may need to be sedated again which can
prolong ventilator days even more. Extubation should not be delayed if the patient
has passed SBT.
It is possible that patient can be extubated with tube feeds going, and he may do
just fine, but there is some risk of failure of extubation trial and need for
reintubation. In that situation, the stomach should be empty. Also, the patient is
awake, and he may not need ongoing tube feeding as he may be able to take oral
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 nutrition very soon.
Ideally, tube feeding should be held when a patient appears to do well on a
spontaneous breathing trial (SBT). For another patient, it may have been ok to delay
extubation for one more hour while holding tube feeding. But this patient has been
on an SBT for 4 hours now which has led to anxiety and frustration.
Extubation should not be delayed any further.
The best strategy would be to suction all tube feed contents from the stomach and
then proceed with extubation. It is possible as the patient has an NG tube. It may
not have been possible in the presence of nasoduodenal or nasojejunal tube, but in
that case, the stomach may not have many contents either. Before extubation,
always consider enteral access needs for ongoing care. If the patient is likely to pass
swallow, remove the NG tube and start a diet. If the patient is at risk for failure,
keep the NG tube and do a swallow test and the decide about an ongoing need for
the tube. For high-risk patient for extubation trial failure, be very careful about
advancing the diet.

Research Concepts:

Extubation

Question 20: A 16-year-old competitive swimmer presents due to increased coughing and
shortness of breath during physical exercise. She also reports chest tightness and
mentions these symptoms start within 15 minutes of starting swimming exercises.
She has a past medical history of allergic rhinitis. There is wheezing on auscultation. An
exercise challenge test is performed. A 10% drop should be observed in which of the
following to confirms this patient's most likely diagnosis?

Choices:

1. Forced vital capacity (FVC)

2. Forced expiratory volume in 1 second (FEV1)
3. Peak expiratory flow rate (PEFR)
4. Forced expiratory flow (FEF)
Answer: 2 - Forced expiratory volume in 1 second (FEV1)

Explanations:

Exercise-induced bronchoconstriction is defined as a transient airway obstruction

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 following exercise.
It is measured by a fall in FEV1. A fall in FEV1 of at least 10 percent post-exercise is
generally considered diagnostic.
Post-exercise cough is a common feature of exercise-induced bronchospasm.
Shortness of breath, chest tightness, or wheezing may also be found.

Research Concepts:

Exercise Induced Asthma

Question 21: A 17-year-old girl has had a cough associated with exercise for four months.
She started an exercise program 4 months ago as part of a weight loss program. Exercise
includes walking on a treadmill at the fitness center. She has seasonal allergies with
current rhinorrhea and sometimes has a cough at night, for which she takes
diphenhydramine. Past medical history includes allergic rhinitis and gastroesophageal
reflux disorder. Medications include
as-needed famotidine and diphenhydramine. She occasionally has white sputum. Her
vitals are normal, and her body mass index (BMI) is 35.6. Exam shows mildly
erythematous nasal turbinates and pharynx. Lungs are clear. What is the next best step
to elucidate the cause of her cough?

Choices:

1. Chest radiograph
2. Spirometry before and after bronchodilator use
3. Serum IgE
4. Trial of antihistamine

Answer: 2 - Spirometry before and after bronchodilator use

Explanations:

This patient with a history of allergies and new onset of cough after starting an
exercise program likely has asthma and/or a nasal cause of her cough, including
allergic rhinitis, exercise- induced rhinosinusitis, or upper airway cough syndrome
versus exercise-induced bronchoconstriction (EIB). Cough that occurs at night is
more indicative of asthma, allergic rhinitis, or gastroesophageal reflux disorder. The
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 environment in which she is exercising and the type of exercise, walking, which is
less likely to induce the large increase in ventilation that is the root cause of EIB in
susceptible individuals, puts her at low risk for EIB. CHEST guidelines recommend
the evaluation of cough in adolescent athletes, including asthma, EIB, respiratory
tract infection, upper airway cough syndrome, and environmental exposures.
Spirometry before and after the use of bronchodilators can help to confirm the
diagnosis of asthma. Up to 90% of people with asthma experience Exercise-induced
bronchoconstriction (EIB). Exercise testing with spirometry, specifically changes in
FEV1, can be undertaken in the future for a diagnosis of EIB.
The patient likely also has an allergic component to her presentation. Upper
respiratory tract infections are also more common in people with EIB due to
inflammatory changes to the lung tissue, including increased mucus production.
To appropriately diagnose and treat this patient, the entire airway from nose to
lung must be considered.

Research Concepts: Exercise Induced

Asthma

Question 22: A 52-year-old coal miner presents to the clinic for evaluation of bilateral
wrist pain that began insidiously. Physical examination shows bilateral MCP joint pain
and synovitis. ANA titer is 1:20 and anti-CCP level is highly positive. Hand x-rays show
marginal erosions and early subluxation of the metacarpal phalangeal joints. CBC and
comprehensive metabolic panel are normal. Chest CT shows bilateral upper lobe
nodularity and interstitial fibrosis. Which of the following is the most likely diagnosis?

Choices:

1. Caplan syndrome
2. Felty syndrome
3. Sjogren syndrome
4. Reactive arthritis

Answer: 1 - Caplan syndrome

Explanations:

Caplan syndrome is an overlapping disorder between occupational

pneumoconiosis and rheumatoid arthritis (RA). This has been described in
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 association with asbestosis, silicosis, and coal worker's pneumoconiosis.
Patients may either have a preexisting diagnosis of RA or develop RA after fibrosis
has occurred.
Improved safety precautions and mandatory respirator equipment have reduced
the incidence of Caplan syndrome.

Research Concepts:

Silicosis

Question 23: A 16-year-old male with cystic fibrosis presents to the clinic for a follow-up
visit. He takes enzyme supplementation with meals, and he has been using chest
physiotherapy twice daily.
Genetic testing reveals homozygous G551D mutation of cystic fibrosis transmembrane
regulator (CFTR) protein. He is started on ivacaftor to improve his CFTR protein function.
Which of the following is most helpful in monitoring the effectiveness of the
medication?

Choices:

1. Venous blood gas

2. Biannual chest radiograph
3. Sweat chloride level
4. Complete blood count with differential

Answer: 3 - Sweat chloride level

Explanations:

Elevated sweat chloride content is diagnostic for cystic fibrosis. Sweat chloride
content is a surrogate for CFTR function.
Chloride quantification is the most sensitive and specific way to measure CFTR
function.
Sweat chloride may be measured in patients receiving CFTR- modulating therapies
such as ivacaftor.
While other modalities are being researched for the diagnosis of CF, such as sweat
conductance, analysis of sweat chloride levels remains the gold standard.

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Research Concepts:

Sweat Testing

Question 24: A 60-year-old female presents with progressive shortness of breath and
marked limitation with physical activity.
Auscultation of the chest reveals prolonged expiration. She has a history of chronic
obstructive pulmonary disease and pulmonary hypertension. Which group can she be
classified into, according to WHO Classification for pulmonary hypertension?

Choices:

1. Group 4
2. Group 5
3. Group 2
4. Group 3

Answer: 4 - Group 3

Explanations:

Group 3 PH is classified as pulmonary hypertension (PH) secondary to advanced

chronic lung diseases.
Group 2 PH is classified as secondary to left heart disease, valvular heart disease, or
restrictive cardiomyopathy.
Group 4 PH is secondary to chronic thromboembolic disease. Group 5 PH is secondary
to a complex group of disorders which include metabolic disorders, systemic
disorders, hematologic diseases, and miscellaneous causes.

Research Concepts:

Secondary Pulmonary Hypertension

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Question 25: A 30-year-old male with a history of sickle cell disease and ischemic stroke 1
year ago underwent a left hip replacement for aseptic necrosis of the left femoral head.
He presents to the emergency department 2 weeks after the surgery with difficulty
breathing and chest pain. Prior to complete evaluation, the patient becomes
unresponsive and has a cardiac arrest. Despite adequate cardiopulmonary resuscitation,
the patient does not survive. The autopsy results show multiple fat emboli in the lung
with pathologic evidence of ischemic stroke. When filling out the death certificate, which
of the following will be noted as the immediate cause of death?

Choices:

1. Cardiorespiratory arrest
2. Myocardial infarction
3. Fat embolism
4. Ischemic stroke

Answer: 3 - Fat embolism

Explanations:

The sudden onset of chest pain and dyspnea is highly suggestive of an embolic
process in the lung in this patient. This is the most attributable immediate cause of
death.
Sickle cell disease causes chronic hypoxia, which can lead to fragments of necrotic
bone marrow tissue being dislodged from the marrow. This embolus can
subsequently occlude the pulmonary artery.
Gurd and Wilson proposed criteria for the diagnosis of fat embolism. This condition
can be seen in patients with sickle cell disease and has a high mortality rate.
The cause of death section in the death certificate should be filled out as
specifically as possible. In Part I, one reports the causal events that lead to death
and consists of Line Ia to Line Id. The most “immediate” or “recent“ event that
leads to the demise is listed on Line Ia. The other conditions are listed on Line Ib
to Line Id in a sequential manner. The last and most remote condition leading to
death is listed as the “underlying” cause of death. All conditions that fall between
the immediate and underlying cause of death are known as intermediate or
intermediary.

Research Concepts: Death Certification

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Question 26: A 32-year-old woman is evaluated for exertional dyspnea. Medical history is
significant for systemic sclerosis.
Pulmonary examination reveals bilateral fine basal crackles. Pulmonary function test showed
a restrictive pattern with reduced DLCO. CT of the chest showed increased reticular
markings, and ground glass opacification mainly in the lower zones with no honeycombing
changes. What is the most likely diagnosis?

Choices:

1. Nonspecific interstitial pneumonitis

2. Respiratory bronchiolitis interstitial associated interstitial lung disease
3. Acute interstitial pneumonia
4. Desquamative interstitial pneumonia
Answer: 1 - Nonspecific interstitial pneumonitis

Explanations:

Systemic sclerosis-associated interstitial lung diseases are typically those of fibrotic

nonspecific interstitial pneumonia (NSIP) or, less commonly, usual interstitial
pneumonia (UIP). NSIP is a common pattern due to underlying connective tissue
disease which includes systemic sclerosis, polymyositis, dermatomyositis,
rheumatoid arthritis, and Sjogren syndrome. Most common findings on chest CT in
NSIP may include increased reticular markings, traction bronchiectasis, volume
loss, and ground glass opacification mainly in the lower zones. Honeycomb changes
are more common with UIP and usually absent in NSIP.
Research Concepts:

Nonspecific Interstitial Pneumonitis

Question 27: A 32-year-old man presents for evaluation of a cough that has been present
for several weeks. He reports that the cough is productive of "sandy" sputum. He also
reports generalized malaise and intermittent fever. He was seen at an urgent care clinic
four weeks ago for the same cough and completed a course of oral antibiotics without
improvement. He has no significant past medical history, does not take any medication,
does not smoke, and works as a farmer in the Ohio river valley. Vital signs and physical
examination are unremarkable. A chest x-ray shows bilateral, enlarged, calcified hilar and
mediastinal lymphadenopathy. Complement fixation testing for Histoplasma capsulatum
reveals a titer of 1:16. What is the most likely diagnosis?

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 Choices:

1. Symptomatic pulmonary histoplasmosis

2. Acute diffuse pulmonary histoplasmosis
3. Chronic pulmonary histoplasmosis
4. Broncholithiasis secondary to histoplasmosis

Answer: 4 - Broncholithiasis secondary to histoplasmosis

Explanations:

The majority of the patients with Histoplasma capsulatum exposure remain

asymptomatic, and fewer than 5% of the patients develop symptomatic disease.
Symptomatic pulmonary histoplasmosis is the most common syndrome seen with
H. capsulatum infection; however, a variety of presenting syndromes can be seen in
patients with pulmonary histoplasmosis. This patient presents with broncholithiasis
secondary to histoplasmosis.
Patients with broncholithiasis secondary to histoplasmosis present with chronic
cough, hemoptysis, fever, chills, and purulent sputum production. The expectorate
is often reported to contain small stones with a gravel-like or gritty consistency. This
occurs due to the erosion of calcified lymph nodes into the bronchi. Severe
hemoptysis may also occur if they erode into the bronchial arteries.
Antigen testing is usually negative, and serologic testing only reveals low-titers in a
small percentage of patients. Organisms may be demonstrated in the evaluation of
the calcified nodes, but cultures usually are negative.
Granulomatous mediastinitis and fibrosing mediastinitis are other sequelae of
histoplasmosis. Cultures and antigen tests are usually negative. Tissue testing with
fungal stains may show organisms consistent with H. capsulatum.
Research Concepts: Histoplasmosis

Question 28: A 35-year old male soldier on active duty presents following the detonation
of an improvised explosive device (IED). He was standing 50 feet from the device when it
exploded and was dressed in the appropriate gear, including his helmet. Vital signs read a
blood pressure of 89/55 mmHg, pulse rate of 120 beats per minute, and respiratory rate of
20 breaths per minute. On physical examination, the patient demonstrates severe pain and
respiratory distress indicated by decreased breath sounds and hyper-resonance to
percussion over the right lung field. Left lung fields were clear to auscultation. Jugular
venous distension is also noted on inspection of the neck. No signs of penetrating injury or
lacerations are present on examination. Which of the following change in parameters
would be expected in this patient?
Page 30 of 955
Choices:

1. Increased intrapleural pressure

2. Decreased intrapleural pressure
3. Increased lung compliance
4. Increased right lung volume
Answer: 1 - Increased intrapleural pressure
Explanations:

The patient sustained a barotrauma injury resulting in a tension pneumothorax,

which is characterized as hemodynamic instability due to obstructive shock,
decreased breath sounds, and hyper-resonance to percussion.
An outward increase in atmospheric pressure caused by the explosion resulted in
increased intrapleural pressure inside the pleural cavity, causing the right lung to
collapse.
An increase in intrapleural pressure decreases the transpulmonary gradient, which
results in decreased lung compliance and distensibility, preventing the lung from
expanding; this results in more effort in the breathing cycle to overcome the
increased alveolar tension and airway resistance to expand the lung. Management
is an urgent needle thoracostomy to relive the excess air within the pleura.
Lung compliance is defined as how easy it is for the lungs to expand and maintain
the distension under a change of pressure. In the case of a tension pneumothorax,
the added pressure within the pleural cavity compressing the lung overwhelms the
ability for it to expand, resulting in decreased lung compliance.
As the intrapleural pressure is positive due to the excess air, it compresses the
lung, which prevents it from expanding. Thus, resulting in decreased volume in the
right lung.

Research Concepts: Physiology, Transpulmonary Pressure

Question 29: A 17 year-old male is brought to the emergency department via ambulance
with multiple gunshot wounds to his chest. The patient is tachycardic, hypotensive, and
saturating 92% on room air. The patient is in moderate respiratory distress with a
Glasgow Coma Scale score of 14. Chest radiography reveals complete opacification of the
right hemithorax. A chest tube is placed and immediately drains 1,100 ml of blood. What
is the next best step in management?

Choices:

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 1. Close observation
2. Thoracotomy
3. Pig-tail catheter placement
4. Endotracheal intubation

Answer: 2 - Thoracotomy

Explanations:

According to the Advanced Trauma Life Support guidelines, surgical intervention

(tube thoracostomy) is warranted in the setting of traumatic hemothorax when
chest tube immediately drains 1,000 ml, drainage exceeds 250 ml of blood per hour
for three consecutive hours, or 1500 ml of blood drains in 24 hours. Other
indications are cardiac tamponade, chest wall defect, large clotted hemothorax, or
massive air leak, among others.
Adequate evacuation of a hemothorax is essential to prevent complications such as
fibrothorax or empyema. Fibrothorax and empyema lead to an increase in
morbidity and mortality and length of hospital stay in these patients.
Pig-tail catheter is placed initially in the setting of a simple pneumothorax in a
hemodynamically stable patient. This patient's presentation is consistent with
massive hemothorax that needs surgical management with tube thoracotomy for
proper drainage. A pig-tail catheter will easily be clogged with blood clots and will
not provide sufficient drainage.
Endotracheal intubation should be performed in urgently if the patient is unable to
protect his airway or demonstrates signs of cardiovascular collapse.

Research Concepts: Hemothorax

Question 30: A 47-year-old male patient is brought to the emergency department with
mental status changes and hypotension. His heart rate is 110 beats/min, blood pressure
85/55 mmHg, and respiration rate of 14. He is lethargic and confused. Electrolytes show
sodium is 135 meq/L, potassium 3.5 meq/L, chloride 102 meq/L, bicarbonate 22 meq/L,
BUN 45 mg/dL, and creatinine 1.8 mg/dL. PO2 is 60, PCO2 is 30, and pH is 7.46. What acid-
base disorder is this patient experiencing?
Choices:

1. Respiratory alkalosis
2. Metabolic alkalosis
3. Metabolic and respiratory alkalosis
4. Respiratory acidosis
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Answer: 1 - Respiratory alkalosis

Explanations:

Normal human physiological pH is 7.35 to 7.45. A decrease in pH below this range

is acidosis, and an increase above this range is alkalosis. Respiratory alkalosis is by
definition a disease state where the body’s pH is elevated to greater than
7.45 secondary to some respiratory or pulmonary process. Carbon dioxide (CO2)
levels are physiologically regulated by the pulmonary system through respiration,
whereas the bicarbonate levels are regulated through the renal system with
reabsorption rates. Therefore, respiratory alkalosis is a decrease in serum CO2.
While it is theoretically possible to have decreased CO2 production, in every
scenario this illness is a result of hyperventilation where CO2 is breathed away.
Respiratory alkalosis is the most common acid-base abnormality with no
discrimination between sexes. The exact frequency and distribution of disease are
dependent upon the etiology.
Likewise, the morbidity and mortality rates are dependent on the etiology of the
disease.
Respiratory alkalosis in itself is not a life-threatening diagnosis. However, the
prognosis is variable depending on etiology.

Research Concepts:
Physiology, Metabolic Alkalosis

Question 31: A 17-year-old is brought to the emergency department by ambulance after

developing sudden shortness of breath. A chest radiograph shows a 10% pneumothorax.
Vital signs are stable, including oxygen saturation of 96% on room air. What is the most
appropriate next step in management?

Choices:

1. Immediate chest tube placement

2. Needle aspiration
3. High flow oxygen
4. Low flow oxygen

Answer: 4 - Low flow oxygen

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 Explanations:

Pneumothorax is the accumulation of air within the pleural space. The usual cause
of pneumothorax is a penetrating wound such as a stabbing, gunshot wound, or
deceleration-type injury, as seen in motor vehicle collisions.
Spontaneous pneumothorax also can occur as a result of a ruptured bleb. This
typically affects tall, thin men or those who smoke. Clinical findings include
decreased breath sounds on the side involved, shortness of breath, chest pain, and
cough. A chest radiograph is the initial diagnostic study.
Treatment may require immediate intervention but depends on the extent of the
pneumothorax and the patient's clinical symptoms. Observation with
supplemental oxygen administration is the only treatment necessary if the
pneumothorax involves less than 15-20% of lung volume.
However, high flow oxygen is not needed; low flow oxygen is usually sufficient for mild
pneumothoraces.
For larger pneumothoraces, chest tube thoracostomy is necessary. Tension
pneumothoraces require emergent decompression with a large-bore needle placed in
the second intercostal space, followed by chest tube placement.

Research Concepts: Spontaneous

Pneumothorax

Question 32: A 17-year old patient has been receiving mechanical ventilation with a
balloon-cuffed tracheostomy tube for the past 3 weeks after suffering a severe blunt
laryngeal injury. On two occasions, within 24 hours, about 30 ml of blood was suctioned
from the tracheostomy tube. What is the most potentially serious source of the bleeding?

Choices:

1. Lung pathology
2. Granulation tissue at the tracheostomy site
3. Erosion into the internal jugular vein
4. Erosion into the innominate artery

Answer: 4 - Erosion into the innominate artery

Explanations:

Any patient with tracheal bleeding that amounts to more than blood streaking of

Page 34 of 955
 the tracheal aspirate, 48 hours or more after tracheostomy, must be assumed to
have tracheal erosion into the innominate artery until proven otherwise.
Episodes of such minimal blood loss tend to precede or herald the development of
a massive and frequently fatal hemorrhage. Recognition of the significance of such
seemingly minor bleeding episodes, with appropriate subsequent management,
offers the best chance for survival.
Patients with severe bleeding should be immediately re- intubated, and corrective
surgery should be undertaken if the diagnosis is confirmed. Massive bleeding from
the tracheostomy site invariably comes from erosion of the innominate artery and
is usually fatal unless rapidly controlled.
In most cases, bleeding stops temporarily with further inflation of the balloon cuff
until the patient is taken to the operating room.
Sometimes the innominate artery can be compressed against the back of the
sternum with a finger introduced through the tracheostomy incision between the
trachea and the artery.

Research Concepts:

Tracheo Innominate Artery Fistula

Question 33: A 39-year-old man is diagnosed with pulmonary alveolar proteinosis

following bronchoscopy with lavage. His serum GM-CSF levels appear normal, but his
anti-GM-CSF IgG antibody levels are markedly elevated. What is the treatment of
choice?

Choices:

1. Systemic corticosteroids
2. Inhaled GM-CSF
3. Plasmapheresis
4. Whole lung saline lavage

Answer: 4 - Whole lung saline lavage

Explanations:

The treatment of choice in pulmonary alveolar proteinosis is whole lung lavage,

which has been shown to improve mortality, symptoms, and respiratory function in
retrospective analyses.
Although autoimmunity is the likely cause of his pulmonary alveolar proteinosis,
Page 35 of 955
 systemic corticosteroids have been found to worsen outcomes due to risk of
infections without improvement in disease.
Autoimmune pulmonary alveolar proteinosis represents about 90% of all
pulmonary alveolar proteinosis cases, while secondary and congenital pulmonary
alveolar proteinosis represent 5% together.
Whole lung lavage may be curative in autoimmune pulmonary alveolar proteinosis
after repetitive treatments, whereas it is not curative in secondary or congenital
pulmonary alveolar proteinosis.

Research Concepts:

Pulmonary Alveolar Proteinosis

Question 34: A 20-year-old college student from Illinois was admitted for chronic
headaches for the past 4 months. She has no travel history or occupational exposure to
toxins or infectious agents. Her vital signs are stable. The physical exam is remarkable for
lymphadenopathy, erythema nodosum, ataxia, and right facial droop without facial
sparing. An MRI with gadolinium shows abnormal signal intensities in the cerebellum and
brainstem. A lumbar puncture reveals elevated protein and mild pleocytosis. If a lymph
node biopsy is done, what is the most likely histopathology that would be seen?

Choices:

1. Encapsulated yeast
2. Caseating granulomas
3. Fibrosis
4. Non-caseating granulomas

Answer: 4 - Non-caseating granulomas

Explanations:

This patient has neurosarcoidosis. Non-caseating granulomas are the hallmark of

sarcoidosis.
A lumbar puncture will show elevated protein and mild-to- moderate pleocytosis.
An MRI with contrast may show leptomeningeal enhancement. A lumbar puncture
may help exclude infection of the central nervous system, malignancy, or multiple
sclerosis.

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Research Concepts:
Neurosarcoidosis

Question 35: A 58-year-old male is referred for dyspnea on exertion and cough of 3 weeks
duration. His primary care provider had diagnosed him with pneumonia and was
prescribed two courses of antibiotics without significant improvement in symptoms. Vitals
are normal except low oxygen saturation. Lung auscultation reveals intermittent crackles.
High-resolution CT of the chest shows bilateral infiltrates predominantly in the lower
lobes along with small pleural effusions. Which is the most appropriate next test that will
enable to make a diagnosis?

Choices:

1. Bronchoscopy with bronchoalveolar lavage

2. Serology for IgG antibodies to common allergens
3. Positron emission tomography with fluorodeoxyglucose
4. Angiotensin-converting enzyme level

Answer: 1 - Bronchoscopy with bronchoalveolar lavage

Explanations:

Cryptogenic organizing pneumonia (COP) is the most likely diagnosis in this patient
given the persistent pulmonary opacities despite antibiotic treatment.
Mixed cellularity on bronchoalveolar lavage (BAL) with elevated lymphocytes and
low CD4:CD8 ratio supports a diagnosis of COP.
BAL also helps rule out atypical infections which could present similarly.
A thorough history should be taken to exclude other diagnoses and exclude
secondary organizing pneumonia.

Research Concepts:

Cryptogenic Organizing Pneumonia

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Question 36: A 51-year-old male presents with fever, productive cough, and worsening
chronic right shoulder pain. He has a history of interstitial lung disease and
dermatomyositis. He admits he is undergoing immunosuppressive therapy and is
admitted one month ago for pneumonia. He denies trauma or recent corticosteroid
injections to the shoulder. On exam, there is evidence of dermatomyositis, and his right
shoulder is limited in all planes of motion with a fluctuant mass in the superior and
posterior aspects of the joint. His lungs are clear to auscultation. Bedside ultrasound
reveals a large subacromial bursal fluid collection, and a radiograph of the chest shows
interstitial infiltrates. AFB smear and Xpert MTB/RIF Assay of an aspirate are positive.
What is the most appropriate treatment for this patient?

Choices:

1. Ethambutol orally and rifampin, isoniazid, and pyridoxine intravenously

2. High dose corticosteroids and levofloxacin intravenously
3. Incision and drainage of the bursal fluid collection followed by doxycycline orally
4. Surgical debridement of the right shoulder and vancomycin intravenously

Answer: 1 - Ethambutol orally and rifampin, isoniazid, and pyridoxine intravenously

Explanations:

This patient is immunocompromised and at risk for fungal and atypical infections.
His likely diagnosis is septic bursitis and pulmonary infection likely from
Mycobacterium. The patient exhibits pulmonary and extrapulmonary signs and
symptoms, including pulmonary infiltrates, evidence of dermatomyositis, and deep
bursal infection. Diagnosis of Mycobacterial infection involves sputum and bursal
fluid culture in this patient and histopathology. Treatment for disseminated disease
is the same for pulmonary and includes ethambutol, rifampin, isoniazid, and
pyridoxine.
High-dose corticosteroid is the treatment for his dermatomyositis, and levofloxacin
is for pneumonia in an immunosuppressed individual. However, the patient also
has septic bursitis, and levofloxacin would be inadequate.
Given the patient is immunocompromised, this patient should be admitted for
intravenous antibiotics. If the patient was immunocompetent, then doxycycline could
cover both septic bursitis and pneumonia.
Given the patient's history, he likely has a Mycobacterium infection, which requires
a 3 to 4 drug regimen.

Research Concepts: Septic Bursitis

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Question 37: A 36-year-old woman presents with worsening shortness of breath. Other
than obesity, she has no significant past medical history and takes no medication. Her
blood pressure is 105/92 mmHg, respiratory rate 24/min, heart rate 106/min, and
oxygen saturation 90% on room air. Her BMI is 40 kg/m^2.
Examination demonstrates jugular venous distention and clear lung sounds. A portable
chest X-ray is unremarkable. Laboratory results show hemoglobin of 15 g/dL, platelets
290000/microL, and leukocytes 5000/microL. Sodium level is 142 mEq/L, potassium 4.3
mEq/L, chloride 99 mEq/L, bicarbonate 35 mEq/L, BUN 26 mg/dL, creatinine 1.0 mg/dL,
and glucose 100 mg/dL. Recent pulmonary function testing demonstrates FEV1 72%
predicted, FVC 70% predicted, and FEV1/FVC 80%. Which of the following is the best
next step in managing this patient?

Choices:

1. Obtain CT angiogram of the chest

2. Obtain arterial blood gas
3. Administer IV corticosteroids
4. Perform ventilation-perfusion scan

Answer: 2 - Obtain arterial blood gas

Explanations:

This patient's BMI is 40 kg/m2, and she presents with worsening shortness of breath.
She likely has underlying obesity hypoventilation syndrome (OHS), as recent
pulmonary function testing demonstrates no airflow obstruction, and her serum
bicarbonate is elevated.
An arterial blood gas (ABG) on room air should be obtained for any patient with
suspected OHS to look for daytime hypercapnia.
An ABG will help determine if this patient has acute on chronic hypercapnia
respiratory failure and needs positive pressure.
Noninvasive ventilation may be indicated for this patient.

Research Concepts:

Obesity-Hypoventilation Syndrome

Page 39 of 955
Question 38: A patient with mild, persistent asthma has been well controlled with low-
dose inhaled corticosteroids. He presents for follow up complaining of some limitation
with normal activities and needing albuterol for symptom relief 3 to 4 days per week over
the past month. Which of the following is the preferred next step?

Choices:

1. Begin an oral corticosteroid burst

2. Medium-dose inhaled corticosteroid
3. Add a leukotriene receptor antagonist
4. Begin omalizumab

Answer: 2 - Medium-dose inhaled corticosteroid

Explanations:

This patient is currently on step 2 of asthma controller therapy, and his level of
control for this scenario is "not well controlled." Therefore the next step (step 3) is
a medium-dose inhaled corticosteroid.
A less preferred option is adding a leukotriene receptor antagonist, such as
montelukast, to the low-dose inhaled corticosteroid.
Inhaled corticosteroids are considered to be superior to leukotriene receptor
antagonists when used as monotherapy. If good control is demonstrated for at
least 3 months, a trial of stepped-down treatment is appropriate. Close follow-up
is needed to assess the effectiveness of the change in treatment.

Research Concepts:

Asthma

Question 39: A 16-year-old female presents to the emergency department with an acute
onset of shortness of breath, chest tightness, and wheezing that has not responded to
her inhalers at home for over 4 hours. She has a past medical history of asthma. She is
using accessory muscles to breathe and can only speak in one or two words. The
difference in systolic blood pressure between inspiration and expiration is 10%. She
needs 2 liters of oxygen to maintain saturation at 94%. She is diffusely wheezing but does
not have any secretions. She is started on albuterol and ipratropium nebulizer treatment
and is given an intravenous dose of methylprednisolone. What is the next best step in
the management of this patient?
Page 40 of 955
Choices:

1. Heliox with 40:60 parts of helium and oxygen

2. Bi-level positive airway pressure support
3. Intravenous magnesium sulfate
4. Continue current management and reassess in 1 hour

Answer: 4 - Continue current management and reassess in 1 hour

Explanations:

Short-acting inhaled beta-agonists are the drug of choice in acute asthma

exacerbations. Anticholinergics have a variable response in acute asthma
exacerbation with a somewhat underwhelming bronchodilatory role. However,
they can be useful in patients with bronchospasm induced by beta-blockade or
severe underlying obstructive disease with FEV1 less than 25% predicted.
Most available data support a distinct benefit of corticosteroids in status
asthmaticus in an emergency setting. At a physiologic level, corticosteroids reduce
airway inflammation and mucus production and potentiate beta-agonist activity in
smooth muscles and reduce beta-agonist-induced tachyphylaxis in patients with
severe asthma.
As such, this patient has been started on appropriate initial therapy and should be
monitored for response prior to escalating therapy or providing ventilatory
support.
Magnesium inhibits calcium-mediated smooth muscle constriction, decreases
acetylcholine release in the neuromuscular junction, and affects respiratory muscle
force generation. Intravenous magnesium sulfate has therefore been a useful
adjunct in patients with acute status asthmaticus refractory to beta-agonists. There
is a demonstrated reduction in pulsus paradoxus and enhancement in peak flow
with the use of Heliox. However, its routine use is hindered by the prohibitive cost,
infrequent indication, and need for recalibration of gas blenders and flow meters
when used with mechanical ventilation.

Research Concepts:

Status Asthmaticus

Page 41 of 955
Question 40: A 25-year-old female has had a 4-month history of substernal chest pain and
dyspnea on exertion. The electrocardiogram shows right axis deviation. An arterial blood
gas shows pH 7.46, PO2 80 mmHg, and PCO2 32 mmHg. A chest x-ray shows enlarged
pulmonary arteries, but no infiltrates. A spiral CT shows subsegmental defects not
consistent with pulmonary embolism. An echocardiogram shows no primary cardiac
disease, but there is right heart strain. Which of the following would be the most
appropriate next step in evaluation?
Choices:

1. Ventilation perfusion scan

2. Bronchoscopy
3. Right heart catheterization
4. Antineutrophil cytoplasmic antibody

Answer: 3 - Right heart catheterization

Explanations:

The patient most likely has primary pulmonary hypertension. Features on a chest x-
ray include large central pulmonary arteries, right ventricular hypertrophy, and
clear lung fields. An ECG typically shows right ventricular hypertrophy with right
atrial enlargement, right axis deviation, and increased amplitude of P waves due to
right atrial enlargement (lead II).
Echocardiography is the most sensitive test, which helps assess right ventricular size
and pressure-volume overload. It also gives an estimate of pulmonary artery
pressure. In primary pulmonary hypertension, there is right atrial and ventricular
enlargement and tricuspid regurgitation. An arterial blood gas may reveal an
increased A-a gradient and hypoxia. Pulmonary function tests will show an impaired
diffusing capacity of the lungs for carbon monoxide (DLCO).
Right heart catheterization is the criterion standard diagnostic test to detect
elevated pressures and confirm pulmonary hypertension. Once diagnosed,
additional studies should be performed to evaluate for the etiology of pulmonary
hypertension.
Causes of pulmonary hypertension include thromboembolism, chronic obstructive
pulmonary disease, obstructive sleep apnea, and heart disease.
In those from developing countries, infections with filariasis and schistosomiasis
should be considered.

Research Concepts: Idiopathic Pulmonary Artery Hypertension

Page 42 of 955
Question 41: A 65-year-old female with a past medical history of hypertension and a
large ischemic stroke 5 years ago with resultant left-sided hemiparesis presents to the
emergency department with acute onset of pleuritic chest pain with shortness of breath.
She is tachypneic, diaphoretic, and in visible distress. Her vital signs show a heart rate of
125 beats/min, respiratory rate of 25/min, blood pressure of 100/60, and pulse oximetry
of 85% on room air. CT angiography of the chest shows a filling defect in the proximal
pulmonary vasculature bilaterally. What is the best treatment option for this patient?

Choices:

1. Argatroban infusion
2. Catheter-directed thrombolysis
3. Inferior vena cava filter placement
4. Heparin infusion
Answer: 4 - Heparin infusion

Explanations:

This patient presents with a massive to submassive pulmonary embolism (PE).

Catheter-directed thrombolysis (CDT) is indicated for massive PE or for submassive
PE with hemodynamic compromise. However, due to the risk of complications,
contraindications for the use of CDT must be reviewed prior to consideration of
this therapy.
Though thrombolysis is administered locally during CDT, the thrombolytic agent can
disperse systemically. Contraindications to CDT include a prior ischemic stroke,
cerebral bleed, cerebral mass, vascular deformation, a recent bleeding ulcer in the
gastrointestinal tract, recent brain/spine surgery, major abdominal or pelvic
surgery, or any source of active hemorrhage.
The most common and most feared complication of CDT is a hemorrhagic stroke.
This patient's history of prior stroke puts her at a higher risk of intracranial bleeding
following thrombolytic agent use. This is a relative contraindication to CDT for her.
She should be treated with intravenous anticoagulation with close monitoring of
her neurologic status.
Inferior vena cava placement is indicated in patients who have contraindications to
anticoagulation. Given her remote stroke and current hemodynamically devastating
pulmonary embolism, a trial of anticoagulation is warranted. Argatroban is
indicated in cases of heparin-induced thrombocytopenia.
Research Concepts: Catheter Directed Thrombolysis Of Pulmonary Embolism

Page 43 of 955
Question 42: A 26-year-old female presents to the emergency department with acute
onset of shortness of breath and wheezing that has not responded to home rescue
inhalers over the past 6 hours. Her medical history is significant for anxiety, bipolar
disorder, irritable bowel syndrome, hypothyroidism, gastroesophageal reflux disease,
and a recent diagnosis of bronchial asthma. This is her 4th episode of severe asthma
exacerbation in the past 4 months. Each one of them required endotracheal intubation.
Surgical history is significant for a caesarian section last year. Her symptoms escalate
rapidly in the emergency department and she requires mechanical intubation. Her
bloodwork shows an absolute eosinophil count of 320/microL. Alarmed by these
recurrent episodes of severe asthma, a computed tomography (CT) angiogram of the
chest is ordered as well. It does not show pulmonary embolism or chronic bronchiectasis.
What is the next best step in the management of this patient?
Choices:

1. Send aspergillus specific antibody and IgE level

2. Send 5-hydroxy indole acetic acid level and chromogranin assay
3. Perform bronchoscopy when extubated
4. Speech therapy evaluation once extubated
Answer: 3 - Perform bronchoscopy when extubated
Explanations:

Recurrent status asthmaticus requiring and reversed by endotracheal intubation

should always raise concern for tracheal pathologies like tracheomalacia or excessive
dynamic airway collapse (EDAC) which can be diagnosed by evaluation of upper airway
post-extubation.
Risk factors for EDAC include prior intubation, GERD, chronic respiratory inflammation,
and thyroid disease.
The CT scan may appear normal particularly if done in the inspiratory phase.
Treatment once diagnosed may involve the placement of a tracheal stent.
Evaluation by speech therapy can be effective for pure vocal cord dysfunction once
tracheal collapse or tracheomalacia has been ruled out by airway evaluation.
Research Concepts:

Status Asthmaticus

Question 43: A 55-year-old female from New Zealand presents for a routine exam. She is
completely asymptomatic. Vital signs are normal. Physical examination is normal. A
routine chest x-ray reveals a mass in the lower lung. The Mantoux is negative, and the
Casoni skin test is positive. What is the mode of infection in this patient?

Page 44 of 955
Choices:

1. Direct penetration of skin from soil

2. Food contaminated with eggs of the organism
3. Human to human transmission
4. Vector-borne

Answer: 2 - Food contaminated with eggs of the organism

Explanations:

Echinococcus is rare in North America. It is, however, quite common in Australia,

New Zealand, Mediterranean countries, and South America.
Echinococcus multilocularis eggs are the infectious agents for humans. They are
dispersed in the environment through the feces of carnivorous animals. The eggs
can contaminate drinking water and food, including fruits and vegetables.
Humans are intermediate hosts.
The cyst is dangerous because rupture can occur and extend the disease process.
Rupture also can lead to aspiration, asphyxiation, or hypersensitivity reactions.
Asymptomatic patients can be treated with albendazole.
However, symptomatic patients need surgery, taking great care not to spill the
contents to prevent massive allergy. The remaining lung space is obliterated, and if
the compressed lung has been destroyed, it may need to be resected.

Research Concepts:
Ecchinococcus

Question 44: A 55-year-old man presents with a cough, shortness of breath, prolonged
morning joint stiffness, and symmetric arthritis. He has worked as a coal miner most of
his life. Physical exam shows tender metacarpophalangeal (MCP) and proximal
interphalangeal (PIP) joints, along with rales, wheezes, and crackles on lung examination.
What is the most likely diagnosis?

Choices:

1. Seronegative spondyloarthropathy
2. Caplan syndrome
3. Silicosis
4. Lung adenocarcinoma
Page 45 of 955
Answer: 2 - Caplan syndrome

Explanations:

Caplan syndrome presents with a cough and shortness of breath, along with
symptoms of rheumatoid arthritis such as prolonged morning stiffness, with
systemic, symmetric arthritis. Physical examination typically shows rheumatoid
arthritis findings for joints such as swollen, tender metacarpophalangeal (MCP) and
proximal interphalangeal (PIP) joints, along with possible pulmonary findings such
as rales, wheezes, and crackles.
The findings of this syndrome consist of rheumatoid nodules in the lungs noted as
rounded opacities 0.5 to 5 centimeters which may cavitate and resemble
tuberculosis on chest radiography.
The opacities can differ in size, varying from small opacities which appear as simple
pneumoconiosis to very large opacities which can appear as progressive massive
fibrosis. There may be accompanying pleural effusion. Usually, the opacities
coincide with the onset of arthritis, but there are reported cases where arthritis
developed 10 years before the lung lesions. The nodules may grow, remain
unchanged, disappear, and then reappear.
Lung function tests may reveal a mixed restrictive and obstructive picture with a
total loss of lung volume along with reduced diffusing capacity of the lungs for
carbon monoxide (DLCO). Rheumatoid factor and antinuclear antibodies may be
present. Silicosis, asbestosis, and tuberculosis should always be in the differential.
Research Concepts:
Caplan Syndrome

Question 45: A 65-year-old man presents with a two-month history of loud snoring,
nocturnal choking episodes with witnessed apnea, and excessive daytime sleepiness.
Epworth Sleepiness Scale score is 20/24, and he takes no medications. His pulse is
90/min, blood pressure 150/87 mmHg, pulse oximetry 91% on room air, and body mass
index 38 kg/m2. Oropharyngeal exam reveals macroglossia Mallampati class IV. Further
examination demonstrates enlarged turbinates bilaterally with septal deviation, clear
lungs to auscultation, regular heart rate and rhythm, an obese abdomen, and bilateral
lower extremity pitting edema. Sleep studies show severe obstructive sleep apnea (apnea-
hypopnea index 35 events/hour) and sustained hypoxia (pulse oximetry 20% of the
recording less than 88%). Morning arterial blood gas analysis results include pH 7.35,
PaO2 50 mmHg, and PaCO2 50 mmHg. What is the best initial treatment?

Page 46 of 955
Choices:

1. Weight loss
2. Bilevel positive airway pressure (BiPAP)
3. Continuous positive airway pressure (CPAP)
4. Nasal intermittent mandatory ventilation

Answer: 3 - Continuous positive airway pressure (CPAP)

Explanations:

The presence of hypoventilation during wakefulness (PaCO2 greater than 45 mmHg)

as measured by arterial PCO2, end-tidal PCO2, or transcutaneous PCO2 indicates a
diagnosis of obesity hypoventilation syndrome (OHS).
The current recommendation is to use continuous positive airway pressure (CPAP)
as the initial treatment of OHS with concomitant sleep apnea for most patients.
Some patients require bilevel positive airway pressure (BiPAP), but the initial
treatment is CPAP.
Weight loss is the most important treatment for OHS but not the initial treatment.
Bariatric surgery may be necessary.

Research Concepts:

Obstructive Sleep Apnea

Question 46: A 25-year-old male with no known liver disease was recently started on
isoniazid, rifampicin, ethambutol, and pyrazinamide for the management of pulmonary
tuberculosis. He drinks one to two alcoholic beverages weekly. He is noted to have
mildly elevated liver enzymes on labwork done this morning and is asymptomatic.
What is the next step in management?

Choices:

1. Discontinue isoniazid
2. Start the patient on an alternative treatment regimen
3. Continue with the current treatment regimen and closely monitor
4. Perform a workup for the cause of his abnormal liver enzymes elevation
Answer: 3 - Continue with the current treatment regimen and closely monitor

Page 47 of 955
Explanations:

Transient, asymptomatic liver enzyme elevations are seen in 20% of isoniazid

recipients. The condition usually is self-limited; therefore, it is appropriate to
continue with the medication as long as the patient is asymptomatic.
In this patient with no known liver disease or prior isoniazid intolerance who
consumes a minimal amount of alcohol, the cause of his mildly elevated liver
enzymes most likely is related to the isoniazid. There is no need to work up the
patient to look for other causes, especially because he is asymptomatic.
If liver enzymes progressively increase or the patient develops symptoms of
hepatitis, isoniazid should be discontinued, and the liver enzymes should be closely
monitored. There is no standard cut-off for the lab values, but usually once the
bilirubin is more than 3 mg/dL or the liver enzymes are five times the upper limit of
normal, it is advisable to discontinue the medication.
Once the liver enzymes are back to baseline, it is safe to restart the potentially
hepatotoxic medications one at a time with careful monitoring before starting
each.

Research Concepts:
Isoniazid Toxicity

Question 47: A 70-year-old female was found unresponsive on the floor of her apartment.
During a phone conversation two days ago with her daughter, her voice was loud, and
she reported myalgias. According to her daughter, she is allergic to penicillin, has
recurrent methicillin-resistant Staphylococcus aureus skin infections, and consumes
alcohol regularly. Two weeks ago, she returned from a cruise trip to the Bahamas.
Emergency services noted vomitus soiling on the floor adjacent to her, and she was
intubated for airway protection. In the emergency department, her temperature was 39 C
(102.2 F), her heart rate was 105 beats per minute, her blood pressure was 90/50 mmHg,
her oxygen saturation was 96% on FiO2 70%, pressure support mode ventilation with a
positive end- expiratory pressure of 10, pressure support of 14 with the spontaneous rate
of 28 breaths per minute, and minute ventilation of 10 L/min. The blood alcohol level was
155 mg/dL, white blood cell count 24,000/microliter, serum creatinine 2 mg/dL, and
serum sodium 130 mg/dL. The liver functions were normal. A chest x-ray confirmed the
correct placement of the endotracheal tube and a dense right lower lobe infiltrate.
Computed tomography (CT) of the brain was normal, and cerebrospinal fluid analysis
demonstrated no white cells and normal glucose and protein. Blood cultures were sent,
and intravenous vancomycin 1000 mg and levofloxacin 500 mg were given in the
emergency department. The patient was transferred to the medical intensive care unit.
Which of the following changes to her antibiotic regimen would be most appropriate?
Page 48 of 955
Choices:

1. Change vancomycin and levofloxacin to linezolid and ampicillin- sulbactam

2. Add ampicillin-sulbactam, increase levofloxacin to 750 mg, continue
vancomycin
3. Continue vancomycin, decrease levofloxacin to 500 mg every other day, and add
ertapenem or meropenem
4. Stop vancomycin and levofloxacin and treat with intravenous meropenem only

Answer: 3 - Continue vancomycin, decrease levofloxacin to 500 mg every other day, and
add ertapenem or meropenem

Explanations:

Her risk factors of alcohol use disorder and circumstantial suspicion of aspiration
necessitate a regimen targeting gram- negative, anaerobic, and oral gram-positive
pathogens.
Although the patient has an allergy to penicillin, the risk of cross- allergenicity with
carbapenem is only 5%. Aztreonam has no activity against gram-positive or anaerobic
pathogens.
Levofloxacin has minimal activity against anaerobes, but the recent cruise trip to the
Bahamas placed her at risk for Legionella, which is usually susceptible to
fluoroquinolones. The dose should be reduced due to her renal impairment.
Severe sepsis and a history of recurrent methicillin-resistant Staphylococcus aureus
skin infections require the use of vancomycin.

Research Concepts:

Aspiration Pneumonia

Question 48: A 65-year-old male with known GOLD stage 4 chronic obstructive
pulmonary disease was diagnosed with unresectable stage 3b adenocarcinoma of the
right lung. He was also diagnosed with hypertrophic pulmonary osteoarthropathy
resulting in excruciating pain in both arms and elbow. What will be the medication of
choice for symptom relief that has the best outcome?

Page 49 of 955
Choices:

1. Hydrocodone
2. Bevacizumab
3. Intravenous pamidronate
4. Ibuprofen

Answer: 3 - Intravenous pamidronate

Explanations:

Intravenous pamidronate and zoledronic acid have the best success rate in symptom
suppression in hypertrophic pulmonary osteoarthropathy (HPOA) with bronchogenic
carcinoma.
Therapeutic response was noted regarding symptom suppression as well as
radiographic resolution of periostitis in bone scan.
HPOA lesions are typically poorly responsive to opioids. Although NSAIDs are
helpful, typically a COX -2 inhibitor like celecoxib has better efficacy. The role of
bevacizumab is still experimental.
Research Concepts:

Secondary Hypertrophic Osteoarthropathy

Question 49: A 16-year-old male athlete presents with a four-day history of severe tooth
pain, sore throat, and neck pain. His temperature is 103 F (39.4 C), heart rate 144
beats/minute, and respiratory rate 25 breaths/minute. The examination is notable for an
apprehensive male with unilateral neck tenderness. A rapid streptococcal test and
monospot test are negative, and a chest x-ray shows bilateral infiltrates. Which of the
following is the most likely causative organism?

Choices:

1. Klebsiella pneumoniae
2. Group A streptococcus
3. Fusobacterium necrophorum
4. Escherichia coli

Answer: 3 - Fusobacterium necrophorum

Page 50 of 955
Explanations:

Lemierre syndrome is a rare disease, occurring most commonly in otherwise healthy

young adults,
Lemierre syndrome is septic phlebitis of the internal jugular vein and may also cause
pulmonary septic emboli, as seen in this vignette.
The most common organism responsible is the anaerobe Fusobacterium
necrophorum.
Primary treatment is a combination of surgical drainage and antibiotics.

Research Concepts:

Anaerobic Infections

Question 50: A 75-year-old female with a history of Parkinson disease presents to your
clinic with shortness of breath. Her symptoms developed over the past 2 years. The
shortness of breath mainly occurs when she stands up and improves when she lies flat.
Her temperature is 36.9C, blood pressure 132/78 mmHg, heart rate 80 beats/min, and
oxygen saturation 93% on room air while sitting.
The physical examination shows no major abnormalities. A chest x- ray and ECG are
within normal limits. What is the best next step?

Choices:

1. Bubble contrast echocardiogram

2. Remeasure the oxygen saturation in different positions
3. CT of her chest
4. Refer to cardiology

Answer: 2 - Remeasure the oxygen saturation in different positions

Explanations:

The first step to diagnose platypnea-orthodeoxia syndrome (POS) is the clinical

assessment of the patient and measuring the oxygen saturation in different
positions.
If the oxygen saturation drops more than 5% from the supine to the upright
position and improves with recumbency, a POS diagnosis should be considered.
Bubble contrast echocardiogram with agitated saline should be the next diagnostic
step to identify whether an intracardiac defect shunt is present.

Page 51 of 955
 Treatment of POS should be directed towards correction of the underlying anomaly,
when feasible.

Research Concepts:

Platypnea

Question 51: A 46-year-old woman with a past medical history of liver cirrhosis presents
with shortness of breath. Examination demonstrates jugular venous distention, spider
angiomas, and bilateral pedal edema. Precordial auscultation reveals a continuous
murmur audible throughout the precordium. A chest x-ray is normal, and
echocardiography shows normal left-sided chambers, pulmonary artery pressure of 45
mmHg, and a dilated right ventricle. What is the best next step in the management of this
patient?

Choices:

1. CT chest without contrast

2. Ventilation-perfusion scan
3. Cardiac catheterization
4. Symptomatic treatment with routine follow-up

Answer: 3 - Cardiac catheterization

Explanations:

Patients with liver cirrhosis are prone to arteriovenous malformation. Because the
chest x-ray is normal, pleural effusion and hepatopulmonary syndrome are
essentially ruled out.
The clinical scenario and an echocardiogram in this patient suggest pulmonary artery
hypertension and right ventricular volume overload.
An abnormal communication between the coronary arteries and cardiac chambers is
referred to as coronary cameral fistulae.
Cardiac catheterization is diagnostic for coronary cameral fistula formation or
interatrial shunt formation due to a hyperestrogenic state secondary to liver
cirrhosis.

Page 52 of 955
 Research Concepts:
Coronary Cameral Fistula

Question 52: A 17-year-old female is admitted with status asthmaticus. She is treated with
continuous albuterol nebulization, intravenous corticosteroids, and bilevel positive airway
pressure mechanical respiration. The patient's respiratory status improves, but she develops
generalized weakness, fatigue, and myalgias. The cardiac monitor shows prolonged QT
interval, flattened T waves, and ST depression. What is the most likely etiology of these
changes?
Choices:

1. Hypocalcemia
2. Hypokalemia
3. Corticosteroid-induced myopathy
4. Cardiac ischemia
Answer: 2 - Hypokalemia

Explanations:

Beta-agonists, such as albuterol, can cause hypokalemia.

This is secondary to insulin secretion and its action on the NaK ATPase. This increases
the cellular uptake of potassium.
Initially, this can cause fatigue, muscle weakness, and myalgias but can progress to
complete paralysis and hypoventilation.
Intravenous replacement of potassium is limited by pain and sclerosing of veins.

Research Concepts:
Status Asthmaticus

Question 53: A 65-year-old homeless male is admitted with the chief complaints of fever,
shortness of breath, and weight loss. He has been having a productive cough with
hemoptysis off and on for one month. He has a history of alcohol use disorder. On
examination, he is febrile with a blood pressure of 110/80 mmHg, pulse 98/min regular,
respiratory rate 24/min, and oxygen saturation of 90% on room air. On auscultation, there
are coarse crackles bilaterally but more prominent on the right side. You notice that there
is a draining sinus on the chest wall. A chest radiograph shows pulmonary infiltrates and a
few cavitary lesions. Dark brown granules are seen on a frozen section. Gram stain shows
purple-staining fine filaments. CBC shows leukocytosis with elevated neutrophils. C-
reactive protein and erythrocyte sedimentation rates are elevated.
Which of the following is used to treat this condition?

Page 53 of 955
Choices:

1. Incision and drainage

2. Radiation therapy
3. High-dose penicillin
4. Amphotericin

Answer: 3 - High-dose penicillin

Explanations:

Dark brown granules can be sulfur and represent actinomycosis. Histologically, sulfur
granules appear black.
Actinomyces can be cultured. The preliminary diagnosis usually is made by looking
for sulfur granules with microscopy. Imaging is usually needed to determine the
extent of infection. The gold standard test is a histological examination and
bacterial culture of a biopsy which can be obtained with bronchoscopy
(pulmonologist), a CT-guided biopsy (interventional radiologist), or video-assisted
thoracoscopy surgery (VATS) performed by a thoracic surgeon. Anaerobic cultures
of pleural fluid rarely grow the organism. Sputum culture will not be useful unless
the patient has a cavitary disease.
The imaging for actinomycosis is nonspecific. In the acute presentation, it can look
like any other pneumonia. In chronic forms, it can present as a pulmonary mass or
can cavitate. In the case of a mass malignancy, Actinomycosis is an important
diagnosis to consider. Especially when it cavitates, tuberculosis is an important
differential diagnosis to consider. The computed tomography scan findings can vary
depending upon the duration of illness and can include consolidation, cavitation,
pleural effusion, lymph node enlargement, atelectasis, and ground glass
opacification.
Treatment is with high-dose penicillin.

Research Concepts:

Actinomycosis

Page 54 of 955
Question 54: A 46-year-old female is rushed to the emergency department following a
motor vehicle accident in which she fell asleep at the wheel and ran her car into a light
pole. While still trapped in the wreckage, she received third-degree electrical burns from
an active wire, exposed because of the crash, over the dorsal surface of her right arm and
shoulder. Besides the burns, the patient is suffering from several broken ribs. An
ultrasound-guided FAST exam reveals one of the broken ribs punctured the right lung
causing the patient to experience respiratory distress. Vital signs are a weight of 156
pounds (71 kg), blood pressure 100/53 mmHg, heart rate 110 beats/min, respiratory rate
35/min., temperature 37.3 C (99.1 F), and oxygen saturation of 75%, which continues to
drop. On physical exam, the patient appears obtunded, her lips show blue discoloration,
and hypertonicity of the neck muscles is appreciated when palpating the trachea. The
emergency care provider decides to intubate to stabilize the patient’s breathing while
waiting for the trauma team to arrive. The emergency care provider infuses 35 mg IV
rocuronium before intubating but has difficulty securing the airway due to continued
muscle tightness appreciated in the larynx. Why would the administration of rocuronium
not be the best choice for facilitating intubation in this patient?

Choices:

1. Rocuronium only works well in patients with a lower body mass.

2. The patient is suffering from third-degree burns.
3. Steroidal non-depolarizing neuromuscular blockers should not be used for
intubation, only benzylisoquinolines.
4. Rocuronium was the right choice; the patient is a fast metabolizer.

Answer: 2 - The patient is suffering from third-degree burns.

Explanations:

Rocuronium is infused IV at 0.45 to 0.90 mg/kg for intubation with 0.15 mg/kg
boluses if needed for maintenance.
Burn patients exhibit resistance to non-depolarizing neuromuscular blockers due ,to
being in hyperkalemic states. Hyperkalemia causes resistance, while hypokalemia
augments activity. Other electrolyte abnormalities to keep in mind are hypocalcemia
and hypermagnesemia, both of which augment blockade.
Both steroidal (rocuronium, vecuronium, pancuronium) and benzylisoquinoline
(atracurium, cisatracurium, mivacurium) agents exhibit the same mechanism of
action. What differentiates them is their chemical structure and reversal; the
steroidal agents are reversed with sugammadex, and the benzylisoquinoline
agents with neostigmine/glycopyrrolate.
Page 55 of 955
 Rocuronium is one of the few agents in this drug class that is not metabolized but
instead cleared mainly by the liver and slightly by the kidneys in its original form.
Its volume of distribution is not affected by renal disease; however, its action is
prolonged by severe hepatic failure and pregnancy.

Research Concepts:

Non-depolarizing Neuromuscular Blockers

Question 55: A 65-year-old male patient presents to the hospital for routine follow-up of
hypertension and to discuss smoking cessation. He has smoked a pack of cigarettes a day
since he was in high school. Today, he is complaining of swelling and pain in both wrists.
No other joints are affected. He denies injury, fever, morning stiffness, and rashes. He also
reports a 20-pound (9 kg) weight loss in the last three months and denies shortness of
breath, chest pain, or hemoptysis. He does not have any gastrointestinal or genitourinary
symptoms. His blood pressure is well controlled. The physical exam is remarkable for
palpable effusion in both wrists without evidence of synovial inflammation, and limited
range of motion due to pain. There is no small joints tenderness. He has gross clubbing of
the fingers in both hands. Which of the following is the most appropriate next step in the
evaluation of this patient?

Choices:

1. Rheumatoid factor
2. ANA
3. Joint aspiration with synovial fluid analysis
4. Chest X-ray

Answer: 4 - Chest X-ray

Explanations:

This patient's presentation is most consistent with hypertrophic osteoarthropathy,

most likely secondary to a pulmonary malignancy. Given the patient's smoking
history and recent weight loss, a chest x-ray would be the best test to screen for
pulmonary neoplasm.
Hypertrophic osteoarthropathy (HOA), consists of the presence of digital clubbing,
increased the periosteal activity of the tubular bones, arthralgias, and joint effusion
and is characterized by abnormal proliferation of the skin, soft tissues and osseous
tissues in the distal parts of extremities. There are two forms of the disease -
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 primary and secondary. Primary HOA (PHO), also called pachydermoperiostosis,
comprises of digital clubbing, periostosis, and pachydermia and is a rare genetic
disease, while secondary hypertrophic osteoarthropathy is associated with a
variety of pulmonary, cardiac and other conditions.
ANA would be the correct answer if SLE were suspected. Given this patient's weight
loss, smoking history, and lack of rash and morning stiffness, the more likely diagnosis
is secondary hypertrophic osteoarthropathy. This patient has bilateral arthropathy,
making gout and septic arthritis less likely.
The rheumatoid factor would be more appropriate as a screen for rheumatoid
arthritis (RA). While RA may present with wrist effusion and pain, it would be
extremely unlikely for RA to be the cause of his distal joint swelling and pain. He
also denies morning stiffness, a hallmark of rheumatoid arthritis.

Research Concepts: Hypertrophic

Osteoarthropathy

Question 56: A 58-year-old man is seen in the emergency department after suffering a
smoke inhalation injury following a house fire. He was intubated for dyspnea with stridor
and currently is on a ventilator with 100% FiO2. He has copious secretions that are being
treated with aggressive pulmonary hygiene. His carboxyhemoglobin level is 26% and
arterial blood gas shows pH
6.9. What is the definitive management?

Choices:

1. Nebulized albuterol
2. Intravenous methylprednisolone
3. Transfer to a facility with hyperbaric oxygen therapy
4. Empiric broad-spectrum antibiotics

Answer: 3 - Transfer to a facility with hyperbaric oxygen therapy

Explanations:

Carboxyhemoglobin levels are typically less than 2% and less than 5% in non-
smokers and smokers. A level of greater than 9% is certainly due to exogenous
carbon monoxide exposure, irrespective of the former smoking history. Nebulized
beta-2- adrenergic agonists and muscarinic receptor antagonists have been proven
in animal models to improve respiratory function following inhalation injury.
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 Corticosteroids have not been proven to be beneficial in inhalation injury patients.
Hyperbaric oxygen therapy (HBOT) is indicated for carboxyhemoglobin levels greater
than 25%, unconscious patients, those with neurologic findings, or in cases of severe
metabolic acidosis, pH less than 7.1. Treatment often requires transfer to a facility
with HBOT capabilities, but treatment should not be delayed.
Carbon monoxide treatment includes high oxygen therapy. Hyperbaric oxygen
treatment (HBO) has been shown to increase the clearance rate of CO from blood,
but its limited availability restricts its usage. Most health care centers instead use
100% FiO2 oxygen therapy for treatment. Antibiotics should be started in patients
with inhalation injury who have complications of pneumonia. Pneumonia is a
common short- term complication of severe inhalation injury and usually presents
4 to 5 days after the initial injury.

Research Concepts:

Inhalation Injury

Question 57: A patient is being admitted to the hospital for further evaluation due to
concern for Hantavirus pulmonary syndrome after presenting with dyspnea, vomiting,
and fever. What laboratory abnormality is most significant on presentation
demonstrating the need for admission?

Choices:

1. Thrombocytopenia
2. Hypernatremia
3. Hypokalemia
4. Leukocytosis

Answer: 1 - Thrombocytopenia

Explanations:

Thrombocytopenia is often present at the stage of disease requiring admission for

further observation. This often precedes the descent into pulmonary failure by a
couple of days.
Hyponatremia is more common than hypernatremia in Hantavirus pulmonary
syndrome.
Potassium is not normally greatly affected in the early stages of Hantavirus
pulmonary syndrome.
Atypical lymphocytes and premature white blood cells may be present on
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 admission, but leukocytosis alone is not significant enough to warrant admission.

Research Concepts:

Hantavirus Syndrome

Question 58: A 65-year-old nursing home patient presents with a 10-day history of a
productive cough, shortness of breath, and fever. She has a history of alcohol use disorder
and a penicillin allergy.
Chest x-ray shows an irregularly shaped cavity with an air-fluid level in the right lower lobe.
What are the most appropriate antibiotics?

Choices:

1. Levofloxacin and ampicillin

2. Ceftriaxone and metronidazole
3. Clindamycin and erythromycin
4. Vancomycin, clindamycin, and ceftriaxone

Answer: 4 - Vancomycin, clindamycin, and ceftriaxone

Explanations:

The location of the abscess makes anaerobic bacteria most likely.

Clindamycin would provide coverage for anaerobic bacteria. Clindamycin, as
empiric treatment for a lung abscess, is no longer recommended given the risk of
Clostridioides difficile infection but remains an alternative for penicillin-allergic
patients. Methicillin-resistant Staphylococcus aureus is covered with vancomycin
and linezolid.
The patient would most likely be hospitalized and started on at 2 to 3 antibiotics.
Treatment should be for 4 to 6 weeks. Chest x-ray changes are gradual, but one will
see a decrease in the abscess cavity.

Research Concepts:

Lung Abscess

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Question 59: A 45-year-old man presents with worsening dyspnea and nonproductive
cough for the past three months. He has smoked one pack per day for the last 20 years
and does not take any medication. His height is 1.65 meters, weight is 980 kg, heart rate
90/minute, blood pressure 135/90 mmHg, and pulse oximetry 90% on room air. Lung
auscultation demonstrates basal crackles bilaterally without wheezing, and the rest of the
exam is normal.
Pulmonary function tests show the following: forced expiratory volume in the first second
(FEV1) 70% predicted, forced vital capacity (FVC) 65% predicted, FEV1/FVC 80, total lung
capacity 69% predicted, residual volume 70% predicted, and diffusion capacity not
corrected 61% of predicted. High-resolution CT shows a combination of lower lobe
predominant ground glass changes and fibrosis. What feature of a surgical lung biopsy will
distinguish this patient's condition from other types of pulmonary fibrosis?

Choices:

1. Homogenous distribution of fibrosis

2. Presence of foamy macrophages
3. Presence of ferruginous bodies within alveoli
4. Presence of hemosiderin in macrophages

Answer: 1 - Homogenous distribution of fibrosis

Explanations:

Desquamative interstitial pneumonia (DIP) is a distinct clinicopathologic condition

that differs substantially from the usual interstitial pneumonia (UIP).
UIP has a temporally heterogeneous distribution of fibrosis in biopsy specimens, as
opposed to a more homogeneous distribution in DIP.
The majority of patients with DIP are young men who smoke tobacco.
Foamy macrophages within alveoli are characteristic of amiodarone toxicity.
Asbestos-induced interstitial lung disease shows the presence of ferruginous
bodies within the alveolar interstitium. The presence of hemosiderin in
macrophages is a distinctive feature of alveolar hemorrhage and is absent in DIP.

Research Concepts:

Desquamative Interstitial Pneumonia

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 Question 60: A 39-year-old female was admitted to the hospital after she sustained
extensive third-degree burn to her lower limbs and abdomen 4 days ago. She developed
acute kidney injury and worsening respiratory distress that required mechanical
ventilation. Chest radiograph showed bilateral pulmonary infiltrates. Respiratory rate is
set at 14 breaths per minute, but she is breathing at a rate of 28 breaths per minute.
Initial arterial blood gas showed ph 7.55, PaCO2 28 and PaO2 55 on 70% FiO2, positive
end-expiratory pressure (PEEP) of 5 cm water, and a tidal volume of 10 ml per kg of ideal
body weight. What is the next step in the management of this patient?
Choices:

1. Decrease respiratory rate to 10 and increase FiO2 to 100%

2. Start deep sedation and neuromuscular blockade, increase the PEEP to 10 and set
the tidal volume to 6 ml per kg
3. Increase FiO2 to 100% and repeat ABGs in one hour
4. Sedate the patient deeply and reassess after 30 minutes

Answer: 2 - Start deep sedation and neuromuscular blockade, increase the PEEP to 10 and
set the tidal volume to 6 ml per kg
Explanations:

The patient meets the criteria for acute respiratory distress syndrome (ARDS) as she
has developed acute respiratory symptoms within one week of clinical insult (4 days
after severe, extensive burn) with radiographic features of bilateral patchy
infiltrates and hypoxemia (PaO2/FiO2 ratio 78.5) that are not fully explained by
cardiogenic pulmonary edema.
The patient should be started on low tidal volume ventilation with a target plateau
pressure less than 30 mmHg, a ventilation strategy that is associated with
decreased mortality and improved clinical outcomes.
Deep sedation and neuromuscular blockade are used in the early stage of severe
ARDS to ensure safe, low-pressure ventilation and to avoid further lung injury
especially in patients who are hard to control and are not synchronizing with the
mechanical ventilation.
Increasing FiO2 alone without increasing the PEEP is not enough in this case as
higher positive end-expiratory pressure (PEEP) is recommended to prevent
alveolar collapse (atelectrauma) and increase the tidal volume participating in the
gas exchange. Furthermore, decreasing respiratory volume or deeply sedating
patients are not appropriate in this patient with severe ARDS.
Research Concepts: Respiratory Distress Syndrome

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Question 61: A 47-year-old female patient with a history of antiphospholipid antibody
syndrome who has been noncompliant with warfarin presents with a deep vein
thrombosis and dyspnea. On examination, her blood pressure is 90/60 mmHg, respiratory
rate is 22/min, and her heart rate is 92/min. Computerized tomography of the chest
shows a saddle embolus. She does not respond to heparin and fluids. An echocardiogram
shows right ventricular hypokinesis.
What is the most appropriate next step?

Choices:

1. Urgent referral for surgical embolectomy

2. Recombinant tissue plasminogen activator
3. Continue administration of fluids and heparin
4. Add lepirudin

Answer: 2 - Recombinant tissue plasminogen activator

Explanations:

Anticoagulation alone is an inadequate treatment for this patient. Current guidelines

for the management of unstable patients recommend immediate treatment with
anticoagulation.
Fibrinolytic treatment with recombinant tissue plasminogen activator is indicated
unless there are major contraindications. If the patient does not improve or
fibrinolysis is not possible, the best choice is surgical embolectomy. Surgery is the
last resort and never the first consideration. Placing such a patient on bypass is
associated with mortality in excess of 50%.
Furthermore, even those who survive are faced with several complications like acute
respiratory distress syndrome (ARDS), bleeding, and shock.
After surgery, the patient will need lifelong treatment with warfarin. Today, tPA is
recommended as the treatment of choice. A dose of 100 mg is given over 2 hours,
and there is a rapid resolution of the elevated pulmonary artery pressure.

Research Concepts:
Antiphospholipid Syndrome

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Question 62: A 65-year-old man presents with a three-day history of increasing shortness
of breath and cough productive of yellow sputum and blood streaks. Usually, he can walk
three blocks and climb one flight of stairs, but since yesterday, he is dyspneic within one
block of walking. He denies fever, chills, leg swelling, orthopnea, and paroxysmal
nocturnal dyspnea. His past medical history includes diabetes mellitus, hypertension,
obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD). He reports
compliance with tiotropium and a beta-agonist, but his inhalers are not providing him any
relief. His blood pressure is 148/88 mmHg, and his respiratory rate is 24/min. Pulse
oximetry is 88% on room air, and the patient is using accessory muscles and speaking in
short sentences. Chest auscultation demonstrates prolonged expiration and bilateral
wheezes. A complete blood count shows hemoglobin 17 g/dL, WBC count 15,000/mm3,
and normal platelet count, and a basic metabolic panel is within normal limits. A chest x-
ray shows hyperinflated lung fields with no infiltrates. Arterial blood gas analysis reveals a
pH of 7.3 with PaCO2 52 mmHg and PaO2 55 mmHg. Outpatient records are obtained,
including his PFTs, which show an FEV1/FVC ratio of 65% and FEV-1 55% and DLCO 44% of
predicted. He is diagnosed with COPD exacerbation and is started on oxygen,
azithromycin, ipratropium bromide/salbutamol nebulization, and corticosteroids. There is
minimal improvement in the patient's symptoms, and he is placed on noninvasive positive
pressure ventilation (NIV) and oxygenation. The NIV settings are as follows: inspiratory
pressure 18 cmH2O, expiratory pressure (EPAP) 5 cmH2O, and respiratory rate 12
/minute. Which of the following best describes the mechanism of the expected
improvement in his oxygenation after supplemental oxygenation and NIV treatment?

Choices:

1. Improved oxygenation of lung areas with a high V/Q ratio

2. Improved oxygenation of lung areas with a low V/Q ratio
3. Increased oxygen diffusion across the alveolar-capillary membrane
4. Increased pulmonary blood flow

Answer: 2 - Improved oxygenation of lung areas with a low V/Q ratio

Explanations:

Airflow restriction in chronic obstructive pulmonary disease (COPD) causes

ventilation-perfusion (V/Q) mismatch, resulting in areas of the lung with a high V/Q
ratio and some localized areas with a low V/Q ratio. Mechanisms responsible for
developing a low V/Q in patients with acute exacerbation of COPD include airway
narrowing due to bronchospasm, inflammation, or airway obstruction due to
excessive mucus.
Treatment with noninvasive positive pressure ventilation (NIV) and oxygen
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 supplementation improves ventilation in low V/Q areas more than high V/Q
areas.
Improved ventilation in low V/Q areas causes improvement in oxygen saturation.
An increase in FiO2 increases the PaO2, which enhances arterial oxygenation.
In patients with emphysema, there is destruction of the alveolar- capillary
membrane. Hence both V/Q mismatch and reduced mixed venous oxygen levels
(due to increased consumption of oxygen by the excessive use of the respiratory
muscles) are responsible for hypoxemia development in acute exacerbation of
COPD.
Oxygen supplementation may adversely affect ventilation and a slight increase in
PaCO2 levels due to multiple factors, including increased dead space, oxygenation
of poorly ventilated areas, and the V/Q mismatch. Therefore, controlled
administration of oxygen and titration to maintain O2 saturation levels between 90-
94% is recommended.

Research Concepts:

Emphysema

Question 63: A 45-year-old male presented with an intentional overdose of his home
regimen of antihypertensive medication. He is otherwise healthy apart from a history of
hypertension. The initial presentation was with profound refractory shock and
bradycardia requiring initiation of norepinephrine ( running at eight mcg/minute) and
vasopressin. His mean arterial pressure is 59 mm Hg. A minimally invasive solution
(arterial line) that provides dynamic and flow-based hemodynamic monitor was used to
assess hemodynamics at the bedside and his cardiac output is 5.1 liters/min with a stroke
volume variability of 11%. 6 hours after the presentation he starts becoming rapidly short
of breath and was therefore electively intubated. On low tidal volume ventilator settings
with a PEEP of 5 and FIO2 of 100%, his PO2 is 82 mm Hg. Chest x-ray shows diffuse
bilateral infiltrates worse than prior. Which intervention will be most effective at his
condition to improve his outcome?

Choices:

1. Additional IV fluids as his stroke volume variation is elevated

2. Addition of milrinone as an inotrope
3. Increasing dose of insulin dextrose infusion
4. Referral for extracorporeal membrane oxygenation

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Answer: 4 - Referral for extracorporeal membrane oxygenation
Explanations:

With a normal cardiac output, and significantly low P/F ratio and bilateral alveolar
infiltrates, this individual is likely developing acute respiratory distress syndrome
with non-cardiogenic pulmonary edema, a manifestation seen in rare cases of
calcium channel blocker overdose
Beyond low tidal volume mechanical ventilation, strategies that would improve clinical
outcome if instituted early will be prone ventilation or referral to extracorporeal
membrane oxygenation (ECMO).
If cardiac function is well preserved V- V ECMO should be considered without further
delay
His stroke volume variation is within 13%. cardiac output is normal. Neither
additional fluids nor inotropes will be helpful in the scenario. Fluids may worsen his
pulmonary edema and respiratory failure.

Research Concepts:

Calcium Channel Blocker Toxicity

Question 64: A 60-year-old male with a history of coronary artery bypass surgery 3 weeks
ago presents for follow up examination and reports worsening dyspnea since surgery. He
reports significant worsening of his breathing on lying down flat and has been sleeping in
his recliner. He has been a smoker for 40 years but denies a history of lung problems. His
pulmonary function tests showed reduced FEV1 (70%) and FVC (60%) with preserved
FEV1%. On repeating the tests in the supine position, the FEV1 reduced further to 50%
predicted and FEV1 to 60%. What is the most likely cause of his symptoms?

Choices:

1. Post-coronary artery bypass grafting syndrome

2. Post-procedure pleural effusion
3. Congestive heart failure
4. Diaphragmatic palsy

Answer: 4 - Diaphragmatic palsy

Explanations:

Diaphragmatic palsy is seen up to 20% of patients undergoing coronary artery

bypass surgery. Topical hypothermia used during cardiac bypass is the main
Page 65 of 955
 mechanism for phrenic nerve injury. The phrenic nerve also can be mechanically
damaged during dissection of the internal mammary artery. With time, complete
recovery is expected.
Most cases of phrenic nerve palsy are unilateral, occurring in left side more
commonly than the right due to its long course in the thorax. Patients with good
cardiopulmonary reserve are usually asymptomatic.
Patients present with dyspnea and significant orthopnea. Spirometry shows a
restrictive pattern with reduced FVC. On repeating the test in the supine position,
there is a further drop in lung function. In unilateral diaphragmatic palsy, FVC drops
by 20% to 40%. In bilateral diaphragmatic palsy FVC drops by 40% to 60% compared
to a less than 10% drop in lung function of healthy individuals.
Most cases resolve spontaneously. If patients are symptomatic, then invasive
positive pressure ventilation therapy can be tried. Refractory cases can be treated
with either diaphragmatic plication or phrenic nerve pacing.

Research Concepts:
Diaphragm Disorders

Question 65: A 45-year-old man presents for a six-month history of progressive dyspnea
and nonproductive cough. He has smoked one pack per day of cigarettes for 20 years, and
he works as a plumber. Current medications include antacids and acetaminophen as
needed. His oxygen saturation is 92% on room air. Bibasilar crackles without wheezing is
noted on auscultation. The rest of the exam is within normal limits. Pulmonary function
tests show the following: forced vital capacity (FVC) 62% of predicted, forced expiratory
volume at 1 second (FEV1) 59% of predicted, total lung capacity 70% of predicted, vital
capacity 50% of predicted, residual volume 70% of predicted, and diffusion lung capacity
(DLCO) 49% of predicted. High-resolution CT (HRCT) shows diffuse ground-glass disease
bilaterally with no enlarged mediastinal or hilar lymphadenopathy. What is the best next
step in the management of this patient?
Choices:

1. HRCT findings should be sufficient to confirm the diagnosis

2. Bronchoscopy
3. Surgical lung biopsy
4. Initiate antifibrotic therapy
Answer: 3 - Surgical lung biopsy

Explanations:

While high-resolution CT findings are helpful in the initial diagnostic workup, it is

often nonspecific when classic radiological findings of idiopathic pulmonary fibrosis
Page 66 of 955
 (IPF) are lacking. Classic findings include honeycombing with or without peripheral
traction or bronchiectasis and subpleural basal predominant with heterogeneous
distribution.
Bronchoscopy is used to rule out infectious etiology; however, it is not
recommended to confirm the diagnosis due to the inability to obtain adequate lung
samples. Transbronchial biopsy specimens are considered inadequate to diagnose
desquamative interstitial pneumonia (DIP) or to distinguish it clearly from
overlapping disease patterns like respiratory bronchiolitis-associated interstitial lung
disease (RB-ILD) in early stages and nonspecific interstitial pneumonitis (NSIP) in late
stages.
Surgical lung biopsy is considered the criterion standard in diagnosing DIP and other
types of interstitial lung disease (ILD). In DIP, open lung biopsy shows infiltration of
alveoli with macrophages rich in eosinophilic cytoplasm and a brown pigment called
"smoker's pigment."
The initiation of antifibrotics is only indicated in eligible patients with a confirmed
diagnosis of idiopathic pulmonary fibrosis (IPF).
Research Concepts: Desquamative Interstitial Pneumonia

Question 66: A 42-year-old male is climbing the Abruzzi Spur route of K2 on day 7 of the
expedition. He has been complaining of shortness of breath that has progressively
worsened over the course of the last several hours. A portable ultrasound machine is
available on the expedition. What would you expect to see on lung ultrasound?

Choices:

1. A-line predominant in anterior lung fields

2. Bilateral pleural effusions
3. Absent lung sliding
4. Scattered B-lines throughout all lung fields

Answer: 4 - Scattered B-lines throughout all lung fields

Explanations:

Patients with high altitude pulmonary edema can show scattered B-lines on point-
of-care ultrasound imaging.
B-lines seen on point-of-care ultrasound can be caused by increased fluid in the
lungs due to pulmonary edema, infection, or heart failure.
B-lines seen on point-of-care ultrasound appear as "comet- tails." A couple B-lines
are normal, but if very large or multiple in a lung field, this is considered abnormal.
Page 67 of 955
 A line (multiple, horizontal lines) seen on point-of-care ultrasound are a normal
artifact and do not denote pathology.

Research Concepts:

High Altitude Cardiopulmonary Diseases

Question 67: A 49-year-old White male presents with two episodes of hemoptysis in the
past three hours. His vitals are significant for a blood pressure of 90/60 mmHg and a
heart rate of 110 bpm. Two years ago, he was diagnosed with a small vessel necrotizing
anti-neutrophil-cytoplasmic-antibody-associated vasculitis when his myeloperoxidase-
antineutrophil cytoplasmic antibody came back positive. He also suffers from end-stage
renal disease (ESRD). His medications include azathioprine and glucocorticoids. What will
a lung biopsy most likely show?

Choices:

1. Granulomatous lesions involving upper and lower airways

2. Linear deposits of immune complexes on immunofluorescent microscopy
3. Pulmonary capillaritis
4. Wedge-shaped infarction of an area of lung parenchyma

Answer: 3 - Pulmonary capillaritis

Explanations:

MPA is a myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA)

associated vasculitis involving the lungs, kidney, and skin, amongst other tissues. It
forms an important component of a group of disorders termed as a pulmonary-
renal syndrome.
Lung involvement may be present at onset or may herald an acute flare in a patient
in remission.
Patients generally present with hemoptysis secondary to diffuse alveolar
hemorrhage and necrotizing vasculitis.
Histopathological findings on lung biopsy show diffuse capillaritis. It is important to
note that the degree of inflammation on lung biopsy does not necessarily correlate
with disease activity.

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Research Concepts:

Microscopic Polyangiitis

Question 68: A 14-year-old female with a past medical history of cystic fibrosis presents
for a routine outpatient visit. She was recently hospitalized one month ago for an acute
illness. During that hospitalization, she was found to have a one-time fasting plasma
glucose of 130 mg/dl. She reports baseline health without any symptoms of weight loss,
polyuria, or polydipsia. Which of the following is the most appropriate next step in the
management of this patient?

Choices:

1. Start a long-acting basal insulin

2. Start rapid-acting pre-meal insulin
3. Obtain a Hemoglobin A1c level
4. Obtain a 2 hour 75-gram oral glucose tolerance test

Answer: 4 - Obtain a 2 hour 75-gram oral glucose tolerance test

Explanations:

A 2-hour 75 g oral glucose tolerance test is the only acceptable screening test for cystic
fibrosis related-diabetes.
At baseline health, the diagnosis of cystic fibrosis-related diabetes can be made
with a 2-hour oral glucose tolerance plasma glucose level of greater than or equal
to 200 mg/dl, fasting plasma glucose of greater than or equal to 126mg/dl, HgA1c
level of greater than or equal to 6.5%, and/or random glucose greater than or
equal to 200 mg/dl with clinical symptoms.
To make the diagnosis of cystic fibrosis-related diabetes during an acute illness
requires a 2-hour postprandial plasma glucose level greater than or equal to mg/dl
or a fasting plasma glucose of greater than or equal to 126mg/dl that persist for 48
hours.
HbA1c levels may be falsely low in individuals with cystic fibrosis, and a normal
hemoglobin A1c level does not rule out cystic fibrosis-related diabetes.
Research Concepts:

Cystic Fibrosis Related Diabetes

Page 69 of 955
Question 69: A 17-year-old student presents for his routine wellness exam. He denies any
current symptoms or complaints. His vitals include a temperature of 98.6 F (37 C), a blood
pressure of 110/80 mmHg, a pulse of 97 beats per minute, respiration of 15 breaths per
minute, and oxygen saturation of 97% on room air.
Physical examination reveals normal bilateral breath sounds. His chest x-ray was normal
except for the abnormal origin of the right bronchus high above the carina. What would be
the next best step in management regarding this finding?

Choices:

1. Observation only
2. Medical treatment with bronchodilators and anticholinergics
3. CT chest
4. Flexible bronchoscopy

Answer: 1 - Observation only

Explanations:

Observation only is appropriate as the patient is asymptomatic. When patients are

symptomatic and present with non-life- threatening infections, they can be
treated medically.
Referrals to cardiothoracic surgeons for definitive surgery are based on the severity
of the patient's symptoms and associated comorbidities.
Usually, lobectomy or segmentectomy is done based on the location and relation to
surrounding structures.
Research Concepts:

Tracheal Bronchus

Question 70: A 44-year-old previously healthy female presents to the emergency

department in septic shock. Initial vitals are temperature 101.5 F, heart rate 115 bpm,
blood pressure 110/50 mmHg, respiratory rate 24/minute, and pulse oximetry (SpO2)
78% on a non-rebreather mask. She is intubated for hypoxemic respiratory failure and
acute respiratory distress syndrome secondary to pneumonia. She is placed on inverse
ratio ventilation (IRV) to improve her oxygenation. Over the next 5 minutes, her SpO2
steadily increases to 95%. However, her repeat blood pressure has decreased to 70/40
mmHg. What is the most likely etiology of her hemodynamic compromise?

Page 70 of 955
Choices:

1. Pneumothorax
2. Increased systemic inflammatory response syndrome (SIRS) response and
vasodilation secondary to inflammatory mediators released in the lungs in response
to barotrauma
3. Distributive shock secondary to sepsis
4. Decreased venous return

Answer: 4 - Decreased venous return

Explanations:

Hemodynamic compromise secondary to decreased venous return is a known

complication of inverse ratio ventilation (IRV). The increased mean airway pressures
used in IRV translate to increased intrathoracic pressure, which may cause an
iatrogenic obstructive shock picture.
Patients with preexisting hemodynamic instability are at increased risk for shock
when placed on IRV.
Patients with sepsis may have an element of distributive shock that goes
unrecognized due to compensation. However, if an additional insult occurs, such
as an obstruction to right ventricular preload, this shock may rapidly
decompensate.

Research Concepts:

Inverse Ratio Ventilation

Question 71: A 17 year-old-male mountain climber and his colleagues are attempting to
summit Mount Everest. After ascending to an altitude of about 5500 meters on the second
day, he complained of headaches, anorexia, nausea, and malaise. On day three of the
expedition, he developed ataxia, impaired cognition, irrational behavior and errors in
reading his map. What is the most likely diagnosis?

Choices:

1. Acute mountain sickness

2. High-altitude cerebral edema (HACE)
3. High-altitude pulmonary edema (HAPE)
4. Meningitis

Page 71 of 955
Answer: 2 - High-altitude cerebral edema (HACE)

Explanations:

Acute mountain sickness (AMS) is a syndrome characterized by headaches,

anorexia, nausea, and malaise. AMS occurs when exposed to altitudes of 4000
meters, typically for 2 or more days. Headache must be present for a diagnosis of
acute mountain sickness. Treatment includes NSAIDs and supplemental oxygen.
Prophylaxis is with acetazolamide.
High-altitude cerebral edema (HACE) is thought to be the end stage form of acute
mountain sickness. The hallmark symptom of HACE is ataxia, but patients may also
experience seizure, altered mental status, or other neurologic symptoms.
This patient has symptoms of acute mountain sickness and ataxia. Hence, he has
HACE, not AMS. Treatment is descent from altitude, corticosteroids, and oxygen.
Acetazolamide may also be started.
Symptoms of high-altitude pulmonary edema (HAPE) are breathlessness, chest
pain, headache, fatigue, and dizziness. It occurs at an altitude of about 2000 to
2500 meters, with significant elevation of pulmonary artery pressure leading to
capillary breakdown and subsequent edema.

Research Concepts:

High Altitude Cerebral Edema

Question 72: A 65 year-old-male presented to the emergency department with 2 episodes

of coughing up bright red blood over the last 24 hours. He denies any preceding fever,
prolonged cough, chest pain, or shortness of breath. He had a similar episode one month
ago which resolved spontaneously. He has a history of pulmonary tuberculosis when he
was 7 years old and completed 1 year of treatment. A computed tomography (CT) scan of
the chest showed a 4.1 cm x 3.8 cm cavitary lesion in the left upper lobe with a space-
occupying lesion within it. He is admitted to an isolation room to rule out tuberculosis.
Three sputum samples are collected and ruled out tuberculosis. He undergoes a
bronchoscopy with bronchoalveolar lavage and biopsies which do not give any specific
findings other than acute inflammation. Serologic testing for human immunodeficiency
virus is negative. His pulmonary function tests are within normal limits. What is the most
appropriate treatment option for this patient?

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Choices:

1. Continued surveillance
2. Surgical resection of the cavity lesion
3. Systemic voriconazole
4. Transcatheter instillation of voriconazole
Answer: 2 - Surgical resection of the cavity lesion

Explanations:

For an asymptomatic patient with episodes of hemoptysis, surgery is considered

the best treatment option for an aspergilloma if lung function permits.
The 5-year survival rate is 84% for those with aspergillomas that are surgically
resected compared to 41% for conservatively treated patients.
Resection with lung-sparing surgery has been the preferred approach with resection
along the anatomical segment.
Pneumonectomy, although less favored can be necessary for special circumstances
such as multiple unilateral complex mycetoma, intraoperative injury to major
vessels, second stage pneumonectomy for pulmonary torsion, and megamycetoma
with significantly destroyed surrounding lung tissue.

Research Concepts:

Aspergilloma

Question 73: A 45-year-old male patient with a past medical history of diabetes mellitus
presents complaining of chills, fevers, and malaise for one day. His current blood glucose
is 278 mg/dL. He has been taking insulin for the last two years. A chest x-ray reveals a
right-sided consolidation. Computed tomography (CT) scan shows pleural effusion,
consolidation, a nodule, and ground-glass opacities. Biopsy showed a dimorphic fungal
organism adjacent to thrombosed vessels. What is the treatment of choice for this
patient?

Choices:

1. Posaconazole and surgery

2. Limited resection and posaconazole
3. Amphotericin B and limited resection
4. Amphotericin B and radical debridement
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 Answer: 4 - Amphotericin B and radical debridement

Explanations:

Mucormycosis is a lethal infection and can erode into all tissue planes. It is a rare
infection usually involving the rhinocerebral sinuses. Treatment consists of
amphotericin B and radical debridement.
Risk factors for developing mucormycosis are diabetes mellitus and
immunosuppression, including patients undergoing chemotherapy or with leukemia.
The organism causes necrosis and is found adjacent to thrombosed blood vessels.
These patients need immediate surgery with radical debridement.
The immune function should be reconstituted, for example, recovery of neutropenia,
and reversal of acidosis.

Research Concepts:
Mucormycosis

Question 74: A 42-year-old woman is evaluated for exertional dyspnea and fatigue. Her
symptoms began four months ago and have been steadily worsening. Medical history is
significant for essential hypertension. She takes amlodipine. On physical examination,
vitals are stable, oxygen saturation breathing ambient air is 91%. Pulmonary examination
reveals bilateral fine basal crackles. Pulmonary function test showed reduced DLCO. CT
chest showed increased reticular markings, traction bronchiectasis, volume loss, and
ground glass opacification mainly in the lower zones with no honeycombing changes. Lung
biopsy confirmed the diagnosis of nonspecific interstitial pneumonitis (NSIP). What is the
best treatment?

Choices:

1. Long-term taper prednisone

2. Lung transplant
3. Supportive treatment
4. Cyclophosphamide
Answer: 1 - Long-term taper prednisone
Explanations:

This patient has moderate to severe disease with significant impairment on their
pulmonary function tests as well as diffuse changes on HRCT chest scan. The patient is

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 typically started on systemic corticosteroid therapy, prednisone at a dose of 0.5 to
1mg/kg ideal body weight (IBW) up to a maximum dose of 60 mg/day for one month,
followed after that by a dose of 30 to 40 mg/day for an additional two months. For
those who respond or stabilize with this treatment, the prednisone should be
gradually tapered over 6 to 9 months to a dose of 5 to 10mg/day or every other day
with a goal of potential cessation in therapy after one year.
Typically, patients are monitored on prednisone for 3 to 6 months to assess for
response to treatment and tolerance prior to consideration for a second
immunosuppressive agent like azathioprine or mycophenolate. For patients with
more severe initial disease some advocate starting systemic steroid therapy along
with a second immunosuppression agent together.
Refractory disease despite systemic steroid and immunosuppressive agents.
Consideration may be given for cyclophosphamide, rituximab, or calcineurin
inhibitors. Those that are not responsive may be considered for lung
transplantation.
NSIP unlike Idiopathic pulmonary fibrosis (IPF) responds well to steroids

Research Concepts: Nonspecific Interstitial Pneumonitis

Question 75: A 41-year-old white male presented to the clinic for a second opinion. He
has been an otherwise healthy, highly functional individual until three years ago when he
suddenly started having a cough with frequent episodes of chest tightness and wheezing.
There has not been any change in the home or work setting or his immediate
environment. He was seen by his primary care provider and then a pulmonologist and
diagnosed with adult- onset bronchial asthma. Over the course, he has had a stepwise
escalation of his asthma treatment, and he is now on an inhaled corticosteroid-beta-
agonist combination, montelukast, inhaled anticholinergics, and is still needing oral
prednisone for more than half of the year with frequent use of albuterol. The last chest x-
ray was a year ago and was reported with some interstitial prominence. The initial
evaluation reveals high peripheral eosinophilia along with an elevated erythrocyte
sedimentation rate. Allergy testing for environmental allergens was unremarkable
although he had high serum IgE. He also has evidence of sinus tenderness with nasal
polyps. A computed tomography (CT) chest is ordered. Which of the following findings is
likely to be present?

Choices:

1. Asymmetric diffuse bilateral peripheral ground-glass infiltrates

2. A cavitary lesion in the upper zone with a central soft tissue mass and an air crescent
sign
3. Multiple bilateral pulmonary cavitary lesions
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4. A hilar mass with ipsilateral mediastinal conglomerate mass
Answer: 1 - Asymmetric diffuse bilateral peripheral ground-glass infiltrates
Explanations:

Eosinophilic granulomatosis with polyangiitis is often diagnosed as refractory adult-

onset asthma. Refractory asthma with peripheral eosinophilia, rhinosinusitis, and
elevated IgE should prompt further workup including CT chest and serology.
One distinguishing feature of eosinophilic granulomatosis with polyangiitis from
granulomatosis with polyangiitis (GPA) is the absence of cavitary lung disease in the
former. Nasal septal perforations are also absent, unlike the latter condition.
Classical CT findings of eosinophilic granulomatosis with polyangiitis include
peripheral ground glass infiltrates or bronchocentric nodular infiltrates. CT of the
chest will usually reveal asymmetric diffuse bilateral peripheral ground-glass
infiltrates along with bronchial wall thickening. Bilateral bronchocentric nodular
infiltrates can also occur, but unlike GPA, they do not cavitate.
Pleural effusion although rare is found in 20% to 30% of the patients.

Research Concepts: Churg Strauss Syndrome

Question 76: A 17-year-old male with AIDS presents with worsening exertional dyspnea,
fever, and a nonproductive cough. His temperature is 102 F, heart rate 120 beats/min,
and respiratory rate 24. A physical exam reveals mild crackles and rhonchi bilaterally. A
chest x-ray shows diffuse bilateral infiltrates. PaO2 is 69 mmHg on room air. He has no
known drug allergies. What is the best initial treatment?

Choices:

1. Intravenous trimethoprim/sulfamethoxazole
2. Intravenous pentamidine
3. Intravenous corticosteroids followed by IV
trimethoprim/sulfamethoxazole
4. Intravenous corticosteroids followed by IV levofloxacin

Answer: 3 - Intravenous corticosteroids followed by IV trimethoprim/sulfamethoxazole

Explanations:

Corticosteroids decrease mortality in patients with severe Pneumocystis jiroveci

pneumonia (PCP).
Trimethoprim/sulfamethoxazole is the drug of choice, but pentamidine is used for

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 those with sulfa allergy.
Levofloxacin does not cover PCP. However, if there are infiltrates, it can be added
for possible bacterial pneumonia. Adjunctive corticosteroids can decrease the
inflammatory response associated with PCP. Also, they can reduce the decline of
oxygenation and reduce the incidence of respiratory failure.

Research Concepts:

Pneumocystis Jirovecii Pneumonia

Question 77: A 56-year-old male who suffered a multiorgan injury is intubated in the
intensive care unit. His ventilator settings rate is 14, FiO2 60%, total volume 450 ml, and
positive end- expiratory pressure of 12 cmH2O. At night, the nurse notices a significant
amount of subcutaneous emphysema and elevated peak pressures. What should be the
next step in the management of this patient?

Choices:

1. Blood gas
2. CT scan
3. Place chest tubes
4. Bronchoscopy

Answer: 3 - Place chest tubes

Explanations:

In any ventilated patient with a high positive end-expiratory pressure (PEEP),

barotrauma can often present with a pneumothorax. Sometimes it may present as
subcutaneous emphysema.
Many patients on the ventilator with high PEEP have prophylactic chest tubes
inserted. PEEP can also cause a decline in cardiac output.
In such a scenario, the placement of chest tubes can be life- saving, as
hemodynamic compromise can occur at any time. No time should be wasted
obtaining chest x-rays.
In rare cases, the endotracheal tube can cause a posterior tear in the trachea and
cause subcutaneous emphysema.
Research Concepts: Iatrogenic Pneumothorax
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Question 78: A 57-year-old male with alcoholic liver cirrhosis presents to the emergency
department after 2 days of hematemesis. He currently is not taking any medications. A
previous chart shows esophageal varices listed in the history. Today's CBC shows a
hemoglobin of 5.8 g/dL and hematocrit of 17.8%. The prothrombin time and INR are 22.5
and 1.7, respectively. One unit of packed red blood cells and one unit of fresh frozen
plasma are ordered to transfuse. Within 2 hours of starting the transfusion, the patient
becomes dyspneic, and the lungs sound very congested. His blood pressure is 95/62 mmHg,
and heart rate is 112 beats/min. An emergent chest x-ray and arterial blood gas are
ordered. What is the best next step?

Choices:

1. Intubate the patient

2. Stop the transfusion and notify the blood bank
3. Continue the transfusion and give IV furosemide 40 mg emergently
4. Stop the transfusion and discard the blood products

Answer: 2 - Stop the transfusion and notify the blood bank

Explanations:

The best treatment for transfusion-related acute lung injury (TRALI) is to stop the
transfusion. The blood transfusion will worsen the patient's condition. TRALI usually is
associated with plasma components such as platelets and fresh frozen plasma.
Supportive care is the mainstay of TRALI treatment. Oxygen supplementation is
needed. Also, IV fluids and vasopressors are needed for blood pressure support. The
unused blood should be sent back to the blood bank.
Intubating the patient and protecting the airway is the next step if the patient's
respiratory status worsens.
Diurectics should be avoided in TRALI treatment.

Research Concepts:

Transfusion-related Acute Lung Injury

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Question 79: An 80-year-old male with a history of dementia and a cerebrovascular
accident with residual symptoms of paralysis from the waist down presents to his primary
care provider for his annual wellness exam. The patient currently lives at home with his
wife as his caregiver. He has no home health services set up at this time. On exam, he has
poor dentition, the heart rate is regular, and his lungs are clear to auscultation. The
neurological exam shows reflexes that are 2/5 in the upper extremities and absent in the
lower extremities. Lower extremities are paralyzed, and sensation is not intact. There are
no sacral pressure ulcers. The patient does not have dysphagia. Later, he developed a
fever, cough, and altered sensorium with opacity in the right lower lung on the
radiograph. Which of the following was the highest risk factor?

Choices:

1. Poor dentition
2. Dementia
3. Paralysis of limbs
4. Cerebrovascular accident

Answer: 1 - Poor dentition

Explanations:

Microorganisms from the oral cavity cause a significant amount of aspiration

pneumonia. It generally occurs in the form of silent aspiration. Everyone silently
aspirates, even if they do not have a neurological medical condition or reduced
level of consciousness, and everyone has bacteria in their oral cavity.
There is a higher risk for pathogenic microorganisms in the oral cavity in the presence
of poor dentition.
Organisms in the oral cavity are often gram-negative and anaerobic. Gram-negative
bacteria and anaerobes were the common cause of aspiration pneumonia, and
aspiration pneumonia is still treated with antibiotics used against gram- negative and
anaerobic bacteria.
Patients in the nursing home or patients who have a history of dementia or
cerebrovascular accident and are unable to take care of themselves at home and
have home health services are generally the ones with poor oral hygiene. These
patients are unable to brush their teeth themselves and must rely on others.
Patients with dentures have better oral hygiene and are less likely to have poor
oral hygiene as a risk factor for aspiration pneumonia. These patients can better
care for their dentures, whether they can do it themselves or someone else does it
for them.
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 To reduce the risk factor of poor oral hygiene, it is recommended to clean patients'
mouths often. One agent commonly used in hospitals includes oral chlorhexidine
rinse in the intensive care unit for mechanically ventilated patients.

Research Concepts:

Aspiration Pneumonia

Question 80: A 53-year-old male, who had been previously diagnosed with liver cirrhosis,
presents to the clinic with persistent back pain. He undergoes imaging studies and is
diagnosed with thoracolumbar tuberculosis. He is planned for anti-TB therapy (ATT).
Which of the following is most accurate regarding anti-TB medications in a patient with
liver disease?

Choices:

1. The insult to the liver caused by anti-TB treatment is self-limiting and therefore,
there is no need to modify the dosage
2. The dosage of ATT in patients with liver cirrhosis is modified on the basis of
underlying liver function (Child-Turcotte-Pugh score)
3. All the anti-TB drugs have a similar mechanism of liver insult
4. Patients of all ages have a similar propensity for liver damage secondary to ATT

Answer: 2 - The dosage of ATT in patients with liver cirrhosis is modified on the basis of
underlying liver function (Child-Turcotte- Pugh score)

Explanations:

Guidelines have been proposed on the modifications of ATT dosage based on the
Child-Turcotte-Pugh (CTP) score. Patients with stable liver function (CTP score 8)
should not be treated with more than 2 hepatotoxic drugs, while patients with CTP
between 8 and 10 should be treated with only a single hepatotoxic drug. Those
with CTP > 10 or severe liver dysfunction should not be treated with any
hepatotoxic drug.
Pyrazinamide (PYZ) is the most hepatotoxic drug.
Isoniazid (INH) causes idiosyncratic-type hepatotoxicity. Both rifampicin (RMP) and
pyrazinamide cause both idiosyncratic and dose-dependent hepatotoxicity.
In patients receiving combination therapies involving INH, but not RMP, the
incidence of hepatotoxicity is around 1.6%. When regimens involving both INH and
RMP are employed, the incidence of hepatotoxicity is increased to 2.5%. Elderly
patients have a higher incidence of liver decompensation following ATT.
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Research Concepts:

Pott Disease

Question 81: A 26-year-old man presented with a 1-week history of shortness of breath
and cough. He used over-the-counter cold medication and felt better. But for 2 days, he
has been getting a high fever, productive cough, and chills at night. In the emergency
department, his vitals were blood pressure 110/56 mmHg, pulse 130 bpm, temperature
39.6 C (103.2 F). Chest x-ray showed left pleural effusion. He was started on intravenous
fluids and antibiotics for community-acquired pneumonia given after drawing blood
cultures. Pulmonology service was consulted, and a bedside pleural ultrasound showed a
left moderate pleural effusion with septations.
Diagnostic thoracentesis findings were pH 7.0, lactate 649 mg/dL, and glucose of 2
mg/dL. What is the next step in management?

Choices:

1. Continue with intravenous antibiotics

2. Indwelling intrapleural catheter placement
3. Consult cardiothoracic surgery for video-assisted thoracoscopic surgery
4. Small-bore chest tube placement with intrapleural tPA and DNAase

Answer: 4 - Small-bore chest tube placement with intrapleural tPA and DNAase
Explanations:

This patient has community-acquired pneumonia, probably post- influenza.

Staphylococcus aureus is the likely causative organism in these patients. S. aureus is
notorious for causing empyema and abscesses.
Thoracentesis confirmed a parapneumonic effusion. High lactate, low glucose, and
pH of less than 7.2 is an indication for drainage of the parapneumonic effusion. The
current recommendation is to place a small-bore chest tube followed by 3 days of
intrapleural tPA and DNAase to lyse all the septations and adhesions.
An indwelling intrapleural catheter may be indicated for chronic infective pleural
effusions in highly selected cases. They have no role in the acute management of
empyemas or parapneumonic effusions.
Early video-assisted thoracoscopic surgery (VATS) has been shown to improve
outcomes in a few small studies and the moment recommended by CT surgery
guidelines, but there is no consensus among the societies. However, VATS should be
done within 7 to 8 days of chest tube placement. Doing VATS later than 8 days
increases the risk of a trapped lung.
Research Concepts: Intrapleural Catheter
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Question 82: A 62-year-old male with a history of hypertension, diabetes mellitus, chronic
obstructive pulmonary disease (COPD) on 2L of home oxygen, congestive heart failure,
and atrial fibrillation on warfarin presents to the emergency department with shortness
of breath. His initial vitals are temperature 101.3 F, heart rate 121 bpm, blood pressure
150/90 mmHg, respiratory rate 24/minute, and pulse oximetry (SpO2) 80% on 10 L non-
rebreather mask. His exam is significant for rales in the left lower lung field and
decreased air movement diffusely as well as 1+ pitting edema to his lower extremities
bilaterally. Chest x-ray shows hyperinflated lungs, and a focal infiltrate in the left lower
lobe. EKG shows atrial fibrillation with a rapid ventricular response without signs of
ischemia. He is intubated for hypoxemic respiratory failure secondary to pneumonia.
However, his oxygenation does not improve with standard ventilator settings, and
inverse ratio ventilation (IRV)is being considered.
Which of the following patient factors is most likely to complicate this patient's management
if he were to be placed on IRV?
Choices:

1. Respiratory failure secondary to pneumonia

2. History of COPD
3. History of heart failure
4. Hemodynamic status
Answer: 2 - History of COPD

Explanations:

This patient's history of severe COPD, indicated by his need for home oxygen,
decreased air movement on exam, and hyper- inflated lungs, put him at increased risk
for auto-positive end- expiratory pressure (PEEP) if placed on IRV.
Typical management of mechanical ventilation for patients with obstructive lung
disease often involves increasing the expiratory time to allow adequate exhalation
time, not decreasing it as is seen in IRV.
Decreased expiratory time will lead to incomplete exhalation in this patient with
subsequently decreased ventilation and increasing intrathoracic pressures
resulting in barotrauma.
In severe cases, intrathoracic pressure may continue to build with subsequent
breaths as each additional breath creates additional volume which is unable to be
exhaled. This may result in hemodynamic compromise or pneumothorax.
Research Concepts: Inverse Ratio Ventilation

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Question 83: A 55-year-old female presents with an unremitting cough in addition to
polyuria, polydipsia, and menstrual irregularities for the past few months. A chest x-ray
shows perihilar lymphadenopathy. Biopsy of a lymph node reveals non-caseating
granulomas. Which part of the brain most likely is affected that is causing her
endocrinologic problems?

Choices:

1. Cerebellum
2. Hypothalamus
3. Corpus callosum
4. Cortical lesions

Answer: 2 - Hypothalamus

Explanations:

Neurosarcoidosis in rare cases may cause neuroendocrine dysfunction involving the

hypothalamus.
Symptoms of neurosarcoidosis may present as neurogenic diabetes insipidus.
The spinal cord can be involved causing a cauda equina clinical presentation.
Endocrinology should be consulted in cases where the hypothalamus is affected.
Research Concepts:

Neurosarcoidosis

Question 84: A 56-year-old female is referred to the clinic by her gynecologist, where she
had gone to get cervical cancer screening. During the office visit there, she fell asleep
mid-conversation. Given her body habitus, the gynecologist was concerned for
obstructive sleep apnea and made the referral. Blood work done at the OBGYN visit is
significant for elevated serum bicarbonate at 32 mEq/L. She denies smoking. There is
some concern for obstructive sleep apnea (OSA) and obesity hypoventilation syndrome
(OHS). Which of the following is most accurate about OHS?

Choices:

1. An alternative neuromuscular, mechanical or metabolic explanation for

hypoventilation can be coexistent
2. Presence of awake alveolar hypoventilation characterized by daytime

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hypercapnia (arterial PCO2 greater than 45 mmHg)
3. A consequence of diminished ventilatory drive and capacity related to individual
patients being overweight (BMI greater than 25)
4. Presence of awake hypoxia characterized by arterial PO2 less than 65 mmHg

Answer: 2 - Presence of awake alveolar hypoventilation characterized by daytime

hypercapnia (arterial PCO2 greater than 45 mmHg)
Explanations:

OHS is defined as the presence of awake alveolar hypoventilation characterized by

daytime hypercapnia (arterial PCO2 greater than 45 mm Hg [5.9 kPa]) that is
thought to be a consequence of diminished ventilatory drive and capacity related
to obesity (BMI greater than 30) in the absence of an alternative neuromuscular,
mechanical or metabolic explanation for hypoventilation.
Daytime Hypercapnia is the hallmark of OHS, differentiating it from OSA alone.
Although OHS/Pickwickian syndrome could have a component of hypoxia
coexistent in the more severe cases, it is not required for defining OHS.
Other causes of hypoventilation have to be ruled out before making the final
diagnosis.
Obesity is required at a range of BMI greater than 30.

Research Concepts:

Pickwickian Syndrome

Question 85: An 18-month-old, previously healthy child is admitted for pneumonia with
empyema. After fluid drainage using video-assisted thoracoscopic surgery, a 2 cm lung
abscess is seen. Which of the following would be the most appropriate therapy?

Choices:

1. CT-guided needle drainage

2. Open thoracostomy urgently
3. Open thoracostomy after resolution of fever
4. Long-term intravenous antibiotics
Answer: 4 - Long-term intravenous antibiotics
Explanations:

Most lung abscesses can be treated with long-term parenteral antibiotics.

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 Staphylococcus aureus is the primary cause of a lung abscess in children who are
born and raised in the United States.
If methicillin-resistant S. aureus is determined to be the source of a lung abscess,
vancomycin and linezolid should be considered.
Thoracostomy can result in contamination of uninfected tissue.

Research Concepts:

Lung Abscess

Question 86: A 65-year-old male presented with dyspnea and hypoxemic respiratory
failure. He has gastric cancer with liver, lung, and bone metastases. On presentation, he
is hypotensive, tachypneic, and clearly in distress. He was placed on home hospice 3
weeks ago with an expected prognosis of less than one month.
Chest x-ray showed large right-sided pleural effusion and moderate left pleural effusion.
His son states that he presented similarly 3 weeks ago and had had fluid removed from
his right side. He felt much better post-procedure. He has a do not resuscitate order
placed on the chart. What can be done for his recurrent pleural effusion?

Choices:

1. Chest tube placement and positive-pressure suctioning

2. Thoracentesis
3. Chest tube placement and talc pleurodesis
4. Bedside pleural catheter placement

Answer: 2 - Thoracentesis

Explanations:

The choice of therapy depends on the expected survival of the patient. This patient
has malignant pleural effusion, and his life expectancy is less than 1 month.
Therefore, it is less painful if symptomatic relief is provided by repeated
thoracentesis. He may not survive long enough to require another thoracentesis
since his last procedure was three weeks ago.
Thoracentesis should be performed immediately if the acute respiratory failure is
due to pleural effusion. Afterward, an indwelling pleural catheter can be placed if
the patient has recurrent symptomatic pleural effusions, an uncorrectable
underlying cause like malignancy or congestive heart failure, and the patient has an
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 expected survival of more than one month.
Talc pleurodesis is only successful in 70% of patients with malignant pleural effusions;
therefore, it is not the first choice procedure.
A bedside pleural catheter should not be placed because it is tunneled catheter and
carries the risk of a tunnel or pleural infection.

Research Concepts:

Intrapleural Catheter

Question 87: A 60-year-old male with a history of smoking presents to the emergency
department with a cough for the past 6 months. He reports weight loss, hemoptysis, and
hoarseness. The patient denies recent travel, recent illness, or a new exercise program.
On exam, the patient is afebrile, and his vitals are within normal limits. The provider
notes anisocoria with the left pupil at 2 mm and the right pupil at 4 mm. Additionally, the
provider notes drooping of the left upper eyelid. During a workup for the most likely
diagnosis, what additional finding can be expected?

Choices:

1. Diffuse end expiratory wheezing

2. Flushing and dryness of the left face
3. Rhonchi and green sputum production
4. Positive anti-acetylcholine receptor antibody

Answer: 2 - Flushing and dryness of the left face

Explanations:

This patient's presentation is suspicious for a Pancoast tumor, which is a cause of

Horner syndrome. Additionally, Pancoast tumors can cause hoarseness secondary to
recurrent laryngeal nerve compression.
Horner syndrome is characterized by the classic triad of unilateral ptosis (drooping
of the eyelid), miosis (constricted pupil), and anhydrosis (flushing and dryness to
the face).
Horner syndrome is due to the disruption of the sympathetic nervous innervation to
the head, including disruption of the pupillary dilation pathway.
In subtle presentations of Horner syndrome, cocaine eye drops can be applied to
the affected eye. If there is an absence of pupillary dilation, in addition to the
presence of ptosis, miosis, and anhydrosis, Horner syndrome can be confirmed.
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Research Concepts:

Horner Syndrome

Question 88: A 40-year-old woman with fevers, cough, and productive sputum for five
days, is admitted to the intensive care unit requiring intubation and mechanical
ventilation. She presented to the emergency department with acute respiratory distress
syndrome (ARDS) secondary to pneumonia. Oxygenation saturation had been satisfactory
on an FIO2 of 50% and positive end-expiratory pressure (PEEP) of 6 cm H2O but dropped
to the low 80% despite an increase in FIO2 to 100%. On physical examination, the patient
is intubated and sedated. Lung exam reveals diffuse rales and rhonchi. The examination of
the heart is unremarkable except for tachycardia (heart rate of 115 beats/min). She has
2+ peripheral edema. A chest x-ray shows diffuse bilateral infiltrates. She is being
ventilated using an assist/control mode with a tidal volume of 6 mL/kg and a plateau
pressure of 25 cm H2O. Which of the following is the most appropriate strategy for PEEP
in this patient?

Choices:

1. Increase PEEP in 2- to 3-cm H2O increments and lower FIO2 to at most 60%, if
possible. Arterial oxygen saturation of at least 88% and 95% or less must be maintained
2. Set the PEEP below the lower inflection point on a pressure- volume curve of
the lung
3. Maintain PEEP to correspond to the expiratory pressure that minimizes
compliance of the lung
4. Maintain PEEP of at least 14 cm H2O and increase up to 20 cm H2O for FIO2 of 0.5 to
0.8. Monitor cardiac output using a pulmonary artery catheter

Answer: 1 - Increase PEEP in 2- to 3-cm H2O increments and lower FIO2 to at most 60%,
if possible. Arterial oxygen saturation of at least 88% and 95% or less must be
maintained
Explanations:

In this patient with ARDS secondary to pneumonia, increasing PEEP in 2- to 3-cm H2O
increments and subsequently lowering FIO2 to at most 60% while maintaining an
arterial oxygen saturation of at least 88% and 95% or less is appropriate.
This strategy has been used by ARDSnet and associated with improved outcomes. It is
a "lung protective strategy".
Lower PEEP is associated with reduced barotrauma. There is no utility for a
pulmonary artery catheter in the management of PEEP.
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Research Concepts: Pulmonary Edema

Question 89: A 17-year-old female patient who was in a motorcycle collision comes to
the emergency department. She is groaning and speaking in a low voice. She has multiple
abrasions, a blood pressure of 80/50 mmHg, and a respiratory rate of 22 breaths per
minute. She is cold to the touch, and there is extensive subcutaneous emphysema in the
right upper chest and neck. A focused assessment with sonography in trauma (FAST)
exam is performed. What is the next step in management?

Choices:

1. Chest x-ray
2. Urgent chest computed tomography scan
3. Tube thoracostomy
4. Fluid resuscitation

Answer: 3 - Tube thoracostomy

Explanations:

Airways should be the top priority.

Subcutaneous emphysema with respiratory distress is a pneumothorax until proven
otherwise.
If available, FAST imaging should be done. If not, the tube is placed at the fifth
intercostal and the midaxillary line.
In the field, needle decompression can be done and may be appropriate in the
hospital. In the emergency department, tube thoracostomy is preferred. An arrow
catheter can be used and later converted.
Research Concepts:

Tension Pneumothorax

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Question 90: An 18-year-old with intellectual disability and cerebral palsy, tracheostomy
and ventilator dependent, had two days of increased secretions with color change to
green. The worried parents bring him to the emergency department (ED) with one day of
increased ventilator settings and oxygen requirement. In the emergency department, his
temperature is 39.2 C (102.5 F), heart rate 140 beats/minute, blood pressure 75/50
mmHg, and oxygen saturation 82% on room air. A chest x-ray shows a right lower lobe
infiltrate. The mother states that he recently finished a 14-day course of levofloxacin.
Blood and tracheal cultures are obtained, and it is decided to start antibiotic treatment.
His last tracheal culture, which was obtained five months ago, grew methicillin-resistant
Staphylococcus aureus (MRSA). Based on this information which of the following
antibiotic/antibiotic combinations will provide adequate coverage while awaiting the
blood and tracheal cultures?

Choices:

1. Vancomycin
2. Clindamycin
3. Vancomycin plus piperacillin-tazobactam plus gentamicin
4. Cefepime

Answer: 3 - Vancomycin plus piperacillin-tazobactam plus gentamicin

Explanations:

Empiric treatment for ventilator-associated pneumonia should include coverage

against methicillin-resistant Staphylococcus aureus, Pseudomonas, and other gram
negatives. Earlier treatment reduces the risk of complications. However, treatment
should be tailored based on the identification of the organisms on tracheal and
blood cultures because prolonged broad- spectrum antibiotics are associated with
development of resistant infections as well as side effects.
This patient was presenting in septic shock and was on antibiotics over the past
three months, which are considered a risk factor for starting broad-spectrum
antibiotics. Other risk factors include acute respiratory distress syndrome, five days
or more of hospitalization before the development of ventilator- associated
pneumonia, and acute renal replacement therapy before the development of
ventilator-associated pneumonia. In addition, one should use the local antibiotic
susceptibility pattern as well as the patient's past microbiology data.
In a patient with more than one risk factor for a multidrug- resistant organism, the
empiric treatment should cover methicillin-resistant Staphylococcus aureus with
either vancomycin or linezolid plus two anti-Pseudomonas agents such as
piperacillin-tazobactam, cefepime, meropenem, and aztreonam plus an
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 aminoglycoside such as gentamicin, amikacin, or tobramycin. In the absence of risk
factors, only one anti-Pseudomonal agent should be used. Monotherapy with
aminoglycosides should be avoided.
The combination of antibiotics should be given intravenously initially. It should be
tailored once the antibiotic susceptibility results return. The decision to tailor
antibiotics should also take into consideration the progression of clinical and
laboratory markers of infection, such as fevers, white blood cells, and procalcitonin.

Research Concepts:

Ventilator-associated Pneumonia

Question 91: A 55-year-old woman presents with increasing exertional dyspnea and
productive cough for past 3 weeks with intermittent fevers. Chest radiograph had
consolidations over both lower lung zones. She has completed 2 courses of antibiotics
without any improvement in her symptoms. She has never smoked and has no toxic or
industrial exposures. She lives in the city and has had no pet or bird exposures. On
examination, she is afebrile, has mild respiratory distress but otherwise normal exam.
Pulmonary function tests reveal restriction and impaired diffusing capacity of the lungs
for carbon monoxide (DLCO). High-resolution CT of the chest reveals ground-glass
opacities over bilateral mid to lower lung zones along with areas of dense consolidations.
Bronchoscopy with bronchoalveolar lavage revealed a white cell count of 500/mm3 with
55% lymphocytes, 12% eosinophils, 23% neutrophils and 10% monocytes. Bacterial and
fungal cultures remained negative.
Transbronchial lung biopsy specimens revealed inflammatory cell infiltrate and
granulation tissue plugs in small airways. What is the most appropriate next step in the
management of this patient?

Choices:

1. Refer patient to thoracic surgery for a surgical lung biopsy

2. Start the patient on 1 mg/kg/day of prednisone
3. Start a course of antifungal therapy with itraconazole
4. Perform a home inspection and send serum hypersensitivity panel testing
Answer: 2 - Start the patient on 1 mg/kg/day of prednisone

Explanations:

Cryptogenic organizing pneumonia (COP) should be considered in patients

presenting with symptoms and chest radiograph concerning for pneumonia but not
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 improving on antibiotics.
Pulmonary function tests typically reveal restriction and impaired diffusion capacity.
A mixed cellularity on bronchoalveolar lavage (BAL) should prompt suspicion for
COP. BAL also helps to rule out infections. If clinical presentation, radiographic
appearance and BAL exam is consistent with COP, surgical lung biopsy is not
required for diagnosis.

Research Concepts:

Cryptogenic Organizing Pneumonia

Question 92: A 65-year-old male was admitted to the hospital with fever, productive
cough, and shortness of breath. Initial evaluation revealed leukocytosis with a left shift,
and chest radiograph showed a left lower lobe infiltrate. He was started on appropriate
intravenous antibiotics with oxygen support via nasal cannula. After 2 days of
hospitalization, the patient experienced worsening respiratory distress with an increased
requirement of oxygen, and he became more confused. Repeat chest radiograph showed
the development of new-onset right-sided infiltrate and worsening of the left side
infiltrate. Arterial blood gas, while the patient is breathing on 6 L/min via a face mask,
showed a pH of 7.32, PaCO2 of 38 mmHg, and a PaO2 of 53 mmHg. What is the most
appropriate next step in management?
Choices:

1. Transfer to the intensive care unit and start non-invasive ventilation with a serial
assessment of the patient’s clinical condition
2. Transfer to intensive care unit, intubate and start volume assist- control ventilation
with tidal volume 6 ml/kg of ideal body weight target plateau pressure of 30 cm H2O
3. Transfer to intensive care unit, intubate and start pressure support ventilation
4. Transfer to intensive care unit, intubate and start volume assist- control ventilation
with tidal volume 10 ml/kg of ideal body weight, and target plateau pressure of 45 cm
H2O.
Answer: 2 - Transfer to intensive care unit, intubate and start volume assist-control
ventilation with tidal volume 6 ml/kg of ideal body weight target plateau pressure of 30
cm H2O
Explanations:

Pneumonia is a common cause of acute respiratory distress syndrome (ARDS) in

hospitalized patients. Early recognition of worsening clinical conditions and the
development of ARDS is essential in the management of these patients.
Patients who developed ARDS should be transferred to ICU, intubated and
mechanical ventilation should be started with volume assist-control with a tidal
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 volume of 6 ml/kg of ideal body weight with a target inspiratory plateau pressure of
30 cm of H2O to avoid barotrauma and further lung injury.
Low tidal volume and low-pressure ventilation are associated with a significant
reduction in mortality and various clinical outcomes when compared with the
higher tidal volume of 12 ml/kg and higher plateau pressures of 45 cm H2O.
Management of ARDS should also involve treatment of the underlying cause,
prevention of complications associated with a hospital stay, including nosocomial
infections, venous thromboembolism, stress ulcers, and aspiration.
Research Concepts: Respiratory Distress Syndrome

Question 93: A 30-year-old male with a history of post-traumatic stress disorder (PTSD)
has become depressed because of a job loss. The patient's brother found him
unconscious in the garage with the car running. The brother shut the car off, opened the
garage doors, and dragged the patient outside and called 911. The patient was intubated
at the scene by a paramedic after having a seizure and was given lorazepam 2 mg IV. The
patient is now in the emergency department with a blood pressure of 142/80 mmHg,
heart rate 120 beats/min, sinus rhythm on monitoring, and ventilated on assist control of
20. His temperature is 98.6 F. Oxygen saturation is 100% with FiO2 60%. The patient's
carboxyhemoglobin is 35%.
The hospital has a hyperbaric oxygen wound care department with monoplace
chambers. It primarily is used to treat outpatients, and the staff has limited critical care
experience. There is a tertiary care medical center 45 miles away that has a multiplace
chamber with critical care ability. What is the most appropriate treatment?

Choices:

1. Treat the patient in the monoplace chamber at your facility with patient intubated
to protect his airway, but no ventilator for the chamber. Have IV available for
delivering medication such as lorazepam and continue on heart monitor
2. Increase the FiO2 to 100% and hold sedation in hopes that the patient can regain
consciousness enough to be able to extubate and then treat in monoplace chamber at
your facility
3. Transfer the patient to the multiplace chamber (the nearest facility with critical care
capability) as soon as possible
4. Admit the patient to your facility and treat in the intensive care unit because acute
treatment with hyperbaric oxygen therapy is not needed and can be delayed if patient
develops delayed sequelae of carbon monoxide poisoning

Answer: 3 - Transfer the patient to the multiplace chamber (the nearest facility with critical

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care capability) as soon as possible
Explanations:

If the staff at the monoplace facility have training and are comfortable with
treating critically ill and intubated patients on ventilators the patient could stay at
the facility. Intubated patients can be treated if a ventilator designed for use with
the monoplace chamber is available and if the cuff for the endotracheal tube
needs to have the air removed and replaced with normal saline. In the described
scenario, the patient would not be best treated at the presenting facility. If the
patient were to have seizures in the monoplace chamber, this could be treated
with IV benzodiazepines, but protection of the patient's airway is more difficult to
manage.
It is appropriate to increase the Fi02 to 100% to help to reduce the half-life of the
carbon monoxide, but it is not sufficient treatment in this case. The best treatment
is hyperbaric oxygen therapy which should be done as soon as possible to maximize
the benefit of the therapy.
Transfer of the patient to the nearest hyperbaric facility with critical care
capabilities is the best treatment option for this patient. The risk of transferring
the patient is relatively low as opposed to the risk of not treating the patient with
hyperbaric oxygen therapy or delaying treatment. Hyperbaric oxygen has the most
benefit the sooner it is done in patients with carbon monoxide poisoning.
Delaying treatment may result in irreversible damage from the carbon monoxide
poisoning especially if the patient has neurologic damage. Reversibility, especially
for neurologic damage, is time-dependent.
Research Concepts:

Hyperbaric Treatment Of Carbon Monoxide Toxicity

Question 94: A 50-year-old man with chronic obstructive pulmonary disease (COPD)
presents with dyspnea, fatigue, and copious sputum production. Twenty-four hours ago,
he developed a low-grade fever and clear rhinorrhea. Physical exam reveals a middle-
aged man in respiratory distress, including accessory muscle use. He has marked
wheezing and no air entry bilaterally. He is immediately treated with oxygen and
nebulizer therapy but fails to improve. Bronchoscopy is done for diagnosis and
therapeutic reasons. What percentage of patients with COPD exacerbation have
microorganisms in the lower airways during bronchoscopy?

Choices:

1. Less than 3%

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2. About 10%
3. About 50%
4. More than 90%

Answer: 3 - About 50%

Explanations:

Bronchoscopy may be performed to sample the airways for bacteria in patients who
are not responding to treatment.
Studies suggest that at least 50% of patients have microorganisms in the lower
airway during chronic obstructive pulmonary disease (COPD) exacerbation.
A significant number of patients also have colonization of the airways, making it
difficult to interpret the data. However, one distinguishing feature is the
bacterial burden increases in the airways during an exacerbation.
New organisms are most likely in patients with symptoms of wet cough and purulent
sputum.

Research Concepts:

Chronic Obstructive Pulmonary Disease

Question 95: A 55-year-old male with PMH of asthma/ COPD overlap syndrome was
admitted to the ICU for acute hypercapnic respiratory failure. He failed to non-invasive
positive pressure ventilation and had to be emergently intubated for increased work of
breathing. He was treated with intravenous steroids, bronchodilators, and his exam
revealed audible wheezing. On Day 3 of being on a mechanical ventilator, he started
following commands during the spontaneous awakening trial. Still, he became tachypneic
with a respiratory rate of 32 during the spontaneous breathing trial (SBT) on a CPAP of 5
cm H2O. His rapid shallow breathing index was 116 breaths/minute/liter. What is the best
next step in the management of this patient?

Choices:

1. Extubate the patient to CPAP

2. Obtain ABG
3. Administer a dose of succinylcholine and extubate the patient
4. Place the patient back on the assist control mode of mechanical ventilation
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Answer: 4 - Place the patient back on the assist control mode of mechanical ventilation

Explanations:

A variety of respiratory, cardiac, psychological, neurologic, neuromuscular, and

equipment related causes leads to difficulty in weaning patients from ventilation.
Patients with RSBI less than 105 are likely to be successfully extubated and RSBI more
than 105 are at increased risk for extubation failure.
SBT should be performed only once a day. Several SBTs a day offer no additional
benefit compared with one.
The above patient with audible wheezing and tachypneic on SBT is most likely to fail
extubation and should not be extubated until his underlying condition improves.

Research Concepts:

Ventilator Weaning

Question 96: A 45-year-old woman with a history of liver cirrhosis presents with shortness
of breath in a standing position which improves when lying supine. Her blood pressure is
110/75 mmHg, pulse 105/minute, respiratory rate 22/minute, and oxygen saturation 85%
on room air. Lungs are clear to auscultation bilaterally, and heart sounds are normal with
no gallop, murmur, or friction rub. The lower extremities show trace edema. Ammonia
level is 51 micromol/L and albumin 2.8 g/dL, chest x-ray is unremarkable, and ultrasound
abdomen reveals mild ascites. Which of the following conditions is most likely responsible
for this patient's presentation?

Choices:

1. Liver cirrhosis
2. Congestive heart failure
3. Low portal pressure
4. Low serum albumin concentration
Answer: 1 - Liver cirrhosis

Explanations:

Pulmonary arteriovenous malformation (PAVMs) is an abnormal connection

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 between the pulmonary artery and pulmonary veins, which lack the normal capillary
structure. This abnormal vascular connection allows systemic venous blood to
bypass the normal pulmonary circulation, resulting in paradoxical embolic stroke or
brain abscess.
PAVMS can be congenital or acquired. However, most PAVMS are congenital due to
hereditary hemorrhagic telangiectasia (HHT).
PAVMs due to acquired medical conditions are usually seen in those with liver
cirrhosis, such as this patient,
Cardiac catheterization is indicated to confirm the diagnosis.
Research Concepts:

Pulmonary Arteriovenous Malformation

Question 97: A 27-year-old female presents with fever, cough with sputum production,
and rigors. She has a past medical history significant for acquired immunodeficiency
syndrome (AIDS) with a CD4 count of 55 cells/mm3. An exam reveals coarse breath
sounds in the right lower lobe, and a chest radiograph reveals an opacity in the same
area. What is the most likely organism causing this patient's condition?

Choices:

1. Mycoplasma pneumoniae
2. Pneumocystis jiroveci
3. Staphylococcus aureus
4. Streptococcus pneumoniae
Answer: 4 - Streptococcus pneumoniae

Explanations:

Streptococcus pneumoniae is the most common cause of lobar pneumonia in all

populations. A retrospective study evaluating the cause of community-acquired
lobar pneumonia in patients with human immunodeficiency virus infection and
AIDS reported the following causative agents in decreasing order of frequency:
Streptococcus pneumonia, Staphylococcus aureus, Pneumocystis carinii,
Haemophilus influenza, and Pseudomonas aeruginosa.
Although S. pneumoniae pneumonia can occur in all populations, it is more
common in patients older than 65 years, younger than 2 years, and those with an
underlying history of alcohol use disorder, smoking, asthma, chronic obstructive
pulmonary disease, or asplenia. The overall rate of confirmed S. pneumoniae
infection in the United States is 5.16 to 6.11 cases/100,000 in adults with the rate of
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 36.4/100,000 in patients older than 65 years and 34.2/100,000 in infants younger
than 12 months.
Pneumococcal infections are present throughout the world and are most common
during the winter and early spring months.
The World Health Organization estimated that 1.6 million deaths in 2005 including 1
million children less than 5 years of age, occurred due to streptococcus
pneumoniae. It is a common co- infection in influenza patients and affects the
morbidity and mortality in such patients.
Pneumocystis jiroveci is a common cause of pneumonia in patients with AIDS with a
CD4 count of less than 200 cells/mm3. However, it is not the most common cause of
pneumonia and usually presents with bilateral opacities.
Research Concepts: Streptococcus
Pneumoniae

Question 98: A 75-year-old male with stage IIIB adenocarcinoma of the lung is undergoing
thoracentesis of a newly-discovered large right pleural effusion for which he was admitted
after presenting with increased dyspnea on exertion ongoing for four weeks. Pleural
pressures are measured and demonstrate initial pleural pressure of
-10 cm H2O; this further decreases to -40 cm H2O after removal of 500 mL of pleural fluid.
A CT chest obtained after thoracentesis reveals the right lung has not re-expanded with
thoracentesis and small hydropneumothorax. This is treated conservatively with
supplemental oxygen, and the patient is discharged home. Cytology from pleural fluid
returns demonstrating adenocarcinoma. One week later, the patient returns to the
emergency department with respiratory distress and is found to have reaccumulation of
large, right pleural effusion. Which of the following treatment options should the patient
receive?

Choices:

1. Indwelling pleural catheter

2. Talc pleurodesis
3. Pleurodesis with bleomycin
4. Placement of pleuro-peritoneal shunt

Answer: 1 - Indwelling pleural catheter

Explanations:

The patient demonstrates trapped lung physiology as demonstrated by initially

negative pleural pressure followed by steep decline in pleural pressure after

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 removal of pleural fluid as well as evidence of no lung re-expansion on follow up
imaging. For patients with recurrent malignant effusion and trapped lung
physiology, an indwelling pleural catheter is the best palliative treatment available.
Indwelling pleural catheters have been shown to result in fewer hospitalization days
related to effusion and improvement in dyspnea.
In certain patients, indwelling pleural catheters can result in spontaneous pleurodesis
and removal thereafter.

Research Concepts:

Malignant Effusion

Question 99: A 75 year-old-male with a history of diabetes, COPD, and tobacco abuse is
diagnosed with left-sided bronchogenic carcinoma. Pulmonary function tests reveal a very
poor reserve with predicted postoperative FEV1 and DLCO of 20%. Cardiopulmonary
exercise test with measurement of maximal oxygen consumption is done to assess fitness
for surgery. What is the cut-off value of maximal oxygen consumption below which other
non-surgical options should be considered?

Choices:

1. 40 ml/kg/min
2. 30 ml/kg/min
3. 20 ml/kg/min
4. 10 ml/kg/min

Answer: 4 - 10 ml/kg/min

Explanations:

Pulmonary function test is usually done as a part of the preoperative workup in all
patients undergoing pneumonectomy. FEV1 and DLCO provide the most accurate
predictors of postoperative morbidity and mortality.
Patients are usually divided into three categories, those with predicted
postoperative FEV1, DLCO more than 60%, between 30-60% and less than 30%.
Predicted postoperative FEV1, DLCO less than 30% is considered high risk and
formal cardiopulmonary exercise test with measurement of maximal oxygen
consumption (VO max) should be done for further risk stratification.
VO max more than 20 ml/kg/min is considered acceptable for postoperative
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 complications. Values less than 10 ml/kg/min is considered high risk and non-surgical
modalities should be pursued.

Research Concepts:

Pneumonectomy

Question 100: A 51-year-old man comes to the emergency department with worsening
shortness of breath for the past two weeks. He reports a history of human
immunodeficiency virus (HIV) infection, but he is not compliant with his antiviral or
prophylactic therapy. On physical examination, he is in tachycardic, tachypneic, and using
accessory muscles with prolonged expiratory phase and bilateral wheezing. A chest x-ray
shows bilateral pulmonary infiltrates. A computed tomogram of the chest reveals bilateral
ground-glass opacities scattered throughout both lung fields. His arterial blood gas shows
pH 7.45, the partial pressure of carbon dioxide (PCO2) of 35 mmHg, the partial pressure of
oxygen (PO2) at 45 mmHg, and bicarbonate level of 24 mmol/L. As the patient is
extremely dyspneic but alert and awake, it is decided to attempt non- invasive mechanical
ventilation. A few minutes after the institution of therapy, the patient becomes agitated,
removes the non-invasive mask, and states, “ I don’t like it, I feel claustrophobic, and it
makes my breathing worse.” Which of the following is the next best step in the
management of this patient?
Choices:

1. Provide sedation and place the patient back on non-invasive ventilation while
trying different mask sizes
2. Place the patient on high flow nasal cannula and monitor his gas exchange and
mental status closely
3. Place the patient on high flow nasal cannula for preoxygenation while setting for
endotracheal intubation
4. Place the patient on Venturi face mask at 50% and continue to coach the patient
Answer: 2 - Place the patient on high flow nasal cannula and monitor his gas exchange and
mental status closely
Explanations:

High flow nasal cannula is an effective alternative for the treatment of non-
hypercarbic respiratory failure. This intervention could potentially avoid
endotracheal intubation in a highly selected patient population.
High flow nasal cannula enhances comfort as well as compliance with therapy.
High flow nasal cannula offers an alternative intervention for patients who cannot
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 tolerate non- invasive mechanical ventilation.
High flow nasal cannula improves oxygenation prior to intubation when compared
to other conventional oxygen supplementation systems.
High flow nasal cannula provides decrease work of breathing by decreasing airway
resistance, providing positive end-expiratory pressure (PEEP), and increase carbon
dioxide washout.
Research Concepts: High Flow Nasal Cannula

Section 2

Question 101: A 65-year-old male presented with symptoms of chronic cough for 1 month
with recurrent episodes of bloody sputum. He also complains of a 10-pound (4.5 kg)
weight loss over the past 2 months. He has also been having some difficulty in swallowing
lately. A CT scan and x-ray of the chest show a cavitary lung lesion in the right upper lobe.
He was admitted to the hospital and started empirically on piperacillin/tazobactam and
levofloxacin. PPD is negative. Sputum cultures are sent on 3 separate occasions, which
come back as negative, but a galactomannan antigen assay done after 2 days came back
as positive. Which of the following is the most appropriate next step in the management
of this patient?

Choices:

1. Bronchoscopy and biopsy

2. Continue the same regimen with swallow evaluation and maintenance of
aspiration precautions
3. Start voriconazole with positive galactomannan
4. CT guided aspiration and biopsy

Answer: 1 - Bronchoscopy and biopsy

Explanations:

Assay against galactomannan antigen, a polysaccharide component of the cell wall,

has a high specificity for diagnosing aspergillus disease.
However, false positives are seen in patients concurrently on piperacillin/tazobactam.
With ongoing weight loss, hemoptysis, and cavitary mass lesions, the workup for
malignant lesions should be completed by bronchoscopy and transbronchial
biopsy.
A confirmation of aspergillus species in fungal stain, culture, or polymerase chain

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 reaction, adds weight to the diagnosis but is not diagnostic by itself. Occasionally
biopsy through bronchoscopy or video thoracoscopy can also help in reaching the
diagnosis

Research Concepts:

Aspergilloma

Question 102: A 28-year-old African American female with a past medical history of
asthma is brought to the emergency department with acute onset shortness of breath
that has progressively worsened over the past 12 hours. According to her boyfriend, she
has not slept all night and has been using her inhaler every hour without any benefit.
Symptoms suddenly became much worse over the past 3 hours. On arrival she appears
anxious, in visible respiratory distress, and unable to speak more than a couple of words
at a time. She is using her accessory muscles to breathe. The calculated difference
between systolic blood pressure at end inspiration and expiration is 14 mmHg. She is
promptly started on nebulized albuterol and ipratropium and administered 2 g of
magnesium sulfate IV as well as 125 mg of methylprednisolone IV. She is also provided
with supplemental oxygen. Two hours later, she is lying in bed and sleeping without
distress. She is wheezing less than before. The difference between systolic blood
pressure at inspiration and expiration is now 5 mmHg. Which of the following is the next
best step in the management of this patient?

Choices:

1. Check her peak expiratory flow rate and FEV1

2. Obtain a chest x-ray to rule out pneumothorax
3. Immediately get an arterial blood gas (ABG) and prepare for endotracheal
intubation
4. Let her rest and continue current management

Answer: 3 - Immediately get an arterial blood gas (ABG) and prepare for endotracheal
intubation
Explanations:

While the ability to lie supine in a patient with status asthmaticus may reflect a
treatment response it has to be assessed in relation to the entire clinical picture.
She appears sleepy but could be lethargic which is indicative of respiratory fatigue.
Lack of wheezing could be a sign of worsened air entry as well.
Similarly, a sudden reduction in pulsus paradoxus can happen with the progression
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 of respiratory failure and hypoventilation from respiratory muscle fatigue.
Preparation for mechanical ventilatory support seems appropriate in this
circumstance.
Pulsus paradoxus is caused by a reduction in left ventricular (LV) outflow with air
hunger and deep inspiration causing an increase in LV and right ventricular (RV)
afterload and ventricular interdependence. Greater than 12% is considered
significant. However, in worsening status asthmatics, patients may be too fatigued
to take deep enough breaths to result in a large variation of pressure.
An ABG performed in this clinical setting may show normal PCO2 which again
should be interpreted in light of prior carbon dioxide partial pressure. Patients in
status asthmaticus present initially with respiratory alkalosis and low PCO2.
Normalization may, therefore, be an ominous sign indicating the rising level and
worsening fatigue of the respiratory apparatus.
If a patient does not have excessive secretions, is somnolent but arousable, and
has no ongoing nausea, noninvasive ventilatory support with bilevel positive airway
pressure (BIPAP) can also be tried for a short duration to be reassessed in 3 to 4
hours.

Research Concepts:

Status Asthmaticus

Question 103: A patient is postoperative day 4 following a right pneumonectomy. He is

afebrile, hemodynamically stable, and has a normal white blood cell count. A chest x-ray
reveals a newly formed air-fluid level. What is the appropriate management at this
time?

Choices:

1. Medical management with intravenous antibiotics

2. Revision of his stump via a median sternotomy
3. Revision and reinforcement of his stump via the original thoracotomy
4. Perform bronchoscopy

Answer: 4 - Perform bronchoscopy

Explanations:

Initial therapy for a bronchopleural fistula requires immediate chest tube

placement and bronchoscopy.
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 Subsequent therapy depends on the time of occurrence of the fistula. Those
bronchopleural fistulas occurring within 1 week of surgery usually are due to technical
failure, have minimal contamination, and the bronchus usually can be closed with a
buttressed muscle flap.
Fistulas that occur later than 10 days usually are associated with an empyema.
Immediate surgery is not recommended. Tube thoracostomy, antibiotics, and jet
ventilation may be required if the air leak is significant. The closed tube drainage
can later be converted to an open window followed by a Clagett procedure. The
above patient is asymptomatic, but a new air- fluid level should raise the possibility
of a bronchopleural fistula. The patient needs a bronchoscopy, although at times a
fistula may not be evident with this approach.
Occasionally, dye has to be injected into the chest cavity, and bronchoscopy
repeated. At this moment, the patient should be closely watched, and a chest tube
set should be placed at the bedside. However, if definitive bronchial dehiscence is
observed, he should return to the operating room for revision of his bronchial
stump with a possible muscle flap.
Research Concepts:

Bronchopleural Fistula

Question 104: A 65-year-old female presents to the emergency department with new-
onset worsening dyspnea of 5 days duration. She has a medical history of heart disease,
hypertension, and breast cancer. She takes lisinopril, aspirin, and undergoes
chemotherapy for her ongoing breast cancer. Her vitals on presentation are the following:
T 99.6, blood pressure 156/97 mmHg, heart rate of 130 bpm, and saturation 70%. She
was immediately placed on high-flow nasal cannula. On physical exam, the patient was in
respiratory distress using accessory muscle. A CT scan shows diffused irregular
interlobular septal thickening with beading not previously seen on prior imaging. What is
the most likely diagnosis?

Choices:

1. Radiation pneumonitis
2. Lymphangitic carcinomatosis
3. Pulmonary embolism
4. Pulmonary edema
Answer: 2 - Lymphangitic carcinomatosis
Explanations:

Pulmonary lymphangitic carcinomatosis is a metastatic lung disease where an

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 adenocarcinoma infiltrates the lymphatic ducts, causing obstruction. On a CT scan,
it shows up as thickening of the interlobular septum.
The patient has a history of breast cancer. Breast cancer is known to infiltrate the
pulmonary lymphatic system.
The imaging pattern described may not be diagnostic but is at least suggestive of
lymphangitic spread and with the appropriate clinical scenario makes lymphangitic
carcinomatosis more likely. A definitive diagnosis is obtained with a tissue biopsy,
but a presumptive diagnosis is acceptable. Prognosis is generally poor, and the only
therapy is to address the underlying malignancy.

Research Concepts:

Lymphangitic Carcinomatosis

Question 105: A 64-year-old male presents to the emergency department with

complaints of shortness of breath and chest palpitations. He has a significant history of
hypertension, chronic obstructive pulmonary disease (COPD), and is an active tobacco
smoker. He states that he recently had upper respiratory symptoms about one week ago,
and since has progressively had worsening shortness of breath. Medications include an
albuterol inhaler, maintenance combination inhaler, and hydrochlorothiazide. On exam,
vitals are blood pressure 150/85 mmHg, heart rate 160 bpm, respiratory rate 24/minute,
and oxygen saturation 94% on 2 liters by nasal cannula. Cardiac exam reveals tachycardia
and regular rhythm. Lung exam reveals bilateral end-expiratory wheezes. ECG reveals
narrow complex tachycardia at 160 bpm with electrical alternans. Chest x-ray reveals
hyperinflated lung volumes. Which of the following is the next step to control the
patient's heart rate?

Choices:

1. Adenosine given at an initial decreased 3 mg bolus secondary to COPD

2. Vagal maneuvers
3. Diltiazem
4. Digoxin

Answer: 2 - Vagal maneuvers

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Explanations:

Active wheezing is a contraindication for adenosine administration as it can cause

bronchospasm, worsening respiratory failure in these patients.
ACC/AHA/HRS guideline therapy for first-line management of supraventricular
tachycardia (SVT) in a hemodynamic stable adult is vagal maneuvers.
Other pharmacologic therapies for SVT include nondihydropyridine calcium
channel blockers and beta blockers are considered as second-line therapy in
patients who fail first- line therapy or have a contraindication for use.
Adenosine, as well as dipyridamole, are also contraindicated for pharmacologic stress
testing in patients with active wheezing secondary to the risk of bronchospasm
subsequent respiratory failure.

Research Concepts:
Supraventricular Tachycardia

Question 106: A 59-year-old postmenopausal woman presents to the hospital with a four
weeks history of shortness of breath and right-sided pleuritic chest pain. Associated
symptoms are mild cough, orthopnea, and pedal edema. The patient denies fever, chills,
abdominal pain, or nausea. She has a 40-pack-year history of smoking. On examination,
she looks cachectic, with diminished right- sided breath sounds. Mild abdominal
distention is noted. On bimanual examination, a left-sided pelvic adnexal mass is
palpated. Laboratory tests show normocytic anemia with a hemoglobin of 10 gm/dL. The
white cell count is 10,000 cells per microliter. A complete metabolic panel shows bilirubin
0.8 mg/dL, alkaline phosphatase (ALP) 55 IU/L, aspartate transaminase (AST) 12 IU/L, and
alanine transaminase (ALT) 20 IU/L. Serum creatinine is 0.8 mg/dL. A chest X-ray shows a
large right-sided pleural effusion. What is the appropriate next step in evaluating this
patient?

Choices:

1. Whole-body PET CT scan

2. Serum CA 125 Levels
3. Echocardiogram
4. CT scan of the abdomen and pelvis
Answer: 4 - CT scan of the abdomen and pelvis
Explanations:

Important differential diagnoses for an unexplained pleural effusion, ascites, and

pelvic adnexal mass include ovarian malignancy and Meigs syndrome. The next
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 step is to evaluate for the presence of ascites and confirm the possible ovarian
mass that was palpated. CT scan or a pelvic ultrasound are good imaging
modalities to accomplish this.
Meigs syndrome is a benign condition. Early detection and treatment will lead to a
good prognosis. The pleural effusion and ascites will resolve permanently once the
patient’s tumor is resected.
Serum CA 125 is elevated in both ovarian cancer and Meigs syndrome. Its real
value lies in the surveillance and evaluation of response to cancer treatment.
Even though PET CT scan helps determine malignant and metastatic lesions. Its role is
limited in Meigs syndrome as the frozen section is essential for the diagnosis.
Research Concepts:

Meigs Syndrome

Question 107: A 40-year-old man with no significant past medical history presents to
the emergency department with fever, malaise, and right-sided pleuritic chest pain.
Two weeks before admission, he complained of a sore throat with a low-grade fever.
His chest imaging reveals a right-sided empyema, and his neck ultrasound revealed a
right internal jugular vein thrombus. Septic thrombophlebitis is suspected. What is the
best next step in management?

Choices:

1. Intravenous antifungal treatment

2. Intravenous ampicillin/sulbactam
3. Intravenous imipenem
4. Oral metronidazole

Answer: 2 - Intravenous ampicillin/sulbactam

Explanations:

Lemierre syndrome presents with fever and a brief upper respiratory illness and
later develops septic embolization and distant infection, e.g., lung empyema and
internal jugular vein septic thrombophlebitis. The treatment plan is usually
intravenous antibiotics targeted toward Fusobacterium necrophorum the most
common causative organism.
Fusobacterium necrophorum is usually the causative organism for Lemierre
syndrome, but due to the concern of mixed infection with other oral microbial
flora, Monotherapy with Metronidazole is not recommended.
Fusobacterium necrophorum is an uncommon cause of pharyngitis, untreated is
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 usually complicated by suppurative thrombophlebitis of Lemierre syndrome. Due
to possible beta- lactamase production, it is recommended to treat with a
combination of a beta-lactam antibiotic and a beta-lactamase inhibitor or a
carbapenem.
Fusobacterium necrophorum a common inhabitant of oral mucosa can cause
oropharyngeal infection and result in complications of suppurative
thrombophlebitis of Lemierre syndrome and distant infections and require
prolonged antibiotic treatment from 4-6 weeks.

Research Concepts:
Septic Emboli

Question 108: A 30-year-old, previously good health, non- smoker, triathlete is helped out
of the water due to extreme exhaustion and dyspnea. While being examined, he begins
coughing up blood-tinged sputum. He is transported to the local emergency room on
100% oxygen due to oxygen saturation of 91%. All other vitals are stable. What is
expected on chest x-ray when he arrives at the hospital?

Choices:

1. Cardiomegaly
2. Unilateral pleural effusion
3. Widened mediastinum
4. Kerley B lines

Answer: 4 - Kerley B lines

Explanations:

While there is some component of heart failure in immersion pulmonary edema

(IPE) it may or may not be significant enough to show up on chest x-ray.
Pleural effusions may be seen with IPE but it would be bilateral. While there is a
redistribution of blood centrally during submersion which may lead to the increased
diameter of the inferior vena cava, it may not be radiographically significant, and
there is a rapid redistribution after removal from the water.
Kerley B lines are indicative of pulmonary edema.

Research Concepts:

Immersion Pulmonary Edema

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Question 109: A 50-year-old man is brought by emergency medical services (EMS) after
sustaining a gunshot injury. He has a past medical history of type 2 diabetes mellitus,
coronary artery disease, tobacco smoking, and chronic obstructive pulmonary disease. He
undergoes an exploratory laparotomy, during which he received 5 liters of IV normal
saline during the surgery. Soon after extubation, he develops acute respiratory distress.
He is tachycardic. Lung auscultation reveals bibasilar rales. Arterial blood gas analysis on
room air reveals a PaO2 of 59, pH 7.47, PaCO2 36, and bicarbonate 21. His arterial blood
gas does not improve with the administration of 100% oxygen. What is the most likely
cause of his respiratory distress?
Choices:

1. Excessive anesthesia
2. Pulmonary edema
3. Pneumonia
4. Bronchial asthma exacerbation
Answer: 2 - Pulmonary edema

Explanations:

This patient has hypoxemia, and since he has an elevated A-a gradient leaves only
shunting and V/Q mismatch as a potential cause for his condition.
His failure to improve with 100% oxygen makes V/Q mismatch less possible, as
might occur in the case of pulmonary embolism or exacerbation of bronchial
asthma.
Shunting would explain his hypoxemia. Pulmonary edema, pneumonia, and vascular
shunt are frequent causes of shunting. His many risk factors make pulmonary
edema the most likely explanation for his arterial blood gases abnormalities and
rales on the pulmonary exam.
Research Concepts:Hypoxia

Question 110: A 65-year-old male with a history of diabetes mellitus type 2 and
hypertension complains of right shoulder pain that started 10 days ago and lower back
pain that started 3 days ago. He says the pain in his shoulder is new, but he has been
having lower back pain for 8 months. He adds that the lower back pain has increased in
intensity during the past 3 days. He smokes 2 packs of cigarettes daily for the past 20
years and drinks 2 beers every week. Vital signs show blood pressure of 132/83 mmHg,
heart rate of 84 beats per minute, respiratory rate of 17 breaths per minute, and oxygen
saturation of 97% on room air. A chest x-ray reveals a mass in the apex of the right lung.
Which of the following findings would indicate advanced disease and require immediate
intervention?

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Choices:

1. Elevated blood calcium levels

2. Asymmetric pupil size
3. Right-hand muscle atrophy, weakness, and paresthesia
4. Right lower limb hyperreflexia

Answer: 4 - Right lower limb hyperreflexia

Explanations:

This patient presenting with shoulder pain, and a mass in the apex of the lung in the
setting of a long history of heavy smoking likely has a Pancoast tumor, also called
superior sulcus tumor.
The superior sulcus region of the lung has been used in the past to refer to
structures in the apex of the lung. A superior sulcus tumor is a lung tumor, usually a
subset of non-small cell lung cancers, that arises in the superior sulcus area.
The most common presenting symptom of Pancoast tumor is shoulder pain, which
is due to the tumor invading the brachial plexus and extending into the parietal
pleura. Depending on the behavior of the tumor, other clinical manifestations may
be present. If the tumor invades the paravertebral and inferior cervical sympathetic
ganglia, the patient will present with Horner syndrome (ptosis, miosis, anhidrosis). If
the tumor invades the C8 to T1 brachial plexus roots, the patient will present with
weakness and atrophy of the intrinsic muscle of the hand and pain and paresthesia
of the 4th and 5th digits, forearm, and medial arm. Supraclavicular lymph node
enlargement and weight loss are also commonly seen in patients with Pancoast
tumors.
Pancoast tumors metastasize to the intervertebral foramina and cause spinal cord
compression in about 25% of patients that can manifest as lower extremity
hyperreflexia. New onset or worsening back pain in patients with a Pancoast tumor
suggests that the tumor may have spread to the spinal cord. Early diagnosis and
appropriate treatment are crucial to preserving the patient's neurological function.
Since there is a wide variety of tumors that can arise in the superior sulcus,
histologic diagnosis is required before initiating treatment. Hence, a core needle
biopsy is required for a definitive diagnosis. The overwhelming majority of
Pancoast tumors are non-small cell cancers of the lung. This includes squamous
cell carcinoma, adenocarcinoma, and large cell carcinoma. Although most superior
sulcus tumors are non-small cell lung cancers, less than 5% of non-small cell lung
cancers arise in that area.

Research Concepts:Lung Pancoast Tumor

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Question 111: A 65-year-old male Vietnam war veteran with no medical comorbidities
was admitted to the intensive care unit in a tertiary care center following the sudden
onset of high-grade fever, intense headache, cough, and hemoptysis. He was profoundly
hypoxic on admission needing intubation and mechanical ventilation. Inotropes were
needed for septic shock. Bloodwork showed leukocytosis with 13% bands, hemoglobin
12.4 g/dL, and mild thrombocytopenia. Serum creatinine, electrolytes, and blood urea
were within the normal range. Liver enzymes included aspartate aminotransferase 70 U/L
and alanine aminotransferase 85 U/L, but alkaline phosphatase and serum total bilirubin
were normal.
Computed tomography chest with contrast revealed multilobar infiltrates, most
pronounced in the right middle and lower lobes, associated with a moderate-sized
effusion. Blood cultures were drawn and he was started on empiric antibiotic therapy.
However, his FiO2 requirements increased from 40% to 70%, platelet counts decreased to
42,000/microliter, and infiltrates increased on chest x- ray. Culture results are still
pending. On further questioning, his family reports that one week ago he returned from a
week-long stay in Martha's Vineyard at his son's house, where he reportedly pulverized a
rabbit while mowing the lawn. What is the most appropriate next step?

Choices:

1. Add doxycycline
2. Add albendazole
3. Thoracentesis to rule out empyema
4. Add gentamicin

Answer: 4 - Add gentamicin

Explanations:

Tularemia pneumonia must be included in the differential diagnosis of severe

community-acquired pneumonia because of recent travel to Martha's Vineyard and
the associated history of lawn mower use.
Necrotizing pneumonia occurs following inhalation of aerosolized Francisella
tularensis, either from accidental pulverization of flea-infested or infected rabbits
or rodents by a lawn mower or from soil containing excreta of an infected rodent.
Streptomycin or gentamicin are first-line agents for the treatment of tularemia.
Empiric therapy is indicated soon after suspicion arises.
Diagnosis is usually made by serology, due to the high risk of inhalational hazard to
the microbiologist by culturing this organism.
Research Concepts: Tularemia

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Question 112: A 21-year-old male with a past medical history of severe asthma, anxiety,
and obesity presents to the emergency department with acute onset dyspnea. A review
of the medical records shows that he has been hospitalized four times in the last year
and required intubation once when he was 18 years of age. On the initial exam, he was
found to be tachypneic with a respiratory rate of 34, diaphoretic, and using accessory
muscles for respiration. An arterial blood gas (ABG) done in the emergency department
showed a pH of 7.35, PCO2 45, and PaO2 92 on room air. He was intubated and
paralyzed due to difficulty syncing with the event. He was placed on AC mode ventilation
with a tidal volume of 8cc/kg, respiratory rate 23, PEEP of 5, and FiO2 40%. A repeat ABG
shows a pH of 7.19, PCO2 60, and PaO2 109. Apart from adjusting tidal volume and
respiratory rate, what else can be done to improve his ventilation?

Choices:

1. Increase inspiration time

2. Increase FiO2
3. Increase PEEP
4. Square the flow curve (increase inspiratory flow)

Answer: 4 - Square the flow curve (increase inspiratory flow)

Explanations:

This is a young patient with asthma who has been difficult to ventilate requiring him
to be paralyzed. His arterial blood gas (ABG) shows a respiratory acidosis even though
he has a good tidal volume and a rapid respiratory rate on the ventilator.
Increasing his respiratory rate could lead to auto-PEEP. One way to prevent this is
by increasing the flow rate of air into the respiratory system allowing for faster
delivery of the tidal volume and more time for exhaling. This is called squaring of
the flow curve.
Decreasing, not increasing, the inspiratory time (decrease in the I:E ratio) will allow
for more time for exhalation, thereby helping to prevent auto-PEEP and allowing for
an increased respiratory rate.
Increasing FiO2 will not lead to improvement in the PCO2. The patient's oxygenation is
already good without needing further improvement.
Increasing PEEP will improve oxygenation but will not affect his CO2.

Research Concepts: Ventilation Assist Control

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Question 113: A 24-year-old patient with asthma comes to the emergency department
with acute shortness of breath and wheezing. She was given nebulization, corticosteroids,
and was placed on BI-PAP. She continued to be in respiratory distress and was eventually
intubated. Her initial arterial blood gas (ABG) was pH 7, PCO2 100, and PO2 60. After two
days, a sedation vacation was attempted, and ABG was drawn on assist mode of
ventilation which showed her pH was 7.15, PCO2 80, and PO2 80 on 30% oxygen. All other
labs and images are normal. The patient is hemodynamically stable and following
commands. Her negative inspiratory force (NIF) was -40 H20. Which of the following
would be considered contraindicated for pressure support ventilation?

Choices:

1. pH-7.15, abnormal acid-base balance

2. NIF -40 cm H2O
3. Mental status
4. Normal blood pressure

Answer: 1 - pH-7.15, abnormal acid-base balance

Explanations:

Pressure support breathing is a mode of ventilation that is made up of patient-

triggered, pressure-limited, flow-cycled breaths. It is valuable to note that the
patient has consistent control over breath frequency, breath duration and flow
while in a pressure support ventilation environment. The volume of each breath is
a direct result of set pressures, patient effort, and potentially other mechanical
settings that may oppose ventilation.
Patients must initiate his or her own breaths. Apneic patients are required to be in a
controlled breath environment in which the ventilator may fully sustain the
respiratory function.
It is essential that a patient be hemodynamically stable and have sufficient
respiratory effort to qualify for pressure support mode.
Patients who have a major acid-base imbalance on controlled setting should not be
considered for pressure support mode as they can become more unstable.

Research Concepts: Pressure Support

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Question 114: A 28-year-old-male presented with a two-year history of cough,
hemoptysis, and shortness of breath. Chest x-ray showed a left hilar opacity. Chest
computed tomography (CT) scan revealed an oval mass in the left upper lobe
obstructing the left upper lobar bronchus with a collapse of the upper lobe segments.
The patient underwent a left upper lobectomy with regional lymph node dissection
through a left posterolateral thoracotomy.
Histopathological examination of the surgical specimen revealed a tumor proliferation
arranged in a trabecular pattern with a fine vascular stroma. The tumor cells were
uniform with finely granular nuclear chromatin and abundant eosinophilic cytoplasm.
There was one mitosis per 2 mm2 and no foci of necrosis.
Immunohistochemically, the tumor cells were positive for chromogranin A,
synaptophysin, and CD56. The Ki-67 index was about 1%. What is the most likely
diagnosis?
Choices:

1. Small cell carcinoma

2. Typical carcinoid
3. Atypical carcinoid
4. Squamous cell carcinoma
Answer: 2 - Typical carcinoid
Explanations:

Typical carcinoids are carcinoid tumors with less than 2 mitoses per 2 mm2 without
necrosis.
Carcinoid tumors are characterized by growth patterns suggesting neuroendocrine
differentiation. Organoid and trabecular patterns are most common; however,
rosette formation, papillary growth, and follicular growth may also be seen.
The tumor cells are usually uniform in appearance with a polygonal shape, finely
granular nuclear chromatin, inconspicuous nucleoli, and moderate to abundant
eosinophilic cytoplasm. The background stroma is classically highly vascularized.
Immunohistochemistry may be required to confirm neuroendocrine and epithelial
differentiation. An antibody panel including chromogranin A, synaptophysin, and
CD56 is recommended. In carcinoids, Ki67 is low less than 10% to 20%.

Research Concepts:

Lung Carcinoid Tumors

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Question 115: A 28-year old was admitted with sudden onset of breath while walking. He
is a heavy smoker. Chest x-ray reveals a 90% pneumothorax on the right side. The
emergency room resident placed a size 32F tube to evacuate the pneumothorax. An hour
later the patient complained of severe shortness of breath and his pulse oximeter
revealed oxygen saturation of 89%. A portable chest x-ray revealed vascular congestion in
the right lung. He was taken to the intensive care unit and placed on the ventilator
because of severe respiratory distress. Which of the following is true about this
condition?

Choices:

1. It only occurs in elderly people

2. The incidence is very high
3. It affects patients with extensive pneumothorax
4. It occurs only with exudate but not transudate effusion evacuations
Answer: 3 - It affects patients with extensive pneumothorax

Explanations:

Pulmonary re-expansion edema occurs when there is rapid emptying of the pleural
cavity.
It has a low incidence but has a high mortality.
It can occur in people with effusions or lung collapse that has been present for
more than 7 days.
When effusions of more than 3 liters are rapidly evacuated the condition can
occur.
Research Concepts: Pneumothorax

Question 116: A 22-year-old patient weighing 66 kg presents to the chest clinic with
frequent exacerbations of asthma with multiple ICU admissions. Her asthma is generally
triggered by pollen and house dust mites. Physical examination shows significant
cushingoid features. She takes beclometasone/formoterol and montelukast. Her blood
investigations demonstrate eosinophilia, and she has a total IgE of 400 IU/ml. She also
has haematuria and generalized aches and pains in her knees. Which of the following is
the next best step in the management of this patient?

Choices:

1. Switch to triple therapy inhaler

2. Increase dose of beclometasone/formoterol

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 3. Prescribe omalizumab
4. Prescribe methotrexate

Answer: 3 - Prescribe omalizumab

Explanations:

Omalizumab is a monoclonal antibody against IgE.

It is indicated in this case as her serum total IgE and body weight are appropriate as
per the nomogram.
Churg-Strauss vasculitis is not a contra-indication for omalizumab treatment.
Omalizumab has been shown to expose underlying Churg- Strauss vasculitis as
patients steroid doses are typically lowered with ongoing omalizumab treatment.

Research Concepts:

Omalizumab

Question 117: A 28-year-old woman presents to the office to establish care. She has no
significant past medical history and takes no regular medication. She reports that she is
interested in going deep-sea diving. However, she recently read about cerebral arterial gas
embolism occurring in deep-sea divers. She asks if she can be screened for this before she
begins her dives. Which of the following tests is most useful as a screening test to prevent
arterial gas embolism in divers?
Choices:

1. Pulmonary function test

2. Chest x-ray
3. Echocardiography
4. Ventilation-perfusion scan

Answer: 3 - Echocardiography

Explanations:

Arterial gas embolism is one of the most common causes of pulmonary barotrauma. It
occurs when air bubbles enter the pulmonary circulation. One of the risk factors is
right to left shunt through a patent foramen ovale (PFO). Echocardiography can help

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 identify a PFO.
The best type of echocardiography to identify this lesion is a bubble study. In a
bubble study, agitated saline is introduced into the veins and soon enters the right
atrium, followed by the right ventricle.
If a PFO exists, the bubbles can be seen traveling past the area of the defect. The
tests mentioned (chest x-ray, pulmonary function test, or VQ scan) will not help
prevent diving-related air embolism.
The treatment for arterial air embolism is hyperbaric oxygen therapy.

Research Concepts:

Arterial Gas Embolism

Question 118: An 18-year-old male presents to the outpatient clinic for evaluation of a
localized skin abscess. After collecting history and performing a physical exam, the
clinician prescribes an oral antibiotic medication and performs a small incision and
drainage of the lesion. On his way out the door, the patient says, "after that experience, I
can't wait to smoke my vape." Which of the following is most accurate regarding the
potential health risks this patient may face from vaping in the future?

Choices:

1. He may see an increase in bronchitic symptoms including coughing and

wheezing
2. He may see an increase in his physical endurance
3. He may see a decrease in his risk of peptic ulcer disease
4. He may see a decrease in his risk of depression

Answer: 1 - He may see an increase in bronchitic symptoms including coughing and wheezing

Explanations:

Studies have shown that adolescents who currently consume e- cigarette aerosols
have a two-fold increase in bronchitic symptoms (cough, wheezing, etc.) when
compared to those who do not consume.
Early studies suggest a short-term increase in vital signs such as blood pressure
and heart rate.
Traditional cigarettes have shown an increased risk of acute coronary disease, heart
failure, and hypertension with possible side effects on thrombogenesis. However,
the effects of nicotine from e-cigarette delivery systems are currently limited
without any clear conclusions on cardiovascular impacts.
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 Nicotine alone has been associated with negative cardiovascular outcomes,
including hypertension, development of coronary artery disease, and heart failure.

Research Concepts:

Electronic Vaping Delivery Of Cannabis And Nicotine

Question 119: A 50-year-old male is admitted to the intensive care unit with acute
respiratory distress syndrome. The patient is intubated and on mechanical ventilation.
Chest x-ray shows bilateral infiltrates with subcutaneous emphysema,
pneumomediastinum, and pneumopericardium. Vital signs are within normal limits with
no desaturation. What is the clinical intervention necessary at present?

Choices:

1. Pericardiocentesis
2. Needle thoracostomy
3. Observe and monitor with serial chest x-rays
4. Extubate patient

Answer: 3 - Observe and monitor with serial chest x-rays

Explanations:

The patient has subcutaneous emphysema, pneumomediastinum, and

pneumopericardium. The air leak syndrome is not causing any hemodynamic
instability. The best therapeutic option at present is clinical observation and
monitoring with chest x-rays.
Pneumomediastinum radiologically can be seen as a column of air in the
mediastinum. Pneumopericardium is seen as a collection of air around the
pericardial sac on routine chest X-ray Needle thoracostomy is the treatment for
tension pneumothorax. Pericardiocentesis is the evacuation of fluid from the
pericardial space. This is not indicated for pneumopericardium, which just requires
monitoring.

Research Concepts:

Air Leak

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Question 120: A 25-year-old male, who has been HIV positive for about 8 years, is
admitted to the hospital with respiratory distress. The patient had focal neurological
deficits earlier and now is in a comatose state. The pulmonary and central nervous system
biopsies show dichotomously branching septate hyphae. What is the most likely
underlying condition?

Choices:

1. Severe neutropenia
2. CD4+ cell count less than 600
3. Diabetic ketoacidosis
4. Multiple myeloma

Answer: 1 - Severe neutropenia

Explanations:

Invasive aspergillosis is found primarily in patients with neutrophil counts less than
500/mm3.
It also is seen with chronic granulomatous disease and cystic fibrosis.
The use of antifungals and antimicrobials is needed. Immunological support includes
the administration of IV purified immunoglobulins and antiretroviral therapy.
Frequent evaluation of CD4+ count should be done.

Research Concepts:

Neutropenia

Question 121: A 65-year-old male is advised by his vascular surgeon for hyperbaric
oxygen therapy (HBOT) for his non-healing diabetic foot ulcer. He has a history of
diabetes mellitus type 2, hypertension, and congestive heart failure. Vital signs before
starting HBOT treatment show a blood pressure of 130/80 mmHg, heart rate 80/min,
temperature 98.8 F, and oxygen saturation 98% on room air. After 1 hour in monoplace
hyperbaric chamber, the patient starts having shortness of breath and becomes very
uncomfortable. The treatment is stopped, the patient is made to sit in the chair, and
symptoms resolve after some time. Which of the following is the most likely cause of the
patient's symptoms?

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Choices:

1. Barotrauma to the lungs

2. Development of pulmonary edema
3. Decrease in blood pressure
4. Tachycardia

Answer: 2 - Development of pulmonary edema

Explanations:

Hyperbaric oxygen therapy causes an increase in systemic vascular resistance and

bradycardia than can result in decreased cardiac output leading to acute
pulmonary edema. Patients who have underlying congestive heart failure,
especially ejection fraction less than 35% are at high risk. High- risk patients should
be evaluated before starting HBOT or multiplace chamber can be used where
patients can sit rather than lying down in a supine position.
Barotrauma is more common in patients with underlying lung conditions like COPD or
emphysema. Also, symptoms were resolved with a sitting position that indicates a
sign of fluid overload.
HBOT treatment causes an increase in blood pressure by increasing systemic vascular
resistance.
Hyperbaric oxygen therapy caused bradycardia by increasing vagal tone that can lead
to a decrease in cardiac out.

Research Concepts:

Hyperbaric Cardiovascular Effects

Question 122: A 16-year-old previously healthy woman presents to the clinic with fever
and throat pain. She was diagnosed with a viral infection 2 weeks ago. Her condition has
worsened, and she now complains of left lateral neck pain. Vital signs show a fever of 102
F, pulse 120/min, blood pressure 115/70 mmHg, and 100% oxygen saturation on room
air. Physical examination shows a sick but non-toxic appearing female with a "cord sign"
present deep to the anterior border of the sternocleidomastoid on the right side. She also
has palpable lymph nodes present bilaterally. Which of the following is the most likely site
for metastatic infection in this patient?
Choices:

1. Bones
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2. Liver
3. Lungs
4. Breasts

Answer: 3 - Lungs

Explanations:

The sign and symptoms, along with the examination findings in this patient, are
suggestive of Lemierre syndrome.
It is a rare complication of bacterial pharyngitis/tonsillitis. It involves an extension
of the infection into the lateral pharyngeal spaces of the neck with subsequent
septic thrombophlebitis of the internal jugular vein.
The lungs are the most common site of metastatic infection (85%), but joints, liver,
kidney, brain, bones, heart, and meninges can all be involved.
Imaging should include a chest radiograph to evaluate for septic emboli and other
pulmonary complications, including pulmonary effusions, lung abscess, and
empyema.
Research Concepts:Lemierre Syndrome

Question 123: A 40-year-old woman presents to your internal medicine clinic with a
history of 3 months of a dry cough. She reports no other medical problems in the past,
and she takes no medications. She migrated from India to the United States 2 years ago.
She reports that the cough is dry and fluctuates, some days it bothers her more than
others. She has noticed that the cough is worse at night. She also reports having an
occasional fever of 101
=F over the last 3 weeks. She denies night sweats, weight loss, and anorexia. She denies
symptoms of reflux, sinusitis and post-nasal drip. On examination, her heart rate is 70
bpm, blood pressure is 110/70 mmHg, respiratory rate of 14/minute and pulse oximetry
of 99% on room air. Her lungs are clear to auscultation. S1 and S2 heard with no murmurs,
abdomen is soft with no tenderness or organomegaly, no skin rashes are noted. A chest x-
ray was done when she started to have this cough 3 months ago which had shown a small
interstitial/nodular opacity in the right lower lobe. At that time, a Mantoux was done
which was negative. Today on repeat chest x- ray, the opacity is no longer present. A CBC
with differential shows the total WBC count to be 13.7 with total eosinophils of 2.1 x
10(9)/L. What would the best test be to make the diagnosis?

Choices:

1. ANA and ANCA antibody testing

2. Stool for ova and parasites, antibody testing for Strongyloides and Ascaris
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3. Interferon-gamma release assay
4. CT of the chest without contrast
Answer: 2 - Stool for ova and parasites, antibody testing for Strongyloides and Ascaris

Explanations:

Loeffler syndrome is characterized by transpulmonary passage of helminth larva

through the lungs resulting in fleeting pulmonary opacities and peripheral
eosinophilia.
Ascaris larvae are the most common cause worldwide. Loeffler syndrome is
benign, self-limiting without significant morbidity.
Anthelminthic drugs are not effective against the larval stages, so there is no
specific treatment for Loeffler syndrome.

Research Concepts:

Pulmonary Eosinophilia

Question 124: A 66-year-old female patient with a history of obstructive sleep apnea,
hypertension, diabetes mellitus, class 3 obesity, and asthma presents with five days of
worsening dyspnea and associated wheezing and cough. Her vital signs on presentation
are blood pressure 168/70 mmHg, oxygen saturation 85% on room air, respiratory rate 32
breaths per minute, and pulse 110 beats per minute. On exam, she has diffuse expiratory
wheezing. A chest x-ray does not show any significant infiltrates. Her labs are grossly
normal, except her arterial blood gas (ABG) shows a pH of 7.2, pCO2 56 mmHg, pO2 55
mmHg, and bicarbonate of 21 mmol/L. Nebulization and corticosteroids are started. She is
placed on BiPAP and transferred to a step-down unit. Repeat ABG shows a pH of 7.1 and
pCO2 of 70 mmHg. She is prepared to be intubated and moved to the ICU. Rapid
sequence intubation is attempted but fails after four attempts. The patient develops
bradycardia then cardiac arrest.
Which of the following could have been the cause of intubation failure?

Choices:

1. Placement of two fingers in the superior laryngeal notch

2. Placement of three fingers on the floor of the mandible between the mental angle
and the neck near the hyoid bone
3. Placement of two fingers between the incisors
4. Placement of three fingers between the incisors
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Answer: 3 - Placement of two fingers between the incisors

Explanations:

Measurement of three fingers between the upper and lower teeth of the open
mouth of a patient indicates the ease of access to the airway through the oral
opening. A typical patient can open their mouth sufficiently to permit the
placement of three of their fingers between the incisors. Adequate mouth
opening facilitates both insertions of the laryngoscope and obtaining a direct view
of the glottis.
Measurement of three fingers from the anterior tip of the mandible to the anterior
neck provides an estimate of the volume of the submandibular space. A typical
patient can place three fingers on the floor of the mandible between the mental
angle and the neck near the hyoid bone. Normally this distance should measure
close to 7 cm. If this distance is less than three finger-widths, the laryngeal axis will
be at a more acute angle with the pharyngeal axis, indicating that alignment of the
oral opening to the pharyngeal opening will be difficult. It also indicates that there
will be less space to displace the tongue within the throat. The rule has limitations
as the distance can vary according to height and ethnicity. For this reason, an
alternative in the form of a ratio of height to thyromental distance (RHTMD) has
been suggested.
Measurement of two fingers between the floor of the mandible to the thyroid notch
on the anterior neck identifies the location of the larynx relative to the base of the
tongue. A typical patient can place two fingers in the superior laryngeal notch.
If the larynx is too high in the neck, measuring less than two fingers, direct
laryngoscopy will be difficult and potentially impossible; this is because the angle
between the base of the tongue to the larynx is too acute to be negotiated for direct
visualization of the larynx easily.
Research Concepts:

3-3-2 Rule

Question 125: A patient is being evaluated for a nonhealing wound in an irradiated field.
He had squamous cell carcinoma of the neck and received 8000 Gy of radiation along
with chemotherapy 12 months ago. Which historical chemotherapy agent would be most
concerning for the development of pulmonary fibrosis during a course of hyperbaric
oxygen therapy?

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Choices:

1. Adriamycin
2. Bleomycin
3. Cis-platinum
4. Doxyrubicin

Answer: 2 - Bleomycin

Explanations:

Bleomycin has been implicated in the development of pulmonary fibrosis in

patients exposed to high oxygen tensions. The incidence of pulmonary fibrosis is
lower with lower doses of bleomycin.
The exact causal relationship between hyperbaric oxygen and bleomycin causing
pulmonary fibrosis has not been established but it is possible that bleomycin
exposure lowers the lungs' tolerance to pulmonary oxygen toxicity.
When treating a patient with a history of bleomycin exposure with hyperbaric
oxygen therapy, it is prudent to establish baseline pulmonary function and monitor
closely during the treatment course for any signs of toxicity.

Research Concepts:

Hyperbaric Complications

Question 126: A 21-year-old presents with shortness of breath. After a detailed workup
diagnosis of primary pulmonary hypertension was made. Which class of medication has
shown improvement in mortality in primary pulmonary hypertension?

Choices:

1. Calcium channel blocker

2. Prostacyclin
3. Guanylate cyclase stimulators
4. Direct thrombin inhibitors
Answer: 2 - Prostacyclin

Explanations:

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 Continuous long-term intravenous epoprostenol infusion for which a semi-
permanent central venous catheter is required is considered the most effective
therapy. It has been shown to improve mortality, but its short half-life and high
cost are the limitations.
For those who cannot tolerate intravenous infusion, inhaled or subcutaneous
prostanoids can be considered. Treprostinil can be used intravenously,
subcutaneously, and by inhalation. Oral prostanoids are still under clinical trials.
Benefits include vasodilation, platelet inhibition, antiproliferative, and inotropic
effects.
Soluble guanylate cyclase stimulators are under clinical trials and are beneficial in
pulmonary artery hypertension as they have a dual mode of action. They stimulate
the receptor to mimic nitric oxide action and increase the sensitivity of guanylyl
cyclase to endogenous nitric oxide. Riociguat has been shown to improve exercise
capacity and decrease pulmonary vascular resistance in previous studies.
Oral high-dose calcium channel blockers such as diltiazem and nifedipine are the
first line of treatment but are used only in those with vasoreactivity testing
positive for acute vasodilator response with short-acting pulmonary vasodilators
such as adenosine, nitric oxide, or epoprostenol. The criteria for testing positive is
a fall in pulmonary artery pressure to more than 10 mmHg with an increase or no
change in cardiac output.
Although first line but useful only in 5% of patients with idiopathic pulmonary
artery hypertension and should not be used in nonresponders to vasoreactivity
test due to the risk of harm rather than any improvement.
Research Concepts: Idiopathic Pulmonary Artery Hypertension

Question 127: A 37-year-old woman with chronic progressive dyspnea undergoes right
heart catheterization for evaluation of her symptoms. Her mean pulmonary artery
pressure is 35 mmHg, pulmonary vascular resistance is 5 Wood units, pulmonary artery
wedge pressure is 12 mmHg, and cardiac output is 4.5 L/min. She was administered
inhaled nitric oxide, after which her mean pulmonary artery pressure decreased to 22
mmHg while he cardiac output was unchanged. What is the most appropriate initial
treatment for this patient?

Choices:

1. Phosphodiesterase 5 inhibitor
2. Endothelin receptor antagonist
3. Calcium channel blockers
4. Prostacyclin analogs

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Answer: 1 - Phosphodiesterase 5 inhibitor

Explanations:

Patients with pulmonary arterial hypertension should undergo vasoreactivity testing.

This can be done during the right heart catheterization. Inhaled nitric oxide at 10
to 20 parts per million is usually preferred, but intravenous epoprostenol,
intravenous adenosine, or inhaled iloprost can also be used.
If there is a reduction in mean pulmonary artery pressure of 10 mmHg to the point
where the absolute mean pulmonary artery pressure is 40 mmHg with either
unchanged or increased cardiac output, it is considered a positive test.
The best initial therapy for patients with a positive test is high- dose calcium
channel blockers

Research Concepts:

Pulmonary Hypertension

Question 128: A 70-year-old man with long-standing chronic obstructive pulmonary

disease is rushed to the emergency department with severe shortness of breath and
gasping for air. He has a history of smoking one pack of cigarettes daily for 40 years. He
weighs 70 kg and is 1.7 meters tall. Vital signs are temperature
98.6 F (37 C), pulse 110/min, respiratory rate 30/min, blood pressure 155/105 mmHg, and
oxygen saturation (SaO2) 89% on room air. He appears to be in distress and is using
accessory muscles to breathe. Lung auscultation demonstrates bilateral wheezing and
reduced air entry, and the cardiac exam demonstrates tachycardia with regular rhythm
and no murmur. The lower extremities show 2+ edema and clubbing. Initial arterial blood
gas analysis results are pH 7.21, PCO2 55 mmHg, PO2 54 mmHg, and HCO3 19 mEq/L.
What is the best next step in the management of this patient?

Choices:

1. Endotracheal intubation and mechanical ventilation

2. A trial of noninvasive ventilation to a target minute ventilation of 10 L/min and SaO2
90-94%
3. Initiate high nasal flow oxygen at 30 L/min and 100% FiO2
4. Initiate CPAP 15 cmH2O and FiO2 40%

Answer: 2 - A trial of noninvasive ventilation to a target minute ventilation of 10 L/min and

SaO2 90-94%
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Explanations:

Patients with chronic obstructive pulmonary disease (COPD) who experience

acute exacerbation usually have high mortality at 12 months.
Several retrospective and prospective studies have shown that acute COPD
exacerbations are associated with a decline in FEV1. This is more prominent in those
who continued to smoke (8/10 mL/year more reduction) than those who did not.
Likewise, a further decline was seen in patients who experienced frequent COPD
exacerbations (> 2.92 exacerbations per year) compared with those with fewer
exacerbations.
Any acute exacerbation should be promptly treated because delays often result in
protracted hospital stays. The aim is to reduce the burden of COPD. The current
recommendation is to admit to the intensive care unit and initiate noninvasive
ventilation (NIV) unless contraindicated. This has decreased mortality and
morbidity in these patients compared with high nasal flow oxygen.
The initial settings of NIV should include a pressure that allows adequate ventilation
(usually 10 L/min). Arterial blood gases need to be closely monitored (every 1-4
hours) to adjust the settings or indicate a need for intubation. The target SaO2
should be 90-94%, as high oxygen levels have been associated with worse outcomes
in these patients.

Research Concepts:

Chronic Obstructive Pulmonary Disease

Question 129: The first-line FDA-approved agent to treat metastatic non-small cell
lung cancer is being considered for a 67- year-old patient. It is most appropriate to
evaluate this patient for which gene mutation before initiating treatment?

Choices:

1. KRAS
2. p53
3. Fragile histidine triad (FHIT)
4. Epidermal growth factor receptor (EGFR)

Answer: 4 - Epidermal growth factor receptor (EGFR)

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Explanations:

Patients with metastatic non-small cell lung cancer (NSCLC) should be checked for
epidermal growth factor receptor (EGFR) mutation because targeted therapy with
tyrosine kinase inhibitors improves survival in patients with the mutation.
Afatinib is a targeted therapy that irreversibly inhibits the ErbB family of tyrosine
kinases.
The first-line FDA-approved indication is to treat locally advanced or metastatic
NSCLC that harbors nonresistant EGFR mutations.
There are three known tyrosine kinase inhibitors (EGFR TKIs) widely used as a
treatment for advanced NSCLC with proven efficacy: gefitinib, erlotinib, and afatinib.

Research Concepts:

Afatinib

Question 130: A 45-year-old white female presents to the hospital with new-onset diffuse
swelling and pain in both legs, wrists, and elbows. She had a similar episode a year back
that resolved with pain medications. On examination, knee joints appear swollen but not
warm. Her temperature is 38 C. White blood cell count is 13,000/microL. ESR and CRP are
mildly elevated. A knee joint arthrocentesis shows WBC of 400/microL with negative
microbial culture. Serology workup shows positive ANA titer. Chronic medical history is
significant for hypertension, dyslipidemia, and chronic lung disease that she cannot
specify. Home medications include lisinopril, amlodipine, albuterol, hydrochlorothiazide,
and atorvastatin. Which of the following investigations would be most helpful in
confirming her underlying disease process?

Choices:

1. Technetium bone scan

2. Rheumatoid factor and anti-CCP
3. Whole body PET scan
4. Anti-ds-DNA and antihistone antibody

Answer: 1 - Technetium bone scan

Explanations:

Secondary hypertrophic osteoarthropathy can be a manifestation of chronic lung

disease in the absence of malignancy.
Page 127 of 955
 Bone scintigraphy with technetium 99m (99mTc) methylene diphosphonate (MDP)
is the gold standard and is a more sensitive test.
Enhanced tracer uptake in a symmetric distribution along cortical margins of
tubular bones in the bone scan is described by the "double stripe" or "tramline"
sign.
There is an immense utility of radionuclide scan as a marker of treatment response, as
scintigraphic findings do resolve with successful treatment of underlying etiology.

Research Concepts:

Secondary Hypertrophic Osteoarthropathy

Question 131: A 70-year-old female with chronic obstructive pulmonary disease is placed
on mechanical ventilation for respiratory failure. Intubation required rocuronium for
paralysis. The ventilator was placed on assist-control (AC) mode with a rate of 12, a
fraction of inspired oxygen (FIO2) of 1.0, a tidal volume of 500, and positive end-
expiratory pressure (PEEP) of 0. Arterial blood gas after intubation demonstrates pH 7.23,
PaCO2 75 mmHg, and PO2 350 mmHg, so FIO2 is decreased to 0.70. Half an hour later the
patient becomes hypotensive with a blood pressure of 75/40 mmHg, heart rate 135 beats
per minute, and respiratory rate 26/minute. The trachea is midline, and there are breath
sounds in both lung fields.
Bilateral wheezing persists until the next inspiration. The high- pressure alarm has
triggered. What is the preferred initial management?

Choices:

1. Disconnect the ventilator and manually ventilate the patient

2. Administer intravenous fluid bolus
3. Perform bilateral needle decompression of thorax
4. Start dopamine infusion

Answer: 1 - Disconnect the ventilator and manually ventilate the patient

Explanations:

Mechanical ventilation of patients with chronic obstructive pulmonary disease may

develop intrinsic positive end-expiratory pressure also known as auto-positive end-
expiratory pressure (PEEP).
Obstructive lung disease requires a longer time for expiration to avoid the
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 development of auto-PEEP and dynamic hyperinflation. This can be avoided by
having a low inspiratory: expiratory ratio (I:E).
As auto-PEEP and dynamic hyperinflation progress there is an increase in
transthoracic pressure. This results in decreased preload into the right ventricle. As
preload decreases you can get resulting hypotension. The increased alveolar
pressure can also result in pneumothorax, but this has not yet happened in this
patient.
The ventilator settings will need to be adjusted. There will need to be a prolonged
expiration time. As the patient is overbreathing the ventilator, she will need to be
highly sedated to allow for ventilator synchrony. If needed the inspiratory flow
rate can be increased to help lower the I:E ratio.
Research Concepts: Mechanical Ventilation

Question 132: A 22-year-old female with a medical history of cystic fibrosis presents for a
routine visit. Her annual 2-hour 75-gram oral glucose tolerance test showed a plasma
blood level of 220 mg/dL. Additional testing revealed a fasting plasma glucose of 190
mg/dL and a hemoglobin A1c level of 7.5%. She receives education and counseling
regarding her new diagnosis. Her clinician informs her that insulin is the best therapy to
reduce associated comorbidities with this condition. What is the most common
complication if this patient is left untreated?

Choices:

1. Neuropathy
2. Retinopathy
3. Coronary artery disease
4. Cerebral vascular accident

Answer: 1 - Neuropathy

Explanations:

Microvascular complications are the most common finding in individuals with

cystic fibrosis-related diabetes. Complications rarely present in individuals with
CFRD and fasting hyperglycemia for less than 10 years.
A study series by Schwarzenberg et al. looked at 285 individuals with CFRD with
fasting hyperglycemia for 10 years. They reported neuropathy in 55% of subjects,
gastropathy in 50% of subjects, retinopathy in 16% of subjects, and
microalbuminuria in 14% of subjects.
No microvascular complications have not been reported in CFRD individuals that
do not experience fasting hyperglycemia. Macrovascular complications are
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 commonly seen in type 1 and type 2 diabetes; however, they are rarely seen in
CFRD.

Research Concepts:

Cystic Fibrosis Related Diabetes

Question 133: A 16-year-old boy presents to the clinic for a routine physical examination.
This summer, he will be working at a local amusement park and requires the appropriate
documentation to be completed by his primary care provider. The patient has no
significant past medical history and currently takes no medications. Physical examination
reveals a healthy young boy who appears his stated age. When asked about social
history, the patient denies any history of tobacco use. However, upon further
questioning, it is revealed that the patient "just smokes his vape" at weekend parties.
According to the recent studies, which of the following micro- constituents found within
e-cigarette products is paired with the correct potential side effect?

Choices:

1. Nicotine and carcinogenesis

2. Glycerol and gastrointestinal symptoms
3. Propylene glycol and local squamous metaplasia
4. Acetylaldehyde and axonal demyelination

Answer: 3 - Propylene glycol and local squamous metaplasia

Explanations:

Aerosolized glycerol and propylene glycol have been associated with focal squamous
metaplasia of the upper airways. Glycerol itself is not associated with gastrointestinal
symptoms, unlike nicotine.
The major constituents of e-cigarette aerosols include nicotine, glycerol, propylene
glycol, and artificial flavorings. Isolated inhalation of nicotine has been associated
with localized oxidative stress and inflammation to the pulmonary endothelium, in
addition to reduced levels of inflammatory mediators such as glutathione.
Heavy metals including chromium, nickel, and lead have also been found within
combustible e-cigarette vapor and have known carcinogenic effects.
Acetylaldehyde is also a known carcinogen and has been found in micro quantities in
some solvent mixtures in e-cigarette devices.

Research Concepts:Electronic Vaping Delivery Of Cannabis And Nicotine

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Question 134: A 64-year-old male presents to the emergency department with chief
complaints of fever for 3 days, cough with sputum production, and chest pain for 2 days.
His vitals include a temperature of 103 F, respiratory rate of 35/min, pulse 84/min, and
blood pressure 104/70 mmHg. He is admitted for inpatient treatment and is started on
empiric antibiotic coverage based on the local resistance patterns. On the second day,
his vitals continue to deteriorate, and an arterial blood gas analysis shows a partial
pressure of oxygen to be 54 mmHg. He is transferred to the intensive care unit and is
ventilated with supplemental oxygen therapy of 50% oxygen at a tidal volume of 7 ml/kg,
and positive end-expiratory pressure of 10 mmHg. His condition improves, and his
oxygen saturation is maintained at 89%. On the third day, his fever recurs, and his
oxygen saturation drops despite being on high FiO2. Chest radiography shows new onset
infiltrates. What is the best next step in the management of this patient?

Choices:

1. CT scan of the chest

2. Continue empiric antibiotic therapy
3. Blood cultures
4. Mini bronchoalveolar lavage (Mini- BAL)
Answer: 4 - Mini bronchoalveolar lavage (Mini- BAL)

Explanations:

Ventilator-associated pneumonia (VAP) is any pneumonia observed 48 hours

after being on a ventilator in a hospital setting. VAP should be suspected in
ventilated patients with new-onset dyspnea, falling oxygen saturation, or new
onset of lung infiltrates.
Management of VAP, unlike the management of community- or hospital-acquired
pneumonia, involves both radiological evidence and invasive sampling before the
administration of antibiotics. After the culture and sensitivity reports of
bronchoalveolar lavage are available, the antibiotic regimen should be tailored
appropriately.
Mini-BAL is done by inserting a catheter through the endotracheal tube, instilling
normal saline, and aspirating the sample.
Mini-BAL is a less invasive, less expensive, and less- cumbersome technique than
BAL.
Research Concepts:Ventilator-associated Pneumonia

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Question 135: A 35-year-old man presents to the clinic due to several days of worsening
asthma symptoms. He has lived with asthma since childhood which was previously
controlled with albuterol as needed. The patient notes his asthma has been
uncontrolled since a respiratory tract infection and reports having to use his albuterol
inhaled 4-5 times a day and increased nighttime symptoms of shortness of breath and
wheezing. What stage of asthma does he most likely have?

Choices:

1. Mild intermittent asthma

2. Mild persistent asthma
3. Moderate persistent asthma
4. Severe persistent asthma

Answer: 4 - Severe persistent asthma

Explanations:

This patient has an asthma exacerbation. The patient had well- controlled asthma
but now has a respiratory infection, making his asthma and breathing worse. He
has nighttime awakenings more frequently.
Patients who have a continuous asthma attack daily and more frequent nighttime
awakenings have severe persistent asthma. The peak flow while exhaling on
spirometry would be less than 60% of the predicted best.
Symptoms occur throughout each day and limit daily physical activities. He has
nighttime occurrences more frequently.

Research Concepts: Pathophysiology Of

Asthma

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Question 136: A 45-year-old woman with no known past medical history comes in for an
evaluation of a 4-week history of progressively worsening dyspnea, palpitations, and
swelling of the legs. She has diarrhea and an unintentional weight loss of 2.3 kg (5 lb). On
physical examination, she is afebrile, blood pressure is 89/60 mmHg, pulse rate is
115/min, respiratory rate is 22/min, and oxygen saturation of 92% on room air. There is
jugular venous distention extending to the jaw. The thyroid gland is palpable without any
identifiable nodules. A hyperdynamic precordium with an S3 is heard on the cardiac exam.
She has 2+ edema of bilateral lower extremity extending to the knee. The white cell count
is 5,000/microL (5.0 × 10^9/L) with a normal differential. Results of the basic metabolic
panel are normal. An electrocardiogram shows sinus tachycardia. An echocardiogram
reveals a left ventricular ejection fraction of 10% without any valvular regurgitation. A
chest x-ray shows pulmonary vascular congestion. Which of the following is the most
appropriate next test to perform for this patient?

Choices:

1. Antinuclear antibody level

2. Endomyocardial biopsy
3. Thyroid studies
4. Viral titers

Answer: 3 - Thyroid studies

Explanations:

This patient is exhibiting signs and symptoms suggestive of hyperthyroidism. She also
has pulmonary edema secondary to acute heart failure.
Hyperthyroidism is a reversible cause of heart failure hence all patients with new-
onset heart failure must be considered for an evaluation for thyroid dysfunction.
It is caused due to the overstimulation of the heart due to excess thyroid
hormone, which resembles sympathetic stimulation.
Endomyocardial biopsy is rarely recommended due to its invasive nature of testing.
Viral titers are useful in the diagnosis of the responsible pathogen but do not have
any utility in the treatment of pulmonary edema and heart failure.

Research Concepts:

Pulmonary Edema

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Question 137: A 76-year-old patient with past medical history significant for heart failure
with reduced ejection fraction (HFrEF) with 30% to 35%, chronic obstructive pulmonary
disease, and iron deficiency anemia was admitted for acute dyspnea on exertion with
wheezing. CBC revealed hemoglobin of 6.2 g/dL and hematocrit of 20%. A packed red
blood cell transfusion was initiated. 7 hours later, the patient develops worsening of
dyspnea with oxygen saturation of 72% on room air. Body temperature is reported as
101.2 F. Lung sounds show rales bilaterally. Neck vein is distended, and the patient
developed hypertension. CBC showed WBC of 10.1 and platelet count of 237/microliter.
What is the most likely diagnosis?

Choices:

1. Transfusion associated circulatory overload (TACO)

2. Hemolytic transfusion reaction
3. Acute exacerbation of chronic obstructive pulmonary disease
4. Transfusion related acute lung injury (TRALI)

Answer: 1 - Transfusion associated circulatory overload (TACO)

Explanations:

TACO and TRALI both can have rales, but TACO has neck distended vein due to
circulatory overload and develops hypertension.
TRALI develops hypotension and fever.
Patients with systolic dysfunction are more vulnerable to TACO than TRALI with
cardiogenic pulmonary edema.
TRALI likely to show leukopenia and thrombocytopenia.

Research Concepts:

Transfusion-related Acute Lung Injury

Question 138: A 17-year-old male presents to the emergency department in Arizona with
vomiting, dyspnea, fever, and generalized myalgias. The vital signs demonstrate fever,
tachypnea, tachycardia, and mild hypoxia. The patient is found to have
thrombocytopenia, metamyelocytes, leukocytosis, and bilateral pulmonary infiltrates on
chest x-ray. Which organism is the most likely etiology?

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Choices:

1. Influenza A
2. Hantavirus
3. Human immunodeficiency virus (HIV)
4. Pneumocystis jiroveci

Answer: 2 - Hantavirus

Explanations:

Hantavirus presenting as cardiopulmonary syndrome, such as in this patient, is

common in the Southwestern United States.
Thrombocytopenia is the most common significant laboratory abnormality on
presentation when patients are reaching admission criteria. Metamyelocytes may
also be seen in the setting of significant leukocytosis.
Bilateral infiltrates seen on the chest x-ray may have an acute respiratory distress
syndrome appearance due to the fluffy nature due to increased capillary
permeability.
Hantavirus often presents with fever, chills, diarrhea, malaise, and dyspnea.
Hantavirus is predominantly acquired through aerosolization of rodent urine and
droppings.

Research Concepts:

Hantavirus Syndrome

Question 139: A 65-year-old male with a past medical history positive for type 2 diabetes,
hyperlipidemia, and bipolar disorder arrives at the clinic complaining of shortness of
breath. After careful evaluation and diagnostic testing, the patient is found to have
pulmonary artery hypertension. The provider wants to put him on a medication that
would antagonize endothelin-1. Which of the following mechanisms of action of a possible
preexisting medications the patient is already taking would be contraindicated if the
physician prescribes this new medication to treat his pulmonary artery hypertension?

Choices:

1. Inhibition of HMG CoA reductase

2. Inhibit potassium efflux from pancreatic beta cells
3. 5HT-1 agonist

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4. Inhibiting IMPase

Answer: 2 - Inhibit potassium efflux from pancreatic beta cells

Explanations:

Glyburide is contraindicated when taking bosentan. Glyburide acts by inhibiting

potassium efflux from pancreatic beta cells; to allow the release of insulin.
Glyburide is acted upon by the CYP P450 enzyme system. The use of glyburide with
bosentan may lead to dangerously elevated levels of bosentan. These high levels
may increase the risk of adverse effects such as hypotension, syncope, flushing, and
hepatic dysfunction.
When using glyburide and bosentan together may also lead to an increased risk of
hepatotoxicity and an elevation in liver enzymes.
Statins work by inhibiting HMG CoA reductase, thereby limiting the production of
cholesterol and LDL. Patients with elevated lipid profile may benefit from taking
statins to decrease their risk of developing a heart attack or stroke. Triptans, which
are used in the treatment of migraines, work by agonizing the 5HT-1 receptors.
These medications are not contraindicated with the use of bosentan. Lithium is
used in the treatment of bipolar 1.
Although the mechanism of which it aids with mood stabilization is not clear, the
mechanism of action proposed is by inhibiting inositol triphosphate. Statins,
triptans, and lithium are not contraindicated, nor do they increase the risk of
adverse effects when taking bosentan. Of the answer choices, only glyburide is
contraindicated with the use of bosentan. Another medication contraindicated with
the use of bosentan is cyclosporin A because it may lead to an increased plasma
level of bosentan.

Research Concepts:
Bosentan

Question 140: During the winter, a patient presents with headache, nausea, vomiting,
and dizziness. A medical history reveals that the patient is homebound and conserving
money by using his fireplace to keep warm. An arterial blood gas reveals he has a
decreased oxygen-carrying capacity and a normal arterial PO2. To which gas has the
patient most likely been exposed?

Choices:

1. Methane
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2. Carbon monoxide
3. Nitrogen dioxide
4. Sulfur dioxide

Answer: 2 - Carbon monoxide

Explanations:

Carbon monoxide (CO) can be produced whenever carbon- containing materials are
burned, especially when ventilation is inadequate.
CO binds much more readily to hemoglobin than oxygen (220:1) and
carboxyhemoglobin is formed rather than oxyhemoglobin.
The oxygen-carrying capacity is diminished and will eventually lead to tissue
hypoxia.
One hundred percent hyperbaric oxygen therapy is the treatment of choice.
Nitrogen dioxide, sulfur dioxide, and methane can all cause hypoxia but do not
affect the oxygen-carrying capacity of blood. Nitrogen dioxide and sulfur dioxide
are direct respiratory mucous membrane irritants. Methane, an asphyxiant, simply
decreases the amount of oxygen available for oxygenation.
Research Concepts:

Carbon Monoxide Toxicity

Question 141: A 29-year-old male patient with a history of sickle cell disease presents to
the emergency department with difficulty breathing and chest pain. He has a temperature
of 38.6°C (101.5°F), a heart rate of 104 beats per minute, and a respiratory rate of 24
breaths per minute. The patient is diagnosed with septic shock secondary to
Streptococcus pneumoniae. He received all recommended vaccinations until age 18. He
has not received any vaccinations in the past 10 years. What serotype of S. pneumoniae is
most likely responsible for his condition and what could have prevented this infection?

Choices:

1. Streptococcus pneumoniae serotype 19A, immunization with PPSV13

2. Streptococcus pneumoniae Serotype 36C, immunization with PSV13
3. Streptococcus pneumoniae Serotype 13, immunization with PPSV23
4. Streptococcus pneumoniae Serotype 25A, immunization with PSV13

Answer: 1 - Streptococcus pneumoniae serotype 19A, immunization with PPSV13

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Explanations:

This patient has completed an initial series of PVC 13. Given that he has sickle cell
disease, he should receive PCV13 between the ages of 19 and 64, and at a
minimum, the PPSV23 should be given 8 weeks after PCV13.
PPSV23 is recommended in all immunocompromised or asplenic patients.
Vaccination is also recommended in patients with high-risk conditions such as
chronic heart disease, cirrhosis, cochlear implants, diabetes mellitus, cerebrospinal
fluid leaks, or chronic lung disease.
The most common serotype of Streptococcus pneumoniae is serotype 19 and is
covered by both PPSV23 and PSV13 vaccinations.
Patients who are given PPSV23 vaccination due to high-risk conditions are
recommended to have a repeat dose of PPSV23 every 5 years.

Research Concepts:
Streptococcus Pneumoniae

Question 142: A 45-year-old man presented to the emergency room because of acute
right-sided chest pain. The pain started while he was moving furniture and improved by
rest. He has a past medical history of atrial fibrillation on rate controlled with metoprolol
and diabetes on sitagliptin, with no significant family history. Initial vital signs showed
blood pressure of 126/81 mm/Hg; pulse rate was 85 beats/min, oxygen saturation was
94% on room air. Physical examination revealed bilateral air entry, regular S1, S2 with no
added sounds or murmurs. Initial labs showed troponin of 0.03 with Creatinine of 1.7.
EKG showed atrial fibrillation. He was admitted for further evaluation and management.
Subsequent troponin at 6 and 12 hours were negative, and he was discharged home. On
follow up with his primary care provider, the medical resident decided to proceed with CT
coronary angiography, but the attending thinks it is an inappropriate next step. What was
the attending concern?

Choices:

1. CT angiography is contraindicated with atrial fibrillation.

2. He has a high risk and should go for cardiac cath.
3. He has Creatinine of 1.7
4. He has a history of diabetes

Answer: 3 - He has Creatinine of 1.7

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Explanations:

After acute coronary syndrome has been ruled out, the clinician has an abundance
of diagnostic options to choose from when aiming to determine the presence of
CAD and quantify its extent in these patients. Coronary computed tomographic
angiography (CCTA) is an anatomic test that can be used in intermediate-risk
patients to provide a diagnostician with these answers quickly.
Absolute contraindications are a patient history of severe or anaphylactic reaction
to iodinated contrast, inability to cooperate with scan protocols, hemodynamic
instability, decompensated heart failure, acute myocardial infarction, and renal
impairment. Contrast-induced acute kidney injury (CI-AKI) is the acute impairment
of renal function further to the intravascular administration of iodinated contrast
media and occurs most frequently after coronary angiography, percutaneous
coronary intervention, and contrast-enhanced computed tomography. CI- AKI has
been associated with the development of acute renal failure, worsening of chronic
kidney disease, the requirement for dialysis, prolonged hospital stay, and higher
mortality rates and health care costs.
Whole-heart CT enables evaluation of coronary arteries with high image quality,
low radiation exposure, and high diagnostic accuracy in patients with chronic atrial
fibrillation, with a diagnostic performance similar to that in patients with sinus
rhythm.

Research Concepts:
Coronary CT Angiography

Question 143: A 34-year-old male is admitted to the hospital with a 4-day history of fever
and dyspnea. He is known to be human immunodeficiency virus-positive but poorly
compliant with his antiretroviral therapy (ART). His recent CD4 count was 180 cells/µl.
On examination today his heart rate is 102 beats per minute, his respiratory rate is 35
breaths per minute, his temperature is 39 C (102.2 F), and his oxygen saturation is 90% on
room air. He has coarse crackles on the right side of his chest. His arterial PaO2 is 57 mmHg.
A chest x-ray shows perihilar infiltrates, and a methenamine silver stain shows cysts. Given
the likely diagnosis, what is the initial treatment of choice for this patient?

Choices:

1. IV trimethoprim/sulfamethoxazole
2. Oral trimethoprim/sulfamethoxazole
3. Pentamidine
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4. Clindamycin-primaquine

Answer: 1 - IV trimethoprim/sulfamethoxazole

Explanations:

Pneumocystis jiroveci pneumonia (PJP) causes interstitial infiltrates on chest x-ray.

Patients with PJP typically present with worsening exertional dyspnea,
nonproductive cough, and fever. Visualization of cysts with methenamine silver
staining of a sputum specimen is diagnostic.
Trimethoprim/sulfamethoxazole (TMP-SMX) is recommended for patients with
severe disease.
Individuals should receive intravenous therapy until they are clinically stable (eg,
PaO2 =60 mmHg, respiratory rate less than 25) and are able to be transitioned to
oral treatment.
Clindamycin-primaquine or pentamidine may be administered intravenously in
patients with severe disease and sulfonamide allergy.

Research Concepts:

Pneumocystis Jirovecii Pneumonia

Question 144: A 65-year-old male develops respiratory failure, fevers, productive cough,
and failure to thrive. He is a current smoker and retired factory worker where he was
exposed to indium for years. His only medical history is myelodysplastic syndrome. He is
hypoxic at rest. CT of the thorax shows a crazy paving pattern and pulmonary alveolar
proteinosis is suspected. Flexible bronchoscopy with lavage is performed and is positive
for periodic acid-Schiff positive macrophages and amorphous debris. Laboratory results
include an elevated lactate dehydrogenase and beta-D-glucan, and a silver stain shows
fungal elements in the lavage fluid. His anti-GM- CSF IgG antibody levels are
undetectable. What is the best management?

Choices:

1. Whole lung lavage now and again in 2 weeks

2. Antimicrobial therapy for Pneumocystis jirovecii pneumonia
3. Systemic corticosteroids
4. Whole lung lavage now and again in 2 weeks, and antimicrobial therapy for
Pneumocystis jirovecii pneumonia

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Answer: 4 - Whole lung lavage now and again in 2 weeks, and antimicrobial therapy for
Pneumocystis jirovecii pneumonia

Explanations:

Secondary pulmonary alveolar proteinosis (PAP) has a strong association with

hematological diseases, and myelodysplastic syndrome is found in 34% of cases.
Secondary PAP has a strong association with environmental and occupational
exposures, with one study reporting 48% of cases having significant exposure.
The lavage findings of periodic acid-Schiff positive macrophages and amorphous
debris are specific to PAP. This patient should undergo whole lung lavage. His
absent anti-GM-CSF antibodies suggest secondary PAP and 5% of these patients will
develop opportunistic infections such as Pneumocystis jirovecii pneumonia;
therefore, he should also receive antimicrobial therapy.
Fever is uncommon in autoimmune pulmonary alveolar proteinosis. Given this
patient’s presentation, a concomitant infection must be considered.

Research Concepts:

Pulmonary Alveolar Proteinosis

Question 145: A 71-year-old male presents to the office for evaluation of dyspnea. He has
mild chronic obstructive pulmonary disease, which has been well controlled with inhalers.
An echocardiogram and chest x-ray done 2 months ago were normal. He has a 20 pack-
year smoking history and quit smoking 30 years ago. The review of systems is positive for
dyspnea and new onset constipation. He is a retired truck driver. The family history is
noncontributory, and the physical examination is normal. What is the best next step in
evaluation?

Choices:

1. Fecal occult blood and CBC with mean corpuscular volume (MCV)
2. Repeat chest x-ray and echocardiogram
3. CT chest
4. Prostate-specific antigen

Answer: 1 - Fecal occult blood and CBC with mean corpuscular volume (MCV)

Explanations:

The patient's new onset constipation is suggestive of colon cancer.

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 Fecal occult blood should be checked, and the patient should be referred to a
gastroenterologist for a colonoscopy if positive.
A CBC will show anemia and the mean corpuscular volume (MCV) will be low if the
patient has colon cancer. The patient will lose blood in the stool and become iron
deficient over time.
If an elderly patient has microcytic and hypochromic anemia, colon cancer should
be ruled out first.

Research Concepts:

Constipation

Question 146: A 78-year-old male with a past medical history of stroke, diabetes mellitus,
hypertension, and chronic obstructive pulmonary disease comes in from a nursing home
for evaluation of an increased effort necessary for him to breathe. On initial evaluation,
he appears in distress and is placed on noninvasive positive pressure ventilation for an
oxygen saturation of 80% on room air. He is found to be tachycardic and hypotensive, with
a blood pressure of 80/40 mmHg. A chest x-ray shows a left lower lobe consolidation.
What is the best initial antibiotic coverage?

Choices:

1. Metronidazole
2. Levofloxacin
3. Amoxicillin and clavulanic acid
4. Cefepime and vancomycin

Answer: 4 - Cefepime and vancomycin

Explanations:

This patient with likely pneumonia should be broadly covered for gram-negative and
gram-positive organisms, including Pseudomonas and methicillin-resistant
Staphylococcus aureus (MRSA).
Cefepime and vancomycin are the appropriate broad-spectrum coverage.
In patients requiring intensive care unit admission with risk factors for multidrug-
resistant organisms, broad-spectrum antibiotics are appropriate first-line
treatment.
Metronidazole is added to the treatment regimen when aspiration pneumonia is
suspected. Amoxicillin and clavulanic acid is an outpatient treatment option for

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 patients who appear well.

Research Concepts:
Nursing Home Acquired Pneumonia

Question 147: A 35-year-old female recently diagnosed with pulmonary arterial hypertension
(PAH) presents to the clinic for initiating treatment. She reports that she is not able to carry
out any physical activity without being short of breath. She is treatment- naive. Which
medication is going to improve both the World Health Organization (WHO) functional class
and six-minute walk distance (6MWD) for this patient?

Choices:

1. Continuous intravenous (IV) treprostinil

2. Continuous subcutaneous treprostinil
3. Continuous intravenous (IV) epoprostenol
4. Inhaled treprostinil

Answer: 3 - Continuous intravenous (IV) epoprostenol

Explanations:

Continuous IV epoprostenol is the only option that will improve both the WHO
function class and 6MWD in patients with PAH and WHO functional class IV who
are treatment-naive.
Continuous IV treprostinil will improve 6MWD but not the functional class.
Epoprostenol has shown to improve PAH symptoms, exercise capacity, and it is the
only treatment that reduces the mortality of patients with idiopathic PAH.
Continuous subcutaneous treprostinil will improve 6MWD but not the functional
class in patients with PAH and WHO functional class IV who are treatment-naive.
IV epoprostenol's adverse effects are flushing, hypotension, dizziness, nausea, and
vomiting. Once the patients develop the side effects, the dose can be decreased until
the dose-limiting effects resolve.
There is no renal or hepatic adjustment needed for epoprostenol. Inhaled
treprostinil is the right choice in patients with PAH and WHO functional class IV
who are treatment-naive and unable to tolerate parenteral prostanoid therapy.

Research Concepts:
Treprostinil

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Question 148: A 54-year-old female with acute on chronic systolic congestive heart failure
and acute hypoxemic respiratory failure is now day 3 on mechanical ventilation. Diuretics
and inotropes prescribed resulted in diuresis and improvement in hypoxemia. Vital signs
show a heart rate of 94/min, blood pressure 112/68 mmHg, respiratory rate 16/min, and
SpO2 98%. She is sedated with fentanyl and propofol and opens her eyes to voice but
does not follow commands. Current ventilator settings are pressure control mode,
respiratory rate 16/min, driving pressure 20 cmH2O, PEEP 8 cmH2O, and FiO2 40%.
Average tidal volume is 300 mL on these settings. An arterial blood gas shows pH 7.47,
pCO2 38 mmHg, and pO2 88 mmHg. Sedation is stopped and 20 minutes later, the
patient is alert and following commands. PSV mode is started, with driving pressure 20
cmH2O, PEEP 8 cmH2O, and FiO2 40%. After 10 minutes on these settings, the respiratory
rate is now 28/min with average tidal volume 420 mL. Current vital signs are a pulse rate
of 120/min, blood pressure 108/58 mmHg, respiratory rate 28/min, and SpO2 94%. The
patient appears anxious. Chest X-ray shows stable cardiomegaly, clear lungs, and
endotracheal tube in the appropriate position. An arterial blood gas shows pH 7.52, pCO2
30 mmHg, and pO2 68 mmHg. What is the best explanation for the patient's tachypnea?

Choices:

1. Oxygen consumption has increased

2. Airway resistance has increased
3. Oxygen delivery has decreased
4. Lung compliance has decreased

Answer: 1 - Oxygen consumption has increased

Explanations:

Work of breathing and thus oxygen consumption is higher in PSV than in control
modes of ventilation. Patients with shock or low cardiac output may need more
respiratory support.
The flow delivered by the driving pressure can provide a tidal volume and minute
ventilation higher than the patient could achieve without ventilator support. This
higher minute ventilation improves oxygen delivery and carbon dioxide offloading.
PSV is relatively contraindicated in patients who have a depressed respiratory
drive, very high oxygen consumption, or high airway resistance.
After PSV is initiated, the patient should be directly observed for several minutes to
ensure that the goals of ventilation, oxygenation, and patient comfort are met.
Research Concepts: Pressure Support Ventilation

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Question 149: A 56-year-old male with a history of smoking and metastatic melanoma
comes to the clinic for shortness of breath.
The patient started treatment with ipilimumab and nivolumab for melanoma two
months ago and has received two cycles. He reports exertional dyspnea for 3 to 4 days
with a non-productive cough. He denies any preceding fever. The oxygen saturation on
room air was 93%. On examination, he is not in respiratory distress, and bilateral crackles
were noted in lung bases. You obtain a stat CT chest without contrast that shows
bilateral ground-glass opacities without focal consolidation. How should this patient be
managed?

Choices:

1. Admit the patient to the hospital for atypical pneumonia

2. Start outpatient broad-spectrum antibiotics
3. Start prednisone at 1 mg/kg
4. Refer to pulmonary for outpatient bronchoscopy

Answer: 3 - Start prednisone at 1 mg/kg

Explanations:

This patient likely has immune-mediated pneumonitis because he is afebrile, a CT

scan shows ground-glass opacity without an infiltrate, and he received combination
immunotherapy recently. Immune-mediated pneumonitis is seen in about 3% of
patients treated with single-agent anti-PD 1 agent such as nivolumab and about 6%
of patients treated with a combination of nivolumab with ipilimumab. Prednisone
1mg/kg body weight is the initial drug of choice. Once clinical improvement is seen,
prednisone can be tapered. Immunosuppressive agents such as mycophenolate
have been shown to have benefits in refractory cases.
Starting broad-spectrum antibiotics is not warranted since the workup is not
suggestive of an infectious etiology.
Routine bronchoscopy is unnecessary for diagnosing immune- mediated pneumonitis
and can be used when the etiology is uncertain or if the patient does not improve with
corticosteroids. Admitting this patient is not indicated since he
appears to be oxygenating well.

Research Concepts:

Metastatic Melanoma

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Question 150: Following a left lung lobectomy, a 66-year-old patient develops hypotension,
tachycardia, and hypoxia. Fleischner sign is noted on chest x-ray. A loud P2 is heard on
auscultation. The EKG shows variable ST-segment changes in the anterior leads.
Which of the following is the diagnostic test of choice for this patient's suspected
condition?

Choices:

1. Cardiac enzymes
2. Time of flight MRI
3. Contrast-enhanced CT chest
4. Bronchoscopy

Answer: 3 - Contrast-enhanced CT chest

Explanations:

Pulmonary embolism should be the first consideration in a postoperative patient who

suddenly decompensates.
A contrast-enhanced CT chest is the diagnostic test of choice for evaluating
pulmonary artery emboli. CT typically demonstrates filling defects in the
pulmonary arteries, including the main pulmonary arterial trunks or the segmental
and subsegmental arteries.
Radiographs often demonstrate nonspecific findings. Fleischner sign on a chest
radiograph can be seen, which corresponds to an enlarged pulmonary artery.
A Hampton hump, which corresponds to a peripheral lung infarction, can also be
seen as a peripheral wedge-shaped opacity. Westermark sign corresponds to
regional decreased blood flow with difficult to visualize peripheral pulmonary
vasculature (oligemia).
Research Concepts:

Acute Pulmonary Embolism

Question 151: A 55-year-old government employee of the U.S. Army Research Institute
for Infectious disease presents with sudden onset of fever, cough, dyspnea, and myalgias.
He reports that he was working in the laboratory when a small explosion occurred in one
of the isolation rooms containing various specimens. He appears unwell and in moderate
respiratory distress. His chest x-ray demonstrates a widened mediastinum. Which of the
following is the most appropriate initial therapy?

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Choices:

1. Aztreonam and clindamycin

2. Ceftriaxone and vancomycin
3. Ciprofloxacin, doxycycline, and clindamycin
4. Ampicillin and tobramycin

Answer: 3 - Ciprofloxacin, doxycycline, and clindamycin

Explanations:

This patient likely has pulmonary anthrax due to Bacillus anthracis. Anthrax is a
category A agent of bioterrorism, with the highest risk of weaponization. Pulmonary
or inhalational anthrax is caused by inhalation of the spores, which causes a viral
prodrome similar to a flu-like illness. Hemorrhagic mediastinitis is a characteristic
manifestation and is responsible for the widened mediastinum. A CT scan should be
ordered in a patient suspected of having this diagnosis if the x-ray is non-diagnostic.
Patients should be treated with intravenous (IV) ciprofloxacin 400 mg every 12
hours or doxycycline 100 mg every 12 hours plus at least 2two other antibiotics
(e.g., imipenem, clindamycin, rifampin, or an aminoglycoside). Treatment must
continue for at least 60 days or until 3 doses of the anthrax vaccine can be given.
Anthrax spores should be disinfected with bleach solutions. Alcohol-containing
cleaning products and hand sanitizers have no effect on the spores.
Anthrax has demonstrated immediate resistance to ceftriaxone and should not be
used. Aztreonam covers gram-negative bacteria with minimal gram-positive
coverage. Tobramycin has gram-negative coverage with minimal gram-positive
coverage and should not be used in the treatment of B. anthracis.
Research Concepts:
Anthrax Infection

Question 152: A 55-year-old male presents with dyspnea on exertion and hypoxia. He has
had a dry cough for months. He currently smokes and has hypertension and
hypothyroidism. A chest x-ray shows a batwing pattern, and a subsequent CT shows crazy
paving. He undergoes flexible bronchoscopy with lavage which shows periodic acid-Schiff
positive macrophages and amorphous debris. His serum GM-CSF levels are normal, but
his anti-GM-CSF IgG antibody levels are elevated. What is true about his diagnosis?

Choices:

1. Pulmonary alveolar proteinosis is a disease with overproduction of surfactant by

alveolar macrophages
Page 147 of 955
2. He has autoimmune pulmonary alveolar proteinosis. Hypothyroidism and other
autoimmune diseases are uncommon in these patients
3. He has secondary pulmonary alveolar proteinosis because his GM-CSF levels are
low
4. A crazy paving pattern on CT thorax has a 94% specificity for the diagnosis of
pulmonary alveolar proteinosis

Answer: 2 - He has autoimmune pulmonary alveolar proteinosis. Hypothyroidism and other

autoimmune diseases are uncommon in these patients
Explanations:

Pulmonary alveolar proteinosis is a disease of failure-to-clear the alveoli of

surfactant proteins. Overproduction has not been found in pulmonary alveolar
proteinosis.
Ninety percent of pulmonary alveolar proteinosis is autoimmune and will have
elevated IgG anti-GM-CSF antibodies as does this patient. Autoimmune pulmonary
alveolar proteinosis is not frequently associated with other autoimmune diseases.
Concomitant disease is seen in less than 2% of patients. Secondary pulmonary alveolar
proteinosis is not associated with elevated anti-GM-CSF IgG antibody levels. GM-CSF
levels are normal in all forms of pulmonary alveolar proteinosis.
Crazy paving is frequently associated with pulmonary arterial proteinosis but is neither
sensitive nor specific. Bronchoscopy is frequently required to confirm the diagnosis.
Research Concepts:

Pulmonary Alveolar Proteinosis

Question 153: A 28-year-old female presents with a pleural effusion and undergoes
ultrasound-guided thoracentesis. The fluid collected is sent for cytopathologic
examination, and a population of atypical cells is identified. Which of the following
immunohistochemical markers, if positive, likely indicate the cells are of mesothelial
origin?

Choices:

1. MOC-31
2. Ber-EP4
3. Calretinin
4. CDX2

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Answer: 3 - Calretinin

Explanations:

Distinguishing reactive mesothelial cells from malignant/neoplastic populations of

cells in pleural effusion analysis can be difficult, and utilizing immunohistochemical
(IHC) markers can aid in the diagnosis and differentiation of mesothelial
proliferation.
Calretinin, D2-40, and cytokeratin 5/6 are among the most important IHC markers
to examine when determining if mesothelial cells are present in pleural effusion
samples.
CDX2 is a marker for gastrointestinal adenocarcinoma and is a useful IHC to
differentiate between malignant mesothelioma and metastatic gastrointestinal
adenocarcinoma.
Ber-EP4, MOC-31, and CEA are markers which if positive likely indicate carcinoma cells
in pleural effusion.

Research Concepts:

Benign Mesothelioma

Question 154: A 65-year-old male smoker with a past medical history of chronic
obstructive pulmonary disease (COPD) presents with worsening shortness of breath and
cough with expectoration. On examination, he is awake but in severe distress and using
accessory muscles. Chest auscultation reveals prolonged expiration and bilateral wheezes.
Arterial blood gas analysis reveals a pH of 7.20, pCO2 of 72 mmHg, and pO2 of 50 mmHg.
Pulmonary function tests show FEV1/FVC 60% of predicted. Chest x-ray shows flattened
diaphragm and widened intercostal spaces. Inhaled short-acting beta-agonists, steroids,
oxygen, and non-invasive ventilation with Bilevel positive airway pressure are tried, but
the condition does not improve. The patient is intubated, and on day three does well on a
spontaneous breathing trial. What is the best next step in the management of this
patient?
Choices:

1. Extubate to nasal cannula

2. Room air
3. Tracheostomy and percutaneous endoscopic gastrostomy
4. Extubate to bilevel positive airway pressure
Answer: 4 - Extubate to bilevel positive airway pressure

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Explanations:

Prophylactic non-invasive ventilation like bilevel positive airway pressure (BiPAP)

following extubation has been shown to decrease the reintubation rate in chronic
respiratory disease especially in hypercarbic chronic obstructive pulmonary disease
(COPD) patients who were mechanically intubated for respiratory failure.
Hypercapnia in this patient points towards the chances of extubation failure. To
prevent extubation failure, this patient should be extubated to BiPAP.
The early use of non-invasive ventilation (NIV) post-extubation also has reduced
hospital mortality in such high-risk intensive care unit patients.
Noninvasive ventilation post-extubation in mechanically ventilated patients with
COPD has also has shown to reduce the duration of mechanical ventilation, length of
intensive care unit stay and, decreased incidence of ventilator-associated
pneumonia.
Since the mechanically ventilated patients with COPD has passed the spontaneous
breathing trial and is hypercapnic, the best next step is extubating to non-invasive
ventilation. NIV prevents acute respiratory failure and decreases mortality in such
patients. With BiPAP, such patients are likely to show a higher PaO2, lower
PaCO2, respiratory rate, especially when compared with patients using an oxygen
mask.

Research Concepts: Emphysema

Question 155: A 75-year-old female with a 50-pack-year history of tobacco use presents
with a 2-week history of worsening dyspnea on exertion. She has had a dry cough but no
fever, night sweats, or chills. Her neck shows no jugular venous distention. Heart tones
are distant but regular without murmurs. A lung exam reveals right lower lung dullness to
percussion and decreased breath sounds. A chest radiograph shows a pleural effusion but
no infiltrates or lymphadenopathy. Laboratories are normal. What is the appropriate
management?

Choices:

1. Broad-spectrum antibiotics
2. CT of the chest
3. Bronchoscopy
4. Thoracentesis

Answer: 4 - Thoracentesis

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Explanations:

There is no evidence of infection, so antibiotics would not be appropriate.

CT of the chest may have a small yield, but thoracentesis will provide the most
rapid diagnosis.
Sampling the pleural fluid by thoracentesis will determine if the fluid is exudate or
transudate in nature and aids in diagnosis.
Thoracentesis also will provide symptomatic relief.
Research Concepts:

Pleural Effusion

Question 156: A 40-year-old female with no significant past medical history presents with
nonspecific respiratory symptoms. A chest x-ray shows a proximal mass. A CT scan shows a
polypoid endobronchial mass measuring 2 cm. Endoscopic resection of the mass is
performed. The microscopic examination reveals a polypoid mass covered by squamous
epithelium without atypical cells or invasion. What is the most likely diagnosis?

Choices:

1. Squamous cell carcinoma

2. Squamous cell papilloma
3. Glandular papilloma
4. Mixed papilloma

Answer: 2 - Squamous cell papilloma

Explanations:

Squamous cell carcinoma is a malignant epithelial tumor characterized by an

infiltrative growth with nests of atypical cells and squamoid pearls.
Squamous cell papilloma is a benign tumor with a fibrovascular core covered by
regular squamous epithelium.
Glandular papilloma is a benign tumor with a fibrovascular core covered by respiratory
pseudostratified epithelium.
Mixed papilloma is a benign tumor that shares the features of squamous cell and
glandular papillomas.

Research Concepts:

Pulmonary Papilloma
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Question 157: A 17-year-old female with a past medical history of intravenous drug use
presents to the emergency department with dyspnea, fever, chills, and a productive
cough. She was hospitalized one week ago for pneumonia and admits to not completing
her outpatient course of antibiotics. Her heart rate is 112/min, blood pressure 120/80
mmHg, respiratory rate 26/min, and oral temperature 103.2 F (39.5 C). The patient is
rigorous throughout the exam. A focused cardiopulmonary exam demonstrates sinus
tachycardia, tachypnea, diffuse rhonchi in bilateral lung fields, and decreased breath
sounds at the left lung base. Imaging shows multifocal pneumonia with a large left-sided
pleural effusion.
Diagnostic thoracocentesis is completed, and pleural fluid culture and sensitivity are
pending. Given the likely diagnosis, what is the most appropriate antibiotic treatment?

Choices:

1. Vancomycin only
2. Cefepime, metronidazole, and vancomycin
3. Cefepime plus amikacin
4. Amikacin only

Answer: 2 - Cefepime, metronidazole, and vancomycin

Explanations:

This patient most likely has hospital-acquired empyema due to her recent
hospitalization. With hospital-acquired empyema, it is imperative to cover for gram-
positive cocci, including methicillin- resistant Staphylococcus aureus (MRSA).
Pseudomonas also must be covered with cefepime or ceftazidime. Vancomycin is
also appropriate for hospital-acquired empyema.
Anaerobic bacteria are notorious for invading the pleural space, likely from its
anaerobic environment; however, they usually yield culture-negative media
because they are slow-growing organisms.
When selecting antibiotics for empyema, treatment must always include anaerobic
coverage. Metronidazole is an appropriate antibiotic for anaerobic coverage.
Amikacin does not penetrate the pleural space and is not active in acidic
environments such as in an empyema.
Research Concepts:

Thoracic Empyema

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Question 158: A 25-year-old woman admitted to the hospital suffering from pain in the
pectoral and axillary region, weakness and muscle loss at the base of the thumb. An x-ray
result shows that the patient has a cervical rib. What is the most likely cause of these
symptoms?

Choices:

1. Arterial thoracic outlet syndrome

2. Venous thoracic outlet syndrome
3. Rib tumor
4. Neurogenic thoracic outlet syndrome

Answer: 4 - Neurogenic thoracic outlet syndrome

Explanations:

The cervical rib commonly causes the neurogenic thoracic outlet syndrome by
compressing the lower trunk of the brachial plexus. The base of the thumb muscle's
function is lost due to the compression of the lower trunk; because the lower trunk
is the origin of the nerves innervating this muscle.
The syndrome is common in females.
The onset of the syndrome is common in people who are 20-50 years of age.

Research Concepts:

Anatomy, Thorax, Ribs

Question 159: A 42-year-old white male has had five emergency department and urgent
care visits in the past six months for asthma symptoms. He also reports chronic nasal and
sinus congestion and ill-defined malaise, fatigue, and weight loss in spite of a good
appetite. He was diagnosed with asthma 6 months ago. He works in construction,
restoring old houses, and complains that he has been exposed to black mold at work
routinely for the past year. On examination, he has tenderness in the right knee and ankle
joints as well as wrist joints. He does not have a skin rash. Among other findings, he also
happens to have nasal polyps but no mucosal erosions. Routine blood work shows mildly
elevated eosinophil count at 400/dl and a creatinine of 1.7 mg/dl. Which
pathophysiological process is the cause of his spectrum of clinical findings?

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Choices:

1. Th2 mediated hypersensitivity response to aspergillus antigen

2. Eosinophil-mediated damage to small and medium-sized blood vessels and
extravascular tissue
3. P-ANCA (perinuclear staining anti neutrophilic cytoplasmic antibody)
mediated small and medium vessel damage
4. C-ANCA (cytoplasmic staining anti neutrophilic cytoplasmic antibody)
mediated small and medium vessel damage

Answer: 3 - P-ANCA (perinuclear staining anti neutrophilic cytoplasmic antibody) mediated

small and medium vessel damage
Explanations:

Refractory, adult-onset asthma with frequent exacerbations should prompt a

search for rarer etiologies beyond simple bronchial asthma. Idiopathic
hypereosinophilic syndrome, allergic bronchopulmonary aspergillosis, eosinophilic
granulomatosis with polyangiitis, and granulomatosis with polyangiitis are
significant differentials to consider. However, nasal crusting with septal perforation
is a hallmark of granulomatosis with polyangiitis and differentiates it from
eosinophilic granulomatosis with polyangiitis.
P-ANCA (perinuclear staining anti neutrophilic cytoplasmic antibody) is often seen
in eosinophilic granulomatosis with polyangiitis. C-ANCA (cytoplasmic staining anti
neutrophilic cytoplasmic antibody) mediated small and medium vessel damage is
the primary pathophysiological process in 80% of patients with granulomatosis
with polyangiitis.
Granulomatosis with polyangiitis (GPA) is a multisystem vasculitis that does involve
the lungs and upper respiratory tract but not with an eosinophilic asthma-like
presentation. It presents with multiple pulmonary nodules that often cavitate, nasal
crusting, and septal perforation, along with renal failure, migrating polyarthralgia,
and other system involvement.
Upper respiratory symptoms are more common in eosinophilic granulomatosis with
polyangiitis with chronic rhinosinusitis (47% to 93%) and nasal polyps (62% to 77%).
However, nasal granulomas, erosion, and crusting or epistaxis, as seen in GPA, are
absent here.

Research Concepts:

Churg Strauss Syndrome

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Question 160: A 32-year-old man presents with a two-week history of a dry cough and
fever. He has no significant medical history and is not on any medication. He reports
recent travel to various countries visiting caves to study bats. Clinical evaluation reveals
normal vital signs without hypoxemia. Pulmonary examination demonstrates mild
crackles bilaterally, and abdominal examination demonstrates mild splenomegaly.
Tender, red nodules are present on both lower extremities. Chest x-ray shows bilateral
patchy infiltrates with mediastinal lymphadenopathy. Serum angiotensin-converting
enzyme level is elevated, and interferon- gamma release assay is negative. What is the
best next step in the management of this patient?
Choices:

1. Corticosteroid therapy
2. Antifungal therapy
3. Serum and urine fungal antigen testing
4. Serum chitotriosidase level
Answer: 3 - Serum and urine fungal antigen testing
Explanations:

Histoplasmosis, especially acute diffuse pulmonary histoplasmosis, has many

features in common with sarcoidosis. Histoplasmosis should be considered and
ruled out using specific testing in all patients suspected of having sarcoidosis using
serum and urinary Histoplasma antigens and/or Histoplasma serum serology. The
detection of Histoplasma antigen in urine or serum will make the diagnosis of
active histoplasmosis in this patient, which is the most likely cause of his
presentation given his exposure history.
Erroneously diagnosing histoplasmosis as sarcoidosis can lead to devastating
consequences, as the treatment for the latter is corticosteroid therapy which may
exacerbate the fungal infection.
Shared findings in histoplasmosis and sarcoidosis include bilateral patchy pulmonary
infiltrates, mediastinal or hilar lymphadenopathy, erythema nodosum,
transaminitis, splenomegaly, and an elevated serum angiotensin-converting enzyme
concentration. Noncaseating granulomas are also seen in both diseases.
This patient has acute pulmonary histoplasmosis; however, he is not in respiratory
distress, is not hypoxic, and his symptoms have been present for less than four
weeks. He is classified as having mild to moderate severity of acute pulmonary
histoplasmosis and does not require antifungal therapy unless his symptoms worsen
or persist beyond four weeks.
Research Concepts: Histoplasmosis

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Question 161: A 55-year-old man with a history of chronic obstructive pulmonary disease,
bronchiectasis, and tobacco use disorder is brought to the emergency department (ED)
due to unresponsiveness. His wife says her husband has not felt well for the past four
days because of "an upper respiratory viral infection." His symptoms included generalized
malaise, fevers, shortness of breath, and cough. His home medications are fluticasone and
salmeterol twice a day and albuterol as needed for shortness of breath. He went to an
urgent care center two days ago and was prescribed azithromycin, prednisone, albuterol,
and ipratropium nebulization which only provided temporary relief. In the ED, his vital
signs are blood pressure 140/72 mmHg, heart rate 98/min, respiratory rate 10/min,
temperature 38.3 C (101 F), and pulse oximetry 88% on room air. On physical
examination, the patient is lethargic, mildly responsive to painful stimuli, and has
decreased air movement on auscultation of his chest. Arterial blood gas (ABG) analysis
shows pH 7.02, pO2 55 mmHg, and pCO2 100 mmHg, and chest x-ray reveals bilateral
multifocal infiltrates. The patient is endotracheally intubated and placed on mechanical
ventilation. Initial settings are a respiratory rate of 20/min, tidal volume of 500 mL, a
fraction of inspired oxygen 1.0, and positive end-expiratory pressure of 5 cm H20. He is
started on inhaled bronchodilators, intravenous methylprednisolone, broad-spectrum
antibiotics, and oseltamivir. He becomes asynchronous with the ventilator requiring
sedation and later neuromuscular blockade. His repeat ABG shows a pH of 6.95, pO2 70
mmHg, pCO2 120 mmHg, and he is currently hypotensive.
Due to difficulty with ventilation, the patient is placed on a venovenous extracorporeal
membrane oxygenator (VV-ECMO). The patient is cannulated for VV-ECMO. The inflow
cannula is inserted in the right femoral vein and the outflow cannula in the right internal
jugular vein with flows of 3 liters per minute, a sweep of 4.0, and a fraction of inspired
oxygen of 1.0. ABG on these settings show pH 7.26, pO2 50 mmHg, pCO2 70 mmHg. The
patient is later rolled and cleaned by ICU nursing. The flow alarm triggers after rolling the
patient, so repeat labs are obtained and show a pH of 7.18, PaO2 48 mmHg, and PCO2 86
mmHg. What is the best next step in management?
Choices:

1. Start the patient on inhaled nitric oxide

2. Increase the dose and frequency of methylprednisolone
3. Perform a transesophageal echocardiogram to assess cannula placement
4. Increase oxygen flow to 4 liters/minute

Answer: 3 - Perform a transesophageal echocardiogram to assess cannula placement

Explanations:

It is possible to perform VV-ECMO cannulation blindly, but it is recommended to

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 cannulate for ECMO under direct visualization, usually with fluoroscopy or ultrasound,
to confirm appropriate placement of the inflow and outflow cannulas. Bedside
transesophageal echocardiography can immediately identify the jet from the cannula
pointing in the wrong direction which will cause recirculation. This is likely what
happened in this vignette when the patient was moved.
There are two ways to insert the cannulas in the double VV- ECMO cannulation. The
inflow cannula is usually inserted in the femoral vein and advanced to the junction
of the inferior vena cava (IVC), and the right atrium and the outflow cannula can be
inserted into the right internal jugular vein and advanced through the superior vena
cava to the right atrium. The second approach is to insert the inflow cannula into
the femoral vein and advance to the mid-IVC, and the outflow cannula can be
inserted in the contralateral femoral vein with the tip ending in the right atrium.
Correct placement of the cannulas is important to avoid recirculation phenomenon
(when the oxygenated blood that is being returned to the patient is drained by the
inflow cannula before being circulated through the body). This is usually due to the
two cannulas being in close proximity.
The flow rate, the fraction of inspired oxygen, and the amount of recirculation of
blood will all affect the ability of the VV-ECMO circuit to oxygenate the blood.
Increasing the flow when pO2 is low is appropriate, but the placement of the
cannulas should always be confirmed first.
Research Concepts:

Extracorporeal Membrane Oxygenation In Adults

Question 162: A 32-year-old male presents for complaints of headache, dizziness, and
generalized weakness, that started this afternoon but is progressively worsening. He
works as a painter and was operating a gas-powered paint sprayer indoors for
approximately 10 hours today. He is alert, oriented, and has an unremarkable physical
exam. He reports no medical problems and smokes 1 pack of cigarettes per day as well as
alcohol use socially. Carboxyhemoglobin level obtained via blood gases is 12%. Which of
the following is the next best step in the management of this patient?

Choices:

1. Transfer to a hyperbaric treatment center

2. Treatment with high-flow oxygen until carboxyhemoglobin level is 3%
3. Treatment with high-flow oxygen for 6 hours
4. Cardiac monitoring, ECG, and troponin in addition to normobaric oxygen
Answer: 3 - Treatment with high-flow oxygen for 6 hours

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Explanations:

Current recommendations for asymptomatic patients without high-risk features

is treatment with normobaric oxygen for 6 hours. Oxygen competes with carbon
monoxide for binding at the heme group of hemoglobin. The half-life of
carboxyhemoglobin in room air is 4 hours or more.
However, this is substantially decreased to just 40 to 80 minutes with high-flow
oxygen. By increasing the rate of oxygen flow up to 60 liters per hour, the high
concentration of oxygen molecules can displace carbon monoxide from the
hemoglobin molecule more readily, enhancing elimination.
Though hyperbaric oxygen hastens elimination twice as fast, high-flow oxygen is
more accessible, easier to initiate, and safer with much less concern for
barotrauma.
Treatment with normobaric high-flow oxygen would be appropriate for this patient.
Recommendations currently suggest considering hyperbaric treatment in those with
neuropsychiatric complaints, acute coronary syndrome, those who are comatose or
have an altered level of consciousness, pregnant women, anyone over the age of
65, and those with initial carboxyhemoglobin levels greater than 25%. Hyperbaric
oxygen is not the standard of care in any particular scenario, and any decision to
initiate this should be made in conjunction with a toxicologist and/or Poison
Control, taking into consideration the patient's age, comorbidities, mental status, as
well as feasibility and distance from a hyperbaric center. Despite hastening
carboxyhemoglobin elimination by decreasing the half-life of carboxyhemoglobin to
just 23 minutes, the use of hyperbaric oxygen has not been translated into
improved outcomes or decreased mortality. Of note, hyperbaric oxygen may cause
barotrauma, pulmonary edema, and seizures as well as potentially increase
oxidative stress and free radical production. Although this patient should certainly
receive high-flow oxygen, the appropriate management for asymptomatic patients
and without high-risk features (chest pain, loss of consciousness, altered level of
consciousness, focal neurologic deficits) is treatment for 6 hours or until levels
normalize. A small amount of carbon monoxide is produced endogenously with the
metabolism of heme, so a baseline carboxyhemoglobin level is thought to be
around 1 to 3 percent in non-smokers and as high as 10 percent in smokers. For this
reason, it would be not reasonable to treat the above patient with a goal of 3
percent since their baseline is likely higher. ECG and troponin are not routinely
obtained in carbon monoxide toxicity but are warranted in the presence of angina,
dyspnea, or palpitations.
Management should always include a carboxyhemoglobin level obtained via blood
gases, as well as a pregnancy test in females since this may change management.
Imaging with a chest x-ray or head CT is frequently obtained to rule out other
causes but is not routinely necessary. In cases of non-accidental poisonings, a full
toxicology panel including salicylate/acetaminophen levels and urine drug screen is
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 recommended.

Research Concepts:
Carboxyhemoglobin Toxicity

Question 163: A 45-year-old male presents to the emergency department with dyspnea
on exertion. He reports dyspnea over the past 2 months that has progressively worsened.
He also has a cough that is non-productive. He denies fevers or sick contacts.
Lung auscultation reveals bibasilar fine crackles and his pulse oximetry on room air is
89%. Chest radiography shows peri-hilar infiltrates without air-bronchograms and is
described by the radiologist as a “batwing pattern.” There is no cardiomegaly or pleural
effusions. Which of the following is most likely to confirm the suspected diagnosis?

Choices:

1. High-resolution computed tomography (HRCT) of the chest with contrast

2. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy
3. Measurement of serum granulocyte-macrophage colony- stimulating
factor (anti-GM-CSF) antibody levels
4. Lung biopsy via video-assisted thoracoscopic surgery (VATS)

Answer: 2 - Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy

Explanations:

A batwing pattern on a chest x-ray suggests pulmonary alveolar proteinosis (PAP)

but is not specific. This patient's x-ray does not have air-bronchograms which would
suggest pneumonia.
Also, the x-ray does not show cardiomegaly or pleural effusions which may suggest
cardiogenic pulmonary edema.
CT scanning is likely to show diffuse ground glass with interlobular septal
thickening, also known as "crazy paving." This pattern is suggestive but not
diagnostic. Additional testing is needed to confirm the diagnosis.
Bronchoscopy is able to definitively diagnose pulmonary alveolar proteinosis.
Lavage typically shows increased cellularity with lymphocyte predominance.
Cytology usually shows macrophages with periodic acid–Schiff-positive material.
Lavage alone will confirm the diagnosis in 75% of cases. Bronchoscopy with lavage
is needed to rule out infection as well.
Transbronchial biopsies are positive 42% of the time. Elevated serum anti-GM-
CSF antibody levels are indicative of autoimmune PAP. However, low levels of
GM-CSF antibodies
are present in healthy individuals and are not diagnostic on their own.
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Research Concepts:
Pulmonary Alveolar Proteinosis

Question 164: A 31-year-old male presents to the emergency department with a high
fever for the past two days, vomiting, back pain, and dyspnea. The patient was staying in
a rural cabin noted to have rodents in North Korea and recently returned. Upon
admitting the patient to the intensive care unit for respiratory distress,
thrombocytopenia, hypotension, and marked leukocytosis with premature white blood
cells, the patient asks if there is a point that will predict a good outcome. What phase
would predict good long- term recovery?

Choices:

1. Oliguric
2. Polyuric
3. Convalescent
4. Febrile

Answer: 2 - Polyuric

Explanations:

Hantavirus hemorrhagic fever and renal syndrome is found to have 5 distinct

phases: febrile, hypotensive, oliguric, polyuric, and convalescent.
The febrile period lasts around 3 to 7 days which can be accompanied by
conjunctival hemorrhages and fine palatal petechiae in the mouth. This phase is
followed by the hypotensive phase which yields one-third of the mortality of
hemorrhagic fever and renal syndrome.
The oliguric phase may need treatment with dialysis if renal function deteriorates
significantly. One-half of the fatalities in hemorrhagic fever and renal syndrome
caused by Hantavirus occur in this phase. The onset of the polyuric phase is a positive
prognostic indicator.
The convalescent phase is a return towards the patient's clinical and laboratory
baseline that may take up to 6 months.

Research Concepts:

Hantavirus Syndrome

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Question 165: An adult female presents with a sore throat and a dry cough. She has had a
low-grade fever for 3 days. She says her colleagues at work have had similar symptoms.
The chest x-ray is unremarkable. She has a WBC of 14.6/microL. The provider thinks she
has community-acquired pneumonia. Which of the following would be the best first
choice?

Choices:

1. Azithromycin
2. Ampicillin
3. Trimethoprim-sulfamethoxazole
4. Tetracycline

Answer: 1 - Azithromycin

Explanations:

For patients under 65 with no comorbid conditions and less severe pneumonia,
there are three options, amoxicillin, a macrolide such as clarithromycin or
azithromycin, or doxycycline.
Streptococcus pneumonia, Haemophilus influenzae, and Moraxella
catarrhalis account for approximately 85% of community-acquired
pneumonia.
Patients who are healthy but have received antibiotics in the last three months can be
treated with a macrolide plus amoxicillin- clavulanate.
Patients with comorbid conditions are treated with amoxicillin/clavulanate or a
cephalosporin and either doxycycline or a macrolide. Another option is
monotherapy with a respiratory fluoroquinolone.

Research Concepts:

Community-Acquired Pneumonia

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Question 166: A 16-year-old male diagnosed with acute lymphoblastic leukemia presents
to the emergency department with cough, brownish sputum, and fever. He has a history
of bronchial asthma, which was previously well controlled with regular inhaled
bronchodilators. He has never had such an episode before and believes that his cancer is
spreading to his lungs now. He is taking oral chemotherapy medications and has shown a
good response to therapy but has had prolonged neutropenia. Chest x-ray shows an
infiltrate on the right lower lung zone. His vital signs are normal.
Which of the following organisms is most likely responsible for the patient's condition?
Choices:

1. Streptococcus pneumoniae
2. Aspergillus fumigatus
3. Staphylococcus aureus
4. Mycoplasma pneumoniae
Answer: 2 - Aspergillus fumigatus

Explanations:

Aspergillus species are causative organisms for fungal infection in

immunocompromised individuals. Aspergillus fumigatus is the most common
ubiquitous airborne fungus responsible for allergic bronchopulmonary aspergillosis
(ABPA) in immunocompromised patients. Long duration of neutropenia and high
dose corticosteroids are risk factors.
Aspergillus fumigatus, a widely distributed spore-bearing fungus, causes multiple
diseases in humans. These diseases include aspergilloma, different forms of
hypersensitivity diseases, including ABPA, allergic bronchial asthma,
bronchocentric granulomatosis, extrinsic allergic alveolitis, and invasive pulmonary
aspergillosis.
A. fumigatus has a very small spore (conidia) size (2-3 microns), which enables the
spores to penetrate deeply into the lung. Spores are capable of withstanding
extraordinary atmospheric conditions. The pigment of conidia also confers some
protection against phagocytosis.
In immunocompetent individuals, Aspergillus conidia are easily eliminated from
the airway by innate immune system mechanisms, so no pulmonary fungal
infection manifests. In immunocompromised individuals, Aspergillus conidia are
not eliminated due to host immune defense imbalance, so they colonize airways,
germinate into somatic hyphae and stimulate a chronic allergic inflammatory
response.

Research Concepts: Allergic Bronchopulmonary Aspergillosis

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Question 167: A 60-year-old Indonesian man is brought by ambulance with generalized
weakness, joint pain, and double vision. The family reported that the patient had fallen
twice this week due to the inability to ambulate. The wife states that the patient had been
dragging his feet. Further history revealed that they had gone for a 30th wedding
anniversary cruise two weeks ago and ate "just about everything." The patient returned
home and felt ill with a fever, productive cough, and sinus congestion resolved with rest
and acetaminophen. The patient received his annual influenza vaccination. On neurological
exam, the patient had inaccuracies on the visual field testing, blunted corneal reflexes,
numbness in his mouth, and loss of taste for sweets. Deep tendon reflexes showed trace in
patellar deep tendon reflexes and +1 in upper extremities.
Relevant past medical history includes past polysubstance use, intravenous heroin, and
inhaled marijuana, with the last use being 25 years ago. A chest X-ray showed hilar
adenopathy. A lumbar puncture was performed, and cerebrospinal fluid studies showed
elevated protein. Serological studies were positive for anti- ganglioside antibodies. Pulse
oximetry showed a saturation of 84% on room air. An ABG was performed and showed a
PaO2 of 50 mmHg and a PaCO2 of 52 mmHg. Which of the following findings will predict a
poor prognosis in this patient?

Choices:

1. Presence of autoantibodies against ganglioside proteins

2. Hilar adenopathy on chest X-ray
3. Multiple focal cranial nerve deficits on exam
4. Evidence of hypoxemia on room air

Answer: 4 - Evidence of hypoxemia on room air

Explanations:

This clinical presentation is suspicious for Miller Fisher syndrome (MFS), a rare
variant of Guillain Barre syndrome (GBS). The classical triad of symptoms includes
acute ophthalmoplegia, areflexia, and ataxia. Distal lower extremity weakness, pain,
and paresthesias may be present. Other physical exam findings include diplopia,
cranial nerve palsies, and dampened corneal reflex. However, clinical symptoms
alone do not predict this condition's prognosis.
The presence of elevated cerebrospinal fluid (CSF) protein with normal findings in
the rest of CSF studies should be suspicious for GBS. The anti-ganglioside antibody
is a specific finding for Miller Fisher syndrome, brainstem encephalitis, or other
forms of GBS, including a pharyngeal-cervical-brachial weakness. In the setting of
hyporeflexia and lack of oropharyngeal dysphagia, Miller Fisher is the most likely
diagnosis. However, serology is not used as a predictor of mortality and morbidity;
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 but rather as a specific finding to confirm the diagnosis of MFS.
Multifocal deficits in MFS have been reported in the literature, not surprising given
the pathophysiology of this condition, including the targeting of the myelin sheaths
of the central and peripheral nervous system. Although this phenomenon is known
in many cases of MFS, it is not a predictive factor of patient mortality or morbidity.
The most worrisome finding in a patient more than 50 years of age regarding
prognosis is the presence of hypoxemia on room air, as it is a risk factor for
impending respiratory failure in patients. Additionally, this finding is a major
criterion for intensive care unit admission in adults. Mechanical ventilation and ICU
admission are recommended in patients with at least one major criterion or 2
minor criteria. Major criteria include hypercapnia with PaCO2 above 48 mm Hg,
hypoxemia with PaO2 below 56 mm Hg while the patient is breathing ambient air,
vital capacity less than 15 mL/kg of body weight, and negative inspiratory force
less than -30 cm H2O. Minor criteria include an inefficient cough, impaired
swallowing, and atelectasis. Life-threatening complications are more likely to occur
in patients who meet the criteria for intensive care unit admission. These
complications include sepsis, pneumonia, pulmonary embolism, autonomic
dysfunction, and gastrointestinal bleeding. The risk of mortality or morbidity is
higher in these patients. Among severely affected patients, 20 to 33% may be
unable to walk for more than six months after symptom onset, especially if
infected with Campylobacter jejuni. Patients may also suffer from chronic
psychiatric illness due to persistent pain and disability, among other complications.

Research Concepts:

Miller Fisher Syndrome

Question 168: A patient with severe neutropenia presents with pneumonia. Bronchial
alveolar fluid reveals dichotomously branching, generally with acute angles and septate
hyphae. What is the most likely etiology?

Choices:

1. Cryptococcus
2. Candida
3. Aspergillus
4. Malassezia

Answer: 3 - Aspergillus

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Explanations:

Aspergillus spores are commonly airborne. These asexual spores are responsible for
initiation of aspergillosis. Inhalation of infectious conidia is a frequent event.
Invasive infections with Aspergillus are controlled by phagocytic cells such as airway
epithelial cells and alveolar macrophages. Activation of cellular immunity is important
in killing invasive hyphae.
The most common causal agent of invasive aspergillosis, Aspergillus fumigatus,
responds to low-oxygen environments for pathogenesis and disease progression. It
is one of the major microbes in cystic fibrosis.
For the earliest stages of the disease, a chest x-ray is less sensitive than a chest CT.
The pulmonary form of the disease classically presents as single or multiple
nodules that may or may not be associated with cavitation, consolidations, or
peribronchial infiltrates. Tree-in-bud patterns may be seen in some cases.

Research Concepts:

Aspergillus Fumigatus

Question 169: A 35-year-old female comes into the office with the chief complaint of
shortness of breath. She was diagnosed with asthma four years ago and was treated
with albuterol inhalers.
However, she noticed that her dyspnea increased during her recent pregnancy six months
ago. Vital signs are temperature of 37.5 C, blood pressure 120/68 mmHg, heart rate of 69
bpm, and oxygen saturation of 89% on ambient air. Her chest auscultation reveals
diminished breath sounds over the middle lung zone without crackles or wheezing. The
rest of the physical exam is unremarkable. What is the best next step in diagnosis?

Choices:

1. High resolution computed tomography (HRCT)

2. Oral azithromycin
3. Chest x-ray
4. Complete blood count

Answer: 3 - Chest x-ray

Explanations:

High resolution computed tomography (HRCT) is the best radiological diagnosis for

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 suspected lymphangioleiomyomatosis. However, starting with a chest x-ray is
recommended as an initial test to exclude other diagnoses.
The patient does not have signs of infectious etiology. Although her decreased
breath sounds on auscultation could be due to pneumonia, she will still require a
chest x-ray before initiating treatment.
Chest x-ray is a reasonable diagnostic test for the initial diagnosis of
lymphangioleiomyomatosis. Cysts are difficult to be seen on the chest x-ray.
However, it can help show pleural effusions or pneumothorax if present and can
help exclude other diagnoses.
Complete blood count would not be the first test to order in this patient. Given her
respiratory symptoms and no indication of systemic disease, CBC is not mandatory at
this point.

Research Concepts:
Lymphangioleiomyomatosis

Question 170: A 55-year-old woman living in a low- and middle- income country (LMIC)
presents with shortness of breath and cough for several months that is not improving. She
denies a history of smoking tobacco and admits to cooking in her home using a wood
stove. She is a thin woman who appears older than her stated age and is in no apparent
distress. Her blood pressure is 120/75 mmHg, pulse 90/min, and oxygen saturation 90%
on room air. Lung auscultation demonstrates distant breath sounds bilaterally. The rest of
the examination is within normal. What is the best next step in assessing this patient?

Choices:

1. No test is necessary as the patient has classical symptoms of chronic obstructive

pulmonary disease (COPD)
2. Obtain an arterial blood gas analysis
3. Obtain a chest x-ray
4. COPD screening questionnaire combined with peak expiratory flow measurement

Answer: 4 - COPD screening questionnaire combined with peak expiratory flow

measurement

Explanations:

Recent studies have shown that questionnaires, such as COPD in LMICs Assessment
questionnaire (COLA-6), combined with peak expiratory flow measurement, are
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 accurate and feasible in screening for chronic obstructive pulmonary disease
(COPD).
Eighty to ninety percent of COPD deaths occur in low- and middle-income countries
(LMICs); therefore, screening tools can help change the outcome of undiagnosed
disease.
A third of people in LMICs have a history of cigarette smoking, and another third
have exposure to biomass smoke.
Screening for COPD in asymptomatic adults is not beneficial in developed
countries. No evidence exists that screening for COPD in asymptomatic patients
will improve quality of life, morbidity, or mortality.

Research Concepts:

Chronic Obstructive Pulmonary Disease

Question 171: A 65-year-old female with a past medical history positive for asthma,
obesity, hypertension, and diabetes presents to the office with a chief complaint of
cough. The cough is mostly dry and happens at night and early morning after waking up.
She has chronic shortness of breath with moderate activity. In the clinic, her vitals are
normal, and physical examination is just remarkable for obesity and decreased breath
sounds bilaterally. Lab workup shows normal complete blood count and elevated
bicarbonate on the basic metabolic panel. Thyroid function tests are within normal limits.
Chest x-ray shows basal atelectasis. Pulmonary function tests show FEV1 of 72%
predicted, FEV1: FVC 82%, TLC 72% of predicted, DLCO 104% of predicted. She had an
excellent bronchodilator response. For her asthma, she is currently using an albuterol
inhaler when required. She does not give any pertinent history for allergies, denies any
postnasal drip or runny nose, and does not have any pets. The clinician starts her on a
longer-acting beta-agonist and steroid inhaler. Her inhalational technique is appropriate.
Two months later, her symptoms have not changed. The clinician decides to add a proton
pump inhibitor and see if gastroesophageal reflux disease is causing her symptoms.
Follow-up after one month reveals that her symptoms are only 20% better, and she is
frustrated. What is the next best step to look for the cause of her cough and treat it
accordingly?

Choices:

1. Her cough is psychogenic, and she needs a psychiatric referral

2. Cough is likely related to her asthma, and she should be given a steroid challenge
3. Her cough could be related to sleep apnea, and she should have a sleep study and
get the treatment accordingly

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 4. She should undergo bronchoscopy to clear her lungs

Answer: 3 - Her cough could be related to sleep apnea, and she should have a sleep study
and get the treatment accordingly
Explanations:

Chronic cough can be very frustrating for a patient and clinician and should be
approached systematically. The patient can have multiple causes of her cough.
Taking a meticulous and detailed history is very important. Upper airway cough
syndrome is the most common etiology of a chronic cough. There is a broad
spectrum of illnesses that encompass this disease, including allergic rhinitis, non-
allergic rhinitis, post-infectious, and bacterial or viral rhinosinusitis.
Essentially, upper airway cough syndrome is a longstanding post nasal drip that
irritates the upper airway, inducing cough. A chronic cough is a more difficult
diagnosis and typically will require referral to a cough specialist or a pulmonologist
for evaluation. Possible causes include upper airway cough syndrome,
gastroesophageal reflux disease, non-asthmatic eosinophilic bronchitis, chronic
bronchitis, postinfectious cough, intolerance to angiotensin-converting enzyme
inhibitor medication, malignancy, interstitial lung diseases, obstructive sleep
apnea, chronic sinusitis, and psychosomatic cough.
The next best step in approaching her chronic cough would be to get a sleep study
and rule out obstructive sleep apnea. If a cough is mostly in the night, and the
patient has signs and symptoms suggestive of obstructive sleep apnea, then one
may order a sleep study to confirm the diagnosis and treat sleep apnea
accordingly. Obstructive sleep apnea is characterized by a partial or complete
obstruction of the airway transiently during sleep. This increase in airway
resistance causes a reflexive diaphragmatic and chest muscle spasm and cough to
open the obstructed airway and pull air into the lungs. This typically occurs as a
result of lax musculature in the pharynx or due to the increased weight of the neck
collapsing the pharynx in patients with obesity

Research Concepts:

Cough

Question 172: A patient with pulmonary alveolar proteinosis tested positive for anti-GM-
CSF IgG antibodies. He has significant dyspnea on exertion. He is depressed after his poor
performance on his pulmonary function tests. He asks if his lung function will ever return
to normal. What is true about pulmonary lung function testing and pulmonary alveolar
proteinosis?

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 Choices:

1. A reduced diffusion capacity of around 40% to 50% is the most common finding
2. A reduced FEV1 to FVC ratio of around 60% to 70% is the most common finding
3. The alveolar-arterial gradient is typically less than 10 mmHg
4. Oxygen desaturation on a 6-minute walk test is only a late complication of
pulmonary alveolar proteinosis

Answer: 1 - A reduced diffusion capacity of around 40% to 50% is the most common finding

Explanations:

A restrictive pattern is the most common finding on spirometry in patients with

pulmonary alveolar proteinosis (PAP).
Spirometry may show an airflow obstruction or a mixed restriction and obstruction
in patients who smoker or have underlying emphysema.
A reduced diffusion capacity is the most common finding on pulmonary function
testing and is often as low as 40% to 50%. Hypoxia is common in PAP and patients may
present with desaturations on a walk test or an elevated alveolar-arterial gradient
above 40 mmHg.
Research Concepts:

Pulmonary Alveolar Proteinosis

Question 173: A patient with cirrhosis of liver presents with anginal chest pain. A stress
test is positive. The patient undergoes cardiac catheterization, and a selective coronary
angiogram is negative for coronary artery disease. But the dyes injected into the right and
left coronary ostia filled the ventricles. Which of the following mechanisms is most likely
responsible for the patient's symptoms?

Choices:

1. Steal phenomenon
2. Increased oxygen demand due to chamber hypertrophy
3. Increased blood flow to ventricles
4. Due to hypoalbuminemia

Answer: 1 - Steal phenomenon

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Explanations:

Patients with cirrhosis of the liver are prone to coronary cameral fistula due to
hyperestrogenic state, which leads to blood emptying into the veins or chambers
without perfusing capillaries. Impairment in supply-demand mismatch leads to
anginal chest pain.
Chamber hypertrophy is not found in a cirrhotic patient unless they have
concomitant valvular heart disease.
Increased blood flow to ventricles leads to hypervolemia and congestive heart failure.
It is not known to cause angina.
Hypoalbuminemia leads to ascites but no angina.

Research Concepts:

Coronary Cameral Fistula

Question 174: A patient presents to the clinic and complains of photophobia, has light skin,
and silvery hair. He appears to be an albino and complains of suffering frequent bouts of
sinusitis, pneumonia, and acne. He was diagnosed with neuropathy at age 16, but no one
has ever diagnosed the cause. What syndrome do you suspect might be responsible for his
symptoms?

Choices:

1. Sezary Disease
2. Caplan Syndrome
3. Felty Syndrome
4. Chediak-Higashi Syndrome

Answer: 4 - Chediak-Higashi Syndrome

Explanations:

Chediak-Higashi Syndrome typically presents with clotting problems, leaving the

patient prone to easy bruising.
Chediak-Higashi Syndrome causes neuropathy, usually diagnosed when the patient
is a teenager.
Chediak-Higashi Syndrome causes impaired phagocytosis of bacteria, which
impairs bacteriolysis, leading to frequent infections of the skin, mucous
membranes, and respiratory tract from bacterial infections.
People with Chediak Higashi Syndrome suffer from oculocutaneous albinism. They
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 typically have light pigmentation of the skin, hair, and eyes, and frequently
complain of photophobia and sensitivity to light.

Research Concepts:
Lymphoproliferative Disorders

Question 175: A 65-year-old female presents with a headache, dizziness, and confusion.
She has no history of smoking and is taking no medication. On exam, she is tachycardic,
hypotensive, confused, and agitated. Blood work reveals an elevated
carboxyhemoglobin, which remains elevated with 100% oxygen therapy for 4 hours.
What is the treatment of choice?

Choices:

1. Hyperbaric oxygen
2. Ethylenediaminetetraacetic acid (EDTA)
3. Dialysis
4. Non-rebreathing mask

Answer: 1 - Hyperbaric oxygen

Explanations:

Hyperbaric oxygen therapy is the fastest way to eliminate carbon monoxide from
the blood.
Hemoglobin has a very high in affinity for carbon monoxide. Hyperbaric oxygen causes
the carbon monoxide to be displaced from the hemoglobin molecule faster than it
would occur under normobaric or sea level conditions.
Normobaric oxygen via face mask should be initiated as soon as possible. However,
hyperbaric oxygen treatment is the treatment of choice for a significant carbon
monoxide poisoning.

Research Concepts:

Carbon Monoxide Toxicity

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Question 176: A 70-year-old male presents with a 3-month history of dyspnea with a
recent occurrence of hemoptysis. He has a past medical history of a 40 pack-year smoking
history. His vitals are stable, and his physical examination is unremarkable. A computed
tomography (CT) scan of the chest shows a 4.3 cm spiculated mass in the left upper lobe
with an enlarged hilar lymph node. The patient undergoes surgical excision which shows
that the mass is a poorly differentiated adenocarcinoma with negative margins. Hilar
lymph nodes are positive, but mediastinal lymph nodes are negative. What is the most
appropriate management?

Choices:

1. Palliative care
2. Adjuvant chemotherapy
3. Adjuvant chemoradiation
4. Adjuvant radiation

Answer: 2 - Adjuvant chemotherapy

Explanations:

Treatment options for non-small-cell lung carcinoma (NSCLC) include

chemotherapy, radiation, surgical resection, and combinations of these. This
patient has options and should not be directed to palliative care at this time.
This patient has stage II non-small cell lung cancer (NSCLC) as his mass is less than 5
cm and is localized. With stage II and stage III NSCLC, it is recommended to
undergo adjuvant chemotherapy.
Studies have not shown a survival benefit with chemoradiation for stage II NSCLC.
Chemoradiation can be an option for stage III NSCLC with mediastinal
lymphadenopathy.
As this patient had negative surgical margins, it would not be recommended that
he undergo radiation.

Research Concepts:

Non Small Cell Lung Cancer

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Question 177: A 55-year-old male who recently flew from India is brought to the
emergency department for hemoptysis. The patient was first seen at the primary care
clinic where he complained by fevers and chills as well as profuse sweating at night. He
then proceeded to cough up a large volume of blood and was sent to the emergency
department. The patient was tried on a course of inhaled tranexamic acid. This did not
control the bleeding. Finally, the decision was made to intubate the patient. After, the
patient was sent to the CT which showed a left upper lobe cavitary lesion and also a
bronchial artery source of the bleeding. The patient has a blood pressure of 101/70
mmHg, a heart rate of 98 bpm, oxygen saturation of 100%, and currently being ventilated
at a respiratory rate of 15 breaths per minute. What is the next step in management?

Choices:

1. Perform bronchoscopy and use cold saline lavage in order to control the source
of bleeding and isolate the etiology of the hemoptysis
2. Take the patient to the operating room for surgical lobectomy to bleeding control
3. Replace the single-lumen endotracheal tube with a double lumen endotracheal tube
4. Perform bronchial artery embolization to stop bleeding

Answer: 4 - Perform bronchial artery embolization to stop bleeding

Explanations:

CT scan is as accurate as bronchoscopy in localizing source of bleeding, and CT is

superior for finding the cause of the bleeding. The patient has risk factors that
point to tuberculosis as the source of bleeding, and bronchoscopy can further
exacerbate hemoptysis by stimulating coughing.
Surgical lobectomy has high mortality rates in emergent cases. Although the
patient may need a lobectomy in the future, a stable patient would benefit from
embolization before going through scheduled lobectomy.
Double-lumen endotracheal tubes are technically difficult to place and do not allow
optimal source control due to the smaller diameter of the lumens.
Immediate success rates of bronchial artery embolization are reported to be 82% to
98%, and would most benefit a stable patient in the immediate term. While surgical
lobectomy may be required down the line due to recurrence, the patient can be
further worked up and medically optimized during the interim.
Research Concepts:

Pulmonary Hemorrhage

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Question 178: A 65-year-old male with history of stage IIIb squamous cell cancer of the
lung presents with increasing dyspnea on exertion and orthopnea ongoing for four weeks
with gradual worsening. On presentation, he is noted to be 90% on ambient air and is
tachypneic to a respiratory rate of 30/minute. Labs are at baseline. A chest x-ray
demonstrates large pleural effusion with contralateral mediastinal shift. He undergoes
large-volume thoracentesis of 3 liters with immediate relief of dyspnea. The next morning,
he develops respiratory distress with new hypoxia requiring supplemental oxygen. What is
the most likely cause of the patient's newly developed respiratory distress?

Choices:

1. Pneumothorax ex vacuo
2. Hemothorax
3. Reexpansion pulmonary edema
4. Pulmonary embolism

Answer: 3 - Reexpansion pulmonary edema

Explanations:

Reexpansion pulmonary edema occurs after the removal of fluid or air from the
pleural space quickly over a short period of time. The mechanism of edema is
believed to be increased capillary permeability. Risk factors for this condition
include young age, a long duration of lung collapse, and rapid reexpansion.
Treatment is largely supportive.
Thoracentesis operators should not perform large-volume thoracentesis. No more
than 1.5 liters of fluid should be removed in any instance.
Research Concepts:

Malignant Effusion

Question 179: An African American female is brought to the emergency department with
acute onset shortness of breath that has progressively worsened over the past 4 hours at
home. She has a peak flow meter at home, and the number prior to arrival was 220 L,
which is 51% of predicted. She has known bronchial asthma but hasn't had an
exacerbation requiring an ED visit or hospitalization before. Her FEV1 in spirometry six
months back was at 89%. After 2 hours of management in the emergency department,
she feels significantly better and is able to speak in short sentences. Last breathing
treatment was 15 minutes back. Repeat PEFR is 310 L/min, which is 68% of predicted. Her
wheezing has improved, and she wants to go home. Which of the following is the next
best step in the management of this patient?
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Choices:

1. Discharge her home as her initial PEFR was above 50% and 200 L/min
2. DIscharge her home as PEFR improved by 12% and above 300 L/min
3. Assess one more peak flow and symptoms in another 2 hours in the ED
4. Discharge her home as she has normal FEV1 and no prior history of severe
exacerbation

Answer: 3 - Assess one more peak flow and symptoms in another 2 hours in the ED

Explanations:

Kelsen and colleagues in a study showed a 50% relapse rate in patients treated for 2
hours or less in a facility as opposed to 4% in those treated and observed for an
additional 2 to 4 hours.
Therefore even though she feels better, she should be requested to stay back in ED
for at least 4 hours.
In a study by Stein and Cole, an adequate response to treatment in ED was
characterized as visual improvement in symptoms which sustains 30 minutes or
beyond the last bronchodilator dose, and a PEFR greater than 70% of predicted. Her
response immediately post-treatment was 67%.
In the same study by Stein and Cole, initial PEFR on presentation did not predict
the need for hospitalization.
An adequate response to treatment was also characterized by an improvement in
FEV1 by 10% or above 70% of predicted, although it may not be the most practical
approach at the bedside.
Research Concepts: Status Asthmaticus

Question 180: A 45-year-old male presents with nonspecific symptoms of worsening

dyspnea and cough. He is a lifelong nonsmoker and recently moved from the Ohio river
valley area. He works as a welder. He was treated for 1 year for tuberculosis 20 years ago.
He does not take any medication regularly but took nitrofurantoin for a urinary tract
infection a year ago. High-resolution CT shows diffuse, lower lobe predominant, ground glass
changes. A surgical lung biopsy is positive for desquamative interstitial pneumonia (DIP).
What in his history is a possible risk factor for developing DIP?

Choices:

1. Prior residence in the Ohio river valley area

2. History of tuberculosis
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3. Use of nitrofurantoin a year ago
4. Occupational history

Answer: 4 - Occupational history

Explanations:

The Ohio river valley area is known for putting individuals at risk of exposure to
Histoplasma capsulatum infection, not diffuse interstitial lung disease like
desquamative interstitial pneumonia (DIP).
There has been no association known between past exposure of tuberculosis and
DIP. Tuberculosis leaves apical predominant scarring, as opposed to a lower lobe
distribution in DIP. Nitrofurantoin can cause acute pneumonitis and fibrosis but has
not been associated with DIP.
Welders, machinists, polishers, and tool grinders with exposure to copper,
beryllium, and nickel are the most common occupational exposures associated
with DIP.
Research Concepts:

Desquamative Interstitial Pneumonia

Question 181: A 25-year-old female comes to an outpatient clinic with a yearly cough
which starts only after a cold in late fall and early winter season and lasts until mid-
summer. During this time patient has severe coughing spells and the spells get better
without treatment. She denies any wheezing, paroxysmal nocturnal dyspnea, post nasal
drip, allergies, gastroesophageal reflux-like symptoms, and denies choking on food.
Family history is noncontributory. She does not have any pets or recent travel. She denies
intravenous drugs or alcohol abuse and is a nonsmoker.
Physical examination is unremarkable. Blood workup, spirometry, and chest x-ray are
normal. What is the most likely cause of the cough?

Choices:

1. Cough variant asthma

2. Aspiration
3. Chronic obstructive pulmonary disease
4. Sinusitis

Answer: 1 - Cough variant asthma

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 Explanations:

Cough variant asthma presents primarily with coughing, not wheezing as in typical
asthma.
These patients will have normal spirometry at baseline, but positive methacholine
challenge, when tested.
This should be suspected if a cough is non-productive, repetitive, occurs day and
night, and is exacerbated by exercise, cold air or upper respiratory infection.
Look for positive family history or seasonal variation. This is thought to be due to
the fact that cough receptors are more prevalent in the proximal airways, and
decrease in density as the airways get smaller. The inflammation is more prominent
in the proximal airways where cough is stimulated, and less so distally, where
inflammation and narrowing would cause wheezing and dyspnea. Treatment is the
same for cough variant asthma as for typical asthma.

Research Concepts:

Cough

Question 182: A 50-year-old male with a history of chronic obstructive pulmonary disease
(COPD) was admitted for acute hypercapnic and hypoxic respiratory failure secondary to
COPD exacerbation. He developed severe acidosis from hypercapnia and required
immediate intubation and admission to the intensive care unit. On the second day of
hospitalization, he was improving, and plans were made to start a weaning trial the next
morning. Overnight the ventilator starts sounding alarms. When the clinician arrives, he
sees that the ventilator shows a peak pressure of 58 and a plateau pressure of 26. A
physical exam reveals bilateral breath sounds and good air movement. There is no
engorgement of the jugular veins, and the blood pressure is within normal limits. What
are the most likely diagnosis and the next step in management?
Choices:

1. Acute mucous plugging or kink in the airway; suction the patient and assess airway
2. Worsening COPD; give a pulse dose of corticosteroids and start continuous
nebulizer treatment
3. Tension pneumothorax; place a needle in the second intercostal space followed by
a chest tube
4. Air trapping secondary to auto-PEEP; adjust the I:E
(inspiratory:expiratory) ratio

Answer: 1 - Acute mucous plugging or kink in the airway; suction the patient and assess
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airway
Explanations:

An increase in the peak pressure without change in plateau pressures is indicative

of increased airway pressures, which is likely secondary to a mucous plug, the
patient biting down on the tube, or the tube being kinked. Initial management is to
evaluate the airway and suction the patient for possible mucous plug(s).
Worsening chronic obstructive pulmonary disease would likely present as decreased
breath sounds bilaterally and poor air movement. Also, a synchronous increase in
plateau pressure would be expected.
Tension pneumothorax would present with hypotension, hypoxia, and increased
plateau pressure. One would expect for the patient to have decreased breath
sounds unilaterally and to have jugular venous distention.
Auto-PEEP with air trapping causes an increase in both peak and plateau pressures.
Patients frequently seem to be dyssynchronous with the ventilator.

Research Concepts: Ventilation Assist Control

Question 183: A 17-year-old male involved in a knife fight is brought into the emergency
department by emergency medical services with dyspnea and hemoptysis secondary to an
anterior neck and trachea laceration below the thyroid cartilage. His oxygen saturation is
87% and falling. The patient is unconscious, and despite two attempts at endotracheal
intubation, a definitive airway has not been established. What is the best method of
securing this patient’s airway?

Choices:

1. Cricothyrotomy
2. Tracheostomy through existing injury
3. Tracheostomy above the level of injury
4. Tracheostomy below the level of injury

Answer: 2 - Tracheostomy through existing injury

Explanations:

With a tracheal injury, cricothyrotomy is not indicated due to the cricoid cartilage
being a potential stent maintaining the airway open and the risk of damaging it.
Tracheostomy through an existing injury preserves the most tissue for later repair.
Airway adjuncts above the level of the injury would not be beneficial for obtaining
proper respiration.
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 After tracheal injury repair, a tracheostomy below the level of the injury may be used
to protect the healing area.

Research Concepts:

Tracheal Injury

Question 184: A 28-year-old male with no prior history is admitted to the intensive care
unit for acute hypoxic respiratory failure. He has no prior medical problems but is a
current smoker. He had recently started smoking a month back due to anxiety issues.
His wife at the bedside denied any use of medications recently or illicit substances. She
reports that he was well until about 2 days ago when he started feeling short of breath on
walking, and today he could barely move without getting short of breath and gasping for
air. When he arrived in the emergency department, he was found to have pulse oximetry
of 65% on room air with a respiratory rate of 35/minute, so he was intubated. He is
currently intubated on assist control setting of tidal volume 400, rate of 22, FiO2 of 80%
and PEEP of 14. He is sedated and synchronous with the ventilator. On examination, he
has bilateral crackles, and his plateau pressure on the ventilator is 28. S1 and S2 are
heard, no murmurs or rubs, the abdomen is soft, nontender with normal bowel sounds,
extremities are warm with good peripheral perfusion, no rashes are seen. Chest x-ray that
shows bilateral opacities occupying most of the lung fields bilaterally, no lobar
consolidation or pleural effusions are seen. CBC shows an elevated WBC count of 14.3
with 83% neutrophils.
Electrolytes, renal function, and liver function tests are all within normal limits. A urine
drug screen was done which was negative. He is started on ceftriaxone, azithromycin,
pantoprazole, and enoxaparin. A bronchoalveolar lavage is done which shows RBC 176,
WBC 652 with 35% eosinophils, 43% neutrophils and 22% macrophages. The gram stain is
negative for organisms. What would be the best next step in management?
Choices:

1. Intravenous methylprednisolone
2. Chest CT without contrast
3. Upgrade antibiotics to vancomycin and cefepime
4. Consult thoracic surgery for a VATS guided lung biopsy

Answer: 1 - Intravenous methylprednisolone

Explanations:

Idiopathic acute eosinophilic pneumonia is a rare disease, predominantly occurring in

young male smokers
There is a temporal association with cigarette smoking.
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 Most patients with acute eosinophilic pneumonia have a severe hypoxemic
respiratory failure, with at least 70% patients needing mechanical ventilation.
Intravenous corticosteroids are the mainstay of therapy with a clinical response seen
as early as 12 hours, and almost always within 48 hours.
Research Concepts: Pulmonary Eosinophilia

Question 185: A 68-year-old female presents for complaints of 4-month left-sided chest
pressure and shortness of breath. She has a significant medical history of
gastroesophageal reflux (GERD), chronic obstructive pulmonary disease (COPD), and
hypertension. The patient describes her symptoms are worse with exertion and relieved
with rest. Her current medications are lisinopril, hydrochlorothiazide, albuterol, and
combination inhaled corticosteroid/long-acting beta agonist. On physical exam, vitals are
blood pressure 140/80 mmHg, heart rate 90 bpm, respiratory rate 20/minute, and
oxygen saturation 94% on room air. A lung exam is significant for bilateral end-
expiratory wheezes throughout all lung fields. ECG is significant for left axis deviation
and left ventricular hypertrophy (LVH). The patient is planned for a cardiac stress test.
Which of the following diagnostic tests is contraindicated in this patient?

Choices:

1. Coronary catheterization
2. Dobutamine stress echocardiography
3. Exercise stress echocardiogram
4. Adenosine myocardial perfusion imaging

Answer: 4 - Adenosine myocardial perfusion imaging

Explanations:

Adenosine is a vasodilator that can cause bronchospasm. Active wheezing in

asthma and COPD are contraindications for pharmacologic vasodilators.
Adenosine and other pharmacologic vasodilators assess significant coronary artery
disease by a mechanism called a coronary steal.
Other vasodilators, such as regadenoson and dipyridamole, like adenosine, are
contraindicated in patients who are actively wheezing as they can cause
bronchospasm.
Adenosine has a very short half-life, and adverse effects are usually transient and
short-lived. However, bronchospasm can cause significant and fatal consequences
and should be avoided in patients with active wheezing.

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Research Concepts:

Adenosine

Question 186: A 32-year-old woman with a past medical history of acute myelocytic
leukemia presents complaining of cough with a small amount of bright red blood. She
had a one-week history of cough productive of thick brown sputum, fever, and pleuritic
chest pain. A chest x-ray done 5 days ago revealed a right upper lobe infiltrate; she was
immediately started on oral antibiotics by her primary care provider. However, the
symptoms persist. The patient underwent allogeneic stem cell transplantation for her
acute myelocytic leukemia 5 weeks ago, complicated by acute graft- versus-host disease
and neutropenia. Temperature is 39.5 C (103. 1 F), blood pressure is 100/62 mmHg, pulse
is 110/min, and respiratory rate is 20/min. The physical exam is significant for right- sided
crackles. Laboratory results show leukocytes 1500/microL, hematocrit 28%, and platelets
138,000/microL. Chest x-ray shows a right upper lobe infiltrate, increased in size
compared to the previous x-ray. Chest CT scan reveals several nodular lesions with
surrounding ground-glass opacities in the right upper lobe. Sputum gram stain shows no
organisms. What is the best initial therapy for this patient?

Choices:

1. Voriconazole
2. Voriconazole + caspofungin
3. Caspofungin
4. Embolization
Answer: 1 - Voriconazole

Explanations:

Caspofungin is effective against invasive aspergillosis in patients who are

refractory to or not tolerating voriconazole. The main population at risk of
developing invasive aspergillosis is immunocompromised patients. These patients
will typically present with a triad of fever, chest pain, and hemoptysis. Chest CT
reveals pulmonary nodules with the "halo" sign. Treatment consists of
voriconazole with or without caspofungin.
Caspofungin is not recommended as first-line therapy for invasive aspergillosis.
Patients on caspofungin should be monitored for hepatotoxicity, as it has been
associated with increased liver enzymes.

Research Concepts:Caspofungin
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Question 187: A 60-year-old male patient presents with severe multilevel spondylosis
presents with progressive weakens of his upper extremities. He is not able to lift his both
hand above the shoulder and not able to do any fine activities with his hands. For the past
4 weeks, his weakness has progressed significantly. He also reports progressive exertional
breathlessness. His reports that when he lays down flat, he gets choking sensation and has
to get up from the bed. His MRI of spine shows severe multilevel cervical cord
compression. Chest x-ray showed elevated left diaphragm. What is the next best step in
the evaluation of this patient?
Choices:

1. MRI of the brain to look for intracranial pathology as strokes are common in this
patient population
2. Echocardiogram to rule out congestive heart failure in view of orthopnea
3. Polysomnography to rule out sleep apnea as patient reports symptoms in the
night
4. Ultrasound of thorax to look for diaphragmatic movements with deep breathing
to rule out diaphragmatic palsy

Answer: 4 - Ultrasound of thorax to look for diaphragmatic movements with deep breathing
to rule out diaphragmatic palsy
Explanations:

Diaphragmatic palsy is usually detected incidentally on routine chest x-ray as an

elevated diaphragm. Normally the dome of the right diaphragm is at the level of the
anterior end of the fifth rib, and the left diaphragm is one intercostal space lower
than that. All patient with suspected diaphragmatic palsy should undergo
fluoroscopic evaluation to look for the caudal and outwards movements of the
diaphragm with deep inspiration or sniffing. In the recent times, ultrasound of the
chest is increasing used to detect diaphragmatic movements. It can be done bedside
and also avoids the radiation exposure of fluoroscopic examination. The diaphragm
appears as a thin hypoechoic line when viewed through the subhepatic or sub
splenic view on b mode. On deep inspiration, diaphragm contacts and moves
towered abdomen.
This can be easily measured and tracked in the M mode, and the diaphragmatic
excursion can be measured.
In severe paralysis, the normal diaphragmatic contraction on the opposite side will
create negative pressure and sucks the diaphragm into the thorax during the
inspiration causing paradoxical cranial movements of the diaphragm with
inspiration.
Research Concepts: Diaphragm Disorders

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Question 188: A 68-year-old male current smoker with a 30- pack-year history presents
with an impaired vision that improves with the chin-up position. He also reports
occasional left shoulder pain, which he attributes to lifting heavy objects at work. The
exam reveals left eyelid drooping, a warm and dry left side of the face, and mild weakness
of his left-hand grip. What is the initial step in diagnostic management?

Choices:

1. Chest x-ray
2. Computed tomography (CT) scan of the chest with contrast
3. Magnetic resonance imaging (MRI) of the chest
4. Bronchoscopy

Answer: 1 - Chest x-ray

Explanations:

Superior pulmonary sulcus tumors, also called Pancoast tumors, arise from the
apical pleuropulmonary groove superior to the first rib. When these tumors involve
the surrounding structures such as the brachial plexus, cervical paravertebral
sympathetic nervous system, and stellate ganglion, they cause a group of signs and
symptoms collectively called Pancoast syndrome.
Pancoast or superior sulcus tumors, when they compress or invade the surrounding
structures, cause a group of symptoms collectively called Pancoast syndrome. They
typically involve the brachial plexus first and cause shoulder and arm pain in almost
all patients. They can also involve the parietal pleura, ribs, or vertebral bodies and
cause pain.
A chest x-ray can be used for initial screening, which shows the increased size of
the apical cap or apical mass of the lung. CT scan provides additional information
with regards to the extent of the tumor, satellite nodules, as well as mediastinal
adenopathy, all of which are vital in the staging of these tumors. MRI of the neck,
chest and upper abdomen usually is done after the diagnosis is made and before
surgery to identify the extent of vascular and brachial plexus involvement.

Research Concepts:
Pancoast Syndrome

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Question 189: A 62-year-old male is referred by his primary care provider to the
pulmonary clinic for evaluation of dyspnea on exertion. He can walk two to three city
blocks without dyspnea but lately has been dyspneic when walking up hills or climbing
stairs. He is a nonsmoker and worked in coal mines from 20 to 25 years of age. Since
then, he has been a school teacher. He has no history of weight loss or night sweats and
no family history of any type of cancer. His father had emphysema diagnosed at 50 years
of age and mother at 62 years of age. His father was a heavy smoker and worked in coal
mines. His primary care office sent his echocardiogram and chest x-ray reports. The
echocardiogram shows an ejection fraction of 50%, with mild elevation of pulmonary
artery pressures at 30 mmHg. The chest x-ray shows emphysema in both lower lobes.
What are the best next tests to order?

Choices:

1. Pulmonary function tests (PFTs) and right heart catheterization

2. PFTs and left heart catheterization
3. CT chest with pulmonary embolism protocol
4. PFTs and alpha anti-trypsin level

Answer: 4 - PFTs and alpha anti-trypsin level

Explanations:

Pulmonary function tests (PFTs) and alpha anti-trypsin levels should be ordered
next. The patient likely has emphysema induced by low antitrypsin levels, causing
his dyspnea on exertion.
PFTs will show obstructive lung disease with a low diffusing capacity of the lungs for
carbon monoxide (DLCO).
Low alpha anti-trypsin levels affect the lower parts of lungs. This is why the chest x-
ray showed emphysema in both lower lobes. Respiratory causes of dyspnea on
exertion include asthma, acute exacerbation of asthma, chronic obstructive
pulmonary disease (COPD), acute exacerbation of COPD, pneumonia, pulmonary
embolism, lung malignancy, pneumothorax, or aspiration.

Research Concepts:

Dyspnea on Exertion

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Question 190: A 59-year-old male presents with complaints of an acute worsening of
cough and shortness of breath he has had over the last few weeks. The patient has a
history of type 2 diabetes mellitus and HIV and has recently run out of medications. He
does not know what they were. Vitals and exam reveal that the patient is mildly hypoxic
on room air with tachypnea and some difficulty speaking full sentences but is otherwise
maintaining his airway. The patient’s chest radiograph shows bilateral interstitial
infiltrative markings, and labs are remarkable for a CD4 count of 160 cells/microL and
elevated lactate dehydrogenase (LDH). An arterial blood gas is performed, and the
calculated A-a gradient is greater than 40 mmHg. The patient has a history of
anaphylactic reaction to one of his medications for diabetes. Which of the following is
the best choice for treatment?

Choices:

1. Dapsone plus prednisone

2. Clindamycin plus primaquine
3. Trimethoprim-sulfamethoxazole
4. Trimethoprim-sulfamethoxazole plus prednisone

Answer: 2 - Clindamycin plus primaquine

Explanations:

The patient is likely presenting with a severe case of Pneumocystis pneumonia based
on his history, symptoms, and chest radiograph findings, along with his low CD4 count
below 200, elevated LDH, and elevated A-a gradient.
The appropriate alternative treatment in an HIV-positive patient with a sulfa allergy
and severe disease associated with Pneumocystis pneumonia is clindamycin plus
primaquine.
Trimethoprim-sulfamethoxazole is the first-line treatment in most patients. However,
this patient has a severe allergy, specifically anaphylaxis, to one of his medications for
diabetes (probably sulfonylurea, a sulfa drug.
Therefore sulfa drugs trimethoprim-sulfamethoxazole and dapsone should be
avoided.

Research Concepts:

Pneumocystis Jirovecii Pneumonia

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Question 191: A 41-year-old male complains of increasing dyspnea on exertion over the
past 4 months. He has a cough that is usually dry but occasionally produces thick sputum.
He smokes but has no significant past medical or family history, and does not use illicit
drugs. The patient is asymptomatic at rest but dyspneic with mild exertion. Pulse
oximetry is 90% on room air. Lungs have bilateral basilar fine crackles. Hemoglobin is 17
grams/dL, WBC count is normal, and lactate dehydrogenase is elevated. A CT shows
interlobular septal thickening with bilateral ground-glass opacities.
Bronchoscopy with bronchoalveolar lavage yields milky fluid. The analysis shows periodic
acid-Schiff positive macrophages and amorphous debris. What is the most likely diagnosis?

Choices:

1. Pulmonary alveolar proteinosis

2. Pneumocystis jirovecii pneumonia
3. Granulomatosis with polyangiitis
4. Bronchiolitis obliterans organizing pneumonia

Answer: 1 - Pulmonary alveolar proteinosis

Explanations:

There is a strong association with smoking, with up to 85% of patients who are
diagnosed with pulmonary alveolar proteinosis. Chest computed tomography may
display a “crazy paving” pattern which is interlobular thickening with overlying
ground- glass opacities. This pattern is bilateral, peri-hilar, and often with a basilar
dependency.
Patients may have polycythemia from chronic hypoxia as well as an elevated lactate
dehydrogenase. However, this is not specific to pulmonary alveolar proteinosis and
may be found in other illnesses, including Pneumocystis jirovecii pneumonia.
Therefore, bronchoscopy must be performed.
Milky appearing lavage return that contains amorphous material which stains positive
for periodic acid-Schiff is definitive for the diagnosis of pulmonary alveolar proteinosis
and no other lung disease will cause this.
Research Concepts:

Pulmonary Alveolar Proteinosis

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Question 192: A 32-year-old male farmer is brought with increasing dyspnea, fever, chills, and
malaise. He has no significant medical history, and on examination, there is no wheezing. A
chest radiograph is unremarkable, but a computed tomography (CT) scan of the chest shows
upper lung predominant, centrilobular, ground- glass nodules. Microscopy reveals rod-
shaped organisms. He has been working with hay for over five years. What is the most likely
organism causing this illness?

Choices:

1. Cryptococcus neoformans
2. Actinomyces species
3. Penicillium chrysogenum
4. Histoplasma capsulatum

Answer: 2 - Actinomyces species

Explanations:

Actinomyces can cause hypersensitivity pneumonitis after exposure to hay.

Hypersensitivity pneumonitis occurs after inhalation of spores from moldy hay.
Penicillium chrysogenum can cause a similar picture in woodworkers.
A CT chest in acute hypersensitivity pneumonitis typically reveals upper- and
mid-lung predominant ground-glass or micronodular opacities.
Research Concepts:
Hypersensitivity Pneumonitis

Question 193: An otherwise healthy 35-year-old presents with chronic cough and
shortness of breath. Baseline pulmonary function testing and spirometry are normal.
Diagnosis of asthma is suspected, and methacholine challenge testing is performed,
showing a decrease in FEV1 by over 20% at a minimum administration of 300 mcg
methacholine. Which of the following is the most accurate interpretation of the results?

Choices:

1. Suggestive of bronchial hyperreactivity

2. Confirmatory for the diagnosis of asthma
3. Essentially exclude a diagnosis of asthma
4. Results are likely false negative for the diagnosis of asthma

Answer: 1 - Suggestive of bronchial hyperreactivity

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Explanations:

Methacholine challenge test entails administration of sequentially increasing

concentrations of methacholine prepared in two to four-fold dilutions.
Forced expiratory volume in 1 minute (FEV1) is measured at 30 seconds and 90
seconds post aerosol inhalation. Methacholine dosing or concentration is increased in
a stepwise fashion until FEV1 drops by more than 20% or specific airway conductance
(SGaw) by 35 to 40%.
A test is considered positive if the “provocative dose (PD20)” or “provocative
concentration (PC20)” to cause a 20% decrease in FEV1 is less than or equal to 200
mcg or 8 mg/mL, respectively. If using SGaw, 100 mcg or 4 mg/mL indicates a positive
test.
A positive test result is non-specific and suggestive of airway hyperreactivity, rather
than confirmatory of a diagnosis of asthma.

Research Concepts:

Methacholine Challenge Test

Question 194: An adult school bus driver presents with a one- week history of a pruritic,
vesicular rash and a recent development of dyspnea and coughing. Physical exam finds
new and old skin lesions, and a chest x-ray confirms nodular infiltrates. Which is the most
probable causative organism?
Choices:

1. Mycoplasma pneumoniae
2. Epstein-Barr virus
3. Varicella-zoster virus
4. Tuberculosis
Answer: 3 - Varicella-zoster virus

Explanations:

The case of the rash with vesicles in varying stages of development and subsequent
pneumonia suggests varicella- zoster.
Varicella pneumonia typically develops between 3 and 7 days following the rash, and,
in adults, it is the leading cause of mortality and morbidity from the varicella virus.
The prodromal symptoms in adolescents and adults are myalgia, nausea, decreased
appetite, and headache followed by a rash, oral sores, malaise, and a low-grade
fever. Oral manifestations may precede the skin rash. The rash may be more
widespread in adults, fever may last longer, and they are more likely to develop
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 pneumonia. Because watery nasal discharge containing live virus precedes
exanthems by 1 to 2 days, the infected person becomes contagious 1 to 2 days
before diagnosis.
The goal of treatment is symptom relief. As a protective measure, those infected
are usually required to stay at home while they are infectious. Cutting the nails
short or wearing gloves may prevent scratching and the risk of secondary infections.
Topical calamine lotion may relieve pruritus. Daily cleaning of the skin with warm
water will help avoid secondary bacterial infection. In adults, infection tends to be
more severe, and treatment with antiviral drugs, such as acyclovir or valacyclovir, is
advised if started within 24 to 48 hours of rash onset. Adults should be advised to
increase water intake to reduce dehydration. Acetaminophen is recommended for
headaches. Antihistamines relieve itching. Those at risk of developing complications
or those with significant exposure may be given intramuscular varicella-zoster
immune globulin, a preparation containing high titers of antibodies to the varicella-
zoster virus, to help prevent the disease. Sorivudine, a nucleoside analog, may be an
effective treatment for primary varicella in healthy adults.
Research Concepts: Varicella Zoster (Chickenpox)

Question 195: A 72-year-old female with a BMI of 22 is ready for extubation as she has
passed a spontaneous breathing trial as per the intensive care unit ventilator liberation
protocol. Patient has been intubated for 11 days due to acute respiratory distress
syndrome related to community-acquired pneumonia. Review of the record showed that
intubation was difficult and multiple attempts had to be made to successfully intubate
her. The patient is placed patient back on volume control with a tidal volume of 500 and
the cuff deflated.
An average of the lowest 3 tidal volumes was taken and none of them were less than 390
ml. What is the next best step for the management of this patient?

Choices:

1. Go ahead and extubate as the patient had a positive cuff leak test
2. Place patient back on full support and call otolaryngology for evaluation
3. The patient will most likely need a tracheostomy placement
4. Give a stat dose of methylprednisolone IV 20 mg now and then every 4 hourly for
4 total doses before re-assessing cuff leak test

Answer: 4 - Give a stat dose of methylprednisolone IV 20 mg now and then every 4 hourly
for 4 total doses before re-assessing cuff leak test
Explanations:

The cuff leak test is used to predict airway laryngeal edema and post-extubation
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 stridor. It is not recommended in every patient but should be used in selected
patients who are at risk. This group includes patients with difficult intubation,
airway trauma, and prolonged intubation. Edema is most common in female
patients with low BMI who may have a narrow airway in the first place.
Cuff leak can be assessed qualitatively by listening to the leak while the cuff is
deflated. It can also be done quantitatively by placing the patient on volume
control ventilation and calculating the difference between inspired and expired
volume while the cuff is deflated. If the difference is less than 110 ml or less than
20% of delivered volume, it suggests that cuff leak is absent.
The best strategy for absent cuff leak is to initiate steroid therapy. 2 common
regimen includes one dose of 40 mg methylprednisolone 4 hours before
extubation or 20 mg every 4 hourly for 4 doses.
If despite a course of corticosteroids, cuff leak is still absent, the patient should be
extubated over an airway exchange catheter which can facilitate re-intubation or
extubation should be done in the operating room with otolaryngology consultation.
Research Concepts: Extubation

Question 196: A 10-year-old male presents to the emergency department with cough,
dyspnea, and hemoptysis that started yesterday. He has no known medical history and is
not on any medications. His parents report frequent respiratory tract infections in the
past, several of which required hospitalizations for intravenous antibiotics. Currently, the
patient appears to be in mild respiratory distress with active hemoptysis and has a low-
grade fever. Chest auscultation reveals crackles and rhonchi in the left lower base. He is
started on supplemental oxygen and broad-spectrum antibiotic therapy. Laboratory
testing reveals leukocytosis, microcytic anemia, and thrombocytosis. Serum bilirubin and
creatinine levels are normal. The coagulation profile is normal. Further testing reveals iron
deficiency. Chest imaging reveals ground-glass opacities in the left lower lobe. Areas of
interlobular septal thickening are noted. Bilateral honeycomb cysts are also seen. He
undergoes flexible bronchoscopy with bronchoalveolar lavage. The fluid tests heavily for
Prussian blue-stained macrophages. Culture results are still pending. Autoimmune
serology is negative. What is the most appropriate treatment plan for this patient?

Choices:

1. Stop antibiotics and start high-dose corticosteroid therapy

2. Switch antibiotics to isoniazid, rifampin, pyrazinamide, and ethambutol
3. Stop antibiotics and start cyclophosphamide plus high-dose corticosteroid
therapy
4. Continue current treatment and await culture results

Answer: 1 - Stop antibiotics and start high-dose corticosteroid therapy

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Explanations:

This patient likely has idiopathic pulmonary hemosiderosis (IPH). Patients with this
disease have shown benefits with long- term glucocorticoid therapy. During an
acute episode of diffuse alveolar hemorrhage secondary to IPH systemic
glucocorticoid therapy is the treatment of choice. In observational data, this
treatment has been shown to reduce morbidity and mortality in these patients.
Patients with acute IPH and respiratory failure secondary to alveolar hemorrhage
may require invasive ventilation support. For patients with this presentation, it is
recommended they be started on IV methylprednisolone in pulse dosing of 500 to
2000 mg/day for 5 days. In children, 20 mg/kg per day of corticosteroids is
recommended. Once the patient is stabilized (hemoptysis resolves) they should be
transitioned to oral corticosteroids. Long-term therapy with 10 to 15 mg/day of
corticosteroids is usually recommended.
The role of additional immunosuppressive agents for the treatment of this disease
is less clear. There are no randomized controlled trials given the rarity of this
disease. Observational data has shown a benefit with the addition of
hydroxychloroquine, azathioprine, and cyclophosphamide. But this is usually in
patients already on glucocorticoid therapy that is ineffective in controlling acute
episodes of bleeding.
Cyclophosphamide with high-dose glucocorticoid therapy would be indicated for
patients with capillaritis. Patients who present with diffuse alveolar hemorrhage
should be tested for autoimmune disorders before being classified as IPH. This
patient has a negative autoimmune profile which makes this treatment option less
beneficial.
Research Concepts:

Idiopathic Pulmonary Hemosiderosis

Question 197: A 63-year-old female patient who was found confused with altered mental
status at home was brought to the emergency department which initial chest x-ray
showed suspected aspiration pneumonia with right lower lobe infiltrate and was
admitted to intensive care unit. Due to low hemoglobin of 5.1 g/dL, 2 packed red blood
cells (PRBCs) were ordered, and 1 PRBCs transfusion was immediately started. After 6
hours posttransfusion, oxygen saturation dropped and required a non-rebreather mask
from previous 2 L oxygen by nasal cannula to keep oxygen saturation up to 91%. Blood
pressure dropped from 132/87 mmHg to 87/62 mmHg. Chest auscultation revealed
coarse breath sounds from the anterior chest with bilateral crackles. Pretransfusion CBC
had WBC of 10.2 and platelet of 180. Repeat CBC showed WBC of 2.1 and platelet of 78.
Intravenous furosemide 40 mg was given with no effect. What is the most likely the
diagnosis?

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Choices:

1. Flash pulmonary edema

2. Transfusion-related acute lung injury (TRALI)
3. Acute respiratory distress syndrome (ARDS)
4. Transfusion-associated circulatory overload (TACO)

Answer: 2 - Transfusion-related acute lung injury (TRALI)

Explanations:

This case is most likely TRALI as, within 6 hours post- transfusion, the patient
developed hypotension.
TRALI does not respond to diuretic as this is noncardiogenic pulmonary edema as
opposed to flash pulmonary edema and TACO.
Other answer choices are possibilities, but this happened after transfusion
Leukopenia and thrombocytopenia happen with TRALI as TACO, flash pulmonary
edema and ARDS do not change WBC and platelet values.

Research Concepts:

Transfusion-related Acute Lung Injury

Question 198: A 65-year-old male presents with a cough and hemoptysis for four weeks.
CT showed a 1.5 cm right upper lobe lesion and normal-sized lymph nodes. PET-CT
showed fludeoxyglucose (FDG) uptake in the mass and right hilar lymph node. What is
the next step in his care?

Choices:

1. Do preoperative clearance for surgery

2. Refer to oncology
3. Perform convex probe endobronchial ultrasound sampling of hilar lymph node
4. Perform convex probe endobronchial ultrasound sampling of mediastinal and
hilar lymph nodes

Answer: 4 - Perform convex probe endobronchial ultrasound sampling of mediastinal and

Page 192 of 955

hilar lymph nodes

Explanations:

This is a high-risk patient for lung cancer. According to PET-CT, he has stage IIB
disease; therefore, surgery is an option.
Before surgery, N2 and N3 diseases should be ruled out. PET showed uptake in
only an N1 node, but PET has a significant false-negative rate. As per ACCP
guidelines, N1 disease on PET should be confirmed with tissue biopsy.
The sampling of a hilar lymph node will only give a diagnosis but not staging.
Preoperative clearance is only done after ruling out metastatic and extensive
disease.

Research Concepts:

Lung Cancer

Question 199: A 65-year-old woman with a history of chronic obstructive pulmonary

disease presents to the emergency department with shortness of breath and increased
sputum production. She is treated with nebulized bronchodilator therapy and oxygen,
with gradual improvement of the dyspnea. Further review shows that she was admitted to
the hospital earlier this year with the same complaint and diagnosis. According to the
American College of Chest Physicians, which of the following will most likely prevent
frequent readmission to the hospital in this patient?

Choices:

1. Long-term macrolide therapy

2. Long-term systemic corticosteroid therapy
3. Continuous oxygen therapy
4. Nebulized bronchodilator therapy
Answer: 1 - Long-term macrolide therapy

Explanations:

Current guidelines by the American College of Chest Physicians recommend long-term

macrolide therapy be initiated in patients with moderate to severe exacerbations of
chronic obstructive pulmonary disease (COPD) after one or more exacerbations in one
year, despite being on optimal bronchodilator therapy.
It is hoped that prolonged antibiotic therapy will reduce hospitalizations and the
frequency of COPD exacerbations. COPD exacerbations can also be reduced by
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 ensuring smoking cessation, annual influenza vaccination, pneumococcal
vaccination, and long-acting beta-agonist therapy.
Some patients may also benefit from pulmonary rehabilitation and avoidance of
triggering agents.

Research Concepts:

Chronic Obstructive Pulmonary Disease

Question 200: A 17-year-old male who lives in a homeless shelter is brought to the
emergency department by emergency medical services for significant respiratory
distress. He has a history of alcohol use disorder and intravenous drug use. He has had
hemoptysis for several weeks. He is admitted to the intensive care unit and intubated for
respiratory failure. A chest x-ray shows a left- sided, moderate size pleural effusion with
mediastinal shift and perihilar lymphadenopathy. What is the most probable cause of his
pleural effusion?

Choices:

1. Haemophilus influenzae
2. Staphylococcus aureus
3. Mycobacterium tuberculosis
4. Pseudomonas aeruginosa

Answer: 3 - Mycobacterium tuberculosis

Explanations:

Pleural effusion is the accumulation of fluid in the pleural cavity. The mechanism by
which fluid accumulates in the pleural cavity includes infection producing exudates,
increased capillary permeability causing the production of exudative fluid in the
pleural cavity, and increased hydrostatic pressure or decreased oncotic pressure
leading to the formation of transudates.
In this vignette, all of the organisms listed can cause pleural effusion. The
combination of the patient being homeless and using intravenous drugs make him
more likely to have tuberculosis.
The most common cause of pleural effusion in the pediatric population is infection.
The infectious agents that can cause pleural effusion include Streptococcus
pneumoniae, Hemophilus influenza type B, Staphylococcus aureus, Mycobacterium
tuberculosis, and Pneumocystis jiroveci in immunocompromised patients.
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 Diagnosis can be confirmed by an acid-fast bacilli (AFB) smear and culture,
interferon-gamma release assay, or pleural fluid adenosine deaminase. According
to the Centers for Disease Control and Prevention, culture remains the criterion
standard for laboratory confirmation of tuberculosis disease.

Research Concepts:

Parapneumonic Pleural Effusions And Empyema Thoracis

Section 3

Question 201: A 33-year-old farmer was referred to the tertiary hospital due to fever,
shortness of breath, and chest pain for two weeks. He had no history of chronic disease,
and before the present illness, he had been perfectly healthy. He also did not have any
history of medication or travel for the past 3 months. During the first hospitalization, he
was diagnosed having pneumonia of the left upper lobe and treated with antibiotics. Ten
days after the treatment, the pneumonia progressed. The differential white blood count
revealed 20% eosinophils, and the serum IgE was elevated. The sputum culture was
negative for any bacteria, the direct smear of the sputum was negative for fungi or acid
bacilli, and the blood cultures were negative for any culturable bacteria. Stool
examination was negative for ova or any parasites. Surprisingly, during hospitalization, the
chest X-ray revealed migratory infiltrates of the lungs. What could be the possible
condition in this patient?

Choices:

1. Interstitial lung disease due to bacterial infection

2. Acute respiratory distress syndrome due to viral infection
3. Fungal pneumonia
4. Loeffler syndrome due to helminths infection

Answer: 4 - Loeffler syndrome due to helminths infection

Explanations:

The patient is a farmer who has a higher risk of contracting soil- transmitted
helminths.
Treatment with antibiotics did not improve the patient's condition; thus, organisms
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 other than bacteria should be suspected.
Eosinophilia and elevated serum IgE, along with pulmonary symptoms, define the
Loeffler syndrome.
The patient had no history of consuming drugs prior to hospitalization. Based on
history taking and laboratory examination, Loeffler syndrome due to helminths
infection is the possible cause.

Research Concepts:

Ancylostoma

Question 202: A 10-year-old female with asthma comes in with a complaint of a low-grade
fever and increased wheezing. Sputum examination shows Curschmann spirals. There is
peripheral eosinophilia on the CBC. Which of the following is the most likely cause of the
exacerbation?

Choices:

1. Tree pollen
2. Aspergillus fumigatus
3. Staphylococcus aureus
4. Streptococcus pneumonia

Answer: 2 - Aspergillus fumigatus

Explanations:

Aspergillus fumigatus causes eosinophilic pneumonia in those with asthma and

those with cystic fibrosis. Chest CT has become the imaging method of choice in
evaluating patients suspected of having allergic bronchopulmonary aspergillosis
(ABPA).
The diagnosis of ABPA is based on a serum IgE level greater than 1000 IU/L, a
positive specific IgG to Aspergillus, and a positive prick skin test for Aspergillus
antigen.
Tree pollen, Streptococcus pneumonia, and Staphylococcus aureus would not
cause eosinophilic pneumonia. Common causes of eosinophilic pneumonia are
fungal, parasitic, drug- induced, vasculitic, or cryptogenic.
ABPA is estimated to occur in 2.5% of patients with asthma. Clinical presentation of
ABPA is characterized by asthma and recurrent exacerbations. In severe cases,
episodes of bronchial obstruction, fever, malaise, expectoration of brownish mucus
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 plugs, and hemoptysis may occur.
Research Concepts:

Aspergillus Fumigatus

Question 203: A 17-year-old female presents to the emergency department with chest
pain and a racing heart for 30 minutes after an attempted suicide. She has a history of
asthma and emptied the entire inhaler in less than an hour. On physical exam, her eyes
are dilated, and she is found to have dry mucous membranes. Blood pressure is 150/86
mmHg, pulse is 120 bpm and temperature of 101
F. Blood is drawn immediately and sent for a complete metabolic panel and arterial
blood gas. An EKG shows sinus tachycardia and U waves. CK-MB and troponin levels
were within the range in the first blood draw. Her lab report shows a pH of 7.20, pO2 of
80 mmHg, pCO2 of 33 mmHg, bicarbonate of 12 mEq/L, potassium of
2.8 mEq/L, phosphate of 1.2 mEq/L, chloride of 100 mEq/L and sodium of 132 mEq/L.
Which of the following medications is likely responsible for her symptoms?

Choices:

1. Fluticasone
2. Prednisone
3. Ipratropium
4. Salmeterol

Answer: 4 - Salmeterol

Explanations:

Long-acting beta-agonists are frequently used to treat asthma. When taken in

excess they cause a sympathomimetic syndrome, metabolic acidosis, and
hyperlactatemia. The patient has a high anion gap metabolic acidosis. Her blood pH
is 7.20 with bicarbonate less than 24 mEq/L. Anion gap= Na – (Cl + HCO3) = 132 –
(100+12) = 132 – 112 = 20 mEq/L.
A sympathomimetic syndrome is symptoms of pupil dilation, dry mouth, tachycardia,
and other signs of heightened sympathetic stimulation.
Supportive therapy is used to treat this overdose.

Research Concepts:Salmeterol

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Question 204: A 70-year-old man is being treated with ceftriaxone and azithromycin for
left community-acquired pneumonia and left pleural effusion. He undergoes diagnostic
thoracentesis under ultrasound guidance for the pleural effusion. The pleural fluid is
turbid, there is no frank pus, the pH is less than 7.2, and the glucose concentration is
normal. Cultures are sent for sensitivity.
What is the best treatment for this patient?

Choices:

1. Continue current antibiotic regimen until culture results are completed

2. Broaden the antibiotic coverage
3. Perform video-assisted thoracoscopic surgery with drainage of the fluid and add
metronidazole
4. Perform a thoracotomy with decortication of the lung and add metronidazole

Answer: 3 - Perform video-assisted thoracoscopic surgery with drainage of the fluid and add
metronidazole

Explanations:

Parapneumonic effusions require diagnostic thoracocentesis to further evaluate its

etiology and to guide therapeutic strategies. Aspiration of frank pus from the pleural
space during thoracocentesis invariably needs surgical drainage. If there is uncertainty
about whether a turbid fluid is infected, a pleural fluid pH of 7.2 warrants an invasive
procedure for drainage.
The recommended approach is through a video-assisted surgery (VATS) for
drainage of the empyema. Thoracotomy is only needed if VATS fails or the patient
is not a candidate for VATS.
Anaerobic coverage should be initiated in any patient with suspected empyema,
and appropriate antibiotics should not be delayed pending culture results. Failure
to treat empyema appropriately with urgent drainage and adequate antibiotic
coverage can lead to poor outcomes.

Research Concepts:

Thoracic Empyema

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Question 205: A 36-year-old female patient presents with a chief complaint of dyspnea. Her
dyspnea has been progressively worsening over the past six months. She has three
children, and her youngest child is 12 months of age. She is a nurse, has no recent travel
history, no family history of lung disease or cancer, and is a nonsmoker. She denies
orthopnea or paroxysmal nocturnal dyspnea. Her physical exam is normal. Her oxygen
saturation is 96% at rest and on ambulation drops to 86%. Basic blood work and a chest x-
ray are ordered. The complete blood count with differential and chest x- ray are normal.
What is the best next test to order?

Choices:

1. Ventilation-perfusion scan
2. Echocardiogram with bubble study
3. Stress echocardiogram
4. Computed tomography (CT) scan of the chest

Answer: 2 - Echocardiogram with bubble study

Explanations:

The best next test to order for evaluation of her dyspnea is an echocardiogram with
a bubble study. She most likely has a right to left shunt.
Causes of hypoxia include hypoventilation, ventilation-perfusion mismatching,
diffusion abnormalities, and shunt.
A bubble study is done by injecting agitated saline in the vein and performing an
echocardiogram simultaneously. If the bubbles appear on the left side of the heart
within two to three cardiac cycles, then the patient has a right to left shunt.
The most common cause of a right to left shunt is a patent foramen ovale.

Research Concepts:

Dyspnea

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Question 206: A 65-year-old female presents with dyspnea, chills, and non-radiating right
chest pain on inspiration for the past two days. The patient has a history of well-
controlled diabetes mellitus. Her last hemoglobin A1c was 7.1%. The patient was last seen
one month ago for suprapubic pain accompanied by urinary urgency. She was diagnosed
with acute cystitis and prescribed cephalexin. Symptoms resolved soon after starting this
medication. Her home medications are metformin and a multivitamin she started taking
recently. Her heart rate is 88/min, blood pressure 135/87 mmHg, respiratory rate 22/min,
temperature 101.2 F, and oxygen saturation is 99% on room air. The physical exam shows
bronchial breath sounds in the right lower lobe. Chest x-ray shows a right lower lobe
opacity. Due to recent exposure to beta-lactam (cephalosporin), she was prescribed
levofloxacin. The patient returns seven days later with minimal symptom improvement.
Which of the following is the most likely reason for her lack of progress?

Choices:

1. Decreased fluoroquinolone bioavailability due to chelation effect with cations

2. Medication nonadherence
3. Multidrug-resistant (MDR) organisms
4. Lung abscess

Answer: 1 - Decreased fluoroquinolone bioavailability due to chelation effect with cations

Explanations:

Quinolones chelate with tri- and divalent cations such as magnesium (Mg2+),
aluminum (AL2+), calcium (Ca2+), iron (Fe2+), and zinc (Zn2+).
This patient was likely taking her prescribed antibiotic with her multivitamin
concurrently, which reduced the absorption and, therefore, the bioavailability of
levofloxacin.
Reduced bioavailability will affect tissue penetration resulting in treatment failure. To
avoid this interaction, patients must take fluoroquinolone 2 hours before or after
multivitamins.
Fluoroquinolones directly inhibit bacterial DNA synthesis resulting in bacterial cell
death. Members of this class include moxifloxacin, levofloxacin, ciprofloxacin,
ofloxacin, norfloxacin, and delafloxacin.

Research Concepts: Levofloxacin

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Question 207: A 54-year old male presents with a 3-month history of worsening cough
with recurrent hemoptysis. He has smoked 2 packs of cigarettes a day for the past 30
years. He has had a 10kg(22lb) weight loss during this period. His temperature is
37.3 C (99.1F), blood pressure is 120/76mm Hg, respirations per minute are 20, the pulse
is 70/min. A chest x-ray shows a 3-cm mass in his left upper lung lobe with centrally
located cavitation. Subsequently, a diagnosis of squamous non-small cell lung cancer is
made. Which of the following drugs is approved for use in first-line metastatic squamous
NSCLC in combination with paclitaxel and carboplatin?

Choices:

1. Pembrolizumab
2. Natalizumab
3. Rituximab
4. Eculizumab

Answer: 1 - Pembrolizumab

Explanations:

Pembrolizumab is approved for use in first-line metastatic squamous NSCLC with

paclitaxel (or paclitaxel protein-bound) and carboplatin.
In the KEYNOTE-407 study, pembrolizumab showed a median overall survival of 15.9
months in this population as compared to
11.3 months on chemotherapy alone.
Additionally, in non-small cell lung cancer, pembrolizumab is also approved for
first-line metastatic non-squamous NSCLC without EGFR/ALK tumor abnormalities
in combination with platinum chemotherapy and pemetrexed.
Additionally, in non-small cell lung cancer, pembrolizumab is also approved as first-
line single-agent use for nonresectable or metastatic NSCLC without EGFR/ALK
tumor abnormality with tumor PD-L1 expression greater than 1% and single-agent
use in metastatic NSCLC with tumor PD-L1 expression greater than 1% who have
progressed after platinum-based chemotherapy (EGFR/ALK tumor abnormality
patients with progression after targeted therapy for their respective tumor
abnormality).

Research Concepts:
Pembrolizumab

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Question 208: A 59-year-old man is admitted for pulmonary embolism and rivaroxaban is
initiated. Three days later he has a hypotensive episode, and his hemoglobin and
hematocrit drop significantly. He is transfused with four units of packed red blood cells
and given 2 liters of normal saline and prothrombin complex concentrate (PCC) therapy.
Two days later, hemoglobin and hematocrit are within the normal range, and the patient
is hemodynamically stable. What is the most appropriate next step in management?

Choices:

1. Administer andexanet alfa to completely reverse rivaroxaban effects

2. Administer a second dose of PCC to completely reverse rivaroxaban
effects
3. Initiate aspirin and monitor the patient for signs of bleeding
4. Resume rivaroxaban and monitor the patient for signs of bleeding

Answer: 4 - Resume rivaroxaban and monitor the patient for signs of bleeding

Explanations:

Andexanet alfa is a reversal agent that is an FDA-approved factor Xa inhibitor (i.e.,

rivaroxaban) in patients with life- threatening or uncontrolled bleeding.
Prothrombin complex concentrate (PCC) is a blood coagulation factor replacement
product that is FDA-approved for the reversal of vitamin K antagonists. PCC has
been used off-label to reverse the effects of direct oral anticoagulants, like
rivaroxaban.
It is important to resume anticoagulation therapy as soon as it is medically appropriate
to reduce the risk of thrombotic events.
This patient has received PCC and is hemodynamically stable; therefore, he no
longer needs a reversal agent. Anticoagulation with rivaroxaban should be resumed,
and the patient should be monitored for signs of bleeding.

Research Concepts:

Andexanet Alfa

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Question 209: An 87-year-old female is admitted to the intensive care unit for severe sepsis
secondary to a urinary tract infection.
Despite appropriate fluid resuscitation and antibiotic therapy, she continues to be
lethargic and is intubated due to her inability to maintain her airway. The ventilator is set
to a tidal volume of 360 mL (6 mL/kg), a rate of 12 breaths per min, an FiO2 of 50%, and a
PEEP of 15. Soon after intubation, her blood pressure drops, and she requires the
initiation of inotropic agents. Which of the following maneuvers is most likely to help
improve her blood pressure?

Choices:

1. Place the patient in a prone position

2. Decrease PEEP to 5
3. Increase FiO2 to 100%
4. Increase the tidal volume to 8 mL/kg

Answer: 2 - Decrease PEEP to 5

Explanations:

Patients undergoing mechanical ventilation undergo a change in their respiratory

physiology. In normal respiration, negative intrathoracic pressure caused by
contraction of the diaphragm generates air entry into the lungs. At the same time,
the negative pressure increases venous return to the right atrium.
This, in turn, increases the preload, stroke volume, and cardiac output. In
mechanically ventilated patients, this negative pressure is turned into positive
pressure through the ventilator. Positive intrathoracic pressure effectively
"squeezes" the right atrium, decreasing venous return and diminishing cardiac
output.
In our case of a septic patient, diminishing cardiac output by any minute margin can
have significant deleterious effects on blood pressure. The higher the PEEP, the higher
the intrathoracic pressure and the higher the effect on cardiac output.
Diminishing PEEP to a more physiologic level can help restore some of the cardiac
output and improve blood pressure in this patient.
Of the given options, only decreasing PEEP would have an effect on blood
pressure. None of the other displayed answers would have any effect on blood
pressure.

Research Concepts: Ventilator Management

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Question 210: A 65-year-old male presented to the emergency department with
shortness of breath. Initial arterial blood gas (ABG) showed a pH of 7.31 with a partial
pressure of carbon dioxide (PCO2) at 44 mmHg and partial pressure of oxygen (PO2) at 45
mmHg. A chest x-ray showed bilateral pulmonary infiltrates. Non- invasive ventilation
with a bilevel positive airway pressure mask (BiPAP) was tried without success. His blood
pressure dropped to 80/40 mmHg. He was intubated immediately. He was treated with
antibiotics, vasopressors, and corticosteroids for septic shock due to bilateral pneumonia.
Over the next few days, the patient‘s clinical status improved, and he was no longer in
need of vasopressors. The patient was placed on a spontaneous breathing trial. After 40
minutes, his ABG shows a pH of 7.39, PCO2 of 38 mmHg, and PO2 of 63 mmHg on 60%
oxygen at 5 cm of water of positive end- expiratory pressure (PEEP). He is following
commands and has mild to moderate airway secretions. Rapid shallow breathing index is
150. Which of the following is the next best step in the management of this patient?

Choices:

1. Avoid extubation due to high oxygen requirements and attempt weaning trial the
next morning
2. Extubate patient to non-rebreather mask and consider non- invasive
ventilation at night and during daytime naps
3. Extubate patient to venturi face mask 50% and consider high flow nasal cannula if
clinical status or gas exchange deteriorates
4. Extubate patient to high flow nasal cannula
Answer: 1 - Avoid extubation due to high oxygen requirements and attempt weaning trial
the next morning
Explanations:

The patient is not ready for extubation. The rapid shallow breathing index is high.
The secretion burden is still moderate. The patient is still on a high level of oxygen
support.
A rapid shallow breathing index of less than 105 has an 80 percent chance of not
needing reintubation.
It is not advisable to extubate a patient with moderate amounts of secretion
burden.
High flow oxygen systems offer the advantage of providing PEEP to improve
oxygenation and alveolar recruitment. This mechanism of oxygenation
improvement is not found with low flow oxygen systems. It is the preferred
device to extubate patients as it provides benefits in respiratory mechanics by the
above-stated mechanism.
Research Concepts: High Flow Nasal Cannula

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Question 211: A SCUBA diver is brought to the emergency department after a dive. He
states he is still training and did his first deep dive today. He states that his instructor told
him he may be ascending a bit fast. He complains of facial swelling, and eye redness that
he noticed just after the dive and complained of his mask feeling too tight. He also
complains of a mild headache and tingling in his arms which he attributes to the cold
water and tight mask. Mild bruising is noted on the face and periorbital areas. Eye
movements are normal and no double vision is present. Which of the following is the next
best step in the management of this patient?

Choices:

1. Reassure patient that the bruising and redness in his eyes will improve in a
couple of weeks
2. Order an MRI of the orbits just to be sure there is no orbital hemorrhage
3. Consult ophthalmology to perform a dilated fundoscopic examination
4. Place the patient on oxygen, perform a thorough neurologic exam and contact a
hyperbaric treatment center

Answer: 4 - Place the patient on oxygen, perform a thorough neurologic exam and contact a
hyperbaric treatment center

Explanations:

The patient is displaying symptoms concerning for decompression illness. It is

important for the examine to realize that while the patient's injuries from a mask
squeeze are mild, other dive related injuries may occur concurrently.
The patient has evidence suggestive of a decompression illness injury involving the
CNS.
This would require supplemental oxygen, a thorough neurologic exam, as well as
contacting a hyperbaric treatment center for further treatment and possible
transfer to a facility with a decompression chamber.
This patients mask squeeze is a mild injury and does not require a fundoscopic
exam.

Research Concepts:

Diving Mask Squeeze

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Question 212: A 54-year-old man working in the sanitation department presents with acute-
onset shortness of breath. He says that over the past two days, he has suddenly become
very short of breath. He denies smoking or any recent illness. His past medical history is
unremarkable. He is admitted and requires immediate mechanical ventilation. Chest x-rays
show diffuse, bilateral air-space opacities. Two days later, he expires. The pathology shows
diffuse alveolar damage and fibrosis. What is the most likely diagnosis?

Choices:

1. Vaping associated pulmonary injury

2. Acute interstitial pneumonia
3. Cryptogenic organizing pneumonia
4. Bird flu

Answer: 2 - Acute interstitial pneumonia

Explanations:

Acute interstitial pneumonia (also known as Hamman-Rich syndrome) is an acute,

rapidly progressive idiopathic pulmonary disease that often leads to fulminant
respiratory failure and acute respiratory distress syndrome (ARDS).
It can be distinguished clinically from other types of interstitial pneumonia by the
rapid onset of respiratory failure in a patient without preexisting lung disease.
Chest x-ray usually shows a pattern that is similar to ARDS, which is diffuse,
bilateral air- space opacities.
Acute interstitial pneumonia (AIP) has the histopathological pattern of diffuse
alveolar damage (DAD) that is indistinguishable from the histologic pattern found in
ARDS. The histologic discerption depends on the timing of the biopsy. The early
phase (within a week of the initial tissue injury) is exudative, characterized by
edema in the interstitium and alveolus. After that, a late phase, which is also called
the organizing phase, shows fibroblastic proliferation and type 2 cell hyperplasia.
Research Concepts:Acute Interstitial Pneumonia

Question 213: A 32-year old male presents to the clinician with complaints of high fever,
stomach cramps, and diarrhea for the past week. He has smoked a pack of cigarettes every
day for the past ten years. During the examination, the clinician notes a harsh cough.
Further evaluation with chest x-ray reveals unilateral lobar infiltrates. Which of the
following antimicrobial agents is most appropriate to treat the most likely pneumonia?

Choices:

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1. Vancomycin
2. Cephalexin
3. Levofloxacin
4. Ampicillin

Answer: 3 - Levofloxacin

Explanations:

The patient most likely has Legionnaires disease, severe pneumonia seen in smokers
who have been exposed to a contaminated environmental water source.
Legionella are Gram-negative aerobes, including L. pneumophila. Common
symptoms of Legionella pneumonoia include fever, gastrointestinal symptoms, CNS
symptoms, and cough.
Effective antibiotics classes include quinolones, macrolides, tetracyclines, and
ketolides. Currently favored treatment is with respiratory quinolones or newer
generation macrolides.
Pediatric cases are most often treated with azithromycin.

Research Concepts:

Legionnaires' Disease

Question 214: A 2-year-old presents to the emergency department with a barking cough,
inspiratory stridor, and sternal wall retractions at rest. She appears minimally agitated.
Racemic epinephrine is administered via a nebulizer. For how long is it appropriate to
monitor this child for possible rebound of stridor?

Choices:

1. At least 1 hour
2. At least 3 hours
3. At least 6 hours
4. At least 8 hours

Answer: 2 - At least 3 hours

Explanations:

This patient has moderately severe croup. Nebulized epinephrine is associated

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 with a reduction in croup symptoms 30 minutes following administration.
If epinephrine is given for croup, monitor for at least 3 hours for rebound of the
condition.
Five milliliters of L-adrenaline 1:1000 is considered as safe as the racemic form.
Epinephrine also is used to treat anaphylaxis, asthma, bradycardia, cardiac arrest and
shock, toxins, and overdoses.

Research Concepts:

Epinephrine

Question 215: A 27-year-old female with no significant past medical history presents
with an ongoing intermittent cough and associated shortness of breath. Baseline
spirometry and pulmonary function testing are within normal limits with good quality
and reproducibility. Methacholine challenge testing is performed, which reveals a
decrease in forced expiratory volume in 1 second (FEV1) of 15% after administration of
the maximal dose of methacholine (400 micrograms). Which of the following is the most
accurate interpretation of these results?

Choices:

1. She has moderate airway hyperreactivity

2. She has severe airway hyperreactivity
3. These results essentially confirm a diagnosis of asthma
4. These results essentially exclude a diagnosis of asthma

Answer: 4 - These results essentially exclude a diagnosis of asthma

Explanations:

In a bronchoprovocation challenge test, the dose of the provocative agent (in this
case methacholine) that causes the desired fall in FEV1 is used to interpret the
results. In a methacholine challenge test, the concentration of methacholine that
causes a 20% fall in the FEV1 is used to determine airway hyperactivity. In patients
with asthma, this dose is usually less than 200 micrograms (or 8 mg/mL).
The value of this test lies in its negative predictive value. A cutoff level of 200 to
400 micrograms ( 8 to 16 mg/mL) yields 100% sensitivity for the diagnosis of
asthma. Therefore, asthma can essentially be ruled out in this patient.
The positive predictive value of this test is limited. A false- positive result can be
seen in patients with allergic rhinitis, acute bronchitis, cystic fibrosis, and chronic
obstructive pulmonary disease (COPD).
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 According to epidemiologic data, up to 7% of the population (higher if patients
with smoking history are included) have airway hyperreactivity on provocation
testing without any symptoms. These patients may have normal variation in airway
hyperreactivity without overt asthma.

Research Concepts:
Methacholine Challenge Test

Question 216: A 16-year-old male presents to the emergency department with difficulty
breathing. His symptoms and clinical presentation are consistent with status asthmaticus.
WIthin 3 hours, he rapidly deteriorates with evidence fo fatigue, altered mental status and
combined respiratory and metabolic acidosis. He was therefore intubated and placed on
mechanical ventilation. Initial ventilator settings had to be adjusted due to asynchrony on
ventilator and hypotension from intrinsic PEEP. He is still diffusely bronchospastic and is
getting albuterol via a metered dose inhaler attached to the inspiratory limb of vent
circuit. He is on assist-control volume-control mode ventilation. Which of the following is
most accurate regarding his ongoing treatment strategy?

Choices:

1. Ventilation mode should be changed to pressure regulated volume control or VC+

2. Ongoing method of albuterol administration is appropriate as MDI has a better effect
on inspiratory flow-resistive pressure
3. Albuterol administration should always be via a nebulizer in a ventilated patient
4. There is no definitive appropriate strategy of albuterol administration but an
assessment of airway peak to pause pressure gradient can decide the appropriate
therapy in an individual patient

Answer: 4 - There is no definitive appropriate strategy of albuterol administration but an

assessment of airway peak to pause pressure gradient can decide the appropriate therapy in
an individual patient
Explanations:

There is an ongoing debate about the use of MDI versus nebulizers in ventilated
patients.
While small volume nebulizers have been shown to have reduced aerosol
percentage delivery to lungs, MDI has been demonstrated to have a poor effect on
inspiratory flow-resistive pressure.
Assessment of airway peak to pause pressure gradient can be a rational indicator to
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 use when either one of the delivery modes is used. A 15% or greater decline in the
gradient is considered to be a favorable response to be aimed for.
A higher dose of the medication is needed in both MDI or nebulized delivery in an
intubated patient.
Research Concepts: Status Asthmaticus

Question 217: A 45-year-old male patient from Guatemala presents to the emergency
department with a complaint with "coughing up blood." A chest x-ray was performed that
shows what seems like left upper lobe cavitary lesions with associated hilar
lymphadenopathy. While reevaluating the patient, he suddenly starts coughing up large
quantities of bright red blood. The patient was placed in the left lateral decubitus position
and Trendelenburg position, but the patient is still having large amounts of hemoptysis.
Oxygen saturation for the patient continues to drop, and the patient becomes lethargic.
The decision is made to intubate the patient. The patient is intubated and currently
hemodynamically stable. The pulmonologist is at bedside ready for bronchoscopy and
hospital transport is also at bedside ready to take the patient to CT scan. The surgical team
is also on their way for evaluation of the patient. What is the best plan of action?

Choices:

1. Wait for surgery to evaluate the patient for possible emergent lobectomy
2. Take the patient to CT before performing bronchoscopy
3. Perform bronchoscopy for definitive care before performing CT
4. Wait for all consultants to be at the bedside for further discussion

Answer: 2 - Take the patient to CT before performing bronchoscopy

Explanations:

In a stable patient such as this who is already intubated, CT has demonstrated equal
ability as bronchoscopy for localization of the source of bleeding.
CT scan is able to determine the cause of the bleeding more often than
bronchoscopy and allows for guidance of embolization.
Surgical lobectomy is considered last line treatment given the high rates of
mortality and is significantly safer when performed non-emergently.
Bronchoscopy has the advantage of being able to be performed at the bedside
without transportation of the patient and allows for pulmonary isolation
techniques if hemostasis has not been achieved.

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 Research Concepts:

Pulmonary Hemorrhage

Question 218: A 40-year-old male presents with gradually worsening shortness of breath
for the past six months. He has also noted pain and swelling over the wrists and
metacarpophalangeal (MCP) joints bilaterally. Recently he has noticed generalized myalgia
and symptoms of the Raynaud phenomenon. His medical problems include hypertension,
for which he takes amlodipine 10 mg/day. He has a seasonal allergy to pollens. He is an
active smoker and has smoked one pack per day for the last 20 years. He worked as a
stone crusher for the previous ten years. On physical examination, the patient appears
pale and has sclerodactyly over bilateral hands and tenderness over bilateral wrists and
MCP joints. Fine crepitations are heard over bilateral lower lungs on auscultation.
Labs showed hemoglobin 10 gm/dl, erythrocyte sedimentation rate 65 mm/hr, creatine
phosphokinase 1200 mcg/L, positive antinuclear antibodies, and anti-U1 ribonucleic
protein (RNP). Chest x-ray showed bibasilar infiltrates. Computed tomography (CT) chest
showed ground-glass opacities and centrilobular nodules over bilateral lower lobes.
Transbronchial biopsy of the lung showed findings typical for silicosis. Based on positive
anti-U1 RNP, Raynaud phenomenon, arthritis, sclerodactyly, and myositis, a diagnosis of
mixed connective tissue disease (MCTD) was made. He was started on prednisone 20 mg
daily and methotrexate 25 mg weekly. During a follow-up at one month, he showed
significant improvement in his respiratory and joint symptoms. Which of the following
mechanism is likely responsible for the pathogenesis in this patient?

Choices:

1. Hypersensitivity reaction
2. Apoptosis
3. Immunosuppression
4. Molecular mimicry

Answer: 4 - Molecular mimicry

Explanations:

Molecular mimicry is a phenomenon in which amino acid sequences from non-self

proteins can mimic host epitopes and induce autoantibody response.
Chemicals (e.g, vinyl chloride and silica) and other environmental factors e.g.,
infections, drugs, toxins, and UV radiation have been found to be associated with
the development of mixed connective tissue disease (MCTD).
Genetic association of MCTD with HLA-DR4 and DR2 phenotypes have been found
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 which indicated that T cell receptors and HLA molecules might be involved in the
generation of anti-U1-RNP.
Another possible mechanism for the pathogenesis of MCTD is an apoptotic
modification. During apoptosis, proteins undergo post-translational modification.
These modified proteins become concentrated in the surface blebs of apoptotic
cells and become available to the immune system. Apoptotic modification of U1 70
kDa antigen is believed to be characteristic of MCTD.

Research Concepts:

Mixed Connective Tissue Disease

Question 219: A 72-year-old female with a known diagnosis of obesity hypoventilation

syndrome presented to the sleep clinic with complaints of progressively worsening
nocturnal choking episodes, despite using continuous positive airway pressure (CPAP).
The PaCO2 and pulse oximetry levels obtained in the clinic were 40 mmHg and 80%,
respectively. What should be the ideal therapeutic option for this patient at this time?

Choices:

1. Weight loss surgery

2. Supplemental oxygen therapy
3. Tracheostomy
4. Medroxyprogesterone

Answer: 2 - Supplemental oxygen therapy

Explanations:

According to current guidelines, if pulse oximetry levels remain persistently below

90% despite the CPAP therapy, supplemental oxygen therapy can be tried.
Weight loss surgery is usually the last resort.
Bi-PAP can also be tried in patients with increasing episodes of apnea or hypopnea on
CPAP therapy.
Medroxyprogesterone use is not regularly recommended.

Research Concepts:

Obesity-Hypoventilation Syndrome
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Question 220: A 28-year-old male poultry-farm worker with no significant past medical
history except cigarette smoking presents to the emergency department with fever,
headache, and a dry cough for the last 3 days. He describes the headache as severe and
has associated photophobia as well. Physical examination reveals rales and rhonchi in the
left lower lung field. Laboratory testing reveals low normal leukocyte count with
neutrophilia. Erythrocyte sedimentation rate and C-reactive protein level are elevated.
Which of the following is the recommended method to confirm the suspected diagnosis?
Choices:

1. Sputum culture
2. Blood culture
3. Polymerase chain reaction (PCR)
4. Complement fixation testing
Answer: 3 - Polymerase chain reaction (PCR)

Explanations:

Chlamydia psittaci infection is an important cause of community- acquired

pneumonia and usually presents with abrupt onset of fever, severe headache,
myalgia, and a dry cough. Young to middle-aged males are at higher risk with
special concern for those with occupational exposure, such as with poultry-farm
workers, pet shop workers, and veterinarians.
Chlamydia psittaci is an obligate intracellular organism. It is endocytosed by surface
microvilli and infects the alveolar-lining cells creating intracytoplasmic inclusions
consisting of reticulate bodies. Since C. psittaci growth takes place within host cells,
it is difficult to culture using standard techniques and often cannot be grown using
typical bacterial culture media. Only specialized laboratories can culture the
organism. Moreover, there is concern over the highly infectious nature of the
organism, therefore obtaining cultures to identify the organism is discouraged.
Molecular real-time PCR testing allows for rapid detection and has high sensitivity
and specificity. PCR testing may be conducted using whole blood, throat
specimens, and urine.
Complement fixation testing was traditionally the most common method of
diagnosing this infection. However, complement fixation testing cannot
differentiate among the chlamydial species. The test requires acute and
convalescent samples to make an accurate diagnosis, thus delaying confirmation
by several weeks. It is not the preferred method of testing.
Research Concepts: Psittacosis Pneumonia

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Question 221: A 13-year-old male begins inhaled corticosteroid therapy for mild
persistent asthma. During the office visit, he is counseled on proper inhaler technique.
He also is advised to rinse his mouth and throat with water after each use, expectorating
the rinsate. This is intended to prevent overgrowth by which of the following organisms?

Choices:

1. Blastomyces dermatitidis
2. Candida albicans
3. Histoplasma capsulatum
4. Pneumocystis jirovecii

Answer: 2 - Candida albicans

Explanations:

Oral thrush or candidiasis, caused by Candida overgrowth, is a common local adverse

effect associated with inhaled corticosteroids.
Effects of local deposition in the oropharynx and larynx include oral thrush,
dysphonia, cough, and throat irritation. Systemic effects result from ingestion as
well as absorption from the lung. The majority of inhaled corticosteroid doses
delivered by metered dose inhalers are deposited in the oropharynx. This drug can
then be swallowed, undergo first-pass metabolism, and enter the systemic
circulation. Methods to reduce the amount of drug being ingested include rinsing
the mouth after each use, using a spacer, and proper technique. Dry powder
inhalers have reduced deposition in the oropharynx and larynx. In addition to
prevention of oral thrush, rinsing the mouth after each use of inhaled
corticosteroids can reduce systemic adverse effects.
Research Concepts:Inhaled Corticosteroids

Question 222: A 35-year-old male is being evaluated for shortness of breath and chest
pain. He is found to have a pulmonary embolism and started on anticoagulation. In his
nine months' follow up appointment, he is found to have signs of right heart failure and
pulmonary hypertension on echocardiogram. Right heart catheterization confirms
pulmonary hypertension. His clot burden is unchanged on pulmonary angiography. Which
of the following is the next best step in the management of this patient?

Choices:

1. Initiate a different anticoagulant

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 2. Surgery-pulmonary thromboendarterectomy
3. Admission to the hospital for intravenous anticoagulation such as unfractionated
heparin or subcutaneous low molecular weight heparin
4. Double-lung transplantation
Answer: 2 - Surgery-pulmonary thromboendarterectomy

Explanations:

Surgery is the only definitive therapy for chronic thromboembolic pulmonary

hypertension.
The evaluation for surgery should occur early in the disease course for chronic
thromboembolic pulmonary hypertension, even if the symptoms or hemodynamic
abnormalities are mild because early surgery may prevent the development of an
irreversible lung and heart disease.
Medical therapy is not curative, and its effects are relatively modest. There are
no studies that compare anticoagulation. Double-lung transplantation is an
alternative surgical option for patients who are not candidates for pulmonary
thromboendarterectomy.

Research Concepts:

Chronic Thrombo-Embolic Pulmonary Hypertension

Question 223: A heavy smoker presents with hemoptysis. He has never been to a
physician before. He takes no medications and has no allergies. He has been homeless
for the past 5 years. No other pertinent history is available. A chest x-ray is ordered and
the radiologist reports that the patient has a lesion with an "air-crescent" sign. What is
the likely diagnosis?

Choices:

1. Lung cancer
2. Tuberculosis
3. Aspergillosis
4. Hamartoma

Answer: 3 - Aspergillosis

Explanations:

In radiology, the air crescent sign finding on chest x-ray and computed tomography
Page 215 of 955
 that is crescenteric and radiolucent is usually due to lung cavitary lesion that is filled
with air and has a round radiopaque mass.
Classically, it is due to an aspergilloma, a form of aspergillosis, that occurs when the
fungus Aspergillus grows in a cavity in the lung.
Aspergillosis tends to grow in old lung lesions like scars and tuberculous cavities.
The diagnosis is based on clinical features and serology.

Research Concepts:

Aspergillosis

Question 224: A 65-year-old man with a history of type 2 diabetes mellitus, chronic
obstructive pulmonary disease (COPD), hypertension, and left lower extremity deep
venous thrombosis (DVT) presents to the emergency room with abdominal pain and has
not had a bowel movement in four days. Abdominal x-ray shows distended bowel and
possible free air under the right hemidiaphragm. CT abdomen is done which does not
show free air under the diaphragm. Which of his co-morbidities, predispose him to this
condition?

Choices:

1. Hypertension
2. Type 2 diabetes
3. COPD
4. DVT

Answer: 3 - COPD

Explanations:

Normally, suspensory ligaments and fixation of the colon will prevent interposition
of the colon between the liver and diaphragm. Variations in this anatomy lead to
the pathological interposition of the colon seen in Chilaiditi syndrome.
Other factors that can predispose one to develop Chilaiditi syndrome include
congenital malpositions, functional disorders such as chronic constipation caused by
colonic elongation and redundancy, gaseous distension of the colon, small liver due to
cirrhosis or hepatectomy, ascites due to increased intra- abdominal pressure,
substantial weight loss in patients with obesity. Chronic obstructive pulmonary
disease can also predispose a patient to Chilaiditi syndrome because it causes
enlargement of the lower thoracic cavity.
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 Abnormally high diaphragm or diaphragmatic paralysis, which can be seen in
conditions such as diaphragmatic muscular degeneration or phrenic nerve injury,
can also predispose a patient to Chilaiditi syndrome.
Mental retardation and schizophrenia are also associated with anatomic variations
that result in Chilaiditi sign

Research Concepts:
Chilaiditi Syndrome

Question 225: A 52-year-old woman presents to the outpatient clinic for a routine health
visit. Since her previous visit this time last year, the patient has had no significant changes
to her health.
However, during the interview, she reveals that for the past month, she has felt
progressively short of breath when doing her usual routine. In addition, she occasionally
suffers from a non-productive cough after physical activity. She has a known 35-pack-
year history but has been resistant to smoking cessation interventions in the past. In
addition to working up her symptoms, she is encouraged to cut down her use of
cigarettes. Nicotine replacement patches, gum, and varenicline are offered, but she
refuses. The only treatment modality she is open to includes switching to e-cigarettes.
Which of the following is most accurate regarding this smoking cessation treatment?
Choices:

1. E-Cigarettes are as effective as varenicline

2. E-Cigarettes are as effective as nicotine replacement
3. E-Cigarettes may potentially decrease exposure to additives compared to
traditional cigarettes
4. E-Cigarettes can reduce the damage caused by a lifetime of smoking
Answer: 3 - E-Cigarettes may potentially decrease exposure to additives compared to
traditional cigarettes
Explanations:

The long-term health effects of e-cigarettes are still unknown, but when compared
to traditional tobacco products, they do contain far fewer chemical constituents.
Therefore, it is hypothesized that e-cigarettes may be used as a method of harm
reduction in chronic heavy smokers.
In patients resistant to other forms of treatment, e-cigarettes may be
attempted to minimize exposure to carcinogens and contaminants.
When working with such patients, it is vitally important to check in continually and
to keep offering treatment modalities that do not include e-cigarettes. In addition,
the negative consequences of nicotine itself on the cardiovascular and respiratory
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 systems should be emphasized at each visit.
Varenicline, bupropion, and nicotine patches/gum remain the only treatment
options that have consistently been shown in the literature to help reduce the
consumption of tobacco.

Research Concepts: Electronic Vaping Delivery Of Cannabis And Nicotine

Question 226: A 35-year-old male presents complaining of persistent wheezing and

poorly controlled asthma. He was diagnosed with asthma 4 years ago. Initially, he was
well controlled on inhaled corticosteroids, salbutamol and montelukast. However for the
last one year, his asthma has been poorly controlled, requiring three emergency room
visits, and he has received five courses of oral prednisone. He reports compliance with his
inhalers and demonstrates good inhaler technique. His reports needing albuterol 4 to 5
times a day and frequently wakes up at night. He also complains of thick brown
productive sputum he has had on and off for the last few months. On examination, his
heart rate is 85, blood pressure of 120/75, respiratory rate of 20, pulse oximetry on room
air is 97%. He has scattered mild expiratory wheezes bilaterally on examination, and he is
not using any accessory muscles of respiratory. S1 and S2 with no murmurs or rubs,
cranial nerves are intact, and power is 5/5 bilaterally in upper and lower extremities. No
rashes are noted. His spirometry done 6 months ago showed an FEV1 of 55% with
FEV1/FVC ratio of 62%. His basic metabolic profile is normal and complete blood count is
normal except an eosinophil count of 0.8 x 10^9/L. What would be the best approach in
this patient?

Choices:

1. Continue current therapy, ensure compliance and follow up in 3 months

2. Stool for ova and parasites
3. Serum IgE levels and Aspergillus IgG and IgE antibody
4. Omalizumab for poorly controlled asthma

Answer: 3 - Serum IgE levels and Aspergillus IgG and IgE antibody
Explanations:

Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction

to Aspergillus fumigatus exclusively in patients with bronchial asthma and cystic
fibrosis.
It should be suspected in patients with poorly controlled asthma with worsening
peripheral eosinophilia and central bronchiectasis.
The diagnosis of ABPA is made based on (1) presence of asthma or cystic fibrosis,
Page 218 of 955
 (2) elevated IgE more than 1000 and positive skin test to Aspergillus or elevated
IgG levels to Aspergillus fumigatus, and (3) At least two of the following (a) central
bronchiectasis, (b) peripheral eosinophilia greater than 500 cells/microliter, and
(c) elevated serum precipitins to Aspergillus fumigatus.
Treatment of ABPA involves systemic glucocorticoids and itraconazole.

Research Concepts: Pulmonary Eosinophilia

Question 227: A 65-year-old female from Southeast Asia traveled by air to Toronto and
was found to have acid-fast bacteria in the sputum. She was immediately started on
rifampin. Four days later, she was seen in the emergency department with a swollen right
leg and started on heparin for 3 days and then placed on oral warfarin. Despite
immediate treatment for her pathology, she expired 7 days later. At autopsy, she was
found to have pulmonary emboli.
Which of the following most likely triggered the chain of events that led to her death?

Choices:

1. Miliary tuberculosis
2. Starting rifampin
3. Overdosing warfarin
4. Underdosing heparin

Answer: 2 - Starting rifampin

Explanations:

Rifampin is often a first-line drug used to treat tuberculosis. It is frequently used in

combination with other tuberculosis agents like isoniazid and pyrazinamide.
Rifampin is also one of the most potent inducers of the cytochrome P450 enzymes
and, thus, is often associated with drug interactions.
Rifampin can increase the breakdown of warfarin, and thus the levels become
subtherapeutic and lead to deep vein thrombosis and pulmonary emboli.
When a patient on warfarin is started on drugs like rifampin, more frequent
monitoring of the INR is mandatory or the rifampin should be discontinued.

Research Concepts:

Rifampin
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 Question 228: A 42-year-old man was admitted two days ago after an intentional
overdose of his medications at home. His chronic medical conditions include
hypertension, mild pulmonary hypertension, and Raynaud syndrome. He does not smoke
or drink alcohol. The initial presentation was with acute shock and hypoxic respiratory
failure requiring emergent endotracheal intubation. Initial lab work did not show any renal
or hepatic dysfunction. He has since been on vasopressors with a maximal norepinephrine
dose of 10 micrograms per minute 24 hours ago and is slowly being weaned.
He has also received insulin and dextrose infusion and several grams of calcium chloride
within the first 24 hours. On the third day, the nurse noticed new skin rashes over his
extremities. He does not have any fever. Bloodwork shows normal coagulation
parameters and platelets. However, the glomerular filtration rate shows an acute drop to
32. In addition, transaminases are four times elevated from baseline. To what could one
attribute these changes in his clinical picture?

Choices:

1. Progression of shock and multiorgan failure

2. Vasopressor toxicity with poor end-organ perfusion
3. Calcium chloride effect
4. Acute leptospirosis
Answer: 3 - Calcium chloride effect

Explanations:

The patient likely has a calcium channel blocker overdose, as his medical conditions
of hypertension and Raynaud syndrome require treatment with a calcium channel
blocker agent. He has no fever or leukocytosis and had normal renal and liver
function. This is therefore unlikely to be an infection like leptospirosis.
Calcium chloride or gluconate are often used in the initial treatment of calcium
channel blocker overdose. Overaggressive use in the first 24 hours is often seen and
can rarely result in calciphylaxis acutely presenting with skin necrosis, rash, acute
kidney injury, and abnormal liver function.
Progression of multiorgan failure or vasopressor adverse effects is unlikely to
develop now when his needs are slowly improving. Although hemodialysis is not
indicated in the treatment of calcium channel blocker toxicity, it may be indicated
with worsening toxicity of calciphylaxis and kidney injury in the setting of calcium
channel blocker overdose.
Research Concepts: Calcium Channel Blocker Toxicity

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Question 229: A 58-year-old man with chronic obstructive pulmonary disease is brought
to the emergency department for disorientation. He has been taking theophylline for six
months, and the bottle is empty. His theophylline level is 51 mcg/mL. Which action should
be taken first?

Choices:

1. Load immediately with phenobarbital

2. Give prochlorperazine to prevent vomiting and decrease the risk of aspiration
3. Administer 1 amp of calcium gluconate
4. Contact the on-call nephrologist to discuss arranging urgent hemoperfusion.

Answer: 4 - Contact the on-call nephrologist to discuss arranging urgent hemoperfusion.

Explanations:

Determining if a patient has an acute or chronic theophylline overdose is vital.

Those with acute overdose are at higher risk for gastrointestinal and cardiac
complications.
Theophylline toxicity often present with seizures that are most effectively treated with
a benzodiazepine, not a long-acting barbiturate such as phenobarbital.
Additional medications with anticholinergic or antihistaminic properties, such as
prochlorperazine, should be avoided.
Neurologic complications are more likely in chronic overdose situations. This patient
likely has chronic ingestion, and levels greater than 40 mcg/mL should be considered
for urgent hemoperfusion.

Research Concepts:

Theophylline Toxicity

Question 230: A 27-year-old woman is being treated for active pulmonary tuberculosis.
Treatment includes daily isoniazid, rifampicin, ethambutol, and pyrazinamide. Three
weeks into treatment, she is found to be HIV positive with a CD4 count of 414
cells/mm3. Her vital signs are normal, and the physical examination is unremarkable.
Pending initiation of HIV therapy, which of the following is the most appropriate
management for this patient?

Choices:

1. Add streptomycin to the regimen

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2. Switch to a thrice-weekly regimen
3. Add gentamicin to the regimen
4. No change is necessary

Answer: 4 - No change is necessary

Explanations:

First-line treatment for pulmonary tuberculosis (TB) occurs in two phases. In the
intensive phase, the regimen consists of isoniazid, rifampicin, ethambutol, and
pyrazinamide daily for two months. No change in the drug regimen is necessary for
this patient.
The intensive phase is followed by isoniazid and rifampicin daily for four months.
The continuation phase can be extended in patients with HIV who are not receiving
antiretroviral therapy (ART) during TB treatment.
Streptomycin has fallen out of favor as a first-line agent in the treatment of TB.

Research Concepts:

Primary Lung Tuberculosis

Question 231: A 40-year-old male with a history of well- controlled diabetes mellitus and
hypertension presents with atypical symptoms suspicious for possible underlying asthma.
A recent annual check-up revealed elevated low-density lipoprotein on lipid profile. The
patient has a past surgical history of hernia repair and an incidentally discovered thoracic
aortic aneurysm. Baseline spirometry and pulmonary function testing are of good quality
and within normal limits. What is the next best step in the management of this patient?

Choices:

1. Trial of bronchodilators
2. Repeat pulmonary function test
3. Methacholine challenge test
4. No further management is necessary

Answer: 1 - Trial of bronchodilators

Explanations:

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 Indications for methacholine challenge testing include evaluating symptoms
clinically suggestive of asthma and response to therapy. In patients with
contraindications to bronchoprovocation testing, such as known aortic aneurysm, it
is reasonable to initiate a trial of bronchodilators to assess response to therapy.
Bronchodilators are used to treat asthma, and patient responsiveness can be used to
assess reversible airway hyperreactivity when bronchoprovocation testing is
contraindicated.
Airflow limitations in FEV1 less than 60% predicted or 1.5 L or inability to
consistently reproduce quality spirometry are considered contraindications.
Additional contraindications include recent myocardial infarction within the past
three months, uncontrolled hypertension, known aortic aneurysm (as in this
patient), recent ophthalmologic surgery, or patients at risk for intracranial pressure
elevation.
Methacholine challenge is contraindicated in this patient with a history of aortic
aneurysms due to the risk of rupture from increased intrathoracic pressure. A trial
of bronchodilators to assess response is appropriate.

Research Concepts:
Methacholine Challenge Test

Question 232: A 45-year-old woman presents with a two-day history of flu-like symptoms.
She is a veterinarian who visited a rural cattle farm three days ago to evaluate cows
reported to be ill. She denies hemoptysis, hematochezia, or recent known sick contacts
other than the acutely ill cows. The vital signs show a temperature of
100.9 F (38.3 C), heart rate of 105 bpm, respiratory rate of 18/minute, oxygen saturation
of 96% on room air, and blood pressure of 110/70 mmHg. Chest x-ray shows a widened
mediastinum with hilar adenopathy. What is the most appropriate treatment for this
patient?

Choices:

1. Rifampicin monotherapy
2. Meropenem plus vancomycin
3. Levofloxacin plus gentamicin
4. Ciprofloxacin plus clindamycin

Answer: 4 - Ciprofloxacin plus clindamycin

Explanations:

Inhalation anthrax is rare, and a high index of suspicion should be maintained,

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 given the potential for weaponization.
Treatment for inhalational anthrax requires a multidrug regimen with one
bactericidal agent plus one protein-synthesis inhibitor. IV ciprofloxacin plus
clindamycin or linezolid is the preferred regimen.
This question stem includes multiple historical features that should trigger
concern for inhalation anthrax, including rural setting, acutely ill cattle
exposure, and occupational hazard (veterinarian).
Anthrax results in a prodromal viral respiratory illness that lasts about one week,
followed by acute hypoxia, dyspnea, and acute respiratory distress syndrome. In some
patients, mediastinal widening and hilar adenopathy are seen on x-ray.

Research Concepts:

Anthrax Infection

Question 233: A 71-year-old male reports chest pain and shortness of breath during a right
subclavian central venous catheter placement. After halting the procedure, you discover
absent right- sided lung sounds. His vitals are stable with mild tachypnea. What is the first
step in the management of this patient?

Choices:

1. Perform a needle decompression in the fifth intercostal space of the midclavicular

line
2. Emergently place a tube thoracostomy in the seventh intercostal space of the
midaxillary line
3. Call for chest radiography to confirm the diagnosis
4. Perform a needle decompression in the fifth intercostal space of the midaxillary line

Answer: 4 - Perform a needle decompression in the fifth intercostal space of the

midaxillary line

Explanations:

In recent studies, needle decompressions have been shown to be more effective in

lateral versus medial approaches in patients with pneumothorax. For this patient, a
needle decompression in the fifth intercostal space of the midaxillary line should be
performed.
Needle decompressions are considered temporary measures with final
management consisting of a tube thoracostomy.
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 Correct tube thoracostomy placement is commonly in the fifth intercostal space of the
midaxillary line.
Iatrogenic pneumothorax is a patient safety indicator (PSI) condition. It is
defined as a traumatic pneumothorax that is caused secondary to an invasive
procedure or surgery.

Research Concepts:

Iatrogenic Pneumothorax

Question 234: A 17-year-old male from Egypt presents for a planned surgical procedure
following an unremarkable pre- anesthesia evaluation. Just after induction of anesthesia,
a large worm is seen squirming in the pharynx. Vital signs remain stable during induction,
but the surgery is canceled. Given the likely diagnosis, what complication may arise if the
patient is treated with the appropriate medication at this time?

Choices:

1. Anaphylactic reaction
2. Bowel obstruction
3. Pneumonitis
4. Ruptured appendix

Answer: 3 - Pneumonitis

Explanations:

This patient has ascariasis. Ascaris lumbricoides tend to accumulate in the lungs and
intestines.
These parasitic worms grow very large and have an aversion to anesthetic gasses.
Ascaris infection should be treated to prevent complications from parasite
migration; however, during active migration through the lungs, medical therapy
can increase the risk of pneumonitis.
Albendazole and mebendazole are effective in treating adult worms and can cause
pneumonitis.
Research Concepts:

Ascariasis

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Question 235: A 17-year-old female presents with a three-day history of fever, chills,
diarrhea, malaise, and dyspnea. She has recently returned from a camping trip to New
Mexico, where she was exposed to rodents at her campsite. Vitals are heart rate
110/minute, respiratory rate 25/minute, blood pressure 100/70 mmHg, and temperature
101 F (38.2 C). Physical examination demonstrates bilateral crepitations. A blood smear
reveals marked leukocytosis with an appearance of immunoblasts, which exceed 10% of the
total. A chest radiograph shows bilateral fluffy infiltrates. The organism most likely
responsible for this patient's presentation belongs to the family of which of the following?

Choices:

1. Bunyaviridae
2. Coronaviridae
3. Orthomyxoviridae
4. Paramyxoviridae

Answer: 1 - Bunyaviridae

Explanations:

Hantavirus presenting as a cardiopulmonary syndrome, such as in this patient, is

common in the Southwestern United States due to the particular genotypes found
in the US. Immunoblasts and thrombocytopenia are common, requiring hospital
admission. Hantavirus also is known to cause hemorrhagic fever with renal
syndrome in Asia and Europe and has more severe features of cardiac, hepatic, and
renal failure.
Hantavirus is an RNA virus that belongs to the family of Bunyaviridae. The virus
increases capillary permeability and decreases blood pressure causing an acute
respiratory distress syndrome-like picture with shock and potential renal failure.
Hantavirus has an incubation period of 7 to 28 days and presents with fever, chills,
diarrhea, malaise, and dyspnea. This is followed by hypotension, oliguria, and a
characteristic diuresis in hemorrhagic fever with renal syndrome type.
Both syndromes are acquired from infected rodents through urine or stool
droppings. Rodent control is vital in preventing infection.
Research Concepts:

Hantavirus Cardiopulmonary Syndrome

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Question 236: A 40-year old presents with complaints of fever, muscle pain, dyspnea, and
a cough that has been going on for a few months. The patient denies any recent travel, use
of drugs, smoking, or any other illness. The patient had a negative tuberculin skin test a
few days ago. The patient has crackles on auscultation; the rest of the exam is normal. A
chest x-ray reveals bilateral hilar adenopathy. Urine analysis reveals hypercalciuria. Which
rash may develop?

Choices:

1. Raynaud phenomenon
2. Erythema migrans
3. Pyoderma gangrenosum
4. Erythema nodosum

Answer: 4 - Erythema nodosum

Explanations:

Erythema nodosum is a classic finding in a patient with sarcoidosis.

It presents on the lower extremity with painful, erythematous nodules.
The most specific skin lesion of sarcoid is lupus pernio. Others may
develop a violaceous rash on the face and maculopapular plaques.
Research Concepts:

Sarcoidosis

Question 237: A 26-year-old woman presents with a six-month history of shortness of

breath. This symptom started one week after she was diagnosed with lung cancer. All her
vital signs are within normal limits. Chest x-ray shows moderate to large left-sided pleural
effusion. The patient states she has had fluid in her lung drained before. The appropriate
procedure will be performed. Which of the following is the most appropriate position for

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this intervention?

Choices:

1. Sitting
2. Supine
3. Left lateral decubitus
4. Right lateral decubitus

Answer: 1 - Sitting

Explanations:

Thoracentesis is performed to remove fluid from the pleural cavity. Often even
with stable vital signs, patients may have orthopnea.
The preferred body position is sitting, with the patient leaning slightly forward
and the arms supported on a bedside table. In the sitting position, ultrasound can
readily visualize large fluid pockets much easier as well as identify organs of
interest such as the diaphragm.
For most patients, the sitting position is well tolerated and provides ample access
to the back.
The lateral decubitus position can be used to insert a chest tube. The arm must
be over the shoulder to open up the intercostal space.
Research Concepts:Thoracentesis

Question 238: A 78-year-old man with a history of COPD with significant bullous lung
disease on the previous CT scan of the chest and recent infection and pleural effusion
presents to the emergency department with severe shortness of breath. The patient
undergoes a CT scan of the chest, which shows pleural effusion. Thoracentesis is
performed with the pleural manometry. In the shown image, which of the pressure finding
on manometry is most consistent with trapped lung?

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 Choices:

1. A
2. B
3. C
4. D

Answer: 4 - D

Explanations:

Choice D in the graph represents the patient with trapped lung who starts with
negative pleural pressure, and it drops sharply on pleural fluid drainage.
The trapped lung is usually seen in a patient with lung cancer with an
endobronchial lesion, which prevents the lungs from expanding.
Post thoracentesis, patients who have a blockage with either an endobronchial
lesion or mass adhering to pleura and preventing lung expansion can develop
pneumothorax ex vacuo.
Choice A in the graph represents a patient with positive pressure and increasing
with time suggestive of pneumothorax. Choice B in the graph shows the pleural
pressure of a patient with normally expanded lung during thoracentesis. Choice C
in the graph shows the patient with entrapped lung with pressure being positive
and gradually becomes negative on withdrawing the pleural fluid.

Research Concepts:

Pleurodesis

Question 239: A 20-year-old man with a history of beta- thalassemia presents to the clinic
with complaints of increasing cough and right-sided lower chest pain for the last 10 days.
The patient has had an associated fever for one week as well. He underwent a
splenectomy at the age of 9 years. Examination shows a weak-looking man with
crepitations in the right lower lung fields of the chest. He receives transfusion regularly,
and his last transfusion was 10 days ago. He takes deferoxamine for iron chelation. An
initial set of investigations is shown below.

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 Reference range
Patient results

Hemoglobin 10.7g/dL 13.2-17.5 g/dL

4100-
WBC count 13200/microL
10900/microL
Neutrophils 50% 54%-62%
Lymphocytes 42% 25%-33%
Monocytes 6% 3%-7%
Eosinophils 2% 1%-3%
150000-
Platelets 148000/microL
400000/microL
Computed tomography (CT) scan of the lung shows a pulmonary nodule in the right lower
lung with pleural effusion. Fine-needle aspiration from the nodule is carried out.
Histopathology of the aspirate is shown in the figure. Which of the following interventions
is most likely to have prevented the patient from developing this lung condition?

Choices:

1. Prophylactic antibiotic therapy

2. Aggressive transfusion to maintain hemoglobin >12 g/dL
3. Use of an alternate source of chelation than deferoxamine
4. Ensuring leukoreduced blood transfusions only

Answer: 3 - Use of an alternate source of chelation than deferoxamine

Explanations:

Mucormycosis is a fungal infection caused by molds Rhizopus. It is manifested by

a variety of different syndromes in humans, particularly in immunocompromised
patients and those with diabetes mellitus. Another important risk factor for this

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 infection is the use of deferoxamine for iron chelation.
The deferoxamine-iron chelate, called feroxamine, is a siderophore for the species
Rhizopus, increasing iron uptake by the fungus, which stimulates fungal growth and
leads to tissue invasion. Spores inhaled can settle in the alveolus and proliferate.
This can develop into pneumonia and rapidly disseminate systematically in
individuals with the risk factor present.
The appearance of Rhizopus on microscopy shows broad hyphae (5 to 15-micron
diameter), irregularly branched, and having rare septations, as seen in this
histology image.
Prophylactic antibiotic therapy is not used for the prevention of mucormycosis.
Maintaining hemoglobin >12 g/dL in thalassemia helps in the prevention of certain
complications but not Rhizopus infection. Leukoreduced transfusion has no impact
on the risk of mucormycosis.

Research Concepts:
Mucormycosis

Question 240: A 56-year-old female with a past medical history of degenerative spine
disease, alcohol use disorder, and obesity presents with a 10-hour history of severe
abdominal pain and vomiting. On examination, she has tenderness in the epigastrium
and low-grade pyrexia. Her computed tomography scan of the abdomen is obtained, as
shown. Her laboratory investigations are below:

WBC 15.5 * 109/L (4.0 - 11.0)

Calcium 7.6 mg/dL (8.5-10.5)
Amylase 1056 U/L (70 - 300)
Bilirubin 0.3 mg/dL (0.3 - 1)
ALP 93 u/L (30 - 100)
ALT 30 u/L (3 - 40)
γGT 41 u/L (8 - 60)

She suddenly becomes increasingly short of breath, and her respiratory rate increases to
30 breaths per minute. She also develops central cyanosis. Given her likely diagnosis,
which of the following is the characteristic finding in this condition?

Choices:

1. Increased transfer factor

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2. High compliance
3. Fluid in the horizontal fissure on chest x-ray
4. Shunt

Answer: 4 - Shunt

Explanations:

The patient has developed acute respiratory distress syndrome secondary to acute
pancreatitis. Edema in the peripancreatic fat is consistent with acute pancreatitis.
Acute respiratory distress syndrome (ARDS) causes a significant shunt, leading to
severe hypoxemia.
ARDS is characterized by an increase in capillary permeability, leading to a fluid influx
in the alveoli.
Damage to type I and type II pneumocytes results in decreased clearance of fluid from
the alveolar space and decreased production of surfactant.
ARDS is uniformly associated with pulmonary hypertension, contributing to the
ventilation-perfusion mismatch and decreased transfer factor (gas exchange). Also,
it is related to reduced compliance and reduced pulmonary artery wedge pressure.
Fluid in the horizontal fissure on the chest x-ray is consistent with fluid overload.

Research Concepts:

Acute Respiratory Distress Syndrome

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 Question 241: A 72-year-old man presents to the hospital with shortness of breath. Past
medical history is significant for COPD on 2 L/min of oxygen by nasal cannula. The patient
is hemodynamically stable, saturating 94% on 2 L/min of the nasal cannula. CT thorax
shows a right-sided pleural effusion. The echocardiogram is unremarkable. The patient
undergoes diagnostic and therapeutic thoracocentesis. Light's criteria is suggestive of
transudate effusion. The patient says his symptoms are not improved. Repeat CT thorax
post thoracocentesis is shown below. Which of the following is the most likely diagnosis?

Choices:

1. Lung cancer
2. Aspergillosis
3. Pneumothorax
4. Trapped lung

Answer: 4 - Trapped lung

Explanations

The CT is showing chronic atelectasis with thickened visceral pleura. Following

drainage of the effusion, the lung failed to expand, creating a vacuum and an air-fluid
level.
Malignancy is one of the causes of recurrent pleural effusions and trapped lung.
Trapped lung can present as one of the complications of pneumothorax.
Complicated pulmonary infections causing loculated effusions can cause trapped
lung.

Research Concepts:

Trapped Lung

Question 242: A 23-year-old male patient with no past medical history presents to the
hospital after a traumatic bike accident. His vital signs are a temperature of 99.2 F, pulse
76 beats/minute, blood pressure 120/72 mmHg, and respirations 22 breaths/minute. A
chest radiograph showed an "inverted comma" sign near a fine convex line in the right
chest. Based on what this radiographic finding indicates, what may mimic the appearance
of this finding?

Choices:

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 1. Pneumothorax or bulla
2. Pleural effusion or lobar consolidation
3. Tuberculosis
4. Interstitial lung disease

Answer: 1 - Pneumothorax or bulla

Explanations:

The appearances of an "inverted comma" sign near a fine

convex line are suggestive of the normal variant, the azygos lobe on plain film, or
computed tomography scan. This may cause it to be confused with an abscess,
bulla, or pneumothorax.
The fine, convex line that crosses the apex may mimic the appearance of the
wall of a bulla or the pleural line seen in pneumothorax.
The convex line is due to the invagination of the pleural layers during
embryological development when the posterior cardinal vein migrates through
the right upper lobe.
In addition, consolidation of an azygos lobe has been reported and may mimic a
lung mass.

Research Concepts:

Anatomy, Thorax, Lung Azygos Lobe

Question 243: A 16-year-old man presents to the clinic, due to an abnormal EKG found on
a sports physical done at school. The 12-lead ECG the findings are as follows: inverted P
waves in leads 1
and aVr, dominantly negative QRS in lead 1, low voltage in leads V4- V6, and inverted T
waves in lead 1 and aVL. Which of the following is the most likely cause of his ECG
findings?

Choices:

1. Idiopathic hypertrophic cardiomyopathy

2. Unstable angina
3. Wolff Parkinson White syndrome
4. Dextrocardia
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 Answer: 4 - Dextrocardia

Explanations:

Dextrocardia is a rare cardiac anomaly that presents itself with unusual and specific
electrocardiographic features which include inversion of P waves in leads I and aVL,
reversed R wave progression in chest leads, low voltage QRS axis in V4 to V6, and
inverted T waves in lead I and aVL.
Primary ciliary dyskinesia (PCD), formerly known as immotile cilia syndrome, is a
disorder of motile cilia structure and function that results in chronic oto-
sinopulmonary disease. Primary ciliary dyskinesia typically presents with respiratory
distress in infants, early onset year-round cough, and nasal congestion. Kartagener
syndrome is a triad of chronic sinusitis, bronchiectasis, and situs inversus resulting
from ciliary dyskinesia.
When you suspect a patient has dextrocardia, place the ECG lead backward, i.e.
left limb leads should be placed on the right side. If the leads are in their usually
conventional location, the EKG will show inverted P and T waves, in lead 1.
Wolf-Parkinson White syndrome would present with a delta wave on EKG. Unstable
angina would be uncommon in an otherwise healthy child and can often have
normal EKG patterns unless at the time of pain. Hypertrophic cardiomyopathy
would not result in low voltage on an EKG>
Research Concepts:
Ciliary Dysfunction

Question 244: A 21-year-old woman presents to the clinic with exertional shortness of
breath. She has a history of systemic lupus erythematosus (SLE). She currently takes
azathioprine and hydroxychloroquine. She does not smoke cigarettes or drink alcohol. Her
vitals signs show a heart rate of 99/min, respiratory rate 22/min, oxygen saturation 96%
on room air, and blood pressure 120/80 mmHg. She is afebrile. Examination reveals
reduced right-sided chest expansion. Chest auscultation demonstrates reduced air entry at
the right lung base but otherwise clear lung fields. The heart sounds are normal with no
added sounds or murmurs. She appears clinically euvolemic. Her jugular venous pulse is
not raised, and there is no peripheral edema. Abdominal and neurological examinations
are normal. Blood testing is normal, including a white blood cell count and CRP. Plain
radiography of the chest shows a progressive elevation of the right hemidiaphragm. A CT
chest with contrast shows normal lung parenchyma and excludes a pulmonary embolism.
A transthoracic echocardiogram is normal. Lung function testing shows a restrictive deficit
with reduced total lung capacity.
Which of the following complications is most likely to develop in this patient?

Page 235 of 955

Choices:

1. Sjogren syndrome
2. Carcinoid syndrome
3. Relapsing polychondritis
4. Psoriatic arthritis
Answer: 1 - Sjogren syndrome

Explanations:

Shrinking lung syndrome is the diagnosis. This is a rare complication of autoimmune

diseases, most commonly SLE. It is characterized by exertional dyspnoea. Reduced
chest expansion may be present. Elevation of the unilateral or bilateral
hemidiaphragm is characteristic. Lung function demonstrates a restrictive deficit
and reduced total lung capacity. A comprehensive investigation is needed to
exclude other causes of shortness of breath.
Sjogren syndrome is associated with shrinking lung syndrome, both in primary form
and in overlap with systemic lupus erythematosus.
Shrinking lung syndrome has also been reported in scleroderma, polymyositis, and
rheumatoid arthritis.
The condition is mostly steroid-responsive but respiratory failure occurs as a
complication in a select number of cases.

Research Concepts: Shrinking Lung Syndrome

Question 245: A 54-year-old male with a past medical history of COPD presented due to
shortness of breath. On the initial presentation, his heart rate was 80/min, respiratory
rate was 32/min and O2 saturation of 81% on room air. He was placed on NIMV, however,
due to worsening respiratory status, the patient was intubated endotracheally and was
placed on a mechanical ventilator. On day 4 of hospitalization, the patient developed a
temperature of 102 along with increased secretions. His FiO2 increased from 0.6 to
1.0 and peak inspiratory pressure to 40cmH2O. Which of the following measures would
have prevented this outcome?

Choices:

1. Use of respiratory filter in the ventilator circuit

2. Keeping endotracheal tube cuff pressure 20cmH2O.
3. Head elevation to 30 degrees
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4. Switching to nasotracheal intubation

Answer: 3 - Head elevation to 30 degrees

Explanations:

The patient has developed ventilator-associated pneumonia (VAP). Typical onset of

symptoms is seen after 48 hours of endotracheal intubation. symptoms include
hypoxemia, tachypnea, fever, and increased or purulent secretions.
The use of respiratory filter has not been associated with a reduced risk of VAP. CDC
recommends using respiratory filters only in patients with pulmonary TB. Endotracheal
Cuff pressure lower than 20 cmH2O is associated with a higher incidence of
development of pneumonia. Recommendation to keep intra- tracheal cuff pressure in
the 20-30cm H2O range.
Most recent ATS and IDSA guidelines recommend keeping head of the bed
elevated to 30 degrees to reduce VAP risk Orotracheal intubation is preferred over
nasotracheal intubation as nasotracheal intubation is associated with higher
sinusitis risk.
Research Concepts:

Ventilator Complications

Question 246: A 66-year-old woman is admitted to the intensive care unit for diagnosis of
septic shock due to right lower lobe pneumonia. She is given broad-spectrum antibiotics,
and fluid resuscitation is begun. Despite aggressive fluid resuscitation, she continues to be
hypotensive. A right subclavian line is attempted and inserted after 2 attempts. A few
minutes later, the patient started to have worsening shortness of breath and hypotension
with increasing pressor requirements. Which of the following is the next best step in the
management of this patient?

Choices:

1. Lung ultrasound
2. Broaden antibiotic coverage
3. tPA
4. CT angiogram of the chest

Answer: 1 - Lung ultrasound

Explanations:

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 This patient had a right-sided subclavian line placed after multiple attempts leading
to pneumothorax.
Pneumothorax is one of the common complications of subclavian line placement. It
can present as hypoxemia and shock.
Urgent decompression of the pleural space is needed with the placement of a
chest tube. Lung ultrasound can be performed quickly and efficiently at the
bedside, which can show absence of pleural sliding and a lung point.
Although a CT scan may be helpful, logistically, it can take time leading to delayed
diagnosis and potentially catastrophic complications.

Research Concepts:

Central Venous Access of The Subclavian Vein

Question 247: A 70-year-old male with alcohol use disorder presents with complaints of
fever, generalized weakness, and cough with foul-smelling sputum for two weeks. He
states that he was lying on his stomach when the cough started. His vital signs show a
temperature of 101 F (38.3 C), a heart rate of 112 beats per minute, and a respiratory rate
of 25 breaths per minute. Gram staining and culture of the sputum reveal gram-negative
rods. Which of the following lung lobes is most likely to be affected in this patient?

Choices:

1. Right upper lobe

2. Left lower lobe
3. Right and left upper lobe
4. Right and left lower lobe
Answer: 1 - Right upper lobe

Explanations:

The right mainstem is more vertical and wider than the left mainstem bronchus.
The site involved in aspiration pneumonia depends on the position at the time of
aspiration.
The involvement of the right upper lobe is more common in patients who aspirate
in the prone position and those with alcohol use disorder.
The common clinical features that should raise suspicion for aspiration include sudden
onset dyspnea, fever, hypoxemia, radiological findings of bilateral infiltrates, and
crackles on lung auscultation.
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 Research Concepts:

Aspiration Pneumonia

Question 248: A 32-year-old female presents with a dry cough, fever, and shortness of
breath for two weeks. She has a history of acquired immunodeficiency syndrome (AIDS)
and is not taking any medications. She also has a history of Steven Johnson syndrome
with the use of sulfonamides. She has multiple sex partners. Her temperature is 38.5 C
(101.3 F), respiratory rate is 24 breaths per minute, heart rate is 98 beats per minute,
and blood pressure is 120/85 mm Hg. Her oxygen saturation is 84% on room air.
Examination reveals extensive whitish plaques in the oral cavity and generalized
lymphadenopathy. Bilateral diffuse crackles are present on chest auscultation. Her white
blood cell count is 13,000/mm3, and her serum lactate dehydrogenase is 400 U/L. Chest x-
ray shows bilateral diffuse interstitial infiltrates. Which of the following is the most
appropriate therapy for this patient?
Choices:

1. Dapsone
2. Pentamidine
3. Azithromycin
4. Cotrimoxazole
Answer: 2 – Pentamidine

Explanations:

This patient with AIDS presents with two weeks of fever, dry cough, decreased oxygen
saturation, and bilateral diffuse interstitial infiltrates, which is suggestive of Pneumocystis
pneumonia (PCP). PCP is an opportunistic infection caused by the fungus Pneumocystis
jiroveci. PCP usually occurs when the CD4 count is less than 200. The disease attacks the
alveoli, causes fibrosis, and impairs oxygen exchange. It has a poor prognosis in patients
with AIDS. It is diagnosed by the detection of the organism in the sample obtained from
bronchoalveolar lavage.
The recommended treatment for PCP is trimethoprim- sulfamethoxazole (TMP-SMX) for a
period of 21 days. Corticosteroids should be added for severe hypoxia. Other alternative
medications to treat PCP include pentamidine, dapsone, atovaquone, and primaquine.
Since this patient is allergic to sulfonamides, sulfamethoxazole should be avoided.
Dapsone is a sulfone generally tolerated by patients who have adverse reactions to TMP-
SMX. However, for severe reactions to TMP-SMX (e.g., Stevens-Johnson syndrome/toxic
epidermal necrolysis, serum sickness, a rash with fever and systemic symptoms, or
hemolytic anemia), it is advisable to avoid dapsone. Aerosolized pentamidine can be used
in this patient. Azithromycin can be used for the treatment of infection with

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 Mycobacterium avium complex (MAC), which usually presents with fever, diarrhea,
lymphadenopathy, and hepatosplenomegaly.
Research Concepts:
‘Pneumocystis Jirovecii Pneumonia

Question 249: A 55-year-old male with a 45 pack-year history of smoking presents to the
clinic to establish primary care and discuss age-appropriate screening options for cancer.
His pulse rate is 78 beats per minute, blood pressure is 140/80 mmHg, and oxygen
saturation on room air is 96%. Air entry is decreased bilaterally with occasional rhonchi
and crepitations on chest auscultation. He is advised by the primary care provider to
undergo a low-dose computed tomography scan (LDCT) for screening. The patient asks
regarding the available literature and benefits of the screening test. Which of the
following would be the best response to his question?

Choices:

1. LDCT results in a decrease in lung cancer mortality by 20%

2. LDCT results in a decrease in lung cancer mortality by 50%
3. LDCT results in a decrease in lung cancer morbidity by 20%
4. LDCT results in a decrease in lung cancer morbidity by 80%

Answer: 1 - LDCT results in a decrease in lung cancer mortality by 20%

Explanations:

The National Lung Screening Trial (NLST) was conducted by the American College
of Radiology Imaging Network. NLST enrolled 53,454 current or former heavy
smokers between 55 and 74 years of age.
Participants had to have a smoking history of at least 30 pack years. Also,
participants had to be without signs, symptoms, or a history of lung cancer.
Patients were randomized to low-dose helical computed tomography
(LDCT) or standard chest X-ray. They were scanned for three years and
followed for 3.5 years.
The NLST showed that the use of LDCT resulted in a decrease in lung cancer
mortality by 20% and mortality from any cause by 6.7%.

Research Concepts:

Lung Cancer Screening

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Question 250: Which of the following characteristically shows macroscopic nodularity?

Choices:

1. Anthracosis
2. Silicosis
3. Berylliosis
4. Silo filler's disease

Answer: 2 - Silicosis

Explanations:

Macroscopic nodularity gives silicosis a unique appearance among the

pneumoconioses.
The nodules are fibrous and slowly increase in size until they can be recognized on
roentgenographic examination.
Microscopically the nodules are composed of collagenized and densely hyalinized
tissue arranged in concentric bands.
An inflammatory reaction is absent. Silica crystals may be visualized with polarized
light within the nodules.
Research Concepts:

Berylliosis

Question 251: A 65-year-old man presents with low-grade fever, productive cough, and
weight loss. His symptoms have persisted for the past four weeks, even though he has
been using acetaminophen (paracetamol) and cough syrup. He has recently immigrated
from India. His medical history is significant for gastroesophageal reflux disease, diabetes
mellitus, and pancreatitis. He smokes a pack of cigarettes a day and drinks two beers
every night. Family history is noncontributory. Vital signs show a heart rate of 90/min,
respiratory rate of 20/min, blood pressure of 120/70 mmHg, and a temperature of 99 F
(37.2 C). Physical examination and chest x-ray are unremarkable. However, a sputum
examination shows the presence of acid-fast bacilli, which on PCR shows a mutation in the
rpoB gene. Which of the following best describes an implication of this mutation?

Choices:

1. The patient will require a shorter duration of treatment.

2. The organism is sensitive to rifampicin.
3. The organism is likely resistant to isoniazid.
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 4. This organism is likely pan-drug resistant.
Answer: 3 - The organism is likely resistant to isoniazid.

Explanations:

This patient presents with symptoms of tuberculosis.

Nucleic acid amplification tests and PCR can be used to detect the presence of rpoB
gene mutations, which suggest resistance to rifampicin.
Rifampicin resistance is a marker of multidrug-resistant TB (MDR TB) with a very
high proportion of these isolates being resistant to isoniazid as well.
MDR TB may require a longer duration of therapy using second and third line anti-
tuberculous drugs depending on the site of infection.

Research Concepts:

Primary Lung Tuberculosis

Question 252: An autopsy is performed on a 72-year-old man found dead in his home. He
has not sought medical care in many years and has no known past medical history.
Histological staining of his lungs reveals emphysematous changes. Which of the following
would be most characteristic of this disease on Verhoeff stain?

Choices:

1. Glycogen deposition
2. Atrophy of elastic tissue
3. Disorganized collagen deposition
4. Short, branched elastin fibers

Answer: 2 - Atrophy of elastic tissue

Explanations:

Emphysema is a form of obstructive lung disease involving the breakdown of elastic

fibers composing the walls of alveoli.
The Verhoeff stain is used to identify elastic fibers within a tissue.
On Verhoeff stain, emphysema can be identified by the atrophy of elastin fibers.
Emphysematous patients have elevated levels of elastin-derived peptides that reflect
the breakdown of pulmonary elastin.

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 Research Concepts:

Histology, Verhoeff Stain

Question 253: A 39-year-old female with a past medical history of diabetes mellitus
presents to the emergency department with complaints of high fever, headache, dry
cough, abdominal discomfort, joint pains, and myalgias. The patient is currently working at
a bird exhibition. Physical examination is notable for rales in the left lower lung fields. Vitals
show a temperature of 100.8 degrees F (38.2 C), pulse rate of 110/minute, respiratory rate
of 17/minute, and blood pressure of 123/70 mmHg. The complete blood count is notable
for mild leukopenia and anemia. Liver function tests are mildly elevated. Which of the
following is the most likely treatment for this patient's underlying illness?

Choices:

1. Tetracyclines
2. Macrolides
3. Fluoroquinolones
4. Penicillins

Answer: 1 - Tetracyclines

Explanations:

Psittacosis represents a zoonotic bacterial infectious disease caused by the obligate

intracellular organism, Chlamydia psittaci. Psittacosis, also called parrot fever and
ornithosis, is transmitted from contact with infected birds and causes a wide- ranging
spectrum of disease and severity.
After replication in the respiratory system, the infection can spread hematogenous to
affect multiple organ systems. It is often initially described as an influenza-like syndrome
characterized by fevers, chills, headaches, and a cough.
Treatment for this bacterial infection is based on intracellular activity, pharmacokinetics,
and evidence from clinical trials recommending tetracycline antibiotics, particularly
doxycycline, in the individual without contraindications. In pregnancy and in patients where
doxycycline is contraindicated, the infection is best treated with macrolide antibiotics, such
as azithromycin and erythromycin, for a 7-day course. Third-line antibiotics include
fluoroquinolones, which are less effective than tetracyclines and macrolides.
Laboratory workup may show a normal to slightly lowered white blood cell count initially
during the acute phase of the illness, with noted leukopenia later in the disease course.
Anemia has also been observed, most commonly attributed to hemolysis.

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 Liver function testing, specifically aspartate and alanine aminotransferase, as well as
gamma-glutamyl transpeptidase (AST, ALT, GGT), have also been shown to be variably
elevated in psittacosis.
Research Concepts: Psittacosis

Question 254: A 70-year-old man with a history of hypertension, hyperlipidemia,

uncontrolled diabetes mellitus with an HbA1c of 9%, and sarcoidosis treated with high-
dose corticosteroids is admitted to the hospital for fever, cough, and hemoptysis. He is
diagnosed with pneumonia and is started on appropriate antibiotic therapy; however, he
fails to improve clinically. Biopsy of the affected lung tissue shows a fungus with broad,
non-septate hyphae with right-angle branching. What is the most common clinical
presentation of this infection?

Choices:

1. Cutaneous
2. Pulmonary
3. Rhinocerebral
4. Gastrointestinal
Answer: 3 - Rhinocerebral

Explanations:

Nonseptate hyphae with right-angle branching are seen on biopsy in patients

infected with Rhizopus species. These organisms are ubiquitous. They are found
outdoors in soil and vegetation. They are also a common mold found in homes.
Aggressive zygomycotic infections occur in immunocompromised individuals. Most
commonly, they tend to occur in patients with uncontrolled diabetes, especially
those with ketoacidosis. They also occur in patients with malignancies, hematologic
disorders, transplants, burns, or those receiving immunosuppressive medications.
For reasons unknown, two- thirds of zygomycosis occurs in males.
These organisms can invade blood vessels and cause rapid destruction. The
infection rapidly accelerates and extends into adjacent tissues and structures.
Necrotic and black tissue develops in the nares, palate, or orbit. The organisms
can invade vessels and initiate a clotting response that leads to infarction. This
tissue death leads to acidosis, which continues to feed the fungal organisms'
growth and destruction.
There are several different classifications of zygomycosis: rhinocerebral,
pulmonary, gastrointestinal, cutaneous, and disseminated. Rhinocerebral is the
most common form and initially resembles sinusitis with congestion, sinus pain,
and drainage.
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Research Concepts:

Hyperbaric Zygomycotic Infections

Question 255: A 60-year-old man with no significant past medical history except tobacco
use disorder presents for the evaluation of a chronic cough. CT of the chest shows a left-
sided peripheral lung mass with radiologic features suggestive of malignancy. A unilateral
left-sided pleural effusion is also present. Tissue evaluation of the lesion reveals
neoplastic gland formation with thyroid transcription factor 1 (TTF-1) expression.
Thoracentesis reveals exudative fluid without evidence of malignant cells. What is the
best next step in the management of this patient?

Choices:

1. Repeat thoracentesis
2. Medical pleuroscopy
3. Surgical thoracoscopy
4. Surgical excision of the lung lesion

Answer: 1 - Repeat thoracentesis

Explanations:

Bronchogenic carcinoma with associated ipsilateral malignant pleural effusion is

considered unresectable; however, it must be noted that not all pleural effusions in
patients with lung cancer are malignant.
A benign pleural effusion may occur due to lymphatic obstruction, post-
obstructive pneumonitis, or atelectasis. Two consecutive cytologic evaluations of
the pleural fluid must be obtained. The best next step for this patient is to repeat
thoracentesis at this time.
If two consecutive cytology specimens are negative for malignancy in patients with
bronchogenic carcinoma, surgical thoracoscopy or medical pleuroscopy is
recommended to evaluate the pleural space before surgical resection of the primary
lesion. Medical pleuroscopy has a sensitivity of greater than 90% for detecting
malignancy when present in patients with bronchogenic carcinomas.
Pleural involvement in lung cancer can manifest as pleural thickening, nodules, or
malignant pleural effusion. During the course of their illness, approximately 10-15%
of patients with lung cancer will have a malignant pleural effusion, with some

Page 245 of 955

 showing a unilateral pleural effusion as the only presenting feature.

Research Concepts:
Lung Cancer

Question 256: A 65-year-old man presents to the emergency department with shortness
of breath, cough, and chest discomfort. His blood pressure is 130/90 mmHg, pulse rate
110/min, respiratory rate 32/min, and temperature 102 F (38.8). On examination, there
are decreased breath sounds bilaterally and the presence of bilateral inspiratory
crepitations at lower lung lobes. Fingernail clubbing is also noted. A chest x-ray reveals
peripheral patchy areas bilaterally. The patient's condition deteriorates, and he dies
despite resuscitative efforts. His family requests an autopsy to find the exact cause of
death. Histopathology of the lung reveals findings suggestive of bronchiolitis obliterans-
organizing pneumonia. Which of the following sets of findings was most likely seen on the
biopsy?

Choices:

1. Diffuse alveolar damage localized to peribronchiolar parenchyma and presence of

fibroblastic plugs
2. Widespread septal destruction of alveolar spaces and the presence of
mucus plugs
3. Hyaline membrane formation with fibrinous exudate
4. Granulomatous inflammation in small airways

Answer: 1 - Diffuse alveolar damage localized to peribronchiolar parenchyma and presence

of fibroblastic plugs
Explanations:

Bronchiolitis obliterans organizing pneumonia (BOOP), also known as cryptogenic

organizing pneumonia (COP), is a type of idiopathic pulmonary fibrosis.
Histology of lung airways will show diffuse alveolar damage, which is localized to
peribronchiolar parenchyma, and the presence of fibroblastic plugs.
The histology usually is non-specific and reveals heterogeneous zones of the normal
and affected lung. Interstitial inflammation, honeycomb change, and fibrosis are
common, though these changes can be seen with other forms of advanced lung
disease.
The physical exam should be focused on evaluating lung involvement, the extent
and severity of the disease, and excluding another diagnosis. The classic pulmonary

Page 246 of 955

 exam usually reveals fine bibasilar “velcro” crackles during inspiration. Clubbing may
also be present.

Research Concepts:Idiopathic Pulmonary Fibrosis

Question 257: A 35-year-old male presents to the clinic with complaints of cough and
hemoptysis. He started having a low-grade fever and a cough six months back. He has had
blood-streaked sputum for the last three months. The patient claims to have lost about 20
pounds (9 kg) in weight in the past three months. He is homeless and has no fixed abode.
He has smoked five cigarettes per day for the last five years. His examination reveals a
pulse of 95 beats per minute, respiratory rate of 15 per minute, blood pressure of 120/70
mmHg, and temperature of 100 F (37.8 C). Auscultation of his chest reveals bronchial
breathing and coarse crackles in his left upper lobe. His investigation reveals a WBC count
of 8,000 per microL, hemoglobin of 12 gm/dl, and erythrocyte sedimentation rate of 75
mm per hour. A purified protein derivative shows an induration of 16 mm. A chest x-ray
reveals the presence of a cavitary lesion in the left upper lobe. He is admitted to the ward,
and treatment is initiated. The next day he develops massive hemoptysis and dies of
hemorrhagic shock. The autopsy reveals the extension of cavitation into the wall of the
bronchial artery with inflammation and thinning of the artery. What is the most likely
diagnosis?
Choices:

1. Granulomatosis with polyangiitis

2. Bronchial carcinoma
3. Aspergilloma
4. Rasmussen's aneurysm
Answer: 4 - Rasmussen's aneurysm
Explanations:

This patient is a homeless individual who displays signs of a chronic pulmonary infection.
His symptoms of fever, cough, and hemoptysis and an x-ray finding of a cavitary lesion with
positive Mantoux point to a diagnosis of pulmonary tuberculosis. The invasion of the
bronchial artery by the growing cavity weakens the arterial wall and causes aneurysm
formation. Rupture of the aneurysm can heralds life-threatening bleed.
Rasmussen's aneurysm is an uncommon complication of pulmonary tuberculosis, especially
in the era of chemotherapy. The inflammatory cavity extends into the adventitia and media
of bronchial arteries leading to thinning of vessels. Rupture leads to massive hemoptysis.
The treatment of choice in aneurysmal bleeding is the angioembolization of the bronchial
artery. Other measures include intravenous vasopressors and endobronchial tamponade
and surgical resection in refractory cases.
Mild hemoptysis is common in pulmonary TB, but the erosion of the arterial wall can result in
life-threatening hemoptysis.
Page 247 of 955
 Bronchial carcinoma and aspergillosis can lead to frank hemoptysis but is unlikely given the
autopsy findings.
Research Concepts: Tuberculosis

Question 258: A 57-year-old undercover journalist presented to the emergency

department with myalgias, fatigue, shortness of breath for the past 2 days, and was noted
to have a high fever. His temperature was 39.6 degrees C, pulse 118/min, blood pressure
100/60 mm of Hg, and respiratory rate 32/min. Radiographic findings revealed large
bilateral pleural effusions in addition to CT findings of necrotic mediastinal and hilar lymph
nodes, peribronchial thickening, and pleural effusions. Thoracentesis was performed, and
bloody effusion was noted. These features are suggestive of which of the following
infections?

Choices:

1. Klebsiella pneumoniae
2. Tuberculosis
3. Inhalation anthrax
4. Lymphoma

Answer: 3 - Inhalation anthrax

Explanations:

These findings are indicative of inhalation anthrax wherein CT findings of alveolar

and lymph node necrosis and bloody effusions on thoracentesis are classic
diagnostic clues.
Inhalational anthrax is an agent of bioterrorism. The journalist was exposed to it
while working undercover.
Chest x-rays are not as revealing as the CT scan. With findings of necrosis visualized
on CT scan. If a patient is presumed to have inhalational anthrax, a CT scan should
be performed as early as possible.
CT scan findings of lymphoma include enlarged discrete homogenous soft-tissue
attenuation bulky lymphadenopathy. Chest radiograph findings include anterior
and/or middle mediastinal stripes and lines widening and opacities.
Tuberculosis is known to cause cavitary lesions most often localized in the upper
lobes. Klebsiella pneumoniae affects the middle and lower lobes commonly in
patients with alcohol use disorder as a result of aspiration.

Page 248 of 955

Research Concepts: Anthrax

Question 259: A 65-year-old male with a 50-pack-year history of smoking is diagnosed

with stage II squamous cell cancer, with a centrally located tumor of the right upper lobe.
After undergoing neoadjuvant chemotherapy, he undergoes a right upper lobe pulmonary
sleeve resection. Two days later, he develops acute onset hypoxia, tachycardia, and
hypotension. Chest x-ray shows diminished vascular markings. What is the next best
diagnostic study for this postoperative complication?

Choices:

1. Ventilation/perfusion scan
2. Lateral decubitus x-ray
3. Echocardiogram
4. CT angiography of the chest
Answer: 4 - CT angiography of the chest

Explanations:

After pulmonary sleeve resection, post-operative complications include anastomotic

dehiscence, acute respiratory distress syndrome (ARDS), or pulmonary artery
thrombosis.
Since chest x-ray is clear with diminished markings, one has to rule out pulmonary
artery thrombosis.
CT pulmonary angiography can confirm thrombosis. Atelectasis may present
similarly, and incentive spirometry and bronchoscopy may be required.

Research Concepts:

Pulmonary Sleeve Resection

Question 260: A 65-year-old male with a history of severe chronic obstructive pulmonary
disease (COPD) is admitted after presenting with respiratory distress. This is his fourth
visit this year for COPD exacerbations, all of which required prolonged corticosteroid
tapers. Currently, the patient is at 10 mg of prednisone daily and is hesitant to stop the
medication. It is decided to continue the patient on a chronic low dose of corticosteroid
dose given the frequency of his COPD exacerbations while optimizing his inhaler regimen.
What is recommended to help prevent corticosteroid- induced myopathy in this patient?

Page 249 of 955

Choices:

1. Prescribe dexamethasone instead of prednisone

2. Initiate physical therapy including resistance exercises
3. Regularly monitor creatine kinase (CK) levels
4. Recommend abstinence from physical activity

Answer: 2 - Initiate physical therapy including resistance exercises

Explanations:

Physical therapy with resistance exercises has shown to prevent and treat
corticosteroid-induced myopathy, even in patients unable to taper off steroids.
The condition typically develops with doses higher than 10 mg prednisone
equivalents/day used for 4 weeks or longer.
However, 2 to 3 weeks of higher doses (such as 40 to 60 mg prednisone/day) has been
associated with more acute presentations.
There is no role for labwork in monitoring for corticosteroid- induced myopathy,
and creatine kinase (CK) is typically normal. Physical activity should be encouraged
in patients at risk for corticosteroid-induced myopathy, as sedentary lifestyles
increase the risk of developing corticosteroid-induced myopathy. Dexamethasone is
a fluorinated glucocorticoid that is more likely to cause corticosteroid-induced
myopathy compared to nonfluorinated agents such as prednisone or
hydrocortisone.

Research Concepts:
Corticosteroid Induced Myopathy

Question 261: A 43-year-old man presents to the emergency department with shortness
of breath and tachypnea. CT angiography reveals a left-sided pulmonary embolus. A
decision is made to treat with alteplase and unfractionated heparin. When should
unfractionated heparin be started?

Choices:

1. Start heparin before the alteplase infusion

2. Start heparin at the same time as the alteplase infusion
3. Do not give heparin if the patient has received alteplase
Page 250 of 955
 4. Start heparin immediately following the alteplase infusion when the aPTT returns
to baseline or twice baseline

Answer: 4 - Start heparin immediately following the alteplase infusion when the aPTT
returns to baseline or twice baseline

Explanations:

Heparin administration concomitantly or immediately following alteplase infusion

has been studied in the treatment of myocardial infarction and pulmonary
embolism, respectively.
This is however not the case in patients with acute ischemic stroke. It is recommended
to not give other anticoagulants or antiplatelets within 24 hours of treating ischemic
stroke with alteplase.
This is done to reduce the risk of bleeding.
In patients with pulmonary embolism, heparin is started after the alteplase infusion
when the aPTT is back to baseline or twice baseline.

Research Concepts:

Alteplase

Question 262: A 35-year-old man with HIV presents with hemoptysis, dyspnea, and
fatigue. The client has not been compliant with his antiretroviral therapy. Scattered
crackles are heard bilaterally on chest auscultation. His CD4 count is 130 cells/mm3. A CT
scan of the chest shows ground-glass opacities in both lungs. Which of the following is the
first-line treatment for this client's suspected condition?

Choices:

1. Trimethoprim-sulfamethoxazole
2. Azithromycin-trimethoprim
3. Penicillin
4. Ceftriaxone-azithromycin

Answer: 1 - Trimethoprim-sulfamethoxazole

Explanations:
Page 251 of 955
 This client has developed pneumocystis jiroveci pneumonia (PCP). Clients presenting
with PCP may show signs of fever, cough, dyspnea, and, in severe cases, respiratory
failure.
Pneumocystis is thought to be transmitted from person to person via an airborne
route.
The first-line treatment for both HIV-infected and uninfected patients is 21
days of trimethoprim-sulfamethoxazole (TMP- SMX).
For mild to moderate disease, give TMP 15 to 20 mg/kg/day and SMX 75 to 100
mg/kg/day orally in 3 divided doses or TMP-SMX double strength (DS) 2 tablets 3
times per day.
Typically, clients at risk are those with any underlying disease state that alters host
immunity such as those with cancer, HIV, transplant recipients, or those being treated
with immunosuppressive medications.

Research Concepts:

Prevention Of Opportunistic Infections In HIV/AIDS

Question 263: A 49-year-old woman is being evaluated in the ICU. She has been on a
mechanical ventilator for Guillain-Barre syndrome for the past 10 days and has undergone
an ultrasound- guided percutaneous tracheostomy an hour ago. Multiple attempts were
required to insert the needle intratracheally, which was followed by significant oozing
after the procedure. A bedside fibreoptic bronchoscopy, in the meantime, reveals a tear
of 1 cm in the posterior wall of the trachea (Cardilo grade II). Tracheostomy tube was,
however, placed successfully, and the bleeding is currently under control. Examination
reveals minimal subcutaneous emphysema. A chest x-ray does not show any
pneumothorax or pneumomediastinum. The patient continues to be on ventilator, stable
clinically, hemodynamically, and oxygenation wise. Which of the following is the next best
step in the management of this patient?

Choices:

1. Urgent surgical repair

2. Conservative management
3. Bronchoscopy and stenting
4. Bronchoscopic glue injection

Answer: 2 - Conservative management

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Explanations:

This patient has most likely sustained an iatrogenic posterior tracheal wall tear,
which fits into Cardilo morphologic classification Level II. The size of the tear is 1 cm.
The best way to manage the patient is a conservative approach with follow up
bronchoscopies.
Conservative management is advocated in tracheal tears less than 2 cms, and also
in tears 2-4 cms on a case to case basis. Tears more than 4 cms will have to
undergo surgical repair.
Cardilo et al. proposed a morphologic classification to identify patients with
intubation related posterior tracheal wall injuries who could be managed without
surgical repair, and many experts have extrapolated the above classification to
other iatrogenic injuries too. Level I is mucosal or submucosal injury, Level II
represents further extension with muscular wall involvement with subcutaneous
or mediastinal emphysema.
Level IIIA represents complete laceration with herniation of oesophageal or
mediastinal soft tissue, and Level IIIB represents all the above findings plus
oesophageal injury or mediastinitis.
Level I could undergo conservative management with Level II management on a
case to case basis. All conservatively managed patients need a bronchoscopic
follow up. Level IIIA & IIIB represents a definite indication for surgery.
A semi-conservative option of bronchoscopic stenting could be tried in patients who
are unfit for surgical correction either transiently or permanently. Trial of placement
of covered Self Expandable Metallic Stent (SEMS) is bronchoscopically performed so
that the ensuing inflammatory reaction around the stent will obliterate the airway
defect. These stents are subsequently removed after 4-6 weeks with reinsertions
done if indicated. Surgical repair could be considered even at this stage if it is still
indicated, and the patient is fit for the procedure.

Research Concepts:
Tracheobronchial Tear

Question 264: A 66-year-old male with a history of chronic obstructive pulmonary

disease (COPD) is being evaluated for long- term oxygen therapy (LTOT). He has been on
both short and long- term beta-agonists for many years. He has limited exercise
endurance and has had many hospital admissions over the past five years. However, for
the past 12 months, his condition has stabilized. The arterial blood gas revealed a PaO2
of less than 55 mmHg on two separate occasions. Which of the following would warrant
the use of LTOT in this patient?

Choices:

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1. Presence of left ventricular failure
2. Hypocapnia
3. Polycythemia
4. Secondary hypertension

Answer: 3 - Polycythemia

Explanations:

One criterion that may indicate long-term home oxygen is the presence of
polycythemia. These patients have excessive sludging of the capillaries and,
consequently, suffer from oxygenation problems.
Other criteria that also support the use of long-term home oxygen in the presence
of pulmonary hypertension include a PaO2 less than or equal to 8.0 kPa (60
mmHg), right heart failure, and hematocrit >55 percent.
Patients with a resting oxygen saturation of 89% are also candidates for long-term
home oxygen.
Conditions for which long-term home oxygen is required include cystic fibrosis,
pulmonary hypertension, interstitial lung disease, neuromuscular disease, and end-
stage lung cancer.

Research Concepts:

Home Oxygen Therapy

Question 265: How is functional residual capacity defined?

Choices:

1. The sum of residual volume and end respiratory volume

2. The volume of air present in the lungs at the end of passive expiration
3. The vital capacity minus the residual volume
4. The minute tidal volume

Answer: 2 - The volume of air present in the lungs at the end of passive expiration

Explanations:
Page 254 of 955
 Functional residual capacity is the volume of air present in lungs at end of passive
expiration.
FRC is a combination of ERV and RV. FRC cannot be
measured with spirometry.
Helium dilution technique is one way to determine FRC of lung.

Research Concepts:

Physiology, Functional Residual Capacity

Question 266: A 26-year-old male presents to the hospital with complaints of oliguria,
dyspnea, nausea, and vomiting for three days. On examination, he has a low-grade fever,
his blood pressure is 160/90 mmHg, his pulse is 92 beats per minute, and there are coarse
crackles on the auscultation of his chest. A chest radiograph shows bilateral infiltrates.
Initial laboratory workup shows a creatinine of 5.65 mg/dl, hemoglobin of 8.5 g/dl, and
potassium of
6.0 mEq/l. Pulmonary function tests are suggestive of a raised transfer factor. What is the
renal biopsy most likely to reveal?

Choices:

1. Sclerosis of segments of the glomerular tuft with mesangial expansion

2. Glomerular thrombosis without necrosis
3. Diffuse mesangial deposits of immunoglobulin A
4. Necrosis with epithelial cell crescents
Answer: 4 - Necrosis with epithelial cell crescents

Explanations:

Goodpasture syndrome consists of diffuse pulmonary hemorrhage and acute or

rapidly progressing glomerulonephritis.
Anti–glomerular basement membrane (GBM) antibodies are present in the disease.
The biopsy tissue should be sent for analysis under light microscopy, electron
microscopy, and immunofluorescence. Light microscopy shows nonspecific findings
of a proliferative or necrotizing glomerulopathy with cellular crescents.
The crescents become fibrotic over time, leading to the development of frank
glomerulosclerosis, tubular atrophy, and interstitial fibrosis.

Research Concepts:

Goodpasture Syndrome
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Question 267: A 30-year-old woman presents to the clinic with shortness of breath. She
has a chest CT which shows diffuse alveolar shadowing and ground-glass appearance.
Spirometry is requested, which shows FEV1 of 70% and FEV1/FVC ratio of 75%. She
mentions that when she was much younger, she had recurrent episodes of hemoptysis,
iron-deficiency anemia with several iron transfusions, and recurrent chest infections. She
also has a bronchoalveolar lavage report, which shows hemosiderin-laden macrophages.
She was treated with prednisone at the time but has had recurrent episodes. Which of
the following complications best explains this patient's current presentation?

Choices:

1. Bronchiectasis
2. Pulmonary fibrosis
3. Adult-onset asthma
4. Chronic obstructive pulmonary disease

Answer: 2 - Pulmonary fibrosis

Explanations:

The correct answer is pulmonary fibrosis. Pulmonary fibrosis can develop as a

complication of recurrent idiopathic pulmonary hemorrhage/hemosiderosis.
Idiopathic pulmonary hemorrhage/hemosiderosis occurs due to bleeding into the
alveoli. The hemoglobin is broken down into hemosiderin, which is taken up by the
alveolar macrophages. If recurrent, pulmonary fibrosis may occur as a complication.
Bronchoalveolar fluid analysis shows hemosiderin-laden macrophages, and a chest CT
scan may show diffuse alveolar opacities and ground glass appearance.
The spirometry in pulmonary fibrosis shows a restrictive picture with normal FEV1 and
normal or elevated FEV1/FVC.

Research Concepts:

Idiopathic Pulmonary Hemorrhage

Question 268: A 60-year-old man with a 30 pack-year smoking history presents to the clinic
for fatigue and cough. His symptoms started ten months ago and have progressively
worsened. He has noticed a couple of episodes of blood-tinged sputum while coughing. He
has lost 10 pounds (4.5 kg) in the last four months. Grade 2 clubbing is present on the
general examination. A computed tomography scan of the thorax shows a 10 mm left
peripheral pulmonary nodule. Which of the following is the next step in management?

Page 256 of 955

Choices:

1. Transbronchial lung biopsy (TBLB)

2. Computed tomography-guided percutaneous lung biopsy
3. Video-assisted thoracoscopic surgery
4. Open lung biopsy
Answer: 2 - Computed tomography-guided percutaneous lung biopsy
Explanations:

Percutaneous transthoracic lung biopsy (PTLB) is a type of close lung biopsy that
may also be referred to as percutaneous or transthoracic needle biopsy, where a
needle is inserted through the chest wall via computed tomography fluoroscopic
guidance into the suspected area to obtain a tissue sample. This procedure is
recommended for peripheral lesions.
Indications for PTLB according to the British thoracic society (BTS) guidelines (in
near-verbatim language) include 1) new or enlarging solitary nodule or mass on
chest radiography that is not amenable to diagnosis by bronchoscopy or
computed tomography shows it is unlikely to be accessible by bronchoscopy, 2)
multiple nodules in a patient with no previous history of malignancy, or who have
had a prolonged remission or more than one primary malignancy, 3) persistent
focal infiltrates for which no diagnosis has been made by sputum, or
bronchoscopy, blood culture, serology, and 4) hilar mass.
Depending on the decision to perform core biopsy alone or along with fine-needle
aspiration, several options for percutaneous lung biopsy needles are available,
including aspiration and cutting needles. The needle choice also depends upon
factors like the size of the lesion, needle trajectory, and operator preference.
For central and endobronchial lesions, bronchoscopy with bronchoalveolar lavage
with or without transbronchial biopsy is indicated.
Research Concepts: Lung Biopsy Techniques And Clinical Significance

Question 269: A 36-year-old woman comes to the physician to discuss management plans
for her chronic back pain. She has had lower back pain for the past nine years. The pain is
worse with rest, improves with movement, and can awaken her during the night. She takes
naproxen twice daily with some relief. Currently, the patient is afebrile and
hemodynamically stable. The joint examination does not reveal any warmth, erythema, or
swelling. Tenderness over the sacroiliac joints bilaterally and reduction in the range of
motion of the lumbar spine are noted. Laboratory studies are notable for an erythrocyte
sedimentation rate of 31 mm/h. A plain anteroposterior radiograph of the pelvis shows the
fusion of the sacroiliac joints.
Pulmonary function testing will reveal which of the following pattern?

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 Choices:

1. Restrictive pattern with reduced vital capacity and total lung capacity but
normal FEV1/FVC ratio
2. Restrictive pattern with reduced vital capacity, total lung capacity, and FEV1/FVC
ratio
3. Restrictive pattern with increased vital capacity, total lung capacity, and normal
FEV1/FVC ratio
4. Obstructive pattern with increased vital capacity, total lung capacity, and
normal FEV1/FVC ratio
Answer: 1 - Restrictive pattern with reduced vital capacity and total lung capacity but normal
FEV1/FVC ratio

Explanations:

Peripheral joint involvement occurs in 40% of patients with ankylosing spondylitis.

Hips, shoulders, and sternum are often affected in the first 10 years of the disease.
Other peripheral joints are involved to a minor degree.
Temporomandibular joint involvement is also common.

Research Concepts:

Ankylosing Spondylitis

Question 270: A 64-year-old male with no past medical history presents complaining of
high fever, chills, and dry cough for the past three months. His temperature is 102.0 F
(38.9 C). His chest X-ray shows interstitial fibrosis. The patient admits to working in a
metal shop without a mask. He is given prednisone but shows no improvement after two
weeks. While lung biopsy results are pending, what treatment should be started for this
patient?

Choices:

1. Ceftriaxone
2. Prednisone
3. Methotrexate
4. Folic acid

Answer: 3 - Methotrexate

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Explanations:

Patients who fail to respond to corticosteroids should start immunosuppressive

agents such as methotrexate or azathioprine.
Chronic beryllium disease (CBD), also known as berylliosis, is a granulomatous
hypersensitivity disease that occurs in 2 to 5% of beryllium-exposed workers. A less
likely diagnosis is giant cell pneumonia secondary to chromium.
The current Occupational Safety and Health Administration (OSHA) guidelines have
reduced the permissible exposure limit for beryllium to 0.2 micrograms/m^3
averaged over 8 hours or less than 2 micrograms/m^3 over 15 minutes.
Unless an individual lives very close to an industrial site, the general population is
unlikely to develop CBD because ambient air levels of beryllium usually are very
low (less than 0.03 nanograms/m^3).

Research Concepts:

Berylliosis

Question 271: A 75-year-old American Society of Anesthesiologists class-III (ASA-III) man

with a history of coronary artery disease, chronic renal disease, and obstructive sleep
apnea is taken to the operating room for inguinal hernia repair. He had been seen by a
cardiologist and cleared for surgery. General anesthesia via laryngeal mask airway (LMA)
is considered with maintenance using desflurane. Vital signs are normal prior to pre-op,
and induction and placement of the LMA are uneventful. Ten minutes later, during
surgical prep, the patient's vital signs show HR 115/min, BP 148/96 mmHg, RR 14/min,
SpO2 99%, EtCO2 45 mmHg, and T
98.9 F (37.1 C). The end-tidal desflurane value reads 8.5, and the only other medication
administered at this point was cefazolin. What is the most likely cause for the patient's
clinical condition?

Choices:

1. Rapid titration of desflurane

2. Malignant hyperthermia
3. Insufficient depth of anesthetic
4. Allergic reaction to perioperative antibiotic administered

Answer: 1 - Rapid titration of desflurane

Explanations:

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 Desflurane, especially when rapidly titrated, will stimulate the sympathetic nervous
system.
A higher flow rate on the anesthesia machine can lead to an increase in the fraction
of inspired volatile, which will yield more rapid titration of anesthetic. This rapid
change in end-tidal volatility, rather than a slow titration, can increase heart rate
and blood pressure transiently.
In this patient with a history of coronary artery disease, sympathetic stimulation
should be avoided to prevent further ischemia.
While desflurane is a malignant hyperthermia triggering agent, it is unlikely, given
the patient's modest elevation in EtCO2, which is more likely explained by his
history of OSA. The elevation in HR and BP are non-specific, and it would be much
more likely to have malignant hyperthermia with a much more rapid elevation in
EtCO2. The non-specific nature of isolated tachycardia and hypertension are much
more commonly associated with rapid titration of desflurane as opposed to MH in
this scenario.
Inadequate depth of anesthesia certainly presents as hypertension and tachycardia.
However, it is much less likely in this scenario where the patient has no surgical
stimulation yet as the prep is ongoing, and it has been 10 minutes since the
stimulation of placing the LMA occurred. In addition, the patient's MAC is greater
than 1, which is more than adequate given the lack of stimulation at this time. It is
because of the rapid titration of the volatile agent desflurane that likely led to
tachycardia and hypertension. Allergic or anaphylactic reactions are common with
steroidal non-depolarizing neuromuscular blocking drugs as well as perioperative
antibiotics. However, it is much more commonly associated with hypotension,
tachycardia, and increased peak airway pressures. The etiology of this patient's
tachycardia and hypertension are much more likely caused by sympathetic
stimulation from desflurane. The mechanism by which the sympathetic stimulation
occurs is not fully understood, but rapid titration tends to increase the incidence of
stimulation.

Research Concepts:

Desflurane

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Question 272: A 49-year-old woman presents to the clinic for follow-up. She was seen last
month with complaints of pain in her fingers bilaterally with associated hand swelling. She
has a history of Raynaud phenomenon, not requiring treatment. She also reports
heartburn, especially at night, and a nonproductive cough. Further inquiry reveals ongoing
fatigue and some shortness of breath with strenuous activity. She denies dyspnea with
normal activity or at rest. Physical examination, including a thorough cardiopulmonary
examination, is unremarkable. Vital signs are within normal limits.
Laboratory data obtained last week shows normal renal function and markedly positive anti-
centromere antibodies. She is started on ranitidine and amlodipine. What additional testing
is indicated at this time?
Choices:

1. Right heart catheterization

2. Serum NT-pro-B type natriuretic peptide level
3. Echocardiography
4. CT angiography of the chest with contrast
Answer: 3 – Echocardiography
Explanations:

Screening for pulmonary arterial hypertension (PAH) is recommended at the time

of diagnosis of systemic scleroderma (SSc) and annually thereafter. This leads to
early diagnosis of PAH and better clinical outcomes with early initiation of PAH-
directed therapy. As such, patients with SSc are recommended to undergo annual
pulmonary function testing and an annual echocardiogram to screen for PAH.
Pulmonary function tests and transthoracic echocardiography can help identify
sequelae of PAH and help eliminate other causes of pulmonary hypertension such
as left heart failure and chronic parenchymal lung disease.
Most patients with PAH have a decreased lung diffusion capacity for carbon
monoxide (DLCO) with preserved lung volumes if interstitial lung disease is absent.
Transthoracic echocardiography (TTE), using continuous-wave Doppler
measurements, may be used to estimate current pulmonary arterial pressure
based on the peak tricuspid regurgitation velocity (TRV).
If results from the above testing are positive, the patient should be referred for a
right heart catheterization (RHC). The gold standard diagnostic technique for
pulmonary hypertension is RHC; however, it is invasive and associated with
complications and high cost. Therefore, it is not considered an appropriate initial
screening test.
Research Concepts: Scleroderma-Associated Pulmonary Arterial Hypertension: Early
Detection For Better Outcomes

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 Question 273: A 65-year-old man with severe chronic obstructive pulmonary disease
(COPD) presents for worsening dyspnea. Despite optimal medical treatment, he continues
to have progressive dyspnea limiting his daily activities. He has a 30-pack- year smoking
history and quit a year ago. A CT thorax shows a heterogeneous emphysema pattern with
cysts and bullae bilaterally in the upper lobes. He undergoes lung volume reduction
surgery (LVRS). Two weeks later, he reports his dyspnea has improved. His blood pressure
is 135/82 mmHg, pulse 80/minute, respiratory rate 16/minute, and oxygen saturation 94%
on room air. Body mass index 29 kg/m2. Lung exam demonstrates distant breath sounds,
and bilateral lower extremity edema is noted. Which of the following best describes
changes in this patient's lung physiology following LVRS?

Choices:

1. Lung compliance will increase.

2. Lung compliance will decrease.
3. Lung compliance will not change.
4. Lung expansion will decrease for a given change in
transpulmonary pressure.

Answer: 3 - Lung compliance will not change.

Explanations:

Static pulmonary compliance is the change in lung volume per unit change in
transpulmonary pressure, which is the pressure difference between the
interalveolar and the pleural pressures. Chronic obstructive pulmonary disease
(COPD) is one example of a lung disease associated with high lung compliance. In
COPD, the alveolar walls become damaged due to cigarette smoke's inflammatory
effect, resulting in loss of lung elasticity.
However, the degree of change in lung compliance following lung volume reduction
surgery (LVRS) depends on the distribution and severity of lung damage from
emphysema.
When emphysematous lung tissues are heterogenous, removing these bullae and
cysts will increase vital capacity without significantly changing lung compliance. The
compliance in this patient remains unchanged because the emphysematous lung
tissue is heterogeneous and has lost its elasticity; therefore, removing it will not
affect postoperative lung elasticity while improving lung volumes (vital capacity).
However, if emphysema is diffuse, the lung volume reduction surgery will lead to
the removal of bullae and normal lung tissue with high lung elasticity; therefore,
postoperative lung compliance will decrease.
Given that lung compliance is high in patients with COPD, the lung expands to a
Page 262 of 955
 greater extent than in conditions with lower compliance for a similar increase in
transpulmonary pressure. In patients with heterogeneous emphysema, lung
volume reduction surgery (LVRS) will result in a significant change in lung
compliance; hence the ability of the lung to expand for a given transpulmonary
pressure will not change.

Research Concepts:

Pulmonary Compliance

Question 274: A 29-year-old man presents with a one-month history of a persistent

cough that is now accompanied by bloody phlegm. He also reports night sweats, lack of
appetite, and unintentional loss of 4 kg during that period. He denies any recent travel
history but mentions he made a trip to Brazil one year ago. All his vital signs are within
normal limits. On lung auscultation, bronchial breathing is heard. An acid-fast bacilli
smear is positive. A member of the rifamycin group is prescribed as part of a drug
treatment regimen. By which of the following mechanisms is this medication is known to
induce drug interactions?

Choices:

1. Competitive binding site activity

2. Inhibition of CYP450 enzymes
3. Inhibition of gastric absorption of the other drugs
4. Induction of CYP450 enzymes

Answer: 4 - Induction of CYP450 enzymes

Explanations:

The patient in the clinical scenario presents with active tuberculosis, for which he is
prescribed rifampin.
Rifampin belongs to the family of rifamycins, and it is a potent inducer of many
drug-metabolizing enzymes, notably cytochrome P450 (CYP) 3A4 and drug
transporter proteins, such as hepatic P-glycoprotein.
The drugs with which rifamycins interact are predominantly metabolized via this
metabolic pathway. Hence potent induction of these enzymes will decrease
systemic levels of these medications.
By inducing the liver enzymes, rifamycins can increase the breakdown of many drugs
and undermine their efficacy.

Page 263 of 955

Research Concepts:

Rifampin

Question 275: A 45-year-old female nurse presents to discuss her recent medical reports.
She works in a nursing facility that admits military personnel who have been posted in
several developing countries. She has experienced no symptoms and has no significant
personal or family medical history. During her annual health check- up, she received a
tuberculin skin test. The redness of the area has a diameter of 15 mm, and the induration
around the injection site has a diameter of 11 mm. A chest x-ray shows no abnormalities.
What is the appropriate management for this patient?

Choices:

1. No treatment is necessary
2. 4 months of daily rifampin
3. A four-medication combination for two months, followed by a two- medication
combination for four months.
4. Six months of isoniazid

Answer: 2 - 4 months of daily rifampin

Explanations:

This patient has an 11 mm induration but no symptoms or radiographical evidence

of tuberculosis; thus, this is latent TB. Induration of 10 mm or greater indicates
positivity in persons with an above baseline risk of reactivation. Some of the
conditions that increase risk include chronic kidney disease on dialysis, silicosis,
diabetes mellitus, malignancy, underweight status, jejunoileal bypass, gastrectomy,
injection drug abuse, age less than 4-years, born in a country with a high incidence
of TB, and who immigrated within the past 5 years, and residents or workers in
prisons, jails, healthcare facilities, and homeless or refugee shelters.
2020 LTBI treatment guidelines include the NTCA- and CDC- recommended
treatment regimens that comprise three preferred rifamycin-based regimens and
two alternative monotherapy regimens with daily isoniazid. These are only
recommended for persons infected with Mycobacterium tuberculosis that is
presumed to be susceptible to isoniazid or rifampin. A regimen of 3 months of once-
weekly isoniazid plus rifapentine is a preferred regimen that is strongly
recommended for children aged more than 2 years and adults. Another option is 4
months of daily rifampin for HIV-negative adults and children of all ages. Three
months of daily isoniazid plus rifampin is a preferred treatment that is conditionally
Page 264 of 955
 recommended for adults and children of all ages and for patients with HIV.
Regimens of 6 or 9 months of daily isoniazid are alternative recommended
regimens.
Latent TB infection is prevalent, and treatment of patients can reduce the burden
of active tuberculosis, especially if screening is performed in populations at high
risk for progression to active disease. Current United States guidelines endorse the
use of either the tuberculin skin tests (TST) or interferon-gamma release assay test
for this purpose, although there are some minor differences in their performance
in some populations. In general, both types of tests should not be used routinely in
individual patients. A decision to test should presuppose the intention to treat
latent tuberculosis if detected.
Research Concepts:

Primary Lung Tuberculosis

Question 276: A 76-year-old man with nasopharyngeal carcinoma presents to the office
with complaints of progressive shortness of breath and difficulty swallowing his food. He
has refused chemotherapy/radiation therapy in the past due to the belief that it “will only
kill him faster.” He is willing to undergo additional procedures or treatments if it helps
improve his quality of life, as he wants to feel comfortable enough to enjoy life with his
new grandson. He had already been evaluated by an outpatient pulmonologist for
shortness of breath and was found to have tracheal stenosis on recent bronchoscopy.
Which of the following is the next best step in the management of this patient?

Choices:

1. Recommend palliative chemotherapy/radiation again

2. Tracheal stent placement
3. Corticosteroids
4. Hospice evaluation

Answer: 2 - Tracheal stent placement

Explanations:

Treatment options for laryngotracheal stenosis (LTS) include endoscopic dilatation,

surgery, stent placement, laser therapy, or immunosuppression to restore airway
patency, depending on the underlying etiology as well as degree and complexity of
stenosis.
In this patient with stenosis, possibly due to malignancy, palliative radiation
therapy, immunotherapy, or chemotherapy could be options. However, if he has
Page 265 of 955
 symptomatic stenosis, stenting would still first be required to maintain patent
airway during such treatment.
Tracheal stenting is a palliative option for patients with advanced and unresectable
cancer-causing airway obstruction. Stenting is a challenging and risky approach that
requires a risk-benefit conversation with the patient.
Higher performance status prior to surgery has been linked to better patient
outcomes. A Japanese study by Matsuo et al. aimed to clarify indications for stent
placement, which include: 1) severe central airway obstruction with dyspnea and
flow limitation on a flow-volume curve, 2) prognosis will be prolonged by stent
placement, and 3) peripheral airways and lungs are intact.

Research Concepts: Laryngotracheal Stenosis

Question 277: A 78-year-old male is brought in with confusion, fever, cough, and
shortness of breath. He has a history of hypertension, end-stage renal disease (ESRD) on
hemodialysis three times a week, stroke with residual weakness on the left side with
aphasia, leukemia on chemotherapy, and has been residing in a nursing home for the past
year. The patient also had two falls at the nursing home with no loss of consciousness. His
vital signs are a temperature of 101 F (38.3 C), a heart rate of 106 beats per minute, and a
blood pressure of 90/60 mmHg. Initial evaluation shows the patient has confusion, poor
oral hygiene, and poor skin turgor. On auscultation, rales are noted in the right lower
lobe. A chest x-ray shows right lower lobe consolidation. Computed tomography (CT)
head reveals no acute findings. Blood cultures are drawn, and IV fluids are given. The
initial report of sputum analysis reveals Candida species. Which of the following is the
strongest risk factor for the patient's condition?

Choices:

1. Older age
2. Poor dentition
3. End-stage renal disease on hemodialysis
4. Chemotherapy

Answer: 4 - Chemotherapy

Explanations:

Immunosuppressed patients, such as those undergoing chemotherapy, are at

increased risk for fungal organisms such as Candida species.
Candida fungemia usually needs at least 14 days of systemic antifungal treatment.
Page 266 of 955
 Candida albicans is the most common cause of candidemia in nursing home-acquired
pneumonia.
Early consideration of antifungal treatment in the patient undergoing chemotherapy
and neutropenia reduces mortality.

Research Concepts:

Nursing Home Acquired Pneumonia

Question 278: A 62-year-old male patient presents with recurrent fever. He has had
leukemia for the past three years. On examination, his blood pressure is 105/70 mmHg,
his heart rate is 87 beats per minute, and his respiratory rate is 17 breaths per minute.
He has had neutropenia for a month and today his lab investigations reveal a white blood
cell count of 3100 cells/microL with neutropenia. The patient is diagnosed with systemic
fungal infection with diploid and Gram-positive fungus. Which of the following is an
exception to the complications of this systemic infection?

Choices:

1. Infective endocarditis
2. Fungal meningitis
3. Bronchopulmonary candidiasis
4. Fungal septicemia
Answer: 3 - Bronchopulmonary candidiasis

Explanations:

Candidiasis is an opportunistic infection caused by Candida, a type of fungi. Fungi

are eukaryotic organisms found in the form of yeasts, molds, or dimorphic fungi.
Candida is a form of yeast. Candidiasis occurs most commonly as a secondary
infection in immunocompromised individuals.
Systemic candidiasis requires treatment with oral or intravenous antifungal
medications, including caspofungin, fluconazole, and amphotericin B.
Systemic candidiasis presents as prolonged neutropenia and fever refractory to
antibiotics in leukemic patients.
Bronchopulmonary candidiasis is a rare complication of pre- existing pulmonary
disease. Oral thrush, vaginitis, and cutaneous candidiasis are common lesions of
candidiasis.
Septicemia, endocarditis, and meningitis occur as terminal complications in leukemic
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 patients.
Research Concepts:

Candidiasis

Question 279: A 35-year-old male presents with a non- productive cough and shortness of
breath for the last three days. He works in a factory that makes detergents and
waterproofing chemicals. His vitals show a low-grade fever, a blood pressure of 130/80
mmHg, a pulse rate of 110 beats per minute, and a respiratory rate of 24 breaths per
minute. Which of the following is associated with fluoropolymer-associated respiratory
disease?

Choices:

1. Patients may have hypocalcemia

2. Recovery generally takes 10-14 days
3. Deaths have not been reported
4. Flu-like symptoms have been reported to last longer than pulmonary
symptoms

Answer: 1 - Patients may have hypocalcemia

Explanations:

Fluoride is the most electronegative element, it binds tightly to cations such as

calcium.
Due to calcium-binding, fluorocarbon exposure could lead to hypocalcemia,
similar to that seen following hydrofluoric acid exposures.
Most patients (60% in one study) present with non-productive cough and dyspnea.
Other common symptoms include chest pain, fever, nausea, vomiting, fatigue,
malaise, and myalgias. Respiratory failure, ARDS, pulmonary fibrosis, and death
have been reported.

Research Concepts:

Fluorides and Fluorocarbons Toxicity

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 Question 280: A 55-year-old woman presents into the emergency room from a local dive
school because she is confused, having trouble breathing and coughing. She has a past
medical history significant for obesity, hypothyroidism on levothyroxine, a prior c-
section, and a total hysterectomy two years ago. Her instructor said she was doing well
on the dive and followed the appropriate rate for ascent but seemed to be having
trouble breathing when she came out of the water. He feels terrible because the patient
recently lost her husband in a terrible accident, and he thought the dive class would help
her cope since she hadn't left the house for two days. The ambulance driver says her
blood pressure was 100/68 mmHg, heart rate 90/min, respiratory rate was 40/min
initially but improved to 28/min, and her O2 saturation was 89% initially and 96% with
oxygen administration 2L via nasal cannula.
On exam, she is conscious, pale, and cool in her distal extremities. She is using accessory
muscles to breathe, but breath sounds are equal bilaterally. Her heart is a regular rate and
rhythm with no appreciable murmur. The provider notes frothy pink sputum with a forceful
cough. Which of the following is the underlying cause of this patient's decompensation?
Choices:

1. Pulmonary embolism
2. Takatsubo cardiomyopathy
3. Decompression sickness
4. Acute aspiration
Answer: 2 - Takatsubo cardiomyopathy

Explanations:

While acute pulmonary embolism can have a similar presentation, her only risk
factor is a recent sedentary period. She is postmenopausal but not currently on
hormonal therapy. It is far more likely given the acute onset while diving. This is
immersion pulmonary edema.
The recent loss of her husband was a precipitating factor for Takotsubo
cardiomyopathy, which would increase her risk of immersion pulmonary
edema.
While most first-hand accounts are less reliable, her dive instructor is trained to
monitor dives and watch for possible decompression sickness triggers. Immersion
pulmonary edema is more likely, and the confusion is likely related to her
immersion pulmonary edema.
While it is important to consider aspiration pneumonia, her ascent and emersion
were witnessed by a trained instructor, making this less likely.
Research Concepts:Immersion Pulmonary Edema

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Question 281: A 13-year-old boy is brought to the clinic for respiratory difficulties associated
with exercise. She reports “noisy breathing,” chest tightness and shortness of breath. Which
of the following possible findings is most consistent with exercise-induced laryngeal
obstruction (EILO) rather than exercise-induced bronchoconstriction (EIB) in this patient?

Choices:

1. Symptoms respond to bronchodilators

2. Symptoms are expiratory
3. Symptoms also occur at rest
4. Symptoms resolve within minutes of stopping exercise

Answer: 4 - Symptoms resolve within minutes of stopping exercise

Explanations:

EILO does not respond to bronchodilators. This is more suggestive of EIB.

EILO symptoms are usually inspiratory. Expiratory symptoms are more suggestive
of EIB.
EILO symptoms do not occur at rest.
EILO symptoms usually occur at peak exercise and resolve within minutes of
stopping exercise. In contrast, EIB symptoms usually present following the exercise
activity, thought to be related to cooling of the airways.
Research Concepts:

Exercise Induced Laryngeal Obstruction

Question 282: A 6-year-old girl is admitted with pneumonia and has physical findings of
rhonchi, wheezes, and digital clubbing. The patient has a history of thick mucus, frequent
respiratory infections, and pancreatic insufficiency. What is the most likely underlying
condition?

Choices:

1. Severe combined immune deficiency

2. Asthma
3. IgA deficiency
4. Cystic fibrosis

Answer: 4 - Cystic fibrosis

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 Explanations:

Cystic fibrosis is a genetic defect that results in thickened secretions, recurrent

respiratory infections, and pancreatic insufficiency.
Digital clubbing is seen in chronic respiratory disease. Cystic fibrosis (CF) is
part of newborn screening, and if suspected confirmed by a sweat test. Sweat
testing is the primary diagnostic test for CF but CF can be diagnosed by
identifying mutations in the CFTR gene.
Currently, cystic fibrosis (CF) is not curable. Treatment includes respiratory therapy
(mechanical agitation, bronchodilators, anticholinergics, mucolytics, and inhaled
corticosteroids), antibiotics for acute and chronic lung infections, pancreatic enzyme
supplementation, nutritional support, and an active lifestyle.

Research Concepts:

Cystic Fibrosis

Question 283: A 20-year-old male presents to the office with complaints of abdominal
distention and bloating. The patient indicates a history of recurrent sinopulmonary
infections and chronic diarrhea since childhood. On physical examination, his temperature
was 37.7 °C, heart rate of 70/min and blood pressure of 110/70 [Link] is noted to
have mild scleral icterus and spider angiomata on his chest. Abdominal examination is
significant for moderate ascites. History is negative for any family history of liver disorders
or a history of alcohol use. The patient denies taking any over-the- counter medications.
Lab results showed a hemoglobin 11.0 g/dL, platelet count 78,000, serum creatinine 0.9
mg/dL, Sodium 140mmol/L, total bilirubin 2.1 mg/dL, Albumin 3.1g/dL, AST 80 U/L, ALT 94
U/L, ALP 250 U/L and INR 1.2. Ultrasound examination of the abdomen demonstrated
coarse nodular liver consistent with cirrhosis and moderate ascites. The patient had an
extensive workup that was negative for infectious, autoimmune and other common
hereditary disorders but showed a significantly elevated sweat chloride test performed on
2 separate occasions. Which of the following is the next best step in the management of
this patient?
Choices:

1. Liver biopsy
2. MRI of the liver
3. Upper endoscopy to screen for esophageal varices
4. Refer the patient for liver transplantation
Answer: 3 - Upper endoscopy to screen for esophageal varices

Explanations:
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 This patient has cystic fibrosis-associated liver disease (CFLD) in the setting of
significantly elevated sweat chloride levels, liver cirrhosis on imaging, history of
recurrent sinopulmonary infections and chronic diarrhea.
Considering the ultrasound examination of the abdomen is suggestive of coarse
nodular liver consistent with cirrhosis with signs of portal hypertension confirming
the diagnosis of CFLD, the next step would be to screen for esophageal varices in
this patient.
The management of liver cirrhosis in patients with cystic fibrosis involves
monitoring for complications by regular monitoring of liver function tests every 6 to
12 months, screening for esophageal varices every 2 to 3 years.
Patients with chronic liver disease also require regular screening for hepatocellular
carcinoma by imaging modalities with either ultrasound, CT or MRI imaging every 6
months.
Research Concepts: Cystic Fibrosis And Liver Disease

Question 284: A 55-year-old man presents to the clinic complaining of loud snoring and
frequently falling asleep at work. He works as a mechanic technician in an auto factory.
He complains of decreased productivity and is afraid that he will be let go from his job if
this continues. Epworth sleepiness scale is 20/24. The patient occasionally has vivid
dreams and feels sometimes he cannot breathe or move immediately upon awakening.
He has gained over 20 kg in the last two years. He has smoked one pack of cigarettes
daily for 30 years and recently started to smoke marijuana (one "joint" every night). The
patient takes ibuprofen and tramadol for arthritis-related pain. His heart rate is
90/minute, blood pressure 154/98 mmHg, oxygen saturation 94% on room air, neck
circumference 44 cm, and BMI 36 kg/m^2. The oral exam shows Mallampati class IV,
macroglossia with tongue indentation, and no visible tonsils. The lower extremities
demonstrate 2+ pitting edema bilaterally. Recent pulmonary function tests show a forced
vital capacity of 82% of predicted, forced expiratory volume in one second (FEV1) is 55%
of predicted, and FEV1/FVC of 60%. What is the most appropriate next step in the
management of this patient?
Choices:

1. Obtain a drug screen and advise the patient to quit smoking marijuana
2. Obtain a home sleep apnea test
3. Obtain in a laboratory polysomnography study
4. Obtain multiple sleep latency test

Answer: 3 - Obtain in a laboratory polysomnography study

Explanations:

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 The patient likely has obstructive sleep apnea (OSA) based on his weight gain and recent
onset of hypersomnolence. Other risk factors include a patient age of more than 50 years,
male sex, BMI greater than 35 kg/m2, neck circumference greater than 40 cm, and
hypertension, which are associated with an increased risk for OSA. This patient is at high
risk for OSA.
He also has severe obstructive lung disease overlapping with suspected OSA (overlap COPD
and OSA). In these patients, in- laboratory polysomnography is recommended over the
home sleep apnea test due to airflow obstruction and possible nocturnal hypoxia.
Although counseling patients to quit smoking, including marijuana, and evaluating for drug-
induced etiology for excessive daytime sleepiness is essential, it is not sufficient. A formal
study is required to confirm the high probability of OSA. Multiple sleep latency tests (MSLT)
are a diagnostic tool for unexplained hypersomnia to confirm the severity of daytime
sleepiness. The test is not recommended alone except after suspected OSA is ruled out and
the patient objectively had an adequate sleep the night before (at least 6 hours), preferably
by PSG or actigraphy.
Research Concepts: Obstructive Sleep Apnea

Question 285: A 30-year-old female presents with nausea, intractable vomiting, and a
headache since last night. She reports that she was unable to sleep at night and made
frequent trips to the bathroom due to an increased urinary frequency. The symptoms
started after she came back from a BBQ at her friend's house. She also mentions, she saw
her family doctor two days ago and was given metronidazole for bacterial vaginosis. She
has a history of asthma controlled with inhaled beta-agonists and aminophylline. She
smokes a pack a day but doesn't use alcohol or illicit drugs. Her blood pressure is 110/90
mmHg, the pulse is 120/min and irregular.
On examination, she appears restless and agitated. There is a tremor in the outstretched
hand. ECG shows no p waves and the absence of isoelectric baseline. Laboratory results
indicate a serum theophylline level of 30 mcg/mL. What is the most likely cause of the
increased serum levels of theophylline?

Choices:

1. Tobacco use
2. Metronidazole
3. Aminophylline overdose
4. BBQ meat

Answer: 2 - Metronidazole

Explanations:

Aminophylline, upon entering the body releases theophylline. Theophylline is a

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 substrate of the CP450 system. Drugs that inhibit this system lead to decreased
clearance of theophylline. Metronidazole is a CP450 inhibitor due to which the
serum concentration of theophylline increased leading to signs of theophylline
toxicity.
Theophylline has a narrow therapeutic index. When the serum concentration rises
above 20 mcg/ml, the signs of toxicity include nausea, intractable vomiting, cardiac
arrhythmias, seizures, increased urination, insomnia, and restlessness will
manifest.
BBQ meat and tobacco use are associated with increased clearance of theophylline
and would not cause an increase in the serum concentrations.

Research Concepts:

Aminophylline

Question 286: A 58-year-old male had a unilateral lung transplant for very severe
emphysema lung from alfa 1 antitrypsin deficiency. He had done well post-op with the
best post-transplant FEV1 of 82%. However, 2 years after the transplant, he started
showing new-onset shortness of breath with minimal exertion along with recurrent dry
cough. FEV1 on home spirometry dropped to 60%. As symptoms did not improve despite
oral antibiotics and a higher dose of steroids, he presented to the transplant clinic after 3
more weeks. He is on cyclosporine and mycophenolate along with prednisone. PFT there
showed an FEV1/FVC ratio of 80 with FEV1 of 55%. The total lung capacity was 62%. CT
chest showed upper lobe predominant ground glass changes with some scarring and
traction bronchiectasis in the transplanted lung. Bronchoscopy was done. Cultures were
all negative, and transbronchial biopsy showed findings of alveolar fibrin deposits with
peribronchial fibrosis.
Bronchial lumen appeared patent. What should be the treatment intervention for his
condition?

Choices:

1. Immediate enlisting for a double lung transplant

2. Use of IL-2 receptor antagonist basiliximab
3. Fundoplication
4. Switch from cyclosporine to tacrolimus

Answer: 4 - Switch from cyclosporine to tacrolimus

Explanations:
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 Clinical features and timelines are consistent with chronic lung allograft dysfunction
( CLAD). However, the restrictive nature of pulmonary function abnormality with
alveolar changes sparing bronchiolar lumen is diagnostic of Restrictive allograft
Syndrome ( RAS).
Unlike bronchiolitis obliterans syndrome (BOS), retransplant outcomes in RAS are
worse, and therefore lung allocation on a diagnosis of RAD involves more
stringent criteria.
Treatment strategies for RAS are similar to BOS with high failure rates. Change of
Immunosuppressive regimen from cyclosporine to tacrolimus will therefore be the
first necessary step.
There are anecdotal reports of some improvement with pirfenidone and a CD 52
antagonist alemtuzumab.

Research Concepts: Lung Transplant Rejection

Question 287: A 45-year-old male farmer presents with chronic cough, shortness of
breath, and fatigue for 6 months. He states that this chronic presentation developed after
an acute attack of dry cough, shortness of breath, fever, myalgias, and joint pains, which
resolved within 24 hours. The examination is remarkable for bibasilar rales and clubbing.
Blood work shows IgG antibodies to aspergillus in high titers. Which of the following is the
main immune reaction consistent with this patient's current presentation?

Choices:

1. Immune complex-mediated (type III) hypersensitivity reaction

2. Immediate or anaphylactic (type I) hypersensitivity reaction
3. T-cell mediated (type IV) hypersensitivity reaction
4. Cytotoxic (type II) hypersensitivity reaction

Answer: 3 - T-cell mediated (type IV) hypersensitivity reaction

Explanations:

In the case of hypersensitivity pneumonitis, the inflammation is mediated by two

processes, type III and type IV hypersensitivity reactions.
The inhaled antigen initially causes an immune complex- mediated (type III)
hypersensitivity reaction, which is responsible for granuloma formation.
As exposure to the offending antigen continues and becomes chronic, a T-cell
mediated (type IV) hypersensitivity reaction is elicited, which is responsible for
fibrosis.
In the case of chronic hypersensitivity pneumonitis (farmer's lung), T-cell mediated
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 (type IV) hypersensitivity reaction will be the main immune reaction.

Research Concepts:

Farmers Lung

Question 288: A 48-year-old man undergoes right pneumonectomy under general

anesthesia. On the seventh postoperative day, the patient suddenly developed shortness
of breath and coughing. His saturation is 78% on 100% FiO2. The
chest radiograph shows a deviation of the trachea to the left side and decreased fluid level in
the right hemithorax compared to the chest
x- ray of the sixth postoperative day. Which of the following is the most likely
diagnosis?

Choices:

1. Bronchopleural fistula
2. Post-pneumonectomy syndrome
3. Empyema
4. Post-pneumonectomy pulmonary edema

Answer: 1 - Bronchopleural fistula

Explanations:

A bronchopleural fistula is more likely to occur after right pneumonectomy than after
left pneumonectomy.
Dehiscence of the bronchial stump after right pneumonectomy presents with
sudden onset of dyspnea, desaturation, coughing, and even subcutaneous
emphysema.
In the chest radiograph, there is increased air on the side of the pneumonectomy due
to air leakage leading to contralateral deviation of the trachea and mediastinum and
decreased fluid level.
A decrease in the height of the fluid level by 1.5 cm or more is indicative of a fistula.

Research Concepts: Bronchopleural Fistula

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Question 289: A 56-year-old man presents to the emergency department (ED) with a six-
day history of worsening dyspnea, dry cough, and fatigue. His medical history includes
diabetes mellitus and hyperlipidemia, for which he takes metformin and simvastatin. He
has never smoked cigarettes or used illicit drugs. In the ED, he becomes severely
hypoxemic and requires immediate mechanical ventilation and admission to the intensive
care unit (ICU). In the ICU, his blood pressure is 110/75 mmHg, pulse 105/minute,
respiratory rate 24/minute, and oxygen saturation 90% on FiO2 50%. Lung auscultation is
notable for bilateral crackles without wheezing or lower extremity edema. Work up is
negative for infectious, toxic, or autoimmune etiologies. Chest x-rays show an interstitial
pattern bilaterally, and HRCT shows ground-glass opacification. Lung biopsy reveals diffuse
alveolar damage with edema in the interstitium and alveolus. What is the most
appropriate treatment?

Choices:

1. Rotating antibiotics
2. Azathioprine
3. Supportive care
4. Cyclosporine

Answer: 3 - Supportive care

Explanations:

Acute interstitial pneumonia (AIP) is a rapidly progressive idiopathic pulmonary

disease that often leads to fulminant respiratory failure and acute respiratory
distress syndrome (ARDS). Symptoms usually start as a viral-like prodrome
followed by shortness of breath with cough and fever.
There is no proven treatment for AIP. Management is mainly based on supportive
care, and adequate oxygenation often cannot be achieved without invasive
mechanical ventilation.
As in ARDS, arterial blood gases can identify the severity of respiratory distress based
on Berlin Criteria (PaO2/FiO2), which will guide treatment.
Once the diagnosis of AIP is made, high-dose systemic corticosteroids can be initiated
in selected patients with some reported success. However, the benefit of
immunosuppressive therapies (such as cyclosporine and azathioprine) have been
minimal.

Research Concepts: Acute Interstitial Pneumonia

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Question 290: A 36-year-old woman is transfused three bags of whole blood after a
motor vehicle collision. Four hours after the transfusion, her blood pressure is 95/65
mmHg, heart rate 110/min, and oxygen saturation 82% on room air. On auscultation,
bibasilar crepitations are audible over both lungs. A chest x-ray shows exudative bilateral
infiltrates. She has no known cardiac history.
Which of the following is the defining feature of the most likely diagnosis?

Choices:

1. The onset of symptoms during or within 6 hours of transfusion

2. A drop in oxygen saturation below 85% on room air
3. A ratio of the partial pressure of oxygen to a fractional inspired oxygen
concentration of less than 200 mmHg
4. Pulmonary vascular overload

Answer: 1 - The onset of symptoms during or within 6 hours of transfusion

Explanations:

The findings in this clinical vignette point towards the diagnosis of a transfusion-
related acute lung injury (TRALI).
TRALI is a clinical syndrome in which there is acute, noncardiogenic pulmonary
edema associated with hypoxia that occurs during or after a transfusion. Physical
symptoms include fever, hypotension, and tachycardia. Clinical findings include
exudative bilateral infiltrates on chest radiograph, no evidence of pulmonary
vascular overload, and hypoxemia of SpO2 less than 90% on room air with a ratio of
the partial pressure of oxygen to a fractional inspired oxygen concentration of less
than 300 mmHg.
The disorder is not only diagnosed clinically but is usually confirmed by radiographic
findings. Diagnostic criteria for TRALI includes the symptoms developing during or
within 6 hours of transfusion without any risk factors for developing acute lung
injuries such as sepsis from pneumonia, aspiration, or shock.
TRALI is caused by damage to pulmonary vasculature from human neutrophil
antigen (HNA) or human leukocyte antigen (HLA) antibodies in donor blood binding
to antigens of a recipient.

Research Concepts:

Non-infectious Complications Of Blood Transfusion

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Question 291: A 40-year-old man presents to the outpatient clinic for a follow-up. He
has had a series of tests for his symptoms of cough, hemoptysis, and chest pain. He
denies a history of smoking and is otherwise healthy. A physical exam is significant for
bibasilar crackles. Bronchoalveolar lavage reveals alveolar macrophages engorged with
periodic acid-Schiff (PAS) positive material and acellular eosinophilic bodies in a
background of eosinophilic granules. Which of the following radiologic features is most
likely to be seen in this patient's suspected disease?

Choices:

1. Interstitial fibrosis
2. A crazy-paving appearance
3. Pleural effusion
4. Diffuse alveolar damage

Answer: 2 - A crazy-paving appearance

Explanations:

Radiologic features can be suggestive of pulmonary alveolar proteinosis.

Consolidation may be observed in patients with pulmonary alveolar proteinosis.
The abnormalities tend to involve the perihilar regions and lower lobes.
One of the mainstay findings on CT of the chest is homogenous ground-glass
opacity. The crazy-paving appearance consists of interlobular septal thickening
associated with ground-glass opacities.

Research Concepts:

Pulmonary Alveolar Proteinosis

Question 292: A 75-year-old female presents with a four-month history of shortness of

breath and non-productive cough. She has a past medical history of hypertension, well-
controlled on medication, and has a 35-pack-year smoking history. There is no history of
exposure to inhaled dust, metals, asbestos, or mold. On lung auscultation, there are fine
bibasilar velcro crackles during inspiration. Clubbing is also noticed. Rheumatoid disease,
autoimmune disease, and drug toxicity are ruled out. On high- resolution computed
tomography (HRCT) of the chest, there are irregular linear opacities/coarse reticulation
and bilateral subpleural basal predominant traction bronchiectasis. Which of the
following would be most likely seen on pulmonary function testing?

Choices:
Page 279 of 955
1. Obstructive pattern
2. Restrictive pattern
3. Mixed pattern
4. Increased diffusing capacity for CO2

Answer: 2 - Restrictive pattern

Explanations:

The patient in the clinical scenario presents with clinical and imaging findings of
idiopathic pulmonary fibrosis (IPF).
Pulmonary function tests would reveal a restrictive defect in idiopathic pulmonary
fibrosis.
Pulmonary function tests would also show diminished carbon monoxide diffusing
capacity.
Based on serial assessments, a decrease in forced vital capacity (FVC) of greater
than 10 percent over six months predicts nearly a 2.4 times increase in the risk of
death from the disease.

Research Concepts:

Idiopathic Pulmonary Fibrosis

Question 293: A 45-year-old female patient presents to the emergency department with
acute onset worsening shortness of breath. The patient reports her symptoms started
suddenly and were accompanied by right lower extremity swelling and calf pain for the
past few days. Her vital signs are heart rate 120 beats per minute, blood pressure 89/50
mmHg, respiratory rate 33 breaths per minute, and oxygen saturation of 85% on 2 liters
nasal cannula. Physical exam reveals bilateral clear breath sounds, moderate respiratory
distress, right calf erythema, and asymmetric right lower extremity edema. The initial
chest x-ray reveals no acute pathologies. Despite starting the appropriate therapy, the
patient continues to be in severe respiratory distress and has become more tachypneic
and fatigued. Intubation is complicated by an episode of emesis. A follow-up chest x-ray
on day 4 of hospitalization shows a right lobe infiltrate. Which action contributed to this
outcome?

Choices:

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1. Hyperinflating the endotracheal tube cuff
2. Advancing the endotracheal tube too distally
3. Hyperventilating the patient prior to intubation
4. Lack of preoxygenation prior to intubation

Answer: 3 - Hyperventilating the patient prior to intubation

Explanations:

Hyperventilation prior to endotracheal intubation leads to insufflation of the

stomach and regurgitation of the gastric contents leading to aspiration.
The obtuse angle of the right mainstem bronchus in relation to the trachea makes
aspiration and foreign body advancement into the right mainstem bronchus more
likely.
Aspiration may be prevented by providing pre-oxygenation with a non-rebreather
mask prior to intubation and a nasal cannula. In apneic patients, bag-valve-mask
ventilation may be used with caution to provide volumes just enough to see the
chest rise.

Research Concepts:

Endotracheal Tube Intubation Techniques

Question 294: A 67-year-old man is admitted to the hospital for difficulty breathing. He
has a past medical history that is significant for COPD on 3 L of home oxygen that
increases to 5 L on exertion, hypertension, and diabetes. On arrival to the emergency
department, the patient is hypoxic and in respiratory distress, breathing at 32 breaths per
minute. He is placed on BiPAP but becomes progressively more somnolent, requiring
termination of noninvasive ventilation and intubation. Initial ABG after intubation shows
pH 7.11, pCO2 113 mmHg, pO2 60 mmHg, and SpO2 90% on the following ventilator
settings: tidal volume 400 mL, respiratory rate 12/min, FiO2 60%, and PEEP 10. Which of
the following is the next best step in the management of this patient?
Choices:

1. Increase the tidal volume to 500 mL

2. Increase respiratory rate to 15 breaths per minute
3. Increase PEEP to 18
4. Increase FiO2 to 80%

Answer: 1 - Increase the tidal volume to 500 mL

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Explanations:

Although both increasing tidal volume and respiratory rate will increase minute
ventilation, their effect on managing CO2 and respiratory acidosis is not the same.
The reason for this is that although the change in minute ventilation may be the
same, by increasing respiratory rate, we also increase dead space ventilation. The
reason for this is that there is a set volume of air that does not get to the alveoli
with every breath and is usually calculated to be around 150 mL in adult patients,
which represents dead space ventilation. By increasing respiratory rate, the dead
space ventilation every minute is multiplied by the respiratory rate. On the other
hand, increasing tidal volume increases effective ventilation without increasing
dead space ventilation.
Both answers 1 and 2 would increase the minute ventilation from 4.8 L/min to 6
L/min, and both are expected to improve CO2 and pH. Nevertheless, by increasing
respiratory rate, we also increase dead space ventilation from 1.8 L/min to 2.25
L/min (assuming 150 ccs dead space) which means that effective minute ventilation
would be 3.75 L/min with a rate of 15 and 4.2 L/min with a tidal volume of 500 ccs.
More effective ventilation means more alveolar ventilation and improved CO2
removal, which will improve acidosis.
The other options would have no effect on ventilation.
Research Concepts: Ventilator Management

Question 295: A 65-year-old female presents with severe dyspnea on exertion. She has a
45-pack-year history of smoking. On high-resolution computed tomography imaging of
the chest, she has heterogeneous, upper-lobe predominant emphysema. Over the past
year, she has become more short of breath with exertion despite complying with her
medical therapy. Her arterial blood gas shows a partial pressure of oxygen (PaO2) at 65
mm Hg and a partial pressure of carbon dioxide (PaCO2) at 55 mm Hg. Her 6-min walk
distance is 50 meters. Her exercise capacity is 20 W. Which of the following is the most
likely outcome of lung volume reduction surgery (LVRS) in this patient?

Choices:

1. Increased mortality compared to medical therapy

2. Improvement in exercise tolerance, improved quality of life, and improved overall
mortality
3. Equivalent mortality compared to medical therapy alone
4. Increased exercise tolerance and improved quality of life, but not improved overall
mortality

Answer: 2 - Improvement in exercise tolerance, improved quality of life, and improved

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overall mortality

Explanations:

In the national emphysema treatment trial (NETT), patients with upper-lobe

emphysema and poor exercise capacity had lower mortality after lung volume
reduction surgery (LVRS) compared to medical therapy alone.
In the national emphysema treatment trial (NETT), low exercise capacity was less
than 25 W for females and less than 40 W for males.
In the national emphysema treatment trial (NETT), patients with non-upper-lobe
emphysema with poor exercise capacity had similar survival in both groups.
In the national emphysema treatment trial (NETT), patients with upper-lobe
emphysema and good exercise capacity had no difference in survival between
medical treatment and lung volume reduction surgery.

Research Concepts:

Lung Volume Reduction Surgery

Question 296: A 71-year-old man with a history of type 2 diabetes mellitus is admitted to
the hospital with dyspnea after testing positive for SARS CoV-2. He is currently receiving
10 L/min of oxygen via a non-rebreather mask as he is unable to tolerate high- flow nasal
cannula. He is given remdesivir but is unable to tolerate corticosteroids due to
uncontrolled diabetes mellitus leading to severe hyperglycemia. Which of the following is
the next best step in the management of this patient?

Choices:

1. Add baricitinib
2. Add ivermectin
3. Continue current management
4. Add hydroxychloroquine

Answer: 1 - Add baricitinib

Explanations:

Kalil et al., in their recent study, the Adaptive COVID-19 Treatment Trial -2 (ACTT-2),
shed light on the utility of combination therapy with remdesivir and baricitinib for
hospitalized individuals with COVID-19.

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 The efficacy of the combination treatment was most pronounced in patients with an
ordinal score of 6 (On high flow nasal cannula); in this group, the time to recovery
was 10 days in the combination group and 18 days in the control group (rate ratio
for recovery, 1.51; 95% CI, 1.10 to 2.08). Overall, the combination group also had
30% higher odds of improvement at day 15 than the control group (odds ratio, 1.3;
95% CI, 1.0 to
1.6).
Baricitinib is cleared by the kidneys by the process of active secretion and
filtration. Naturally, its half-life is extended in patients with renal failure or ESRD.
It is cleared efficiently with hemodialysis. However, the data on its clearance with
continuous renal replacement and extracorporeal membrane oxygenation is slim.
The manufacturers have advised against the use of baricitinib in patients with
end-stage renal disease. There is no evidence to support the use of
hydroxychloroquine or ivermectin outside of a clinical trial setting.
Research Concepts: Safe and Effective Use of Baricitinib And Remdesivir In Hospitalized
Patients With Coronavirus (COVID- 19)

Question 297: A 49-year-old male with a history of severe postoperative nausea and
vomiting is undergoing a right inguinal hernia repair under general anesthesia. The patient
is 6 feet 3 inches (1.9 m) and weighs 175 lbs (79.3 kg). He has a past medical history of
cigarette smoking for 20 years. A colleague has completed a pre- operative evaluation on
the patient and reports that the patient has a mandibular opening of 5 cm, able to extend
his neck to 20 degrees, a Mallampati classification of 4, and a grade 1 upper lip bite test.
Which of the following is the best predictor of difficult intubation?

Choices:

1. Neck extension to 20 degrees

2. His smoking history
3. Mallampati classification of 4
4. Grade 1 upper lip bite test
Answer: 3 - Mallampati classification of 4

Explanations:

A higher Mallampati score is associated with higher intubation failure rates as a result
of poor visualization of the glottis. A Mallampati classification of 4 means that only the
hard palate is visible when the patient is asked to open his mouth.
The Mallampati classification involves the size of the tongue in relation to the oral
cavity. The more the tongue obstructs the view of the pharyngeal structure, the
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 more difficult the airway might be.
The Mallampati classification includes class I: the entire palatal arch, including the
bilateral faucial pillars, are visible down to their base, class II: the upper part of the
faucial pillars and most of the uvula are visible, class III: only the hard and soft
palates are visible, and class IV: only the hard palate is visible.
The patient's weight (BMI), the mandibular opening of 5 cm, the ability to extend
his neck to 20 degrees, and the grade 1 upper lip bite test are all indicators of easier
intubation. Neck extension greater than 15 degrees is associated with the "sniffing
position." The sniffing position requires flexion of the neck to 35 degrees and head
extension to 15 degrees. Neck immobility interferes with the ability to align the
pharyngeal axis, oral axis, and laryngeal axis. The upper lip bite test assesses the
patient's ability to place their lower incisors over their upper lip. This acts as a
predictor of the ability to subluxate the mandible during laryngoscopy. A grade of 1
means that the patient can fully cover the upper lip with the lower incisors.
Research Concepts: Airway Assessment

Question 298: A 65-year-old male presents to the emergency department for a worsening
of shortness of breath for one week. He has a 40-pack-year smoking history. A chest x-ray
shows a large pleural effusion on the left side. He undergoes a large volume thoracentesis
in the emergency department with symptomatic relief. CT scan with contrast shows a
large left-sided lung mass invading the posterior mediastinum. The patient is diagnosed
with stage IV lung cancer and admitted. Analysis of the pleural fluid shows no malignant
cells. Repeat thoracentesis reveals a white liquid. Which of the following is the most
appropriate way to confirm the diagnosis at the bedside?
Choices:

1. Based on the whitish supernatant layer on the top of the pleural fluid, if left
undisturbed for sometime
2. Based on several loculation noted on bedside ultrasonography
3. Based on the presence of cholesterol crystals noted on bedside microscopy
4. Based on CT scan showing large lung mass

Answer: 1 - Based on the whitish supernatant layer on the top of the pleural fluid, if left
undisturbed for sometime
Explanations:

This patient most likely has chylothorax secondary to infiltration of the

thoracic duct from lung cancer, leading to the accumulation of chyle in
the pleural space. Chylothorax is usually milky in color but can be

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 serosanguinous based on diet. As chyle is rich in chylomicrons
containing long-chain fatty acids and lighter than fluid, it will float on
the fluid if the pleural fluid is left undisturbed for a long time, unlike in
empyema where the neutrophil-rich cells will settle at the bottom.
Pleural fluid triglycerides levels of more than 110 mg/dl strongly
suggest, and the presence of chylomicrons confirms the diagnosis of
chylothorax. It is usually exudative and lymphocyte- rich.
The patient has stage IV lung cancer secondary to mediastinum
involvement and is also prone to malignant effusion. Pleural fluid is
positive for malignant cells in only 70% of patients with malignant
pleural effusion in the first thoracentesis. Hence repeat thoracentesis is
required for an accurate diagnosis.
However, in this case, the color of the fluid strongly suggests chylothorax.
The fibrinogen content is less and hence does not form any
loculation, unlike malignant effusion. Cholesterol crystals can
accumulate in long-standing effusion seen in rheumatoid arthritis
and tuberculosis, mimicking pleural effusion called pseudo-chylous
effusion.

Rh Concepts:

Chylothorax

Question 299: A 65-year-old male with a past medical history of chronic alcohol use
disorder presents with a productive cough with blood-tinged sputum for the past several
days. The chest radiograph shows an infiltrate in the posterior aspect of the right upper
lung, and a sputum culture shows gram-negative, encapsulated, and non- motile
bacterium. Which of the following is the best antibiotic choice to treat the patient's
condition?

Choices:

1. Ceftriaxone
2. Azithromycin
3. Aztreonam
4. Fosfomycin

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 Answer: 1 - Ceftriaxone

Explanations:

Current regimens for community-acquired Klebsiella pneumoniae pneumonia

include a 14-day treatment with either a third or fourth generation cephalosporin as
monotherapy or a respiratory quinolone as monotherapy or either of the previous
regimes in conjunction with an aminoglycoside.
If the patient is penicillin-allergic, then a course of aztreonam or a respiratory
quinolone should be undertaken. Azithromycin has no activity against Klebsiella.
For nosocomial infections, a carbapenem can be used as monotherapy until
sensitivities are reported.
When an extended-spectrum beta-lactamase infection is diagnosed, carbapenem
therapy should be initiated due to its rate of sensitivity across the globe.

Research Concepts:

Klebsiella Pneumonia

Question 300: A 17-year-old female presents to the emergency department with a

complaint of difficulty breathing that started a few minutes ago. It is associated with
throat tightness and hoarseness of her voice. She also complains of headaches and
blurred vision. On further questioning, she reveals that she has multiple red raised marks
on both her arms. These symptoms started after she tried a new chocolate product in the
market. A detailed medical history reveals no known medical condition. Her vital signs
show blood pressure 96/80 mmHg, respiratory rate 20/min heart rate 100/ min, and
temperature 98.6 F (37 C). A physical examination performed reveals generalized
urticaria and swelling on inspection as well as inspiratory stridor. What is the most
appropriate step that will lead to the diagnosis?

Choices:

1. In vitro immunoglobulin E (IgE) tests

2. Urinary 24-hour 5-hydroxy indole acetic acid levels
3. Serum tryptase
4. Serum histamine

Answer: 3 - Serum tryptase

Explanations:

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 This patient is having an anaphylactic reaction to one of the components of the
chocolate. Anaphylaxis is a life-threatening condition diagnosed on the basis of clinical
signs and symptoms like dyspnea, urticaria, headaches, etc. However, in certain
situations, laboratory tests may be ordered.
Serum tryptase measurements can be used to diagnoses the condition if the patient is
seen soon after an episode. Serum tryptase or beta-tryptase levels usually peak at 60-
90 minutes at the start of an episode and persist for almost 5 hours.
Basal levels of mature and total tryptase can be used to differentiate between
anaphylaxis and systemic mastocytosis. Between episodes of anaphylaxis, the basal
levels of mature tryptase are normal. However, it is the opposite for mastocytosis.
Urinary 24-hour 5-hydroxy indole acetic acid levels are measured when carcinoid
syndrome is considered. Serum histamine measurements can also be used, but
serum tryptase measurements are preferred. In vitro immunoglobulin E (IgE) tests
are used to determine the stimulus for anaphylaxis.

Research Concepts: Anaphylaxis

Section 4

Question 301: A provider has been treating a patient with a long documented history of
being verbally abusive towards the provider and office staff. The provider would like to
no longer treat this patient. The provider provides the patient and the patient's family
with both verbal and written notice that she will be transferring care to another provider
of their choice. By providing verbal and written notification of discontinuation of care
and continuation of care until an alternative provider can be provided, the provider has
most likely avoided which of the following potential complications?

Choices:

1. Breach of duty and negligence

2. Protected against litigation
3. Constructive abandonment
4. Unintentional abandonment

Answer: 1 - Breach of duty and negligence

Explanations:

If the health care provider responsible for patient care provides written notice of
terminating the patient-provider relationship provided at least 30 days in advance,
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 provides care during this transition period, and helps provide resources for the patient
to obtain new care, the provider actively avoids abandoning the patient.
Litigation can always occur.
Constructive abandonment is when the patient is not seen frequently enough,
which causes harm to the patient to ensue. Unintentional abandonment can occur
when there is a mistake in coverage or scheduling conflict and the patient does
not get treated.

Research Concepts:

Abandonment

Question 302: A 33-year-old woman presents to the clinic with facial rash, fever,
arthralgias, and cough. She has no past medical history, and the exam shows a faint
rash on the face and minimal tenderness over the right wrist and right knee. Blood
counts, liver function, renal function, CRP, and ANA are all unremarkable. Chest x-ray
shows enlarged hilar lymph nodes. Lymph node biopsy is performed. Which of the
following findings is most likely to confirm the diagnosis in this patient?

Choices:

1. Epithelioid granulomas
2. Hemosiderin laden macrophages
3. Large granular lymphocytes
4. Langerhans cells

Answer: 1 - Epithelioid granulomas

Explanations:

The classic biopsy finding in sarcoidosis is the presence of epithelioid granulomas

with a scarce amount of lymphocytes on the periphery. These are also described as
"naked granulomas" due to the absence of dense lymphocyte infiltration.
Granulomas are formed as a result of the activation of CD4 T lymphocytes and
macrophages, which release cytokines.
The giant cells located within sarcoid granulomas may contain intracytoplasmic
inclusions like asteroid bodies and Schaumann bodies.
Hemosiderin laden macrophages are seen in diffuse alveolar hemorrhage. Large
granular lymphocytes are seen in LGL leukemia. Langerhans cells are tissue-derived
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 dendritic cells which contain Birbeck granules.

Research Concepts:

Lupus Pernio

Question 303: A 76-year-old man presents for his follow-up for a small cell lung
carcinoma. The patient was diagnosed after presenting with progressive hemoptysis,
weight loss, and fatigue. His vital signs show oxygen saturation 96% on room air,
respiratory rate 14 per minute, heart rate 88bpm, blood pressure 133/88 mmHg, and
temperature 98.9 F. Blood tests show increased calcium, and complete blood count (CBC)
is unremarkable. The patient will start a chemotherapy regimen that includes etoposide,
and he is informed that routine CBCs will be done periodically because this regimen can
cause leukopenia. When will this patient's greatest risk of infection be after starting
treatment with etoposide?

Choices:

1. The first week after starting therapy

2. One to two weeks after starting therapy
3. One month after starting therapy
4. Six to eight weeks after starting therapy

Answer: 2 - One to two weeks after starting therapy

Explanations:

The greatest risk for infection is about 7 to 14 days following the initial administration
of etoposide.
Myelosuppression places these patients at increased risk for infections. Hand
hygiene is of the utmost importance in this patient dynamic to prevent the spread
of contagions.
Due to the risk of further exacerbating myelosuppression, patient education
should include the need to avoid individuals who have recently received
vaccinations.
Educate patients to avoid crowded areas, especially during the influenza season.
Report any changes in conditions such as a sore throat, fever, or a cough.

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 Research Concepts:

Etoposide

Question 304: A 65-year-old man is evaluated on his sixth postoperative day for fever and
worsening oxygenation for 2 days. The patient underwent aortic valve replacement for
severe aortic stenosis. He now has a fever and increasing secretions.
Temperature is 39 C (102.2 F), the pulse is 120/min, blood pressure is 80/50 mmHg and
the respiratory rate is 32/min. Chest auscultation reveals crackles in his right lung field.
Leukocyte count is 20,000/mm3. A chest x-ray shows infiltrate in the right middle and
lower lobes. A lower respiratory tract sample is sent for Gram stain and culture. What is
the most appropriate antibiotic regimen in this patient?
Choices:

1. Respiratory fluoroquinolone and aminoglycoside

2. Third-generation cephalosporin and a macrolide
3. Anti-pseudomonal cephalosporin or meropenem, anti- pseudomonal
fluoroquinolone, and vancomycin
4. Anti-pseudomonal carbapenem and vancomycin
Answer: 3 - Anti-pseudomonal cephalosporin or meropenem, anti- pseudomonal
fluoroquinolone, and vancomycin
Explanations:

This patient who is hospitalized has a fever, worsening oxygenation and lung
infiltrates, which is suggestive of hospital- acquired pneumonia. Hospital-acquired
pneumonia (HAP) is defined as pneumonia that occurs 48 hours or more after
hospital admission and not incubating at the admission time.
The most common organisms causing HAP are gram-negative rods (including
Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, and
Enterobacter species) and gram-positive cocci (e.g., Staphylococcus aureus,
which includes methicillin-resistant S. aureus MRSA, and Streptococcus spp.).
Empirical antibiotic therapy for HAP is based on the presence of risk factors for
multi-drug resistant (MDR) pathogens (e.g., intravenous antibiotics use within the
past 90 days) or risk factors for mortality (e.g., presence of septic shock or need for
ventilatory support). Intravenous antibiotic use within 90 days of HAP is considered
a risk factor for multidrug-resistant Pseudomonas and MRSA.
For patients with HAP who have a high risk of mortality (for e.g., this patient likely
has a septic shock) or have a risk for MDR pathogen, antibiotics from 2 different
classes with activity against P. aeruginosa should be prescribed, e.g.,
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 ceftazidime/piperacillin-tazobactam/cefepime plus an aminoglycoside
(amikacin/gentamicin). Similarly, an antibiotic should be added against MRSA,
which includes vancomycin or linezolid.
If there is no increased risk for mortality or there is no risk factor for MDR
pathogen, a single agent to cover common pathogens can be prescribed for HAP. It
includes piperacillin-tazobactam or cefepime.
Research Concepts: Nosocomial Pneumonia

Question 305: A 40-year-old female on vacation goes for a recreational dive at her all-
inclusive resort. She has a history of hypertension, obesity, and sarcoidosis in her
twenties, and she does not take any medications. She completes all dive safety training
and instructions, and she experiences no issues during her 60-minute dive. She reports a
strong wave that carried her a short distance from the dive site, but she was able to swim
back up to the site after several minutes. She did not panic or feel in danger but felt short
of breath from exertion. Upon resurfacing, she experienced severe chest pain and
shortness of breath. She was in distress, anxious, and required urgent transport to a
medical facility. Her vitals at the hospital included a heart rate of 135 beats per minute,
respirations of 30 breaths per minute, blood pressure of 88/43 mmHg, pulse oximetry was
unobtainable, and a temperature of 36 degrees Celsius (96.8 F). Physical exam of the neck
and chest revealed distended neck veins, chest asymmetry, and tympanic, hyper-resonant
sounds on the left side. A chest x-ray was taken, and afterward, the patient rolled her
eyes to the back of her head, became unresponsive and pulseless. The chest x-ray showed
tension pneumothorax. What is the most likely risk factor leading to this injury?
Choices:

1. Obesity
2. Hypertension
3. Prior history of sarcoidosis
4. Age

Answer: 3 - Prior history of sarcoidosis

Explanations:

A review of the divers alert network fatality data shows that barotrauma is the
most reported injury related to diving. Sinus and ear barotrauma are most
common, followed by pulmonary barotrauma.
Divers with preexisting or prior lung disease are at increased risk of pulmonary
barotrauma while diving.
Any person with current or preexisting lung disease should be medically screened
before diving.
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 Individuals with asthma (controlled or uncontrolled), obstructive lung disease,
emphysema, bullae, cysts or cystic lung disease, fibrosis, tuberculosis (active or past),
sarcoidosis, and spontaneous pneumothorax history are at increased risk for
pulmonary barotrauma during diving.
Research Concepts: Pulmonary Barotrauma

Question 306: Which of the following is the most common cause of community-acquired
bacterial pneumonia in the elderly?

Choices:

1. Mycoplasma pneumoniae
2. Legionella pneumophila
3. Streptococcus pneumoniae
4. Staphylococcus aureus

Answer: 3 - Streptococcus pneumoniae

Explanations:

Streptococcus pneumoniae is the most common cause of bacterial community-

acquired pneumonia in children and the elderly.
It is responsible for 60 percent of these infections. Resistant S. pneumoniae
is becoming increasingly more prevalent.
Legionella causes atypical pneumonia, but the elderly may be more susceptible to
this infection.

Research Concepts:

Community-Acquired Pneumonia

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Question 307: A 65-year-old woman comes to the emergency department because of acute
onset shortness of breath and coughing up blood for the past 5 hours. She has hypertension
and type 2 diabetes mellitus. She also has a history of developing thrombocytopenia after
using an anticoagulant for deep vein thrombosis. On examination, she appears anxious; her
pulse is 112 beats/min, respirations are 24 breaths/min, and her blood pressure is 110/60
mmHg. She has normal breath sounds with no wheezing on auscultation of the chest. Her
chest x-ray shows no abnormalities, but her ventilation-perfusion scan shows a small defect
in the right middle lobe. The drug most likely used for the patient acts on which of the
following substances?
Choices:

1. Glycoprotein IIb/IIIa
2. Factor VII
3. Antithrombin
4. Factor Xa

Answer: 4 - Factor Xa

Explanations:

Novel oral anticoagulants (NAOCs) like rivaroxaban are direct factor Xa inhibitors
and can be used as anticoagulants for acute pulmonary embolism and continued for
the prevention of recurrent venous thromboembolic events.
This is an appropriate choice of anticoagulant in this patient with a history of heparin-
induced thrombocytopenia where heparin is contraindicated.
NOACs are becoming a safe and effective choice of oral anticoagulant in managing
hemodynamically stable patients with acute pulmonary embolism without shock or
hypotension.
NOACs like rivaroxaban offer a convenient and cost-effective single-drug
therapeutic approach. The ease of not requiring frequent clinical appointments
for lab monitoring and route of administration makes management more
convenient and enables earlier discharge and outpatient treatment in low-risk
patients.
Warfarin is not the drug of choice for acute pulmonary embolism because the onset of
action is typically 24 - 72 hours, and peak therapeutic effect is only seen 5 to 7 days
after initiation.
Heparin acts by indirectly inactivating thrombin and activated factor X (factor Xa)
through binding with antithrombin to enhance its activity and is the initial
treatment of choice for most patients with acute pulmonary embolism, but given
the history of heparin-induced thrombocytopenia in this patient, this drug is
contraindicated.

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 Research Concepts: Rivaroxaban

Question 308: A 24-year-old male with no significant past medical history presents to the
emergency department with complaints of fever, vomiting, and epigastric abdominal pain.
Symptoms began a week before this presentation, along with worsening dyspnea, a
nonproductive cough, and one episode of hemoptysis. A chest x-ray done at a private
family practice clinic showed left perihilar and right basilar interstitial prominence. The
provider sent the patient home on 500 mg of oral azithromycin.
Despite taking azithromycin for one day, his dyspnea worsened, and he began to cough
up yellow-brown sputum. He denied any previous similar symptoms and denied previous
hospital admission for pneumonia. He denied any recent sick contacts or recent travel. He
admitted to vaping tetrahydrocannabinol (THC) oil cartridges for the last 3-4 years but
denied smoking cigarettes or vaping nicotine. CBC was remarkable for mild leukocytosis.
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated. Blood
cultures and respiratory viral polymerase chain reaction (PCR) were negative. CT chest
showed bilateral diffuse interstitial and mixed infiltrates in his lungs. Which of the
following is the next best step in the treatment of this patient?
Choices:

1. Nebulization with ipratropium bromide

2. Intravenous methylprednisone
3. Tablet hydroxychloroquine
4. Tablet oseltamivir
Answer: 2 - Intravenous methylprednisone
Explanations:

Given the patient's history, the patient is most likely suffering from vaping
associated pulmonary injury. Absence of recent travel history, sick contacts,
negative blood cultures, and respiratory viral PCR exclude viral pneumonia.
Azithromycin should be used with caution in patients who smoke marijuana as
interaction with THC can cause QT prolongation.
Bilateral ground-glass opacities are characteristically seen in this disease, often
with areas of lobular or subpleural sparing on chest CT.
Current literature reports that clinical improvement has primarily been noted, mostly
after administering high-dose steroids.
Diluents such as vitamin E in THC containing vaping products have been implicated in
the pulmonary injury seen in these patients.
Research Concepts:Vaping Associated Pulmonary Injury

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Question 309: A 45-year-old man is admitted to the intensive care unit for acute
respiratory failure secondary to influenza pneumonia. He is endotracheally intubated,
and connected to a mechanical ventilator. Over the next 12 hours, despite optimizing
ventilator settings, his oxygenation continues to remain low.
Neuromuscular blockade (paralytics) is employed to abolish ventilator patient
asynchrony. A dose of 50 mg of rocuronium as an IV push is given. Soon after the dose of
rocuronium, the patient is noted to have tachycardia at 190/min and an EKG reveals
sinus tachycardia. Blood pressure is 190/100 mmHg. Which of the following is the next
best step in the management of this patient?

Choices:

1. Intravenous diphenhydramine
2. Intravenous nicardipine infusion
3. Intravenous midazolam infusion
4. Conservative management

Answer: 3 - Intravenous midazolam infusion

Explanations:

The patient was dosed a paralytic agent without appropriate sedation due to
prescriber error.
This leads to severe patient discomfort and agony and can be seen to manifest as
sinus tachycardia and high blood pressure. The right approach is providing
adequate sedation prior to dosing a paralyzing agent in mechanically ventilated
patients.
Medication errors are most common at the ordering or prescribing stage. Typical
errors include the healthcare provider writing the wrong medication, wrong route or
dose, or the wrong frequency.
These ordering errors account for almost 50% of medication errors.

Research Concepts:

Medication Dispensing Errors And Prevention

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 Question 310: A 39-year-old woman with a history of hypertension presents with
shortness of breath. She has been smoking one pack of cigarettes per day for the last 20
years. Her medications include multivitamins and an oral contraceptive pill. She is
afebrile, with a blood pressure of 82/50 mmHg, heart rate 110/min, respiratory rate
24/min, and oxygen saturation 91% on room air.
Examination demonstrates tachypnea, tachycardia, and right lower leg swelling and
redness. A chest x-ray is normal, and the lab results show an elevated D-dimer. What is the
best next step in the management of this patient?

Choices:

1. Doppler ultrasound of the right lower leg

2. Bedside echocardiography
3. Ventilation-perfusion (V/Q) scan
4. Initiate low molecular weight heparin

Answer: 2 - Bedside echocardiography

Explanations:

Acute pulmonary embolism (PE) associated with hemodynamic instability requires

prompt assessment at the bedside.
Transthoracic echocardiography allows prompt evaluation for thrombus in the right
ventricle or main pulmonary artery.
Treatment of a patient with acute PE who is hemodynamically unstable and has no
contraindication or increased bleeding risk should be thrombolysis, followed by
anticoagulation.
The decision for empiric anticoagulation depends on clinical suspicion and
hemodynamic stability. While initiating anticoagulation with unfractionated
heparin would be appropriate until a thrombolytic is initiated, using low molecular
weight heparin has a longer half-life and may preclude the eligibility to use
thrombolytics.
Ventilation-perfusion (V/Q) scan is a useful diagnostic test for pulmonary
embolism in hemodynamically stable patients.
However, in hemodynamically unstable patients, a rapid test is needed to make
treatment decisions quickly. Another diagnostic test is CT scan angiography, if
available.

Research Concepts: Acute Pulmonary Embolism

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Question 311: A 38-year-old female diver experiences shortness of breath, joint pain, and
mental cloudiness after a rapid ascent while holding her breath. Upon recovery, she is
immediately treated with oxygen and observed for several hours. At her follow up
appointment two days later, she denies any respiratory symptoms or joint pain.
On exam, she does not appear to have any mental confusion but does have a mottled,
reticulated purplish-red rash over her trunk and legs. What is the most appropriate
treatment for this patient?

Choices:

1. No further treatment is necessary

2. Topical capsaicin cream and oral ibuprofen
3. Gabapentin to prevent chronic post-decompression sickness neurologic
syndrome
4. To treat the underlying issue with the administration of 100% oxygen

Answer: 4 - To treat the underlying issue with the administration of 100% oxygen

Explanations:

Livedo reticularis, one possible rash that occurs after decompression sickness, is
actually due to skin changes from tissue damage of inert gas bubbles.
There are numerous possible complications and sequelae from decompression illness;
livedo reticularis is the cutaneous manifestation. Joint pain, neurologic symptoms,
and cardiopulmonary symptoms are also possible.
Decompression illness occurs secondary to the development of bubbles outside
their normal location and concentration secondary to a decrease in environmental
pressures. There is no indication for oral or topical medications for treatment. The
mainstay of treatment is 100% oxygen.
While individuals may die from decompression illness, the rash that may occur in living
patients is called livedo reticularis.
Research Concepts:

Aerospace Decompression Illness

Question 312: A 54-year-old man with a past medical history of hypertension, coronary
artery disease, and type 2 diabetes mellitus with flu-like symptoms for the past two days.
He reports working in a nursing home that had a COVID-19 outbreak recently. Vitals are
temperature 38.9 C (102 F), heart rate 103/min, blood pressure 122/80 mmHg, and
oxygen saturation 99% on room air. Point of care testing for SARS-CoV-2 is positive. What
is the most appropriate treatment for this patient?
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Choices:

1. Remdesivir plus baricitinib

2. Ritonavir-boosted nirmatrelvir
3. Dexamethasone plus tocilizumab
4. Supportive care with analgesics and antipyretics

Answer: 2 - Ritonavir-boosted nirmatrelvir

Explanations:

The patient described in this clinical vignette has mild COVID-19 illness but has
multiple risk factors for progression to severe disease. According to the latest
guidelines by the NIH, the treatment for COVID-19 in patients with mild to
moderate disease without hypoxia is ritonavir-boosted nirmatrelvir.
Ritonavir-boosted nirmatrelvir is used for outpatients who are at high risk of disease
progression with a low threshold to consider hospitalization for closer monitoring.
Nirmatrelvir is an oral protease inhibitor with antiviral activity against all
coronaviruses known to infect humans. Ritonavir is a potent cytochrome P450
inhibitor, which is required to increase nirmatrelvir concentrations in the serum.
Therapy should be initiated within five days of symptom onset, and a five-day
course of treatment is required. This therapy has multiple severe and complex drug-
drug interactions; therefore, a thorough evaluation of the patient's home
medication list should be carried out before prescribing this treatment.
Nirmatrelvir plus ritonavir should be used cautiously in patients with preexisting
liver disease and renal failure. It should not be given to patients with an estimated
glomerular filtration rate of less than 30 mL/min or liver failure with a Child-Pugh
class C.
Research Concepts:Emerging Variants of SARS-CoV-2 And Novel Therapeutics Against
Coronavirus (COVID-19)

Question 313: A previously healthy 17-year-old boy is brought to the emergency

department by his mother for new-onset wheezing and skin rash. Approximately 30
minutes prior to arrival, the boy was playing with his new pet tarantula when he was
suddenly bitten on the arm. A rash immediately developed at the bite site, which was
immediately cleaned with soap and water. Within the next 20 minutes, the rash spread
diffusely to other parts of his body, and the boy started developing wheezing. The patient
has no known past medical history and no known allergies. Examination reveals
generalized hives and audible wheezing. His airway remains patent; oxygen saturation
remains at 98% with mild tachypnea. What is the next best step in management?
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Choices:

1. Diphenhydramine, famotidine, and methylprednisolone IV

2. Epinephrine IM
3. Nebulized albuterol/Ipratropium
4. Spider antivenin

Answer: 2 - Epinephrine IM

Explanations:

The rapid onset of hives and wheezing following a tarantula envenomation is

consistent with an anaphylaxis reaction.
Although rare, tarantula envenomation can lead to anaphylaxis. Anaphylaxis
secondary to tarantula envenomation should be treated the same way as anaphylaxis
of any other cause.
The mainstay of anaphylaxis treatment consists of epinephrine 1:1000 intramuscularly
at a dose of 0.01 mg/kg with a maximum dose of 0.5 mg.
Antihistamines such as diphenhydramine and famotidine, as well as
corticosteroids such as methylprednisolone, are important adjuncts to
epinephrine, but the mainstay of anaphylaxis treatment is epinephrine.
Although wheezing can occur from anaphylaxis, nebulized albuterol/ipratropium
would be more appropriate for wheezing secondary to asthma. The child has no
history of asthma, so an asthma exacerbation is far less likely. Although there are
antivenins for Latrodectus species (black widow) and Loxosceles reclusa (brown
recluse - antivenin available only outside the U.S.), no antivenin for tarantula bites
exist.
Research Concepts: Tarantula Spider Toxicity

Question 314: A 54-year-old male with a past medical history of hypertension, coronary
artery disease, and chronic kidney disease stage II presents with flu-like symptoms for the
past four days. He reports working in a nursing home that had a COVID-19 outbreak
recently. The patient is noted to be febrile, normotensive, and saturating at 99% on room
air. A focused physical examination is unremarkable. Point of care testing for SARS-CoV-2 is
positive.
What is the most appropriate treatment for this patient?

Choices:

1. Dexamethasone
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2. Sarilumab
3. Sotrovimab
4. High-titer convalescent plasma

Answer: 3 - Sotrovimab

Explanations:

The patient described in this clinical vignette presents with mild- moderate COVID-
19. Monoclonal antibody treatments such as sotrovimab are most effective if used
early during the course of illness in patients who are at high risk for developing
severe illness.
With Omicron as the dominant circulating variant of concern in the community,
sotrovimab is the only monoclonal antibody that is effective.
It should only be used in nonhospitalized patients and is not authorized by the FDA
for clinical use in hospitalized patients who require supplemental oxygen. If used in
patients hospitalized for COVID-19 illness, it may worsen clinical outcomes.
Dexamethasone should not be used in patients who are not hypoxic.

Research Concepts:

Evaluating And Referring Patients For Outpatient Monoclonal Antibody Therapy

For Coronavirus (COVID-19) In The Emergency Department

Question 315: One week ago, a 45-year-old farmer developed itching in his right foot,
which resolved spontaneously. Today, he presents with wheezing and difficulty breathing.
He is breathless at rest, his respiratory rate is 26/minute, and his oxygen saturation is 94%
on 2 liters of oxygen via nasal cannula. Lung auscultation demonstrates bilateral
expiratory wheezes. Blood tests show hemoglobin 8.7 g/dL, mean corpuscular volume 72
fl, white cell count 7.2 10^9/L, eosinophils 2.3%, ferritin 27 ng/mL, and C reactive protein
4 mg/L. Chest x-ray shows bilateral pulmonary infiltrates, and bronchoalveolar lavage
shows pulmonary eosinophilia and filariform larvae. Given the likely diagnosis, what is the
most appropriate treatment?

Choices:

1. Single-dose albendazole
2. Single-dose mebendazole
3. Five days of clindamycin

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4. Three days of ivermectin

Answer: 1 - Single-dose albendazole

Explanations:

The most probable diagnosis is cutaneous larva migrans secondary to hookworm

infection. Albendazole is effective in the intestinal stage, when the parasites migrate
under the skin, and in the pulmonary stage.
Individuals may also have to be treated with iron supplements, folate, vitamin B12,
and an appropriate diet.
Despite treatment, reinfection and drug resistance are common. Most patients
with cutaneous larva migrans can be treated on an outpatient basis.

Research Concepts:

Hookworm

Question 316: A 65-year-old male comes to the clinic complaining of feeling sleepy during
the day and having headaches. When he undergoes a sleep study, the K-complexes in
nonrapid eye movement (NREM) stage 2 sleep are observed to have shorter durations,
smaller amplitudes, and rougher positive waves. What is the underlying cause of the
condition in this patient?

Choices:

1. The repetitive collapse of the airway during sleep

2. Inflammation of temporal arteries
3. Foreign body in the bronchial tree
4. Impaired diffusion of gases through the lung interstitium

Answer: 1 - The repetitive collapse of the airway during sleep

Explanations:

Obstructive sleep apnea (OSA) is a condition caused by the repetitive collapse of the
airways during sleep.
This collapse leads to episodes of apnea and hypopnea, which causes headaches
and increased sleepiness during the day.
K-complexes (KC) in patients with OSA have shorter durations, smaller amplitudes, and
rougher positive waves.
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 Also, untreated OSA patients do not have a decrease in the KC amplitude as the night
progresses, as usually found in healthy individuals and those treated for OSA.

Research Concepts:

Physiology, K Complex

Question 317: A 65-year-old male comes in with difficulty breathing over the last three
months which has worsened gradually. He has a smoking history of 20-pack-tears but no
history of alcohol consumption or illicit drug use. He is a retired worker in a concrete
manufacturing company for 12 years and frequently travels to Ohio regularly to visit his
son. Examination reveals fine bilateral crackles throughout the lung fields. An electrolyte
panel from 2 weeks ago is normal. A urinary antigen assay is negative. A chest x-ray from
6 months ago reveals a 'snow storm' appearance with 8 mm nodules. The nodules today
measure between 12 and 16 mm while one shows central cavitation. What is the most
likely cause of this change?

Choices:

1. Acute silicosis
2. Mycobacterium tuberculosis
3. Chronic obstructive pulmonary disease
4. Mesothelioma

Answer: 2 - Mycobacterium tuberculosis

Explanations:

This retired concrete factory worker, with breathlessness, fine crackles on

auscultation, 20-pack-years of smoking, and negative urine antigen protein, is most
likely a case of silicosis. The change in nodular size and single cavitation suggest
secondary tubercular infection.
Three clinical entities exist along the spectrum of disease, including chronic forms,
accelerated forms, and acute silicosis. Nodular or pure silicosis can occur after 20 or
more years of exposure in occupations. An accelerated form of the disease occurs
after heavier exposure for 5 to 10 years. Acute silicosis is an unusual reaction caused
by heavy exposure over a short period to high levels of silica of small particle size.
Complications of silicosis are represented by progressive massive fibrosis and
tuberculosis and nontuberculous mycobacteriosis. Mycobacterial infection should
be suspected clinically when there is a rapid enlargement of small nodules or when
nodules undergo cavitation.
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 Mesothelioma is associated with asbestosis after 20 to 40 years of exposure.

Research Concepts:
Silicosis

Question 318: A 70-year-old male with a non-small cell lung carcinoma is being evaluated
for pneumonectomy. He has a past medical history of severe chronic obstructive
pulmonary disease, coronary artery disease, hypertension, and hyperlipidemia. His
temperature is 37.9 C (100.2 F), blood pressure 130/70 mmHg, heart rate 88, respiratory
rate 22/min, SPO2 90% on 4L nasal cannula. He has spirometry testing done the week
prior to his preoperative surgical visit. His lung pattern showed an obstructive pattern.
Preoperative FEV1 is 30%, FEV1/FVC 70%, and diffusion capacity(DLCO) 30-49%. Which of
the following results is indicative of higher postoperative pulmonary complications?

Choices:

1. SPO2 of 90% on 4L nasal cannula

2. DLCO of 30-49%
3. FEV1/FVC 70%
4. Ppo FEV1 is 30%

Answer: 4 - Ppo FEV1 is 30%

Explanations:

Preoperative prediction FEV1 is 30% highly indicative of poor pulmonary outcomes

after surgery.
Patients with pre-operative prediction FEV1 is 30% at high risk of respiratory failure,
remaining intubated in the postoperative period, and even death after surgery. A
serious discussion with the patient about postoperative outcomes should be
discussed. Preoperative prediction FEV1 = preoperative FEV l × (19 segments–
number of segments to be removed) ÷ 19. There are 19 points for the lung
segments based on this formula. Each segment has a value. The upper right lobe
equals 3; the right middle lobe equals 2, right lower lobe equals 5; upper left lobe
equals 3, lingula -equals 2, lower left lobe equals four segments. Although DLCO of
30-49% and FEV1/FVC 70% are indicative of severe COPD and a worse outcome
postoperatively, preoperative prediction FEV1 of 30% has a better predictive value
of the poor pulmonary outcome.
Research Concepts:

Spirometry
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Question 319: A 75-year-old woman with a past medical history of hypertension, which
has been well controlled on lisinopril 10 mg for ten years, presented to your office for a
follow-up of pneumonia with blastomycosis, which was diagnosed three weeks ago. At
that visit, you prescribed a systemic medication to treat the infection. The infection is
improving, but her blood pressure is now 166/92. She denies any changes in diet and is
compliant with all her medications. You decide to increase her lisinopril dose to 20
mg/day. What is the subsequent preferred management?

Choices:

1. Encourage daily anaerobic exercise

2. Control systolic blood pressure
3. Check fasting blood sugar
4. Add B12 daily supplements
Answer: 2 - Control systolic blood pressure

Explanations:

Itraconazole is used to treat blastomycosis.

Hypertension that does not improve with treatment is considered refractory
hypertension.
Itraconazole can cause refractory hypertension.
While the other options can cause hypertension, they do not typically cause refractory
hypertension.
Research Concepts:

Itraconazole

Question 320: A 59-year-old woman with no significant past medical history (including no
smoking history) presents to the emergency department after an episode of hemoptysis.
She undergoes CT of the chest that demonstrates a right lower lobe mass measuring 3.2 x
2 cm, with spiculated margins, highly suspicious for primary lung malignancy. The CT
images also picked up a left adrenal mass, 1.8 x 2 cm, suspicious for metastatic disease.
She is admitted for expedited workup and undergeoes IR-guided biopsy of right lung
mass, with pathology confirming lung adenocarcinoma. Additional molecular studies for
any targetable driver mutations are negative. Her performance status is excellent with no
neurologic symptoms, and she is discharged home with an upcoming medical oncology
appointment. Which of the following is the next best step in the management of this
patient?

Choices:
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1. Left adrenal mass biopsy
2. FDG-PET/CT scan
3. Thoracic surgery evaluation for right lobectomy
4. Start systemic therapy using osimertinib

Answer: 2 - FDG-PET/CT scan

Explanations:

The patient needs to complete a staging workup and will need a PET/CT to assess
for all sites of metastasis. This would help with proper tailoring of treatment for the
patient.
If proven to be oligometastatic (single adrenal metastasis), then based on the
patient's performance status, she could be a candidate for definitive treatment with
right lobectomy along with left adrenalectomy or radiation, followed by completion of
4-6 cycles of adjuvant chemotherapy.
The left adrenal mass biopsy is not warranted if radiographic findings are pointing
towards metastatic appearance, especially in the presence of a biopsy-proven
primary site.
Osimertinib is currently approved for metastatic lung adenocarcinoma harboring
EGFR mutations only. It was initially approved for T790M mutation, which is
resistant to first and second-generation TKI therapies.
Research Concepts:

Adrenal Metastasis

Question 321: A male has a myocardial infarction and requires emergent endotracheal
intubation. The provider intubates the patient and notices a massive amount of aspiration
during the procedure.
What should be administered to ensure proper antibiotic coverage?

Choices:

1. Penicillin G
2. IV ceftriaxone
3. Metronidazole
4. Clindamycin

Answer: 4 - Clindamycin
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Explanations:

Treatment of aspiration pneumonia involves the use of clindamycin to cover

anaerobes.
Another possible option is a beta-lactam/beta-lactamase inhibitor such as
amoxicillin/clavulanate.
Emergent bronchoscopy is indicated in witnessed aspirations. Ongoing management is
supportive and includes supplemental oxygen and/or mechanical ventilation.
If no infiltrate is seen after 48 to 72 hours, antibiotic therapy can be discontinued.

Research Concepts:

Aspiration Pneumonia

Question 322: A 65-year-old man presents with worsening chronic obstructive

pulmonary disease (COPD) despite tiotropium once daily, budesonide formoterol
combination long-acting inhaler twice daily, and albuterol inhaler as needed. He has a
45-pack-year history of smoking. On assessment today, the patient states that he has
had increased dyspnea and anxiety for the past few weeks, not relieved by the inhalers.
The patient is afebrile and has a pulse of 99/minute, oxygen saturation of 93% on 2 L/min
of oxygen via nasal cannula, and a body mass index of 19 kg/m2. Examination
demonstrates breathlessness after walking a short distance, distant breath sounds
bilaterally, mild pitting edema in both legs, and clubbing in both hands. Arterial blood gas
analysis shows pH 7.36, PaCO2 44 mmHg, PaO2 50 mmHg, and oxygen saturation of 87%
on room air. Spirometry reveals a post-bronchodilator FEV1/FVC ratio of 0.65 and FEV1
33% predicted. On the 6-minute walk, the patient can walk only 190 meters. What is the
best next step in treatment?

Choices:

1. Theophylline
2. Prednisone
3. Alprazolam
4. Morphine

Answer: 4 - Morphine

Explanations:

This patient's presentation is consistent with severe chronic obstructive pulmonary

disease (COPD) despite maximal therapy. The BODE index for COPD can be used to
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 calculate the estimated mortality within 52 months related to his COPD. The index
includes values for FEV1, a 6-minute walk test, BMI, and the dyspnea scale.
This patient's BODE index is 8 and estimated mortality within 52 months is 89%.
Therefore, he is a candidate for palliative therapy.
Morphine is recommended as a palliative treatment for chronic breathlessness in
patients with advanced COPD who are symptomatic despite maximal therapy and
have a poor prognosis.
Eligible patients should have PaCO2 45 mmHg to avoid worsening hypercapnia.

Research Concepts:

Chronic Obstructive Pulmonary Disease

Question 323: A 60-year-old man with a history of COPD, idiopathic pulmonary fibrosis,
and a 50-pack-year history is brought to the emergency department (ED) for
unresponsiveness. Per his wife, the patient was not feeling well for the past four days
with an upper respiratory viral infection. Symptoms included generalized malaise, fevers,
shortness of breath, and cough. He went to urgent care two days ago, and he was sent
home with azithromycin, prednisone, albuterol, and ipratropium nebulization which only
provided temporary relief. In the ED, vital signs show blood pressure 150/82 mmHg, heart
rate 110/min, respiratory rate 10/min, temperature 38.7 C, and SpO2 80% on room air.
On physical exam, the patient is very lethargic and unresponsive to painful stimuli. On
lung exam, he has decreased air movement. Arterial blood gas (ABG) shows pH 7.02, pO2
55 mmHg, and pCO2 100 mmHg. Chest x-ray shows bilateral multifocal infiltrates. The
patient is intubated and placed on mechanical ventilation. Initial settings are a
respiratory rate of 20/min, tidal volume 500 mL, FiO2 1.0, and PEEP of 5 mmHg. He is
started on inhaled bronchodilators, intravenous methylprednisolone, and broad-
spectrum antibiotics. He becomes asynchronous with the ventilator requiring sedation
and later neuromuscular blockade. His repeat ABG shows pH 6.95, pO2 70 mmHg, pCO2
120 mmHg, and he is currently hypotensive. In which of the following situations is
venovenous extracorporeal membrane oxygenation (VV-ECMO) contraindicated?

Choices:

1. The patient has end-stage idiopathic pulmonary fibrosis and is currently on the
transplant list for lung transplantation.
2. He is diagnosed with extensive disease small-cell lung cancer and is undergoing
chemotherapy.
3. He has pulmonary hypertension with a mean pulmonary arterial pressure of 55
mmHg.
4. The patient has a history of stroke with some residual weakness; he is able to
Page 308 of 955
perform all of his activities of daily living.

Answer: 2 - He is diagnosed with extensive disease small-cell lung cancer and is

undergoing chemotherapy.

Explanations:

ECMO is contraindicated in any patient with an end-stage disease without a specific

endpoint such as recovery, transplant, or other durable mechanical support devices.
In patients with extensive disease, small-cell lung cancer with a very short life
expectancy would not be a candidate for ECMO support as the patient may not be
able to be weaned off of ECMO, and there would be no mortality benefit.
ECMO is contraindicated in patients with overwhelming infection associated with
multiorgan dysfunction as they are unlikely to survive such an insult or have a good
outcome.
VV-ECMO is specifically not recommended for patients with cardiogenic shock as
these patients also need cardiac support, and they may not survive with VV-ECMO
alone.
ECMO is also contraindicated in patients with a severe neurological injury who are
bedbound and without the quality of life, as this life-sustaining support will not
improve their quality of life or provide any benefit.
Research Concepts:

Extracorporeal Membrane Oxygenation In Adults

Question 324: A 71-year-old man with chronic obstructive pulmonary disease presents for
fever, cough, myalgias, and problems with taste and smell for the past week. He states he
was seated next to someone who was coughing without a mask while flying home from
vacation three weeks ago. Vital signs are heart rate 104/min, respirations 20/min,
temperature 101.2°F (38.4°C), blood pressure 168/102 mmHg, and pulse oximetry 96% on
room air.
Physical exam shows an ill-appearing male with lungs clear to auscultation. Rapid antigen
testing confirms COVID-19 infection. What is the most appropriate initial therapy for this
patient?

Choices:

1. Sotrovimab
2. Dexamethasone
3. Ritonavir
4. Remdesivir
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Answer: 1 - Sotrovimab

Explanations:

Sotrovimab is the only monoclonal antibody (mAb) authorized for use in patients
with mild to moderate COVID-19 illness. This is due to the predominance of the
Omicron variant which is resistant to other mAbs.
MAbs have been shown to have the greatest effect in individuals at high risk of
developing severe COVID-19 illness if administered early (within 10 days of
symptoms onset).
Advanced age is the strongest risk factor for progression to severe disease and
COVID-19 related adverse outcomes. People aged 65 years or older accounted for
81% of COVID-19 related deaths in the United States in 2020. The mortality rate in
this age group has been shown to be 80 times the rate of those aged 18 to 29
years.
According to the Centers for Disease Control (CDC) comorbidities that increase the
risk of progression to severe COVID-19 illness include the presence of cancer,
cerebrovascular disease, chronic kidney disease, interstitial lung disease, pulmonary
hypertension, chronic obstructive pulmonary disease, cirrhosis, diabetes mellitus,
congestive heart failure, coronary artery disease, schizophrenia, obesity with a body
mass index of greater than or equal to 30 kg/m2, pregnancy, smoking, and
tuberculosis.
Research Concepts: Providing Access To Monoclonal Antibody Treatment Of Coronavirus
(COVID-19) Patients In Rural And Underserved Areas

Question 325: A 68-year-old male with a past medical history of congestive heart failure
with recurrent pleural effusions undergoes an indwelling pleural catheter insertion. Three
weeks later, the patient presents with fever, difficulty breathing, and cough. The patient
says he is unable to drain the pleural catheter. Computed tomography chest reveals large
right-sided pleural effusion, and the pleural catheter was in place. Diagnostic
thoracentesis shows empyema with loculated effusion. With therapeutic thoracentesis,
the patient's lung fails to expand. What is the best next step?

Choices:

1. Repeat thoracentesis
2. Remove the pleural catheter and replace the new one
3. TPA through the pleural catheter
4. Decortication

Answer: 4 - Decortication
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Explanations:

It is characterized by the lung's inability to expand and fill the thoracic cavity due
to a restricting fibrous visceral pleural peel. The resulting chronic pleural space is
fluid-filled, and the persistence of the fluid is solely due to hydrostatic equilibrium.
As the patient's lung is not expanding secondary to the trapped lung, repeated
thoracentesis is not helpful.
As the patient has empyema, pleural catheters should be removed, but as the patient
has extensive, complicated effusion with trapped lung, decortication is the treatment
of choice.
Decortication is an option for lung re-expansion if symptoms persist 6 months after
empyema resolution.
TPA through the pleural catheters can be tried to see if catheter drains. Still, as the
patient has empyema with trapped lung, it is recommended to remove the existing
pleural catheter, followed by decortication.
Repeated pleural catheter insertion, especially in the setting of empyema, is not
recommended.

Research Concepts:

Trapped Lung

Question 326: A 40-year-old male presents with the complaint of a productive cough. He
also mentions losing his breath while walking to the grocery store two blocks away. The
problem had been going on for six months durations with off and on treatment with
inhalers and antitussive medications. He has seasonal asthma since childhood, but these
symptoms are occurring during the off-season as well, and are not responsive to his
inhalers. His vitals show a temperature of 100 F, blood pressure of 112/86 mmHg, pulse of
88 bpm, and a respiratory rate of 20 breaths per minute. On chest auscultation, ronchi are
audible, and an x-ray shows bilateral opacities in upper and middle lung zones. His WBC is
10,000 per microliter of blood, and bronchioalveolar lavage shows an eosinophil count of
40%. What is the minimum duration of his treatment?

Choices:

1. At least 2 weeks
2. At least 4 weeks
3. At least 3 months
4. At least 1 year

Answer: 3 - At least 3 months

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Explanations:

The patient with a history of seasonal allergy has chronic symptoms of pneumonia.
Combined with an eosinophil count of more than 25% on BAL, his clinical and x-ray
findings lead to the diagnosis of chronic eosinophilic pneumonia.
The treatment for this patient is oral prednisone, beginning at a dose of 0.5 mg/kg
per day. There is no optimum duration of treatment. However, the initial dose is
maintained until two weeks after the resolution of symptoms and x-ray findings.
The patient is followed at subsequent visits, and steroids are tapered off, usually
around 12 to 14 weeks.
Treatment may be required for a few months to more than a year, depending on
the patient.
Short term prednisone therapy is used for acute interstitial pneumonia.

Research Concepts:

Eosinophilic Pneumonia

Question 327: A 65-year-old male patient presents with a history of persistent non-
productive cough and breathlessness on exertion. In addition, he has been having fatigue
and excessive tiredness for the past few months, which has started to affect his
professional life. On examination, there are scattered end-inspiratory crackles bilaterally.
He also has a painful nodular rash on his legs. The chest radiograph suggests bilateral hilar
lymphadenopathy, while labs reveal elevated immunoglobulins. What is the best initial
step for this patient?

Choices:

1. Oral methotrexate
2. Oral prednisolone
3. Bronchoscopy and biopsy
4. Oral leflunomide
Answer: 2 - Oral prednisolone

Explanations:

This is a case of pulmonary sarcoidosis, a disorder characterized by non-caseating

granuloma formation. Corticosteroids are the mainstay of treatment when the
patient has significant symptoms, such as dyspnea and cough.
Methotrexate or hydroxychloroquine may be given as steroid- sparing agents.
Most of the patients go into remission within two years.
Page 312 of 955
Research Concepts:

Cough

Question 328: A 49-year-old man presents to the clinic with complaints of productive
cough, fatigue, and oral ulcers. He is a sex worker and uses condoms inconsistently. Vital
signs reveal a temperature of 39 C, blood pressure 110/80 mmHg, pulse 112 beats per
minute, respiratory rate 20 per minute, and oxygen saturation is 84%. Physical exam
reveals bilateral upper lobe crackles. Chest x- ray shows bilateral interstitial infiltrate in
upper and middle lobes and air-filled cystic cavities. The 4th generation HIV antibody
panel is positive. CD4 count 160 per cubic milliliter. Viral RNA levels are pending. What is
the most likely organism responsible for cavity formation in the patient's lungs?

Choices:

1. Pneumocystis carinii
2. Staphylococcus aureus
3. Proteus mirabilis
4. E. coli

Answer: 1 - Pneumocystis carinii

Explanations:

Pneumocystis pneumonia is associated with immunocompromised patients with

atypical pneumonia and can result in pneumatocele formation. In literature, single
or multiple pneumatoceles as sequelae of the pneumocystis pneumonia have been
described.
It is often missed, and pneumatocele can present in a complicated form, e.g.,
pneumothorax, tension pneumothorax, empyema, tension pneumatocele.
In complicated pneumatocele, drainage, antibiotic use, or surgery ( percutaneous
pigtail or needle compression or chest tube) or VATS or open lobectomy/
pneumonectomy or pneumatocele removal/deroofing are available options.
Observation only can result in spontaneous resolution of the pneumatoceles in
immunocompromised patients.
In children, staphylococcus aureus is most commonly reported to be associated
with post pneumonia pneumatocele formation.

Research Concepts:
Pneumatocele
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Question 329: A rapid response is called for a patient due to acute hypoxic hypercapnic
respiratory failure. The patient is a 67- year-old male with a past medical history of
obesity hypoventilation syndrome and chronic obstructive pulmonary disorder. The nurse
reports that over the past one hour, the patient has become increasingly lethargic, and his
arterial blood gas (ABG) analysis revealed the patient's pCO2 went from 65 mm Hg to 100
mmHg. The patient was prepared to intubate. Upon review of his airway, there is a
Mallampati score of 4, and the patient has a submental distance of 1 finger length. What
would be the most critical step to ensure successful intubation in this patient?

Choices:

1. Use a tracheal tube inducer

2. Extend the lower cervical spine, and flex the upper cervical spine
3. Flex the lower cervical spine and extend the upper cervical spine
4. Attempt a surgical airway

Answer: 3 - Flex the lower cervical spine and extend the upper cervical spine

Explanations:

Positioning the patient correctly will help mitigate a difficult airway. Positioning
the patient with C6-C7 flexed and C1-C2 extended will allow the clinician the best
chance of visualizing the glottis in this situation. This position is called the "sniffing
position."
The epiglottis serves as the primary landmark that will direct successful
endotracheal intubation. The origin of the epiglottis can be found at the base of
the tongue. The valley between the tongue and the epiglottis is called the
vallecula.
At least two to three medical professionals are required to manage the airway for
rapid sequence induction. A clear delineation of roles is necessary for successful
endotracheal intubation. The lead clinician is responsible for directing the team,
managing the patient's airway, and intubating the patient. A nursing staff member
is responsible for providing induction and paralytic medications at the onset of the
procedure.
At this point in time, a surgical airway is not necessary.

Research Concepts:

Tracheal Rapid Sequence Intubation

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Question 330: A 65-year-old male patient presented to the clinician with complaints of
dyspnea on exertion, palpitations, chest pain, dizziness, and fatigue. History revealed that
the patient has been drinking alcohol for 20 years of age but has stopped drinking for the
past 2 years. On examination, the patient had edema in ankles, legs, and hands. The
clinician ordered an electrocardiogram that showed right and left ventricular
hypertrophy, left bundle branch block, and low voltage QRS complexes. Transthoracic
echocardiogram revealed an ejection fraction of 25–30% with a severely hypokinetic
distal septum and distal anterior wall and an akinetic apical wall. He was refractory to
anti-anginal and guideline- directed medical therapy for heart failure. A chest x-ray of the
patient revealed an enlarged right atrium, a prominent pulmonary outflow tract, enlarged
pulmonary arteries, and pruning of peripheral pulmonary vessels. Which of the following
factor will be the most likely cause of death if the lung transplant is delayed in this case?

Choices:

1. Chronic obstructive pulmonary disease8

2. Primary pulmonary hypertension
3. Interstitial lung disease
4. Chronic restrictive pulmonary disease

Answer: 2 - Primary pulmonary hypertension

Explanations:

Patients with primary pulmonary hypertension have the highest mortality while
waiting for a transplant.
Lung transplantation is the last resort treatment option for pulmonary hypertension
when it is no longer controlled by the medications effectively.
Depression of cardiac function and elevated right ventricular pressures are
predictors of death in patients with pulmonary hypertension.
Complications of a lung transplant include hyperacute transplant rejection, ischemia-
reperfusion injury, acute transplant rejection, and bronchial anastomosis failure, etc.

Research Concepts:

Lung Transplantation

Page 315 of 955

Question 331: A 28-year old prison inmate presents with a 7-day history of productive
cough, malaise, headache, and low-grade subjective fever. He denies shortness of breath,
night sweats, or weight loss. He also mentions another inmate having similar symptoms.
His current temperature is 99.8 F (37.7 C), and he is hemodynamically stable. Chest
auscultation reveals bilateral crackles and wheezes. On skin examination, erythematous,
macular, target-like lesions are noted on the upper chest and arms bilaterally. There is no
mucosal involvement. Lab work includes a hemoglobin level of 10.9 g/dl and a leukocyte
count of 12000 cells/mm3. Chest x- ray shows bilateral peribronchial and perivascular
interstitial infiltrates, airspace consolidation, and reticulonodular opacification.
What the mechanism of action of the most appropriate treatment for this patient?

Choices:

1. Disrupting of the conversion of lanosterol to ergosterol via binding to cytochrome P-

450
2. Inhibiting the reduction of dihydrofolic acid to tetrahydrofolic acid after binding to
dihydrofolate reductase
3. Inhibiting protein synthesis after binding to the 23S rRNA of the 50S ribosomal
subunit
4. Inhibiting cell wall synthesis by binding to the acyl-D-ala-D-ala portion of the
growing peptidoglycan cell wall

Answer: 3 - Inhibiting protein synthesis after binding to the 23S rRNA of the 50S ribosomal
subunit
Explanations:

This clinical scenario depicts a patient with atypical pneumonia caused by

Mycoplasma pneumoniae. Despite its name, M. pneumoniae is associated with
infections in other anatomical sites such as skin, central nervous system, blood,
heart, and joints. The four most common findings seen on chest x-ray are
peribronchial and perivascular interstitial infiltrates (49%), airspace consolidation
(38%), reticulonodular opacification (8%), and nodular or mass-like opacification
(5%). In about 20% of patients, involvement is bilateral.
The most appropriate treatment for a patient with atypical pneumonia caused by
Mycoplasma pneumoniae is a macrolide such as azithromycin, clarithromycin, or
erythromycin.
Azithromycin binds to the 23S rRNA of the bacterial 50S ribosomal subunit. It
blocks bacterial protein synthesis by inhibiting the translocation step of protein
synthesis and the assembly of the 50S ribosomal subunit.
Fluoroquinolones, such as levofloxacin, and tetracyclines, such as doxycycline, are
alternate therapies for Mycoplasma pneumonia. Fluoroquinolones inhibit

Page 316 of 955

 prokaryotic enzymes topoisomerase II (DNA gyrase) and topoisomerase IV.
Tetracyclines act upon the conserved sequences of the 16S rRNA of the 30S
ribosomal subunit to prevent binding of t-RNA to the A site.

Research Concepts: Mycoplasma Infections

Question 332: A 3-year-old girl is brought to the hospital after falling off a trampoline. She
is found to have a right radial fracture. Her medical history is significant for eczema,
seasonal allergies, and asthma. Surgical repair is planned. Which of the following is the
most critical prerequisite for surgery in this patient?

Choices:

1. History and physical exam only

2. Chest radiograph
3. Renal function testing
4. Pulmonary function testing

Answer: 1 - History and physical exam only

Explanations:

Before surgery, it is crucial to determine whether a patient's asthma is well-controlled

or poorly controlled.
Elective surgery should be postponed until asthma is well controlled.
A detailed history and focused physical exam are required for a complete preoperative
evaluation.
Preoperative labs, chest radiographs, and tests to assess pulmonary function are rarely
recommended.

Research Concepts:

Asthma Anesthesia

Question 333: A 58-year-old man is recovering from a myocardial infarction which

required emergent CABG and placement of the patient on veno-arterial (VA) ECMO. The
patient is about to start weaning trials from the VA ECMO support circuit. Which of the
following is the most appropriate management of the ECMO circuit while weaning the
patient?

Page 317 of 955

Choices:

1. Stop all anticoagulation only

2. Stop the anticoagulation and periodically flush the cannulas every 10 minutes
3. Continue the anticoagulation and periodically flush the cannulas every 10 minutes
4. Remove the cannulas and stop the anticoagulation

Answer: 3 - Continue the anticoagulation and periodically flush the cannulas every 10
minutes

Explanations:

When weaning from VA ECMO, anticoagulation should be continued throughout

the entire process. Even when the circuit is on an off trial and the patient is not on
support, the anticoagulation must be continued.
When the patient is on a weaning trial, the circuit should be flushed with
heparinized saline every 10 minutes. Another possible option is to flash the circuit
with blood from the circuit to prevent thrombosis.
The lines and cannulas can be left in place 24 hours after the patient is deemed
weaned off of the VA ECMO circuit. The cannulas can be left in place for 24 hours
just in case the patient needs to go back on ECMO emergently.
When weaning from VA ECMO, anticoagulation should not be stopped as it can
lead to circuit thrombosis. The cannulas and lines will need to be flushed to prevent
thrombosis. The cannulas should not be removed until the patient is fully weaned
and goes 24 hours without any signs of decompensation.

Research Concepts:

Extracorporeal Membrane Oxygenation Weaning

Question 334: A 67-year-old gentleman presents with complaints of weight loss, fatigue,
and gradually worsening right shoulder pain. This is associated with numbness and
tingling of his fourth and fifth digits and along the medial aspect of his right forearm. He
has a history of tobacco use with a 50-pack year history of cigarette smoking. On physical
examination, he appears cachectic, has a weakness of his right shoulder and hand, and
has ptosis of the right eye. Which of the following imaging modality is essential in the
staging of this process?

Choices:

1. Computed tomography (CT) scan of the chest

Page 318 of 955
 2. Pan CT scan
3. Magnetic resonance image (MRI) of the brain
4. MRI of the lungs

Answer: 4 - MRI of the lungs

Explanations:

This patient's presentation is concerning for Pancoast or superior sulcus tumor. In

such patients, respiratory symptoms typically appear later, and there is a risk of
involvement of the neurovascular structures in the region of the axilla and thoracic
outlet.
Ipsilateral shoulder and arm weakness and paresthesias are suspicious for the
involvement of the brachial plexus.
Lung MRI is an essential part of the work-up and staging of this lesion as it better
delineates soft tissue margins, and vascular and neural invasion, thus determining
whether or not a mass is resectable.
A contrast-enhanced chest CT is also an important part of workup and would give
information about the size of the lesion, additional lesions and, lymphadenopathy.
However, the staging of a Pancoast tumor in a patient with symptoms of brachial
plexus involvement is incomplete without MRI evaluation, which gives better
information about resectability.

Research Concepts:

Lung Imaging

Question 335: A 48-year-old man presents to the clinic with weight loss, night sweats, and
malaise. He is found to have enlarged mediastinal lymph nodes on computed tomography
of the chest with uptake on positron emission tomography in stations 3a, 5L, and 6L. What
is the most appropriate method to obtain a tissue sample in this patient?

Choices:

1. Endoscopic ultrasound
2. Extended cervical mediastinoscopy
3. Video-assisted thoracoscopic surgical biopsy
4. Endobronchial ultrasound

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Answer: 2 - Extended cervical mediastinoscopy

Explanations:

Stations 3a, 5, and 6 are not accessible by endobronchial ultrasound (EBUS) due to
their proximity to the great vessels within the mediastinum. Although the
procedure has higher morbidity than EBUS, they will be accessible by extended
cervical mediastinoscopy.
Extended cervical mediastinoscopy is useful when nodal stations are not accessible
by EBUS or when EBUS samples are negative. EBUS has been shown to have a high
sensitivity and should be the first-line test whenever technically feasible. Video-
assisted thoracoscopic surgical biopsy is appropriate if the surgeon feels that the
target nodes are not easily accessible by mediastinoscopy. Endoscopic ultrasound is
only performed for nodal stations 8 and 9.
Where multiple nodal stations demonstrate avidity on positron emission
tomography, clinicians should choose the least invasive procedure which will still
allow good nodal sampling.

Research Concepts:

Sonography Endobronchial Assessment, Protocols, And Interpretation

Question 336: A 35-year-old man presents to the emergency department due to high
fevers, diarrhea, and shortness of breath after returning from a vacation at a hotel resort.
Urine antigen testing is positive for Legionella. Which of the following is the most severe
dermatologic complication of the best initial therapy for this patient?

Choices:

1. Stevens-Johnson syndrome
2. Atopic dermatitis
3. Pemphigus vulgaris
4. Pruritis

Answer: 1 - Stevens-Johnson syndrome

Explanations:
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 High fevers, diarrhea, and shortness of breath are hallmark symptoms of Legionella.
The treatment of choice for Legionella is macrolides.
One of the most severe dermatologic complications of macrolide use is Stevens-
Johnson syndrome.
Pemphigus vulgaris is an autoimmune condition that results in blistering of the skin,
which may resemble Stevens-Johnson but is not caused by the drug.

Research Concepts:

Macrolides

Question 337: A 65-year-old male patient with severe chronic obstructive pulmonary
disease (COPD) is ventilated in the intensive care unit (ICU) with positive end-expiratory
pressure (PEEP) of 5 cmH20. He has poor breathing effort, and his saturation is under
85%. The clinician decides to increase the PEEP to 10 cmH2O. During the middle of the
night, the clinician gets an urgent call from the nurse that the patient is hypotensive and
cyanotic. She further states that she tried to listen to his chest but there are no sounds on
auscultation. What is the initial plan of action for this patient?

Choices:

1. Urgent thoracotomy
2. Transport to radiology for a chest x-ray
3. Bronchoscopy to rule out atelectasis or blocked endotracheal tube
4. Immediate bilateral chest tube placement

Answer: 4 - Immediate bilateral chest tube placement

Explanations:

This scenario is typical of a tension pneumothorax after increasing PEEP. The most
likely plan of action for this patient is bilateral chest tube intubation.
When PEEP is 10 cmH20 or higher, the risk of barotrauma is increased.
Some clinicians routinely place chest tubes in ventilated patients who are getting high
PEEP.
In any ventilated patient, a pneumothorax can quickly become fatal, and it is
important to have a chest tube set at the bedside.

Research Concepts:

Tension Pneumothorax
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Question 338: A 50-year logger from Wisconsin presents to the out-patient department
with complaints of low-grade fever and a discharging wound on the right upper tibia for
the last 12 weeks. The symptoms started with low-grade fever and mild discomfort
around the right knee. This was followed by the appearance of a small boil that
spontaneously started discharging. He also complains of low- grade fever and night
sweats. He has taken multiple courses of oral antibiotics but has not seen any significant
improvement. He has no significant past medical history and is otherwise well. He does
recollect mild cough and flu-like symptoms before the onset of knee pain. On
examination, his vitals are a temperature of 99 F, pulse 80 beats per minute, respiratory
rate 15/min, and blood pressure of 115/75 mmHg. His local examination reveals a
draining sinus at the upper end of the right tibia and mild erythema a discomfort on
palpation. His systemic examination is unremarkable. An x-ray shows a lytic lesion
consistent with osteomyelitis. Microbiological analysis of discharge shows the presence
of thick-walled cells measuring about 10 microns in size with broad-based budding also
observed when stained with periodic acid Schiff stain. What is the likely pathogen
responsible for his disease?

Choices:

1. Mycobacterium tuberculosis
2. Blastomyces dermatitidis
3. Staphylococcus aureus
4. Salmonella typhi

Answer: 2 - Blastomyces dermatitidis

Explanations:

Blastomycosis can present with x ray findings of a mass or consolidation and can
mimic cancer.
Blastomycosis, also known as Blastomycotic dermatitis or Gilchrist disease, is a
fungal infection of humans, dogs, and cats caused by Blastomyces dermatitidis.
Blastomycosis causes clinical symptoms similar to histoplasmosis. The disease
occurs in eastern North America, particularly in the western and northern Great
Lakes basin, extending to the shore of the St.
Lawrence river valley, southward to the central Appalachian Mountains in the east,
and to the Mississippi River valley in the west. It is also seen in continental Africa, the
Arabian Peninsula, and the Indian subcontinent.
Blastomycosis presents in one of the following ways: (1) A flu- like illness with chills,
fever, arthralgia, myalgia, headache, and a nonproductive cough which should
resolve within days; (2) An acute illness resembling bacterial pneumonia, with chills,
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 high fever, a productive cough, and a pleuritic chest pain; (3) A chronic illness that
mimics tuberculosis or lung cancer, with low- grade fever, a productive cough,
weight loss, and night sweats, and weight loss; (4) A fast, progressive, and severe
disease with acute respiratory distress syndrome, fever, shortness of breath,
tachypnea, hypoxemia, and diffuse pulmonary infiltrates; (5) Skin lesions, may be-
be verrucous (wart-like) or ulcerated with pustules at the margins; (6) Bone lytic
lesions may cause pain;
(7) Prostatitis may be asymptomatic and cause pain with urination; (8) Laryngeal
involvement may result in hoarseness. 40% of immunocompromised individuals
have central nervous system involvement with brain abscess, epidural abscess, or
meningitis.
Blastomycosis is caused by the dimorphic microfungus Blastomyces dermatitidis. It is
the asexual state of Ajellomyces dermatitidis. The fungus lives in soil, rotten wood,
and near
lakes and rivers. The moist, acidic soil in the surrounding woodland typically
harbors the fungus.

Research Concepts:
Blastomycosis

Question 339: A 29-year-old female presents to the emergency department after

exposure to an illness. She states that she was volunteering in a healthcare camp for
refugees yesterday, where she was taking care of a male patient from the Democratic
Republic of Congo. The patient had a high-grade fever and a cough with hemoptysis. His
clinical condition rapidly declined and he is now deceased. She also recalls that the patient
had tender, enlarged inguinal lymph nodes. On exam, she is well-appearing with normal
vital signs. She has no skin changes, and her lungs are clear to auscultation. Her workup
demonstrates a normal complete blood count without leukocytosis and the chest x-ray is
without any abnormalities. Reviewing records from the deceased patient reveals sputum
culture growing a gram-negative coccobacillus with bipolar staining on Giemsa stain. What
is the next best step in the management of this patient?

Choices:

1. Reassurance and discharge home with outpatient follow up

2. Admission with droplet isolation and monitoring for 72 hours
3. Prophylactic treatment with chloramphenicol
4. Prophylactic treatment with doxycycline

Answer: 4 - Prophylactic treatment with doxycycline

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Explanations:

Pneumonic plague presents as fever, cough, hemoptysis, and pleuritic chest pain
with or without buboes.
Those with close exposure (within 2 meters) to a person with pneumonic plague
require prophylactic treatment.
The preferred prophylactic treatment for the plague includes doxycycline, a
fluoroquinolone, or trimethoprim- sulfamethoxazole.
Asymptomatic patients with possible close exposure to plague do not require
droplet precautions or isolation.

Research Concepts:

Plague

Question 340: A 65-year-old woman presents to the emergency department with

shortness of breath. She recently was in a 22-hour car ride from Florida. Her blood
pressure is 122/85 mmHg, pulse 110/minute and respiratory rate 25/minute. CT of the
chest confirms a pulmonary embolism. Shortly after, the patient develops a wide complex
tachycardia on telemetry but remains hemodynamically stable. A stat ECG is ordered.
Which of the following is most likely to be seen on the ECG in this patient?

Choices:

1. QRS complex of 0.08 s

2. Irregular R-R Intervals
3. RS interval > 100 ms in a precordial lead
4. P-R interval prolongation

Answer: 3 - RS interval > 100 ms in a precordial lead

Explanations:

Pulmonary embolism is one of several etiologies for causing a ventricular tachycardia.

Other etiologies include structural heart disease, electrolyte disturbances,
channelopathies and medications that prolong the QT interval.
Ventricular tachycardia on ECG has findings that include regular R-R intervals, rapid
ventricular rate with an undistinguishable atrial rate (absence of p-waves), AV
dissociation and a wide QRS complex (more than 0.12 sec).
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 Other findings that suggest ventricular tachycardia include a QRS complex greater
than 0.14 s with right bundle branch morphology or greater than 0.16 s with left
bundle branch morphology, RS interval > 100 ms in a precordial lead, negative QRS
concordance in the precordial leads and ventricular fusion beats.
Patients who develop ventricular tachycardia may initially be hemodynamically stable.
However, these patients can quickly decompensate.

Research Concepts:

Pulseless Ventricular Tachycardia

Question 341: What is the most appropriate test to order in the case of a elderly male
with chronic obstructive pulmonary disease and hypertension who takes enalapril,
aspirin, hydrochlorothiazide, theophylline, and an over the counter medication for
heartburn who is found on exam to have a normal blood pressure, tachycardia, a tremor,
and an otherwise normal cardiac exam?

Choices:

1. Urine drug screen

2. Chest x-ray
3. Theophylline level
4. Echocardiogram

Answer: 3 - Theophylline level

Explanations:

Theophylline is prescribed for chronic obstructive pulmonary disease and

asthma.
Theophylline toxicity manifests as tachyarrhythmias, tremors, agitation, nausea,
vomiting, metabolic acidosis abnormalities and if severe can lead to seizures or
ventricular fibrillation.
Theophylline is used less frequently now due to its severe side effect profile.
Theophylline is metabolized by the cytochrome P450 system in the liver.
Theophylline levels can become toxic if another agent is taken that competes with it
for metabolism such as cimetidine.

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Research Concepts:

Theophylline Toxicity

Question 342: A 65-year-old man with a long-standing smoking history presents to the
clinic for routine follow-up. The patient undergoes the CT screening for lung cancer and is
found to have a 2 cm peripheral lesion on the right concerning cancer. The biopsy shows
adenocarcinoma of the lung. Assuming that he does not have any other cancer sites,
which of the following offers the best long- term survival for this patient?

Choices:

1. External beam radiation followed by radiofrequency ablation of the tumor

2. Chemoradiation followed by lobectomy
3. Surgical resection of the tumor
4. Immunotherapy followed by radiofrequency ablation of the tumor

Answer: 3 - Surgical resection of the tumor

Explanations:

This patient has early-stage adenocarcinoma of the lung, and surgery offers the
best long-term survival.
Surgery should be pursued in all patients in whom surgery can be safely pursued
and feasible depending on the cancer stage. Radiation can be used as an adjunct
therapy by itself or combined with chemotherapy, where surgery is not feasible.
Immunotherapy is used in the advanced stages of lung cancer.

Research Concepts:
Adenocarcinoma

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Question 343: A 45-year-old female is seen in the transplant clinic. She received a bilateral
lung transplant for interstitial lung disease from a deceased donor two months ago. She
has been experiencing cough, fever, and shortness of breath for the past 7 days.
She is currently on tacrolimus, mycophenolate mofetil, and prednisolone for her
transplant. Examination reveals a pulse of 105 beats per minute, blood pressure of
120/70 mmHg, respiratory rate of 35 breaths per minute, a temperature of 99°F (37.2°C),
and oxygen saturation of 85% on room air. A chest x-ray reveals the presence of bilateral
infiltrates. Her blood work reveals a white blood cell (WBC) count of 6,000 per microL,
serum creatinine of 0.8 mg/dl, serum alanine aminotransferase (ALT) level of 110 IU/l and
a C- reactive protein (CRP) level of 25 mg/l. Her partial pressure of oxygen (PaO2) is 65
mmHg. A transbronchial biopsy is performed.
Histopathological examination of the tissue reveals the absence of perivascular
infiltrates, but the presence of eosinophilic intranuclear inclusions in the pneumocytes.
Which of the following medications would have prevented the development of the
patient's present condition?

Choices:

1. Trimethoprim-sulphamethoxazole
2. Valganciclovir
3. Anti-lymphocyte globulin
4. Itraconazole

Answer: 2 - Valganciclovir

Explanations:

Patients who have received transplants are at risk of transplant rejection and
opportunistic infections as well as infections by routine organisms. This patient has
presented with severe pulmonary symptoms, and biopsy revealed the presence of
viral cytopathic effect making the likely diagnosis of cytomegalovirus (CMV)
pneumonitis. Prophylactic valganciclovir can reduce the development of severe
infections in patients with a transplant.
There is a risk of CMV infection in transplant patients, especially if either the donor
or the recipient are seropositive. The highest risk is with donor positive and
recipient negative serotypes. It is recommended to give prophylactic oral
valganciclovir in lung transplant patients, who show donor or recipient
seropositivity for CMV.
The usual dosage for valganciclovir is 900 mg once daily for 6 to12 months post-
transplant. An alternate regimen is frequent antigenic and viral load monitoring,
followed by the treatment of patients that demonstrate viral replication.
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 Intravenous ganciclovir is recommended in patients who are unable to tolerate oral
formulation. Trimethoprim- sulphamethoxazole is administered for the prevention
of pneumocystis and toxoplasma infections. Whereas, individuals at high risk for
aspergillosis can be administered oral itraconazole. Anti lymphocyte globulin is used
in the induction of immunosuppression in lung transplant patients and reduces the
chances of graft rejection.

Research Concepts:
Cytomegalovirus

Question 344: A 55-year-old man with a history of lung cancer with hepatic metastasis is
admitted to the hospital due to a 5 cm pneumothorax found on a chest x-ray. He is
planned for a chest tube placement today. Labs show hemoglobin 11 g/dL and platelets
28,000/microL. Which of the following is the next best step in the management of this
patient?

Choices:

1. Transfuse whole blood

2. Transfuse red blood cells
3. Transfuse platelets
4. Place the chest tube

Answer: 3 - Transfuse platelets

Explanations:

The standard guideline for platelet transfusion for bedside procedures is less than
50,000/microL. Some studies have shown safety down to 30,000/microL when
using ultrasound guidance.
The guideline for platelet transfusion for major surgical procedures is less than
100,000/microL.
Other procedures like bronchoscopy, kidney biopsy, liver biopsy guideline or
platelet transfusion are less than 50,000/microL. Intra and postoperative
guidelines for platelet transfusion are also less than 50,000/microL.
Research Concepts:

Determining the Need for Blood Transfusion

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Question 345: A 60-year-old woman with chronic obstructive pulmonary disease and
chronic hypoxic respiratory failure presents for follow-up. She reports exertional
shortness of breath that seems to be worsening and is now associated with chest pain.
She is compliant with her inhalers and supplemental oxygen and no longer smokes.
Examination demonstrates clear lung sounds bilaterally, an elevated jugular venous
pressure, wide splitting of the second heart sound, and a holosystolic murmur of tricuspid
regurgitation. Which of the following is most likely to be seen on cardiac catheterization in
this patient?

Choices:

1. Mean pulmonary arterial pressure of 15 mmHg

2. Mean pulmonary arterial pressure of 25 mmHg
3. Mean pulmonary capillary wedge pressure of 25 mmHg
4. Pulmonary vascular resistance of 2 Woods units

Answer: 2 - Mean pulmonary arterial pressure of 25 mmHg

Explanations:

This patient likely has cor pulmonale. Cor pulmonale is a complication of pulmonary
hypertension (PH) in patients with chronic lung disease or chronic hypoxemia. It is
defined as right ventricular dysfunction secondary to group 3 PH.
Cardiac catheterization in this patient will show a mean pulmonary arterial
pressure of greater than 20 mmHg, mean pulmonary capillary wedge pressure of
less than or equal to 15 mmHg, and a pulmonary vascular resistance of greater
than or equal to 3 Woods units.
Symptoms usually consist of exertional dyspnea not attributable to underlying
pulmonary disease. Exertional chest pain and/or syncope are other presenting
features that should raise concern for cor pulmonale.
The severity of PH in patients with group 3 PH appears to correlate with the
severity of the underlying lung disease.
Research Concepts:Cor Pulmonale

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Question 346: A 65-year-old man presents to the clinic on the insistence of his wife for
disordered sleep. His wife states that her husband has episodes in which he suddenly stops
breathing in the middle of the night. Even though he spontaneously starts breathing, she is
worried that these episodes could worsen. On detailed inquiry, the wife admits that her
husband has always been a loud snorer. On a review of symptoms, the husband admits
feeling tired throughout the day. He also admits having dozed off while driving last week.
Vitals show a blood pressure of 138/85 mmHg, pulse 88/min, and respiratory rate 19/min.
His body mass index is 37 kg/m2. Cardiac examination is significant for a loud S1 and S2. The
most frequent respiratory events will most likely occur during which stage of sleep?

Choices:

1. N1
2. N2
3. N3
4. REM

Answer: 4 - REM

Explanations:

This patient has typical symptoms of obstructive sleep apnea (OSA). His high body
mass index, episodes of apnea at night time, and decreased concentration during
the day are typical of this disorder. The best investigation for the diagnosis of OSA
is polysomnography (PSG).
The majority of patients with OSA will have the most frequent respiratory events
during REM due to the hypotonia that occurs during this stage of sleep.
The apnea-hypopnea index (AHI) is the average number of obstructive events per
hour. If the AHI is more than or equal to 5, the diagnosis of OSA is made. An AHI
of 5 to 14 is considered mild sleep apnea, 15 to 29 is moderate, and 30 or more
is severe OSA.
The Epworth Sleepiness Scale can be used to gauge a patient's likelihood of oxygen
dosing in different settings as an indicator of inadequate restorative nighttime
sleep. The score ranges from 0 to 24, and more than 10 is suggestive of a sleep
disorder rather than generalized fatigue.

Research Concepts: Obstructive Sleep Apnea

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Question 347: A 42-year-old male patient, living in New York City, travels to do hiking on the
Inca Trail (more than 6000 feet). There he presents to a local clinic complaining of a
worsening headache and nausea. His vitals are unremarkable. On examination, he has no
altered mental status or ataxia. The remainder of the examination reveals no definite acute
abnormalities. What is the mechanism by which prophylactic medication could have
prevented this condition?
Choices:

1. Increasing bicarbonate diuresis

2. Increasing sodium diuresis
3. Decreasing potassium secretion
4. Stimulating red blood cell production

Answer: 1 - Increasing bicarbonate diuresis

Explanations:

This patient has acute mountain sickness (AMS). Acetazolamide is commonly used
for the prophylaxis of AMS. It acts as a carbonic anhydrase inhibitor in the proximal
convoluted tubule, limiting the reabsorption of bicarbonate. This causes a decrease
in the blood pH, which in turn stimulates an increase in minute ventilation. It
essentially augments the body's natural acclimatization response. Acetazolamide is
best used for prophylaxis rather than treatment, although it can have a role in
treatment as well.
Sodium balance does not play a significant role in the pathophysiology of AMS. The
two medications commonly used for AMS prophylaxis, acetazolamide, and
dexamethasone, do not derive their prophylactic effects from alterations in
sodium balance. Potassium balance does not play a significant role in the
pathophysiology of AMS.
The optimal rate of ascent (sleep altitude) should be no more than 500 m per day at
levels greater than 2500 m. Also, allowing at least one day to acclimate around 2500
meters before the further ascent, and then again for every additional 1000 meters
ascent, will reduce risk. Avoiding exercise and alcohol for the first 48 hours until
acclimated may also minimize the risk of symptoms. If acute mountain sickness
does occur, the further ascent is not advisable until acclimated.
Stimulation of red blood cell production is an important part of long term
acclimatization to altitude. However, the effects of this process are not seen for
several weeks. Thus, it does not play a significate role in the acclimatization for
most altitude travelers as most will only be at altitude for several days. Medications
that artificially stimulate red cell production, such as epoetin alfa, have no role in
AMS prophylaxis.
Research Concepts: Acute Mountain Sickness

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Question 348: An 83-year-old male is admitted to the intensive care unit following a large
hemorrhagic stroke and intubation for decreased Glasgow coma score. He has a history of
myocardial infarction several years ago with stent placement and peripheral vascular
disease. An arterial blood gas is obtained and shows a normal PaCO2. He is becoming
hemodynamically unstable. Repeat computed tomography scan brain now shows a large
midline shit with potential for herniation. While awaiting transfer to the operating room
for a craniotomy, what adjustments to the patient’s PaCO2 may help prevent herniation?

Choices:

1. A slight increase in minute ventilation to induce mild hypocarbia

2. A large increase in minute ventilation to induce extreme hypocarbia
3. A slight decrease in minute ventilation to induce mild hypercarbia
4. A large decrease in minute ventilation to induce extreme hypercarbia

Answer: 1 - A slight increase in minute ventilation to induce mild hypocarbia

Explanations:

There is a fixed amount of space inside the skull. This space is occupied by blood,
brain, and cerebrospinal fluid. An increase in space required by one element will
result in less space for the other elements. If more space is required than is
available, then brain tissue may be forced through the foramen magnum resulting
in death.
Changes in PaCO2 can control cerebral vasculature. Hypocarbia will cause
cerebral vasoconstriction. Hypercarbia will cause cerebral vasodilation.
Mild hypocarbia produces slight cerebral vasoconstriction, which may reduce the
volume of blood in the brain temporarily to create space. This may temporarily
prevent the patient from herniating. Hyperventilation and induction of mild
hypocarbia is only a temporizing measure for definitive treatment, as prolonged
exposure to hypocarbia will eventually result in the resetting of central
chemoreceptors to diminishing therapeutic effect. Extreme hypocarbia is dangerous
to the patient as it can cause significant vasoconstriction and cerebral ischemia.
Any hypercarbia (mild or extreme) in this patient will cause cerebral vasodilation
and an increase in intracranial blood flow. In a patient with pending herniation,
cerebral vasodilation is likely to hasten herniation and death.

Research Concepts: Hypercarbia

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Question 349: A 56-year-old male comes in for the evaluation of shortness of breath and
lower extremity swelling. His past medical history is significant for diabetes and
hypertension. Vital signs are as follows: pulse rate 85/min, blood pressure 122/72 mm Hg,
respiratory rate 19/min, and temperature 98.6 F (37 C). Physical examination reveals a
systolic murmur in the parasternal area. There is 3+ pedal edema. Doppler
echocardiography shows a pressure of 52 mm Hg in the pulmonary vasculature. Which of
the following indicate a poor prognosis for patients with this condition?
Choices:

1. Pericardial effusion, tricuspid annular systolic excursion (TAPSE) less than 1.5 cm
present on echocardiogram
2. Pro-brain natriuretic peptide 150 pg/ml, 6-minute walk test more than 300 m
3. Pulmonary vascular resistance greater than 3 Wood units, diffusing capacity of the
lungs for carbon monoxide (DLCO) greater than 32%
4. WHO Functional Class II and creatinine 1.0 mg/dL
Answer: 1 - Pericardial effusion, tricuspid annular systolic excursion (TAPSE) less than 1.5
cm present on echocardiogram
Explanations:

The REVEAL Registry PAH Risk Score Calculator is a tool clinicians may use to help
prognosticate patients with pulmonary artery hypertension. The tool has been
validated as a predictive algorithm for 1-year survival.
Factors that are independently associated with decreased survival include the
following: men older than 60 years, pulmonary arterial hypertension (PAH)
associated with portal hypertension or connective tissue disorder, family history of
PAH, WHO Class III or IV, renal insufficiency, resting systolic BP less than 110 mm Hg,
heart rate greater than 92 beats per minute, six-minute walk test less than 165 m,
brain natriuretic peptide greater than 180 pg/ml, pulmonary vascular resistance
greater than 32 Woods units, presence of pericardial effusion on echocardiogram,
TAPSE (tricuspid annular plane systolic excursion) less than 1.5 cm, percentage
predicted diffusing capacity of the lung for carbon monoxide (DLCO less than 32%).
Pericardial effusion is associated with the severity of right- ventricular failure though
it is not well understood why some patients with pulmonary artery hypertension
develop pericardial effusion, and others do not.
Four variables have been found to show increased 1-year survival: modified
NYHA/WHO functional class I, 6-minute walk test of 440 m, brain natriuretic
peptide less than 50 pg/mL, and percent predicted DLCO of 80%.

Research Concepts: Pulmonary Idiopathic Hypertension

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Question 350: A 35-year-old woman presents to the clinic with three months of exertional
shortness of breath. She has a past medical history of systemic lupus erythematosus. Her
antibody profile includes antinuclear antibody, anti-Ro, and anti-La. She currently takes
hydroxychloroquine. She does not smoke cigarettes or drink alcohol. She works as a
nursing assistant. Her vital signs show heart rate 101/min, blood pressure 120/77 mmHg,
respiratory rate 22/min, oxygen saturation 96% on room air, and temperature
37.1 C. On examination, there is reduced chest expansion bilaterally but equal air entry.
The jugular venous pulse is not raised, there is no peripheral edema, and the heart
sounds are normal and regular with no added sounds or murmurs. Abdominal and
neurological examinations are normal. She has a body mass index of 21 kg/m2. Blood
testing is unremarkable, including white cell count and C reactive protein (CRP). A CT
chest with contrast excludes a parenchymal lung disease and pulmonary emboli. A
transthoracic echocardiogram is normal, with no evidence of pulmonary hypertension
and a preserved ejection fraction. Respiratory function tests demonstrate a restrictive
deficit with reduced lung volumes. Which of the following findings is most likely to be
seen on the patient's chest x-ray?
Choices:

1. Elevated hemidiaphragms
2. Enlarged pulmonary arteries
3. Consolidation
4. Pleural effusion
Answer: 1 - Elevated hemidiaphragms
Explanations:

Shrinking lung syndrome is a rare complication of systemic autoimmune disease,

most commonly associated with systemic lupus erythematosus. Typically, it is
characterized by symptoms such as dyspnoea and pleuritic chest pain in
association with the unilateral or bilateral elevation of the hemidiaphragms. Lung
function testing demonstrates a restrictive deficit with reduced total lung volumes.
Unilateral or bilateral elevation of the hemidiaphragm is an almost ubiquitous
finding in this condition. Basal atelectasis is also common. Other findings include
pleural effusions and pleural thickening.
Alternative causes of a raised hemidiaphragm include phrenic nerve palsy,
contralateral cerebrovascular accident, atelectasis, pneumonectomy, lobectomy,
and sub-diaphragmatic pathologies such as tumors, hepatomegaly, and subphrenic
abscess.
Investigations such as contrast CT of the chest and transthoracic echocardiography
are commonly arranged to exclude competing differential diagnoses such as
interstitial lung disease, diffuse alveolar hemorrhage, lupus pneumonitis, and
pulmonary hypertension.
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Research Concepts:
Shrinking Lung Syndrome

Question 351: A 24-year-old woman presents with a five-month history of excessive

daytime sleepiness. She denies snoring, gasping for air at night, morning headaches, or
difficulty initiating or maintaining sleep. She is in graduate school and works from 6 p.m.
till midnight. She goes to bed at 1:00 AM and wakes up at 6:00 AM with an alarm for
school. She has been finding herself dozing off in class frequently. On the weekends, she
can sleep for seven to eight hours and feels significantly less sleepy during the day. She
denies cataplexy, hypnagogic or hypnopompic hallucinations. She has no significant past
medical history and does not take any medication.
She does not smoke cigarettes, drinks alcohol at social events, and denies substance use.
Her vital signs are within normal range, and the physical exam is unremarkable.
Polysomnography (PSG) is done to evaluate for sleep-disordered breathing. Given the
likely diagnosis, the PSG is expected to show which of the following?

Choices:

1. Prolonged sleep latency, reduced sleep efficiency, and increased stage N3 sleep
2. Short sleep latency, reduced sleep efficiency, and reduced stage N3 sleep
3. Short sleep latency, increased sleep efficiency, and increased stage N3 sleep
4. Prolonged sleep latency, increased sleep efficiency, and reduced stage N3 sleep

Answer: 3 - Short sleep latency, increased sleep efficiency, and increased stage N3 sleep
Explanations:

This patient likely suffers from insufficient sleep syndrome (ISS) based on her
clinical presentation. Her estimated total sleep time is reduced for her age and is
curtailed by an alarm due to her daytime schedule. Also, she reports improvement
in symptoms after extending her sleep time. She has had daytime sleepiness for
over three months due to insufficient sleep. Her presentation is not better
explained by another sleep disorder, medical disorder, or medication or drug
effect.
A sleep study is not required to diagnose ISS. However, the study's findings may
show a short sleep latency to compensate for sleep loss.
Patients with insufficient sleep may show an increased sleep efficiency to compensate
for chronic sleep deprivation.
Another finding on the polysomnogram of patients with chronic insufficient sleep is
increased stage N3 sleep, also referred to as stage N3 rebound. Stage N3 is the
slow-wave, restorative part of sleep and increases in patients with insufficient
Page 335 of 955
 sleep.

Research Concepts: Sleep Insufficiency

Question 352: A 55-year-old piping insulation worker from Bangladesh presents to the
clinic with five months of difficulty breathing and chest pain. He says that these symptoms
are associated with fatigue and lethargy. He also has an unrelenting cough, which started
as a dry cough, progressed to productive cough, and now even has streaks of blood in it.
He works as a plumber and has been insulating leaky pipes for the past 35 years and has
never had any such complaint before this. He has a history of smoking one pack of
cigarettes for the past 35 years. However, he has never had alcohol before. He also has a
collection of parrots and pigeons at his home, which he cares for in his free time. On
examination, breath sounds are decreased on the left lower lobe of the lung. Percussion
note is dull, and vocal fremitus is reduced. X- ray imaging of the left lung shows blunting
of the costophrenic angle along with small areas of calcifications on the margins of the
lung. A diagnosis of occupational disease is made. Which of the following is the most likely
culprit for his presentation?

Choices:

1. Arsenic
2. Lead
3. Asbestos
4. Bird feces

Answer: 3 - Asbestos

Explanations:

Pleural mesothelioma is the most likely cause of this patient's presentation.

Pleural mesotheliomas are caused by exposure to asbestos. It has a very rapid
downhill course and is usually seen in middle- aged men.
While exposure to asbestosis is the leading risk factor, other cases have been linked
to radiation, talc, or mica exposure. In this patient, occupational exposure to
asbestos can be expected due to his line of work.
Bird feces, lead, and arsenic isn't linked to developing malignant mesothelioma.

Research Concepts:

Malignant Mesothelioma
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Question 353: An 84-year-old man with a past medical history of type 2 diabetes mellitus,
hyperlipidemia, hypertension, and coronary artery disease presents to the hospital with
complaints of fever, cough, and new-onset shortness of breath for the past three days.
Admission vitals are temperature 39°C (102.3°F), heart rate 98/min, blood pressure 90/60
mmHg, and oxygen saturation 94% on room air. Initial routine laboratory investigation
shows severe leukopenia, metabolic acidosis, and significantly elevated serum lactate of
3.8 mg/dL (reference range: 0.5 to 2.2 mg/dL). D-Dimer is 120 ng/mL (reference range: 0
to 243 ng/mL). ALT and AST are 200 IU/L and 158 IU/L, respectively. A chest x-ray shows
bilateral multifocal opacities. The patient is given IV fluids and empiric antibiotics. His
clinical condition deteriorates with respiratory decompensation, and he is placed on
mechanical ventilation. SARS CoV-2 PCR test is positive. What is the most appropriate
treatment for this patient?

Choices:

1. Sotrovimab
2. Dexamethasone
3. Hydroxychloroquine
4. Supportive therapy only

Answer: 2 - Dexamethasone

Explanations:

The patient described in this clinical vignette is admitted with severe/critical

COVID-19 illness. The best next step in managing this patient is to start
dexamethasone.
Severe COVID-19 illness is associated with inflammation- related lung injury driven
by cytokines, which is seen in this patient based on his chest x-ray demonstrating
bilateral lung infiltrates.
The RECOVERY trial reported that the use of dexamethasone resulted in lower 28-
day mortality in patients on invasive mechanical ventilation or oxygen support.
Sotrovimab is indicated only in non-hospitalized patients with laboratory-
confirmed SARS-CoV-2 and mild-to-moderate COVID-19 illness who are at high risk
for progressing to severe illness and/or hospitalization. Hydroxychloroquine and
chloroquine are not indicated in the management of COVID-19.
Research Concepts:Emerging Variants of SARS-CoV-2 And Novel Therapeutics
Against Coronavirus (COVID-19)

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Question 354: A 35-year-old man has been on veno-arterial ECMO for 4 days since
undergoing heart transplantation following dilated cardiomyopathy refractory to medical
management. He has a left femoral artery arterial cannula and a right femoral vein venous
cannula in place. He is receiving anticoagulation with unfractionated heparin. During sign-
out, one of the nurses notes that the arterial pressure waveform has decreased in
amplitude. The artery is confirmed to be still patent and all equipment is functional.
Which of the following is the most likely cause of this finding?

Choices:

1. Acute arterial thrombosis secondary to heparin-induced

thrombocytopenia
2. Decreased circulating levels of anti-thrombin
3. Increasing left ventricular distention due to the afterload induced by veno-arterial
ECMO
4. Left atrial thrombus formation

Answer: 3 - Increasing left ventricular distention due to the afterload induced by veno-
arterial ECMO

Explanations:

When the left femoral artery is cannulated for induction of veno- arterial ECMO, an
increase in afterload can produce left ventricular distension and failure of the left
ventricle.
When the left ventricle is distended and no longer able to overcome the afterload
produced by ECMO, the arterial waveform decreases and may flatten, which would
represent the non-pulsatile nature of ECMO.
When an arterial waveform decreases in amplitude, the first step is to check the
equipment and to ensure the artery is still patent. A left atrial thrombus may occur
if the left ventricle cannot contract strongly enough to overcome the afterload
produced by ECMO; however, it would not influence the arterial waveform.

Research Concepts:

Extracorporeal Membrane Oxygenation Anticoagulation

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Question 355: A 51-year-old female presents to the clinic for evaluation of dyspnea. She
has a past medical history of systemic sclerosis diagnosed five years ago. She reports
exertional dyspnea for the past 12 months, which has become severe over the last three
months, now occurring with minimal activity and often at rest. She reports a syncopal
episode last week when trying to get out of bed.
She is not on any medication and has not seen a healthcare provider for two years.
Physical examination reveals a blood pressure of 105/70 mmHg, a heart rate of 94 beats
per minute, and a respiratory rate of 18 breaths per minute. Her oxygen saturation is 90%
on room air at rest. Cardiovascular examination reveals a wide splitting of the second
heart sound, a holosystolic murmur of tricuspid regurgitation, and an elevated jugular
venous pulse. Her lungs are clear to auscultation. Pulmonary function testing reveals
normal lung volumes and a decreased diffusion capacity for carbon monoxide. A
ventilation-perfusion scan is normal. Right heart catheterization reveals a mean
pulmonary artery pressure of 36 mmHg with no change with inhaled nitric oxide.
Pulmonary capillary wedge pressure is normal. What is the most appropriate treatment
for this patient's condition?

Choices:

1. Bosentan monotherapy
2. Sildenafil monotherapy
3. Ambrisentan
4. Bosentan and epoprostenol

Answer: 4 - Bosentan and epoprostenol

Explanations:

This patient has scleroderma-associated pulmonary hypertension (PAH) and

presents with World Health Organization (WHO) functional class IV symptoms. She
requires PAH-directed therapy with a parenteral prostanoid-containing combination
regimen. Bosentan is indicated to improve exercise ability and decrease the
worsening of PAH in patients with connective tissue disease resulting in PAH.
Prostacyclin analogs include epoprostenol, iloprost, and treprostinil. As the longest
approved prostacyclin, epoprostenol is the preferred agent and is administered as a
continuous intravenous infusion through a central venous catheter and must be
provided by a specialty pharmacy.
Patients require instruction on the safe use of this medication as abrupt
discontinuation may have adverse outcomes.
Epoprostenol is available in two formulations, one of which is stable at room
temperature and does not degrade with exposure to light, per the drug monograph.

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 Ambrisentan plus tadalafil combination would be preferred if the patient had WHO
functional class II or III symptoms.

Research Concepts:

Scleroderma-Associated Pulmonary Arterial Hypertension: Early Detection For Better

Outcomes

Question 356: A 50-year-old woman with a history of HIV and sialolithiasis presents to the
clinic with a dry cough. Laboratory testing demonstrates the presence of anti-SSA
antibodies. Physical examination reveals dry eyes and dry mouth, with evidence of dental
caries. Which of the following findings is most likely to present on a high-resolution CT of
the chest of this patient?

Choices:

1. Thin-walled cysts and interlobular septal thickening

2. Hilar adenopathy
3. Enlarged main pulmonary artery
4. Unilateral pleural effusion

Answer: 1 - Thin-walled cysts and interlobular septal thickening

Explanations:

Sjogren syndrome is an autoimmune disease most commonly affecting middle-aged

women and is characterized by T-cell infiltration of various organs, most often the
lacrimal and salivary glands.
Sjogren syndrome typically presents with lymphocytic interstitial pneumonia,
characterized by diffuse interstitial infiltration of lymphoplasma cells.
Lymphocytic interstitial pneumonia is characterized by diffuse ground-glass
opacities with thin-walled central or perivascular cysts. There may be
centrilobular nodules, bronchovascular bundle thickening, and interlobular
septal thickening.
In Sjogren syndrome, the most common findings on CT are bronchiectasis and
centrilobular nodular or branching linear hyperattenuating areas, ground-glass
opacities, and honeycombing.

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Research Concepts:

Collagen-Vascular Disease Associated With Interstitial Lung

Question 357: A 57-year-old male with a past medical history of chronic rhinorrhea, nasal
itching, and sneezing undergoes pulmonary function testing to evaluate the cause of his
symptoms.
He currently does not have any shortness of breath. He has no other past medical history.
He reports smoking one pack of cigarettes daily for the past two years. Pulmonary
function testing revealed a mild obstructive pattern with a 2% improvement in forced vital
capacity after bronchodilation. Total lung capacity and residual volume are within normal
limits. Allergen-specific serum immunoglobulin E levels are elevated. What is the most
likely diagnosis?

Choices:

1. Allergic asthma
2. Allergic rhinitis
3. Chronic obstructive pulmonary disease
4. Restrictive lung disease

Answer: 2 - Allergic rhinitis

Explanations:

The patient presents with rhinitis symptoms without evidence of asthma on

pulmonary function testing.
Asthma is diagnosed with pulmonary function testing demonstrating the obstructive
pattern. An increase in forced vital capacity forces expiratory volume in 1 second or
greater than 12% and 200 ml after bronchodilation.
Allergen-specific elevation of serum immunoglobulin E levels strengthens the
diagnosis.
Although an obstructive pattern can be due to chronic obstructive pulmonary
disease, the patient has no symptoms of the disease and has normal lung capacity
and residual volumes. Moreover, a 2-pack-year smoking history is unlikely to yield
chronic obstructive pulmonary disease.

Research Concepts:
Immunoglobulin E

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Question 358: A 64-year old comes to your office for a follow-up evaluation. The patient
recently underwent lung volume reduction surgery. He states he is feeling well and can
walk more than before the procedure. Which of the following tests could help you more
objectively assess the patient's reported improvement in exercise tolerance after the
procedure?

Choices:

1. Pulmonary function test

2. Computerized tomography of the chest
3. Echocardiogram
4. Six-minute walk test

Answer: 4 - Six-minute walk test

Explanations:

The primary indication for the six-minute walk test is for evaluating the response
to treatment in patients with moderate or severe cardiac or pulmonary disease.
After lung volume reduction surgery, patients with COPD show an increase in their
six-minute walking distance.
In contrast, patients on bronchodilator therapy alone do not show an
improvement in six-minute walking distance. This response is not different
from that observed with a placebo. Six-minute walking distance also
improves with pulmonary rehabilitation.
Research Concepts:Six Minute Walk Test

Question 359: A 43-year-old male with a history of hypertension and diabetes mellitus
presents to the emergency department with three months of worsening progressive
shortness of breath. He has never smoked and reports no family history of lung cancer.
Current medications are hydrochlorothiazide 25 mg daily and amlodipine 5 mg daily. His
vital signs include a temperature of 98°F (36.7°C) orally, blood pressure of 140/88 mmHg,
a heart rate of 95 beats per minute, a respiratory rate of 22 breaths per minute, and
oxygen saturation of 88% on room air. Physical examination reveals an obese male with
bilateral crackles at the bases of both lungs. The patient is placed on oxygen, and a
computed tomography (CT) scan of his chest with contrast was performed, which
demonstrated a 10 mm solid homogenous nodule in the left upper lobe. Bilateral
interstitial edema and trace pleural effusions are also noted.
Echocardiography reveals heart failure with reduced ejection fraction. What is the most
appropriate next step in the management of this patient's pulmonary nodule?

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Choices:

1. Surgical wedge resection

2. Repeat CT scan in three months
3. Repeat CT scan in twelve months
4. Perform a percutaneous needle biopsy of the nodule

Answer: 2 - Repeat CT scan in three months

Explanations:

A pulmonary nodule is a well-defined lesion that is surrounded by pulmonary

parenchyma and is less than 30 mm. Pulmonary nodules can be benign or
malignant. Although this patient presents with shortness of breath, he has a clear
alternate etiology of his hypoxia.
The size of the nodule is a predictor of malignancy. Data from retrospective studies
show that, when assessed on a CT scan, nodules less than 5 mm have a less than 1%
chance of being malignant. Nodules that are 5 to 9 mm have a 2% to 6% chance of
being malignant. Nodules that are 10 to 20 mm have an 18% chance of being
malignant, and nodules that are greater than 20 mm have a greater than 50%
chance of being malignant.
The presence of fat or calcification on the border of the nodule is a reliable indicator
of a benign pulmonary nodule.
Patients with nodules larger than 8 mm should be further evaluated for cancer. A
nodule that has a low probability of being malignant should be followed with a CT
scan after three months. A nodule that has a high risk of being malignant should be
evaluated with a positron emission tomography (PET) scan, with or without a
biopsy. This patient is relatively young and has no risk factors or family history of
lung cancer and thus has a low probability of lung cancer. He should be followed
up with a CT scan in three months.

Research Concepts:
Solitary Pulmonary Nodule

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Question 360: A 65-year-old male with a 50-pack-year history of smoking is diagnosed
with stage IIIa adenocarcinoma of the lung, with a centrally located tumor of the right
upper lobe. After undergoing induction chemotherapy and radiation with a partial
response, the patient receives a right upper lobe pulmonary sleeve resection. Three days
later, his right chest tube demonstrates an air leak. The patient has a fever, tachypnea,
and tachycardia. A CT chest demonstrates a large anastomotic defect at the bronchus,
extraluminal air surrounding the anastomosis, and small right pleural effusion with a right
pleural chest tube. What is the definitive treatment for this patient's postoperative
complication?

Choices:

1. Immediate bronchoscopic stent placement

2. Completion pneumonectomy
3. Revision of the bronchial artery
4. Bronchoscopic application of fibrin glue

Answer: 2 - Completion pneumonectomy

Explanations:

Anastomotic dehiscence after pulmonary sleeve resection can occur in up to 6% of

patients postoperatively. One of the potential risk factors is due to technical errors
such as de- vascularizing the bronchial blood supply or too much tension on the
anastomosis.
Bronchoscopy, with direct visualization of the anastomotic defect, can diagnose
anastomotic dehiscence or leak after pulmonary sleeve resection. CT findings such
as a defect in the bronchial wall and extraluminal air surrounding the anastomosis
are also highly sensitive.
If the dehiscence is small, conservative management with the placement of drains
and antibiotics may be used for treatment. Large anastomotic bronchial dehiscence
is a serious complication because revision can be challenging. Definitive treatment
is reoperation and completion pneumonectomy.

Research Concepts:

Pulmonary Sleeve Resection

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Question 361: An 18-year-old male presents to the emergency department with a history
of progressive dyspnea, cough, nausea, and abdominal discomfort for the last month.
Physical examination is significant for gynecomastia and small-sized bilateral testicles. A
chest x-ray reveals an anterior mediastinal mass extending into the right hemithorax.
Levels of alpha-fetoprotein and beta-human chorionic gonadotropin are elevated. What
genetic condition should be screened for in this patient?

Choices:

1. McArdle disease
2. Turner syndrome
3. Klinefelter syndrome
4. Kartagener syndrome

Answer: 3 - Klinefelter syndrome

Explanations:

Mediastinal mass with elevated alpha-fetoprotein and beta- human chorionic

gonadotropin issues a concern for mediastinal germ cell tumors.
Mediastinal germ cell tumors can present with chest pain, cough, dyspnea, fever,
night sweats, and weight loss.
There is an association with mediastinal germ cell tumors and Klinefelter syndrome.
Cytogenic analysis should be performed on all patients with mediastinal germ cell
tumors.
Research Concepts:

Mediastinal Germ Cell Tumors

Question 362: A 65-year-old male with a past medical history of alcohol use disorder
presents to the emergency department with fever, productive cough, and shortness of
breath. He reports fever has been present for at least 2 weeks with subsequent cough and
progressive shortness of breath. The cough recently became productive of foul-smelling
sputum. On clinical examination, he is febrile and tachypneic, but not hypotensive. His
oxygen saturation on room air is 92%. He is pale, poorly nourished, and has very poor
dental hygiene. The lung exam shows dullness over the right base with rales bilaterally. A
chest radiograph shows a right-middle lobe air-fluid level. Which of the following is the
most likely cause of his current presentation?

Choices:

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1. Klebsiella pneumoniae
2. Peptostreptococcus spp
3. Mycobacterium tuberculosis
4. Streptococcus pneumoniae

Answer: 2 - Peptostreptococcus spp

Explanations:

Anaerobes are the most common cause of lung abscesses and frequently occur as a
consequence of aspiration pneumonia.
The major pathogens known to occur in the oral flora and cause lung abscesses are
Peptostreptococcus spp, Bacteroides melaninogenicus, and Fusobacterium
nucleatum.
Lung abscesses secondary to an anaerobic infection frequently present with an
indolent course and show relatively slow progression.
Risk factors for lung abscess formation include alcohol use disorder, seizures, and poor
oral hygiene. Disorders leading to ineffective gag reflex/aspiration also increase the
risk of this disease.
Klebsiella pneumoniae can cause lung abscesses, especially in patients with
immunocompromised status, however, it is less frequent than anaerobes.
Research Concepts:

Lung Abscess

Question 363: A 44-year-old man presents to the emergency department for abdominal
pain. He is found to have acute appendicitis and undergoes laparoscopic appendectomy.
On postoperative day 2, the patient suddenly develops shortness of breath and cough
with bloody sputum, and his medical records note that he has a 10-pack-year history of
smoking. His temperature is 38 C (100.4 F), blood pressure 140/80 mmHg, heart rate
110/min, respiratory rate 25/min, and oxygen saturation 91% on room air. He weighs 100
kg, and his body mass index is 40 kg/m2. On examination, he appears anxious, the
trachea is midline, and he is tachycardic with no murmur or rubs. Lung auscultation
demonstrates diminished breath sounds bilaterally. The abdomen is soft, and the surgical
dressing is noted on the lower part of the abdomen. CBC and basic metabolic profile are
normal. The left calf is swollen, red, and tender. What is the best next step in
management for this patient?

Choices:

1. D-dimer
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2. Doppler ultrasound
3. CT pulmonary angiography
4. Ventilation-perfusion (VQ) scan

Answer: 3 - CT pulmonary angiography

Explanations:

This patient has multiple risk factors for deep vein thrombosis and pulmonary
embolism (PE).
With his high probability of acute PE (Wells score greater than 6), CT pulmonary
angiography is the best next step.
If CT angiography was not feasible, a ventilation-perfusion (VQ) scan would be the
best next modality to confirm PE in this patient.
D-dimer test is recommended for patients with low- intermediate probability of PE
(Wells score 2 to 4) but not for patients with high probability, like this patient.

Research Concepts:

Acute Pulmonary Embolism

Question 364: A 65-year-old male presents with complaints of fever and chest pain for
three days. He also reports a productive cough for the last two weeks. He denies any
night sweats, weight loss, dyspnea, swelling of the legs, headache, or any skin rashes. He
has had a history of alcohol use disorder for the last 20 years. He does not smoke. On
examination, his temperature is 101°F (38.3°C), his heart rate is 98 beats per minute, and
his oxygen saturation is 95% on room air. Chest auscultation reveals bilateral crackles.
Abdominal and neurological examinations are normal. His electrocardiogram is normal.
Chest x-ray shows multiple consolidations bilaterally. His interferon-gamma (IFN-γ)
release assay is negative. Sputum examination shows the growth of a gram- positive and
partially acid-fast organism. What is the most appropriate treatment for this patient?

Choices:

1. Rifampin plus isoniazid

2. Amoxicillin plus dapsone
3. Trimethoprim-sulfamethoxazole (TMP-SMX)
4. TMP-SMX plus amikacin

Answer: 3 - Trimethoprim-sulfamethoxazole (TMP-SMX)

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 Explanations:

This patient's presentation is most consistent with pulmonary nocardiosis. Nocardia

species are positive for the modified acid- fast stain.
Trimethoprim-sulfamethoxazole is the first-line agent for the treatment of mild to
moderate pulmonary nocardiosis.
Nocardia asteroides are typically regarded as an opportunistic infection.
Nocardia can also affect other organs like skin, brain, and lymph nodes. In patients
with limited disease, TMP-SMX monotherapy is sufficient. In severe or disseminated
cases without central nervous system involvement, TMP-SMX plus amikacin is
recommended.

Research Concepts:

Nocardiosis

Question 365: A 50-year-old man with hypertension presents with snoring, frequent
fatigue, general sleepiness, and an inability to focus during tasks. He wakes up frequently
during the night, and his wife reports that he gasps for air and verbalizes during sleep. His
pulse is 89/minute, blood pressure 159/80 mmHg, oxygen saturation 93% on room air,
body mass index 40 kg/m², and neck circumference of 40 cm. An oropharyngeal exam
demonstrates a crowded oropharynx, enlarged tonsils to 2+ bilaterally, and macroglossia.
The lower extremities have 2+ edema, and the rest of the exam is within normal limits. A
home sleep apnea test shows a 41 events/hour respiratory event index. Which of the
following metabolic findings is most likely in this patient?

Choices:

1. Decreased insulin resistance

2. Decreased plasma ghrelin
3. Increased plasma leptin
4. Increased insulin-like growth factor-1
Answer: 3 - Increased plasma leptin

Explanations:

This patient most likely has obstructive sleep apnea (OSA) due to obesity. During
the night, he has intermittent cessation of airflow of the nose and mouth due to
Page 348 of 955
 upper airway obstruction. During this intermittent upper airway collapse, he briefly
arouses, restores airway patency, and falls back to sleep. These respiratory events
can lead to intermittent hypoxia (IH).
Leptin levels can increase in response to IH. Most studies have shown that plasma
leptin levels are increased in patients with OSA compared to those without OSA.
The relationship between apnea-hypopnea index (AHI) and leptin is independent of
BMI. This patient likely has increased insulin resistance and leptin levels, which do
not change quickly with OSA treatment. Leptin is a hormone that regulates
metabolism and influences appetite. There is evidence that patients with OSA have
lower insulin-like growth factor-1, which is predictive of diabetes risk.
Baseline plasma levels of ghrelin are significantly higher in patients with OSA than in
controls. After a few days of CPAP treatment, plasma ghrelin decreased in almost all
OSA patients; however, it takes longer for leptin to decrease.

Research Concepts:
Obstructive Sleep Apnea

Question 366: A 52-year-old woman presents for evaluation of unintentional weight loss
over the past year (26 lbs or 11.8 kg) and a cough for the past three months. She has had
three courses of different antibiotics and oral corticosteroids with no improvement.
She admits to a 25 pack-year history of smoking cigarettes and reports occasional
marijuana use. Contrast-enhanced CT of the chest shows a 5.2 cm mass in the left upper
lobe and mediastinal lymphadenopathy. A positron emission tomography (PET) scan
demonstrates uptake in the left upper lobe mass at stations 7 and
10. There is an area of uptake in her spleen as well. What is the TNM stage of this
patient's cancer?

Choices:

1. T2N2bM1b
2. T3N1M0
3. T3N1bM1c
4. T3N2a2M1b

Answer: 4 - T3N2a2M1b

Explanations:

There have been significant changes made in the 8th edition of the TNM
Page 349 of 955
 classification. Tumors greater than 5 cm but smaller than 7 cm are considered T3
rather than T2b.
Hilar or intrapulmonary lymph nodes (N1 nodes) are further classified into subgroups.
If only a single hilar or intrapulmonary node is positive, then it is classified as N1.
Multiple nodal involvement is classified as N1b.
Mediastinal lymph nodes (N2 nodes) are divided into subgroups based on their
involvement as well as N1 nodal involvement.
N2a1 is a single N2 station without concurrent N1 involvement, i.e., skip
metastasis. N2a2 describes a single N2 station with concurrent N1 involvement
irrespective of the number of N1 nodes involved. N2b indicates multiple N2 nodes
are involved. Metastasis is classified as M0, M1a, M1b, and M1c. M0 means no
metastasis. M1a is a tumor with separate nodules in the contralateral lobe, pleural
or pericardial nodules, or malignant pleural or pericardial effusion. M1b is a single
metastatic lesion outside the thoracic cavity. M1c is multiple extrathoracic
metastatic lesions either in a single organ or multiple organs.

Research Concepts: Lung Cancer

Question 367: Which part of the respiratory system is mainly involved in cystic fibrosis
causing excess production of viscous mucus?

Choices:

1. Trachea
2. Primary bronchioles
3. Secondary bronchioles
4. Terminal bronchioles

Answer: 4 - Terminal bronchioles

Explanations:

Cystic fibrosis affects mainly the terminal bronchioles.

It is an autosomal recessive condition with mutation of cystic fibrosis transmembrane
conductance regulator (CFTR) on chromosome 7, band q31.
Several different mutations have been found with varying impairment of chloride
mucosal transport.
It also affects other parts of the body including the pancreas, liver, and heart.

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Research Concepts:

Cystic Fibrosis

Question 368: A 28-year-old woman presents with a six-month history of worsening

dyspnea, cough, and lower extremity edema. Her blood pressure is 160/95 mmHg, pulse
rate 100/min, respiratory rate 36/min, temperature 98.6 F (37 C), and oxygen saturation
75% on room air. Examination demonstrates bilateral pedal edema and crepitations in
both lungs on chest auscultation. An echocardiogram shows decreased right ventricular
function and a pulmonary artery pressure of 50 mmHg. On further questioning, the
patient states her mother had the same symptoms in her thirties and died at a young
age. Genetic testing of the patient reveals a mutation in the BMPR2 gene. She is
prescribed bosentan and a prostaglandin analog. She presents two months later with
minimal improvement in her symptoms. On examination, there are decreased breath
sounds in the right lung. After a detailed evaluation, the patient undergoes a lung
transplant and is started on cyclosporine postoperatively. She presents again two weeks
later with white patches on her tongue that are easily scraped off. Laboratory analysis
reveals a raised serum creatinine level. Given the likely diagnosis, what is the most
appropriate treatment for this patient's oral condition?
Choices:

1. Furosemide
2. Voriconazole
3. Sulfamethoxazole
4. Regular mouthwash
Answer: 2 – Voriconazole
Explanations:

The raised serum creatinine level in this patient indicates cyclosporine-induced

nephrotoxicity. She has also developed oral candidiasis, for which voriconazole
is appropriate.
Voriconazole inhibits cytochrome P450. Therefore, cyclosporine is not metabolized,
and prolonged levels persist with smaller dosages. Cyclosporine doses will have to
be decreased.
Cyclosporine drug levels must be monitored. Before starting cyclosporine, it is
mandatory that one look at all the medications the patient is taking to make sure
that the risk of drug interactions is minimal.
Furosemide is a loop diuretic. Sulfamethoxazole is a sulfur antibiotic used to
prevent Pneumocystis jirovecii pneumonia in immunocompromised transplant
patients. Regular mouthwash does not prevent oral candidiasis, especially in

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 transplant patients. Oral nystatin is often prescribed for the first six months for the
patient to use daily.

Research Concepts:Lung Transplantation

Question 369: A 24-year-old male presents for the evaluation of shortness of breath. He
has been having this problem for two weeks along with a cough that occurs mostly at
night. He does not complain of fever, runny nose, or swelling of the legs. He went to India
one month ago on vacation. Chest examination shows wheezing in both lung fields.
Complete blood count shows a high eosinophil count.
Chest x-ray is done which shows reticulonodular opacities on the right lung. Which of the
following are the earliest histopathological changes seen in the lung of patients affected
with this disease?

Choices:

1. Eosinophilic interstitial infiltration

2. Lymphocyte infiltration
3. Histiocyte infiltration
4. Fibrosis of the lung

Answer: 3 - Histiocyte infiltration

Explanations:

The earliest histopathological finding in a patient with tropical pulmonary

eosinophilia (TPE) is histiocyte infiltration. Patients with travel to a filarial endemic
region with symptoms of nocturnal cough, dyspnea, and increased eosinophil
count on blood workup along with reticulonodular opacities in the lung, likely have
TPE.
Histiocyte infiltration leads to symptoms like nocturnal cough, dyspnea, and wheezing.
TPE is a syndrome resulting from a hyper-immune response to microfilariae trapped in
the lungs.
Histiocyte infiltration is followed by eosinophilic interstitial infiltration which is
followed by pulmonary fibrosis in the long term if left untreated.

Research Concepts:

Tropical Pulmonary Eosinophilia

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Question 370: A 16-year-old male patient is brought in by his parents with complaints of
persistent cough for one week and excessive use of his inhaler. Previously, he had been
well on a fluticasone/salmeterol inhaler and montelukast daily. His parents are concerned
that he may not have taken his medication. On examination, his respiratory rate is 32
breaths per minute, his peak expiratory flow rate (PEFR) is 235 L per minute (predicted:
590 L per minute), and his oxygen saturation is 89%. He is started on oxygen therapy,
albuterol and ipratropium bromide nebulizer every 4 hours, and intravenous (IV)
hydrocortisone. Later in the evening, he is found to have pO2 of 57 mmHg, pCO2 of 44
mmHg, pH of 7.36, respiratory rate of 15 breaths per minute, and PEFR of 230 L per
minute. What is the most appropriate next step in the management of this patient?

Choices:

1. Oral aminophylline
2. Mechanical ventilation
3. IV albuterol
4. Back-to-back albuterol nebulization

Answer: 2 - Mechanical ventilation

Explanations:

If a patient has received multiple doses of an inhaled bronchodilator and shows no

response, the factors that should be used to determine mechanical ventilation are
the severity of airflow obstruction, duration of asthma, response to medications,
and impending respiratory failure due to fatigue. The most appropriate next step, in
this case, would be to involve the ICU team and consider mechanical ventilation.
Despite management, his peak expiratory flow rate has declined further, and he is
making less respiratory effort now, which may be indicative of impending
respiratory failure.
There is evidence of hypoxemia with hypercapnia on arterial blood gases, which
should be taken as an indication to include the ICU team.
Mortality is higher when the ICU team is involved late in patients with severe
asthma exacerbations.

Research Concepts:

Asthma

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Question 371: A 43-year-old woman presents to a clinic at 5280 feet elevation for bilateral
fingertip tingling. She lives in a coastal city and is in the mountains for a research project.
The patient has no past medical history, takes no medication, and is a vegetarian. She
denies nausea, vomiting, chest discomfort, and shortness of breath. Neurologic exam
shows intact sensation to pin-prick, temperature, 2- point discrimination, position sense,
and vibratory sense. Gait, deep tendon reflexes, finger-to-nose, tandem gait, and heal-to-
toe walking are all within normal limits. Which of the following is the best initial step in
the management of this patient?

Choices:

1. Electromyography
2. B12 level
3. Acetazolamide
4. Reassurance

Answer: 4 - Reassurance

Explanations:

The patient is most likely hyperventilating in response to decreased atmospheric

pressure.
The patient increases her respiratory rate but decreases her pCO2, creating a
respiratory alkalosis with subsequent dissociation of protein-bound calcium to ionized
calcium.
Increased ionized calcium then causes the sensation of tingling in the fingertips.
Therefore, no treatment is required rather the patient should be reassured.

Research Concepts:

High Altitude Pulmonary Edema

Question 372: A 40-year-old man with a history of polyarthralgia presents to the clinic with
dry cough and dyspnea for several days.
Physical examination is remarkable only for bilateral basal crackles on pulmonary
auscultation. Laboratory testing demonstrates a positive ANA titer and elevated C-reactive
protein. Which is the most likely abnormality to be seen on high-resolution computed
tomography of the chest in this patient?

Choices:

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1. Consolidation
2. Ground glass opacities
3. Honeycombing
4. Bronchiectasis

Answer: 2 - Ground glass opacities

Explanations:

Ground glass opacification is a feature of usual interstitial pneumonia (UIP),

nonspecific interstitial pneumonia (NSIP), cryptogenic organizing pneumonia
(COP), diffuse alveolar damage (DAD), and lymphocytic interstitial pneumonia (LIP).
Usual interstitial pneumonia and nonspecific interstitial pneumonia are commonly
seen in patients with rheumatoid arthritis.
Computed tomography patterns in rheumatoid arthritis include subpleural
reticulation or ground-glass opacities with or without honeycombing, centrilobular
branching structures with or without bronchial dilatation or traction bronchiectasis,
and consolidation. The reticular pattern predominates in early disease, whereas
honeycombing and consolidation typically appear in progressive disease.
In nonspecific interstitial pneumonia, there are bilateral and symmetric ground-glass
opacities and subpleural reticulation, occasionally with microcystic honeycombing,
with subpleural sparing.
Usual interstitial pneumonia may be indistinguishable from nonspecific interstitial
pneumonia, with ground glass opacities and subpleural reticulation in an
apicobasal gradient.
Consolidation and honeycombing, however, are more common in usual interstitial
pneumonia.

Research Concepts: Collagen-Vascular Disease Associated With Interstitial Lung

Question 373: A 65-year-old man with a long-standing history of alcohol intake and
hypertension is brought to the emergency department with a history of sudden onset
headache followed by collapse two hours back. On examination, his pulse rate is
84/minute, blood pressure 184/116 mmHg, respiratory rate 16/minute, and oxygen
saturation is 97%. His airway is clear, and air entry is bilaterally equal in all lung fields. His
Glasgow coma scale (GCS) score is E3V4M6, and pupils are bilaterally 3 mm in size and
react to light. He has terminal neck stiffness. A computed tomogram scan of his brain is
showing diffuse subarachnoid hemorrhage involving the basal cisterns. He was admitted
to the neurosurgery intensive care unit and planned for a cerebral angiogram. Two hours
later, the patient developed tachypnea (respiratory rate of 28/minute), GCS score, and
pupils remaining the same. Within 2 minutes, his saturation drops down to 80%, and he
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 has to be intubated and ventilated. On chest auscultation, there are bilateral basal
crackles. Blood-stained frothy sputum is coming up in the endotracheal tube. A chest X-
ray shows bilateral hyperdense infiltrates in the lung parenchyma. The stimulation of
which of the following trigger centers projecting to the spinal cord is likely to be the
cause of his clinical deterioration?

Choices:

1. Area A1
2. Area A3
3. Area A5
4. Area A7

Answer: 3 - Area A5

Explanations:

The patient has the diagnosis of neurogenic pulmonary edema (NPE) secondary to
subarachnoid hemorrhage.
The exact source of sympathetic outflow is not yet identified. Some trigger zones
that have been identified for NPE include the hypothalamus and the medulla (areas
A1 and A5, the nucleus of the solitary tract, and the area postrema).
Area A1 is situated in the ventrolateral aspect of the medulla and projects into the
hypothalamus.
Area A5 is located in the upper portion of the medulla and projects into the
preganglionic centers for spinal cord sympathetic outflow.

Research Concepts: Neurogenic Pulmonary Edema

Question 374: A 25-year-old man presents to the emergency department with shortness
of breath, productive cough, and fever. The patient has a past medical history of cystic
fibrosis. The patient states that his condition has worsened over the past two months. On
examination, there are decreased breath sounds and crepitations in the right lung. A high-
resolution CT scan (HRCT) of the chest shows mucus plugging in the bronchi,
bronchiectasis, and a mosaic attenuation pattern. The patient has been prescribed
multiple antibiotics over the last year. A right lung transplant is planned for the patient.
The patient undergoes an uncomplicated lung transplant. On the fifth postoperative day,
the patient complains of increasing shortness of breath. The patient's oxygen saturation is
falling despite oxygen supplementation. Which of the following should be administered
immediately to this patient?

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Choices:

1. Methotrexate followed by azathioprine

2. High dose steroids
3. Anti-lymphocytic serum
4. Intravenous ipratropium

Answer: 2 - High dose steroids

Explanations:

This patient has most likely developed an acute lung transplant rejection. Acute
lung rejection tends to occur within the first 4 months after a transplant. The
patient may be entirely asymptomatic or present with dyspnea, fever, decreased
forced expiratory volume in one second (FEV1), or opacities in the lung.
Most patients respond to corticosteroids during the first rejection.
Persistent rejection can be treated with cytolytic therapy. There is a
dramatic improvement in 6 to 12 hours.
The standard treatment is pulse intravenous methylprednisolone followed by high oral
prednisone.
Once the rejection is treated, patients need to be started on maintenance therapy.

Research Concepts:

Lung Transplant Rejection

Question 375: A 32-year-old patient with a recent diagnosis of tuberculosis presents to

the clinic for an antenatal visit at 18 weeks gestation. The ultrasound findings are within
normal limits. She is taking isoniazid and ethambutol. What will be the advice that should
be given by the attending clinician to the mother regarding these drugs?

Choices:

1. She should switch the isoniazid to streptomycin

2. She should switch the ethambutol to levofloxacin
3. She should switch the isoniazid to pyrazinamide
4. She should continue the same drugs as they are relatively safe
Answer: 4 - She should continue the same drugs as they are relatively safe

Explanations:

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 Drugs like isoniazid and ethambutol can cross the placenta, but they are not
teratogenic and relatively safe, so women should continue taking them.
The mother should also be advised that there are lesser chances of transplacental
transmission of bacteria through the placenta, and most cases of transmission
occur after birth.
However, if the child born is born, and mother who still has active tuberculosis
should avoid contact until she is treated. Drugs like streptomycin, amikacin, and
kanamycin are contraindicated in pregnancy.
Research Concepts:

Tuberculosis

Question 376: A 16-year-old girl presents with breathing problems. Her mother states
that the patient has had trouble breathing for the past hour and has been coughing and
wheezing. The patient has a history of refractory asthma. Medications include albuterol,
fluticasone, salmeterol, and prednisone. The patient is given oxygen, albuterol,
ipratropium, and prednisone with minimal improvement. The patient’s peak expiratory
flow rate is less than 50% expected and PaCO2 is 45 mmHg. What should be the next
step in the management of this patient?

Choices:

1. Extracorporeal membrane oxygenation (ECMO)

2. Intravenous enflurane
3. Intravenous magnesium sulfate
4. Erythromycin

Answer: 3 - Intravenous magnesium sulfate

Explanations:

Initial treatment of refractory acute asthma is oxygen, albuterol and ipratropium

nebulizers, and corticosteroids. If there is no improvement, escalation with
intravenous magnesium sulfate is required.
Prolonged acute asthma may lead to tiredness, causing type 2 respiratory failure
and the need for intubation and mechanical ventilation.
These patients are best managed in the ICU.
If all those efforts fail, they may be given inhaled anesthetics and placed on
ECMO. Antibiotics do not help in acute asthma.

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Research Concepts:

Status Asthmaticus

Question 377: A 55-year-old female is brought to the emergency department by her

husband for complaints of fever, headache, weakness, and two episodes of falls over the
past two weeks with worsening confusion over one week. Medical history is notable for a
diagnosis of hypertension, diabetes, and Crohn's disease, being treated with azathioprine.
On examination, her temperature is 101 F (38.3 C), the pulse is 98 beats/minute, and the
oxygen saturation is 95% on room air. She does have neck stiffness and photophobia.
She is awake but oriented only to person. CT brain shows a space- occupying lesion in
the left parietal lobe suspicious for intracerebral abscess. CT chest shows multiple
nodular lesions in bilateral lung fields with cavitation. Sputum examination shows the
growth of a gram-positive and partially acid-fast organism. She is started on
antimicrobial therapy and starts to respond within a week. What should be the
appropriate duration of antimicrobial therapy?

Choices:

1. 14 days after resolution of fever

2. 3 months after resolution of fever and mental status changes
3. 6 months after sputum culture negativity
4. 1 year or longer based on brain imaging after a year

Answer: 4 - 1 year or longer based on brain imaging after a year

Explanations:

Disseminated nocardial infection in the brain is notorious for relapses with inadequate
antimicrobial therapy, particularly in immunosuppressed individuals.
The appropriate duration of therapy is therefore at least a year or longer based on
the resolution of the abscess and central nervous system changes in MRI brain
after a year.
Brain abscesses will require surgical intervention if the mass effect is large or if
there is no improvement after two weeks of antibiotic therapy.
A treatment duration of 6 months is sufficient for pulmonary nocardiosis without
further dissemination.

Research Concepts:Nocardiosis

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Question 378: A 50-year-old man with a history of diabetes, hypertension, and recurrent
alcoholic pancreatitis presents to the emergency department due to worsening shortness
of breath and abdominal discomfort for the past week. Vital signs include temperature
98.6 F (37 C), blood pressure 145/90 mmHg, heart rate 115/min, respiratory rate 18/min,
and SpO2 92% on 1 L/min nasal cannula. Physical examination shows a dry oral mucosa,
no murmurs on the cardiac exam, decreased breath sounds at the left hemithorax, mild
generalized abdominal tenderness, and no hepatosplenomegaly. Initial labs show sodium
130 mEq/L, potassium
3.1 mEq/L, chloride 109 mEq/L, bicarbonate 13 mEq/L, albumin 3.3 g/dL. A chest x-ray
shows a moderate left pleural effusion. The pleural fluid amylase level is 2000 U/L. CT and
magnetic resonance cholangiopancreatography (MCRP) show a fistula from the pancreas
to the left pleura cavity. Which of the following is the next best step in the management of
this patient?

Choices:

1. Nil per os (NPO), fluid replacement, and start octreotide

2. Endoscopic retrograde cholangiopancreatography
3. Surgical repair
4. Fistulography

Answer: 1 - Nil per os (NPO), fluid replacement, and start octreotide

Explanations:

Proper correction of fluids and electrolyte derangements should be addressed in a

patient with pancreatic fistula before any definitive treatment such as endoscopic
or surgical interventions.
Patients with pancreatic fistula should be kept nil per os (NPO), ideally postpyloric
feeding or temporary parenteral nutrition.
Supportive care measures are necessary to stabilize and optimize patients with
pancreatic fistula. Further control of pancreatic secretion is accomplished medically
via somatostatin analogs, such as octreotide.
Patients with pancreatic fistula need replacement of any nutritional deficiencies.
Research Concepts:

Pancreatic Fistula

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Question 379: A 38-year-old male presents with complaints of chest tightness and
frequent coughing and, at times, shortness of breath. He mentions that the symptoms
are particularly worse at the start of each week. The cough is not associated with sputum
production. Physical examination is notable for the presence of bilateral wheezing
predominantly in the lower lung fields. The patient works in the textile industry.
Pulmonary function testing reveals a decline in FEV1 to less than 80% of the predicted.
Spirometry reveals no significant increase in FEV1 post-bronchodilatory challenge. The
complete blood count is normal. Which of the following is the next best step in the
management of this patient?

Choices:

1. Diuretics
2. Bronchodilators
3. Antibiotics
4. Oxygen therapy
Answer: 2 - Bronchodilators

Explanations:

Byssinosis is a collection of respiratory symptoms elicited by exposure to raw non-

synthetic textiles during their manufacturing process. Classically, exposure to
cotton dust during the manufacturing process causes byssinosis. However,
exposure to jute, flax, and hemp fibers have been implicated in its development.
In the initial stages, symptoms manifest as frequent coughing, chest tightness,
dyspnea, and at times, wheezing, particularly within a few hours of exposure (or
reexposure) to the workplace. Hence, patients usually report symptoms towards the
beginning of their workweek and thus the term monday fever. This is in contrast to
patients with occupational asthma who experience symptoms towards the end of
their workweek.
The diagnosis is often difficult because the condition can mimic asthma and many
other pneumoconioses. Pulmonary function testing (PFT) can support suspected
byssinosis by revealing a decline in forced expiratory volume over 1 second (FEV1)
below 80% of their predicted values or a greater than 5% decline in their intrashift
FEV1. In a small proportion of the patients, physical examination was notable for
the presence of fine basilar rales. X-ray examination demonstrated the presence of
hyperlucency, diaphragm flattening, and emphysema. Diffuse,
ill-defined haziness, mainly in the lower lung fields, was also seen. The available
literature on radiological findings is limited. However, ground-glass opacities
distributed largely in a basal fashion with centrilobular nodules, on high resolution
computed tomography, have been reported.

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 Symptomatic management with short- and long-acting, inhaled beta-agonists, and
perhaps corticosteroid inhalers may be necessary. Bronchodilators may be required
for many months to improve symptoms. A short course of steroids does help those
with severe symptoms. A change in the work environment is the most appropriate
management.

Research Concepts:

Byssinosis

Question 380: A 64-year-old male with a history of diabetes and hypertension presented
with abdominal discomfort, diarrhea, flushing, and weight loss for the past 6 months.
The patient reports 4-6 episodes of bowel movements that are not associated with
intake of food. No recent ill contacts were reported. The patient then underwent
diagnostic assessments including CT imaging that showed a gastric mass, 2.2 x 3.1 cm
located in the cardia. He underwent a biopsy by endoscopy that showed a well-
differentiated neuroendocrine tumor. The patient has been evaluated by the medical
and surgical oncology and it was decided to further assess the patient with somatostatin
receptor-based imaging. What type of somatostatin receptor (SSTR) is specific for the
malignancy suspected in this patient?

Choices:

1. SSTR1
2. SSTR2
3. SSTR3
4. SSTR4

Answer: 2 - SSTR2

Explanations:

Most well-differentiated neuroendocrine tumors express higher levels of

somatostatin receptors that facilitate further assessments with somatostatin
analogs that are radiolabeled. The affinity of radiolabeled somatostatin-based
imaging such as gallium-68 dotatate is highest for subtype to somatostatin
receptors. The gastric neuroendocrine tumors express high levels of somatostatin
receptors subtype 2 (SSTR2).
The effects of somatostatin are usually mediated through 5 somatostatin receptor
family genes-SS TR 1 to assess TR 5. Few studies indicated that SST R2 was
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 associated with a favorable prognosis. T
The expression of SSTR-2 is significantly higher in gastrointestinal primaries.

Research Concepts:

Neuroendocrine Tumor Lu-177-Dotatate Therapy

Question 381: A 45-year-old man presents with fatigue, weight loss, and muscle
weakness, and double vision at the end of the day. He has a past medical history of
Hodgkin lymphoma, which was treated with mantle irradiation during childhood. He
denies any fever, night sweats, shortness of breath, or chest pain. He drinks 2 to 3 glasses
of wine per day and has a 30 pack-year smoking history. On examination, there is muscle
weakness that improves on repeated movements. A CT scan reveals a 2 x 3 cm mass in the
right lobe of the lung. Blood tests show positive antibodies against SOX1. Which of the
following interventions would have reduced the risk of this complication?

Choices:

1. Chest physiotherapy
2. Smoking cessation
3. Moderation of alcohol use
4. Albuterol inhaler use

Answer: 2 - Smoking cessation

Explanations:

The patient is presenting with secondary lung cancer years after mantle irradiation
of the chest for treatment of Hodgkin lymphoma.
Muscle weakness that improves with activity and autoantibodies against the SOX1
gene suggests Lambert-Eaton myasthenic syndrome, which is seen in lung cancers.
The risk of secondary lung cancer is increased by 20 times if associated with smoking.
Therefore, smoking cessation can reduce the risk of secondary lung malignancies in
lung cancer patients.
Alcohol use is associated with cirrhosis and subsequently, hepatocellular carcinoma. It
does not affect lung cancer risk.

Research Concepts:Adverse Effects Of Radiation Therapy

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Question 382: A 30-year-old man with a history of Hodgkin lymphoma on ABVD
(doxorubicin, bleomycin, vinblastine, dacarbazine) chemotherapy is admitted to the
hospital with fever, neutropenia, and pulmonary infiltrates. His condition does not
improve with IV cefepime. CT of the chest suggests a diagnosis of pneumonia due to
filamentous fungi. An antifungal regimen is initiated, following which the patient
develops seizures. Which drug combination most likely caused this adverse neurological
outcome?

Choices:

1. Adriamycin plus amphotericin B

2. Vincristine plus amphotericin B
3. Adriamycin plus voriconazole
4. Vinblastine plus voriconazole

Answer: 4 - Vinblastine plus voriconazole

Explanations:

ABVD protocol used in the first-line management of Hodgkin lymphoma comprises

adriamycin-doxorubicin, bleomycin, vinblastine, and dacarbazine.
CT scan findings such as consolidation, air crescent sign, and halo sign are
suggestive of fungal pneumonia and require treatment with broad-spectrum
antifungals, namely voriconazole or amphotericin B.
Vinblastine is metabolized by the cytochrome P450 family of enzymes and is also
known to be a substrate for the P- glycoprotein efflux transporter.
Voriconazole is known to inhibit the CYP 3A4 enzyme, and concomitant use with
vinblastine predisposes to neurotoxicity. Other azoles such as posaconazole and
itraconazole inhibit vincristine transport by P-glycoprotein, thus potentiating its side
effects.

Research Concepts:

Vinca Alkaloid Toxicity

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Question 383: A 65-year-old man presents to the clinic for a follow-up appointment. He
has a history of chronic obstructive pulmonary disease, for which he takes 5 mg of
prednisone every day for the past 2 years. He also uses an albuterol nebulizer as needed,
along with budesonide and salmeterol inhalers. Of late, he has been noticing increased
swelling of his legs and belly along with facial puffiness. He feels more fatigued than usual
and states that he cannot walk more than 50 m without rest. He quit smoking 20 years
ago, and he has a 30-pack-year smoking history. On examination, bilateral lower
extremity pitting pedal edema is noted, which is extending to his knees. Jugular venous
distention is noted at 30 degrees angle. Cardiac auscultation is significant for loud
pulmonic sound in the left second intercostal space. A 2D echocardiogram shows elevated
pulmonary artery pressures. Which of the following is most likely to be found on
pulmonary function testing in this patient?

Choices:

1. Severely reduced diffusion capacity

2. DLCO greater than 30% of predicted
3. Diminished lung volumes
4. FEV1/FVC greater than 1.0

Answer: 1 - Severely reduced diffusion capacity

Explanations:

Clinical features suggestive of right-sided heart failure, including fatigue, exertional

chest pain, loud pulmonic heart sound, jugular venous distension, peripheral
edema in the setting of underlying lung disease, can implicate cor pulmonale.
Pulmonary function testing in patients with pulmonary hypertension is more likely to
show a severely reduced diffusion capacity of less than 30% of predicted.
There is a rapid decline of arterial oxygenation on exercise in these patients.
Imaging like a CT scan shows an enlarged main pulmonary artery with a diameter of
more than 29 mm. FEV1/FVC is usually less than 0.7 in patients with chronic
obstructive pulmonary disease.

Research Concepts:

Cor Pulmonale

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Question 384: A 46-year-old man presents with respiratory distress. He reports difficulty
breathing and light-headedness for 20 minutes during landing after a long-distance flight.
He also states that he has idiopathic pulmonary hypertension and neglected to take his
medication earlier today. His heart rate is 103 bpm, blood pressure 124/88 mmHg,
respiratory rate 24 breaths/min, SpO2 88% on room air, and temperature 98.6 F (37 C).
Examination demonstrates cyanotic lips, tachypneic, clear lung fields on auscultation,
distended jugular veins, and a wide, persistent S2 heart sound. Which of the following
agents, if administered, would make this patient's condition worse?

Choices:

1. Aerosolized nitric oxide

2. Endothelin analog
3. Prostacyclin agonist
4. Phosphodiesterase-5 inhibitor

Answer: 2 - Endothelin analog

Explanations:

This patient has pulmonary hypertension; intrapulmonary pressures are elevated,

often due to inappropriate vasoconstriction of the pulmonary arterioles. The patient's
symptoms, therefore would worsen with agents that induce additional
vasoconstriction and would improve with agents that cause vasodilation.
Endothelin is a potent vasoconstrictor peptide that contributes to vascular
homeostasis. The peptide is typically secreted by the endothelium with the
vasculature in response to hypoxemia (low partial pressure of oxygen within the
bloodstream), toxins released by bacteria, oxidized LDL, and inflammation, such
that blood flow is shunted away from areas of the lung with poor ventilation.
Endothelin worsens pulmonary hypertension. Administration of endothelin would
cause further vasoconstriction of the lung, leading to widespread hypoxemia and
respiratory failure.
Pulmonary hypertension is exacerbated by hypoxia, or decreased oxygen levels in
the pulmonary airways, which naturally occurs at altitude due to a decreased partial
pressure of oxygen. Treatment entails the administration of prostacyclin analogs,
nitric oxide, endothelin receptor antagonists, cGMP agonists, or phosphodiesterase
inhibitors, all of which vasodilate the pulmonary arteries.
Research Concepts:Physiology, Pulmonary Vasoconstriction

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Question 385: A 47-year-old man undergoes a right pneumonectomy for uncontrolled
necrotizing pneumonia. The procedure is uneventful and without immediate
complications. However, on day three post-operatively, he develops sudden onset
breathlessness with a drop in saturation associated with tachycardia. On auscultation,
there are decreased breath sounds, and a chest x- ray reveals a massive pleural effusion
on the right side with mediastinal shift to the contralateral side. What is the most
appropriate next step in the management of this patient?

Choices:

1. Re-exploration
2. Diuretics
3. Place the patient in a propped up position at 45 degrees and give supplemental
oxygen
4. Insert a chest drainage tube

Answer: 4 - Insert a chest drainage tube

Explanations:

Post pneumonectomy is a common cause for thoracic duct injury and leak.
A patient with a mediastinal shift requires urgent decompression, and insertion of
the chest tube should be the first line of management.
Thoracic duct leak usually presents in the immediate post- operative period.
If there is no mediastinal shift, and the patient is comfortable, conservative
management with supplemental oxygen and diuretics is the most appropriate
initial strategy.

Research Concepts:

Thoracic Duct Leak

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Question 386:

A 24-year-old man presents with new onset fever, myalgias, and arthralgias. He states he
has shortness of breath but denies cough, sputum production, or chest pain. He recently
flew from South America to his home in Arizona. He has no history of hypertension and
has never had bronchial asthma. He has requested water and ice chips several times. He
feels that his heart has been "jumping out of his chest." He has smoked 2 packs per day
for 10 years. He is fully vaccinated against COVID-19. He says he is having these
symptoms each month, and they seem to occur in a pattern. He denies alcohol or drug
use. He says he works in the scrap metal business as a "cutter." Physical examination
reveals a temperature of 102 degrees Fahrenheit (39 Celsius), blood pressure of 155/70
heart rate of 114, and respiratory rate is 24. Pulse oxygen measurement is 93% on room
air. No sternocleidomastoid retraction is present. Heart: Regular tachycardia with no
murmurs, gallops, or rubs. Lungs: extensive wheezing bilaterally but moving air.
Abdomen: no mass, organomegaly, or tenderness. Bowel sounds are normal. The left
calf is 1.0 cm bigger than the right calf at the largest part of each calf but non-tender.
There are no enlarged cervical, axillary, or inguinal nodes. Which of the following
further history is most likely found in this patient?
Choices:

1. Afebrile in mornings but highest fever accompanied by shortness of breath,

myalgias, arthralgias at 6-8 pm daily
2. Febrile with myalgias, and arthralgias every 2 days with highest fever 3-4 pm
lasting until 8 pm, then no symptoms
3. Worse symptoms of fever, myalgias, and arthralgias on Fridays but asymptomatic
on Sunday
4. Worse symptoms on Mondays with fever, myalgias, arthralgias but asymptomatic on
Sundays
Answer: 4 - Worse symptoms on Mondays with fever, myalgias, arthralgias but
asymptomatic on Sundays
Explanations:

This patient is a welder who is possibly not working in an appropriately-ventilated

environment. A cutter is a type of welder using an electric arc to melt and cut metals
for demolition. This patient’s symptoms and the pattern of his symptoms are typical
of metal fume fever.
Metal fume fever occurs from the inhalation of ultra-fine particles of metals. Most
often this is due to inhalation of zinc oxide.
In metal fume fever symptoms classically are worse on Monday and Tuesday and
almost gone on Sundays.
Metal fume fever can be characterized by unusual thirst during exacerbations.

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Research Concepts:

Metal Fume Fever

Question 387: A 16-year-old patient presents to the clinic complaining of wheezing and
rhonchi. Her vital signs are unremarkable. Chest x-ray is negative for infiltrate,
consolidation, or foreign objects. What is the mechanism of action behind the next best
course of action?

Choices:

1. Inhibition of acetylcholine receptors

2. Increasing mucociliary clearance in the bronchial airways
3. Increasing cyclic AMP leading to relaxation of airway smooth muscle
4. Inhibition of cytokine release from mast cells
Answer: 3 - Increasing cyclic AMP leading to relaxation of airway smooth muscle

Explanations:

Beta-2 agonists lead to an increase in intracellular cyclic AMP which activates

protein kinase A to phosphorylate Gq-couple receptors. This ultimately leads to
the relaxation of airway smooth muscles.
Beta-2 agonists have bronchodilatory effects as well as anti- bronchoconstrictive
effects which is able to treat the wheezing. Beta-2 agonists activate beta-2
adrenergic receptors which are associated with G-coupled proteins. A signal
transduction cascade leads to increased intracellular cyclic AMP ultimately
resulting in the relaxation of airway smooth muscles.
Beta-2 agonists can have adverse side effects in the form of tachycardia, arrhythmia,
cardiotoxicity, metabolic changes, and musculoskeletal tremors.

Research Concepts:

Beta 2 Agonists

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Question 388: A 55-year-old woman presents with a 2.1 cm predominantly ground glass
lung nodule in the right upper lobe (RUL) that has grown in size from 1.0 cm compared to
a CT scan done 6 months ago. She undergoes a CT-guided transthoracic core needle
biopsy, complicated by iatrogenic alveolar hemorrhage. The histopathology shows
atypical cellular proliferation replacing normal alveolar epithelia with nuclear and
nucleolar prominence. There is no disruption of the alveolar basement membrane.
Immunostaining is positive for thyroid transcription factor-1 (TTF-1), cytokeratin-7 (CK- 7),
and negative for cytokeratin-20 (CK-20). She also has a 1.2 cm pure ground glass nodule in
the right lower lobe (RLL), which was only 3 mm on a prior CT scan. For an appropriate
treatment decision, a biopsy of the RLL nodule is offered, but she is traumatized by the
previous complication and wants to know the physician's expert opinion about the nature
of the second lesion.
What is the most likely etiology of the second lesion?

Choices:

1. It is a metastatic lesion through aerogenous spread.

2. It is a synchronous malignant lesion.
3. It is a metastatic lesion through lymphatic spread.
4. It is a metastatic lesion through vascular spread.
Answer: 2 - It is a synchronous malignant lesion.

Explanations:

The histology description from the right upper lobe (RUL) lesion fits the criteria for
noninvasive adenocarcinoma with lepidic growth. Immunostaining is suggestive of a
non-mucinous subtype. Adenocarcinoma with lepidic growth rarely metastasizes
through vascular or lymphatic invasion. Therefore, multiple lesions are either
through aerogenous spread or are synchronous lesions.
Skip lesions through aerogenous spread is a common finding. The presence of
mucinous subtype or significant solid component is more indicative of aerogenous
metastasis than a synchronous disease.
Consolidation tumor ratio, defined as a ratio of the maximum diameter of the area of
consolidation to the tumor, has also been used as a marker for metastasis and
prognosis in non-solid adenocarcinomas with lepidic growth.
Multiple synchronous lesions can be found on CT.

Research Concepts: Bronchoalveolar Cancer

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Question 389: A 50-year-old man with a history of diabetes, hypertension, and recurrent
alcoholic pancreatitis presents to the emergency department due to worsening shortness
of breath and abdominal discomfort for the past week. Vital signs include a temperature
of 98.6 F, blood pressure 145/90 mmHg, heart rate 115/min, respiratory rate 18/min, and
oxygen saturation 93% on 2 L/min oxygen by nasal cannula. Physical examination shows a
dry oral mucosa, no murmurs on the cardiac exam, diminished breath sounds at the left
hemithorax, mild generalized abdominal tenderness, and no hepatosplenomegaly. Intial
labs show sodium 130 mEq/L, potassium 3.1 mEq/L, chloride 109 mEq/L, bicarbonate 13
mEq/L, and albumin 3.3 g/dL. A chest x-ray shows a moderate left pleural effusion.
Pleural fluid amylase level is 2000 U/L. CT and MCRP show a fistula tract from the
pancreas to the left pleura cavity. Which of the following structures is most likely to have
been damaged first in the pathogenesis of the patient's condition?

Choices:

1. Anterior pancreatic duct

2. Lung parenchyma
3. Posterior pancreatic duct
4. Anteroseptal myocardium

Answer: 3 - Posterior pancreatic duct

Explanations:

A posterior pancreatic duct disruption can form a pathway to the pleural space and
mediastinum.
An anterior pancreatic duct disruption will mainly communicate freely to the
peritoneal cavity leading to pancreatic ascites.
Pancreatic fistula is an abnormal connection between the pancreatic ductal
epithelium and another epithelium surface. The pathophysiology of a pancreatic
fistula is due to pancreatic duct disruption.

Research Concepts:

Pancreatic Fistula

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Question 390: A 17-year-old male presents with a two-month history of chronic cough
and low-grade fever at night that started after spending time in South-East Asia. Vital
signs show a heart rate of 90/min, respiratory rate of 20/min, blood pressure of 110/80
mmHg, and temperature of 99 F (37.2 C). Examination is remarkable for crepitations in the
upper lung zone bilaterally. Chest x-ray shows bilateral upper lobe infiltrates with no
cavitation. Sputum microscopy demonstrates acid-fast bacilli. HIV testing is negative, and
other investigations are negative for extrapulmonary disease. Treatment with an
intensive-phase regimen of HRZE 5 days per week for 15 doses (3 weeks) followed by a
twice-weekly regimen for 12 doses is initiated. He is then started on maintenance
isoniazid and rifampin twice weekly for 36 doses (18 weeks). However, two weeks into
treatment, he is newly diagnosed with HIV. What is the most appropriate next step in the
management of this patient?

Choices:

1. Continue with the current therapy

2. Change isoniazid and rifampin to a daily regimen
3. Switch rifampin to rifabutin and continue with twice-weekly dosing
4. Switch rifampin to rifabutin and have the patient take medications daily

Answer: 2 - Change isoniazid and rifampin to a daily regimen

Explanations:

Daily tuberculosis therapy with rifampin and isoniazid is needed in patients with HIV,
though certain regimens in the treatment of these diseases can interact with each
other.
Twice-weekly regimens are not recommended in people living with HIV, in
persistently smear-positive disease, or in cavitary disease.
In twice-weekly regimens, if doses are missed, there is a risk of subtherapeutic
therapy, which is mitigated to an extent with daily regimens.
Rifabutin is commonly employed in patients with TB and HIV coinfection when the
patient is on protease inhibitors because compared to rifampin, rifabutin is a less
potent inducer of cytochrome P3A. The patient's HIV ART regimen has not yet
been determined in this vignette.
Research Concepts:

Active Tuberculosis

Page 372 of 955

Question 391: A 94-year-old male with a past medical history of hypertension, peripheral
vascular disease, osteoporosis, recurrent pneumonia, and severe cervical spondylosis
presents to the emergency department with a six-month history of worsening dyspnea at
rest and on exertion. His blood pressure is 125/76 mmHg, his temperature is 36.6 C (97.8
F), his heart rate is 96 beats per minute, his respiratory rate is 24 breaths per minute, and
his oxygen saturation is 92% on room air. The patient denies ever using tobacco, alcohol, or
any recreational drugs. He has no known allergies. His lab work reveals a white blood cell
count of 9800 cells/uL, hemoglobin of 14.6 mg/dL, and platelets of 167,000 cells
/uL. On exam, his respiratory function worsens when lying supine to the point that he
goes into respiratory failure and requires immediate intubation. His chest x-ray reveals
low lung volumes with minor bibasilar atelectasis. What other sign, if present on the
physical exam, would lead to the most likely diagnosis in this patient?

Choices:

1. Nocturnal hypoventilation in the upright position

2. Diaphragmatic dyskinesia
3. Paradoxical abdominal wall movement with inspiration
4. Use of accessory respiratory muscles
Answer: 3 - Paradoxical abdominal wall movement with inspiration
Explanations:

Bilateral diaphragmatic paralysis is serious. The diagnostic feature is a paradoxical

inward movement of the abdomen during inspiration. Other non-specific features
include limited diaphragmatic excursion and lower chest dullness.
Most patients with bilateral diaphragmatic paresis are tachypneic and use their
accessory respiratory muscles. Various measures have been introduced to evaluate
the diaphragm function, and the selected technique is dictated by local availability
and expertise.
Plain chest radiographs have poor specificity for diagnosing bilateral palsy. The
findings are limited to non-specific features like insufficient lung volumes or bilateral
basilar lung atelectasis. Similarly, fluoroscopy or dynamic chest radiography has
poor sensitivity, specifically in diagnosing bilateral diaphragmatic paresis.
However, other minimally-invasive measures, including lung and diaphragmatic
ultrasonography, have a favorable specificity and are highly reproducible in
diagnosing bilateral diaphragm paralysis. Bilateral diaphragm paralysis results in
restrictive pulmonary disorders.
Research Concepts: Phrenic Nerve Injury

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Question 392: A 66-year-old male presented to the emergency department regarding the
one-week history of hemoptysis. He says that he is coughing more than he used before.
But over the last week, he started to see blood in sputum. He has hypertension and a
longed history of heavy smoking 2 packs a day for the last 42 years. He also reports some
recent weight loss. On examination, he appears anorexic, cardiac examination shows
normal heart sounds, and the lungs examination shows right-sided coarse breathing
sounds. The chest X-ray shows a right-sided central mass, confirmed with a CT-scan that
showed a mass of 3 cm in size. The biopsy shows keratin pearls. Which of the following is
a possible finding in this patient condition?

Choices:

1. Hyperkalemia
2. Hypercalcemia
3. Hypernatremia
4. Hypoglycemia

Answer: 2 - Hypercalcemia

Explanations:

This patient presentation fits lung cancer. Squamous cell carcinoma shows keratin
pearls in the biopsy.
Squamous cell carcinoma can cause hypercalcemia, as the tumor secretes
parathyroid-hormone related peptide, which can cause hypercalcemia.
Squamous cell carcinoma presents with positive sputum and is the most common
occult cancer. Recently, photochemical dyes with the use of lasers have helped in
improving the localization and treatment of superficial cancers.
Usually, the treatment is surgical and lesser resections are not possible.
Recurrences are rare, but newer primaries do occur. These patients need follow-
up at 6-12 month intervals.

Research Concepts:

Squamous Cell Lung Cancer

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Question 393: A 55-year-old male with a 75 pack-year history of smoking presents to the
clinic to establish primary care and discuss age-appropriate screening options for cancer.
His pulse rate is 78/min, blood pressure is 140/80 mmHg, and saturation at room air is
96%. Air entry is decreased bilaterally with occasional rhonchi and crepitations on chest
auscultation. He is advised by the primary care provider to undergo a low-dose CT scan
(LDCT) for screening.
Which of the following are the criteria for this patient's screening test?

Choices:

1. All adults between ages 55 and 80 years

2. Adults more than 40 years of age with a 20 pack-year smoking history
3. Adults aged 55 to 80 years with a 30 pack-year smoking history
4. Adults less than 60 years of age who are active smokers and have no other risk factors
Answer: 3 - Adults aged 55 to 80 years with a 30 pack-year smoking history
Explanations:

All adults aged 55 to 80 years do not meet the criteria for a high- risk population. As
lung cancer screening involves exposure to possible harmful radiation and potential
other risks to screening, identifying a high-risk population is essential.
According to the National Comprehensive Cancer Network (NCCN), there is a utility
in screening patients with a 20 pack- year history of smoking. However,
recommendations are for patients over 55 years of age with additional risk factors
such as family history, occupational exposure to carcinogens, or personal history of
chronic obstructive pulmonary disease (COPD).
According to the National Lung Screening Trial, patients aged 55 to 80 years with a
30 pack-year history of smoking who are active smokers or quit within the last 15
years qualify for annual low-dose CT screening.
Patients with a life-limiting condition should not be screened.

Research Concepts:

Lung Cancer Screening

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Question 394: A 65-year-old man is being evaluated for worsening dyspnea and fever on
his fifth day of hospital admission. He presented to the emergency department five days
ago with dyspnea for two days. He has a history of chronic obstructive pulmonary disease.
Examination revealed bilateral diffuse wheeze. He was admitted to the hospital and was
intubated after not responding to medical treatment. The chest x-ray at that time
revealed no infiltrates. He now has a fever and increasing secretions. Temperature is 39 C
(102.2 F), the pulse is 110/min, blood pressure is 100/60 mmHg, and respiratory rate is
34/min.
Chest auscultation now reveals crackles in his right lung field. The leukocyte count is
18,000/mm3. Chest x-ray shows right middle and lower lobe infiltrate with an endotracheal
tube in position. What is the next best step in the management of this patient?
Choices:

1. Lower respiratory tract sampling and culture

2. Repeat chest x-ray
3. Blood cultures
4. Lung biopsy
Answer: 1 - Lower respiratory tract sampling and culture
Explanations:

With a history of COPD, hospitalization, and intubation, this patient now has
developed fever and a new pulmonary infiltrate. This suggests healthcare-
associated pneumonia (HCAP) or nosocomial pneumonia. It includes hospital-
acquired pneumonia (which develops after 48 hours of hospital admission) and
ventilation-acquired pneumonia (which develops after 48 hours of endotracheal
intubation).
The diagnosis of nosocomial pneumonia is often made based on clinical history and
presentation. The lower respiratory tract should be sampled if the chest x-ray shows
any abnormalities like infiltrates. Invasive or non-invasive methods can obtain the
sampling. The sample is then stained and observed under the microscope. Culture is
also done. Empirical antibiotics should be given while awaiting the results of culture
and sensitivity.
Blood cultures are specific but are insensitive. CT scan of the chest can be done if the
lower respiratory tract sampling reveals no organisms.
The chest x-ray may reveal a new infiltrate, but this is not specific as it may also be
due to atelectasis or pulmonary edema. The definitive diagnosis of nosocomial
pneumonia can be made with a tissue biopsy, but this is rarely ever done.
Therefore it is reserved for those patients who do not respond to antibiotic therapy or
when non-infectious etiology is suspected.

Research Concepts: Nosocomial Pneumonia

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Question 395: A 41-year-old male patient with a family history of asthma presents to the
emergency department of tertiary care hospital with complaints of shortness of breath
and difficulty in breathing. Upon further inquiry, the patient states that he works in a
section involved with the pretreatment of wastewater in the textile industry. His vital
measurements indicate that he has a blood pressure of 110/80 mmHg, a heart rate of 94
beats per minute, and a breathing rate of 29 breaths per minute. His arterial blood gases
and chest radiography have been done. Oxygen has been attached.
Which of the following is the next best step in the management of this patient?

Choices:

1. Budesonide
2. Vitamin D
3. Acetylcysteine
4. Flumazenil
Answer: 1 - Budesonide

Explanations:

The history of working in a textile wastewater pretreatment plant along with

respiratory complaints are suggestive of ozone toxicity. Arterial blood gas and chest
radiography should be performed in such patients as exposure to other pulmonary
irritants are possible. The management of ozone toxicity consists of applying the
trauma ABCDE protocol and supportive care. Most patients do improve with
corticosteroid/oxygen therapy.
Budesonide has been shown to inhibit the airway neutrophilic inflammatory response,
although it does not prevent functional impairment of the airway.
Budesonide is also used in the long term treatment of asthma and chronic
obstructive pulmonary disease(COPD).
Common side effects of budesonide therapy include respiratory infections,
headaches, tiredness, cough, vomiting, and joint pains. Serious complications are an
increased risk of infection, a decrease in bone strength, and cataracts.

Research Concepts:

Ozone Toxicity

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Question 396: A 44-year-old male presents to the clinic with complaints of stiffness his
joints, feelings of tiredness, and progressively worsening shortness of breath. He also
mentions the bluish discoloration of the fingers of his hands and the inability to perform
sexually. His past medical history reveals gastroesophageal reflux disorder. ECG is done,
which shows right axis deviation and dominant R wave in lead V1 accompanied by
dominant S waves in lead V6. Which of the following findings on chest x-ray is most likely
to correlate with ECG of this patient?

Choices:

1. Kerley B lines
2. Upper lobe pulmonary venous congestion
3. Markedly enlarged cardiac silhouette with splaying of the carina
4. Central pulmonary artery enlargement

Answer: 4 - Central pulmonary artery enlargement

Explanations:

The sign and symptoms of this patient are suggestive of scleroderma. One of the
complications of scleroderma is cor pulmonale. Cor pulmonale is characterized by
right heart failure. Cor pulmonale usually results in right ventricular hypertrophy.
Central pulmonary artery enlargement is a typical finding in right heart failure.
The condition originates in the pulmonary circulation system. Vascular changes are a
result of tissue damage and chronic hypoxic pulmonary vasoconstriction.
Research Concepts:

Cor Pulmonale

Question 397: A 65-year-old man with a history of tobacco use disorder is evaluated for
shortness of breath. Pulmonary function test show FEV1 80%, FVC 90%, FEV1/FVC 88%, and
DLCO 37%. A
chest CT shows bilateral upper lobe dominant emphysema and diffuse parenchymal lung
disease with pulmonary fibrosis.
Transthoracic echocardiography shows reduced right ventricle systolic function and
elevated pulmonary artery systolic pressure. Right heart catheterization is then
performed. Which of the following parameters from right heart catheterization will
diagnose group 3 pulmonary hypertension? (mPAP: mean pulmonary artery pressure,
PVR: pulmonary vascular resistance, PAOP: pulmonary artery occlusion pressure)

Choices:
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1. mPAP 18, PVR 1.8, PAOP 16
2. mPAP 22, PVR 4, PAOP 10
3. mPAP 25, PVR 2.2, PAOP 14
4. mPAP 19, PVR 3.2, PAOP 17

Answer: 2 - mPAP 22, PVR 4, PAOP 10

Explanations:

This patient's presentation is consistent with combined pulmonary fibrosis and

emphysema (CPFE) plus pulmonary hypertension (PHTN).
Pre-existing lung disease and elevated pulmonary artery pressures are required
for the diagnosis of group 3 PHTN. Pre-capillary group 3 PHTN is diagnosed with
mPAP greater than 20 mmHg, elevated PVR greater than 3 Wood units, and
PAOP within the normal limit (less than 12 mmHg).
PAOP greater than 12 with elevated mPAP is present in group 2 PHTN and combined
pre and post-capillary PHTN.
Research Concepts:

Pulmonary Hypertension Due To Lung Disease Or Hypoxia

Question 398: A 46-year-old man from North Dakota comes to the office with complaints
of fever and cough with sputum production for one week. He also reports feeling short of
breath and occasional chest pain. He denies hemoptysis, night sweats, weight loss, and leg
swelling. He works on a ranch with horses. His temperature is 101 F (38.3 C), pulse
89/min, and respiratory rate 21/min. The chest examination reveals stridor. Abdominal
and skin exams are normal.
Chest x-ray shows widened mediastinum. Infection with a category A bioterrorism agent is
suspected, and the CDC is contacted. Which of the following organism characteristics will
most likely be seen in blood culture?

Choices:

1. Gram-positive and spore-forming rod

2. Gram-positive and non-spore-forming rod
3. Gram-negative and non-spore-forming rod
4. Gram-negative and spore-forming rod
Answer: 1 - Gram-positive and spore-forming rod

Explanations:

Page 379 of 955

 Bacillus anthracis is a gram-positive and spore-forming organism found in the soil.
It usually is transmitted by handling contaminated animals and animal products.
Inhalational anthrax presents following an incubation period of approximately 1
to 6 days post-exposure, with a non-specific prodromal phase including fever,
night sweats, nausea, vomiting, malaise, chest pain, and nonproductive cough.
The second stage of illness occurs as bacterial replication in mediastinal lymph
nodes results in hemorrhagic lymphadenitis and mediastinitis and progression to
bacteremia.
Chest x-ray classically demonstrates a widened mediastinum (the result of
significant lymphadenopathy) without pulmonary infiltrates. However, pleural
effusions and pulmonary infiltrates, both of which may be hemorrhagic, can be
seen.
Treatment for inhalational anthrax requires a multidrug regimen with one bactericidal
agent plus one protein-synthesis inhibitor. Intravenous ciprofloxacin plus clindamycin
or linezolid are the preferred agents.

Research Concepts:

Anthrax

Question 399: A 65-year-old female with a past medical history of hypertension, deep
vein thrombosis, chronic tobacco use, and end-stage pulmonary fibrosis began
deteriorating while on a mechanical ventilator nine days after having video-assisted
thoracoscopic surgery (VATS) for a lung mass. During postoperative care in the critical
care unit, the patient became hypotensive and hypoxic and had a respiratory rate of 38
breaths/minute, and a fever of 102 F. Arterial blood gas did not reveal any abnormalities.
A chest X-ray showed a right lower lung opacity. Bronchoscopy showed normal
anastomosis and a large left lung mucus plug. A CT scan of thorax revealed abnormal
posterior displacement of the right middle lobe with anterior displacement of the right
lower lobe of the lung.
What is the next best step in the management of this patient?

Choices:

1. Observation
2. Thoracocentesis
3. Start heparin
4. Lobectomy

Answer: 4 - Lobectomy

Page 380 of 955

Explanations:

Only observing the patient is life-threatening in the setting of lung torsion. The
pathology results from obstruction of a bronchovascular pedicle, causing
ischemia. This patient must be taken for surgery as soon as possible.
CT scan of the thorax revealed an abnormal posterior displacement of the right
middle lobe with anterior displacement of right lower lobe, suggesting a lung
torsion. Displacement of the lobe is classically seen on a CT scan.
Lung torsion is a medical emergency as it involves vascular and bronchial
obstruction. Heparin drip is not indicated in patients with a lung torsion.
This patient needs to be taken to the operating room for a thoracotomy to have a
lobectomy of the involved pedicle and try to salvage any lung tissue.

Research Concepts:

Lung Torsion

Question 400: A 78-year-old white man with a past medical history of hypothyroidism
presents to the emergency department with a history of common cold-like symptoms and
nasal discharge for the last couple of days, which progressed to cough with scanty
expectoration. Recently, he also started having malaise, nausea, vomiting, and decreased
urine output. His vital signs are within normal limits. Labs reveal serum creatinine 4.1
mg/dL and BUN 78 mg/dL. His potassium is 5.5 mEq/L and bicarbonate 16 mEq/L. His
urinalysis is suggestive of 2+ protein and moderate blood. Chest X- ray shows prominent
bronchovascular markings. Renal ultrasound shows normal size kidneys and no signs of
urinary retention. Tests for anti-GBM antibodies and ANCA, including PR3 and MPO, are
sent. His renal function does not respond to the initial intravenous fluid resuscitation, and
ultimately hemodialysis is initiated. An urgent kidney biopsy is also done simultaneously.
His ANCA result is positive. He receives pulse dose methylprednisolone with
cyclophosphamide. Unfortunately, his renal function does not respond to the present
regimen, and he ends up on dialysis for life long. Which of the following interventions is
most likely to have prevented this outcome?

Choices:

1. Starting plasmapheresis as early as possible

2. Using rituximab instead of cyclophosphamide
3. Using methotrexate with methylprednisolone
4. Using methylprednisolone alone
Page 381 of 955
Answer: 1 - Starting plasmapheresis as early as possible

Explanations:

The clinical vignette is suggestive of a diagnosis of ANCA- associated rapidly

progressive glomerulonephritis (RPGN). The treatment is induction
immunosuppression with pulse dose methylprednisolone along with
plasmapheresis followed by maintenance immunosuppression with usually
cyclophosphamide or rituximab.
The initial induction, along with plasmapheresis, has evidence of better outcomes as
compared to methylprednisolone alone.
There is no evidence of the superiority of rituximab over cyclophosphamide for the
maintenance of immunosuppression. Methotrexate is not recommended for induction
immunosuppressive therapy.

Research Concepts: Rapidly Progressive Glomerulonephritis

Section 5

Question 401: A 67-year-old man presents to the clinic for evaluation for severe
obstructive sleep apnea despite positive pressure therapy, which he continues to use but
is interested in additional treatment options. He also states that he would be willing to
undergo a procedure but, at his age, would like to avoid any procedure with a prolonged
hospital stay and recovery. On exam, he is mildly obese (BMI 30 kg/m2) with a neck
circumference of 18 inches; he has mild midface deficiency and evidence of a previously
repaired cleft palate. Despite an appropriately fitting CPAP and optimal settings, a
therapeutic polysomnogram reveals an apnea- hypopnea index (AHI) of 32. Which of the
following is the most appropriate management strategy for this patient?

Choices:

1. Decrease intraluminal pressure of the upper airway compared to the surrounding

tissue
2. Stimulate the genioglossus nerve during sleep
3. Advance the maxillomandibular skeleton
4. Remove excess tissue from the soft palate and uvula to prevent obstruction
Answer: 2 - Stimulate the genioglossus nerve during sleep
Explanations:

Page 382 of 955

 This patient has severe OSA that is refractory to positive pressure therapy and is
seeking further treatment options. The correct answer is an implantable neural
stimulator device that stimulates the genioglossus during sleep would serve to
protrude the tongue and decrease airway collapse.
This patient is a good candidate for this procedure, given his refractory OSA
despite CPAP with a BMI of less than 32 kg/m2. This procedure is also favorable for
him as it is generally performed as an outpatient without expected prolonged
recovery.
Decreasing intraluminal pressure of the upper airway compared to the surrounding
tissue is incorrect as a decrease in the intraluminal pressure of the upper airway
compared to surrounding tissues would cause the upper airway to collapse rather
than remain patient. Advancing the maxillomandibular skeleton is incorrect
because although the patient and mild midface insufficiency, his age (67) and
desire to avoid a procedure with a difficult recovery and hospital stay make this a
less optimal option. Performing a uvulopharyngoplasty in a patient with a history
of cleft palate is contraindicated as these patients often have velopharyngeal
insufficiency at baseline, which may be worsened by uvulopharyngoplasty.
Research Concepts: Sleep Apnea
Syndrome

Question 402: A 65-year-old male went into cardiac arrest in the hospital.
Cardiopulmonary resuscitation (CPR) was performed following advanced cardiac life
support (ACLS) guidelines. After treatment, the patient was rescued from the arrhythmia.
An hour later, the patient had developed a temperature of 100.4 degrees F, a pulse of 110
beats per minute, and a respiratory rate of 26 breaths per minute. Chest auscultation is
evident for decreased breath sounds across the right lung. The patient is in significant
visible pain with labored breathing. Which of the following is the most likely current
diagnosis?

Choices:

1. Pneumonia
2. Supraventricular tachycardia
3. Pneumothorax
4. Mediastinitis

Answer: 3 - Pneumothorax

Explanations:

The patient in this scenario likely received high-quality chest compressions during
Page 383 of 955
 the cardiac arrest. These chest compressions often reach a depth and force to break
ribs during a cardiac arrest that can lead to pneumothorax.
Patients who are revived after cardiac arrest should be monitored very closely in
the intensive care unit to assess any complications such as pneumothorax that can
be ruled out with routine chest x-ray.
Due to the rapidness of the pathology after ACLS, pneumonia and mediastinitis are
less likely.
Clinically, this patient has developed pneumothorax. With the increased respiratory
rate, decreased breath sounds on auscultation, and heart rate is 110 bpm,
supraventricular tachycardia is unlikely.

Research Concepts: Cardiopulmonary

Resuscitation

Question 403: A 34-year-old male presents to the HIV clinic for routine evaluation. The
patient was diagnosed with HIV 3 weeks ago. He is currently taking a combination of
bictegravir, emtricitabine, and tenofovir and reports compliance with them. He
immigrated from Pakistan 2 years ago. His CD4 count is 120 cells/mm3 and HIV RNA
300,000 copies/ml. Past medical history is significant for ulcerative colitis. The patient
takes mesalamine and is on azathioprine for remission maintenance. He reports an 11 kg
weight loss over the past 6 months. He had flu vaccination and underwent a tuberculin
skin test with an induration of 4 mm read after 72 hours during his last visit. Complete
blood count shows a white blood cell count of 10,300 per microliter, hemoglobin 10
gm/dl, and platelets 140,000.
Complete metabolic panel and urinalysis were unremarkable. Urine drug screen positive for
marijuana. Vital signs show a temperature of
36.7 C, respiratory rate of 18/min, heart rate of 93/min, and blood pressure of 128/84
mmHg. What is the most appropriate next step in the management of this patient?

Choices:

1. Repeat tuberculin skin test

2. Prophylaxis for Mycobacterium avium complex infection
3. Start Isoniazid for 9 months
4. Chest x-ray and sputum acid-fast bacillus (AFB) culture
Answer: 1 - Repeat tuberculin skin test

Explanations:
Page 384 of 955
 If the clinical suspicion is high, repeat testing with a tuberculin skin test or
interferon-gamma release assay (depending on which test was done initially) can
be done if the initial test is negative or indeterminate (borderline).
Repeating a positive second test increases the sensitivity for detecting
tuberculosis. However, in immunocompromised patients, a repeated negative test
can be due to a lack of immune reaction rather than an exclusion of the
Tuberculosis diagnosis.
High suspicion of the disease has to be used in this setting to decide whether or not to
treat, always considering the risk and benefits of therapy.
Induration of 5 mm or greater indicates a positive test in a high- risk person. High-
risk patients include HIV infection, close contact with an active tuberculosis
patient, organ transplant recipient, and other forms of immunosuppression (taking
TNF antagonists, and other biologics).

Research Concepts:Tuberculosis Screening

Question 404: A 34-year-old man with class 2 obesity presents for daytime sleepiness. He
reports that even if he sleeps for 6 to 7 hours, he still wakes up tired in the morning and
often with a headache. The tiredness and associated sleepiness last all day. His wife
reports that he snores, and polysomnography shows an apnea- hypopnea index of 15.5
events/hour. The clinician recommends using nasal auto continuous positive airway
pressure (auto-CPAP) at 5 to 15 cm H2O during sleep. He returns one month later and
says he cannot tolerate this treatment due to claustrophobia. What is the best next step
in managing this patient?
Choices:

1. Refer to the dentist for a custom-made oral appliance

2. Continue auto-CPAP but with a reduced pressure
3. Convert to bilevel PAP
4. Continue auto-CPAP but use a full face mask
Answer: 1 - Refer to the dentist for a custom-made oral appliance

Explanations:

Oral appliances are recommended as an alternative treatment for mild-to-

moderate obstructive sleep apnea (AHI 5 to 30 events/hour) who cannot tolerate
continuous positive airway pressure (CPAP).
Oral appliances often successfully treat upper airway resistance syndrome (UARS),
simple snoring, and mild-to-moderate obstructive sleep apnea (OSA).
Reducing CPAP pressure or converting to bilevel PAP is not recommended when the
patient is not tolerating PAP. Individuals with claustrophobia and who do not
Page 385 of 955
 tolerate PAP likely will not do well with a full face mask or a different pressure.

Research Concepts:

Obstructive Sleep Apnea

Question 405: A 56-year-old male with a history of chronic obstructive pulmonary disease
presents to the office with shortness of breath. A chest x-ray was performed, which
showed consolidation. Upon drainage thorough the chest tube, drop rate count indicated
hyper-viscous pus infiltrate. Which of the following medications is used in combination
with dornase alfa to decrease the viscosity of the pus and facilitate drainage?

Choices:

1. Albuterol
2. Mannitol
3. Tissue plasminogen activator (tPA)
4. Ephedrine
Answer: 3 - Tissue plasminogen activator (tPA)

Explanations:

Tissue plasminogen activator (tPA) is used with dornase alfa to thin the pus infiltrate in
emphysema for easier drainage.
Tissue plasminogen activator (tPA) and dornase alfa can be used two hours apart or
simultaneously.
If the combination is used separately, then tPA must be given first, and after 2
hours, dornase alfa should be administered.
If the combination of dornase alfa and tPA is used simultaneously, both can be
administered one after another with at least two hours of dwell time.

Research Concepts:

Dornase Alfa

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Question 406: A 26-year-old male comes to the office due to severe congestion and
rhinorrhea for six months. He also complains of headaches, sneezing, and itching
sensation in his nose with tearing of eyes during these episodes. The symptoms have
affected his quality of life. He reports no fever, sore throat, shortness of breath, or
cough. His mother has had asthma since her childhood.
On examination, his vital signs are within normal limits, and examination of his ears,
nose, and throat is normal. The radioallergosorbent test shows an increase in specific IgE
levels for dust mites, molds, pollens, and grasses. For his condition, the clinician
prescribes a drug that allows the production of leukotriene A4, B4, cysteinyl
leukotrienes, prostaglandins, and thromboxanes but inhibits the action of leukotrienes
C4, D4, and E4. Which of the following laboratory findings on follow-up visits would
necessitate discontinuation of the drug?

Choices:

1. Thrombocytosis
2. Elevated creatinine level
3. Elevated transaminase level
4. Leukocytosis
Answer: 3 - Elevated transaminase level

Explanations:

There are over 100 reported cases of severe hepatic failure with zafirlukast. Signs of
hepatitis, including right upper quadrant pain, jaundice, and pruritus, should
warrant monitoring transaminase levels and discontinuation of zafirlukast if clinical
suspicion of hepatoxic effects occurs. The resolution of transaminases occurs in
most cases after discontinuation of therapy.
Neuropsychiatric adverse events, including depression and insomnia, have also been
reported using zafirlukast.
Other side effects of zafirlukast include headache (10%), dizziness, neuropathy,
myalgia, back pain, arthralgia, edema, and malaise.
In patients over 55 years of age, there are reports of increased respiratory tract
infections, especially if zafirlukast is used in conjunction with corticosteroids.

Research Concepts:

Zafirlukast

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Question 407: A 45-year-old woman presents to the clinic with a six-month history of
dyspnea on exertion and fatigue. She wakes up multiple times from sleep gasping for air
and rarely feels refreshed in the morning. Her medical history is significant for obesity,
hypertension, diabetes mellitus, and hyperlipidemia. Her temperature is 37 C (98.6 F),
blood pressure 155/92 mmHg, and pulse 90/min.
Physical exam demonstrates marked obesity with a BMI of 45 kg/m^2, no lower
extremity edema, and clear sounds on auscultation. A chest X-ray is challenging to
interpret due to marked obesity, but there are no obvious cardiopulmonary findings. Her
arterial blood gas (ABG) analysis during the day shows a PO2 of 73 mmHg and a PCO2 of
52 mmHg. Nocturnal positive pressure ventilation is initiated. Three months later, the
patient reports no significant improvement, and her ABG analysis show marked
hypercapnia. Which of the following best explains why this patient's hypercapnia
persists?
Choices:

1. Desensitization of peripheral chemoreceptors to hypercapnia due to decreased

bicarbonate retention
2. Desensitization of peripheral chemoreceptors to hypercapnia due to increased
bicarbonate retention
3. Desensitization of central chemoreceptors to hypercapnia due to decreased
bicarbonate retention
4. Desensitization of central chemoreceptors to hypercapnia due to increased
bicarbonate retention

Answer: 4 - Desensitization of central chemoreceptors to hypercapnia due to increased

bicarbonate retention
Explanations:

This clinical vignette describes a patient with obesity hypoventilation syndrome

(OSA), a condition that affects morbidly obese individuals. Many patients also have
accompanying obstructive sleep apnea.
Obesity affects lung and chest wall mechanics leading to hypoventilation and
resultant hypercapnia. Patients initially compensate by increasing respiratory drive
and work of breathing. However, respiratory fatigue rapidly ensues.
As the condition progresses, chronic hypercapnia results in respiratory acidosis with
compensatory HCO3 retention by the kidneys. Bicarbonate decreases the sensitivity
of central chemoreceptors to changes in PCO2 levels leading to persistent
hypercapnia.
As a diuretic that inhibits carbonic anhydrase, acetazolamide reduces HCO3
retention. This helps restore the sensitivity of central chemoreceptors to blood
CO2.
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Research Concepts: Obesity-Hypoventilation Syndrome

Question 408: A 16-year-old male patient presents with complaints of severe

mucocutaneous lesions that are making it difficult for him to eat or drink anything. He
states that he has had a sore throat, chest pain, productive cough, and high-grade fever
for the past week. On examination, there is a vesicular rash with bullae in some places.
Most of the lesions have a central clearing, and others have a necrotic center. Lab
investigations reveal hemoglobin of 9.8 g/dl and reticulocytosis. Monospot is negative. A
chest radiograph shows non-homogenous haziness bilaterally. What is the most
appropriate treatment in this case?

Choices:

1. Ceftriaxone
2. Azithromycin
3. Linezolid
4. Ciprofloxacin
Answer: 2 - Azithromycin

Explanations:

Mycoplasma can also be associated with severe extrapulmonary complications.

These complications may be due to the organism itself. It may be triggered by the
resulting immunological response to the bacteria.
M. pneumoniae infection may be associated with urticaria, erythema nodosum, or
Steven Johnson syndrome. The skin lesions are seen in about one-third of patients.
Treatment of M. pneumoniae includes macrolides, doxycycline, or
fluoroquinolones. Azithromycin is the most frequently used antibiotic and is
usually prescribed for 5 days (500 mg for the first dose, followed by 250 mg daily
for 4 days). Patients receiving doxycycline or fluoroquinolones should be given 7 to
14 days of treatment.
Macrolide resistance continues to emerge, so if a patient is not responding to
macrolides, other antibiotics can be given.
Routine antibiotic prophylaxis is not required for the exposed contacts except for
those who are prone to serious mycoplasmal infection, like patients with sickle cell
disease or antibody deficiency. For prophylaxis, doxycycline or macrolides are used.

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Research Concepts: Mycoplasma Pneumonia

Question 409: A 65-year-old male with long-term nicotine abuse history presents with a
worsening cough and weight loss over the last 2 years. He has not seen a clinician in the
last several years.
Chest x-ray reveals a large spiculated mass in the left lung which is a new finding when
compared to previous imaging from 5 years ago. Physical examination reveals reduced leg
and arm mass as compared to previous examinations with evidence of atrophy.
Further workup reveals stage 4 nonsmall cell lung cancer which is inoperable. Palliative
chemotherapy is planned and the patient is expected to have a prognosis of less than 2
months. The patient seeks advice regarding constant fatigue and poor oral intake, asking
for treatment of his anorexia and cachexia. Which of the following should be prescribed
for this patient?

Choices:

1. Bimagrumab
2. Dexamethasone
3. Mirtazapine
4. Olanzapine
Answer: 2 - Dexamethasone

Explanations:

There are no approved medications for the treatment of cancer- associated

anorexia and cachexia. When prescribed, the primary expected benefits will be
increased appetite and modest weight gain. There is no survival benefit from
pharmacologic treatment of cancer-associated anorexia and cachexia.
According to the American Society of Clinical Oncology, in patients with terminal
cancer and poor prognosis (days to weeks) dexamethasone should be used to treat
cancer- associated anorexia.
For patients with longer life expectancies, progesterone analogs such as megestrol
acetate or medroxyprogesterone acetate are the recommended treatment option.
Bimagrumab is a humanized anti-ActRII monoclonal antibody under study for non-
small cell lung cancer-associated cachexia and has shown efficacy against cancer
cachexia in animal models. It is currently under investigation and is not yet an
approved therapy for this disease.
Research Concepts:

Anorexia and Cachexia

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Question 410: A 78-year-old male presents to the emergency department with shortness
of breath. The patient has a past medical history of chronic obstructive pulmonary disease
(COPD), smoking, paroxysmal atrial fibrillation, kyphoscoliosis, and ischemic stroke with
dysphagia. Physical examination is notable for rales auscultated in the right lower lung
fields. VItals reveal a temperature of 100.2 F, pulse rate of 98/min, respiratory rate of
22/min, and blood pressure of 110/70 mmHg. An arterial blood gas (ABG) performed at
the time of presentation revealed a pH of 7.18, PaCO2 of 90 mmHg, PaO2 of 88mmHg,
and bicarbonate of 45 mmol/L. Which of the following is a contraindication to the use of
non-invasive ventilation with average volume-assured pressure support (AVAPS) in this
patient?

Choices:

1. Kyphoscoliosis
2. Paroxysmal atrial fibrillation
3. Respiratory acidosis
4. Dysphagia

Answer: 4 - Dysphagia

Explanations:

Average volume-assured pressure support (AVAPS) has been successful in the

treatment of COPD-associated acute hypercapnic respiratory failure.
Average volume-assured pressure support (AVAPS) is a relatively newer modality
of non-invasive ventilation that integrates the characteristics of both volume and
pressure- controlled non-invasive ventilation.
Its contraindications include impaired cough reflex/swallowing (lack of airway
protection).
AVAPS is contraindicated in the presence of cardiac arrest/hemodynamic
compromise/unstable arrhythmia. AVAPS has been associated with a significant
improvement in arterial blood gases and forced vital capacity of patients with
kyphoscoliosis-related chronic respiratory failure.

Research Concepts:

Average Volume-Assured Pressure Support

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Question 411: A 28-year-old woman presents to the clinic for 2-3 months of worsening
exertional dyspnea. She has a history of systemic lupus erythematosus and takes regular
hydroxychloroquine. She does not smoke cigarettes or drink alcohol. Her vital signs show
a heart rate of 92/min, respiratory rate 22/min, oxygen saturation 95% on room air, and
blood pressure 111/77 mmHg. She is afebrile. Examination reveals reduced right-sided
chest expansion. Chest auscultation demonstrates clear lung fields with no added sounds.
Her jugular venous pulse is not raised, and there is no peripheral edema. Her heart
sounds are normal with no added sounds or murmurs. Abdominal and neurological
examinations are normal. Routine blood tests (including white blood cell count and CRP)
are normal. The thiopurine methyltransferase (TPMT) level is noted to be low (10
nmol/h/g Hb). Plain radiography of the chest demonstrates an elevated right
hemidiaphragm.
Contrast CT of the chest shows normal lung parenchyma and excludes a pulmonary
embolism. Transthoracic echocardiography demonstrates a normal ejection fraction.
Lung function testing demonstrates a restrictive deficit with reduced total lung capacity.
She is initially treated with prednisolone and inhaled salbutamol but fails to respond and
develops worsening lung function and progressive dyspnea. Which of the following is the
next best step in the management of this patient?

Choices:

1. Rituximab
2. Azathioprine
3. Tocilizumab
4. Lobectomy
Answer: 1 – Rituximab
Explanations:

This patient with a history of SLE has a likely diagnosis of shrinking lung syndrome.
This is characterized by dyspnea, reduced chest expansion, elevation of the
hemidiaphragm(s), and a restrictive ventilatory defect with reduced total lung
capacity. It is a complication of systemic autoimmune disease, most commonly
SLE. It is a diagnosis of exclusion, and therefore additional investigations such as
laboratory tests, CT scans, and echocardiography are used to exclude competing
diagnoses.
Prednisolone is typically the first-line treatment (+/- inhaled beta- 2 agonists).
However, if this fails, other immunosuppressants and biologic medications have
been shown to be effective.
Rituximab is an anti-CD20 monoclonal antibody. There is case report evidence of this
treatment demonstrating improvement in symptoms and lung function results in
those patients with refractory shrinking lung syndrome.
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 Other possible treatments for refractory shrinking lung syndrome include
azathioprine and cyclophosphamide. Azathioprine is contraindicated in this case
due to a low TPMT level. The treating clinician may want to avoid
cyclophosphamide if possible in a young woman of child-bearing age. There is no
proven role for surgery or tocilizumab.

Research Concepts: Shrinking Lung Syndrome

Question 412: A 54-year-old male patient was recently admitted for an ST-elevation
myocardial infarction (STEMI). His angiogram reveals a blockage in 4 vessels requiring
coronary artery bypass surgery. Ten days after the surgery, the patient reports
experiencing shortness of breath. The patient has dyspnea at all times but it is worse
when lying down and after a big meal. The patient has not experienced this before. His
electrocardiogram (ECG) is normal. On a chest x-ray, the left side of the diaphragm is
higher than the right. What test can be used to evaluate the severity of this condition?

Choices:

1. Computed tomography of the chest

2. Magnetic resonance imaging (MRI) of the chest
3. Pulmonary function test
4. Three-dimensional echocardiography

Answer: 3 - Pulmonary function test

Explanations:

Pulmonary function tests will show a restrictive lung pattern, with a forced
expiratory volume in one second/forced vital capacity (FEV1/FVC) less than 0.8 or
80%. A restrictive lung pattern is seen when the lungs can not expand properly.
Phrenic nerve injury is common during coronary artery bypass surgery due to its
proximity to the internal mammary artery, which is utilized as a bypass graft. Injury
to the left phrenic nerve can lead to left-sided diaphragmatic paralysis. Most
patients are asymptomatic, but some can present with mild to severe difficulty in
breathing.
Pulmonary function tests in a normally healthy individual have an FEV1/FVC of
80%. However, patients with unilateral phrenic nerve injury will decrease by 20%-
40%. The FEV1/FVC may drop by 40%-60% if the entire diaphragm is affected.
When lying down and or after a big meal, it is more difficult for the diaphragm to
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 expand, but the overall decrease in FEV1/FVC is approximately 10%.

Research Concepts:

Elevated Hemidiaphragm

Question 413: A 42-year-old woman presents to the clinic with three months of cough
and shortness of breath. She also has associated fatigue. She denies excessive sputum
production, bowel changes, sleep changes, and palpitations. She has smoked one pack of
cigarettes per day over the past 20 years and occasionally drinks a beer now and then. Her
past medical history is significant for rheumatoid arthritis diagnosed five years back. She
inconsistently takes methotrexate and uses methylprednisolone for exacerbations. She
works as a supervisor at the local mining camp and spends most of her time outdoors.
Examination shows vitals within normal limits. Auscultation reveals diffuse rales that do
not clear with coughing. The chest x-ray shows multiple lung nodules 0.5 to 1.0 cm in
diameter. Given the likely diagnosis, which disease condition has a higher prevalence
among patients with this syndrome?

Choices:

1. Tuberculosis
2. Sarcoidosis
3. Pancoast tumor
4. Emphysema

Answer: 1 - Tuberculosis

Explanations:

This patient has a cough, shortness of breath, and multiple lung nodules in the
presence of rheumatoid arthritis. This leads to the diagnosis of Caplan syndrome.
Caplan syndrome is an autoimmune condition where the body's inflammatory cells
attack its tissue and, in the case of rheumatoid arthritis (RA), the synovium. It is
believed that in these patients, there is an alteration that causes the increased
immune response to foreign materials in the lungs.
The findings of this syndrome consist of rheumatoid nodules in the lungs noted as
rounded opacities 0.5 to 5 centimeters, which may cavitate and resemble
tuberculosis on chest radiology. The opacities can differ in size, varying from small
opacities, which appear as simple pneumoconiosis and extensive opacities, which
can appear as progressive massive fibrosis.
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 There is a high prevalence rate of progressive massive fibrosis (PMF) and tuberculosis
amongst miners and ex-miners with rheumatoid arthritis.

Research Concepts: Caplan Syndrome

Question 414: This 45-year old Indian female has been ventilated for severe acute
respiratory distress syndrome secondary to COVID-19 pneumonia. Her oxygen
requirement has gone up in the past few minutes. Air entry was equal on both sides, and
a bedside chest ultrasound revealed the presence of pleural slides bilaterally, with
bibasal consolidation and copious B lines. The echocardiography was normal. Her current
ventilator settings are show volume control ventilation FiO2 0.7, tidal volume 350 cc,
respiratory rate 32 per minute, PEEP 12 cms H2O. Her predicted body weight (PBW) is 60
kg. Her latest ABG revealed PaO2 56 mm Hg, PaCO2 68 mm Hg, pH 7.273, HCO3 38
mEQ/L. The peak pressure is 38 cms H20, and the plateau pressure is 30 cms. What
should be the next best step in the management of this patient?

Choices:

1. Increase FiO2 and PEEP

2. Recruitment maneuvers
3. Proning
4. Diuresis
Answer: 3 - Proning

Explanations:

This patient has severe ARDS with a P/F ratio of 80 is very likely to get benefit from prone
position ventilation. Prone position ventilation is not only known to improve hypoxemia in
ARDS patients but also known to minimize lung injury by increasing homogeneity of
ventilation. The latter aspect has been shown in animal studies.
Prone position ventilation has been shown to improve the mortality in ARDS patients, as
shown in a 2010 metanalysis, and also at the landmark PROSEVA trial on severe ARDS
patients published in 2013. The reduced mortality is believed to be partly contributed by
decreased risk for ventilatory induced lung injury since prone position ventilation
improves the homogeneity of ventilation.
Prone position ventilation improves oxygenation by improving the end-expiratory lung
volume and by rectifying the ventilation- perfusion mismatch. Also, it reduces the mass
effect of the heart and mediastinum on the lower lobes and improves regional ventilation.
Prone position ventilation is relatively avoided in hemodynamically unstable patients and
patients with unstable spinal cord or abdominal injuries. Increased incidence of pressure
ulcers, increased endotracheal tube obstruction, and Intercostal tube displacements are
reported with prone position ventilation. ECMO is an alternate option to be considered

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 when there is a strong contraindication/inability to perform prone positioning.
Research Concepts: Ventilator-Induced Lung Injury (VILI)

Question 415: A 5-year-old boy with chronic nasal congestion and snoring is being
evaluated for adenoidectomy. His past medical history is significant for asthma. He uses
albuterol as needed, last used yesterday. Which of the following anesthetics, if used, is
most likely to worsen the patient's bronchospasm?

Choices:

1. Sevoflurane
2. Ketamine
3. Desflurane
4. Propofol

Answer: 3 - Desflurane

Explanations:

Desflurane increases the risk of respiratory adverse events, especially in children with
asthma or a history of recent upper airway infection.
Desflurane increases bronchial smooth muscle tone and airway resistance.
Desflurane should be avoided in patients with asthma. Ketamine and propofol
blunt airway reflexes and sevoflurane has bronchodilating properties.

Research Concepts:

Asthma Anesthesia

Question 416: A 45-year-old male who has sex with men presents with the complaint of
increasing dyspnea for three weeks. He does not have a history of tobacco smoking. On
examination, he has a low-grade fever. On auscultation, his chest has bilateral inspiratory
crackles. The chest radiograph shows no obvious changes. A 6-minute walk test reveals a
drop in his oxygen saturation on minimal exertion. His sputum is sent for the
examination, which is unremarkable. What is the most appropriate test to diagnose the
underlying pathology?

Choices:

1. Bronchoalveolar lavage
Page 396 of 955
2. Pulmonary function tests
3. CD4/CD8 ratio
4. Transbronchial needle aspiration (TBNA)
Answer: 1 - Bronchoalveolar lavage

Explanations:

This patient likely has Pneumocystis jirovecii pneumonia (PCP) due to an underlying
human immunodeficiency virus (HIV) infection.
His saturation drops on exertion, and his chest radiograph is normal; both support the
diagnosis of PCP.
Sputum is sent to look for cysts of PCP, but if it fails to be helpful, it is advisable
to perform a bronchoalveolar lavage. PCP cysts appear on silver stain.

Research Concepts:

Dyspnea on Exertion

Question 417: A 48-year-old woman presents to the clinic for a routine check-up. The
patient seems to be well controlled on her current medication regimen to treat
hypertension, hyperlipidemia, and asthma. However, she finds it hard to increase her
physical activity during the day due to excessive sleepiness. The patient states she gets 7
to 9 hours of sleep a night but still feels tired when she wakes up in the morning, like "I
barely slept at all." The patient also states she frequently wakes up with a headache. She
also says her husband has had to move to a guest bedroom to sleep at night due to her
loud snoring. On exam, the patient's BMI is 36 kg/m^2, the oropharynx is crowded, and
Mallmpatii class III. The nasal turbinates are enlarged bilaterally. The rest of the exam is
unremarkable. Which of the following is the best initial step in managing this patient?

Choices:

1. Obtain a home sleep apnea test

2. Obtain an in-laboratory polysomnography
3. Initiate nasal steroid
4. Refer to a dentist for a custom-made oral appliance
Answer: 2 - Obtain an in-laboratory polysomnography

Explanations:

Sleep-disordered breathing (SDB) consists of a spectrum of conditions ranging from

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 snoring to upper airway resistance syndrome (UARS) to obstructive (OSA) or central
sleep apnea (CSA).
Diagnostic testing for SDB includes a variety of modalities, from home portable
monitoring devices (i.e., home sleep apnea test) to in-laboratory polysomnography
(PSG). This patient has a high probability of SDB based on her symptoms and
asthma; therefore, PSG is the next step in evaluating SDB.
UARS is more common in premenopausal or perimenopausal women than in men
or post-menopausal women. It is defined by having snoring, associated with
evidence of flow limitation resulting arousal (RERAs) without definitive
denaturation to qualify for scoring hypopnea or apnea. Therefore, a PSG is required
to make this diagnosis, and HSAT will not be sufficient. The treatment for UARS
includes addressing the primary causes, ranging from treating nasal congestion and
dental malocclusion to using continuous positive airway pressure and dental
appliances. However, CPAP and oral appliances are used after the diagnosis is
confirmed.

Research Concepts: Upper Airway Resistance Syndrome

Question 418: A 17-year-old man presents to the emergency department with complaints
of high-grade fever with rigors and chills, anorexia, abdominal pain, and nausea for the past
four days. He has also been experiencing cough with occasional brown sputum production
and chest pain for the past two days. He has been experiencing mild fever, anorexia,
nausea, and myalgias for the past week but did not consult a provider. The patient
mentions that he returned from a trip to Hawaii ten days ago. Vitals show a blood pressure
of 95/65 mm Hg, a pulse of 112/min, a respiratory rate of 18/min, and a temperature of
39.4 C (103 F). Physical examination reveals an ill-looking man with conjunctival redness. No
inflammatory exudates are noted in the conjunctiva. Scleral icterus is present.
Tenderness is present in the muscles of the trunk and extremities. Laboratory
investigations reveal a leukocyte count of 18000 cells/mm3 and a platelet count of
70,000/mm3, an aspartate aminotransferase level of 82 U/L, and an alanine
aminotransferase level of 96 U/L. Which frequent complication of the disease has the
patient most likely developed?

Choices:

1. Pulmonary embolism
2. Pulmonary hemorrhage
3. Pleural effusion
4. Empyema
Answer: 2 - Pulmonary hemorrhage
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Explanations:

The most likely diagnosis considering the patient’s history, physical examination,
and laboratory investigations is leptospirosis.
Leptospirosis can present in the form of two distinct clinical syndromes, the icteric and
anicteric syndromes.
The icteric phase of leptospirosis is classically known as Weil disease. This is a
severe infection, and the manifestations include fever, renal failure, jaundice,
hemorrhage, and respiratory distress.
The icteric phase may also involve the heart, CNS, and muscles. This illness is
usually severe and may last weeks or months if the patient survives.

Research Concepts:

Leptospirosis

Question 419: A 65-year-old male with end-stage chronic obstructive pulmonary disease
(COPD) presents to the office complaining of shortness of breath for one week and
reports "having trouble getting enough air." his pulse is 70/min, blood pressure is 140/90
mm of Hg and saturation on pulse oximetry is 94% at room air. Breath sounds are
decreased bilaterally with bibasal crackles and end-expiratory rhonchi. Which of the
following should be avoided in this case?

Choices:

1. Morphine as needed
2. A fan blowing to face
3. Anti-anxiety medication
4. High flow oxygen therapy
Answer: 4 - High flow oxygen therapy

Explanations:

Opioids are the first-line treatment for dyspnea in dying patients with comfort-only
goals. In an opioid-naïve patient, low doses of oral (10 to 15 mg) or parenteral (2 to
5 mg) morphine will provide relief for most patients. Remember that dyspnea is a
subjective sensation of difficulty breathing and can be caused by various conditions.
Understanding the patient's goals of care is essential. Are they actively dying, and is
comfort their priority?. Or do they want to be able to interact with their family?.
Ensuring upright positioning (as is comfortable) and increasing air movement can
assist in the patient's comfort without sedation.
Page 399 of 955
 Anxiety can be a cause of dyspnea. Obtaining a thorough assessment of the
patient's history and symptoms can assist in creating an individual plan of care that
addresses the cause of the patient's dyspnea.
Oxygen may be helpful only in patients with documented hypoxia. There is little
reason even with hypoxia to administer oxygen at rates higher than 6 L/min. In
some patients, this can block respiratory drive, causing immediate death.

Research Concepts: Dyspnea in Palliative Care

Question 420: A 3-year-old boy with muscular dystrophy is being discharged home with a
tracheostomy. The parents have been trained by respiratory care personnel about the use
of suctioning equipment. What is the most appropriate frequency to suction the
tracheostomy tube of their child?

Choices:

1. Every 30 minutes
2. When they see visible secretions at the tracheostomy site
3. When the patient wakes up from sleep
4. Every 3 hours
Answer: 2 - When they see visible secretions at the tracheostomy site

Explanations:

There is no set advised frequency for airway suctioning as per the American
Association of respiratory care.
The patient should be suctioned in the hospital or at home if there are visible
secretions in the airway if there is a drop in pulse oximetry reading.
For an awake patient with muscle weakness (like muscular dystrophy) - they can
indicate when they are unable to breathe and require suctioning, even before
visible secretions appear or drop in pulse oximetry.
In a mechanically ventilated patient, a sawtooth waveform of airflow on the ventilator
is also considered an indication that the patient requires airway suctioning.

Research Concepts:

Airway Suctioning

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Question 421: A 35-year-old man presents to the emergency department with
complaints of headache and malaise. He reports a 2-month history of night sweats,
cough with mild sputum production, and worsening fatigue. He denies exposure to
cigarette smoke, birds, pets, construction sites, pigeon droppings, caves, lakes, streams,
and other bodies of water. He has no known exposure to tuberculosis. He recently
tested negative for HIV. However, he traveled to Vancouver, Canada to visit his friend
about six months ago. His vital signs are temperature 99.7 F (37.6 C), blood pressure
128/68 mmHg, pulse 101/min, and respiratory rate 24/min. There is no focal
neurological deficit, and meningeal signs are negative.
Chest auscultation reveals rhonchi and wheeze in the right infra- axillary region. The rest
of the examination is unremarkable. Chest x- ray shows a mass-like lesion in the right
middle lobe.
Bronchoalveolar lavage culture grows a fungus with budding cells. Which of the following
pathogens is the most likely cause of this patient’s condition?

Choices:

1. Histoplasma capsulatum
2. Pneumocystis jirovecii
3. Coccidioides immitis
4. Cryptococcus gatti
Answer: 4 - Cryptococcus gatti

Explanations:

The two species of Cryptococcus that are commonly associated with infections in
humans are Cryptococcus neoformans and Cryptococcus gatti. The lungs and brain
are the most frequent sites for infection. Cryptococcus neoformans is usually
associated with infections in immunocompromised patients, while Cryptococcus
gatti is associated with infections in immunocompetent patients.
The incubation period for Cryptococcus species is typically longer than most
bacterial, viral, and some other fungal diseases of the lower respiratory system,
such as histoplasmosis and coccidioidomycosis.
Cryptococcus species have long periods of incubation period in the range of 6-7
months and may even have a prolonged dormant phase of years followed by
reactivation.
The incubation period of Histoplasma capsulatum is 2-17 days, whereas it is 1-4
weeks for Coccidioides immitis. The incubation period of Pneumocystis jirovecii is
variable and can be as long as 3 months.
Research Concepts:Cryptococcus

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Question 422: A 43-year-old man presents to the emergency department after being
involved in a motor vehicle collision. His past medical history is significant for coronary
artery disease. A complete blood count shows a hematocrit of 27%, and blood
transfusion is started. During transfusion, the patient complains of a severe headache,
chest tightness, and dyspnea, and he develops a cough. Vital sign comparisons from
pretransfusion to posttransfusion are as follows: temperature 98.6 F to 98.8 F, blood
pressure 115/70 mmHg to 165/95 mmHg, heart rate 74/min to 121/min, and respiratory
rate 18 breaths per minute to 32 breaths per minute. The transfusion is discontinued,
and he is treated with supplemental oxygen by nasal cannula and an intravenous
diuretic. A chest x-ray shows diffuse bilateral infiltrates. After an hour, the patient starts
feeling much better, and his vital signs have improved. Which of the following features
differentiates the most likely diagnosis in this person from transfusion-related acute lung
injury?

Choices:

1. Dyspnea
2. Diffuse bilateral infiltrates on the chest x-ray
3. Hypertension
4. Tachypnea

Answer: 3 - Hypertension

Explanations:

The person in this clinical vignette is experiencing transfusion- associated circulatory

overload. Transfusion-related acute lung injury (TRALI) and transfusion-associated
circulatory overload (TACO) are the two major causes of morbidity and mortality in
patients receiving a blood transfusion.
It is difficult to differentiate between TRALI and TACO, but the edema in TACO is
cardiogenic, and that in TRALI is non- cardiogenic. As the patient mentioned in the
vignette has a history of cardiac disease, TACO is the more likely diagnosis. Also,
the patient in the vignette developed posttransfusion hypertension, which is
consistent with TACO, not TRALI. TRALI is associated with posttransfusion
hypotension. This is the main feature that differentiates the two conditions.
Dyspnea, tachypnea, and diffuse bilateral infiltrates on chest x- ray can be present
in both TRALI and TACO.

Research Concepts: Non-infectious Complications Of Blood Transfusion

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Question 423: A 65-year-old woman presents with a five-day history of fever, worsening
dyspnea, and fatigue. Past medical history includes essential hypertension and
hyperlipidemia. Her temperature is 100.4 (38 C), heart rate 132/min, respiratory rate
29/min, and blood pressure 133/77 mmHg. Oxygen saturation is 87% on 6 liters of oxygen
via nasal cannula. Lung auscultation is remarkable for bilateral crackles, and the cardiac
and lower extremity exams are within normal limits. A chest radiograph reveals patchy
bilateral opacities. Tests for influenza A and B are negative. Blood and sputum samples are
collected for stain and culture, and broad- spectrum antibiotics are started. High-
resolution computed tomography (HRCT) shows ground-glass opacities and diffuse air
space consolidation bilaterally. HRCT with the patient prone shows resolution of posterior
ground-glass attenuation. What is the most appropriate next step in management?

Choices:

1. Echocardiography
2. Left heart catheterization
3. Right heart catheterization
4. Lung biopsy

Answer: 1 - Echocardiography

Explanations:

Acute interstitial pneumonia (AIP) is a rapidly progressive idiopathic pulmonary

disease that often leads to fulminant respiratory failure and acute respiratory distress
syndrome (ARDS). ARDS is characterized by the rapid onset of diffuse pulmonary
edema without cardiac etiology.
To rule in ARDS, cardiac causes of pulmonary edema must be ruled out.
Echocardiography is needed to rule out cardiomyopathy or valvular dysfunction.
Left heart catheterization is done if initial testing, including troponin levels and
echocardiography, reveals a significant decline in cardiac function that might be
related to ischemia. Right heart catheterization or insertion of a Swan-Ganz catheter
is reserved for inadequately treated severe pulmonary hypertension.

Research Concepts:

Acute Interstitial Pneumonia

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Question 424: A 65-year-old male patient was brought to the emergency department for
non-productive cough, low-grade fever, and severe dyspnea for the past two weeks. He
was diagnosed with HIV eight years ago. His vital signs show blood pressure of 110/70
mmHg, pulse 82/min, temperature 101°F (38.3 C), and a respiratory rate of 21/min. His
oxygen saturation is 93% on room air which drops on exertion. Arterial blood gas analysis
shows a partial pressure of oxygen of 70 mmHg. A chest x-ray reveals bilateral ground-
glass interstitial infiltrates. What should be used for treatment?

Choices:

1. Trimethoprim-sulfamethoxazole alone
2. Ceftriaxone alone
3. Trimethoprim-sulfamethoxazole and corticosteroids
4. Trimethoprim-sulfamethoxazole and ceftriaxone
Answer: 3 - Trimethoprim-sulfamethoxazole and corticosteroids

Explanations:

The most likely diagnosis in this patient is Pneumocystis jirovecii pneumonia.

Trimethoprim-sulfamethoxazole is the treatment recommended for patients with
Pneumocystis jirovecii pneumonia. The parenteral route is recommended in people
with severe disease. New recommendations suggest the use of glucocorticoids in
HIV-infected patients with a room air arterial blood gas partial pressure of oxygen
that is less than or equal to 70 mm Hg, and alveolar-arterial (A-a) gradient greater
than or equal to 35 mm Hg, or hypoxia on pulse oximetry should receive steroids.
Any patients needing corticosteroids should be admitted to the hospital for
monitoring and into the intensive care unit for respiratory failure and continued
monitoring.
Research Concepts:Pneumocystis Jirovecii Pneumonia

Question 425: A 17-year-old female patient presents with complaints of three months of
nonproductive cough, exertional dyspnea, fatigue, and malaise. She denies weight loss,
fever, chills, sweats, recent travel, or sick contacts. On examination, her blood pressure is
135/85 mmHg, her heart rate is 89 beats per minute, and her respiratory rate is 18
breaths per minute. Physical examination reveals she has tender red papules over her
shins. The patient said she first noticed the bumps when she changed oral contraceptive
pills but assumed they would disappear. An X-ray of the chest shows bilateral hilar
lymphadenopathy with pulmonary infiltrates. The culture of bronchoalveolar lavage fluid
is negative. What is the most likely diagnosis?

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Choices:

1. Sarcoidosis
2. Tuberculosis
3. Idiopathic pulmonary fibrosis
4. Histoplasmosis
Answer: 1 - Sarcoidosis

Explanations:

The combination of constitutional symptoms, erythema nodosum, respiratory

complaints, blurred vision, and bilateral hilar lymphadenopathy in a young adult
strongly indicates the diagnosis of sarcoidosis. Erythema nodosum (EN) is a
common acute nodular septal panniculitis characterized by the sudden onset of
erythematous, firm, solid, deep nodules or plaques that are painful on palpation
and mainly localized on extensor surfaces of the legs.
Erythema nodosum is associated with various diseases, such as streptococcal
pharyngitis, infectious mononucleosis, Epstein- Barr virus, and certain drugs.
Bilateral hilar lymphadenopathy on an x-ray of the chest is often seen in sarcoidosis.
Erythema nodosum is a common skin manifestation of sarcoidosis. Elevated serum
angiotensin- converting enzyme (ACE) levels and hypercalcemia are other findings
characteristic of sarcoidosis. Other cutaneous features include lupus pernio, Darier-
Rousy (subcutaneous), Heerfordt syndrome, and scarring alopecia.
While an x-ray of the chest can be indicative of pulmonary tuberculosis, it is
difficult to explain the other findings present in the case by this diagnosis, such as
non-productive cough, absence of fever, and no travel history. X-ray of the chest
may be compatible with histoplasmosis, but the patient lacks the symptoms and
signs typically present in patients with histoplasmosis. The negative culture of
bronchoalveolar lavage fluid goes against this diagnosis. Idiopathic pulmonary
fibrosis may have pulmonary infiltrates and the same clinical presentation but does not
present with erythema nodosum.
Research Concepts: Erythema Nodosum

Question 426: A 35-year-old male with an anterior mediastinal mass and elevated levels of
alpha-fetoprotein, beta-human chorionic gonadotropin, and lactate dehydrogenase has
been undergoing chemotherapy for the last two months. A repeat CT scan of the chest
reveals a large mass extending into the right chest. His tumor marker levels have returned
to normal levels. What is the best next step in therapy?

Choices:
Page 405 of 955
1. Surgical resection
2. Surgical resection followed by radiation therapy
3. Further chemotherapy
4. Observe and repeat CT scan annually
Answer: 1 - Surgical resection

Explanations:

This patient has a non-seminomatous mediastinal germ cell tumor which is

considered a poor-risk disease.
Even though tumor markers have returned to normal, evidence of residual tissue
on CT scan requires surgical intervention because residual germ cell tissue can lead
to growing teratoma syndrome.
This residual tissue is generally a teratoma or scar tissue. Occasionally the CT scan
does not show residual tissue and surgery is not required.

Research Concepts:

Mediastinal Germ Cell Tumors

Question 427: A 45-year old woman is admitted for elective left- sided lobectomy of
upper lobe for lung nodule with suspicion of malignancy. She was diagnosed with a 1.2
cm pulmonary nodule 3 months ago. On repeat CT chest, the size of the nodule increased
to 3 cm. Preoperative flexible bronchoscopy showed an aberrant right- sided tracheal
bronchus originating 5 cm above the carina. During anesthesia, what is the best device
for intraoperative ventilation of this patient?

Choices:

1. Left-sided double-lumen endotracheal tube

2. Regular endotracheal tube and a bronchial blocker
3. Regular endotracheal tube only
4. Right-sided double-lumen endotracheal tube

Answer: 2 - Regular endotracheal tube and a bronchial blocker

Explanations:

As the position of the abnormal tracheal bronchus is too far from carina, a regular
endotracheal tube with a bronchial blocker would be a better approach for
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 ventilation in this patient.
Tracheal bronchus can arise anywhere from the cricoid cartilage to the carina.
Appropriate selection of the endotracheal tube is dictated by the distance of the
tracheal bronchus from carina, whether it is right or left-sided and type of the
surgery.
Due to a higher location than the carina, there is a risk of tracheal bronchus
obstruction by the tracheal cuff of the regular endotracheal tube and possibly with
the left-sided double-lumen endotracheal tube.
Right-sided double-lumen endotracheal tubes are contraindicated in a right-sided
tracheal bronchus.

Research Concepts:

Tracheal Bronchus

Question 428: An 85-year-old woman admitted to the ICU with severe adult respiratory
distress syndrome (ARDS) has been in the ICU for the last two weeks. She has been on a
mechanical ventilator, was given paralytics and proned. Her ARDS improves, and her
requirements come down. She is shifted to pressure support mode with settings of
pressure Support of 5 mmHg, positive end-expiratory pressure (PEEP) of 5 mmHg, and
FiO2 of 40% after stopping all sedation for 30 minutes. Her tidal volume with each breath
is noticed to be 125-150 ccs. Which of the following steps is most appropriate to improve
her tidal volume?

Choices:

1. increase positive end-expiratory pressure (PEEP) to 10 mmHg

2. Increase pressure support to 10 mmHg
3. Increase FiO2 to 80%
4. Wait for ten minutes on current settings

Answer: 2 - Increase pressure support to 10 mmHg

Explanations:

Increasing the pressure support from 5 to 10 mmHg will increase the amount of
air that is pushed into the patient while they take a breath on pressure support
mode of ventilation.
Higher the pressure support on pressure support mode of ventilation, higher is the
tidal volume of each breath taken by the patient.
The pressure support is calibrated based on the endotracheal tube size, patient
Page 407 of 955
 BMI, patient strength, etc. Most studies have determined pressure support of 5 to
be the minimum safe number for extubation consideration. However, this number
changes based on the patient factors as mentioned above.
PEEP improves oxygenation. Likewise, FiIO2 improves oxygenation.

Research Concepts:

Pressure Support

Question 429: A 67-year-old male with a 50-pack-year smoking history presents to the
hospital for dyspnea and productive cough.
He is diagnosed and treated for a COPD exacerbation and is discharged with a scheduled
follow-up in the clinic two weeks later. In the clinic, he has no complaints. The physical
exam is significant for a BMI of 32 but is otherwise unremarkable. Additional workup is
obtained, including a pulmonary function test that demonstrates evidence of severe
obstructive ventilatory defect without evidence of restrictive ventilatory defect and a
blood gas that is significant for a pH of 7.37, PaCO2 of 50 mmHg, and PaO2 of 117 mmHg
on room air. Which of the following, if present, will qualify this patient for a bi- level
positive airway pressure device (BPAP) at home?
Choices:

1. None; the patient qualifies due to COPD with chronic hypercapnic respiratory failure
2. None; the patient qualifies due to thoracic restrictive disorder with hypercapnic
respiratory failure
3. Polysomnography demonstrating apnea-hypopnea index of 32 events/hour
4. The patient does not qualify for BPAP
Answer: 4 - The patient does not qualify for BPAP

Explanations:

There are many indications for BPAP in the chronic setting, including thoracic
restrictive disorder, COPD, and obesity hypoventilation syndrome. However, these
diseases require additional criteria to be met before initiation of BPAP.
Non-invasive ventilation for COPD with stable hypercapnia has been shown to have
survival benefits and improved clinical outcomes. However, this patient would not
qualify as he does not meet the PaCO2 goal of =52 mmHg.
This patient would qualify for a diagnosis of obesity hypoventilation syndrome
(OHS) if his apnea-hypopnea index was 32 events/hour. OHS is defined as obesity
(body mass index =30 kg·m^-2), daytime hypercapnia (arterial CO2 =45 mmHg), and
diagnosis of OSA (apnea-hypopnea index =5 events/hour). Patients with OHS and
coexistent OSA are started on continuous positive airway pressure (CPAP); BPAP is
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 recommended if CPAP is not tolerated or fails to correct ventilation (CO2
=45mmHg).
This patient does not have any evidence of neuromuscular disease or chest wall
deformity, and his pulmonary function test shows no evidence of a restrictive
ventilatory defect. He would not meet the criteria for initiation of BPAP based on
thoracic restrictive disorder.
Research Concepts: Noninvasive Ventilation

Question 430: A 45-year-old man is being evaluated for liver transplantation. He has
hepatitis C cirrhosis, diagnosed 2 years ago. He has a history of intravenous drug use from
20 years ago. The patient complains of worsening shortness of breath for the last 6 weeks.
On exam, his blood pressure is 110/70 mmHg, heart rate 84/ min, and respiratory rate
18/min. He does have any swelling of any part of his body. Spider naevi are present on the
skin. His oxygen saturation is 96% on room air while lying down but decreases to 91% when
he sits up. A chest x-ray does not show any abnormalities.
Which of the following is the next best step in the management of this patient?
Choices:

1. CT chest
2. Pulmonary function tests
3. Nuclear stress test
4. Echocardiography with agitated saline

Answer: 4 - Echocardiography with agitated saline

Explanations:

Hepatopulmonary syndrome (HPS) is the most likely diagnosis. The patient has
platypnoea and orthodeoxia. Contrast- enhanced echocardiography with agitated
saline is the gold standard for diagnosing pulmonary vascular dilatation.
Platypnoea is a worsening of dyspnea when moving from supine to upright position.
Orthodeoxia implies a decrease in PaO2 of more than 5% or more than 4 mmHg
when moving from supine to upright position.
Initial screening involves using a pulse oximeter to evaluate patients' PaO2. O2
saturation 96% signifies PaO2 70 mmHg and is considered a positive screen.
CT chest may show enlarged dilated vessels but are usually done to exclude
pulmonary pathology. Pulmonary function tests may show decreased diffusion
capacity for carbon monoxide.
Research Concepts: Hepatopulmonary
Syndrome

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Question 431: A 65-year-old male presents to the thoracic surgery clinic for six months
follow up cardiac bypass surgery. He reports gradual worsening dyspnea since the time
of discharge. He is not able to walk two blocks without taking a break. He denies chest
pain or a cough and reports that cardiac bypass surgery has not helped him in any way.
He is sleeping in a recliner from the past one month and had to stop swimming as he gets
more short of breath when he gets immersed in water. He has seen a pulmonologist one
week back and got a chest radiograph done which showed decreased lung volume on the
left side. Which other test would help in reaching the diagnosis?

Choices:

1. Spirometery
2. Upper GI endoscopy
3. Bronchoscopy
4. Thoracoscopy

Answer: 1 - Spirometery

Explanations:

Diaphragmatic palsy is a known complication after cardiac bypass surgery seen up

to 30% of patients. The cold cardioplegic solution can cause thermal injury to the
close by phrenic nerve leading to diaphragmatic palsy. It is usually unilateral, and
the left side is commonly involved compared to the right side. Unless there is also a
secondary mechanical injury to the phrenic nerve, the palsy is transient and is
resolved by one week. It is usually diagnosed by the elevated diaphragm in a
postoperative routine chest x-ray.
Patients with diaphragmatic palsy may report orthopnea secondary to decreased
chest excursion in the supine position and also cephalic movements of abdominal
contents. Some patients will report increased dyspnea on immersion in water up to
chest height.
Spirometry shows more than a 15% decline in lung functions when repeated from
sitting to the supine position. Maximum inspiratory pressure is also reduced.
As most palsy resolves spontaneously, no treatment is typically needed. For persistent
symptomatic patients, diaphragmatic plication gives good symptomatic relief.

Research Concepts: Diaphragm Disorders

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Question 432: A 69-year-old man presents to the emergency department with worsening
dyspnea and leg swelling for the last three weeks. He has a 25 pack-year smoking history.
His vital signs include temperature 97.4 F, regular heart rate of 78/min, and blood
pressure of 122/86 mmHg. Physical examination shows jugular venous pulsations 10 cm
above the sternal angle, bilateral pitting edema below the knees, and hepatomegaly. The
cardiac examination does not reveal any abnormal findings. An echocardiogram shows a
left ventricular ejection fraction of 65%.
Lung auscultation reveals scattered wheezes. However, no crackles or rales are heard.
What is the most likely cause of the above findings in this patient?

Choices:

1. Pulmonary vessel vasoconstriction

2. Chronic thromboembolic pulmonary hypertension
3. Pulmonary vessel collagen deposition
4. Left-sided heart failure
Answer: 1 - Pulmonary vessel vasoconstriction

Explanations:

Jugular venous distention, pitting lower extremity edema and hepatomegaly are
the findings in decompensated right-heart failure. The most likely cause of right
heart failure in this patient is chronic hypoxic vasoconstriction of pulmonary
vessels secondary to chronic obstructive pulmonary disease (COPD), given the
history of smoking in this patient. The other causes of secondary pulmonary
hypertension can be systemic sclerosis, chronic thromboembolism, etc. can also
cause right heart failure, but the presentation doesn't support these causes.
Hypoxia in COPD patients over time leads to pulmonary inflammation and
compensatory pulmonary vasoconstriction. These changes subsequently cause
vascular remodeling and increased pulmonary capillary pressure, resulting in
pulmonary hypertension.
Pulmonary hypertension secondary to COPD, when chronic and untreated, can lead
to concentric right ventricular hypertrophy due to increased strain on the right
ventricle. This eventually results in the right heart function to decline.
The left ventricle functions normally, and the left ventricular ejection fraction is not
affected in these patients.

Research Concepts: Secondary Pulmonary Hypertension

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Question 433: A 16-year-old female patient who has asthma is brought in by her parents
as they are planning to stay in their farmhouse this summer. They are worried about
their daughter as she has a history of having an acute exacerbation of asthma on
exposure to pollen. What should she be given to avoid asthma exacerbations?
Choices:

1. Ipratropium
2. Albuterol
3. Cromolyn sodium
4. Salmeterol

Answer: 2 - Albuterol

Explanations:

A beta-agonist is the best option for the prevention of an acute asthma attack. It
can be used for exercise-induced asthma or if a patient is going to be exposed to an
unavoidable trigger.
All patients should be prescribed a short-acting, beta-2 agonist “rescue” inhaler.
Most commonly, this is an albuterol metered- dose inhaler (MDI). Beta-agonist
medications function by binding to beta-adrenergic receptors within the
bronchioles.
This patient would benefit from a low-dose corticosteroid inhaler for prevention.
Budesonide at 180 to 360 µg twice daily is an option.
Cromolyn sodium is a mast cell stabilizer. It stabilizes cell membranes but is only
available for use in a nebulizer. It prevents asthma attacks but is not convenient.
Thus compliance is an issue. Inhaled corticosteroids are used more often for long-
term prevention.

Research Concepts:

Asthma Medications

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Question 434: A 55-year-old nulliparous woman presents to the clinic with complaints of
pleuritic chest pain, lower backache, and constipation. She also complains of
constitutional symptoms of low- grade fever, malaise, generalized fatigue, and loss of
appetite.
Physical examination demonstrates pallor, intercostal fullness, dullness to percussion on
the right lung bases, and reduced breath sounds in the right inframammary region.
Whispering pectoriloquy and egophony are absent. A chest radiograph demonstrates
blunting of the costophrenic angle. Thoracic ultrasonography is performed.
Which of the following possible features on thoracic ultrasound is most suggestive of a
malignant etiology in this patient?

Choices:

1. Pleural thickening more than 0.5 cm

2. Shred sign
3. Diaphragmatic thickening more than 7 mm
4. Echogenic pleural fluid
Answer: 3 - Diaphragmatic thickening more than 7 mm

Explanations:

Malignant pleural effusion due to direct tumor seeding is seen in 2%-12% of breast
cancer patients. While the pleural fluid yield for the diagnosis of malignant pleural
mesothelioma approaches 6%, it approaches 80% in cases of adenocarcinoma.
Ultrasound has a higher sensitivity than chest radiography in the diagnosis of pleural
fluid. Pleural involvement by the tumor is usually visualized as a hypoechoic mass
forming an obtuse angle with the chest wall or a mass with complex echogenicity.
The presence of pleural thickening more than 1 cm, visceral pleural thickening,
pleural nodularity, and diaphragmatic thickening more than 7 mm have been
shown to be associated with increased chances of malignant pleural involvement.
Ultrasound examination has also been shown to be an effective means of diagnosing
residual fluid post thoracentesis, lung re- expansion, and post-procedure
pneumothorax.

Research Concepts:

Malignant Pleural Effusion

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Question 435: A 75-year-old man presented to his primary care physician with fever and a
persistent cough of 3 days. He had lost 15 pounds (7 kg) during the prior 3 months; he had
not been dieting. His social history was remarkable for enjoying both beer and wine. He
was a cigarette smoker; he smoked at least 2 packs per day for the last 50 years. Physical
examination revealed a frail man who was febrile and tachypneic. His right upper lobe of
the lung breath sounds was decreased. Cutaneous examination showed more than 100
benign-appearing pigmented plaques, each approximately 15 x 6 millimeters, located on
his chest and back; after additional inquiry, it was established that the pigmented lesions
had recently all appeared within the last 3 months. Based on his skin lesions, what is the
most appropriate next step evaluation for this patient?

Choices:

1. Chest roentgenogram
2. Echocardiogram
3. Skin biopsy of a single skin lesion
4. Stool sample microscopic examination
Answer: 1 - Chest roentgenogram

Explanations:

Cutaneous melanoacanthoma is a benign rare skin neoplasm. Cutaneous

melanoacanthoma can morphologically mimic other pigmented lesions such as
seborrheic keratosis. Cutaneous melanoacanthoma is not associated with systemic
symptoms such as fever, cough, or weight loss. A chest roentgenogram is the most
appropriate evaluation for this patient. His symptoms are suggestive of
pneumonia. The history of smoking and non- intentional weight loss raises the
possibility of post-obstructive pneumonia secondary to primary lung carcinoma.
The eruptive onset of new benign-appearing pigmented plaques consistent with
seborrheic keratoses presents the possibility of a cutaneous paraneoplastic
syndrome: the sign of Leser-Trelat.
Cutaneous melanoacanthoma typically presents as a single slowly enlarging
pigmented plaque or nodule on the head and neck or trunk. Cutaneous
melanoacanthoma can present as a solitary patch; however, multiple flat pigmented
lesions have not been described in patients with cutaneous melanoacanthoma.
However, in Carney complex [which is also referred to as LAMB (lentigines, atrial
and cutaneous myxoma, and blue nevi) syndrome and NAME (nevi, atrial myxoma,
myxoid neurofibroma, and ephelides) syndrome], there is also endocrine
overactivity (such as Cushing syndrome), Sertoli cell testicular cancer (in men) and
the pigmented lesions appear at an earlier age on both the skin and the mucous
membranes.
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 However, this patient does not have any other features suggestive of the Carney
complex.
Patients with cutaneous melanoacanthoma seldom present with multiple lesions.
However, a cutaneous melanoacanthoma can clinically mimic a seborrheic keratosis.
Cutaneous melanoacanthoma typically presents in elderly individuals older than 60
years. It is usually a single lesion that has been present for a mean duration of 6
years before diagnosis. A stool sample might be considered to evaluate a patient
for a systemic parasitic infection as the etiology of his unintentional weight loss,
fever, and pulmonary symptoms. The lung fluke is a parasitic flatworm that can
cause paragonimiasis. Individuals can acquire the infection by eating crab or
crayfish that not only carry immature flukes but also are undercooked. A
microscopic examination of the stool can detect fluke eggs.
However, neither a cutaneous melanoacanthoma nor a seborrheic keratosis (which
can present with the new onset of multiple pigmented plaques) has not been
associated with paragonimiasis. An echocardiogram might be considered in a
younger individual with multiple flat brown patches (lentigos) to rule out atrial
myxoma. Hence, since the recent onset of multiple benign-appearing pigmented
plaques is more probable to represent numerous seborrheic keratoses, a skin
biopsy of a single lesion would not be the most appropriate evaluation at this time
for the patient with fever, cough, and weight loss.

Research Concepts:

Cutaneous Melanoacanthoma

Question 436: A 42-year-old man with a past medical history of non-Hodgkin lymphoma
presents to the clinic for a follow-up. The patient has been experiencing persistent
cough, chest pain, and fatigue for the last six months. He has been in remission for five
years and fears that lymphoma might be back. His high-resolution CT scan on the last
visit shows bilateral symmetrical areas of ground-glass opacities. Bronchoalveolar
lavage reveals alveolar macrophages engorged with Periodic Acid Schiff (PAS) positive
material and acellular eosinophilic bodies in a background of
eosinophilic granules. Which of the following processes is most likely implicated in the
pathogenesis of this disease?

Choices:

1. Radiation exposure
2. Overactivation of macrophages
Page 415 of 955
3. T-cell mediated injury
4. Dysfunction of macrophages

Answer: 1 - Radiation exposure

Explanations:

The pathology of alveolar proteinosis is attributed to the dysfunction of

macrophages. A number of theories have been proposed.
One theory suggests either impairment of macrophages in clearing secretions or
over-production of the surfactant due to impaired ability of macrophages to clear.
The theory of impaired macrophage function is supported by the association of this
disease with the immunodeficiency diseases causing the dysfunction of macrophages.
Malignancies such as lymphomas have also been implicated in the secondary
causes of alveolar proteinosis.

Research Concepts:

Alveolar Proteinosis

Question 437: A 58-year-old woman with ovarian cancer with recent chemotherapy is
admitted for fever, chills, and burning micturition. She has a fever of 38.9 C, pulse
130/min, blood pressure 90/40 mmHg, and respiratory rate 19/min. She has altered
mental status and is intubated for airway protection and shock. Her FiO2 is 0.25, and PEEP
is 5. Her PaO2 on ABG is 90 mmHg. She is started on norepinephrine after intravenous
fluid resuscitation as she continued to remain hypotensive. On exam, there are mild
bibasilar crackles on auscultation and the chest x-ray shows bilateral infiltrates. Lung
injury prevention score (LIPS) of this patient is 4. (2 points for shock, 1 point for sepsis and
1 point for chemotherapy).
Which of the following best describes the likelihood of this patient developing acute
respiratory distress syndrome (ARDS)?

Choices:

1. Very low
2. Low
3. High
4. Cannot be determined

Page 416 of 955

Answer: 3 - High

Explanations:

LIPS score of 1-3 is considered low score, and these patients are at low risk for
developing ARDS. Low scores have a 95% negative predictive value.
LIPS score of 4 or more had 90% sensitivity but only 31% specific in predicting
patients with ARDS.
Having shock, cardiac surgery, or aortic vascular surgery are some of the strongest
risk factors for ARDS and have the highest score on LIPS score.
Option 1,2 and 4 are incorrect as this patient has LIPS score of 4, and is at high risk
for developing ARDS.

Research Concepts:

Acute Respiratory Distress Syndrome

Question 438: A 16-year-old male is brought to the emergency department after being
found unconscious. He had injected heroin in an abandoned house and was unresponsive
when EMS arrived.
EMS administered 2 mg intranasal naloxone, followed by 2 mg intravenous naloxone.
The patient is now struggling to breathe and has an oxygen saturation of 90% on 15 liters
of oxygen through a nonrebreather mask. The lung exam shows normal resonance to
percussion and bilateral crackles. What will likely be seen on the point of care lung
ultrasound in this patient?

Choices:

1. Lung hepatization
2. Consolidation at the apex
3. Lack of pleural sliding
4. Numerous B lines on a single view
Answer: 4 - Numerous B lines on a single view

Explanations:

This patient likely has acute pulmonary edema associated with opioid overdose and
naloxone administration.
Page 417 of 955
 Pulmonary ultrasound will show B lines and can show pleural effusion.
This patient requires positive pressure ventilation, bilevel positive airway pressure
(BiPAP), or move directly to endotracheal intubation and mechanical ventilation.
Pulmonary ultrasound will show lung hepatization in pneumonia.

Research Concepts:

Heroin

Question 439: A 16-year-old male with severe acute respiratory distress syndrome due to
influenza requires venovenous Extracorporeal membrane oxygenation (ECMO) for
refractory hypoxemia and hypercarbia. The intensive care unit team wishes to have a
cooperative patient that is not completely sedated. They elect to trial dexmedetomidine
for sedation and analgesia. Despite a dose of 0.7 mcg/kg/hr, the patient is agitated,
tachycardic, and hypertensive. The resident elects to continue to increase the dose of
dexmedetomidine. What is the maximum dose of a dexmedetomidine infusion?

Choices:

1. 0.7 mcg/kg/hr
2. 1.5 mcg/kg/hr
3. 2.5 mcg/kg/hr
4. No maximum exist
Answer: 4 - No maximum exist

Explanations:

The package insert states dosing recommendations of 0.2 to 0.7 mcg/kg/hr.

Doses higher than 1.5 mcg/kg/hr are commonly used. There is no evidence
that infusion rates higher than 1.5 mcg/kg/hr provide any additional benefit.
There is no maximum that exists but hemodynamic adverse effects will likely limit
the dosing rate.

Research Concepts: Dexmedetomidine

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Question 440: A 65-year-old man is brought by his daughter to the emergency
department with complaints of high-grade fever, severe chest pain, and hemoptysis for
the past two days. The patient just finished his last dose of chemotherapy for non-Hodkin
lymphoma last week. Presently, he has a temperature of 38.3 C (102 F), blood pressure of
123/78 mm Hg, pulse of 122/min, respirations of 18/min, and oxygenation saturation of
93% on room air.
Laboratory studies reveal an absolute neutrophil count of 208 cells/mm3. A chest x-ray
shows segmented infiltrates. The patient is admitted, and presumptive treatment is
begun for community- acquired pneumonia. The patient is started on broad-spectrum
antibiotics. Blood and sputum cultures are sent for bacterial and fungal growth. By day
three, the patient has not improved. He continues to have high-grade fevers and a
worsening cough.
Bronchoscopy with bronchoalveolar lavage and biopsy is performed on the fourth day of
hospitalization. Histopathologic examination of the tissue and lavage fluid reveals narrow,
septated hyphae with acute angle branching. Fungal cultures obtained at admission also
grow a similar organism. In addition to discontinuing the broad- spectrum antibiotics,
which of the following is the most appropriate step in management?

Choices:

1. Start miconazole
2. Start amphotericin B and nystatin
3. Start voriconazole with or without caspofungin
4. Start cefepime and tetracycline

Answer: 3 - Start voriconazole with or without caspofungin

Explanations:

Invasive aspergillosis should be suspected in someone who is

immunocompromised (neutropenia, steroids, HIV) with severe chest pain, high-
grade fevers, and hemoptysis.
The treatment of choice for invasive aspergillosis is voriconazole with or without
caspofungin.
Liposomal amphotericin B is used if the patient is intolerant to voriconazole.
Miconazole is a nonabsorbed antifungal agent, FDA approved for the treatment of
oropharyngeal candidiasis.

Research Concepts: Aspergillosis

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Question 441: A 65-year-old female patient presents to the emergency department after
being found at her nursing home with an acute altered mental state. History is unable to
be obtained due to a lack of collateral information. As per the nursing home attendant
accompanying the patient to the hospital, the patient had a renal transplant four months
ago and has been following with her transplant nephrologist regularly. A chest X-ray is
significant for diffuse bilateral infiltrates. She is intubated and transferred to the medical
ICU for further management. What is the best way of reaching a definitive diagnosis in
this patient?

Choices:

1. CT thorax without contrast

2. LDH levels
3. CT brain with contrast
4. Bronchoscopy with lavage and silver staining

Answer: 4 - Bronchoscopy with lavage and silver staining

Explanations:

Solid-organ transplant patients are on immunosuppressive therapy to prevent

organ rejection and are susceptible to many infections.
The term Immunocompromised implies individuals with any impairment of
resistance to infections. There are three subsets to which the immunosuppressed
individual could be further classified. These categories are neutropenic, humoral
immunodeficient, and cellular immunodeficient. It is common for the
immunocompromised host to have multiple pulmonary disease processes
coexisting during the acute phase of infection. This is a combination of community-
acquired, nosocomial, Pneumocystis Pneumonia (PCP), viral and/or fungal
infections.
Complete blood count with differential, comprehensive chemistry, HIV testing with
viral load, and blood cultures should be obtained on initial evaluation as well.
Further research has indicated that immunocompromised patients not infected
with HIV, presenting with normal chest x-ray with elevated lactate dehydrogenase
levels in the setting of unexplained respiratory symptoms, had a much higher
percentage of PCP pneumonia. Thus, these individuals should have much lower
thresholds for performing a CT scan of the thorax. Recent data have suggested the
use of nucleic acid amplification to quickly develop targeted therapy.
A definitive diagnosis is made with sputum cultures and PCR analysis obtained by
induced sputum or bronchoalveolar lavage via bronchoscopy in select patients.
These results are significantly important in the immunocompromised without HIV

Page 420 of 955

 infection as lower counts of specific organisms (such as PCP) still indicate significant
results. Invasive procedures such as bronchoscopy are best to be considered early in
management.

Research Concepts:

Pneumocystis Jirovecii Pneumonia

Question 442: A 45-year-old man comes for a follow-up evaluation. His pulmonary
function test results show FEV1 is 76% of predicted, FVC is 72% of predicted, elevated
FEV1/FVC, with normal DLCO. He was initially referred for persistent daytime sleepiness
despite good sleep hygiene, with consistent nine hours of sleep a night. He has recently
developed leg cramps after walking. He has a 30-pack-year smoking history. Vital signs are
stable. Physical exam reveals a neck circumference of >38 cm. His peripheral pulses of
lower extremities are decreased. What is the most likely etiology of persistent sleepiness?

Choices:

1. Restless leg syndrome

2. Interstitial lung disease
3. Smoking
4. Obesity
Answer: 4 - Obesity

Explanations:

The patient’s mildly reduced pulmonary function tests indicate a restrictive disease,
such as obesity. Obesity causes a physical and mechanical compression of the chest
cavity and diaphragm. Respiratory muscles have an increased work of breathing
with increased airway resistance. The extra-abdominal adipose tissues decrease
diaphragmatic movement, leading to quicker, shallower breaths in order to
maintain oxygenation and perfusion.
Obesity also contributes heavily to obstructive sleep apnea, which presents with
daytime sleepiness despite an adequate number of hours slept at night.
A neck circumference > 35.5 cm in men and >32 cm in women indicates obesity.
Smoking does not cause daytime sleepiness. Restless leg syndrome may cause daytime
sleepiness, but the patient usually gives a history of unusual leg sensation while
sleeping.
Research Concepts:

Obesity
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Question 443: A 65-year-old man with a 30 pack-year smoking history presents to the
clinic for fatigue and cough. His symptoms started ten months ago and have progressively
worsened. He has noticed a couple of episodes of blood-tinged sputum while coughing. He
has lost 10 pounds (4.5 kg) in the last four months. Grade 2 clubbing is present on the
general examination. A CT scan of the thorax shows a 10 mm left endobronchial lesion.
Which of the following is the next step in management?

Choices:

1. Surgical lung biopsy

2. Transbronchial lung biopsy
3. CT guided percutaneous lung biopsy
4. Video-assisted thoracoscopic surgery (VATS)
Answer: 2 - Transbronchial lung biopsy

Explanations:

For central and endobronchial lesions, bronchoscopy with bronchoalveolar lavage

with or without transbronchial biopsy is indicated.
Transbronchial biopsy is useful for diffuse as well as localized pulmonary disorders.
It is often the primary diagnostic modality when sarcoidosis, interstitial lung
disease, hypersensitivity pneumonitis, infective etiology like tuberculosis, or lung
disease of unclear etiology is suspected.
Transbronchial biopsy is not as sensitive as percutaneous lung biopsy except for
lesions less than 2 cm. Also, it has a lower diagnostic yield in general as compared to
surgical and percutaneous lung biopsies.
Open or surgical biopsy (OLB) has been considered the gold standard for the diagnosis
of lung parenchymal lesions.
However, a trial of a less invasive method is usually preferred unless any major
contraindications and OLB should be considered only when obtaining a diagnosis
would change the line of management, and the underlying disease does not have
high mortality.

Research Concepts:

Lung Biopsy Techniques And Clinical Significance

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Question 444: A 17-year-old female has cystic fibrosis but stays as active as possible and
requires oxygen with exertion. Her sputum culture report reveals the colonization of
Staphylococcus aureus and Pseudomonas aeruginosa. On a spirometry exam, the forced
expiratory volume in one second (FEV1) is 26%, and the forced expiratory volume in one
second/forced vital capacity (FEV1/FVC) ratio is 40% of the predicted value. Arterial blood
gas analysis on room air shows a pH of 7.40, PO2 of 60 mmHg, and PCO2 of 44 mmHg.
What is the most appropriate management?

Choices:

1. Surveillance with biennial pulmonary function test

2. Maximize the dosage of the corticosteroid inhalers
3. Lobectomy of the most affected lung lobes
4. Double lung transplantation
Answer: 4 - Double lung transplantation

Explanations:

Indications for lung transplantation in those patients affected with cystic fibrosis
include FEV1 of less than 30% of the predicted value, PO2 less than 50 mmHg on
room air, increasing hospitalizations, recurrent hemoptysis, or pulmonary
hypertension.
Causes of death in the early postoperative period are due to graft dysfunction,
non-cytomegalovirus (CMV) infections, acute rejection, and cardiovascular failure.
In patients with cystic fibrosis, both lungs must be transplanted. If only one lung is
transplanted, the chronically colonized lung will transfer the bacteria to the newly
transplanted lung, and the new lung will fail.
Primary graft dysfunction is the most important postoperative complication.
Injuries to the graft may occur during harvesting, transportation, and
implantation.

Research Concepts:

Lung Transplantation

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 Question 445: A 48-year-old woman presents to the hospital with severe shortness of
breath with associated fever, sweats, weakness, myalgias, and weight loss. She has a past
medical history of severe facial burns from a house fire as a child that left her blind. She is
also a carrier of sickle trait. She had a permanent tracheostomy and required mechanical
ventilation for a prolonged period after the fire due to inhalation injuries. She lives at
home with her mother who helps her with household activities as well as provides
tracheostomy care. She does not smoke or drink alcohol.
On arrival, vitals reveal temperature 38.2 C, heart rate 102/minute, respiratory rate
26/minute, blood pressure 98/72 mmHg and requiring 4 liters of supplemental oxygen
via nasal cannula.
Computed tomography (CT) thorax reveals multiple opacities in the right middle and
lower lung zones. Labs are significant for leukocytosis with elevated C-reactive protein
(CRP) and erythrocyte sedimentation rate (ESR). Despite treatment with antibiotics and
bronchodilators, her oxygen requirements remain high. CT guided percutaneous
transthoracic needle lung biopsy reveals foamy macrophages with lipid-filled
granulomas. Which of the following is the most likely mechanism of her lung injury?

Choices:

1. Prolonged foreign body reaction to fat

2. Chronic bony infarcts
3. Mutations in p53 tumor suppressor gene
4. Surfactant accumulation and leakage of proteinaceous fluid within alveoli
Answer: 1 - Prolonged foreign body reaction to fat

Explanations:

Tracheostomy care often involves lubrication of tracheostomy cannula with

petroleum jelly or mineral oils, both containing a fatty substance, which puts the
patient at risk for exogenous lipoid pneumonia (ELP). ELP has been reported with
chronic inhalation of these fatty substances due to chronic foreign body reaction to
fat.
Characteristic histological features include lipid-laden macrophages obtained by
bronchoalveolar lavage or lung biopsy. Special stains used to identify lipids include
oil red O or Sudan staining.
Exogenous lipoid pneumonia is due to the inhalation of oily products. It can be
acute due to the massive inhalation of fatty substances or chronic with long-term
exposure to irritants. The pathophysiologic mechanism of lung injury is due to
chronic foreign body reaction to fat. Fatty products are taken up by alveolar
macrophages that cannot metabolize the substance and leads to chronic
granulomatous reaction.
Page 424 of 955
 Computed tomography (CT) findings of exogenous lipoid pneumonia can mimic
bacterial pneumonia on imaging. Bronchoalveolar lavage or lung biopsy is needed
to confirm the diagnosis of ELP. The most characteristic CT findings in lipoid
pneumonia include bilateral ground-glass opacities and airspace consolidation.

Research Concepts: Lipoid Pneumonia

Question 446: A 57-year-old male with a history of asthma, diabetes mellitus type 2,
hypertension, hyperlipidemia, obstructive sleep apnea, coronary artery disease presents
with complaints of shortness of breath and cough. Vital signs include temperature 99F,
heart rate 89/min, blood pressure 134/84 mmHg. The physical exam is remarkable for
significant wheezing in the lungs. Laboratory values show WBC 9,200 cells/mm3 and
lactic acid 0.9 mg/dl.
Urinalysis is unremarkable. Chest x-ray shows a hyper expansion of the lungs, but no
infiltrates or fluid. The patient is admitted to the hospital for asthma exacerbation and
started on IV steroids. Upon arrival to the floor, the patient decompensates quickly and
is intubated and placed on the ventilator. The patient has a prolonged stay on the
ventilator, and on day 4 of hospitalization, the patient spikes a temperature of 102 F
(38.8 C). Chest x-ray now reveals an infiltrate in the left middle lobe. Which of the
following increases his risk for infection with multidrug-resistant pathogens in this
patient?
Choices:

1. Diabetes mellitus type 2

2. Asthma
3. IV steroids
4. Ventilator-associated pneumonia
Answer: 4 - Ventilator-associated pneumonia
Explanations:

The patient did not have any signs of infection at the time of the presentation. He
was admitted for asthma exacerbation. But later in the hospital course, on day 4,
he was found to have a fever and an infiltrate in the lungs. He has ventilator-
associated pneumonia (VAP).
Multidrug-resistant organisms (MDR) are also a significant cause of infections in the
hospitals, particularly in the intensive care unit, with a propensity to increase the
length of stay and mortality. MDR organisms are resistant to at least two antibiotics
of different classes or mechanism of action, often suspected of hospital-acquired
pneumonia and ventilator-associated pneumonia.
Page 425 of 955
 Antibiotic treatment selection and duration of antibiotics in ventilator-
associated pneumonia should be targeted based on the infection, suspected
organisms, and clinical picture of the patient. The usual treatment is seven days
of antibiotics, but a longer duration might be needed in ventilator-associated
pneumonia.
Diabetes mellitus type 2, asthma, and steroid use per se are usually not associated
with multidrug-resistant (MDR) pathogens.
Research Concepts: Hospital Acquired
Infections

Question 447: A 55-year-old woman undergoes surgical resection of a conspicuous

peripherally located lung mass. Histologic evaluation reveals a predominant cystic
component filled with pools of mucin surrounded by a fibrous wall. The abundant pools of
mucin are growing within and distending the airspace. The surface of the fibrous wall is
lined by well-differentiated cuboidal mucinous epithelium. What is the most likely
diagnosis?

Choices:

1. Mucinous cystadenocarcinoma
2. Colloid adenocarcinoma with cystic changes
3. Lymphoepithelial adenocarcinoma
4. Cribriform adenocarcinoma

Answer: 2 - Colloid adenocarcinoma with cystic changes

Explanations:

Colloid adenocarcinoma shows extracellular mucin in abundant pools. This often

distends alveolar spaces with the destruction of their walls. The mucin pools
contain clusters of mucin- secreting tumor cells. The surrounding tumor cells often
contain goblet cells or may contain other mucin secreting cells.
Colloid adenocarcinoma is found more often as mixed adenocarcinoma than as a
pure subtype. A tumor is classified as a colloid adenocarcinoma when it is the
predominant component.
The previous terminology of mucinous cystadenocarcinoma is no longer used.
Patients with these histologic features should be classified as colloid
adenocarcinoma with cystic changes.
Other uncommon variants of invasive adenocarcinoma include enteric-like,
lymphoepithelial, and fetal adenocarcinomas.

Page 426 of 955

Research Concepts:

Lung Cancer

Question 448: A 55-year-old woman presents after coughing up blood. She has had a dry
cough for 1 month, which she put down to seasonal allergies. She is a smoker with 12
pack-year smoking history. A lung biopsy shows atypical squamous and glandular cells.
There is no evidence of cells of neuroendocrine origin. On chest radiography, which of
the following would be the most likely earliest presentation of this cancer?

Choices:

1. Cavity
2. Solitary nodule
3. Hilar adenopathy
4. Consolidation
Answer: 2 - Solitary nodule

Explanations:

A solitary pulmonary nodule (SPN) is seen in the majority of non-small cell

cancer.
Ninety-five percent of patients with non-small cell lung cancer (NSCLC) are
symptomatic at presentation, and most have some evidence of lung pathology on
chest x-ray.
The majority of solitary pulmonary nodules are not malignant, but depending on
clinical and imaging context, many require workup.
The workup of an SPN may vary and can involve careful history, comparison to old
studies, CT (including dynamic contrast enhancement characteristics), and positron
emission tomography-computed tomography (PET/CT).

Research Concepts:

Non Small Cell Lung Cancer

Page 427 of 955

Question 449: A 68-year-old male presents four weeks after left upper lobectomy for non-
small cell lung cancer, with complaints of fever, chills, and shortness of breath. On arrival,
his temperature is 101 degrees Fahrenheit (38.3 C), heart rate is 120 beats per minute,
respiratory rate is 28 per minute, blood pressure is 70/50 mmHg, and oxygen saturation is
88% on room air. Pertinent examination reveals reduced breath sounds on the left side.
He is started on supplemental oxygen. A chest x-ray reveals hydropneumothorax on the
left side. He is started on fluid resuscitation, broad-spectrum antibiotics, and an urgent
chest tube thoracostomy is done with purulent drainage and a continuous air leak. What
is the next best step in management?

Choices:

1. Urgent operating room for reclosure of the bronchial stump

2. Discontinue the chest tube after the initial drainage of purulent fluid
3. Conservative management with antibiotics and continuous chest drainage
4. After initial drainage, apply sclerosing agents such as talc and bleomycin for
pleurodesis
Answer: 3 - Conservative management with antibiotics and continuous chest drainage

Explanations:

The patient most likely has a bronchopleural fistula secondary to the dehiscence of the
bronchial stump due to infection.
These patients should undergo urgent drainage of the pleural cavity with a chest
tube thoracostomy. They should be managed conservatively with adequate
antibiotics, continuous drainage until the infection is controlled and fully treated.
Reclosure of the bronchial stump should be done after the clearance of the infection.
Pleurodesis is not advised in acute settings with smoldering infections.
Suture reclosure of the bronchial stump with vascularized flap coverage is curative
for the fistula presenting acutely, normally less than two weeks after surgery. The
patient has a bronchopleural fistula with an ongoing leak, discontinuing chest tube
is not advised and should be undertaken only when the leak has stopped.

Research Concepts: Bronchopleural Fistula

Page 428 of 955

Question 450: A 65-year-old woman with a past medical history of prediabetes presents
with dyspnea on exertion that has become progressively worse over the past month.
Associated symptoms include cough productive of clear sputum. She denies hemoptysis,
fever, chills, recent sick contacts, or travel. She has no history of smoking and takes only
metformin. On physical exam, fingernails and toenails are thickened and yellow; however,
no cracking or maceration of the feet is present. A chest radiograph is significant for
unilateral right pleural effusion without any signs of mass, consolidation, or
lymphadenopathy. Thoracocentesis is performed and is consistent with exudative pleural
effusion. Which of the following additional findings is most likely to be discovered on a
physical exam?

Choices:

1. Lymphedema
2. Positive hepatojugular reflex
3. Increased tympany on percussion of the right lung field
4. Fluorescence of toes under Wood's lamp
Answer: 1 - Lymphedema

Explanations:

Yellow nail syndrome consists of 1) slow-growing, yellow nails,

2) lymphedema, and 3) pulmonary manifestations, such as pleural effusion, chronic
cough, or recurrent infections.
Analysis of pleural fluid after thoracentesis in a patient with yellow nail syndrome
is usually exudative, with high pleural fluid protein compared to serum protein and
normal LDH.
The diagnosis of yellow nail syndrome requires only two of the three clinical
signs/symptoms (yellow nails, lymphedema, and pulmonary manifestations). Nails
usually are slow-growing, and unlike nails in onychomycosis, they do not usually
fluoresce under Wood's lamp as the discoloration is not due to fungal infection.
Nails can be clear yellow to yellow-brown in color.
The lower extremities are the most common area for lymphedema in yellow nail
syndrome, but it can also be seen in other locations, such as the upper extremities.

Research Concepts: Yellow Nail Syndrome

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Question 451: A 40-year-old female presents to the clinician with a history of recurrent
episodes of productive cough. She denies any weight loss, hemoptysis, and recent travel.
She states she is a life long non-smoker. She was seen in the past for the same problem
and was diagnosed with chronic bronchiectasis. Examination reveals coarse crackles and
rhonchi in the right upper lung lobe. A chest x- ray showed a right upper lobe opacity. A
review of records indicates that this is her fifth time in the same year, where she has
recurring new infiltrates in the right upper lung lobe evident on chest x-ray and chest CT
scans. Which of the following is the best imaging modality to examine the
tracheobronchial tree anomalies?

Choices:

1. Flexible bronchoscopy
2. 3D multidetector CT chest
3. MRI chest
4. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan
Answer: 2 - 3D multidetector CT chest

Explanations:

Multidetector 3D CT chest is the best imaging modality to examine

tracheobronchial tree anomalies.
Multidetector 3D CT reveals a better understanding and relationship of the
tracheobronchial tree with the surrounding vascular structures.
The addition of 3D technology plays a pivotal role in the treatment decisions of
the tracheal bronchus. It helps identify the pulmonary vasculature variation
before surgery so that necessary steps can be taken, and patient outcomes can
be improved.
Studies have shown that multidetector 3D CT is superior to MRI chest.
Research Concepts:

Tracheal Bronchus

Question 452: A 45-year-old woman with no past medical history is seen in the emergency
department for fevers, chills, cough, and hemoptysis. She is admitted to the hospital and
diagnosed with multidrug-resistant tuberculosis. Which of the following best describes
multidrug-resistant tuberculosis (TB)?

Choices:

1. Resistance to one TB drugs

Page 430 of 955
2. Resistance to two TB drugs (but not both isoniazid and rifampin)
3. Resistance to isoniazid and rifampin
4. Resistance to isoniazid and rifampin, plus resistance to any fluoroquinolone
and 1 of the 3 injectable second-line drugs
Answer: 3 - Resistance to isoniazid and rifampin

Explanations:

Drug resistance in tuberculosis is defined specifically. Multidrug- resistant tuberculosis

is defined as resistance to both isoniazid and rifampin.
Monoresistant tuberculosis is resistance to any single TB treatment.
Poly-resistant tuberculosis is resistance to two TB drugs (but not both isoniazid and
rifampin).
Extensively drug-resistant tuberculosis is resistance to isoniazid and rifampin, plus
resistance to any fluoroquinolone and 1 of the 3 injectable second-line drugs.

Research Concepts:

Active Tuberculosis

Question 453: A 24-year-old man with no significant past medical history presents with
worsening dyspnea, cough productive of yellow-brown sputum, and one episode of
hemoptysis. A week ago, a chest x-ray ordered by a primary care provider showed left
perihilar and right basilar interstitial prominence, and the patient was prescribed oral
azithromycin 500 mg x 1 dose on day 1, followed by 250 mg daily on days 2-5. He denies
previous similar symptoms or previous hospital admission for pneumonia. He also denies
recent sick contacts or recent travel. He admits to vaping tetrahydrocannabinol (THC) oil
cartridges for the last 3-4 years but denies smoking tobacco. A complete blood count is
remarkable for mild leukocytosis and elevated erythrocyte sedimentation rate (ESR) and
C-reactive protein (CRP). Blood cultures and respiratory viral polymerase chain reaction
(PCR) are negative. CT chest shows bilateral diffuse interstitial and mixed infiltrates. The
patient's dyspnea worsens after hospital admission, requiring a non- rebreather mask
and high-dose intravenous corticosteroid therapy.
Given the likely diagnosis, what is the cause of this patient's condition?

Choices:

1. Tetrahydrocannabinol
2. SARS-COV 2
Page 431 of 955
3. Vitamin E acetate
4. Nicotine
Answer: 3 - Vitamin E acetate
Explanations:

Given this patient's history, he is most likely suffering from vaping-associated

pulmonary injury. Absence of recent travel history or sick contacts and negative
blood cultures and respiratory viral PCR exclude viral pneumonia.
E-cigarettes function by heating a liquid to produce an aerosol that users inhale
into their lungs. Vitamin E acetate is an additive, more notably in THC-containing e-
cigarettes.
Current literature and laboratory data show that vitamin E acetate is strongly linked
to an outbreak of e-cigarette or vaping- associated lung injury (EVALI).
Vitamin-E oil, which does not cause harm when ingested as a vitamin supplement
or applied to the skin, is known to cause a severe inflammatory reaction in the
pulmonary parenchyma when inhaled.

Research Concepts: Vaping Associated Pulmonary Injury

Question 454: A 29-year-old woman presents to the emergency department with

difficulty moving her legs. Three days ago, she started having weakness in the lower
limbs with some paresthesias. Now, she can barely walk, and she complains of some
shortness of breath. The patient's history is irrelevant except for an upper respiratory
tract infection two weeks ago that has now resolved. On examination, her temperature
is 36.5 C (97.7 F), the pulse is 120/min, and the blood pressure is 120/80 mm Hg while
lying supine, and 98/68 mm Hg upon standing. Physical examination shows marked
weakness affecting the lower extremities bilaterally. Ankle and knee reflexes are absent,
but sensations are normal. She undergoes pulmonary function testing for the evaluation
of her shortness of breath. She starts the test by taking normal breaths.
The values recorded on the screen are small compared to healthy individuals. Which of
the following is most likely responsible for the volume change?

Choices:

1. Antibodies against the acetylcholine receptors in the

neuromuscular junction
2. Demyelination of phrenic nerve fibers
3. A genetic mutation affecting a muscular component
4. Antibodies against the presynaptic calcium channels
Answer: 2 - Demyelination of phrenic nerve fibers
Page 432 of 955
Explanations:

The patient's symptoms of progressive ascending muscle weakness, paresthesia,

and autonomic dysfunction following an upper respiratory tract infection are most
likely consistent with Guillain-Barré syndrome. The condition is caused by
antibodies attacking the peripheral nerves.
During spirometry, the patient takes a normal breath, followed by a maximum
inhalation, a maximum exhalation, and then another normal tidal breath.
Tidal Volume (Vt) refers to the volume of air moved during normal inspiration and
expiration.
The primary muscle of inspiration is the diaphragm, which is innervated by the
phrenic nerve. As Guillain-Barré syndrome progresses, it affects the phrenic nerve
leading to diaphragmatic dysfunction and a resultant decrease in tidal volume.

Research Concepts: Physiology, Tidal Volume

Question 455: Which respiratory parameter meets criteria for successful weaning?

Choices:

1. Inspiratory pressure = -22 cmH2O

2. PCO2 = 55 mmHg
3. PEEP = 15 cmH2O
4. PO2 = 60 mmHg on FiO2 60%

Answer: 1 - Inspiratory pressure = -22 cmH2O

Explanations:

An inspiratory pressure that is lower than -20 cmH2O is a criterion for mechanical
ventilator weaning.
Vital capacity must be greater than 15 mL/kg.
PaO2 must be greater than 60 mmHg on 40% oxygen. PCO2 must be less than
45 mmHg.

Research Concepts:

Ventilator Management

Page 433 of 955

 Question 456: A 55-year-old man with a 40 pack-year smoking history presents to the
hospital with complaints of double vision and pain in the right shoulder that radiates
down the right arm. He also reports a history of significant weight loss. Physical
examination demonstrates pallor, right-sided ptosis, miosis, left supraclavicular
lymphadenopathy, and apparent enophthalmos. Systemic examination reveals the
presence of reduced air entry with the presence of egophony and whispering
pectoriloquy. Which of the following features of conventional cytology is most likely to
affect its usefulness in diagnosing this patient?
Choices:

1. Low yield
2. Low sensitivity
3. Low specificity
4. Lack of reproducibility
Answer: 2 - Low sensitivity

Explanations:

This patient has presented with a history suggestive of possible lung malignancy
(Pancoast tumor). The systemic findings point towards a diagnosis of pleural
effusion. Though malignant pleural effusion is exudative in nature, transudative
effusion may be seen in a minority of cases.
A volume of 40-60 mL of pleural fluid is usually considered adequate in performing
a cytological analysis. Light’s criteria (proposed by Richard Light) include pleural
fluid protein to serum protein ratio more than 0.5, pleural fluid LDH to serum LDH
more than 0.6, and pleural fluid LDH more than two-thirds of the serum LDH is
used to diagnose an exudative pleural effusion.
The following pleural fluid parameters usually point towards the diagnosis of
malignant etiology: pH less than 7.30, LDH levels greater than 1000 U/L, reduced
pleural fluid glucose concentration (30-50 mg/dL), and lymphocyte values greater
than 50%-70%. Other markers that have been shown to indicate malignant
involvement of the pleura include elevated levels of carcinoembryonic antigen,
mucin, and Leu1.
While the use of a cell block and cytocentrifuge have been proposed to increase
detection, low sensitivity continues to be a deterrent to the use of conventional
cytology in the diagnosis of malignant pleural effusion. This can be attributed to a
continued inability to distinguish malignant cells from reactive mesothelial cells.
Overcrowding of cells and processing artifacts may also contribute to the low yield.
Research Concept: Malignant Pleural Effusion

Page 434 of 955

Question 457: A patient with a long history of a congenital heart disorder is found to have
an increased Lovibond angle. What is associated with this finding?

Choices:

1. Pulmonary hypertension
2. Clubbing
3. Endocarditis
4. Aortic regurgitation

Answer: 2 - Clubbing

Explanations:

Lovibond angle is the angle between the nail plate base and the adjacent skin.
This angle is usually less than 180 degrees. If the angle is
more, it is a sign of clubbing.
People who develop clubbing will show obliteration of a diamond-shaped window
at the base of the nail bed when the dorsal surface of two fingers from opposite
hands are opposed. (Schamroth sign).

Research Concepts:

Nail Clubbing

Question 458: A 30-year-old female at 20 weeks of gestation presents with acute

shortness of breath. On physical examination, she is tachypneic with low-normal oxygen
saturation. Her chest radiograph is normal. She subsequently undergoes a V/Q scan,
which does not show any mismatched defects but does show increased uptake in the
thyroid gland. Which of the following is the next step in the management of this
patient?

Choices:

1. Renal ultrasound
2. Computed tomography angiography (CTA)
3. Repeat the V/Q scan
4. Echocardiogram

Answer: 4 - Echocardiogram
Page 435 of 955
Explanations:

One of the differentials for this patient's presentation is a pulmonary embolism.

However, other causes of dyspnea should also be considered. Imaging options include
a CT PE study, or V/Q scan, both of which have similar radiation exposure. In pregnant
women, only the perfusion component of the scan is performed.
Peripheral, wedge-shaped mismatched defects, i.e., a perfusion defect without a
ventilation defect in areas without any radiographic abnormality, are concerning for
pulmonary emboli on a V/Q scan.
The presence of uptake in systemic vascular beds such as the thyroid gland,
kidneys, and brain indicates that the tracer has entered systemic circulation,
raising concern for a right-to-left shunt, which may also be contributing to the
patient's presentation, thus prompting cardiac workup.
One must be aware of important incidental findings that may alter the
management of a patient, even if they are not directly associated with the
indication for the study.

Research Concepts:

Lung Imaging

Question 459: A 72-year-old male is evaluated in the neurological intensive care unit
after being admitted for a subarachnoid hemorrhage. He has a past medical history of
bilateral lung transplants for idiopathic pulmonary fibrosis. He currently is on tacrolimus
and prednisone at home. He has an intraventricular drain placed, and his intracranial
pressure is continuously being monitored. His sedation was weaned off to maintain a
Richmond agitation-sedation scale (RASS)of 0 to -1. The patient becomes febrile with
worsening hypoxemia with an alveolar infiltrate bilaterally on the chest x-ray.
Bronchoscopy for bronchoalveolar lavage is planned. What is the best strategy for
sedation for bronchoscopy?

Choices:

1. Maintain light sedation to assess frequent mentation.

2. Deep sedation and paralysis if needed.
3. Use ketamine as a sedative of choice.
4. No sedation in a patient with subarachnoid hemorrhage should be used. Adequate
topical lidocaine should suffice.

Answer: 2 - Deep sedation and paralysis if needed.

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Explanations:

This patient has an intracerebral hemorrhage and is susceptible to even small

changes in intracranial pressure changes.
Bronchoscopy can lead to a sudden increase in intracranial pressures by the
mechanism of coughing and increasing intrathoracic pressures.
Deep sedation with propofol is the preferred way with patients undergoing
bronchoscopy.
However, despite adequate topical anesthesia and propofol, the patient has coughing
episodes, and neuromuscular blockade should be used.
These patients may still, however, have transient increases in their intracranial
pressure and would decrease post procedurally. Ketamine should never be used for
patients who are susceptible to intracranial pressure changes, as it can increase
intracranial pressure.

Research Concepts: Bronchoscopy

Question 460: A 65-year-old male presents with severe shortness of breath and
productive cough. He is intubated and ventilated. However, his respiratory status
continues to deteriorate, requiring a high fraction of inspired oxygen (FiO2) of 0.9 to
maintain oxygen saturation of 88% to 92%. A chest x-ray shows diffuse bilateral
infiltrates. Given the likely diagnosis, which of the following is a recognized component
of the management strategy in this condition?

Choices:

1. Mechanical ventilation with high tidal volume

2. Standard ventilation with high tidal volumes
3. Positioning at 45 degrees
4. Lung-protective ventilation
Answer: 4 - Lung-protective ventilation

Explanations:

Acute respiratory distress syndrome (ARDS) is defined as an acute disorder that

starts within 7 days of the inciting event and is characterized by bilateral lung
infiltrates and severe progressive hypoxemia in the absence of any evidence of
cardiogenic pulmonary edema.
A lung-protective ventilatory strategy is advocated to reduce lung injury. The NIH-
NHLBI ARDS Clinical Network Mechanical Ventilation Protocol (ARDSnet) sets the
following goals: tidal volume (V) from 4 to 8 mL/kg of ideal body weight (IBW),
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 respiratory rate (RR) up to 35 breaths per minute, SpO2 88% to 95%, plateau
pressure (P) less than 30 cm H2O, pH goal 7.30 to 7.45, and inspiratory-to-
expiratory time ratio less than 1.
To maintain oxygenation, ARDSnet recognizes the benefit of positive end-expiratory
pressure (PEEP). The protocol allows for a low or a high PEEP strategy relative to
FiO2. Either strategy tolerates a PEEP of up to 24 cm HO in patients requiring 100%
FiO2.
Since patients with ARDS are bed-bound, frequent position changes are highly
recommended to prevent bedsores and deep venous thrombosis. In alert patients,
one can minimize the sedation and sit them in a chair.

Research Concepts: Acute Respiratory Distress Syndrome

Question 461: A 59-year-old man is brought to the emergency department for a

suspected allergic reaction. Per the wife, the patient's face started swelling after eating
shrimp salad at home.
When EMS arrived at the scene, the patient's lips, face, mouth, and tongue were swollen,
the patient spoke in muffled voice in 3-4 word sentences, and his vital signs were
significant for a heart rate 125/min, blood pressure 90/55 mmHg, respiratory rate 45/min
and SpO2 88%. EMTs administered epinephrine two times and attempted orotracheal
intubation but were unable to visualize relevant anatomy and placed a supraglottic
device to secure the airway then transported the patient. In the emergency department,
the patient is noted to be in severe respiratory distress with heart rate 145/min, blood
pressure 88/49 mmHg, and SpO2 75% despite oxygenation through the supraglottic
device. Physical examination reveals swollen lips, face, a very swollen tongue, and
expiratory wheezing is auscultated diffusely with inspiratory stridor. The wife arrives
shortly after to the emergency department and states that the patient has been intubated
three times in the past for three separate occasions for anaphylaxis. A cricothyrotomy is
planned. What anatomical landmarks are most appropriate to identify to pierce the
cricothyroid membrane in this patient?

Choices:

1. Thyroid cartilage and cricoid cartilage

2. Thyroid cartilage and sternal notch
3. Hyoid bone and laryngeal prominence
4. Hyoid bone and cricoid cartilage
Answer: 1 - Thyroid cartilage and cricoid cartilage

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Explanations:

A cricothyrotomy is a type of a surgical airway, and the procedure is indicated when

oxygenation and ventilation are not possible or have been unsuccessful through
intubation or supraglottic devices. Ideally, A cricothyrotomy should be performed in
a sterile fashion in the operation room. However, certain life-threatening conditions
or illnesses that indicate impending airway collapse or cardiac arrest require an
emergent cricothyrotomy. The initial vertical incision is made over the cricothyroid
membrane, which can be located in the midline of the neck from the inferior border
of the inferior edge of the thyroid cartilage to the superior edge of the cricoid
cartilage (choice 1).
Once the midline excision is made, copious bleeding is expected from disruption of
the neck veins, but all bleeding should be addressed after the airway has been
secured. After the vertical incision, blunt dissection must be performed to expose
the pale and white-colored cricothyroid membrane, and a horizontal incision
should be made through this membrane.
The laryngeal prominence of the thyroid membrane, colloquially known as Adam's
apple, signifies the superior edge, and the cricoid cartilage is the inferior border for
the vertical incision made for cricothyrotomy.
The laryngeal prominence of the thyroid cartilage signifies the upper border of the
landmark for the vertical incision, and the cricoid cartilage signifies the inferior
border for the vertical incision in the midline for the cricothyrotomy.

Research Concepts:

Cricothyrotomy

Question 462: A 45-year-old male patient presented to a clinician with a history of

dyspnea when lying down, coughing, wheezing sounds when breathing, and excessive
sweating. Pulse- oximeter showed his oxygen saturation to be 85% and pulse at 126 bpm.
His blood pressure was 150/95 mmHg. His electrocardiogram was done, which was
normal, but the symptoms persisted. The clinician started the patient on intravenous
furosemide, intravenous morphine, high flow oxygen, and ordered him to be kept in a
propped up position, which improved his symptoms. Now the clinician wanted to obtain a
mixed venous sample from the patient to determine SvO2, but when the pulmonary
artery catheter was placed, the patient suddenly developed massive hemoptysis. What
would be the most appropriate next step for the clinician to take in this case?

Choices:

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1. Removal of pulmonary artery catheter
2. Endobronchial intubation
3. Suctioning of oropharynx
4. Check hemoglobin using point of care testing
Answer: 2 - Endobronchial intubation

Explanations:

Massive hemoptysis temporally related to the manipulation of a Swan Ganz (PA)

catheter is indicative of pulmonary artery rupture. Endobronchial intubation is an
immediate step in unilateral pulmonary artery rupture to protect the good lung.
Pulmonary artery rupture is a very rare complication of Swan Ganz (PA) catheter
placement. Pulmonary artery rupture has a very high mortality rate, which hinders
the ability of the affected lung to ventilate properly. However, it is important to
remember that the Swan Ganz (PA) catheter is rarely used today.
Endobronchial Intubation ensures proper ventilation of the unaffected lung, which
gives the clinician time to manage the perforation of the pulmonary artery in the
affected lung.
Pulmonary artery catheterization should be done under fluoroscopy (most common)
or at the bedside with the use of ultrasound and echocardiography for safe catheter
placement.

Research Concepts:
Pulmonary Artery Catheterization

Question 463: A 69-year-old man presents with a one day history of dyspnea is admitted
to the intensive care unit following the identification of a large pulmonary embolism on a
CT pulmonary angiogram. He remains hemodynamically stable. After 6 days of receiving
heparin 5000 units SC 8-hourly, the patient’s platelet counts drop from 372 x 10^9/L to
180 x 10^9/L (150-400 x 10^9/L).
The team calculates a 4T score of 6. What are the most appropriate next steps in the
management of this patient?

Choices:

1. Send a PF4 ELISA and continue heparin while awaiting results.

2. Send a PF4 ELISA and discontinue heparin.
3. Send a PF4 ELISA and switch heparin to argatroban.
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4. Discontinue heparin as the patient is at risk of bleeding due to
thrombocytopenia.

Answer: 3 - Send a PF4 ELISA and switch heparin to argatroban.

Explanations:

A 4T score of 6 correlates with a high probability of heparin- induced

thrombocytopenia (HIT). This is an indication to discontinue heparin and initiate
alternative anticoagulation while awaiting test results to confirm the diagnosis.
In addition to the clinical signs and 4T score calculation, the diagnosis should
be confirmed with the PF4 ELISA and the serotonin release assay (SRA).
Discontinuing heparin without providing alternative anticoagulation puts the
patient at risk of potentially fatal thromboembolic complications.
The anticoagulant of choice in an acute HIT is argatroban. Argatroban is a direct
thrombin inhibitor that does not interact with PF4 or heparin-induced antibodies.
Argatroban has a short half-life of about 50 minutes; it is given as a continuous
infusion and requires aPTT monitoring, similar to heparin.

Research Concepts:

Heparin Induced Thrombocytopenia

Question 464: A patient with adenocarcinoma of the lung presents to the emergency
department with shortness of breath. Chest imaging revealed significant unilateral pleural
effusion. A bedside procedure was performed. The patient immediately begins violently
coughing and complaining of pleuritic chest pain. The chest radiograph shows unilateral
haziness, and fluffy infiltrates. Which of the following is the mechanism of the patient's
complication?

Choices:

1. Traumatic chest insertion into the lung

2. Intercostal neuralgia
3. Re-expansion pulmonary edema
4. Congestive heart failure
Answer: 3 - Re-expansion pulmonary edema

Explanations:

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 In patients with a malignant pleural effusion, it must be determined whether the
lung will expand or not after evacuation of the effusion.
If the lung expands completely, the effusion can be treated by sclerosis to prevent
recurrence. If the lung is trapped and the patient is symptomatic, a Denver shunt
may be an option.
Most of these patients are too ill to undergo pleurectomy/decortication, and the
malignant pleural effusion is usually resistant to chemotherapy.
Unilateral re-expansion edema occurs when pleural fluid is rapidly evacuated in a
patient with lung collapse that has persisted for more than 2-3 days. Patients
present with violent coughing and air hunger.

Research Concepts: Noncardiogenic Pulmonary Edema

Question 465: Which of the following parts of the alveolar

septum is responsible for surfactant production?

Choices:

1. Type 1 pneumocyte
2. Alveolar capillary endothelium
3. Alveolar macrophage
4. Type 2 pneumocyte
Answer: 4 - Type 2 pneumocyte

Explanations:

The alveolar septum has numerous capillaries and thin walls for gas exchange.
Type 2 pneumocytes secrete dipalmitoylphosphatidylcholine (DPPT) surfactant to
decrease alveolar surface tension.
In addition to capillary endothelial cells, the alveolar septum contains Type 1
pneumocytes that are very thin and line the alveoli.
Alveolar macrophages, also known as dust cells, are active in defending against
pathogens and irritants.

Research Concepts:

Surfactant

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Question 466: A 65-year-old man with a history of insulin- dependent diabetes and
hypertension presents to the office for a physical exam. Due to the patient's 40 pack-year-
history of smoking, it is decided to obtain a low dose chest CT scan as a cancer screening
test. No nodules or masses are seen, but it is incidentally noted that the patient has an
elevated left hemidiaphragm. The patient states that he has no symptoms and continues
to run 6 miles every day without excessive dyspnea. What is the most appropriate
management strategy for this patient?

Choices:

1. Surgical plication
2. Routine follow up
3. Phrenic nerve transplant
4. Phrenic nerve stimulator

Answer: 2 - Routine follow up

Explanations:

If a patient remains asymptomatic and the unilateral diaphragmatic paralysis is not

impacting their quality of life, there is no need for invasive techniques to correct the
issue. It is satisfactory to treat the patient conservatively.
Even symptomatic patients with unilateral diaphragmatic paralysis have some
resolution in symptoms, even without treatment.
It is recommended to wait at least 6 months, if possible, before pursuing surgical
options for symptomatic patients with unilateral diaphragmatic paralysis.
Invasive procedures carry risk in themselves, such as bleeding, infection, or need for
further procedures. It is best to avoid risking these complications if possible,
especially in an asymptomatic patient.

Research Concepts:

Unilateral Diaphragmatic Paralysis

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Question 467: A 65-year-old female with a known history of multiple stable compression
fractures of the spine returns to the clinic for an annual check-up. Upon review of
systems, the patient admits to progressively worsening dyspnea and dizziness. Physical
examination reveals worsening thoracolumbar curvature. However, motor and
neurologic findings remain normal. Which of the following is the next best step in
management?

Choices:

1. Echocardiography
2. Spinal cord decompression
3. Pulmonary function testing
4. CT scan of the chest
Answer: 3 - Pulmonary function testing

Explanations:

Pulmonary dysfunction can include both obstructive and restrictive pulmonary

changes.
Physical examination should include a thorough inspection of symmetry, spinal
alignment, flexibility, and work of breathing. Studies have shown a relationship
between increased Cobb angle and poor performance on pulmonary function
testing.
Dizziness in this scenario may be secondary to comprised respiratory status. Therefore
pulmonary causes should be ruled out before a neurology referral.

Research Concepts: Kyphoscoliosis

Question 468: A 65-year-old female presents with complaints of nonproductive cough,

sudden onset chest pain, and shortness of breath for the day. She has used tobacco for
the last 10 years. On general physical examination, she is dyspneic with a heart rate of
105 beats per minute. On the chest examination, there are decreased movements of the
chest wall, and decreased breath sounds are observed. The chest x-ray shows a sharp
white line with no lung markings, and the peripheral space is radiolucent compared with
the left lung. What is the most common cause of this patient's condition in females?

Choices:

1. Marfan syndrome
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2. Implants of endometrial tissue on the diaphragm
3. Chronic obstructive pulmonary disease
4. Pulmonary Langerhans cell histiocytosis
Answer: 3 - Chronic obstructive pulmonary disease

Explanations:

The most common cause of spontaneous pneumothorax is chronic obstructive

pulmonary disease in men and women. It usually is due to the rupture of a
pulmonary bleb or bulla.
Catamenial pneumothorax is associated with the menstrual cycle in females and
results from diaphragmatic deposits of endometrial tissue. Almost always, an
associated pleural effusion is observed on imaging, which represents a
concomitant hemothorax. This type of pneumothorax is very rare.
Pulmonary Langerhans cell histiocytosis represents bronchiolocentric smoking-
induced lung injury and may present with pneumothorax in approximately 10% to 20%
of patients.
Pneumothorax in Marfan syndrome also is due to the rupture of a bulla but is seen
in less than 5% of all secondary pneumothoraces.

Research Concepts:

Spontaneous Pneumothorax

Question 469: A 61-year-old man presents to the clinic for follow up. He has a history of
diastolic heart failure, severe gastroesophageal reflux disease (GERD), Raynaud
phenomenon with digit ulceration and pitting, and skin thickening. Physical examination
reveals telangiectasias over the face with abnormal nailfold capillaries and calcifications
involving the digits with pitting and ulcerations. Lung examination reveals scattered
bibasilar ronchi and rales. Laboratory tests reveal positive anti-centromere antibodies,
and pulmonary function tests reveal a restrictive pattern. An echocardiogram reveals
grade III diastolic dysfunction. Which of the following features is most strongly associated
with early mortality in this patient?

Choices:

1. Raynaud phenomenon
2. Severe GERD
3. Digit ulceration
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4. Cardiac involvement

Answer: 4 - Cardiac involvement

Explanations:

Several studies have shown that a significant number of systemic sclerosis

mortality was related to the presence of cardiac disease including heart failure and
arrhythmias.
Cardiac involvement was found to be the third leading cause of death in systemic
sclerosis after interstitial lung disease and pulmonary arterial hypertension.
It is important to early diagnose and manage myocardial disease in systemic
sclerosis.
Myocardial involvement in systemic sclerosis commonly presents with diastolic
heart failure and less commonly with systolic heart failure. Severe Raynaud
phenomenon, GERD, and digit ulcerations are findings of systemic sclerosis but
were not shown to be most associated with mortality in systemic sclerosis.

Research Concepts:

Scleroderma And Primary Myocardial Disease

Question 470: A 65-year-old man presents with hemoptysis and shortness of breath for
the past 3 weeks. There is no history of night sweats or weight loss. On chest x-ray, a coin-
shaped lesion is noted in the left mid zone, with pop-corn like calcifications. CT scan of the
chest shows a 4 cm fat-containing nodular structure impeding the right main bronchus.
Sputum is negative for atypical cells and acid- fast bacilli. CT-guided percutaneous fine-
needle aspiration biopsy confirms that it is a benign lesion. What is the cellular
composition of this lesion?

Choices:

1. Mixture of mature hyaline cartilage, fat, or smooth muscle

2. Whorled appearance of smooth muscle bundles separated by well-vascularized
connective tissue
3. Hypercellular and infiltrative pattern of atypical cells
4. Cells containing fungi with septate hyphae
Answer: 1 - Mixture of mature hyaline cartilage, fat, or smooth muscle

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Explanations:

This patient most likely has a pulmonary hamartoma.

The histological makeup of these tumors is a mixture of mature mesenchymal
tissue, like adipose tissue, cartilage, bone, or smooth muscle bundles, and
fibromyxoid tissue, with varying proportions of each component.
They are non-invasive, slow-growing, nodular lesions, sometimes displaying cleft-
like spaces, lined by respiratory epithelium.
Most hamartomas occur in the peripheral parenchyma, with exceptions observed in
the central chest wall.

Research Concepts:

Pulmonary Hamartoma

Question 471: A 23-year-old African American woman is in the 23rd week of her second
pregnancy and presents to the emergency department with acute onset shortness of
breath, cough, yellow thick sputum, and subjective fever for 3 days. Her 3-year-old son
had been sick last week. She has had a fairly uneventful first trimester in spite of her
known history of bronchial asthma and has been needing albuterol only 1-2 times a week.
Clinical examination is consistent with bilateral rhonchi and wheeze. Vital signs show a
temperature of 101 F with a blood pressure of 121/84 mmHg. She is saturating 94% on
room air. Which of the following possible immune-mediated change in her body with
relation to her pregnancy is most likely responsible for her acute presentation?

Choices:

1. Downregulation of Natural Killer cells (NK) and upregulation of Treg cells

2. Downregulation of T helper cell type 2 induced immunity (Th2)
3. Downregulation of IL-4 and interferon-gamma
4. Increase in T helper cell type 1 population
Answer: 1 - Downregulation of Natural Killer cells (NK) and upregulation of Treg cells

Explanations:

Pregnancy is associated with changes in the immune system that helps to reduce
the likelihood of fetal rejection by maternal antibodies. One of the key
components is to reduce the activity of NK cells with an increase in regulatory T
cells t inhibit attack on fetal tissue. However, that predisposes the mother to a
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 more severe presentation of viral infection as well.
Similarly, Treg cells also suppress Th1 induced fetal rejection. During pregnancy, there
is a shift towards Th2 predominant inflammatory state with a high Th2/Th1 cytokine
response.
Interleukin 4 and interferon-gamma synthesizing T-lymphocytes are both increased in
pregnant women with asthma.

Research Concepts:

Asthma In Pregnancy

Question 472: A 65-year-old male presents to the hospital with a complaint of increased
cough for the past two weeks. He also complains of changes in sputum production and
increased dyspnea. On further questioning, he reveals that he was diagnosed with yellow
nail syndrome five years ago. His vital signs show blood pressure 100/70 mmHg,
respiratory rate of 18/min, temperature 38.3 C (101 F), and heart rate 100/min. An
examination performed reveals clubbing and bilateral prominent wheezes on
auscultation. The pulmonary function test performed shows an obstructive pattern.
What is the most likely indication for adjunctive surgical treatment in his condition?

Choices:

1. Premorbid history of yellow nail syndrome

2. Presence of finger clubbing
3. Removal of an area suspected of harboring resistant organisms
4. The appearance of bibasal consolidates on chest x-ray
Answer: 3 - Removal of an area suspected of harboring resistant organisms

Explanations:

Bronchiectasis is a chronic lung disease characterized by persistent and lifelong

widening of the bronchial airways and weakening of the function mucociliary
transport mechanism owing to repeated infection contributing to bacterial invasion
and mucus pooling throughout the bronchial tree.
In certain patients with severe or complex disease, surgery is an effective
alternative to therapy. Features of acute exacerbation of bronchiectasis include a
change in sputum production, increased dyspnea, increased cough, fever, increased
wheezing, and reduced pulmonary function.
Removal of destroyed lung partially obstructed by a tumor AND Removal of destroyed
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 lung partially obstructed by a tumor are important indications for surgery in
bronchiectasis.
Single or double-lung transplantation has been used as a treatment of severe
bronchiectasis, predominantly when related to cystic fibrosis. It is considered when
FEV falls below 30% of the predicted value. Female patients and younger patients
may need to be considered sooner.
Research Concepts: Bronchiectasis

Question 473: A 30-year-old woman with a past medical history of narcolepsy with
cataplexy was recently seen at the clinic for the continued complaint of excessive daytime
sleepiness despite recently replacing modafinil with armodafinil. Her cataplexy remains
well controlled with fluoxetine. She agrees to begin treatment with dextroamphetamine-
amphetamine in hopes of improving her score on the Epworth Sleepiness Scale. A day
later, she presents to the emergency department disoriented with anxiety and diarrhea.
Vital signs reveal that she is febrile while physical examination demonstrates agitation and
inducible clonus in the lower extremities, bilaterally. What is the most likely diagnosis?

Choices:

1. Acute mania
2. Neuroleptic malignant syndrome
3. Malignant hyperthermia
4. Serotonin syndrome

Answer: 4 - Serotonin syndrome

Explanations:

Serotonin syndrome is diagnosed clinically using the Hunter criteria: Administration of

a serotonergic agent in the setting of inducible clonus with either agitation or
diaphoresis.
It can occur with the use of a single serotonergic agent as prescribed/taken in excess
or with the co-ingestion of multiple serotonergic agents simultaneously.
Its manifestations are due to an increase of serotonin in the central nervous
system. Typical presentation includes altered mental status, increased autonomic
activity, and neuromuscular changes.
Great care should be taken to avoid the prescription of multiple serotonergic agents in
a single patient.
Research Concepts:

Cataplexy
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Question 474: A 65-year-old female presents with complaints of fatigue and shortness of
breath for the past four and a half months. The patient has a past medical history of breast
cancer, diabetes mellitus, and gastroesophageal reflux disease. Her breast cancer was
treated with a combination of radiation and chemotherapy and is now in remission. Her
medications include famotidine and metformin. She has never traveled outside the United
States. Her vital signs are a blood pressure of 130/70 mmHg, a heart rate of 79 beats per
minute, and a temperature of 98.6 F (37 C). General physical examination shows
conjunctival pallor, pedal edema, and a rise in jugular venous pressure following
inspiration. Which of the following is pertinent to the involved alterations?
Choices:

1. Increase right atrial (RA) pressure while the pulmonary wedge pressure
decreases
2. Differential pressure between right atrial (RA), right ventricular (RV), left
ventricular (LV), and pulmonary wedge pressure
3. Increased venous return with inspiration as pulmonary venous pressure
decreases
4. Pulmonary veins to left atrial (LA) flow decreases on inspiration
Answer: 4 - Pulmonary veins to left atrial (LA) flow decreases on inspiration
Explanations:

The most likely diagnosis in this scenario is radiation therapy- induced constrictive
pericarditis. Studies have shown a 2% to 30% incidence of constrictive pericarditis
after radiation therapy. An echocardiogram will confirm the diagnosis.
Physical examination findings are elevated jugular venous pressure (JVP), pulsus
paradoxus with greater than 10 mmHg drop in systolic blood pressure on
inspiration, Kussmaul sign (lack of inspiratory drop in JVP), and pericardial knock
that is an accentuated heart sound occurring earlier than S3.
There are dissociation intrathoracic and intracardiac pressures. This leads to
decreased venous return with inspiration as pulmonary venous pressure decreases.
However, the left atrium pressure does not, and pulmonary veins to the left atrial
(LA) flow decreases on inspiration. This intrathoracic and intracardiac pressure
dissociation is a distinguishing feature from cardiac tamponade as in cardiac
tamponade the changes in intrathoracic pressure are still conducted to the heart
and there is an increase in systemic venous return with inspiration.
In both disorders, there is the equalization of the right atrial (RA), right ventricular
(RV), left ventricular (LV), and pulmonary wedge pressure; however cardiac
tamponade, the pressure decreases with inspiration, whereas in constrictive
pericarditis, the RA pressure remains constant while the pulmonary wedge
pressure decreases.
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Research Concepts: Constrictive Pericarditis

Question 475: A 65-year-old female is evaluated for shortness of breath with exertion and a
chronic cough. She is often unable to walk farther than 200 feet without stopping to catch
her breath. She is a current smoker with a 33-pack-year smoking history. She has no prior
hospitalizations. On physical examination, her vital signs are within normal limits at rest.
Auscultation of her lungs reveals bilateral expiratory wheezes. The remainder of her physical
examination is normal. Spirometry is performed and shows an FEV1 of 72% of predicted.
Her spost-bronchodilator FEV1/FVC ratio is 60%. Her modified medical research council
(mMRC) dyspnea score is 3. She is counseled on smoking cessation. Which of the following is
the most appropriate pharmacological treatment for this patient?

Choices:

1. Monotherapy with a short-acting bronchodilator as needed

2. Roflumilast
3. Long-acting bronchodilator and an inhaled corticosteroid
4. Short-acting bronchodilator as needed and a long-acting bronchodilator
Answer: 4 - Short-acting bronchodilator as needed and a long- acting bronchodilator

Explanations:

This patient has an FEV1/FVC ratio of 0.7 consistent with the diagnosis of chronic
obstructive pulmonary disease (COPD). Her post-bronchodilator FEV1 % of
predicted is 60%, and she has an mMRC score of 3. According to the 2020 global
initiative for chronic obstructive lung disease (GOLD), she falls within GOLD 2,
Group B.
A short-acting bronchodilator as needed and a long-acting bronchodilator is indicated
in GOLD group B patients.
Long-acting bronchodilators have been shown to improve FEV1, dyspnea, and the
number of hospitalizations in patients with COPD. It is indicated in patients who are
within GOLD groups B- D.
Monotherapy with a short-acting bronchodilator as needed is not adequate for this
patient with moderate disease. Roflumilast is a phosphodiesterase-4 inhibitor used
in severe cases, often with an FEV1 50% of predicted. Inhaled corticosteroids are
reserved for severe to very severe cases of COPD.

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Research Concepts:

Chronic Obstructive Pulmonary Disease

Question 476: A 37-year-old man presents to the clinic for evaluation of dry cough and
worsening dyspnea on exertion. The patient is an active smoker with 18 pack-year
smoking history. Lung examination is normal. A chest x-ray shows hyperinflation and
reticulonodular markings. A chest CT scan shows a mosaic pattern with air trapping and
multiple bilateral apical irregular cysts and centrilobular nodules. The pulmonary
function test shows an obstructive defect with moderately reduced FEV1. A
transbronchial biopsy is done. Which of the following findings is most likely to be seen in
the histopathology of this patient?

Choices:

1. Giant cell infiltration with lymphocytes

2. Bronchiolocentric stellate scarring
3. Disruption of endothelial lining with inflammatory exudate
4. Proliferating fibrous tissue

Answer: 2 - Bronchiolocentric stellate scarring

Explanations:

Langerhans cell histiocytosis is caused by Langerhans cell, a member of the

dendritic cell family and an antigen-presenting cell that stains positively with S-
100 protein and has a unique surface antigen CDla.
The lesions of Langerhans cell histiocytosis in the lung are bronchiolocentric,
obstructing the small airways. Histologically, this appears as a bronchiolocentric
stellate scar.
Langerhans cell also carries the Birbeck granule, which is a rod- shaped cytoplasmic
inclusion. It can be seen on electron microscopy of tissue or BAL in these patients.
Langerhans cell histiocytosis does not cause vasculitis or giant cell formation.

Research Concepts:

Bronchiolitis Obliterans

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Question 477: A 48-year-old man with a past medical history of lung transplant due to
chronic sarcoidosis presents for a routine surveillance bronchoscopy. He subsequently
undergoes bronchoscopy with transbronchial biopsies. After the procedure, the patient is
taken to the recovery area where, 15 minutes later, he develops acute chest pain and
shortness of breath. His vital signs are a heart rate of 130/minute, respiratory rate
30/minute, blood pressure 100/70 mmHg, pulse 123/minute, and oxygen saturation of
86% on 2 liters of oxygen via nasal cannula. The patient is immediately placed on a
nonrebreather mask. Chest auscultation demonstrates diminished breath sounds on the
right. Arterial blood gas shows pH 7.34, PaO2 50 mmHg, and PaCO2 44 mmHg. What is the
best next step in the management of this patient?

Choices:

1. Oral intubation and admission to the intensive care unit

2. Start non-invasive ventilation
3. Order an emergency chest x-ray and prepare for chest tube placement
4. Administer methylene blue
Answer: 3 - Order an emergency chest x-ray and prepare for chest tube placement
Explanations:

This scenario depicts a tension pneumothorax, which is most likely to occur in the
context of endobronchial biopsy, transbronchial biopsy, and needle aspiration. The
incidence of pneumothorax is 1 to 3% in patients undergoing transbronchial
biopsies. Small pneumothoraces may be managed conservatively. However, larger
pneumothoraces that cause decompensation need emergent intervention with
chest tube insertion.
Most cases of iatrogenic pneumothorax occur within minutes or hours after the
intervention but can be delayed up to 24 hours. Therefore, it is recommended to
obtain a chest x-ray after a high-risk procedure or when the patient is
symptomatic to rule out pneumothorax.
Noninvasive ventilation is contraindicated in patients with tension pneumothorax
as it can worsen the air leak and cause hemodynamic collapse.
Acquired methemoglobinemia could occur from exposure to local anesthetics,
including benzocaine (in teething rings and ointments), lidocaine, and prilocaine
used during bronchoscopy. In acquired methemoglobinemia, hypoxemia may be
absent (PaO2 is within normal limits), and hypoxia on pulse oximetry does not
improve with the administration of oxygen.
Research Concepts: Bronchoscopy

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Question 478: A 55-year-old man undergoes pulmonary function testing for further
workup of chronic cough that has not improved significantly with medical therapy. Which
finding most correlates with a weak cough and difficulty clearing secretions in this
patient?

Choices:

1. Maximum expiratory pressure less than 60 cmH2O

2. Maximum expiratory pressure less than 100 cmH2O
3. Maximum inspiratory pressure less than -90 cmH2O
4. Maximum inspiratory pressure less than -140 cmH2O

Answer: 1 - Maximum expiratory pressure less than 60 cmH2O

Explanations:

The respiratory muscle strength is assessed with maximal inspiratory pressure (MIP)
and maximal expiratory pressure (MEP). The MIP reveals the strength of the
diaphragm and other inspiratory muscles, whereas the MEP indicates the strength
of the abdominal and other expiratory muscles. MIP and MEP are measured three
times, and maximal value is reported. For adults 18 to 65 years of age, MIP should
be less than -90 cmHO in men and -70 cmHO in women. In adults older than 65
years of age, MIP should be less than -65 cmH2O in men and -45 cmH2O in women.
Normal MEP should be higher than 140 cmH2O in men and 90 cmH2O in women.
MEP less than 60 cmH2O indicates a weak cough and difficulty clearing secretions.
Both the rapid shallow breathing index and MIP act as good predictors of
successful weaning from a ventilator. A MIP value exceeding -30 cm of H2O is
associated with successful extubation.
Research Concepts:

Pulmonary Function Tests

Question 479: A 66-year-old man undergoing hospice care after being diagnosed with
lung cancer reports increased dyspnea and chest pain in addition to the blood in the
sputum. He also reports a significant decrease in weight during the last few months.
Which of the following best explains the patient's deteriorating condition?

Choices:

1. Spread of cancer to the opposite lung

2. Metastasis to the esophagus
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3. Saddle clot
4. Tuberculosis

Answer: 1 - Spread of cancer to the opposite lung

Explanations:

The most commonly involved sites for lung cancer metastasis are the opposite
lung, adrenal gland, bone, brain, and liver.
Thus, when a patient experiences new-onset symptoms of lung cancer, such as
cough/blood in sputum, pain in the chest, fatigue, loss of weight, difficulty in
breathing, or hoarseness, the symptoms are most likely related to metastasis to
the opposite lung.
To improve outcomes, an interprofessional team approach with close
communication between the members may perhaps lead to earlier diagnosis and
treatment.
Lung cancer symptoms occur due to local effects of the tumor, such as cough due to
bronchial compression by the tumor, due to distant metastasis, stroke-like
symptoms secondary to brain metastasis, paraneoplastic syndrome, and kidney
stones due to persistent hypercalcemia.

Research Concepts:

Lung Metastasis

Question 480: A 16-year-old male presents to the clinic with complaints of shortness of
breath, cough, and hemoptysis. The patient states that his condition has worsened over
the past 6 months. The patient has a past medical history significant for iron deficiency
anemia, for which he received multiple blood transfusions. On examination, the patient
appears pale, and there is the presence of crepitations in both lungs. A high-resolution CT
(HRCT) shows diffuse alveolar shadowing. Bronchoalveolar lavage is performed, which
reveals hemosiderin-laden macrophages. Laboratory analysis reveals a decreased
hemoglobin level. An echocardiogram is unremarkable. No viral or bacterial etiology is
detected on detailed chemistry analysis. Presence of which of the following will rule out
the patient's suspected diagnosis?

Choices:

1. Anti-glomerular basement membrane antibody

2. Antineutrophil cytoplasmic antibodies
3. Mycobacterium tuberculosis
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4. IgG antibody against cytomegalovirus

Answer: 1 - Anti-glomerular basement membrane antibody

Explanations:

This patient most likely has idiopathic pulmonary hemorrhage (IPH). However, the
same pulmonary symptoms occur in Goodpasture syndrome.
Goodpasture syndrome pathophysiology is associated with anti- glomerular basement
membrane (GBM) antibody cross-reacting with the lung basement membrane. Anti-
GBM antibody is not present in IPH.
Iron deficiency anemia is characteristic of both disease states as a result of repeat
episodes of intra-alveolar bleeding. Early radiographic findings are similar. Alveolar
opacities are replaced with reticulonodular opacities within 2 to 3 days.
Both disease states are characterized by recurrent episodes of hemorrhage.

Research Concepts:

Idiopathic Pulmonary Hemorrhage

Question 481: A 71-year-old man with a past medical history of Parkinson disease,
hypertension, and hyperlipidemia presents to the hospital with a one-day history of
dysphagia and cough that started last night while eating dinner. Vital signs are within
normal limits, and a physical exam is significant for decreased breath sounds on the right
side. A chest x-ray is unremarkable. What is the best next step in the management of this
patient?

Choices:

1. Noncontrast CT of the chest

2. Diagnostic bronchoscopy
3. Esophagogastroduodenoscopy (EGD)
4. Bedside swallow study
Answer: 2 - Diagnostic bronchoscopy

Explanations:

When a partial foreign body airway obstruction is suspected, a diagnostic

bronchoscopy should be strongly considered, even in the absence of radiological
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 findings.
While radiographs may be useful to confirm the diagnosis of foreign-body airway
obstruction, they should not be used alone to exclude the diagnosis, as most
aspirated foreign bodies are radiolucent.
Long-term complications of undiagnosed airway foreign bodies are atelectasis,
pneumonia, or bronchiectasis, necessitating bronchoscopy to remove the foreign
body.
For patients requiring bronchoscopy, potential complications include bleeding,
infection, airway perforation, and pneumothorax. However, the risk of
complications is small for most patients, and the benefits generally outweigh the
potential risks.

Research Concepts:

Foreign Body Airway Obstruction

Question 482: A 17-year-old man comes to the outpatient department with complaints of
cough and breathlessness for the past one week. He also reports noisy sound when he
breathes. He does not complain of fever, weight loss, or allergy. He has a travel history to
Indonesia two years ago. On chest examination, bilateral wheezes heard. Blood work
shows a high eosinophil count. The chest x-ray shows reticulonodular opacity in the right
lung. Which of the following is the most likely complication, if the disease is untreated?

Choices:

1. Chronic obstructive pulmonary disease

2. Pulmonary fibrosis
3. Squamous cell carcinoma of the lung
4. Adenocarcinoma of the lung
Answer: 2 - Pulmonary fibrosis

Explanations:

This patient most likely has tropical pulmonary eosinophilia (TPE). If this condition is
treated late or left untreated, it can lead to pulmonary fibrosis with chronic
respiratory failure. It is caused by Wuchereria bancrofti or Brugia malayi.
Most of the patients with TPE have shown good response after treatment with
diethylcarbamazine.
Page 457 of 955
 It is postulated that lower respiratory tract inflammatory cells release superoxide
and hydrogen peroxide, which causes chronic respiratory tract inflammation and
mild interstitial lung disease in a patient with TPE.
Despite treatment, mild interstitial lung disease has been found to persist in some
patients.

Research Concepts:

Tropical Pulmonary Eosinophilia

Question 483: A 40-year-old man presents to the clinic to establish care. A month ago, he
was admitted to the hospital for difficulty breathing triggered by painting his home. He
has smoked one pack of cigarettes daily for the last 20 years. Upon discharge, the patient
was prescribed the following inhalers: tiotropium/olodaterol two puffs daily and
albuterol two puffs every 4 hours as needed. On examination, the patient is in no
apparent distress; the lungs demonstrate distant breath sounds without wheezing, and
the rest of the exam is within normal limits.
Pulmonary function tests (PFTs) and bronchodilator response have not been performed
for this patient. In addition to counseling him to quit smoking before ordering the PFTs,
what is the most appropriate recommendation for this patient?

Choices:

1. Continue all inhalers, including on the day of the PFTs

2. Stop all inhalers until the PFTs are completed
3. Hold the tiotropium/olodaterol inhaler 48 hours before and albuterol 6
hours before the PFTs
4. Continue albuterol as needed and hold tiotropium/olodaterol inhalers on the
day of the PFTs
Answer: 3 - Hold the tiotropium/olodaterol inhaler 48 hours before and albuterol 6 hours
before the PFTs

Explanations:

In preparation for pulmonary function tests (PFTs), bronchodilator medications

should be held so that bronchodilator response can be assessed after baseline
spirometry.
The duration for holding the inhalers differs based on the type of short or long-acting
inhaler. Short-acting inhaled beta-agonists (e.g., albuterol) should be held for at least
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 4 to 6 hours before spirometry.
Long-acting inhalers such as tiotropium should be held for 36-48 hours before
spirometry.
Not holding these inhalers can affect the accuracy of the spirometry and the ability to
detect bronchodilator response.

Research Concepts:

Pulmonary Function Tests

Question 484: A 50-year-old woman presents to the office complaining of shortness of

breath upon standing that improves when lying flat in bed. Her past medical history is
only significant for hypertension, which is well controlled on amlodipine 5 mg daily. She
denies any history of tobacco use. The physical exam is unremarkable except for oxygen
saturation of 92% on room air, which improves to 98% after lying supine for 1-2 minutes.
Bloodwork is only significant for a hemoglobin level of 16 g/dL. A chest X-ray shows a 2
cm oval mass of uniform density in the left lower lobe.
Contrast echocardiography reveals a shunt measurement of >5% consistent with
pulmonary arteriovenous malformation (AVM), and CT of the chest reveals a single 2 cm
pulmonary AVM in the left lower lobe of the lung. Which of the following is the next best
step in the management of this patient?

Choices:

1. Phlebotomy
2. Hydroxyurea
3. Supplemental oxygen
4. Endovascular embolization
Answer: 4 - Endovascular embolization

Explanations:

Symptomatic patients with pulmonary AVMs should be referred for evaluation for
possible embolization.
Embolization therapy results in improvement of dyspnea, blood oxygenation as well as
decreased in shunt fraction.
Single pulmonary AVMs are more amenable for embolization therapy. Patients
with complex pulmonary AVMs not amenable for embolization should be evaluated
for possible surgical resection. However, this procedure carries similar risks and
morbidity as other thoracic surgical procedures.
There have been reports of patients developing new pulmonary hypertension after
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 embolization therapy thus it has been recommended estimation of post-
treatment pulmonary hemodynamics by transient occlusion of the PAVM with a
balloon-tipped catheter.

Research Concepts:

Pulmonary Arteriovenous Malformation (AVMs)

Question 485: A 65-year old obese woman with chronic insomnia and snoring underwent
posterior spinal fusion under general anesthesia. She is started on morphine
postoperatively. Her vital signs and arterial blood gas are as follows: RR 12/min; SpO2
88%; BP 112/68 mmHg; HR 89 bpm; pH 7.22, pCO2 60, PaO2 56
[Link] of the following lung volumes should be considered to be improved while
choosing her ventilation support?

Choices:

1. Functional residual capacity

2. Residual volume
3. Inspiratory reserve volume
4. Total lung capacity
Answer: 1 - Functional residual capacity

Explanations:

This patient has obesity and obstructive sleep apnea. CPAP improves Functional
residual capacity and decreases ventilation efforts.
Application of CPAP or positive end-expiratory pressure (PEEP) recruits partially
collapsed alveoli decreasing physiological dead space.
CPAP can increase functional residual capacity above closing capacity, improve lung
compliance, and correct ventilation/perfusion abnormalities.
CPAP does not alter the residual volume in the lung at the end of forced expiration
and the total lung capacity after maximal inspiration. If improvement in tidal
volume is desired, then one can switch from CPAP to bilevel positive airway
pressure (BiPAP), where a higher difference between inspiratory positive airway
pressure (IPAP) and expiratory positive airway pressure (EPAP) can generate higher
tidal volumes.

Research Concepts:

Continuous Positive Airway Pressure

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Question 486: A 65-year-old male presents to the emergency department with the
complaint of worsening dyspnea for five days. He has a high-grade fever and a productive
cough. He has been suffering from the chronic obstructive pulmonary disease (COPD) and
he is on a maintenance dose of ipratropium nebulizer. His past history is suggestive of two
intensive care unit admissions in the past two years for acute exacerbations of COPD. On
examination, he is conscious and oriented, he is febrile with a pulse of 94/min regular and
blood pressure of 160/90 mmHg. On auscultation, there are coarse crackles in the left
lower chest and bilateral rhonchi all over.
He is being administered 40% O2 by the mask. His arterial blood gas suggests a pH of 7.30,
paO2 60 mmHg, paCO2 45 mmHg, bicarbonate 29 mmol/l. His chest radiograph reveals
opacification in the left lower zone and fluid in the bases bilaterally. How should his
ventilatory support be managed?

Choices:

1. Bi-level positive airway pressure (BiPAP)

2. High flow oxygen around 15 liters
3. Continuous positive airway pressure (CPAP)
4. Elective intubation and mechanical ventilation
Answer: 1 - Bi-level positive airway pressure (BiPAP)

Explanations:

This patient has right-sided consolidation in the context of COPD.

BiPAP is an extremely useful way to manage such patients. If BiPAP fails to improve
his condition then intubation and ventilation would be the best next step.
In disease states such as pulmonary vascular diseases, interstitial disease, or
obstructive lung disease the ratio of available lung ventilation to capillary perfusion
is skewed netting hypoxic environments. This results in inefficient oxygen transfer
into the capillary space with a resulting decreased partial pressure of oxygen in the
blood.
During rest blood flow through the arterioles of the lungs is slow enough to allow
for proper diffusion regardless of an increased A-a gradient. However, under
exercise conditions, cardiac output increases. When this occurs, there is less time
for oxygenation to occur in the lung which leads to transient hypoxia. Examples of
limited diffusion disease include lung fibrosis and chronic obstructive pulmonary
disease. The result is a normal partial pressure of oxygen in the alveolar space, but a
low partial pressure of oxygen in the arterial space.
Research Concepts: Partial Pressure Of
Oxygen

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Question 487: A 54-year-old man with a past medical history of hypertension presents to
the hospital with complaints of flu-like symptoms for the past 4 days. Upon admission, the
patient is noted to be febrile with a fever of 38.9°C (102°F) and hypoxic, with oxygen
saturation of 92% on room air. Initial laboratory workup is unremarkable except for
leucopenia. An initial chest x-ray demonstrates bilateral interstitial opacities. SARS-CoV-2
test comes back positive. The patient is given oxygen supplementation 2 L/min via nasal
cannula with improvement in his oxygen saturation to 98%. He remains hemodynamically
stable over the next few hours and due to restrained resources secondary to the ongoing
epidemic, he is planned for discharge home with supplemental oxygen. Followup within 24
hours is ensured. Which of the following medications is indicated for the treatment of this
patient upon discharge?
Choices:

1. Tocilizumab
2. Sotrovimab
3. Dexamethasone
4. Baricitinib
Answer: 3 – Dexamethasone
Explanations:

The patient described is admitted with moderate COVID-19 illness and is planned
for discharge home with supplemental oxygen. The current guidelines recommend
treatment with dexamethasone 6 mg orally once daily for the duration of
supplemental oxygen need or 10 days (whichever comes first) for these patients.
This recommendation comes from the latest National Institutes of Health (NIH)
guidelines (January 2022). Although supporting data for this recommendation
comes from the RECOVERY trial, it is important to remember that patients
discharged from the emergency department despite new oxygen requirements
were not studied in this trial. The NIH panel makes this recommendation due to the
epidemic-driven strained resources of the healthcare system. They highlight the
importance of pulse oximetry monitoring upon discharge and close follow-up to
ensure that these patients continue to do well.
NIH guidelines state that currently there is insufficient evidence to support or
advise against routine use of remdesivir in this setting.
Sotrovimab is a monoclonal antibody that has received emergency use
authorization by the FDA for clinical use in nonhospitalized patients with mild to
moderate COVID-19 illness who DO NOT require supplemental oxygen and are at
high risk of developing severe illness. It retains its efficacy against the Omicron
variant and is currently the only monoclonal antibody approved for use in this
group.

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Research Concepts:Monoclonal Antibody Therapy For High-Risk Coronavirus
(COVID 19) Patients With Mild To Moderate Disease Presentations

Question 488: A 74-year-old man presents to the hospital complaining of bilateral limb
ataxia. He also has progressive dizziness and dysarthria that have been worsening over
the last three weeks. He denies having hypertension or diabetes mellitus. He has a 45-
pack-year smoking history. The patient denies using alcohol or illicit drugs. Imaging of his
lungs shows a left lung mass, and the patient dies after three weeks of chemotherapy and
symptomatic care. Diffuse cerebellar Purkinje cell degeneration is seen on autopsy. Which
of the following best explains the pathophysiology behind the patient's symptoms?

Choices:

1. Anti-Yo antibodies cross-reacting with cerebellar antigens

2. Distant brain metastasis from a primary lung lesion
3. Anti-Hu antibodies cross-reacting with cerebellar antigens
4. Subacute sclerosing panencephalitis from a childhood measles infection
Answer: 3 - Anti-Hu antibodies cross-reacting with cerebellar antigens

Explanations:

This patient has paraneoplastic cerebellar degeneration. His long history of

smoking and the imaging of the lung highly suggests the presence of lung cancer.
Small cell lung cancer is associated with the production of anti-Hu antibodies that
target the Purkinje cells of the cerebellum.
Anti-Yo antibodies can also target the Purkinje cells of the cerebellum. However, the
presence of anti-Yo antibodies is more strongly associated with gynecologic and breast
cancers.
Anti-Tr antibodies can also target the Purkinje cells of the cerebellum. However, the
presence of anti-Tr antibodies is more strongly associated with Hodgkin lymphoma.
Subacute sclerosing panencephalitis (SSPE) is a rare complication that occurs
primarily in children or young adults several years after they were initially exposed
to measles. SSPE is caused by a defective type of measles that fails to mature and
thus continues to replicate in the cells continuously. It is not cleared, and
eventually, the inflammation and apoptosis present with panencephalitis.

Research Concepts: Paraneoplastic Syndromes

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Question 489: A 65-year-old man presents with complaints of dyspnea, dry cough, and
fatigue. The patient has a past medical history significant for a mediastinal tumor, for
which he underwent radiation therapy 4 weeks ago. A chest x-ray today shows multiple
infiltrates in the lung field surrounding the tumor. The patient has most likely developed
which of the following?

Choices:

1. Idiopathic pulmonary fibrosis

2. Radiation pneumonitis
3. Radiation fibrosis
4. Lower respiratory tract infection

Answer: 2 - Radiation pneumonitis

Explanations:

This patient has developed radiation pneumonitis.

Early phase clinical effects of lung irradiation include congestion, cough, dyspnea,
fever, and chest pain caused by radiation pneumonitis.
Radiographic studies reveal infiltrates within the irradiated field. The natural course
of pneumonitis is a gradual resolution of the acute phase followed by a chronic
phase causing inflammation and fibrosis, which develops over months to years.
Research Concepts:

Adverse Effects Of Radiation Therapy

Question 490: A 14 year-old-boy, recently diagnosed with Marfan syndrome is being

evaluated for pulmonary assessment. On physical examination, he is a tall boy standing
with a slouch. No acute distress. Heart rate 76/min, respirations 18/min, BP 116/72 mm
Hg., weight 60 Kg, height 175.3 cm, and has a high arched palate. Lungs clinically clear,
heart systolic murmur in the apical area, no hepatosplenomegaly, has hyper-extensible
joints, and moderate pectus excavatum deformity. He already had a CT scan done to
calculate Haller index which was reported to be 7.2. Which of the following are results is
most likely to be seen on spirometry?

Choices:

1. Normal forced vital capacity (FVC)and normal expiratory volume in one second
(FEV1)

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2. Reduced FVC and reduced FEV1
3. Elevated FVC and elevated FEV1
4. Normal FVC and reduced FEV1

Answer: 2 - Reduced FVC and reduced FEV1

Explanations:

Patients with severe pectus excavatum deformity and an elevated Haller index of
greater than 7 are likely to show a restrictive pattern on spirometry.
Proportionately diminished values for FVC and FEV1 are suggestive of a restrictive
pulmonary defect.
Normal values on spirometry are seen in a patient with mild or moderate pectus
deformity.
Elevated values for FVC and FEV1 may reflect large lung volume which is not a
feature of pectus excavatum. Normal FVC and reduced FEV1 suggests obstructive
defect as in the cases of asthma.

Research Concepts:

Pectus Excavatum

Question 491: A 47-year-old man presents to the emergency department complaining of

cough, subjective fevers, and night sweats for the past week. He has recently immigrated
to the United States from Russia where he worked as a computer programmer. He eats a
diet high in fish and reports drinking one to two beers once a week during the weekend.
On physical examination, he is noted to have abnormally enlarged fingertips and
curvature of the nails.
Which disease process is associated with his condition?

Choices:

1. Vitamin D deficiency
2. Bronchogenic carcinoma
3. Calcium deficiency
4. Iron deficiency
Answer: 2 - Bronchogenic carcinoma

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Explanations:

Nail clubbing is seen in lung cancer and other chronic pulmonary and
cardiac diseases.
Despite the broad literature on the subject of clubbing, there have never been
well-controlled studies to determine exactly which conditions produce clubbing.
Most of the data we have on clubbing is based on case reports and everyone is
extrapolating these findings to many disorders. Clubbing is known to occur in many
disorders besides just lung and heart pathology. Many GI disorders (Inflammatory
bowel disease) also produce clubbing.

Research Concepts:

Nail Clubbing

Question 492:

A 40-year-old man is brought to the emergency department after being found by his wife
drowsy and unresponsive in bed. He had not felt unwell recently according to the wife.
However, there were no obvious precipitants around his presentation. Initial workup
shows normal routine blood investigations, EKG, and chest x-ray. Arterial blood gas
analysis on 15 L/min oxygen via non-rebreather is shown below.
Reference range
Patient value

pH 7.28 7.34-7.45
pO2 86 mmHg 75-105 mmHg
pCO2 53 mmHg 33-45 mmHg
Bicarbonate 35 mg/dL 21-28 mEq/L
Lactate 22.5 mg/dL 4.5-19.8 mg/dL
Sodium 134 mEq/L 134-144 mEq/L
Potassium 4.3 mEq/L 3.6-5.0 mEq/L
Hemoglobin 13 g/dL 13.2-17.5 g/dL

Physical examination is difficult due to his large body habitus, but it did not reveal any
significant findings. The patient's wife denies active smoking. Which of the following is
the most likely diagnosis?

Choices:

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1. Obesity hypoventilation syndrome
2. Exacerbation of chronic obstructive pulmonary disease
3. Pulmonary embolism
4. Carbon monoxide poisoning
Answer: 1 - Obesity hypoventilation syndrome

Explanations:

Obesity hypoventilation syndrome is defined as daytime hypercarbia, obesity, and

sleep dysfunction. It commonly presents as an acute on chronic respiratory failure.
Due to the altered lung function and chronic retention of carbon dioxide due to
sleep apnea, the respiratory drive is depressed. This can be well compensated,
evident by the raised bicarbonate, but if the underlying cause is not addressed,
which is obesity, further exacerbation of the condition occurs until it precipitates an
acute respiratory failure.
Carbon monoxide poisoning can present similarly, but other household members
would be affected as well. Exacerbation of COPD can present like this, but his smoking
history and lack of previous comorbidities make it less likely. Pulmonary embolism
would present as a type 1 failure with tachypnoea and breathlessness.

Research Concepts:

Obesity and Comorbid Conditions

Question 493: A 50-year-old man is ascending Kangchenjunga, the third-highest peak in

the world. He arrived the day before and immediately started his climb. He reached an
altitude of 7000 meters and started to develop shortness of breath. A provider is climbing
with the group and quickly assesses him. The patient has crackles throughout his lung
fields bilaterally and has an oxygen saturation of 60%. At this time, the group is hit with a
severe snowstorm in which they are able to find some coverage to protect them. There is
minimal visibility in the storm. What is the best course of action?

Choices:

1. Descend immediately
2. Wait for the storm to ascend
3. Portable hyperbaric oxygen therapy
4. Acetazolamide
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Answer: 3 - Portable hyperbaric oxygen therapy

Explanations:

In this case, it is important to be able to recognize the risk factors, signs, and
symptoms of high altitude pulmonary edema. This patient is at an elevation of
greater than 2500 meters. He is also short of breath and suffering from hypoxia.
In this case, the patient is experiencing severe symptoms of high altitude
pulmonary edema (HAPE), in a resource-poor area, and it is unsafe for them to
descend at this time. Due to these factors, it is more appropriate to place the
patient in a portable hyperbaric chamber, which will promote oxygenation and
help counteract the massive pulmonary vasoconstriction. If symptoms persist, it is
appropriate to descend once dangerous conditions have improved.
Factors that need to be considered are the severity of symptoms, access to
resources, and safety of the situation. In this case, the patient is severely ill and in a
resource-poor area. Of note, conditions are unsafe, and descent is not an option.
The other answers are inappropriate and unsafe. Descending in the middle of a
snowstorm will put the patient and the rest of the group at risk. Acetazolamide has no
clear role in the setting of established HAPE. The patient's symptoms will get worse
with ascension.

Research Concepts:High Altitude Pulmonary Edema

Question 494: A 32-year-old homeless woman from New York City presents to the clinic to
establish care. She is HIV-positive and nonadherent with her medications. She presents
with a stiff neck and a CT scan that shows soap bubble lesions. What is the most common
adverse effect of the most appropriate medication for this patient?

Choices:

1. Gastrointestinal bleeding
2. Drug-induced hepatitis
3. Weight gain
4. Constipation
Answer: 2 - Drug-induced hepatitis

Explanations:

A homeless and immunocompromised patient living in New York City may come into
Page 468 of 955
 contact with pigeons which could increase their risk of acquiring cryptococcus, which
is a fungus treatable with conazole drugs.
Immunocompromised patients have a higher risk of acquiring systemic fungal
infections, which can be treated with conazole drugs.
Conazole drugs are known to cause hepatotoxicity, especially ketoconazole.
Conazole drugs cause hepatotoxicity because they are metabolized by the liver.

Research Concepts:

Antifungal Ergosterol Synthesis Inhibitors

Question 495: A 65-year-old male presents to the emergency department with

shortness of breath, cough, and chest discomfort. His blood pressure is 130/90 mmHg,
pulse rate is 110/min, respiratory rate is 32/min, and the temperature is 102 F (38.8).
On examination, there are decreased breath sounds bilaterally and the presence of
bilateral inspiratory crepitations at lower lung lobes.
Fingernail clubbing is also noted. A chest x-ray reveals peripheral patchy areas bilaterally.
The patient's condition deteriorates, and dies despite resuscitative efforts. His family
requests an autopsy to find the exact cause of death. Histopathology of the lung reveals
findings suggestive of bronchiolitis obliterans-organizing pneumonia. Which of the
following findings were most likely seen?

Choices:

1. Diffuse alveolar damage localized to peribronchiolar parenchyma and presence of

fibroblastic plugs
2. Widespread septal destruction of alveolar spaces and the presence of
mucus plugs
3. Hyaline membrane formation with fibrinous exudate
4. Granulomatous inflammation in small airways
Answer: 1 - Diffuse alveolar damage localized to peribronchiolar parenchyma and presence
of fibroblastic plugs

Explanations:

Bronchiolitis obliterans organizing pneumonia (BOOP), also known as cryptogenic

organizing pneumonia (COP), belongs to idiopathic pulmonary fibrosis.
Histology of lung airways will show diffuse alveolar damage, which is localized to
peribronchiolar parenchyma, and the presence of fibroblastic plugs.
The histology usually is non-specific and reveals heterogeneous zones of the normal
and affected lung. Interstitial inflammation, honeycomb change, and fibrosis are
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 common, though these changes can be seen with other forms of advanced lung
disease.
The physical exam should be focused on evaluating lung involvement, the extent
and severity of the disease, and excluding another diagnosis. The classic pulmonary
exam usually reveals fine bibasilar “velcro” crackles during inspiration. Clubbing may
also be present.
Research Concepts:Idiopathic Pulmonary Fibrosis

Question 496: A 64-year-old woman comes to the clinic for a routine follow-up. A review
of her systems is unremarkable. She has a family history of breast cancer in her mother at
the age of 52 and colon cancer in her elder sister at 59. She has smoked for almost a pack
a day for 30 years but quit smoking around 14 years ago. She drinks a glass of wine every
4th day. She had normal mammography
1.4 years ago, a normal colonoscopy two years ago, and a normal pap smear seven
months ago. Which of the following is the next best step in managing this patient?

Choices:

1. Low dose helical CT scan of the chest

2. Pelvic ultrasound
3. Mammography
4. No test is recommended
Answer: 1 - Low dose helical CT scan of the chest

Explanations:

"The USPSTF recommends annual screening for lung cancer with low-dose
computed tomography in adults ages 55 to 80 years with a 30 pack-year smoking
history and currently smoke or have quit within the past 15 years. Screening to be
discontinued once a person has not smoked for 15 years or developed a health
problem that substantially limits life expectancy or the ability or willingness to
have curative lung surgery."
High-resolution CT can detect not only small solitary pulmonary nodules, most of
which are benign but, regardless, is a common presentation of lung cancer but can
also detect AAH, or atypical adenomatous hyperplasia, which is a precursor lesion for
lung cancer.
Screening for breast cancer in a patient with high-risk factors can be initiated as
early as 40 years of age but is performed every two years.
Colonoscopy is performed every 3 to 5 years in a person with a 1st-degree family
history of colon cancer.
Research Concepts:
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Lung Cancer Screening

Question 497: A 70-year-old male presents with shortness of breath. His condition is
associated with fever and dry cough. He has diabetes mellitus and maintained on
metformin. The vital signs show a temperature of 37.8 C (100.4 F), blood pressure 120/70
mmHg, cardiac rate 110/min, respiratory rate 30 breaths/min, and oxygen saturation of
89%. The chest and lung examination reveal symmetrical chest expansion, intercostal
retractions, and crackles on both lung fields. Oxygen therapy was started via a 40%
venturi mask. The chest CT scan shows ground-glass opacities with patchy distribution
and right upper lobe consolidation. A nasopharyngeal specimen was submitted for RT-
PCR and the results were positive for coronavirus. Which of the following laboratory exam
findings would you expect in this patient?
Choices:

1. A normal or decreased total white blood cell count (WBC) and a decreased
lymphocyte at the beginning of the disease
2. A decreased neutrophil-to-lymphocyte ratio (NLR), and platelet-to- lymphocyte ratio,
can correlate with the entity of the inflammatory storm
3. Low or normal C-reactive protein values
4. High procalcitonin value
Answer: 1 - A normal or decreased total white blood cell count (WBC) and a decreased
lymphocyte at the beginning of the disease

Explanations:

The clinical spectrum of COVID-19 varies from asymptomatic or paucisymptomatic

forms to clinical conditions characterized by respiratory failure that necessitates
mechanical ventilation and support in an ICU, to multiorgan and systemic
manifestations in terms of sepsis, septic shock, and multiple organ dysfunction
syndromes (MODS).
Severe pneumonia is classified as a fever associated with severe dyspnea,
respiratory distress, tachypnea (> 30 breaths/min), and hypoxia (SpO2 90% on room
air). However, the fever symptom must be interpreted carefully as even in severe
forms of the disease, it can be moderate or even absent. Cyanosis can occur in
children. In this definition, the diagnosis is clinical, and radiologic imaging is used for
excluding complications.
In the early stage of the disease, a normal or decreased total white blood cell
count and a decreased lymphocyte count can be found.
Increased levels of C-reactive protein can be demonstrated. Usually, an elevated
neutrophil-to-lymphocyte ratio, and platelet- to-lymphocyte ratio, are the
expression of the inflammatory storm. Moreover, the correction of these indices
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 can be used as indices of a favorable trend. Unless there is a bacterial overlap, a
normal procalcitonin value is found.
Research Concepts:Features, Evaluation, and Treatment of Coronavirus
(COVID-19)

Question 498: A 20-year-old woman with no significant past medical history presents to
the emergency department with a three- day history of fever (up to 102 F), fatigue,
diarrhea, and worsening shortness of breath. She does not smoke cigarettes, but she
does have urine toxicology that is positive for cannabis. Upon further questioning, she
admits to using an electronic cigarette with tetrahydrocannabinol products daily for the
past year. Chest radiograph reveals bilateral interstitial opacities. Empiric antibiotics are
started to cover for bacterial pneumonia. Her clinical status decompensates, requiring
intubation for acute hypoxic respiratory failure. Computed tomography (CT) reveals
airspace consolidation with bilateral ground-glass opacities. Labs reveal elevated
inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), while HIV
testing is negative. Which of the following is most likely to be seen on bronchoalveolar
lavage (BAL) in this patient?

Choices:

1. Foamy macrophages containing eosinophilic granules and PAS- positive amorphous

material
2. Positive Sudan III stain for lipid-laden alveolar macrophage (LLAM)
3. Diffuse intra-alveolar foamy exudates with cysts on silver methenamine
stain
4. Cell count with an eosinophilic predominance (30%)
Answer: 2 - Positive Sudan III stain for lipid-laden alveolar macrophage (LLAM)

Explanations:

Electronic cigarette used is an ever-growing epidemic among young adults in the United
States. Inhalations of nicotine and or tetrahydrocannabinol (THC) containing oils have
been associated with ‘Vaping-associated lung injury’.
There is a growing number of cases of vape-associated lung disease, and clinicians
worldwide should play a part in educating their patient’s about the deleterious effects of
vaping. Exogenous lipoid pneumonia secondary to vaping can present with generalized
symptoms that can be confused with several different pathologies. Including but not
limited to fatigue, myalgia’s, nausea, vomiting, diarrhea as well as respiratory symptoms
including cough, progressive dyspnea, and hypoxemia. Therefore clinicians should have a
high suspicion of electronic cigarette use especially in the patient’s that present with acute
severe lung disease with a history of underlying comorbidities.
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 Characteristic computed tomography (CT) findings of lipoid pneumonia include alveolar air-
space consolidation and bilateral ground-glass opacities. Some differentials include
pneumonia, acute respiratory distress syndrome, diffuse hemorrhage, and cor pulmonale.

Research Concepts: Lipoid Pneumonia

Question 499: A 38-year-old patient with no significant past medical history presents to
the emergency department with complaints of a sudden onset of high fever, chills,
headache, cough, myalgias, and diarrhea for the past two days. The cough is
nonproductive. The patient works as a librarian and has several pets at home, including a
parrot, a dog, and fish. Her vital signs show a temperature of 101.4 F (38.5 C), a heart rate
of 80 beats per minute, a respiratory rate of 20 breaths per minute, and a blood pressure
of 110/70 mmHg. Chest X-ray reveals a peripheral left lower lobe infiltrate. Laboratory
workup reveals normal white blood cell count and hyponatremia. What is the
recommended diagnostic test to confirm this patient's suspected disease?

Choices:

1. Induced sputum culture

2. Urinary antigen testing
3. Micro-immunofluorescence antibody testing
4. Lung biopsy
Answer: 3 - Micro-immunofluorescence antibody testing

Explanations:

The patient likely has psittacosis, caused by the gram-negative, obligatory

intracellular bacterium Chlamydia psittaci. History of exposure to birds, lobar
pulmonary infection with relative bradycardia, normal white blood cell count, and
hyponatremia are the clinical clues for this diagnosis.
In the appropriate clinical scenario, a diagnosis is made by meeting any one of the
criteria listed below: 1) Isolation of the causative organism from respiratory
secretions, 2) A noted four- fold or more significant increase in antibody titer
between serum samples collected two weeks apart via the complement-fixation
test (CFT) or micro-immunofluorescence (MIF), or 3) A single IgM antibody titer
detected by MIF of 1:16 or higher.
It should be noted that the isolation of C. psittaci via culture during the acute
infection is the most reliable diagnostic test. Still, it is not recommended as it
requires a biosafety level three facility due to the risk of transmission.
Molecular techniques are emerging as more reliable and rapid diagnostic tools for
identifying this infection. These include polymerase chain reaction (PCR) and

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 metagenomic next- generation sequencing (mNGS) techniques. Limited availability
and high cost currently limit their widespread use.
Research Concepts: Psittacosis

Question 500: A 68-year-old female presents to the pulmonary clinic with a chief
complaint of productive cough and nocturnal dyspnea for the past one year. She does
not have any significant medical history and does not take any medications. She had a
total hysterectomy at the age of 45. No history of the chest or abdominal trauma. She is
a lifelong non-smoker. She does endorse a 6 lb weight loss over the past three months.
Her vital signs are within normal limits. Lung examination reveals decreased tactile
fremitus and decreased breath sounds at the right lung base. The remainder of the
physical examination was unremarkable. CXR shows raised right hemidiaphragm. A
Coronal CT of the chest shows the mushroom-like focal elevation of right
hemidiaphragm without a break in continuity. A sniff test/diaphragm fluoroscopy will
show which of the following feature?

Choices:

1. Paradoxical motion of the elevated hemidiaphragm

2. Right diaphargm moves upwards during expiration
3. Left hemidiaphragm move downwards during inspiration
4. Flattening of the right hemidiaphragm

Answer: 1 - Paradoxical motion of the elevated hemidiaphragm

Explanations:

This patient's findings of unilateral decreased tactile fremitus, breath sounds along
with upward buldge on cxr and Coronal CT findings are most consistent with a
diagnosis of diaphragm eventration
Diaphragm eventration may be diagnosed using fluoroscopic sniff test also called as
diaphragm fluoroscopy.
Diaphragm eventration can remain undiagnosed for decades as most patients are
asymptomatic. Signs and symptoms are no specific and eventration is often an
incidental finding on chest imaging.
The normal hemidiaphragm contracts and moves downwards during inspiration;
and relaxes or moves upwards during expiration. Both normal hemidiaphragms
move together quiet breathing. This can be seen on diaphragm fluoroscopy. In
eventration an affected hemidiaphragm does not move downwards during
inspiration and therefore a paradoxical motion can occur.
Research Concepts: Diaphragm Eventration
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Section 6

Question 501: A 40-year-old male is ventilated for severe acute respiratory distress
syndrome secondary to H1N1 pneumonia. His ventilator settings are as follows: volume
control mode at FiO2 0.6, tidal volume 510 ml, and positive end-expiratory pressure
(PEEP) of 12 cm of H2O. The predicted body weight (PBW) was calculated to be 60 kg. He
is sedated and paralyzed. His latest arterial blood gases show PaO2 58 mmHg, PaCO2 39
mmHg, pH 7.361, and HCO3 29 mEq/L. His peak pressure is 34 cm of H20, and his plateau
pressure is 30 cm of H2O. He is hemodynamically stable and is saturating 93% on the
above settings. Which of the following complications is most likely to occur in this
patient?
Choices:

1. Atelectrauma
2. Effort-induced (self-inflicted) lung injury
3. Barotrauma
4. Volutrauma with biotrauma
Answer: 4 - Volutrauma with biotrauma
Explanations:

This patient with severe acute respiratory distress syndrome is ventilated with a tidal
volume, which is much more than 6 ml/Kg of predicted body weight (PBW), which is very
likely to promote volutrauma. His plateau pressures are acceptable as per acute respiratory
distress syndrome (ARDS) lung-protective ventilatory strategy, i.e., 30 cm H2O. Volutrauma
would incite biotrauma with the release of inflammatory mediators, which could cause
detrimental effects not only locally, but also systemically in the form of multiorgan failure.
Predicted body weight is calculated using a formula that incorporates height as well as
gender, as mentioned. Females: PBW (kg) = 45.5 + 0.91 * (Height [cm] - 152.4) & Males:
PBW (kg) = 50 + 0.91 * (Height [cm] - 152.4).
It's recommended that ARDS patients be ventilated at a low tidal volume of 6 ml per Kg of
predicted body weight (PBW) to prevent volutrauma. A 2012 meta-analysis has shown
survival benefits with a tidal volume of 6-8 ml Kg of predicted body weight (PBW) in non-
ARDS patients. Biotrauma is caused not only by volutrauma but also by atelectrauma.
In ARDS, cyclical opening and closing of the atelectatic alveoli causes injury to the adjacent
non-atelectatic alveoli due to shear stress forces. This is called atelectrauma. The
application of PEEP helps in the prevention of atelectrauma. Effort-induced lung injury
often results from volutrauma due to high efforts in patients already having an injured
lung. Effort-induced lung injury could occur in invasive as well as non-invasive ventilation.

Research Concepts:Ventilator-Induced Lung Injury (VILI)

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Question 502: A 65-year-old male presents to the emergency department with cough
and shortness of breath. He reports that he worked on a farm and developed these
symptoms shortly after getting some grain to feed the animals. He has normal vital
signs, including SpO2 of 98% on room air and a heart rate of 88/min. His physical exam
is unremarkable. Which of the following is the best step in management?

Choices:

1. Discharge the patient and have him follow up with his primary care doctor
2. Obtain a chest x-ray and admit for a 24-hour observation
3. Administer an albuterol breathing treatment and discharge the patient
4. Obtain a CT of the chest and admit to the intensive care unit

Answer: 2 - Obtain a chest x-ray and admit for a 24-hour observation

Explanations:

Given delayed pulmonary toxicity, patients with nitrogen dioxide toxicity should be
admitted and observed for 24 hours.
Patients should also get a baseline chest x-ray.
If a patient has worsening pulmonary symptoms, they should be treated with
supplemental oxygen.
Delayed complications can occur 2-8 weeks after exposure.

Research Concepts:

Nitrogen Dioxide Toxicity

Question 503: A 16-year-old female presents with a persistent cough present for eight
weeks that is not improving on two different courses of antibiotics. She is otherwise
healthy and has no preexisting medical illnesses. She has a lot of birds in her house
because her mother is fond of keeping birds. On auscultation of the chest, there are
crackles all over. Pulmonary is consulted, and bronchoscopy with bronchoalveolar lavage
is performed, and dimorphic budding yeast is identified on microscopy. What is this
organism?

Choices:

1. Aspergillus niger
2. Histoplasmosis
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3. Blastomycosis
4. Staphylococcus aureus
Answer: 2 - Histoplasmosis

Explanations:

Histoplasmosis capsulatum is a dimorphic budding yeast. Also known as Darling

disease, Ohio valley disease, reticuloendotheliosis, caver's disease, and spelunker's
lung, is a disease caused by the dimorphic fungi Histoplasma capsulatum native to the
Ohio, Missouri, and Mississippi River valleys of the United States. The two phases of
Histoplasma are the mycelial phase and the yeast phase.
Pulmonary histoplasmosis in asymptomatic patients is self- resolving and requires
no treatment. Once symptoms develop treatment with antifungal medicines should
be considered. In mild, tolerable cases no treatment other than close monitoring is
necessary.
Once symptoms progress to moderate or severe or if they are prolonged for greater
than four weeks, treatment with itraconazole is indicated. The anticipated duration
is 6-12 weeks total. Response should be monitored with chest x-ray.
Furthermore, observation for recurrence is necessary for several years following the
diagnosis. If the illness is determined to be severe or does not respond to
itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up
to 1 year.
Cotreatment with methylprednisolone is indicated to improve pulmonary compliance
and reduce inflammation, thus improving work of respiration.

Research Concepts:

Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough

Question 504: 45-year man with progressive shortness of breath and fever is admitted to
the intensive care unit with acute respiratory failure requiring mechanical ventilation.
Ventilator settings are as follows: mode assist control, tidal volume 500 mL, respiratory rate
12/min, positive expiratory pressure (PEEP) 10 cmH2O, and FiO2 100%. The patient
tolerates this treatment overnight, but early in the morning, the ventilator pressure alarm is
triggered several times.
Bedside pressures are peak 45 cmH2O and plateau 40 cmH2O. What is the most
appropriate next step in management?

Choices:

1. Observation
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2. Change ventilator mode to pressure control
3. Obtain a portable chest x-ray
4. Thoracentesis
Answer: 3 - Obtain a portable chest x-ray

Explanations:

All patients on mechanical ventilation are at risk of barotrauma. Positive pressure

ventilation can increase the pressure across the alveolar space leading to alveolar
rupture and barotrauma. Barotrauma can manifest in one or more of the following
conditions: pneumothorax, pneumomediastinum, pneumoperitoneum, and/or
subcutaneous emphysema.
Daily bedside assessments of the ventilator and a physical exam of the patient, in
addition to chest radiography, are important for the early identification of signs of
barotrauma. The plateau pressure is known as a surrogate or estimation for the
pressure in the alveoli. There is no exact plateau pressure threshold at which
barotrauma occurs; however, in general, the higher the plateau pressure, the
greater the risk of barotrauma.
Most cases occur in those with a plateau pressure >35 cmH2O.

Research Concepts:

Barotrauma And Mechanical Ventilation

Question 505: A 65-year-old female presents to the clinic with complaints of increasing
exertional dyspnea, intermittent fevers, and productive cough for the past three weeks.
Her blood pressure is 150/90 mmHg, pulse rate is 90/min, respiratory rate is 28/min, and
the temperature is 99 F. On examination, there is the presence of inspiratory crackles in
the lower lobes of both lungs. A chest x-ray shows bilateral consolidations. She has never
smoked and has no toxic or industrial exposure. She lives in the city and has had no pet
or bird exposures. Pulmonary function tests (PFTs) reveal restriction and impaired
diffusing capacity of the lungs for carbon monoxide (DLCO). A High-resolution CT scan of
the chest reveals ground- glass opacities over bilateral mid to lower lung zones along
with areas of dense consolidations. Bronchoscopy with bronchoalveolar lavage revealed
a white cell count of 500/mm3 with 55% lymphocytes, 12% eosinophils, 23% neutrophils,
and 10% monocytes. What is the histopathologic hallmark of this patient's suspected
diagnosis?

Choices:

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1. Interstitial fibrosis with temporal and spatial heterogeneity
2. Diffuse interstitial inflammatory cell infiltration
3. Excessive formation of granulation tissue obstructing small airways
4. Loosely formed granulomas with lymphocytic infiltration
Answer: 3 - Excessive formation of granulation tissue obstructing small airways

Explanations:

The classic pathological finding in cryptogenic organizing pneumonia is the excessive

proliferation of fibrous tissue in the alveolar sacs and ducts and even obstructing the
bronchiolar lumen.
These organized plugs of intraluminal granulation tissue are referred to as Masson
bodies.
Granulation tissue extends uniformly into the alveolar ducts and does not distort
pulmonary architecture, unlike usual interstitial pneumonia.
Mild mononuclear inflammation may be seen in the lung surrounding the lesion, but
intense inflammatory should raise suspicion for other conditions.

Research Concepts:

Cryptogenic Organizing Pneumonia

Question 506: A 31-years-old man presents to the hospital with a chief complaint of
productive cough. He also reports nausea and malaise. His vital signs show a temperature
of 38.6 C and respiratory rate of 32/min. He has a history of one-time cocaine use with his
friends 4 days before. He also has a history of gingivitis a week ago and had not resolved.
What is the most likely risk factor responsible for the patient's condition?

Choices:

1. Esophageal dysmotility
2. Cocaine use
3. Immunosuppression
4. Dental infection
Answer: 4 - Dental infection

Explanations:

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 Productive cough and fever increase the likelihood of lung abscess as one of the
differential diagnoses.
Gingivitis is a dental infection that may predispose to lung abscess infection.
Lung abscesses are more common in immunocompromised hosts (HIV-AIDS, post-
transplantation, or those receiving prolonged immune suppressive therapy). Lung
abscesses are also common in those patients with high risk for aspiration: seizures,
bulbar dysfunction, and cognitive impairment. Lung abscess is in the group of lung
infections such as lung gangrene and necrotizing pneumonia which is characterized
by multiple abscesses
The patient has no risk factors for immunosuppression.

Research Concepts:

Lung Abscess

Question 507: A 72-year-old male with chronic obstructive pulmonary disease (COPD),
congestive heart failure, diabetes mellitus, and hypothyroidism presents to the
emergency department with cough and shortness of breath. The patient is found to have
acute on chronic hypercapnic respiratory failure. His pH on arterial blood gas is 7.1, pCO2
90 mmHg, and pO2 100 mmHg on a nonrebreather mask. Upon evaluating his mouth,
the clinician is unable to pass more than two fingers between upper and lower teeth.
Because of the possibility of a difficult airway, the patient is intubated with a video
laryngoscope after giving intravenous etomidate and rocuronium. The patient is now
transferred to ICU. Which of the following is the next best step in the management of
this patient?

Choices:

1. Keep the patient paralyzed after intubation so he cannot self extubate himself
2. Plan tracheostomy as the patient has a difficult airway
3. Place "Difficult Airway" sign outside of the patient's room
4. Avoid suctioning the patient as it will traumatize the tissue and it will lead to airway
edema
Answer: 3 - Place "Difficult Airway" sign outside of the patient's room

Explanations:

The 3-3-2 rule helps to predict difficult airways. This patient has a distance of fewer
than 2 fingers width between upper and lower teeth, which predicts a difficult
airway.
In the case of a difficult airway, the patient is usually intubated with rapid
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 sequence intubation where paralytic medications are given. These medications
should not be given continuously once the patient is intubated. The continuous
infusion of paralytic medication increases the risk of myopathy.
Once the patient with a difficult airway is intubated, it is important that the
interprofessional team in the ICU is aware of the patient's difficult airway. This can
be achieved by placing the "difficult airway" sign outside of the patient's room.
The "difficult airway" sign allows respiratory therapists to have an emergency
intubation kit ready in the ICU if the patient's self extubates or fails planned
extubation.

Research Concepts:

3-3-2 Rule

Question 508: A 70-year-old female undergoes radiographic imaging of the chest for surgical
clearance prior to an elective orthopedic surgery. She is found to have a pulmonary nodule.
Further questioning reveals poor functional capacity and tolerance for the last several
months. She also reported poor appetite and unintentional weight loss but thought this
was related to "old age." Which of the following is the most likely cause of this
pulmonary lesion?

Choices:

1. Malignant melanoma
2. Esophageal cancer
3. Uterine leiomyoma
4. Giant cell tumor of the bone
Answer: 1 - Malignant melanoma

Explanations:

The most common cancers that metastasize to the lungs are malignant melanoma,
sarcoma, bronchogenic carcinoma, colon cancer, renal cell carcinoma, breast
cancer, and testicular cancer.
The probability of a pulmonary nodule being a malignant metastatic nodule in a
patient with prior history of extrathoracic malignancy is 25%.
Pulmonary metastases usually present as round variable-sized nodules with diffuse
thickening of the interstitium. However, atypical features of pulmonary metastases
are frequently seen which makes it difficult to differentiate between metastatic
malignant, primary malignant, and benign lesions based on radiographic evidence
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 alone. Calcifications, for example, can occur in metastatic sarcoma or
adenocarcinoma. Calcifications are also seen in benign granulomas and
hamartomas.
Uterine leiomyomas and giant cell tumors of the bone are benign tumors that
rarely metastasize to the lung.

Research Concepts:

Lung Metastasis

Question 509: A 30-year-old female patient with a past medical history of lower extremity
DVT three years ago presented to the emergency department after a 6-hour flight with
the complaint of shortness of breath. She has been smoking a pack per day for the past 12
years. She is currently not on any medications, including oral contraceptive pills. The
patient reports gradually increasing shortness of breath over the past three months, and
she is no longer abe to run uphill. On physical examination, the pulse is 78 bpm, blood
pressure is 110/70 mmHg, and equal in both arms. Saturation is 96% on room air but
drops to 87% on standing. A chest x-ray is unremarkable. Her hemoglobin is 10.7 g/dl,
creatinine 0.8 mg/dl. An echocardiogram doesn't demonstrate a valvular pathology and
has a normal ejection fraction. Which is the most appropriate diagnostic test in this
patient?

Choices:

1. CT angiography
2. Ventilation-perfusion scan
3. Pulmonary function test
4. Transesophageal echocardiography with agitated saline
Answer: 4 - Transesophageal echocardiography with agitated saline

Explanations:

Platypnea is commonly associated with orthodeoxia, and both result from

diseases that cause intracardiac or extracardiac right-to-left shunting significant
enough to cause hypoxia.
Patent foramen ovale (PFO) is a type of intracardiac shunt and can present as
platypnea-orthodeoxia syndrome.
An echocardiogram with an agitated saline bubble study is a very useful initial test
to evaluate the presence of intracardiac or extracardiac shunts. The appearance of
microbubbles in the left atrium during the first three beats after the opacification of
the right chambers suggests an intracardiac shunt. In contrast, the appearance of
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 microbubbles on the left side after more than 3 to 6 beats suggests an extracardiac
shunt, for example, an intrapulmonary shunt like in hepatopulmonary syndrome.
PFO usually does not require any treatment as it may present in up to 25% of
people. If the patient is symptomatic with platypnea-orthodeoxia or to prevent
paradoxical embolic stroke, then device closure may be an option.
Research Concepts:

Platypnea

Question 510: A 65-year-old male patient presents with a 10-day history of lethargy, chills,
a cough with blood-tinged green sputum, and pleuritic chest pain. He has been human
immunodeficiency virus (HIV) positive for ten years and was started on highly active
antiretroviral treatment one year ago. His latest CD4 count was 340 cells/mm3. On
examination, he looks unwell, with a low-grade fever, a blood pressure of 100/60 mmHg,
a heart rate of 115 beats per minute, and an oxygen saturation of 97% on room air. On
auscultation, there are coarse crackles in the right lower part of the chest. His chest
radiograph shows consolidation of the right lower lobe. What is the most likely diagnosis
in this case?

Choices:

1. Cytomegalovirus pneumonitis
2. Staphylococcal pneumonia
3. Streptococcus pneumonia
4. Lymphoid interstitial pneumonitis
Answer: 3 - Streptococcus pneumonia

Explanations:

This patient has community-acquired pneumonia, the most common cause of which is
Streptococcus pneumoniae.
Streptococcus pneumoniae is a Gram-positive, alpha, or beta- hemolytic, facultative
anaerobic member of the genus Streptococcus.
Symptoms of community-acquired pneumonia include shortness of breath, cough,
productive sputum, etc.
Lymphoid interstitial pneumonitis is caused by the infiltration of the alveolar tissue
by lymphocytes and plasma cells.

Research Concepts:Cough
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Question 511: A 75-year-old white man presents to the emergency department with one
episode of a small amount of hemoptysis. He has also had a dry cough and decreased
urine output for the last 2 days. He denies fever, chills, or dysuria. He denies frank
hematuria. On examination, his respiratory rate is 24/min, heart rate 88/min, and blood
pressure 130/78 mmHg. Labs reveal serum creatinine 2.4 mg/dL and BUN of 26 mg/dL.
His urinalysis is positive, with 1+ protein and moderate blood. His chest x-ray is
suggestive of bilateral fluffy infiltrates. He never had kidney disease in the past, and his
most recent serum creatinine during his visit was 1 mg/dL 3 months back. He denies the
recent use of NSAIDs other medications. A renal biopsy is planned. Soon after admission,
he develops progressive respiratory discomfort, requiring mechanical ventilatory support.
What is the best initial therapy for this patient?

Choices:

1. IV methylprednisone
2. Oral prednisone
3. Plasmapheresis
4. Oral azathioprine

Answer: 1 - IV methylprednisone

Explanations:

The clinical vignette is suggestive of pulmonary-renal syndrome. Timely treatment is

the key to preserving renal function. The recommended guideline is to start pulse
dose steroids as soon as this condition is suspected
It is not advisable to wait for the biopsy result to confirm the cause of the rapidly
progressive glomerulonephritis.
Pulse dose methylprednisone 500- 1000 mg IV for 3-5 days is recommended.
Once the diagnosis is confirmed plasmapheresis can be initiated.

Research Concepts:

Rapidly Progressive Glomerulonephritis

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Question 512: A 10-year-old African American girl with a history of moderate persistent
asthma is brought into the clinic for continued shortness of breath and wheezing. She is
currently being treated with a low-dose steroid and a short-acting beta-agonist. The
child’s family reports their daughter's symptoms are worse at night or when she is
exposed to cold air. The family listed no known drug allergies but did indicate a dairy
allergy. After further evaluation of the patient's severe chronic asthma symptoms, she is
prescribed a low dose of an inhaled corticosteroid and long-acting beta-2 agonist
combination. Before leaving the clinic, she is administered one dose of fluticasone
propionate/salmeterol 100/50 mcg inhalation powder. Shortly after administration, she
develops chest tightness and requires oxygen therapy and albuterol. Which of the
following best explains the girl’s sudden worsening of symptoms?

Choices:

1. Incorrect dose
2. Hypersensitivity to fluticasone/salmeterol inhalation powder formulation
3. Incorrect route of administration
4. Expected transient side effect of salmeterol
Answer: 2 - Hypersensitivity to fluticasone/salmeterol inhalation powder formulation

Explanations:

Hypersensitivity is a contraindication for salmeterol. Salmeterol is

contraindicated in patients with a known hypersensitivity to any ingredient in
the preparation, including lactose and milk protein.
In children between the ages of 4 and 11, the standard recommendation for the
treatment of asthma is one inhalation of fluticasone/salmeterol 100/50 mcg twice
daily.
The patient should be given an HFA aerosolized formulation that does not contain
lactose or milk protein in its preparation.

Research Concepts:

Salmeterol

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Question 513: Enlargement of which of the following groups of mediastinal nodes may
be an indication for surgery in a patient diagnosed with lung cancer?

Choices:

1. Anterior mediastinal nodes

2. Aortopulmonary nodes
3. Subcarinal nodes
4. Paratracheal nodes
nswer: 2 - Aortopulmonary nodes

Explanations:

It has been observed that in patients with lung cancer and positive
aortopulmonary (AP) window nodes, the results of surgery are much better
than expected.
The rate of metastases to the AP lymph nodes is high in patients with left-
sided lung cancer.
Despite being N2 nodes, some surgeons report good results with complete
excision of the primary lung cancer and lymph node dissection.
Chemotherapy is often offered to these patients after surgery, but relapse rates are
high. A modest increase in survival has been shown in some studies, but there is no
survival advantage in geriatric patients.
Research Concepts:

Lung Cancer

Question 514: A 65-year-old woman with a history of hyperlipidemia and asthma presents
to the clinic with worsening shortness of breath but no chest pain, wheezing, cough, or
gastrointestinal symptoms. She has been smoking two packs of cigarettes per day for the
last 30 years. Medications are atorvastatin 20 mg daily, daily inhaled fluticasone, and
albuterol rescue inhaler as needed. Vital signs include a temperature of 37 C orally, a
blood pressure of 120/80 mmHg, a pulse of 100/min, a respiratory rate of 24/min and
increased when walking, and oxygen saturation of 90% in room air. Physical exam reveals
no jugular venous distention, regular heart rate without murmur or gallop, normal breath
sounds bilaterally. Labs reveal a hematocrit of 24%, a mean corpuscular volume of 68 fL, a
white blood cell count of 8,500/microL. Chest x- ray revealed normal heart size, clear lung
field except for a right lower lobe 8 mm solid nodule. Her microcytic anemia is evaluated
with ferritin, serial stools for occult blood, and she is prescribed ferrous sulfate 325 mg
once daily. She is referred for colonoscopy.
Which of the following is the next best step in the management of the nodule?
Page 486 of 955
Choices:

1. Perform a contrast-enhanced CT in three months

2. Obtain a percutaneous needle biopsy of the nodule
3. Perform a contrast-enhanced CT now
4. Surgical removal of the nodule
Answer: 3 - Perform a contrast-enhanced CT now

Explanations:

Solid nodules between 6 mm and 8 mm require an initial CT with afollow-up CT in

6-12 months and again at 18-24 months. The management is the same for low and
high-risk patients with nodules 6-8 mm in size.
Nodules located in the lower lung fields are more likely to be benign.
It takes time for nodules to grow, and therefore, a CT before six months in a patient
with a smaller nodule would not be beneficial.

Research Concepts:

Solitary Pulmonary Nodule

Question 515: A 14-year-old male presented to the clinic for a well-patient visit. He
tells the clinician that one of his close friends has recently been diagnosed with
tuberculosis. What are the chances of the patient getting the disease?

Choices:

1. He cannot develop the disease because it is a bloodborne disease.

2. He can develop the disease because it is an airborne disease.
3. He cannot develop the disease as it is a sexually transmitted disease.
4. He can develop the disease as it is a waterborne disease.
Answer: 2 - He can develop the disease because it is an airborne disease.

Explanations:

Tuberculosis (TB) is a serious airborne lung infection; therefore, close contact with a
TB patient can develop the disease.
When a person comes in contact with a patient with active TB, his TB skin test is
performed to check whether he has been exposed to the disease or not.
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 The TB skin test will be positive after 2 to 12 weeks.
A person with a positive TB skin test has the highest chance of developing active TB
within the next 2 years.

Research Concepts:

Tuberculosis

Question 516: A 67-year-old male patient presents with complaints of shortness of breath
and cough for the past six months. He states he has worked in manufacturing metals for
the past 40 years. He gave up smoking 20 cigarettes/day around ten years ago. On
examination, his oxygen saturations are 98% on room air, his respiratory rate is 14
breaths per minute, and there are some crackles in his lung bases bilaterally. Finger
clubbing is also noted.
His B-type natriuretic peptide is 88 pg/ml. Spirometry reveals FEV1
1.57 L (50% of predicted), FVC 1.63 L (39% of predicted), and FEV1/FVC 96%. Which of
the following investigations is most likely to confirm the diagnosis?

Choices:

1. Acute vasodilator testing

2. Ventilation/perfusion scan
3. Flow-volume loop
4. High-resolution computed tomography scan
Answer: 4 - High-resolution computed tomography scan

Explanations:

Nonidiopathic interstitial pulmonary fibrosis (non-IPF) describes a group of

interstitial lung diseases (ILD) that cause inflammation and fibrosis of the lung
interstitium leading to impaired gas exchange due to a known cause. Depending on
the specific disorder, it can also affect the trachea, bronchi, bronchioles, alveoli,
and pleura. Most of these diseases are characterized by their clinical, radiographic,
pathologic, and physiologic findings.
The classic features often include progressive shortness of breath and cough, chest
imaging abnormalities, and inflammatory and fibrotic changes on histology. A
restrictive pattern with a decreased diffusing capacity for carbon monoxide (DLCO)
is often seen in pulmonary function testing (PFT).
High-resolution computed tomography (HRCT) has an important role in confirming
Page 488 of 955
 ILD. The specificity of HRCT is dependent on the etiology of the disease. Patterns on
HRCT, along with the clinical history, can often make the diagnosis and assist in
staging. Common findings may include reticular opacities, centrilobular or
perilymphatic nodules, ground-glass appearance, consolidation, and
honeycombing.
Honeycombing is a nonspecific late finding and appears as small cystic airspaces
within areas of fibrosis. It develops over months to years and is associated with
advanced disease.
Research Concepts: Interstitial Pulmonary
Fibrosis

Question 517: An unvaccinated 5-year-old girl is brought to the emergency department

with a fever, sore throat, and poor appetite for the last two days. She is accompanied by
her mother, who states that her daughter has been very tired, unwilling to go to soccer
practice, and claims that she has been eating less despite offering her favorite food.
When asked her name, her response is muffled and barely audible. On oral exam, there is
an erythematous soft palate with half of the uvula visible. What is the most appropriate
characterization of this child's airway if intubation is necessary?

Choices:

1. Mallampati class IV; easy to intubate

2. Mallampati class I; requires surgical preperation
3. Meets 3-3-2 criteria; difficult airway
4. Mallampati class II; moderately difficult to intubate
Answer: 4 - Mallampati class II; moderately difficult to intubate

Explanations:

Unvaccinated children should always raise concern for dangerous infectious

pathogens.
Muffled voices, particularly in children, is an ominous sign of potential airway
compromise.
Intubation difficulty can be determined using the L.E.M.O.N. criteria: look for facial
structure or injury, evaluate 3-3-2, Mallampati Class, obstruction of the airway, neck
mobility.
Mallampati classifications: Class 1: full uvular visualization, Class 2: the distal
portion of the uvula is occluded by the tongue, Class 3: the entire uvula is occluded
except for the base or proximal portion, Class 4: the uvula is unable to be visualized.

Page 489 of 955

Research Concepts:

Trauma Care Principles

Question 518: A 69-year-old male with a history of hypertension and chronic tobacco
abuse is in the hospital for a laryngeal mass. He is postoperative day 14 after
tracheostomy to relieve his upper airway obstruction due to the mass. The patient
seemed to be improving initially after the procedure, but his condition has now changed
significantly. Vital signs are blood pressure: 95/50, heart rate:132 beats per minute,
temperature: 98.2 Fahrenheit (36.7 C), and respiratory rate:30 breath per minute. There is
blood coming from the ostomy site, and the patient has had several episodes of
hemoptysis. The tracheostomy tube is noted to be at the level of the 6th tracheal ring.
What is most likely causing this patient's clinical deterioration?

Choices:

1. Aortic dissection
2. Damage to the superior vena cava
3. Surgical site infection
4. Tracheo-innominate artery fistula
Answer: 4 - Tracheo-innominate artery fistula

Explanations:

One of the life-threatening complications of a tracheostomy is the formation of a

tracheo-innominate artery fistula. These typically present at least one week after
the procedure with a peak incidence at around 13 days post-operation.
Tracheo-innominate fistulas form primarily due to pressure erosion from direct
contact of the tracheostomy cuff over a high riding innominate artery. Infection
from the ostomy site, as well as long term steroid therapy, can contribute to this as
well.
The innominate artery is commonly observed to cross the trachea as high as the 6th
tracheal ring. Therefore it is recommended to perform a tracheostomy no lower
than the third or fourth tracheal ring to decreased the risk of tracheo- innominate
fistula.
Any patient with a history of tracheostomy who develops signs of hemorrhage,
especially if there is bleeding from the ostomy site or hemoptysis, should be
suspected to possibly have a tracheo-innominate artery fistula due to their high
rate of mortality.

Page 490 of 955

Research Concepts:

Anatomy, Thorax, Brachocephalic (Right Innominate) Arteries

Question 519: A 47-year-old male is admitted with COVID-19 pneumonia requiring 4 liters
of oxygen via nasal cannula. He has been treated with remdesivir and dexamethasone for
4 days with minimal improvement. The decision is made to add baricitinib. Which of the
following is the most appropriate lab test to be monitored when treating a patient with
baricitinib?

Choices:

1. SARS-Cov-2 cycle threshold

2. Arterial blood gas
3. Creatinine phosphokinase
4. No monitoring is needed

Answer: 3 - Creatinine phosphokinase

Explanations:

Repeat COVID-19 testing or SARS-Cov-2 cycle threshold during treatment with

baricitinib will not result in a change in management.
Frequent arterial blood gas testing is unnecessary in a patient with no respiratory
distress, stable oxygen requirements, and reliable pulse oximetry.
A rapid decrease in neutrophil count, drop in hemoglobin, the elevation of
creatinine phosphokinase, the elevation of liver enzymes, and the elevation of
serum creatinine can be associated with the use of baricitinib and should be
monitored. Close monitoring for adverse effects is required in patients being treated
with baricitinib. Laboratory testing may assist in identifying hematologic, renal, or
hepatic dysfunction that can occur as a result of baricitinib.

Research Concepts:

Safe and Effective Use of Baricitinib And Remdesivir In Hospitalized Patients With
Coronavirus (COVID- 19)

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Question 520: A 38-year-old woman with a history of cystic fibrosis diagnosed seven
years ago presents to the clinic with a chronic productive cough. She reports that her
cough is present every day, mostly in the morning. She describes green, thick, and
abundant sputum. She also complains that she develops shortness of breath after walking
a block. She denies fever, weight loss, night sweats, blood in the sputum, sick contacts,
recent travel. Upon evaluation, vital signs are within normal limits. Auscultation reveals
bilateral crackles. A previous CT done a month ago demonstrates bilateral nodular lesions
with diffused bronchiectatic changes in both lung bases. Her laboratory records confirm a
negative PPD test 2 months ago, as well as CBC, BMP, and liver enzymes within normal
limits. Based on the patient history and test results, what is the most appropriate next
step?

Choices:

1. Sputum for acid-fast bacilli

2. Three sputum sample collected in three different days that are positive for NTM
(MAC) on DNA amplification test and AFB smear
3. Positive sputum culture for nontuberculous mycobacteria (NTM)/ mycobacteria
avium-complex (MAC)
4. B-galactomannan test
Answer: 3 - Positive sputum culture for nontuberculous mycobacteria
(NTM)/ mycobacteria avium-complex (MAC)

Explanations:

This patient has a high suspiciousness for non-tuberculosis mycobacterial infection.

Nuclei-acid amplification (NAA) is the most accurate test to identify mycobacteria
tuberculosis.
Culture remains the gold standard for NTM laboratory confirmation.
Usually, the way that is recommended to collect sputum in on three different days.
Also, a positive AFB specimen cannot discriminate between tuberculous
mycobacterial vs. NTM. B- galactomannan test is used to identified aspergillus
infection. It has no role in the diagnosis of NTM.

Research Concepts:

Lung Nontuberculous Mycobacterial Infections

Page 492 of 955

 Question 521: A 58-year-old male presents for annual lung cancer screening with chest
CT chest, which shows the presence of a 3 cm mass in the right upper lobe. He is referred
for lung biopsy, which is reported as a squamous cell carcinoma of the lung.
Metastatic workup is negative, and the decision is made to proceed with video-assisted
thoracoscopy (VATS) for resection of the mass. Which of the following predicts a good post-
operative pulmonary reserve for this patient?

Choices:

1. Predicted post-operative DLCO of 25%

2. Maximal oxygen consumption (VO2) of 7 ml/min/kg
3. Predicted postoperative FEV1 of 60%
4. pre-operative pCO2 of 53
Answer: 3 - Predicted postoperative FEV1 of 60%

Explanations:

Preoperative assessment is aimed at assessing lung mechanics (FEV1, MVV, FVC,

RV/TLC ratio), parenchymal function (DLCO, PaO2, PaCO2), and cardiopulmonary
reserve (VO2 max, exercise tolerance). A predicted postoperative FEV1 (ppo FEV1)
of 60% is a good predictor of the adequate pulmonary reserve for this patient. FEV
>40% generally predicts that the patient will tolerate the procedure.
DLCO is a measure of the rate of diffusion of carbon monoxide particles across the
alveolar membrane. A DLCO greater than 40% is a good marker for adequate post-
operative pulmonary reserve.
For cases in which FEV1 and DLCO are borderline, cardiopulmonary exercise testing
is used to predict the reserve of the entire cardiopulmonary axis. Maximal oxygen
consumption (VO2) is calculated. A VO2 greater than 10ml/min/kg is required to
proceed with surgery.
Patients with PaCO2 greater than 50 mm Hg or PaO2 less than 60 mm Hg are
vulnerable for postoperative complications.

Research Concepts:

Video-Assisted Thoracoscopy

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Question 522: A 56-year-old man is being evaluated in the clinic for shortness of breath.
The patient is a known cause of cirrhosis due to hepatitis C due to intravenous drug use in
his 30s. The patient says his shortness of breath is better with lying supine but gets worse
when he sits down. Pulse oximetry shows a saturation of 90% on room air. Arterial blood
gas analysis is done and shows partial pressure of Oxygen to be 50 mmHg and arterial
oxygen gradient (A- aO2) 15 mmHg. Echocardiography with agitated saline is done and is
positive for pulmonary vascular dilatation. The patient is started on O2 therapy. Which of
the following therapies is most likely to provide the greatest long term survival benefit to
this patient?

Choices:

1. Long term O2 therapy

2. Transjugular intrahepatic portosystemic shunt (TIPS)
3. Liver transplantation
4. Aspirin
Answer: 3 - Liver transplantation

Explanations:

Liver transplantation is the only established treatment that has shown to provide
long term survival benefits for hepatopulmonary syndrome (HPS) patients. It
improves hypoxemia in 6-12 months.
Hepatopulmonary syndrome is defined as reduced arterial oxygen saturation due
to dilated pulmonary vasculature in the presence of advanced liver disease or
portal hypertension.
Contrast-enhanced echocardiography with agitated saline is the gold standard for
diagnosing pulmonary vascular dilatation.
For transjugular intrahepatic portosystemic shunt, data is limited regarding the
benefit, and clinical outcomes can vary. Also, there is a risk of aggravating the
hyperkinetic circulatory state, which may augment intrapulmonary vasodilatation,
shunting, hypoxia and may increase the gravity of HPS.
Research Concepts: Hepatopulmonary
Syndrome

Question 523: A 42-year-old woman presents to the office with a complaint of feeling
progressively short of breath on exertion, cough, having trouble sleeping at night,
dysphagia, intermittent wheezing, and joint pain in both hands and wrists. She recently
moved to the United States from Kenya and has not been seen by a clinician in over ten
years. What is the next best step in the management of this patient?

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 Choices:

1. Laryngoscopy
2. Montgomery t-tube
3. Open surgery
4. Tissue ablation
Answer: 1 - Laryngoscopy

Explanations:

Evaluating a patient with suspected laryngotracheal stenosis (LTS) includes a

detailed history and physical examination.
History should include any previous endotracheal intubations and their duration,
history of infection, autoimmune disease, vasculitis, trauma, surgery, as well as
current symptoms.
LTS can be evaluated by laryngoscopy or bronchoscopy.
The clinician may obtain a computed tomography (CT) scan of the neck in severe
cases in which the obstruction does not allow for direct laryngoscopy or patients
who have traumatic injury to the trachea, and in planning for surgical treatment.
Performing spirometry on these patients helps establish a baseline and monitor
their status over time.

Research Concepts: Laryngotracheal Stenosis

Question 524: A 16-year-old male presents to the clinic for follow up after recently being
diagnosed with mild persistent asthma requiring inhaled fluticasone therapy. He states his
asthma is well- controlled but he has developed a sore throat with odynophagia.
Examination reveals normal vital signs. Oral examination reveals white plaques on the
posterior pharynx. What preventive practice could have prevented this complication?

Choices:

1. Prescribing combination corticosteroid and beta-agonist inhalers

2. Oral rinse after each dose of inhaled corticosteroid
3. Prophylactic oral antifungal therapy
4. Using a spacer to administer inhaled corticosteroid
Page 495 of 955
Answer: 2 - Oral rinse after each dose of inhaled corticosteroid

Explanations:

One of the most common complications of inhaled corticosteroid therapy is oral

thrush. It is essential to advise patients on the importance of oral hygiene and
specifically rinsing the mouth thoroughly after each dose to prevent it.
Using a spacer to administer metered-dose inhalers helps ensure the entire dose is
delivered to the bronchial tree rather than being lost to air from improper
administration. A patient who presents with uncontrolled asthma despite an
escalation of therapy and reported compliance should be an evaluation for their
method of taking the inhalation to ensure proper technique. Combined
corticosteroid and beta-agonist therapy is reserved for patients with moderate
persistent asthma that is not responsive to corticosteroid therapy alone.
There is no role for prophylactic antifungal therapy for patients with asthma.

Research Concepts:

Allergic And Environmental Induced Asthma

Question 525: A 65-year-old man presents with a two-day history of worsening shortness
of breath, wheezing, and fever. He also admits to a cough productive of yellow sputum.
He has a history of chronic obstructive pulmonary disease (COPD) and quit smoking six
months ago. He uses a short-acting bronchodilator as needed and a long-acting
bronchodilator daily. He has no other significant past medical history and has never been
hospitalized. His heart rate is 105/min, temperature 38.5 C (101.3 F), and oxygen
saturation 84% on room air. He is tachypneic with a respiratory rate of 26/min.
Lung examination reveals diffuse wheezing and left basilar rales. He is given
bronchodilator treatments and placed on high-flow nasal cannula oxygen with
improvements in oxygen saturation to 92% and respiratory rate to 20/min. Sputum and
blood cultures are collected. Arterial blood gas analysis shows a pH of 7.27, pCO2 65
mmHg, and PO2 60 mmHg. Chest x-ray is significant for left lower lobe infiltrates. What is
the most appropriate management for this patient?

Choices:

1. Admit to inpatient medical floor and start systemic corticosteroids.

2. Admit to inpatient medical floor and start systemic corticosteroids and antibiotics.
3. Admit to the intensive care unit to initiate noninvasive positive pressure
Page 496 of 955
ventilation (NPPV) in addition to starting systemic corticosteroids and antibiotics.
4. Manage as an outpatient with short-acting beta-2 agonists, systemic
corticosteroids, and antibiotics.
Answer: 3 - Admit to the intensive care unit to initiate noninvasive positive pressure
ventilation (NPPV) in addition to starting systemic corticosteroids and antibiotics.

Explanations:

This patient presents with chronic obstructive pulmonary disease (COPD)

exacerbation due to pneumonia. The patient should be evaluated in the inpatient
setting due to his current state of hypoxemia requiring supplemental oxygen and,
more importantly, acute on chronic hypercapnic respiratory failure. Acute
exacerbations of COPD should be treated with short- acting beta-2 agonists and
systemic corticosteroids. However, medical treatment alone (answer choice 1) is
not sufficient because the patient has evidence of acute on chronic hypercapnia
respiratory failure. This requires noninvasive positive pressure ventilation (NPPV)
in the intensive care unit setting for titration of pressures and frequent arterial
blood gas samples.
Antibiotics should be used to treat this patient's pneumonia. Commonly used
antibiotics include macrolides, tetracyclines, or aminopenicillins.
With this patient's state of hypoxemia and requiring supplemental oxygen,
outpatient therapy would not be appropriate. Oral corticosteroids are preferred
because intravenous corticosteroids have not shown to be more effective than oral
and may cause an increase in side effects.
Research Concepts:Chronic Obstructive Pulmonary Disease

Question 526: A 75-year-old man presents to the hospital with complaints of shortness
of breath. He has a history of ischemic cardiomyopathy and had a recent stent two years
ago. His home medications include atorvastatin, aspirin, and bisoprolol. He lives with his
daughter, who states that her father's functional status has gradually been deteriorating
over the last few years. The patient's recent pulmonary function tests show decreased
forced expiratory volume in one second (FEV1), forced vital capacity (FVC), total lung
capacity (TLC), and diffusing capacity of the lungs for carbon monoxide (DLCO) are
severely reduced. FEV1/FVC ratio is normal. Physical exam revealed fine basal crackles
and fixed rash on the digital extensor surfaces. The patient denied any muscle problem
or weakness. Interstitial lung disease is suspected, and a high- resolution computed
tomography is ordered, which was suggestive of interstitial lung disease. Blood work was
significant for elevated anti-nuclear antibody levels, but otherwise, unremarkable. Which
of the following findings on the high resolution computed tomography scan supports the
suspected diagnosis?

Page 497 of 955

Choices:

1. Pleural plaques with linear calcification

2. Non-specific interstitial pneumonia
3. Usual interstitial pneumonia
4. Bilateral symmetric hilar adenopathy
Answer: 2 - Non-specific interstitial pneumonia

Explanations:

This patient probably has interstitial pneumonia with autoimmune features (IPAF).
IPAF is a term to define individuals with both interstitial lung disease (ILD) and
mixtures of other clinical, serologic, and pulmonary morphologic characters, which
originate from an underlying autoimmune condition, but do not meet current
rheumatologic criteria for a defined connective tissue disease (CTD).
It was reported that patients with interstitial pneumonia with autoimmune features
(IPAF) accounted for 7.3% of patients with interstitial lung disease (ILD).
Non-specific interstitial pneumonia (NSIP) pattern is the most common radiological
pattern in patients with connective tissue disease-interstitial lung disease, including
interstitial pneumonia with autoimmune features. High resolution computed
tomography scan patterns consistent with non-specific interstitial pneumonia,
organizing pneumonia, or lymphocytic interstitial pneumonia should raise suspicion
for the possibility of interstitial pneumonia with autoimmune features.
Usual interstitial pneumonia (UIP) pattern is less commonly seen in patients with
connective tissue disease-interstitial lung disease except for patients with
rheumatoid arthritis. Typically usual interstitial pneumonia pattern is associated
with idiopathic interstitial pneumonia (IPF), which is not a newly proposed
parenchymal lung disease. Unlike non-specific interstitial pneumonia, the usual
interstitial pneumonia pattern is not included in the proposed criteria for
interstitial pneumonia with autoimmune features. Pleural plaques with linear
calcification in association with a basilar predominance of reticular opacities
suggest asbestosis and are not associated with interstitial pneumonia with
autoimmune features. Bilateral symmetric hilar adenopathy suggests sarcoidosis
or another granulomatous disease.

Research Concepts:

Idiopathic Interstitial Pneumonia With Autoimmune Features

Page 498 of 955

Question 527: A 70-year-old male presents to the clinic. He has a 50-pack-year smoking
history and is known to have chronic obstructive pulmonary disease (COPD). He is
afebrile, with a respiratory rate of 24 breaths per minute, a heart rate of 105 beats per
minute, a blood pressure of 138/82 mmHg, and an oxygen saturation of 96% on room air.
The physical exam is remarkable for barrel chest and hyper-resonant lung sounds. The
patient is breathing with pursed lips and leaning forward with his hands resting on his
knees. Which of the following most likely explains this patient's breathing pattern?

Choices:

1. Fixed upper airway obstruction

2. Anxiety
3. Hypo-compliance of the alveoli
4. Hyper-compliance of the alveoli

Answer: 4 - Hyper-compliance of the alveoli

Explanations:

Under normal physiological conditions, exhalation is a passive process resulting

from the passive elastic recoil of the lungs, the chest wall, and the diaphragm.
However, in the setting of COPD exacerbation, there is an obstruction of the
airways on expiration owing to damage and increased volume of the alveoli. This
results in decreased elasticity of the peri-alveolar tissues, and premature
compression of the bronchioles before respiration is complete, with resultant
trapping of air in the lower airways.
During forced exhalation, the patient actively recruits the accessory muscles of
breathing, which include the intercostal muscles, the diaphragm, and the abdominal
wall muscles. The pursing of the lips is a way to apply auto-PEEP (positive end-
expiratory pressure); essentially narrowing the area of egress of gases from the
respiratory tree. This results in increased end- expiratory pressure, physiologically
'stenting' the bronchioles open to allow for more normal air egress from damaged
lung tissues. This is a hallmark of COPD.
The 'tripod' position, as assumed by this patient, facilitates the recruitment of
accessory muscles during airway obstruction.

Research Concepts: Airway Obstruction

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Question 528: A 75-year-old female undergoes an elective cholecystectomy. The
procedure is uneventful, and she is extubated without issues. Three hours later, in the
post-anesthesia care unit, she is found to be hypoxic and in moderate respiratory
distress, saturating 91% on a non-rebreather mask. Chest X-ray demonstrates bibasilar
atelectasis. A decision is made to initiate bilevel positive airway pressure (BPAP). Which
of the following is a mechanism by which BPAP will reduce this patient’s work of
breathing?

Choices:

1. Increasing the intrinsic positive end-expiratory pressure

2. Contributing to the transpulmonary pressure required during inspiration
3. Decreasing airway resistance during inspiration
4. Decreasing lung compliance
Answer: 2 - Contributing to the transpulmonary pressure required during inspiration

Explanations:

The patient is in acute hypoxic respiratory failure, likely secondary to her post-
operative atelectasis following abdominal surgery.
By providing expiratory positive airway pressure (EPAP), BPAP helps the body
overcome the dynamic intrinsic positive end- expiratory pressures threshold
required to initiate a breath and increase lung compliance. Increasing the intrinsic
positive end- expiratory pressure is one of the complications of non-invasive
ventilation and would reduce this patient's inspiratory capacity and increase her
work of breathing.
By providing inspiratory positive airway pressure (IPAP), BPAP contributes to the
transpulmonary pressure required during inspiration.
While BPAP can modify airway resistance, this typically does not contribute to the
patient’s work of breathing.

Research Concepts:

Noninvasive Ventilation

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Question 529: A 65-year-old male presents for evaluation of a dry cough and shortness of
breath. He reports the cough started a few months ago and was only "irksome," which is
why he did not seek medical care. During the last few weeks, he has felt tired and short of
breath when going on his daily walks. He denies any chest pain, nausea, fevers, or chills.
He has never smoked and has no other medical conditions. He does not drink alcohol and
does not take any illicit drugs. He takes a multivitamin daily; otherwise, he is not on any
medications. He lives with his wife of 35 years and retired from his job working in the
metal-alloy industry five years ago. Vital signs are within normal limits. The physical exam
is unremarkable except for mild dry crackles at the bases of both lungs. Computed
tomography (CT) of the chest reveals parenchymal nodules bilaterally with septal
thickening and ground-glass pattern.
Pulmonary function testing is obtained, which reveals a restrictive pattern of disease. He
undergoes metal-specific lymphocyte proliferation testing, which is negative. What is the
next best step in the management of this patient?
Choices:

1. Repeat lymphocyte proliferation test

2. Lung biopsy
3. Bronchoscopy with bronchoalveolar lavage
4. Serum angiotensin-converting enzyme (ACE) level
Answer: 1 - Repeat lymphocyte proliferation test

Explanations:

Chronic beryllium disease (CBD), also known as berylliosis, is a hypersensitivity

granulomatous disease that occurs in 2% to 5% of beryllium-exposed workers. This
patient's history of exposure and presentation with restrictive lung disease
showing typical CT findings makes CBD the most likely diagnosis.
The beryllium lymphocyte proliferation test is the best initial test for patients
suspected of having CBD. It is often used in industries with beryllium exposure to
monitor workers for beryllium sensitization.
The sensitivity of a single peripheral blood beryllium lymphocyte proliferation test is
68%, and the specificity is 96%. In patients suspected of having CBD with a negative
initial lymphocyte proliferation test, it is best to repeat it.
If the second test is positive or borderline, the patient likely has CBD. If the second
test is negative and the clinical picture is suggestive of CBD with adequate
exposure history, they may still have CBD. Further testing with bronchoalveolar
lavage and/or tissue biopsy would be indicated at that point.
Research Concepts: Berylliosis

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Question 530: A 56-year-old man with a 40 pack-year history of smoking undergoes open
repair of a perforated duodenal ulcer. On the second postoperative day, the patient
complains of shortness of breath and has decreased breath sounds at the right lung base.
The patient is afebrile. His blood pressure is 130/80 mmHg, the pulse is 84/min, but he is
hypoxaemic with SpO2 of 88%. Chest X-ray shows a triangular opacity in the right lower
chest. Which of the following is the most appropriate strategy to prevent this condition?

Choices:

1. Preoperative broad-spectrum antibiotics

2. Preoperative dexamethasone
3. Active breathing exercises
4. Smoking cessation 1 week before surgery
Answer: 3 - Active breathing exercises

Explanations:

This patient has developed postoperative atelectasis. Obstructive atelectasis

occurs due to airway blockage, resulting in air retention distal to the occlusion. This
affected lobe or segment collapses when the retained air is absorbed.
Postoperative atelectasis usually sets in within 48 hours of the procedure. The
patient presents with hypoxemia and respiratory alkalosis, as these patients usually
hyperventilate to compensate for the drop in PaO2.
Postoperative atelectasis can be prevented by initiating early chest physiotherapy
and active breathing exercises.
The use of broad-spectrum antibiotics or routine use of glucocorticoids is not useful
for preventing respiratory complications in this setting. Patients should stop
smoking at least 8–10 weeks before surgery to reduce the risk of pulmonary
complications.

Research Concepts:

Atelectasis

Page 502 of 955

Question 531: A 21-year-old man admitted for pulmonary contusions is being evaluated in
the intensive care unit. He was started on ECMO five days ago due to worsening
oxygenation on the ventilator after a blunt chest wall injury. The patient's PF ratio has
greatly improved to 315 today after being on VV ECMO support.
Which of the following is the most appropriate method of decreasing the patient's carbon
dioxide level?

Choices:

1. Increase the plateau pressures while decreasing the sweep function on the
ECMO circuit
2. Decrease the sweep function on the ECMO circuit
3. Increase the positive end-expiratory pressure on the vent
4. Increase the sweep function on the ECMO circuit
Answer: 4 - Increase the sweep function on the ECMO circuit

Explanations:

The ECMO sweep function that is most related to the ventilator is the rate function.
The rate function on the ventilator allows the removal of CO2 from the patient.
The sweep function on the ECMO circuit allows the adjustment of how much CO2 is
removed from the blood of the patient.
When we increase the rate on the ventilator, this allows the patient to blow off
more CO2, thus dropping the overall CO2 in the patient's blood.
The sweep gas flow rates are equal to the blood flow rates in the patient. Blood
flow rates have to be high enough in the circuit to remove the adequate amount
of CO2.
CO2 levels are not related to FiO2, plateau pressures, or positive end-expiratory
pressures when comparing CO2 level management on the ventilator functions to
the ECMO circuit.

Research Concepts:

Extracorporeal Membrane Oxygenation Weaning

Page 503 of 955

Question 532: A 72-year-old with a 40 pack-year smoking history has severe COPD on
pulmonary function tests, and a CT scan of the chest shows severe emphysema and
bronchiectasis. She has had two exacerbations in the last year. She is currently on triple
therapy with inhaled corticosteroids (ICS), the long-acting muscarinic antagonist (LAMA),
and long-acting beta-agonists (LABA). She can walk 50 feet before she gets winded. She
often struggles with her mood, anxiety, and gets panicky due to ongoing breathing
problems. Which of the following outcomes is most likely to be associated with pulmonary
rehabilitation in such patients?

Choices:

1. A decrease in diffusion capacity

2. Slower decline in FEV1 over time
3. Improvement in total lung capacity
4. Slower decline in diffusion capacity over time
Answer: 2 - Slower decline in FEV1 over time

Explanations:

Pulmonary rehabilitation has shown to decrease the decline of FEV1 over time in
COPD patients. There have been conflicting studies in terms of improvement of
overall lung function. More robust studies are needed to assess the improvement in
overall lung function.
The lack of improvement in lung function was previously was considered a lack of
efficacy of pulmonary rehabilitation.
However, the multiple benefits from pulmonary rehabilitation have proven that to
be wrong.
Studies have not shown significant improvement in total lung capacity from
pulmonary rehabilitation.
Pulmonary rehabilitation has not been shown to decrease diffusion capacity.
Smaller studies have shown mild improvement in diffusion capacity with pulmonary
rehabilitation.

Research Concepts:

Pulmonary Rehabilitation

Page 504 of 955

Question 533: A 75-year-old man with a history of metastatic lung cancer is brought to the
hospital for difficulty breathing. A chest x-ray reveals a left-sided pleural effusion. A goal
of care discussion is performed, and a chest tube is placed with significant relief of
symptoms after removing 500 ml of fluid. After draining the fluid, an elastance of less than
15 cm H2O was measured. The patient would like to be comfortable and would like to
avoid readmissions. Which of the following is the next best step in managing this patient?

Choices:

1. Left-sided tunneled pleural catheter

2. Extended-release oxycodone
3. Pleurodesis
4. Remove the catheter and discharge the patient to inpatient hospice
Answer: 3 - Pleurodesis

Explanations:

Malignant pleural effusions can lead to significant distress and frequently recur,
leading to readmission.
Due to a high chance of recurrence, readmission can be avoided if a tunneled
catheter is placed or pleurodesis is performed. An elastance of less than 19 cm H2O
after draining 500 ml of fluid predicts a 98% chance of success. This is defined as
pleural fluid control at one month.
Since the patient requested optimization of comfort and readmission avoidance,
pleurodesis should be attempted first. A tunneled catheter can lead to discomfort,
and malfunction can sometimes lead to readmission.

Research Concepts:

End Of Life Evaluation And Management Of Pain

Page 505 of 955

Question 534: A 36-year-old man presents to the emergency department with difficulty
breathing and a dry cough with fatigue that has been worsening for the last six days. His
son called 911 today after he fell on the floor. He has a medical history of diabetes and
hyperlipidemia, for which he takes metformin and simvastatin. He never smoked
cigarettes or used illicit drugs; however, he admits to vaping THC products over the last 2
years. In the emergency department, he becomes severely hypoxemic and requires
immediate mechanical ventilation. He is admitted to the intensive care unit. Work up is
negative for infectious, toxic, or autoimmune etiologies. X-rays reveal an interstitial
pattern bilaterally. HRCT shows ground-glass opacification. Lung biopsy reveals diffuse
alveolar damage with edema in the interstitium and alveolus. Which of the following best
describes the most appropriate ventilator settings for this patient?

Choices:

1. Tidal volume 8-10mL/kg; No PEEP

2. Tidal volume 8-10mL/kg; incremental FiO2/PEEP combinations
3. Tidal volume 4-6mL/kg; No PEEP
4. Tidal volume 4-6mL/kg; incremental FiO2/PEEP combinations
Answer: 4 - Tidal volume 4-6mL/kg; incremental FiO2/PEEP combinations

Explanations:

Given the patient's history, the patient is most likely suffering from vaping
associated pulmonary injury. Work up is negative for infectious, toxic, or
autoimmune etiologies.
The patient has most likely developed acute respiratory distress syndrome.
ARDSnet advocates the use of a lung-protective strategy to minimize volutrauma and
barotrauma.
The lung-protective strategy is comprised of low tidal volumes (4-6 mL/kg) and
careful titration of FiO2/PEEP to achieve maximal oxygenation.

Research Concepts:

Vaping Associated Pulmonary Injury

Page 506 of 955

Question 535: A 44-year-old woman with a past medical history of antiphospholipid
antibody syndrome presents to the clinic with exertional dyspnea for four months. She is
compliant with anticoagulant treatment. EKG, labs, and chest x-ray are unremarkable. A
ventilation-perfusion scan confirms the diagnosis. Which of the following sets of
hemodynamic readings from the pulmonary artery catheter is most consistent with the
patient's diagnosis? (Key- right atrial pressure: RA pressure; right ventricular pressure: RV
pressure; mean pulmonary artery pressure: mPAP; pulmonary capillary wedge pressure:
PCWP; cardiac index: CI)

Choices:

1. RA pressure: 10 mmHg, RV pressure: 17/4 mmHg, mPAP: 28 mmHg, PCWP: 19

mmHg, CI: 1.1 L/min/m2
2. RA pressure: 10 mmHg, RV pressure: 30/15 mmHg, mPAP: 29 mmHg, PCWP: 10
mmHg, CI: 2.9 L/min/m2
3. RA pressure: 2 mmHg, RV pressure: 15/2 mmHg, mPAP: 18 mmHg, PCWP: 5
mmHg, CI: 4.3 L/min/m2
4. RA pressure: 2 mmHg, RV pressure: 15/2 mmHg, mPAP: 18 mmHg, PCWP: 5
mmHg, CI: 2.2 L/min/m2
Answer: 2 - RA pressure: 10 mmHg, RV pressure: 30/15 mmHg, mPAP: 29 mmHg, PCWP: 10
mmHg, CI: 2.9 L/min/m2

Explanations:

Chronic pulmonary embolism (also known as chronic thromboembolic pulmonary

hypertension - CTEPH) is a potentially life-threatening condition and is associated
with high morbidity and mortality. Chronic thromboembolism can cause CTEPH
and overt right heart failure.
Pulmonary capillary wedge pressure (PCWP) less than 15 mmHg and elevated
mPAP of more than 20 mmHg at rest are consistent with pulmonary hypertension
likely secondary to CTEPH in this patient.
In CTEPH, RA and RV pressures are elevated with low to normal cardiac index.
Elevated CI with low mPAP, RA, and RV pressures is consistent with septic shock.
Option 4 is consistent with hypovolemic shock.

Research Concepts:

Chronic Thrombo-Embolic Pulmonary Hypertension

Page 507 of 955

Question 536: A 30-year-old African American female patient presents with a rash on her
shins for 3 weeks. She also reports mild exertion which worsens on heavy physical
activity. She claims she didn't have this before and it started a month ago. Her menstrual
cycles are regular with mild dysmenorrhea. Her LMP was 12 days ago. She has no travel
history or exposure to sick contacts. She is sexually active and uses contraceptive pills.
She works at a publication firm. She drinks alcohol and smokes cigarettes occasionally
but takes no illicit drugs. She got her flu vaccine last month. Physical examination reveals
red-purple papules that are tender on touch. The abdomen is soft and non-tender. Heart
sounds are audible without any gallops or murmurs. What is the most appropriate initial
test in the given setting?
Choices:

1. Chest X-ray
2. Angiotensin-converting enzyme levels
3. Serum calcium
4. Antinuclear antibodies
Answer: 1 - Chest X-ray
Explanations:

The patient likely has sarcoidosis given her rash, exertional fatigue, age, and
ethnicity. Sarcoidosis is a systemic disorder characterized by the immune-mediated
formation of noncaseating granulomas. T-cell dysfunction and increases B- cell
reactivity is involved. Pulmonary symptoms are most common. Therefore this
patient should have a chest x-ray done as it is the best initial test to look for hilar
lymphadenopathy and reticular opacities. The biopsy of lung tissue or lymph node
is the gold standard for diagnosis, which shows non-caseating granulomas.
It may be asymptomatic, or symptoms present include dry cough, fatigue, purplish
tender rash at shins, and anterior uveitis. Differentials include non-Hodgkin
lymphoma: Hodgkin lymphoma, pneumoconiosis, histoplasmosis, and tuberculosis.
Inflammatory markers are elevated.
In pulmonary and asymptomatic sarcoidosis, no treatment is usually required.
Corticosteroids are the first line in symptomatic and extrapulmonary sarcoidosis.
Immunosuppressive agents are used after steroids.
Calcium is frequently elevated because of increased activity of 1,25-(OH)2-
vitamin D3. Angiotensin-converting enzyme (ACE) blood levels are usually used to
monitor disease activity and therapy. ANA levels that may be elevated have no
significant value in diagnosis.
Research Concepts: Sarcoidosis

Page 508 of 955

Question 537: A 17-year-old man presents with a three-day history of fever, difficulty
breathing, and a persistent cough productive of brownish sputum. His past medical
history includes asthma, for which he uses albuterol and medium-dose inhaled
fluticasone. His last asthma exacerbation was several months ago. He denies smoking
cigarettes or using recreational drugs. His vital signs show oxygen saturation of 95% on
room air, respiratory rate 19 per minute, heart rate 110 beats per minute, blood pressure
121/87 mmHg, and temperature 101 F (38.3 C). Blood tests reveal leukocytosis with
eosinophil levels of 9% (0% to 6%). Auscultation of the lungs demonstrates good air entry
with bilateral wheeze. Chest
x- ray shows upper lobe opacities bilaterally, and a CT chest shows right-sided
bronchiectasis. A skin test for the suspected microbe is positive. Given the likely
diagnosis, what is a drug of choice for this patient's condition?

Choices:

1. Griseofulvin
2. Fluconazole
3. Voriconazole
4. Amphotericin-B
Answer: 3 - Voriconazole

Explanations:

Aspergillus is a fungus found globally that can cause infection in patients with
underlying lung disease or who are immunocompromised.
Voriconazole or itraconazole are the drugs of choice for aspergillosis.
Allergic bronchopulmonary aspergillosis (ABPA) will present with recurrent
exacerbations of asthma, with the most prominent finding being dyspnea and
wheezing, along with coughing up large amounts of sputum with brown plugs.
Corticosteroids are given with the antifungal to reduce the inflammation and improve
the symptoms during an acute exacerbation.

Research Concepts:

Aspergillosis

Page 509 of 955

Question 538: A 61-year-old female presents for dyspnea on exertion and a
nonproductive cough that has been ongoing for over a year. She is a nonsmoker. She
reports that she has been having a steady decline in exercise capacity in the past year. She
denies any fevers, weight loss, or chest pain. She does report a sensation of heartburn for
which she takes an antacid, and pain in both her hands for several years. On exam, she is
noted to have no clubbing but has an ulnar deviation of her metacarpal joints in both
hands and tenderness in wrists and metacarpal joints with a limited range of motion. The
chest exam reveals bibasilar fine crackles. Her spirometry is as follows:

FEV1 1.57 L (50% of predicted)

FVC 1.63 L (39% of predicted)
FEV1/FVC 96%
Which of the following investigations will confirm her diagnosis?
Choices:

1. Acute vasodilator testing

2. High-resolution computed tomography (HRCT) scan
3. Ventilation/perfusion scan
4. Flow-volume loop
Answer: 2 - High-resolution computed tomography (HRCT) scan

Explanations:

Idiopathic pulmonary fibrosis (IPF) is a lung disorder where there is scarring of the lungs
from an unknown cause. It is usually a progressive disease with a poor long-term prognosis.
The classic features of the disorder include progressive dyspnea and a nonproductive cough.
Pulmonary function tests usually reveal restrictive impairment and diminished carbon
monoxide diffusing capacity.
The diagnosis can be made without biopsy if there are compatible imaging tests,
appropriate clinical history, and exclusion of other conditions. The classic pattern of
imaging on computed tomography scan will show a peripheral distribution of bilateral
fibrosis, more pronounced at the bases.
High-resolution CT (HRCT) of the chest should be performed. The characteristic feature on
HRCT is a “usual interstitial pneumonia” (UIP) pattern, which on imaging consists of bilateral
subpleural basal predominant honeycombing or traction bronchiectasis or bronchiectasis.
Peripheral reticular opacities are usually most notable in the lower lobes.
Ground glass opacities and consolidation are atypical for a UIP pattern and, when present
on imaging, should lead to suspicion for conditions other than IPF.
Research Concepts: Idiopathic Pulmonary
Fibrosis

Page 510 of 955

Question 539: A 42-year-old man is in the intensive care unit to help manage his
complications secondary to acute pancreatitis. The patient's vitals and most recent
complete blood count and basic metabolic panel are all within normal limits. The patient
had a tracheostomy placed 10 days ago, secondary to prolonged respiratory distress. The
patient suddenly has about 100 cc of bright red blood come out of his tracheostomy tube.
The bleeding resolves spontaneously, and his vital signs remain stable. The skin
surrounding the tracheostomy site all appears intact. What is the next appropriate step
in management?
Choices:

1. Inflate the tracheostomy tube balloon further

2. Perform a bronchoscopy
3. Proceed directly to the operating room
4. Apply silver nitrate to the skin around the tracheostomy site
Answer: 2 - Perform a bronchoscopy
Explanations:

This patient likely has a tracheoinnominate fistula and the bleed seen in the
question stem is a so-called "herald bleed" which comes shortly before full rupture
of the innominate artery into the trachea.
This patient is stable and the bleed appears to have temporarily resolved, therefore
this patient should undergo bronchoscopy to evaluate the etiology of his bleeding
and assist with preoperative planning. This patient will likely require ligation of the
innominate artery to resolve this pathology.
If the bleeding continued then a finger should be inserted into the tracheostomy
site to occlude the bleeding before proceeding immediately to the OR for ligation of
the innominate artery. This particular patient is stable after his bleed which also
appears to have temporarily resolved spontaneously. The patient should undergo a
bronchoscopy to evaluate the bleed and will likely have to go to the OR once the
workup is complete.
Applying silver nitrate to the skin surrounding the tracheostomy is a reasonable
treatment option if the patient has some minimal skin bleeding from around the
tracheostomy site. However, this patient has intact skin around the tracheostomy
site, and the large volume of his bleeding is likely a "herald bleed" from a
tracheoinnominate fistula. As this patient is stable, the appropriate next step to
take is to perform a bronchoscopy to further assess the source of his bleeding.
Given the likelihood that this patient has a tracheoinnominate fistula, the
healthcare team should also be prepared to proceed immediately to the operating
room if significant bleeding occurs.
Research ConceptsTracheal Trauma

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Question 540: A 65-year-old female patient with a history of interstitial lung disease
presented to the hospital with productive cough and fever of 102.4 F (39.1 C). On
examination, her heart rate was 110/min, respiratory rate 32/min, and blood pressure
was 92/74 mmHg. Initial lab results showed a hemoglobin of 10.6 g/dl, white cell count of
18,000/microliter, platelet count of 180,000, creatinine of
1.8 mg/dl, and total bilirubin of 1.6 mg/dL. Six hours after presentation, the patient
developed hypoxemia with an O2 saturation of 70% on room air. Blood gases revealed a
pH of 7.52, PaO2 of 48 mmHg, PCO2 of 26 mmHg, and HCO3 of 24 mEq/L. On
examination, there were bilateral coarse crackles. Chest Xray revealed infiltrates all over
the lung zones. The patient underwent emergent endotracheal intubation due to acute
respiratory failure and was started on broad-spectrum antibiotics for sepsis management.
Twenty-four hours later, the patient develops tachypnea and tachycardia. FiO2 is
increased to 0.8 from 0.4 due to hypoxia. Currently, the ventilator is on volume control
mode, FiO2 is 0.8, positive end-expiratory pressure (PEEP) is 10, tidal volume is 8cc/kg,
and set respiratory rate is 18/min. A chest Xray is obtained, which shows the worsening of
previous findings. What is the most appropriate next step?

Choices:

1. Lower the tidal volume to 6 cc/kg

2. Reduce PEEP to 5 cc/kg
3. Add anti-pseudomonal agent
4. Administer diuretics
Answer: 1 - Lower the tidal volume to 6 cc/kg
Explanations:

The correct diagnosis of this patient's worsening respiratory distress is ventilator-

associated lung injury (VALI). VALI is commonly seen in ARDS patients.
VALI is a clinical diagnosis with clinical manifestations of worsening hypoxemia,
tachypnea, and tachycardia while the patient is on a mechanical ventilator. It can be
challenging to differentiate VALI from ARDS with the critical difference of being on a
mechanical ventilator.
Mechanism of injury is through volutrauma, through alveolar overdistension,
atelectrauma, and inflammation.
Management includes reducing the tidal volume to 6cc/kg, using applied PEEP to
overcome atelectasis and other lung-protective strategies, including conservative
fluid use.

Research Concepts: Ventilator Complications

Page 512 of 955

 Question 541: A 24-year-old woman presents to the hospital with sudden onset of
shortness of breath and left-sided chest pain, which began two hours ago while she was
at work. She has been coughing since the pain started and coughed up frank blood
multiple times on the way to the emergency department. She reports a deep venous
thrombosis 5 years ago, which was diagnosed after a prolonged hospital stay following a
cholecystectomy. She completed 3 months of apixaban and has since been taken off all
anticoagulants. She smokes 1 pack per day. Medications are multivitamins and oral
contraceptive pills. Her blood pressure was 80/45 mmHg, heart rate 130 per minute, and
respiratory rate 40 per minute. Examination of the chest reveals regular tachycardia,
clear lung sounds in all lung fields, and non-reproducible left-sided chest pain without
any deformity of the left chest. EKG shows sinus tachycardia without ST-T wave changes.
Her blood pressure improves to 100/60 mmHg with 2 liters of IV normal saline, yet her
heart rate remains in the 120s, and is now requiring 4 liters per minute of oxygen via
nasal cannula to maintain oxygen saturation greater than 90%. Bedside transthoracic
echocardiography shows right ventricle hypokinesis and regional wall motion
abnormalities sparing the right ventricular apex. What is the next step in her treatment?
Choices:

1. Start intravenous heparin

2. Start apixaban and monitor the patient
3. CT with intravenous contrast
4. Administer tissue plasminogen activator 100 mg over 2 hours
Answer: 4 - Administer tissue plasminogen activator 100 mg over 2 hours
Explanations:

The classical symptoms of sudden onset chest pain and shortness of breath, in
addition to her previously diagnosed deep vein thrombosis (DVT), oral
contraceptive use, and smoking history, further support the diagnosis of
pulmonary embolism (PE). The treatment of pulmonary embolism is based on the
likelihood of pulmonary embolism as the diagnosis.
Based on the Well’s PE score, this patient is high risk with a Well’s score of 7,
previously diagnosed DVT, tachycardia, PE is the most likely diagnosis or at least as
likely to be causing the patient’s symptoms, and hemoptysis.
When a patient is a high risk based on Well's criteria, starting empiric
anticoagulation should not be delayed. CT pulmonary angiography is used in stable
patients to confirm the diagnosis. A transthoracic or transesophageal
echocardiogram can be done in unstable patients to confirm the diagnosis.
Research Concepts: Pleurisy

Page 513 of 955

Question 542: A 70-year-old male presents with fever, cough, and shortness of breath.
He has underlying COPD due to a significant smoking history of 50 pack years. He
endorses significant sputum production that has increased from baseline. He also finds
difficulty with ambulation and is unable to ambulate across his bedroom. This is
worsened from his baseline. Vital signs reveal a low-grade temperature, HR 88, RR 22,
and Bp of 136/72. A chest x- ray is negative. The WBC count is 15,000 mL. Culture results
are pending. The mecA gene is detected. Appropriate antibiotic therapy should include
which of the following?

Choices:

1. Nafcillin
2. Linezolid
3. Ceftriaxone
4. Aztreonam

Answer: 2 - Linezolid

Explanations:

The mecA gene is present in staph infections causing MRSA, therefore linezolid is a
correct choice as it treats MRSA. Nafcillin does not treat MRSA. The chest
radiograph can still be normal as this lags behind the clinical signs and symptoms.
Linezolid and vancomycin are both valid choices for treating MRSA infection. Chest
radiograph can still be normal in a developing pneumonia.
Ceftriaxone will not cover MRSA infection, mecA gene is present in staph
infections causing MRSA. Linezolid is, therefore, the appropriate answer in this
clinical scenario. Aztreonam will not cover mecA positive staphylococcus which
denotes a MRSA infection. As this is therefore a MRSA infection, Linezolid is the
appropriate answer.

Research Concepts: Staphylococcal

Pneumonia

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Question 543: A 35-years-old male with no significant past medical history presents to the
clinic for evaluation of dyspnea. The patient states that he has been experiencing
shortness of breath with exertion for the past 6 months that improves with lying on his
back.
Vital signs are as following: blood pressure 118/80 mmHg, respiratory rate 19/minute,
temperature 36 C (96.8 F), oxygen saturation 91%, and pulse 89/minute. Oxygen
saturation is noted to go up to 99% while lying supine. Physical exam reveals small
thread-like red lines on the lower lip. Cardiac auscultation reveals normal S1 and S2
with no murmurs. The abdomen is soft and not tender. What is the most likely diagnosis
for this patient?

Choices:

1. Intracardiac shunt
2. Hepatopulmonary syndrome
3. Hereditary hemorrhagic telangiectasia
4. Idiopathic pulmonary fibrosis
Answer: 3 - Hereditary hemorrhagic telangiectasia

Explanations:

The patient is exhibiting platypnea-orthodeoxia syndrome where oxygenation

improves while lying in the supine position, and hypoxia results from increased
shunting of blood while upright.
This syndrome can be seen with either intracardiac or pulmonary shunts. However,
the patient's physical exam findings of the normal cardiac and abdominal
examination, as well as small telangiectasias noted in the lower lip, are more
consistent with a pulmonary arteriovenous malformation (AVMs).
The most common cause of pulmonary AVMs is hereditary hemorrhagic
telangiectasia (HHT), which is the most likely diagnosis for this patient.
Screening with contrast echocardiography for pulmonary AVMs should be
performed in all patients with HHT. Confirmatory testing with CT is a reasonable
option in patients with a high degree of suspicion for pulmonary AVMs.

Research Concepts:

Pulmonary Arteriovenous Malformation (AVMs)

Page 515 of 955

Question 544: A 65-year-old man who is homeless presents to the clinic with complaints
of cough and difficulty breathing for the past three months. He says that his cough is
associated with sputum production and is occasionally streaked with blood. He also
reports associated fever and immense sweating at night. His past medical history is
significant for multiple admissions due to intravenous drug overdose. He has smoked one
pack of cigarettes per day for the past 25 years and drinks alcohol regularly. On
examination, his blood pressure is 100/60 mmHg, pulse 95/min, respiratory rate 22/min,
and temperature 37.5 C (99.5 F). Chest auscultation chest reveals decreased breath
sounds over the right upper lobe and a stony dull percussion note in the right lower lateral
lung. A CT scan of the chest confirms the presence of effusion and demonstrates pleural
thickening. Blood work will most likely show which of the following?

Choices:

1. Decreased protein count

2. Raised glucose concentration
3. Raised adenosine deaminase level
4. Increased pH
Answer: 3 - Raised adenosine deaminase level

Explanations:

This patient most likely has pulmonary tuberculosis.

Raised adenosine deaminase levels specifically point towards a diagnosis of pulmonary
tuberculosis.
Pleural fluid analysis can also aid in the diagnosis of pulmonary tuberculosis.
Pulmonary tuberculosis is associated with productive cough, low-grade fever
with night sweats, and pleural effusion.
Research Concepts:

Tuberculosis

Question 545: A 65-year-old man presents to the emergency room with acute
exacerbation of cough, sputum production, fever, respiratory distress, and hypoxia for
the last 24 hours. He has been a chronic smoker for 50 years and is regularly followed in
the pulmonary clinic for breathing problems and the need for home oxygen. He was
vaccinated for seasonal influenza last month. His chest X-ray shows multiple focal
infiltrates. His influenza polymerase chain reaction (PCR) has been done. What is the next
step in management for this patient?

Choices:
Page 516 of 955
1. Oseltamivir and oxygen
2. Oseltamivir, oxygen, and an appropriate antibiotic
3. Antibiotic and oxygen
4. Oxygen only
Answer: 2 - Oseltamivir, oxygen, and an appropriate antibiotic

Explanations:

This patient has chronic obstructive pulmonary disease (COPD) based on his chronic
symptomatology. Patients with COPD are at higher risk of acquiring both seasonal
influenza and bacterial pneumonia.
While annual influenza vaccination reduces the risk of acquiring influenza and
pneumonia and the risk of complications, high-risk patients should still receive
prompt treatment with oseltamivir as influenza vaccination is not 100% effective.
Oseltamivir started within 48 hours of the onset of symptoms, has been shown to
have high efficacy in reducing illness burden and rate of complications. Hence,
oseltamivir should be started immediately, even though the results of influenza
PCR are not yet available.
While oseltamivir will help treat an influenza infection, an appropriate antibiotic,
along with supportive management like oxygen, needs to be coadministered as a
patient with COPD is also at risk of community-acquired bacterial pneumonia.

Research Concepts:

Oseltamivir

Question 546: A 65-year-old male patient with a history of emphysema presents to the
hospital complaining of sudden onset dyspnea and pleuritic type chest pain on the left
side. He is aa smoker of 25/day. On examination, he looks very restless, pale and sweaty.
His blood pressure is 140/85 mmHg, the pulse is 120/min regular, the respiratory rate is
32/min, and oxygen saturation on room air is 88%. He has reduced chest expansion, hyper
resonant note, and decreased air entry on the left side. He is commenced on oxygen
supplementation and analgesia. What is the next best step in management?
Choices:

1. Urgent surgical intervention

2. Urgent CT scan of the chest
3. Chest drain insertion
Page 517 of 955
4. Chest aspiration
Answer: 3 - Chest drain insertion

Explanations:

There are two types of pneumothorax: traumatic and atraumatic. The two subtypes of
atraumatic pneumothorax are primary and secondary. A primary spontaneous
pneumothorax (PSP) occurs automatically without a known eliciting event, while a
secondary spontaneous pneumothorax (SSP) occurs subsequent to an underlying
pulmonary disease.
On examination, the following findings are noted respiratory discomfort, increased
respiratory rate, asymmetrical lung expansion, decreased tactile fremitus, hyper
resonant percussion note, decreased intensity of breath sounds or absent breath
sounds.
In secondary spontaneous pneumothorax, if size/depth of pneumothorax is less
than 1 cm and no dyspnea then the patient is admitted, high flow oxygen is given
and observation is done for 24 hours.
If size/depth is between 1-2 cm, needle aspiration is done, then the residual size of
pneumothorax is seen, if the depth after the needle aspiration is less than 1 cm
management is done with oxygen inhalation and observation and in case of more
than 2cm, tube thoracostomy is done. In case of depth more than 2 cm or
breathlessness, tube thoracostomy is done.

Research Concepts: Pneumothorax

Question 547: A 45-year-old male with a past medical history of human

immunodeficiency virus infection presents to the emergency department with complaints
of a sudden onset of headache, fever, chills, and chest pain. The patient also mentions
having dry cough and myalgias. He has a summer job at a pet shop where he is
responsible for cleaning bird cages. His vital signs show a temperature of 101.4°F (38.6°C),
heart rate of 112 beats per minute, respiratory rate of 16 breaths per minute, and blood
pressure of 110/70 mmHg. His electrocardiogram is notable for concave ST- segment
elevation and a PR segment depression in most of the leads. Physical examination is
notable for crackles in the left lower lung field. The complete blood count is notable for
anemia and mild leukopenia. A chest X-ray is significant for lobar consolidation. Blood
cultures are drawn. Which of the following is the next best step in evaluating this patient?

Choices:

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1. Sputum Gram stain and culture
2. Bronchoscopy with bronchoalveolar lavage
3. Urinary antigen testing
4. Micro-immunofluorescence antibody titer
Answer: 4 - Micro-immunofluorescence antibody titer

Explanations:

Psittacosis represents a zoonotic bacterial infection caused by the obligate

intracellular organism, Chlamydia psittaci.
Psittacosis, which is also called parrot fever and ornithosis, is transmitted from
contact with infected birds and causes a wide- ranging spectrum of disease and
severity.
The CDC has published guidelines for the diagnosis of psittacosis. In the appropriate
clinical scenario, a diagnosis is made by meeting any one of the criteria listed below:
Isolation of the causative organism from respiratory secretions, A noted
four-fold or greater increase in antibody titer between serum samples collected two
weeks apart via the complement-fixation test (CFT) or micro-immunofluorescence
(MIF), A single IgM antibody titer detected by MIF of 1:16 or higher.
It should be noted that isolation of C. psittaci culture during the acute infection is the
most reliable diagnostic test, but it is not recommended as it requires a biosafety level
three facility due to the risk of transmission and, thus, is rarely performed.
Cardiac manifestations include myocarditis, pericarditis, culture- negative
endocarditis, and aortitis.
Research Concepts: Psittacosis

Question 548: A 37-year-old male presents to his primary care provider with complaints of
recurrent epistaxis, and dyspnea.
Pertinent findings on examination include hypoxemia with oxygen saturation of 88%, and
several telangiectasias of the lip and oral mucosa. On further evaluation, computed
tomography of the chest and pulmonary angiography reveal a pulmonary arteriovenous
malformation (PAVM) with a feeding artery diameter of 3 mm. Which of the following is
the best modality of treatment for this patient?

Choices:

1. Surgical excision
2. Lung transplant
3. Transcatheter embolization
4. Endothelin receptor antagonist
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Answer: 3 - Transcatheter embolization

Explanations:

This patient is presenting with a symptomatic lesion that is 3 mm in size. The most
appropriate intervention at this point would be embolization therapy.
The most widely used and successful form of treatment is percutaneous
transcatheter embolization, which involves occlusion of the feeding artery of the
PAVM.
Complications of PAVM can occur independent of feeding artery diameter size.
Therefore, embolization therapy must be considered early in the disease course.
The most common complication of embolization therapy is self- limiting pleuritic chest
pain.

Research Concepts:

Pulmonary Arteriovenous Malformation

Question 549: A 54-year-old male, with a left upper lobe nodule and enlarged mediastinal
lymph nodes, is undergoing Chamberlain procedure. Which of the N2 stations of the
patient can be assessed by the procedure?

Choices:

1. Stations 1 and 3
2. Stations 7 and 11
3. Stations 5 and 6
4. Station 5 and 10
Answer: 3 - Stations 5 and 6

Explanations:

Stations 5 and 6 (aortopulmonary window) are assessed with the Chamberlain

procedure (anterior mediastinotomy). They can also be accessed through extended
mediastinoscopy, whereas station 6 can be accessed through left-sided video-
assisted thoracoscopic surgery (VATS).
According to the 8th TNM edition, for a patient with left upper lobe nodule, station
1 is considered N3 lymph node, stations 2 to 9 are considered N2, and stations 10
to 14 are considered N1.
Stations 5 and 6 can also be accessed through extended mediastinoscopy,
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 whereas station 6 can be accessed through left-sided video-assisted
thoracoscopic surgery (VATS).
Combined endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS)
bronchoscopy can provide access to stations 2, 3 posterior 4, 7, 8, 9, 10, and 11. It
is a procedure that is rapid, safe, less invasive, and better tolerated by the patient.
In the last ten years, it has widely replaced mediastinoscopy in the diagnosis and
staging of mediastinal lymph nodes.

Research Concepts: Mediastinotomy

Question 550: A patient develops sudden shortness of breath after thoracic surgery.
This surgery was done due to a large malignancy of the right upper lung found on
computed tomography imaging. Which of the following is most likely to be related to
his post-surgical disease process?

Choices:

1. It is frequently seen after left pneumonectomy.

2. The etiology is independent of preoperative fluid management.
3. It usually becomes evident one week after surgery.
4. Epidural anesthesia is associated with this disorder.
Answer: 4 - Epidural anesthesia is associated with this disorder.

Explanations:

Post pneumonectomy pulmonary edema is a lethal condition with a high mortality

rate.
Even though it is diagnosed early, a simple fluid reduction does not always reverse
the patient's clinical status.
Epidural anesthesia has been associated with this condition. Because of the
vasodilatation and hypotension, these patients receive more fluids, which contribute
to the edema.
Most patients with this condition require re-intubation, swan, diuresis, positive
end-expiratory pressure (PEEP), nutrition, and prolonged intensive care unit
support.

Research Concepts: Noncardiogenic Pulmonary Edema

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Question 551: A 74-year-old woman presents for evaluation of a pulmonary lesion. A CT-
guided biopsy is performed. After the procedure, she develops shortness of breath and is
admitted for a suspected chronic obstructive pulmonary disease exacerbation and a
central line is placed. The patient has chest pain, along with difficulty swallowing and
breathing. On examination, she has swelling of the neck, and the skin over the chest feels
like tissue paper. Breath sounds on the right side are decreased, and the chest x-ray
shows air in the mediastinum. What is the most likely cause of this condition?

Choices:

1. Thoracentesis
2. Contusion
3. Central line cannulation
4. Pneumonia
Answer: 3 - Central line cannulation

Explanations:

A common cause of iatrogenic pneumothorax is central line cannulation.

Pneumothorax after central lines is very common but not often reported.
Pneumothorax after a biopsy can be iatrogenic.
Accessing the subclavian vein is related to a higher incidence of pneumothorax than
the jugular route.
The operator should have an intimate knowledge of neck anatomy and experience
performing the procedure.

Research Concepts:

Iatrogenic Pneumothorax

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Question 552: A 39-year-old man presents with a chief complaint of excessive daytime
sleepiness for the last two years that affects his daytime function and work and is
associated with headaches in the morning hours. Epworth sleepiness scale is 20/24. Sleep
habits are as follows: bedtime is 10 pm, wake-up time is 9 am, and sleep onset latency is 5
minutes. Family history his sister and mother have sleepiness problems also. On exam,
weight is 68 kg, height is 1.7 meters, and Body mass index (BMI) is 23 kg/m2. Blood
pressure 125/80 mmHg, pulse 70/minute, and O2 saturation 96% on room air. Oral exam
Mallmpati class II. The rest of the exam is within normal limits. Polysomnography test
showed the apnea-hypopnea index of 4.1 events/hour with a total sleep time of 700
minutes.
Following that morning, multiple sleep latency tests showed one sleep-onset rapid eye
movement sleep period (SOREMP) and a mean sleep latency of 7 minutes from 5 naps. A
two-week sleep diary revealed similar sleep habits reported by the patient with regular
bed and wake-up times. What is the following best next step in the management of this
patient?
Choices:

1. Obtain an MRI of the brain

2. Initiate modafinil 100-200 mg orally in the morning
3. Initiate sodium oxybate 4.5 gm twice per night
4. Obtain hypocretin CSF level
Answer: 2 - Initiate modafinil 100-200 mg orally in the morning

Explanations:

The presentation, in this case, is classical for Idiopathic Hypersomnia with chronic
(more than three months) and disabling excessive daytime sleepiness with
difficulty waking up from sleep that affects daytime function.
Once the diagnosis of IH is confirmed by ruling out other diagnoses such as sleep-
disordered breathing and narcolepsy using polysomnography and MSLT, it is
appropriate to initiate treatment with stimulants.
The first line treatment for IH is modafinil orally 100-400 mg daily upon awakening.
The drug is well tolerated and effectively reduces sleepiness symptoms as
measured by the Epworth sleepiness scale and multiple wakefulness latency tests
(MWLT).
There is no indication for brain MRI in this case as no focal neurological symptoms or
signs are present in the case.
Likewise, there is no indication to obtain CSF fluid for hypocretin level
measurements in this case, as narcolepsy is unlikely based on the MSLT results. In
IH, the mean sleep latency is generally less than 8 minutes, and the number of
SOREMPs is less than two.

Page 523 of 955

Research Concepts: Idiopathic Hypersomnia

Question 553: A 45-year-old female presents for a follow-up evaluation. Her past medical
history is significant for amyopathic dermatomyositis. She is on 20 mg of prednisone
daily, along with vitamin D and calcium. She mentions that she has more fatigue for the
last three months and feels like her exercise capacity is decreasing. She denies any weight
loss. She appears in no distress, and her vital signs are stable. On examination, she has
violaceous erythema and edema of eyelids and periorbital tissue, a rash of the dorsal side
of the hands and feet' interphalangeal joints. She has crackles in the bases of the lungs
and a normal cardiovascular examination. She had a video-assisted thoracoscopic surgery
and biopsy of right lung about two years ago, which showed homogeneous inflammatory
and fibrosing interstitium with the preservation of alveolar architecture. After a thorough
discussion, her prednisone dose was increased to 50 mg daily, and a follow-up
appointment was made at three months. Which of the following test will be more helpful
in monitoring response to treatment?

Choices:

1. Chest x-ray.
2. Repeat lung biopsy.
3. Pulmonary function test.
4. Home pulse oximetry.
Answer: 3 - Pulmonary function test.

Explanations:

Forced vital capacity(FVC) and diffusing capacity for carbon monoxide(DLCO) help
monitor the disease's progression, response to treatment, and prognosis.
Pulmonary function tests are useful in assessing the obstructive or restrictive
pattern of lung disease, lung volumes, and diffusing capacity for carbon
monoxide(DLCO).
The typical pulmonary function test findings in nonspecific interstitial pneumonitis
include the restrictive pattern with reduced total lung capacity(TLC) and diffusing
carbon monoxide capacity.
A chest x-ray may show worsening interstitial prominence but does not help
monitor response to treatment or prognosis.

Research Concepts:

Nonspecific Interstitial Pneumonitis

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Question 554: An 18-year-old tall and slim male presents to the emergency department
with chest pain. His condition started three days ago with shortness of breath, easy
fatigability, and sharp chest pain in the right upper chest, pain grade of 7/10, and non-
radiating. The vital signs show a temperature of 37.5 C (99.5 F), blood pressure 110/70
mmHg, heart rate 110/min, and a respiratory rate 30/minute. Chest and lung
examination shows symmetrical chest expansion, intercostal retractions, decreased
breath sounds, and a hyper resonant right upper lung field. Cardiac examination reveals a
regular rate, regular rhythm, and no murmur. Chest X-ray shows a collapsed right upper
lobe of the lung with absent vascularity.
Electrocardiogram was unremarkable. Which of the following is a complication of treatment
of this patient's condition?

Choices:

1. Acute respiratory distress syndrome

2. Bronchiectasis
3. Parapneumonic effusion
4. Re-expansion pulmonary edema

Answer: 4 - Re-expansion pulmonary edema

Explanations:

Pneumothorax is an accumulation of air or gas in the pleural space (the space

between the visceral and parietal pleura of the chest cavity), which can impair
ventilation, oxygenation, or both. This condition can vary in its presentation from
asymptomatic to life-threatening.
Primary spontaneous pneumothorax often affects young males, tall and thin, built,
and often smokers. The incidence of recurrence is 20 to 60% in the first three years
after the first episode.
This patient has a primary spontaneous pneumothorax, which occurs in people
with no underlying lung disease or inciting event.
One of the possible complications of a pneumothorax treatment is re-expansion
pulmonary edema. Acute respiratory distress syndrome and parapneumonic
effusion are complications seen in pneumonia, while bronchiectasis is a pulmonary
tuberculosis complication.
Research Concepts:

Acute Pneumothorax Evaluation and Treatment

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Question 555: A 66-year-old man is being evaluated for weight loss, back pain, and
chronic cough. A chest x-ray reveals a 4 cm spiculated nodule in the left upper lobe. The
patient denies any smoking history but did work as a uranium miner for nearly thirty
years. Which of the following is most likely responsible for the patient's disease?

Choices:

1. Uranium
2. Radon gas
3. Xenon
4. Gamma radiation
Answer: 2 - Radon gas

Explanations:

Uranium mines have a high level of radon gas.

Radon gas increases the likelihood of developing a lung carcinoma.
Radon is made of alpha particles that can settle on alveoli tissue after being inhaled
and cause cellular damage over time.
Uranium exposure would have had cutaneous symptoms. Xenon is made of beta
particles and would have had more systemic symptoms. Gamma radiation is
usually a result of nuclear detonation.

Research Concepts:

Radiation Syndrome

Question 556: A 45-year-old man presents with progressive exertional dyspnea, fever,
and dry cough. He has a past medical history of HIV. Blood tests show CD4 count 150
cell/mm3 (500- 1500). A chest x-ray reveals bilateral interstitial infiltrates. The patient is
started on trimethoprim-sulfamethoxazole but does not improve and shows signs of
severe infection. Which of the following is the most effective method of administration of
the drug that should be prescribed for this patient's new symptoms?

Choices:

1. Intramuscular
2. Nebulized
3. Intravenous
4. Oral
Page 526 of 955
Answer: 2 - Nebulized

Explanations:

Pentamidine is an antiprotozoal drug for pneumocystis jiroveci pneumonia and other

related infections.
It can be administered IV, IM, orally, or as an inhaled dose.
It can be given therapeutically or prophylactically to HIV-positive patients.
A nebulized dose is more commonly used prophylactically and in treatment.

Research Concepts:

Pentamidine

Question 557: A 70-year-old woman admitted with acute hypoxic respiratory failure and
acute kidney injury requiring intermittent hemodialysis. The patient had a low-grade fever
and a cough for two weeks. The respiratory rate was 29/min, and oxygen saturation of
89% on 4L O2 support. She had crackled in the bases of the chest bilaterally, and a chest x-
ray showed hazy opacifications and small- sized nodules in lower lung zones. Lab workup
was significant for erythrocyte sedimentation rate (ESR) of 90 and high ANCA titers of
1:320 (against nuclear myeloperoxidase in a perinuclear pattern).
Her white blood cell, platelets, and hemoglobin were within the normal range. Blood
culture and sputum culture were negative for any growth. The patient underwent a
bronchoscopy, and a lung biopsy was taken. What is the biopsy likely to reveal?

Choices:

1. Gram-positive cocci in clusters

2. Abundant fibroblasts
3. Capillaritis and leukocytoclastic changes
4. Granulomatous inflammation
Answer: 3 - Capillaritis and leukocytoclastic changes

Explanations:

The patient presented with signs and symptoms of vasculitis affecting the lungs.
Serology is positive for anti-MPO antibodies, which is associated with microscopic
polyangiitis (MPA). Given the clinical presentation and lab results, autoimmune
vasculitis is more likely than an infectious process.
The chest x-ray showing infiltration can be an alveolar hemorrhage. MPA commonly

Page 527 of 955

 affects the kidneys and, less often, the lungs.
In MPA, tissue biopsy will show capillaritis without granuloma formation in addition to
leukocytoclastic changes and crescentic glomerulonephritis in kidneys.
Granulomatous inflammation is usually seen in granulomatosis with polyangiitis
(GPA) and it is usually associated with a c- ANCA pattern of anti-proteinase 3
antibodies.

Research Concepts:

ANCA Positive Vasculitis

Question 558: A 37-year-old patient with a past medical history significant for end-stage
renal disease secondary to lupus nephritis presents to the hospital to receive a kidney
transplant. The patient’s laboratory data is significant for a potassium of 5.6 mEq/L. An
arterial line is placed prior to induction. The patient is then induced with etomidate,
fentanyl, and a neuromuscular blocking agent. The patient's blood pressure decreases
from 150/80 mmHg to 80/40 mmHg following induction. Subsequently, the patient's
blood pressure increases to 130/65 mmHg without intervention. What medication could
have been given prior to induction to attenuate the hypotension?

Choices:

1. Phenylephrine
2. Midodrine
3. Odansetron
4. Diphenhydramine
Answer: 4 - Diphenhydramine

Explanations:

The majority of adverse reactions associated with atracurium administration are

related to histamine release.
Studies have previously demonstrated that a mean arterial pressure fall of 30 mmHg
can be seen within 2 minutes of administration.
Histamine receptor type-1 and histamine receptor type-2 blocking agents have
been used effectively to attenuate this hypotensive response.
Slower injection speed, from 30 to 60 seconds, has also been shown to reduce
histamine release and the associated adverse effects.

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Research Concepts:

Atracurium

Question 559: An 83-year-old man recently hospitalized in the intensive care unit (ICU) for
community-acquired pneumonia presents to an outpatient imaging center for a follow-up
chest x-ray to ensure his pneumonia has completely resolved. The imaging technologist
positions him appropriately for a posterior-anterior view of his chest, takes the image,
and sends him home. Once the technologist prepares the image in the Picture Archive
Communication System (PACS) for reading, the attending radiologist opens the study and
begins reading it. The attending radiologist opens up his last chest X-ray from his ICU stay
in the hospital for comparison and confirms pneumonia has resolved. However, the
attending radiologist notices a decreased cardiothoracic ratio compared to the man’s
previous x-ray. Which of the following best explains this discrepancy?

Choices:

1. The man’s heart was closer to the digital detector in the hospital.
2. The man’s heart was closer to the x-ray beam in the outpatient imaging center.
3. The man’s heart was further from the x-ray beam in the outpatient imaging center.
4. The man’s heart was closer to the x-ray beam in the hospital.
Answer: 4 - The man’s heart was closer to the x-ray beam in the hospital.

Explanations:

In the hospital, especially in the intensive care unit, it is common to have a chest x-
ray done at the bedside.
Bedside chest x-rays are done anterior-posterior, meaning the heart is closer to
the x-ray beam and further from the detector, which makes the heart appear
larger than it actually is.
In posterior-anterior chest x-rays, the patients' chest is against the x-ray detector,
and further from the x-ray beam than it would be in a bedside chest x-ray, so the
heart is closer to its actual size.
The man's last x-ray in the hospital was likely done at the bedside, meaning it was
an anterior-posterior x-ray. Anterior- posterior chest x-rays cause the heart to
appear larger than it actually is. Compared to the posterior-anterior film he had
done at the outpatient imaging center, it would appear as if the heart shrunk. In
reality, it was just the positioning of the patient that made the heart appear
smaller than it did in the hospital.
Page 529 of 955
Research Concepts:

X- ray Production Technical Evaluation

Question 560: An 85-year-old man with a history of colon cancer presents to the clinic for
follow up with left-sided chest discomfort.
He has an ECOG performance status 3. He underwent subclavian venous cannulation for
chemotherapy five days ago. CT chest reveals high output thoracic duct leak. What is the
most appropriate management strategy for this patient?

Choices:

1. Intercostal drainage tube and parenteral nutrition

2. Thoracocentesis and parenteral nutrition
3. Pleurodesis with bleomycin
4. Thoracic duct embolization
Answer: 4 - Thoracic duct embolization

Explanations:

A high output thoracic duct leak requires intervention after failed conservative
management.
Patient with ECOG 3 is not fit for surgery.
Thoracic duct embolization is an acceptable procedure in patients who are not fit
for surgical intervention.
Thoracocentesis and thoracic drainage will alleviate temporarily, but they are not
definitive treatment.

Research Concepts:

Thoracic Duct Leak

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Question 561: A 4-year-old girl with a history of asthma is brought to the hospital with
shortness of breath. She has two-word speech dyspnea with audible wheezing.
Intercostal retractions are noted. Continuous albuterol treatments, intramuscular
epinephrine, and methylprednisolone are administered. Upon reassessment, the patient
is unresponsive. The patient is intubated. Vital signs after intubation show a weak pulse
38/min, respiratory rate 25/min, blood pressure 65/43 mmHg, and SpO2 100%. What is
the next best step in the management of this patient?

Choices:

1. Atropine
2. Epinephrine
3. Chest compressions
4. 20 mL/kg IV crystalloid bolus
Answer: 3 - Chest compressions

Explanations:

According to the American Heart Association, pediatric bradycardia can be treated

with atropine, epinephrine, and/or chest compressions.
Since this patient is bradycardic and hypotensive, the most appropriate next step
should be chest compressions.
Although atropine and epinephrine are within the American Heart Association
guidelines, this patient has maximal optimization of oxygen status and is
bradycardic as well as hypotensive. The next step should be chest compressions
followed by atropine and/or epinephrine.
This patient is hypotensive (for age) and will require IV fluids, however, the next
most appropriate step in management would be chest compressions.

Research Concepts:

Cardiac Arrest

Question 562: A 46-year-old male presents to the hospital with a head injury along with a
hemopneumothorax bilaterally after an assault. Emergent bilateral intercostal chest tube
drains are placed. Neurological examination reveals an absence of brainstem reflexes.
While performing the apnea test, there are episodes of desaturation and hypotension
observed in the patient. What is the next best step to accurately diagnose the brain stem
status in the patient?

Choices:
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1. Computed tomography of the head
2. Cerebral angiography and electroencephalogram
3. Repeat apnea test after few hours interval
4. Continue supportive management

Answer: 2 - Cerebral angiography and electroencephalogram

Explanations:

The periods of hypotension and hypoxemia observed while evaluating the apnea test
would preclude the diagnosis of brain stem death.
To confirm brainstem death in such a scenario, ancillary tests like angiography and
EEG are justified.
The presence of absent brainstem reflexes along with two appropriately made
ancillary tests such as- the absence of blood flow beyond the circle of Willis in
angiography and absence of electrical activity on an electroencephalogram for at
least 30 minutes is also justifiable for pronouncing brain stem death in the patient.
A repeat apnea test is not justified in hemodynamically unstable patients. Computed
tomography of the head is not included in the recommendations for diagnosing
brainstem death.

Research Concepts:

Brainstem Death

Question 563: A 40-year-old woman with severe persistent asthma presents to the
emergency department (ED). She is well known to the intensive care unit (ICU), having
required intubation with mechanical ventilation in the past. On initial evaluation, the
patient is maintaining adequate oxygen saturation; however, she is tachypneic while on
noninvasive positive pressure ventilation, and her chest examination reveals diffuse
wheezing. In the ED, the patient is intubated, and her transport to the ICU is to be
expedited following portable chest radiography. After arriving at the ICU, the respiratory
therapist notes elevated peak inspiratory pressures, unequal chest wall expansion, and
unilateral right-sided wheezing. Attempts to view the post-intubation radiograph are
unsuccessful as the file is corrupted. Bedside thoracic sonography reveals the presence
of lung sliding in the right lung field. While lung sliding is absent in the left lung field,
rhythmic pleural movements in concert with the cardiac cycle are noted. Suddenly, the
patient develops hypoxia. A normal waveform is seen on the pulse oximeter. What is the
best next step in the management of this patient?
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Choices:

1. Reposition the pulse oximeter

2. Increase the PEEP
3. Perform an emergent right-sided needle thoracostomy
4. Retract the endotracheal tube
Answer: 4 - Retract the endotracheal tube

Explanations:

Right main bronchus intubation requires prompt identification and treatment with
retraction of the endotracheal tube (ETT) to a suitable position (=2 cm) above the
tracheal carina.
In this patient, elevated peak inspiratory pressures, unequal chest wall expansion,
and right-sided unilateral wheezing are highly suggestive of right main bronchus
intubation. The absence of wheezing in the left lung field is consistent with the
absence of airflow because airflow is required to produce wheezing.
Proper placement of the ETT must be established as soon as possible after
insertion. Clinical examination should always be performed; however, it is
insufficient for the determination of ETT placement. Quantitative capnography is a
simple but accurate method for confirming the placement of the ETT in the airway
(rather than the esophagus) and should always be performed. This method,
however, cannot determine the depth of the ETT in the trachea, which is best
established with a chest radiograph.
The findings of bedside thoracic sonography effectively rule out pneumothorax,
making emergent needle thoracostomy unnecessary. While increasing PEEP is a
solution to hypoxia, it is inappropriate in this clinical scenario, as doing so could
potentiate barotrauma, given the already elevated peak inspiratory pressures.
Repositioning the pulse oximeter would be unhelpful, given the normal waveform
on the pulse oximeter.
Research Concepts: Wheezing

Question 564: A patient undergoes a right pneumonectomy. He was successfully

extubated postoperatively. Twelve hours after surgery, he started to develop progressive
dyspnea and a gradual increase in his oxygen requirements to maintain saturation above
92%. A chest x-ray was ordered and revealed a left-sided opacity.
What is the most likely cause?

Choices:

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1. Pneumonia
2. Postpneumonectomy pulmonary edema
3. Atelectasis
4. Pulmonary embolism
Answer: 2 - Postpneumonectomy pulmonary edema

Explanations:

In the early postoperative period, the most likely cause of desaturation is

postpneumonectomy pulmonary edema. Aggressive treatment is required to
decrease postoperative morbidity and mortality. While pneumonia is a well-known
postoperative complication, it is uncommon to present in the immediate
postoperative period. The patient will also show signs of infection like fever and
elevated white cell count.
Postpneumonectomy pulmonary edema is the most likely explanation for the
patient's symptoms. This is supported by the x-ray finding of increased opacity
opposite the surgical side.
Atelectasis is unlikely in this scenario. It will usually present with basal opacity and
low-grade fever 24 to 48 hours after surgery. Most patients require intubation,
diuresis, and prolonged intensive unit care. The most likely cause is thought to be
due to excessive fluids. Pulmonary embolism usually presents with sudden onset
dyspnea and hypotension a few days after surgery.

Research Concepts: Pneumonectomy

Question 565: A 40-year-old female with morbid obesity presents to the hospital with
symptoms of shortness of breath on exertion. A physical examination is normal except
for a body mass index (BMI) of 42 kg/m^2. A CT chest is done to rule out intrinsic lung
pathology but is unremarkable. Which of the following pulmonary function test results
is most likely to correlate with this patient’s presentation?

Choices:

1. Normal FEV1/FVC, low FEV1, very low forced vital capacity (FVC), low total lung
capacity (TLC), normal residual volume (RV), and low DLCO.
2. Normal FEV1/FVC, low FEV1, very low FVC, low TLC, low RV, and normal DLCO.
3. Low FEV1/FVC, very low FEV1, low FVC, increased TLC, increased RV, and
low DLCO.
Page 534 of 955
4. Low FEV1/FVC, very low FEV1, low FVC, increased TLC, increased RV, and
normal DLCO.

Answer: 2 - Normal FEV1/FVC, low FEV1, very low FVC, low TLC, low RV, and normal
DLCO.

Explanations:

Morbid obesity can cause a restrictive lung disease pattern, in which the FEV1/FVC
ratio may be normal.
Total lung capacity (TLC) is typically low due to reduced volumes from external
pressure placed on the lung parenchyma. The diffusing capacity of the lung for
carbon monoxide (DCLO) is typically normal because there is no alveolar pathology
affecting gas exchange.
Residual volume (RV) following expiration can be normal or reduced in restrictive lung
disease secondary to obesity.

Research Concepts:

Pulmonary Function Tests

Question 566: A 65-year-old male comes in complaining of shortness of breath for the last
few months. He has a history of hypertension and chronic kidney disease. His home
medications include metoprolol, aspirin, and atorvastatin for his elevated cholesterol. He
lives alone, and he has usually been able to take care of himself until recently. He quit
smoking several years ago. Upon further questioning, the patient has been complaining of
chronic joint pain for more than 10 years. The patient's recent pulmonary function tests
show a restrictive disease pattern and a decreased diffusion capacity. High-resolution
computed tomography (HRCT) shows nonspecific interstitial pneumonia (NSIP). The
clinician suspects connective tissue disease-associated interstitial lung disease (CTD-ILD),
and she orders full blood work. Which of the following is included in the diagnostic criteria
for idiopathic interstitial pneumonia with autoimmune features?

Choices:

1. Lymphocytes > 70%

2. ESR above 60 mm/hr
3. Anti-nuclear antibody titer above 1:320
4. CRP level above 30 mg/L
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Answer: 3 - Anti-nuclear antibody titer above 1:320

Explanations:

The published idiopathic interstitial pneumonia with autoimmune features (IPAF)

criteria required the presence of interstitial lung disease by high-resolution
computed tomography (HRCT) or solid lung biopsy (SLB); exclusion of an alternate
etiology for the interstitial lung disease; failure to meet the criteria for a defined
connective tissue disease; and 1 or more features from at least 2 of the clinical,
serologic, and morphologic domains.
ANA should be more than 1:320 upper limit of normal to meet the proposed
diagnostic criteria.
The radiographic subdomain describes patterns from high- resolution chest
tomography (HRCT) that include nonspecific interstitial pneumonia (NSIP), organizing
pneumonia (OP), and lymphocytic interstitial pneumonia (LIP).
The article also excluded non-specific markers of inflammation such as erythrocyte
sedimentation rate or C- reactive protein.
Research Concepts:

Idiopathic Interstitial Pneumonia With Autoimmune Features

Question 567: Which of the following is the most appropriate statement regarding
surfactant production in-utero?

Choices:

1. "Surfactants are produced around 8-10 weeks of gestation."

2. "Surfactant is secreted by type II alveolar epithelial cells lining the alveoli."
3. "Most babies have enough naturally-produced surfactant around 25 weeks of
gestation."
4. "Surfactants help to decrease lung compliance."
Answer: 2 - "Surfactant is secreted by type II alveolar epithelial cells lining the alveoli."

Explanations:

Pulmonary surfactant is a lipoprotein complex responsible for preventing the

collapse of alveoli and increasing lung compliance.
It is secreted by type II alveolar epithelial cells lining the alveoli. It is a complex
molecule containing phospholipid dipalmitoylphosphatidylcholine, surfactant
apoproteins, and calcium ions. They reduce the surface tension by partial
dissolution.
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 Surfactants are produced around 24-28 weeks of gestation. Most babies have
enough naturally-produced surfactant around 35 weeks of gestation.

Research Concepts:

Surfactant

Question 568: A 65-year-old man with rheumatoid arthritis and chronic stable constrictive
bronchiolitis presents for an evaluation of chronic cough for the past two months. He has
had two empiric courses of antibiotics for “bronchitis” but has a recurrence of cough and
shortness of breath within one week of discontinuing antimicrobial therapy. Due to the
persistence of his symptoms of breathlessness, he was referred for pulmonary evaluation.
His cough is nonproductive. He experiences paroxysms of “coughing fits” with gagging.
Associated symptoms include 5 lb (2.3 kg) weight loss and hypoxia with activity with a
saturation falling to 84% after walking 100 meters. His immunosuppressive regimen for his
rheumatoid arthritis consists of prednisone at 5 mg daily and a reduced dose of rituximab
every 8 months since 2008. He was previously intolerant of methotrexate, and his erosive
synovitis was poorly controlled on etanercept. Three consecutive morning sputa revealed
(+) acid-fast bacilli (AFB) organisms, subsequently characterized to be Mycobacterium
avium complex (Mycobacterium avium-intracellular). A high-resolution CT (HRCT) imaging
of the chest was obtained and revealed moderated diffused airway wall thickened and
mildly extensive foci of cylindrical bronchiectasis. There is a moderately extensive
component of nodularity, ground glass, and bronchovascular consolidation. Which of the
following best characterizes the most likely risk factor for his underlying infection?

Choices:

1. Rituximab associated T lymphocyte lymphopenia

2. Absent response to vaccination/immunization
3. Depletion of plasma cell following treatment with rituximab
4. Secondary hypogammaglobulinemia with altered T-lymphocyte function
Answer: 4 - Secondary hypogammaglobulinemia with altered T- lymphocyte function

Explanations:

Baseline and periodic monitoring of serum immunoglobulin levels (IgG, IgA, and
IgM) and peripheral B cells before initiation of rituximab are recommended to
identify those at risk of developing hypogammaglobulinemia during treatment, as
occurred in the current case and potentially benefit from replacement therapy.
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 The high-resolution CT (HRCT) imaging of the chest revealed moderated diffused
airway wall thickened and mildly extensive foci of cylindrical bronchiectasis. There
is a moderately extensive component of nodularity, ground glass, and
bronchovascular consolidation. Overall, the pattern is one of the progressive
multifocal nodular, mucus plugging, and consolidation concerning infection or
aspiration. Non- tuberculosis mycobacterial should be considered.
Advanced age, immunosuppression, and the use of corticosteroids are all risk
factors for acquiring these organisms. Once the organisms enter the individual, they
usually settle in the lower airways; in some cases, the bacteria incite an
inflammatory reaction with an influx of lymphocytes.
While rituximab depletes peripheral blood B cells following therapy, recovery or
normalization of the peripheral B-cell population typically occurs in approximately 9
months following the infusion. With repeated doses of rituximab, persistent
hypogammaglobulinemia with an increased risk of infection may occur in a subset
of patients and be clinically significant, requiring immune globulin replacement
therapy. Additionally, with repeated doses of rituximab, altered T-cell immunity, but
not T-cell lymphopenia, has been observed with an increased risk of viral and fungal
infections.

Research Concepts:

Lung Nontuberculous Mycobacterial Infections

Question 569: A 65-year-old female patient presents to the hospital with a 2-month
history of facial flushing, nausea, abdominal pain, diarrhea, and wheezing. The patient has
no significant medical history and takes no medications. The patient’s blood pressure is
124/70 mmHg, pulse 60/min, respirations 12/min, and temperature
98.0 F (36.7 C). Chest auscultation shows wheezing bilaterally. A 24- hour urine collection
shows elevated levels of 5-Hydroxyindoleacetic acid (5-HIAA). The best treatment for this
patient’s condition is also used in the treatment of which of the following conditions?

Choices:

1. Acromegaly
2. Rheumatoid arthritis
3. Breast cancer
4. Short stature
Answer: 1 - Acromegaly

Explanations:
Page 538 of 955
 Octreotide has been shown to decrease complications of carcinoid. It is also used
to treat acromegaly. Octreotide is available as short-acting subcutaneous injection
as well as depot form intramuscular injection (Sandostatin LAR) which can be
administered monthly. Patients should start with 20 mg to 30 mg IM every four
weeks, and a gradual dose increase may be necessary. Short-acting octreotide can
be started for a patient with severe or refractory symptoms.
For medical management, there are two somatostatin analogs available,
Octreotide and Lanreotide. Somatostatin is an amino acid peptide which is an
inhibitory hormone, which is synthesized by paracrine cells located ubiquitously
throughout the gastrointestinal tract. It inhibits the release of most of the
gastrointestinal, endocrine hormones. About 80% of neuroendocrine tumors have
somatostatin receptors. Using somatostatin analog inhibits the release of biogenic
amines which leads to control of symptoms such as flushing and diarrhea.
Carcinoid syndrome is diagnosed with elevated 24-hour urine 5- HIAA. Treatment
options include octreotide or lanreotide.
The most common side effects associated with somatostatin analogs are nausea,
abdominal bloating, and steatorrhea, which is due to pancreatic malabsorption.
Supplementing pancreatic enzymes usually helps to alleviate adverse symptoms.

Research Concepts: Carcinoid Syndrome

Question 570: A 67-year-old man presents to the clinic for a follow-up for obstructive
sleep apnea (OSA). He has moderate OSA, for which he uses continuous positive airway
pressure (CPAP) diligently, with significant improvement in his apnea-hypopnea index
(AHI) and symptoms with which he is very pleased. Which of the following describes the
most likely primary benefit he can expect in the long term with this treatment?

Choices:

1. Decreased mortality
2. Improved overall quality of life
3. Decreased incidence of cerebrovascular events
4. Decreased incidence of coronary artery disease
Answer: 2 - Improved overall quality of life

Explanations:

In positive pressure therapy, the positive transmural pharyngeal pressure so that the
upper airway remains patent as the intraluminal pressure exceeds the surrounding
pressure.
The American Academy of Sleep Medicine recommends offering positive pressure
Page 539 of 955
 therapy to all patients diagnosed with OSA.
Current large randomized controlled trials have concluded that positive airway
pressure reduces respiratory event frequency, daytime sleepiness, frequency of
motor vehicle collisions, improves blood pressure control, and improves the
overall quality of life.
Positive pressure therapy has not been shown to significantly affect mortality,
cerebrovascular events, or coronary artery disease in large randomized controlled
trials and meta-analyses.

Research Concepts:

Sleep Apnea Syndrome

Question 571: A 55-year-old man presents with increased somnolence and morning
headaches. He wakes up with a predominantly occipital headache that is moderate in
severity, lasts all morning, and is not associated with other symptoms, including nausea,
vomiting, or visual disturbance. He has long-standing essential hypertension, and his
medications are lisinopril and a multivitamin. He smoked one pack per day for 20 years
but quit ten years ago. His blood pressure is 155/90 mmHg, pulse 90/minute, oxygen
saturation 93% on room air, and body mass index 36 kg/m2. The neurological exam is
within normal limits, and the oral exam demonstrates Mallampati class IV and tongue
indentation.
Polysomnography shows an apnea-hypopnea index of 45 events/hour and sustained
hypoxia. A follow-up arterial blood gas analysis on room air shows pH 7.35, PaCO2 49
mmHg, PaO2 50 mmHg, and bicarbonate 33 mEq/L. What is the most likely mechanism
for this patient's morning headaches?

Choices:

1. Cerebral vasodilation
2. Cerebral vasoconstriction
3. Sleep deprivation
4. Increased cerebral perfusion pressure
Answer: 1 - Cerebral vasodilation

Explanations:

Obesity hypoventilation syndrome (OHS) is associated with nocturnal hypoventilation

and daytime hypercapnia.
The daytime hypercapnia can lead to cerebral vasodilation, resulting in increased
blood flow and intracranial pressure, which can initially manifest as morning
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 headaches. The increase in intracranial pressure can eventually progress to seizures,
coma, and death.
The physiological changes resulting from hypercapnia are dependent on the acuity of
CO2 rise and the presence of compensation (bicarbonate level adjustments via the
kidney compensation to respiratory acidosis).
Other complications of central hypoventilation are polycythemia and respiratory
acidosis. Severe hypercapnic acidosis can lead to hypotension, cardiovascular
instability, and cerebral depression. Given that systemic blood pressure (MAP) is
not changed and intracranial pressure (ICP) is increased during hypoventilation-
induced hypercapnia, the cerebral perfusion pressure (CPP) will decrease, not
increase, based on the following formula: CPP = MAP - ICP.
Research Concepts: Obesity-Hypoventilation Syndrome

Question 572: A 67-year-old man is evaluated for severe chronic obstructive pulmonary
disease (COPD). He continues to have dyspnea despite maximal medical therapy and
pulmonary rehabilitation. He smoked cigarettes for over 40 years and quit one year ago.
He has no other comorbid conditions. Spirometry reveals a post-bronchodilator FEV1 35%
of predicted. His total lung capacity (TLC) is 120% predicted, and DLCO is 40%. A 6-minute
walk test demonstrates he is able to walk 150 meters. High-resolution computed
tomography (HRCT) of the chest confirms severe emphysema predominantly in the upper
lobes. There is no mediastinal shift or large areas of hyperlucency. Which of the following
interventions is most appropriate for improving survival and exercise capacity in this
patient?

Choices:

1. Repeat pulmonary rehabilitation

2. Single lung transplantation
3. Bullectomy
4. Lung volume reduction surgery
Answer: 4 - Lung volume reduction surgery

Explanations:

This is a patient with upper lobe predominant, severe COPD. Lung volume reduction
surgery (LVRS) has been shown to improve the quality of life and survival in these patients.
LVRS involves the excision of emphysematous areas of the lung to reduce hyperinflation. It
also increases the lungs' ability to recoil, leading to improved expiratory flow and
decreasing the frequency of exacerbations.
LVRS can be done safely using selection criteria developed by the National Emphysema
Treatment Trial (NETT). The criteria include age less than 75 years, upper lobe
predominant emphysema, patient quit smoking greater than six months ago, BMI = 31.1
Page 541 of 955
 kg/m2 (men) or = 32.3 kg/m2 (women), Arterial CO2
= 60 mmHg at rest on room air, post-bronchodilator FEV1 less than 45% of predicted for all
ages, FEV1 greater than 15% of predicted if age 70 or greater, total lung capacity greater than
100% of predicted, residual volume greater than 150% predicted (hyperinflation), and a 6-
minute walk distance greater than 140 meters post-rehabilitation.
This patient completed pulmonary rehabilitation and repeating it is unlikely to provide
significant improvement. Bilateral lung transplantation has been shown to provide longer
survival than single lung transplantation and is not routinely considered in patients greater
than 65 years of age. Bullectomy is not indicated as this patient's HRCT is not suggestive of
bullous formation.
Research Concepts:Chronic Obstructive Pulmonary Disease

Question 573: A 30-year-old man presents for a check-up. He was diagnosed with alpha-1
antitrypsin (AAT) deficiency two years ago when he presented with signs and symptoms
of chronic obstructive pulmonary disease (COPD) and liver cirrhosis. All his vital signs are
within normal limits. Blood test shows thrombocytopenia, international normalized ratio
(INR) 2.4 and mildly elevated transaminases. He is scheduled for a liver transplant. From
which of the following conditions is this patient at an increased risk?

Choices:

1. Cholelithiasis
2. Ectopia lentis
3. Diabetes mellitus
4. Abdominal aortic aneurysm
Answer: 4 - Abdominal aortic aneurysm

Explanations:

Alpha-1 antitrypsin (AAT) is a protease inhibitor that inhibits proteolytic enzymes

such as elastase, especially in the lungs. AAT deficiency is inherited in an autosomal
co-dominant fashion.
The abnormal gene for AAT results in the production of an abnormal AAT protein.
In AAT deficiency, the abnormal AAT proteins are unable to inhibit the proteolytic
enzymes. This imbalance between AAT function and elastase causes widespread
lung damage resulting in emphysema.
In the liver, the abnormal AAT protein cannot be secreted and so accumulates in
hepatocytes. Here it causes liver damage culminating in acute liver failure in
newborns or cirrhosis in adolescents and adults.
The imbalance between AAT function and proteolytic enzymes also damages the
vessel walls. This results in intracranial and intraabdominal aneurysms, which are
Page 542 of 955
 common extrapulmonary manifestations of AAT deficiency.

Research Concepts:

Alpha 1 Antitrypsin Deficiency

Question 574: A 65-year-old gentleman is seen for progressive shortness of breath which
is worse with exertion. He has smoked one pack of cigarettes for the past 30 years. He
was diagnosed with chronic obstructive pulmonary disease one year ago and was started
with a long-acting muscarinic inhaler (LAMA.) Vital signs showed SpO2 93%, heart rate
109 bpm, and blood pressure 140/78. On physical examination, there was scattered
expiratory wheeze in both lungs. A transthoracic echocardiogram was obtained for his
dyspnea evaluation showed normal left and right ventricular systolic function and
pulmonary artery systolic pressure of 65 mm Hg. What will be the appropriate next step
in the management of his dyspnea?

Choices:

1. Inhaled treprostinil
2. Addition of long-acting beta-agonist
3. Right heart catheterization
4. Oral sildenafil
Answer: 2 - Addition of long-acting beta-agonist

Explanations:

This patient is going through an exacerbation of chronic obstructive pulmonary

disease (COPD), which is the cause of his shortness of breath. The most
appropriate treatment will be to optimize therapy for COPD. Elevated pulmonary
pressure is likely from his uncontrolled pulmonary disease.
First-line treatment for pulmonary hypertension (PH) secondary to lung disease is to
optimize the underlying cause of PH, which in this case is due to uncontrolled COPD.
Adding a long-acting bronchodilator (LABA) to his treatment regimen will be the
most appropriate next step.
Oxygen supplementation will be appropriate if the patient is hypoxemic at rest or
on a six-minute walk test to avoid prolonged hypoxia which can worsen pulmonary
hypertension. Oral sildenafil and other systemic vasodilators are not approved for
treatment in patients with pulmonary hypertension due to lung disease or hypoxia.
Inhaled treprostinil in INCREASE trial improved six-minute walk distance in patients
Page 543 of 955
 with interstitial lung disease. Right heart catheterization is generally reserved for
patients undergoing evaluation for lung transplant or patients with symptoms not
explained by the underlying condition.

Research Concepts: Pulmonary Hypertension Due To Lung Disease Or Hypoxia

Question 575: A 47-year-old female with a medical history of type-2 diabetes mellitus,
migraine headaches, and Crohn disease presents with the complaint of dry cough for two
months. Her cough is non-productive with no relief from over the counter cough
suppressant medications. Her regular medications include adalimumab for her Crohn
disease and metformin for her type-2 diabetes mellitus. A review of systems reveals that
she also has drenching night sweats, weight loss of 4 pounds, and fatigue. She denies
alcohol use, illicit drug use, and recent travel. Admits tobacco use. She is employed as a
social worker at a homeless shelter in a large metropolitan city. Physical exam findings
include blood pressure of 110/70 mmHg, the oral temperature of 37.8 degrees Celsius,
heart rate of 80 beats per minute, respiratory rate of 18, and pulse oximetry of 95%
saturation on room air. Respiratory exam findings included diffuse bilateral lower lobe
wheezing, diminished right middle lobe breath sounds, and vesicular bilateral upper lung
lobe breath sounds. A posterior-anterior two-view chest x-ray reports right-sided hilar
lymphadenopathy with middle lung lobe cavitation with absent air-fluid levels and right
middle lobe opacity. Based on the radiographic findings, what is the most likely
diagnosis?
Choices:

1. Pulmonary embolism
2. Primary tuberculosis
3. Pulmonary sarcoidosis
4. Primary pulmonary malignancy

Answer: 2 - Primary tuberculosis

Explanations:

The patient most likely has primary pulmonary tuberculosis secondary to

immunosuppressive therapy and occupational exposure to individuals at high risk
of pulmonary tuberculosis infections. The patient has a medical history significant
for Crohn disease that is managed with adalimumab. Adalimumab is a monoclonal
antibody against tumor necrosis factor-alpha. Adalimumab is a biological agent
that is associated with the complication of opportunistic infections such as
pneumocystis pneumonia, primary tuberculosis, and pulmonary fungal infections
such as Histoplasmosis, Coccidioidomycosis, Candidiasis, Aspergillosis,
Page 544 of 955
 Blastomycosis.
Although primary tuberculosis is less common in developed countries, tuberculosis
infections remain prevalent among patients with either the following
immunocompromised conditions human immunodeficiency virus and acquired
immune deficiency syndrome (HIV/AIDS), chronic renal failure, treatment with
immunosuppressive, and patients with substance use disorder as an opportunistic
infection.
The Ghon complex is a non-pathognomonic radiographic finding on a chest x-ray that
is significant for pulmonary infection of tuberculosis.
The Ghon complex present in primary tuberculosis is hallmarked with a pulmonary
lesion (also known as a Ghon lesion or Ghon focus) and with regional lymph node
involvement of lymphadenopathy or calcifications.

Research Concepts: Ghon Complex

Question 576: A 45-year-old female with a past medical history of asthma presented to
the clinic for evaluation of worsening shortness of breath and fevers for the last few
weeks. She was diagnosed with asthma 10 years ago and is on an inhaled corticosteroid
once daily. She also reports a cough although it is not productive. She increased her home
corticosteroid inhaler frequency when her symptoms first started which provided some
relief. She presented to the clinic today due to progressive symptoms. On initial
evaluation, she is febrile but is hemodynamically stable. Pulse oximetry is 92% on room
air. Bilateral wheezing is noted on pulmonary auscultation. Laboratory evaluation is
notable for peripheral eosinophilia. Chest x-ray reveals bilateral peripheral opacities
throughout both lung fields. Bronchoscopy with bronchoalveolar lavage reveals marked
eosinophilia. Further testing reveals elevated serum IgE levels but Aspergillus-specific IgG
is negative. She is started on 0.5 mg/kg/day of oral corticosteroid therapy with dramatic
improvement in her symptoms within 48 hours. She is now afebrile without any hypoxia.
What is the next best step in the management of this patient?

Choices:

1. Continue current dose of oral corticosteroids and repeat chest x- ray to reevaluate
pulmonary infiltrates
2. Continue current dose of oral corticosteroids and repeat chest x- ray in 4 weeks to
reevaluate pulmonary infiltrates
3. Continue current dose of corticosteroids for a total of 5 days and then taper to
complete 10 days of therapy
4. Continue current dose of corticosteroids for a total of 5 days and then stop without
Page 545 of 955
a taper
Answer: 2 - Continue current dose of oral corticosteroids and repeat chest x-ray in 4
weeks to reevaluate pulmonary infiltrates
Explanations:

Chronic eosinophilic pneumonia follows a progressive course. The presentation is

subacute with symptoms present for weeks to months before diagnosis. These
patients usually present with moderate weight loss, dyspnea, fever, and cough. The
physical examination will reveal wheezing, especially in those with adult- onset
asthma.
Patients with chronic eosinophilic pneumonia usually have marked eosinophilia on
bronchoalveolar lavage, typically accounting for more than 40 percent of white
blood cells.
Moderate leukocytosis with peripheral eosinophilia is present in most patients.
Serum IgE levels are elevated in about 50% of the patients. Peripheral infiltrates on
chest radiographs giving the classic "photographic negative" pattern are
pathognomonic for the disease.
Systemic glucocorticoid therapy is the treatment of choice. Treatment is continued
until there is a resolution of both symptoms and radiographic opacities which
usually takes at least 4 to 6 weeks. Treatment is usually continued for an additional
2 weeks after the resolution of clinical and radiographic disease. Some patients
may require longer maintenance therapy.
The prognosis for patients with chronic eosinophilic pneumonia is excellent despite
the risk of recurrences. Relapse does not appear to indicate treatment failure or a
worse prognosis.
Research Concepts: Eosinophilic Pneumonia

Question 577: A 47-year-old man is admitted to the medical ICU with severe sepsis,
multilobar pneumonia, and acute respiratory distress syndrome. He develops oliguric
acute kidney failure on the third day and has produced only 240 mL of urine over the
past 24 hours despite adequate intravenous hydration. He is currently mechanically
ventilated, requiring 80% FiO2. There is no significant past medical history. Current
medications include piperacillin/tazobactam, vancomycin, norepinephrine, vasopressin,
proton pump inhibitor, and propofol. On physical examination, the patient is intubated
and sedated; he has a low-grade fever, blood pressure is 95/60 mmHg, heart rate is
130/min, and CVP is 14 cm H2O. There is no rash. Generalized anasarca is noted. Coarse
breath sounds and inspiratory crackles are heard on chest auscultation. Labs reveal BUN
103 mg/dL, creatinine 4.3 mg/dL, sodium 137 mEq/L, potassium 6 mEq/L, chloride 97
mEq/L, HCO3 16 mEq/L, phosphorus 7.2 mg/dL, and pH 7.2. Urinalysis shows 3+ blood,
erythrocytes 0-2/hpf, multiple granular casts, and tubular epithelial cells. What is the
most appropriate step in the management of this patient?

Page 546 of 955

Choices:

1. Initiate continuous renal replacement therapy

2. Initiate intermittent hemodialysis
3. Initiates slow continuous ultrafiltration
4. Start a furosemide infusion
Answer: 1 - Initiate continuous renal replacement therapy

Explanations:

Continuous renal replacement therapy is most appropriate for this patient due to
hemodynamic instability in the setting of oliguric acute tubular necrosis (ATN).
The urinary findings of granular casts and decreased urine output in the setting of
hypotension are most consistent with the oliguric phase of acute tubular necrosis.
Slow continuous ultrafiltration is a type of extracorporeal therapy for the removal of
excess plasma water. Although it would effectively treat this patient's volume
overload, it would not correct the metabolic and electrolyte derangements.
Furosemide infusion is unlikely to be effective in correcting the metabolic
derangements in this patient. Furthermore, there is no evidence to support the use of
furosemide infusion over intermittent dosing.

Research Concepts: Acute Kidney Injury

Question 578: A male infant born at 24 weeks gestation is brought to the clinic for a 6-
month well-child check. The infant is oxygen dependant and is receiving multivitamins
and budesonide twice daily. Which of the following radiological findings is most
consistent with the patient's pulmonary diagnosis?

Choices:

1. Diffuse perihilar infiltrates and normal vascular development

2. Diffuse perihilar infiltrates and some airway fibrosis
3. Hazy lung fields with hyperinflation and normal vascular development
4. Hazy lung fields with hyperinflation and some airway fibrosis
Answer: 4 - Hazy lung fields with hyperinflation and some airway fibrosis

Explanations:

Page 547 of 955

 The infant in this scenario is dependant on oxygen and has bronchopulmonary
dysplasia. The radiographic findings in BPD include hazy ling fields, minimal cystic
emphysema, and hyperinflation.
BPD involves an arrest in lung development and is associated with abnormal
microvascular development.
In the current era, infants with BPD demonstrate abnormal alveolar septation,
some pulmonary fibrosis, and decreased airway reactivity. However, it is much less
than what was seen with old or classical BPD.
Because of the abnormal lung pathology, these infants are at risk for developing
pulmonary hypertension.

Research Concepts: Bronchopulmonary Dysplasia

Question 579: A 16-year-old female presents with fever, severe cough with sputum, and
chest pain. She has no relevant medical history. Her father died of lung cancer. She does
not use tobacco or alcohol. Her temperature is 101 F, her blood pressure is 110/70
mmHg, and her respiration is 20/min. On physical examination, coarse breath sounds are
heard over her chest, along with wheezing. There is an increased tactile fremitus on the
right side of her chest. Drug-resistant Streptococcus pneumoniae is seen in 30% of
isolates in the area. Which of the following is an appropriate line of management in this
patient?

Choices:

1. Amoxicillin on an outpatient basis

2. Azithromycin on an outpatient basis
3. Trimethoprim/sulfamethoxazole after admitting the patient
4. Levofloxacin after admitting the patient
Answer: 2 - Azithromycin on an outpatient basis

Explanations:

A young, healthy patient with community acquired pneumonia that is stable can
be treated as an outpatient with a macrolide, most commonly azithromycin,
erythromycin, or clarithromycin. Patients with comorbid conditions should be
treated with a respiratory quinolone such as levofloxacin or a high-dose beta-
lactam plus a macrolide.
Criteria for admission include respiratory rate greater than 30 bpm, blood pressure
less than 90/60 mmHg, mental status changes, or blood urea nitrogen greater than
Page 548 of 955
 20 mg/dL. Patients with severe disease or who can not tolerate an oral regimen
will also need to be admitted for IV antibiotics for an extended duration until they
can be switched to oral antimicrobials. For patients with a CURB 65 score of greater
than or equal to 2, inpatient management is recommended. A respiratory
fluoroquinolone monotherapy or combination therapy with beta lactam
(cefotaxime, ceftriaxone, ampicillin-sulbactam, or ertapenem) and macrolide are
recommended options for nonintensive care settings.

Research Concepts:

Community-Acquired Pneumonia

Question 580: A 16-year-old female is bought to the clinic by her mother. She has a
history of moderate persistent asthma and has been prescribed a medium-strength
inhaled corticosteroid (ICS), long-acting beta-agonist (LABA) inhaler, and montelukast.
She reports getting asthma symptoms, including coughing and wheezing, daily and needs
to use her albuterol rescue inhaler almost daily. She has had 5 visits to the emergency
department for asthma symptoms and has used 5 courses of oral steroids in the last 12
months. The rest of the physical examination is normal. The spirometry shows a
significant obstructive pattern. Allergy workup has been negative in the past. What is the
next step in her care?

Choices:

1. Consider increasing the dose of ICS and LABA

2. Prescribe a course of oral steroids
3. Check adherence to daily asthma medications
4. Switch to nebulized inhaled steroids daily and discontinue ICS and LABA
Answer: 3 - Check adherence to daily asthma medications

Explanations:

Before increasing the dose of ICS and LABA, check the patient's adherence to
prescribed medications.
Though her asthma is suboptimally controlled, she does not have an active asthma
exacerbation needing oral steroids at this point.
This is the most common cause of suboptimal asthma control, especially among
teenagers. A good clinical history to check medication compliance is very
important before prescribing higher strength asthma medications.
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 Children with persistent asthma have respiratory symptoms ranging from > 2
days/week to daily or several times/day, night times awakenings >2/month, minor
to a significant limitation to normal daily activity = or >2 asthma exacerbations in 6
months, or wheezing = or > 4 times/year lasting for > 1 day and risk factors for
persistent asthma as defined in the introduction.
Steps two through four describe controller treatment recommendations for children
with persistent asthma. A short- acting beta-2 agonist should also be available for
rescue for asthma exacerbations.

Research Concepts:

Asthma Medication in Children

Question 581: A 40-year-old woman presents to the clinic with dry cough and dyspnea.
Physical exam demonstrates a discoid rash. Laboratory testing reveals the presence of
anti-Smith antibodies.
Which of the following findings is most likely to present on a high- resolution CT of the chest
of this patient?

Choices:

1. Tree-in-bud nodules and bronchial wall thickening

2. Bibasilar ground-glass opacities and traction bronchiectasis
3. Multifocal consolidations and crazy paving
4. Bibasilar reticular opacities and honeycombing
Answer: 2 - Bibasilar ground-glass opacities and traction bronchiectasis

Explanations:

Systemic lupus erythematosus is a complex multisystem autoimmune disease

that predominantly affects women and non-Caucasians.
Typical histopathologic findings are those of nonspecific interstitial pneumonia or
usual interstitial pneumonia.
Nonspecific interstitial pneumonia can be classified as the cellular or fibrotic type,
depending on the degree of interstitial inflammation and fibrosis. There is diffuse
cellular inflammation in a homogenous pattern with patchy intervening lung tissue
and preservation of lung architecture.
Ground-glass opacities and consolidations may reflect interstitial pneumonitis and
fibrosis. Interstitial abnormalities include interlobular septal thickening, irregular
linear hyperattenuating areas, and architectural distortion.

Page 550 of 955

Research Concepts:

Collagen-Vascular Disease Associated With Interstitial Lung

Question 582: A 45-year-old male patient from Guatemala presents to the emergency
department with a complaint with "coughing up blood." A chest X-ray was performed
that shows what seems like left upper lobe cavitary lesions with associated hilar
lymphadenopathy. While re-evaluating the patient, he suddenly starts coughing up large
quantities of bright red blood. The patient was placed in the left lateral decubitus
position and Trendelenburg position, but the patient still has large hemoptysis amounts.
O2 saturation for the patient continues to drop, and the patient becomes lethargic. What
is the next best step in the management of this patient?

Choices:

1. Urgent computed tomography scan of the chest

2. Intubate patient using size 7.0mm ET tube into the left main stem
3. Intubate patient using size 8 mm ET tube into the right main stem
4. Place the patient on high flow oxygen
Answer: 3 - Intubate patient using size 8 mm ET tube into the right main stem

Explanations:

The patient is likely suffering from hemoptysis secondary from cavitary tuberculosis in
the left upper lobe. Proper endotracheal tube size 8mm or above should be chosen to
allow for further intervention via bronchoscopy.
Intubation of the right main bronchus in this patient will allow for isolation of the
unaffected side, allowing for proper ventilation and the prevention of blood
aspiration.
An 8 mm endotracheal tube will allow for the passage of bronchial blockers and
bronchoscope.
Maneuvers such as placing the patient in the left lateral decubitus position or
Trendelenburg will isolate the bleeding to the affected lobe or side.

Research Concepts:

Pulmonary Hemorrhage
Page 551 of 955
Question 583: A 37-year-old woman presents with complaints of intermittent dry cough
and chest tightness since she started a new job as a chambermaid at a hotel 5-weeks ago.
Her symptoms are worst at night. She does not have any rhinitis, postnasal drip, or
history of allergic rhinitis. She has never smoked and doe not take any medicine. On
physical examination, the patient appears comfortable and speaks full sentences without
any problem. Oral and nasal mucosa appears normal. On auscultation of lungs, wheeze is
reported in the left lung. The chest x-ray report comes out normal. Which of the following
is the next best step in identifying the cause of the patient's current symptoms?

Choices:

1. CT scan of the chest

2. Dermal patch testing to identify trigger allergies
3. Spirometry with pre and post-bronchodilator testing
4. Follow up with albuterol

Answer: 3 - Spirometry with pre and post-bronchodilator testing

Explanations:

For a suspected case of asthma, detailed history, including identifying possible triggers
at work (allergies to dust mites at hotels), should be evaluated. Spirometry with pre
and postbronchodilator testing is the standard diagnostic approach when identifying
asthma.
If the spirometry comes out normal, a methacholine challenge test should be
performed to evaluate for asthma.
After pulmonary testing, dermal patch testing to identify the trigger should be
done.
CT scan of the chest is non-contributory for asthma evaluation.

Research Concepts:

Asthma

Page 552 of 955

Question 584: A 56-year-old on a ventilator has a pH = 7.29, PCO2 = 53, HCO3 = 24, PO2
=83 while on the following ventilator settings: Volume-cycled assist control, tidal volume
500 ml, FiO2 30 percent, set rate 12, total rate 12, PEEP 5. What change in ventilator
settings would be most appropriate?

Choices:

1. Decreasing FiO2
2. Increasing rate
3. Add PEEP
4. Change mode to SIMV
Answer: 2 - Increasing rate

Explanations:

Increasing the rate of ventilation will decrease the PaCO2 level and improve
oxygenation.
An increase in blood carbon dioxide would normally result in an increase in the
respiratory rate in a person not on a ventilator.
A decrease in blood pH also normally leads to an increase in breathing rate. A
decrease pH is caused by an increase in hydrogen ions in the blood.
An increase in breathing rate should decrease carbon dioxide concentration and result
in an increased oxygen concentration resulting in a decrease in hydrogen ions and a
pH increase until homeostasis is met.

Research Concepts:

Ventilator Management

Page 553 of 955

Question 585: A 43-year-old obese woman who was extubated 15 minutes ago is
complaining of mild difficulty in breathing with a feeling of choking sensation in the
throat. She is not able to speak. The woman was intubated last evening with an 8-mm
Portex tube after a head injury, which resulted in an episode of a generalized tonic-clonic
seizure. CT brain was normal. The emergency department notes mention a difficult
airway. Examination reveals a conscious patient who is tachypneic with a respiratory rate
25/minute and an oxygen saturation 100% on mask oxygen at 5 L/minute.
Blood pressure is 140/74 mmHg, and the heart rate is 128/minute. A bedside
cardiorespiratory clinical evaluation reveals a high pitched sound during inspiration. What
is the most pragmatic way to anticipate the risk of this complication?
Choices:

1. X-ray of the neck anteroposterior and lateral views

2. Laryngeal ultrasonography
3. Cuff leak test
4. CT neck
Answer: 3 - Cuff leak test

Explanations:

Post intubation laryngeal edema is the most common manifestation of post-intubation

laryngeal injury, and it contributes significantly to the development of post-extubation
stridor (up to two -thirds of the cases). Cuff leak test is a simple bedside test performed on
high-risk patients to identify patients with post-intubation stridor.
Cuff leak test has shown variable sensitivity but excellent specificity (almost always above
90%) with a high negative predictive value in most studies. A negative cuff leak of fewer
than 110 ml or less than 24% of the delivered tidal volume predicts a high risk for post-
extubation stridor for which post- intubation laryngeal edema is a significant contributor.
A cuff leak test is recommended for all high-risk patients for post-extubation stridor,
including patients who were ventilated for more than six days, undergone traumatic
intubation, female gender, those having larger endotracheal tube size, and reintubation
after unplanned extubation.
Laryngeal ultrasonography with measurement of air column width (ACW) and air column
width difference (ACWD) before and after cuff deflation has shown a promising correlation
in predicting post-extubation stridor risk in few studies (significantly lower ACWD difference
values and lower ACW values after deflation favoring the risk) although evidence for
routine recommendation lacks at this stage.
Research Concepts:

Post Intubation Laryngeal Edema

Page 554 of 955

Question 586: A 17-year-old male patient presents to the hospital with complaints of
cough productive of sputum, nausea, vomiting, diarrhea, and fever. He reports traveling
to India recently to meet his family. On examination, he is tachypneic with a respiratory
rate of 34/min, blood pressure is 90/60 mmHg, and heart rate is 60/min. His laboratory
findings reveal a white cell count of 24,000 per microliter, serum sodium of 128 mmol/L,
and a BUN of 27 mg/dL. Urine examination shows microhematuria. What is the best
investigation to reach a diagnosis in this case?

Choices:

1. CD4 count
2. Saliva antigen testing
3. Urine antigen testing
4. Immune serologic tests
Answer: 3 - Urine antigen testing

Explanations:

This patient appears to be suffering from Legionella pneumophila. The risk

factor, in this case, was his travel to another country. It is diagnosed with urine
antigen testing. Some bacterial causes of pneumonia present with specific
biochemical evidence, such as Legionella may present with hyponatremia and
microhematuria.
Some examination findings are specific for certain etiologies, such as bradycardia -
Legionella, dental illnesses - Anaerobes, impaired gag reflex - Aspiration
pneumonia, cutaneous nodules
- Nocardiosis, and bullous myringitis - Mycoplasma. Atypical pneumonia
presents with pulmonary and extra-
pulmonary manifestations, such as Legionella pneumonia, often presents with altered
mentation and gastrointestinal symptoms.

Research Concepts:

Bacterial Pneumonia

Page 555 of 955

Question 587: A 65-year-old patient presents to the emergency department with fatigue,
shortness of breath, orthopnea and mild cough for the past month. His past medical
problems include hypertension, diabetes mellitus, unstable angina, hyperlipidemia, and
supraventricular tachycardia. Family history is significant for stroke in paternal
grandfather, hypertension in mother and stable angina in father. He has a 40-pack-year
smoking history. He drinks alcohol every night. His medications include aspirin,
metoprolol, losartan, and atorvastatin. His blood pressure is 150/90 mmHg, the pulse is
90 bpm, oxygen sat is 90%, afebrile and respirations are 22/[Link] examination
reveals bibasilar crackles, an extra heart sound, and pedal edema bilaterally. Which of
the following is the most likely cause of patients' symptoms?
Choices:

1. Impaired contractility of the left ventricle

2. Diastolic dysfunction of the right ventricle
3. Increased venous pressure in the saphenous veins
4. Renin-angiotensinogen system activation
Answer: 1 - Impaired contractility of the left ventricle
Explanations:

The patient in the vignette most likely has left-sided heart failure as given by his
symptoms of dyspnea, orthopnea and physical findings of pedal edema and an extra
heart sound (S3). He has strong risk factors which includes hypertension,
hyperlipidemia, smoking and diabetes mellitus all of which predispose to the
development of heart failure.
The likely cause of the patient's symptoms is the impaired contractility of the left
ventricle resulting in the backward flow of blood to the left atrium and into the
pulmonary vasculature thus resulting in pulmonary edema.
He should be given furosemide to increases diuresis and decrease the increased
interstitial pressure in the alveoli from the buildup of blood in the pulmonary
vasculature. He also should be given oxygen by facemask to increase the alveolar
exchange of oxygen and carbon dioxide.
Increased venous pressure in the saphenous veins causes varicose veins. Diastolic
dysfunction of the right ventricle results in right-heart failure which is characterized
by increased JVP, hepatomegaly, and pedal edema. RVF has no pulmonary
symptoms. Renin-angiotensinogen system activation is a cause of hypertension
which indirectly can lead to the development of heart failure.
Research Concepts: Left Ventricular
Failure

Page 556 of 955

Question 588: A 49-year-old male patient presents to the office for follow-up. His
hemoglobin has been progressively increasing for the past five years and is now up to 17
mg/dL. He is a nonsmoker, and his only other symptoms are ongoing fatigue and
occasional daytime sleepiness. He was recently admitted to the hospital before his last
outpatient primary care visit, where an arterial blood gas was performed for shortness of
breath. His partial pressures of oxygen and carbon dioxide were 91 mmHg and 52 mmHg,
respectively. After being discharged, he underwent a sleep study at his wife's request,
who claims he snores a lot. The sleep study revealed many apneic and hypopneic episodes
with an apnea-hypopnea index of 18. The current examination reveals a BMI of 35kg/m2
and clear lung fields. Pulmonary function tests are ordered. Which of the following
describes the most likely expected results of this investigation?

Choices:

1. Predominantly obstructive defect with lower FVC and FEV1 and reduced FEV1/FVC
ratio
2. Predominantly restrictive defect with lower FVC and FEV1 but a normal FEV1/FVC
ratio
3. Predominantly obstructive defect with increased FVC and FEV1 but a reduced
FEV1/FVC ratio
4. Predominantly restrictive defect with increased FVC and FEV1 but a normal FEV1/FVC
ratio
Answer: 2 - Predominantly restrictive defect with lower FVC and FEV1 but a normal
FEV1/FVC ratio

Explanations:

Spirometry analysis of patients with obesity hypoventilation syndrome (OHS)

reveals a predominantly restrictive defect with lower FVC and FEV1 but a normal
FEV1/FVC ratio, likely from a combination of the inertial load of the increased fat
around the chest wall and abdomen further worsened by the effect of gravity
during sleep.
He is a nonsmoker, and his benign lung exam clinically excludes obstructive pulmonary
disease.
This restrictive breathing pattern can also contribute to increasing the dead space
ventilation by a predominantly lowered tidal volume and increased respiratory
rate.
Restrictive defects will have lowered lung volumes but intact or increased FEV1/FVC
ratio.
Research Concepts:Pickwickian Syndrome

Page 557 of 955

Question 589: An 80-year-old male with a prior history of heavy smoking, hypertension,
coronary artery disease, prior coronary artery bypass surgery, and known pulmonary
hypertension has been referred for right heart catheterization. The patient is being
evaluated for pulmonary hypertension pharmacotherapy, and the pulmonary clinician
requests a trial of vasodilator therapy in the catheterization lab. Venous access is
obtained via the right internal jugular vein, and the pulmonary catheter is advanced into
position. After obtaining the right atrial and ventricular pressures, there is difficulty in
advancing to the right pulmonary capillary wedge position. After three attempts,
pulmonary capillary wedge pressure is obtained. As the pressure readings are being
recorded, the patient suddenly complains of dyspnea and starts coughing. His heart rate
increases, and his blood pressure decreases to 85/40 mmHg. He is disoriented and is
unable to speak properly. Which of the following is the most appropriate management?

Choices:

1. Remove the pulmonary artery catheter immediately and call for emergent surgical
evaluation
2. Administer supplemental oxygen
3. Emergent intubation, left lateral decubitus position, emergent surgical
evaluation
4. Emergent intubation, right lateral decubitus position, emergent surgical
evaluation
Answer: 4 - Emergent intubation, right lateral decubitus position, emergent surgical
evaluation

Explanations:

The patient likely has pulmonary artery perforation. The pulmonary catheter
should be left in place with the balloon inflated to mitigate the ongoing bleeding.
Administering supplemental oxygen can be helpful, but it is not the definitive
management.
Emergent intubation with a dual lumen endotracheal tube is appropriate. The
patient should be placed in the lateral decubitus position on the side of the
affected lung.
The pulmonary artery catheter was used to obtain pulmonary capillary wedge
pressure on the right side, which would be suspected perforation site. Placing the
patient in the right lateral decubitus position is the correct answer as he is
experiencing right pulmonary artery perforation.

Research Concepts:Right Heart Cardiac Catheterization

Page 558 of 955

Question 590: A 16-year-old male presents to the emergency department after being
involved in a high-speed motor vehicle collision. An accurate history is difficult to obtain
as the patient's Glasgow coma scale (GCS) is deteriorating rapidly. He has stridor,
hemoptysis, and hoarseness in his voice. Physical exam reveals mediastinal emphysema
and decreased breath sounds on the right side of the chest. A right-sided chest tube is
placed, and only air gushes out. After 5 minutes, air continues to gush out of the chest
tube, and the patient is still in severe distress. Computed tomography (CT) of the chest
confirms the suspected diagnosis.
What will be the management of this patient's likely injury?

Choices:

1. A right tracheal injury requiring a right thoracotomy

2. A left tracheal injury requiring a left thoracotomy
3. A right tracheal injury requiring an exploratory laparotomy
4. A right tracheal injury requiring needle decompression
Answer: 1 - A right tracheal injury requiring a right thoracotomy

Explanations:

Patients with tracheal injuries will present with airway obstruction, subcutaneous
emphysema (35% to 85%), mediastinal emphysema, and hoarseness/aphonia. The
patient has a right tracheal injury. An urgent right thoracotomy is required.
A strong indication for an intrathoracic tracheal injury is the presence of significant
air leak despite a tube thoracostomy. The majority of tracheal injuries from blunt
trauma occur 2 cm proximal to the carina and on the right main bronchus (25%)
with definitive management of carinal tracheal injuries requiring a right
thoracotomy. Especially in the setting of rapid deceleration injuries, it can cause
shearing forces on the carina. Left mainstem bronchus injuries require a left
thoracotomy and cervical tracheal injuries are treated with a collar incision
Research Concepts:Thoracotomy

Question 591: A 5-month-old infant is brought to the emergency department with

difficulty breathing. Her illness started three days ago with a cough and a runny nose. Her
mother states that she began breathing heavily overnight, and her difficulty breathing has
worsened progressively. Her vital signs reveal heart rate 140/min, temperature 39.1 C
(102.38 F), and a respiratory rate of 65 breaths per minute. A physical examination
reveals intercostal recessions and central cyanosis, and on auscultation of chest, diffuse,
bilateral wheezes with scattered crackles are heard while the remainder of her exam is
unremarkable. Which of the following would raise concern for this infant having a severe
course?
Page 559 of 955
Choices:

1. Age less than six months

2. Premature birth at 29 weeks
3. Family history of bronchiolitis
4. History of neonatal diabetes

Answer: 2 - Premature birth at 29 weeks

Explanations:

This presentation of the clinical scenario is consistent with bronchiolitis, a viral

infection of the lower respiratory tract, most commonly caused by a respiratory
syncytial virus.
Bronchiolitis causes signs of increased work of breathing, such as tachypnea and
retractions. In addition, it also causes small airway obstruction, as evidenced by
wheezing and crackles.
A history of prematurity i.e., less than 30 weeks of estimated gestational age, is a risk
factor for the development of severe bronchiolitis. Other risk factors include
congenital heart disease, neuromuscular disease, immunodeficiency, and chronic
respiratory illness.
Most cases of bronchiolitis will be mild and self-limited. Children with moderate to
severe respiratory distress, signs of dehydration, or hypoxia may require
hospitalization for supportive care. History of diabetes does not have any effect on
the prognosis.
Research Concepts:

Bronchiolitis

Question 592: A 57-year-old female patient presents to the emergency department with
high-grade fever, arthralgias, and an itchy skin rash for three days. She has also
experienced chest pain for the past 1 day, worse with deep breathing. She has a history of
rheumatoid arthritis diagnosed one year ago, which has been under good control with
adalimumab (4 months) and methotrexate (1 year). Other significant past medical history
includes a history of hypertension for which she is on hydrochlorothiazide. On
examination, she has a high-grade fever, heart rate is 100/minute, blood pressure is
134/88 mmHg. She appears in distress because of pain. The skin exam reveals diffuse
maculopapular rash on her lower extremities. The chest exam reveals bibasal decreased
breath sounds. The musculoskeletal exam is significant for tenderness and swelling with
effusion in bilateral knees, and few proximal interphalangeal joints in the hands.
Page 560 of 955
Laboratory evaluation reveals complete blood count with hemoglobin 10.0 mg/dL,
platelet count 105,000, and WBC 3000. The erythrocyte sedimentation rate is 78 mm/hr.
The chest Xray reveals bilateral pleural effusions. Further serological workup is pursued,
which reveals a positive anti-nuclear antibody, anti-dsDNA antibody, rheumatoid factor,
and anti-CCP antibody. The rest of the autoimmune profile is normal. Serological work-up
one year ago at the time of her rheumatoid arthritis diagnosis was significant for positive
anti-CCP and rheumatoid factor, and a negative anti-nuclear antibody. Which of the
following is the most likely diagnosis?

Choices:

1. New-onset systemic lupus erythematous

2. Drug-induced lupus secondary to hydrochlorothiazide
3. Drug-induced lupus secondary to adalimumab
4. New extra-articular manifestation of rheumatoid arthritis
Answer: 3 - Drug-induced lupus secondary to adalimumab

Explanations:

New-onset fever, arthralgia, rash, serositis, and pancytopenia in a patient who was
recently started on an anti-TNF agent should raise a strong suspicion of drug-induced
lupus.
Anti-TNF agents can cause positive ANA and positive anti- dsDNA antibodies. Anti-
histone antibodies may not always be present.
Management is the withdrawal of the anti-TNF agent (and avoiding all anti-TNF
agents in the future). NSAIDs or a short course of corticosteroids may be considered
if symptoms do not resolve within a few weeks of discontinuing the anti-TNF agent.
It may take several months for the serologies to turn negative.
Hydrochlorothiazide induced lupus is usually associated with a positive anti-
histone antibody and not an anti-dsDNA antibody. New-onset lupus is possible,
but the timeline and typical serologies/symptoms are more characteristic of anti-
TNF induced lupus. While rash, arthralgias, serositis, and pancytopenia can be
seen as extra-articular manifestations of rheumatoid arthritis, fevers are unusual
secondary to rheumatoid arthritis and the serological workup now is consistent
with new-onset drug-induced lupus secondary to an anti-TNF agent in this patient
with rheumatoid arthritis.

Research Concepts:

Tumor Necrosis Factor Inhibitors

Page 561 of 955

Question 593: A 65-year-old man with acute asthma exacerbation arrives at the
emergency department via ambulance. He receives continuous nebulized albuterol,
inhaled ipratropium, prednisone, and oxygen en route. Upon arrival to the hospital, he still
shows signs of respiratory distress. He receives an intravenous bolus of an off-label,
second-line agent that causes bronchodilation by inhibiting calcium binding to smooth
muscle receptors. Which of the following side effects will most likely be seen with the
administration of this medication?

Choices:

1. Hypercalcemia
2. Flushing
3. Migraine headache
4. Hypertension
Answer: 2 - Flushing

Explanations:

This patient is experiencing a severe asthma exacerbation requiring transfer to the

hospital.
He received the first-line agents (i.e., albuterol nebulizer, ipratropium inhaler,
systemic corticosteroids, and oxygen) recommended for severe asthma exacerbation.
Magnesium sulfate is a second-line agent with an off-label indication for patients with
inadequate response to first-line therapy.
Magnesium sulfate causes bronchodilation and is administered as a single
intravenous (IV) bolus for severe asthma exacerbation. Magnesium sulfate may be
used (off-label) to treat migraine headaches. IV magnesium sulfate may cause
hypotension. Prolonged use may cause hypocalcemia. The side effect that will most
likely be seen with the administration of magnesium sulfate for this patient is
flushing.

Research Concepts:

Magnesium Sulfate

Page 562 of 955

Question 594: A 30-year-old woman presents to the emergency department with severe
breathing difficulty. She has a history of asthma. Chest auscultation reveals bilateral
wheeze, and she is unable to complete a sentence. Treatment is commenced with back-
to-back nebulizations with salbutamol and ipratropium bromide; IV hydrocortisone is also
given. She is confused and exhausted. Rapid sequence induction and intubation with a
size 8.0 endotracheal tube is performed. However, it is impossible to ventilate the
patient, and the saturations drop to 70% on 100% oxygen. Which of the following is the
next best step in the management of this patient?

Choices:

1. Check the position and patency of the endotracheal tube

2. Needle decompression
3. Administer further salbutamol and ipratropium nebulizers
4. Magnesium sulfate
Answer: 1 - Check the position and patency of the endotracheal tube

Explanations:

If it is impossible to bag a patient after intubation, you must ensure your

endotracheal tube's patency and position. This question is really more about
testing your ability to apply common sense in a stressful situation rather than acute
severe asthma management.
Severe bronchospasm may make ventilation very difficult, and only very low tidal
volumes may be achievable, but a complete obstruction to any gas flow is unlikely.
Gas trapping makes over-distension a hazard, and there is a high risk of
barotraumas and pneumothoraces. If the patient is truly impossible to ventilate,
you should disconnect the circuit and manually decompress the chest before
further ventilation attempts.
Generally, ventilation strategies should include low tidal volumes and a low respiratory
rate with prolonged expiratory times. The use of PEEP is controversial.

Research Concepts:

Status Asthmaticus

Page 563 of 955

Question 595: A 55-year-old male presents to the emergency department with low-grade
fever, headache, runny nose, and a cough. He is a farmer by profession and does not have
any comorbidities. Physical examination reveals bilateral end-inspiratory rales at the lung
bases. Chest x-ray shows diffuse bilateral interstitial opacities. Total serum IgE is 150
IU/mL. Mantoux test reading is 5 mm, and a skin test for Valley fever is negative. What is
the most likely cause of his illness?

Choices:

1. Mycobacterium tuberculosis
2. Aspergillosis
3. Coccidioidomycosis
4. Thermoactinomyces

Answer: 4 - Thermoactinomyces

Explanations:

Thermoactinomyces can cause pulmonary or systemic reactions from inhaling dust

from moldy straw or hay, especially in those who are hypersensitive to dust antigens.
This is most commonly secondary to Thermoactinomyces vulgaris or
Micromonospora faeni. Foreign substances such as dust, mold, or gasses can cause
hypersensitivity pneumonitis. Symptoms generally resolve if exposure to the
allergen is avoided. Occupational change may be necessary.
The patient is having low-grade fever, but a Mantoux test reading is 5 mm, which
suggestive of negative, so tuberculosis is ruled out from diagnosis. Also, skin test
for Valley fever (coccidioidomycosis) is negative, so it is also ruled out from
diagnosis. Total serum IgE is 150 IU/mL. If it is >1000 IU/mL, then aspergillus
infection should be considered.
Research Concepts: Hypersensitivity
Pneumonitis

Question 596: A 65-year-old patient with a right upper lobe carcinoma in situ, metastasis
to the right hilar region, and distant metastasis to the vertebral body. What stage of
cancer does this case have?

Choices:

1. TisN1M1
2. T2N0M0
3. T3N1M1
Page 564 of 955
4. T4N2M1

Answer: 1 - TisN1M1

Explanations:

A TisN1M1 indicates that the lung carcinoma is in situ, has metastasis to the lymph
nodes in the peribronchial or the ipsilateral hilar region, and has distant metastasis.
This patient has stage IV cancer with metastases.
The five-year survival rate for stage IV lung cancer patients is less than 5%.
Although newer biological drugs are available, these agents are prohibitively
expensive and only increase survival by a few months. The toxicity of these agents
is significant, and therapy should be used with caution.

Research Concepts:

Lung Cancer

Question 597: A 65-year-old woman of Asian descent presents for fatigue, cough, and
10-kilogram weight loss over the past three months. She also reports intermittent
hemoptysis. On examination, there is decreased chest expansion on the right side. A
chest x-ray shows an irregular mass of increased attenuation in the right upper lobe. An
image-guided biopsy is performed, and the specimen is sent for histopathology and
molecular analysis. Molecular analysis for epidermal growth factor receptor (EGFR)
mutation is positive.
What is the most likely diagnosis?

Choices:

1. Nonmucinous adenocarcinoma
2. Keratinizing squamous cell carcinoma
3. Sarcomatoid carcinoma
4. Small cell carcinoma
Answer: 1 - Nonmucinous adenocarcinoma

Explanations:

The most likely diagnosis in this patient is nonmucinous adenocarcinoma. A female

patient of Asian descent with a positive EGFR mutation is strongly suggestive of
Page 565 of 955
 adenocarcinoma.
Adenocarcinoma is the most common histologic subtype of non- small cell lung
cancer (NSCLC). It is also the most common cancer in women and nonsmokers.
Classic histochemical markers include napsin A, cytokeratin-7, and thyroid
transcription factor-1.
EGFR mutations have a higher prevalence in patients of Asian descent (up to 62%).
The presence of an EGFR mutation confers a favorable prognosis in patients with
advanced NSCLC.
Atezolizumab can be used in patients who express EGFR and ALK mutations and fail
targeted therapy.

Research Concepts:

Lung Cancer

Question 598: A 65-year-old male presents with complaints of worsening of shortness of

breath and cough for three days. He reports that he has been having these symptoms for
6 months but since he has returned from an adventuresome trip to Battambang bat
caves, his symptoms have aggravated. He has three parrots and two cats. He runs a
bakery of his own. His tobacco use is 30-pack- years. On examination, the blood pressure
is 130/80 mmHg, pulse 89/min regular, respiratory rate 22/min and oxygen saturation on
room air is 89%. On auscultation of the chest, you find rales all over. Pulmonary is
involved, the patient undergoes bronchoscopy, and dimorphic budding yeast is identified
on microscopy. Which of the following risk factors is associated with the development of
this disease?

Choices:

1. Living in Arizona
2. Having cats for pets
3. Living near the Ohio river valley
4. Working in an infectious disease hospital

Answer: 3 - Living near the Ohio river valley

Explanations:

Histoplasmosis is caused by inhaling the microconidia of Histoplasma spp. fungus

Page 566 of 955
 into the lungs. The mycelial phase is present at ambient temperature in the
environment, and upon exposure to 37 C such as in a host’s lungs, it changes into
budding yeast cells. This transition is an important determinant in the
establishment of infection.
Inhalation from the soil is a major route of transmission leading to infection.
Histoplasma is endemic to the Ohio and Mississippi River regions of the United
States.
Human-to-human transmission has not been reported. Infected individuals may
harbor many yeast forming colonies chronically which remain viable for years after
initial inoculation. The finding that individuals who have moved or traveled from
endemic to non-endemic areas may exhibit a reactivated infection after many
months to years supports this long-term viability.
There is also a strong association with exposure to bird and bat feces with
Histoplasmosis.

Research Concepts:

Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough

Question 599: A 66-year-old woman presents to the clinic for a routine follow-up. She got
admitted to the hospital for COVID-19 pneumonia requiring intubation and prolonged
hospital stay. She was discharged to acute rehab. Now she is doing near to her baseline.
Her medical history is significant for coronary artery disease, atrial fibrillation,
hypothyroidism, hypertension, anxiety, insomnia, and restless leg syndrome. She
currently takes aspirin, metoprolol, atorvastatin, amiodarone, warfarin, levothyroxine,
amlodipine, melatonin, and ropinirole. On examination, she appears in no distress, and
her vital signs are within normal limits. She has a normal examination. Her TSH is 2.5
mIU/L, and the last echocardiogram showed an ejection fraction of 55%. EKG shows rate-
controlled atrial fibrillation. She is up to date on her vaccinations and cancer screening.
Which of the following is the next best step in the management of this patient?

Choices:

1. Six-minute walk test

2. Mini-Mental status exam
3. Patient health questionnaire -9 ( PHQ-9)
4. Serum vitamin B12 and folic acid levels
Answer: 3 - Patient health questionnaire -9 ( PHQ-9)

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Explanations:

Post COVID-19 recovered patients should be screened for common

psychological issues such as anxiety, depression, insomnia, PTSD in follow-up
office visits regularly.
The PHQ-9 is the depression module has nine DSM-IV criteria scored from 0-3 (not
at all – nearly every day). It is widely used in primary care.
Though it is not a screening tool for depression, it is commonly used to monitor
depression symptoms and response to treatment. It is used to make a tentative
diagnosis of depression in at-risk populations - e.g., recently discharged patients
with stroke, CAD, CABG and ICU stay.
Checking B12 and folic acid levels is needed to rule out organic and reversible causes
of depression, but these tests should be performed after PHQ-9.
Research Concepts:Post Acute Coronavirus (COVID-19) Syndrome

Question 600: A 16-year-old boy complains of dry cough form 1 week. The cough is
persistent, indolent and associated with mild fever. His chest x-ray shows bilateral
pulmonary infiltrates. What is the most common cause of this type of pneumonia in a
young male?

Choices:

1. Klebsiella pneumoniae
2. Mycoplasma pneumonia
3. Chlamydia psittaci
4. Staphylococcus aureus
Answer: 2 - Mycoplasma pneumonia

Explanations:

A young patient with persistent dry cough and mild fever with supportive chest x-ray
has atypical pneumonia.
Atypical pneumonia is caused by some different types of bacteria that are
generally not cultured on standard media. "Atypical" pneumonia mostly caused by
Legionella spp, Mycoplasma pneumoniae, C. pneumoniae, and Chlamydia psittaci.
M. pneumoniae is one of the most common causes of "atypical" pneumonia in
series from the United States and other parts of the world. Mycoplasma infection
can occur at any age, but infection rates are highest among school-aged children,
military recruits, and college students.

Research Concepts:Bacterial Pneumonia

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Section 7

Question 601: A patient presents with progressive shortness of breath and repeated
bouts of hemoptysis. Both chest X-rays and a CT scan of the chest do not reveal any
significant lesions, and bronchoscopy is negative. What test is used to make his
diagnosis?

Choices:

1. Angiography
2. Echocardiogram
3. MRI
4. Nuclear scan
Answer: 2 - Echocardiogram

Explanations:

The symptoms are caused by mitral stenosis.

It is important to know that there are many causes of hemoptysis. If the lungs are
normal, one should consider myocardial pathology.
The cause of hemoptysis may be pulmonary vein and bronchial vein connections of
fistulas. Hemoptysis can be frightening but is not life-threatening in most cases.
The patient should be admitted and undergo a cardiac catheterization followed by
surgery.

Research Concepts:

Mitral Stenosis

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Question 602: A 15-year-old boy (weighing 50 kg) is admitted to the intensive care unit
for acute respiratory failure secondary to bacterial pneumonia. Two days into his hospital
stay, his hypoxemia worsens, and he is subsequently cannulated on venovenous ECMO
using internal jugular and femoral veins. His ventilator settings include respiratory rate
20/min, tidal volume 300 mL, PEEP 5 cmH2O, and FiO2 40%. The oxygen saturation of the
blood entering
the oxygenator is 90%, and the oxygen saturation leaving the oxygenator is 100%. The
oxygen saturation in the venous blood in the superior vena cava is 65%, and the patient’s
current arterial oxygen saturation is 85%. His ECMO flow is at 3.5 L/min with a cardiac
output of 6 L/min. The FiO2 at the membrane is 100%.
Which of the following is the next best step in the management of this patient?

Choices:

1. Increase the ventilator settings to a PEEP of 10 cmH2O and increase the FiO2
to 80%
2. Repositioning of the venous cannulae
3. Change the oxygenator
4. Increase the ECMO pump flow
Answer: 2 - Repositioning of the venous cannulae

Explanations:

Recirculation is a phenomenon exclusive to venovenous ECMO, in which reinfused

oxygenated blood is withdrawn through the drainage cannula without passing
through the systemic circulation.
The problem of recirculation is usually diagnosed when there are low patient
oxygen saturation and high pre-oxygenator saturations and can be identified by
the proximity of the drainage and the reinfusion cannulae on x-ray.
Increasing the pump flow might improve the oxygen saturations but will eventually
increase recirculation and cause further hypoxemia.
The oxygenator is working fine as the blood leaving the oxygenator is 100%, so it is
not a problem with the oxygenator.

Research Concepts:

Extracorporeal Membrane Oxygenation In Children

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Question 603: A 67-year-old woman presents to the clinic with excessive daytime
sleepiness and early morning headaches for the past two years. She states that she is eager
to lose weight but cannot exercise because she quickly becomes tired. Her past medical
history is significant for type 2 diabetes mellitus and hypercholesterolemia. She has been
told that she snores during her sleep. She denies depression, anhedonia, lack of
concentration, and suicidal ideation. Her current medications include vitamins and
supplements. Physical examination reveals she is afebrile, heart rate is 80/min, blood
pressure 130/80 mmHg, respiratory rate 12/min, and SpO2 97% on room air. Her body
mass index is 35 kg/m2, and her neck size is 18 inches (46 cm). The oral exam shows a
crowded oropharynx and enlarged tonsils. Cardiovascular and pulmonary examinations are
normal. If her condition is untreated, which of the following is the most likely
complication?

Choices:

1. Memory loss
2. Chronic respiratory failure
3. Systemic hypertension
4. Valvular heart disease
Answer: 3 - Systemic hypertension

Explanations:

Obstructive sleep apnea (OSA) is associated with a wide range of complications if

untreated.
The most common cardiovascular complications include systemic hypertension,
coronary artery disease, heart failure, cardiac arrhythmias, and stroke.
It is also associated with type 2 diabetes mellitus, metabolic syndrome, and
nonalcoholic fatty liver disease.
Pulmonary hypertension and right heart failure are less commonly associated with
OSA. Chronic respiratory failure is not a known consequence of sleep apnea. While
memory loss has been associated with long-term untreated OSA, hypertension is
more commonly associated with untreated OSA in population studies.

Research Concepts:

Sleep Apnea Syndrome

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Question 604: A 74-year-old man with idiopathic pulmonary fibrosis is hospitalized for
shortness of breath and hypoxia. After a detailed discussion with the patient regarding
goals of care, the patient places a do not resuscitate, and a do not intubate order. He
wants his son to visit him and requests a temporary measure to keep him alive for the next
three days. A decision to start oxygen supplementation via high-flow nasal cannula is
taken. Which of the following measures is most appropriate to help ensure the comfort of
this patient during this treatment?

Choices:

1. Maintain the lowest amount of flow while maximizing oxygen to maintain comfort
2. Maintain the lowest amount of oxygen while maximizing flow to maintain comfort
3. Maintain the lowest amount of oxygen as well as the flow needed to keep the patient
comfortable
4. Deliver heated and humidified oxygen via a high-flow nasal cannula
Answer: 4 - Deliver heated and humidified oxygen via a high-flow nasal cannula

Explanations:

High-flow nasal cannula (HFNC) therapy is an oxygen supply system capable of

delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 liters
per minute.
All settings are controlled independently, allowing for greater confidence in delivering
supplemental oxygen and better outcomes when used.
Heating and humidifying the oxygen relays better comfort and prevents drying of the
nasal mucosa. The temperature of the heated air should be based on feedback from
the patient, and adjustments should be made accordingly.
Humidification also avoids skin breaks and damage to the nasal mucosa. In addition,
it avoids the formation of painful crusts that can lead to sneezing, discomfort, and
epistaxis.

Research Concepts:

End Of Life Evaluation And Management Of Pain

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Question 605: A 17-year-old female patient presents to the emergency department with
headache, nausea, and dizziness. Her roommate is also in the emergency department for
similar symptoms but resolved after leaving home. On exam, the patient's heart rate is 90
beats per minute, and she is maintaining a saturation of 100% on the room air. Except for
mild confusion, her neurological examination has no abnormalities. Blood testing confirms
her diagnosis, and she improves with oxygen. At which concentration of the offending
agent do visual symptoms occur?

Choices:

1. 10 percent
2. 20 percent
3. 30 percent
4. 60 percent

Answer: 3 - 30 percent

Explanations:

A carboxyhemoglobin level of 30 percent produces visual disturbance.

Carboxyhemoglobin (COHb) forms when carbon monoxide binds to hemoglobin,
and it may be physiologic or pathologic. It forms when protoporphyrin breaks
down to bilirubin during hemolysis or in carbon monoxide and methylene chloride
poisoning. Methylene chloride metabolizes into carbon monoxide following
inhalation, ingestion, or dermal contact.
The reference range of COHb in nonsmokers is 3% and up to 15% in smokers.
It is important to note whether a patient is taking phenobarbital, phenytoin, or
progesterone because they can increase carbon monoxide production.

Research Concepts: Carboxyhemoglobin

Toxicity

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Question 606: A 54-year-old man presents with a ten-day history of dry cough,
intermittent mild fever, and generalized malaise. He has no significant past medical
history and does not smoke. He reports a recent vacation exploring caves three weeks
ago. Physical examination, including vital signs, is unremarkable except for a low- grade
fever. Chest x-ray demonstrates right-sided hilar lymphadenopathy with a patchy right
upper lobe infiltrate.
Immunodiffusion testing for the suspected diagnosis reveals a detectable M-band and H-
band. Which of the following would be an indication for antimicrobial treatment in this
patient?

Choices:

1. If he develops evidence of mediastinal fibrosis

2. If he develops broncholithiasis
3. If he develops a chronic cavitary lesion
4. Antimicrobial therapy is indicated now and should be started as soon as possible
Answer: 3 - If he develops a chronic cavitary lesion

Explanations:

Most patients with histoplasmosis are asymptomatic and have mild disease.
Treatment for mild histoplasmosis is not indicated unless the symptoms persist for
more than four weeks.
Treatment is indicated for all patients with histoplasmosis who develop chronic
infection with a chronic cavitary lesion. Chronic histoplasmosis results in
progressive loss of pulmonary function in most patients and has a high mortality.
The treatment of choice is itraconazole given as a loading dose of 200 mg orally
three times daily for the first three days, then a maintenance dose once daily for at
least one year.
Broncholithiasis and mediastinal fibrosis are chronic sequelae of histoplasmosis but
are thought to be manifestations of resolving infection and are not an indication for
antimicrobial therapy.
Symptomatic treatment with bronchoscopy to remove broncholiths or stenting of
obstructed vessels with mediastinal fibrosis is the general approach for patients
who develop these complications.

Research Concepts: Histoplasmosis

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Question 607: A 72-year-old woman with a history of dementia is scheduled for elective
abdominal hernia repair. She has a history of anaphylaxis to penicillin. She takes
alprazolam for insomnia at night. The patient was given alprazolam at 11 pm night prior to
surgery by mistake by nursing home staff even after giving NPO order. The patient is
somnolent. The patient is asked to open her mouth. The anesthetist cannot see the soft
palate. He thinks that the patient is not following command because of her mentation, so
he asks the patient again to open mouth as wide as possible. Now he can see soft palate
and base of uvula. Which of the following puts her at the highest risk for difficult
intubation?

Choices:

1. Her mentation
2. Administration alprazolam night prior to surgery
3. Visualization of only soft palate and uvula
4. Dementia

Answer: 3 - Visualization of only soft palate and uvula

Explanations:

Mallampati scoring is used to anticipate difficulty in intubation. Mallampati Class I:

Structures visualized- soft palate, uvula, fauces, anterior, and posterior pillars.
Mallampati Class II: Structures visualized- soft palate fauces and uvula. Mallampati
Class III: Structures visualized- soft palate and the base of the uvula. Mallampati Class
IV: Soft palate is not visible.
Mallampati scoring is done in a sitting position with the mouth as wide as possible. It
does not include the patient's mentation in difficult airway classification.
Class I is the easiest intubation, and Class IV is the most difficult intubation.

Research Concepts:

3-3-2 Rule

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Question 608: A 17-year-old man with no comorbidities is brought to the emergency
department with a history of a fall from the balcony of the second floor of his house while
posing for a selfie. On examination, his pulse rate is 60/minute, blood pressure 110/80
mmHg, respiratory rate 16/minute, and oxygen saturation is 98%.
His airway is clear, and air entry is bilaterally equal in all lung fields. His Glasgow Coma
Scale (GCS) score is E4V5M6, and pupils are bilaterally 3 mm in size and reacting to light.
He has grade 3 power in both lower limbs with a sensory level at T10. A chest X-ray taken
shows apparent lung parenchyma. A magnetic resonance imaging scan of the spine is
taken, which shows a compression fracture at T12 with cord contusion. He is admitted to
the spine unit. Three hours later, the patient develops tachypnea (respiratory rate of
30/minute), while GCS score and pupils remain the same. Within 2 minutes, his
saturation drops down to 80%, and he has to be intubated and ventilated. On chest
auscultation, there are bilateral basal crackles. A chest X-ray shows bilateral hyperdense
infiltrates in the lung parenchyma. Which of the following pathophysiological
mechanisms can be part of the cause of his clinical deterioration?

Choices:

1. Pulmonary venule adrenergic hypersensitivity

2. Pulmonary arteriole adrenergic hypersensitivity
3. Pulmonary venule noradrenergic hypersensitivity
4. Pulmonary arteriole noradrenergic hypersensitivity
Answer: 1 - Pulmonary venule adrenergic hypersensitivity

Explanations:

Neurogenic pulmonary edema is a very rare disorder that develops after a neurological
injury. It is usually a diagnosis of exclusion.
Following an injury to the brain or spinal cord, the massive sympathetic discharge directly
affects the pulmonary vascular bed. This can be followed by pulmonary edema, regardless
of any systemic changes. This is usually due to the adrenergic hypersensitivity of pulmonary
venules. the cause of neurogenic pulmonary edema is multifactorial, involving interaction
between the CNS, autonomic nervous system, and the cardiopulmonary system.
Patients with a traumatic head injury, spine injury, status epilepticus, and subarachnoid
hemorrhage are often known to develop neurogenic pulmonary edema.
The symptoms are sudden, with dyspnea and mild hemoptysis being the common features.

Research Concepts: Neurogenic Pulmonary Edema

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Question 609: A 45-year-old man presents with a six-week history of cough with
occasional streaks of blood. He also reports a low-grade fever and 14 pound (6.4 kg)
weight loss during the same period. He has no significant past medical history, and he
recently immigrated from South Asia. Vitals are temperature 99°F (37.2°C), pulse 90 beats
per minute, respirations 21 breaths per minute, and blood pressure 90/50 mmHg.
Examination of the respiratory system reveals coarse crackles in the left upper zone.
Blood work shows a white blood cell count of 5000 per microL, erythrocyte
sedimentation rate of 50 mm per hour, and serum creatinine of 0.7 mg/dl. A purified
protein derivative test shows an induration of 17 mm. Chest x-ray reveals reticulonodular
shadowing in the left upper zone. Sputum examination confirms the diagnosis, and he is
started on appropriate treatment. He presents two weeks later, stating his cough and
fever have resolved, but he has developed oral ulcers, joint pain, and a rash on his
cheeks. Which of the following is the most likely cause of the new symptoms?

Choices:

1. Drug allergy to antitubercular therapy

2. Tuberculosis-immune reconstitution inflammatory syndrome (TB- IRIS)
3. Cutaneous tuberculosis
4. Drug-induced lupus
Answer: 4 - Drug-induced lupus

Explanations:

This patient recently immigrated from South Asia and presents with symptoms of
chronic cough, weight loss, and hemoptysis. His cavitary pneumonia and a positive
Mantoux test confirm the diagnosis of pulmonary tuberculosis. The standard
regimen is an intensive phase with four drugs, followed by maintenance with two
drugs. This individual has likely developed drug- induced lupus caused by isoniazid.
Drug-induced lupus is characterized by the development of mucosal ulcers,
arthralgias, malar rash, photosensitivity, and hematological abnormalities. It is
diagnosed by elevated antinuclear antibodies and, more specifically, positive anti-
histone antibodies.
It is theorized that slow acetylators are predisposed to the development of drug-
induced lupus erythematosus. Antibodies are traditionally directed against the
H2A-H2B dimer complex. Withdrawal of the offending agent leading to resolution
of symptoms clinches the diagnosis.

Research Concepts: Tuberculosis

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Question 610: A 16-year-old boy presents to the emergency department with fever and
breathing difficulty for 3 days. He recently returned from a trip to New Mexico for a music
festival, where he had stayed in a run-down motel. He remembers seeing rats and rat
dropping in his motel room. Clinical examination shows a heart rate of 105/min,
respiratory rate of 25/min, blood pressure of 100/70 mmHg, and temperature of 102 F
(38.8 C). Respiratory examination reveals bilateral crackles. Examination of the other
systems is unremarkable. Investigations show a WBC count of 13000 cells/microL, platelet
count of 90,000 cells/microL, CRP of 56 mg/dL, ALT of 89 U/L, and an ESR of 32 mm/h. A
chest radiograph shows bilateral hazy infiltrations. The diagnosis is confirmed with a
positive viral IgM, and the Infectious diseases team feels that he acquired it from
exposure to the rat feces. Which of the following is true about this disease?

Choices:

1. It has a high person to person transmission rate

2. It has been identified in more than half the states in the United States
3. Healthy individuals have a low risk of death
4. Ribavirin showed an improvement in survival

Answer: 2 - It has been identified in more than half the states in the United States

Explanations:

This patient has Hantavirus syndrome, most likely caused by the Sin Nombre virus.
The transmission is via contact with infected mouse bodily fluids, and there is no
case in the U.S. where infection from an infected human has been documented.
While many cases have been clustered in the four corners area, the CDC had
confirmed 217 cases in 30 different states by 1999.
Mortality is as high as 50 to 70%.
Treatment is generally supportive with no specific drug found to be effective.
Research Concepts:

Hantavirus Cardiopulmonary Syndrome

Question 611: A 65-year-old male patient presents to the hospital with shortness of
breath that has gradually worsened over a period of one year. A chest x-ray shows the
prominence of the pulmonary vasculature. On auscultation, there is loud P2. The
provider says that the open-heart surgery will be safer if the patient is prescribed
sildenafil citrate for about six to eight weeks. What is the most likely diagnosis?

Choices:
Page 578 of 955
1. Mitral stenosis
2. Aortic stenosis
3. Coarctation of aorta
4. Hypertrophic cardiomyopathy
Answer: 1 - Mitral stenosis

Explanations:

Pulmonary hypertension is often a late complication of mitral stenosis. It occurs as

a result of pulmonary artery vasoconstriction, interstitial edema, and elevated left
atrial pressure.
The elevated pulmonary arterial pressure can cause right ventricular dilatation, and
tricuspid regurgitation, which in turn can lead to, elevated jugular venous pressure,
liver congestion, ascites, and pedal edema.
In the past decade, many studies have shown that the administration of sildenafil
for a few months can reduce pulmonary artery pressure and make surgery safer.
Pulmonary hypertension is a progressive disease with treatment focused on the
management of symptoms and treatment of underlying diseases.
Research Concepts:

Pulmonary Hypertension

Question 612: A 58-year-old male presents with a history of a dry cough and hemoptysis.
Vital signs are stable and the patient is afebrile. Physical exam reveals mild wheezing. A
chest x-ray reveals a central mass without distant metastases. What is the most likely
cause of the patient's condition?

Choices:

1. Squamous cell carcinoma

2. Adenocarcinoma
3. Small cell carcinoma
4. Large cell carcinoma
Answer: 1 - Squamous cell carcinoma

Explanations:

Squamous cell lung cancer is most likely to present as a large, central mass without
distant metastases.

Page 579 of 955

 About 30% of all lung cancers are squamous cell carcinoma (SCC) and centrally
located. They may be associated with hypercalcemia.
Centrally located tumors may present with a dry cough, hemoptysis, wheezing, or
post-obstructive pneumonia. Bronchoscopy is invaluable in the diagnosis of SCC. SCC
tends to be locally invasive and positive lymph nodes are common.
Hence, a CT scan of the chest is mandatory during work up to assess for mediastinal
nodes.

Research Concepts:

Squamous Cell Lung Cancer

Question 613: A 42-year-old woman with no significant past medical history is scheduled
for elective repair of a femoral hernia. A newly trained anesthetist on duty attempts
intubation for airway protection during surgery. He used fentanyl 100 micrograms
intravenous for sedation during the first attempt at 8:00 am. The patient coughs when
attempting intubation, so he removes the laryngoscope. After the first failed attempt, he
uses midazolam 5 mg intravenous for sedation and attempts intubation. Again he fails to
intubate the patient. The pulse oximeter shows a reading of 85%, so the patient is placed
on bag and mask ventilation for about 5 minutes. Now, the pulse oximeter shows a
reading of 99%. The patient is given 42 mg of intravenous rocuronium and propofol, and
she is successfully intubated on the third attempt at 8:15 am. Which of the following best
defines difficult intubation according to the American Society of Anesthesiology?

Choices:

1. More than one intubation attempt

2. Time for intubation longer than 10 minutes
3. Use of etomidate during intubation
4. Need of bag and mask ventilation between intubation attempts
Answer: 2 - Time for intubation longer than 10 minutes

Explanations:

According to the American Society of Anesthesiologists, intubation is considered

difficult when an appropriately trained and experienced anesthesiologist requires
more than three attempts or longer than 10 minutes for successful endotracheal
intubation.
Midazolam (benzodiazepine), fentanyl (opioid), and rocuronium (nondepolarizing
Page 580 of 955
 neuromuscular blocker) are commonly used medications before intubation to achieve
sedation. The use of these medications does not define difficult intubation.
LEMON (Look, Evaluate, Mallampati Scoring, Obstruction, and Neck mobility) score is
an important tool to assess the airway before intubation.
This patient had hypoxia and successful intubation on the third attempt most likely
because a LEMON score was not calculated, and the team was unprepared for a
difficult airway.

Research Concepts:

3-3-2 Rule

Question 614: A 21-year-old female patient presents with complaints of a non-productive

cough for the past two months. She states that the cough usually worsens at night and
that she recently recovered from an upper respiratory tract infection. She does not use
tobacco or drink alcohol. She is sexually active and uses condoms consistently. She has no
medical problems and does not take any medications. Her vital signs show a blood
pressure of 125/75 mmHg, a heart rate of 83 beats per minute, a respiratory rate of 15
breaths per minute, and a temperature of 37 C (98.6 F). The lungs are clear to auscultation
bilaterally. A chest x-ray is unremarkable. What is the most appropriate management
option for this patient?

Choices:

1. First-generation oral antihistamine

2. Second-generation oral antihistamine
3. Oral corticosteroids
4. Oral corticosteroids with antihistamines
Answer: 1 - First-generation oral antihistamine

Explanations:

This patient has a chronic cough, and the most likely cause is an upper airway
cough syndrome, given the patient's history of an upper respiratory tract infection.
Upper airway cough syndrome includes all nasopharyngeal conditions (including
allergic rhinitis, rhinosinusitis, and laryngopharyngitis) that may be associated with
post-nasal drip and subtle irritation along with secretions in the back of the throat
and the upper airways that present with a cough as the only symptom.
Throat examination may reveal signs of pharyngitis and cobblestone appearance.
These conditions can be silent (no symptoms besides a cough) in up to 20% of cases.
It is best managed by first-generation oral antihistamines such as chlorpheniramine.
Page 581 of 955
 The diagnosis of silent upper airway cough syndrome can reliably be made only after
patients show significant improvement with prescribed treatment.

Research Concepts:

Chronic Cough

Question 615: A 60-year-old male presents with severe dyspnea on exertion. He has a 45-
pack-year history of smoking. He has a long history of cough and shortness of breath, and
currently, he is oxygen-dependent on 4 L and still smokes one pack per day. His
pulmonary function tests demonstrate forced expiratory volume in one second (FEV1)
20% and diffusing capacity for carbon monoxide (DLCO) 20%. His 6-minute walk distance
is 140 m, and he requires 6 L/min of oxygen to maintain saturations greater than 90%
during exercise. On high-resolution computed tomography (CT) imaging of the chest, he
has homogenous emphysema. Which is the most likely outcome of lung volume reduction
surgery (LVRS) in this patient?

Choices:

1. Improvement in exercise tolerance, improved quality of life, and improved overall

mortality
2. Equivalent mortality compared to medical therapy
3. Increased exercise tolerance
4. Increased mortality compared to medical therapy
Answer: 4 - Increased mortality compared to medical therapy

Explanations:

Lung volume reduction surgery (LVRS) is considered for patients with chronic
obstructive pulmonary disease (COPD) or severe emphysema. A large,
collaborative, multicenter, randomized control trial for LVRS, known as the
national emphysema treatment trial (NETT), was published in 2003 to assess the
effectiveness of LVRS on quality of life and survival advantage compared to
available medical therapy.
The national emphysema treatment trial (NETT) identified a high-risk subgroup
of lung volume reduction surgery (LVRS) patients with increased 30-day
mortality compared to medical therapy. These patients had FEV1 20%, DLCO
20%, or high- resolution CT showing homogenous emphysema.
In the national emphysema treatment trial (NETT), patients with non-upper-lobe
Page 582 of 955
 emphysema with poor exercise capacity had similar survival in both groups.
Patients with upper-lobe emphysema and poor exercise capacity had lower
mortality after lung volume reduction surgery (LVRS) than medical therapy alone.
In the national emphysema treatment trial (NETT), patients with upper-lobe
emphysema and good exercise capacity had no difference in survival between
medical treatment and lung volume reduction surgery (LVRS).
Research Concepts: Lung Volume Reduction Surgery

Question 616: A 35-year-old woman with a 10-year history of asthma presents for the
evaluation of ongoing cough. The asthma had been well controlled until one year ago
when she began having frequent exacerbations and ongoing symptoms of cough with
shortness of breath that has limited her activity. Her cough is occasionally productive of
brown sputum. She is compliant with her medications, does not smoke, and denies fever,
chills, or weight loss. Her vital signs are within normal limits, and there is no wheezing on
pulmonary examination. Chest x-ray shows linear atelectasis and evidence of dilated and
thickened airways. Perihilar opacities are also noted. Which of the following is the best
next step in the evaluation of this patient?

Choices:

1. Serum galactomannan level

2. Aspergillus fumigatus-specific IgE level
3. Antineutrophil cytoplasmic antibody level
4. Peripheral blood eosinophil count
Answer: 2 - Aspergillus fumigatus-specific IgE level

Explanations:

This patient is most likely suffering from allergic bronchopulmonary aspergillosis

(ABPA). Aspergillus fumigatus specific IgE is the most sensitive test in the diagnosis
of ABPA. Aspergillus skin test (AST) and aspergillus fumigatus specific IgE levels are
the investigations most commonly used for diagnosing sensitization to Aspergillus
fumigatus.
The diagnosis of ABPA requires aspergillus skin test positivity or detectable IgE levels
against Aspergillus fumigatus plus an elevated total serum IgE concentration and a
predisposing condition, such as asthma or cystic fibrosis. Supportive findings include
radiographs typical of ABPA and a total eosinophil count greater than 500
cells/microL.
Typically the total serum IgE concentration is greater than 1000 IU/mL. However, if
a patient meets all other criteria for ABPA, they may be diagnosed with ABPA even
if the serum IgE concentration is less than 1000 IU/mL.
Page 583 of 955
 Serum galactomannan is nonspecific and is not useful in the identification of ABPA.

Research Concepts:

Allergic Bronchopulmonary Aspergillosis

Question 617: A 48-year-old male presents to the emergency department for worsening
shortness of breath. He has a small bore (indwelling pleural catheter) chest tube. The
patient states that the tube was placed several months ago by a specialist to assist with
complications from their lymphoma. What is the best initial step in the management of
this patient?

Choices:

1. Tube irrigation with cold sterile saline

2. Place an order to observe neutropenic precautions
3. Chemically decontaminate the chest tube port
4. Chest tube removal and chest computed tomography (CT) scan
Answer: 2 - Place an order to observe neutropenic precautions

Explanations:

Long-term small-bore (indwelling pleural catheter) chest tubes are often left in
place for patients who chronically accumulate malignant pleural effusions. Consider
that this patient may have had recent chemotherapy and consider neutropenic
precautions until confirmed with the patient's oncologist.
A history from the patient to find out more about why the small- bore catheter was
placed should be obtained. Contacting the specialist to discuss the patient's
condition should be considered.
Care and maintenance of the long-term medical appliance are likely best managed
by the patient, who has probably received extensive education and training from
a home health nurse.
With patients suffering malignant pleural effusion, fluid removal is palliative and
not curative.

Research Concepts:

Care Of A Chest Tube

Page 584 of 955
Question 618: A 45-year-old male underwent lung transplantation due to severe chronic
obstructive pulmonary disease (COPD). This was done at the advice of his clinicians, who
deemed that he could no longer have a "normal" life if he did not opt for lung transplant
surgery. A few months later, the patient developed generalized weakness and complained
of losing a significant amount of weight. The complete blood count revealed anemia and
thrombocytopenia. Ultrasound abdomen showed hepatosplenomegaly. On examination,
enlarged lymph nodes were found. Which of the following pathogens is most commonly
associated with developing this post-lung-transplant disorder?

Choices:

1. Cytomegalovirus
2. Epstein-Barr virus
3. Adenovirus
4. Hepatitis C virus
Answer: 2 - Epstein-Barr virus

Explanations:

The Epstein-Barr virus is associated with post-lung-transplant lymphomas.

Post-lung-transplant lymphoproliferative disorder (PTLD) is one of the most
frequent post-transplant malignancies.
The risk of PTLD is directly proportional to the intensity and duration of the
immunosuppression used for the transplant. Cytomegalovirus is associated with post-
lung transplantation syndrome but is not associated with post-lung transplant
lymphoproliferative disorder.

Research Concepts: Lymphoproliferative Disorders

\

Page 585 of 955

Question 619: A 33-year-old male presents to the emergency department for a cough,
persistent vomiting, and back pain of 1- month duration, which acutely worsened,
including new-onset encephalopathy three hours ago. While in triage, the patient had a
syncopal episode but regained consciousness shortly afterward. The patient denied oral
intake due to nausea and vomiting. He is a hotel chef who recently immigrated from
Argentina and is currently living in temporary shelters with his family. His vitals show a
blood pressure of 80/52 mmHg, a heart rate of 100 beats per minute, a respiratory rate of
17 breaths per minute, and oxygen saturation of 98% on room air. On physical
examination, the patient was clinically dehydrated and was noted to have a mild degree
of skin pigmentation. A computed tomography (CT) scan of the chest revealed multiple
cavitations in the upper lobe. His abdominal CT scan showed evidence of bilateral adrenal
cortex fibrosis from chronic infection. Laboratory investigations reveal sodium 133 mEq/L,
potassium 3.1 mEq/L, glucose 91 mEq/L. His serum cortisol levels are low, and the
adrenocorticotropic hormone is high. The patient was admitted for observation and
treatment. What is the most likely infectious etiology underlying this patient's condition?

Choices:

1. Mycobacterium tuberculosis
2. Pneumocystis jirovecii
3. Mycobacterium avium
4. Ebstein-Barr virus
Answer: 1 - Mycobacterium tuberculosis
Explanations:

Worldwide, and particularly in the developing world, tuberculosis is the most

common etiology of infection-induced adrenal insufficiency. It leads to adrenal
insufficiency by infecting the gland, leading to chronic inflammation, fibrosis, and
eventual destruction of the adrenal cortex.
A CT scan of the abdomen may show calcification of the adrenals, as seen with
adrenal tuberculosis.
Consider adrenal tuberculosis in patients who recently immigrated to the USA
from an endemic area, who are immunocompromised, recently released from jail,
or homeless. After stabilization, the patient will need to be tested for tuberculosis
with a tuberculin skin test.
Other infective etiologies may lead to an adrenal crisis; however, they are less likely to
cause pulmonary defects and are less common than tuberculosis.
Research Concepts: Addisonian Crisis

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Question 620: A 65-year-old man with tobacco use disorder presents with rigors and
cough. His temperature is 101.2 F (38.4 C), respiratory rate 32/min, heart rate 112 bpm,
oxygen saturation 90% on room air, and blood pressure 116/80 mmHg. He appears to be
in mild respiratory distress and is found to have crackles in the right lower lobe. Lab tests
show a WBC count of 15000/microliter with 10% bands, BUN of 30 mg/dL, and serum
creatinine of 1.5 mg/dL. A chest x-ray shows an infiltrate in the right lower lobe. He
denies recent hospitalization and has no risk factors for MRSA or Pseudomonas. What is
the most appropriate management?

Choices:

1. Admit to the medicine floor and treat with ceftriaxone and azithromycin
2. Discharge to home on levofloxacin
3. Admit to the ICU and treat with cefepime and metronidazole
4. Admit to the progressive care unit and treat with piperacillin- tazobactam and
vancomycin
Answer: 1 - Admit to the medicine floor and treat with ceftriaxone and azithromycin

Explanations:

This patient with community-acquired pneumonia needs to be admitted to the

hospital as his CURB-65 score is 3. The criteria include age 65 years or older,
confusion, BUN >19.6 mg/dL, respiratory rate >30/min, and systolic blood pressure 90
mmHg and diastolic 60 mmHg.
CURB-65 score estimates mortality, and this patient's age, respiratory rate, and
BUN meet the criteria. His score of 3 confers a 30-day mortality of 9.2%.
A score of 2 or more requires inpatient treatment, and he should be treated with a
beta-lactam and a macrolide or a respiratory quinolone.
The use of cefepime and metronidazole or piperacillin- tazobactam and vancomycin
are not indicated as the patient has not been recently hospitalized, nor does he
have risk factors for MRSA or Pseudomonas.

Research Concepts:

Community-Acquired Pneumonia

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Question 621: An adolescent with severe persistent asthma and perennial allergies is not
well controlled on step 5 asthma controller therapy. Which of the following medications
should be considered next to improve control?

Choices:

1. Montelukast
2. Theophylline
3. Zileuton
4. Omalizumab
Answer: 4 - Omalizumab

Explanations:

Omalizumab is a monoclonal anti-IgE antibody therapy aimed at treating the allergic

component of asthma.
Omalizumab is FDA approved for children ages 12 years and above with severe allergic
asthma who continue to do poorly despite receiving step 5 or 6 asthma controller
therapy.
Omalizumab is administered every 2 to 4 weeks by the subcutaneous route.
Omalizumab has a black box warning for potential anaphylaxis. Patients should be
advised to carry emergency self-treatment.
Research Concepts:

Omalizumab

Question 622: A 36-year-old male presents with a non- productive cough, dyspnea,
intermittent fevers, headache, and myalgias for the past two weeks. His other medical
problems include type II diabetes mellitus, for which he takes insulin. The patient is
severely allergic to glipizide. His family moved to the United States from Bangladesh
fifteen years ago. He has been sexually active with multiple female partners and uses
condoms inconsistently. His vital signs show a blood pressure of 110/70 mmHg, a heart
rate of 106 beats per minute, a temperature of 100 F (37.8 C), and a respiratory rate of 28
breaths per minute. The patient has labored and rapid breathing. Oropharyngeal
candidiasis and cervical lymphadenopathy are seen on general physical examination. A
chest radiograph reveals diffuse bilateral peri-hilar interstitial infiltrates. The patient is
admitted and is administered appropriate medications. However, he develops shortness
of breath suddenly after six hours. What medication could have caused this?

Choices:

Page 588 of 955

1. Dapsone
2. Pentamidine
3. Primaquine
4. Trimethoprim-sulfamethoxazole
Answer: 2 - Pentamidine

Explanations:

Pneumocystis jirovecii pneumonia (PCP) is a fungal infection that most commonly

affects the immunocompromised and, in some cases, can be severely life-
threatening. Typically, patients at risk are those with any underlying disease states
that alter host immunity, such as those with cancer, human immunodeficiency
virus (HIV), transplant recipients, or those taking immunosuppressive therapies and
medications.
This patient has pneumocystis pneumonia. PCP is considered an acquired
immunodeficiency syndrome (AIDS)-defining illness. This patient has all the risk
factors and symptoms of AIDS.
Treatment options for PCP include dapsone, atovaquone, primaquine, and
pentamidine. This patient is severely allergic to glipizide which is a sulfa drug and
hence trimethoprim- sulfamethoxazole cannot be given.
Pneumothorax is a common complication of PCP and this risk is increased with
pentamidine.

Research Concepts: Pneumocystis Jirovecii Pneumonia

Question 623: A 41-year-old female arrives at the emergency department (ED) with a
history of left eye decreased vision for the last seven days, but worst in the last two.
Visual acuity is 20/400 on the left eye with 20/20 on the right. She denies any recent
trauma, headache, nausea, or vomiting. Her past medical history is negative for systemic
disease, and she is not taking any medications. She told the examining physician that
seven years ago, she was treated for two weeks with corticosteroids for a chest X-ray,
which showed bilateral lung lesions. As the coughing improved and the lesions resolved by
a repeat study, the steroids were weaned and never had another similar episode. Which
laboratory workup is best indicated in this patient to exclude ocular disease involvement
causing compressive optic neuropathy?

Choices:

1. Antinuclear antibodies
2. Angiotensin-converting enzyme
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3. Anti-thyroid antibodies
4. Bone-specific alkaline phosphatase
Answer: 2 - Angiotensin-converting enzyme

Explanations:

If sarcoidosis is suspected, the angiotensin-converting enzyme may help as it is

elevated in 52%-90% of patients with active sarcoidosis.
Patients with compressive optic neuropathy usually present with chronic progressive
vision loss, but inflammatory conditions can have a more acute presentation.
Magnetic resonance imaging is the imaging modality of choice in compressive
optic neuropathy due to the fantabulous soft- tissue resolution of the anterior
visual pathway and parasellar area. Typically an orbit and brain magnetic
resonance imaging with and without contrast are ordered.
Corticosteroids might be useful in compressive optic neuropathy caused by
sarcoidosis and thyroid ophthalmopathy.

Research Concepts:

Compressive Optic Neuropathy

Question 624: A 35-year-old man presents with a seven-day history of intermittent fever
and a diffuse pruritic rash. For the past two days, he has had a troublesome cough and
two episodes of hemoptysis. He also reports difficulty breathing for the past day. He has
no significant past medical history, but he has smoked a pack of cigarettes daily for the
past twenty years. His blood pressure is 100/50 mmHg, pulse 105 beats per minute,
respiratory rate 26 breaths per minute, and temperature 100 F (37.8 C). His general
physical examination demonstrates a diffuse maculopapular rash with vesicles and
pustules. Dry scabs cover the lesions on his back. Lung exam reveals occasional scattered
rhonchi. Laboratory investigations show a white blood cell count of 8,000/microL,
hemoglobin of 12 gm/dl, platelet count of 130,000/microL, serum creatinine of 0.9
mg/dl, and serum ALT of 40 IU/L. A chest x-ray demonstrates bilateral fine
reticulonodular opacities. What is the most appropriate treatment for this patient?

Choices:

1. Intravenous voriconazole
2. Intravenous acyclovir
3. Intravenous ampicillin-sulbactam
Page 590 of 955
4. Intravenous pentamidine
Answer: 2 - Intravenous acyclovir

Explanations:

This individual presents with a skin rash and respiratory symptoms. The rash is a
pruritic maculopapular rash with vesicles and pustules with dry scabs covering the
lesions on his back. The presence of lesions in various stages of healing is
characteristic of varicella-zoster infection. The development of pulmonary
symptoms, along with radiographic findings, suggests the diagnosis of varicella
pneumonia. Treatment is with parenteral antiviral medication.
Varicella pneumonia is a rare and potentially life-threatening complication of
chickenpox. The symptoms of pneumonia, including fever, cough, dyspnea, and
occasionally hemoptysis, typically develop during the first week of varicella-zoster
infection. Risk factors for developing severe varicella pneumonia include
immunosuppression, smoking, chronic obstructive pulmonary disease, and
pregnancy. Radiographic findings of 5- 10 mm micronodules in the lung parenchyma
are characteristic. Intravenous acyclovir is the recommended treatment for patients
with severe cases of varicella, including those with pneumonia, encephalitis, and
severe hepatitis. Immunocompromised patients infected with varicella should also
be treated with intravenous acyclovir.
Voriconazole is an antifungal medication used to treat infections caused by several
species of Candida, Aspergillus, Fusarium, and other less-common fungal species
typically seen in patients who are immunocompromised. Antibacterial medications
such as ampicillin-sulbactam are not helpful in varicella pneumonia unless there is
a superimposed bacterial infection. Pentamidine is used for fungal infections such
as those caused by Pneumocystis jirovecii. Pneumocystis jirovecii causes
pneumonia in individuals who are immunocompromised, such as patients with
AIDS.
Research Concepts:

Varicella Zoster (Chickenpox)

Question 625: A 65-year-old male presents with cough and hemoptysis. He is a longtime
smoker. Chest CT shows a 3 cm spiculated nodule in the left lower lobe. Biopsy reveals
squamous cell carcinoma. What is the appropriate next step in the management of this
patient?

Choices:

1. Surgery
Page 591 of 955
2. Positron emission tomography-CT
3. CT of the brain
4. Radiation therapy
Answer: 2 - Positron emission tomography-CT

Explanations:

Workup begins with good history taking and physical examination.

Staging studies include CT of the chest, abdomen, and pelvis, MRI of the brain, and
positron emission tomography (PET)-CT. Tissue diagnosis and staging studies are
crucial to help guide treatment recommendations.
Positron emission tomography-computed tomography (PET-CT) is a nuclear
medicine study that combines a PET scanner and a CT scanner to give a single
superimposed image. This technique gives information on the metabolic activity in
the body obtained by PET, correlating to the body anatomy obtained by CT.

Research Concepts:

Radiation Therapy For Early Stage Non-Small Cell Lung Cancer

Question 626: A 26-year-old man presents with a worsening cough and shortness of
breath for two weeks. His medical history is significant for lung transplantation a few
months ago. His vital signs show a heart rate of 100/min, respiratory rate of 22/min,
blood pressure of 100/70 mmHg, and a temperature of 99 F (37.2 C).
Physical examination is remarkable for features consistent with consolidation in the
transplanted lung. Based on CT thorax and bronchoscopy, a diagnosis of locally invasive
Aspergillus infection at the bronchial anastomosis is made. After administering inhaled
amphotericin, he is discharged on voriconazole as daily prophylaxis for the first 12
months. In the follow-up period, this patient will need to be monitored as he is at risk for
developing which malignancy?

Choices:

1. Adenocarcinoma of the lung

2. Squamous cell cancer of the skin
3. Hodgkin lymphoma
4. Kaposi sarcoma

Answer: 2 - Squamous cell cancer of the skin

Page 592 of 955

Explanations:

Both locally invasive and disseminated Aspergillus infections occur in lung

transplant patients. The infection can occur at the site of the bronchial
anastomosis and cause ulceration.
The treatment is inhaled amphotericin followed by 12 months of prophylaxis with
voriconazole.
Patients on voriconazole need to be monitored as they are at an increased risk of
developing squamous cell cancer of the skin.
Voriconazole is also associated with numerous other skin conditions, including
photosensitivity, DRESS syndrome, melanoma, etc.

Research Concepts:

Aspergillosis

Question 627: A 70-year-old man is brought to the emergency department after being found
in an altered mental status, requiring endotracheal intubation in the field. Post-intubation
assessment reveals that the pulse-oximetry remains at 60%, the capnography waveform is
flat, and the value is 0. What is the next best step in the airway management of this patient?

Choices:

1. Cricothyrotomy
2. Remove the endotracheal tube and repeat endotracheal intubation
3. King tube placement
4. Laryngeal mask airway
Answer: 2 - Remove the endotracheal tube and repeat endotracheal intubation

Explanations:

A flat capnography waveform with a value of zero and the patient remaining
hypoxic would indicate that the endotracheal tube is not in the trachea and is
likely in the esophagus. The tube would need to be removed, and repeat
intubation would need to be performed to obtain proper placement of the
endotracheal tube (ET).
Appropriate placement of the tube would be noted with a good (nonflat)
capnography waveform and a range value of 35 to 45 mmHg.
The gold standard for assessing the placement of an ET is direct visualization with
Page 593 of 955
 the help of a laryngoscope. Additional ways to assure proper confirmation of
endotracheal tube placement include carbon dioxide, capnography waveform,
chest x-ray, ultrasound, and clinical assessment. The AHA (American Heart
Association) recommends continuous waveform capnography besides clinical
assessment as the most reliable method of confirming and monitoring the correct
placement of an ET tube. Bedside mobile ultrasound is another resource that some
emergency departments have to confirm the position of the ET tube. Many
physicians frequently use a chest x-ray to assess the placement of the ET tube.
Clinically, abnormal tube placement can be diagnosed with absent breath sounds on
the left chest if right mainstem intubation occurred and no bilateral breath sounds
bilaterally if esophageal intubation occurred. Additionally, with esophageal
intubation, air may be auscultated in the mid-epigastric region upon ventilation
administration. Lastly, low oxygen saturation will be noted.
Research Concepts:

Airway Management

Question 628: A 32-year-old man presents with his wife for fertility evaluation. He says
they have been trying to have a child for the last three years with no success. He has no
past medical history. However, he does note that he tends to get a lot of chest infections.
The patient states he has never been to a clinician as far as he can recall. On examination,
heart sounds are noticed to be on the right side of the chest. From which of the following
should this condition be differentiated?

Choices:

1. Cystic fibrosis
2. IgG subclass deficiency
3. Primary ciliary dyskinesia
4. Granulomatosis with polyangiitis
Answer: 3 - Primary ciliary dyskinesia

Explanations:

Primary ciliary dyskinesia (PCD) is a genetic condition where the cilia in the
respiratory system are defective. This prevents the clearance of mucous from the
lungs, nasal sinuses, and middle ear leading to frequent respiratory infections.
Kartagener syndrome is a type of PCD associated with situs inversus.
PCD is the most common differential diagnosis for situs inversus.

Page 594 of 955

 Cilia are also present in the brain ventricles and reproductive system. This can
cause infertility in males secondary to abnormal movement of sperm. In females,
PCD can cause infertility and ectopic pregnancy, also due to dysfunctional cilia.

Research Concepts:

Situs Inversus

Question 629: A 55-year-old woman presents with a three-day history of cough and fever.
Her medical history is significant for a deceased donor renal transplant (DDRT) due to
end-stage renal disease, for which she is on chronic immunosuppression therapy. She
works as an emergency department nurse, where she has been taking care of numerous
COVID-19 positive patients. She denies shortness of breath, and her oxygen saturation is
96% on room air.
Physical exam is unremarkable. COVID-19 testing is positive, and intravenous therapy
with sotrovimab is being considered. Which of the following adverse effects is most likely
to occur in this patient with sotrovimab infusion?

Choices:

1. Hypersensitivity reaction
2. Hepatic dysfunction
3. Renal insufficiency
4. Sepsis

Answer: 1 - Hypersensitivity reaction

Explanations:

Although monoclonal antibodies are generally well-tolerated, they have been

associated with the risk of immune-mediated reactions, including anaphylaxis,
serum sickness, and antibody generation.
Data describing the adverse effects of antiviral monoclonal antibodies used in COVID-
19 are limited.
The most frequently reported adverse effect of sotrovimab is infusion-related
immediate hypersensitivity reaction manifesting as pruritus, flushing, rash, and
facial swelling.
Hypotension, dyspnea, and anaphylaxis may occur. The medication should be given
in facilities capable of managing these potentially life-threatening complications,
Page 595 of 955
 and patients should be monitored for at least 1-hour post-infusion.

Research Concepts:

Evaluating And Referring Patients For Outpatient Monoclonal Antibody Therapy

For Coronavirus (COVID-19) In The Emergency Department

Question 630: A 61-year-old man is admitted to the hospital with COVID-19 pneumonia.
The patient is intubated and mechanically ventilated and is currently being evaluated for
oxyhemoglobin desaturation measured on bedside pulse oximetry. A physical exam
reveals decreased breath sounds on the left side, and the patient is hemodynamically
stable. Which of the following is the next best step in the management of this patient?

Choices:

1. Bedside ultrasound of the chest

2. Bronchoscopy
3. Chest x-ray
4. Needle decompression

Answer: 1 - Bedside ultrasound of the chest

Explanations:

A pneumothorax can lead to a further increase in airway pressures, collapse of

aerated portions of the lung leading to worsening oxygenation, and the formation of a
tension pneumothorax leading to hemodynamic compromise.
An unexplained drop in blood pressure or oxygen saturation should be evaluated at
the bedside. While an emergent chest x- ray is being arranged, a bedside sonogram
can help diagnose a pneumothorax. Under normal circumstances, in the absence of
a pneumothorax or a large pleural effusion, the interface between the lung and the
chest wall can be well visualized on a sonogram. This interface is unique in the fact
that a shimmering movement is noted with the lung moving against the chest wall;
this is known as lung sliding. Providers can be trained to detect a pneumothorax
with relative ease, and treatment can be started promptly. In the absence of lung
sliding, steps can be taken to relieve the pneumothorax even when the chest x-ray
is awaited.
In case of hemodynamic instability due to a tension pneumothorax, a needle
thoracostomy performed using a large- bore needle (14-16 Gauge) in the second
intercostal space in the midclavicular line can be lifesaving.
This patient is hemodynamically stable and does not require a needle thoracostomy.
Page 596 of 955
Research Concepts:

Mechanical Ventilation And Extracorporeal Membrane Oxygenation Considerations In

COVID-19

Question 631: A 16-year-old male presented to the emergency department after a fire at
his school. He suffered 22.5% of total body surface area burns. On presentation, the
patient was disoriented, and his Glasgow coma scale (GCS) was 13/15. No hoarseness of
voice or stridor was observed. The chest x-ray was clear.
Nasoendoscopy showed a black powdery substance in the nasal aperture and mild
erythema throughout the airway but no signs of edema. Direct laryngoscopy was normal.
What is the next step in the management of the patient?

Choices:

1. Magnetic resonance imaging of the chest

2. Fibreoptic bronchoscopy
3. Discharge after initial resuscitation
4. Computed tomography of the chest
Answer: 2 - Fibreoptic bronchoscopy

Explanations:

Fiberoptic bronchoscopy is used to examine the breathing passages and can be used
diagnostically as well as therapeutically.
In this procedure, a bronchoscope is used and a small flexible lighted tube with an
eyepiece that is used to view the lungs from inside.
It is used for the diagnosis and to know the extent of inhalation injury.
A chest X-ray of the patient is performed followed by nasoendoscopy. CT scan and
MRI of the patient are not required in most of the cases.

Research Concepts:

Inhalation Injury

Page 597 of 955

Question 632: A 65-year-old male patient is brought to the hospital with complaints of
high-grade fever, confusion, and shortness of breath. He is a street dweller and is known
well to the hospital staff because of repeated presentations of alcohol intoxication. On
examination, he has a high-grade fever, and chest auscultation reveals coarse crackles. A
chest radiograph is suggestive of non-homogenous haziness with evidence of cavitation
and abscess formation. Extended-spectrum beta-lactamase is suspected here. What
should be the treatment of choice in such cases?

Choices:

1. Linezolid
2. Respiratory quinolone
3. 4th generation cephalosporin
4. Carbapenems
Answer: 4 - Carbapenems

Explanations:

This patient is suffering from Klebsiella pneumonia which is evident from the clinical
history and radiographic findings. His history of alcohol use disorder and cavitations
are suggestive of Klebsiella as the etiology.
Current regimens for community-acquired K. pneumoniae pneumonia include a
14-day treatment with either a third or fourth-generation cephalosporin as
monotherapy or a respiratory quinolone as monotherapy or either of the
previous regimes in conjunction with an aminoglycoside.
Extended-spectrum beta-lactamase (ESBL) K. pneumoniae was seen in Europe in
1983 and the United States in 1989. ESBLs can hydrolyze oxyimino cephalosporins
rendering third- generation cephalosporins ineffective against treatment. Due to
this resistance, carbapenems became a treatment option for ESBL.
When ESBL is diagnosed, carbapenem therapy should be initiated due to its rate of
sensitivity across the globe. When CRE (carbapenem-resistant Enterobacteriaceae)
is diagnosed, infectious disease consultation should be obtained to guide
treatment.

Research Concepts: Klebsiella Pneumonia

Page 598 of 955

 Question 633: A 35-year-old male presents to the clinic with chief complaints of fever,
productive cough, and pleuritic-type chest pain for the past 2 weeks. The patient's history
reveals that he has been treated for pneumonia multiple times in the past. On physical
examination, there is a dullness to percussion on the affected area, egophonia, increase
palpable fremitus and fine crackles. The chest X-ray of the patient reveals a pulmonary
effusion, and an ultrasound revealed increased pleural fluid levels. CT scan of the patient
revealed thickening of the pleura, pleural enhancement, and a split pleural sign. Which of
the following is the most common cause of this patient's current pathology?
Choices:

1. Trauma
2. Chest tube
3. Pneumonia
4. Malignancy
Answer: 3 - Pneumonia

Explanations:

The presentation of empyema may be similar to pneumonia with cough, sputum production,
fever, and pleuritic-type chest pain.
However, patients with empyema may have symptoms for a more extended period.
Research has shown that patients presented after a median of 15 days after the onset of
symptoms. On physical exam there may be dullness to percussion on the affected area,
egophonia, increase palpable fremitus, and fine crackles.
CT scan of the chest must be done in patients with suspected empyema. It may be an
alternative option after a chest x-ray or ultrasound. CT scan ideally is done with
intravenous (IV) contrast to enhance the pleura. Some of the characteristics of empyema
on CT scan are thickening of the pleura (present in approximately 80% to 100% patients),
pleural enhancement, split pleural sign, bubbles in the absence of tube drainage, and
septations.
If an effusion is visualized with the chest x-ray, the next step is an ultrasound. Ultrasound is
useful because it is widely available, it can be done at a patient's bedside, it is more
sensitive at identifying pleural effusions than an x-ray, it allows differentiation between
parenchyma and pleural fluid, and it also has therapeutic use.
Around 20% of patients with pneumonia will develop a parapneumonic effusion that may
lead to empyema. Seventy percent of patients with empyema have parapneumonic
effusion, the other 30% of cases are related to trauma, post- thoracic surgery, esophageal
ruptures, or cervical infections, and a small number of cases are not associated with
previous pneumonia or intervention.
Research Concepts:Empyema

Page 599 of 955

Question 634: A 65-year-old woman is hospitalized with worsening shortness of breath for
the past week. She was diagnosed with granulomatosis with polyangiitis (GPA) three
years ago. She was treated with cyclophosphamide initially then switched to azathioprine
and methotrexate for maintenance therapy after successful induction. Since then, the
patient has been doing well until this hospitalization. In the hospital, the patient had a
low-grade fever, respiratory rate of 27/min, and oxygen saturation of 89% oxygen
support. On auscultation, the patient had crackles in bilateral lower lung zones, and chest
x-ray showed hazy opacifications and small-sized nodules in lower lung zones. Lab workup
was significant for erythrocyte sedimentation rate (ESR) of 95 and high ANCA titers of
1:160 against proteinase three antibodies in a cytoplasmic pattern. Her white blood cell,
platelets, and hemoglobin were within normal limits. The patient was started on
methylprednisone. Which of the following is the most appropriate treatment?
Choices:

1. Etanercept
2. Mycophenolate mofetil
3. Cyclophosphamide
4. Rituximab
Answer: 4 – Rituximab
Explanations:

Cyclophosphamide and rituximab both are used to induce remission and to treat relapse of
GPA. However, while both provide the same efficacy in treatment, rituximab has fewer side
effects. Furthermore, the RAVE study (rituximab versus cyclophosphamide for ANCA-
associated vasculitis) showed that rituximab is superior to cyclophosphamide in patients
with disease relapse.
Rituximab is the preferred treatment for the patient with GPA relapse as it can provide the
same efficacy of remission induction as cyclophosphamide with fewer side effects.
Moreover, in relapse cases, rituximab is superior to cyclophosphamide because, in trials,
67% of patients achieved remission at six months versus 42% of patients treated by
cyclophosphamide.
The patient experienced a relapse of her GPA disease. At the same time, she was on
maintenance therapy manifested by respiratory failure, changes on x-ray of the chest, and
elevated ESR and ANCA antibodies. Etanercept is not used to treat GPA relapse or induction as
it showed an increased risk for solid malignancies.
Mycophenolate mofetil is not used for GPA relapse or induction. It is used mainly for
maintenance therapy or remission induction in mild disease without organ threatening
features, which does not apply to this patient.
Research Concepts: ANCA Positive
Vasculitis

Page 600 of 955

Question 635: A 50-year-old woman presents to the hospital with gradually worsening
shortness of breath over the past few weeks. She has a past medical history of type 2
diabetes and decompensated hepatic cirrhosis secondary to hepatitis C. She is noted to
be on supplemental oxygen at 3 L/min, which was started a few months back. SpO2
checked on 3 L/min of supplemental oxygen is 79% when she is standing and rapidly
increases to 92% when supine. Her pulse is 110/min, with blood pressure 86/50 mm Hg.
A-a O2 gradient is 20 mm Hg. Her chest x-ray shows bibasilar ground- glass opacities. CT
abdomen is significant for worsening portal hypertension and moderate ascites. The
patient reports that her oxygen saturation has never been corrected with supplemental
oxygen and that her oxygen requirement is going up. Prior transesophageal
echocardiography (TEE) with a bubble study showed a bubble appearance in the left
atrium and left ventricle after the third beat of the cardiac cycle. Her oxygen
supplementation is increased to 5 L/min. Which of the following is the next best step in
the management of this patient?

Choices:

1. Liver transplantation
2. Correction of cardiac abnormality
3. Increase supplemental oxygen
4. CT angiography
Answer: 1 - Liver transplantation

Explanations:

Hepatopulmonary syndrome is an important cause of platypnea- orthodeoxia

syndrome.
Diagnostic criteria for Hepatopulmonary Syndrome consist of liver disease and/or
portal hypertension, An elevated room air alveolar-arterial oxygen gradient {P(A-
a)O2 gradient} > 15 mm Hg or > 20 mm Hg when age > 65 years, Evidence of
intrapulmonary vascular dilatations in the basal parts of the lungs, absence of other
significant cardiopulmonary diseases. An echocardiogram with an agitated saline
bubble study is a very useful initial test to evaluate the presence of intracardiac or
extra-cardiac shunts. The appearance of microbubbles in the left atrium during the
first 3 beats after opacification of the right chambers suggests an intracardiac shunt,
whereas the appearance of microbubbles on the left side after more than 3 to 6
beats suggests an extracardiac shunt, for example, an intrapulmonary shunt like in
hepatopulmonary syndrome.
Liver transplantation is the definitive treatment for hepatopulmonary syndrome.
Research Concepts: Platypnea

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Question 636: A 65-year-old male presents with cough for five weeks that has not
improved on two different courses of antibiotics. He is otherwise healthy and has no pre-
existing medical illnesses. Bronchoalveolar lavage is performed, and dimorphic budding
yeast is identified on microscopy. What therapy is most appropriate at this time?

Choices:

1. Azithromycin
2. Prednisone
3. Itraconazole
4. Amphotericin B
Answer: 3 - Itraconazole

Explanations:

Pulmonary histoplasmosis in asymptomatic patients is self- resolving and requires

no treatment. Once symptoms develop, treatment with antifungal medicines should
be considered. In mild tolerable cases, no treatment other than close monitoring is
necessary.
Once symptoms progress to moderate or severe or if they are prolonged for
greater than 4 weeks, treatment with itraconazole is indicated. The anticipated
duration is 6 to 12 weeks total.
The response should be monitored with chest x-rays. Furthermore, observation for
recurrence is necessary for several years following the diagnosis.
If the illness is determined to be severe or does not respond to itraconazole,
amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year.
Cotreatment with methylprednisolone is indicated to improve pulmonary
compliance and reduce inflammation, thus improving the work of respiration.

Research Concepts:

Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough

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Question 637: A 70-year-old man with a history of uncontrolled diabetes mellitus and
alcohol use disorder presents with foul- smelling sputum, fever, and malaise despite
being compliant with azithromycin for the past five days for community-acquired
pneumonia. His temperature is 101.7 F (38.7 C), blood pressure 130/80 mmHg, pulse
110/min, and respirations 23/min. Examination demonstrates very poor dentition and
crackles over the left lung. A chest x-ray shows a left upper lobe infiltrate. What is the
most appropriate next step in treatment?

Choices:

1. Ciprofloxacin
2. Amoxicillin-clavulanate
3. Trimethoprim-sulfamethoxazole
4. Ampicillin
Answer: 2 - Amoxicillin-clavulanate

Explanations:

This elderly patient with uncontrolled diabetes mellitus, alcohol use disorder, poor
dentition, and signs of pneumonia most likely is suffering from aspirational
pneumonia due to anaerobic organism infiltration.
Aspirational pneumonia caused by anaerobic organisms usually presents with foul-
smelling sputum, fever, and malaise.
Risk factors for anaerobic aspirational pneumonia include poor dentition,
dysphagia, impaired consciousness, and advanced age.
Treatment for anaerobic aspiration pneumonia in a patient with diabetes and alcohol
use disorder should include amoxicillin- clavulanate for anaerobic coverage.
Research Concepts:

Anaerobic Infections

Question 638: A 65-year-old man presents to the hospital with pleural-based lung mass
on a low dose lung cancer screening CT chest. The mass is in the right upper lobe (3.5 cm
in diameter) surrounded by emphysema without mediastinal or hilar lymphadenopathy.
The patient has continued to smoke one pack per day for the last 35 years. A
percutaneous CT-guided needle biopsy of the mass is performed. Which of the following
is the most immediate and the most reported complication of a percutaneous lung
biopsy?

Choices:

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1. Hemithorax
2. Pneumothorax
3. Atelectasis
4. Air embolism
Answer: 2 - Pneumothorax

Explanations:

Percutaneous lung lesion biopsy (PLLB) is the most common indication for
percutaneous needle biopsy of the deep tissues of the thorax.
Pneumothorax is the most immediate and the most reported complication of a
percutaneous lung biopsy (17–27%).
The size of pneumothorax necessary to cause shortness of breath is highly variable
and depends on the underlying condition of the lungs.
Bleeding, air embolism, and atelectasis are less common complications following CT-
guided needle biopsy for a large peripheral mass.

Research Concepts:

Lung Biopsy

Question 639: A 17-year-old male patient presents to the emergency department with
acute onset chest pain and shortness of breath. He does not have any past medical
history. On examination, he is tall and lean with a blood pressure of 135/85 mmHg, a
heart rate of 90 beats per minute, a respiratory rate of 20 breaths per minute, and
oxygen saturation of 94% on room air. The trachea is central and the apex beat is not
displaced. His breath sounds are absent on the left side of the chest, and his percussion
note is hyperresonant. What is the best next step in management?

Choices:

1. Urgent chest x-ray

2. Obtain an arterial blood gas
3. Computed tomography pulmonary angiogram (CTPA)
4. Tube thoracostomy

Answer: 1 - Urgent chest x-ray

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Explanations:

When pneumothorax is suspected in a stable patient, a chest x- ray provides additional

information beyond confirmation.
A chest x-ray can be used to evaluate the extent of pneumothorax and its potential
causes.
It also can be used as a baseline study from which to go forward and guide the
therapeutic plan. Treatment will be guided by the risk stratification of the patient.
If the patient is unstable or there are clear signs of tension pneumothorax, needle
decompression should be done. Do not wait for confirmation with a chest x-ray.

Research Concepts: Pneumothorax

Question 640: A 66-year-old man presents to the clinic with complaints of fatigue and
worsening shortness of breath. His medical history is significant for severe chronic
obstructive pulmonary disease (COPD) that is currently being treated with inhaled long-
acting beta-agonist. He states that he is very compliant with his medications, and he
needs his short-acting beta-agonist inhalers at least one to two times a week. He was
diagnosed with obstructive sleep apnea, for which he uses nightly continuous positive
airway pressure (CPAP). He has a 35-pack-year smoking history, and he quit a year ago. He
has been experiencing worsening fatigue over the past three months and now feels tried
even while walking one block of his neighborhood. On examination, he has extreme
obesity with a body mass index of 42.38 kg/m2. His pulse rate is 90 beats per minute, and
his blood pressure is 150/70 mmHg. Neck veins are pulsatile. Bilateral lower extremity
pitting edema is noticed until the mid-shins. Auscultation reveals uniformly distant breath
sounds. A soft, blowing, diastolic murmur is heard in the left second intercostal space.
Which of the following is the next best step in the management of this patient?

Choices:

1. Furosemide
2. Coronary angiogram
3. Propranolol
4. Digoxin
Answer: 1 - Furosemide

Explanations:

This patient has a chronic obstructive pulmonary disease (COPD) secondary to

Page 605 of 955
 chronic smoking. Long-standing uncontrolled COPD can cause pulmonary
hypertension and in turn, lead to cor-pulmonale. Worsening pulmonary
hypertension can lead to pulmonary regurgitation.
Diuretics relieve pulmonary congestion and reduce some of the symptoms secondary
to volume overload.
FIndings seen on an EKG in a patient with pulmonary regurgitation secondary to
pulmonary artery hypertension are mostly secondary to right ventricular
hypertrophy. These include right bundle branch block with rSR pattern in V1 and V2,
increased R to S ratio in V1 (which is an RV lead), and P pulmonale (tall peaked P
waves).
Nonspecific beta-blockers exaggerate bronchospasm.

Research Concepts: Cor Pulmonale

Question 641: A 28-year-old woman is brought to the hospital with sudden onset
worsening shortness of breath and cough with blood mixed sputum for the past 2 days.
She has also been having bloating, diffuse abdominal pain, and diarrhea. Vital signs show
respiratory rate 28/min and oxygen saturation 82% on room air. She is afebrile. Chest x-
ray shows bilateral interstitial infiltrates peripherally. Blood work shows an elevated
eosinophil count of 1200/microL. Physical examination shows an erythematous
serpentine rash in her arm that apparently has moved somewhat from its previous
location and is intensely itchy. Her initial blood culture and respiratory culture as well as
influenza assay are negative. Among the initial workup, the pregnancy test comes back
positive. Based on the initial evaluation of her condition a diagnosis is reached and
confirmed. She is prescribed the appropriate antimicrobial therapy. On day 3, she
develops a sudden alteration of mental status with a witnessed seizure-like episode. She is
intubated for airway protection. CT scan of the head shows findings suggestive of cerebral
edema. Initiation of which of the following additional medications is most likely to have
prevented the neurological complication?

Choices:

1. Acyclovir
2. Methylprednisolone
3. Acetazolamide
4. Valproic acid
Answer: 2 - Methylprednisolone

Explanations:

Acute presentation of a strongyloides infection can include nonspecific abdominal

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 symptoms along with an acute pneumonitis and alveolar hemorrhage from the
migration of larva in pulmonary capillaries. However, a more pathognomonic rash is
larva currens or migrans from the migration of the filariform larva under the skin
resulting in a hypersensitivity response in the host. It results in a transient linear
erythematous serpiginous rash that shifts at a rate of 2-10 cm/hour.
Her clinical presentation is suggestive of acute CNS inflammatory response upon
initiation of antihelminthic therapy with albendazole.
Albendazole should be administered with high-dose glucocorticoids and
anticonvulsants to avoid a central nervous system inflammatory response.
Albendazole is the recommended antimicrobial in pregnant patients.

Research Concepts: Strongyloidiasis

Question 642: A 65-year-old female presents to the clinic with severe dyspnea on
exertion. She has a 45-pack-year history of smoking. On high-resolution CT imaging of the
chest, she has heterogeneous, upper-lobe predominant emphysema. Over the past year,
she has become more short of breath with exertion despite complying with her medical
therapy. Her partial pressure of oxygen (PaO2) is 65 mmHg, and partial pressure of
carbon dioxide (PCO2) is 55 mmHg. Her 6-minute walk distance is 50 meters. Her exercise
capacity is 20 W. What is the most likely complication after undergoing the
recommended surgical intervention?

Choices:

1. Deep vein thrombosis

2. Urinary tract infection
3. Pulmonary embolism
4. Air leak
Answer: 4 - Air leak

Explanations:

In the national emphysema treatment trial (NETT), patients with upper-lobe

emphysema and poor exercise capacity had lower mortality rates after lung
volume reduction surgery (LVRS) compared to medical therapy alone.
Air leak is one of the most common complications following lung volume reduction
surgery (LVRS). In the national emphysema treatment trial (NETT), an estimated
90% of patients developed air leaks in the 30-day postoperative period.
Although common, air leaks were not persistent. In the NETT, only 12% of patients
had an air leak that lasted greater than 30 days.
It was concluded that having an air leak post-operatively was not associated with
Page 607 of 955
 the specific surgical technique.

Research Concepts:

Lung Volume Reduction Surgery

Question 643: A 35-year-old man is transported by paramedics to the emergency

department with acute-onset chest pain and shortness of breath when coughing. He
reports a 4-month history of progressive shortness of breath, weight loss, and dry cough.
He smokes 2 packs of cigarettes a day and has for 15 years. He has no other past medical
history and no risk factors for HIV, and he takes no medications or herbal supplements.
He is found to have a 75% pneumothorax on the left with nodular infiltrates at the right
base, not involving the costophrenic angle. A chest tube is placed. CT scan shows multiple
small cystic spaces at the apices and bilateral nodular opacities at the lung bases. Given
the likely diagnosis, which of the following is an essential treatment?

Choices:

1. Biopsy and chemotherapy

2. Smoking cessation
3. Pleural sclerosis
4. Thoracotomy and surgical resection of nodules
Answer: 2 - Smoking cessation

Explanations:

Langerhans cell histiocytosis (LCH) is an idiopathic condition characterized by the

proliferation of abnormal Langerhans cells (antigen-presenting immune cells). The
disease has characteristics of both an abnormal reactive process and a neoplastic
process.
LCH may initially present as a rash. It can be disseminated and involve the bone
marrow, lungs, liver, spleen, lymph nodes, gastrointestinal (GI) tract, and pituitary
gland.
Pulmonary LCH is almost always seen in those who smoke. Thirty-three percent of
patients improve with smoking cessation; however, the other 67% develop
progressive interstitial disease. Both CT scans and MRIs are invaluable for assessing
the hypothalamic-pituitary area. Fluorodeoxyglucose (FDG) PET scanning also is
used to assess patients with LCH. The technique is far more sensitive than a bone
scan for early detection of disease in the spleen, lymph nodes, and lungs.
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 FDG PET scanning is also used to monitor disease during treatment. No systemic
medications have been shown to improve LCH.

Research Concepts: Langerhans Cell Histiocytosis

Question 644: A 65-year-old male presents with complaints of fever, shortness of breath,
and chest pain. He had two episodes of right-sided pneumonia in the past year, which
were treated appropriately. His medical history includes Parkinson disease with an
abnormal gait, hypertension, osteoarthritis, and unstable angina. He has a 20-pack-year
smoking history. His blood pressure is 145/80 mmHg, heart rate is 100 beats per minute,
respiratory rate is 21 breaths per minute and he has a low-grade temperature. Chest
examination reveals bronchial breath sounds and dullness in the lower lobes. His
complete blood count shows a white blood cell count of 12,000/mm3 and hemoglobin of
12 mg/dl. Which of the following predisposes to the current symptoms exhibited by the
patient?

Choices:

1. Male gender
2. Parkinson disease
3. Older age
4. Hypertension
Answer: 2 - Parkinson disease

Explanations:

The patient's symptoms and prior history of infection in the same lung area likely
point toward aspiration pneumonia. His significant history of Parkinson disease,
which affects the muscles of swallowing, puts him at an increased risk for
aspiration pneumonia. He has two prior episodes of pneumonia which were likely
due to the same dysfunction in the swallowing apparatus. Since the right bronchus
is shorter and wider than the left, contents tend to spill into the right lower lobe
causing an inflammatory response as evidenced by the clinical findings of dullness
and bronchial breath sounds.
Intravenous antibiotics should be started with blood work sent for cultures. A
swallowing study should also be done.
Other risk factors for aspiration pneumonia include acid reflux, pregnancy, and other
neurological disorders like stroke.
Older age or hypertension alone without stroke is not a significant risk factor.
Page 609 of 955
Research Concepts:

Aspiration Pneumonia

Question 645: A 75-year-old man presents to the hospital with complaints of generalized
fatigue and shortness of breath for the past two weeks. The symptoms started gradually
and have become worse with time. A detailed medical history reveals that he has been
diagnosed with diabetes mellitus about thirty years ago and is on metformin. His vital
signs show blood pressure: 85/65 mmHg, pulse rate: 112 beats per minute, temperature:
39 C (102.2 F), respiratory rate: 28 breaths per minute, and oxygen saturation: 89% at
room air. A physical examination was carried out, which reveals a decrease of 20 mmHg
of blood pressure on inspiration. Furthermore, abdominal examination reveals
hepatomegaly and peripheral edema.
Echocardiography was carried out, which shows an echolucent free space between the
visceral and parietal pericardium. What physical finding, in addition to these, is most likely
to be found in this case?

Choices:

1. Biot respiration
2. Cheyne–Stokes respiration
3. Kussmaul sign
4. Crescendo-decrescendo murmur
Answer: 3 - Kussmaul sign

Explanations:

The clinical scenario is consistent with the diagnosis of effusive- constrictive

pericarditis. Constrictive pericarditis is a disease involving scarring and loss of
elasticity of the pericardium surrounding the heart, leading to impaired filling.
Effusive- constrictive pericarditis (ECP) is a syndrome involving both constriction of
the visceral pericardium and an effusion causing a tamponade-like effect on the
heart.
It presents with symptoms of volume overload such as shortness of breath, ascites,
and peripheral edema. Tachycardia occurs reflexively due to decreased cardiac
output.
There are many findings on physical examination. One of which is Kussmaul sign, a
rise in right atrial pressure, and eventually the jugular venous pressure during
inspiration.
Other physical findings include dyspnea, hepatomegaly, an added heart sound, and
Page 610 of 955
 pulsus paradoxus, which refers to a drop in blood pressure of greater than
10mmHg during inspiration.

Research Concepts: Constrictive-Effusive Pericarditis

Question 646: A 68-year-old African American male with a past medical history of
hypertension and diabetes presents to the hospital with a chief complaint of cough, green
sputum, shortness of breath, and fever. He has not had any contact with individuals with
upper respiratory infections. He had a flu shot this year. His medications include lisinopril
20 mg daily and metformin 500 mg twice a day. Vital signs are temperature 101 degrees
Fahrenheit, blood pressure 156/82 mmHg, regular pulse 94/min, respiratory rate 22/min,
and SpO2 92% on room air. Physical exam demonstrated rhonchi in the left lower field
and no egophony. Lab studies: WBC count of 13400/microL, hemoglobin 14.0 g/dL,
platelets 225000/microL, BUN 20 mg/dL, and creatinine 1.01 mg/dL. A chest x-ray
demonstrates consolidation in the left lower lung field and a 7 mm nodule in the right
middle lobe. Intravenous fluids, ceftriaxone, and azithromycin are started. Which of the
following is the next best step in evaluating the pulmonary nodule?

Choices:

1. CT chest
2. Biopsy of the nodule
3. Bronchoscopy
4. Sputum cytology
Answer: 1 - CT chest

Explanations:

Incidental nodules 6-8 mm in size do not need immediate workup and can be
followed up with CT in 6-12 months.
A CT scan of the chest would be able to help distinguish more characteristics of the
nodule and allow a more accurate measurement of the nodule, which would help
guide the diagnosis and treatment.
Obtaining a CT while this patient is in the hospital is reasonable to not only get a
better picture of the nodule but also to help visualize other lung architecture that
may help guide treatment while they are in the hospital. This is more useful when
the patient is failing to improve with initial management.
This patient meets sepsis criteria by both qSOFA and SIRS criteria. Patients with
sepsis pneumonia should be admitted to the hospital. Treatment of sepsis includes
intravenous fluids and antibiotics. Cultures should be obtained to help guide
antibiotic choice.
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Research Concepts: Solitary Pulmonary Nodule

Question 647: A 55-year-old female underwent insertion of an indwelling pleural

catheter on the right side due to malignant pleural effusion secondary to breast cancer.
There were no complications during the procedure. A routine post-procedure chest x-ray
shows right apical pneumothorax. What will be the next step in management?

Choices:

1. Put the patient on 100% oxygen and call cardiothoracic surgery for chest tube
placement
2. Needle thoracostomy on the right side
3. Drain the pleural catheter and repeat the chest x-ray
4. Reassure and discharge the patient
Answer: 3 - Drain the pleural catheter and repeat the chest x-ray
Explanations:

Pneumothorax happens when the needle punctures the pleural, and the air from
the lung enters the pleural space due to lower intrapleural pressure during
inspiration. It can be a potentially serious complication and can be fatal if not
relieved immediately. Usual procedures include insertion of a 16 to 18 gauge needle
in the second intercostal space, needle thoracostomy. A small- bore chest tube can
also be placed.
Pneumothorax post indwelling pleural catheter (IPC) insertion is fairly uncommon
because usually pleural effusion is big and lung is very atelectatic, hence, far away
from the insertion needle.
The pneumothorax post IPC happens due to the entry of air from the outside rather
than from the lung. When the needle is inserted through the skin and punctures
the parietal pleural, it forms a track. That track is later dilated multiple times during
the procedure. The patient, meanwhile, is breathing spontaneously. Air can enter
the pleural space through the dilated tract when the patient exhales because, at
this time, the intrapleural pressure is lower than the atmospheric pressure,
therefore, facilitating air entry from outside into the pleural space.
Treatment is usually draining the IPC and repeating the chest x- ray. If the
pneumothorax is reduced, then it is likely due to pleural rupture by the needle. The
patient can be instructed to keep draining the catheter daily for a few days and
then repeat the chest x-ray. If the pneumothorax does not improve post- drainage,
then it is likely secondary to air from outside, IPC is drained as usual, and the
patient is reassured.

Research Concepts: Intrapleural Catheter

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Question 648: A 16-year-old male patient comes to the outpatient clinic with complaints
of dyspnea on exertion for four months. His symptoms are aggravated with weather
changes, predominantly in winters and rainy season. The patient does not have any
significant comorbidities. Diffuse expiratory rhonchi are present on auscultation in
bilateral lung fields. EKG and echocardiography are within normal limits. Chest x-ray
shows increased bronchovascular markings. What is the next best step in management?

Choices:

1. Start the patient on inhalers

2. Spirometry
3. Diffusing capacity of lung for carbon monoxide (DLCO)
4. Body plethysmography

Answer: 2 - Spirometry

Explanations:

Spirometry before and after a bronchodilator use is indicated as the initial step in the
diagnosis of a patient suspected to have bronchial asthma.
A low FEV1/FVC on spirometry indicates airway obstruction. Reversibility of
obstruction post-bronchodilator is suggestive of asthma. DLCO is done if FEV1
remains unchanged post- bronchodilator. A low DLCO is suggestive of COPD or
emphysema. A normal or high DLCO is seen in the case of asthma.
Body plethysmography is helpful in measuring lung volumes and is considered as the
gold standard. It is indicated when FVC is decreased on spirometry.
Research Concepts:

Diffusing Capacity Of The Lungs For Carbon Monoxide

Page 613 of 955

Question 649: A 65-year-old man visiting from Japan comes to the hospital with
complaints of productive cough and shortness of breath on exertion for the past four
days. He has chronic obstructive pulmonary disease and sinus infection. He was treated
with numerous antibiotics, each time transiently improving but the symptoms have
recurred. He denies any fever, chills, or chest pain. The patient works in a construction
company. The patient has a distant smoking history. Currently, he is afebrile and
hemodynamically stable. A chest x-ray reveals hyperinflation with diffuse nodules. CT of
the chest reports diffuse centrilobular nodules and dilated bronchioles. Pulmonary
function test reveals an FEV1 of 55% of predicted and an FEV1/FVC ratio of 55%. There is
no significant improvement with albuterol. Total lung capacity is 130% of predicted. Which
of the following is a known risk factor for the condition, this patient is most likely suffering
from?
Choices:

1. Smoking history
2. Profession related to construction
3. Ethnicity
4. Alpha 1 antitrypsin deficiency
Answer: 3 – Ethnicity
Explanations:

Diffuse panbronchiolitis (DPB) is a distinct clinical and pathologic syndrome that

involves the upper and lower respiratory tracts. Diffuse panbronchiolitis occurs
mainly among the Japanese and has rarely been reported outside East Asia.
However, cases of DPB have been recognized in the United States, Canada, Latin
America, and Europe, raising concerns that it might be under-diagnosed in these
populations.
Common symptoms and signs include chronic sinusitis, cough, wheeze, dyspnea,
and weight loss. Chest examination may reveal decreased breath sounds, coarse
crackles, or wheezes. Clubbing is uncommon.
Pulmonary function tests typically show an obstructive defect, although a mixed
obstructive-restrictive pattern may also be seen. Diffusing capacity (DLCO) is
variably reduced.
The chest radiograph findings in DPB include normal or hyperinflated lung
volumes, diffuse ill-defined nodules up to 3 mm in diameter, and/or an increase in
bronchovascular markings. High resolution computed tomography (HRCT) scanning
typically shows centrilobular nodular and linear opacities corresponding to
thickened and dilated bronchiolar walls with intraluminal mucous plugs.
Inhomogeneity in lung density, due to peripheral air trapping, may also be seen.
Research Concepts: Bronchiolitis

Page 614 of 955

Question 650: A 39-year-old man presents with intermittent cough, hemoptysis, and
chest pain. He denies a history of smoking and is otherwise healthy. A physical exam is
significant for bilateral basal crackles. High-resolution CT reveals bilateral ground-glass
opacities associated with interlobular septal thickening.
Bronchoalveolar lavage (BAL) is performed. Which of the following findings on cytological
examination of the BAL is most consistent with this patient's suspected diagnosis?

Choices:

1. High neutrophil count and infective organisms

2. Grungy background with necrotic tumor cells
3. Amorphous, Periodic Acid-Schiff positive material
4. Macrophages and reactive bronchial cells
Answer: 3 - Amorphous, Periodic Acid-Schiff positive material

Explanations:

Imaging features are not specific in alveolar lipoproteinosis but characteristically show
bilateral ground-glass opacities and interlobular septal thickening.
The Periodic Acid-Schiff stain is useful in making the diagnosis of alveolar
lipoproteinosis when it is positive.
Characteristic amorphous eosinophilic material filling the alveoli is an expected
finding on cytological examination.
The pathogenesis is thought to be related to a deterioration in the function of
macrophages.
Research Concepts:

Alveolar Proteinosis

Question 651: A 65-year-old man with suspected non-small cell lung cancer undergoes
endobronchial ultrasound trans-bronchial needle aspiration (EBUS-TBNA). While
sampling station 11R, the patient begins to have significant bleeding from the biopsy site
and hemoptysis. His blood pressure drops to 95/55 mmHg, pulse rate rises to 105/min,
and oxygen saturation drops to 90% despite the application of 15 L/min supplemental
oxygen via a non-rebreather mask. What is the best next step in the management of this
patient?

Choices:

1. Administer warm saline and adrenaline through the working channel of the
Page 615 of 955
EBUS scope
2. Advance and wedge the scope to tamponade the bleeding
3. Lay the patient in the right lateral decubitus position with the bed in Trendelenburg
position
4. Administer general anesthesia and initiate single lung selective ventilation

Answer: 2 - Advance and wedge the scope to tamponade the bleeding

Explanations:

If a significant vessel is hit while performing EBUS-TBNA, hemorrhage can be rapid

and life-threatening. Blood can fill the field of view, make navigation difficult, and
advance and wedge the scope can tamponade bleeding and prevent blood from
rapidly filling the airways and causing respiratory arrest. This should be the first
intervention.
Laying the patient on the side of the active bleeding will prevent gravity from spilling
blood into the contralateral bronchial tree.
The patient should also be kept in an anti-Trendelenburg position.
Ice-cold saline and adrenaline can be used to reduce bleeding in these situations,
but if the bleeding is arterial, more definitive intervention may be required.
Securing the patient’s airway in a life-threatening hemorrhage is essential. Rapid
sequence induction and protective ventilation may save the patient’s life while
awaiting a procedure to stop bleeding.

Research Concepts:

Sonography Endobronchial Assessment, Protocols, And Interpretation

Question 652: A 30-year-old man undergoes an uncomplicated endobronchial ultrasound

(EBUS) to sample mediastinal lymphadenopathy for suspected sarcoidosis. After the
procedure, the patient develops chest pain with his oxygen requirement increasing from 1
L/min via nasal cannula to 10 L/min via a non-rebreather mask. What is the most likely
reason for his deterioration?

Choices:

1. Iatrogenic pneumothorax
2. Mucous plugging
3. Methemoglobinemia
4. Bronchospasm
Page 616 of 955
Answer: 1 - Iatrogenic pneumothorax

Explanations:

Pneumothorax is a rare complication of EBUS which presents soon after nodal

sampling due to an iatrogenic air leak.
Symptoms include acute breathlessness and pleuritic chest pain. Management can
often be conservative if the pneumothorax is small, though a Seldinger intercostal
chest drain should be inserted if it is progressive or the patient is acutely unwell.
Mucous plugging or impaction may occur following EBUS but is unlikely in patients
without suppurative lung disease.
Methemoglobinemia is a recognized side-effect of topical anesthetic administered
during bronchoscopic procedures, including EBUS, and should remain in the
differential for patients with acute postprocedural hypoxia. They will present with
peripheral cyanosis, and arterial blood gas analysis will demonstrate raised
methemoglobin levels.
Bronchospasm or laryngospasm may occur during bronchoscopy or EBUS and
usually develops while the scope is still within the airways.

Research Concepts:

Sonography Endobronchial Assessment, Protocols, And Interpretation

Question 653: A 32-year-old woman presents with a one-year history of snoring,

unrefreshing sleep, and tiredness. She denies choking or witnessed apnea. She takes oral
contraceptive pills, does not smoke, and does not drink alcohol. Vital signs are a blood
pressure of 129/70 mmHg, a pulse of 75/minute, respirations of 17/minute, and pulse
oximetry is 95% on room air. Body mass index is 35 kg/m^2. On examination, the
oropharynx is mildly crowded with 1+ tonsils and enlarged nasal turbinates bilaterally. Her
Epworth sleepiness scale is 12/24. A home sleep apnea test (HSAT) report shows a
respiratory event index of 4.2 events/hour with no sustained hypoxia. What is the best
next step in the management of this patient?

Choices:

1. Weight loss program

2. In-laboratory polysomnography
3. Refer for tonsillectomy
4. Prescribe oral appliance
Answer: 2 - In-laboratory polysomnography

Page 617 of 955

Explanations:

This clinical scenario suggests upper airway resistance syndrome (UARS) and an
intermediate probability of obstructive sleep-disordered breathing (based on
obesity, snoring, and tiredness).
UARS represents a continuum of sleep-disordered breathing that occurs when
inspiratory airflow is limited, leading to arousals from sleep. The combination of
increased resistance and effort with multiple arousals leads to daytime fatigue
and/or excessive daytime sleepiness.
The diagnostic test is full in-laboratory polysomnography, which allows for assessing
inspiratory flow limitation via a nasal flow pressure catheter and identifies arousals
using electroencephalography. A home sleep apnea test (HSAT) is inadequate for
diagnosis.
Treatment includes weight loss, improved sleep habits, medical therapy for nasal
obstruction (or allergy), and positive airway pressure (PAP) therapy. Tonsillectomy
or weight loss alone is insufficient and not recommended as first-line treatments.
Once the diagnosis is confirmed, oral appliance treatment may be used as a
second-line treatment.
Research Concepts:

Upper Airway Resistance Syndrome

Question 654: A 48-year-old man presents with worsening fatigue. He reports excessive
daytime sleepiness, falling asleep during meetings, while reading or watching television,
and occasionally at a traffic light. His wife has recently moved to a separate room due to
his snoring and frequent movement during sleep. He has hypertension, currently
controlled with medication. His body mass index is 33.5 kg/m2, neck circumference 18
inches, and Mallampati class 3 oropharynx. A sleep study shows an apnea- hypopnea
index of 23.1/h and a periodic limb movement index of 37/h. What is the best next step in
the management of this patient?

Choices:

1. Treat periodic limb movement disorder and obstructive sleep apnea

simultaneously.
2. Initiate continuous positive airway pressure therapy.
3. Treat periodic limb movement disorder before obstructive sleep apnea.
4. Provide patient education regarding proper sleep hygiene.
Answer: 2 - Initiate continuous positive airway pressure therapy.

Explanations:
Page 618 of 955
 This patient has obstructive sleep apnea (OSA) and periodic limb movement
disorder. A periodic limb movement index of greater than 15 per hour is significant
and called periodic limb movements of sleep.
Periodic limb movements of sleep can be seen in patients with untreated OSA;
therefore, OSA treatment with continuous positive airway pressure therapy is the
best next step in the management of this patient.
Consider all the possible differential diagnoses when a patient has periodic limb
movements of sleep during the sleep study, including narcolepsy, restless leg
syndrome, obstructive sleep apnea, rapid eye movement sleep behavior disorder,
and uremia.
Periodic limb movement disorder is a diagnosis of exclusion. If this patient did not
have OSA, then he can be diagnosed with periodic limb movement disorder as he
has both daytime and nocturnal sleep symptoms with evidence of periodic limb
movements in the sleep study.

Research Concepts: Periodic Limb Movement Disorder

Question 655: A 55-year-old male is referred to the thoracic surgery department after a
1.3 cm solid nodule in the left upper lobe of the lung discovered on a chest CT scan. After
a complete evaluation, the nodule came out to be positive on PET scan without any
evidence of mediastinal adenopathy. The patient was stratified as low-risk postoperative
dyspnoea. What surgical procedure should be done in this case?

Choices:

1. Open wedge resection

2. VATS lobectomy with lymph node sampling
3. Open lobectomy with lymph node sampling
4. VATS lobectomy
Answer: 2 - VATS lobectomy with lymph node sampling

Explanations:

Wedge resection is considered in ground glass opacifications (GGO) nodules 1cm

or in patients who cannot tolerate a complete anatomical lung resection in early-
stage lung cancer. However, in the last scenario, the recurrence risk is higher.
The National Comprehensive Cancer Network (NCCN) and the International
Association for the Study of Lung Cancer (IASLC) recommend Video-assisted
thoracoscopic surgery (VATS) lobectomy as the first option in early-stage lung
cancer with lymph node sampling or resection. In this case, there is no
Page 619 of 955
 contraindication for performing a VATS lobectomy.
However, if there is a contraindication, the open surgery is indicated. VTAS is
contraindicated in tumors >5 cm.
Regardless of the negative result in the nodal mediastinal evaluation (Early-stage
lung cancer), The National Comprehensive Cancer Network (NCCN) and the
International Association for the Study of Lung Cancer (IASLC) recommend
lobectomy plus lymph node sampling or dissection.

Research Concepts:

Lobectomy

Question 656: A 34-year-old female with a past medical history of gluten sensitivity and
eosinophilic esophagitis presents with complaints of exhaustion. She is a second-year
medical resident and a single mother of 1 child who is six years old. Her family history is
significant for a father with psoriatic arthritis, currently on biologic agents for control; a
paternal aunt with psoriatic and rheumatoid arthritis; a maternal grandmother with
hypothyroidism; and a maternal grandfather with osteoarthritis. The patient says she has
been working 70 to 80 hours per week in the hospital, sleeping 4 to 5 hours per night, and
is under extreme stress in both her professional and personal life. She recently was sent
to a psychiatrist who evaluated her and started her on lisdexamfetamine and bupropion;
however, she does not wish to continue these medications. Her review of symptoms is
positive for "feeling swollen," puffy face, recent new onset shortness of breath with
exertion, and decreased exercise tolerance. What is the next appropriate step in the
evaluation of this patient?
Choices:

1. Send the patient to a pulmonologist

2. Obtain pulmonary function tests
3. Obtain a complete blood count, basic metabolic panel, thyroid- stimulating
hormone, and anti-TPO
4. Give the patient an in-office bronchodilator challenge test, and then send the
patient for a chest x-ray
Answer: 3 - Obtain a complete blood count, basic metabolic panel, thyroid-stimulating
hormone, and anti-TPO

Explanations:

This patient does not require immediate evaluation by a pulmonologist as a primary

Page 620 of 955
 work up. There are multitude issues that can cause this patient's symptoms, including
stress, thyroid disease, or renal issues.
A pulmonary function test would be warranted for someone with symptoms of
asthma or chronic obstructive pulmonary disease. It was not mentioned that this
patient is a smoker or has any family or personal history of asthma or lung disease.
Baseline lab tests are a good starting point for the evaluation of a patient. First,
rule out metabolic causes of this patient's symptoms; which in this case are
consistent with thyroiditis.
While this patient does have shortness of breath with exertion, it is unlikely that at
age 34, this patient would develop new onset asthma. Evaluate for more likely
issues before further workup.
Research Concepts:Hashimoto Thyroiditis

Question 657: A 55-year-old male presents with complaints of a chronic cough

associated with occasional light yellow sputum production and an occasional light
streaks of blood noted in the sputum for the last three months. He also had a weight loss
of 15 pounds. He does feel feverish during evening and night times and sometimes
sweats profusely at night. Extensive testing is done, and the patient is diagnosed to have
Mycobacterium kansasii. The patient is started on a treatment with a three-drug regimen
based on guidelines. What is the most appropriate duration of therapy for this patient?

Choices:

1. Treat for 9 months from the time of negative sputum cultures

2. Treat for 9 months and discontinue treatment if the patient is not having any
further symptoms
3. Treat for 6 months and check sputum cultures and if they are negative then
stop treatment
4. Treat for 12 months from the time of negative sputum cultures

Answer: 4 - Treat for 12 months from the time of negative sputum cultures

Explanations:

The recommended duration of therapy is at least 12 months or more with the goal
to have culture negative results for 12 months on therapy.
Regimens of duration less than 12 months have high relapse rates or lower cure
rates.
The first line therapy recommended by IDSA-ATS guidelines for
M. kansasii is rifampin, ethambutol, and isoniazid.
Page 621 of 955
 Rifampin resistance can be seen in patients who had prior exposure to rifampin and
has been associated with failure of treatment. M. kansasii isolates should be routinely
tested for susceptibility to rifampin.

Research Concepts: Mycobacterium Kansasii

Question 658: A 65-year-old man with metastatic lung adenocarcinoma is intubated for
respiratory distress and placed on mechanical ventilation. After an extensive discussion
with the family, it was decided to palliatively extubate the patient after the patient’s son
arrived the following day. Which is the most appropriate intervention for managing pain
and discomfort in this situation?

Choices:

1. As needed doses of intravenous lorazepam

2. Continuous infusion of fentanyl
3. Continuous infusion of intravenous rocuronium
4. As needed doses of intravenous morphine sulfate
Answer: 2 - Continuous infusion of fentanyl

Explanations:

The selection of an opiate agent should consider the patient's individual needs. For
example, a mechanically ventilated patient with a palliative intent of therapy
should get a continuous infusion of fentanyl, midazolam, or hydromorphone to
help maintain comfort and abolish ventilator asynchrony.
As-needed doses of pain medication can frequently lead to breakthrough pain and
discomfort in mechanically ventilated patients.
Pain in the mechanically ventilated patient is seen as grimacing and biting the
endotracheal tube and ventilator asynchrony.
Patients should never be paralyzed without sedation as it causes intense
discomfort leading to tachycardia and hypertension.

Research Concepts:

End Of Life Evaluation And Management Of Pain

Page 622 of 955

Question 659: A 26-year-old male patient who has HIV and cavitary lung disease presents
to the hospital with sudden onset cough with large amounts of blood in sputum. He is
immediately hospitalized and, for the next 24 hours, has 150 ccs of bright red blood in
several episodes. He emergently undergoes bronchial arterial embolization procedure to
arrest hemoptysis. Earlier the next morning, the nurse notices that the patient has been
incontinent of urine. Upon examination, he has no sensation below his waist and cannot
move his legs as well. What is the likely etiology of his new presentation?

Choices:

1. Acute intracerebral embolic stroke

2. Acute transverse myelitis from spinal ischemia
3. Acute presentation of Guilan Barre syndrome
4. CNS aspergilloma
Answer: 2 - Acute transverse myelitis from spinal ischemia

Explanations:

Bronchial arteries arise from descending thoracic aorta in the T5-T6 segment, with
variants arising from the aortic arch or ascending aorta and occasionally from
other aortic branches in thorax or abdomen. Important in the same context is the
path of the anterior spinal artery receiving collaterals from up to 8 segmental
medullary arteries, ventral to lower thoracic and upper lumbar spinal cord.
Anterior spinal arterial embolization causing acute transverse myelitis is the most
devastating outcome of bronchial arterial embolization.
Acute presentation is with a sudden loss of bladder and bowel control with
sensorimotor loss below a sensory level. Symptoms can occur as early as 4 hours after
onset.
Its incidence has been increasingly rare with advanced angiographic technique, use
of microcatheters, and hypo or iso- osmolar contrast agents. Its rate of occurrence
over the years has been reported between 1.4- 6.5%.
Research Concepts:

Aspergilloma

Page 623 of 955

Question 660: A 27-year old male complains of chest pain, difficulty breathing, and
shortness of breath. His vital sign is remarkable for tachypnea and hypoxia. He reports
that symptoms started after being nearby a blast accident at a construction site. Physical
examination is unremarkable for any external chest injuries. A chest X-ray was done, which
is unremarkable. What is the next step for the management of this patient's condition?

Choices:

1. Discharge home with pain medication and outpatient follow up

2. Admit for supportive care and close monitoring with repeat chest X-ray
3. Thoracostomy
4. Perform emergent intubation
Answer: 2 - Admit for supportive care and close monitoring with repeat chest X-ray
Explanations:

Most pulmonary contusion requires supportive therapy until contusion heals. As

contusion can gradually evolve in 24 to 48 hours after trauma, close monitoring is
required. The goal of therapy is to prevent respiratory insufficiency, failure, and
complications.
Contusion findings may not appear on chest X-ray immediately after injury with an
average delay of 6 hours and sometimes may not be apparent until 48 hours post-
injury. In suspected pulmonary contusion, chest X-ray should be repeated after 12
hours of injury as X-ray findings lag behind the clinical presentation and can be
missed on the initial X-ray done in the immediate post-trauma period.
Supportive care like postural drainage, suctioning, chest physiotherapy, coughing, and
deep breathing can be tried to prevent atelectasis. Positive pressure ventilation,
which uses continuous positive airway pressure and bilevel positive airway pressure,
may be used.
If positive pressure ventilation fails, invasive ventilation is required. Thoracostomy
is not recommended at this stage. It is used in pneumothorax, hemothorax, and
hemopneumothorax.

Research Concepts: Pulmonary Contusion

Page 624 of 955

Question 661: A 78-year-old man presents to the emergency department with severe
dyspnea, cough, and shortness of breath. He has no known medical conditions. However,
he reports that 12 days earlier, he returned from a trip to China. A respiratory virus
endemic to the region is suspected. However, the patient's vital signs do not reveal a
fever. Nevertheless, clinical investigations confirm the suspicion. Which of the following
best explains the lack of fever in this patient?

Choices:

1. Rarely, fever might not be present in this infection

2. False-positive result
3. Typically, fever is not present in this infection
4. The patient has a subacute clinical infection
Answer: 1 - Rarely, fever might not be present in this infection

Explanations:

Fever may not be present in some patients with the Middle East respiratory
syndrome coronavirus, such as those who are very young, elderly,
immunosuppressed, or taking certain medications.
Careful clinical judgment should guide the testing of patients without fever.
Fever is a typical symptom of the syndrome.
Even non-severe forms generally manifest themselves with fever.

Research Concepts:

Features, Evaluation, and Treatment of Coronavirus (COVID-19)

Question 662: A 65-year-old male presents with shortness of breath, weight loss, and dry
cough. A chest x-ray shows an enlarged cardiac silhouette. CT of the chest was then
obtained, which shows mediastinal lymphadenopathy. CT guided biopsy is performed,
and the pathology reports come back positive for CD20+, Burkitt mature B cell lymphoma.
What is the appropriate regimen and dosage of the monoclonal antibody?

Choices:

1. Rituximab 750 mg/m2 with dose-adjusted etoposide, prednisolone,

vincristine, cyclophosphamide, doxorubicin

Page 625 of 955

2. Rituximab 1000 mg/m2 on days 1 and 15
3. Rituximab 375 mg/m2 once weekly for 4 doses
4. Rituximab 375 mg/m2 with dose-adjusted etoposide, prednisolone,
vincristine, cyclophosphamide, doxorubicin
Answer: 4 - Rituximab 375 mg/m2 with dose-adjusted etoposide, prednisolone, vincristine,
cyclophosphamide, doxorubicin
Explanations:

Rituximab is a monoclonal antibody directed against the CD20 antigen on B-

lymphocytes. It is used for the treatment of rheumatoid arthritis, granulomatosis with
polyangiitis, and many malignancies. Rituximab 375 mg/m2 with dose-adjusted
etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin is used for
Burkitt mature B cell lymphoma.
Rituximab 375 mg/m2 with cyclophosphamide, doxorubicin, vincristine,
prednisone is approved for newly diagnosed diffuse large B-cell non-Hodgkin
lymphoma. It has been tested as 21 days or 14-day regimen, but the 21-day
regimen remains the standard first-line treatment in patients with this
hematological malignancy.
Rituximab 1000 mg/m2 is mostly used in the management of rheumatoid arthritis,
administered on days 1 and 15.
Rituximab 375 mg/m2 once weekly for 4 doses has been used in the management
of immune thrombocytopenia (ITP) and pemphigus vulgaris. Rituximab 375 mg/m2
with dose-adjusted etoposide, prednisolone, vincristine, cyclophosphamide,
doxorubicin is used for Burkitt's mature B cell lymphoma.

Research Concepts: Rituximab

Page 626 of 955

Question 663: A 65-year-old female with a history of chronic obstructive pulmonary
disease (COPD), pulmonary hypertension, obesity hypoventilation syndrome, congestive
heart failure, and morbid obesity presents to the hospital with progressively worsening
shortness of breath for two days. On examination, she is dyspneic and using accessory
muscles of respiration. Her oxygen saturation is 78% on 2 L oxygen supplementation; the
pulse is 110/min regular, blood pressure is 175/85 mmHg, and respiratory rate is 28/min.
On auscultation, she has expiratory rhonchi all over. Labs reveal a white blood cell count
of 18,000. The basic metabolic profile shows an elevated creatinine of 3 mg/dL. Arterial
blood gas shows a pH of 7.22, bicarbonate 22 mEq/L, pO2 52 mmHg, and pCO2 45 mmHg.
A chest x-ray shows the right lower lobe pulmonary infiltrate. She is started on antibiotics,
steroids, and nebulizations. She is also placed on non-invasive positive pressure
ventilation with settings of inspiratory positive airway pressure (IPAP) 18 cmH2O and
expiratory positive airway pressure (EPAP) 5 cmH2O. The nurse calls a rapid response as
her mental status declines. A decision is made to intubate her. When the anesthesia team
reaches the bedside, they see a huge leak around the mask, which they fix, after which
her minute ventilation and oxygenation improve. Which of the following adjustments to
her noninvasive positive pressure ventilator is most appropriate to aid in her intubation?

Choices:

1. Decrease the backup rate to 5 so that she is more compliant with the machine
2. Switch to CPAP pressure of 12 cmH2O
3. Increase her FiO2 to 100%, EPAP to 12 cmH2O and IPAP to 24 cmH2O
4. Switch to high flow nasal cannula
Answer: 3 - Increase her FiO2 to 100%, EPAP to 12 cmH2O and IPAP to 24 cmH2O
Explanations:

Understanding the basics of oxygenation and ventilation is crucial when it comes to

critical care and critical procedures like intubation. Before intubation,
preoxygenation is very important. The alveolar gas equation is used to calculate
alveolar oxygen partial pressure as it is not possible to collect gases directly from the
alveoli. The equation helps calculate and closely estimate the PaO2 inside the
alveoli. The variables in the equation can affect the PaO2 inside the alveoli in
different physiological and pathophysiological states. Alveolar gas equation: PAO2 =
(Patm
- PH2O) FiO2 - PaCO2/RQ.
EPAP acts as a PEEP and helps to recruit more alveoli that eventually help in
preoxygenation. Increasing the IPAP will help in keeping the difference between
your IPAP and EPAP which will help in ventilation (Co2).
Increasing Fio2 will again help in oxygenation. With the help of preoxygenation
and ventilation, the procedure of emergent intubation can be carried out more
Page 627 of 955
 easily as this will give the operator time before the patient has a desaturation
event. In normal physiological conditions, the alveolar pO2 is close to 100, and the
operator gets 2 to 3 minutes before the patient desaturates. But if the patient is
given 100% fiO2 before, the operator has almost 8 to 9 minutes before the
patient desaturates.

Research Concepts: Alveolar Gas

Equation

Question 664: A 63-year-old man with metastatic lung cancer is being evaluated in the
ICU. He is intubated for acute respiratory failure. The patient appears in respiratory
distress and is tachypneic on the respirator. He is on a continuous dose of fentanyl via
the intravenous route. On examination of the ventilator, the inhaled tidal volume is 200
mL higher than the exhaled tidal volume. The respiratory rate as seen on the ventilator is
40/min. Which of the following is the next best step in the management of this patient?

Choices:

1. Increase the dose of fentanyl

2. Push 2-3 mL of air in the endotracheal tube balloon
3. Intravenous rocuronium
4. Intravenous midazolam

Answer: 2 - Push 2-3 mL of air in the endotracheal tube balloon

Explanations:

Intubated patients should be evaluated for ventilator-patient asynchrony to mitigate

pain.
A discrepancy in the inhaled and exhaled tidal volume can depict an air leak, and
air must be instilled into the endotracheal tube balloon to abolish the leak.
Patients who are mechanically ventilated should have respiratory therapists
performing frequent adjustments to the ventilator, changing the ventilatory circuit,
and suction.
Pulmonary medicine should be involved in abolishing ventilator- patient synchrony,
which can cause severe distress.

Research Concepts:End Of Life Evaluation And Management Of Pain

Page 628 of 955
Question 665: A 17-year-old male with a past medical history of diabetes mellitus type 1
presents after being hit by a bus while crossing an intersection. On examination, he is
afebrile. His Glasgow Coma Scale score is 3/15, and both pupils are fixed and dilated. The
patient's head and neck are arched backward, and his extremities are extended. Before
receiving any sedation for elective intubation to protect the airway, his spontaneous
breaths were slow regular gasping inspirations with a pause followed by an inadequate
expiration. There are no skin rashes noted. His fingerstick glucose is 300 mg/dL. His
arterial blood gases reveal severe respiratory acidosis. His urine drug screen is pending.
What is the likely cause of this patient's abnormal breathing pattern?

Choices:

1. Diabetic ketoacidosis
2. Opiate overdose
3. Spinal shock
4. Traumatic brain injury

Answer: 4 - Traumatic brain injury

Explanations:

This patient exhibits an apneustic breathing pattern characterized by a slow deep

inspiration followed by a pause with a very short, inadequate expiration.
An apneustic breathing pattern most commonly presents after damage to the
upper pons and occasionally the upper medulla secondary to trauma.
Neurologic features associated with apneustic breathing include decerebrate
posturing, fixed dilated pupils, coma, quadriparesis, and absent corneal reflex.
The two most common causes of pontine and medullary damage are traumatic
brain injury and stroke. Occasionally, the sedative medication ketamine will cause
an apneustic breathing pattern. Metabolic acidosis may lead to Kussmaul breathing
to increase the pH with hyperventilation. Prolonged hypoxia causes neurogenic
central hyperventilation. This patient's slow deep gasping inspiration with a pause
followed by inadequate exhalation is consistent with the apneustic breathing
pattern.

Research Concepts:

Abnormal Respirations

Page 629 of 955

 Question 666: A 57-year-old female patient is admitted to the hospital with worsening
epigastric abdominal pain, nausea, and vomiting. She has a past medical history of
diabetes, hypertension, and alcohol use disorder. She is diagnosed with acute
pancreatitis and is admitted to the ICU for treatment. Her course is complicated by the
development of pancreatic necrosis with the acute respiratory syndrome and sepsis. She
is intubated and placed on mechanical ventilation. While undergoing central venous
catheterization via the subclavian vein, the patient goes into cardiac arrest and requires
cardiopulmonary resuscitation(CPR). Spontaneous circulation returns after 8 min of CPR.
Which of the following is the next best step in management?
Choices:

1. Arterial blood gas analysis

2. Chest radiography
3. Echocardiography
4. Venous oximetry
Answer: 2 - Chest radiography
Explanations:

Tension pneumothorax is a common complication with a central venous catheter

insertion, often seen with subclavian vein catheterization. Emergent chest
radiography is done to confirm [Link] the routine use of bedside
ultrasonography of the chest in most intensive care unit ,reliable findings on the
ultrasound can be sufficient to pick up a [Link] the patient is unstable
and suspicion is strong, do not wait for chest radiography; immediately perform
needle thoracostomy to decompress the chest.
Tension pneumothorax is life-threatening, especially in patients that are critically ill.
It occurs due to the progressive accumulation of intrapleural air in the thoracic wall.
It displaces the mediastinum to the other side comprising hemodynamic stability. In
this patient, the increasing pressure hindered venous return to the heart, thereby
causing cardiac arrest.
Needle decompression is performed using a 14-16 gauge needle inserted into the
second intercostal space along the midclavicular line. A chest x-ray is performed
after the procedure to ensure the expansion of the lung. A chest tube is inserted as
soon as possible. As the patient is clinically fragile, it is important to monitor the
patient closely.
Arterial blood gas analysis and venous oximetry can be performed subsequently to
determine hemodynamic status after the patient is stabilized.
Research Concepts: Venous Oxygen
Saturation

Page 630 of 955

Question 667: A 41-year-old man with no significant past medical history presents to the
base camp medical tent at Mount Everest with complaints of exertional chest pain and
bilateral peripheral edema. He has been training at basecamp for three months and
plans to attempt an Everest summit in a few weeks. He has also experienced two
episodes of exertional syncope while climbing between base camp (5400 m) and camp 1
(6100 m). His blood pressure is 120/80 mmHg, and his Sp02 is 89%. Examination
demonstrates jugular venous distension, 2+ bilateral lower extremity edema, and a
holosystolic murmur heard best at the subxiphoid area. EKG shows tall QRS complexes
and tall P waves. What is the gold standard diagnostic test to confirm the suspected
condition?

Choices:

1. Echocardiogram
2. Pulmonary function tests
3. Ventilation-perfusion scan
4. Right heart catheterization

Answer: 4 - Right heart catheterization

Explanations:

It is essential to recognize the signs and symptoms of right- sided heart failure as it
relates to high-altitude pulmonary hypertension (HAPH). If an individual takes
significant time to reside and train at high altitudes (Everest base camp is >5000
meters), he will be at risk of developing elevated pulmonary pressures and
pulmonary vascular resistance, eventually presenting as right heart failure.
While an echocardiogram will give an estimate of pulmonary artery systolic
pressure, chamber sizes, and right ventricular function, it is purely an estimate
and somewhat operator- dependent and often inconclusive. Valvulopathy and
structural heart defects can have similar echocardiogram findings to HAPH.
Right heart catheterization (RHC) is the gold standard to confirm the diagnosis of
HAPH and determine the extent of clinical hemodynamic instability and disease
prognosis. This diagnostic modality will also allow the clinician to rule out left-sided
cardiac pathology as the possible cause of PH.
A diagnostic criterion for HAPH is an mPAP >30 mmHg on RHC. Other measurements
taken with RHC such as mPCWP are also essential to rule out alternative causes of
pulmonary hypertension.

Research Concepts:Altitude Induced Pulmonary Hypertension

Page 631 of 955

Question 668: A 17-year-old patient presents with severe chest trauma following a
motor vehicle collision. The patient is short of breath and tachypneic. His primary chest
x-ray is unremarkable. He is admitted to the surgery floor. His follow-up chest x-ray after
24 hours signifies irregular, non-lobular opacification of the pulmonary parenchyma. His
vital signs are pulse rate: 89 beats per minute, blood pressure: 108/78 mmHg,
respiratory rate: 23 breaths per minute, and temperature: 37.9 C (100 F). What is the
preferred management?

Choices:

1. Intravenous heparin infusion and check PTT every 6 hours

2. Chest CT scan without intravenous contrast
3. Continous supportive treatment with suctioning and chest physiotherapy
4. Flexible bronchoscopy and lavage with cold saline
Answer: 3 - Continous supportive treatment with suctioning and chest physiotherapy
Explanations:

Supportive care like postural drainage, suctioning, chest physiotherapy, incentive

spirometry, encouraging coughing, and deep breathing can be tried to prevent
atelectasis.
Prone positioning of the patient with contusion reduces pressure on the diaphragm,
and positioning of the contused lung in a non- dependent position helps in
recruiting alveoli. Noninvasive ventilation can cause gastric distention and
aspiration, especially if the level of consciousness is impaired.
It is of utmost importance to provide minimum positive end- expiratory pressure
(PEEP) to maintain the lungs open, recruit maximum alveoli, and prevent
barotrauma. If positive pressure ventilation fails, invasive ventilation is required.
Large tidal volume can have adverse effects; hence the use of low tidal volume is
suggested.
Patients with severe hypoxia and with poor response to other therapies can
benefit from nitric oxide. Diuretics can be used in a contusion to reduce pulmonary
venous resistance and pulmonary capillary hydrostatic pressure. If fluid therapy is
required to maintain euvolemia, measuring pulmonary artery pressure is
recommended to avoid pulmonary edema.

Research Concepts: Chest Trauma

Page 632 of 955

Question 669: A 16-year-old female patient with asthma comes in for a follow-up. She
currently uses inhaled albuterol 100 mcg as needed combined with beclomethasone
dipropionate 400 mcg twice a day. Despite this, she is having frequent exacerbations of
asthma and recently required a course of oral steroids. What is the most appropriate
next step in management?

Choices:

1. Add oral albuterol

2. Add tiotropium
3. Add salmeterol
4. Stop beclomethasone and start fluticasone

Answer: 3 - Add salmeterol

Explanations:

This patient is on the second step of asthma management, where she is using an
inhaled beta 2-agonist as needed and inhaled steroids twice a day.
However, her frequent exacerbations indicate that the therapy is inadequate and
needs to be escalated.
The next step in asthma management would be to add an inhaled long-acting beta
2-agonist (LABA).
The response to LABA would decide whether it is to be continued or not. If there is
a benefit from LABA but the response is inadequate then the inhaled steroid dose
is increased to 800 mcg/day. If there is no response to LABA it is stopped and the
next step of asthma management is initiated.

Research Concepts:

Asthma Medications

Page 633 of 955

Question 670: A 76-year-old African-American male presents to the clinic for a follow-up
evaluation. His past medical history is significant for nonspecific interstitial pneumonitis,
for which he takes prednisone 10 mg daily. He also has dyslipidemia, hypertension,
diabetes mellitus type 2, and chronic hypoxic respiratory failure. He is currently on
atorvastatin, amlodipine, spironolactone, metformin, and glyburide. He is prescribed 2 L
of oxygen for ambulation. He has a 35-pack-year smoking history. In the last three weeks,
he is progressively getting short of breath, fatigued, and has decreased exercise tolerance.
He denies any chest pain, diaphoresis, or paroxysmal nocturnal dyspnea. On examination,
he is in no distress. His vital signs are within normal limits. There is no pallor or
thyromegaly. Chest auscultation shows bibasilar crackles and normal S1-S2. The abdomen
is soft and non-tender. Trace pitting edema is present bilaterally in the lower extremities.
His electrocardiogram (ECG) shows normal sinus rhythm with T wave inversions in lateral
leads, similar to a previous ECG. Which of the following is the next best step in the
management of this patient?

Choices:

1. Stress testing
2. AP and lateral chest x-ray
3. 6-minute walk test in the office
4. Computed tomography of the chest with contrast
Answer: 3 - 6-minute walk test in the office
Explanations:

This patient has a progressive decline in his exercise tolerance. A 6-minute walk
test is a simple office-based test that helps the provider understand the respiratory
parameters (oxygen saturation, respiratory rate, lung auscultation). It can also help
evaluate the progression of disease severity.
Exercise tolerance and oxygen requirement should be evaluated in every office visit
for patients with nonspecific interstitial pneumonitis.
Titrating oxygen requirements will help with better functioning in oxygen-
dependent patients with nonspecific interstitial pneumonitis.
The patient has multiple risk factors for coronary artery disease, and will likely need
a stress test. However, the 6-minute walk test can evaluate for hypoxia at this time
and allow the necessary treatment. Oxygen titration will likely improve his
symptoms and increase his daily quality of life.

Research Concepts:Nonspecific Interstitial Pneumonitis

Page 634 of 955

Question 671: An 82-year-old man is admitted to the hospital for dyspnea and sputum
production. He has a long-standing history of chronic obstructive pulmonary disease
(COPD) and has been admitted three times over the past six months. He currently uses
ipratropium, prednisone, roflumilast, and 4 L/min home oxygen. He is diagnosed with
another episode of COPD and given appropriate treatment. As part of his management,
palliative options are discussed and he states he would like to pursue palliative care
moving forward. Which of the following therapies is most appropriate to be offered as
part of his future treatment?

Choices:

1. Intubation
2. Lobectomy
3. Morphine
4. Montelukast
Answer: 3 - Morphine

Explanations:

The patient has chosen palliative care as his future COPD management. Palliative
care for COPD includes offering therapies that improve the patient's symptoms or
anxiety, without the aim of improving mortality (possibly worsening mortality).
Appropriate palliative therapies for COPD include bronchodilating inhalers, home
oxygen, and morphine.
Although morphine suppresses the respiratory drive, it is used to decrease the anxiety
associated with dyspnea in patients with COPD.
Intubation and lobectomy are aggressive treatments, not appropriate for palliative
care. Montelukast is not recommended in patients with COPD.

Research Concepts:

Palliative Care

Page 635 of 955

Question 672: A 65-year-old male presents to the clinic with complaints of dyspnea,
cough, and low-grade fever. The patient underwent a right lung transplant 3 weeks ago.
The patient has a past medical history significant for chronic obstructive pulmonary
disease. On examination, there are decreased breath sounds in the right lower lobe. A
chest x-ray reveals ill-defined lower lobe opacities and pleural effusion. His forced
expiratory volume (FEV1) has decreased by more than 10% compared to three days after
the surgery. He fails to respond to pulse intravenous methylprednisolone. What is the
next step in the management of this patient?

Choices:

1. Retransplant
2. Administer anti-lymphocyte globulin
3. Intravenous macrolides
4. Extracorporeal membrane oxygenation
Answer: 2 - Administer anti-lymphocyte globulin

Explanations:

Acute lung rejection tends to occur within the first 4 months after a transplant. The
patient may be entirely asymptomatic or present with dyspnea, fever, decreased
forced expiratory volume in one second (FEV1), or opacities in the lung.
Anti-lymphocyte globulin (ALG) contains antibodies against human T cells and is
used to treat acute rejection in organ transplantation.
For steroid-resistant patients, anti-lymphocyte serum usually can reverse the
rejection.
The standard treatment is pulse intravenous methylprednisolone followed by high oral
prednisone.
Research Concepts:

Lung Transplant Rejection

Question 673: A 65-year-old woman with a past medical history of hypertension, diabetes
mellitus type 2, and chronic obstructive pulmonary disease is referred to the emergency
department by her PCP for complaints of low-grade fever, cough, and myalgia. She
reports she works as a medical assistant. She denies any symptoms of shortness of breath
and reports checking her saturation using a pulse oximeter which showed SpO2 of 98%
on room air. She is tested for rapid SARS-CoV-2, which comes back positive. Besides
discussing smoking cessation and supportive care, which of the following is the most
appropriate recommendation for this patient?

Page 636 of 955

Choices:

1. Dexamethasone
2. Sotrovimab
3. Hydroxychloroquine
4. Nirmatrelvir and ritonavir
Answer: 4 - Nirmatrelvir and ritonavir

Explanations:

The patient described in the above clinical vignette has mild COVID-19 illness. Given
her longstanding history of tobacco use and age of more than 65 years with other
comorbid conditions, she is at high risk of disease progression.
Nirmatrelvir and ritonavir are most effective if used early during the course of
illness.
Additionally, the patient should be followed up after administering nirmatrelvir
and ritonavir until she has complete clinical recovery
Hydroxychloroquine is not indicated in the management of COVID-19 either as
an inpatient or on an outpatient basis. Dexamethasone is authorized for use in
patients with severe COVID-19 requiring respiratory support. Sotrovimab is
not effective against the omicron variant.

Research Concepts:

Evaluating And Referring Patients For Outpatient Monoclonal Antibody Therapy

For Coronavirus (COVID-19) In The Emergency Department

Question 674: A 46-year-old male patient comes to the clinician with wheezing,
tachypnea, and retractions. He was in his usual state of health this morning and spent the
day outside waterproofing the fabric on his boat. He has a past medical history of COPD,
for which he uses inhalers only as needed and continues to smoke. The patient is afebrile,
with oxygen saturation of 91%, blood pressure of 148/92 mm Hg. His labs are within
normal limits, and his chest x-ray reveals hyperinflation with no infiltrates. The patient
states no other new issues, and he has used this sealant many times in the past.
What is the most likely cause of his current respiratory problem?

Choices:

1. Pneumonia
Page 637 of 955
2. Seasonal allergies
3. Chronic smoking
4. Waterproofing sealant
Answer: 4 - Waterproofing sealant

Explanations:

Though the patient has used the sealant in the past, due to the clean air act, there
was a transition of fluoroalkane structure to fluoroalkene structure, which is more
toxic.
Fluorocarbon based products are used a wide variety of household items, including
lubricants, sealants, leather conditioners, etc. have a high index of suspicion for
product exposure in acute respiratory symptoms.
Patients with underlying lung disease are at higher risk for reactions to exposure.
This is highly unlikely to be pneumonia based on history, including afebrile, abrupt
onset without new symptoms suggesting infectious disease. Though chronic
smoking puts the patient at higher risk for COPD exacerbations and increases the
severity, the waterproofing agent was the more likely cause of acute illness.

Research Concepts:

Fluorides and Fluorocarbons Toxicity

Question 675: A 58-year-old male with a past medical history of prostate cancer, status
post prostate resection 5 years ago, as well as long-standing osteoarthritis and cigarette
smoking which is 3 weeks status post left knee replacement presents to the emergency
department with a complaint of 3 days of progressive pleuritic chest discomfort, shortness
of breath, and a mild cough with blood-tinged sputum. His left lower extremity has been
persistently swollen since the surgery. His vital signs include a heart rate of 104 beats per
minute, blood pressure of 138/84 mm Hg, pulse oximetry reading of 97% on room air, and
an oral temperature of 37.4 C (99.32 F). Which of the following is most accurate regarding
his diagnosis?

Choices:

1. The left upper lobe of his lung is the most likely region of the lung to be affected by
this condition.
2. Air bronchograms on a CT of the chest are highly suggestive of this diagnosis.
Page 638 of 955
3. An area of radiographic oligemia (increased lucency) on a chest x- ray makes this
diagnosis less likely.
4. A peripheral wedge-shaped hyperdensity seen on a chest x-ray in the appropriate
clinical setting is a specific finding for this diagnosis.
Answer: 4 - A peripheral wedge-shaped hyperdensity seen on a chest x-ray in the appropriate
clinical setting is a specific finding for this diagnosis.
Explanations:

Pulmonary embolism is the most common cause of pulmonary infarction and,

though there are numerous risk factors and signs of pulmonary embolism, clinical
signs and symptoms of deep vein thrombosis, heart rate over 100 beats per minute,
immobilization or surgery within the previous 4 weeks, history of previous venous
thromboembolism, hemoptysis, malignancy, exogenous hormone use, and age over
50 are frequently cited. Hampton’s hump (wedge-shaped consolidation at the lung
periphery), Westermark’s sign (radiographic oligemia or increased lucency), and
Fleischer sign (prominent pulmonary artery) are specific chest x-ray findings for
pulmonary infarction. Though chest x-rays can show specific findings that are highly
suggestive of pulmonary infarction, these findings have poor overall sensitivity,
making CT angiogram of the chest the preferred method for diagnosis of pulmonary
embolism with or without infarction. CT angiogram findings associated with
pulmonary infarction include a feeding vessel or "vessel sign," central lucency, and
semicircular shape. Additionally, the finding of air bronchograms on CT makes the
presence of a pulmonary infarction less likely.
Unilateral infarct occurs most common with pulmonary infarction, with the lower
lobes having a strong predilection over the upper lobes, and the right lower lobe is
the most frequently affected.

Research Concepts:Pulmonary Infarction

Question 676: A 55-year-old man presents to the clinic with complaints of fatigue, which
has been worsening for the past 2 months. He feels that it is very difficult for him to walk
to the grocery store, which is one block away. More recently, he has been feeling fatigued
even while doing his daily chores. He experiences episodic presyncopal events. He never
passed out completely. He also states that his legs and belly are more swollen than usual.
He also reports a dry cough, which has been present for the past 2 months. He was never
a smoker. He was diagnosed with interstitial lung disease 2 years ago, and he is on
riociguat for the same. On examination, he is obese with a BMI of 32 kg/m2. His neck veins
are distended, and he has bilateral lower extremity pitting pedal edema. Auscultation is
significant for a pansystolic murmur in the left parasternal area.
Which of the following is most likely to be seen on the CT chest of this patient?

Page 639 of 955

Choices:

1. Mean pulmonary artery diameter of 17 mm

2. Normal lung parenchyma
3. Mean pulmonary artery diameter greater than 29 mm
4. Normal biventricular size
Answer: 3 - Mean pulmonary artery diameter greater than 29 mm

Explanations:

Clinical features suggestive of right-sided heart failure, including fatigue, exertional

chest pain, loud pulmonic heart sound, elevated jugular venous distension (JVD),
and peripheral edema in the setting of underlying lung disease can implicate cor
pulmonale.
Pulmonary function testing in patients with pulmonary hypertension is more likely to
show a severely reduced diffusion capacity of less than 30% of predicted.
There is a rapid decline of arterial oxygenation on exercise in these patients.
Imaging like a CT scan shows an enlarged main pulmonary artery with a diameter of
more than 29 mm.

Research Concepts:

Cor Pulmonale

Question 677: A 65-year-old male with a history of cerebrovascular accident 5 years prior
has right-sided hemiparesis. The patient has increased cough with sputum production for
more than 6 weeks. Vitals are temperature 99 degrees Fahrenheit, heart rate 78
beats/min, blood pressure 110/89 mmHg, oxygen saturation 98% room air. The patient
was started on broad-spectrum antibiotics 5 days ago. The patient's chest computed
tomography showed a cavitary lesion with air-fluid levels measuring > 6 cm. What is the
best next step in the definitive management of this patient?

Choices:

1. Surgical drainage of the lesion

2. Narrow the spectrum of antibiotic therapy
3. Bronchoscopy with fluid cytology
4. Continue with current management

Answer: 1 - Surgical drainage of the lesion

Page 640 of 955
Explanations:

Abscesses larger than six centimeters are unlikely to resolve with antibiotic therapy
alone and might require surgical or percutaneous intervention.
Surgical intervention is considered in patients who fail to respond to medical
therapy with segmentectomy or lobectomy. In patients who are poor surgical
candidates percutaneous and endoscopic drainage can be considered.
Early signs and symptoms of lung abscess cannot be differentiated from
pneumonia and include fever with shivering, cough, night sweats, dyspnea, weight
loss and fatigue, chest pain and sometimes anemia.

Research Concepts:

Lung Abscess

Question 678: A 67-year-old male with a past medical history of chronic obstructive
pulmonary disease, hypertension, and sleep apnea presents with complaints of excessive
fatigue limiting his daily activity, increasing dyspnea, a 15-pound (7 kg) unintentional
weight loss over the last 6 months, and an episode of hemoptysis which occurred one day
ago. He has been noncompliant with medical therapy for the last several years. He has a
45-pack-year smoking history and is still smoking. A computed tomography (CT) scan of
the chest demonstrates a 6 cm irregular mass with spiculated borders in the right upper
lobe. A small portion of the liver is caught on the chest imaging, which demonstrates
multiple suspicious lesions. A positron emission tomography (PET) scan shows widespread
lesions in the liver with increased uptake in addition to increased uptake in the lung mass.
A biopsy of the lung mass is performed, which reveals squamous cell carcinoma of the
lung. Testing for gene mutations is negative. The patient is given cisplatin, gemcitabine,
and a monoclonal antibody. Which of the following best describes the mechanism of
action of the monoclonal antibody prescribed to this patient?
Choices:

1. Vascular disruption
2. Soluble molecule inhibition
3. Antibody-dependent cell-mediated phagocytosis
4. Immune-mediated cell destruction
Answer: 1 - Vascular disruption
Explanations:

Page 641 of 955

 The patient was ultimately diagnosed with metastatic squamous cell cancer and
started on the appropriate chemotherapy (cisplatin and gemcitabine) with
concurrent vascular endothelial growth factor-A (VEGF-A) inhibitor bevacizumab.
Inhibition of VEGF-A inhibits the neovascularization associated with malignancies
and can help decrease tumor burden.
Soluble molecule inhibition refers to the inhibition of cytokines, as seen with TNF-
alpha inhibitors like adalimumab. These agents have no role in the inhibition of
VEGF-A in metastatic squamous cell cancers.
Immune-mediated cell destruction encompasses antibody- dependent cellular
toxicity and antibody-dependent cell- mediated phagocytosis, neither of which are
related to the mechanism of action for bevacizumab.
Gemcitabine is particularly effective for squamous cell cancers in combination with
cisplatin chemotherapy.

Research Concepts:Understanding How Monoclonal Antibodies Work

Question 679: A 5-year-old boy with well-controlled atopic dermatitis is brought to the
clinic by his parents with excess day time sleepiness and noisy breathing, which is worse at
night for the past 6 months. Physical exam reveals a tired child who is not in distress,
tends to keep his mouth open and speaks with a nasal twang. His ENT exam is remarkable
for some tonsillar hypertrophy without exudates, and his tympanic membranes are not
bulging, but have decreased light reflex bilaterally. His chest exam is unremarkable with
no wheeze or stridor. What is the next best step in the management of this patient?

Choices:

1. Refer to allergist
2. Obtain radiograph of the neck
3. Obtain polysomnography
4. CT scan of the mastoid
Answer: 3 - Obtain polysomnography

Explanations:

The patient in this vignette has likely obstructive sleep apnea (OSA).
The gold standard test for OSA is polysomnography. This can also determine the
severity of OSA by calculating the apnea- hypopnea index. Apnea-hypopnea index
= total number of apneas and hypopneas/total duration of sleep in hours.
An apnea-hypopnea index of less than one is considered to be normal in children. An
apnea-hypopnea index of more than 20 is considered severely abnormal.
Page 642 of 955
 Lateral neck radiograph can sometimes suggest adenoidal hypertrophy but is not
diagnostic of OSA. In acute airway obstruction, lateral radiographs may be able to
identify a radioopaque foreign body, supraglottic when 'thumb sign' present, soft
tissue enlargement suggestive of a retropharyngeal abscess and 'steeple sign
suggestive of croup. Overall, lateral neck radiographs are not diagnostic of OSA or
other upper airway obstructive diseases. The tympanic membrane findings suggest
middle ear effusion, but there was no indication of mastoid involvement; therefore
CT of the mastoid is not indicated. Nasal allergies can contribute to adenoidal
hypertrophy, and evaluation by an allergist can help with managing allergies.
However, polysomnography is needed to confirm the diagnosis of OSA.

Research Concepts: Apnea In Children

Question 680: A 65-year-old female presents with shortness of breath on exertion (SOB).
She has a past medical history of hypertension, diabetes mellitus, chronic systolic heart
failure with an ejection fraction of 30%. The patient also reports fevers for five days
associated with productive cough with yellow sputum. The patient was admitted to the
medical floor for further evaluation. A chest x-ray shows moderate bilateral effusions. The
patient was started on furosemide for possible congestive heart failure exacerbation with
minimal improvement of symptoms and started on ceftriaxone and azithromycin for
possible community-acquired pneumonia.
Diagnostic and therapeutic thoracocentesis was performed, given that the patient is
febrile. Serum LDH is 200 U/L; serum protein is 5g/dl. Pleural fluid LDH is 120U/L; pleural
fluid protein is 2 g/dl. The patient is afebrile, but her shortness of breath is not improved.
Computed tomography chest was done as patient symptoms are not improved, which
showed loculated effusion on the right side with pleural thickening and non-expandable
lung. What is the best next step of management?

Choices:

1. Video-assisted thoracoscopic surgery (VATS)

2. Continue aggressive diuresis and consider ischemic workup
3. Consider changing antibiotics to vancomycin and piperacillin
4. Continue current management
Answer: 1 - Video-assisted thoracoscopic surgery (VATS)
Explanations:

Video-assisted thoracoscopic surgery should be considered for trapped lung. It is also

important to avoid repeat thoracocentesis for pleural effusions associated with
Page 643 of 955
 trapped lung, given it will further complicate loculated effusions.
Video-assisted thoracoscopic surgery is gaining more importance and can
potentially avoid open thoracotomy, associated with more complications.
Video-assisted thoracoscopic surgery is associated with a decreased hospital stay,
decreased postoperative pain, and early recovery.
Continuing current management or changing antibiotics in effusions associated
with the trapped lung is not beneficial. In the case of non-expandable lung, post
thoracocentesis, especially in the thickened pleural setting, one should consider
trapped lung, and VATS should be considered as soon as possible to void further
complications more extensive surgeries.

Research Concepts:Trapped Lung

Question 681: A 17-year-old male is climbing Denali on day 4 of the expedition. He felt
short of breath with exertion yesterday but now reports feeling short of breath at rest.
His vitals are as follows: blood pressure 117/78 mmHg, heart rate 112/min, respiratory
rate 25/min, oxygen saturation 86% on room air, temperature 99.9 F (37.7 C). What is
the most appropriate treatment for this patient's condition?

Choices:

1. Administer oxygen, stop at current altitude, and rest for one day
2. Immediate descent
3. Dexamethasone
4. Azithromycin
Answer: 2 - Immediate descent

Explanations:

Immediate descent is the most important treatment for high- altitude pulmonary
edema. This patient is hypoxic and dyspneic even at rest and must descend.
Oxygen administration is beneficial if available in treating high- altitude pulmonary
edema; however, the best treatment option is immediate descent. Oxygen may be
used in conjunction with descent but should not replace it.
Patients experiencing early, mild symptoms of high-altitude pulmonary edema
such as early fatigue with exertion may be candidates to pause ascent and rest for
2-3 days to acclimatize at altitude before continuing ascent at a slower pace.
Dexamethasone has not been proven to be an effective treatment for high-altitude
pulmonary edema, although it is used in the treatment of high-altitude cerebral
edema. Azithromycin is useful in the treatment of pneumonia, but this patient's
Page 644 of 955
 hypoxia and temperature elevation are better explained by high-altitude
pulmonary edema given the clinical scenario.

Research Concepts:

High Altitude Cardiopulmonary Diseases

Question 682: A 65-year-old male is admitted with a 5 day history of a cough productive
of rust colored sputum and fevers. He has a 40-pack-year history and a history of
hypertension on lisinopril. The cardiac exam is normal, but the right chest is dull to
percussion halfway up with decreased breath sounds. Chest radiograph shows
consolidation of the right lower lobe and an effusion. Select the factor that would not
indicate the need for a chest tube.

Choices:

1. Positive Gram stain

2. Pleural fluid glucose of 100 mg/dL
3. Pleural fluid pH less than 7.2
4. Loculation
Answer: 2 - Pleural fluid glucose of 100 mg/dL

Explanations:

Parapneumonic effusions should be evaluated by thoracentesis if thicker than 1 cm.

Criteria for tube thoracostomy are pH less than 7.2, glucose less than 60 mg/dL,
loculation, frank purulent material, positive Gram stain, or positive culture.
Failure to drain such conditions can result in empyema limiting lung reexpansion.
In most cases, parapneumonic effusions that are sterile will resolve within a week
with appropriate antibiotic treatment. However, a repeat CT scan is needed to
determine if the effusion is resolving or empyema is forming.

Research Concepts:

Parapneumonic Pleural Effusions And Empyema Thoracis

Page 645 of 955

Question 683: A 35-year-old male presents with fever, non- productive cough, and
shortness of breath for the last three days. He works in a factory that makes detergents
and waterproofing chemicals. He has been a smoker for the past 15 years. Which of the
following can further decrease the risk of fluoropolymer- associated respiratory illness in
this patient?

Choices:

1. Maintain adequate hydration

2. Apply products with a trigger spray
3. Smoking cessation
4. Avoid products whose ingredient list or MSDS indicates the presence of
fluoropolymers

Answer: 3 - Smoking cessation

Explanations:

Avoidance of smoking is recommended to avoid exposure to fluoropolymer pyrolysis

products.
Harmful content in tobacco smoke will further increase oxidative stress in this patient.
The toxic potency of fluoropolymer thermal decomposition and combustion products
is approximately 10 times that of most common polymers.
Many of these products do not note the presence of a fluoropolymer on the MSDS
as it often comprises less than 1% of the total ingredients. In addition, identifying
the primary manufacturer of some of these products is difficult as several levels of
distributors may be involved in the packaging and marketing of the final product,
further complicating efforts to obtain the MSDS.
Research Concepts:

Fluorides and Fluorocarbons Toxicity

Question 684: A 67-year-old female presents to the office for evaluation following the
identification of a solitary lung nodule with malignant features. She has a 40-pack-year
smoking history and still smokes 1-pack-per-day. Her medical history is also significant for
hypertension, hyperlipidemia, and emphysema. She is not on supplemental oxygen at this
time. On imaging review, the provider notes a 1.5cm peripheral nodule in the left middle
lobe. Which of the following is the most appropriate next step in the workup?

Choices:

Page 646 of 955

1. Resection via segmentectomy or lobectomy
2. Pulmonary function testing
3. Positron emission tomography-computed tomography scan
4. Repeat imaging in 6-12 months
Answer: 2 - Pulmonary function testing

Explanations:

This patient with a concerning nodule requires further workup. Pulmonary

function testing provides an understanding of their capacity to undergo lung
resection.
Biopsy of the lesion would also be appropriate, but pulmonary function testing
may be completed beforehand.
It is important to assess the ability to tolerate resection before operating. It is also
too early to know what level of resection would be indicated.
Positron emission tomography-computed tomography scan can be useful in biopsy-
proven malignancy but is not the initial workup. It is also inappropriate to follow a
concerning lesion with serial imaging without attempting to biopsy the tissue.

Research Concepts:

Segmental Lung Resection

Question 685: A 70-year-old female is admitted to the intensive care unit with respiratory
failure and acute respiratory distress syndrome (ARDS). After several changes to the
ventilator, her oxygen saturation is less than 90%. Current ventilator settings are positive
end-expiratory pressure of 10 cm H2O, a fraction of inspired oxygen of 60%, plateau
pressure less than 30 cm H2O, tidal volume of 6 mL/kg of ideal body weight, and
respiratory rate of 18 breaths per minute. An arterial blood gas result comes back with a
pH of 7.27, PaCO2 of 60 mmHg, and a P/F ratio of less than 100 (consistent with severe
ARDS). What changes should be made to the ventilator settings for hypercarbia?

Choices:

1. Continue current ventilator settings

2. Increase inspiratory flow rate
3. Increase the tidal volume to greater than 8 mL/kg ideal body weight
4. Decrease positive end-expiratory pressure
Page 647 of 955
Answer: 1 - Continue current ventilator settings

Explanations:

For severe acute respiratory distress syndrome, some degree of hypercarbia is

acceptable if oxygenation goals are being met.
This is known as permissive hypercarbia or permissive hypercapnia. Some sacrifices
are made to ventilation to adhere to a lung-protective ventilation strategy in
severe acute respiratory distress syndrome.
Acute respiratory distress syndrome is often characterized by refractory hypoxemia.
In the exudative phase of early acute respiratory distress syndrome, an exaggerated
inflammatory response makes the lungs especially susceptible to ventilator- induced
trauma. Multiple studies have confirmed the benefit of limiting tidal volume to 6-8
mL/kg ideal body weight for lung- protective ventilation strategy, with a tradeoff for
mild ventilatory compromise.
Exceptions to permissive hypercarbia include patients with conditions where mild
acidosis or CO2 retention could cause more harm than benefits, such as those with
elevated intracranial pressures of pregnancy.
Increasing either the respiratory rate or tidal volume would boost ventilation and
correct the acidosis and CO2 clearance. Current ventilator settings should be
maintained for this patient. In this scenario, increasing positive end-expiratory
pressure would not impact hypercarbia substantially.
Research Concepts: Hypercarbia

Question 686: A 17-year-old girl presents to the hospital complaining of severe shortness
of breath. She has a history of poorly controlled asthma, for which she takes a
combination inhaler of corticosteroids and long-acting beta-agonists, and montelukast 10
mg at night. She has had two ICU admissions in the past six months for asthma
exacerbations. On examination, she looks tired, and her blood pressure is 135/75 mmHg,
the pulse is 104/min regular. On auscultation, there is decreased air entry and wheeze all
over the chest. Peak flow has only improved from 160 l/min on admission to 210 l/min
after three salbutamol nebulizers. Her predicted peak expiratory flow is 590. A chest
radiograph reveals left basal non- homogenous haziness. Arterial blood gases show a
PaO2 of 58 mmHg. Which of the following indicates life-threatening asthma?

Choices:

1. PaCO2 of 34 mmHg
2. PaO2 of 55 mmHg
3. X-ray changes
Page 648 of 955
4. A pH of 7.45
Answer: 2 - PaO2 of 55 mmHg

Explanations:

Acute asthma is classified as acute severe asthma, life- threatening asthma, and near-
fatal asthma.
Criteria for life-threatening asthma include some physical findings, such as the
silent chest, cyanosis, poor respiratory effort, exhaustion, and altered
consciousness level.
Some other parameters include peak expiratory flow of less than 33% best or
predicted, SpO2 less than 92%, Pa02 less than 60 mmHg, normal PaCO2, and
arrhythmia.
ICU admission with consideration of tracheal intubation and mechanical ventilation
should be considered in such cases.

Research Concepts:

Asthma

Question 687: A 65-year-old male presents to the pulmonologist for evaluation. He suffers
from frequent cough and chest tightness.
He also reports being short of breath after walking short distances. He is a chronic smoker
and has a 50-pack-year smoking history. He is otherwise well and takes no medication. His
chest auscultation reveals bilateral decreased air entry, prolonged expiration, and
expiratory wheeze. His pulmonary function test reveals FEV1/FVC less than 0.7 without
significant reversibility on bronchodilatation. His predicted FEV1 is 60%. He is started on a
short-acting bronchodilator as required. A longer-acting once-daily agent is also added to
his regimen. The agent is a quaternary ammonium derivative that slows disease
progression, decreases hospitalizations, and improves exercise tolerance. Which of the
following effects will be seen in the bronchial smooth muscle as a result of this agent?

Choices:

1. Increased adenyl cyclase activity

2. Decreased intracellular calcium
3. Increased chloride influx
4. Increased myosin light chain phosphorylation
Answer: 2 - Decreased intracellular calcium

Explanations:
Page 649 of 955
 This patient has presented with shortness of breath and cough and is a chronic smoker. His
pulmonary function tests are consistent with the presence of obstructive airway disease. His
FEV1 indicates the presence of moderate chronic obstructive pulmonary disease (COPD). The
long-acting agent added to his regimen is the quaternary amine tiotropium.
Tiotropium is indicated in moderate and severe COPD and has been shown to improve
bronchospasm, decrease exacerbations, and slow disease progression. It is an
anticholinergic agent and decreases intracellular calcium leading to smooth muscle
relaxation.
The primary effect of tiotropium is by blocking the M3 muscarinic receptors on bronchial
smooth muscles. This decreases the generation of the second messenger’s inositol
triphosphate 3 and diacylglycerol. This, in turn, decreases calcium that is essential for
smooth muscle contraction.
Long-acting muscarinic agonists play an important role in the management of COPD. Beta-
agonists increase adenylyl cyclase activity and cause smooth muscle relaxation.
Phosphorylation of myosin light chain will cause contraction of smooth muscle and cause
bronchospasm.

Research Concepts: Tiotropium

Question 688: A middle-aged old male presents to the clinic for a follow-up of systemic
sclerosis. Lately, he has been feeling more tired and short of breath. He denies any other
new symptoms. He was diagnosed with limited systemic sclerosis 11 years ago when he
had presented with skin thickening and tightening of his bilateral hands, Raynaud
phenomenon, a digital ulcer on the tip of the finger, and esophageal dysmotility. He has
pain and is currently on hydroxychloroquine, nifedipine, and omeprazole, with
improvement in his symptoms. His past medical history is significant for hypothyroidism,
for which he is also on levothyroxine. Vital signs are within normal limits. The physical
exam reveals thickening of the skin involving both hands from the tips of the fingers up to
the wrist joints. There are no active digital ulcers or cyanosis of the digits. Several
telangiectasias are present on the hands. The remainder of the exam is normal.
Laboratory workup, including CBC, creatinine, urinalysis, and liver function tests, are
normal. The chest x-ray is normal. Pulmonary function tests show normal forced vital
capacity, total lung capacity, forced expiratory volume, and FEV1/FVC. The diffusion
capacity is 54%. What is the next best step in the management of this patient?

Choices:

1. Computed tomography scan of the chest

2. Transthoracic echocardiogram
3. Cardiac magnetic resonance
Page 650 of 955
4. Right heart catheterization
Answer: 2 - Transthoracic echocardiogram

Explanations:

Isolated reduction in the diffusion capacity (DLCO) can be an indicator of pulmonary

arterial hypertension (PAH), which can be seen in systemic sclerosis in 30 to 50% of
the patients, more commonly in limited systemic sclerosis.
A transthoracic echocardiogram is the next best step in the evaluation of this
patient and can show an elevation in peak right ventricular systolic pressure.
If the transthoracic echocardiogram shows elevation in peak right ventricular
systolic pressure, it should be followed by right heart catheterization to confirm
the diagnosis and rule out other etiologies.
A high-resolution computed tomography (CT) scan should be done in patients
where there is a suspicion of interstitial lung disease.

Research Concepts:Systemic Sclerosis

Question 689: A 55-year-old woman undergoes a hip replacement after a fall. Two days
postoperatively, she develops sudden shortness of breath and tachycardia. On
examination, she is tachypneic with a heart rate of 120/min and blood pressure of 120/57
mmHg. The lungs are clear to auscultation. The lower extremities have swelling in the
right more than the left with calf tenderness.
Blood gas analysis reveals a pH of 7.38, PCO2 35 mmHg, PO2 72 mmHg, and bicarbonate of
23 mEq/L. Duplex ultrasound of the lower extremity shows a large clot in the right
iliofemoral vein. Which of the following is most likely to be seen on a chest radiograph?

Choices:

1. Westermark sign
2. Hampton hump
3. Pleural effusion
4. No abnormality

Answer: 4 - No abnormality

Explanations:

The chest x-ray of a patient with pulmonary embolism is most often normal.
Following a chest x-ray, a CT pulmonary artery angiography should be obtained or a
ventilation-perfusion (V/Q) scan when CT angiography is contraindicated. If the
Page 651 of 955
 patient has a history of contrast allergy, a V/Q scan can be substituted when a
premedication regimen is inappropriate and a chest -x-ray is normal.
Westmark sign describes the relative area of oligemia or paucity of pulmonary
markings on a chest x-ray due to vasoconstriction and decreased blood flow. It is
seen in less than 10% of patients.
Hampton hump describes wedge-shaped opacity, which is pleural-based
with a convex medial border representing pulmonary infarction.
Pleural effusion accompanies pulmonary infarction in acute and subacute phases. It
may be absent in the hyperacute phase or when infarction is close to resolving.

Research Concepts:

Acute Pulmonary Embolism

Question 690: A 65-year-old man presents to the hospital after a business trip to Oman.
He is found to have a fever up to 39 C. Soon after the presentation, he becomes hypoxic
and needs to be intubated. Arterial blood gas shows pO2 55 mmHg, and a chest x- ray
shows bilateral pulmonary opacities, widespread, homogeneous, involving three
quadrants. Coronavirus infection is suspected. Which of the following accurately explains
the criteria for diagnosing this patient?

Choices:

1. Precise clinical and radiological criteria

2. Positive PCR on two specific genomic targets or a single positive target with
sequencing on a second
3. Clinical evaluation alone
4. Single PCR target
Answer: 2 - Positive PCR on two specific genomic targets or a single positive target with
sequencing on a second

Explanations:

A confirmed case is defined as an individual with laboratory confirmation of

Middle East respiratory syndrome coronavirus (MERS-CoV) infection.
Confirmatory laboratory testing requires a positive PCR on at least two specific
genomic targets or a single positive target sequencing on a second.
A patient under investigation is defined as a person with severe or milder disease
but with absent or inconclusive laboratory results for the Middle East respiratory
Page 652 of 955
 syndrome coronavirus (MERS-CoV) infection.
A positive test on a single PCR target is not conclusive for confirming the diagnosis.

Research Concepts:

Features, Evaluation, and Treatment of Coronavirus (COVID-19)

Question 691: A 45-year-old man is found unresponsive in the park across the street
from the hospital and is brought to the emergency department by bystanders. Medical
records in the hospital reveal a past medical history of deep venous thrombosis,
myocardial infarction, and chronic back pain. His heart rate is 102 bpm, blood pressure
113/82 mmHg, respirations 9 breaths/min and shallow, SpO2 89% on room air, and he is
afebrile. The Glasgow Coma Scale score is 3. Examination demonstrates constricted
pupils, cyanotic lips, shallow breaths, clear lung fields on auscultation, and cool skin.
Drug overdose is expected, and an antidote is given. Arterial blood gas (ABG) samples are
sent for evaluation; meanwhile, he is placed on supplemental oxygen with improvement
in his SpO2. An EKG is unchanged from his most recent inpatient EKG. Considering the
blood samples were taken before the supplemental oxygen, what ABG results are
expected for this patient?

Choices:

1. Respiratory alkalosis with an increased alveolar-arterial oxygen gradient

2. Respiratory acidosis with an increased alveolar-arterial oxygen gradient
3. Respiratory acidosis with a decreased alveolar-arterial oxygen gradient
4. Respiratory acidosis with a normal alveolar-arterial oxygen gradient
Answer: 4 - Respiratory acidosis with a normal alveolar-arterial oxygen gradient

Explanations:

Although this patient has several comorbidities that can contribute to hypoxia, his
level of consciousness, breathing pattern, and constricted pupils are most
consistent with opioid overdose. Improvement with a reversal agent (naloxone) and
supplemental oxygen implies he is able to effectively perfuse his lungs. Patients with
a normal A-a gradient usually do not have a disease of the alveolar-capillary subunit.
In the absence of pulmonary or alveolar pathology, the cause of this patient's
hypoxemia is his diminished respiratory drive; therefore, he has a normal A-a
gradient. Some causes of hypoxemia in patients with a normal A-a gradient include
respiratory depression and decreased atmospheric oxygen tension.
Page 653 of 955
 The A-a gradient is the difference between oxygen tension in the alveoli and the
blood. If both of these values decrease, the A-a gradient will likely remain within
normal limits.
Opioids are a central nervous system depressant, causing reduced ventilation.
Reduced ventilation causes decreased oxygen tension in the respiratory tract and
arterial blood, leading to respiratory acidosis and a relatively normal A-a gradient
Research Concepts:Physiology, Alveolar to Arterial Oxygen Gradient

Question 692: A 17-year-old female, with no comorbidities, is brought to the emergency

department with a history of a motor vehicle accident involving a car (which she was
driving) and a bus, one hour back. On examination, her pulse rate is 80/minute, blood
pressure 130/80 mmHg, respiratory rate 16/minute, and oxygen saturation is 98%. Her
airway is clear, and air entry is bilaterally equal in all lung fields. Her Glasgow Coma Scale
(GCS) score is E3V4M6, and her pupils are bilaterally 3 mm in size and react to light. A
chest X-ray taken shows clear lung parenchyma. A computed tomogram scan of the brain
is taken, which shows an undisplaced right frontal bone fracture and an underlying
contusion of 15 ml volume. There is no midline shift or mass effect. She is admitted to the
neurosurgery intensive care unit. Two hours later, the patient develops tachypnea
(respiratory rate of 30/minute), while GCS score and pupils remain the same. Within 2
minutes, her saturation drops down to 80%, and she has to be intubated and ventilated.
On chest auscultation, there are bilateral basal crackles. A chest X-ray shows bilateral
hyperdense infiltrates in the lung parenchyma. Which part of the brainstem is likely to
contribute to the current deterioration in her clinical condition?
Choices:

1. The dorsolateral aspect of the pons

2. The ventrolateral aspect of the pons
3. The dorsolateral aspect of the medulla
4. The ventrolateral aspect of the medulla
Answer: 4 - The ventrolateral aspect of the medulla

Explanations:

The patient has neurogenic pulmonary edema. Rapid developments characterize the
early stages of neurogenic pulmonary edema. The patients are usually children or
young adults who have suffered an intracranial injury recently.
The clinical signs boil down to classic signs of pulmonary edema with the absence of
signs of left ventricular failure usually found in cardiogenic edema.
Although for classic neurogenic pulmonary edema, the manifestation could be
detected clinically within 2 to 12 hours post-injury; presentation may take days
in some cases.
Page 654 of 955
 Area A1, situated in the ventrolateral aspect of the medulla, is one of the main
trigger centers for neurogenic pulmonary edema. It is composed of catecholamine
neurons that project to the hypothalamus.

Research Concepts:Neurogenic Pulmonary Edema

Question 693: A 71-year-old male with a history of diabetes, hypertension, and chronic
obstructive pulmonary disease presents to the emergency department for fever, cough,
myalgias, and problems with taste and smell for the past week. The patient states he was
seated next to someone who was coughing without a mask while flying back from
vacation 3 weeks ago. Vitals signs are heart rate of 104/min, respirations 20/min,
temperature 101.2°F (38.4°C), blood pressure 168/102 mmHg, and pulse oximetry 96% on
room air.
Physical exam shows an ill-appearing male with lungs clear to auscultation. Rapid antigen
testing confirms COVID-19 infection. The patient has been deemed a high-risk patient with
mild to moderate symptoms and referred for outpatient therapy with monoclonal
antibodies. The patient was hesitant to accept treatment due to concerns about side effects.
Which side effect would be most likely during outpatient treatment of this disease?

Choices:

1. Tinnitus
2. Nausea
3. Hypercoagulability
4. Nephrotoxicity
Answer: 2 - Nausea

Explanations:

The patient can be reassured that most patients tolerate monoclonal antibody
treatment of COVID 19 well. The most reported side effect of treatment is nausea and
diarrhea.
The risk of other adverse events such as infusion-related immediate hypersensitivity
reactions manifesting as pruritus, flushing, rash, and facial swelling was also noted but
much less frequently.
Before administration of medication, patients need to give consent and be
advised of all the possible adverse effects. The risk of immune-mediated
reactions includes anaphylaxis, serum sickness, and antibody generation with
monoclonal antibody use; however, the incidence remains low to date.

Page 655 of 955

Research Concepts:

Providing Access To Monoclonal Antibody Treatment Of Coronavirus (COVID-19) Patients

In Rural And Underserved Areas

Question 694: A 28-year-old female patient presents to the emergency department with a
panic attack. Her physical exam reveals a pulse of 107 beats per minute and a respiratory
rate of 30 breaths per minute. Her laboratory reports show calcium 10.0 mg/dL, albumin
4.0 g/dL, phosphate 0.8 mg/dL, and magnesium 1.5 mEq/L. Arterial blood gases show a
pH of 7.56, pCO2 22 mmHg, and pO2 97 mmHg. What is the reason for deranged
phosphate in this patient?

Choices:

1. A shift of phosphate from the extracellular to the intracellular space

2. Hyperparathyroidism
3. Vitamin D deficiency
4. Hypomagnesemia resulting in decreased parathyroid hormone
Answer: 1 - A shift of phosphate from the extracellular to the intracellular space

Explanations:

Panic attacks cause respiratory alkalosis due to over-breathing causing excessive loss
of carbon dioxide.
The most common causes of respiratory alkalosis are anxiety, pulmonary embolism, or
high ventilation rate.
Respiratory alkalosis is one of the commonest causes of hypophosphatemia which
results from a shift of phosphate from the extracellular to the intracellular
compartment.
Hypophosphatemia is also seen with malnutrition, during the refeeding stage
when excessive carbohydrate intake causes phosphate to shift into the
intracellular compartment.

Research Concepts:

Respiratory Alkalosis

Page 656 of 955

Question 695: A 35-year-old male is seen in the outpatient department with complaints
of cough and low-grade fever for the past 3 months. The patient developed fever 3
months back, which was low grade and associated with night sweats. He also has had a
troublesome cough. He had an episode of hemoptysis, which prompted the visit. His
history is significant for HIV infection 8 years ago, for which he has never taken
treatment. Examination reveals a temperature of 99 F, a pulse of 90 beats per minute, a
blood pressure of 110/70 mmHg, and a respiratory rate of 22 breaths per minute. His
general physical examination reveals the presence of oropharyngeal thrush and mild
pallor. Chest examination reveals coarse crackles and bronchial breathing in the left
upper lobe. His investigations reveal a WBC count of 3,000 per microL, hemoglobin of 10
gm/dl, platelet count of 150,000 per microL, erythrocyte sedimentation rate of 50 mm
per hour, serum creatinine of 0.8 mg/dl and a CD4+ count of 60 per microL. A Mantoux
test is performed, which shows no induration. A chest x-ray reveals cavitation and
reticulonodular shadowing in the right upper lobe. Sputum demonstrates the presence
of acid-fast bacilli. What should be the management plan for this patient?
Choices:

1. Start antiretroviral therapy (ART) and antitubercular treatment (ATT) together

2. Start antitubercular treatment (ATT) now and antiretroviral therapy (ART) after 6 months
3. Start antitubercular treatment (ATT) now and antiretroviral therapy (ART) after 2 weeks
4. Start antiretroviral therapy (ART) now and antitubercular treatment (ATT) after 2 weeks
Answer: 3 - Start antitubercular treatment (ATT) now and antiretroviral therapy (ART) after 2 weeks
Explanations:

This patient with a history of AIDS now presents with fever, cough, and hemoptysis. His
examination, investigations, and x- ray confirm the presence of pulmonary tuberculosis. This
patient also simultaneously has HIV with severe immunosuppression (CD4+ 60/microL). The
recommendations are to immediately start antituberculous therapy, followed by the
initiation of anti- retroviral after 2 to 4 weeks.
Delaying treatment with antiretroviral drugs prevents the development of immune
reconstitution inflammatory syndrome (IRIS). This is a syndrome characterized by
paradoxical worsening of symptoms of primary disease when treatment with antiretroviral
agents is initiated.
The presenting infection should be treated immediately, and retroviral started no earlier
than 2 weeks. The earlier the antiretroviral agents are initiated, the greater the likelihood
of IRIS. Unnecessary delay of antiretroviral therapy leads to an increased risk of death
from AIDS.
Individuals with HIV infection and tuberculosis represent an important management
dilemma. Treatment with ART boosts the immune system and can cause a reversion of
tuberculin anergy in patients with a negative PPD test. Careful monitoring for the
development of IRIS is required.
Research Concepts: Tuberculosis

Page 657 of 955

Question 696: A 35-year-old male is found unconscious with a needle in his arm. On
arrival at the hospital, the patient is given naloxone with no response and is intubated for
airway protection. In the first 24 hours, the patient is febrile with a temperature of 38.5 C
(101.3 F) twice. Blood cultures are growing methicillin-resistant staphylococcus aureus
(MRSA). The patient is started on appropriate antibiotics, and on his third day of
hospitalization, he develops hypoxic respiratory failure requiring 100% oxygen. His blood
pressure is 80/55 mmHg, oxygen saturation 88%, temperature
39.4 C (102.9 F), heart rate 120/min, and respiratory rate 28/min. A chest x-ray shows
bilateral lung whiteout. Volume cycled assisted control mechanical ventilation is initiated.
Which of the following best describes the most appropriate mechanical ventilation for this
patient?

Choices:

1. Square waveform will allow for slower delivery of inspiration.

2. Square waveform will allow shorter expiration.
3. Ramp waveform will decrease the flow as delivered oxygen volume increases.
4. Ramp waveform will increase the flow as delivered oxygen volume increases.
Answer: 3 - Ramp waveform will decrease the flow as delivered oxygen volume
increases.
Explanations:

This patient has acute respiratory distress syndrome (ARDS). ARDS is respiratory
failure due to diffuse alveolar damage and increased intrapulmonary shunting.
This is often caused by sepsis, as is the case with this patient.
In a landmark study, it was shown that low tidal volume ventilation reduces
mortality in ARDS by decreasing volutrauma and airway inflammation. The ARDSnet
protocol dictates that ARDS patients should be started on 8 ml/kg of ideal body
weight and decreased to 6 ml/kg as tolerated. Volume-cycled assist control (AC)
permits fine titration of the volume reliably.
Ramp waveform is an AC parameter that, upon breath delivery, decelerates with
inhalation. Square waveform keeps a constant delivery of breath upon inhalation.
Ramp waveform allows for a decrease of flow as the volume is delivered to the
patient. This is optimal in patients with diffuse lung injury, such as in ARDS,
because it allows for a more homogenous delivery of oxygen, in addition to being
more comfortable to the patient. Square waveform allows for faster delivery of
oxygen to the patient, which decreases inspiration time and increases expiratory
time, which is optimal in conditions such as asthma or pulmonary disease
exacerbation.
Research Concepts: Ventilation Assist Control

Page 658 of 955

Question 697: A 46-year-old male patient presents to the emergency department with
complaints of fever, night sweats, chills, myalgias, and cough for the past two weeks. He
has also experienced abdominal pain in the past week. The patient reports
undocumented, unintentional weight loss during this time as well. He recently moved to
Ohio to his family home after he lost his job. He has a past medical history of HIV, which
was diagnosed two years ago. The patient mentions that he has been inconsistent in
taking his medication in the past six months, as he has not been able to afford it. He does
not use tobacco and drinks alcohol occasionally on weekends. Vitals show a temperature
of 38.1°C (101°F), respirations of 22/min, a pulse of 96/min, and a blood pressure of
110/70 mmHg. Physical examination reveals enlarged cervical lymph nodes and
hepatosplenomegaly. Pulmonary examination reveals bilateral crackles. Chest x-ray shows
focal, patchy infiltrates, and mediastinal lymphadenopathy. The tuberculin skin test is
negative. Laboratory investigations reveal a CD4 count of 90/mm3. What is the best next
step in the management of this patient?

Choices:

1. Urine antigen testing for a fungus

2. Obtain blood cultures
3. Obtain hepatitis B and C antigen and antibody tests
4. Start the patient on empiric trimethoprim-sulfamethoxazole

Answer: 1 - Urine antigen testing for a fungus

Explanations:

The most likely diagnosis is progressive disseminated histoplasmosis in the setting

of untreated HIV. Given the patient's untreated HIV, change in location to an
endemic area, clinical presentation, and chest x-ray findings, this is the most likely
diagnosis.
These patients present with fever, weight loss, hepatosplenomegaly, and hematologic
disturbances.
Urine antigen testing for the fungal infection is the best next step.
Starting the patient on empiric trimethoprim-sulfamethoxazole would be
appropriate for pneumocystis infection. Obtaining blood cultures and hepatitis B
and C antigen and antibody tests are also appropriate but the next best step would
be to obtain the urine antigen test.

Research Concepts: Histoplasmosis

Page 659 of 955

Question 698: A 65-year-old woman with a past medical history of hypertension, diabetes
mellitus, and tobacco use disorder presents with weakness in the medial two fingers of her
left hand along with numbness and tingling in the lateral two fingers and dorsum of the same
hand. She also reports a chronic cough for many years which has recently become more
severe. She has a low- grade fever, her blood pressure is 130/70 mmHg, her pulse is 78 beats
per minute, her respiratory rate is 20 breaths per minute, and her oxygen saturation is 90%
on room air. On physical exam, the patient is unable to flex the lateral two fingers, and motor
strength is 2/5 in the left hand compared with the right. What is the best initial diagnostic
test?

Choices:

1. Chest x-ray
2. MRI of the thoracic inlet
3. Positron emission tomography
4. Nerve conduction studies
Answer: 1 - Chest x-ray

Explanations:

Pancoast tumors can present as superior vena cava syndrome or thoracic outlet
syndrome due to compression of the brachial plexus resulting in motor and
sensory changes in the upper extremity, which is the most likely diagnosis in this
scenario.
Pancoast tumors occupy the apex of the lung and can be detected on a chest x-ray.
Of note, small nodules may not be apparent on a chest x-ray, and high-resolution
computed tomography of the chest may be required.
Further imaging of the torso and brain will be required to determine the extent of the
disease and assess for possible metastases.

Research Concepts:

Lung Metastasis

Page 660 of 955

Question 699: A 17-year-old woman presents to the office with difficulty breathing and
chest tightness for the past two months. She has also been complaining of nighttime
awakenings due to cough, persistent rhinorrhea, and nasal congestion, which she never
experienced in the past. She has been taking inhaled albuterol as needed and daily inhaled
fluticasone for her condition for the past six months. She has diabetes mellitus type 1
managed with insulin. She is an athlete and has a sprint competition coming up in 4
months and is worried that her symptoms will affect her performance. She has been
taking aspirin for symptomatic relief of her muscle pain and soreness. She does not have
any symptoms while she is exercising or running. On examination, her vital signs are
within the normal range except for an oxygen saturation of 93% on room air. Physical
examination reveals a bilaterally prolonged expiration phase with active wheezing. The
examination of the nose shows multiple mucosal growths bilaterally. Her spirometry is
normal, and a bronchoprovocation test is planned for her next visit. Which of the
following is appropriate for her condition?

Choices:

1. Long-acting beta-agonist
2. Systemic corticosteroids
3. Stop aspirin and add a leukotriene modifying agent
4. Mast cell stabilizer
Answer: 3 - Stop aspirin and add a leukotriene modifying agent
Explanations:

This patient has aspirin-induced asthma with a classic triad of chronic

rhinosinusitis with nasal polyps and precipitation of asthma and rhinitis attacks in
response to aspirin. The patient should be advised to stop taking aspirin and other
non-steroidal anti-inflammatory drugs (NSAIDs).
The use of aspirin in aspirin-sensitive asthmatic patients causes inhibition of the
COX pathway, leading to the overproduction of leukotriene. This causes
bronchoconstriction and precipitates life-threatening asthmatic exacerbations.
Leukotriene receptor antagonists like zafirlukast and montelukast; and leukotriene
synthesis inhibitors like zileuton have been beneficial for aspirin-induced asthma.
They block the airway obstruction caused due to lysine-aspirin inhalation in
patients with aspirin-induced asthma.
The leukotriene receptor antagonist like zafirlukast is also commonly used for the
maintenance treatment of asthma and is often used in conjunction with an inhaled
steroid or long-acting bronchodilator.
Research Concepts:Zafirlukast

Page 661 of 955

Question 700: A 16-year-old female presents to the healthcare provider with trouble
breathing and shortness of breath. It started about an hour after she woke up this
morning. Oxygen saturation is 86%. The physical exam reveals tachypnea and diffuse
expiratory wheeze bilaterally. The remaining physical exam is normal. Based on the most
likely diagnosis, she is given an IV medication to augment bronchodilation and improve
her acute symptoms. This medication acts by inhibiting phosphodiesterase. Which of the
following is an absolute contraindication to the drug she most likely received?

Choices:

1. Pregnancy
2. History of recurrent thyroid storm episodes
3. History of anaphylaxis from caffeine
4. History of seizure disorder

Answer: 3 - History of anaphylaxis from caffeine

Explanations:

Based on the patient's presentation and physical exam findings, it is most likely that
she is having an acute asthma exacerbation. Treatments for acute asthma
exacerbations include B-agonists, muscarinic antagonists, inhaled corticosteroids,
and methylxanthines.
Methylxanthines are the only of the aforementioned medications that can be
administered intravenously to improve acute symptoms. Methylxanthines act by
inhibiting phosphodiesterase which results in increase cAMP levels causing
bronchodilation. The only absolute contraindication to methylxanthines is a history
of hypersensitivity reaction to any xanthine-derivative compounds. Caffeine is a
xanthine-derivative compound and therefore a history of anaphylaxis to it is an
absolute contraindication to methylxanthine use. All the other options listed are
relative contraindications--not absolute contraindications--to methylxanthine use.

Research Concepts: Methylxanthines

Page 662 of 955

Section 8

Question 701: A 16-year-old male presents to the emergency department after blunt
trauma to the chest sustained during a motor vehicle accident. He is in respiratory
distress. He complains of shortness of breath and difficulty breathing. He has tachypnea,
hypoxia, and tachycardia. On physical examination, his chest is tender to palpate, and
auscultation is remarkable for rales on the side of the injury. You order a chest CT which
shows nonsegmental patchy airspace opacities in the lung periphery with thin subpleural
sparing and confirms the diagnosis. The patient is started on positive pressure ventilation.
What is the most likely diagnosis?

Choices:

1. Pneumothorax
2. Pneumonia
3. Pulmonary contusion
4. Pulmonary hemorrhage
Answer: 3 - Pulmonary contusion

Explanations:

Pulmonary contusion is an injury to lung parenchyma in the absence of laceration

to lung or vascular structures due to blunt chest trauma, shock wave associated
with penetrating chest trauma, or explosion injuries.
Any chest trauma, blunt, penetrating, or a combination of both, can develop
pulmonary contusion. Pulmonary contusion is the most commonly identified lung
injury (30% to 75%) in blunt chest traumas.
Sudden acceleration or deceleration of the body during a motor vehicle collision
causes pulmonary contusion. Explosions, fall from great heights, and sports injuries
are other causes.
Chest CT is more sensitive imaging in diagnosing pulmonary contusion. A higher
resolution of CT scan can detect contusion immediately after the trauma. For the
patient described in the case, chest CT findings are consistent with a pulmonary
contusion diagnosis.

Research Concepts:Pulmonary Contusion

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Question 702: A 50-year-old female presents with a three-month history of worsening
exertional dyspnea. She reports dyspnea with minimal exertion but not at rest. She also
reports a chronic nonproductive cough. She has a past medical history of systemic
sclerosis with Raynaud phenomenon and gastroesophageal reflux disease. Her vital signs
are within normal limits, and her oxygen saturation is 95% at rest on ambient air. Bilateral
sclerodactyly and tightening of her neck skin are noted on the exam. Her lungs are clear to
auscultation. A loud S2 is heard during cardiac evaluation.
Pulmonary function testing and right heart catheterization confirm the diagnosis. What is
the most appropriate initial therapy for this patient's condition?

Choices:

1. Ambrisentan and tadalafil

2. Bosentan monotherapy
3. Epoprostenol monotherapy
4. Sildenafil and riociguat
Answer: 1 - Ambrisentan and tadalafil

Explanations:

This patient has scleroderma-associated pulmonary arterial hypertension (PAH) with World
Health Organization (WHO) functional class III symptoms. The currently recommended
initial treatment for WHO functional classes II and III is combination pharmacotherapy of
two different drug classes. The combination of endothelin receptor antagonists (ERA) and a
phosphodiesterase-5 inhibitor (PDE5I) is the most commonly prescribed because it is of
proven benefit in PAH.
Historically treatment of PAH involved monotherapy with additional agents added (as
needed) upon clinical worsening. However, in light of findings from studies such as the
Ambrisentan + Tadalafil in Pulmonary Arterial Hypertension (AMBITION) trial, patients
may begin treatment with a combination of medications. The randomized, double-blind,
multicenter AMBITION trial examined the effects of early and aggressive initial
combination therapy with ambrisentan and tadalafil and reported a 50% reduction in
clinical failure compared with monotherapy.
In addition, PAH-related hospitalizations were reduced by 63% with initial combination
therapy. These findings altered the standard of care for patients with WHO functional class
II and III to use an ERA and PDE-5I combination as the initial therapy of choice.
When using combination therapy, PDE-5I and guanylate cyclase stimulant combinations should
be avoided as they increase the risk of adverse effects with a high risk of hypotension.

Research Concepts:Scleroderma-Associated Pulmonary Arterial Hypertension: Early

Detection For Better Outcomes

Page 664 of 955

Question 703: A 16-year-old male with a history of asthma presents to his family care
providers' office for an annual health maintenance examination. He is currently taking a
short-acting beta- agonist as well as budesonide-formoterol fumarate dihydrate daily.
The patient reports that he has allergies and still having night time awakenings for his
asthma symptoms. On physical examination, he has diffuse bilateral wheezing bilaterally,
and he isn't using accessory muscles. Prior to today's visit, he had a prior asthma
exacerbation two months ago, where he went to the Emergency Room. Based on the
patient's history, what is the mechanism of action of the medication that the physician
should consider adding to the current medications regimen of the patient to control
asthma symptoms?

Choices:

1. Anti IgE monoclonal antibody

2. Leukotriene receptor antagonist
3. A mast cell destabilizer
4. Phosphodiesterase inhibitor
Answer: 2 - Leukotriene receptor antagonist

Explanations:

Asthma treatment is determined based on the severity of the patient's symptoms.

Mild intermittent asthma is typically treated with an as-needed beta 2 agonist.
Mild persistent asthma is a typical treatment with albuterol + low dose inhaled
steroid +/_ montelukast or +/- cromolyn. Treatment for moderate persistent
asthma is albuterol + moderate dose inhaled steroid +/- long- acting B2 against +/-
montelukast and +/-theophylline. For severe persistent asthma, the recommended
treatment is albuterol + high dose inhaled steroid + long-acting B2 agonist + oral
steroid +/- montelukast, +/- theophylline.
The patient has moderate persistent asthma. The next step is to add a leukotriene
receptor antagonist to the regimen.
Montelukast is a leukotriene receptor antagonist.
Montelukast has an elimination half-life of 2.7 to 5.5 hours and is principally excreted
in the feces

Research Concepts:Montelukast

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Question 704: A 47-year-old man presents to the emergency department complaining of
cough, subjective fevers, and night sweats for the past week. He has recently immigrated
to the United States from Russia where he worked as a computer programmer. He eats a
diet high in fish and reports drinking one to two beers once a week during the weekend.
On physical examination, he is noted to have abnormally enlarged fingertips and
curvature of the nails.
Which test should be ordered next?

Choices:

1. Pulmonary function tests

2. Liver function tests
3. Cardiac enzymes
4. Chest x-ray
Answer: 4 - Chest x-ray

Explanations:

Clubbing of both hands is an asymptomatic pulmonary process that requires chest x-

ray for further evaluation.
The cause of clubbing is vast and the investigations usually depend on patient signs
and symptoms.
If the chest x-ray proves to be negative, then work up of the cardiovascular
system and ruling out a malignancy is next. Ultrasound of the extremities may
reveal echogenic masses in patients with hypertrophic osteoarthropathy.

Research Concepts:

Nail Clubbing

Page 666 of 955

Question 705: A 45-year-old man presents to the clinic with progressive shortness of
breath and a dry cough. His symptoms started insidiously about two years ago, and now
he has shortness of breath at rest. He has smoked two packs of cigarettes a day for the
past 30 years. Chest examination reveals fine inspiratory crackles at the bases
bilaterally. A chest x-ray is unremarkable.
Pulmonary function testing is suggestive of restrictive lung disease. HRCT shows minimal
fibrosis in the bases bilaterally, with ground glass changes. Lung biopsy shows numerous
mononuclear cells within most of the distal air spaces. He is advised to quit smoking.
Which of the following is the next best step in the management of this patient?
Choices:

1. Bosentan
2. Lisinopril
3. Pirfenidone
4. Prednisone
Answer: 4 – Prednisone
Explanations

The patient most likely has desquamative interstitial pneumonia. An overlap of clinical and
histopathological features is common among smoking-related interstitial pneumonia. A
clinical, radiological, and pathological consensus during the period of longitudinal follow-up,
therefore, becomes necessary to characterize a specific form of SR-ILD and pursue
appropriate treatment. Individuals with a history of relevant exposure to cigarettes,
inhalational drugs of abuse, and occupational risk factors commonly present with a dry
cough and exercise- induced shortness of breath. Although childhood disease has been
rarely reported, as mentioned above, the most common age of presentation is 40 to 60
years. There is a male predominance in the prevalence of this disease, consistent with its
correlation with exposures. Less than 10% of patients are asymptomatic at diagnosis.
Symptoms are, however nonspecific, including dyspnea on exertion (90%), a persistent
cough (70%), with or without sputum production (about 40%). Hemoptysis is very rare.
Clinical examination reveals clubbing in 50% of patients, along with coarse rales in
bilateral bases.
The most important intervention after diagnosis is smoking cessation. Similarly if
associated with specific occupational exposures, avoidance of exposure is also key to
preventing disease progression.
Systemic corticosteroid therapy over months has been reported as the most effective
pharmacologic intervention.
Research Concepts:Desquamative Interstitial Pneumonia

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Question 706: A 48-year-old male presents to the emergency department due to a high-
grade fever and chills. He also reports shortness of breath and cough, starting two days
before the onset of the fever and chills. He denies any illicit drug or significant alcohol use.
The patient has smoked one pack of cigarettes daily for 20 years. On examination, his
temperature is 39.5 C (103.1 F), pulse 102/min, respirations 27/min, and blood pressure
100/65 mmHg.
Lung examination reveals dullness to percussion on his right side. Chest x-ray shows
pulmonary infiltrates, and Gram stain of the sputum shows gram-positive diplococci. A
slow intravenous infusion of levofloxacin 750 mg is ordered over 90 minutes. Which of
the following is likely to be prevented by using slow infusion of the antibiotic rather than
rapid infusion?
Choices:

1. Hypotension
2. QT interval prolongation
3. Crystalluria
4. Tendon rupture
Answer: 1 – Hypotension
Explanations:

Levofloxacin, a broad-spectrum antibiotic, can be used against both penicillin-sensitive and

resistant, gram-positive organisms. It is also called respiratory fluoroquinolone because of
its excellent lung tissue penetration and higher activity against most common respiratory
pathogens, including Streptococcus pneumoniae.
Levofloxacin produces bactericidal effects by interfering with bacterial DNA synthesis. It
does so by inhibiting DNA-gyrase in susceptible organisms, thereby promoting the breakage
of DNA strands, leading to the relaxation of supercoiled DNA. Due to the growing concern
of drug resistance to fluoroquinolones, it should be used only for strongly suspected
bacterial infections.
Due to its high oral bioavailability (99%), levofloxacin can be administered interchangeably
through oral and intravenous routes. However, intravenous administration should be given
by slow infusion over 60 minutes (250-500 mg) or 90 minutes (750 mg) due to the
increased risk of hypotension associated with rapid infusion. Besides, levofloxacin should
not be infused in a solution containing multivalent cations.
Providers should instruct patients to drink adequate amounts of water during the intake of
oral levofloxacin to prevent crystalluria. Before administering this antibiotic, the provider
should screen patients for a history of QT interval prolongation and myasthenia gravis. Due
to the risk of tendon rupture and tendinitis, levofloxacin should be limitedly used in
uncomplicated urinary tract infections, acute bacterial sinusitis, and acute bacterial
exacerbation of chronic bronchitis.

Research Concepts:Levofloxacin

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Question 707: A 55-year-old man with a past medical history of hypertension presents to
the hospital with complaints of flu-like symptoms for the past four days. Admission vitals
are temperature 101°F (38.3°C), oxygen saturation 92% on room air, blood pressure
110/70 mmHg, and heart rate 100/min. Initial laboratory workup is unremarkable except
for mild lymphopenia. His liver function and renal function tests are within normal limits.
Chest x-ray demonstrates bilateral interstitial opacities. SARS CoV-2 PCR test is positive.
The patient is started on 2 L/min of supplemental oxygen via nasal cannula and maintains
his oxygen saturation above 96%. Which of the following is a recommended treatment for
this patient at this time?

Choices:

1. Sotrovimab
2. Tocilizumab
3. Hydroxychloroquine
4. Remdesivir
Answer: 4 - Remdesivir

Explanations:

The patient described in this clinical vignette is admitted with mild to moderate
COVID-19. Considering this patient was hypoxic and required supplemental
oxygen, he will benefit from the initiation of remdesivir.
Remdesivir is a broad-spectrum antiviral agent that has demonstrated antiviral
activity against SARS-CoV-2. Remdesivir has been shown to be most effective when
initiated early (within ten days of symptom onset).
According to the National Institutes of Health (NIH) guidelines, patients with COVID-
19 illness who are hospitalized and require supplemental oxygen remdesivir,
dexamethasone plus remdesivir, or dexamethasone alone should be used. If the
patient has a rapidly escalating oxygen requirement, a second immunomodulatory
drug, such as tocilizumab or baricitinib, should be added.
Sotrovimab is indicated only in non-hospitalized patients with laboratory-
confirmed SARS CoV-2 and mild-to-moderate COVID-19 who are at high risk for
progressing to severe disease and/or hospitalization. Hydroxychloroquine and
chloroquine are not indicated in the management of COVID-19.
Research Concepts:

Emerging Variants of SARS-CoV-2 And Novel Therapeutics Against Coronavirus (COVID-19)

Page 669 of 955

Question 708: A 65-year-old male patient comes in with a 4 week history of productive
cough, weight loss, and low grade fever. His medical history is significant for diabetes
mellitus, hypertension, and cataract. Family history is unremarkable. He returned from a
business trip to Thailand about a month ago. On physical examination, there are a few
enlarged lymph nodes in the cervical region. A chest x-ray is done, and the diagnosis is
established.
Before starting the appropriate treatment, which of the following measures should be
taken?

Choices:

1. Check liver enzyme levels

2. Mini mental state examination
3. Check amylase and lipase levels
4. MRI of the brain
Answer: 1 - Check liver enzyme levels

Explanations:

This patient presents with the signs and symptoms of pulmonary tuberculosis. The
intensive phase includes a four medication combination (isoniazid, rifampin,
ethambutol, and pyrazinamide). It is administered for two months, followed by a
continuation phase consisting of a combination of isoniazid and rifampin for four
months.
Toxicities of isoniazid include liver injury (nausea, fatigue, vomiting, malaise,
abdominal pain), rash, numbness, tingling in extremities, and headache. Toxicities of
pyrazinamide include nausea, painful or swollen joints, and liver injury.
Regular monitoring of liver function tests is essential, and in the case of elevated liver
enzymes, depending on the severity, the medications should be discontinued. Second
or third-line drugs can be used instead.
Educating the patient about potential side effects of treatment is of utmost
importance. They should be counseled about monitoring, which should be done at
least once per month to ensure there are no signs of toxicity, such as liver injury.
Signs of liver injury must also be discussed, which include loss of appetite, vomiting,
dark-colored urine, jaundice, abdominal pain, or fatigue. The patient needs to
immediately stop taking the medication if any of these signs develop and should
notify their healthcare provider.

Research Concepts: Primary Lung

Tuberculosis

Page 670 of 955

Question 709: A 45-year-old man presents to the office with complaints of abdominal
pain that begins 30 to 40 minutes after a proper meal. The patient states he has lost 15
kilograms of weight in the last 2 years through intense exercise. A CT scan is planned for
the patient. An incidental lung nodule is noted during the scan. The patient does not
have any pulmonary complaints. He is a nonsmoker, and there is no family history of lung
cancer. He works as an accountant and denies any significant exposure history. CT scan
of the chest shows a well defined, smooth bordered, dense 3 cm nodule with central
calcification in the right lower lobe close to the pleura. A transthoracic fine-needle
aspiration biopsy is performed. What will be seen on histopathology?

Choices:

1. Fragments of fibroadipose tissue, immature cartilage, spindle cells, and bland

glandular cells
2. Small round tumor cells with occasional tubular structures and spindle cells
3. Cells with horseshoe-shaped nuclei and eccentric cytoplasm
4. Extensive necrosis and marked acute inflammation
Answer: 1 - Fragments of fibroadipose tissue, immature cartilage, spindle cells, and bland
glandular cells

Explanations:

This patient has a pulmonary hamartoma. Pulmonary hamartomas are benign

malformations of common lung tissue that consists of cartilage, epithelium, fat, or
muscle. They are the most common benign pulmonary neoplasm in adults.
Also known as chondroid hamartomas, the histological makeup of these tumors is a
mixture of mature mesenchymal tissue, like adipose tissue, cartilage, bone, or
smooth muscle bundles, and fibromyxoid tissue, with varying proportions of each
component. They are non-invasive, slow-growing, nodular lesions, sometimes
displaying cleft-like spaces lined by respiratory epithelium.
In adults, the majority of parenchymal hamartomas produce no symptoms, often
being incidental findings. Depending on the location and size of the lesion, however,
patients can still develop an array of complaints, including persistent coughing or
wheezing, dyspnea, hemoptysis, rhonchi, higher likelihood of pneumonia,
atelectasis, or even pneumothorax.

Research Concepts:Pulmonary Hamartoma

Page 671 of 955

Question 710: A 65-year-old female presented to the emergency department with chief
complaints of progressively worsening shortness of breath and dry cough. She has a past
medical history of pleurisy at a young age and cholecystectomy. She has essential
thrombocythemia that was diagnosed four years ago, and currently, she is on hydroxyurea
medication. The patient followed with a primary care physician before presentation to the
emergency department and was treated with a course of levofloxacin and prednisone
with no improvement in symptoms. On physical examination, lung auscultation
demonstrates fine bilateral crackles, and the patient is hypoxic. A chest x-ray showed
multiple bilateral opacities. High-resolution computed tomography scan of the chest
reveals bilateral honeycombing at bases and ground-glass opacities in upper lobes. The
lung function test showed a restrictive pattern.
Bronchoscopy with bronchoalveolar lavage fluid was then performed. Bronchoalveolar
lavage fluid (BALF) analysis revealed 350,000 white blood cells/microliter (78%
macrophages, 20% neutrophils and 2% eosinophils). Fluid culture for bacteria, fungi, and
Mycobacterium tuberculosis was negative. What is the best line of treatment in this
patient?

Choices:

1. Initiation of high dose corticosteroids

2. Lung biopsy
3. Discontinuation of hydroxyurea
4. Initiation of broad-spectrum antibiotics
Answer: 3 - Discontinuation of hydroxyurea

Explanations:

Hydroxyurea can cause severe interstitial pneumonitis. It can occur even after
several years from initial drug treatment.
Drug-induced interstitial pneumonitis should be considered in patients being treated
with hydroxyurea and presenting with respiratory symptoms. If not diagnosed, drug-
induced interstitial pneumonitis can lead to lung fibrosis and respiratory failure.
It has been reported that cases of hydroxyurea induced interstitial pneumonitis
were treated with the cessation of drug alone or in combination with high dose
steroids to enhance the resolution of ground-glass opacities.
Discontinuation of hydroxyurea is the mainstay of treatment.

Research Concepts:Hydroxyurea Toxicity

Page 672 of 955

Question 711: A 42-year-old male presents for a follow-up. His past medical history
includes hypertension, type 2 diabetes mellitus, hyperlipidemia, obstructive sleep apnea,
and obesity with a BMI of 36 kg/m2. The patient has been on dietary restrictions as well
as an exercise regimen but has been unable to lose weight over the past year. His main
complaint is shortness of breath, which has limited his ability for physical activity and
exercise. His last pulmonary function tests (PFTs) revealed a low FVC, low FEV1, normal
FEV1/FVC ratio, and decreased DLCO. Chest auscultation today reveals fine crackles in the
bases bilaterally. A high-resolution computed tomography (CT) scan of the chest shows
bibasilar reticular abnormalities with minimal ground-glass opacities. What is the next
step in the management of this patient?

Choices:

1. Nutritionist referral
2. A short course of oral corticosteroid
3. Inhaled corticosteroid and bronchodilator therapy
4. Bariatric surgery
Answer: 4 - Bariatric surgery

Explanations:

The patient should be referred for bariatric surgery evaluation. His PFTs reveal a
restrictive lung disease pattern due to extrapulmonary restriction from his morbid
obesity as well as intrapulmonary restriction from interstitial lung disease (ILD).
It has been shown that patients with obesity and ILD who undergo bariatric
surgery achieve significant weight loss as well as improvement in their PFT
parameters.
Bariatric surgery appears relatively safe in these higher-risk ILD patients, and advanced
ILD improves their candidacy for lung transplantation.
Besides pulmonary restriction, the patient has several other comorbidities that
would make him a candidate for bariatric surgery, including a BMI greater than
35 kg/m2 with obesity- related comorbidities such as hypertension, type 2
diabetes mellitus, and obstructive sleep apnea (OSA).

Research Concepts:

Restrictive Lung Disease

Page 673 of 955

Question 712: A 41-year-old male mountaineer begins to feel sick at 12,000 ft on a
climbing expedition to the summit of Vinson Massif (16,050 ft). He is complaining of
headaches and nausea, which he attributes to an expired can of sardines which he ate for
breakfast. As the party progresses past 13,000 ft, the climber begins to report
incapacitating headaches and is unable to proceed further. He requests to be allowed to
rest at the current altitude. How would the management at this point differ from the
management at 12000 ft?

Choices:

1. Similar management with acetazolamide, dexamethasone, and rest at both

altitudes
2. Mandatory descent with steroids and acetazolamide pharmacotherapy now
versus only pharmacotherapy at 12000 ft
3. Hyperbaric oxygen therapy with mandatory descent now verses only
pharmacotherapy at 12000 ft
4. Symptomatic treatment with NSAIDS and ondansetron at both altitudes

Answer: 2 - Mandatory descent with steroids and acetazolamide pharmacotherapy now

versus only pharmacotherapy at 12000 ft

Explanations:

This patient has severe acute mountain sickness (AMS), defined by the symptoms of
AMS which are incapacitating.
This patient has severe acute mountain sickness (AMS), which is considered a
prelude to high altitude cerebral edema.
Severe AMS and HACE are both treated by immediate descent until the resolution
of symptoms along with the administration of dexamethasone, acetazolamide.
HACE is a medical emergency and may need immediate evacuation and portable
hyperbaric oxygen chamber therapy. It may cause death within 24 hours if treatment
is delayed.

Research Concepts:

EMS High-Altitude Field Prophylaxis And Treatment

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 Question 713: A 65-year-old man with poorly controlled hypertension presents to the
emergency department with shortness of breath, dyspnea on exertion, and severe
orthopnea of the past 2 days. He cannot walk to his bathroom without feeling short of
breath. He has been living in a mountainous area for the past year but travels to the
seaside by airplane often. His blood pressure is 180/110 mmHg, Sp02 is 88%, he has
jugular venous distension, crackles bilaterally, and 2+ pitting edema. What is the most
likely cause of his symptoms?

Choices:

1. High altitude pulmonary hypertension

2. Left ventricular heart failure
3. Asthma
4. Pneumonia
Answer: 2 - Left ventricular heart failure

Explanations:

In this question, it is important to know the risk factors, signs, and symptoms of
high altitude pulmonary hypertension (HAPH). During the evaluation and workup, it
is important to rule out alternative diagnoses.
In this case, the patient has poorly controlled hypertension, which is likely causing
his heart failure. Crackles on examination can be a clue that the symptoms are being
caused by left ventricular failure.
Although this patient lives in high altitudes, he returns from elevation often and has
not been living there for significant time, making HAPH less likely.
There is no wheezing on examination making asthma unlikely. The patient does
not have fever or cough, making pneumonia less likely.
Research Concepts:

Altitude Induced Pulmonary Hypertension

Question 714: A 29-year-old man is an expedition guide at Mount Everest. He states that
during his treks, he has frequently encountered individuals, who despite being healthy,
develop a variety of symptoms such as sleep disturbances, temperature intolerance,
lightheadedness, fatigue, nausea vomiting, and dizziness. What is the most appropriate
tool to classify this patient's symptoms?

Choices:

1. Lake Louise Questionnaire

Page 675 of 955
2. CHADS2VAS2 score
3. Well's criteria
4. HAS-BLED score
Answer: 1 - Lake Louise Questionnaire

Explanations:

The Lake Louise Questionnaire is a scoring system used to assess acute mountain
sickness (AMS).
It defines AMS as the presence of headaches in addition to other symptoms such as
gastrointestinal symptoms, fatigue or weakness and dizziness, or lightheadedness in
a setting of rapid ascent to high altitude.
It is an effective assessment tool and is most frequently used to diagnose acute
mountain sickness.
CHADS2VAS2 score is used to assess the probability of stroke development in
patients with atrial fibrillation. Well's criteria is used to assess the pretest
probability of an individual to develop a pulmonary embolism. HAS-BLED score is
used to assess the incidence of bleeding in patients with atrial fibrillation.
Research Concepts:

Acute Mountain Sickness Score

Question 715: A 39-year-old man is admitted to the medical intensive care unit for COVID-
19 acute respiratory distress syndrome (ARDS), leading to intubation and mechanical
ventilation. He has no other past medical history. On admission to the intensive care unit,
his arterial blood analysis is shown below.
Reference range
Patient result

Ph 7.45 7.34-7.45
pCO2 40 mmHg 33-45 mmHg
75-105
pO2 80 mmHg
mmHg
Bicarbonate 24 mEq/L 21-28 mEq/L
4.5-19.8
Lactate 1.9 mg/dL
mg/dL
His current respirator settings on pressure regulated volume control mode are FiO2 100%,
PEEP 14 cmH2O, rate 18/min, and tidal volume 450 mL (6 mL/kg based on predicted body
weight). He has a peak pressure of 30 cmH2O and a plateau pressure of 25 cmH2O. The
patient appears comfortable on the ventilator. Which of the following is the next best
Page 676 of 955
step in the management of this patient?

Choices:

1. Venovenous ECMO
2. Cisatracurium infusion
3. Prone the patient and re-evaluate
4. Increase tidal volume

Answer: 3 - Prone the patient and re-evaluate

Explanations:

Prone positioning has been used to improve oxygenation in severe ARDS. The
improvement in oxygenation is postulated to be due to improvement in ventilation
and perfusion matching, a better distribution of aeration, improvement of chest
wall mechanics, and better secretion clearance.
The PROSEVA trial, performed by Guerin et al. of the PROSEVA study group, was a
randomized controlled trial comparing prone positioning to supine positioning in
severe ARDS. They found a mortality benefit as well as improved oxygenation in
the prone positioning group.
However, patient selection is key to reap the benefits of prone positioning in severe
ARDS. Patients in the PROSEVA trail were randomized early in the course of ARDS
and were universally treated with low tidal volume ventilation (6 ml/kg of predicted
body weight). They were prone for at least 16 hours after the criteria for proning
were met, these criteria were mechanical ventilation for ARDS for less than 36
hours, and severe ARDS defined as a PaO2: FiO2 ratio of 150 mmHg, with a FiO of
0.6, a PEEP of 5 cmH2O.
This patient meets the criteria for prone positioning and should be promptly
proned.

Research Concepts:

Mechanical Ventilation And Extracorporeal Membrane Oxygenation Considerations In

COVID-19

Page 677 of 955

 Question 716: A 54-year-old woman presents with a chief complaint of excessive daytime
sleepiness, feeling occasional confusion upon awakening in the morning, and fatigue. She
says these symptoms started in college, leading her to often miss morning classes.
Sleepiness affects her work performance as a department manager because she comes to
work late and falls asleep at her desk in the early afternoon. Epworth Sleepiness Scale
score is 16/24. Bedtime is 10 pm, wake-up time is 8:30 am, and sleep onset latency is 10
minutes. She takes two to three naps for one to hours each but does not feel refreshed.
Her BMI is 35.6 kg/m2, blood pressure 139/78 mmHg, pulse 89/minute, and oxygen
saturation 95% on room air. Oral examination is notable for Mallampati class II. The
remaining exam is within normal limits. What is the most appropriate evaluation of this
patient?

Choices:

1. Actigraphy
2. Multiple sleep latency test (MSLT)
3. Polysomnography followed by MSLT
4. Initiation of modafinil
Answer: 3 - Polysomnography followed by MSLT

Explanations:

This vignette depicts idiopathic hypersomnia (IH). IH is characterized by excessive daytime

sleepiness, uncontrollable need to sleep with long unrefreshing naps, and difficulty waking
up from sleep in most instances despite average or more extended amounts of nocturnal
sleep for at least three months. The onset of the disease is insidious, with symptoms
appearing over weeks to months, making it difficult to elucidate any specific triggering
factors.
Patients commonly endorse symptoms of long daytime naps (>1 hour) which are typically
non-refreshing but sleep attacks are not frequently reported. Two clinical subtypes of IH
have been previously reported as IH with long sleep time (IHwLST, >10 hours) and IH
without long sleep time (IHwoLST) in the second edition of ICSD.
Although sleepiness is the hallmark of IH, symptoms of this condition are not limited to
excessive daytime sleepiness and are frequently persistent despite treatment. Specifically,
individuals with IHwLST can present with a history of severe sleep inertia and fatigue.
The diagnosis of IH is by excluding other reasons and causes of hypersomnia. History alone
is insufficient to make the diagnosis of IH; therefore, objective tests such as
polysomnography followed by multiple sleep latency test (MSLT) are essential.

Research Concepts: Idiopathic Hypersomnia

Page 678 of 955

Question 717: A 65-year-old woman presents to the hospital with complaints of fever,
chills, faintness, chest pain, and shortness of breath for one day. The patient has been
recently diagnosed with Hodgkin lymphoma and is on chemotherapy since then. The
clinical symptoms of the patient are most likely due to the adverse effects of the drug.
What test is routinely performed before starting the patient on this drug?

Choices:

1. Chest imaging
2. Renal function tests
3. Pulmonary function tests
4. Complete blood count

Answer: 3 - Pulmonary function tests

Explanations:

Bleomycin belongs to a subfamily of glycopeptide antibiotics and is utilized primarily

as an antineoplastic agent. Bleomycin is used clinically as part of combination
cytotoxic chemotherapy regimens including ABVD (Adriamycin, Bleomycin,
Vinblastine, Dacarbazine). It was first approved by the FDA in 1975 for the
treatment of squamous cell carcinomas, malignant lymphomas, and testicular
cancers.
Bleomycin has since been shown to have a wide array of FDA- approved therapeutic
indications, including germinal cell tumors, gestational trophoblastic disease,
Hodgkin lymphoma, and non- Hodgkin lymphoma. Non-FDA approved indications
include AIDS-associated Kaposi sarcoma, osteosarcoma, malignant melanoma, and
advanced stages of mycosis fungoides.
It is recommended liver enzymes, blood counts, plasma proteins, and electrolytes,
it is advisable that providers acquire periodic chest imaging of patients receiving
bleomycin.
Pulmonary function tests are performed before administering the drug and are not
recommended as a routine investigation. Renal function tests are performed in
patients having renal toxicity or showing signs of renal failure.

Research Concepts: Bleomycin

Page 679 of 955

Question 718: A 65-year-old man presents with a cough. He also has had occasional
hemoptysis, chest pain, and dyspnea on and off for the past two months. The patient
denies any fever or weight loss. He has a past medical history of hypertension, which is
well-controlled. Family history is significant for lung cancer. He has a 20-pack-year
smoking history, drinks alcohol occasionally, and does not use recreational drugs. A CT
scan shows a mass of 10 cm x 7 cm in the right middle lung with central calcification. The
tumor was excised and sent for histopathological examination, which showed the
overgrowth of multiple aberrant cells without any neoplastic cells. Which additional
finding would be most likely observed in the specimen?

Choices:

1. Nodules of cartilage associated with fibrous and adipose tissue admixed with
bronchial epithelium
2. Prominent smooth muscle component and bronchiolar structures with nuclear
atypia
3. Uniform cuboidal cells with granular cytoplasm
4. Islands of malignant squamous cells

Answer: 1 - Nodules of cartilage associated with fibrous and adipose tissue admixed with
bronchial epithelium

Explanations:

Hamartoma is a benign tumor made up of mature but disorganized cells of tissues

indigenous to the particular organ. Pulmonary hamartoma is a tumor-like lesion
composed of an abnormal mixture of pulmonary tissue components. It is most
commonly asymptomatic and is usually discovered incidentally as a coin lesion in a
chest x-ray. But it can be symptomatic or show rapid growth, in which case surgical
resection is indicated. There are two types of pulmonary hamartomas. Chondroid
hamartoma typically consists of nodules of cartilage associated with fibrous and
adipose tissue admixed with bronchial epithelium. The other is leiomyomatous
hamartoma. They are frequently multiple and more commonly located near pleura.
It has a prominent smooth muscle component and bronchiolar structure.
Definite diagnosis and treatment can be achieved by surgical resection with
minimal morbidity. Many case studies have shown no recurrence.

Research Concepts:Hamartoma

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Question 719: A 65-year-old woman presents with fever, cough, and fatigue. Her vital signs
are blood pressure of 141/86 mmHg, a temperature of 101.8 F, a pulse of 90/min, and a
respiratory rate of 28/min. The physical exam is unremarkable. The patient’s laboratory
values are sodium of 140 mmol/L, potassium of 4.1 mmol/L, magnesium of 0.91 mmol/L,
and glucose of 4.5 mmol/L. The clinician suspects systemic blastomycosis. Which of the
following is the mechanism of action of the drug of choice for this patient?

Choices:

1. Binds to sterols in the cell membrane

2. Inhibits purine and pyrimidine uptake
3. Inhibits dihydrofolate reductase
4. Intercalates DNA

Answer: 1 - Binds to sterols in the cell membrane

Explanations:

Amphotericin B is a polyene antifungal drug often used for systemic fungal infections.
Amphotericin B binds to sterols, the main component of fungal cell membranes.
Amphotericin B binding leads to the formation of fungal cell membrane pores, causing
rapid leakage of potassium, sodium, hydrogen, and chloride and subsequent fungal
cell death.
Patients need adequate hydration to attenuate renal damage.
Research Concepts:

Amphotericin B

Question 720: A 40-year old presents with complaints of fever, muscle pain, dyspnea, and
a cough that has been going on for a few months. The patient denies any recent travel, use
of drugs, smoking, or any other illness. The patient had a negative tuberculin skin test a
few days ago. The patient has erythema nodosum on both extremities and crackles on
auscultation; the rest of the exam is normal. A chest x-ray reveals bilateral hilar
adenopathy. Urine analysis reveals hypercalciuria. Which of the following can be part of
the evaluation?

Choices:

1. Calcium and albumin levels

2. CT scan of chest and abdomen
3. Serum angiotensin-converting enzyme and serum amyloid A
Page 681 of 955
4. Kveim test
Answer: 3 - Serum angiotensin-converting enzyme and serum amyloid A

Explanations:

Sarcoidosis is a disease characterized by noncaseating granulomas that may affect any

organ.
Skin is the most easily accessible tissue to biopsy for a definitive diagnosis. Serologic
tests including serum angiotensin- converting enzyme (ACE), adenosine deaminase,
serum amyloid A, and soluble interleukin-2 receptor can be considered. A biopsy is
often required to confirm the diagnosis.
Transbronchial biopsy has a high yield. If that fails, then a mediastinoscopy to
perform a lymph node biopsy is required. The key feature is noncaseating
granulomas in the absence of mycobacteria and fungi.
Calcium levels or a CT scan of the chest would not give a definitive diagnosis. A Kveim
test is most specific for sarcoidosis but is not commonly available.
Research Concepts:

Sarcoidosis

Question 721: A 38-year-old man presents for evaluation of cardiovascular fitness to dive.
He has a past medical history of seasonal allergies for which he takes loratadine. He has
never had a stress test but says that he has an electrocardiogram (EKG) done about six
years ago as part of a physical. The patient wants to start taking scuba classes. Which of
the following would be the most appropriate investigation to clear the patient for this
activity?

Choices:

1. Electrocardiogram
2. Chest x-ray
3. Diver health questionnaire
4. Stress test
Answer: 3 - Diver health questionnaire

Explanations:

Self-contained underwater breathing apparatus (SCUBA) diving is a physiologically

taxing exercise. All major diving organizations require medical screening before a
person may participate in this activity.
The most effective tool is a well-designed screening questionnaire that can further
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 inform the evaluation and determine if further testing is necessary.
Several physiologic changes occur within the body during diving that can predispose
a patient to cardiac events. Most evident, scuba diving causes an increase in
metabolic oxygen consumption from the muscular contraction required to swim
while carrying the necessary gear. Decreased heart rate is also common during
diving due to the increase in vagal tone associated with the mammalian diving
reflex and from the increased partial pressure of hyperbaric oxygen inhaled from the
scuba tank.
An EKG should be followed by an exercise stress test if there is a concern for
coronary artery disease, but is not routinely recommended for evaluation of
cardiovascular fitness in an otherwise healthy man. A chest x-ray is not routinely
indicated in the evaluation of a potential scuba diver.

Research Concepts: Cardiovascular Fitness To Dive

Question 722: A 44-year-old male who has not seen a healthcare provider in twenty years
presents with progressive weakness and shortness of breath for a week. He decided to
seek care because he started to cough up blood. His vital signs show blood pressure
90/40 mmHg, heart rate 110 beats per minute, respiratory rate 35 breaths per minute,
and SpO2 85% despite 100% FiO2 via a simple face mask. He is afebrile. He is intubated
and placed on mechanical ventilation. Copious amounts of blood have been suctioned
from the endotracheal tube. His chest x-ray shows bilateral infiltrates, with the bases
worse than the apices. The labs show sodium 135 mEq/L, potassium 7.9 mEq/L, carbon
dioxide 13 mEq/L, blood urea nitrogen 90 mg/dL, and creatinine 6.7 mg/dL. A Foley
catheter is placed with the return of 50 mL of urine. The urinalysis is significant for red
cell casts and 2+ protein. The patient is transferred to the intensive care unit with plans
for the immediate placement of a temporary dialysis catheter. What is the likelihood that
this patient will regain renal function with aggressive therapy, including plasmapheresis,
cyclophosphamide, and corticosteroids?

Choices:

1. More than 90%

2. 50%
3. 25%
4. Less than 10%
Answer: 4 - Less than 10%

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Explanations:

Goodpasture syndrome is an autoimmune disease characterized by an anti-glomerular

basement membrane that manifests as pulmonary hemorrhage and acute renal failure.
While overall survival is good at more than 80% with appropriate therapy, the return of
renal function is quite poor for those patients requiring renal replacement therapy in the
first 72 hours.
Kidney biopsy will provide a percentage of glomeruli affected and can provide further
prognostic data.
For patients without pulmonary symptoms in whom renal recovery is very unlikely (i.e., for
those that presented with the urgent need for dialysis within the first 72 hours), the risk of
plasmapheresis and immunosuppressive may outweigh the benefits. The choice to
withhold treatment in these cases remains controversial as the disease has not been well-
studied in controlled trials. It remains difficult to predict who in this group exactly will
respond and recover renal function. The overall return of renal function in this group is
approximately 8%, yet many clinicians still opt for a trial of aggressive combined therapy at
this time.

Research Concepts: Goodpasture Syndrome

Question 723: A 28-year-old lives with his parents, who have been ill with coronavirus
disease 2019 (COVID-19). He is worried because a serological test revealed the presence of
IgM. However, a further molecular investigation for the search for viral RNA from a
nasopharyngeal swab has failed. What is the current role of serological diagnosis in
COVID-19?

Choices:

1. Serologic diagnosis has limitations in both specificity and sensitivity but can have an
essential role in broad-based surveillance
2. IgG antibodies provide immunity from future severe acute respiratory distress
syndrome coronavirus-2 (SARS-CoV-2) infection and other coronavirus-induced diseases
3. There is a long duration of the protection
4. Although the tests have low sensitivity and specificity, the results between the
various tests on the market vary little
Answer: 1 - Serologic diagnosis has limitations in both specificity and sensitivity but can have
an essential role in broad-based surveillance

Explanations:

Serologic diagnosis has limitations in both specificity and sensitivity.

Serological diagnosis can have an essential role in broad-based surveillance.

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 Results from different tests vary in the accurate diagnosis of COVID-19.
Many doubts regard if IgG antibodies will provide immunity from future SARS-CoV-2
infection, about the protective titer of antibodies, as well as on the duration of the
protection.

Research Concepts:

Features, Evaluation, and Treatment of Coronavirus (COVID-19)

Question 724: An African American female comes to the emergency room with facial
weakness. The right side started yesterday and the left side today. She has had no
constitutional symptoms or rashes. She lives in Chicago and has no pets. She is employed
in an office and has no hobbies with exposure to chemicals. She has hypertension and is
on hydrochlorothiazide. Her blood pressure is 130/85 mm Hg, her pulse is 85 bpm,
respirations 16/min., and she is afebrile. The right side of the face is paralyzed, but she
can raise her eyebrow on the left. The chest radiograph has bilateral hilar
lymphadenopathy. MRI with gadolinium shows enhancement of the seventh cranial
nerve and meninges bilaterally. Lumbar puncture yields CSF with an opening pressure of
12 cm H2O, with no red cells, 21 white cells with 82% lymphocytes and 28 percent
neutrophils, protein 72 mg/dL, and glucose 62 mg/dL. Gram stain is negative. What does
one expect will happen to her lungs?

Choices:

1. Develop a pulmonary embolus

2. Pneumothorax
3. Develop pleural thickening
4. Fibrosis
Answer: 4 - Fibrosis

Explanations:

Sarcoidosis can cause pulmonary fibrosis.

Sarcoidosis is a multi-organ disease and can affect the brain, kidneys, lungs, and
many other organs.
It classically shows bilateral hilar lymphadenopathy.
Lung fibrosis becomes so severe that it results in pulmonary hypertension, which
results in death.
Research Concepts:Sarcoidosis
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Question 725: A 16-year-old female patient accidentally aspirates her hairpin and now
presents to the emergency department with complaints of dyspnea and stridor. She is
started on heliox by face mask, which is a mix of helium and oxygen in a 70:30 ratio. It has
been made sure that the mask is tightly fixed, and there is no leakage. The patient's
PaCO2 is 40 mmHg, and the patient has an Aa gradient of 9 mmHg. What is this patient’s
PaO2?

Choices:

1. 140 mmHg
2. 90 mmHg
3. 155 mmHg
4. 168 mmHg
Answer: 3 - 155 mmHg

Explanations:

The alveolar gas equation is used to calculate alveolar oxygen partial pressure: PAO2 =
(Patm - PH2O) FiO2 - PaCO2 / RQ. Where PAO2 is the partial pressure of oxygen in the
alveoli, Patm is the atmospheric pressure at sea level equaling 760 mm Hg. PH2O is the
partial pressure of water equal to approximately 45 mm Hg. FiO2 is the fraction of inspired
oxygen. PaCO2 is the carbon dioxide partial pressure in alveoli, which in normal
physiological conditions is approximately 40 to 45 mm Hg, and the RQ (respiratory
quotient).
FiO2 is directly related to the percent composition of oxygen in the inspired air. Without
support at sea level, this is 21% or 0.21. However, each liter of supplemental oxygen in the
inspired air increases this value by approximately 4% or 0.04. Therefore 2 liters of
supplemented oxygen increase the FiO2 at sea level by 8% or 0.08 to 29% or 0.29. The value
of RQ can vary depending upon the type of diet and metabolic state of the person.
A standard value of 0.82 is used for the typical human diet. At sea level without
supplemented inspired oxygenation, the alveolar oxygen partial pressure (PAO2) is:
PAO2 = (760 - 47)
0.21 - 40 / 0.8 = 99.7 mm Hg. This alveolar partial pressure of oxygen then is the driving
force for diffusion of oxygen across the alveolar membranes, through pulmonary capillary
walls, and into the arteriolar blood flow and erythrocytes for transport throughout the
body into peripheral tissues.
The diffusion gradient from alveolar space into the capillary is quantified via the A-a
gradient calculated as A-a oxygen gradient = PAO2 - PaO2. PaO2 is measured using an
arterial blood gas, and PAO2 is calculated as above. A larger gradient indicates pathology
is hindering the transfer of oxygen into the capillary, which has an impact on the available
partial pressure of oxygen throughout the body.
Research Concepts:Partial Pressure Of Oxygen

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Question 726: A 65-year-old female presents to the clinic due to 3 months of progressive
left shoulder pain. The patient says that the pain radiates to her forearm. The patient has
a 30 pack-year smoking history. Vital signs are within normal limits. The physical
examination is positive for drooping of the left upper eyelid and pupillary constriction.
There are no deformities or swelling of the hand joints. Physical examination of the left
shoulder is normal.
Which of the following is the best next step in the management of this patient?

Choices:

1. X-ray of the chest

2. X-ray of the right shoulder
3. Acetylcholine receptor antibody testing
4. Nerve conduction studies
Answer: 1 - X-ray of the chest

Explanations:

This patient with left shoulder pain, a significant smoking history, normal shoulder
examination, and signs of Horner syndrome most likely has a superior sulcus tumor.
Superior pulmonary sulcus tumor (Pancoast tumor) usually arise in smokers are
usually adenocarcinomas.
Patients may present with shoulder pain and ipsilateral Horner syndrome. Since it
is a peripheral tumor, pulmonary signs may not present until later with disease
progression.
Patients with a suspected Pancoast tumor should undergo a chest x-ray. If a lesion is
found on an x-ray, a biopsy of the mass should be performed.

Research Concepts:

Lung Adenocarcinoma

Question 727: A 24-year-old male is being worked up for a mediastinal mass found
incidentally on chest x-ray. He has had progressive dyspnea with a dry cough for the
last 6 months.
Computed tomography of the thorax reveals a well-circumscribed mass measuring 2.5 cm
x 4.2 cm x 2.1 cm with contents that resemble a molar tooth. Beta-human chorionic
gonadotropin and alpha fetal protein levels are within the normal range. What is the next
best step in management?

Choices:
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1. Surgical resection only
2. Chemotherapy only
3. Chemotherapy followed by surgical resection
4. Surveillance
Answer: 1 - Surgical resection only

Explanations:

A young male with a mediastinal mass with evidence of formed teeth and normal
tumor markers has benign teratoma.
Benign mature teratomas do not respond to chemotherapy. Treatment for
symptomatic patients involves surgical resection only.
Surgical intervention is not necessary for benign teratomas if the patient is
asymptomatic.

Research Concepts:

Mediastinal Germ Cell Tumors

Question 728: A 17-year-old man presents to the emergency department with blurred
vision and difficulty swallowing for a day. His past medical or surgical history is
insignificant. On examination, the patient has slurred speech. Moreover, multiple track
marks are seen on both arms, with some surrounding erythema. Examination of the
cranial nerves reveals ptosis in both eyes. Ophthalmic examination reveals bilateral
diplopia and impaired pupil accommodation.
Examination of the upper limbs reveals a lower than the normal tone of muscles, and
power is 4/5 bilaterally. Examination of the lower limbs is unremarkable. Sensations are
intact in both upper and lower limbs. What is the most likely organism causing this
patient’s presentation?
Choices:

1. Clostridium botulinum
2. Clostridium tetani
3. Clostridium butyricum
4. Campylobacter jejuni
Answer: 1 - Clostridium botulinum
Explanations:

Botulism is a neuroparalytic syndrome that results from the systemic effects of an

exo-neurotoxin produced by the gram- positive, rod-shaped, spore-forming,
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 obligate anaerobic bacterium Clostridium botulinum. Other Clostridium species
(Clostridium butyricum and Clostridium baratii) occasionally produce the toxin.
Botulism classically begins with cranial nerve palsies (“bulbar symptoms”) that
progress to the symmetrical descending weakness of the trunk, extremities, and
smooth muscle, with eventual flaccid paralysis. Patients usually have no sensory
deficits except for blurred vision, although paresthesias are occasionally seen.
Typical early symptoms include diplopia (visual disturbances), dysphagia (difficulty
swallowing), dysphonia (voice change), and dysarthria (slurred speech), reflecting
the high susceptibility of cranial nerve efferent presynaptic terminals to the
activity of BoNT.
Involvement of the diaphragm precipitates respiratory failure, often requiring
intubation and mechanical ventilation. Palsies of autonomic smooth muscle cause
constipation and urinary retention.
Food-borne botulism will often present with a prodrome of abdominal pain, nausea,
and vomiting beginning 12 to 72 hours after ingestion of the preformed toxin.

Research Concepts: Botulism

Question 729: A 65-year-old African American male presents with worsening shortness of
breath for 2 weeks duration. He has no medical history and has smoked 1 pack of
cigarettes per day for the last 15 years. Physical exam reveals diffuse bilateral crackles
with a normal cardiovascular exam. Chest CT shows no nodules or vascular occlusions,
and cardiac proteins were normal. Alveolar tissue is biopsied during bronchoalveolar
lavage and, after addition of trichrome staining, extensive blue staining is seen
surrounding each alveolus. Alveolar architecture is preserved. Which of the following is
the most likely diagnosis?

Choices:

1. Idiopathic pulmonary fibrosis

2. Chronic obstructive pulmonary disease
3. Congestive heart failure
4. Lung cancer
Answer: 1 - Idiopathic pulmonary fibrosis

Explanations:

Collagen stains blue with Trichrome stain.

Idiopathic pulmonary fibrosis causes extensive fibrosis surrounding alveoli, causing
difficulty breathing.
In the midst of extensive collagen on biopsy, pulmonary fibrosis is the most likely
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 diagnosis of the choices.
Due to lack of nodules or pulmonary emboli on chest CT, lung cancer and embolism
are unlikely diagnoses. In addition, normal architecture on biopsy is helpful in ruling
out chronic obstructive pulmonary disease. Normal cardiovascular exam and
extensive collagen on biopsy make congestive heart failure less likely.

Research Concepts:

Idiopathic Pulmonary Fibrosis

Question 730: A 65-year-old man presents to the clinic for assessment of his exertional
shortness of breath. He worked in sanitation for 25 years and was exposed to fumes from
the burning of wastes. A pulmonary function test is done in the office, and it shows an
FEV1/FVC ratio of 0.55, with an FEV1 of 60%. He also has significant fatigue and pain in
his lower extremities on walking, limiting his ability to exercise. Based on the
assessment, he has referred him to a pulmonary rehabilitation program. The exercise
program has significantly improved his muscle fatigue, pain, and exercise capacity. Which
of the following is the most likely physiological reason for the improvement in his muscle
fatigue and pain?
Choices:

1. Increased glycogen stores in muscles

2. Delayed lactic acid build-up
3. Stretching of muscle fibers
4. Increased total lung capacity
Answer: 2 - Delayed lactic acid build-up
Explanations:

In chronic lung diseases due to functional and structural abnormalities, the gas
exchange is abnormally affected. The resulting decreased oxygen supply to skeletal
muscles results in an early shift towards anaerobic metabolism. This can lead to
lactic acid build-up, which is a byproduct of anaerobic metabolism. This lactic acid
results in fatigue and pain in exercising muscles. Exercise programs involving high-
intensity exercise can bring about biochemical changes at the cellular level, along
with structural changes in the character of muscle fibers, leading to more aerobic
metabolism and a lesser degree of lactic acid build-up and carbon dioxide
production. Thus resulting in delayed fatigue can enhance exercise tolerance.
Decreased glycogen stores are not the reason for acute fatigue and pain. It is mostly
due to an early build-up of lactic acid in the exercising muscle.
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 Stretching of muscle fibers during exercise can cause discomfort and sometimes
pain. However, within the normal range of motion, and without over-exertion, it
should not cause immediate fatigue.
Hyperinflation in the lungs is seen in patients when they exercise and cause
worsening dyspnea and lung function. It can contribute to decreased exercise
tolerance. The main cause of fatigue and pain in exercising muscles noted in
patients with chronic lung disease is directly related to an early shift to anaerobic
metabolism and lactic acid accumulation.

Research Concepts: Pulmonary Rehabilitation

Question 731: An 80-year-old man with a past history of diabetes and hypertension
presents to the emergency ward with difficulty breathing. He had a myocardial infarction
3 years back, and since then he has had multiple hospitalizations for difficulty breathing.
At present, he complains of dyspnea, orthopnea, fatigue. He lost 16 lb (7.2 kg) weight in
the last 2 years. On examination, the temperature is 36 C, respiratory rate is 90 per
minute, pulse is 90 per minute, blood pressure is 80/50 mm Hg, weak peripheral pulses,
SpO2 80%. Cardiovascular examination reveals elevated jugular venous pressure,
downward displace apex beat, S3 present with no murmurs. Respiratory examination
revealed bilateral basal rales and crackles. Bilateral pedal edema is present. CXR shows an
enlarged cardiac silhouette and evidence of pulmonary edema.
Echocardiography revealed enlarged cardiac chambers with an ejection fraction of 30%.
He is currently on Lisinopril, Carvedilol, Spironolactone, Metformin. Furosemide was
added for volume reduction. He is being evaluated for a biventricular pacemaker.
Supplemental oxygen therapy is started for dyspnea. He is advised for long-term home
supplemental oxygen therapy because of decompensated cardiac function. What is the
major concern about treatment with high flow oxygen for long periods?

Choices:

1. Pneumothorax
2. Pulmonary toxicity
3. Pulmonary hypertension
4. Atelectasis
Answer: 2 - Pulmonary toxicity
Explanations:

Breathing high-flow oxygen for an extended period can lead to pulmonary toxicity.
Pulmonary toxicity results from significant alveolar damage secondary to oxygen-
free radical production from the extended duration of exposure to oxygen at high
pressures. Significant alveolar damage in the lung can lead to pulmonary fibrosis.
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 Central nervous system oxygen toxicity only occurs in hyperbaric conditions.
Eye effects can occur such as retinal injury, transient myopia, cataract promotion, and
optic artery embolism.
Atelectasis can occur after hyperbaric oxygen exposure but is rarely of clinical
significance. Hyperbaric oxygen manipulates surfactant levels which can cause
damage to the alveolar epithelial lining and lead to atelectasis.

Research Concepts:Oxygen Toxicity

Question 732: A 60-year-old female with a long-term history of rheumatoid arthritis and
hypertension presents for evaluation of ongoing cough, hoarseness, and slowly
worsening shortness of breath. She undergoes laryngoscopy and is found to have
laryngotracheal stenosis with 85% luminal obstruction of a stenotic segment 2 cm in
length. Which of the following is the next best step in the management of this patient?

Choices:

1. Tracheal stent placement

2. Open surgical correction
3. Mitomycin C injection
4. Endoscopic balloon dilatation
Answer: 2 - Open surgical correction

Explanations:

There are three classification systems based on anatomic characteristics that take
into account the cross-sectional area of the subglottis. The Cotton-Myer
classification is based on percent stenosis (I = less than 50% obstruction; II = 51%–
70% obstruction; III = 71%–99% obstruction; IV = complete obstruction). This
patient has Cotton-Myer class III stenosis.
The Lano classification is based on subsite involvement (I = one subsite
involvement; II = two subsite involvement; III = three subsite involvement, with the
subsite meaning the glottis, subglottis, and trachea). The McCaffrey classification is
based on the length of stenosis (I = subglottis or trachea less than 1 cm; II =
subglottis greater than 1 cm; III = subglottis & trachea greater than 1 cm; IV = any
lesion involving glottis).
The percent stenosis is important in regards to prognosis, individualized treatment
planning, and risk stratification of tracheostomy dependence. Open surgery is offered
to patients with Myer-Cotton grade III or IV, loss of cartilage, or stenosis longer than 1
cm.
Patients with grade III and IV stenosis in the Cotton-Myer classification were found
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 to be tracheostomy-dependent compared to patients with grade I and II.

Research Concepts: Laryngotracheal Stenosis

Question 733: A 4-year-old boy presents to the clinic with a history of snoring. His weight
is 23 kg. Nocturnal polysomnography is done, showing an apnea-hypopnea index (AHI) of
18. Which of the following is the most appropriate management strategy for this child?

Choices:

1. Continuous positive airway pressure

2. Weight loss
3. Tonsillectomy and adenoidectomy
4. No treatment needed
Answer: 3 - Tonsillectomy and adenoidectomy

Explanations:

The patient mentioned has moderate obstructive sleep apnea syndrome (OSAS).
OSAS occurs when there are transient periods of upper airway obstruction that then
lead to hypoxemia, hypercapnia, and usually sleep disturbance. The usual signs of
OSAS are snoring, gasping, and frequent awakening.
Diagnosis of OSAS can only be made by nocturnal polysomnography (sleep study).
The apnea-hypopnea index (AHI) measures the number of episodes of apnea and
hypopnea in an hour (mild OSAS, 5–15 episodes/hr; moderate OSAS, 15– 30
episodes/hr; severe OSAS, >30 episodes/hr).
In the pediatric population, the initial treatment of OSA is a tonsillectomy and
adenoidectomy. This is usually curative, but further treatment may be needed,
especially in patients with other causes of OSA, as in patients with obesity or
hypotonia. Anesthetic management of patients with OSAS should include a careful
airway examination; consideration should be given to preoperative
echocardiogram if the OSAS is chronic and untreated. These patients may be
difficult to mask ventilate due to their habitus and upper airway obstruction on
induction. They also may be difficult to intubate.

Research Concepts: Obstructive Sleep Apnea

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Question 734: A 65-year-old male patient with a history of chronic obstructive pulmonary
disease (COPD) controlled on inhaled corticosteroids presents to the hospital complaining
of sudden onset dyspnea and left-sided pleuritis type chest pain. A chest radiograph is
performed which shows a 1.5 cm large area of air on the left side without lung markings.
On aspiration, it reduces to 0.75 cm. What is the most appropriate next step in
management?
Choices:

1. Admit overnight for oxygen supplementation

2. Discharge with follow up after 24 hours
3. Admit for chest drain insertion
4. Repeat aspiration

Answer: 1 - Admit overnight for oxygen supplementation

Explanations:

A pneumothorax is defined as a collection of air outside the lung but within the
pleural cavity. It occurs when air accumulates between the parietal and visceral
pleurae inside the chest. The air accumulation can apply pressure on the lung and
make it collapse. The degree of collapse determines the clinical presentation of
pneumothorax.
There are two types of pneumothorax: traumatic and atraumatic. The two subtypes of
atraumatic pneumothorax are primary and secondary. A primary spontaneous
pneumothorax (PSP) occurs automatically without a known eliciting event, while a
secondary spontaneous pneumothorax (SSP) occurs subsequent to an underlying
pulmonary disease.
In secondary spontaneous pneumothorax, if size/depth of pneumothorax is less
than 1cm and no dyspnea then the patient is admitted, high flow oxygen is given
and observation is done for 24 hours.
If size/ depth is between 1-2cm, needle aspiration is done, then the residual size of
pneumothorax is seen, if the depth after the needle aspiration is less than 1cm
management is done with oxygen inhalation and observation and in case of more
than 2cm, tube thoracostomy is done. In case of depth more than 2cm or
breathlessness, tube thoracostomy is done.

Research Concepts: Pneumothorax

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Question 735: A 45-year-old man with a history of alcohol use disorder, asthma, and
morbid obesity is admitted to the hospital for an asthma exacerbation. He has been on
continuous albuterol nebulization for the past 30 minutes without any relief of
respiratory effort despite the use of non-invasive ventilation with FiO2 0.6. Vital signs
show heart rate 124/min, respiratory rate 36/min, blood pressure 100/50 mmHg, and
SpO2 92%. The chest X-ray does not show any infiltrates, but there is lung hyperinflation
with flattening of the diaphragm. Labs show serum creatinine 2.1 mg/dL, bicarbonate 20
mg/dL, and potassium 5.5 mEq/L. Intravenous methylprednisolone 120 mg was given, and
a decision was made to intubate the patient electively. Which of the following is the most
appropriate management strategy for this patient?

Choices:

1. Use of high dose propofol bolus for sedation, fentanyl for analgesia, and
intravenous bolus fluids post-intubation
2. Carefully titrated doses of ketamine or propofol for sedation, fentanyl for
analgesia, pre-intubation intravenous fluids with or without vasopressors
3. Midazolam or lorazepam for sedation, paralysis with
succinylcholine, pre-intubation intravenous fluids
4. Thiopental for sedation, paralysis with rocuronium, pre-intubation intravenous fluids
with or without inotropes
Answer: 2 - Carefully titrated doses of ketamine or propofol for sedation, fentanyl for
analgesia, pre-intubation intravenous fluids with or without vasopressors

Explanations:

Ketamine and propofol have bronchodilatory properties and are the preferred
agents for acute severe asthma.
Additionally, ketamine increases circulating catecholamines and inhibits vagal
activity combating vasoplegia.
High dose propofol for induction would precipitate significant hypotension in this
patient with borderline blood pressure.
Vasoplegia routinely occurs in acute severe/critical asthma due to loss of
sympathetic tone with sedation, and this will be accentuated in the post-
intubation period as intrathoracic pressure falls. Propofol doses should be
carefully titrated to avoid such significant hypotension.
Although midazolam and lorazepam are considerations for patients with alcohol
dependence, they are not ideal choices given the bronchodilatory benefits of
propofol or ketamine.
Succinylcholine should be avoided, given the mild hyperkalemia. Thiopental should not
be used as they cause bronchospasm via histamine release. Rocuronium may be used
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 for the induction of paralysis in patients whose respiratory drive persists despite
sedation. But it is also important to note that this patient is morbidly obese, and
hence the use of paralytics should be considered judiciously in conjunction with the
immediate availability of airway experts to manage a difficult airway.

Research Concepts:

Intubation Endotracheal Tube Medications’

Question 736: A 77-year-old man with a history of chronic obstructive pulmonary disease
(COPD) is brought to the emergency department with difficulty breathing that
progressively worsened in the last four days. He reports associated symptoms of fever,
cough, myalgia, and congestion. The patient states that he picks his grandson up from
preschool every day and noted a lot of his grandson’s friends have been out sick the last
couple of weeks with human metapneumovirus (HMPV). The patient does admit to
smoking 2 packs per day of cigarettes for 35 years. Shortly after his arrival, his respiratory
status significantly declines. His current vital signs show pulse 135/min, respiratory rate
46/min, temperature
101.2 F, blood pressure 92/40 mmHg, and pulse oximetry 83% on 6 L/min nasal cannula.
Which of the following is the most appropriate management strategy for this patient?

Choices:

1. Acetaminophen and ribavirin

2. Mechanical ventilation and intravenous fluids
3. Mechanical ventilation and ribavirin
4. Intravenous fluids and acetaminophen
Answer: 2 - Mechanical ventilation and intravenous fluids

Explanations:

The clinical scenario portrays this patient as displaying signs of respiratory distress
with increased work of breathing, hypoxia, and tachypnea. Therefore, he requires
mechanical ventilation for respiratory support.
The patient is displaying signs of sepsis based on his vital signs from HMPV; therefore,
per sepsis protocol, he does require intravenous fluid resuscitation.
Treatment for HMPV is focused on supportive care measures only as there are no
approved pharmaceutical agents.
This patient has a history of COPD. Within certain patient populations, HMPV can
Page 696 of 955
 cause severe illness requiring hospitalization. Among those are patients who are
elderly, immunocompromised, or have a pre-existing cardiac or respiratory
condition. Ribavirin is not approved for HMPV. Treatment for HMPV is focused on
supportive measures. Therefore, since this patient is displaying signs of severe
respiratory distress, he requires respiratory support with mechanical ventilation
and intravenous fluids administration. Acetaminophen should be given, but he
requires respiratory support first.

Research Concepts: Human

Metapneumovirus

Question 737: As a nurse manager in the emergency department, you are responsible for
the maintenance of the emergency airway equipment. The emergency airway bag/cart
contains several devices to establish/maintain an airway and to provide positive pressure
ventilation. In case of problematic mask ventilation or difficult intubation, a Laryngeal
Mask Airway (LMA) should be used and, therefore, should be included in any airway
bag/cart. When inserted into a patient, where is the laryngeal mask airway usually
situated in relation to the vocal cords?

Choices:

1. Superior
2. Inferior
3. Posterior
4. Lateral

Answer: 1 - Superior

Explanations:

The laryngeal mask airway (LMA) is seated superior to the vocal cords. It is part of
every difficult airway algorithm case of unsuccessful mask ventilation or tracheal
intubation.
An LMA or laryngeal mask is a medical device that keeps the airway open during
anesthesia or unconsciousness. It is a supraglottic airway that bypasses facial hair,
facial deformities, and pharyngeal tissues.
An LMA is composed of an airway tube that connects to an elliptical cuff. The cuff
is inserted through the mouth and down the trachea, where it forms an airtight
seal on top of the glottis. This differs from tracheal tubes that pass through the
glottis.
An LMA is commonly used to channel oxygen or anesthesia gas to a patient's lungs
Page 697 of 955
 during surgery and in the pre-hospital setting for unconscious patients.

Research Concepts:

Laryngeal Mask Airway

Question 738: A 63-year-old man develops a bronchopleural fistula following a

pneumonectomy. He is ventilated in the ICU, but achieving adequate tidal volume is
difficult due to an air leak of 2.5 L/min through the fistula. Which of the following is the
most effective strategy to achieve adequate ventilation in this patient?

Choices:

1. Adding PEEP of 7.5 cmH2O

2. Increasing the flow rate by 2.5 L/min
3. High-frequency jet ventilation
4. Decreasing the respiratory rate
Answer: 3 - High-frequency jet ventilation

Explanations:

Bronchopleural fistula can occur after a pneumonectomy due to the failure of the
bronchial stump to heal. As the bronchus is in direct connection with the pleural
cavity, some of the tidal volumes are lost into the pleural cavity affecting achievable
lung ventilation.
Management of a ventilated patient with a bronchopleural fistula is particularly
challenging, and it is often difficult to wean a patient from the ventilator.
High-frequency ventilation with small tidal volumes, low airway pressure, and a
high respiratory rate provides the best chance of ventilating the lungs in these
patients if conventional ventilation fails.
Jet ventilation can be performed via either high or low-frequency means. High-
frequency jet ventilation (HFJV) is accomplished with specialized ventilators capable
of producing the high pressure, low-volume breaths. Low-frequency jet ventilation
(LFJV), however, is usually accomplished with a manually triggered hand-held
device.

Research Concepts:

Ventilator Management
Page 698 of 955
Question 739: A 67-year-old male presents to the clinic reported a two-month history of
dry cough. He states that he has had several coughing fits over the last three weeks not
resolved with a previously prescribed rescue inhaler. History is significant for seasonal
allergies as a child without exacerbation in several years. He works as an accountant for
the last 30 years. On physical exam patient is normotensive and afebrile with bilateral
expiratory wheezing heard best at bilateral lung bases. The patient is a lifetime non-
smoker and is compliant with his inhaled beta-agonist and inhaled corticosteroid therapy.
What is the next best step in treatment?

Choices:

1. Bronchoscopy
2. Chest X-ray
3. Obtain 24-hour urinary 5-HIAA level
4. Obtain serum chromogranin A level

Answer: 2 - Chest X-ray

Explanations:

This patient presents with reactive airway disease without previous smoking
history or irritant exposure.
Symptoms are refractory to bronchodilatory therapy.
Chest X-ray should be obtained; bronchial carcinoid tumors primarily present as
central lesions.
Depending on the size and location of the tumor there may also be peripheral
atelectasis or air space changes associated with the lesion.
Research Concepts:

Bronchial Carcinoid Tumors

Question 740: Platypnea and orthodeoxia frequently are observed in patients with which
of the following?

Choices:

1. Chronic obstructive pulmonary disease (COPD)

2. Hepatopulmonary syndrome
3. Pulmonary embolism
4. Pneumothorax
Page 699 of 955
Answer: 2 - Hepatopulmonary syndrome

Explanations:

Hepatopulmonary syndrome is a syndrome that occurs in patients with advanced

liver disease. It is characterized by shortness of breath (platypnea) and oxygen
desaturation (orthodeoxia) upon assuming an upright position.
Platypnea and orthodeoxia occur mainly in hepatopulmonary syndrome due to
vasodilation in pulmonary capillary vessels which, can cause decreased alveolar-
arterial oxygen diffusion, ventilation/perfusion mismatch, and arteriovenous shunting.
The only definitive treatment of platypnea and orthodeoxia in patients with
hepatopulmonary syndrome is liver transplantation. Platypnea and orthodeoxia rarely
can occur in patients with pulmonary embolism in the setting of significantly elevated
right atrial pressure.

Research Concepts:

Platypnea

Question 741: A patient is on droplet precaution. What personal protective equipment is

needed if working within 3 feet of the patient?

Choices:

1. Mask
2. Mask and eye protection
3. Mask, eye protection, and gloves
4. Mask, eye protection, gloves, and gown

Answer: 4 - Mask, eye protection, gloves, and gown

Explanations:

Droplet precautions mean that the patient's secretions in droplet form are
contagious.
These droplets do not travel more than 3 feet.
Healthcare workers should wear masks, eye protection, gown, and gloves when
working with these patients.
The patient should wear a mask if being moved about the facility.

Page 700 of 955

 Research Concepts:

Precautions, Bloodborne, Contact, and Droplet

Question 742: A 75-year-old male with a past medical history of hypertension and chronic
renal disease is brought in with complaints of altered mental status and a fever of 101 F
(38.3 C). He has a blood pressure of 105/65 mmHg, a heart rate of 141 beats per minute,
and a respiratory rate of 23 breaths per minute. His lab work reveals a white blood cell
count of 20,000 cells/mm3 and urine analysis is positive for nitrites and leukocyte
esterase. There are 50 white blood cells per high power field and gram-negative rods on
the urine Gram stain. The patient is put on broad-spectrum antibiotics.
Because of poor vascular access, a left subclavian central venous catheter is placed after
multiple attempts, and its position is confirmed with a portable chest x-ray. One hour
later, despite continued resuscitation and medical therapy, the patient became acutely
hypotensive with a blood pressure of 70/45 mmHg. His supplemental oxygen
requirement has also increased from 3 to 10 liters/min via a nonrebreather mask.
Repeated physical examination reveals absent breath sounds over the left chest, tracheal
deviation to the right, and dullness to percussion over the anterior and posterior left
lung. The provider orders a large-bore thoracotomy tube placement instead of urgent
needle decompression. Which of the following is the most important reason for this
approach?
Choices:

1. Dullness to percussion over the left lung on physical examination

2. Chances of fewer complications with a large bore thoracotomy tube
3. Increasing oxygen demand
4. The better success rate
Answer: 1 - Dullness to percussion over the left lung on physical examination

Explanations:

For a patient with suspected tension pneumothorax, if the patient is

hemodynamically unstable and clinical suspicion is high for pneumothorax, then
immediate needle decompression must be performed without delay. Needle
decompression is done at the second intercostal space in the midclavicular line
above the rib with an angio-catheter. It results in re-expansion of the collapsed lung.
However, the risk of lung re-expanding quickly increases the risk of pulmonary
edema. Following needle decompression, a chest tube is usually placed, and an
Page 701 of 955
 immediate chest x-ray is done to assess the resolution of the pneumothorax.
In this patient, there are signs of tension hemothorax as opposed to tension
pneumothorax. The key finding, in this case, was dullness to percussion over the
anterior and posterior left lung on physical examination.
Needle decompression will not allow adequate drainage of blood, causing tension
physiology.
A large-bore thoracotomy tube will drain the blood adequately and also help
measure the rate of bleeding.

Research Concepts: Tension

Pneumothorax

Question 743: A 55-year-old female presents to the clinic complaining of worsening

dyspnea over the past six months. Past medical history includes hypertension, type 2
diabetes, and systemic sclerosis. Vital signs are blood pressure 145/80 mm Hg, heart rate
90/min, spO2 88%, and respiratory rate of 22/min. High-resolution CT of the chest reveals
ground-glass changes as well as honeycombing with volume loss in the lung bases
bilaterally. The patient is started on cyclophosphamide alternated with azathioprine for
one year. What parameter would indicate adequate response to therapy?

Choices:

1. Forced vital capacity (FVC) decreases

2. FVC remains the same
3. Forced expiratory volume in one second (FEV1) decreases
4. FEV1/FVC decreases
Answer: 2 - FVC remains the same

Explanations:

An adequate pulmonary response to treatment would be indicated by a stable or

increased forced vital capacity.
Scleroderma associated-interstitial lung disease (ILD) is a progressive disease, and
the aim of therapy is to slow down or halt disease progression, which can be
measured by closely monitoring FVC on pulmonary function tests.
It has also been shown that the patients with more improvement in symptoms as
well as FVC as the patients with more severe lung fibrosis as evaluated by high-
resolution CT scoring.
Pirfenidone is another medication with antifibrotic as well as anti-inflammatory
Page 702 of 955
 effects that have been shown to decrease the rate of the decline of FVC in patients
with pulmonary fibrosis.

Research Concepts:

Restrictive Lung Disease

Question 744: A 45-year-old man is scheduled for a staging endobronchial ultrasound

(EBUS) of suspected lung cancer. Positron emission tomography (PET) has confirmed a 2
cm peripheral lesion in the left upper lobe. He has partially avid nodules at stations 11L,
4L, and 7. He has no distant metastases. Staging EBUS confirms malignant cells at 11L
consistent with a non-small cell cancer. 4L and 7 are sampled, and nodal material is
obtained, but no malignant cells are seen. Which of the following best identifies the nodal
stage for this patient’s disease?

Choices:

1. T1aM0N0
2. T1aM0N1
3. T1aM0N2
4. T1aM0N3
Answer: 2 - T1aM0N1

Explanations:

EBUS staging of lung cancer has a sensitivity of around 90%. A positive biopsy
sample has a low false-positive rate and should be used to stage patients and
guide oncological treatment planning accurately.
Lung cancer staging by EBUS is based on the International Association for the Study
of Lung Cancer's 8th edition TNM staging. N1 disease is where there is evidence of
ipsilateral peribronchial and/or hilar lymph nodes and intrapulmonary lesions. N2
disease is where there is evidence of ipsilateral mediastinal and/or subcarinal lymph
nodes. N3 disease is where there is evidence of contralateral mediastinal or hilar
lymph nodes or the presence of scalene/supraclavicular nodes.
Sampling of all PET avid lesions is essential as, in this case, staging as N1 disease allows
for consideration of surgical resection and, therefore, curative intent.
For non-small cell lung cancer patients with N1 disease on staging, overall 5-year
survival remains low at around 40%. If there is a single N1 site involved, survival is
around 48% at 5 years, falling to around 30% with multiple N1 sites involved.
Page 703 of 955
Research Concepts:

Sonography Endobronchial Assessment, Protocols, And Interpretation

Question 745: A 31-year-old man has complained of worsening dyspnea, chest pain, and
productive cough for the past month and has lost 6 kg of weight. He has a past medical
history of asthma and is taking an albuterol inhaler daily, and he reports taking his high-
dose inhaled corticosteroid as prescribed. His family history and exposure are negative for
TB. His vitals included a fever of 99.5 F (37.5 C), a blood pressure of 120/85 mmHg, heart
rate of 110 beats per minute, and a respiratory rate of 21 breaths per minute. On
examination, there were sinus tenderness, nasal discharge, and rales. A chest x-ray reveals
bilateral apical infiltrate. Which of the following is most specific for diagnosing the
disease?

Choices:

1. Sputum culture
2. Western blot
3. Serum biomarkers
4. CT scan

Answer: 1 - Sputum culture

Explanations:

The most common initial symptoms of aspergillosis include dyspnea, increased

sputum production, chills, headache, and arthralgias.
As the condition quickly progresses, fever, toxicity, and weight loss manifest. On
examination, there may be sinus tenderness, nasal discharge, rales, dermatologic
changes, or meningeal signs of the central nervous system.
A strong clinical suspicion to identify patients at risk for invasive aspergillosis is the
first step in evaluating for aspergillosis since aspergillosis conidia are inhaled
continuously. The fungal stain of the sputum should be done first to identify a
patient with invasive aspergillosis. In normal hosts, the mere presence of
Aspergillus does not necessarily indicate acute infection; however, in the
immunocompromised host, finding the fungus should prompt the clinician to treat
it as a severe infection.
The culture of the Aspergillus species in the sputum or by bronchoalveolar lavage
with the identification of hyphae, which is the most specific test, will confirm that
Page 704 of 955
 the infection is from Aspergillus and not another mold or fungus. A tissue biopsy of
an aspergilloma may be helpful to confirm the diagnosis and exclude other
conditions that may cause lung masses.

Research Concepts: Aspergillosis

Question 746: An 11-year-old child presents to the hospital with fatigue, hemoptysis, and
shortness of breath. On arrival, his vital signs are blood pressure 119/75 mmHg, pulse
80/minute, respiratory rate 19/minute, and temperature 37.3 C (99.1 F). Further blood
work confirms iron-deficiency anemia. The chest x-ray is unremarkable.
There is no drenching night sweat or weight loss. An autoimmune screen and vasculitis
screen are negative, and all infective causes are excluded. There is no evidence of
bleeding from the gastrointestinal tract or any other site. There is no history of similar
symptoms in any family member or any significant medical condition in the family. A
high-resolution CT scan is requested, which shows diffuse alveolar shadowing and
ground-glass opacities. What investigation is regarded as the gold-standard for correctly
diagnosing this condition?

Choices:

1. Spirometry
2. Lung biopsy
3. Gastric lavage
4. Chest CT scan with contrast
Answer: 2 - Lung biopsy

Explanations:

The correct diagnosis is idiopathic pulmonary hemorrhage/hemosiderosis. It

frequently occurs in children and is characterized by hemoptysis, iron-deficiency
anemia (usually unresponsive to iron-supplementation), and alveolar infiltrates on
chest imaging.
The diagnosis of idiopathic pulmonary hemorrhage is clinical, after other causes of
pulmonary and visceral hemorrhage such as vasculitis and gastrointestinal bleeding
must have been excluded. However, the gold standard for investigation is lung
biopsy.
Other investigations options are broncho-alveolar lavage and gastric lavage, where
the fluid is examined for hemosiderin- laden macrophages.
The treatment of idiopathic pulmonary hemorrhage is with systemic
corticosteroids.

Page 705 of 955

Research Concepts:

Idiopathic Pulmonary Hemorrhage

Question 747: A 65-year-old man describes dyspnea on exertion, which has progressively
gotten worse over the last two years. He also has developed a persistent dry cough and
has lost weight. He does not report any travel, drug use, allergies, or smoking. He used to
work as a postal worker but retire because of his recent dyspnea. On examination, he
appears anorexic and fatigued. He has clubbing. Auscultation reveals dry crackles.
Laboratory work is normal, and the chest X-ray shows a diffuse bilateral reticulonodular
pattern. A High-resolution CT chest is performed, which shows diffuse bibasilar
reticulations without honeycombing. A lung biopsy is done and reveals the "Usual
Interstitial Pneumonia" pattern. What is the treatment of choice for this patient?

Choices:

1. Pirfenidone
2. Bilateral lobectomy
3. Azathioprine
4. Albuterol inhaler
Answer: 1 - Pirfenidone

Explanations:

Antifibrotic agents like pirfenidone and nintedanib have been shown to slow down
the rate of decline in forced vital capacity (FVC) over one year. They have shown
some efficacy in reducing exacerbations of idiopathic pulmonary fibrosis (IPF).
Though meta-analysis and pooled analysis have shown possible survival benefit, the
placebo-controlled randomized trials have not shown definite survival benefit with
either of these medications. The main drawbacks to both these medications are
tolerance since patients can develop side effects with these medications. Liver
function tests need to be monitored when patients are started on these antifibrotic
agents.
Patients with IPF should be referred to lung transplants early since the rate of
decline can be unpredictable, and lung transplants were shown to have good
outcomes.
Azathioprine should not be used to treat IPF since it has been shown to increase
mortality.
Basics of care for patients with chronic lung disease apply, including vaccinations,
Page 706 of 955
 pulmonary rehabilitation, to build endurance. Oxygen supplementation is given to
those who require it.

Research Concepts: Idiopathic Pulmonary

Fibrosis

Question 748: A 26-year-old woman G1P0000 at 24 weeks gestation presents to the clinic
in October for evaluation of cough, rhinorrhea, and subjective fever for 24 hours. The
patient has no significant past medical history and takes only a prenatal vitamin daily.
Vital signs show oral temperature 38 C (100.4 F), blood pressure 120/80 mmHg, pulse
90/minute, respirations 18/minute, and oxygen saturation 96% on room air. Physical
exam reveals a mildly ill-appearing gravid female in no acute distress with lung fields that
are clear to auscultation bilaterally. Continuous fetal monitoring is normal. Nasal swab
ELISA is positive for influenza A. Which of the following is the most appropriate treatment
for this patient to decrease the likelihood of progression to viral pneumonia?

Choices:

1. Zanamivir
2. Symptomatic treatment only
3. Oseltamivir
4. Baloxavir
Answer: 3 - Oseltamivir

Explanations:

Oseltamivir is the treatment of choice for influenza infection in pregnant patients

per Centers for Disease Control and Prevention (CDC) guidelines.
Pregnancy is considered a risk factor for complicated influenza, increasing the odds
of progression to viral pneumonia.
Oral antiviral treatment is the most appropriate treatment for influenza within the
first 48 hours of symptom onset.
Oseltamivir has been shown in limited studies to be of little risk to the fetus during
pregnancy. If the pregnant patient is hospitalized, an increased dose of oseltamivir
may be considered. Zanamivir can be used in pregnancy. However, it is not the drug
of choice. Symptomatic treatment only in a pregnant patient is inappropriate due
to the increased risk of progression to complicated influenza and viral pneumonia.
Baloxavir should be avoided in pregnancy, as there have been no human studies to
determine fetal risk.

Page 707 of 955

Research Concepts:

Viral Pneumonia

Question 749: A 20-year-old male presents to the clinic with increased fatigue and
tiredness over the past few months. He states that his wife is worried because she has
noticed episodes of “absent breathing,” which lasts for 10-15 seconds during the night.
The patient reports that he has felt increasingly tired for the past few months to the
extent that he now uncontrollably falls asleep, even during important meetings. On
detailed inquiry, the patient admits to being a loud snorer for two years. He also reports
anxiety attacks and being claustrophobic. Epworth sleepiness scale is 12/24. Vitals include
a blood pressure of 140/85 mmHg, pulse 89/min, and respiratory rate 20/min. His body
mass index is 30 kg/m^2.
Examination shows a crowded oropharynx and retrognathia. His neck circumference
measures 39.5 cm (15.6 in). A home sleep apnea test shows a respiratory event index of
14 events/hour. Which of the following is the most appropriate treatment option for this
patient?

Choices:

1. Oral appliance
2. Maxillomandibular advancement surgery
3. Implantable hypoglossal nerve stimulator
4. Oxygen therapy
Answer: 1 - Oral appliance
Explanations:

This patient presents with decreased daytime concentration and episodic sleeping, snoring,
and apneic episodes during the night. These symptoms are classic for obstructive sleep
apnea (OSA).
Continuous positive airway pressure (CPAP) during the nighttime is highly effective in
improving long-term outcomes in patients with OSA. However, many patients with severe
claustrophobia are unwilling to try or unable to tolerate CPAP. Maxillomandibular
advancement is an option for patients with retrognathia but is not considered the first
option for mild to moderate OSA.
To qualify for an implantable hypoglossal nerve stimulator, patients must meet the
following criteria: BMI less than 32 kg/m^2, more than 22 years of age, apnea-hypopnea
index 15 to 65 with less than 25% central apneas, unable to tolerate CPAP, and no
complete concentric collapse at the palate on drug-induced sleep endoscopy. Patients
with mild to moderate OSA are candidates for treatment with an oral appliance,
especially when CPAP is not tolerated. Oxygen is sometimes needed as an adjunct
therapy but does not correct the upper airway obstruction; therefore, it cannot be used
Page 708 of 955
 alone as treatment.

Research Concepts: Obstructive Sleep Apnea

Question 750: A previously healthy 52-year-old man presents with cough, abdominal
pain, and low-grade fever. He reports he recently traveled to North Africa but denies sick
contacts. He does not use any medications in routine but reports using a home remedy to
treat constipation for five days. A chest radiograph reveals diffuse bilateral opacities
concerning for pulmonary edema. Abdominal ultrasound reveals hepatosplenomegaly.
Labs reveal unexplained pancytopenia, and arterial blood gas shows profound
hypoxemia. A lung biopsy is performed, which reveals foamy macrophages with a
peribronchial thickening with large vacuoles that stain positive with Oil-Red-O stain.
Which of the following is the first-line treatment besides removing the source?

Choices:

1. Corticosteroids
2. N-acetyl cystine
3. Antibiotics
4. Whole lung lavage

Answer: 1 - Corticosteroids

Explanations:

The patient has lipoid peumonia. Exogenous lipoid pneumonia is most commonly
caused by the aspiration of mineral oil when ingested to treat constipation or
aspiration of industrial oils and nasal application of white petrolatum.
Bronchoalveolar lavage (BAL) may reveal lipid-laden macrophages with large
vacuoles that stain positive with Oil- Red-O stain.
Chest computed tomography (CT) findings include ground-glass opacities, thickened
interlobular septa, crazy paving, and air bronchograms.
Treatment is removing the oil source. Patients may be treated with corticosteroids
if removal of the source does not improve outcomes. Whole lung lavage is the last
step in the management and is usually not required.

Research Concepts:

Lipoid Pneumonia
Page 709 of 955
Question 751: A 23-year-old male(70kg) has been admitted to the intensive care unit after
involved in a motor vehicle accident with multiple fractures of face, neck, and legs and
pulmonary contusion of both lungs. His respiratory status got worsened over the next few
hours, and now he is intubated in an intensive care unit. His chest X- ray shows diffuse
bilateral fluffy infiltrates. His blood pressure is 110/80 mmHg and pulse 110 bpm. His
current ventilator settings include a respiratory rate of 30/min, a tidal volume of 400 ml,
PEEP 25, and FiO2 of 100%, and his recent arterial blood gas showed pH
7.20 PCO2 60 mmHg, PaO2 50 mmHg, HCO3 18 mEq/L. His
hemoglobin and hematocrit are stable. His mean airway pressure (MAP) on the ventilator
is 30, and his oxygen saturations are 85% on nitric oxide at 20 parts per million and
neuromuscular blockade.
What would be the next best step in the management of his refractory hypoxemia?

Choices:

1. Prone the patient as this helps to redistribute the ventilation to dorsal regions of
the lungs
2. Increase the nitric oxide to 40 parts per million
3. Increase the tidal volume to 700 ml because the patient has hypercarbic
respiratory acidosis
4. Consider extracorporeal membrane oxygenation due to his oxygenation
index

Answer: 4 - Consider extracorporeal membrane oxygenation due to his oxygenation

index

Explanations:

Extracorporeal membrane oxygenation (ECMO) is recommended as a last resort

rescue therapy in refractory hypoxemia with when PaO2/FiO2 50 with FiO2 of
100% or oxygenation index above 40.
The formula MAP×FiO2/PaO2×100 calculates the oxygenation index, and the result is
60.
Absolute contraindications for extracorporeal membrane oxygenation rescue
therapy include a preexisting condition not compatible with recovery (end-stage
malignancy, severe neurological injury), and some of the relative
contraindications include uncontrollable bleeding and very poor prognosis of the
primary condition.
Proning this patient is contraindicated due to multiple fractures especially neck.

Research Concepts:Refractory Hypoxemia and Venovenous ECMO

Page 710 of 955
Question 752: A 50-year-old man presents to the clinic with excessive daytime sleepiness
for 2 months. His past medical history is significant for hypertension, type 2 diabetes
mellitus, prolapsed intervertebral disc, and opioid use disorder. He received a course of
amoxicillin for the upper respiratory tract a month before but denies depression,
anhedonia, lack of concentration, or suicidal ideation.
His current medications include amlodipine, metformin, ibuprofen, methadone, and
dietary supplements. Physical examination reveals a thin man with tattoos and needle
marks. Cardiovascular and pulmonary examinations are normal. Laboratory
investigations exclude anemia and hypothyroid. Polysomnography reveals an Apnea-
Hypopnea Index (AHI) of 10 without associated abdominal wall movement. Which of the
following is most likely to be related to the patient’s condition?

Choices:

1. Amlodipine
2. Amoxicillin
3. Metformin
4. Methadone

Answer: 4 - Methadone

Explanations:

Central sleep apnea may be prevalent in up to 30% of stable methadone maintenance

treatment patients.
Polysomnography can effectively identify opioid-associated sleep-disordered
breathing conditions such as sleep-related hypoventilation, obstructive sleep
apnea, and central sleep apnea.
The best treatment option for opioid-associated sleep- disordered breathing
conditions is the withdrawal of opioids. Effective treatment with positive airway
pressure can improve the health and well-being of these patients.

Research Concepts:

Sleep Apnea Syndrome

Page 711 of 955

Question 753: A 43-year-old man presents with a two-week history of nausea, vomiting,
and two to three loose stools per day. He visited Mexico three months ago for a vacation
trip. His past medical history is remarkable for interstitial lung disease diagnosed two
years ago, for which he was started on nintedanib therapy one month ago. He drinks one
to two 12-ounce cans of beer on weekends. His temperature is 37 C (98.6 F), heart rate
62/min, respiratory rate 16/min, and blood pressure 118/76 mmHg.
Examination demonstrates dry mucous membranes, a non-tender, soft abdomen with
hyperactive bowel sounds, and no hepatomegaly. Initial labs show WBC count
8000/mm^3, ALT 60 U/L (normal 7-56 U/L), AST 55 U/L (normal 10-40 U/L), and total
bilirubin 1.2 mg/dL (normal 0.1-1.2 mg/dL). What is the most appropriate next step in
management?

Choices:

1. Hepatitis panel
2. p-ANCA antibody
3. Hold nintedanib
4. Stool studies
Answer: 3 - Hold nintedanib

Explanations:

Gastrointestinal signs and symptoms, including loose stools and elevated liver
enzymes, are the most common side effects associated with nintedanib therapy in the
appropriate setting, as above.
Adverse reactions may require a dose reduction or temporary interruption until
the resolution of the specific adverse reaction. Nintedanib can be resumed at 150
mg every 12 hours, or 100 mg every 12 hours, which may be increased to the full
dose of 150 mg q12hr. If 100 mg every 12 hours is not tolerated, treatment should
be discontinued.
Hepatitis A presents with acute onset of nausea, vomiting, fever, and right upper
quadrant tenderness. The liver enzymes are usually much higher than in this patient.
Crohn disease presents with severe inflammatory diarrhea consisting of crampy
abdominal pain, moderate to severe bloody diarrhea with >6 bowel movements a
day, abdominal tenderness and leukocytosis, and does not have elevated liver
enzymes.
Gastroenteritis presents with nausea, vomiting or diarrhea, fever, and elevated
white count but does not usually have elevated liver enzymes.

Research Concepts: Nintedanib

Page 712 of 955

Question 754: A 68-year-old man with a past medical history of tobacco use disorder
presents for evaluation of worsening cough and shortness of breath. He reports a chronic
"smoker's" cough for multiple years, which has been worsening over the last few months
even though he quit smoking two years ago. He also reports exertional dyspnea, fatigue,
and unintentional weight loss over the last few months. Computed tomography (CT) of
the chest with intravenous contrast reveals a 6 cm spiculated mass in the right upper lobe
of the lung. The tumor is encircling the mediastinal structures, and discrete lymph nodes
from the primary tumor cannot be identified. According to the American College of Chest
Physicians (ACCP), this patient's malignancy is classified as which of the following?

Choices:

1. Group A disease
2. Group B disease
3. Group C disease
4. Group D disease
Answer: 1 - Group A disease

Explanations:

The American College of Chest Physicians (ACCP) has proposed grouping patients
based on tumor extent and lymph node involvement. This patient has group A
disease which consists of patients with bulky tumors encircling or invading
mediastinal structures such that remote lymph nodes cannot be distinguished from
the primary tumor.
Mediastinal invasion is implied in patients with group A disease and lymph node
sampling is not required for staging.
Tissue diagnosis from the primary tumor suffices to identify and stage the malignancy.
Although CT is not the appropriate staging modality, it helps the clinician select the
site for tissue biopsy. In other words, based on these groups, further staging via
noninvasive or invasive methods is planned.

Research Concepts:

Lung Cancer

Page 713 of 955

Question 755: A 50-year-old man is admitted to the hospital with a two-week history of
fever, nonproductive cough, and shortness of breath. He received a bone marrow
transplant a year ago for acute myelocytic leukemia. He has no history of tobacco use or
previous history of a respiratory disorder. His temperature is 38.5 C (101.3 F), blood
pressure 99/50 mmHg, heart rate 110/minute, and pulse oximetry 94% on room air. Lung
auscultation is notable for bilateral crackles. The rest of the exam is within normal. Chest
x-ray shows diffuse infiltrates, and the patient is admitted to the intensive care unit.
Bronchoscopy with bronchoalveolar lavage (BAL) under conscious sedation is planned.
After 100 mL is instilled during BAL, the patient's oxygen saturation drops to 88%. Oxygen
is increased to 4 L/min via nasal cannula, and oxygen saturation improves quickly to 95%.
The bronchoscopy is completed, and 10 mL of alveolar fluid is collected. What is the best
next step?

Choices:

1. Perform endotracheal intubation until the patient is fully awake

2. Place the patient in Trendelenburg and aspirate again
3. Obtain a chest x-ray
4. Observe the patient and titrate oxygen to maintain oxygen saturation
above 92%
Answer: 4 - Observe the patient and titrate oxygen to maintain oxygen saturation above 92%

Explanations:

Depending on local practice, between 20 to 60 ml of room temperature, sterile

normal saline is injected via a handheld syringe and then gradually withdrawn
back into the syringe. This is repeated 1-2 times, and up to 100 ml is instilled. If
only 5% of each injected aliquot returns, this indicates that most of the injected
fluid is retained, and the procedure should be aborted.
A sample yield of 30% or more of the injected aliquot is considered an adequate
return, of which at least 10 ml to 20 ml is required for cellular and infectious
workups.
All patients should breathe supplemental oxygen during the BAL procedure and
titrated to maintain the oxygen saturation above 92%. Complications such as
pneumothorax and bronchospasm are rare; therefore, post-BAL chest-x-rays are
usually not obtained unless the patient has deteriorated and not improved despite
adjustment of oxygen.

Research Concepts: Bronchoalveolar Lavage

Page 714 of 955

Question 756: A 65-year-old male is being evaluated preoperatively for lung resection. His
past medical history is significant for hypertension, chronic obstructive pulmonary disease
(COPD), thoracic aortic aneurysm (4 cm in size), and stage 3 chronic kidney disease (CKD).
He had his right hip replaced one month ago. The patient reports chest discomfort and
fever for the past week for which he was put on an antibiotic. His vital signs show a
temperature of 38.3 C (100.9 F), a respiratory rate of 32 breaths per minute, a blood
pressure of 145/78 mmHg, and a heart rate of 95 beats per minute. On physical
examination, the patient has a palpable abdominal mass, rhonchi in the right lower lung
base with distant breath sounds in all lung fields. Brain natriuretic peptide and troponin
levels from one week ago are within normal limits. Computed tomography (CT) scan of
the chest shows right lower lobe consolidation, stable right upper lobe mass, and stable
thoracic aneurysm. The clinician recommends testing for forced expiratory volume in one
second. Which of the following is an absolute contraindication to this test?

Choices:

1. Hypertensive crisis
2. Recent hip surgery
3. Respiratory infection
4. Pulmonary mass
Answer: 3 - Respiratory infection

Explanations:

Spirometry is one of the most readily available and useful tests for pulmonary
function. It measures the volume of air exhaled at specific time points during
complete exhalation by force, which is preceded by a maximal inhalation. The most
important variables reported include total exhaled volume, known as the forced
vital capacity (FVC), the volume exhaled in the first second, known as the forced
expiratory volume in one second (FEV1), and their ratio (FEV1/FVC).
Respiratory infections are absolute contraindications to spirometry testing. The
patient has right lower lobe consolidation and fever and was ruled out for
myocardial infarction and thoracic aneurysm changes. He is currently on antibiotics
and has a slightly elevated temperature in the preoperative clinic, which indicates
pneumonia. The patient has chronic obstructive pulmonary disease (COPD) and is at
increased risk of community-acquired pneumonia.
Acute or active respiratory infections are an absolute contraindication. This patient
should wait to have the spirometry testing done. First, the testing will not be
accurate in an acute lung infection. Second, testing the patient can spread
infectious droplets into the spirometry device.
Lung masses are not an absolute contraindication, and neither is hip surgery.

Page 715 of 955

 Head, neck, mouth, and throat surgeries are relative contraindications. Patients
can still have spirometry testing after these surgeries as long as the patient can
get a good mouthpiece seal. Hypertensive crisis is a relative contraindication as
well.

Research Concepts:

Spirometry

Question 757: A 48-year-old man is admitted to the intensive care unit (ICU) with
shortness of breath, fever, and a positive rapid influenza test. He has no significant past
medical history. His blood pressure is 100/60 mmHg, heart rate 110 beats/min,
respiratory rate 24 breaths/min, and oxygen saturation 90% on mechanical ventilation.
The mechanical ventilator is set to assisted volume control, respiratory rate 24, tidal
volume 500 mL (7 mL per kilogram), positive end expiratory pressure (PEEP) 10 cmH2O,
and fractional inspiratory oxygen (FiO2) 50%. The ventilator alarms are heard by the ICU
staff. Which of the following pressures on the ventilator most accurately indicates that
barotrauma may be imminent?

Choices:

1. High peak inspiratory pressure

2. High end-inspiratory plateau pressure
3. High tidal volume
4. High flow rate
Answer: 2 - High end-inspiratory plateau pressure

Explanations:

Airway pressures can be used to identify patients at risk for barotrauma.

Controlling peak inspiratory pressure does not reduce mortality and may increase
morbidity.
Plateau end-inspiratory pressure provides the best estimate of the transalveolar
gradient and risk for pneumothorax.
Patients with increased peak inspiratory pressure should have an inspiratory hold
maneuver to measure the plateau pressure on the ventilator. Patients with
elevated inspiratory plateau pressure (more than 30 cmH2O) are at risk of
developing pulmonary barotrauma.

Page 716 of 955

Research Concepts:

Barotrauma And Mechanical Ventilation

Question 758: A 16-year-old girl presents to the hospital after the recent diagnosis of
common variable immunodeficiency (serum IgG levels are 55 mg/dL). She has suffered
more than 10 sinopulmonary infections throughout her life and is currently on
treatment for pneumonia and diarrhea caused by a suspected bacterial infection. What
is the next best step in the management of this patient?

Choices:

1. Continue antibiotics and follow with intravenous immunoglobin after the active
infection has subsided
2. Intravenous immunoglobin followed by fecal transplant after serum IgG levels have
risen
3. Continue antibiotics and initiate vaccination against rotavirus after the active
infection has subsided
4. Initiate intravenous immunoglobin and hold antibiotics until IgG levels have risen
Answer: 1 - Continue antibiotics and follow with intravenous immunoglobin after the active
infection has subsided

Explanations:

Generally, immunoglobin replacement therapy (IVIG) begins after treating an

active infection. The intravenous route is the preferred one with an initial dose of
300-600 mg/kg every three to four weeks.
Bacterial infections must be treated with longer duration schemes (sometimes 2 to
3 weeks), if possible, by an experienced specialist.
After an infection has been eradicated, IVIG therapy is monitored by serum IgG
levels every 6 months.
Active agents in live vaccines can cause infections or vaccine- induced disease.
Some vaccines that contain killed micro- organisms or their subcomponents are
considered safe for these patients. However, they should be followed up by an
experienced clinical immunologist. Immune globulin replacement therapy should
provide passive protection to some diseases that are prevented by live vaccines.

Page 717 of 955

 Live vaccines such as rotavirus are not recommended in these patients.

Research Concepts:

Common Variable Immunodeficiency

Question 759: A 60-year-old man, with a history of hypertension, obesity, and

dyslipidemia, presents with exertional dyspnea and pitting ankle edema. Which of the
following therapies would best treat the findings expected on his chest x-ray?

Choices:

1. Continuous positive airway pressure (CPAP)

2. High flow supplemental oxygen
3. Vasodilators
4. Opioids

Answer: 1 - Continuous positive airway pressure (CPAP)

Explanations:

Congestive heart failure is associated with interstitial and alveolar edema. The
determining factor as to whether fluid is filtered out of pulmonary vasculature and
into the alveoli is a balance between forces in both the alveoli and the capillaries
themselves. Oncotic pressures are determined by protein and other solutes in the
alveoli, as well as the capillary hydrostatic pressure, exert forces that will force
fluid into the alveoli. On the contrary, oncotic pressures in the pulmonary
capillaries and hydrostatic pressure in the alveoli will force fluid back into the
pulmonary capillaries.
Continuous positive airway pressure (CPAP) increases the pressure within the alveoli,
forcing fluid back into pulmonary capillaries. This is the only management strategy or
medication listed that actively pushes fluid out of alveoli.
Supplemental oxygen is provided through the application of CPAP, which acts to
both improve the patient's pulse oximetry and increase the alveolar hydrostatic
pressure. This assumes all other factors like hemoglobin content are normal.
Additional management considerations include vasodilators such as nitroglycerin
and opioids. However, these interventions take time to work. Therefore, the most
rapid intervention in the case of congestive heart failure that will do the most good
to improve ventilation of the patient is CPAP.

Page 718 of 955

Research Concepts:

Continuous Positive Airway Pressure

Question 760: A 36-year-old male patient presents to the clinic because of daytime
sleepiness. He explains that he is a long-route truck driver and cannot afford to feel sleepy
during the daytime. He also complains of associated decreased concentration, poor
memory, and irritability. The patient says that over the past year, his snoring has become
louder and “scarier.” On detailed inquiry, he admits having fallen asleep a couple of times
while driving. He drinks 4-5 beers per day. He also has a 15 pack-year history of smoking.
His past medical history is significant for dyslipidemia managed on statins. Vitals show a
blood pressure of 145/85 mmHg, pulse 95/min, and respiratory rate of 22/min. His body
mass index is 37 kg/m2. The examination is insignificant. What long-term complication is
most likely to develop in this patient if his disease goes untreated?

Choices:

1. Cor pulmonale
2. Ischemic heart disease
3. Restrictive lung disease
4. Obstructive lung disease
Answer: 1 - Cor pulmonale

Explanations:

The most common symptoms of obstructive sleep apnea are increased fatigue,
sleepiness during daytime hours, and snoring. This patient has all three.
In the United States, approximately 4% of men and 2% of women meet the criteria
for obstructive sleep apnea (OSA). Prevalence is higher in Hispanic, African
American, and Asian populations. Prevalence also increases with increasing age, and
at more advanced ages, there are as many women as men who develop the
disorder.
Nighttime polysomnography is the gold standard test for the diagnosis of OSA.
Weight loss and the use of continuous positive airway pressure (CPAP) are the
most effective treatments. The diligent adherence to nightly CPAP use can result in
near-complete resolution of symptoms.
If not treated appropriately, the patient develops pulmonary hypertension that leads
to cor pulmonale. This complication is associated with high morbidity and mortality.

Research Concepts:
Page 719 of 955
Obstructive Sleep Apnea
Question 761: A 24-year-old man presents to the hospital with a chief complaint of a
nonproductive cough and shortness of breath.
The patient is tachycardic with a heart rate of 115/min. His oxygen saturation is 85% on
room air and does not respond to supplemental oxygen. While the nurse is drawing
blood, she comments that his blood appears to be a brown color. The patient reports he
was at work on the farm and gathering grain for the animals when he started to feel
unwell. What is the best initial therapy for this patient?

Choices:

1. Continue supplemental oxygen and wait for the symptoms to abate

2. Intubate the patient for refractory hypoxemia
3. Administer methylene blue and provide supplemental oxygen
4. Discharge the patient to home with supportive care instructions
Answer: 3 - Administer methylene blue and provide supplemental oxygen

Explanations:

This patient has methemoglobinemia as a result of nitrogen dioxide exposure.

Nitrogen dioxide can induce methemoglobinemia. Clues include reported
hypoxemia refractory to supplemental oxygen and chocolate brown blood.
Methemoglobinemia is treated with the antidote methylene blue. Methylene blue
reduces methemoglobin back to hemoglobin.
Always obtain a social history in a patient including work history as this is a clue to
the diagnosis.
Patients with significantly abnormal vital signs such as tachycardia and hypoxemia,
in this case, should not be discharged to home.

Research Concepts:

Nitrogen Dioxide Toxicity

Page 720 of 955

Question 762: A 70-year-old man is being considered for endobronchial ultrasound
transbronchial biopsy (EBUS-TBNA) of enlarged mediastinal lymph nodes. These were
found on computed tomography scanning of the thorax, abdomen, and pelvis performed
for reported weight loss and hemoptysis while admitted to hospital with severe chest
pains. Which of the following is the strongest possible contraindication to EBUS in this
patient?

Choices:

1. Angina in the last 3 months

2. Myocardial infarction 9 months ago
3. Acute coronary syndrome 3 weeks ago
4. Coronary artery bypass graft 2 years ago
Answer: 3 - Acute coronary syndrome 3 weeks ago

Explanations:

An absolute contraindication to EBUS is acute coronary syndrome within the

preceding four weeks. The British Thoracic Society guidelines on fibreoptic
bronchoscopy make this recommendation as bronchoscopy and EBUS may cause
hypoxia and hypotension, which may precipitate further myocardial ischemia.
Patients with significant coronary artery disease or who have undergone
percutaneous coronary intervention in the last year should be discussed with a
cardiologist to make a case-by-case risk assessment.
Patients on dual antiplatelet therapy following percutaneous coronary intervention
should be discussed with the treating cardiologist regarding the cardiac risks of
discontinuing antiplatelet therapy prior to EBUS-TBNA.
Antiplatelets such as clopidogrel should be discontinued for 5-7 days prior to EBUS-
TBNA. Patients on novel oral anticoagulants should hold their medication for at
least 48 hours. Patients taking warfarin should be switched to a short-acting
alternative such as injectable low molecular weight Heparin with an international
normalized ratio of 1.5 prior to EBUS-TBNA.

Research Concepts:

Sonography Endobronchial Assessment, Protocols, And Interpretation

Page 721 of 955

Question 763: A 45-year-old man with no significant past medical history presents to the
clinic complaining of dyspnea and wheezing of 10 months duration, which has gradually
worsened. He has no smoking history or family history of asthma. He has tried an
albuterol inhaler without benefit. CT scan of the chest was performed and shows a
calcified mass at the right bronchial stem. Which of the following is the most likely
histological diagnosis?

Choices:

1. Small cell carcinoma

2. Squamous cell carcinoma
3. Large cell carcinoma
4. Adenocarcinoma
Answer: 4 - Adenocarcinoma

Explanations:

Adenocarcinoma may be seen in the trachea secondary to the direct invasion from
the tumor in the lungs or from the involvement of the mediastinal lymph nodes.
Patients may present with obstructive symptoms in the late decades of life secondary
to the bulkiness of the tumor.
On histology, this tumor would present as large vesicular nuclei and prominent
nucleoli with mucin production seen.
Smokers would generally present with squamous cell carcinoma
Research Concepts:

Tracheal Cancer

Question 764: A patient with a past medical history of long-term smoking and a recent
diagnosis of small cell lung carcinoma has a sodium level of 123 mEq/L and serum
osmolality of 240 milliosmoles/kg. On further testing, the urine osmolality is found to be
500 milliosmoles/kg. Based on the most likely diagnosis, this patient's lab findings are due
to which of the following?

Choices:

1. A decrease in the secretion of antidiuretic hormone (ADH)

2. An increase in the secretion of oxytocin
3. An increase in the secretion of ADH
4. A decrease in the secretion of brain natriuretic peptide
Page 722 of 955
Answer: 3 - An increase in the secretion of ADH

Explanations:

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is due to

excess ADH production from the posterior pituitary or an ectopic source. ADH is
released into the blood circulation as a vasoconstrictor and reabsorbs water from
the collecting duct in the kidney to maintain equilibrium intracellularly and
extracellularly.
Approximately 67% of SIADH cases are associated with small cell lung carcinoma.
Neoplastic cells can produce a variety of peptides that replicate or mimic the
function of biological hormones.
SIADH can present as acute or chronic hyponatremia. In acute hyponatremia, the
patient will have classic neurologic symptoms secondary to brain swelling like
lethargy, somnolence, weakness, seizure, coma, and death if left untreated. Slowly
progressive hyponatremia in chronic SIADH is associated with fewer symptoms and
may include slow reaction times and cognitive slowing.

Research Concepts:

Syndrome of Inappropriate Antidiuretic Hormone Secretion

Question 765: A 65-year-old male patient presents with severe dyspnea on exertion. He
has a 45-pack-year history of smoking. On high-resolution computed tomography (CT)
imaging of the chest, he has heterogeneous, upper-lobe predominant emphysema. Over
the past year, he has become more short of breath with exertion despite complying with
his medical therapy. His PaO2 is 65 mm Hg, and his PCO2 is 55 mm Hg. His 6 minute walk
distance is 75 meters. His exercise capacity is 20 W. Which is the most likely outcome of
lung volume reduction surgery (LVRS) in this patient?

Choices:

1. Increased mortality compared to medical therapy

2. Similar exercise tolerance without a significant change in the overall mortality
3. Equivalent mortality compared to medical therapy
4. Improvement in exercise tolerance, improved quality of life, and improved overall
mortality
Answer: 4 - Improvement in exercise tolerance, improved quality of life, and improved
overall mortality
Page 723 of 955
Explanations:

In the National Emphysema Treatment Trial (NETT), patients with upper-lobe

emphysema and poor exercise capacity had lower mortality after lung volume
reduction surgery (LVRS) compared to medical therapy alone.
In the National Emphysema Treatment Trial (NETT), low exercise capacity was
defined as 25 W for females and 40W for males.
In the National Emphysema Treatment Trial (NETT), patients with non-upper-
lobe emphysema with poor exercise capacity had similar survival in both groups.
In the National Emphysema Treatment Trial (NETT), patients with upper-lobe
emphysema and good exercise capacity had no difference in survival between
medical treatment and lung volume reduction surgery.

Research Concepts:

Lung Volume Reduction Surgery

Question 766: A 47-year-old woman with a history of a motor vehicle collision and long-
term ventilator dependency with a tracheostomy tube's decannulation about 10 years ago
presents with severe stridor. Her surgical history was unclear, and she mentioned that she
had surgery to neck after her decannulation for breathing problems, which subsided after
surgery. She also had tracheal stents placed about 2 years ago for significant tracheal
stenosis. Her chart revealed that she had 2 metallic stents placed about 2.5 cm below vocal
cords and extending within 1cm to the carina. Today on the exam, there is significant
biphasic stridor, and a flapping sound was auscultated with every breath. What is the next
best step in the management of this patient?

Choices:

1. Obtain a CT thorax to rule out parenchymal pathology

2. Start patient on steroids and inhalers for exacerbation of obstructive
lung disease
3. Schedule the patient for flexible bronchoscopy to visualize the trachea and look
for granulation tissue
4. Consult surgery for open tracheoplasty
Answer: 3 - Schedule the patient for flexible bronchoscopy to visualize the trachea and look
for granulation tissue

Page 724 of 955

Explanations:

Patients with metallic stents are prone to have higher complication rates, including
granulation tissue formation and stent migration.
The first step in evaluating any stent complication is to perform a flexible endoscopy
to visualize airways.
As this patient had 2 metallic stents, she likely developed granulation tissue, which
caused her stridor and flapping sound with every breath.
Once bronchoscopy is performed, and the extent of granulation tissue is visualized,
it can be managed either by performing a rigid bronchoscopy or surgical removal.

Research Concepts:

Laryngeal And Tracheal Stents

Question 767: A 71-year-old man is brought to the hospital from a nursing home with a
fever and confusion of one-day duration. His past medical history is significant for
uncontrolled diabetes mellitus, chronic obstructive pulmonary disease, an old stroke with
residual dysarthria and right hemiplegia that has left him bed-bound for the last few
months, and a recent admission for pneumonia that was treated with IV antibiotics. On
arrival, his temperature is 102.1 F, blood pressure 80/60 mmHg, heart rate 130/min,
respiratory rate 30/min, and SpO2 88% on room air. On examination, he seems confused
and has right lower lobe crackles. A chest x-ray confirms a right and middle lobe
pneumonia. His blood pressure does not respond to initial aggressive fluid resuscitation,
and vasopressors are started. Which of the following antibiotic regimens is most
appropriate to treat his condition?

Choices:

1. Ceftriaxone and azithromycin

2. Penicillin G
3. Meropenem, gentamycin, and vancomycin
4. Levofloxacin
Answer: 3 - Meropenem, gentamycin, and vancomycin

Explanations:

Septic shock needs aggressive therapy with IV fluids, pressors, and appropriate

Page 725 of 955

 antibiotic coverage.
Risk factors for pseudomonas pneumonia include structural lung abnormalities (e.g.,
COPD), diabetes mellitus, and recent antibiotic use.
Pseudomonas aeruginosa is usually multi-drug resistant in populations at-risk.
Due to intrinsic resistance, double pseudomonas coverage is sometimes an
approach used in patients with severe septic shock. Vancomycin was added here
for MRSA coverage as well.

Research Concepts: Pseudomonas Aeruginosa

Question 768: An 89-year-old man is admitted to the hospital for respiratory failure
secondary to aspiration pneumonia. He has to be endotracheally intubated with
mechanical ventilation. During the course of his admission, he develops acute renal
failure and septic shock, requiring vasopressors. His family would like to pursue a
palliative approach. However, the patient's son is arriving the following day. They would
like to extubate the patient on his arrival.
Which of the following approaches is most appropriate to ensure comfort while on the
respirator?

Choices:

1. Continuous intravenous sedation and frequent suction

2. Continuous sedation and pulmonary medicine consultation to optimize
ventilator settings
3. Frequent suction and intravenous opiates to help air hunger
4. Continuous intravenous sedation and daily oral care to ensure health and
hygiene in the oral cavity

Answer: 2 - Continuous sedation and pulmonary medicine consultation to optimize

ventilator settings

Explanations:

Patients who are mechanically ventilated should have respiratory therapists

performing frequent adjustments to the ventilator, changing the ventilatory circuit,
and suction.
Pulmonary medicine should be involved for abolishing ventilator- patient synchrony,
which can cause severe distress.
Apart from the medical team caring for the patient, a multidisciplinary approach to
Page 726 of 955
 management is key to improving outcomes.
The mechanically ventilated patient can get fentanyl or hydromorphone due to the
fast action as well as easy titration. Nurses play the most important role in the team
with constant assessments for pain and delivering the pain medications. They should
communicate the patient’s distress, if any, to the entire team.

Research Concepts:

End Of Life Evaluation And Management Of Pain

Question 769:

A 28-year-old woman presents to discuss treatment. She was diagnosed with systemic
sclerosis three years ago and progressive interstitial lung disease (ILD) three months ago.
Her past medical history is significant for heart failure with preserved ejection fraction on
furosemide 20 mg daily and a 3 cm simple left renal cyst. She vapes frequently and is
sexually active without contraception. Her temperature is 37 C (98.6 F), blood pressure
130/80 mmHg, heart rate 76/min, respiratory rate 16/min, and oxygen saturation 98%
on room air. Lung auscultation demonstrates minimal crackles.
Computed tomography (CT) of the chest shows worsening of her progressive ILD. The
clinician discusses potential therapy with nintedanib. What is the most appropriate
investigation before initiating this medication?

Choices:

1. Urine pregnancy test

2. Chest X-ray
3. Echocardiogram
4. Renal function tests
Answer: 1 - Urine pregnancy test

Explanations:

A pregnancy test is necessary before initiating nintedanib because it is associated

with congenital malformations in the fetus.
Nintedanib is an FDA Category D drug: "There is positive evidence of human fetal
risk based on adverse reaction data from investigational or marketing experience
or studies in humans, but potential benefits may warrant use of the drug in
pregnant women despite potential risks."
Pregnancy testing should be performed before the initiation of and periodically
during treatment.
Page 727 of 955
 Women with the capacity to conceive should use highly effective contraception,
preferably a reversible implantable contraceptive device, to prevent pregnancy
while on therapy. Highly effective contraception should be continued for at least
three months after the last dose of nintedanib.
Research Concepts:Nintedanib

Question 770: A 24-year-old woman with a history of major depressive disorder,

endometriosis and chronic low back pain presents to the clinic for excessive daytime
sleepiness for the past 2 years. The patient notes that despite 10 or more hours of sleep
every night at the same time, she feels as though she can fall asleep at almost any time
during the day. The patient also describes frequent night-time awakenings. She denies
recreational drug use and takes her fluoxetine, oral contraceptive, and naproxen as
prescribed. Which of the following is the next best step in the management of this
patient?

Choices:

1. Discontinue fluoxetine
2. Reassurance
3. Prescribe one dose of zolpidem
4. Prescribe sodium oxybate
Answer: 1 - Discontinue fluoxetine

Explanations:

Narcolepsy is a hypersomnia disorder with two types- type 1 (with cataplexy) and
type 2 (without cataplexy). Given the patient's fragmented sleep and chronic
daytime sleepiness with adequate total sleep time, she may have narcolepsy.
When evaluating narcolepsy, antidepressants can cause rapid eye movement (REM)
sleep suppression that may interfere with polysomnogram interpretation.
Fluoxetine must be discontinued prior to polysomnogram.
In addition to fluoxetine, other psychoactive medications should be discontinued
prior to evaluating a patient for narcolepsy with a polysomnogram.
Sodium oxybate and zolpidem are both psychoactive medications
that would interfere with the diagnosis of narcolepsy. Neither should
be started.

Research Concepts:

Sleep Study

Page 728 of 955

Question 771: A 25-year-old male with a history of intravenous drug use is admitted for
sepsis. Admission vital signs include heart rate 100/min, blood pressure 90/65 mmHg,
respirations 20/min, SaO2 91%, and temperature 101.5 F (38.6 C). He is given
intravenous antibiotics and fluid resuscitation. On the second day of his hospitalization,
two blood culture samples grow Staphylococcus aureus. Which finding would confirm
this patient's diagnosis?

Choices:

1. Air bronchograms on computed tomography

2. Scattered bilateral nodular densities with ill-defined margins less than 2 cm in size
3. T wave inversions in leads II, III, aVF, and V1 through V4
4. Multiple comet-tail artifacts on ultrasound

Answer: 2 - Scattered bilateral nodular densities with ill-defined margins less than 2 cm in
size

Explanations:

Scattered bilateral nodular densities with ill-defined margins less than 2 cm in size
on chest x-ray represent pulmonary infarcts from embolic phenomena, which can
be caused by endocarditis. There are several relatively specific x-ray findings
associated with pulmonary infarction. Westermark sign is focal peripheral
hyperlucency caused by oligemia resulting in a collapsed appearance of vessels
distal to the occlusion. Hampton hump is a dome-shaped, pleural-based
opacification in the lung most commonly due to pulmonary embolism and lung
infarction.
Infective endocarditis is diagnosed by Duke's criteria, which include positive blood
cultures, echocardiographic evidence of new endocardial lesion, fever, history of IV
drug use, or congenital valvular abnormality. Vascular phenomena such as septic
pulmonary emboli with infarction also make infective endocarditis more likely. This
would be described as scattered bilateral nodular densities with ill-defined margins
less than 2 cm in size on a chest x-ray.
Whereas embolic pulmonary infarction can be seen as scattered bilateral nodular
densities with ill-defined margins less than 2cm in size on chest x-ray, computed
tomography imaging associated with septic pulmonary infarctions is described as
clearly defined feeding vessels into a peripheral nodule.
Computed tomography finding of air bronchograms makes the diagnosis of a
pulmonary infarction less likely.
Research Concepts: Pulmonary Infarction

Page 729 of 955

Question 772: A 36-year-old female undergoes resection for a complicated goiter
extending into the superior mediastinum. She presents one week later with shortness of
breath. Computed tomography of the chest shows a significant moderate-sized left
pleural effusion. The fluid is drained with the insertion of a pleural catheter which yields
milky fluid with a high triglyceride content. After 7 days of conservative management,
daily pleural outputs are 1000 mL. What is the next best step in the management of this
patient?

Choices:

1. Video-Assisted Thoracoscopy (VATS) with thoracic duct ligation

2. Continue conservative management for 2 more weeks
3. TPN for 1 month
4. Thoracic duct embolization
Answer: 1 - Video-Assisted Thoracoscopy (VATS) with thoracic duct ligation

Explanations:

The patient in the above case has a left-sided chylothorax, most probably from
thoracic duct injury related to resection of the goiter from the mediastinum.
Conservative management for a chylothorax must be tried for 5- 7 days with NPO
and TPN or employment of a low-fat diet.
If conservative management fails, thoracic duct ligation in the low right
mediastinum is indicated.
Thoracic duct embolization is an option for patients who are poor surgical
candidates. This patient will likely tolerate a VATS for thoracic duct ligation.

Research Concepts:

Video-Assisted Thoracoscopy

Page 730 of 955

Question 773: A 5-day-old male presents to the emergency department with severe
respiratory distress and poor feeding for the past five hours. The patient is receiving
treatment with an antimicrobial for the past three days. He is transferred to the neonatal
intensive care unit (NICU), where he is intubated and receives premedication for pain,
muscle relaxation, and vagal blockade. After a few hours, the nurse records an increase
in temperature. Which of the following most likely caused this patient's current
condition?

Choices:

1. Analgesic
2. Antimicrobial
3. Antimuscarinic
4. Muscle relaxant
Answer: 3 - Antimuscarinic

Explanations:

Administering antimuscarinic agents like atropine, to children requires caution due to

the danger of hyperthermia.
Most rapid-sequence intubation kits include prophylactic atropine for use during
endotracheal intubation of children to prevent bradycardia resulting from vagal
stimulation.
Atropine blocks thermoregulatory sweating, which may result in hyperthermia or
atropine fever.
Atropine toxicity causes the patient to feel extremely dry because of inhibited
sweating, salivation, and lacrimation.

Research Concepts:

Atropine

Question 774: A 55-year-old male presents with shortness of breath for 1 week. He is a
former smoker with a smoking history of 15 pack years. No other significant medical
history is reported. Vital signs include blood pressure 135/80 mmHg, pulse 80/minute,
respiratory rate 20/minute, and temperature 37.3 C (99.1 F).
Physical exam reveals diffuse wheezes bilaterally. His chest x-ray shows findings
consistent with emphysema. Incidentally, he is found to have a 2-cm partially calcified
nodule in the right upper lobe. What is the most appropriate next step in evaluating this
nodule?

Page 731 of 955

Choices:

1. Compare with old chest x-rays

2. Obtain a PET CT scan
3. Obtain a chest MRI
4. Bronchoscopy

Answer: 1 - Compare with old chest x-rays

Explanations:

Differential diagnosis of a partially calcified pulmonary nodule includes hamartoma,

granuloma, carcinoid, lung metastases, osteosarcoma, chondrosarcoma, or rarely a
primary bronchogenic tumor.
The most appropriate next step is to compare with prior studies if available to
assess for stability. If the nodule demonstrates progressive enlargement, then one
must be concerned for a malignant etiology and proceed with a CT scan.
If the nodule is stable over many years, observation would be appropriate. If no
previous x-rays are available or growth is noted, a CT scan would be appropriate.
MRI chest is not appropriate for the evaluation of pulmonary nodules.

Research Concepts:

Chest and Mediastinal Imaging

Question 775: A 74-year-old male with a history of diabetes mellitus, ischemic

cardiomyopathy, hypertension, and coronary artery disease presents with a cough. His
symptoms started three days ago after he came back from a two-week vacation in
Mexico. He was not compliant with medications or a cardiac diet while he was there. He
noticed that his weight had increased by 4 kilograms (8.8 pounds). His home medications
are sitagliptin, lisinopril, metoprolol, atorvastatin, furosemide, and aspirin. On physical
examination, blood pressure is 102/57 mmHg, heart rate is 110 beats per minute,
temperature is37.3 C (99.1 F), and oxygen saturation is 88% on room air. Chest
examination reveals bilateral crackles, and he has pitting edema in his ankles. The rest of
the examination is unremarkable. Laboratory studies show creatinine 1.8 mg/dL (baseline
is 0.9 mg/dL), with an estimated glomerular filtration rate (eGFR) of 55 mL/min/1.73 m2
and troponin 0.1 ng/mL (normal baseline). A computed tomography angiogram rules out
pulmonary embolism. He is started on intravenous fluids, and 10 hours later, his
oxygenation deteriorates, and he is subsequently intubated. It is noted that he is not
producing any urine. What is the most likely cause of deterioration in his clinical status?
Choices:
Page 732 of 955
1. A rise in venous pressure and a decrease in glomerular filtration pressure
2. A decrease in cardiac output
3. Drug-induced renal injury
4. Contrast-induced renal injury
Answer: 1 - A rise in venous pressure and a decrease in glomerular filtration pressure
Explanations:

The patient has a history of ischemic cardiomyopathy, hypertension, and coronary

artery disease, presented with cough and a state of fluid overload secondary to
acute heart failure exacerbation due to diet and medication non-compliance with
kidney injury (cardio-renal syndrome type one).
The fluid overload status due to worsening heart function would result in high
venous pressure, which would be transmitted to the efferent arterioles and result
in a net decrease in the glomerular filtration pressure which will cause renal injury.
Intravenous fluid administration in this type of patient results in worsening venous
pressure and further worsening in the glomerular filtration rate.
Creatinine elevation due to contrast-induced renal injury usually appears 48 hours
after contrast administration.

Research Concepts:Cardiorenal Syndrome

Question 776: A 68-year-old female presents with progressive dyspnea over the past few
days. She has dyspnea on exertion at baseline, but her symptoms have rapidly progressed
over the past few days. She denies any fever or chills but reports a chronic dry cough. She
has no history of smoking. Two years ago, she was seen for arthritis. At that time, she had
an elevated antinuclear antibody (ANA) titer. Back then, her presentation did not fit a
specific connective tissue disease, and she improved on a course of corticosteroids for a
few weeks. A few months ago, she was seen by a specialist for her chronic dyspnea.
Pulmonary function testing revealed reduced lung volumes as well as diffusion capacity
with a normal FEV1/FVC ratio. A high-resolution computed tomography (CT) of the chest
three months ago showed a non-specific interstitial pneumonia pattern (NSIP). She could
not follow up with the specialist to discuss these findings. Currently, her vital signs reveal
a blood pressure of 98/65 mmHg, heart rate of 94 beats per minute, and respiratory rate
of 19 breaths per minute. The physical exam is significant for distal digital fissuring and
fine diffuse pulmonary crackles. A chest X-ray shows mild bibasilar reticulation and
minimal bilateral pleural effusion. Which of the following is the most likely cause of her
dyspnea?

Choices:

1. Myocarditis
Page 733 of 955
2. Pleural plaques
3. Ischemic cardiomyopathy
4. Pericardial effusion
Answer: 4 - Pericardial effusion

Explanations:

Several patients with idiopathic interstitial pneumonia (IIP) have clinical features
that suggest an underlying autoimmune process but do not meet established criteria
for a connective tissue disease (CTD). The European Respiratory Society/American
Thoracic Society Task Force has created a consensus regarding the nomenclature
and criteria for that population. ATS/ERS proposed the term “interstitial pneumonia
with autoimmune features” (IPAF) to classify that type of IIP.
The joint statement offered a classification and diagnostic criteria organized
around the presence of a combination of features from three domains: a clinical
domain, a serologic domain, and a morphologic domain consisting of specific chest
imaging, histopathologic or pulmonary physiologic features.
Pericardial effusion, as well as pleural effusion, are reported to be manifestations
of IPAF and are included in the proposed diagnostic criteria.
Cardiomyopathy can be due to ischemic and nonischemic etiologies. It is also
associated with connective tissue diseases such as polymyositis. Pleural plaques
are commonly seen in asbestos-related parenchymal lung diseases associated
with usual interstitial pneumonia (UIP) pattern. Myocarditis can be associated
with different types of connective tissue diseases such as systemic lupus
erythematosus (SLE), but not associated with IPAF and was not included in the
diagnostic criteria.

Research Concepts:

Idiopathic Interstitial Pneumonia With Autoimmune Features

Page 734 of 955

Question 777: Findings of which of the following organisms in the sputum support the
diagnosis of cystic fibrosis (CF) in children?

Choices:

1. Pseudomonas aeruginosa
2. Staphylococcus aureus
3. Klebsiella pneumoniae
4. Candida albicans
Answer: 1 - Pseudomonas aeruginosa

Explanations:

The organisms found in children with CF vary by age. Pseudomonas aeruginosa

becomes increasingly prevalent as the child ages.
The finding of Pseudomonas aeruginosa, especially in the mucoid form,
strongly supports a diagnosis of CF. It is not diagnostic alone.
At birth, the lungs of the infant with cystic fibrosis are normal.

Research Concepts:

Cystic Fibrosis

Question 778: A 23-year-old female professional free-diver is testing her training

progress. She dives to a depth 5 meters, stays there for 15 seconds, then goes to 20
meters of depth for 15 additional seconds before ascending to the surface. What physical
law and principle best explains her lungs' ability to adapt to deeper depths?

Choices:

1. Boyle's Law; thoracic blood volume is increased with increased depth, which
improves alveolar gas exchange
2. Archimedes' Principle; thoracic blood volume is increased with increased depth,
which improves alveolar gas exchange
3. Boyle's Law; thoracic blood volume is decreased with increased depth, which
improves alveolar gas exchange
4. Archimedes' Principle; thoracic blood volume is decreased with increased depth,
which improves alveolar gas exchange
Answer: 1 - Boyle's Law; thoracic blood volume is increased with increased depth, which
improves alveolar gas exchange
Page 735 of 955
Explanations:

The volume of blood in the thoracic cavity is proportional to the depth of the dive.
This shunting of blood is related to increased external water pressure at increased
depths.
This increased thoracic blood volume enhances gas exchange within the alveoli.
With enhanced blood volume for gas exchange, this diver can adapt to increased
physiological demands at depths temporarily.
This process is explained by Boyle's Law (P1V1 = P2V2). Archimedes' Principle
applies to buoyancy is does not play a role in lung function when diving.

Research Concepts:

Shallow Water Blackout

Question 779: A 68-year-old man presents from a nursing home with worsening dyspnea
for three months. He was diagnosed with subacute pulmonary embolism three months
ago and has been on anticoagulation therapy with minimal symptom improvement. CT
pulmonary angiography at that time showed extensive distal emboli. His past medical
history is significant for hypertension, diabetes mellitus, and cerebrovascular accident
with residual left-sided weakness. Vital signs are a blood pressure of 146/88 mmHg, a
pulse of 88/minute, and SpO2 of 94% on room air. On exam, the patient is
in no apparent distress, the lungs are clear with normal breath sounds, a prominent P2
heart sound is auscultated, the heart rate and rhythm are regular, left lower extremity
strength is 3/5, and there is bilateral lower extremity edema. Electrocardiogram (ECG)
and chest x-ray are unremarkable. An echocardiogram reveals a normal ejection fraction
and a right ventricular systolic pressure of 45 mmHg. A right heart catheterization reveals
the following: mean pulmonary artery pressure (mPAP) of 33 mmHg, pulmonary capillary
wedge pressure (PCWP) of 14 mmHg, and pulmonary artery vascular resistance (PVR) 4
Woods units. What is the best initial treatment for this patient?
Choices:

1. Pulmonary endarterectomy
2. Bosentan and sildenafil
3. Epoprostenol
4. Riociguat
Answer: 4 - Riociguat

Page 736 of 955

Explanations:

Medical treatment of chronic thromboembolic pulmonary hypertension (CTEPH) is

based primarily on PAH-targeted therapy, including endothelin receptor
antagonists, phosphodiesterase type-5 inhibitors, and prostanoids.
Riociguat, a guanylate cyclase stimulator, is used primarily in patients ineligible for
surgery or persistent disease after pulseless electrical activity (PEA).
Treprostinil and macitentan have also been extensively studied and proven to be
beneficial in these patients.
Pulmonary endarterectomy is the best treatment to improve hemodynamics and
exercise capacity in operable patients. This patient with limited functional capacity
and distal emboli is not considered operable. Bosentan and sildenafil are
alternatives to riociguat, but riociguat is preferred in mild to moderate disease. IV
epoprostenol therapy is only considered in patients who are severely ill.
Research Concepts:Chronic Thrombo-Embolic Pulmonary Hypertension

Question 780: A 40-year-old man with a history of productive cough and fever presents
to the outpatient clinic bringing his chest X-ray result. The X-ray shows two cavities
with an air-fluid level appearance in the left lobes. What is the best initial therapy for
this patient?

Choices:

1. Metronidazole
2. Metronidazole and cefixime
3. Amoxicillin
4. Ciprofloxacin
Answer: 2 - Metronidazole and cefixime

Explanations:

In addition to multiple cavities in the chest X-ray image, a history of productive

cough and fever is highly suggestive of a lung abscess.
Metronidazole should not be used as a monotherapy. It is not effective as a single
agent because it covers anaerobic organisms but not the microaerophilic
streptococci that are often components of the mixed flora of primary lung
abscesses.
Metronidazole can be in conjunction with a beta-lactam antibiotic such as
ceftriaxone or cefixime.
Treatment regimens for lung abscess should be directed at the identified pathogen.
Ciprofloxacin is not the antibiotic of choice for lung abscess.
Page 737 of 955
Research Concepts:

Lung Abscess

Question 781: A 39-year-old male patient admitted to the hospital with shortness of
breath both at rest and on exertion for the past two weeks. He is only able to take a few
steps before becoming dyspneic. He has lost about 4 lbs in the past two months. He
denies fever, swelling of feet, chest pain, and cough. He works as a truck driver and
endorses having multiple sexual partners. He smokes cigarettes one pack per day and
drinks a pack of beer daily. On physical examination, he does not have any lower
extremity edema or raised JVP; however, there are bilateral crackles. He appears
malnourished. His blood pressure is 100/90 mmHg, the pulse is 98/min, and the
respiratory rate is 30/min. His labs show a WBC count of 23,000/mm3, Hb of 8.0 g/dl,
ProBNP of 40, and chest X-ray suggestive of bilateral fluffy infiltrates. Arterial blood gases
report obtained on room air shows Ph 7.35, PCO2 of 45 mmHg, PaO2 of 62 mmHg, HCO3
of 23. He is started on oxygen via nasal cannula, and his SpO2 improves to 94%. Further
investigations have been ordered. What is the most appropriate next step in managing
this patient?

Choices:

1. Continue with oxygen and wait for results of testing

2. Vancomycin and cefepime for community-acquired pneumonia
3. Trimethoprim/sulfamethoxazole (TMP+SMX) and steroids
4. Perform echo and give IV furosemide
Answer: 3 - Trimethoprim/sulfamethoxazole (TMP+SMX) and steroids

Explanations:

In patients with high-risk sexual behavior and weight loss with acute hypoxic
respiratory failure, one should always suspect HIV infection with underlying
opportunistic infections.
In patients with HIV-associated opportunistic infections and CXR findings of diffuse
infiltrates and acute hypoxia, the common pathogen to be considered is Pneumocystis
jirovecii.
Suspected patients with Pneumocystis jirovecii should be initiated on treatment
with TMP+SMX. Any patient with PaO2 70 and A-a gradient >35 should be started
on steroid therapy.
Pneumocystis pneumonia should be treated with TMP+SMX and steroids for a
Page 738 of 955
 21-day course and supplemental oxygen.

Research Concepts:Pneumonia In An Immunocompromised Patient

Question 782: A 36-year-old female is seen in the emergency department after she
sustains a fracture of her left femur, tibia, and fibula secondary to a motor vehicle
collision. She has a surgical repair of her injuries. On day three of her hospitalization, she
becomes short of breath, confused, and develops a petechial rash on her chest. GCS is 7.
Vitals show a blood pressure of 110/70 mmHg, a temperature of 100 F, respiratory rate of
45/min, and pulse rate of 112/min. Pulse oximetry shows an oxygen saturation of 90%. A
chest radiograph shows a diffuse infiltrate in her right lung fields.
Which of the following is the next best step in the management of this patient?
Choices:

1. Furosemide
2. High-flow oxygen mask
3. Low molecular weight heparin
4. Intubation and mechanical ventilation
Answer: 4 - Intubation and mechanical ventilation

Explanations:

Fat embolism (FE) and fat embolism syndrome(FES) are a clinical phenomenon that is
characterized by systemic dissemination of fat emboli within the system circulation. The
dissipation of fat emboli will disrupt the capillary bed and affect microcirculation, causing a
systemic inflammatory response syndrome.
Fat embolism syndrome is most common in patients with orthopedic trauma. It also can
occur in non-traumatic patients. The following nontraumatic conditions can cause fat
embolism syndrome- Acute or chronic pancreatitis, bone marrow transplant,
liposuction. Fat embolism typically manifests at around 24 to 72 hours after the initial
insult.
There is no specific treatment for fat embolism or fat embolism syndrome. Supportive care
is the mainstay of treatment once a patient develops fat embolism syndrome. Supportive
care is geared towards adequately oxygenating the end organs. Goals of supportive care
are the provision of adequate oxygenation and ventilation, maintenance of adequate
hemodynamic stability, transfusion of packed red blood cells to improve oxygen delivery if
indicated, prophylaxis of deep venous thrombosis with a sequential compression device,
adequate nutrition, and hydration. Supplemental oxygen might be required, and if the
patient develops fulminant acute respiratory distress syndrome, intubation, and
mechanical ventilation might be required.
Indications for Intubation are altered mental status with Glasgow coma score of less than 8
and moderate to several respiratory distresses with no improvement on noninvasive support.

Page 739 of 955

Research Concepts:Fat Embolism

Question 783: A 54-year-old man with no significant past medical history presents with a
ten-month history of dyspnea and wheezing that have gradually worsened. He has never
smoked tobacco, and he has no significant family history. Bronchodilators have been an
ineffective treatment. CT scan of the chest shows a mass at the left outer edge of the
lung. The clinician suspects it is a primary malignant carcinoma. Which of the following is
the most common morphologic variant of the suspected cancer in this man who has
never smoked?

Choices:

1. Adenoid cystic carcinoma

2. Giant cell carcinoma
3. Squamous cell carcinoma
4. Adenocarcinoma
Answer: 4 - Adenocarcinoma

Explanations:

Adenocarcinoma is the most common cause of primary lung cancer seen in patients
who have never smoked.
Studies have shown a low mortality rate in patients with adenocarcinoma
compared to squamous cell carcinoma. Factors that play role in causing
malignancy in patients who have never smoked include age, secondhand smoke,
radon, genetic factors, estrogen, and oncogenic viruses.
Dyspnea is the first symptom, followed by a persistent cough and hemoptysis.

Research Concepts:

Tracheal Cancer

Question 784: A 65-year-old male with a history of hypertension, diabetes mellitus, and
congestive heart failure is currently hospitalized for pneumonia. He develops acute
dyspnea and chest pain. He is tachycardic and tachypneic, and his lungs are clear on
auscultation. No peripheral edema is present. What is the best next step in management?

Choices:

1. CT pulmonary angiography
Page 740 of 955
2. D-dimer level
3. Cardiac ultrasound
4. A ventilation-perfusion scan

Answer: 1 - CT pulmonary angiography

Explanations:

The clinical concern to rule out in the provided scenario is a pulmonary embolism.
The test of choice for this is a CT pulmonary angiogram.
A ventilation-perfusion scan can be used in patients who have a known allergy to
intravenous contrast.
D-dimer levels may be elevated in patients without pulmonary embolus and are thus
too non-specific.
MR angiography is another option for making the diagnosis, but it is less available
and more technically demanding than CT angiography.

Research Concepts:

Acute Pulmonary Embolism

Question 785: A 2-day-old neonate presents with complaints of abdominal distension,

vomiting, and poor feeding. The neonate has failed to pass meconium. On examination,
generalized abdominal distention and decreased breath sounds are noted. An abdominal
x- ray shows multiple air-fluid levels. A contrast enema reveals a microcolon. Further
evaluation should be performed to diagnose which of the following conditions?

Choices:

1. Hirschsprung disease
2. Cystic fibrosis
3. Alpha-1 antitrypsin deficiency
4. Midgut malrotation

Answer: 2 - Cystic fibrosis

Explanations:

Meconium Ileus (MI) is one of the earliest manifestations of cystic fibrosis (CF) and
Page 741 of 955
 presents in up to 20 percent of infants with CF.
CF is caused by a genetic mutation in a gene on chromosome 7 that codes for a
protein transmembrane conductance regulator protein, which functions as a
transmembrane cAMP-activated chloride channel.
An infant that presents with bilious emesis is assumed to have a small bowel
obstruction. The determination of etiology is by ordering both flat and upright
abdominal films. In MI, dilated loops of the bowel with or without air-fluid levels are
present on the abdominal films.
A diagnostic contrast enema should be ordered in a stable infant to detect a
microcolon due to disuse below the obstruction in the terminal ileum.

Research Concepts:

Cystic Fibrosis

Question 786: A 16-year-old boy is brought to the emergency department after a bicycle
accident. He was riding through trails with his friends when he lost control and fell over
the handlebars. The patient was wearing a helmet and landed on his head. Since the
accident, he complains of dyspnea at rest that worsens during exertion, along with some
weakness in his left arm. CT scan of the cervical spine shows compression by the vertebra
on the C4 and C5 nerve roots, which is then confirmed with MRI. Which of the following is
the next best step in the management of this patient?

Choices:

1. Reassurance
2. Cervical decompression
3. Surgical plication
4. Phrenic nerve pacemaker

Answer: 2 - Cervical decompression

Explanations:

Most patients who are asymptomatic with unilateral diaphragmatic paralysis can be
treated conservatively. The best treatment for a patient with a known underlying
cause is to treat the underlying cause.
The phrenic nerve that innervates the diaphragm originates from cervical nerve roots
Page 742 of 955
 three through five. Compression on these nerve roots will inhibit the ability of the
phrenic nerve to transmit signals. (C3, C4, C5 keeps the diaphragm alive).
When the underlying cause can be reversed with surgical correction, such as
decompression, in this case, studies have shown that the patient may notice a
substantial improvement in respiratory function.
Surgical plication is a treatment option for patients who are symptomatic with
unilateral diaphragmatic paralysis with no underlying cause. This procedure is
postponed for at least 6 months, if possible, as most patients become less
symptomatic in time, even with no intervention.

Research Concepts:

Unilateral Diaphragmatic Paralysis

Question 787: A 53-year-old male with no past medical history presents with a dry cough
and night sweats for the past ten years. The patient has worked at an electronic shop for
the past 20 years. CT of the chest shows granulomatous disease. Chest X-ray, arterial
blood gas, and pulmonary function tests are normal. What is the next step in establishing
the diagnosis?

Choices:

1. The beryllium lymphocyte proliferation test

2. Trial of corticosteroids
3. Bronchoalveolar lavage
4. Nintedanib’
Answer: 1 - The beryllium lymphocyte proliferation test

Explanations:

The beryllium lymphocyte proliferation test (BeLPT) is the first step in establishing
the diagnosis of beryllium disease.
Early in the disease, radiography findings are usually normal. In later stages, interstitial
fibrosis, pleural irregularities, hilar lymphadenopathy, and ground-glass opacities have
been reported.
The drugs of choice to treat chronic beryllium disease are corticosteroids. It usually
requires a high starting dose and the treatment duration is often several months
before symptom resolution.
Once a diagnosis of chronic beryllium disease is made, the patient needs life-long
Page 743 of 955
 follow-up with serial arterial blood gases, chest x-ray, and pulmonary function
tests.

Research Concepts:

Berylliosis

Question 788: A 72-year-old man is evaluated three weeks after being discharged from
the hospital. During his hospitalization, he was treated for acute myocardial infarction.
Medical history includes atrial fibrillation, hypertension, heart failure, COPD, and obesity.
The patient is on appropriate therapy for his medical conditions. His vital signs reveal his
blood pressure is 165/88 mmHg, heart rate is 105 beats per minute, respiratory rate of
20 breaths per minute, and oxygen saturation is 92% on ambient air. Other than mild
pitting edema of the lower extremities, his physical exam is unremarkable. Which of the
following tests to assess the patient's cardiac or respiratory function is absolutely
contraindicated at this point?

Choices:

1. Six-minute walk test

2. Pulmonary function test
3. Dobutamine stress echocardiogram
4. Arterial blood gas
Answer: 1 - Six-minute walk test

Explanations:

A history of acute coronary syndrome within the previous month is the only
absolute contraindication to performing a six-minute walk test.
Systolic blood pressure greater than 180 mmHg or a diastolic greater than 100
mmHg, as well as a resting heart rate greater than 120 beats per minute, are
relative contraindications for the six-minute walk test.
The six-minute walk test is generally safe, and most patients will not experience any
complications from the procedure. Since it is self-paced, those patients presenting
at least with relative contraindications may complete or terminate the test before
any adverse events occur.
An acute myocardial infarction within the previous 48 hours is an absolute
contraindication for stress echocardiography.

Page 744 of 955

Research Concepts:

Six Minute Walk Test

Question 789: A 35-year-old previously healthy male presents for evaluation of coryza,
dry cough, and fever for 4 days duration. The patient reports no significant past medical
history, takes no daily medications, and has no known drug allergies. He reports receiving
COVID-19 and influenza vaccines this season. Of note, upon obtaining a travel history, the
patient stated that he recently returned from Saudi Arabia. He had petted a dog and
visited a camel farm while on his trip. His vital signs show a temperature of 101 F (38.3
C), blood pressure of 102/64 mmHg, respiratory rate of 20 breaths per minute, heart rate
of 115 beats per minute, and SpO2 of 95% on room air. Significant findings on the exam
include tachycardia, tachypnea, and mild use of accessory respiratory muscles. Which of
the following diagnoses is most important to consider in this patient?

Choices:

1. Middle East respiratory syndrome coronavirus (MERS-CoV)

2. Severe acute respiratory syndrome coronavirus (SARS-CoV)
3. Rabies
4. Ebola
Answer: 1 - Middle East respiratory syndrome coronavirus (MERS-CoV)

Explanations:

The role of viruses in primary pneumonia is increasing, and viral respiratory

pathogens are increasingly recognized as a cofactor in bacterial pneumonia
secondary to the increasing prevalence of immunosuppression-cancer treatment,
organ transplant, and human immunodeficiency virus.
Middle East respiratory syndrome coronavirus (MERS-CoV) is a subset of the
coronavirus associated with severe pneumonia.
This was first observed in the Middle East and had an initial mortality rate of 30%.
Contact with camels (including camel products such as milk) is a significant risk
factor for acquiring MERS-CoV.
Rabies cannot be transmitted from just petting a dog unless there is contact with
an infected bodily animal fluid.

Page 745 of 955

Research Concepts:

Viral Pneumonia

Question 790: A 44-year-old man has been taking steroids for years for sarcoidosis, and
recently the dosage was increased due to worsening of cough symptoms. His cough has
improved, but he has noticed progressive weakness when using his shoulder muscles and
when climbing stairs. What is the most appropriate management for the cause of his
weakness?

Choices:

1. Perform electromyography
2. Perform a muscle biopsy
3. Reduce corticosteroid dose
4. Increase corticosteroid dose

Answer: 3 - Reduce corticosteroid dose

Explanations:

Chronic use of steroids can cause myopathy, and an increased dose is related to
increased risk of developing symptoms.
There is no specific time limit on when corticosteroid-induced myopathy
develops; it can occur even after years of being on corticosteroids.
Corticosteroid induced myopathy mainly affects the proximal muscles.
Workup such as electromyography and muscle biopsy is not required for
evaluation for corticosteroid-induced myopathy. It is a clinical diagnosis.

Research Concepts:

Corticosteroid Induced Myopathy

Page 746 of 955

Question 791: A 72-year-old female develops acute shortness of breath 2 days after right
upper lobectomy for non-small cell lung cancer. She is hypoxemic with an oxygen
saturation of 80% on room air and is started on supplemental oxygen. A portable chest x-
ray shows air in the right pleural space. An emergent chest tube thoracostomy is done
with improvement in blood pressure and oxygen saturation. However, the patient
becomes drowsy and is intubated for airway protection. The chest tube is at -30 cms of
suction pressure with a profuse air leak. The patient's current vitals are heart rate -
125/minute, BP- 110/80 mmHg, respiratory rate- set at 15, patient breathing at
42/minute, FiO2- 70%, PEEP - 5 cms of H2O. To decrease her respiratory rate, she is
heavily sedated with propofol and then paralyzed. Despite paralysis, she is breathing at
42/minutes with a set respiratory rate of 15. Repeat chest x-ray shows the almost
complete expansion of the right lung. Which of the following is the next best step in the
management of this patient?

Choices:

1. Continue to increase the paralysis dose until the set respiratory rate is achieved.
2. Place another chest tube to ensure proper drainage.
3. Continue to monitor carefully as the defect will eventually seal itself.
4. Decrease the suction to a minimum level to achieve complete expansion.
Answer: 4 - Decrease the suction to a minimum level to achieve complete expansion.

Explanations:

The patient has a bronchopleural fistula from the dehiscence of her bronchial
stump.
The suction pressure is likely large enough to cause the auto triggering of the
ventilator by dropping the airway pressure. The drop in airway pressure is sufficient
for the ventilator to deliver a breath leading to a high respiratory rate.
Treatment is to decrease the suction to a minimum level to ensure the complete
expansion of the lung. This is hoping that this reduced pressure will not drop
airway pressure low enough to cause auto triggering. If, despite lowering suction
pressure, auto triggering is present, then decreasing the trigger sensitivity might
help in stopping this auto-trigger.
Paralysis is only helpful in situations where the trigger is generated by the patient.
In this current scenario, going up on the paralysis dose is not going to affect the
auto triggering.

Research Concepts: Bronchopleural Fistula

Page 747 of 955

Question 792: A 35-year-old woman presents with a seven- month history of bilateral leg
edema and progressively worsening dyspnea with moderate exertion. There is no history
of joint pain or rash, she denies tobacco, alcohol, or illicit drug use, and she currently
takes no medication. Her blood pressure is 130/90 mmHg, and her pulse rate is 90/min.
Examination demonstrates a jugular venous pressure of 10 cmH2O, bilateral lower
extremity pitting pedal edema, a split second heart sound, and a pansystolic murmur at
the left sternal border that increases with inspiration. A transthoracic echocardiogram
shows a normal ejection fraction, pulmonary artery systolic pressure of 70 mmHg, and
severe tricuspid regurgitation.
Acute vasoreactivity testing is 'non-reactive.' Given the likely diagnosis, what is the most
appropriate treatment?

Choices:

1. Anticoagulation with a target INR of more than 2

2. Ambresentan and tadalafil
3. Calcium channel blocker
4. Bosentan monotherapy

Answer: 2 - Ambresentan and tadalafil

Explanations:

The likely diagnosis is pulmonary artery hypertension (PAH). Patients with PAH,
who are non-reactive on acute vasoreactivity testing (AVT), are started on a
combination of an endothelin receptor antagonist (ERA) and a phosphodiesterase
inhibitor (PDE5-inhibitor).
Chronic right ventricular failure (RVF) secondary to primary pulmonary
hypertension can also be treated with an ERA plus a PDE5-inhibitor.
Pulmonary vasodilators reduce pulmonary artery pressure, reduce pulmonary
venous resistance, and improve cardiac output in patients with RVF. ERAs
block endothelin-A and endothelin-B receptors in endothelial and vascular
smooth muscle cells, reducing the vasoconstrictive, proliferative, and
proinflammatory effects of endothelin. PDE5-inhibitors block degradation of
cGMP.
Patients who are non-reactive on AVT, should not be started on a calcium channel
blocker.

Research Concepts:Right Heart Failure

Page 748 of 955

Question 793: A 45-year-old woman presents with burning pain when urinating. She also
mentions that her urine appears darker than normal. Vital signs show oxygen saturation
of 98% on room air, respiratory rate of 22 per minute, heart rate of 84 bpm, blood
pressure 122/86 mmHg, and temperature of 99.6 F (37.6 C). The patient is prescribed an
antibiotic for treatment. She continues to take the drug intermittently for four months
because of recurrent dysuria. At her follow-up appointment, she presents with dyspnea
and a dry cough. She denies any weight loss or a history of smoking. The drug is
immediately stopped due to its known pulmonary toxicity. Which of the following is a
contraindication for prescribing this medication?

Choices:

1. The second trimester of gestation

2. Creatinine clearance is less than 120 ml/min but greater than 60 ml/min
3. A 10 pack-year or more smoking history
4. Acute bacterial pyelonephritis
Answer: 4 - Acute bacterial pyelonephritis

Explanations:

Nitrofurantoin is an antibiotic medication that is used for the treatment of

uncomplicated lower urinary tract infections. It is effective against most gram-
positive and gram-negative organisms. The most significant reaction of
nitrofurantoin is pulmonary toxicity which can be acute, subacute, or chronic.
Nitrofurantoin should not be administered to patients with acute bacterial
pyelonephritis as nitrofurantoin does not reach therapeutic concentrations in the
upper urinary tract, and bacteremia often accompanies this disease.
Patients with anuria, oliguria, or significant impairment of renal function (defined
as a creatinine clearance of less than 60 mL/min or clinically significant raised
serum creatinine) should not take nitrofurantoin.
The drug is contraindicated in pregnant women at term (38 to 42 weeks gestation),
during labor and delivery, or when the start of labor is imminent. It can be given
safely during the second trimester. Administration during the first trimester is also
prohibited as there are concerns relating to congenital malformations.

Research Concepts: Nitrofurantoin

Page 749 of 955

Question 794: A cystic fibrosis patient is admitted to the ICU with a complicated right
lower lobe pneumonia on 4L oxygen by nasal cannula. Initial sputum stain demonstrated
Gram-negative rods, and the patient was given cefepime. He continues to have high
fevers despite antibiotics. The lab calls and reports that they suspect a carbapenem-
resistant enterobacteriaceae is the pathogen. What is the backbone of double or triple
combination therapy?

Choices:

1. Colistin
2. Tigecycline
3. Aminoglycoside
4. Carbapenem

Answer: 1 - Colistin

Explanations:

Colistin is considered by most to be the backbone for most carbapenem-resistant

enterobacteriaceae (CRE) treatment. Tigecycline is the backbone for colistin-
resistant CRE. Aminoglycosides may play a part in double or triple therapy but are
not considered integral to improving outcomes.
Carbapenems may play a part in double or triple therapy but are not considered
integral to improving outcomes

Research Concepts:

Carbapenem Resistant Enterobacteriaceae

Question 795: A 54-year-old farmer presents with chronic, gradually worsening shortness
of breath and cough, often productive of thick phlegm. He says he has been increasingly
tired lately and admits to intermittent low-grade fever. He denies a history of active or
passive tobacco use or the use of harmful chemical pesticides on his farm. His family
history is pertinent for similar symptoms in his father and brother, who work on the same
farm as him. His vitals are normal, but he appears tired and often coughs while talking.
There are mild bibasilar crackles on lung auscultation, more pronounced on inspiration. A
chest radiograph from three months prior is unremarkable. What is the most appropriate
chest imaging modality for further assessment of this patient's presentation?

Choices:

Page 750 of 955

1. Repeat radiograph
2. Contrast-enhanced CT
3. High-resolution computed tomography (HRCT)
4. Non-contrast-enhanced CT

Answer: 3 - High-resolution computed tomography (HRCT)

Explanations:

This patient's presentation raises concern for chronic interstitial lung disease,
specifically hypersensitivity pneumonitis ("farmer's lung"). The most appropriate chest
imaging modality for further assessment of this patient's presentation is HRCT.
HRCT scans are performed in the supine and prone positions and inspiratory and
expiratory phases.
This provides detail about air trapping and small airway disease and whether or not
specific changes are dependent.
Post-processing of HRCT with edge enhancement improves parenchymal detail.

Research Concepts:

Lung Imaging

Question 796: A 65-year-old male with a history of chronic obstructive pulmonary

disease (COPD) presents to the emergency department after acute onset shortness of
breath and chest pain. A chest X-ray is obtained, demonstrating a moderate size
pneumothorax. The patient is admitted a chest tube is placed.
Approximately one to two hours post chest tube placement, the patient develops the
onset of worsening dyspnea and cough productive of foamy sputum. Repeat x-ray
demonstrates appropriate placement of the chest tube and resolution of the
pneumothorax with the development of unilateral interstitial opacities. Which of the
following risk factors is associated with the patient's current pathophysiologic process?

Choices:

1. Diabetes mellitus
2. Hypertension
3. Cardiomyopathy with a reduced ejection fraction
4. COPD
Page 751 of 955
Answer: 1 - Diabetes mellitus

Explanations:

The patient developed re-expansion pulmonary edema (REPE). This is noncardiogenic

pulmonary edema that is due to the rapid re-expansion of the pulmonary
parenchyma.
Pathophysiologically, this process is related to increased capillary permeability that
may be induced by the mechanical stress brought on by pulmonary re-expansion.
Additionally, correction of the pneumothorax with chest tube thoracostomy yields
increased hydrostatic pressure associated with rapid alveolar distension.
It is hypothesized that diabetes augments the risk of developing REPE given prior
studies that have shown associated thickening of the alveolar basement membrane
leading to increased vascular permeability.
REPE is a form of non-cardiogenic pulmonary edema thus is not associated with
cardiomyopathy with a reduced ejection fraction. There has also been no
statistically significant evidence correlating the development of REPE in patients
with co- morbidities of COPD or hypertension compared to those who did not
develop REPE.

Research Concepts: Pulmonary Edema

Question 797: A 65-year-old man who was at the hospital visiting his wife is brought to
the emergency department (ED) by his family members for difficulty breathing. The family
reports that he was in his usual state of health in the hospital cafeteria, laughing at an
ongoing conversation while eating steak before he began coughing and gagging
uncontrollably. He was initially able to speak a few words at a time between coughing and
gagging. His family immediately assisted him down the hall to the ED, and his breathing
and coughing became more strained. In the ED triage area, a healthcare provider
attempted the Heimlich maneuver, but the patient collapsed and was brought
immediately to an ED resuscitation room. Initial vital signs showed a heart rate of
124/min, blood pressure 178/96 mmHg, respiratory rate of 42/min, pulse oximetry of 89%
on a non-rebreather oxygen mask, and a thready radial pulse was present. The patient is
now somnolent with some response to pain stimulus, and he has audible inspiratory and
expiratory stridor. He has significant respiratory retractions throughout his thorax with
poor air movement on auscultation. Chest compressions and bag-valve-mask ventilatory
support are started, and intravenous access is obtained. Concerning this patient’s airway,
which of following is a reasonable next step in management?

Choices:

1. Continue to support the airway with positive pressure by bag- valve-mask

Page 752 of 955
2. Perform an immediate blind finger sweep of the airway to remove any potential
foreign body
3. Order a blood gas and portable x-ray of his chest and neck to confirm the
diagnosis and better direct the airway management
4. Perform immediate direct or video/fiberoptic-assisted laryngoscopy
to evaluate and secure the airway
Answer: 4 - Perform immediate direct or video/fiberoptic-assisted laryngoscopy to evaluate
and secure the airway

Explanations:

Foreign body airway obstruction with an inability to oxygenate or ventilate is a

clinical diagnosis that requires immediate efforts to clear and secure the airway and
should not be delayed for labs or imaging.
Direct laryngoscopy or (if immediately available)
video/fiberoptic-assisted laryngoscopy should be attempted, and any identified
foreign body removed using suction and Magill forceps. Blind finger sweeps of the
airway should be avoided.
If an airway foreign body is believed to be lodged distal to the vocal cords,
endotracheal intubation can be attempted to advance the foreign body into the
right mainstem, followed by withdrawing the endotracheal tube back above the
carina to ventilate the left lung. This should be followed by arrangements for
emergent bronchoscopy in the operating room for foreign body removal.
If an airway foreign body is preventing endotracheal intubation and cannot be
immediately removed, cricothyrotomy should be performed to secure the airway.

Research Concepts:

Foreign Body Airway Obstruction

Question 798: A 56-year-old male presents to the hospital with shortness of breath and
hemoptysis. He had been well until 3 months ago but has lost 15 pounds. The patient's
blood test results include a complete blood count with white blood cells of 9800/mcL,
hemoglobin of 10.5 mg/dL, blood urea nitrogen of 80 mg/dL, and creatinine of 3.0 mg/dL.
Urinalysis shows protein to be 2+, 30 red blood cells per high power field, and occasional
red blood cell casts. Computed tomography (CT) scan of the chest shows diffuse alveolar
infiltrates secondary to hemorrhage. Antimyeloperoxidase titer is positive at 132 U/mL.
Which of the following is the therapeutic agent of choice for induction of remission in this
patient?

Choices:
Page 753 of 955
1. Azathioprine
2. Abatacept
3. Cyclophosphamide
4. Infliximab

Answer: 3 - Cyclophosphamide

Explanations:

Treatment of microscopic polyangiitis involves the induction and maintenance of

remission. Remission has been described as the absence of symptoms attributable
to an active vasculitis process.
Induction in patients with severe organ-threatening disease requires the use of a
combination of cyclophosphamide with glucocorticoids.
An alternative induction regimen, useful for patients experiencing side effects of
cyclophosphamide, involves the use of rituximab with or without glucocorticoids.
This regime has had results comparable to that involving the use of
cyclophosphamide.
The maintenance of induction can be done using methotrexate or azathioprine.

Research Concepts:

Microscopic Polyangiitis

Question 799: A 65-year-old man with worsening Parkinson disease presents to the
hospital with a persistent cough and new- onset fever. There is no dyspnea, and
peripheral oxygen saturation is good (97%). Nevertheless, the plain films demonstrate a
lentiform cavity with air-fluid levels. His temperature is 37.8 C (100 F), pulse is 99 bpm,
and respiratory rate is 16/min. Which of the following is the most appropriate treatment
for this patient?

Choices:

1. Percutaneous drainage, a culture of the drained fluid, and antibiotics

2. Physiologic drainage
3. Bronchiolar lavage, culture of the lavage fluid, and antibiotics
4. Blood culture and antibiotics
Page 754 of 955
Answer: 1 - Percutaneous drainage, a culture of the drained fluid, and antibiotics

Explanations:

In Parkinson disease, the risk of being hospitalized for aspiration pneumonia is over
three times higher than in healthy patients, and this risk increases as patients
advance into later stages of the disease and have a breakdown of their cough and
swallowing function. A known complication of aspiration pneumonia is the
development of a lung abscess.
Plain films of a lung abscess demonstrate air-fluid levels in a generally round cavity,
while empyema is usually lentiform.
Distinguishing features are more readily observable on computed tomography (CT)
scans.
Chest computed tomography is more sensitive to disease presence, location, and
severity than chest radiographs. Findings are most often located in dependent
areas of the lung and include interstitial thickening, prominent septal lines, diffuse
basilar centrilobular nodules, ground-glass opacities, and regions of bronchiectasis.
If a lung abscess secondary to acute or chronic pneumonia and infection develops,
it must be treated with physiotherapy with postural drainage and prolonged
antibiotics. An empyema requires percutaneous drainage for management.

Research Concepts: Chronic Aspiration

Question 800: A 69-year-old woman sees you at a follow-up visit. She is being evaluated
due to shortness of air on exertion, progressively worsening over several months. Her
activity is limited sometimes due to the severity of her dyspnea. Her medical history is
only notable for hypertension, treated with amlodipine. The patient appears thin and
comfortable. Lung auscultation reveals faint "velcro" crackles on both lung bases. A high-
resolution chest CT was obtained before this visit that shows bilateral basal and
subpleural fibrosis with honeycombing. Pulmonary function test results include a total
lung capacity of 3.47 liters (62% of predicted) and a diffusing capacity of carbon monoxide
of 16.25 mL/min/mmHg (58% of predicted). You decide to request a six-minute walk test
to assess the patient's baseline walking distance (6MWD). Which of the following results
would be associated with a twofold increase in mortality in this patient?

Choices:

1. A baseline 6MWD greater than 300 meters

2. A baseline 6MWD of 175 meters
3. A baseline 6MWD under 250 meters
4. A baseline 6MWD under 350 meters
Page 755 of 955
Answer: 3 - A baseline 6MWD under 250 meters

Explanations:

IPF is associated with progressive respiratory insufficiency with associated decreases

in exercise tolerance, resulting from ongoing lung fibrosis. The 6MWD is an
independent predictor of mortality among these patients.
In IPF, a baseline 6MWD under 250 meters is associated with a two-fold increase in
1-year mortality risk.
A decline greater than 50 meters observed on subsequent testing at 24 weeks is in
turn associated with a threefold increase in mortality risk for IPF patients.
The correlation between 6MWD and other pulmonary function parameters predictive
of mortality is weak.

Research Concepts:

Six Minute Walk Test

Section 9

Question 801: A 50-year-old male patient is being evaluated. He has a history of leukemia
and has been treated with a stem cell transplant. Based on his history and physical exam
findings, he has been diagnosed with the virus, the common cause of viral pneumonia in
children. Symptomatic treatment only is recommended as the patient is not ill-appearing.
If the patient should worsen over the next few days, which of the following medications is
a treatment option to treat this pathogen appropriately?

Choices:

1. Ribavirin
2. Oseltamivir
3. Acyclovir
4. Remdesivir
Answer: 1 - Ribavirin

Explanations:

Ribavirin can be used in respiratory syncytial virus (RSV) infections that are
Page 756 of 955
 significantly complicated based on past medical history, presenting symptoms, or
inadequate response to symptomatic treatment.
Ribavirin may be used in oral form in the adult population. Ribavirin would be an
appropriate treatment should symptomatic treatment not suffice.
Oseltamivir and acyclovir are antiviral medications but are not efficacious in the
treatment of RSV. Remdesivir is used in the treatment of mild to moderate
COVID-19 infection.

Research Concepts:

Viral Pneumonia

Question 802: A 65-year-old male patient presents to the clinic with a three-week history
of a persistent cough, hoarseness, fatigue, and shortness of breath, with occasional
hemoptysis. The patient also states he has lost 15 pounds (7 kg) over the past month
without changing his diet. The patient has smoked one pack per day for the past 40 years.
His blood pressure is 144/82 mmHg, his pulse is 84 beats per minute, his respiratory rate
is 17 breaths per minute, and his temperature is 98.0°F (36.7°C). He has absent breath
sounds on the right side. A computed tomography (CT) scan of his chest reveals a
centrally located mass in the right lung. Serum studies show calcium of 12 mg/dL, sodium
of 139 mEq/L, and potassium of
4.0 mEq/L. What is most likely to be seen on the histopathological examination of the mass?

Choices:

1. Intercellular bridging desmosomes and keratin pearls

2. Small dark blue staining cells with scant cytoplasm
3. Solid nests of polygonal cells containing vesicular nuclei
4. Invasive glandular mucin-producing cells
Answer: 1 - Intercellular bridging desmosomes and keratin pearls

Explanations:

This patient has an elevated serum calcium level, extensive smoking history, and a
confirmed centrally located tumor.
Humoral hypercalcemia of malignancy usually is due to the production of a
parathyroid-like hormone protein by the tumor. Hypercalcemia most commonly is
associated with squamous cell carcinoma.
Parathyroid hormone-related protein (PTHrP) is an analogous protein of the
Page 757 of 955
 parathyroid hormone family secreted by mesenchymal stem cells and squamous cell
carcinoma.
Squamous cell carcinoma of the lung is the second most common type of lung
cancer after adenocarcinoma. It generally originates in the bronchi and is centrally
located.
Small cell carcinoma, which generally contains small dark blue staining cells with scant
cytoplasm, generally produces SIADH. Adenocarcinoma, with invasive glandular
mucin-producing cells, does not cause the release of paraneoplastic factors.

Research Concepts:

Non Small Cell Lung Cancer

Question 803: A tall thin male presents with complaints of crackling skin on his chest. He
reports that he is recovering from an episode of bronchitis but denies any shortness of
breath, chest pain, or recent trauma. On examination, subcutaneous emphysema is
observed on the entire chest wall, and chest radiograph demonstrates mediastinal air and
small pneumothorax that is less than 2 cm. Which of the following is most appropriate for
the management of this patient?

Choices:

1. Chest tube placement

2. High flow oxygen
3. Observation and reassurance
4. Thoracic surgery consult

Answer: 3 - Observation and reassurance

Explanations:

The pneumothorax and pneumomediastinum are likely a result of a coughing fit

from bronchitis in a tall-slender male with a possible underlying genetic condition.
In patients that do not require immediate intervention due to cardiovascular or
respiratory compromise, observation and reassurance are appropriate.
If the patient was experiencing discomfort or increased anxiety from the
development of the subcutaneous emphysema, high flow oxygen could help
accelerate the reabsorption through nitrogen washout.
Thoracic surgery consultation would be appropriate if the provider suspected the
Page 758 of 955
 cause of subcutaneous emphysema was due to a fistula or tracheal injury that
required repair.

Research Concepts: Subcutaneous

Emphysema

Question 804: A healthy young person is mountain climbing and develops severe
shortness of breath. The patient has diffuse inspiratory crackles. Which of the following is
the most likely diagnosis?

Choices:

1. Pulmonary embolism
2. Altitude related pulmonary edema
3. Acute respiratory distress syndrome
4. Congestive heart failure
Answer: 2 - Altitude related pulmonary edema

Explanations:

High altitudes can result in cerebral or pulmonary edema.

The most likely cause for altitude related pulmonary edema is hypoxic
vasoconstriction and increased cardiac output leading to pulmonary hypertension.
Those less than 25 years of age are at a higher risk of the development of altitude
related acute pulmonary edema due to increased pulmonary artery hypoxic
vasoconstriction.
HAPE typically occurs 2-5 days after arrival at altitude. It has an insidious onset with
a non-productive cough, decreased exercise tolerance, chest pain, and exertional
dyspnea. Without treatment, it can progress to dyspnea at rest and severe
exertional dyspnea. A cough may become productive of pink/frothy sputum or
frank blood. The patient may also have rales/wheezes, central cyanosis, tachypnea,
and/or tachycardia. SpO2 is often 10% less than expected for altitude, and the
patient will often appear better than expected given their level of hypoxemia and
SpO2 value which typically resides around 40- 70%.

Research Concepts:

High Altitude Pulmonary Edema

Page 759 of 955

Question 805: A 51-year-old female presents for evaluation of dyspnea. She has a past
medical history of hypertension and systemic sclerosis diagnosed five years ago. She has
a history of tobacco use disorder, quitting five years ago. She reports exertional dyspnea
for the past 12 months, which has become severe over the last three months, and now
occurs with minimal activity. She also reports a syncopal episode last week when trying
to go up a flight of stairs. She is not on any medication and has not seen a healthcare
provider for two years. Physical examination reveals a blood pressure of 105/70 mmHg, a
pulse of 94 beats per minute, and a respiratory rate of 18 breaths per minute. Her
oxygen saturation is 93% on room air at rest. Cardiovascular examination reveals a wide
splitting of the second heart sound, a holosystolic murmur of tricuspid regurgitation, and
an elevated jugular venous pulse. Lungs are clear to auscultation. Pulmonary function
testing reveals normal lung volumes and a decreased diffusion capacity for carbon
monoxide. A ventilation-perfusion scan is normal. Which of the following is most likely to
be present on right heart catheterization?

Choices:

1. Mixed venous oxygen saturation of 65% with 10% increase in the right ventricle
2. A pulmonary artery wedge pressure (PAWP) >15 mmHg
3. Pulmonary vascular resistance (PVR) >3 Wood units
4. Vasoreactivity after inhaled nitric oxide administration
Answer: 3 - Pulmonary vascular resistance (PVR) >3 Wood units

Explanations:

This patient likely has pulmonary arterial hypertension (PAH) secondary to

scleroderma (Group 1) and presents with World Health Organization (WHO)
functional class III symptoms.
Patients suspected of having PAH undergo a right heart catheterization (RHC) to
confirm hemodynamic measurements from noninvasive imaging. Diagnosis of PAH
requires documentation of a mean pulmonary arterial pressure (mPAP) of >20
mmHg, pulmonary artery wedge pressure (PAWP) 15 mmHg, and pulmonary
vascular resistance (PVR) of >3 Wood units. As this is a tripartite definition, the
patient must meet all three aspects of the definition to be diagnosed with PAH.
PAH cannot be diagnosed until all of the other WHO pulmonary hypertension (PH)
groups have been eliminated as the cause for the symptoms. Patients will need to
undergo an echocardiogram to rule out left heart disease (Group 2); imaging or
pulmonary function tests to exclude PH due to lung disease or chronic hypoxia
(Group 3); a ventilation/perfusion (V/Q) scan to exclude chronic thromboembolic
disease-associated PH (Group 4).
Once patients have been diagnosed with PAH, their severity is classified using
Page 760 of 955
 either the New York Heart Association (NYHA) or WHO Functional Classification
(FC) systems. These classifications are used to assess disease severity, monitor for
progression of the disease, and track the patient's response to treatment.

Research Concepts:

Scleroderma-Associated Pulmonary Arterial Hypertension: Early Detection For Better

Outcomes

Question 806: A 32-year-old male commercial marine diver is evaluating a sailing vessel
for repairs at 4-8 meters below sea level. He has no past medical history, and he takes no
medications. He drinks alcohol socially and does not smoke tobacco products, vape, or use
illicit drugs. His scuba equipment becomes entangled, and his regulator hose is damaged.
He coughs, loses his regulator, and his face mask starts to fill with water. He rapidly
ascends to the surface without stopping or exhaling. He is rescued at the surface, but he is
unconscious and seizing. Advanced cardiac life support is initiated, and he is immediately
transported to the local hospital. He regains consciousness, is confused, dizzy, and
dysarthric. Chest x-ray reveals pneumomediastinum, bibasilar infiltrates, but no
pneumothorax. Electrocardiogram reveals sinus tachycardia without ischemia. An
intravenous crystalloid solution is infusing, and supplemental oxygen at 100% non-
rebreather is in place. Which of the following is the most appropriate next step in the
management of this patient?
Choices:

1. Dexamethasone administration
2. Hyperbaric oxygen recompression therapy
3. Computed tomography (CT) scan of the head
4. Electroencephalogram (EEG) and intravenous levetiracetam
Answer: 2 - Hyperbaric oxygen recompression therapy
Explanations:

Air-gas emboli are formed when pneumomediastinum air is forced into the
capillaries, pulmonary veins, and central circulation. These bubbles collect in the
heart or brain and obstruct blood flow.
Initial presentation of cerebral arterial gas embolism is the loss of consciousness,
seizure, and/or cardiac arrest due to lack of blood flow in the large vessels or from
air gas emboli in the brainstem. Air-gas emboli can also cause headaches,
confusion, numbness, tingling, paresthesia, fatigue, hemiplegia, paralysis, aphasia,

Page 761 of 955

 or any stroke symptom.
The damaged epithelial and endothelial cells release inflammatory mediators. This
damage to the cells leads to leaky vessels that cause swelling and edema. In the
brain, this manifests as cerebral edema.
The need for recompression and hyperbaric oxygen therapy needs to efficiently
and accurately assessed for the patient. Prompt treatment within the first two
hours provides the most benefit and resolution of symptoms. Delays in
recompression and hyperbaric oxygen therapy of more than 6 hours are
associated with worse outcomes.
Research Concepts: Pulmonary Barotrauma

Question 807: A 38-year-old male patient presents to the emergency department with a
2-day history of sharp chest pain that is worse with deep inspiration. On examination, he
has a low-grade fever, his pulse is 110/min, the respiratory rate is 18/min, the blood
pressure is 118/76 mmHg, and oxygen saturation 89%. On auscultation of the lungs,
there is increased tactile fremitus over the right lower lobe, decreased air entry to the
right lower lobe, and a dull biphasic non-musical grating sound. A chest x-ray shows a
right lower lobe consolidation. He is started on antibiotics and given supplemental
oxygen. What medication could be added to manage his pain and treat the underlying
cause of his symptoms?

Choices:

1. Morphine
2. Tylenol
3. Non-steroidal anti-inflammatory drugs
4. Corticosteroids
Answer: 3 - Non-steroidal anti-inflammatory drugs

Explanations:

This patient's presentation is consistent with pneumonia. The biphasic non-musical

grating sound heard on auscultation is a pleural friction rub.
Pleural friction rub occurs when the roughened surfaces of the visceral and parietal
pleura rub against each other during inspiration and expiration.
Pleurisy results from inflammation of the visceral and parietal pleura. Non-steroidal
anti-inflammatory drugs should be considered in the management of pleuritic chest
pain.
A pleural friction rub is heard in less than 5% of patients with pneumonia. This sound
may also be heard in the setting of mesothelioma, pulmonary embolism, and
Page 762 of 955
 pancreatitis, among other conditions.

Research Concepts:

Pleural Friction Rub

Question 808: A 38-year-old male presents to the clinic for follow up. He complains of
chronic cough, which is sometimes productive of white or yellow sputum and exertional
breathlessness. He reports these symptoms came on gradually over the preceding few
years and thinks his cough is particularly troubling in the mornings and on temperature
changes. His past medical history is only remarkable for recurrent respiratory infections,
dating back to his early childhood.
On further questioning, he reports a few episodes of hemoptysis. His family history
includes asthma in his mother. He takes no regular medication and is a lifelong non-
smoker. Physical examination reveals reduced breath sounds on the left side with some
end- expiratory crepitations and scattered wheeze. Pulse oximetry reveals an oxygen
saturation of 98% on room air. The chest X-ray demonstrates increased lucency and
decreased broncho-vascular markings on the left side. There is no focal consolidation.
Lung function tests demonstrate: FEV1 1.4L (34.4% predicted), FVC 2.52L (51.1%
predicted), VC 2.72L (52.8% predicted), FEV1/VC ratio 0.4, FEV1 post-bronchodilation
1.48L. What is the next best step in the management of this patient?

Choices:

1. Budesonide/formoterol inhaler
2. Erythromycin
3. Chest drain insertion
4. High-resolution CT scan of the chest

Answer: 4 - High-resolution CT scan of the chest

Explanations:

Swyer-James-MacLeod syndrome is believed to develop as a consequence of

bronchiolitis obliterans in childhood.
Lung function tests in Swyer-James-MacLeod syndrome show small airway
obstruction
The hyperlucency observed on the chest radiographs in SJMS can be
misinterpreted as pneumothorax. This can lead to unnecessary procedures and

Page 763 of 955

 increased morbidity.
In SJMS a high-resolution CT scan of the chest may demonstrate emphysema,
bullae, and bronchiectasis. Expiratory slices will also reveal air trapping.
Research Concepts:

Swyer-James-MacLeod Syndrome

Question 809: A 49-year-old man presents to the clinic for evaluation of exertional
dyspnea and fatigue for 3 months. He works as a truck driver who drives long distances.
He recently noticed that he started gaining weight and thus made a resolution to walk
daily.
However, this has not been going well as he thinks he is too deconditioned, and thus,
minimal exertion is causing fatigue and shortness of breath. Yesterday, he pushed
himself to complete a goal distance to walk and had a near-syncopal attack. His medical
history includes provoked deep vein thrombosis (DVT) secondary to long flight one year
ago for which he completed anticoagulation and has been doing well since then. He
denies tobacco, alcohol, or illicit drug use. Vitals and physical exam show no
abnormalities. Routine labs are within normal limits. EKG, chest x-ray, and pulmonary
function tests (PFTs), including a methacholine challenge test, are normal.
Ventilation/perfusion scan (V/Q) confirms CTEPH with large proximal emboli. The patient
returns 3 months after anticoagulation with only minimal improvement of symptoms.
Echocardiogram reveals significantly elevated mean pulmonary artery pressures, which
are increased compared to prior study. Positron–emission tomography (PET-CT) with F-
fludeoxyglucose to rule out sarcoma is negative. What is the next best step in the
management of this patient?
Choices:

1. Bosentan
2. Balloon pulmonary angioplasty
3. Pulmonary endarterectomy
4. IV epoprostenol therapy
Answer: 3 - Pulmonary endarterectomy
Explanations:

Chronic pulmonary embolism (also known as chronic thromboembolic pulmonary

hypertension - CTEPH) is a potentially life-threatening condition and is associated with high
morbidity and mortality. Chronic thromboembolism results in CTEPH and overt right heart
failure; however, advances in medical and surgical treatments have markedly improved
outcomes.
Pulmonary endarterectomy (PEA) is a complex surgical intervention in selected operable
patients, results in normalization of pulmonary hemodynamics, improved exercise
Page 764 of 955
 capacity, and survival.
Pulmonary endarterectomy is the treatment of choice in operable patients.
Bosentan, an endothelin receptor antagonist, is a safe alternative to riociguat used in mild
to moderate CTEPH. Balloon pulmonary angioplasty combined with riociguat is the
treatment of choice in inoperable patients. IV epoprostenol therapy is the drug of choice
for severely ill CTEPH patients.
Research Concepts:Chronic Thrombo-Embolic Pulmonary Hypertension

Question 810: A 65-year-old man presents to the clinic with dyspnea over the past few
weeks. He can only walk about half a mile now before getting short of breath. He used to
be able to walk 1 mile every day as a part of his morning routine without any troubles. He
also reports occasional bouts of non-productive cough over the past month. He denies any
fever or chills. He has one dog at home, which has been there for years. He has smoked
only a little bit when he was in college, but the habit did not stick. Physical exam reveals
some fine crackles on the bases of lung bilaterally. He has some distal interphalangeal
swelling affecting both hands. Pulmonary function tests reveal a restrictive pattern. High-
resolution CT of the chest shows nonspecific interstitial pneumonia pattern. Serological
work-up is significant for elevated rheumatoid factor. The rest of the work up is negative.
Which of the following findings in physical exam findings is most consistent with the
patient's most likely diagnosis over idiopathic pulmonary fibrosis?
Choices:

1. Morning stiffness less than 30 minutes

2. Malar rash
3. Rheumatoid nodules
4. Mechanics hands
Answer: 4 - Mechanics hands
Explanations:

To diagnose idiopathic pneumonia with autoimmune features (IPAF), the ATS/ERS

joint consensus has published IPAF criteria. These criteria required: (1) the
presence of ILD by HRCT or solid lung biopsy (SLB); (2) exclusion of an alternate
etiology for the ILD; (3) failure to meet the criteria for a defined CTD; and (4) 1 or
more features from at least 2 of the following clinical, serologic, and morphologic
domains.
Mechanics hand is one of the diagnostic criteria of IPAF under the clinical domain.
It is commonly seen in patients with dermatomyositis and polymyositis.
Morning stiffness less than 30 minutes, in general, is not typically associated with
connective tissue diseases and is not included in the proposed criteria for the
diagnosis of IPAF. However, morning stiffness that lasts over 60 minutes is one of
the proposed criteria for IPAF diagnosis. Malar rash suggestive of systemic lupus
Page 765 of 955
 erythematosus is not included in the diagnostic criteria or IPAF. It is also not
associated with idiopathic pulmonary fibrosis. Rheumatoid nodules associated
with rheumatoid arthritis patients are not part of the diagnostic criteria of the
proposed IPAF diagnosis.

Research Concepts:Idiopathic Interstitial Pneumonia With Autoimmune Features

Question 811: A 65-year-old male with an unknown past medical history is brought to the
emergency department with shortness of breath and lethargy. The patient is found to be
confused and hypoxic, with an O2 saturation of 65%. The basic metabolic panel includes
sodium 140 mEq/L, potassium 5.8 mEq/L, chloride 100 mEq/L, bicarbonate 19 mEq/L,
blood urea nitrogen 65 mg/dL, creatinine 3.2 mg/dL, and blood glucose 132 mg/dL. The
patient weighs 100 kilograms. The clinician decides to perform emergency intubation.
What induction and paralytic medications should be used?

Choices:

1. Rocuronium 100 mg IV followed by etomidate 30 mg IV

2. Propofol 50 mg IV followed by rocuronium 100 mg IV
3. Etomidate 30 mg IV followed by succinylcholine 100 mg IV
4. Etomidate 30 mg IV followed by rocuronium 100 mg IV
Answer: 4 - Etomidate 30 mg IV followed by rocuronium 100 mg IV

Explanations:

This patient presents with acute hypoxic respiratory failure requiring rapid
sequence intubation. The patient has an anion gap metabolic acidosis as well as an
acute kidney injury, causing hyperkalemia.
The proper dose of etomidate is 0.1-0.6 mg/kg, and the proper dose of rocuronium
is 0.6-1.2 mg/kg, etomidate 30 mg IV, followed by rocuronium 100 mg IV, is the
proper dosing and medications for this patient.
Paralytic agents should always be given after induction agents to avoid paralyzing a
conscious patient.
Due to the hyperkalemia, succinylcholine is contraindicated. The proper dosing of
propofol as an induction agent is 1.5-2.5 mg/kg; therefore, 50 mg would be an
inadequate dosage.

Research Concepts:

Tracheal Rapid Sequence Intubation

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Question 812: A 30-year-old female presents with worsening dyspnea and right-sided
chest pain, which worsens with deep breathing. She had a long-distance trip 1 week ago
where she drove from Florida to Ohio. She is currently pregnant at 20 weeks gestation.
Her past medical history is unremarkable. She does not take any medications. Her vital
signs include a temperature of 99 F, a pulse of 103/min, blood pressure of 106/70 mmHg,
respiratory rate of 16/min, and oxygen saturation of 88% on room air, which improved to
94% on 2 L of oxygen per minute. Physical examination reveals a distended abdomen,
clear lungs, and normal heart sounds. She has trace bilateral lower extremity swelling. An
x-ray chest is performed in the emergency department and reports no acute
cardiopulmonary abnormalities. A V/Q scan is performed, which shows 2 large perfusion
defects involving more than 75% of the apical, anterior basal, and lateral basal segments
of the right lung.
What is the next best step in the management of this patient?

Choices:

1. Order pulmonary function tests

2. Order CT angiogram with IV contrast
3. Repeat V/Q scan
4. Start anticoagulation
Answer: 4 - Start anticoagulation
Explanations:

The American thoracic society guidelines recommend a V/Q scan as the initial test
in the absence of findings suggesting deep venous thrombosis (DVT) and a normal
chest x-ray in pregnant patients. A high probability V/Q scan result implies the
presence of a pulmonary embolism (PE), and the next best step is to start
anticoagulation.
Multiple algorithms or criteria have been developed over time to interpret V/Q
scan findings, including the Prospective investigation of pulmonary embolism
diagnosis (PIOPED) criteria and modified PIOPED II criteria. According to these
criteria, the presence of 2 or more large mismatched ventilation- perfusion defects
indicates a high likelihood of PE.
Other criteria that interpret V/Q scan perfusion imaging are the perfusion-only
modified PIOPED criteria and perfusion-only Prospective investigation of
pulmonary embolism diagnosis (PISAPED) criteria. With perfusion-only modified
PIOPED criteria, PE is said to be present in the presence of 2 or more large
mismatched segmental defects. The perfusion-only PISAPED criteria interpret a
V/Q scan as PE positive with one or more wedge-shaped perfusion defects.
According to the modified PIOPED II criteria, a V/Q scan is classified as having a low
likelihood ratio with any of the following findings: 1-3 small segmental defects,
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 solitary matched defect in a single segment in the mid or upper lung, 2 or more
ventilation-perfusion matched defects with regionally normal chest x-ray,
nonsegmental defect, perfusion defect smaller than the corresponding x-ray lesion,
solitary large pleural effusion, or stripe sign (peripheral perfusion in a perfusion
defect). A V/Q scan is normal if no perfusion defects are seen. All other findings are
classified as a non-diagnostic scan. A non- diagnostic scan requires further imaging
such as CT pulmonary angiography to diagnose a PE.

Research Concepts:

Lung Perfusion Scan

Question 813: A 65-year-old woman is receiving low molecular weight heparin (LMWH)
to treat pulmonary embolism (PE). The medical team initiates warfarin on day 4. On day
5 of heparin therapy, her platelet count drops to 50,000 platelets/microliter. Her
baseline platelet count was 150,000 platelets/microliter on admission. The medical team
suspects heparin-induced thrombocytopenia (HIT). What is the best management for this
patient?

Choices:

1. Discontinue LMWH and warfarin

2. Discontinue LMWH and continue warfarin
3. Discontinue LMWH and warfarin, administer vitamin K and start argatroban
4. Continue LMWH and discontinue warfarin
Answer: 3 - Discontinue LMWH and warfarin, administer vitamin K and start argatroban

Explanations:

The first step in the treatment of HIT is the discontinuation of all forms of heparin
and warfarin. Next, an alternative anticoagulant must be initiated to prevent or
treat any HIT-induced thrombosis. Protein C and S are vitamin K-dependent
anticoagulants. When warfarin is initiated, protein C and S are depleted before
vitamin- K-dependent clotting factors, leading to a hypercoagulable state. If warfarin
is administered at the onset of HIT, protein C and S depletion can severely worsen
coagulation and increase the risk of thromboembolic complications. If recently
started, warfarin must be stopped and reversed with phytonadione (vitamin K) to
replete protein C and S stores.
Warfarin can be started once two criteria have been met. First, the platelet count
must have a substantial resolution and reach a stable plateau, ideally a platelet
Page 768 of 955
 count of at least 150,000 platelets/microL or the patient’s baseline if the baseline
was less than 150,000 platelets/microliter. Second, the patient must be
therapeutically anticoagulated with argatroban or fondaparinux before the
initiation of warfarin. Therapy with fondaparinux or argatroban must overlap with
warfarin for at least 5 days before continuing monotherapy with warfarin.
The risk of thromboembolic complications persists for up to 30 days after stopping
heparin. Therefore, in patients with HIT and no thrombosis, anticoagulation for one
month should be considered. Warfarin may be used for this purpose once the two
criteria mentioned above are met.

Research Concepts:
Heparin Induced Thrombocytopenia

Question 814: A 21-year old male with no significant past medical history presents with
episodes of dry cough not responsive to any medication. A chest x-ray done is
unremarkable. A CT scan of the chest shows an endobronchial mass. Bronchoscopy shows
a polypoid mass near the carina that is resected. Histopathology shows a fibrovascular
core covered by regular squamous epithelium. Which virus is most commonly associated
with this condition?

Choices:

1. HPV 6
2. HSV
3. HHV 8
4. EBV
Answer: 1 - HPV 6

Explanations:

Pulmonary papillomas are benign papillary tumors characterized by a fibrovascular

core covered by an epithelium.
Papillomavirus (HPV) has a key role in squamous cell papilloma.
Serotypes 6 and 11 are frequently reported in simple papillomas, while subtypes
16, 18, and 31 play a key role in malignant transformation.
HHV8, EBV, and HSV are not associated with pulmonary papillomas.

Research Concepts:

Pulmonary Papilloma

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Question 815: A 22-year-old male has progressive dyspnea on exertion and a dry cough
for the last four months. He works at a pet store for seven months, cleaning bird and
reptile cages. The exam is unremarkable. Oxygen saturation drops from 96 percent at rest
to 92 percent with ambulation. His temperature is 37.6 degrees C. His chest x-ray is
normal, but CT of the chest shows lower lung ground- glass opacities and upper lung
centrilobular nodules. Bronchoscopy biopsy shows an interstitial alveolar infiltrate
composed of lymphocytes, plasma cells, and occasional eosinophils. Also noted are
several noncaseating granulomas. Cultures for fungus, bacteria, and viruses are negative.
Which of the following is the best management plan in this patient?
Choices:

1. Antibiotics
2. Antihistamines
3. Antigen avoidance and steroids
4. Long-acting beta-blockers
Answer: 3 - Antigen avoidance and steroids
Explanations:

Bird droppings and feathers can cause hypersensitivity pneumonitis. This is a delayed-type
hypersensitivity that can be acute, subacute, or chronic. This patient has a subacute
presentation.
Hypersensitivity pneumonitis (HP), classified as interstitial lung disease, is a complex
immunological reaction of the lung parenchyma in response to repetitive inhalation of a
sensitized allergen. The name HP defines the disease more appropriately than the previous
term extrinsic allergic alveolitis, as the inflammation involves not only the alveoli but the
bronchioles as well.
The classic high-resolution CT finding is upper and middle lobe predominant patchy
ground-glass or nodular opacities in a bronchovascular distribution, with evidence of air
trapping. On expiratory images, mosaic attenuation indicative of air trapping is better
appreciated. The heterogeneous appearance on CT scan of subacute HP with areas of
ground glass or nodular opacities (high attenuation), air trapping (low attenuation), and
normal parenchyma are referred to as the "head cheese sign." The cornerstone of
treatment is prompt diagnosis and eradication of the causative agent from the patient’s
environment. The condition is typically reversible if diagnosed early in the course of the
disease, and complete antigen avoidance can be achieved. Glucocorticoids have been
shown to hasten initial recovery, particularly in patients with severe symptoms, abnormal
lung function tests, or extensive radiographic involvement.

Research Concepts:
Hypersensitivity Pneumonitis

Page 770 of 955

Question 816: A 76 year-old-man with a past medical history significant for coronary
artery disease, hypertension, hypothyroidism, and recent cerebral vascular accident
presents to the hospital with shortness of breath, non-productive cough, and lethargy.
Home medications include aspirin, metoprolol, atorvastatin, thyroxine and daily liquid
paraffin for chronic constipation. On exam, the patient is tachypneic using accessory
muscles to breathe. Vital signs show temperature 38.5 C, heart rate 106/minute,
respiratory rate 26/minute, blood pressure 112/76 mmHg and saturating at 82% on room
air. Arterial blood glass reveals pH 7.4, pO2 52 mmHg, pCO2 22 mmHg, and bicarbonate
15 mEq/L. Labs are significant for leukocytosis with neutrophilic predominance and
elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Computed
tomography (CT) thorax reveals cardiomegaly with right middle lobe consolidation,
ground-glass opacity (GGO) and thickening of bronchial walls with small right pleural
effusion. The patient is treated with a seven-day course of broad-spectrum antibiotics;
however his oxygen requirements continue to increase, ultimately require intubation and
mechanical ventilation. Infectious and rheumatologic workup remains negative. Which of
the following is the next best step in the management of this patient?

Choices:

1. Computed tomography (CT) angiogram of the thorax

2. Extensive oncologic workup
3. Bronchoalveolar lavage
4. Thoracentesis
Answer: 3 - Bronchoalveolar lavage
Explanations:

Bronchoalveolar lavage or lung biopsy is required to confirm the diagnosis of lipoid

pneumonia.
Laboratory values are non-specific in lipoid pneumonia, and can often be confused
with other pathologies including but not limited to bacterial pneumonia. Further
testing is required to make the diagnosis. Lab work often reveals leukocytosis with
neutrophilic predominance as well as elevated inflammatory markers erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP).
Patients with dysphagia from any cause are predisposed to lipoid pneumonia when
using oily laxatives such as liquid paraffin due to a high risk of aspiration.
Lipoid pneumonia is caused by aspiration or inhalation of fat- containing products.

Research Concepts:Lipoid Pneumonia

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Question 817: A 33-year-old woman presents with progressive shortness of breath. She
states that a year ago, she was able to exercise regularly without any symptoms, but now
she can barely walk a block without running out of breath. She denies any chest pain,
palpitations, dizziness, diarrhea, vomiting, blood in stools, or changes in her menses. Her
vitals at rest noted include a heart rate of 75 beats per minute, a blood pressure of
130/80 mmHg, a respiratory rate of 18 breaths per minute, and oxygen saturation of
95% on room air. On physical examination, a loud S2 is noted. Her labs, chest x-ray, and
electrocardiogram are within normal limits.
Echocardiography shows increased pulmonary artery and right ventricular pressures
without any structural heart disease. Her pulmonary function tests and high-resolution
computed tomography (HRCT) are normal. No embolus is found on pulmonary
angiography. She undergoes right heart catheterization, which is compatible with
echocardiography results with high pulmonary artery pressures and negative
vasoreactivity test. The provider has prescribed medication for her condition. What is the
mechanism of action of the most likely medication prescribed for this patient's condition?

Choices:

1. Increase in cAMP (Cyclic AMP ) levels in the pulmonary vasculature

2. Increase in the efflux of sodium
3. Increase in cGMP (Cyclic GMP) levels in the pulmonary vasculature
4. Increase in potassium influx
Answer: 3 - Increase in cGMP (Cyclic GMP) levels in the pulmonary vasculature

Explanations:

The woman complaining of rapidly progressing shortness of breath has evidence of

pulmonary hypertension confirmed with echocardiography and right heart
catheterization. She does not have any secondary cause of her pulmonary
hypertension, given her negative workup for embolus on pulmonary angiography,
structural heart diseases, or lung pathology.
The presence of abundant phosphodiesterase type 5 (PDE-5) receptors in the
pulmonary vasculature makes phosphodiesterase type 5 inhibitor (PDE5Is) an
important modality to manage pulmonary hypertension. These drugs are preferred
in patients with NYHA class 2 or 3 cardiac diseases with negative acute vasodilator
response.
These drugs inhibit the enzyme phosphodiesterase-5 (PDE-5), present in the smooth
muscle cells of the vessels. By inhibiting this enzyme, these drugs prevent the
degradation of cGMP by PDE-5. cGMP through activation of Protein kinase G causes
relaxation of the vascular smooth muscle. Prevention of degradation of cGMP by
PDE-5 leads to the accumulation of cGMP in the vascular smooth muscle, thereby

Page 772 of 955

 leading to dilatation of the blood vessels through phosphorylation of different
downstream effector molecules. The dilation of the pulmonary vasculature reduces
the pulmonary arterial pressures and alleviates the symptoms encountered in
pulmonary hypertension. They also inhibit the remodeling of the pulmonary
vasculature.
In patients with positive vasodilator response, calcium channel blockers are the
preferred first-line drugs. In patients with NYHA class 4 (shortness of breath at rest),
Prostacyclin agonists like epoprostenol and iloprost are preferred.

Research Concepts:

PDE5 Inhibitors

Question 818: A 45-year-old woman admitted to the hospital for suspected atypical
pneumonia undergoes sputum sample collection. The patient works in a pet bird shop.
The patient has had joint pain, nose bleeding, diarrhea, and a temperature as high as
101.9 F for the past week. Initial labs showed leukocytosis, elevated erythrocyte
sedimentation rate, and elevated C-reactive protein. Ultrasound of the abdomen shows
splenomegaly. X-ray shows patchy infiltrates.
Which of the following sputum analysis test is most likely to confirm the diagnosis in this
patient?
Choices:

1. Gram stain
2. Microscopic examination
3. Sputum cytology examination
4. Polymerase chain reaction
Answer: 4 - Polymerase chain reaction
Explanations:

Psittacosis is a zoonotic infectious disease related to Chlamydia psittaci. The

patients usually have a contact history with infected parrots. Psittacosis is an
infectious disease that can be transmissible to humans from infected birds via
mouth-to-beak contact, or by the airborne inhalation of respiratory secretions,
dried birds feces, or feather dust. There are also rare cases of human-to-human
transmission.
Prostrating high fevers, conjunctivitis, diarrhea, joint pains, and nose bleeds, as well
as the decreasing level of white blood cells, can be shown in the first week of
psittacosis. At the end of the first week, spleen enlargement is common to find by
ultrasound. It may develop a severe lung infection related to acute bacteremic

Page 773 of 955

 pneumococcal pneumonia in the second week. The symptoms would be continuous
high fevers, cough, headaches, as well as dyspnea. Lung X-rays show a diffuse
whiteout of lung fields or patchy infiltrates. Besides, the C-reactive protein and
erythrocyte sedimentation rate can markedly increase.
The patient meets the symptoms of psittacosis, and she had a contact history with
birds.
There are several methods for the diagnosis of psittacosis. Sputum culture follows
with next-generation sequencing or antimicrobial susceptibility testing, molecular
testing such as polymerase chain reaction-based tests, and serology such as
microimmunofluorescent antibody test or complement fixation are used in
different labs according to the specimen received from the patients.

Research Concepts:Sputum Analysis

Question 819: A 64-year-old woman presents to the emergency department with altered
mental status. EMS says the patient's family reports she has had a productive cough and
shortness of breath for the past week. She is alert and oriented to person and month.
Anterior chest auscultation demonstrates left lower lung ronchi. Examination of the left
side of the patient's chest and left arm show sloughing of skin that is concerning for burn
injury. Directed inquiry reveals the patient has been using a hot water bottle to help
relieve her symptoms. Her blood pressure is 96/68 mmHg, pulse 107 beats per minute,
respiratory rate 22 breaths per minute, temperature 38.1 C (100.6 F), and oxygen
saturation 92% on 4 liters of oxygen via nasal cannula. In addition to vancomycin, what is
the most appropriate initial antibiotic for this patient?

Choices:

1. Azithromycin
2. Doxycycline
3. Amoxicillin
4. Cefepime

Answer: 4 - Cefepime

Explanations:

Thermal burn wounds are prone to infection and are often the source of bacteria
responsible for other systemic infections, including septicemia and pneumonia.
This patient may have pneumonia based on presentation, but the source of the
patient's symptoms may also be the burn. It is important to cover for potential skin
flora and possible hematogenous spread as a cause of this patient's presentation.
Page 774 of 955
 The best choice of antibiotic for this patient includes coverage for Pseudomonas,
MRSA, and potential sepsis.
The most appropriate initial antibiotic therapy is vancomycin plus cefepime.

Research Concepts:

Acute and Chronic Thermal Burn Evaluation and Management

Question 820: A 67-year-old man presents to the hospital with a chief complaint of chest
pain. The patient is found to have severe aortic valve insufficiency. He is taken
emergently to the operating room, where he undergoes replacement of his aortic valve.
He is found to have a severely reduced ejection fraction and is unable to come off
cardiopulmonary bypass. His chest remains open for 24 hours until he can be placed on a
veno-arterial ECMO for cardiac support, and he undergoes a left-sided heart pump
system placement. The patient undergoes a cardiac transesophageal echocardiogram
and is found to have an ejection fraction of 12%.
Vital signs show blood pressure of 94/64 mmHg, heart rate of 64/min, and oxygen
saturation of 98%. Which of the following is the primary strategy for weaning this patient
from VA ECMO?

Choices:

1. Norepinephrine infusion
2. Resolution of the underlying cause of cardiogenic shock
3. Decrease oxygenation
4. Removal of the left-sided heart pump system
Answer: 2 - Resolution of the underlying cause of cardiogenic shock

Explanations:

ECMO support cannot be withdrawn until the source of the initial problem is
resolved. VA ECMO support is performed to aid in arterial support of the body for
propulsion when there is cardiogenic shock. Regarding this patient who has a hard
time weaning from cardiopulmonary bypass, they can be placed on VA ECMO until
the source of the cardiogenic shock can be resolved.
Weaning from ECMO cannot be performed on this patient at this time due to his
continued low ejection fraction. Serial transesophageal echoes can be completed to
look for signs of improvement in heart function daily or even more frequently.
Weaning from VA ECMO can usually occur when the ejection fraction has improved to
Page 775 of 955
 25%-30%.
When placing a patient on VA ECMO, a left-sided heart pump system can be placed
to help offload the left ventricle. VA ECMO can cause the left ventricle to form a
thrombus due to congestion of blood in the left ventricle. The left-sided heart
pump system can be placed into the left ventricle to help propel blood forward to
help offload the work of the left ventricle. When weaning VA ECMO, the pump can
be left in place to aid the left side of the heart during weaning.
When weaning VA ECMO, the patient will need an EF greater than 25% to 30%.
Therefore he is not ready to be weaned with heavy pressor support. O2 saturations
are important with regards to weaning VA ECMO, but with this patient's low EF, this
takes precedence when weaning trials are going to be attempted. The left-sided
heart pump system does not need to be removed prior to VA ECMO weaning
attempts.
Research Concepts:

Extracorporeal Membrane Oxygenation Weaning

Question 821: An 18-year-old man who works on a farm presents with an ascending hand
infection. The patient also reports he has been experiencing an insidious cough and
intermittent low- grade fever over the last 2 to 4 weeks. Vital signs show oxygen
saturation 98% on room air, respiratory rate 21 per minute, heart rate 105 beats per
minute, blood pressure 115/82 mmHg, and temperature 98 F. Upon examination, the
patient's right hand is covered with erythematous papulonodular lesions that spread up
to the antecubital fossa. Auscultation of the chest reveals mild inspiratory crackles. A CT
chest demonstrates bilateral lung nodules, prompting a lung biopsy, which finds cigar-
shaped organisms. What is the most likely cause of the patient's symptoms?

Choices:

1. Sporotrichosis
2. Blastomycosis
3. Coccidioidomycosis
4. Mucormycosis
Answer: 1 - Sporotrichosis

Explanations:

Sporotrichosis is a fungal infection caused by Sporothrix schenckii. It presents with

a primary cutaneous infection and is common in farmers. The organism is
dimorphic and has a characteristic cigar shape. Infection to the hand and lung is
typical of sporotrichosis.
Page 776 of 955
 Chest imaging of lung disease in sporotrichosis typically reveals unilateral or bilateral
cavitary lesions, and if left untreated, the cavities gradually enlarge, causing
pulmonary dysfunction.
Diagnosis of cutaneous sporotrichosis can be made through direct examination
of the specimen, such as tissue biopsy or pus from lesions, while sputum culture
aids in diagnosing pulmonary sporotrichosis.
Potassium iodide, amphotericin, and surgery are options for treatment for
sporotrichosis. Prevention and control measures include wearing gloves, long
sleeves, and heavy boots to prevent puncture wounds.

Research Concepts: Sporotrichosis

Question 822: A 30-year-old male with a history of familial hypertriglyceridemia is

admitted to the general medical floor for acute pancreatitis. On day 3 of the
hospitalization, he develops worsening shortness of breath, now requiring 10 L of
supplemental oxygen via a venturi mask with increased work of breathing. He is awake
and responding appropriately to questions. Chest x-ray shows bilateral infiltrates which
were not present on the admission imaging. A decision has been made to transfer the
patient to the intensive care unit (ICU) for closer monitoring. Arterial blood gas shows pH
7.3, PO2 58 mmHg, and PCO2 52 mmHg. Which of the following is the best management
while waiting for an ICU bed?

Choices:

1. A trial of morphine and intravenous furosemide

2. A trial of non-invasive mechanical ventilation such as the use of bilevel positive
airway pressure (BiPAP)
3. Mechanical ventilation
4. Obtain blood cultures and start empiric vancomycin and piperacillin-
tazobactam for presumed pneumonia

Answer: 2 - A trial of non-invasive mechanical ventilation such as the use of bilevel positive
airway pressure (BiPAP)

Explanations:

This patient is developing acute lung injury secondary to acute pancreatitis leading
to noncardiogenic pulmonary edema. While a trial of morphine and diuretics will
help his symptoms eventually, it will not work immediately to reduce his work of
Page 777 of 955
 breathing which can be achieved by the initiation of BiPAP while on the medical
floor. The patient is in type 2 respiratory failure with retention of carbon dioxide.
In patients with pulmonary edema, both cardiogenic and noncardiogenic, use of
BiPAP is becoming increasingly popular as it is noninvasive, effective, reduced the
work of breathing, and has shown to reduce the need for invasive mechanical
ventilation. This patient is awake and responding to questions and will likely be
able to tolerate the BiPAP, which may help relieve his symptoms rapidly.
BiPAP should be always considered in all patients with pulmonary edema if they are
awake and responsive. If this patient is either unable to tolerate BiPAP or becoming
increasing somnolent with worsening hypoxia, a decision to intubate and initiate
mechanical ventilation must be made.
This patient most likely has pulmonary edema secondary acute pancreatitis. A trial
of BiPAP is the immediate next step in the management to relieve hypoxia and
reduce the work of breathing. While a sepsis workup is indicated in hospitalized
patients with new-onset shortness of breath and presence of new infiltrates on the
chest x-ray, this patient has no fever, cough with expectoration to explain an
infectious etiology.
Hence antibiotics are not recommended at this step in his management.
Research Concepts:

Pulmonary Edema

Question 823: A prospective interventional study is carried out on patients admitted to

the ICU with acute exacerbation of COPD and hypercapnic encephalopathy. The ethics
committee approved the study, and permission was obtained from patients or their
proxies. The patients are placed on non-invasive ventilator therapy via an oronasal mask.
It is found that treatment with the modalities- BiPAP S/T + AVAPS (Bilevel positive airway
pressure spontaneous/timed + average volume assured pressure support) was more
superior compared to the treatment with BiPAP S/T alone as evidenced by a more rapid
improvement in the arterial blood gases and Glasgow Coma Score. Compared to the
BiPAP modality, AVAPS is associated with which of the following benefits in patients with
acute exacerbation of COPD?

Choices:

1. Low duration of hospital stay

2. Better patient comfort and satisfaction
3. Can be used in patients with cardiac arrest
4. Doesn't cause gastric insufflation
Answer: 2 - Better patient comfort and satisfaction

Page 778 of 955

Explanations:

Average volume-assured pressure support (AVAPS) is a relatively newer modality

of non-invasive ventilation that integrates the characteristics of both volume and
pressure- controlled non-invasive ventilation.
Although both AVAPS and BiPAP are reliable in the treatment of acute hypercapnic
respiratory failure, AVAPS is associated with a speedy improvement of the patient
clinically.
The patients have also experienced greater comfort and satisfaction comparatively,
and therefore, improved treatment- compliance.
Remember that both the therapies are effectual, and there was no difference in
the duration of hospital stay or the time-period that the patient was on non-
invasive ventilation. Cardiac arrest is a contraindication to the use of non-invasive
ventilation.
Treatment with AVAPS can be complicated with gastric insufflation.

Research Concepts:Average Volume-Assured Pressure Support

Question 824: A 65-year-old farmer was admitted to the hospital following exposure to
nitrogen dioxide after entering a silo and inhaling a reddish-brown cloud. The patient was
admitted for observation. After 24 hours, he got progressively worsening dyspnea, new
bilateral infiltrates on x-ray, and required supplemental oxygenation in the form of bilevel
positive airway pressure (BiPAP).
Why was this patient's dyspnea and hypoxemia delayed?

Choices:

1. Nitrogen dioxide is highly water-soluble and has delayed effects on the lungs
2. Nitrogen dioxide is highly water-soluble and has an immediate effect on the
lungs
3. Nitrogen dioxide has a low water-solubility and therefore can have delayed effects on
the lungs
4. The farmer had a concomitant exposure that delayed the effects of nitrogen dioxide
Answer: 3 - Nitrogen dioxide has a low water-solubility and therefore can have delayed
effects on the lungs

Explanations:

Nitrogen dioxide has a low water-solubility with little to no immediate warning signs.
Page 779 of 955
 A patient may have prolonged exposure without signs or symptoms.
When someone is exposed to nitrogen dioxide, they should be observed for delayed
pulmonary effects.
The lower the water-solubility, the greater the effect on the lower airways.

Research Concepts:

Nitrogen Dioxide Toxicity

Question 825: A 60-year-old man is in the intensive care unit intubated after he
developed a chronic obstructive pulmonary disease exacerbation. Initial pCO2 is 100
mmHg. A repeat blood gas after 20 minutes reveals a pCO2 of 90mmHg. What is the most
appropriate definitive goal of therapy?

Choices:

1. Return to normocapnia
2. Ensure oxygen saturation is 100%
3. pH 7.35-7.45
4. Return to baseline pCO2

Answer: 4 - Return to baseline pCO2

Explanations:

The definitive goal of therapy for acute on chronic hypercapnia, as in the case of
COPD, the patient should be returned to their baseline pCO2. If this was acute
hypercapnia, the patient should be returning to normocapnia.
Overcorrecting the patient's pCO2 can induce seizures and put them in an alkalotic
state.
Normal individuals do not experience alterations in consciousness until pCO2 more
than 75 mmHg. Patients with chronic hypercapnia may not experience alterations
in consciousness until pCO2 more than 90 mmHg. This patient's pCO2 was 100
mmHg and he was likely intubated due to CO2 narcosis.
Giving a patient with COPD too much supplemental oxygen can worsen their
condition, due to a blunting of their respiratory drive. This may actually worsen
their hypercapnia.

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Research Concepts:

Carbon Dioxide Narcosis

Question 826: A 40-year-old male presents to the clinic with complaints of dry, hacking,
nonproductive cough for 1 week. He denies any fever, chest pain or shortness of breath.
The patient states that cough has been progressing and does not have any postural or
diurnal variation. Because of this severe cough, he has not been sleeping well. He
experiences abdominal pain due to severe coughing. He has tried several over-the-
counter cough medications with minimal improvement in his symptoms. His medical
history is significant for type 2 diabetes mellitus and hypertension.
He is on metformin, lisinopril, baby aspirin, and some over-the- counter vitamins. On
examination, the heart rate is 82 bpm, respiratory rate of 16/min and blood pressure is
130/80 mmHg. Lung auscultation is clear. S1 and S2 are well heard without any murmurs
on cardiac auscultation. The patient does not have any history of sinus infection. Which
of the following is the appropriate next step in the management of this patient?

Choices:

1. CT of the paranasal sinuses

2. CT chest
3. Replace lisinopril with losartan
4. Add pantoprazole twice daily
Answer: 3 - Replace lisinopril with losartan

Explanations:

An ACE inhibitor-induced cough is dry, hacking, nonproductive. It usually begins

within the first few months of starting treatment. Other causes of cough should be
considered and excluded prior to discontinuation if any doubt exists.
The cough usually resolves within 1 to 4 weeks after discontinuation of the ACE
inhibitor.
Other adverse effects of ACE inhibitors include hypersensitivity reaction,
angioedema, hyperkalemia, deterioration in renal function.

Research Concepts:

Lisinopril

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Question 827: A 67-year-old man presents for elective coronary artery bypass surgery. His
medical history is significant for hypertension for 15 years and a 30 pack-year history of
smoking. On admission, his heart rate is 80/min, blood pressure 130/88 mmHg,
respiratory rate 19/min, and temperature 37 C (98.6 F). His platelet count is
22,000/microL; hemoglobin 12 g/dL, and white blood cell count 11,000/microL. One unit
of single donor platelets is transfused, and two hours later, he develops dyspnea,
dizziness, chest tightness, and becomes agitated. His blood pressure is 110/70 mmHg,
temperature 38.6 C (101.5 F), and SpO2 84% on room air.
Examination demonstrates bilateral, diffuse, coarse crackles, and chest x-ray shows
bilateral infiltrates. The patient is given supplemental oxygen and prepared for transfer
to a critical unit immediately. Which of the following is the most likely cause of this
patient's current condition?

Choices:

1. Bacterial contamination of platelets

2. Platelets stored for more than three days
3. Platelets donated by a multiparous woman
4. Circulatory overload
Answer: 3 - Platelets donated by a multiparous woman

Explanations:

Transfusion-related acute lung injury (TRALI) is a rare complication of platelet

transfusion associated with respiratory failure. It is primarily caused by the
transfusion of antibodies in plasma from the donor against HLA or human
neutrophil antigens; an example is platelets donated by a multiparous woman.
TRALI occurs within 6 hours of transfusion. These patients develop acute
worsening respiratory symptoms with characteristic features of hypoxemia
(PaO/FIO = 300 mmHg with oxygen saturation 90%).
All other causes of acute lung injury should be ruled out before considering TRALI, it
can be minimized by reducing plasma in platelets transfused such as the use of
platelet additive solutions (PAS).
AABB (American Association of Blood Banks) recommends platelet transfusion in
patients with platelet count 50 x 10^9 cells/L who are scheduled to undergo a
major elective surgery requiring non-neuraxial surgical anesthesia.

Research Concepts: Platelet Transfusion

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Question 828: A 53-year-old man reports to the ski lodge clinic with a chief complaint of
a headache, nausea, and vomiting since waking up this morning. He can keep liquids
down, but solid food makes him nauseated. He has a past medical history significant for
acute mountain sickness during a previous ski trip. Vital signs are stable, and the
neurological exam is normal. Upon further questioning, the patient states that he
arrived from a seaside town last night and is staying at the lodge (elevation 9,000 ft). His
blood pressure is 110/70 mmHg and his pulse is 89/min. What is the most appropriate
management strategy for this patient?

Choices:

1. Descend immediately and never travel above 8,200 ft again

2. Rest at current altitude and treatment with acetazolamide and steroids but be
prepared to descend if symptoms become incapacitating or last longer than 48 hrs
3. Continue to ski while he receives treatment but should be prepared to descend in
altitude if his symptoms worsen or last longer than 48 hrs
4. Reassurance, antiemetics, and NSAIDs

Answer: 2 - Rest at current altitude and treatment with acetazolamide and steroids but be
prepared to descend if symptoms become incapacitating or last longer than 48 hrs

Explanations:

Acute mountain sickness is exacerbated by exertion.

The majority of cases of acute mountain sickness will resolve in one to two days.
Descent is only necessary for severe (debilitating) acute mountain sickness or high
altitude cerebral edema (HACE). Past medical history of prior acute mountain
sickness does not prohibit travelers from traveling to high altitudes.

Research Concepts:

EMS High-Altitude Field Prophylaxis And Treatment

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Question 829: A 57-year-old man with alcohol use disorder presents to the emergency
department with three days of fever, productive cough, shortness of breath, and right-
sided chest pain. He also reports right upper quadrant abdominal pain for the past two
weeks. Vital signs are notable for a temperature of 101 F (38.3 C) and a heart rate of
104/min. Physical examination demonstrates significantly decreased air entry and tactile
vocal fremitus with crackles and some wheezes on the right side. The abdominal exam is
remarkable for tenderness in the right hypochondrium and hepatomegaly. Chest x-ray
shows right-sided obliteration of the costophrenic angle and displaced right lung.
Thoracentesis reveals a chocolate-brown fluid, which is sent for culture. What is the most
appropriate initial pharmacotherapy?

Choices:

1. Azithromycin
2. Albendazole
3. Mebendazole
4. Metronidazole
Answer: 4 - Metronidazole

Explanations:

This patient likely has Entamoeba histolytica pleuropulmonary infection following a

chronic colon infection. Pleuropulmonary involvement after E. histolytica infection
is rare but can occur in patients with underlying malnutrition and alcohol use
disorder. Liver abscesses in E. histolytica infections can rupture into the pleural
space and cause amoebic empyema, lung consolidation, pleuropulmonary abscess
formation, or a hepatobronchial fistula.
Ambeobic pleural effusions resolve with drainage and antimicrobial therapy. The
recommended dose of metronidazole for pleuropulmonary involvement is 750 mg
orally three times a day for 7 to 10 days. Most patients respond to treatment, but in
rare cases, a second course of antibiotics (either metronidazole or tinidazole) may
be required.
In patients who develop invasive amebiasis, treatment with a luminal agent is
warranted, even if stool microscopy is negative. Recommended intraluminal agents
include paromomycin, diiodohydroxyquin, or diloxanide furoate.

Research Concepts:Entamoeba Histolytica

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Question 830: A 65-year-old male with a past medical history significant for coronary
artery disease, congestive heart failure, and chronic obstructive pulmonary disease
presents to the emergency department with increased dyspnea, wheezing, and cough for
two days. His blood pressure is 160/90 mmHg, pulse rate is 70/min, and respiratory rate
is 32/min. An arterial blood gas (ABG) reveals a mixed acid disorder, with a blood pH of
7.2. Due to his work of breathing and respiratory acidosis, the patient is placed on
continuous positive airway pressure (CPAP), but his oxygenation continues to
deteriorate. Which medication combination would be appropriate for rapid sequence
intubation?

Choices:

1. Etomidate and fentanyl

2. Propofol and etomidate
3. Etomidate and succinylcholine
4. Propofol and fentanyl
Answer: 3 - Etomidate and succinylcholine

Explanations:

Rapid sequence intubation involves sequential steps that lead to successful

endotracheal intubation. These steps allow for adequate assessment of the choice,
dose, timing, and sequence of administration of sedatives, analgesics, and paralytics
while ensuring that all equipment is ready and the patient’s clinical status is
optimized. Rapid sequence intubation using neuromuscular blocking agents
(NMBAs) is the standard of care and is associated with a reduction in complications
compared to using sedatives alone.
Paralysis with induction involves the simultaneous administration of the
medications for sedation and paralysis that have been decided earlier in the
preparation phase based on clinical status, allergies, and potential
contraindications. During rapid sequence intubation, the dose of these drugs
should be pre-calculated and administered intravenously as a bolus and never
titrated. The onset and duration of action should all be taken into consideration.
Etomidate should be given in a dose of
0.15 mg/kg to 0.3 mg/kg intravenously, depending on the stability of the patient.
Ketamine is to be given in a dose of 2 mg/kg intravenously. Propofol is given in
doses of 0.5 mg/kg to 2 mg/kg intravenously, depending on hemodynamic stability.
Immediately after the induction agent, the paralytic agent of choice is administered
intravenously. Succinylcholine is given in a 1.5 mg/kg dose, whereas rocuronium is
given in a 1 mg/kg dose. The protection and positioning phase is vital, as the patient
is now paralyzed, and the airway must be protected from aspiration. Minimal bag-
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 mask ventilation should be used to keep oxygen saturations adequate; this will be
possible only if pre- oxygenation was adequate.
Pre-treatment is an additional step involving administering medications that may
optimize the clinical setting where intubation is being done. For example,
intravenous fluids, anxiolysis with benzodiazepines, or opioid medications may be
used before administrating sedatives and NMBAs. Typically a short-acting opioid
such as intravenous fentanyl is administered for pre-treatment.

Research Concepts:

Intubation Endotracheal Tube Medications

Question 831: A 17-year-old patient with cerebral palsy and a history of a longstanding
tracheostomy presents to the emergency department with a history of a pulsatile tracheal
bleed, both from around and through the tracheal tube. This has happened once before
six hours ago, and both have spontaneously stopped. On examination, there is an area of
granulation tissue visible in the anterior trachea behind the manubrium, but no active
bleeding. What is the next best step in the management of this patient?

Choices:

1. Change the tracheostomy tube to a distal XLT tube to bypass the granulation tissue
2. Inflate the balloon cuff and emergently consult thoracic surgery and
interventional radiology
3. Close the tracheostomy with your finger and hold pressure while awaiting thoracic
surgery input
4. Place a small suction tube through the tracheostomy and suction of the blood to
remove any clot while not disturbing the granulation tissue

Answer: 2 - Inflate the balloon cuff and emergently consult thoracic surgery and
interventional radiology

Explanations:

A ruptured tracheo-innominate artery fistula is life-threatening and can rapidly

be fatal. This scenario is a sentinel bleed and must be treated emergently.
In most cases, the bleeding will stop spontaneously, but one can temporarily stop it by
inflating the balloon cuff, but this is only temporary. This must be definitively
managed either by interventional radiology or thoracic surgery.
The innominate artery can also be compressed with the finger by pressing at the

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 back of the manubrium, but this is only real when there is an active,
uncontrollable bleed.
In the operating room, the innominate artery must be ligated or coiled. If there is
an active bleed, the person whose hand is applying pressure should be prepped
into the field, and thoracic surgery will proceed with sternotomy and ligation of the
artery.

Research Concepts:

Tracheostomy

Question 832: A 55-year-old man presents to the clinic with worsening dyspnea on
exertion and dry cough. He underwent left- sided lung transplant two years ago. His
postoperative course was uncomplicated. His current medications include prednisone,
trimethoprim-sulfamethoxazole, and cyclosporine. Lung examination is clear with some
wheezing. Routine labs and a chest X-ray are unremarkable. CT scan shows a mosaic
pattern with air trapping with some peripheral ground-glass opacities. Pulmonary
function testing shows obstructive dysfunction with a severe decrease in FEV1. Which of
the following is the next best step in the management of this patient?

Choices:

1. Discontinue cyclosporine
2. Increase prednisone and cyclosporine dose
3. Surgical biopsy
4. Transbronchial biopsy

Answer: 2 - Increase prednisone and cyclosporine dose

Explanations:

The patient has bronchiolitis obliterans after lung transplant secondary to chronic lung
rejection called bronchiolitis obliterans syndrome (BOS).
The best step is to increase immunosuppression, although it usually doesn’t improve
the outcome.
The diagnosis of BO is based on a combination of clinical, laboratory, and
pulmonary function tests. Transbronchial biopsy is usually low yield and is not
always required unless the diagnosis is not precise.
Surgical biopsy is a high risk in these patients.
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Research Concepts:

Bronchiolitis Obliterans

Question 833: A 17-year-old female with a history of asthma presents with severe
respiratory distress. While being evaluated in the emergency department, she is noted to
have an initial respiratory rate of 34/min. Her weight is 60 kg, and her height is 1.5 meters.
She is awake and alert and using accessory muscles of respiration.
Minutes later, she is found to be lethargic and difficult to arouse. She is immediately
intubated and admitted to the medical intensive care unit. The ventilator is set to a tidal
volume (TV) of 450 ml, respiratory rate 12/minute, positive end-expiratory pressure
(PEEP) 14 cmH2O, and FiO2 40%. Arterial blood gas analysis after intubation show pH
7.35, pCO2 44 mmHg, pO2 80 mmHg, and O2 saturation 95%.
Ventilator parameters show a peak pressure of 42 cmH2O and a plateau pressure of 38
cmH2O. What is the best next step in managing this patient's mechanical ventilation?

Choices:

1. Gradually increase PEEP to 18 cmH2O

2. Change the patient to pressure support ventilation and PEEP of 15 cmH2O
3. Increase the tidal volume to 500 ml while maintaining PEEP at 14 cmH2O
4. Decrease tidal volume to 400 ml

Answer: 4 - Decrease tidal volume to 400 ml

Explanations:

This patient has acceptable arterial blood gas analysis results in the setting of severe
acute asthma exacerbation with controlled hypoxia and hypercapnia. Because of
her severe bronchoconstriction, her ventilator mechanics show very elevated
plateau pressures, indicating impending barotrauma.
Plateau pressures should ideally be maintained below 30 cmH20 in ventilated
patients to prevent ventilation complications.
Decreasing positive end-expiratory pressure (PEEP) should not be done rapidly on a
single mechanical ventilation change. It should be done gradually so the patient
tolerates the changes, preventing complications such as atelectasis.
Of all the answers provided, only decreasing tidal volume will positively reduce
plateau pressure. The less volume is entering the system, the less lung distension,
and the less pressure. This is especially effective in decreasing peak pressure but
may also lower plateau pressure. Decreasing PEEP reduces the driving pressure of
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 ventilation and, therefore, the entire pressure on the system.
Changing the patient to pressure support is inappropriate for patients with acute
asthma exacerbation, respiratory failure, and hypercapnia. This patient requires
more support from the ventilator to resolve the acute respiratory failure. Increasing
the tidal volume would improve this patient's hypercapnia and increase the
ventilatory pressures but increase the risk of barotrauma. The hypercapnia is
currently mild, and it is acceptable to manage the patient with the current settings
until the bronchospasm resolves.
Research Concepts:

Positive End-Expiratory Pressure

Question 834: A 2-day-old boy is evaluated in the neonatal intensive care unit for breathing
problems. The nurse noticed that the baby seems to be breathing normally while awake, but
his breaths become shallow during sleep. An arterial blood sample (ABG) taken during sleep
show PCO2 of 65 mmHg and PO2 of 55 mmHg.
Meanwhile, an ABG while awake shows PCO2 of 45 mmHg and PO2 of 85 mmHg. A rare
congenital disease that affects breathing is suspected. An abnormality is which of the
following sites is most likely?

Choices:

1. Cerebral cortex
2. Corpus callosum
3. Medulla and pons
4. Cerebellum

Answer: 3 - Medulla and pons

Explanations:

The patient in the clinical vignette has breathing problems during sleep that tend
to get better while awake, indicating a problem in the involuntary breathing center
in the brainstem. This clinical presentation is most likely consistent with a rare
genetic disease called congenital central hypoventilation syndrome (CCHS),
sometimes knowns as Ondine's curse.
The problem is most likely caused by a genetic mutation that renders the
respiratory center unresponsive to changes in PCO2 levels.
The medulla and the pons house the involuntary respiratory center and are
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 responsible for breathing control under unconscious conditions (such as during
sleep). When breathing fails to happen unconsciously, the patient becomes
dependent on conscious control (cortex).

Research Concepts:

Physiology, Respiratory Drive

Question 835: An 84-year-old man is being evaluated at a home visit. He was diagnosed
with stage 4 bronchogenic carcinoma two months ago. He has a 60 pack-year history of
smoking. He chose palliative care and has not sought chemotherapy or radiation. The
patient is mostly bed-bound and peaceful. However, he tears up upon coughing blood-
tinged sputum. His family is concerned about the patient being distressed. Which of the
following is the most appropriate recommendation for this patient?

Choices:

1. Reassurance
2. Dark towels
3. Sertraline
4. Palliative radiotherapy
Answer: 2 - Dark towels

Explanations:

The clinical scenario describes a patient with a terminal disease, complaining of

distress due to hemoptysis.
Hemoptysis is a common cause of distress for patients with lung cancer due to the
expression of blood on the hand or a white napkin.
The appropriate recommendation for this patient is to use dark towels or
absorptive sheets that would hide the red color of blood. Dark green or blue
towels are commonly recommended. Reassuring the patient is unlikely to work.
Sertraline is not the most appropriate option as there is no overt sign of
depression. Palliative radiotherapy is usually employed for obstructive or painful
lesions.

Research Concepts:

End of Life Care

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Question 836: A 60-year-old gentleman with a history of idiopathic pulmonary fibrosis,
hypertension, and GERD presents with complaints of progressive worsening of shortness
of breath. The patient was found to be hypoxemic upon arrival in the ER with a SpO2 of
82% on room air. CT chest was negative for evidence of pulmonary embolism. A
transthoracic echocardiogram was performed, which showed normal left ventricular (LV)
systolic function, LV ejection fraction of 60%, and systolic pulmonary artery pressure of 56
mmHg. What will be the appropriate next step in the management?

Choices:

1. Inhaled Treprostinil
2. Oxygen supplementation
3. Right heart catheterization
4. Initiation of Riociguat

Answer: 2 - Oxygen supplementation

Explanations:

This patient is presenting with acute onset dyspnea, which can be due to an
exacerbation of underlying pulmonary fibrosis.
Supplementary oxygen is the most important first step in the management to
alleviate hypoxemia which can further worsen the underlying PH.
This patient is presenting with acute onset dyspnea, which can be due to an
exacerbation of underlying pulmonary fibrosis.
Hypoxic vasoconstriction is one of the major factors contributing to the progression
of PH in group 3 PH.
Further investigation with pulmonary function test, evaluation for anti-fibrotic
treatment, and referral for lung transplant evaluation are required once the acute
exacerbation has resolved.

Research Concepts:

Pulmonary Hypertension Due To Lung Disease Or Hypoxia

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Question 837: A 42-year-old woman presents to the clinic for evaluation of obstructive
sleep apnea (OSA). She was diagnosed with OSA one year ago with an apnea-hypopnea
index (AHI) of 12. A recent polysomnogram shows an improved AHI of 4 with continuous
positive airway pressure (CPAP) use. However, she frequently falls asleep in inappropriate
situations throughout the day. She also reports a history of muscle tone loss upon
awakening. Her BMI is 33 kg/m2. Epworth sleepiness scale score is 15/24 (before CPAP,
16/24). Which of the following is the most appropriate next step in the management of
this patient?

Choices:

1. Increase the CPAP pressure

2. Switch to bilevel PAP (BPAP)
3. Multiple sleep latency test
4. Weight loss and follow up in six months

Answer: 3 - Multiple sleep latency test

Explanations:

This patient presents with a history of mild obstructive sleep apnea (OSA) that has
improved with continuous positive airway pressure (CPAP).
However, she continues to have significant excessive daytime sleepiness not explained
by her sleep study.
Her current symptoms are concerning for narcolepsy, which can be further assessed
with a multiple sleep latency test.
This patient's AHI has improved significantly with her current CPAP use, and her
symptoms are less consistent with residual obstructive symptoms; therefore,
increasing her CPAP pressure or switching to bilevel PAP (BPAP) is not appropriate.

Research Concepts:

Sleep Apnea Syndrome

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Question 838: A 48-year-old man presents with a three-week history of worsening
dyspnea. He has alcoholic cirrhosis that was diagnosed three years ago, and he stopped
drinking alcohol at the time of diagnosis. He denies a history of lung disease or tobacco
smoking. His medications include furosemide 40 mg daily and spironolactone 100 mg
daily. His blood pressure is 108/68 mmHg, heart rate 72/min, and respiratory rate
20/min. Examination demonstrates mild edema in both lower extremities, digital
clubbing, platypnea, and orthodeoxia. Posteroanterior and lateral chest radiographs
show increased bibasilar interstitial markings but are otherwise normal. The A-a gradient
is 20 mmHg and the Pa02 78 mmHg while the patient is upright and breathing room air.
What is the best next step in evaluation?

Choices:

1. Contrast pulmonary angiography

2. Technetium 99 macroaggregated albumin scan
3. Transthoracic echocardiography with bubble study
4. Pulmonary function testing
Answer: 3 - Transthoracic echocardiography with bubble study

Explanations:

Hepatopulmonary syndrome is a disorder of oxygenation in patients with chronic

liver disease. Patients present with dyspnea, platypnea, and orthodeoxia because
of increased shunting at the bases of the lungs.
Hepatopulmonary syndrome is characterized by an increased A- a gradient and
hypoxemia on room air in patients sitting in the upright position.
Transthoracic echocardiography with bubble study will demonstrate a right to left
intrapulmonary shunt after 3-4 cardiac cycles in patients with hepatopulmonary
syndrome.
Contrast pulmonary angiography is invasive and rarely performed except in patients
with suspected arteriovenous malformations that may require embolization. The
technetium 99 macroaggregated albumin scan is used in patients with suspected
hepatopulmonary syndrome and a coexisting pulmonary disorder such as chronic
obstructive pulmonary disease (this is not the first test). Pulmonary function testing
should be considered for patients with suspected chronic obstructive or restrictive
lung disease but not for diagnosing hepatopulmonary syndrome.

Research Concepts: Hepatopulmonary

Syndrome

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Question 839: A 30-year-old male, who lives in California, presents to the hospital with a
complaint of dyspnea that started a week ago. It is associated with cough and mild chest
pain. He also complains of sensitivity to light, weight loss, and fatigue. On further
questioning, he reveals that he has been having migratory joint pain for the past month. A
detailed medical history reveals that he is a farmer by profession and works in the field at
least eight hours per day. He has no known medical condition. His vital signs show blood
pressure 100/80 mmHg, heart rate 100/min, temperature 101 F (38.3 C), and respiratory
rate 20/min. A physical examination performed reveals target lesions on the lower limbs
bilaterally, nuchal rigidity, and rhonchi on auscultation. A blood test performed reveals
900 eosinophils per microlitre of blood. A lumbar puncture was performed. What is the
most likely finding on CSF analysis?

Choices:

1. Hyperglycorrhachia
2. Low protein levels
3. Lymphocytic pleocytosis
4. Predominant polymorphonuclear cell

Answer: 3 - Lymphocytic pleocytosis

Explanations:

This clinical scenario is most consistent with coccidioidomycosis, also known as San
Joaquin Valley fever. The classic triad includes migratory arthralgia, fever, and
erythema nodosum. However, in some cases, erythema multiforme may be
present. Most of the patients present with pulmonary manifestations like chest
pain cough and mild dyspnea. Meningitis is the most common complication of this
disease, especially in patients with acquired immunodeficiency syndrome.
In a patient with coccidioidomycosis, a cerebrospinal fluid analysis reveals a
lymphocytic pleocytosis (increased number of lymphocytes in CSF).
In almost 70% of the patients, with Coccidioides meningitis, eosinophilic pleocytosis is
seen.
A CSF analysis also reveals elevated protein levels and hypoglycorrhachia in patients
with Coccidioides meningitis.

Research Concepts: Coccidioidomycosis

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Question 840: A 65-year-old female immigrant from Pakistan presents with the chief
complaints of severe shortness of breath, productive cough, and inability to carry out
activities of daily living. She has a history of biomass fuel exposure for twenty years in
her hometown. On examination, a restless female with severe respiratory distress, blood
pressure 110/70 mmHg, pulse 112/min regular, respiratory rate 26/min, and oxygen
saturation of 88% on room air. On auscultation, her chest is largely silent with decreased
air entry bilaterally. Her arterial blood gases suggest a type II respiratory failure. Which
of the following should be considered besides supportive care?

Choices:

1. Elective endotracheal intubation

2. High flow oxygen therapy
3. Theophylline
4. Bilevel positive airway pressure

Answer: 4 - Bilevel positive airway pressure

Explanations:

In the case of chronic obstructive pulmonary disease (COPD) with type II respiratory
failure, it is recommended to put the patient on bilevel positive airway pressure.
The non- pharmacological approach includes vaccination (influenza and
pneumococcal), smoking cessation, and pulmonary rehabilitation. Pulmonary
rehabilitation is indicated in all stages of COPD. Bronchodilators are the primary
pharmacologic treatment used. Short-acting bronchodilators provide immediate
relief, and long-acting bronchodilators are used for maintenance in patients with
advanced disease. A long-acting beta2 agonist alone or in combination with an
inhaled corticosteroid has shown to reduce exacerbation. A long-acting
antimuscarinic agent has also been shown to improve dyspnea and reduce
exacerbations. A combination of two different classes of long- acting
bronchodilators can be used in patients with moderate-to- severe COPD when
monotherapy is insufficient. Continuous oxygen therapy is indicated for hypoxemic
patients with COPD when arterial oxygen saturation is equal to, or less than 88% or
partial pressure of oxygen is equal to or less than 55 mmHg.
Based on current estimates, COPD will be the third leading cause of death
worldwide by 2030. In the United States, it is estimated that more than 12 million
people are affected by COPD and is more prevalent in women than men. The
death rate for COPD has declined in men from 1999 to 2010, but it is steady among
women.
Typical symptoms of COPD include a chronic, productive cough, shortness of breath,

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 and wheezing. Acute exacerbation of COPD is usually defined as at least two of the
following three conditions: worsening of shortness of breath, change in purulence,
or quantity of sputum. Physical findings include barrel-shaped chest, diminished
breath sounds, and hyperresonance on percussion. In advanced disease with cor
pulmonale, jugular venous distention, accentuated second heart sound,
hepatomegaly, and pedal edema can be seen. Lung auscultation may show a
prolonged expiratory phase with or without wheezing. Respiratory symptoms are
often relieved with pursed-lip breathing and tripod position.
Pulmonary function test (PFT) is recommended to diagnose COPD. Airflow limitation
is diagnosed when forced expiratory volume in one second (FEV1) to forced vital
capacity ratio is less than 70%. According to Global Initiative for Chronic Obstructive
Lung Disease classification system, the severity of obstructive defect is mild,
moderate, severe, or very severe when FEV 1 percent predicted is greater than 80%,
50% to 79%, 30% to 49%, and less than 30% respectively. Diffusion capacity for
carbon monoxide is reduced in COPD. A chest radiograph often shows
hyperinflation and flattening of the diaphragms, especially in advanced disease.
High-resolution CT of the chest may demonstrate emphysema. An echocardiogram
is used to assess secondary pulmonary hypertension which is due to hypoxemic
vasoconstriction of the pulmonary blood vessels. A walking or nocturnal
desaturation study identifies patients who would benefit from oxygen therapy with
activities or during sleep. Testing for alpha-1 antitrypsin level should be considered
in age younger than 40 years and non-smokers if a significant obstructive defect is
found on PFTs.

Research Concepts:

Chronic Obstructive Pulmonary Disease

Question 841: A 17-year-old female residing in Arizona presents with reddish nodules on
her shins that first appeared two weeks ago. She also reports knee and ankle joint pain,
cough, and pleuritic chest pain for the past three weeks. A detailed medical history
reveals no known medical conditions. Her blood pressure is 130/70 mmHg, heart rate
104/minute, temperature 101.3°F (38.5°C), and respiratory rate 20/minute. Examination
demonstrates tender, reddish nodules on both shins and increased tactile and vocal
fremitus in the left lung. Lab investigations show an erythrocyte sedimentation rate of 40
mm/hr. Chest x-ray shows nodules in the left lung. What is the most appropriate next step
in evaluation?

Choices:

1. Bronchoscopy
Page 796 of 955
2. Pulmonary function tests
3. Immunodiffusion tests
4. Enzyme-linked immunoassay
Answer: 4 - Enzyme-linked immunoassay

Explanations:

This scenario is most consistent with Valley fever, which is caused by Coccidioides
organisms. The classic triad includes erythema nodosum, fever, and migratory
arthralgia. Many patients present with complaints of pulmonary manifestations
such as cough, dyspnea, and pleuritic chest pain. Laboratory investigations show
an elevated erythrocyte sedimentation rate and eosinophilia.
Serologic testing is most frequently used to diagnose primary Coccidioidal
infections.
Enzyme-linked immunoassays (EIA) and immunodiffusion tests are the most
frequently used tests to make the diagnosis. EIA for IgM and IgG should be ordered
first because they are the most sensitive tests available, especially for early
infection.
Immunodiffusion tests should be ordered if EIA is positive. Immunodiffusion tests
measure tube precipitin-type antibodies and complement-fixing-type antibodies.
These tests are less sensitive than EIAs but are more specific.

Research Concepts: Coccidioidomycosis

Question 842: A 55-year-old man presents to the clinic with progressive shortness of
breath, fatigue, and unintentional weight loss of 7 kg over the past 7 months. The patient
also complains of a dry cough. He immigrated from India 7 years ago, where he worked
for 12 years in a garment factory that sandblasted jeans. His symptoms have now forced
him to quit his job as a bank security guard. Chest X-ray shows bilateral upper lobe
predominant haziness. Which of the following is the most likely pathophysiology of the
disease that led to his pulmonary symptoms?

Choices:

1. Silica deposits activate alveolar macrophages, which release cytokines that

stimulate fibrogenesis.
2. Coal deposits adjacent to respiratory bronchioles produce centrilobular
emphysema.
3. Proliferation of type II pneumocytes results in increased cell turnover and
fibrin deposition.

Page 797 of 955

4. Quartz deposits result in diffuse interstitial fibrosis with noncaseating
granulomas.
Answer: 1 - Silica deposits activate alveolar macrophages, which release cytokines that
stimulate fibrogenesis.
Explanations:

Silica is taken up by macrophages in the alveoli and results in the release of

proinflammatory cytokines, including IL-1 and fibroblastic growth factors, which
lead to fibrosis.
When a patient with a certain occupational history of mining, sandblasting, pottery
work, or glassmaking complains of difficulty breathing and cough, and it should
prompt the clinician to consider silicosis as a differential diagnosis.
Progressive lung symptoms for weeks to less than a year suggest most likely acute
silicosis. Chronic silicosis occurs after 10 to 30 years (or during long-term) exposure
to silica.
Patients with silicosis have a slightly increased incidence of lung cancer and a highly
increased risk for tuberculosis.

Research Concepts:Silicosis

Question 843: A 69-year-old man with a history of stage 4 poorly differentiated

adenocarcinoma of the lung is being evaluated for recurrent pleural effusion. The
thoracentesis drains 1800 mL of pleural fluid. Fluid analysis shows pH 7.21, white blood
cell count 100/microL, red blood cell count 240,000/microL, and glucose 90 mg/dL.
Cytology reveals malignant cells, and the patient has undergone thoracentesis three
times in the past month. Which pleural fluid finding most increases the risk for
pleurodesis failure in this patient?

Choices:

1. pH 7.21
2. White blood cell count 100/microL
3. Red blood cell count 240,000/microL
4. Glucose 90 mg/dL

Answer: 1 - pH 7.21

Explanations:

Page 798 of 955

 Patients with a pH of 7.3 have a greater than 50% chance of pleurodesis failure.
Usually, low pH correlates with pneumonia which means the fluid is more complex.
Placement of a flexible pleural catheter may be a better option for these patients.
Low glucose is also a risk factor for increased pleurodesis failure.

Research Concepts:

Pleurodesis

Question 844: A 65-year-old man is being assessed for a 5- month history of loud snoring
and gasping during sleep. He also has a history of frequently falling asleep in a chair while
reading in the afternoon. His medical history is remarkable for congestive heart failure
(ejection fraction 35%). On physical examination, his temperature is 37.4 C (99.3 F), blood
pressure 150/85 mmHg, pulse
rate 90/min, and respiratory rate 14/min. BMI is 36 kg/m2. Neck circumference is 42 cm
(16.5 in), and a low lying soft palate is noted. Lower extremities show 2+ edema.
Polysomnography reveals an apnea-hypopnea index of 35 events/hour, with more than
50% of events being central apneas. Which of the following is the most appropriate next
step in the management of this patient?
Choices:

1. Weight loss
2. Adaptive servo-ventilation
3. Optimize heart failure treatment
4. Auto-continuous positive airway pressure therapy (auto-CPAP)
Answer: 3 - Optimize heart failure treatment
Explanations:

Sleep-disordered breathing (SDB) is characterized by episodes of complete or partial

cessation of flow with an associated decrease in oxygen saturation or arousal from sleep.
The main two types of SDB are obstructive and central. Central sleep apnea is defined by
an apnea-hypopnea index of >5 events/hour, and more than 50% of events are central.
This disturbance results in fragmented, nonrestorative sleep. Other symptoms include
loud, disruptive snoring, witnessed apneas during sleep, and excessive daytime sleepiness.
The most appropriate next step in management is to optimize heart failure treatment.
CPAP should be regarded as first-line therapy in central apnea after optimizing underlying
conditions such as heart failure.
Auto CPAP is contraindicated in central sleep apnea and in patients with heart failure as it

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 may worsen the central events. Likewise, adaptive servo-ventilation (ASV) is
contraindicated for treating central sleep apnea in heart failure patients with reduced
ejection fraction 45%, as a recent randomized controlled trial revealed increased mortality.
Risk factors for central sleep apnea are heart disease, opiates use, neuromuscular
diseases such as spinal cord injury, treatment-emergent central apnea, or idiopathic.
Diet and exercise regimen alone will not correct severe SDB.

Research Concepts: Obstructive Sleep Apnea

Question 845: A 39-year-old male patient presents with complaints of cough, fever, and
progressively worsening pleuritic- type chest pain. He also reports having two episodes of
hemoptysis recently. On examination, he looks unwell, his heart rate is 99 beats per
minute, respiratory rate is 34 breaths per minute, blood pressure is 160/95 mmHg and he
is afebrile. Auscultation of the chest reveals bilateral basal crackles. Lab investigations
show hemoglobin of 9.5 g/dl, a white cell count of 13600 per microliter, and serum
creatinine of 2.3 mg/dL. Further investigations show an erythrocyte sedimentation rate
(ESR) of 75 mm/hour. A chest radiograph is suggestive of patchy perihilar and basal
infiltrates. Pulmonary function tests reveal a raised transfer factor. Plasmapheresis is
initiated. What would be an indication to stop plasmapheresis?

Choices:

1. A decreasing trend of ESR

2. Undetectable levels of anti-glomerular basement membrane antibodies
3. Alleviation of presenting symptoms
4. A decreasing trend of anti-glomerular basement membrane antibodies
Answer: 2 - Undetectable levels of anti-glomerular basement membrane antibodies

Explanations:

The signs and symptoms in this patient, along with the laboratory findings, are
suggestive of Goodpasture syndrome (anti-glomerular basement membrane
antibody disease).
Goodpasture syndrome refers to an anti-glomerular basement membrane (anti-GBM)
disease that involves both the lungs and kidneys, often presenting as pulmonary
hemorrhage and glomerulonephritis.
A kidney biopsy is the gold standard for diagnosis but is not required either to
begin treatment or to continue therapy if a biopsy is not feasible. When
performed, biopsy provides important information regarding the activity and
chronicity of renal involvement that may help guide therapy.
Treatment of Goodpasture syndrome includes corticosteroids, plasmapheresis,

Page 800 of 955

 and/or hemodialysis, and cyclophosphamide. Typically, daily plasmapheresis is
performed until anti- glomerular basement membrane antibodies are
undetectable, with steroid and cyclophosphamide continuing after that for 3 to 6
months until full remission is achieved.

Research Concepts: Goodpasture Syndrome

Question 846: A 36-year-old male presents for a history of recurrent respiratory

infections with cough productive of copious amounts of green, mucopurulent sputum.
His past medical history is significant for recurrent ear infections in childhood. He smokes
20 cigarettes per day and is married with no children. Physical examination reveals
clubbed fingers, coarse crackles and wheezing in both lung bases, no additional heart
sounds, and a normal abdominal exam, except for a scar in the left lower abdomen.
Which investigation will most likely confirm the suspected diagnosis?

Choices:

1. Computed tomography (CT) scan chest with contrast

2. High resolution computed tomography (HRCT) chest
3. Sputum for culture and sensitivity
4. Serum Aspergillus precipitins

Answer: 2 - High resolution computed tomography (HRCT) chest

Explanations:

This patient has bronchiectasis, and the unifying diagnosis is Kartagener syndrome.
The scar suggests situs inversus as he may have had an appendectomy from the left
iliac fossa.
Infertility is also a clue towards the diagnosis as these patients are generally
subfertile.
To confirm bronchiectasis, high resolution computed tomography (HRCT) is the
investigation of choice.

Research Concepts:

Ciliary Dysfunction

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Question 847: A 21-year-old male was admitted to the hospital with pneumonia. This is
his 6th episode within the last eight months. His past medical history is significant for
recurrent lung infections, upper respiratory tract symptoms, and situs inversus. Upon
evaluation, you notice a relatively thin individual. His vital signs reveal a heart rate of 101
beats per minute, blood pressure of 122/80 mmHg, saturating 94% on 2L oxygen, and
temperature of 100.6- degree Fahrenheit. Chest auscultation revealed crepitations in the
left infrascapular region, and normal heart sounds on the right side.
His chest x-ray shows cardiac apex on the right side of his thoracic cavity. He is started on
broad-spectrum antibiotics, and respiratory cultures were sent for analysis. A CT scan of
his chest revealed severe demarcated bronchiectasis of his left middle lobe. Which of the
following is the most appropriate treatment option to provide long term benefits for this
patient?

Choices:

1. Provide a prolonged course of intravenous antibiotics

2. Daily oral antibiotic prophylaxis
3. Partial pneumonectomy
4. Inhaled bronchodilators
Answer: 3 - Partial pneumonectomy

Explanations:

This patient's recurrent respiratory infections and situs inversus are due to
Kartagener syndrome.
Kartagener syndrome is associated with bronchiectasis, which can lead to
recurrent exacerbations.
In patients with severe bronchiectasis affecting the quality of life, lung reduction
surgery or pneumonectomy should be considered.
Though intravenous antibiotics, chronic oral antibiotic use, and inhaled
bronchodilators might all be helpful in the acute setting, they are not the most
appropriate management option for his condition.

Research Concepts:

Dextrocardia

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Question 848: A 65-year-old male presents with increasing dyspnea and a cough, which is
aggravated at night. His past medical history is insignificant. He has never been a tobacco
smoker. He works in a workshop as a car mechanic, mainly to restore run-down cars.
Examination after one week of holiday is insignificant. His pulmonary function tests reveal
a forced expiratory volume (FEV1) 70% of normal, forced vital capacity (FVC) 80% of
normal, and peak expiratory flow rate of 430 l/min. The histamine challenge test is done,
which shows a 20% fall in FEV1 with 2 micromol/l histamine (normal is more than 4
micromol/l). What is the most likely diagnosis?

Choices:

1. Carbon monoxide poisoning

2. Occupational asthma
3. Extrinsic allergic alveolitis
4. Silicosis

Answer: 2 - Occupational asthma

Explanations:

This patient has occupational asthma secondary to isocyanates, which are present in
spray paints that are used in restoring run- down cars.
His pulmonary function test shows an obstructive disease with a hyper-responsive
histamine challenge test.
Serial peak flow rates confirm the diagnosis at work and at home.
Carbon monoxide poisoning presents as a flu-like illness with lethargy and fatigue.

Research Concepts:

Cough

Page 803 of 955

Question 849: A 66-year-old man presents to the clinic accompanied by his daughter with
a complaint of gradual onset of fatigue, anorexia, and constipation over the last five
weeks. He also feels that he has been urinating more often and with a larger volume. Over
the last two days, he has experienced some confusion and lethargy. She also adds that her
dad has a nagging cough with some tinge of blood that has not improved with over-the-
counter medications and has lost 10 kg during that interval. He has a history of
hypertension and for which he takes hydrochlorothiazide. He has smoked three packs of
cigarettes daily for 40 years and drinks socially. On physical examination, he appears
somnolent and disoriented. His reflexes are reduced. Chest and cardiovascular
examinations appear normal. Temporal wasting is noted. His serum calcium is 18.3 mg/dL,
glucose 98 mg/dL, serum sodium 142 mEq/L, serum potassium 4.2 mEq/L. Which other
metabolic abnormality do you expect in this patient, given the underlying diagnosis?

Choices:

1. Low phosphate levels

2. High phosphate levels
3. High sodium levels
4. Increased serum creatinine

Answer: 1 - Low phosphate levels

Explanations:

This patient has elevated serum calcium levels, polyuria, neurologic symptoms, and a
long history of smoking. The most likely diagnosis is humoral hypercalcemia of
malignancy (HHM) from an underlying squamous cell carcinoma of the lung.
PTHrP can be high in several malignancies, such as squamous cell carcinoma of the
lung, clear type renal cell carcinoma, and even bladder cancer. Some cases of
PTHrp have also been seen in breast and ovarian malignancies.
Parathyroid hormone-related protein (PTHrP) is structurally similar to parathyroid
hormone (PTH). It can act on the PTH-1 receptor, thus increasing sodium calcium
levels via an increase in bone resorption. PTHrP can also lead to more calcium
reabsorption in the distal renal tubule. Phosphate levels can drop with PTHrP as it
can act on the proximal tubules and prevent phosphate reabsorption.
Beta-HCG can be elevated secondary to large cell lung cancer. This can lead to
gynecomastia in men.
Research Concepts: Paraneoplastic Syndromes

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Question 850: A 16-year-old boy is being evaluated in the intensive care unit on the
fourth day of admission due to pneumonia. He has been requiring multiple sedatives and
analgesics while on a pressure-assist ventilator. Due to ongoing agitation, the pharmacist
warns an intensivist about the maximum dose of sedatives and opioid use. A plan is made
to change the ventilator mode to neurally- adjusted ventilatory assist (NAVA). Following
the switch, arterial blood gas analysis shows pH 7.42, pCO2 39 mmHg, and pO2 150
mmHg. He is currently on NAVA of 2 cmH2O/microV and Edi max is 8 microV. Which of
the following is the next best step in the management of this patient?

Choices:

1. Decrease NAVA by 0.5 cmH2O/microV

2. Extubate patient now
3. Increase NAVA level by 3 cmH2O/microV
4. Change back to the pressure-assist ventilator
Answer: 1 - Decrease NAVA by 0.5 cmH2O/microV

Explanations:

As NAVA improves asynchrony during ventilation, it may be helpful in decreasing

agitation and lower the need for sedative medications.
Arterial or capillary blood gas is an important tool to monitor ventilator requirements.
If blood gas is acceptable, NAVA level can be weaned by 0.5-1 cmH2O/microV.
It is recommended to consider extubation once the NAVA level reaches
1cmH2O/microV.

Research Concepts:

Neurally Adjusted Ventilatory Assist (NAVA)

Page 805 of 955

Question 851: A 65-year-old male presents with hoarseness of voice. This has been
present for the past year, and it has increased progressively. He has had two episodes of
pharyngitis and sinusitis recently. He does not drink alcohol or use recreational drugs. He
has a 20-pack-year smoking history. His past medical problems include hypertension, acid
reflux disease, stable angina, and laparoscopic cholecystectomy. Medications include
pantoprazole, metoprolol, and lisinopril. He is up to date with all his immunizations and
screenings. He worked as a university lecturer and often gave lectures to large audiences.
He retired five years ago. He is afebrile, his blood pressure is 130/80 mmHg, his heart rate
is 78 beats per minute, and his respiratory rate is 21 breaths per minute. He is currently
sexually active with his girlfriend and uses condoms consistently. Flexible laryngoscopy
reveals edematous vocal folds with a pseudo-polypoid, sac-like, appearance. There is no
overlying leukoplakia or erythroplakia. What is the most likely cause of this patient's
symptoms?

Choices:

1. Malignant transformation of squamous epithelium of the vocal folds

2. Human papillomavirus type 11
3. Fluid accumulation in Reinke's space
4. Increased gastrin secretion
Answer: 3 - Fluid accumulation in Reinke's space

Explanations:

This patient stem describes numerous risk factors and potential etiologies for
dysphonia (voice changes). These include tobacco smoking, professional voice use,
acid reflux disease, and the presence of an angiotensin-converting enzyme
inhibitory that may produce chronic cough.
The laryngoscopic findings described are classic for Reinke's edema.
The exact pathophysiology underlying Reinke's edema remains unknown, though it
is strongly associated with tobacco smoking and acid reflux.
Smoking cessation is important in halting or reversing the changes associated with
Reinke's edema, though severe cases may require surgical management. Reinke's
edema itself is not a pre-malignant lesion.

Research Concepts: Laryngopharyngeal Reflux

Page 806 of 955

Question 852: A 54-year-old White male patient presents with frequent episodes of
hemoptysis for the past few days. His vital signs are significant for a blood pressure of
90/60 mmHg and a heart rate of 110 beats per minute. Five years ago, he was diagnosed
with myeloperoxidase-antineutrophil cytoplasmic antibody-positive vasculitis. At that
time, his renal biopsy revealed diffuse necrotizing and sclerosing glomerulonephritis that
showed minimal immune complex deposits on light and immunofluorescent microscopy
labeled as "pauci-immune crescentic glomerulonephritis." He also suffers from end-stage
renal disease. Currently, his erythrocyte sedimentation rate is 90 mm/hr. Which of the
following parameters correlates best with the severity of disease activity in this case?

Choices:

1. Antineutrophil cytoplasmic antibodies (ANCA) titers

2. Renal biopsy findings
3. Erythrocyte sedimentation rate
4. Pulmonary function tests
Answer: 2 - Renal biopsy findings

Explanations:

The kidney is most commonly involved in microscopic polyangiitis (MPA), and

patients present with hematuria, reduced urine output, or even end-stage
renal disease. Renal biopsy is warranted to establish the diagnosis of MPA, and
the degree of inflammation generally correlates with the clinical severity of the
disease.
The histopathological findings may vary from mild focal and segmental to severe
crescentic glomerulonephritis. Some cases may present with tubulointerstitial
nephritis without involving the glomerulus.
Although myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) is
seen in MPA, it has been observed that some patients may have low or absent
titers; and many individuals without MPA may have raised levels of ANCA.

Research Concepts:

Microscopic Polyangiitis

Page 807 of 955

Question 853: A 50-year-old gentleman is ventilated for severe acute respiratory
syndrome secondary to polytrauma. His ventilator settings are as follows: volume-
controlled ventilation, FiO2 0.8/tidal volume 350 cc/ respiratory rate 30 per minute/ PEEP
14 cms H2O. His predicted body weight(PBW) is 60 kg. His latest arterial blood gases
include PaO2 56 mm Hg, PaCO2 68 mm Hg, pH 7.263, HCO3 38 mEq/L. His peak pressure is
36cms H20, and plateau pressure is 30 cms H2O. The provider is not keen to prone the
patient view of unfixed spinal injury. What is PEEP(positive end-expiratory pressure)
important in acute respiratory syndrome patients in the prevention of?

Choices:

1. Barotrauma
2. Volutrauma
3. Self-inflicted lung injury
4. Atelectotrauma
Answer: 4 - Atelectotrauma

Explanations:

PEEP is very important in preventing atelectrauma in ARDS, which is the lung injury
inflicted on the non-atelectatic alveoli by shear stress forces resulting from the
cyclical opening and closing of adjacent atelectatic alveoli and airways. PEEP will
help recruit alveoli and improve oxygenation.
Studies on atelectrauma have shown that the movement of high surface tension air-
liquid interfaces over the alveolar epithelium is the main culprit of injury resulting in
cellular necrosis.
PEEP will prevent atelectrauma by keeping the alveoli open, thus preventing the
severity of mechanical forces resulting from the alveoli's opening and closing during
the ventilatory cycle.
A suboptimally low PEEP will be insufficient to stabilize the alveoli and keep it open
to prevent the atelectrauma due to cyclical shear stress during the respiratory
cycle. Conversely, suboptimally high PEEP could cause alveolar overdistension and
decreased venous return, both being detrimental.

Research Concepts:Ventilator-Induced Lung Injury (VILI)

Page 808 of 955

Question 854: A 65-year-old woman presents with worsening cough productive of white
mucoid sputum and worsening dyspnea on 2 L of baseline oxygen despite taking
azithromycin and prednisone prescribed at an urgent care center one week ago. Her past
medical history is remarkable for hypertension, severe chronic obstructive pulmonary
disease (COPD), and type 2 diabetes mellitus. The patient reports 6 or 7 episodes of
watery, nonbloody, and foul-smelling diarrhea that started after taking the azithromycin
for a few days. On auscultation, diffuse coarse breath sounds with rales are heard. She is
admitted with an arterial blood analysis showing a pH of 7.25, a pCO2 of 80 mmHg, and a
pO2 of 84 mmHg. The complete blood count shows a WBC count of 14000/microL, a
hemoglobin level of 12.5 g/dl, a hematocrit of 36%, and a platelet count of
336000/microL. The sodium level is 139 mmol/L, potassium 4 mmol/L, chloride 102
mmol/L, bicarbonate 30 mmol/L, BUN 19 mg/dL, and creatinine 0.45 mg/dL. Clostridium
difficile PCR is positive. Chest x-ray shows flattening of the diaphragm and increased
interstitial markings. The patient is started on oral vancomycin and BiPAP in addition to
other treatments for COPD exacerbation secondary to community-acquired pneumonia.
She continues to deteriorate and eventually is intubated. What is the most appropriate
stress ulcer prophylaxis for this patient?

Choices:

1. Stress ulcer prophylaxis is not indicated

2. Calcium carbonate
3. Pantoprazole
4. Sucralfate
Answer: 4 - Sucralfate

Explanations:

Stress ulcer prophylaxis is usually indicated for patients requiring mechanical

ventilation. The most appropriate stress ulcer prophylaxis for this patient is
sucralfate. Proton pump inhibitors should be avoided in patients with Clostridium
difficile diarrhea.
Sucralfate protects the gastric mucosa from pepsin, peptic acid, and bile salts. It is
available as a tablet and a syrup, and the dose administered is 1 gram four times
daily.
This patient presents with community-acquired pneumonia. Stress ulcer prophylaxis
with a proton pump inhibitor, H-2 blocker, or an antacid in patients receiving
ventilation therapy increases the pH of gastric contents causing stagnation of gram-
negative bacilli and subsequently increasing the risk of hospital- acquired
pneumonia.
Research Concepts:Sucralfate

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Question 855: A 27-year-old male healthcare provider presents with shortness of breath,
dry cough, and fever for one week. Before this, he had been in good health without any
significant medical history. He has been working in the pulmonary ward for the past
month and lives with his dog. His vital signs include a heart rate of 112 beats per minute,
blood pressure of 124/85 mmHg, respiratory rate of 24 breaths per minute, and
temperature of 39 C (102.2 F).
His oxygen saturation is 88% on room air. On lung auscultation, there are bilateral
crackles. His inflammatory markers are elevated. On further questioning, he states that
his brother and sister tested positive for COVID-19 last week. Which of the following is
most likely associated with a mortality benefit in this patient?

Choices:

1. Dexamethasone
2. Tocilizumab
3. Azithromycin
4. Convalescent plasma

Answer: 1 - Dexamethasone

Explanations:

The patient most likely developed COVID-19 pneumonia from close contacts.
For mild disease, the treatment options include dexamethasone with or without
remdesivir.
For severe disease, the treatment options include dexamethasone with or without
tocilizumab.
Dexamethasone and anticoagulation have a significant role in the reduction of
mortality risk in patients with COVID-19 pneumonia. Use of remdesivir early in the
course and tocilizumab in severe illness may also reduce mortality to some extent.

Research Concepts:

Viral Pneumonia

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Question 856: A 35-year-old woman is pulled from her car in front of the hospital and
found to be in cardiac arrest. Her initial rhythm is pulseless electrical activity (PEA) on the
monitor. After two rounds of CPR and epinephrine, a pulse at a rate of 120/min is
palpated. A 12-lead EKG reveals sinus tachycardia with occasional PVCs. Her blood
pressure is 72/40 mmHg by the manual cuff.
Norepinephrine and phenylephrine continuous infusions are started. Initial workup
reveals an arterial blood gas pH of 7.10 with a pCO2 of 60 mmHg, pO2 of 72 mmHg, and
bicarbonate of 18 mg/dL. A stat echocardiogram shows an ejection fraction of 15%-20%
with severe mitral regurgitation. The patient's boyfriend reports that she has a history of
transposition of the great arteries that was corrected when she was 5 months old. She is
status-post mitral valve replacement 14 days ago at an outside facility. Prior to becoming
unresponsive, she was complaining of shortness of breath. The decision is made to
transfer the patient to a facility with a cardiothoracic ICU. Due to the patient's persistent
hypotension, the ECMO team is requested to initiate treatment prior to transfer. Which of
the following ECMO configurations is the most appropriate for this patient?
Choices:

1. Venovenous-double lumen catheter inserted in the right internal jugular vein

2. Venoarterial-venous cannula in the right femoral vein, arterial catheter in the
left femoral artery
3. Venovenous-femoral vein cannula, right internal jugular return cannula
4. Venoarterial-venous cannula inserted in the right femoral vein, arterial return
catheter in the right internal carotid
Answer: 2 - Venoarterial-venous cannula in the right femoral vein, arterial catheter in the left
femoral artery
Explanations:

This patient was resuscitated after cardiac arrest due to acute onset congestive heart
failure secondary to mitral valve regurgitation. In order to provide hemodynamic
support, veno- arterial ECMO must be initiated.
The most common veno-arterial ECMO configuration consists of a venous drainage
catheter in the right femoral vein and an arterial return catheter in the left femoral
artery.
Even though this patient's arterial blood gas values are severely altered, and her
CO2 is high, the cause of her acute instability is due to decreased cardiac output,
which is supported only by veno-arterial ECMO.
Internal carotid return catheters are only placed in children less than 15 kg.
Research Concepts:Extracorporeal Membrane Oxygenation Anticoagulation

Page 811 of 955

Question 857: A 52-year-old man comes to the clinic with a productive cough, fever, and
breathing difficulty. He states that his symptoms started 2 weeks ago. He has also had a
weight loss of about 2 kilograms in the past 2 weeks. His blood investigations show a WBC
count of 11,000 per microL, hemoglobin of 16 gm/dl, platelet count of 350,000 per
microL, serum ALT of 20 IU/l, serum AST 15 IU/l, serum creatinine 0.8 mg/dl, CRP of 55
mg/dl, and an ESR of 90 mm/h. Chest radiograph shows multiple cavitary lung lesions.
Sputum culture reveals a gram-positive bacillus that is partially acid- fast. Which of the
following risk factors would predispose this patient to his present condition?

Choices:

1. Exposure to a patient with mycobacterium tuberculosis

2. Swimming in a pond or a lake
3. History of HIV infection
4. History of travel to the tropics

Answer: 3 - History of HIV infection

Explanations:

This man has pulmonary nocardiosis.

Pulmonary nocardiosis is most often seen in immunocompromised patients. HIV
infection is the most common underlying condition in a patient with pulmonary
nocardiosis. However, other immunocompromised conditions can also result in a
Nocardia infection including cancer, chemotherapy, diabetes, transplant patients,
and patients receiving corticosteroids.
Nocardia is a weakly staining gram-positive, catalase-positive, rod-shaped bacteria.
It forms partial acid-fast beaded branching filaments. Most Nocardia infections are
acquired by bacterial inhalation or through the traumatic introduction.
Nocardia is a pathogenic bacteria with a low virulence; therefore disease most
frequently occurs in those with a weak immune system, such as small children, the
elderly, and the immunocompromised.

Research Concepts:

Nocardia

Page 812 of 955

Question 858: A 34-year-old female with poorly controlled asthma has been admitted with
complaints of haematuria. She has noticed this for the last three days and reports dysuria
for the last day and chills, and fatigue. The admitting clinician has requested a urinalysis in
addition to routine blood investigations and prescribed trimethoprim for a presumed urinary
tract infection. Upon review, her heart rate is 90 beats/min; her blood pressure is 140/90
mmHg; her respiratory rate is 24 breaths/min; her arterial oxygen saturation is 90% at room
air; her temperature is 36.5-degree celsius. Her clinical examination reveals mild erythema
and dried blood at the right nasolabial fold. Her respiratory examination revealed bilateral
apical wheeze, coarse inspiratory crackles at the left base, and bronchial breath sounds. The
abdomen is non-tender, and no suprapubic or flank pain on palpation. Her laboratory
investigations revealed Hb
9.0 g/dl, white cell count 11000/ microliter, neutrophils 5500/ microliter, platelets 270/
microliter, creatinine 1.5 mg/dl (baseline creatinine up to 1.0 mg/dl), INR 1.0, pH 7.40, and
Lactate 0.8 mmol/l. What is the next best investigation which will help in the diagnosis?
Choices:

1. Blood culture
2. MPO-ANCA
3. Renal tract ultrasonography
4. High-resolution CT scan
Answer: 2 - MPO-ANCA

Explanations:

Eosinophilic granulomatosis with polyangiitis (EGPA) is the diagnosis here that is frequently
missed if the investigating clinician does not have a high index of suspicion. EGPA is associated
with a positive antineutrophil cytoplasmic antibody (ANCA) (MPO pattern).
The clue here is a history of poorly managed asthma, respiratory findings of wheeze and
left basal crepitations (might suggest hemoptysis), possible epistaxis (nasolabial dried
blood), and frank haematuria. This clinical syndrome is suspicious for a urosepsis mimic.
EGPA treatment requires substantial immune suppression. Myeloperoxidase (MPO) anti-
neutrophil cytoplasmic antibody (ANCA) is positive in 40 to 60% of patients and is specific to
EGPA.
Renal tract ultrasound would be useful in the workup of a patient with severe urosepsis or
recurrent urosepsis. They would help identify an anatomical explanation. HRCT is useful in
the workup of the pulmonary-renal syndrome to look for vasculitis changes and help
identify possible targets for bronchoscopic sampling and intervention. Blood culture will be
helpful if there is more suspicion of urosepsis.

Research Concepts:Complicated Urinary Tract Infections

Page 813 of 955

Question 859: A 40-year-old male presents with facial swelling and flushing over the past
6 months. He also noticed a voice change and dry cough. Blood pressure is 170/93 mm
Hg, heart rate is 112 beats per minute, respiratory rate is 14 breaths per minute. He is
afebrile and maintaining oxygen saturation at 98% on ambient air.
Computed tomography of the chest reveals an encapsulated, lobulated, heterogeneous
mass in the anterior mediastinum that is in continuity with the cervical component of the
thyroid gland. If the patient has a variable extrathoracic obstruction from this mediastinal
mass, which part of the flow-volume loop will be affected?

Choices:

1. Expiration
2. Expiration and inspiration
3. Inspiration
4. Neither inspiration or expiration
Answer: 3 - Inspiration

Explanations:

Flow-volume loops plot inspiratory and expiratory flows on the y- axis against volume
on the x-axis.
Changes in the curves of the loops can help aid in the diagnosis of lung disease.
Extrathoracic obstruction affects the inspiratory loop, whereas intrathoracic
obstruction affects the expiratory loop.
Fixed obstruction affects both inspiratory and expiratory loops.

Research Concepts:

Anterior Mediastinal Mass

Question 860: A 23-year-old G1P1 presents to the clinic with complaints of shortness of
breath that has recently developed and is accompanied by chest pain. She claims that the
shortness of breath began within 24 hours. Her physical examination reveals a heart rate
of 110 beats per minute and unilateral left leg edema. Which radioisotope is most likely to
be used in the imaging of this patient in order to rule out the possibility of a pulmonary
embolism in this patient?

Choices:

1. Phosphorus-32
2. Iodine-131
3. Krypton-81m
Page 814 of 955
4. Strontium-89

Answer: 3 - Krypton-81m

Explanations:

Given the patient's tachycardia and unilateral leg swelling during a hypercoagulable
state (pregnancy) the patient is likely suffering from a pulmonary embolism.
Given a high clinical suspicion of pulmonary embolism, a D- dimer would likely
delay diagnosis and this patient should proceed to imaging. Although CT scans are
the preferred imaging modality for suspected pulmonary emboli, during pregnancy
a V/Q scan is preferred as it prevents radiation exposure to the fetus.
81m-Kr is a gamma emitter (191 Kev), with a 13-second half- life. In gas form, it
can be used as a ventilation agent as part of V/Q imaging. The short half-life
means the study can be repeated in multiple projections. It has no therapeutic
use.
Gamma emitters are more likely used in imaging, while beta emitters are more likely
used in treatment modalities.

Research Concepts: Radiopharmaceuticals

Question 861: A 52-year-old woman is admitted to the hospital with community-

acquired pneumonia. Her past medical history is significant for sarcoidosis, diabetes
mellitus, and hyperStension. She was started on IV antibiotics and some of her home
medications were discontinued at admission. On the second day of admission, the
patient became confused and on examination, her blood pressure is 75/40 mmHg, and
her heart rate is 110 beats/min.
Fingerstick testing indicates a blood glucose level of 45 mg/dL. She immediately received
two ampules of 25% dextrose water and two liters of normal saline, her blood pressure
improved to 86/45 mmHg. She was transferred to ICU and was started on
norepinephrine infusion along with the continuation of aggressive IV fluids. What is the
next best step in the management of this patient's hypotension?

Choices:

1. Resume home medications

2. Obtain central venous catheter to facilitate vasopressors administration
3. IV hydrocortisone
4. IV methylprednisolone

Page 815 of 955

Answer: 3 - IV hydrocortisone

Explanations:

The patient is in an adrenal crisis induced by the stress of her illness. Adrenal crisis is
an exacerbation of adrenal insufficiency. Adrenal insufficiency should be suspected in
unexplained and refractory hypotension in a patient with predisposing factors.
The patient has a history of sarcoidosis, which puts her at risk for adrenal crisis in
view of frequent use of steroids.
The first step in treating refractory hypotension is IV hydrocortisone administration
because of its combined mineralocorticoid and glucocorticoid effect along with
aggressive IV fluids.
Administering a 100 mg bolus of hydrocortisone is standard before administering
vasopressors. Oral prednisone has no role in management of acute adrenal crisis.

Research Concepts:

Adrenal Crisis

Question 862: A 65-year-old female patient presents to the emergency department after
being found non-responsive in her assisted living facility. She has a past medical history
of hypothyroidism, hyperlipidemia, and recent admission for community-acquired
pneumonia. Over the last few days, the nursing staff found her to exhibit progressively
increased work of breathing with occasional green sputum production. Upon admission,
the patient demonstrates a blood pressure of 50/40 mmHg, a heart rate of 115 bpm, and
a respiratory rate of 20 breaths/min. The patient is unresponsive, and exhibits increased
work of breathing. Cardiac auscultation shows diffuse rhonchi on the right lung. A chest
x-ray shows diffuse right lung infiltrate. CBC testing reveals a white blood cell count of
14,000 per microliter. Blood cultures are positive for gram-positive organisms. The
patient is placed on broad-spectrum antibiotics, norepinephrine, and vasopressin.
Monitoring of what parameter will monitor for secondary effects of vasopressin in this
patient?

Choices:

1. Liver function testing

2. Serum/urine sodium and osmolality
3. Renal function testing
4. Venous lactate levels
Page 816 of 955
Answer: 2 - Serum/urine sodium and osmolality

Explanations:

The major vasopressors include phenylephrine, norepinephrine, epinephrine, and

vasopressin. All patients requiring vasopressors or inotropes should have close
monitoring of vital signs, fluid status, and laboratory markers. Vasopressin's effect
on renal function requires close monitoring of serum and urine sodium, osmolality,
and fluid status.
Vasopressin or epinephrine are the two recommended vasopressors to add in
addition to norepinephrine in the treatment of septic shock.
Vasopressin acts on V-1 receptors to stimulate smooth muscle contraction of the
vessels as well as V-2 receptors in the kidneys as an anti-diuretic.
There are no inotropic or chronotropic effects; only BP and SVR are increased with
vasopressin. Vasopressin may induce arrhythmias, mesenteric ischemia chest pain,
coronary artery constriction and MI, bronchial constriction, hyponatremia, and local
tissue necrosis with extravasation.

Research Concepts:Inotropes And Vasopressors

Question 863: A 43-year--old male presented to the clinic with complaints of fever,
pleuritic-type chest pain and productive cough for the past 2 weeks. The history of the
patient reveals that he has been treated for pneumonia multiple times. X-ray and
ultrasound of the patient were suggestive of pleural effusion. A CT scan of the chest was
performed that revealed atypical pleural effusions along the mediastinum and thickened
pleurae. Tube thoracostomy was performed and the fluid was sent for culture and
sensitivity. Which of the following organism is most common to cause this pathology?

Choices:

1. Streptococcus
2. Klebsiella
3. Pseudomonas
4. Haemophilus

Answer: 1 - Streptococcus

Explanations:

Streptococcus pneumoniae is the most common cause of empyema.

Staphylococcus aureus is the most common organism in empyema complicating
Page 817 of 955
 previous surgery and acquired in the hospital. Methicillin-resistant Staphylococcus
aureus can cause up to 20% of cases.
Klebsiella, Pseudomonas, and Haemophilus are the most common aerobic gram-
negative organisms causing empyema. Empyema typically requires tube
thoracostomy in addition to antibiotics.

Research Concepts:

Empyema

Question 864: A 65-year-old male patient presents to the clinic with complaints of a dry
cough and wheeze, particularly at night. He has been suffering from asthma. Six months
ago, his symptoms were well-controlled on inhaled beclomethasone 400 ug twice a day
and occasional use of salbutamol inhaler as required. However, now he is more short of
breath with morning dipping of his peak flow readings. On examination, he is mildly
dyspneic but able to complete sentences. On auscultation, there is wheeze scattered in
his chest.
His peak expiratory flow rate is 70% of predicted. What is the most appropriate next step in
the management of this patient?

Choices:

1. Oral theophylline
2. Add inhaled long-acting beta 2 agonists
3. Increase inhaled beclomethasone to 800 ug twice a day
4. Oral long-acting beta 2 agonists

Answer: 2 - Add inhaled long-acting beta 2 agonists

Explanations:

Medical management includes bronchodilators like beta-2 agonists and muscarinic

antagonists (salbutamol and ipratropium bromide respectively) and anti-
inflammatories such as inhaled steroids (usually beclometasone but steroids via
any route will be helpful).
There are five steps in the management of chronic asthma, treatment is started
depending on the severity and then escalated or de-escalated depending on the
response to treatment.
This patient is at step 2 which includes daily low dose inhaled corticosteroid plus as-
Page 818 of 955
 needed short-acting beta 2 agonists.
However, his symptoms are not under control.
So the treatment needs to be escalated to step 3 that comprises of the low dose
inhaled corticosteroid and long-acting beta 2 agonists plus as-needed short-acting
beta 2 agonists.

Research Concepts:Asthma

Question 865: A 9-year-old boy with a history of asthma and chronic sinusitis is
undergoing endoscopic sinus surgery under general endotracheal anesthesia. The patient
suddenly develops high peak inspiratory pressure (PIP). What is the most likely cause of
the high PIP in this patient?

Choices:

1. Increased upper airway tone

2. Chest wall rigidity
3. Anaphylaxis
4. Bronchial smooth muscle constriction
Answer: 4 - Bronchial smooth muscle constriction

Explanations:

Asthma causes airway hyperresponsiveness from bronchial smooth muscle

constriction and airway inflammation.
While endotracheally intubated bronchospasm often presents as a sudden acute
rise in peak inspiratory pressure.
Bronchospasm can be differentiated from anaphylaxis by the absence of hypotension,
flushing, rash, or angioedema.
Clinically, bronchospasm may present as shortness of breath, wheezing, coughing, or
chest tightness.

Research Concepts:

Asthma Anesthesia

Page 819 of 955

Question 866: A 25-year-old man presents to the emergency department with fatigue,
fever, and myalgia for two days. He had recently traveled to New Mexico, where he ate
some local food, drank water from a stream, and reported rats in the hotel room where
he stayed. His vital signs are heart rate 100/minute, blood pressure 100/70 mmHg,
respiratory rate 24/minute, and temperature 101 F (38.3 C). Investigations show a white
blood cell count of 12000/microL, platelets of 90,000/microL, and serum sodium of 129
mEq/L. A chest radiograph shows bilateral interstitial infiltrates. A serum IgM reveals a
diagnosis of Navajo pneumonia. What is the causative organism?

Choices:

1. Legionella
2. Borrelia burgdorferi
3. Mycoplasma
4. Hantavirus

Answer: 4 - Hantavirus

Explanations:

Hantavirus cardiopulmonary syndrome was first recognized in May of 1993 and is

also called Navajo syndrome.
It is reported in the United States, with seven states accounting for approximately
70% of all cases reported (New Mexico, Colorado, Arizona, California, Washington,
Texas, and Montana).
Patients start with fever and chills, progress to cough and dyspnea, and may have
cardiovascular collapse.
Diagnosis can be made by immunofluorescent or immunoblot assay. ELISA utilizing
IgM is preferred.

Research Concepts:

Hantavirus Cardiopulmonary Syndrome

Page 820 of 955

Question 867: A 33-year-old woman presented with complaints of bilateral, painful red
eyes, joint pains, myalgia, and renal dysfunction. She was referred with the following
labs: hemoglobin
10.3 mg/dl (11.5-16.5), white cell count 8 (4.0-11.0), eosinophil count
0.70 (0.04-0.40), serum urea 76 mg/dl, serum creatinine 1.8 mg/dl, ANA negative, anti-
dsDNA negative, 24-hour urinary total protein 0.9 g (0.2), urinalysis showed 2+ protein,
renal biopsy showed normal- looking glomeruli along with interstitial lymphocytic
infiltrate, occasional granuloma, and eosinophils. What is the most likely diagnosis?

Choices:

1. Sjogren syndrome
2. Behcet disease
3. Systemic lupus erythematosus
4. Sarcoidosis

Answer: 4 - Sarcoidosis

Explanations:

Sjogren syndrome is an autoimmune condition that presents with dry eyes, dry
mouth, and skin involvement. Respiratory, cardiovascular, gastrointestinal, and
nervous systems can be involved.
Oral and genital ulcers with eye involvement in a young patient are the main clues.
Negative ANA and Anti dsDNA make the diagnosis of lupus unlikely. Lupus
nephritis can present with similar clinical features, but biopsy findings are
suggestive of sarcoidosis. This scenario typically presents a case of sarcoidosis.
Clinical features and renal biopsy point towards sarcoidosis.

Research Concepts:

Sarcoidosis

Page 821 of 955

Question 868: A 50-year-old man undergoes coronary artery bypass graft surgery and
requires a mechanical ventilator and cardiac intensive care unit transfer. On arrival to the
unit, the respiratory support is changed to an NAVA ventilator with the SERVO-I
ventilator. Edi catheter is unable to capture the Edi signal. A chest x-ray confirms an
elevation of the left hemidiaphragm. Which of the following is the most likely cause of
these findings?

Choices:

1. Poor respiratory drive

2. Viral infection
3. Left phrenic nerve injury
4. Intercostal nerve injury
Answer: 3 - Left phrenic nerve injury

Explanations:

Phrenic nerve injury during cardiac surgery is a common etiology.

Internal mammary graft with coronary artery bypass graft surgery (CABG) can
cause a unilateral phrenic nerve injury. Although most patients recover within one
year, it may take 2 years or more.
Elevation of the affected side of the diaphragm on chest x-ray suggests phrenic
nerve damage. Fluoroscopic evaluation confirms the diagnosis.
The absence of diaphragmatic activity is a contraindication of NAVA use as it does not
detect activity and trigger a mechanical breath.

Research Concepts:

Neurally Adjusted Ventilatory Assist (NAVA)

Question 869: An 85-year-old female is brought to the emergency department with

severe respiratory distress. On arrival, she is confused and agitated. Vital signs include
blood pressure 100/65 mmHg, pulse 105/minute, respiratory rate 23/minute, oxygen
saturation 70%, and temperature 38.1 C (100.5 F). The patient is immediately intubated.
The respiratory therapist can see a color change on the end-tidal carbon dioxide monitor
with condensation on the inside of the endotracheal tube. Breath sounds are equal
bilaterally. What is the next best step in the management of this patient?

Choices:
Page 822 of 955
1. Obtain a CT scan
2. Continue to monitor the patient
3. Obtain a chest x-ray
4. Listen for bilateral breath sounds twice per hour for 4 hours

Answer: 3 - Obtain a chest x-ray

Explanations:

A chest x-ray is necessary to confirm the placement of the endotracheal tube after an
intubation procedure.
Bilateral breath sounds heard on examination is an indication that the
endotracheal tube is placed correctly, but confirming with a chest x-ray is still
necessary.
Monitoring the patient is not sufficient to ensure that the endotracheal tube is in
place.
A CT of the chest is unnecessary as a chest x-ray is adequate to confirm
placement.

Research Concepts:

Tracheal Rapid Sequence Intubation

Question 870: A 59-year-old female presents to the clinic with a one-month history of
proximal muscle weakness, central obesity, and edema. Additionally, she has noticed, over
the past month, a persistent cough, hoarseness, fatigue, and shortness of breath. The
patient has smoked one pack per day for the past 30 years. Her blood pressure is 134/82
mmHg, her heart rate is 88 beats per minute, her respiratory rate is 14 breaths per
minute, and temperature is 98.0°F (36.7°C). Her breath sounds are absent over the right
upper lobe. A computed tomography (CT) scan is performed and confirms a 5.8 cm mass
in the right upper lobe, which is located centrally. Serum studies show a serum chloride of
100 mEq/L, sodium of 130 mEq/L, and potassium of 4.0 mEq/L. Additionally, the patient
has a fasting glucose of 122 mg/dL. Which of the following is most likely to be present in
this patient?

Choices:

1. Ectopic corticotropin production

Page 823 of 955
2. Elevated parathyroid hormone-related protein
3. Elevated urine 5-HIAA
4. Elevated beta-hCG

Answer: 1 - Ectopic corticotropin production

Explanations:

This patient presents with symptoms of proximal muscle weakness, central obesity,
and edema, in addition to a persistent cough, hoarseness, fatigue, hemoptysis, and
shortness of breath. A CT scan confirms a mass in the right upper lobe, and along
with hyponatremia, points towards the diagnosis of an antidiuretic hormone (ADH)
producing small-cell carcinoma of the lung.
Ectopic Cushing syndrome occurs in 2% to 5% of small-cell carcinoma patients.
Production of ectopic corticotropin (ACTH) results in elevated free cortisol levels.
Additionally, it can present with edema, proximal myopathy, and hypokalemic
alkalosis.
Small cell cancer generally presents with hilar/mediastinal adenopathy. It may
occasionally present with a solitary lung mass. The chest and the hilum are the first
sites of recurrence. In addition to ectopic corticotropin production, small cell
carcinoma is also associated with the paraneoplastic syndromes causing the
syndrome of inappropriate ADH secretion and Lambert Eaton syndrome. However,
symptoms of these syndromes are not present in this patient.

Research Concepts: Small Cell Lung

Cancer

Question 871: A 45-year-old man has a fever, malaise, and dry cough. He is apprehensive
because he was in contact with a patient about ten days before with a coronavirus
disease 2019 (COVID-19). The provider asked him what kind of exposure he had, and he
replied that he had a short dialogue (a few minutes) at a distance of approximately 1.5
meters. Moreover, both had an N95-type mask.
The man also reports that he could not postpone that meeting because of work reasons
and that he had not had other contacts since he had been in quarantine for about a
month. The provider does not find additional important clinical and anamnestic data.
What kind of information should be communicated?

Choices:

1. The clinical history is suggestive of the diagnosis of COVID 19

2. The patient is at no risk
Page 824 of 955
3. The patient should be immediately hospitalized in a COVID center
4. The patient should have a polymerase chain reaction (PCR) for COVID

Answer: 4 - The patient should have a polymerase chain reaction (PCR) for COVID

Explanations:

The symptoms of COVID-19 are often nonspecific. Anamnestic and

epidemiological investigations can provide useful information about the
possibility of contact at risk.
The type of contact (short duration and distance) and the protections used should
have guaranteed safety.
Hospitalization is not indicated but the patient should be tested for COVID 19.

Research Concepts:

Features, Evaluation, and Treatment of Coronavirus (COVID-19)

Question 872: A 2-year-old boy (weighing 10 kgs) is found in the swimming pool face down
approximately 10 minutes after missing.
He is resuscitated with return of spontaneous circulation after 20 minutes of downtime
and is brought to the intensive care unit. His initial ventilator settings are rate of 30/min,
tidal volume of 70 mL, PEEP of 7 mmHg, and FiO2 of 80%. Soon he is escalated to a PEEP
of 12 mmHg and FiO2 of 100% due to his oxygen saturations in the 80’s. His chest x-ray
shows diffuse fluffy infiltrates in both lungs. What is the most likely mechanism of
hypoxemia in this patient?

Choices:

1. Increased ventilation-perfusion (V/Q) ratio

2. Hypoventilation resulting in severe hypercarbia
3. Severe bronchoconstriction with edema leading to decreased air entry into the
lungs
4. Ventilation-perfusion mismatch in the form of intrapulmonary shunting
Answer: 4 - Ventilation-perfusion mismatch in the form of intrapulmonary shunting

Explanations:

Page 825 of 955

 Acute respiratory distress syndrome secondary to drowning or any other insults
causes hypoxemia by the mechanism of intrapulmonary shunting due to alveolar
flooding with exudates and alveolar collapse.
The alveoli that are collapsed and flooded in acute respiratory distress syndrome will
still be perfusing blood but no ventilation resulting in hypoxemia.
There will not be any perfusion deficits to the lungs unless there is hypoxic
vasoconstriction in those affected alveoli.
The ventilation-perfusion ratio is decreased mainly in the lung bases compared to
the apex as the perfusion is relatively more in the bases generally.

Research Concepts:

Refractory Hypoxemia and Venovenous ECMO

Question 873: A 72-year-old-male presents to the hospital complaining of generalized

weakness and fatigue for the past three weeks. The patient recently immigrated from the
Philippines 6 months ago. He states he has had no cough recently but has been noticing
himself waking up sweating in the middle of the night despite being in a comfortable
temperature-controlled apartment. He denies any recent sick contacts, and he is up to
date on his immunizations. He has never had any hospitalizations in the past and does not
follow-up with a doctor regularly. Which of the following should be used when entering
this patient's room?

Choices:

1. An N95 fitted mask

2. A surgical mask
3. Gloves
4. Googles and gown

Answer: 1 - An N95 fitted mask

Explanations:

Due to the patient's presentation and immigration history, TB needs to be ruled out
and he should be placed under airborne precautions until testing is done.
Airborne precautions include an N95 fitted mask and placing the patient in a negative
pressure room.
A negative pressure room should have 6 to 12 air exchanges per hour to ensure
Page 826 of 955
 proper air filtration.
Airborne precautions are in place for organisms transmitted by airflow that are 5 µm
in size or smaller.

Research Concepts:

Precautions, Bloodborne, Contact, and Droplet

Question 874: A 17-year-old female presents with fever, anorexia, nausea, vomiting, and
oliguria for the past four days. She reports that she recently went freshwater swimming
with her friends and returned a week ago. She has no known medical problems, takes no
medication, and does not smoke or drink alcohol. Vitals show a blood pressure of 98/58
mmHg, a pulse of 101/min, a respiratory rate of 26/min, and a temperature of 39 C.
Physical examination reveals conjunctival suffusion without inflammatory exudate.
Laboratory investigations reveal a leukocyte count of 7800 cells/mm3, platelet count of
110000/mm3, aspartate aminotransferase level of 82 U/L, alanine aminotransferase
level of 77 U/L, and a creatinine of 4.4 mg/dl. She is admitted for further treatment.
Given the likely diagnosis, what is the most appropriate antibiotic for this patient?

Choices:

1. Gentamicin
2. Penicillin G
3. Cefuroxime
4. Chloramphenicol
Answer: 2 - Penicillin G

Explanations:

The most likely diagnosis considering the patient’s history, physical examination, and
laboratory investigations is severe leptospirosis (Weil disease).
The treatment of leptospirosis depends on the severity. Outpatient antibiotics
include doxycycline, amoxicillin, or ampicillin. In severe infections, intravenous
penicillin G, third- generation cephalosporins, or erythromycin is preferred.
As this patient has multiorgan dysfunction and requires admission, she needs to be
treated for severe leptospirosis. Patients with icteric leptospirosis or multiorgan
involvement usually need intensive care unit admission as decompensation can
occur rapidly.

Page 827 of 955

Research Concepts:

Leptospirosis

Question 875: A 42-year-old woman presents with an ongoing cough that has been waxing
and waning over the past three months. She has already completed three courses of
antibiotics. Two CT scans done thus far show a dense area of consolidation and a
surrounding rim of infiltrates in the left lower lobe that has increased in size. Blood vessels
are distinctly visible within the area of consolidation. Bronchoscopy and transbronchial
biopsy are performed, and histopathology shows homogenous neoplastic cells with
nuclear enlargement. Immunostaining is strongly positive for cytokeratin 20 (CK20) and
weakly positive for cytokeratin 7 and thyroid transcription factor-1 (TTF-1). What is the
most likely diagnosis?

Choices:

1. Minimally invasive adenocarcinoma

2. Lepidic predominant adenocarcinoma of nonmucinous subtype
3. Lepidic predominant adenocarcinoma of the mucinous subtype
4. Adenocarcinoma in situ
Answer: 3 - Lepidic predominant adenocarcinoma of the mucinous subtype

Explanations:

Lepidic predominant adenocarcinoma is the only subtype of adenocarcinoma with

lepidic growth that shows vascular and stromal invasion. The description of the
visualization of blood vessels within the area of mucinous consolidation, known as the
"angiogram sign," is typical of the mucinous subtype of invasive adenocarcinoma.
Mucinous bronchioloalveolar carcinoma is focally and weakly positive for TTF-1
and CK-7 and may show strong positivity for CK 20.
Consolidation can be peripheral, central, or both. Small peripheral nodules are the
most common radiographic abnormality.
Mucinous bronchioloalveolar carcinoma more often presents as pneumonic infiltrates
with consolidation or pseudo cavitation.

Page 828 of 955

Research Concepts: Bronchoalveolar Cancer

Question 876: A 39-year-old man is accompanied by his wife to the clinic. The wife says
that her husband has irrepressible episodes of passing out during the daytime, even when
he is doing important work. She states that the patient has reduced attentiveness and has
become more irritable over the past few months. The patient and his wife have also
stopped sharing a bed because the wife finds his loud snoring impossible to sleep with. On
further questioning the patient after sending his wife out of the office, the patient
confirms everything. He further adds that he is embarrassed about his behavior and
wishes that there was something he could do to fix everything. He admits to falling asleep
even during office meetings and describes these episodes as involuntary. His body mass
index is 35 kg/m2. His vitals are blood pressure 135/88 mmHg, pulse 95/min, and
respiratory rate 19/min. A nighttime arterial blood sample is sent for acid-base analysis.
What abnormality is most likely to be seen in an arterial blood gas report?

Choices:

1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
Answer: 3 - Respiratory acidosis

Explanations:

This patient most likely has obstructive sleep apnea. Loud snoring, daytime
sleepiness, and decreased concentration, coupled with his body mass index, all
point towards this diagnosis.
Obstructive sleep apnea presents with multiple nighttime episodes of cessation of
breathing.
The apnea during the night causes respiratory acidosis. This respiratory acidosis
leads to renal compensation to increase bicarbonate levels.
He also likely has obesity hypoventilation syndrome.

Research Concepts:

Obstructive Sleep Apnea

Page 829 of 955

Question 877: A 57-year-old man comes to the office for easy fatiguability and headache.
He has a history of allergic rhinitis and exercise-induced asthma managed with daily oral
zafirlukast and inhaled beclomethasone as needed. He has a history of colon cancer with
liver metastasis treated with surgery, chemotherapy, and radiotherapy. He is on
hemodialysis for chronic kidney disease.
Recently he has been diagnosed with metastatic cancer to the brain and liver and is
planned for palliative chemotherapy and radiotherapy. On examination, he looks
cachectic, and his pulse rate is 80/min, blood pressure is 110/70 mm Hg, respiration rate
is 14/min, and oxygen saturation is 92% in room air. He has yellowish discoloration of the
skin. The abdomen is distended with diffuse tenderness on palpation. On auscultation of
the chest, normal breath sounds are heard with no active wheezing. His bilateral cranial
nerves are intact, and bilateral motor strength, reflexes, and sensation are normal.
Laboratory test reveals of hemoglobin 10 gm/dL, white cell count is 5000/mm^3, INR of 4,
blood urea nitrogen 20 mg/dL, serum creatinine of 1.4 mg/dL, creatinine clearance is 50
L/min, aspartate transaminase of 300 U/L, alanine aminotransferase of 350 U/L and
alkaline phosphatase of 200 U/L. Which of the following underlying condition in this
patient is a contraindication to using his current anti-asthmatic drugs?
Choices:

1. Chemotherapy
2. Acute liver injury
3. Chronic kidney disease
4. Metastatic brain cancer
Answer: 2 - Acute liver injury

Explanations:

This patient has acute liver failure secondary to metastatic liver disease.
Zafirlukast is contraindicated in severe or acute liver injury.
Zafirlukast is known as a selective and competitive leukotriene- receptor antagonist.
Other contraindications include known hypersensitivity, acute severe asthma, status
asthmatics, depression, mood changes, suicidal thoughts, and use of drugs like
theophylline, warfarin, erythromycin, and phenobarbitol.
Contraindications of inhaled beclomethasone include hypersensitivity to the drug
or its component, glaucoma, and untreated respiratory infections, and should be
used with caution during pregnancy and lactation.

Research Concepts:Zafirlukast

Page 830 of 955

Question 878: A patient presents requesting guidance for an upcoming trip. They are
planning a trip to a high-altitude location. They state that the last time they went to
altitude, they developed a severe headache that lasted several days before resolving.
They are requesting guidance to help prevent these symptoms from recurring on the
upcoming trip. A medical history review shows an anaphylactic response to
hydrochlorothiazide and hypertension.
Which medication is the best prophylaxis for this patient?

Choices:

1. Ibuprofen
2. Ginkgo biloba
3. Acetazolamide
4. Dexamethasone

Answer: 4 - Dexamethasone

Explanations:

This patient experienced Acute Mountain Sickness (AMS) on their previous trip, and
prophylactic medication for the upcoming trip is reasonable. Ibuprofen can be used
as prophylaxis for AMS and has the advantage over other readily available
medications. However, it lacks the history and evidence that other drugs, such as
acetazolamide and dexamethasone, have and thus are not the best choice.
Ginkgo biloba has been reported to have some efficacy in AMS prophylaxis.
However, the studies are mixed. Ginkgo biloba is also problematic because it is
unregulated as a herbal supplement. Thus, potency, purity, and standardized
dosing cannot be assured. At this time, it should not be recommended to patients
for use in AMS prevention.
Acetazolamide is the most common prophylactic medication used for AMS. It is
supported by evidence and a good safety profile. However, it does contain a sulfa
moiety. It appears to carry a relatively low risk of an allergic response to those with
sulfonamide allergy. But it should be avoided in patients with known anaphylaxis
to sulfa drugs.
Dexamethasone can be used for both prophylaxis and treatment of AMS. It is more
commonly used for treatment but is an excellent choice for prophylaxis in patients
who cannot take acetazolamide.
Research Concepts: Acute Mountain
Sickness

Page 831 of 955

Question 879: A 33-year-old man presents to the clinic with shortness of breath, even at rest
for the past two years. He reports a history of intermittent cough and right-sided pain chest
since his adolescence. Chest X-ray shows a right-sided mediastinal mass.
Chest CT scan shows a right-sided posterior mediastinal, unilocular, cystic mass lesion
having a diameter of 10.9 x 8 cm with a homogeneous, increased fluid attenuation value
of +15 HU. On contrast study, the cyst is thin-walled, non-enhancing except a small part
of its right edge suggesting focal thickening of inflamed mediastinal pleura or
compressed part of lung adjacent to the cyst. The right intermediate bronchus is partially
compressed and slightly displaced by the mass. The CT-guided aspiration reveals its
content to be whitish, opalescent fluid with high protein, epithelial cells, amorphous
calcium. The culture report is negative. A bronchoscopic biopsy specimen reveals
inflammatory changes, and no malignant cells are detected. What is the most likely
diagnosis?
Choices:

1. Hydatid cyst
2. Cystic teratoma
3. Bronchogenic cyst
4. Vascular malformation

Answer: 3 - Bronchogenic cyst

Explanations:

In bronchogenic cysts, symptoms are secondary to cyst infection or compression of

adjacent structures. Non-fistulized bronchogenic cysts are usually responsible for
chest pain. In this patient, the right intermediate bronchus is partially compressed
and slightly displaced by the mass.
Computed tomography scan is the investigation of choice for bronchogenic cysts.
The CT density of bronchogenic cysts is variable from typical water density to high
density related to blood, increased calcium content, anthracosis pigment, or
increased protein content of the fluid. In this case, the chest CT scan showed a
right-sided posterior mediastinal, unilocular, cystic mass lesion with a
homogeneous, increased fluid attenuation value of +15 HU.
Bronchogenic cysts contain clear fluid, proteinaceous mucus, rarely air or
hemorrhagic secretions. In this patient, the CT guided aspiration revealed its
content to be whitish, opalescent fluid with high protein.
The patient reported intermittent cough and right-sided pain chest since his
adolescence. Thus, the occurrence of the cyst is not recent.
Research Concepts: Bronchogenic Cyst

Page 832 of 955

Question 880: A 40-year-old man presents to the clinic with early morning headaches and
excessive daytime sleepiness for six months. He mentions that these symptoms have
affected his daily activities and work performance. He fell asleep during an important work
meeting at one time, and everyone laughed at his loud snores. He states that he eats a
balanced diet and maintains regular exercise but denies blood loss, depression, or lack of
motivation. On physical exam, the patient is afebrile, heart rate 80/min, blood pressure
130/90 mm Hg, respiratory rate 12/min, and SpO2 97% on room air. His body mass index is
33 kg/m2. A crowded oropharynx is noted on the oral exam. Mild bibasilar crackles are
noted on lung examination. His laboratory investigations, such as complete blood count,
vitamin B12, folic acid, and thyroid-stimulating hormone, are within normal limits. Which
of the following is the most appropriate next step in the management of this patient?

Choices:

1. Initiate auto continuous positive airway pressure (Auto CPAP)

2. Polysomnography
3. Nocturnal oximetry monitoring
4. Computed tomography (CT) scan of the head

Answer: 2 - Polysomnography

Explanations:

Patients with obstructive sleep apnea typically present with daytime sleepiness,
loud snoring, and morning headaches. The gold-standard diagnostic test for
patients with obstructive sleep apnea is the attended, in-laboratory
polysomnography. Complications such as systemic hypertension and heart failure
typically follow if obstructive sleep apnea is untreated.
The American Academy of Sleep Medicine recommends that positive airway
pressure should be used to treat obstructive sleep apnea in adults with excessive
sleepiness.

Research Concepts:

Sleep Apnea Syndrome

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Question 881: A 45-year-old female has had progressive shortness of breath for the past
few weeks. She cannot climb even one flight of stairs and can walk only 3 to 4 blocks. She
has also experienced near syncope several times, especially after walking a few steps.
This has never happened before and has no other medical condition. The patient has a
10-pack-year smoking history and drinks alcohol occasionally. The patient's temperature
is 36.7 C (98 F), blood pressure is 130/90 mmHg, pulse is 62/min, and respirations are
14/min. Jugular venous pressure is ten cmH20, and the waveform demonstrates an
elevated 'a' wave. On cardiac auscultation, there is a holosystolic murmur at the left
sternal border and a splitting of the second heart sound. The lungs are clear to
auscultation. Peripheral pulses are full, and no finger or toe clubbing is present. There is
edema up to the knees. ECG shows normal sinus rhythm with right axis deviation. What is
the most likely diagnosis?

Choices:

1. Right pulmonary artery embolism

2. Pulmonary arterial hypertension
3. Acute cardiac tamponade
4. Constrictive pericarditis

Answer: 2 - Pulmonary arterial hypertension

Explanations:

Pulmonary arterial hypertension (PAH) presents with dyspnea and syncope. It is

most frequently seen in females and is more likely to be symptomatic.
Jugular venous distension is seen in patients with PAH. 'a' waves are
elevated in patients with PAH. 'a' waves are presystolic and produced by
right atrial contraction.
Constrictive pericarditis can also cause jugular venous distension but does not
cause 'a' wave elevation.

Research Concepts:

Jugular Venous Distention

Page 834 of 955

Question 882: A 65-year man with a past medical history of diabetes mellitus,
hypertension, congestive heart failure, and chronic obstructive pulmonary disease
presents to the emergency department due to progressively worsening shortness of
breath over the last few days. He is placed on bi-level positive airway pressure (BPAP) due
to worsening hypoxia with oxygen saturation of 68% on room air. His respiratory status
continues to deteriorate, and 20 minutes later, he becomes unresponsive. He is
emergently endotracheally intubated and receives diuretics with an adequate response.
Seventy-two hours later, the patient is noted to have a temperature of 102.5 F (39.2 C),
thick mucopurulent secretions during endotracheal suctioning, and worsening coarse
crackles.
What is the best next diagnostic step for this patient?

Choices:

1. Bronchoalveolar washing
2. Protected specimen brush sampling for semi-quantitative cultures
3. Blind bronchial sampling for quantitative cultures
4. Endotracheal aspiration for quantitative cultures

Answer: 4 - Endotracheal aspiration for quantitative cultures

Explanations:

This patient has developed ventilator-associated pneumonia (VAP), which typically

develops after 48 hours of endotracheal intubation.
Clinical features include fever, hypoxia, tachypnea, mucopurulent secretions,
decreased tidal volume, and new or worse infiltrates on chest x-ray.
Recent guidelines recommend noninvasive testing, such as endotracheal aspiration,
rather than invasive testing, including bronchoalveolar lavage, bronchial washing,
protected specimen brushing, and blind bronchial sampling.
The recommendation is based on the clinical trials, which showed no better
outcomes with invasive testing.

Research Concepts:

Ventilator Complications

Question 883: A 45-year-old female presents with complaints of fever, cough, and
Page 835 of 955
difficulty breathing. She has been having intermittent fevers for the past four weeks. She
also complains of a dry, troublesome cough, which has been present for three weeks.
She has associated dyspnea, which has progressed to such an extent that she finds it
difficult to get out of bed. She has a history of intravenous drug use 10 years ago but
denies any recent use. Her examination reveals a pulse of 105 beats per minute,
respiratory rate of 30 breaths per minute, a temperature of 99°F (37.2°C), a blood
pressure of 90/50 mmHg, and an oxygen saturation of 90% on room air, which falls to 82%
when she walks across the room. Physical examination reveals oropharyngeal thrush and a
violaceous patch on her calf. Her chest auscultation reveals scattered crackles. The rest of
her systemic examination is unremarkable. Her lab work reveals a white blood cell (WBC)
count of 3,000 per microL, hemoglobin of 11 gm/dl, platelet count of 200,000 per
microliters, serum creatinine of
0.9 mg/dl, CD4+ 05 per micro, serum alanine aminotransferase (ALT) level of 90 IU/l, and
serum lactate dehydrogenase (LDH) level of 250 IU/L. An x-ray of the chest demonstrates
bilateral reticulonodular infiltrates. Bronchoalveolar lavage is performed, which
demonstrates cells with basophilic cytoplasmic bodies and intranuclear eosinophilic
inclusion. Which of the following is an appropriate treatment option for the patient's
pulmonary symptoms?

Choices:

1. Microbial folic acid synthesis inhibitors

2. Ergosterol synthesis inhibitors
3. Viral DNA polymerase inhibitors
4. Inhibitors of peptidyltransferase
Answer: 3 - Viral DNA polymerase inhibitors

Explanations:

This patient has acquired immunodeficiency syndrome (AIDS). The pulmonary

symptoms and viral cytopathic effect seen on the cells from bronchoalveolar
lavage make the diagnosis of CMV pneumonitis. The treatment is with ganciclovir.
CMV pneumonitis is a rare complication of advanced HIV infection. Patients
present with cough, dyspnea, and fevers. Treatment is with ganciclovir which
inhibits viral DNA polymerase. It is a pro-drug which requires activation via viral
thymidylate kinase, thus only functions in affected cells.
The usual dose of ganciclovir in CMV pneumonitis is 5 mg/kg/dose given every 12
hours. In individuals who fail to respond to ganciclovir or in whom resistance is
suspected, intravenous foscarnet is an alternative agent.
Often CMV pneumonitis presents with other pulmonary infections. Pneumocystis
jiroveci can present similarly, but bronchoalveolar lavage usually demonstrates the

Page 836 of 955

 presence of cysts. It is treated with trimethoprim-sulphamethoxazole, which
inhibits folate synthesis. Fungal infections are also common in advanced
immunosuppression and can be treated by azoles that inhibit fungal ergosterol
synthesis. Macrolides are used in the prevention of mycobacterium avium
infections, which is another opportunistic infection in AIDS.

Research Concepts: Cytomegalovirus

Question 884: A 31-year-old man presents to the office with complaints of breathlessness
for 2-week. He also reports fever and nocturnal cough. He does not smoke and has no
allergies. He traveled to Kenya one year back. After physical examination and tests, he is
diagnosed with tropical pulmonary eosinophilia. He is given a particular drug with an
excellent treatment response. What is the most likely site of action of this drug?

Choices:

1. Both microfilariae and adult parasites

2. Microfilariae only
3. Adult parasites only
4. Acts on white blood cells only
Answer: 1 - Both microfilariae and adult parasites

Explanations:

The treatment of choice for tropical pulmonary eosinophilia (TPE) is

diethylcarbamazine (DEC) for 21-days.
DEC is active against both microfilariae and adult parasites. Signs and symptoms
respond dramatically with DEC, which is the characteristic of TPE.
It is crucial to diagnose and treat TPE in the early stage. Chronic TPE can result in
pulmonary fibrosis and, subsequently chronic respiratory failure even after the
treatment with DEC.

Research Concepts:

Tropical Pulmonary Eosinophilia

Page 837 of 955

Question 885: A 65-year old male with a history of persistent cough and breathlessness
for one year presents to the clinic. His pulse is 100/min, and his blood pressure is 120/70
mmHg. He has been smoking one pack of cigarettes per day and has no other
comorbidities. He is suggested to undergo a high-resolution computed tomography scan
of the thorax based on his current chest X-ray findings. A right lower lobe lesion is evident
on HRCT, and the patient is advised to undergo transbronchial lung biopsy. The
procedure is done, and the patient complains of sudden breathlessness and chest pain in
the recovery room. His respiratory rate is 34/min, and breath sounds are absent on the
right side. What is the next best step in management?

Choices:

1. Chest X-ray
2. 100% oxygen
3. Needle thoracocentesis
4. Chest tube insertion

Answer: 3 - Needle thoracocentesis

Explanations:

This patient is present with a post-biopsy pneumothorax. Pneumothorax is the most

common complication following lung biopsy.
The high respiratory rate and absent breath sound on auscultation indicate a large
pneumothorax.
The primary step in management, in this case, is needle thoracocentesis.
The following step would be to insert a chest tube following immediate management
with needle thoracocentesis.

Research Concepts:

Lung Biopsy Techniques And Clinical Significance

Page 838 of 955

 Question 886: A 56-year-old man presents with debilitating daytime sleepiness. He used
to fall asleep on his sofa while watching television, but for the past several months, he
has fallen asleep while talking to friends, while waiting in line in the cafeteria, and nearly
when he was driving to work two days ago. His wife accompanies him and says that he
snores loudly. He denies any episodes of falling due to a loss of posture and does not
relate his symptoms to emotions. He also denies hallucinations before falling asleep or
after waking up. Examination reveals a weight of 110 kg, a height of 1.8 meters, a pulse of
90 per minute, blood pressure of 155/86 mmHg, a neck size of 45 cm, and pulse oximetry
of 93% on room air. The patient appears slightly plethoric. The oropharyngeal exam
shows Mallampati class IV. Lungs are clear to auscultation, and heart sounds are distant
but regular. There is no murmur, but there is a prominent P2 with a heave heard in the
right parasternal area. Lower extremities show 1+ edema bilaterally. What is the best
next step in management?
Choices:

1. A home sleep apnea test

2. In-laboratory polysomnography with multiple sleep latency tests the next morning
3. In-laboratory polysomnography with arterial blood gas analysis the following day
4. In-laboratory polysomnography and a six-minute walk distance
Answer: 3 - In-laboratory polysomnography with arterial blood gas analysis the following day
Explanations:

The likely diagnosis is obesity hypoventilation syndrome (OHS) from the history and physical,
which also rule out essential features of narcolepsy, including cataplexy and
hypnogogic/hypnopompic phenomena.
To pursue the diagnosis, a daytime awake hypercapnia should be demonstrated in
addition to performing in-laboratory polysomnography to demonstrate the presence and
severity of sleep-disordered breathing. Nocturnal hypoventilation can be assessed either
by transcutaneous CO2 during the polysomnography or by doing an arterial blood gas
analysis the next morning.
A home sleep apnea test is a good diagnostic test to identify suspected obstructive sleep
apnea in individuals without significant comorbidities or suspected OHS.
A sleep study with multiple sleep latency tests is necessary to confirm narcolepsy and
should be pursued later in this patient after establishing the diagnosis. The absence of the
typical features of narcolepsy other than daytime hypersomnolence does not rule it out but
makes it less likely. Sleep study with positive airway pressure is pursued once a diagnosis is
established; there is a need for positive airway pressure therapy for treatment, and the
correct pressure is to be estimated. There is no indication for six-minute distance testing in
this patient.

Research Concepts: Pickwickian Syndrome

Page 839 of 955

Question 887: A 66-year-old man with a history of COPD is admitted with an acute
exacerbation in the ICU on invasive mechanical ventilation (IMV). Despite adequate
measures, there has been no improvement in his condition. Consent was taken to
consider extracorporeal carbon dioxide removal (ECCO2R). The venovenous ECCO2R was
opted for and installed. PaCO2 levels began to reduce over 24 hours. In about 36 hours,
there was a dark- blue black discoloration around the puncture site, along with the
patient complaining of aching pain in the distal limb. The patient's blood depicted
increasing levels of urea, creatine, CRP, and low platelets. He has also manifests oliguria
by 48 hours. Which of the following is the next best step in the management of this
patient?

Choices:

1. Empiric antibiotics
2. IV methylprednisolone
3. Blood transfusion
4. Discontinue ECCO2R and begin argatroban
Answer: 4 - Discontinue ECCO2R and begin argatroban
Explanations:

The patient was begun on ECCO2R, which is a device that allows the removal of
carbon dioxide and oxygenation of blood through a circuit involving a
semipermeable membrane. The use of ECCO2R needs anticoagulation with heparin
and warfarin.
Heparin, in some individuals, causes heparin-induced- thrombocytopenia (HIT) where
antibodies against the platelet factor 4 (PF4) results in thrombus formation and
thrombocytopenia. This manifests as veno-arterial thrombi, skin changes, low platelet
counts, and/or organ failures. This patient manifested these symptoms, along with
renal failure.
HIT in patients using ECCO2R can be life-threatening and warrants the immediate
discontinuation of the device and anticoagulant. There must be prompt initiation
of novel anticoagulants such as argatroban or fondaparinux (NOAC's). Although
renal insufficiency developed, the causative factor must be desynchronized first
with NOAC's.
Other complications of using ventilators include ventilator- associated
pneumonia, ventilator-induced lung injury and ventilator-induced
diaphragmatic damage. They may need initiation of empirical antibiotics,
fluid therapy or steroids.

Research Concepts: Extracorporeal Carbon Dioxide Removal

Page 840 of 955

Question 888: A 21-year-old woman with a history of cystic fibrosis (CF) presents to the
clinic for follow up. She has transitioned to the adult CF clinic and has had excellent medical
care. At today's visit, she reports losing weight over the past four weeks and has recently
been having more breathing difficulties. Diabetes is the most common comorbid condition
in adults with CF, affecting 40-50 % of those with CF, and is known to impact pulmonary
function and weight loss. Which of the following is the best screening test in the evaluation
of this patient?

Choices:

1. HbA1c
2. Fasting blood sugar
3. 2 hour 75 g oral glucose tolerance test (OGTT)
4. Random blood sugar
Answer: 3 - 2 hour 75 g oral glucose tolerance test (OGTT)

Explanations:

Cystic fibrosis-related diabetes (CFRD) sequelae result in weight loss, a decline in

lung function and protein catabolism primarily, not the microvascular and
microvascular concerns of other populations.
The OGTT correlates with the rate of lung function decline over four years and the risk
of early mortality while fasting blood glucose only identifies hyperglycemia in the
fasting state, which will miss half of those with CFRD.
For three days before the OGTT, the World Health Organization protocol requires
fasting for 8 hours and 150 grams of carbohydrates.
The OGTT, but not the HgbA1c, is sufficiently sensitive to diagnose CFRD.

Research Concepts:

Diabetes Mellitus Screening

Page 841 of 955

Question 889: A patient presents with progressive dyspnea, hypoxia, and lower extremity
edema. She is given high-dose diuretics during the hospital stay with an eventual
improvement of symptoms. A surgical lung biopsy is performed with evidence of intimal
fibrosis, smooth muscle hypertrophy, and obliteration of the pulmonary venules. What is
the only curative option for this disease?

Choices:

1. Intravenous prostacyclin
2. Lung transplantation
3. Atrial septostomy
4. Liver transplantation
Answer: 2 - Lung transplantation

Explanations:

This patient has pulmonary veno-occlusive disease based on histopathology.

The only curative treatment of pulmonary veno-occlusive disease is lung
transplantation.
Pulmonary vasodilators have been utilized as a bridge to transplant but are not
curative and afford several risks.
Early referral for lung transplantation is recommended for all patients with pulmonary
veno-occlusive disease.

Research Concepts:

Pulmonary Veno-Occlusive Disease

Page 842 of 955

Question 890: A middle-aged male presented to the emergency department after a 4-
day history of progressively worsening respiratory symptoms, including dyspnea on
exertion, cough, and fever, with no improvement after initiating a course of antibiotics.
Auscultation revealed scattered bilateral crepitations. No relevant travel or occupational
history was reported, but the patient endorsed daily use of e-cigarette with a fluid
containing both tetrahydrocannabinol (THC) and nicotine. HIV screening was negative.
The patient was not maintaining oxygen saturation with high flow oxygen. Arterial blood
gases (ABGs) showed hypoxic respiratory failure, and the patient was subsequently
intubated and shifted to the ICU for mechanical ventilation. A chest x-ray revealed
bilateral infiltrates. Blood cultures and respiratory viral panel polymerase chain reaction
(PCR) came out negative. Given the most likely diagnosis, which of the following is to be
seen on the chest CT of this patient?

Choices:

1. Crazy paving pattern

2. Bilateral ground-glass opacities with subpleural sparing
3. Honeycombing of the lung fields
4. Perihilar lymphadenopathy and bilateral reticulonodular opacities
Answer: 2 - Bilateral ground-glass opacities with subpleural sparing

Explanations:

Given the patient's history, the patient is most likely suffering from vaping
associated pulmonary injury. Absence of recent travel history, sick contacts,
negative blood cultures, and respiratory viral polymerase chain reaction (PCR)
exclude viral pneumonia.
The key risk factor for e-cigarette or vaping product associated lung injury (EVALI)
is the use of an e-cigarette or similar product. The most common chest CT
findings are bilateral ground-glass opacities with subpleural sparing.
Diluents such as vitamin E in THC containing vaping products have been implicated in
the pulmonary injury seen in these patients.
''Crazy paving pattern'' has been characteristically reported with a large number of
COVID-19 cases. Honeycombing is characteristic of interstitial pneumonia, whereas
perihilar lymphadenopathy, along with bilateral reticulonodular opacities, is
characteristic of sarcoidosis.

Research Concepts:Vaping Associated Pulmonary Injury

Page 843 of 955

Question 891: A 48-year-old female with a past medical history of hypertension and
prediabetes presents to the emergency department complaining of a spinning sensation.
She states it started about 4 hours ago but did not come to the hospital immediately
because she thought it would resolve on its own. She has never experienced symptoms
like this before. It is associated with difficulty ambulating and nausea with three episodes
of non- bloody, non-bilious vomiting. Upon further questioning, she reveals that she has
been an instructor at a diving academy for twenty years. She dives daily, and her
symptoms began on her way home from work. She denies fever, cough, chest pain,
palpitations, difficulty breathing, headache, changes in vision, rashes, abdominal pain,
weakness, or loss of sensation. Her family history is positive for a stroke in her father, who
passed away at age 81. Her vital signs reveal a blood pressure of 139/81 mmHg, a heart
rate of 79 beats per minute, a respiratory rate of 16 breaths per minute, and a SpO2 of
96% on room air. On physical exam, head and neck examinations are atraumatic and
within normal limits, including hearing and otoscopic examinations. The neurological
exam is only notable for mildly ataxic gait but otherwise is intact, including cerebellar
function. Which of the following is the next best step in managing this patient?

Choices:

1. Meclizine
2. Computed tomography (CT) head
3. 100% oxygen via a non-rebreather mask
4. Magnetic resonance imaging (MRI) head

Answer: 3 - 100% oxygen via a non-rebreather mask

Explanations:

This patient is presenting within hours of surfacing from a recreational dive

complaining of vertigo, ataxia, and nausea. The patient's neurological exam is only
positive for mildly ataxic gait without cerebellar dysfunction.
This makes inner ear decompression sickness (IEDCS) a likely diagnosis. The treatment
for suspected and confirmed IEDCS is immediate recompression therapy with
hyperbaric oxygen.
If recompression therapy is not immediately available, the patient should be placed
on 100% oxygen until recompression is available. The patient should also be treated
with fluids, either oral or intravenous depending on the patient's neurological
status.
Meclizine is used to treat benign positional peripheral vertigo (BPPV). It is not used
to treat inner ear decompression sickness and should not be given to this patient.
Although the patient does have risk factors for stroke (smoking and hypertension),
Page 844 of 955
 the patient is young and otherwise healthy. The only physical exam finding is a
mildly ataxic gait, most likely due to vertigo.
There are no focal neurological deficits or evidence of cerebellar dysfunction. This
makes stroke less likely, and a CT or MRI of the head is not indicated at this time in
the workup.

Research Concepts:

Inner Ear Decompression Sickness

Question 892: A 65-year-old male presents to the clinic with complaints of chronic cough
with sputum production that started eight months ago. The sputum is mucoid and has a
high volume. He also complains of occasional dyspnea on exertion. On further
questioning, he reveals that he has had multiple episodes of upper respiratory tract
infections throughout his life. A detailed medical history reveals that he was diagnosed
with Young syndrome in his early middle age. His vital signs are stable. A chest
examination performed reveals bibasal crackles. Spirometry performed reveals
decreased forced expiratory volume in one second (FEV1). What is the characteristic
feature of the finding on a high-resolution computed tomography (HRCT) of the chest in
this condition?

Choices:

1. A bronchoarterial ratio of more than one

2. A bronchoarterial ratio equal to zero
3. A bronchoarterial ratio of less than one
4. A bronchoarterial ratio equal to one

Answer: 1 - A bronchoarterial ratio of more than one

Explanations:

Bronchiectasis is a chronic lung disease characterized by persistent and lifelong

widening of the bronchial airways and weakening of the function mucociliary
transport mechanism owing to repeated infection contributing to bacterial invasion
and mucus pooling throughout the bronchial tree.
Bronchoarterial ratio (BAR) is the ratio of bronchial lumen diameter to the diameter
of its accompanying artery. The normal ratio is usually taken as 1:1.
BAR of more than 1 corresponds to bronchial dilation. Other signs that characterize
Page 845 of 955
 bronchial dilatation include lack of bronchial tapering and visibility of airways
within 1 cm of the pleural surface.
Bronchial dilation is the cardinal sign of bronchiectasis characterized by BAR. High-
resolution computed tomography is more sensitive and provides more specific
information than a chest x-ray.

Research Concepts: Bronchiectasis

Question 893: A 65-year-old male patient presents to the hospital with persistent
dyspnea for six months. The patient has been smoking cigarettes for 30 years. On
examination, he has reduced breath sounds along with the presence of rhonchi in
bilateral lung fields. Tall P waves are seen on EKG, and pulmonary artery systolic pressure
is measured to be 35 mmHg. Spirometry shows a low FEV1/FVC ratio with poor post-
bronchodilator reversibility. A DLCO is done, which is 46 percent of the predicted value.
What is the most likely diagnosis?

Choices:

1. Asthma
2. Interstitial lung disease (ILD)
3. Chronic obstructive pulmonary disease (COPD)
4. Obesity

Answer: 3 - Chronic obstructive pulmonary disease (COPD)

Explanations:

DLCO is a measurement to assess the ability of the lungs to transfer gas from
inspired air to the bloodstream. Carbon monoxide has a high affinity for
hemoglobin, and it follows the same pathway as that of oxygen to finally bind with
hemoglobin. Inhaled carbon monoxide is used for this test due to its high affinity for
hemoglobin (200-250 times that of oxygen).
Pulmonary function tests in COPD show a low FEV1/FVC ratio with poor post-
bronchodilator reversibility and low DLCO. The severity of DLCO is classified as normal
when DLCO is 75% of predicted up to 140%, mild 60% to LLN (lower limit of normal),
moderate 40-60%, and severe less than 40%.
Spirometry, in case of asthma, will have a low FEV1/FVC with good post-
bronchodilator reversibility. DLCO is usually normal/high in the case of asthma.
Even though DLCO is low in the case of ILD, the FEV1/FVC ratio is usually normal to
Page 846 of 955
 high on spirometry.
Even though DLCO may be low in the case of the chest wall and neuromuscular
abnormalities, the FEV1/FVC ratio is usually normal to high on spirometry.

Research Concepts:

Diffusing Capacity Of The Lungs For Carbon Monoxide

Question 894: A 49-year-old otherwise healthy female scuba diver is hospitalized after
she ran out of O2 during a 10-meter dive. She was rescued by her dive partner, who
initiated prompt CPR and activated EMS. The patient is transported to the emergency
department and requires ventilatory support initially. Which of the following is the most
appropriate in-hospital management strategy for this patient?

Choices:

1. Early weaning of ventilation and prophylactic antibiotics

2. Intubation lasting 48 hours or more and keeping patient euthermic
3. Aggressive fluid resuscitation and vasopressors
4. Early weaning of ventilation and keeping patient euthermic
Answer: 2 - Intubation lasting 48 hours or more and keeping patient euthermic

Explanations:

Inpatient management of a drowning patient includes mechanical ventilation for at

least 48 hours, maintaining hemodynamic balance, thermodynamic balance,
acid/base balance, and generally the avoidance of prophylactic antibiotics unless
otherwise indicated.
Intubation for at least 48 hours allows for surfactant regeneration as surfactant is
often destroyed and washed out by the presence of water in the alveoli.
Weaning from ventilation earlier than 48 hours may increase the risk of pulmonary
edema requiring re-intubation.
Prophylactic antibiotics immediately following a near-drowning incident are not
associated with a reduction in the prevalence of pneumonia or decreased mortality.

Research Concepts:Shallow Water Blackout

Page 847 of 955

Question 895: A 16-year-old male patient presents to the hospital with complaints of dry
cough, headache, fever, and malaise for three days. He states that he has had rhinorrhea,
pharyngitis, skin rash, and earache for the past one week. On examination, he looks
unwell with a high-grade fever. His blood pressure is 105/70 mmHg, heart rate is 89/min,
and oxygen saturation is 93% on room air. On auscultation of the chest, there are
scattered rales and wheezes. Laboratory investigations reveal, sodium 129 mmol/l,
hemoglobin 9.7 g/dl, mean cell volume 92 fl, and white cell count 11500 per microliter.
Peripheral smear shows fragmented red blood cells with reticulocytosis. What
dermatological manifestation he is most likely to exhibit?

Choices:

1. Erythema multiforme
2. Prurigo nodularis
3. Pyoderma gangrenosum
4. Granuloma annulare
Answer: 1 - Erythema multiforme

Explanations:

Mycoplasma can also be associated with severe extrapulmonary complications.

These complications may be due to the organism itself it may be triggered by the
resulting immunological response to the bacteria.
M. Pneumoniae infection may be associated with urticaria, erythema multiforme,
erythema nodosum or steven johnson syndrome. The skin lesions are seen in about
one-third of patients.
Gradual onset of symptoms combined with extrapulmonary involvement as well as
a normal WBC count points to atypical pneumonia. Most patients with M.
pneumoniae pneumonia present in outpatient settings and treatment is often with
empiric antibiotics for atypical pneumonia.
Treatment of M. pneumoniae includes macrolides, doxycycline, or
fluoroquinolones. Azithromycin is the most frequently used antibiotic and is
usually prescribed for 5 days (500 mg for the first dose, followed by 250 mg daily
for 4 days). Patients receiving doxycycline or fluoroquinolones should be given 7 to
14 days of treatment.

Research Concepts: Mycoplasma Pneumonia

Page 848 of 955

Question 896: A 34-year African American male presents with worsening abdominal pain,
distension, and diarrhea for the past 5 days. He has been otherwise healthy and works in
landscaping. Four months ago he was diagnosed with new-onset asthma with a dry cough
and wheezing, which has not been getting better despite treatment. He has been on oral
prednisone for 4 weeks now. He has a persistent cough with distinct shortness of breath.
He also appears confused and complains of a severe headache. His vital signs show a
temperature of 102°F (38.9°C), respiratory rate of 30 breaths per minute, heart rate of
110 beats per minute, and oxygen saturation of 84% on room air. Physical examination
reveals a petechial rash on his right leg. His wife states that he recently had a similar itchy
rash on his right arm. Lab work shows significant eosinophilia with an absolute eosinophil
count of 1400 cells/microL. The serum sodium level is 122 mEq/dL. Lumbar puncture
reveals a cerebrospinal fluid (CSF) white blood cell count of 22 x 10^6/L (91%
lymphocytes), CSF protein of 0.46 g/L, and CSF glucose of 8.6 mmol/L. Over the next 24
hours, the CSF and blood cultures turn positive for Escherichia coli. What is the
pathophysiological mechanism of his underlying disease process?
Choices:

1. Entrance of filariform larva by perianal skin

2. The entrance of filariform larva by finger mouth contamination from soil
3. Entrance of rhabditiform larva by mouth
4. Entrance of parasitic eggs by mouth

Answer: 1 - Entrance of filariform larva by perianal skin

Explanations:

This patient's clinical presentation with the pathognomonic rash of larva currens is
diagnostic of Strongyloides infection. His acute presentation, however, with CNS
involvement, and hyponatremia, is suggestive of disseminated strongyloidiasis.
Disseminated strongyloidiasis usually happens in a chronic host harboring the
parasite by autoinfection with acute dissemination from immunosuppression
(secondary to corticosteroid use in this case).
Infective filariform larva prematurely reinvades the host either via intestinal wall or
perianal skin to create a perpetual cycle of infection known as autoinfection.
Autoinfection usually occurs in individuals with impaired cell- mediated immunity. It is
the key pathway to both hyperinfection syndrome and disseminated strongyloidiasis.

Research Concepts: Strongyloidiasis

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Question 897: A 75-year-old woman with a past medical history of chronic kidney disease
3A, hypertension, COPD, and type 2 diabetes presents to the hospital with complaints of
flu-like symptoms for 4 to 6 days. She reports she tested positive for SARS- CoV-2 a day
back at a drive-through testing center. On admission, the patient is febrile (100.8 F) and
hypoxic with SpO2 87% on 4 L/min nasal cannula oxygen. The initial laboratory workup at
admission is unremarkable. CT scan of the chest without contrast shows bilateral ground-
glass opacities. The patient is admitted to low-level monitoring floors, given remdesivir
200 mg at admission, and scheduled to receive 100 mg daily for the next nine days. The
next morning, the patient’s eGFR was 27 mL/min compared to 45 mL/min at admission.
Which of the following is the next best step in managing this patient?

Choices:

1. Continue remdesivir infusion as scheduled

2. Reduce the dose of scheduled remdesivir infusion from 100 mg daily to 50 mg daily
3. Add dexamethasone
4. Discontinue remdesivir
Answer: 4 - Discontinue remdesivir

Explanations:

The patient's presentation of flu-like symptoms of acute hypoxic respiratory failure

with positive SARS-CoV-2 PCR in the setting of COPD is consistent with moderate to
severe COVID-19.
Given the patient's deterioration in eGFR compared to admission, remdesivir
should be discontinued immediately with close monitoring of renal function.
Remdesivir is contraindicated in adult patients with eGFR 30 mL/min.
The most recent dosing recommendation is to discontinue or not use remdesivir if the
patient's eGFR is below 30.

Research Concepts:

Remdesivir

Page 850 of 955

Question 898: A 24-year-old woman is trekking at an altitude of 3000 meters. She
complains of severe headaches and fatigue. Her friend offers her some granola bars, but
she refuses as she states she feels a little nauseated and is not hungry. According to the
Lake Louise questionnaire, what is her most likely acute mountain sickness score?

Choices:

1. 7
2. 3
3. 1
4. 0

Answer: 1 - 7

Explanations:

The Lake Louise score defines acute mountain sickness (AMS) as the presence of
headaches along with additional symptoms such as gastrointestinal symptoms,
fatigue or weakness and dizziness, or lightheadedness.
Each symptom is appointed a point on a scale from 0 to 3 (0= no effect, 1= mild,
2=moderate, 3= severe).
This patient has a severe headache (3 points), severe fatigue (3 points), and mild
nausea with poor appetite (1 point).
Therefore her total AMS score is 7.

Research Concepts:

Acute Mountain Sickness Score

Question 899: A 74-year-old male patient is recovering in the surgical ICU after a motor
vehicle accident. The patient has been treated for multiple extremity fractures and
consistently notes pain level at 8/10. He is currently undergoing a trial of pressure support
ventilation. The current ventilator setting is as follows: pressure support mode 12 cmH2O,
CPAP 5 cmH2O, and 45 % FiO2. The patient presents with the following monitored
parameters 10 min into the PSV mode: VTe 550 ml, spontaneous RR 28 bpm, and BP
160/95 mmHg. The patient presents to be very anxious. Which of the following is the next
best step in the management of this patient?

Choices:

1. Sedate the patient with propofol.

Page 851 of 955
2. Return the patient to a mechanically controlled rate.
3. Give fentanyl for analgesia and monitor the respiratory status.
4. Verbally reassure the patient.
Answer: 3 - Give fentanyl for analgesia and monitor the respiratory status.

Explanations:

When a patient experiences pain, other monitored data such as heart rate and
blood pressure deviate from acceptable ranges. Maintaining a patient comfort level
while keeping the respiratory drive in mind is an important part of a spontaneous
breathing trial.
Pain and anxiety should be ruled out before discontinuing SBT. Sedating this patient
with propofol will halt the weaning process. The goal is to allow the patient to stay
alert and maintain spontaneous respirations. Propofol should only be adminsited
when medically appropriate.

Research Concepts:

Pressure Support

Question 900: A 40-year-old female has been having complaints of chronic cough for the
past four years, not associated with fever. In addition to that, she had joint pains,
involving the various large joints of the body. Morning stiffness is also present, along with
tenderness. On examination, swan neck deformity is seen in the hands. The provider
advised an octreotide scan in addition to the high resolution computed tomography
(HRCT) thorax for evaluation of the lung pathology, saying that the octreotide scan has
excellent accuracy in the diagnosis of this lung pathology. What is the most likely lung
pathology?

Choices:

1. Respiratory tract infection

2. Usual interstitial pneumonia (UIP)
3. Non-specific interstitial pneumonia (NSIP)
4. Lung cancer

Answer: 2 - Usual interstitial pneumonia (UIP)

Page 852 of 955

Explanations:

Octreotide scan can be useful to monitor idiopathic interstitial pneumonitis (IIP) in

specific histological types (non-specific interstitial pneumonia and desquamative
interstitial pneumonia) and may even substitute high resolution computed
tomography in the assessment of usual interstitial pneumonia (UIP) for its
excellent accuracy.
Rheumatoid arthritis can present with interstitial lung disease (ILD), with UIP being
the commonest type.
UIP or, for that matter, interstitial lung diseases symptomatically present with chronic
cough, generally non-productive.
Female sex, joint pains, morning stiffness, and the characteristic "swan-neck"
deformities all point towards a diagnosis of rheumatoid arthritis.

Research Concepts:

Octreotide Scan

Section 10

Question 901: A 26-year-old man presents to the emergency department for high-grade
fevers. He was diagnosed with HIV 4 years ago and then was lost to follow up. His last
known CD4 count was 20/microL. On arrival, his temperature is 39 C, and is he is
saturating 80% on room air. He is visibly tachypneic with a respiratory rate of 26/min. He
is given supplemental oxygen. A chest x-ray shows bilateral alveolar infiltrates. His 1-3-
beta-D-glucan level is 200 pg/mL. He is also given vancomycin and cefepime and
transferred to the medical intensive care unit. On arrival to the ICU, he is intubated for
worsening hypoxemia. Which of the following is the next best step in the management of
this patient?

Choices:

1. Inhaled tobramycin
2. Amphotericin B
3. Co-trimoxazole and methylprednisolone
4. Inhaled pentamidine

Answer: 3 - Co-trimoxazole and methylprednisolone

Page 853 of 955

Explanations:

The patient has HIV with a CD4 count of 20/microL. His clinical and radiological
signs, along with the severe degree of immunosuppression, are highly suggestive
of a PJP infection. An elevated level of 1-3-beta-D-glucan (>80 pg/mL) also
corroborates the PJP infection.
Diagnostic testing can sometimes be forgone if the above criteria are met and
there is no other credible differential diagnosis.
Severe disease is defined as with PaO2 levels less than 60 mm of Hg and A-a O2
gradient >45 mmHg. Intravenous co- trimoxazole is given for severe disease with the
transition to oral once stabilization is achieved.
Pentamidine is reserved only for patients who are either allergic to or cannot
tolerate co-trimoxazole.

Research Concepts: Pneumonia Pathology

Question 902: A 54-year-old man with a 30 pack-year smoking history presents to the
clinic for complaints of wheezing in the setting of cough, dyspnea, and sputum retention.
Prior to the initial consultation, an anteroposterior chest radiograph performed at
maximal inspiratory effort was diagnostically unrevealing, and proton pump inhibitor
therapy was discontinued in view of negative esophageal impedance-pH testing. In-office
PFTs and bronchoprovocation testing are both within normal limits while physical
examination demonstrated expiratory wheezing exaggerated by increased respiratory
effort and occasional coughing. Smoking cessation efforts have been unsuccessful to date.
Which of the following is the next most appropriate diagnostic test for this patient?
Choices:

1. Low-dose computed tomography for annual lung cancer screening

2. Esophagogastroduodenoscopy
3. Computed tomography (inspiratory phase)
4. Dynamic flexible bronchoscopy
Answer: 4 - Dynamic flexible bronchoscopy

Explanations:

The gold standard for the diagnosis of tracheomalacia is dynamic flexible

bronchoscopy; however, dynamic computed tomography is gaining popularity. In
either case, the fact that the patient’s wheezing is exaggerated by increased
expiratory effort and cough highlight the dynamic nature of tracheomalacia.
Page 854 of 955
 The patient’s presentation, although consistent with tracheomalacia, is non-specific
and carries a broad differential diagnosis including, but not limited to COPD (chronic
bronchitis, emphysema), GERD-related cough, and inhalation injury (i.e., cigarette
smoke). In this case, the pulmonary function test (PFTs) and the esophageal
impedance-pH test rule out COPD and GERD, respectively, as the etiology of the
patient's tracheomalacia. It should be noted that PFTs demonstrate an obstructive
defect in ~45% of patients with tracheomalacia; however, normal findings are
present in ~21% of individuals with this disease.
In this case, inhalation injury due to cigarette smoking is the most likely etiology of
the patient's tracheomalacia.
Remember: Low-dose computed tomography for annual lung cancer screening is
indicated in individuals 55 to 80 years of age with at least a 30 pack-year smoking
history who continue to smoke or have quit within the last 15 years.

Research Concepts: Wheezing

Question 903: A 70-year-old woman is readmitted to the ICU with respiratory failure
requiring intubation due to chronic obstructive pulmonary disease (COPD) exacerbation.
She has a history of COPD, type 2 diabetes, coronary artery disease (CAD), and a 7-day
hospitalization 12 days ago. On the 4th day of her admission, she develops increased
sputum production, a temperature of 101.9°F (38.8°C), deteriorating oxygenation, and a
recent infiltrate in the base of the left lung. Which of the following empiric antibiotic
regimen is most appropriate for this patient?

Choices:

1. Azithromycin plus moxifloxacin

2. Linezolid plus tobramycin
3. Cefepime plus vancomycin
4. Ceftriaxone plus azithromycin
Answer: 3 - Cefepime plus vancomycin

Explanations:

Ventilator-associated pneumonia (VAP) is a term used to describe pneumonia (lung

infection) that develops in a patient who has been on mechanical ventilation for
more than 48 hours. Ventilator-associated pneumonia is suspected in the setting of
fever, a change in auscultation exam, a change in the chest x- ray, and an increasing
requirement for respiratory support.
Despite the fact that this patient has early-onset ventilator- associated pneumonia
(VAP) for the recent admission, a history of the previous hospitalization is a risk
Page 855 of 955
 factor for multidrug- resistant (MDR) organisms.
Initial broad-spectrum therapy with coverage of gram-negative bacilli, including
Pseudomonas aeruginosa and possibly methicillin-resistant S. aureus, is
generally most appropriate.
Therefore, cefepime plus vancomycin should be given as empiric therapy in such
patients.

Research Concepts:

Ventilator-associated Pneumonia

Question 904: A 65-year-old male with a history of alcohol use disorder presents with
complaints of fever, malaise, and cough with hemoptysis. He has had these symptoms for
the past three months. On the physical examination, the patient appears ill and has a
low- grade fever. The posterior chest wall has a sinus tract draining fluid with a few sulfur
granules. The chest x-ray reveals a pleural-based cavitary lesion in the superior segment
of the right lower lobe that corresponds with the fistulous tract. A smear of the fluid
from the sinus tract shows slender, branching, gram-positive filamentous organisms.
What is the most appropriate treatment for the patient's condition?

Choices:

1. Penicillin G intravenously for two weeks

2. Penicillin G intravenously for six weeks
3. Resection of the cavitary lesion, followed by ceftriaxone for six weeks
4. Penicillin G intravenously for two weeks, followed by oral therapy for 3 to 6 months
Answer: 4 - Penicillin G intravenously for two weeks, followed by oral therapy for 3 to 6
months

Explanations:

Actinomycosis is a rare subacute to chronic infection caused by the gram-positive

filamentous non-acid fast anaerobic to microaerophilic bacteria, Actinomyces. The
infection is usually a granulomatous and suppurative infection. The chronic form
has multiple abscesses that form sinus tracts and are associated with sulfur
granules. About 70% of infections are due to either Actinomyces israelii or
Actinomyces gerencseriae.
The imaging for actinomycosis is nonspecific. In the acute presentation, it can look
Page 856 of 955
 like any other pneumonia. In chronic forms, it can present as a pulmonary mass or
can cavitate. In the case of a mass malignancy, actinomycosis is an important
diagnosis to consider. Especially when it cavitates, tuberculosis is an important
differential diagnosis to consider. The computed tomography scan findings can vary
depending upon the duration of illness and can include consolidation, cavitation,
pleural effusion, lymph node enlargement, atelectasis, and ground glass
opacification.
Antibiotics are the mainstay of therapy for Actinomyces infections, and penicillin is
the drug of choice.
Prolonged treatment is required to prevent recurrent infection. Resection is not used
in the management of actinomycotic lung abscesses. In patients allergic to penicillin,
tetracycline, clindamycin, ceftriaxone, and ciprofloxacin have been used with success.
Research Concepts: Actinomycosis

Question 905: A 16-year-old man presented to the clinic with complaints of progressively
worsening shortness of breath, productive cough, hemoptysis, burning chest pain while
breathing, and a high fever. He had previously been to a hospital with complaints of
cough and hot sweating episodes and was discharged with antibiotics after a normal chest
X-ray 2 weeks ago. The rest of the medical and surgical history was insignificant. On
readmission, patient vitals were as follows: temperature of 38.9 C, blood pressure of
110/65 mmHg, pulse rate of 120/min, respiratory rate of 40/min, and oxygen saturation
of 92% with oxygen. Results of arterial blood gas analysis of the patient were as follows:
pH 7.28, PCO2 3.8 kPa, PO2 10.1 kPa, and lactate 3.9 mmol/L. Crystalloid intravenous
fluids and intravenous antibiotics were started. A repeat chest X-ray showed a right-sided
dense opacity suggestive of pleural effusion, and the thoracic ultrasound confirmed a
moderate unilateral pleural effusion. Which of the following methods should be used to
obtain the culture and sensitivity of the microorganism responsible for this patient's
condition?

Choices:

1. Sputum culture
2. Thoracocentesis fluid culture
3. Blood culture
4. Fluid obtained from pre-existing drainages
Answer: 2 - Thoracocentesis fluid culture

Explanations:

This patient's presentation may be similar to pneumonia with cough, sputum

production, fever, and pleuritic-type chest pain. However, patients with empyema
Page 857 of 955
 may have symptoms for a more extended period. Research has shown that patients
with empyema presented after a median of 15 days after the onset of symptoms.
On physical exam, there may be dullness to percussion of the affected area,
egophonia, increase palpable fremitus, and fine crackles. However, symptoms and
physical exam findings are nonspecific. Patients not improving with appropriate
antibiotic therapy should be checked for the possibility of empyema.
Pleural fluid cultures have reduced sensitivity; this can improve if the fluid is not
only stored in sterile containers but also in blood culture bottles.
Ideally, the culture fluids should be obtained from thoracentesis, chest tube
placements, or surgical intervention, but never from pre-existing drainages.

Research Concepts:Empyema

Question 906: A 50-year-old man presents to the emergency department due to

worsening shortness of breath and abdominal discomfort for the past week. He has a
history of diabetes, obesity, hypertension, alcoholic pancreatitis, and known recurrent
pleural effusion that was diagnosed 2 months ago. The patient’s current medications
include lisinopril 40 mg daily, metformin 1000 mg twice a day, and octreotide 100 mcg
subcutaneously three times a day.
The patient follows a nutritionist. Vital signs include a temperature of
98.6 F, blood pressure 145/90 mmHg, heart rate 115/min, respiratory rate 18/min, and
oxygen saturation 93% on 3 L/min oxygen by nasal cannula. Physical examination shows a
dry oral mucosa, no murmurs on the cardiac exam, absent breath sounds at the left
hemithorax, and mild generalized abdominal tenderness. A chest x- ray shows a large left
pleural effusion. The pleural fluid analysis shows an amylase level of 5000 U/L. MCRP
shows a fistula tract from the pancreas to the left pleura cavity that is unchanged from
prior imaging. Which of the following is the next best step in the management of this
patient?

Choices:

1. Endoscopic retrograde cholangiopancreatography

2. Surgical repair
3. Computerized tomography of chest, abdomen, and pelvis
4. Inpatient monitoring

Answer: 1 - Endoscopic retrograde cholangiopancreatography

Explanations:

In the treatment of pancreatic fistula, when supportive care and medical management
Page 858 of 955
 such as with octreotide fails, then endoscopic intervention is required.
Surgery is necessary for a pancreatic fistula when the endoscopic approach fails or
it is not feasible.
Prior to any definitive treatment, patients should be fluid resuscitated, electrolyte
replenished, kept nil per os, and given a somatostatin analog to allow the body to
heal and close the fistula.
About 80% and 50%-65% of external and internal pancreatic fistulas respectively
close in four to six weeks with supportive care.

Research Concepts:Pancreatic Fistula

Question 907: A 63-year-old male presented with complaints of blood in the urine. He also
reports cough, shortness of breath, hemoptysis, and rash on his bilateral lower
extremities. Lab workup reveals a hemoglobin of 8.9 mg/dl, blood urea nitrogen (BUN) 88
mg/dl, creatinine 5.6 mg/dl, Urinalysis has significant proteinuria, hematuria, and many
RBC casts were noted. Further lab workup shows a positive c-ANCA and an elevated PR3
antibody titer. CT scan of the chest showed bilateral pulmonary infiltrates. Which of the
following findings is expected on the lung biopsy in this patient?

Choices:

1. Granulomas surrounded by histiocytes and giant cells with central necrosis

2. Non granulomatous lesions
3. Granulomas with central necrosis rich in eosinophils
4. Necrotizing granulomas with fungal hyphae

Answer: 1 - Granulomas surrounded by histiocytes and giant cells with central necrosis

Explanations:

Granulomas surrounded by palisading histiocytes and giant cells with central necrosis
is commonly seen in granulomatosis with polyangiitis (GPA). This was formerly known
as Wegener granulomatosis.
The presence of granulomatous inflammation involving the upper respiratory tract
is said to differentiate GPA from microscopic polyangiitis.
Other histologic features of GPA include small microabscesses, necrosis of collagen,
and partial or complete occlusion of blood vessels.
Vasculitis in GPA affects both the arteries and veins, and sometimes capillaries could
be involved resulting in necrotizing capillaritis that could lead to intra-alveolar
hemorrhage.
Research Concepts: Granulomatosis with Polyangiitis
Page 859 of 955
Question 908: An 18-years-old man with a history of epilepsy is brought to the emergency
unit with shortness of breath for the past 2 hours. He had a fever for almost 6 days and
was not resolved by antipyretic. A day before, he expelled putrid-smelling sputum which
he never had before. His vital signs show a temperature of 38.6 C and respiratory rate of
32/min. What is the most likely physical examination finding expected in this patient?

Choices:

1. Expiratory wheezing
2. Decreasing of fremitus
3. Dullness to percussion
4. Barrel chest

Answer: 3 - Dullness to percussion

Explanations:

The patient's symptoms such as fever, productive cough (putrid sputum with foul-
smelling breath), or malaise suggest lung abscess as the most likely diagnoses.
A history of seizure is one of the risk factors for lung abscess formation.
The cornerstone of lung abscess' treatment is antibiotics. This patient's fever had
not resolved because the patient infection was just treated by antipyretics and had
not taken any antibiotics.
Lung abscess indicates that there is a cavity inside the lung parenchyma. The cavity
contains necrotic debris or fluid.
Percussion of the thorax area where the lung abscess infected will result in the
dullness.

Research Concepts:

Lung Abscess

Page 860 of 955

Question 909: A 48-year-old male with a history of severe persistent asthma was
admitted to the intensive care unit for an acute asthma exacerbation requiring
intubation. The patient experienced severe bronchospasm and was noted to be difficult
to intubate with profound agitation, requiring intermittent doses of cisatracurium, along
with heavy analgesia and sedation with fentanyl, propofol, and intermittent boluses of
midazolam. He received high-dose intravenous corticosteroids for 7 days for the asthma
exacerbation, which are currently being tapered, along with broad-spectrum antibiotics
for presumed ventilator-associated pneumonia. His respiratory status stabilizes and he is
extubated on day 14. After extubating, he is noted to be profoundly weak and unable to
raise his arms over his head. There are no sensory deficits and no focal neurological signs,
he is otherwise alert and oriented, and lungs are clear to auscultation. His creatine kinase
(CK) levels were monitored throughout the admission and have remained normal. Basic
labs are within normal limits. Minimizing the use of which of the following medications
would be recommended to prevent this condition?

Choices:

1. Fentanyl
2. Cisatracurium
3. Propofol
4. Midazolam

Answer: 2 - Cisatracurium

Explanations:

Curare-like paralytic agents (such as cisatracurium), when used with corticosteroids,

can cause an acute myopathy in the intensive care setting.
Minimizing the use of curare-like paralytics is recommended when administering
systemic corticosteroids.
Creatine kinase is only rarely elevated in the setting of acute steroid myopathy in
the intensive care setting; thus, the normal CK level is reassuring of steroid-induced
myopathy.
Propofol can be associated with an acute myopathy, typically CK levels are
elevated along with evidence of renal dysfunction and metabolic acidosis.

Research Concepts:Corticosteroid Induced Myopathy

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Question 910: A 65-year-old male patient with a past medical history of poorly controlled
diabetes and chronic alcohol use disorder presents with dyspnea on exertion and "currant
jelly" sputum production. The radiograph reveals an opacification in the posterior aspect
of the right upper lung with a bulging fissure. Laboratory results suggest a WBC count of
12,000 with neutrophilia on the differential count. Which of the following is a common
complication in patients with this disease?

Choices:

1. Empyema
2. Septic arthritis
3. Liver failure
4. Renal failure
Answer: 1 - Empyema

Explanations:

Klebsiella pneumoniae is part of the Enterobacteriaceae family and is described as

a gram-negative, encapsulate, and non- motile bacterium. Virulence of the
bacterium is provided by a wide array of factors that can lead to infection and
antibiotic resistance.
Pneumonia caused by K. pneumoniae can be complicated by bacteremia, lung
abscesses, and the formation of an empyema. Pneumonia caused by K. pneumoniae
typically causes a lobar infiltrate that is in the posterior aspect of the right upper lung.
Another non-specific sign of K. pneumoniae on a chest radiograph is the bulging
fissure sign. This is related to the large amount of infection and inflammation the
organism can cause.
Research Concepts:

Klebsiella Pneumonia

Question 911: A 24-year-old previously well male with no comorbidities is admitted to the
intensive care unit (ICU) following a traumatic head injury. An endotracheal tube is
inserted, and he is commenced on mechanical ventilation. At admission, the patient’s
blood pressure is 124/80 mmHg; his heart rate is 72 beats/minute, his finger-prick blood
glucose is 6.8 mmol/L (122 mg/dl), his oxygen saturation 92% in room air, his respiratory
rate is 14 breaths/minute, and his body temperature is 36.7 C (98 F). He is placed in a
prone position, and his oxygen saturation is noted to improve to 96% in room air. Three
hours later, a ventilator alarm is activated to signal an acutely decreasing oxygen
saturation in the patient; the oxygen saturation is presently 89%. The patient’s blood
pressure is 108/70 mmHg, his heart rate is 98 beats/minute, his finger-prick blood glucose
Page 862 of 955
is 85 mg/dl, his respiratory rate is 25 breaths/minute, and his body temperature is
unchanged. Which of the following would be the most pertinent on the immediate
assessment of the patient?

Choices:

1. Assess for mucopurulent secretions

2. Assess the lower limbs for unilateral calf edema and tenderness
3. Assess the cardiac rhythm
4. Assess for airway dislodgement or obstruction
Answer: 4 - Assess for airway dislodgement or obstruction

Explanations:

Prone positioning has been shown to improve the oxygenation of dependent lung
regions in mechanically ventilated patients, as it removes the effect of the cardiac
mass on the lungs and redistributes the effect of non-fixed atelectasis of
dependent lung regions to anterior lung regions.
In a prone position, there is an increased risk of airway dislodgement and
obstruction. The underlying mechanism may include a kink in the endotracheal
tube, displacement of the tube into the esophagus or out of the airway (especially
under the effect of gravity), inadequate cuff inflation, cuff leaks, obstruction due to
respiratory secretions, the patient biting on the tube and, external compression
forces.
Optimal monitoring of mechanically ventilated patients often requires
multidisciplinary team collaboration and interprofessional communication (for
example, between the respiratory therapist and physician, in this scenario). It may
lead to early identification of acute changes in a patient’s clinical condition, with
faster time to intervention and better outcomes for patients.
When evaluating the diagnosis underlying an acute decline in oxygenation, deep
vein thrombosis with secondary acute pulmonary embolism, pneumonia (including
ventilator- associated pneumonia in patients who have been mechanically
ventilated for more than 48 hours), and cardiac arrhythmias are among other
differential diagnoses. However, the degree of clinical suspicion is an important
factor to consider. In this scenario, there is a relatively lower degree of clinical
suspicion for those conditions.

Research Concepts:

Ventilator Complications

Page 863 of 955

Question 912: A 45-year-old man is brought to the emergency department after
significant sulfur mustard exposure in a chemical attack. In addition to decontamination
and skin wound management at a burn center, which of the following is most appropriate
to include in the patient's management?

Choices:

1. Monitoring of airway and intubation for delayed onset of acute respiratory

distress syndrome
2. Monitoring of core temperature and cooling for electron transport chain uncoupling
3. Monitoring of coagulation parameters and treatment for disseminated
intravascular contamination (DIC)
4. Monitoring of methemoglobin level and methylene blue treatment for significant
elevation
Answer: 1 - Monitoring of airway and intubation for delayed onset of acute respiratory
distress syndrome

Explanations:

Patients with significant sulfur mustard exposure can develop mucous membrane
irritation and airway burns.
Pulmonary manifestations of exposure can be delayed for hours after initial
exposure.
In significant mustard exposures, the toxin can be systemically absorbed and affect
hematopoietic cell lines resulting in leukopenia.
Mustard gas does not affect the electron transport chain. Patients are not
expected to develop DIC in the absence of other inciting factors. Sulfur mustard
exposure does not induce oxidative stress on hemoglobin and does not necessarily
result in significantly elevated methemoglobin levels.

Research Concepts:

Blister Agents

Question 913: A patient with symptomatic pulmonary sarcoidosis is referred to discuss

treatment options. Which of the following is the most appropriate initial option to prevent
pulmonary fibrosis?

Choices:

1. Cyclophosphamide
Page 864 of 955
2. Systemic corticosteroids
3. Chest irradiation
4. Immunoglobulins
Answer: 2 - Systemic corticosteroids

Explanations:

In symptomatic patients with sarcoidosis, glucocorticoids administration is aimed at

the prevention of pulmonary fibrosis. The course of treatment is usually 3 to 6
months, but many patients do not tolerate the side effects.
Inhaled corticosteroids have been tried but results have been variable.
Other drugs to treat sarcoid include methotrexate, chloroquine, and
cyclophosphamide.

Research Concepts:

Sarcoidosis

Question 914: A 71-year-old man with a long history of cigarette smoking presents with
two months of cough and unplanned weight loss of 20 pounds. A lesion is visualized on a
chest X-ray, and the patient is subsequently diagnosed with stage 4 non-small cell lung
cancer. What diagnostic test will best determine whether the patient is started on a
tyrosine kinase receptor inhibitor vs. chemotherapy?

Choices:

1. BRAF mutation testing

2. PET CT scan
3. MRI
4. EGFR mutation testing
Answer: 4 - EGFR mutation testing

Explanations:

While many different mutations and pathways, including MAPK, are found in non-
small cell lung cancer, mutation in the EGFR in the ErbB family of receptors is the
most common.
Erlotinib is the first-line treatment of patients with EGFR mutation-
Page 865 of 955
 positive non-small cell lung cancer.
In patients with EGFR negative tumors, classic chemotherapy, including cisplatin, is
typically used.
While it might be helpful to obtain MRI and PET CT to ascertain the extent of the
disease, only EGFR mutation testing will determine whether to use erlotinib vs.
chemotherapy.

Research Concepts:

Erlotinib

Question 915: A 46-year-old man with no past medical history gets intubated and is
admitted to the medical intensive care unit for influenza induced adult respiratory
distress syndrome (ARDS). After 7 days of mechanical ventilation on high PEEP, he shows
improvement in his oxygen requirement. Ventilator settings are weaned down and
attempt at spontaneous breathing trial (SBT) is made. He fails his SBT because of copious
secretions. The next morning, he has sudden worsening oxygen saturation, with an
increase in his FiO2 requirements from 40% to 60%. A chest x-ray is obtained, which
shows complete atelectasis of the right middle and right lower lobe. Which of the
following is the next best step in the management of this patient?

Choices:

1. Therapeutic bronchoscopy with airway suctioning and toileting

2. Conservative management
3. Aggressive chest physical therapy including percussion and hypertonic saline
nebulizations
4. Scopolamine patch
Answer: 3 - Aggressive chest physical therapy including percussion and hypertonic saline
nebulizations

Explanations:

The patient has increased airway secretions which have led to mucus plugging
manifesting as atelectasis.
Airway suctioning and toileting, though may be appealing, are not preferred for
mucus plugging and clearing the secretions. Aggressive noninvasive chest
physiotherapy has been shown to be equally efficacious and can obviate the need
for bronchoscopy and potential complications that could arise from the procedure.
Page 866 of 955
 Bronchoscopy should be reserved for patients who cannot undergo these
treatments because of either chest wall trauma or spinal injury.

Research Concepts: Bronchoscopy

Question 916: A 35-year-old female patient presents to the hospital with a history of
shortness of breath and cough for six months. Recently, she has observed a purpuric rash
on several areas of her body and pink-colored urine. Her symptoms have aggravated, and
she is not able to lift her right foot. On auscultation, there is a wheeze all over her chest.
Her lab work shows eosinophilia and positive p-ANCA. She was prescribed some
medications to control her wheezing and shortness of breath, but they have only
aggravated her symptoms. What medication would have resulted in the worsening of her
symptoms?

Choices:

1. Inhaled albuterol
2. Zafirlukast
3. Ipratropium
4. Prednisolone
Answer: 2 - Zafirlukast

Explanations:

Zafirlukast is an oral leukotriene receptor antagonist used only for maintenance

therapy in asthma and used in conjunction with an inhaled steroid or a long-acting
bronchodilator.
It is used as a tablet twice a day. It blocks the action of leukotriene and reduces
cytokine buildup in the airways.
This patient has Churg-Strauss syndrome, which is known to get worse with the use
of leukotriene receptor antagonists.
The action of the cysteinyl leukotrienes on the CysLT1 receptors is blocked by
zafirlukast, which reduces the constriction of the airways, the build-up of mucus in
the lungs, and the inflammation of the breathing passages.

Research Concepts:

Asthma Medications
Page 867 of 955
Question 917: A 74-year-old man is brought to the emergency department with a
syncopal episode. He was walking in the mall when he felt dizzy and fell to the floor. He
has a past medical history of hypertension and takes lisinopril regularly. Vital signs on
examination show blood pressure 125/76 mmHg, pulse 98/min, temperature 36.7 C, and
respiratory rate 20/min. He is saturating at 92% on 2 L/min oxygen. An EKG is significant
only for sinus tachycardia. Orthostatic vital signs are not suggestive of orthostatic
hypotension. A CT head of the patient is unremarkable as well. The patient is admitted to
the hospital on suspicion of an underlying rhythm disorder. Overnight, the patient
develops acute shortness of breath and dies. Which of the following investigations is
most likely to have revealed the cause of the patient's death?

Choices:

1. CT abdomen
2. Pulmonary angiogram
3. MRA brain
4. MRI spine
Answer: 2 - Pulmonary angiogram

Explanations:

The clinical scenario describes a patient with an atypical presentation of

pulmonary embolism. Diagnostic errors result in death or injury to 40,000 to
80,000 patients per year according to the Joint Commission. Diagnostic errors are
most common in primary care solo practice due to workload and the inability to
cross-reference easily with colleagues.
Pulmonary embolism (PE) is often challenging to diagnose. It is known as the "great
masquerader" for a reason. The symptoms can be nonspecific and range from mild
to severe.
Patients present with a broad range of signs and symptoms similar to other
diseases, including shortness of breath, chest pain, confusion, hypotension, and
cardiovascular collapse. PE potentially has very mild symptoms, and it is an
incidental finding in approximately 3% of chest CTs.
Syncope occurs in approximately 10% of patients with pulmonary embolism.

Research Concepts:Medical Error Reduction and Prevention

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Question 918: A 46-year-old woman with systemic sclerosis presents for evaluation of
shortness of breath. Vital signs are pulse rate 81/min, blood pressure 124/71 mmHg,
respiratory rate 18/min, and temperature 98.6 F (37 C). Cardiac auscultation
demonstrates a systolic murmur in the parasternal area at the left 4th intercostal space.
Right heart catheterization reveals precapillary pulmonary hypertension, and
vasoreactivity testing is negative. She is classified as high risk for mortality based on the
European Society of Cardiology/European Respiratory Society risk classification. What is
the best next best step in the management of this patient?
Choices:

1. Calcium channel blocker monotherapy

2. Prostacyclin analog monotherapy
3. Phosphodiesterase 5 inhibitor plus endothelin receptor antagonist
4. Phosphodiesterase 5 inhibitor plus endothelin receptor antagonist plus prostacyclin
analog
Answer: 4 - Phosphodiesterase 5 inhibitor plus endothelin receptor antagonist plus
prostacyclin analog
Explanations:

A comprehensive risk assessment strategy that includes clinical judgment should be

done for each patient with pulmonary arterial hypertension (PAH). The 2022
European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines
risk table divides patients into low (5%), intermediate (5-20%), or high (> 20%) risk
based on estimated one-year mortality.
Other risk scores include the French Pulmonary Hypertension Network (FPHN)
Registry risk equation. The REVEAL 2.0 risk score calculator is an update of the
original risk score calculator. In patients with PAH without cardiopulmonary
comorbidities who are classified as high risk, initial triple therapy with a
phosphodiesterase 5 inhibitor plus an endothelin receptor antagonist plus a
prostacyclin analog should be started. If the patient still remains at high risk on
follow-up, lung transplant evaluation should be initiated.
In patients without cardiopulmonary comorbidities who are low to intermediate
risk, initial therapy should consist of a phosphodiesterase 5 inhibitor plus an
endothelin receptor antagonist.
Calcium channel blockers should not be used in patients with negative vasoreactivity
testing.

Research Concepts: Pulmonary Hypertension

Page 869 of 955

Question 919: A 28-year-old female with a past medical history of asthma is on day 4 of a
trek in Nepal. She is at an elevation of 4300 meters (2.7 miles). She reports worsening
shortness of breath that is now present with minimal exertion, and she has an associated
productive cough. Which of the following best describes the pathophysiologic cause of
this patient's symptoms?

Choices:

1. Hypoxia-induced vasoconstriction causing increased pulmonary pressures

2. Cold air exacerbating pulmonary bronchospasm
3. Increased cardiac output at altitude leading to pulmonary edema
4. Decreased atmospheric pressure causing a large pressure gradient in the
lung and capillary leak
Answer: 1 - Hypoxia-induced vasoconstriction causing increased pulmonary pressures

Explanations:

Hypoxia at altitude leads to vasoconstriction of the pulmonary vessels with

subsequent increased pulmonary pressures, which is thought to occur in an
unequal distribution in high-altitude pulmonary edema (HAPE). This unequal
distribution causes shunting and increased flow to certain areas of the lung, leading
to overperfusion, capillary leak, and edema.
Although cold temperatures are associated with an increased risk of high-altitude
pulmonary edema, the mechanism is not due to bronchospasm. This patient does
have a history of asthma, but at an altitude of 4300 meters (2.7 miles) with
worsening dyspnea and a productive cough, HAPE is the more likely and more
serious cause of her symptoms.
Increased cardiac output alone does not lead to pulmonary edema without other
inciting pathology, regardless of altitude. The pressure difference in the lung is a
contributing factor in pulmonary edema, but vasoconstriction and increased
pulmonary pressures cause the capillary leak and pulmonary edema more than
decreased atmospheric pressure.

Research Concepts:

High Altitude Cardiopulmonary Diseases

Page 870 of 955

Question 920: A 16-year-old boy is intubated for acute respiratory distress syndrome
(ARDS) secondary to pancreatitis. He has a right radial arterial line placed. The patient is
currently on peak inspiratory pressure (PIP) 30 cm H2O, positive end-expiratory pressure
(PEEP) 10, and FiO2 80%. He has a SpO2 of 93% on the ventilator. Which of the following
best describes the primary indication for keeping an arterial line for this patient?

Choices:

1. Measurement of cerebral perfusion pressure

2. Separate access for infusion of medications that are not compatible
together
3. Accurate measurement of oxygenation index
4. As an access point for cardiac catheterization
Answer: 3 - Accurate measurement of oxygenation index

Explanations:

In this patient who has hypoxemic respiratory failure, the arterial line would allow
for the assessment of the oxygenation index (OI). This is a measurement of the
severity of lung disease and is calculated by mean airway pressure/ partial pressure
of oxygen in arterial blood x FiO2.
The partial pressure of arterial blood requires an indwelling arterial catheter,
especially because the trend in the OI is more important than a single value.
An oxygenation index of more than 8 implies acute respiratory distress syndrome
(ARDS), which is moderate, and more than 16 implies severe ARDS.
This patient with pancreatitis would require closer monitoring of blood pressure
and blood gases and not of cerebral perfusion pressure. Medications should never
be administered in the arterial line. The question does not give any description of
cardiac dysfunction, and hence cardiac catheterization is not needed.

Research Concepts:

Arterial Lines

Page 871 of 955

Question 921: A 58-year-old woman presents with a cough and shortness of breath that
began two days ago. She denies hemoptysis, chest pain, or diaphoresis. She was
diagnosed with dermatomyositis eight months ago, for which she has been taking
azathioprine. Other medical history includes hypertension, for which she takes
amlodipine daily. She denies alcohol, tobacco, or illicit drug use. Vital signs show a
temperature of 100.4 F (38 C), blood pressure of 134/88 mmHg, pulse of 102/min, and
respiratory rate of 18/min. Physical examination is notable for diffuse crackles and
rhonchi. Chest x-ray shows ground glass opacities in both lungs.
Given the likely diagnosis, which of the following most increased this patient's risk for her
presenting condition?

Choices:

1. Immunosuppression
2. Hypercoagulability
3. Serositis
4. Vasculitis
Answer: 1 - Immunosuppression

Explanations:

This patient with a fever, cough, shortness of breath, and ground glass opacities on
chest x-ray likely has Pneumocystis pneumonia, caused by P. jirovecii.
Pneumocystis pneumonia is an opportunistic fungal infection, typically occurring in
immunosuppressed individuals.
This patient is taking azathioprine for dermatomyositis. Azathioprine commonly
causes immunosuppression secondary to suppression of T and B lymphocyte
synthesis.
In addition to fungal infections, azathioprine immunosuppression can predispose
patients to bacterial, protozoal, and viral infections. Patients may also be prone to
reactivation of latent infections.

Research Concepts: Immunotherapy

Page 872 of 955

Question 922: A 43-year-old female presents for an evaluation. Her blood pressure is
140/80 mmHg, and her pulse is 84 beats per minute. She has a significant family history
of cocaine use disorder in an uncle and ischemic heart disease in her brother. She smokes
2 packs of cigarettes daily. She wants to discuss treatment for her tobacco use disorder.
Which of the following is the best initial form of therapy for this patient?
Choices:

1. Start vaping as a nicotine replacement aid

2. Motivational interviewing
3. Supportive psychotherapy
4. Dialectic behavioral therapy
Answer: 2 - Motivational interviewing
Explanations:

There is substantial evidence that behavioral interventions alone or in combination

with pharmacotherapy improve smoking cessation achievement. Both behavioral
interventions and pharmacotherapy are effective and recommended, and
combinations of interventions are most effective. The best and most effective
interventions are those that are feasible for the individual.
Behavioral interventions effective in aiding adults in smoking cessation include in-
person counseling, telephone counseling, and self-help materials. These
interventions may increase smoking cessation rates from a baseline of 5% to 11% in
control groups to 7% to 13% in intervention groups. Both minor and intensive in-
person interventions increase the proportion of persons who successfully quit
smoking and remain abstinent.
However, more or longer sessions improve cessation rates. According to the Public
Health Service guidelines, individuals should undergo at least 4 in-person counseling
sessions.
Providers should make it a priority to help patients stop smoking. Smoking even a
few cigarettes a day or only smoking occasionally still significantly increases a
person's chance of developing lung cancer and other health problems. There are
immediate benefits to smoking cessation, which occur hours, weeks, and months
after a person stops smoking.
Assisting patients with smoking cessation is one of the most important primary care
tasks and responsibilities. The benefits of assessing patients’ smoking behavior are
well established. The US Preventive Services Task Force (USPSTF) recommends using
the 5 As, which include asking about smoking, advising to quit, assessing willingness
to quit, assisting in quitting, and arranging follow-up with support.
Research Concepts:Smoking Cessation

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Question 923: A 26-year-old previously well male with no comorbidities is admitted to
the intensive care unit following a traumatic head injury. He is currently on day 4 post
endotracheal intubation and initiation of mechanical ventilation. He has been receiving
enteral feeds directly into the small intestine. He is now noted to have a temperature of
39C, a spontaneous respiratory rate of 30/minute, a blood pressure of 96/64 mmHg, a
heart rate of 122 beats/minute, oxygen saturation of 92% in room air and finger-prick
blood glucose of 6 mmol/L. A complete blood count reveals a hemoglobin of 15.1g/dL
and a white blood cell count of 15 000 cells/mm3. Purulent secretions are noted to be
present in the endotracheal tube. He has been receiving enteral feeds directly into the
small intestine. The culture result of an endotracheal aspirate specimen is pending. He is
commenced on empiric antimicrobial therapy and intravascular fluid volume expansion is
escalated.
Which of the following represents the most likely mechanism of introduction of the
micro-organisms typically implicated in the etiology of the patient’s condition?

Choices:

1. Ileus
2. Urinary catheterization
3. Prone positioning
4. Sedation break
Answer: 1 - Ileus

Explanations:

The patient in this scenario has a likely diagnosis of ventilator- associated

pneumonia (VAP). VAP is defined as the development of pneumonia more than 48
hours after the initiation of mechanical ventilation.
The diagnosis of ventilator-associated pneumonia (VAP) is based on a positive
semi-quantitative culture result from a specimen obtained via a non-invasive
sampling technique (i.e. endotracheal aspiration) and the presence of clinical
criteria (such as pyrexia and leucocytosis [white blood cell count > 11 000
cells/mm3]), as per the American Thoracic Society and Infectious Diseases Society
of America guideline for the management of VAP, jointly published in 2016.
Aerobic gram-negative bacteria (AGNB) are typically implicated in the etiology of
VAP. According to the gastropulmonary hypothesis, gastric colonization with AGNB
occurs, followed by colonization and infection of the respiratory tract via gastric
reflux and aspiration, which may manifest as ventilator- associated pneumonia. As
per the hypothesis, AGNB are introduced into the stomach exogenously (for
example, through contaminated nasogastric tube feeds) or endogenously (via
reflux of intestinal content). Ileus enables the reflux of intestinal content into the

Page 874 of 955

 stomach. The presence of bile acids in the refluxed intestinal content causes an
increase in gastric pH, which promotes aerobic Gram-negative bacterial
colonization and growth in the stomach.
The pH of enteric feeds is between 6 and 7. Although not a part of routine,
standard practice, enteral feeds may be administered directly into the small
intestine to prevent the effect of an increased gastric pH from enteral feeds. An
increased gastric pH promotes aerobic Gram-negative bacterial colonization and
growth in the stomach in the pathogenesis of ventilator- associated pneumonia.

Research Concepts:

Ventilator Complications

Question 924: A 47-year-old male with a history significant for smoking and alcohol
presents with complaints of dry cough, weight loss, and intermittent fever for 6 months.
The patient was using symptomatic treatment. Physical examination and routine
investigations were within the normal range. The radiograph of the chest showed large
well-defined soft tissue mass with no other abnormalities in lung fields. An intrathoracic
mass was suspected. CT and MRI confirmed the posterior mediastinal mass with a high
suspicion of the neurogenic tumor. MRI revealed a mass of 5×4.1 ×
5.4 cm. Surgical excision was done. Histopathology and immunohistochemical
examination of the mass showed aggregates of foamy histiocytes increased Antoni-A
areas with no Verocay bodies, high expression of pericellular collagen IV, and S100
protein positivity. What is the underlying diagnosis?

Choices:

1. Tuberculosis
2. Cellular schwannoma
3. Plexiform schwannoma
4. Bronchogenic carcinoma
Answer: 2 - Cellular schwannoma

Explanations:

The most common differential diagnoses for posterior mediastinal mass include
nerve root tumors (schwannomas or neurofibromas), bronchogenic carcinoma,
sympathetic chain ganglions/paragangliomas, esophageal tumors, and
lymphadenopathy. Cellular schwannoma is a relatively uncommon, but very
important variant of schwannoma. Cellular schwannoma prompts consideration of
Page 875 of 955
 malignancy due to its high cellularity, increased mitotic activity, fascicular growth
pattern, and locally destructive character (though occasional).
The most common locations for cellular schwannoma include mediastinum and
retroperitoneum.
Specific histological features include predominantly or exclusively Antoni A areas
without Verocay bodies.
Cellular schwannomas, even having high cellularity, do not have the malignant
potential and do not metastasize. Local recurrence varies and may be higher
compared to conventional schwannomas. The mitotic activity does not exceed 5
per 10 high power fields.
Research Concepts:Schwannoma

Question 925: A 65-year-old male patient with no significant past medical history
presented with worsening dry cough and shortness of breath. On examination, there are
fine crackles in the bases of both lungs. Upon further questioning, the patient admits to
having a parakeet as a pet. Computed tomography (CT) chest shows a ground-glass
opacification. His pulmonary function tests (PFTs) show FEV1/FVC at around 85% with a
low diffusing capacity for carbon monoxide. What is the gold standard for diagnosing the
patient's condition?

Choices:

1. Magnetic resonance imaging chest

2. Bronchoscopy
3. Induced sputum cultures
4. Spiral computed tomography scan chest
Answer: 2 - Bronchoscopy

Explanations:

Bronchoscopy can yield a definitive diagnosis of interstitial lung disease. Empiric

steroids can be given while awaiting results of bronchoalveolar lavage (BAL).
The patient should avoid his parakeet at home and a repeat computed tomography
(CT) scan should be considered in 3 to 6 months for resolution of symptoms.
A workup for connective tissue disorders should be considered in certain cases
when pulmonary manifestations might be the initial symptoms.
The imaging workup starts with a routine chest radiograph. The most common
radiographic feature observed is a reticular pattern; however nodular or mixed
patterns can be seen.

Page 876 of 955

Research Concepts:

Interstitial Lung Disease

Question 926: A 43-year-old female presents to the clinic for follow-up. She was
diagnosed with adult-onset difficult-to-control severe persistent bronchial asthma 3
years ago. She has had an escalating regimen of bronchodilator therapy including
inhaled corticosteroid, beta-agonist (both long and short-acting), inhaled
anticholinergics, montelukast, as well as low dose prednisone and continues to have
acute attacks once a month needing urgent care or emergency department treatment.
There have also been symptoms of malaise, subjective fever, and pain in large and small
joints. Abnormal findings in the clinical exam include mildly congested nasal mucosa and
expiratory wheezes bilaterally on lung examination. She does not have any joint swelling
or skin rashes.
Routine blood work shows an elevated eosinophil count at 1400/microL. Serum IgE is
120 IU/mL. Computed tomography (CT) chest shows patchy peripheral ground-glass
infiltrates. P-ANCA serology is negative. Which of the following is the next best step in
the evaluation of this patient?
Choices:

1. Nerve conduction study

2. Bronchoscopy and bronchoalveolar lavage
3. Echocardiogram
4. Renal biopsy
Answer: 3 – Echocardiogram
Explanations:

A clinical presentation of difficult-to-control asthma, malaise, fever, polyarthralgia,

along with eosinophilia is highly characteristic of eosinophilic granulomatosis with
polyangiitis (EGPA).
The prevalence of ANCA positivity in EGPA is seen in approximately 40% of the
cases. The common ANCA immunofluorescence pattern is perinuclear, with
specificity for myeloperoxidase (MPO).
Sable–Fourtassou, and colleagues from the French vasculitis study group showed a
higher prevalence of renal disease,
micro-vasculitis, and peripheral neuropathy in the ANCA positive subgroup.
Similarly, Sinico and colleagues showed a similar
end-organ involvement pattern along with alveolar hemorrhage in the ANCA
positive subgroup.
Page 877 of 955
 ANCA-negative patients have a higher prevalence of cardiomyopathy and systemic
manifestations like malaise, and fever, among others. Hence, echocardiography is
indicated in this patient to rule out cardiomyopathy.
Research Concepts:Churg Strauss Syndrome

Question 927: A 40-year-old man is being evaluated for headache, nausea, and fatigue 24
hours after arrival at a base camp on Mount Everest. He admits to consuming canned
food and a 12 oz bottle of beer about 10 hours ago. He describes the headache as
bitemporal and throbbing. Physical examination reveals a 200 lbs man in mild distress. His
vital signs show a blood pressure of 160/90. His lungs sound clear. HEENT examination
reveals mild papilledema but otherwise reactive pupils with 20/20 vision.
Abdominal examination is negative for any tenderness. The neurologic examination
demonstrates mild ataxia and lethargy but is otherwise negative for any focal deficits.
Which of the following is the most likely diagnosis?

Choices:

1. Alcohol intoxication
2. Botulism
3. High altitude cerebral edema
4. Complicated migraine

Answer: 3 - High altitude cerebral edema

Explanations:

High altitude cerebral edema (HACE) is a medical emergency with high mortality
rates without immediate intervention. Failure to descent results in brain herniation
and death.
It can sometimes be difficult to diagnose in early stages without a high index of
suspicion. It can easily be confused with a travel- related illness such as an infection
or intoxication.
Definitive treatment is immediate descent, but hyperbaric oxygen therapy
can be used as a temporizing measure if descent is not immediately
possible.
Besides clinical symptoms, imaging findings most consistent with HACE is white
matter changes on MRI.
Research Concepts:

EMS High-Altitude Field Prophylaxis And Treatment

Page 878 of 955

Question 928: An 18-year-old male presents with a long history of easy bruising and
recurrent nosebleeds, for which he has required multiple admissions. He has a family
history of nosebleeds. Now he has been complaining of a headache, gait difficulty with
weakness, paresthesias, confusion, and nausea. Examination reveals that he has
numerous telangiectasias over his face and lips. Magnetic resonance imaging (MRI)
reveals that he has a ring-enhancing lesion in the brain. What is the cause of the brain
lesion?

Choices:

1. Arteriovenous malformations in the brain

2. Arteriovenous malformations (AVMs) in the lung
3. Fragile blood-brain barrier
4. Acute hemorrhage in the brain
Answer: 2 - Arteriovenous malformations (AVMs) in the lung

Explanations:

Patients with hereditary hemorrhagic telangiectasia develop arteriovenous

malformations of the liver, lungs, brain, and spine. The pulmonary shunts commonly
associated with this disorder put patients at significant risk for the development of
brain abscesses. When there are AVMs in the lung, the normal filtering ability of
the pulmonary circulation is lost and septic emboli can go to the brain.
These patients also experience paradoxical cerebral emboli, strokes, and
subarachnoid hemorrhage, due to an increased risk of intracranial aneurysms.
Brain abscess will present as a ring-enhancing lesion with symptoms of weakness,
seizures, headache, and even paraplegia.

Research Concepts:

Osler-Weber-Rendu Disease

Page 879 of 955

Question 929: A 55-year-old male with chronic obstructive pulmonary disease (COPD)
presents for follow-up. He was diagnosed with COPD 4 years ago. He has a 40 pack-year
smoking history and quit at the time of diagnosis. His COPD has been well- controlled
with inhaled umeclidinium and as needed levalbuterol. He is also on insulin therapy for
type 2 diabetes mellitus and furosemide for heart failure with reduced ejection fraction.
He denies current shortness of breath or recent acute illness. On physical examination,
vital signs are normal. Lung examination is significant for mild scattered expiratory
wheezes. He has mild pitting edema of the lower extremities bilaterally. The remainder of
the physical examination is normal. Spirometry one month ago revealed an FEV1 of 54%
of predicted and an FEV1/FVC ratio of 0.6. His modified medical research council score is
1. He is up-to-date on influenza and pertussis vaccinations. Which of the following is
recommended for this patient today?

Choices:

1. 13-valent pneumococcal conjugate vaccine

2. 23-valent pneumococcal polysaccharide vaccine
3. 13-valent pneumococcal conjugate vaccine today and 23-valent pneumococcal
polysaccharide vaccine in 1 year
4. Non-typeable Haemophilus influenza vaccine

Answer: 2 - 23-valent pneumococcal polysaccharide vaccine

Explanations:

23-valent pneumococcal polysaccharide vaccination (PPSV23) is recommended in

patients younger than 65 with COPD and significant comorbid conditions.
The PPSV23 may reduce the risk of community-acquired pneumonia and
exacerbations in patients with COPD, including those under 65 years of age.
This patient has insulin-dependent diabetes mellitus and chronic heart disease.
PPSV23 is indicated in this patient.
PPV13 is not routinely recommended in immunocompetent patients under the age
of 65. PCV13 and PPSV23 are recommended in COPD patients aged 65 or greater
and should be given at least one year apart. Non-typeable Haemophilus influenza
vaccination has not shown to have a significant reduction in acute exacerbations
or mortality in patients with moderate-to-severe COPD.

Research Concepts:Chronic Obstructive Pulmonary Disease

Page 880 of 955

Question 930: A 66-year-old man presents with fever, cough, and myalgias for the last
three days. He has a history of hypertension and diabetes mellitus. His blood pressure is
140/82 mmHg, temperature 38.1°C (100.5°F), pulse 104/min, respiratory rate 19/min,
and oxygen saturation 98% on room air. The patient does not appear toxic, his lungs are
clear bilaterally, and he shows no increased work of breathing. A rapid SARS CoV-2 test is
positive. What is the best next step in the management of this patient?

Choices:

1. Obtain computed tomography of the chest

2. Refer for outpatient monoclonal antibody treatment
3. Admit for intravenous corticosteroids and monoclonal antibody treatment
4. Discharge home with recommendations for isolation and oximetry monitoring
Answer: 2 - Refer for outpatient monoclonal antibody treatment

Explanations:

This clinical vignette demonstrates a patient with mild symptoms caused by the SARS-
CoV-2 virus, with several risk factors for progression to severe disease.
Monoclonal antibodies directed at the spike protein of the SARS-CoV-2 virus are
indicated in this scenario to neutralize the receptor-binding protein and prevent
viral entry into the cell. Monoclonal antibody therapy is currently indicated for
nonhospitalized patients with mild to moderate symptoms who have risk factors
for progression to severe disease. This patient's risk factors are age 65 and older,
hypertension, and diabetes mellitus. Other risk factors include obesity/overweight
(BMI >/=25 kg/m2), pregnancy, chronic kidney disease, immunosuppression,
chronic lung diseases, sickle cell disease, neurodevelopmental disorders, or
dependence on medical- related technology not related to COVID-19 infection,
such as a tracheostomy.
Emergency use authorizations for monoclonal antibodies indicated for this
purpose have been updated several times based on the circulating variants.
Currently, with the Omicron variant as the dominant variant of concern,
sotrovimab is the only authorized monoclonal antibody for this purpose.

Research Concepts:

Benefits And Risks Of Administering Monoclonal Antibody Therapy For Coronavirus (COVID-
19)

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Question 931: A 65-year-old male with a past medical history of chronic obstructive
pulmonary disease, hypertension, gastroesophageal reflux disorder, schizophrenia, and
bipolar disorder presented to the emergency department complaining of 1 day of
increasing dyspnea and productive cough. His medications are lisinopril, salbutamol
inhaler, budesonide and formoterol inhaler, omeprazole, and olanzapine. He is visibly
anxious and speaks in brief sentences on supplemental oxygen via a nasal canula but
requires intubation with the use of 100% oxygen. Vitals are blood pressure of 102/70
mmHg, heart rate 124 beats/min, temperature
39.6 C (103.2 F), SpO2 77%, and respiratory rate of 32/minute. A chest x-ray reveals
bilateral lung opacities. ECG reveals sinus tachycardia. Echocardiography is performed
and reveals an ejection fraction of 65%. The patient is determined to have mild acute
respiratory distress syndrome. Which of the following most accurately would be
expected to reflect this patient's PaO2/FiO2 ratio?

Choices:

1. 254 mmHg
2. 104 mmHg
3. 320 mmHg
4. 93 mmHg
Answer: 1 - 254 mmHg

Explanations:

The patient has mild acute respiratory distress syndrome (ARDS), defined as a
PaO2/FiO2 ratio of 200-300 mmHg. Given this acuity of onset, etiology is likely
pneumosepsis, and bilateral chest x-ray opacities are not attributed to a
cardiogenic source as the ejection fraction is normal.
ARDS is defined by the patient's oxygen in arterial blood (PaO2) to the fraction of
the oxygen in the inspired air (FiO2). These patients have a PaO2/FiO2 ratio of less
than 300. The definition of ARDS was updated in 2012 and is referred to as the
Berlin definition.
Once ARDS develops, patients usually have varying degrees of pulmonary artery
vasoconstriction and, subsequently, may develop pulmonary hypertension. ARDS
carries a high mortality, and few effective therapeutic modalities exist to combat
this condition.
Research Concepts:Acute Respiratory Distress Syndrome

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Question 932: A 16-year-old male is brought to the emergency department with
shortness of breath. Family history is unremarkable. His height is 180 cm (5 ft 11 in),
weight 55 kg (121 lbs), blood pressure 110/70 mmHg, respiratory rate 25/minutes, pulse
rate 110 beats per minute, and pulse oximetry 90% on room air. The chest examination
demonstrates pectus excavatum, decreased air entry on the right, and hyperresonance
when percussing the same side.
Chest x-ray shows a visceral pleural edge with no lung markings along the line. Which of
the following genetic mutations is associated with this patient's most likely diagnosis?

Choices:

1. SERPINA1 gene
2. COL3A1 gene
3. FBN1 gene
4. TGFBR2 gene

Answer: 3 - FBN1 gene

Explanations:

This vignette depicts a patient with Marfan syndrome who has developed
spontaneous pneumothorax. It is estimated that 10% of spontaneous
pneumothorax cases occur in patients with Marfan syndrome, which is linked to
mutations in the FBN1 gene. The FBN1 gene encodes the glycoprotein fibrillin-1,
which regulates TGFß signaling. Dysregulation of TGFß signaling can lead to
pneumothorax and other thoracic and extrathoracic manifestations of Marfan
syndrome.
A spontaneous pneumothorax occurs most commonly due to the rupture of an
apical bleb. Spontaneous pneumothorax occurs more frequently in males than
females.
Recurrence of spontaneous pneumothorax has been reported in up to 87% of
patients.
Mutations in the COL3A1 gene are usually diagnostic for Ehlers- Danlos syndrome.
Loeys-Dietz syndrome (LDS) is associated with a TGFBR2 mutation. In comparison, a
mutation in the SERPINA1 gene is specific for alpha1-antitrypsin deficiency.

Research Concepts:

Spontaneous Pneumothorax

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Question 933: A 13-year-old female patient presents to your clinic with complaints of
dyspnea and chest tightness while running track. She reports it happens quite often, and
she has to stop exercising. Her symptoms usually improve with rest. She tried inhaled
salbutamol without improvement. As part of your evaluation, the clinician ordered
spirometry. What will be the most likely finding on the spirometry test of this patient?

Choices:

1. Flattening of the inspiratory flow/volume loop

2. Flattening of both expiratory and inspiratory flow/volume loops
3. An obstructive defect of the flow/volume loop during expiration
4. A restrictive defect of the flow/volume loop
Answer: 1 - Flattening of the inspiratory flow/volume loop

Explanations:

Flattening of the inspiratory flow/volume loop is suggestive of variable

extrathoracic obstruction. This reflects obstruction at the level of the glottis or
supraglottis as see in inducible laryngeal obstruction or exercise-induced laryngeal
obstruction (EILO).
The upper airway obstruction in EILO is usually inspiratory and variable. Flattening
of both expiratory and inspiratory flow/volume loops is more suggestive of a fixed
obstruction during both expiratory and inspiratory respiratory cycles and is not
seen in EILO.
EILO does not affect the lower airways. An obstructive expiratory defect is
characteristic of intrathoracic and lower airways obstruction (eg asthma).
A restrictive defect is characterized by decreased lung volume; it is not seen in EILO.

Research Concepts:

Exercise Induced Laryngeal Obstruction

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Question 934: A 37-year-old male presents with a rash on his legs which has been getting
worse over the past three weeks. He has a past medical history of well-controlled asthma
and complains of occasional aches and pains in multiple joints. On examination, he has a
series of raised tender purple-red lumps on the anterior aspect of both his shins. His chest
x-ray reveals bilateral hilar lymphadenopathy. The rest of the investigations are pending.
Given the likely diagnosis, which of the following is the first line in managing this patient?

Choices:

1. Corticosteroids
2. Methotrexate
3. Tocilizumab
4. Mycophenolate mofetil

Answer: 1 - Corticosteroids

Explanations:

Sarcoidosis is a multisystem inflammatory disease of unknown etiology that

usually presents with cough, fever, anorexia, arthralgias, and dyspnea on exertion.
A biopsy is typically required for diagnosis, and a transbronchial lung biopsy has a high
yield. Hilar lymphadenopathy on chest x- ray is classic for sarcoidosis while other
physical manifestations include hepatosplenomegaly, erythema nodosum, and
granulomatous uveitis.
For patients with pulmonary sarcoidosis causing worsening symptoms, stage II to
III radiographic findings should be considered for oral glucocorticoids at 0.3 to 0.6
mg/kg for 4 to 6 weeks. If there is no improvement in symptoms, radiographic
abnormalities, and pulmonary function tests, steroids may be continued for an
additional four to six weeks. Maintainance steroids are not needed; steroid
tapering to a dose of 0.25 to 0.5mg/kg (usually 10 to 20 mg) per day should be
considered over a period of at least six to eight months.
Methotrexate, azathioprine, infliximab, leflunomide, and antimalarial agents may
be considered as steroid-sparing agents in patients who are unable to tolerate
steroids.

Research Concepts: Sarcoidosis

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Question 935: A 52-year-old female patient presents to the hospital complaining of
dyspnea, chest pain, and one episode of hemoptysis a few hours ago. She reports three
episodes of frank hemoptysis in the past three weeks. She is a non-smoker, drinks alcohol
very infrequently, and her last travel was one year ago to Bangkok. On examination, she is
restless and has edema up to the knees. Her blood pressure is 155/95 mmHg, and her
heart rate is 92/min. Her lab investigations reveal hemoglobin 7.9 g/dL, white cell count
14000 per microliter, urea 25 mmol/l, creatinine 5.2 mg/dl, and urinalysis shows 3+
proteins, 3+ blood with no growth on culture. A chest radiograph shows bilateral basal
infiltrates. Pulmonary function tests reveal a raised transfer factor. What is the most
appropriate treatment in this case?

Choices:

1. Corticosteroids and rituximab

2. Prednisolone, cyclophosphamide, and plasmapheresis
3. Prednisolone and azathioprine
4. Prednisolone, cyclosporine, and plasmapheresis
Answer: 2 - Prednisolone, cyclophosphamide, and plasmapheresis

Explanations:

This patient is suffering from Goodpasture syndrome. Upon diagnosis, patients

should be started on prednisone, cyclophosphamide, and daily plasmapheresis to
improve overall mortality in general, and renal survival in particular. If therapy can
start before the patient progresses to the point of needing renal replacement
therapy, the overall renal prognosis is better. Typically, daily plasmapheresis is
performed until anti- glomerular basement membrane antibodies are
undetectable, with steroid and cyclophosphamide continuing after that for 3 to 6
months until full remission is achieved.
The starting dose of cyclophosphamide is 2 mg/kg orally, adjusted to keep a white
cell count of approximately 5000. Treatment of acute life-threatening alveolar
hemorrhage is with IV methylprednisolone pulse therapy 1 g/day for 3 days,
followed by a tapering dose at 1-1.5 mg/kg orally.
Rituximab has been found to have a role in some studies in which the conclusion
was that it led to the undetectable levels of anti-GBM antibodies. The combination
of prednisolone and azathioprine has no role in the management.

Research Concepts: Goodpasture Syndrome

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Question 936: A 23-year-old male farmer with a 7-pack-year history of smoking presents
to the clinic with a slow-growing neck mass which he first noticed one month ago. He also
reports a recent history of multiple episodes of black-colored vomitus. Upon further
evaluation, he also reports associated abdominal pain, loss of appetite, and low-grade
fever. He does not report any history of recent travel, high-risk sexual behavior, or
intravenous drug use.
Physical examination reveals bilateral lower limb swelling without associated erythema or
raised local temperature. He appears poorly built and emaciated with pallor. A neck
examination is suspicious for lymphadenopathy. Testicular examination reveals a palpable
non- tender swelling with a rubbery consistency. On local examination, it is possible to get
above the swelling. Ultrasound demonstrates a hypoechoic lesion without cystic spaces.
Serum LDH is 2.5 times the upper limit of the normal. A diagnosis of intermediate-risk
seminoma is made, and neoadjuvant treatment with bleomycin, etoposide, and cisplatin
is initiated. A chest radiograph is normal. Baseline pulmonary function testing reveals a
forced vital capacity (FVC) of 4 L and diffusion capacity for carbon monoxide at 80% of the
predicted value. Following the fourth cycle of chemotherapy, the patient presents to the
hospital with rapidly progressive breathlessness associated with a history of pleuritic chest
pain. Physical examination reveals dullness on percussion, egophony, and whispering
pectoriloquy on the right side of the chest. A chest radiograph reveals blunting of the right
costophrenic angle without mediastinal shift. Which of the following factors is most likely
responsible for the patient's current condition?

Choices:

1. Smoking
2. Pleural carcinomatosis
3. Infection
4. Chemotherapy

Answer: 4 - Chemotherapy

Explanations:

Pleural effusion is characterized by the presence of fluid in the pleural cavity. The
normal pleural fluid volume is 0.13 mL/kg/body weight (approximately 10 mL in a
normal adult).
Malignant pleural effusion (MPE) is seen in approximately 15% of lung cancer
patients. MPE is usually caused by the direct seeding of the tumor into the pleura.
The underlying pathophysiology involves both increased production and decreased
drainage of fluid.
The patient in this scenario is known to have a high-risk germ cell tumor and has
Page 887 of 955
 presented with symptoms of a paramalignant pleural effusion, which can be
assumed to be related to the use of bleomycin. Interestingly, this patient has
multiple medical issues, such as deep venous thrombosis, which could predispose to
the development of pulmonary thromboembolism, which is another cause of a
paramalignant pleural effusion.
However, the timing of onset, radiographic features, and physical examination
findings point towards a clinical diagnosis of drug-related paramalignant pleural
effusion. Significantly, this patient also has symptoms of retroduodenal
lymphadenopathy, which may be the underlying cause for his presentation with loss
of appetite, gastrointestinal hemorrhage, and abdominal pain.
Paramalignant pleural effusions do not involve direct tumor seeding into the
pleura. Therefore, conventional therapeutic options are used to manage MPE, such
as indwelling pleural catheters and pleurodesis. Thoracoscopic talc slurry and
poudrage are not considered to be effective in the management of this disease.
Treatment of the underlying cause is an important means of managing
paramalignant pleural effusion.
Bleomycin is an M-stage-specific anticancer drug that is classified as an antitumor
antibiotic. It acts by inducing single and double-stranded breaks in the DNA and
leading to cancer cell death. Bleomycin is inactivated by the enzyme bleomycin
hydrolase. The activity of bleomycin hydrolase is minimal in the
skin and lungs. Though it is used as an agent in promoting chemical pleurodesis, it
has been associated with drug-induced lung injury. Older age, smoking, and higher
cumulative dosing are recognized risk factors in the development of bleomycin-
induced lung damage. Recognized HRCT patterns of pulmonary involvement include
diffuse alveolar damage, pulmonary fibrosis, non-specific interstitial pneumonitis,
organizing pneumonia, and hypersensitivity pneumonitis.
Research Concepts:Malignant Pleural Effusion

Question 937: A 67-year-old man presents with daytime sleepiness and fatigue. He snores,
wakes up gasping for air, and has headaches in the morning. His wife mentions he has
breathing pauses at night. He goes to bed at 1 a.m. because his favorite television shows
air late at night. He wakes up at 6 a.m. to drop off his grandchildren at school. He denies
difficulty falling asleep or staying asleep but wakes up two to three times at night for
unknown reasons. He sleeps longer on the weekends but continues to feel sleepy and
fatigued. He has hypertension and diabetes mellitus, for which he takes lisinopril,
hydrochlorothiazide, and metformin. He does not smoke cigarettes and drinks two to
three beers on weekends. His blood pressure is 146/89 mmHg, heart rate 86/min,
respiratory rate 17/min, and BMI 38 kg/m^2. The physical exam demonstrates a crowded
upper airway with macroglossia, Mallampati class IV, and moderately enlarged nasal
turbinates. The rest of the exam is unremarkable, and the Epworth Sleepiness Scale score
is 14. What is the most appropriate next step in management?
Page 888 of 955
Choices:

1. Polysomnography
2. Mean sleep latency test
3. Actigraphy
4. Advise weight loss only
Answer: 1 - Polysomnography

Explanations:

This patient presents with symptoms of snoring, witnessed apnea, morning

headaches, daytime sleepiness, and an elevated BMI suggestive of sleep-
disordered breathing.
Polysomnography (PSG) is the diagnostic test for sleep- disordered breathing, such as
obstructive sleep apnea.
The patient reports an estimated five-hour sleep time curtailed by his habits, and
his total sleep time is less than recommended for his age. The diagnosis of
insufficient sleep syndrome (ISS) requires that the symptoms should not be better
explained by other sleep disorders, medical disorders, or drugs/medications. This
patient's symptoms raise suspicion of sleep-disordered breathing rather than ISS.
The patient can increase his total sleep duration with an adequate opportunity to
sleep, suggestive of co-existing insufficient sleep. However, he continues to report
fatigue after extending his sleep time, raising suspicion of sleep-disordered
breathing.
The patient may be counseled to increase total sleep time as a part of the
management of his excessive daytime sleepiness.
However, a PSG is still indicated to evaluate for sleep- disordered breathing.
Actigraphy can help evaluate circadian rhythm in patients with insufficient sleep
syndrome. The mean sleep latency test is a diagnostic test for narcolepsy, and
based on his clinical presentation, there is low suspicion of narcolepsy.

Research Concepts: Sleep Insufficiency

Page 889 of 955

Question 938: A 55-year-old African American man with hypertension and hyperlipidemia is
being evaluated for increasing dyspnea on exertion. His blood pressure is 160/90 mmHg,
and his pulse is 110/min. On the catheterization of the right heart, the mean pulmonary
artery pressure is 47 mmHg, and the pulmonary capillary wedge pressure is 45 mmHg. The
cardiac output is 4.0 L/min. The patient has a height of 183 cm and a weight of 105 kg. What
is his pulmonary vascular resistance?
Choices:

1. 160 dynes/sec/cm^-5
2. 0.0125 dynes/sec/cm^-5
3. 1 dynes/sec/cm^-5
4. -1 dynes/sec/cm^-5
Answer: 1 - 160 dynes/sec/cm^-5

Explanations:

Pulmonary vascular resistance (PVR) = 80* (mean PAP - PCWP)/CO=160

dynes/sec/cm^-5.
Using the Wood units label for PVR = (mean PAP-PCWP)/CO=1 wood unit.
Normal PVR = 100-200 dynes/sec/cm^-5.
High PVR can be used to diagnose the severity of hypertension, low PVR, in this case,
may require vasoconstrictors.
Research Concepts:Physiology, Pulmonary Vascular Resistance

Question 939: A 45-year-old male presents with complaints of progressive shortness of

breath. He has had the symptoms for the past year. His shortness of breath was gradual in
onset but is progressive. The patient now feels breathless even on mild exertion. He has
been finding it difficult to perform his daily activities. He also reports occasional episodes
of dizziness and loss of consciousness. There is no history of cough or fever. His
examination reveals a blood pressure of 130/50 mmHg, a pulse of 100 beats per minute, a
respiratory rate of 27 per minute, and a temperature of 98 F. His cardiac auscultation
reveals the presence of an early diastolic grade 4/6 murmur best heard over the left 3rd
intercostal space. The murmur increases on expiration. His respiratory, gastrointestinal,
and neurological examinations are unremarkable. His investigations revealed a WBC
count of 5,000 per microL, hemoglobin of 12 gm/dl, platelet count of 200,000 per microL,
serum ALT 35 IU/l, serum AST 35 IU/l, and serum creatinine of 1.1 mg/l. Serologies are
performed, which are anti-HCV negative, anti-Hbs positive, and HbsAg negative. Anti-Hbc
IgM negative, RPR negative, TPHA positive, ANA negative, and RA factor negative. An X-
ray reveals the presence of mediastinal widening and linear calcifications of the ascending
aorta. What is the most likely etiology for this patient’s shortness of breath?

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Choices:

1. Mitral valve stenosis

2. Pericardial effusion
3. Aortic inflammation, regurgitation, and insufficiency
4. Valvular calcification
Answer: 3 - Aortic inflammation, regurgitation, and insufficiency

Explanations:

This patient presents with symptoms of progressive dyspnea. His history of

dizziness and loss of consciousness suggests a cardiovascular cause. The presence
of an early diastolic murmur suggests the presence of aortic regurgitation. The
serology investigation reveals positivity for treponema pallidum (TPHA), and his X-
ray suggests aortic dilation. Linear calcifications of the ascending aorta are closely
associated with the most likely diagnosis of cardiovascular syphilis.
Cardiovascular syphilis is a form of tertiary syphilis characterized by aortitis, aortic
valve regurgitation, and aortic dilatation, eventually resulting in heart failure. The
usual presentation is 15 to 30 years after the primary infection.
Morphologically, the aorta appears dilated with patchy areas of fibrosis and necrosis,
referred to as a "tree bark aorta." Histologically, it is characterized by a chronic
perivascular inflammatory lymphoplasmacytic infiltrate. There is obliterative
endarteritis of the vasa vasorum and subsequent necrosis.
There is co-existent aortic insufficiency, which may lead to left ventricular failure.
Cardiovascular syphilis may cause coronary ostial lesions but does not typically
cause atherosclerosis.
Valvular calcification and stenosis may cause shortness of breath, such as in aortic
and mitral stenosis.

Research Concepts: Syphilis

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Question 940: A 50-year-old male is ascending Mount Everest. He arrived a day before
and immediately started his climb. He has reached an altitude of 4000 meters when he
starts to develop shortness of breath and dyspnea on exertion. He was assessed by a
health care provider who is also climbing with the group. The patient had crackles
throughout his lung fields bilaterally and has an oxygen saturation of 60%. The base camp
is 1000 meters down the mountain. What is the best course of action for this patient?

Choices:

1. Descend to basecamp
2. Stay for the night
3. Continue ascending up the mountain
4. Give him diuretics
Answer: 1 - Descend to basecamp

Explanations:

It is important to recognize the risk factors, signs, and symptoms of high altitude
pulmonary edema (HAPE). The patient is at an elevation of greater than 2500
meters in which he rapidly ascended. The patient also began to experience
shortness of breath with dyspnea on exertion. Additionally, he is severely hypoxic.
In this instance, the patient is experiencing severe symptoms of high altitude
pulmonary edema (HAPE). With significant crackles and hypoxia, the best course of
action is to descend.
Especially since they are on a mountain and in a resource-poor area in which he
cannot receive supplemental oxygen, it is crucial to consider the severity of
symptoms, resources available, and safety of the situation.
If the group had a portable hyperbaric chamber, that would be an appropriate
option if conditions were too dangerous to descend.
Staying at the same altitude or ascending is not appropriate in a severely sick patient.
Diuretics have no role in this case.

Research Concepts:

High Altitude Pulmonary Edema

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Question 941: A 29-year-old female with COVID-19 pneumonia is admitted to the
hospital for supportive care and requires 4 liters of oxygen via nasal cannula. Four weeks
before presentation, she delivered a healthy, full-term baby via spontaneous vaginal
delivery at 38 weeks of gestation. She is started on remdesivir, and the multidisciplinary
team is evaluating whether or not to add baricitinib to her treatment. Which of the
following would be a contraindication for using baricitinib in this patient?

Choices:

1. Her current treatment with remdesivir

2. A change to requiring oxygen via high-flow nasal cannula
3. A change to requiring noninvasive mechanical ventilation
4. She is currently breastfeeding
Answer: 4 - She is currently breastfeeding

Explanations:

Baricitinib can be administered to patients requiring oxygen via high-flow nasal

cannula or noninvasive mechanical ventilation. Because of the unclear evidence
regarding the use of baricitinib in pregnant and breastfeeding women, its use is
contraindicated in these individuals.
This patient has moderate disease requiring hospitalization and oxygen support via
nasal cannula and has a score of 5 on the 8- point ordinal scale for COVID 19 severity.
In the absence of breastfeeding, she would be a candidate for baricitinib.
Baricitinib can be given to patients being treated with remdesivir. Combination
therapy holds the promise of potentially decreasing oxygen requirements and
avoiding worsening in patients with an ordinal score of 5 and 6.

Research Concepts:

Safe and Effective Use of Baricitinib And Remdesivir In Hospitalized Patients With
Coronavirus (COVID- 19)

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Question 942: A 65-year-old male is brought to the emergency department with acute
shortness of breath and hemoptysis. He was trying to save his sister from the house on
fire when he got overcome with smoke. The firefighters rescued him. On examination, he
is short of breath with a blood pressure of 110/65 mmHg, pulse of 118/min regular, and
respiratory rate of 32/min. On auscultation, there are bilateral crackles all over the chest.
He is maintaining 88% SpO2 on room air. He is immediately started on high-flow oxygen.
His arterial blood gas report shows a pH of 7.30, paO2 of 60 mmHg, paCO2 of 45 mmHg,
and bicarbonate of 30mmol/l. A chest radiograph reveals interstitial shadowing
bilaterally. What is the next best management option?

Choices:

1. Continuous pulmonary airway pressure

2. Bi-level pulmonary airway pressure
3. Spiral CT of the chest
4. Intubate and ventilate the patient
Answer: 4 - Intubate and ventilate the patient

Explanations:

This patient has developed acute respiratory distress from inhalation of smoke and
has pulmonary edema.
In this situation, there is decreased PaO2 despite high oxygen supplementation.
That is why intubation and ventilation is the best management step.
The necessary partial pressures of oxygen throughout tissues are variable
depending on the metabolic demands of the tissues. The brain has been found to
require a partial pressure of oxygen of at least 35 mmHg below. Mental functions
become impacted because aerobic metabolism of glucose for energy production
cannot occur efficiently.
Changes in environmental pressure cause a change in the available oxygen for
diffusion into the body. At sea level, the atmospheric pressure is 760 mm Hg.
However, as elevation increases, atmospheric pressure decreases. For example, at
the summit of Mt. Everest, the atmospheric pressure is as low as 260 mm Hg. When
this pressure is used to calculate the alveolar partial pressure of oxygen in the
environment, there is approximately 54.6 mmHg of oxygen available for diffusion.
This is almost half of what is available at sea level.

Research Concepts: Partial Pressure Of

Oxygen

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Question 943: A patient presents with a known EIF2AK4 mutation with progressive
dyspnea on exertion and lower extremity edema. He is also shown to have a split S2 on
physical examination. He is taken for right heart catheterization and has vasoreactivity
testing. RHC values note mean pulmonary arterial pressure of 55 mmHg, pulmonary
capillary wedge pressure of 5 mmHg, and pulmonary vascular resistance of 6 wood units.
On vasoreactivity testing, the patient becomes hypoxic and pulmonary edema is noted on
fluoroscopy. He is given high-dose intravenous diuretics with the resolution of hypoxia.
What would a surgical lung biopsy of this patient most likely show?

Choices:

1. Intimal fibrosis, luminal narrowing, and obliteration of preseptal venules

2. Diffuse alveolar damage with pulmonary hemorrhage
3. Alternating areas of fibrosis, normal lung, and honeycombing
4. A proliferation of pulmonary neuroendocrine cells
Answer: 1 - Intimal fibrosis, luminal narrowing, and obliteration of preseptal venules

Explanations:

This patient has Group 1 Pulmonary Hypertension as noted on RHC.

The patient experiences pulmonary edema with vasoreactivity testing which is
associated with pulmonary veno-occlusive disease.
The patient also has a EIF2AK4 mutation which further confirms pulmonary veno-
occlusive disease as the most likely diagnosis. Histopathology in patients with PVOD
shows intimal fibrosis, luminal narrowing, and obliteration of preseptal venules.

Research Concepts:

Pulmonary Veno-Occlusive Disease

Page 895 of 955

Question 944: A 65-year-old male patient is brought by his caretaker with the chief
complaints of headache, nausea, vomiting, blurring of vision, abdominal pain, and
drowsiness. He has had headaches since the winter started, but the frequency and intensity
have worsened. He has lived alone since his wife passed away last year. On examination, his
blood pressure is 110/70 mmHg, his heart rate is 91 beats per minute and regular, his
respiratory rate is 22 breaths per minute, and his Glasgow coma scale (GCS) is 11/15.
Fundoscopy reveals bilateral disc edema. During his time in the emergency department,
his GCS declines further, and oxygen saturation starts to drop. He is immediately
intubated and placed on mechanical ventilation. Which of the following should be the
target for mechanical ventilation in this case?

Choices:

1. Set PaCO2 between 45 to 50 mmHg

2. Set PaCO2 between 35 to 40 mmHg
3. Set PaCO2 between 30 to 35 mmHg
4. Set PaCO2 to less than 30 mmHg

Answer: 3 - Set PaCO2 between 30 to 35 mmHg

Explanations:

This is a case of raised intracranial pressure secondary to carbon monoxide

poisoning. Hypocapnia can reduce cerebral blood flow by 4% for each mmHg
change in PaCO2. Experts recommend a PaCO2 between 30 to 35.
This decreased PaCO2 can reduce intracranial pressure by vasoconstriction of
blood vessels. Hyperventilation can decrease cerebral oxygenation and may induce
brain ischemia in patients with traumatic brain injury and acute stroke.
The effects of hyperventilation last about 48-72 hours. Once hyperventilation is
used, the PaCO2 levels should return to normal gradually. The rebound
vasodilatation can be detrimental.
Below a PaCO2 of 30, cerebral blood flow reduction is minor. Low PaCO2 can induce
hypoxemia in brain tissues and so is not recommended. While some advocate
normocarbia, a short period of hypocarbia does work and is beneficial.

Research Concepts:Intracranial Hypertension

Page 896 of 955

Question 945: A 28-year-old man comes to the emergency department with acute onset
of dyspnea and mild chest pain. He describes the quality of pain as sharp. He is afebrile,
heart rate of 117 beats per minute, blood pressure of 148/85 mmHg and a respiratory
rate of 23 breaths per minute. Pulmonary examination reveals decreased left-sided
breath sounds. Oral examination reveals multiple thick white patches that can be easily
scrapped off. A chest x-ray shows bilateral alveolar infiltrates and a left-sided
pneumothorax. Tube thoracostomy partially relieves chest pain and dyspnea. Which of
the following test most likely to reveal the diagnosis?

Choices:

1. CT scan of the chest

2. Blood culture
3. Bronchoscopy
4. Alpha 1 trypsinogen levels
Answer: 3 - Bronchoscopy

Explanations:

Pneumocystis Jirovecii and COPD are the two most common conditions associated
with Secondary Pneumothorax. The presence of oral white patches on the tongue
suggests oral thrush which is usually present in an HIV infected patient (or other
causes of immunodeficiency).
Patients with suspected immunodeficiency who present with bilateral opacities on
chest x-ray and a secondary pneumothorax should have a HIV testing and
bronchoscopy with bronchoalveolar lavage to confirm Pneumocystis Jirovecii
infection.
Secondary Pneumothorax by definition is associated with underlying pulmonary
disease and seldom has a benign clinical course if the underlying disease is not
diagnosed and treated.
CT scan at this stage will not reveal a specific diagnosis and provide no change in
early management of the patient's condition.

Research Concepts: Pneumothorax

Page 897 of 955

Question 946: A medical director of the adult intensive care unit (ICU) started using
angiotensin II one year back in the ICU. In the last one-year angiotensin II was
administered to 50 patients. It was observed to work best in patients with a subset of
acute respiratory distress syndrome (ARDS) and septic shock. The director earmarks a
fellow to study the potential relationship between the finding. What is the reason for the
improved efficacy of this medication in ARDS and septic shock patients?

Choices:

1. Angiotensin II works best in patients with a high mortality rate

2. Reason for improved efficacy is unknown
3. Angiotensin II improves lung endothelium function
4. Procalcitonin is high in patients with ARDS and septic shock
Answer: 3 - Angiotensin II improves lung endothelium function

Explanations:

Angiotensin I is converted into angiotensin II by the angiotensin- converting

enzyme, which is produced by the lung endothelium. In acute respiratory distress
syndrome (ARDS), there is an injury of the endothelium leading to a decrease in the
production of this enzyme, resulting in potentially angiotensin II deficiency state.
In patients with ARDS and septic shock, angiotensin II seems to work better because
of this potential hypothesis of angiotensin II deficiency state.
Any other condition which impacts the lungs and causes vasoplegic shock would
potentially benefit from angiotensin II based on a similar mechanism.
Patients with ARDS and septic shock are certainly a very sick group of patients, and
they may have high procalcitonin.
However, that is not the reason for the efficacy of this medication in that group if
patient.

Research Concepts:

Angiotensin II

Page 898 of 955

Question 947: A 17-year-old male presents with progressive dyspnea on minimal
exertion. The patient has no significant medical or surgical history or trauma. He does not
take any medication and has never smoked or vaped. His weight is 60 kg, height 1.7
meters, heart rate 75/minute, blood pressure 121/60 mmHg, and pulse oximetry 92% on
room air. Examination of the anterior chest wall demonstrates a posteriorly depressed
sternum. Bilateral breath sounds are normal, and the patient has no additional physical
examination findings. What is the most appropriate next step to determine the presence
and severity of the restrictive ventilatory defect in this patient?

Choices:

1. Posterior-anterior chest radiograph

2. Pulmonary function tests
3. High-resolution computerized thorax tomography
4. Electrocardiogram

Answer: 2 - Pulmonary function tests

Explanations:

Sternocostal joint deformity causes abnormal sternum depression that results in a

decreased chest anteroposterior diameter. Compression severity is associated with
cardiopulmonary impairment and paradoxical chest wall movement that causes
dyspnea and pain, especially with physical activity.
Pulmonary function tests (PFTs) are the most appropriate next step to determine
the presence and severity of the restrictive ventilatory defect.
When the VC decreases to less than 40% of predicted, the patient should be tested
for hypercapnia by obtaining an arterial blood gas.
A high-resolution computerized tomography scan can be helpful for thoracic
morphology evaluation after complete history, physical exam, and PFTs are
performed.

Research Concepts:

Chest Wall Deformities

Page 899 of 955

Question 948: A 65-year-old male is brought to the emergency department with
complaints of fever, cough, and difficulty breathing. He has had intermittent, high-grade
fevers and persistent cough for the last 3 weeks. He has a past medical history of
intravenous drug use but has been off drugs for the last 5 years. His examination reveals a
blood pressure of 95/55 mmHg, pulse of 110 beats per minute, respiratory rate of 38
breaths per minute, temperature of 101°F (38.3°C), and oxygen saturation of 85% on
room air. The general physical exam reveals a violaceous patch on his right calf. His chest
auscultation reveals scattered crackles bilaterally. His abdominal examination reveals mild
hepatosplenomegaly. His cardiovascular and neurological examinations are
unremarkable. His lab investigations reveal a white blood cell count of 2,000 per microL,
hemoglobin of 10 gm/dl, platelet count of 100,000 per microL, CD4+ count 15/microL, C-
reactive protein of 95 mg/l, serum ALT 220 IU/l, serum AST 150 IU/l, serum sodium 142
meq/l, serum potassium 4.0 meq/l and serum creatinine of 0.9 mg/dl. His chest x-ray
reveals extensive bilateral interstitial infiltrates. His serological investigations are positive
for human immunodeficiency virus (HIV). Toxoplasma IgM antibody is negative but IgG is
positive. Serologic testing for viral hepatitis and cytomegalovirus are negative. The beta-D-
glucan assay is negative. He is placed on mechanical ventilation and started on
appropriate antimicrobial therapy. Bronchoscopy and a transbronchial biopsy are
performed. Which of the following biopsy findings relates with the patient’s likely
disease?

Choices:

1. Presence of chronic granulomatous inflammation with caseation

2. Presence of thick-walled cells with broad-based budding
3. Presence of thin-walled cysts with round intracellular granules
4. Presence of atypical cells with increased nuclear to cytoplasmic ratio
Answer: 3 - Presence of thin-walled cysts with round intracellular granules

Explanations:

This patient has a progressive pulmonary infection. His history of previous

intravenous drug use, the violaceous patch representing Kaposi sarcoma, a low
CD4+ count, and the presence of anti-HIV antibodies indicate the development of
advanced HIV infection. Opportunistic infections are common in advanced HIV. The
serology and x-ray findings indicate the possibility of Toxoplasmosis. In advanced
immunosuppression from uncontrolled HIV, IgM antibody titers may be low or
absent. IgG antibody in the correct clinic scenario makes a presumptive diagnosis
which can be confirmed with histopathology.
Toxoplasma gondii is an opportunistic pathogen that can cause severe multi-system
disease in patients with HIV. The demonstration of the etiologic agents in tissues is
Page 900 of 955
 diagnostic.
The presence of a thin-walled cyst containing intracellular granules is consistent
with bradyzoites of toxoplasma.
Tachyzoites, representing the rapidly dividing state, may also be observed on biopsy
or microbiological examination of lavage fluid. It is seen as a crescentic organism
that invades cells.
Though direct visualization of the organism is definite, the sensitivity of this
method is low. Immunohistochemistry can improve the sensitivity of tissue
biopsies. Tuberculosis appears as chronic granulomatous inflammation in biopsy
specimens.
Pulmonary blastomycosis dermatitidis is characterized by the presence of thick-
walled broad-based budding yeasts.
Pulmonary malignancy demonstrates atypical cells.

Research Concepts:
HIV-1 Associated Toxoplasmosis

Page 901 of 955

Question 949: A 47-year-old male patient who is HIV positive presents to the emergency
department with breathing difficulty which has been increasing for the past 5 days, fever,
and dry cough. He has a low-grade fever. His investigations reveal CD4 cell count of 200
cell/mm^3. His partial pressure of oxygen (Po2) is 70 mmHg and has high serum LDH.
Which medication can be used in its inhaled form in this disease?

Choices:

1. Trimethoprim-sulfamethoxazole
2. Pentamidine
3. Tobramycin
4. Amoxicillin

Answer: 2 - Pentamidine

Explanations:

The most likely diagnosis is pneumocystis jiroveci pneumonia (PCP). Pentamidine is an

anti-infective agent used for the prevention and treatment of pneumocystis jiroveci
pneumonia (PCP).
Pentamidine is available in the inhalation or intravenous form, as orally it
undergoes the first-pass metabolism by the liver.
The recommended dose of pentamidine is 3-4 mg/kg IV/IM once daily for 14-21 days.
Pentamidine is used in the moderate or severe form of PCP. Trimethoprim is also
used in the treatment of PCP, but it is not available in inhaled form. Tobramycin
and amoxicillin are not used as first or second-line agents for the treatment of
PCP.

Research Concepts:

Pentamidine

Page 902 of 955

Question 950: A 40-year-old man is with a history of dyspnea presents to the emergency
department for several days of fever, chills, and night sweats. On physical exam, the
patient is febrile with temperature 102.3 F, heart rate 110/min, and has a holosystolic
murmur and splinter hemorrhages of the nail beds. Transthoracic contrast
echocardiogram shows grade 2 pulmonary shunt and evidence of vegetations on the
mitral valve. On further questioning, the patient notes having progressively worsening
dyspnea and a past hospitalization for massive hemoptysis; however, a diagnosis was
never made. Which of the following underlying conditions is most likely responsible for
the patient's complication?

Choices:

1. A pathologic communication between the pulmonary artery and pulmonary vein

2. A benign nodule of the lung parenchyma
3. A dilated pus-filled bronchus
4. An abnormal connection between the bronchi and the pleural cavity
Answer: 1 - A pathologic communication between the pulmonary artery and pulmonary vein

Explanations:

A pulmonary arteriovenous malformation is a rare condition characterized by a

pathologic communication between the pulmonary artery and pulmonary vein,
creating an intrapulmonary right-to-left shunt.
This shunt impairs gas exchange and is responsible for symptoms of hypoxemia.
PAVMs can be congenital or sporadic.
The majority of cases are associated with hereditary hemorrhagic telangiectasia.

Research Concepts:

Pulmonary Arteriovenous Malformation

Page 903 of 955

Question 951: A 55-year-old man is accompanied by his spouse on an airline flight. During
the flight, the man becomes increasingly agitated, short of breath, with no chest, arm, or
leg pain. A health care provider on the plane recognizes the event, and the man's spouse
relays the patient has a history of severe pulmonary hypertension and has had a recent
cardiac catheterization, which showed no coronary artery disease. The patient has a
normal pulse but appears pale and is not wheezing. Within minutes man's breathing
status improves with an oxygen facemask and with the pilots lowering the cruising
altitude of the airplane. What is the most likely pathophysiology behind this event?

Choices:

1. Myocardial infarction
2. Pulmonary embolus
3. Asthma attack
4. Hypoxic pulmonary vasoconstriction

Answer: 4 - Hypoxic pulmonary vasoconstriction

Explanations:

Hypoxic pulmonary vasoconstriction increases pulmonary vascular resistance.

Hypoxic pulmonary vasoconstriction can occur with the hypoxia that results from
flying at high altitude.
Hypoxic pulmonary vasoconstriction can be alleviated if treated rapidly with oxygen,
improving altitude, and pulmonary vasodilators.
Myocardial infarction, pulmonary embolus, and asthma attack should all be
considered for a patient who is short of breath. The problems listed would likely not
be relieved as quickly as in the above scenario. There was no wheezing note, no
change in pulse rate, no signs consistent with these three diagnoses. A pulmonary
embolus can cause increased hypoxic pulmonary vasoconstriction. However, other
signs and symptoms would be present and be longer in duration. The patient may
need further evaluation at a local hospital to ensure that an infarction or embolus
were not missed.

Research Concepts:

Physiology, Pulmonary Vascular Resistance

Page 904 of 955

Question 952: A 65-year-old male presents for the evaluation of cough and unexplained
weight loss. He also reports a small amount of hemoptysis for the last few weeks. He has
a 40-pack-year history of smoking. A chest X-ray shows a 2 cm spiculated mass in the right
para hilar region. On further evaluation, which of the following is most likely to be
present?

Choices:

1. Cushing syndrome
2. Symptomatic liver metastases
3. Symptomatic bone metastases
4. Limbic encephalitis
Answer: 3 - Symptomatic bone metastases

Explanations:

Lung cancer or bronchogenic carcinoma refers to tumors originating in the lung

parenchyma or within the bronchi. Smoking is the most common cause of lung
cancer. Cough, dyspnea, and hemoptysis are the most common presenting
symptoms.
Metastasis from lung cancer to bone is frequently symptomatic, and patients may
present with bone pain at the site of metastasis in the setting of elevated serum
alkaline phosphatase and hypercalcemia.
Up to 20% of the patients with non-small cell lung cancer may have bone pain
secondary to metastasis on initial presentation; whereas the percentage is as high
as 30% to 40% in patients with small-cell lung cancer. Imaging usually reveals
osteolytic lesions with vertebral bodies as the most common site of metastasis.
Adrenal metastases also occur in lung cancer, but they are rarely symptomatic. Not
all adrenal lesions are malignant lesions, and positron emission tomography (PET)
scanning is recommended to differentiate benign from malignant adrenal lesions in
these patients. Brain metastasis is another common feature of lung cancer in small
cell lung cancers (SCLC) and non-small cell lung cancers (NSCLC). In SCLC, brain
metastases may be present in as high as 20% to 30% of the patients at the time of
diagnosis. Other common sites of metastases in lung cancer include the liver, which
is usually only symptomatic in advanced disease.

Research Concepts:Lung Cancer

Page 905 of 955

Question 953: A 53-year-old male with a history of stroke and left-sided hemiparesis for
the last 2 years, presents with fever and general malaise. He is hemodynamically stable
at the time of presentation. Chest x-ray reveals a lung abscess. He is started on
ampicillin-sulbactam for empiric treatment and a sputum culture is sent. Two days later,
the patient develops hypotension and a worsening respiratory status. His fevers have not
subsided. There is no identified organism on sputum gram stain and the culture is still
pending. A repeat chest x-ray shows that the abscess containing an air-fluid level has
enlarged. What is the next best step in the management of this patient?

Choices:

1. Thoracotomy for resection of the abscessed lobe

2. Bronchoscopy for bronchoalveolar lavage
3. Percutaneous drainage for decompression and cultures
4. Percutaneous infiltration of the mass with antibiotics
Answer: 3 - Percutaneous drainage for decompression and cultures

Explanations:

Percutaneous drain placement under computed tomography (CT) guidance is used

in patients on mechanical ventilators with expanding lung abscess, pre-existing
debilitating conditions, signs of unremitting sepsis, abscess under tension, failure to
wean, and contamination of the contralateral lung.
In this patient, percutaneous decompression is the best procedure as it will allow
decompression/drainage of the abscess and help obtain fluid for cultures. The
incidence of complicating empyema is low. There is usually rapid clinical
improvement post-decompression.
Empiric treatment with ampicillin-sulbactam is an appropriate choice initially,
however, some studies showed increasing rates of penicillin-resistance among
anaerobes. In patients who fail medical therapy despite appropriate antibiotics,
drainage is required to facilitate recovery.
Failure of medical therapy is more common in patients with large cavities.

Research Concepts:

Lung Abscess

Page 906 of 955

Question 954: A 33-year-old woman presents with a one-year history of exertional dyspnea.
She has never smoked and works as a taxi driver. Her body mass index is 35 kg/m^2, vital
signs are normal, and the lung exam demonstrates reduced breath sounds bilaterally.
No lower extremity edema is appreciated. Spirometry shows forced vital capacity (FVC) 72%
of predicted, forced expiratory volume exhaled in the first second (FEV1) 70% of predicted,
and FEV1/FVC ratio of 0.8. What is the next best way to identify this patient's ventilatory
defect?

Choices:

1. Perform a pre and post-bronchodilator test

2. Perform a methacholine challenge test
3. Perform complete pulmonary function testing
4. Perform peak flow meter measurement twice daily
Answer: 3 - Perform complete pulmonary function testing

Explanations:

Spirometry is a physiological test that measures the ability to inhale and exhale air
relative to time. Spirometry is a diagnostic test for several common respiratory
disorders, including asthma and chronic obstructive pulmonary disease (COPD).
This patient's spirometry results are suggestive of a restrictive ventilatory defect
(normal ratio and proportionally reduced forced vital capacity (FVC) and forced
expiratory volume exhaled in the first second (FEV1).
Spirometry can only suggest a restrictive defect; lung volumes are necessary to
confirm the defect. Total lung capacity (TLC) is the gold standard for the diagnosis of
a restrictive defect and requires complete pulmonary function testing.
If FEV1/FVC ratio is low and FVC is less than 0.80, but TLC is normal, the patient
has an obstructive pattern, and FVC is low due to hyperinflation.

Research Concepts:

Pulmonary Function Tests

Page 907 of 955

Question 955: A 47-year-old man presents with a six-month history of sleeping difficulty.
He has a past medical history of alcohol use disorder and priapism. He currently takes no
medications. His vital signs show oxygen saturation of 98% on room air, respiratory rate
of 16 per minute, heart rate of 80 beats per minute, blood pressure of 130/90 mmHg, and
temperature of 36.7 C (98 F). A polysomnography rules out obstructive sleep apnea and
narcolepsy. An over-the-counter medication that acts on the MT 1 and MT 2 receptors is
prescribed. How is this drug metabolized?

Choices:

1. Excreted unchanged by the kidney

2. Metabolized by the liver and excreted mainly in feces
3. Excreted unchanged in the feces
4. Metabolized by the liver and excreted by the kidney

Answer: 4 - Metabolized by the liver and excreted by the kidney

Explanations:

Melatonin acts on MT receptors, and it is used as an over-the- counter sleep

medication.
Ninety percent of melatonin is metabolized in the liver primarily by the enzyme
CYP1A2. It is metabolized by hydroxylation to 6- hydroxymelatonin, conjugated to
sulfuric or glucuronic acid, and excreted in the urine.
Melatonin is physiologically produced by the pineal gland and helps maintain the
body's sleep-wake cycle.
Melatonin is also under study for its anti-oxidative effects, anti- inflammatory
effects, regulation of lipid, and glucose metabolism. It is sometimes used as an
anxiolytic (melatonin receptor agonist) agomelatine.

Research Concepts:

Melatonin

Page 908 of 955

Question 956: A 55-year-old woman with a history of hypertension and renal
transplantation presents to the emergency department with fever and a cough for two
days. Her daily medications include losartan, amlodipine, cyclosporine, and prednisone. A
chest x-ray shows nodular opacities in bilateral lung fields. A follow-up CT shows less than
2 mm diffuse nodular opacities in both lungs. Multiple enlarged lymph nodes are also
noted in the mediastinum and axillae. Fine needle aspiration of the lymph nodes reveals
capsulated organisms. Which of the following is the most appropriate agent in treating
this patient's condition?

Choices:

1. Azithromycin
2. Flucytosine
3. Fluconazole
4. Doxycycline

Answer: 3 - Fluconazole

Explanations:

Cryptococcus is an invasive fungus that causes cryptococcosis, an infection

commonly associated with immunosuppressed individuals and is rare in healthy
individuals.
The two species of Cryptococcus that are commonly associated with infections in
humans are Cryptococcus neoformans and Cryptococcus gattii. Treatment of mild to
moderate disease is with fluconazole; amphotericin-B is preferred in severe disease.
Immune suppression is the major underlying mechanism that is involved in the
causation of cryptococcal disease.
Diseases like AIDS, diabetes mellitus, chronic liver disease, chronic renal disease,
prolonged use of steroids, and patients who undergo organ transplantation are
commonly associated with the development of cryptococcal disease.

Research Concepts:

Cryptococcus

Page 909 of 955

Question 957: A 40-year-old patient with HIV/AIDS has not been on any therapy for 18
months due to economic hardship. Four months ago, he was treated successfully for
avium complex (MAC). For the past four days, he has had a fever, dry cough, and
progressive dyspnea. Vital signs show a temperature of 38.9 C, blood pressure of 88/58
mmHg, heart rate of 140/min, and a respiration rate of 40 breaths per minute. Oxygen
saturation is 80% on room air. The neck shows bilateral lymphadenopathy, the lungs
show bilateral rales, and the abdomen is non-tender. Oxygen by a non-rebreather mask
does not improve the condition of the patient.
Which of the following is appropriate management for this patient?

Choices:

1. Bronchoalveolar lavage for direct immunofluorescence

2. Rapid sequence intubation and intravenous fluids
3. Complete blood count, CD4+ count, viral load, and chest x-ray
4. Sputum culture, complete blood count, and chest x-ray
Answer: 2 - Rapid sequence intubation and intravenous fluids

Explanations:

A further clinical evaluation must wait as the condition of the patient is worsening.
The patient has impending respiratory failure most likely due to Pneumocystis jiroveci
pneumonia.
Arterial blood gas analysis will aid the provider in determining if steroids are required
for a patient with Pneumocystis pneumonia (PCP.)
Chest radiography may also be useful for cardiac presentations or for those
patients who need evaluation for pulmonary infections. If chest radiography does
not reveal an obvious pulmonary process and there is still concern for lung
pathology computed tomography of the chest may be a consideration for further
evaluation.

Research Concepts:

Acquired Immune Deficiency Syndrome

Page 910 of 955

Question 958: A 2-month-old male patient is brought to the hospital with a cough. He
was born to a primigravida at 28 weeks of gestation and weighed 4 pounds (1.8 kg) at
birth. He was also diagnosed with patent ductus arteriosus at birth. His condition started
two days ago with a simple cold, followed by a harsh cough and fever. He can tolerate
feeding. The vital signs show a temperature of 39 C (102.2 F), heart rate 160/min,
respiratory rate 60 breaths/min, and oxygen saturation of 93%. A physical exam reveals
slightly sunken eyeballs, nasal flaring, substernal and intercostal retractions. On
auscultation of the chest, crackles in both lung fields are heard. A chest x-ray was done,
which reveals a distinct interstitial haziness on both sides. Oxygen therapy and IV
hydration are started. What is the most common risk factor for the indication of
mechanical ventilation?

Choices:

1. Lower gestational age

2. Age less than 3 months
3. Congenital heart defect
4. Recurrent infections
Answer: 1 - Lower gestational age

Explanations:

Bronchiolitis is a viral infection affecting the smaller airways that affects children
less than 2 years. Premature infants are at increased risk.
The clinical features of bronchiolitis are primarily due to airway obstruction and
diminished lung compliance.
The most common cause is the respiratory syncytial virus. Other infections that
cause bronchiolitis are adenovirus, coronavirus, and human rhinovirus.

Research Concepts:

Bronchiolitis

Page 911 of 955

Question 959: A 55-year-old female was admitted to the ICU due to Guillain-Barre
syndrome. Over the last 3 days, she had been showing signs of improvement but
required continued propofol sedation and intubation for ventilatory support as well as
parenteral nutrition. On her 4th day of admission, she began to show an acute decline in
cardiac function. Her labs revealed lactic acidosis, elevated creatine kinase, and
hyperkalemia. Which of the following contributed to her worsening status in the ICU?

Choices:

1. High carbohydrate parenteral nutrition

2. Carnitine deficiency
3. Demyelinating polyradiculoneuropathy
4. Direct myocyte injury
Answer: 2 - Carnitine deficiency

Explanations:

Propofol infusion syndrome should be suspected in patients who have had propofol
infusing at a rate of over 4 mg/kg/hr for over 48 hours. Propofol infusion syndrome
is characterized by cardiac abnormalities such as bradycardia, rhabdomyolysis, and
metabolic acidosis. Carnitine deficiency, low carbohydrate levels, use of
glucocorticoids, and mitochondrial disease can be contributors to the development
of propofol infusion syndrome.
Long-term use of propofol can lead to an increase in malonylcarnitine which inhibits
carnitine palmitoyltransferase. Inhibition of this enzyme causes a decrease of
acetylcarnitine transfer into muscle cells, which ultimately can cause a failure of ATP
production in the mitochondria causing a build-up of long, medium, and short-chain
fatty acid by-products.
Carnitine palmitoyltransferase deficiency disrupts fatty acid metabolism and can
result in seizures, hypoketotic hypoglycemia, and hepatic encephalopathy. Carnitine
deficiency can contribute to the development of propofol infusion syndrome by
inhibiting fatty acid metabolism.
Propofol infusion syndrome is characterized by cardiac abnormalities such as
bradycardia, rhabdomyolysis, and metabolic acidosis. Direct myocyte injury can
lead to myoglobinuria, hyperkalemia, rhabdomyolysis, acute kidney injury, and
potentially renal failure. Rhabdomyolysis also correlates with high levels of steroid
therapy in some case reports due to proteolysis of the cardiac contractile
myofilaments.
Research Concepts:Propofol Toxicity

Page 912 of 955

Question 960: A 59-year-old man with a past medical history of heart failure with reduced
ejection fraction, chronic obstructive pulmonary disease, ischemic coronary heart disease,
and essential hypertension is seen in the intensive-care unit for respiratory distress with
acute respiratory distress syndrome (ARDS). The patient's clinical condition has been
progressively deteriorating. He is intubated and sedated. Vital signs include blood
pressure 90/46 mmHg, heart rate 118/min, and temperature 37.5 C (99.5 F). The patient's
hypoxia has been refractory to multiple ventilator settings.
Current ventilator settings include FiO2 100%, tidal volume 460 mL, PEEP 8 cmH2O,
plateau pressure 30 cmH2O, and rate 28 breaths/minute. His oxygen saturation is
measured at 78% and drops to 75% on a subsequent reading 2 hours later. Which of the
following is the next best step in the management of this patient's hypoxia?

Choices:

1. Decrease PEEP, increase plateau pressure

2. Establish extracorporeal membranous oxygenation (ECMO)
3. Prone positioning, paralytics, increase PEEP, and conservative fluid management
4. Decrease PEEP, decrease plateau pressure
Answer: 3 - Prone positioning, paralytics, increase PEEP, and conservative fluid management

Explanations:

This patient should be paralyzed and placed in a prone position. After resuscitation,
there should be conservative fluid management.
Despite advances in critical care, ARDS still has high morbidity and mortality. Even
those who survive can have a poorer quality of life.
For cases of refractory hypoxemia and hypoxia in acute respiratory distress
syndrome (ARDS), ECMO may be the only option to improve oxygenation. This
modality is considered a last resort. Recently, extracorporeal membrane
oxygenation (ECMO) has been advocated as salvage therapy in refractory
hypoxemic ARDS but despite improved oxygenation, there is no improved survival.
Besides the restriction of fluids in high-risk patients, close monitoring for
hypoxia by the team is vital. The earlier the hypoxia is identified, the better
the outcome.

Research Concepts:Acute Respiratory Distress Syndrome

Page 913 of 955

Question 961: A 2.5-month-old, ex-32 week infant male born to a mother with
gestational diabetes is being prepared for discharge from the NICU. He is now at 42 weeks
of adjusted gestational age. He has had a difficult clinical course, requiring intubation
shortly after birth, surfactant, mechanical ventilation for four weeks, and supplemental
oxygen until one week ago. His father asks about long- term pulmonary complications
from his initial diagnosis. Which of the following best explains his concern?

Choices:

1. The infant will not require treatment after discharge from the neonatal
intensive care unit
2. The infant's condition is directly a result of a lack of surfactant production
3. The infant's condition is likely due to structural immaturity and inflammatory
process from both baby's diagnosis as well as prolonged mechanical ventilation
4. The infant has a similar risk for chronic lung conditions in childhood than a
baby that was not diagnosed with respiratory distress syndrome at the same
gestational age
Answer: 3 - The infant's condition is likely due to structural immaturity and inflammatory
process from both baby's diagnosis as well as prolonged mechanical ventilation

Explanations:

This baby most likely has respiratory distress syndrome of the neonate and meets
the criteria for the diagnosis of bronchopulmonary dysplasia (BPD). RDS is the
most common complication of prematurity and can lead to significant morbidity in
late preterm neonates and even mortality in very low birth weight infants. The
most significant risk factors are prematurity and low birth weight, but another
significant risk factor is maternal diabetes.
Chronic complications of RDS are largely related to the treatment of the neonate.
BPD is an important chronic complication of RDS. The pathophysiology of BPD
involves both arrested lung development as well as lung injury and inflammation.
The immature lung of the premature infant has decreased compliance, decreased
fluid clearance, and immature vascular development, which predisposes the lung to
injury and inflammation, further disrupting the normal development of alveoli and
pulmonary vasculature. In addition, oxidative stress from hyperoxia secondary to
mechanical ventilation, and decreased anti-oxidant capabilities of the premature
lung, both lead to further damage to the lung through the increased production of
TGF-beta1 and other pro-inflammatory cytokines. It is not known at this point if the
baby will require further treatment after discharge. His condition (BPD) is not due to
surfactant deficiency directly; however, surfactant deficiency was likely the cause of
the baby's need for mechanical ventilation and respiratory support. Having

Page 914 of 955

 respiratory distress syndrome carries a greater risk for chronic respiratory conditions
in childhood.

Research Concepts:

Neonatal Respiratory Distress Syndrome

Question 962: A 59-year-old recent immigrant from Pakistan comes to the clinic with a
history of productive cough, night sweats, and weight loss for the last 6 months. He has
also noticed mild fever, especially at night. Upon further questioning, he confirms
hemoptysis for the last 1 month. Vital signs include blood pressure 135/80 mmHg, pulse
80/minute, respiratory rate 15/minute, and temperature 38 C (100.4 F). Physical exam
reveals crepitation at the right upper lobe and cervical lymphadenopathy with a single
large mass at the lateral neck. The mass is non-tender, fluctuant, and appears to be
attached to deep structures. A complete blood count reveals a hemoglobin of 13 g/dL and
a leukocyte count of 13,500/mm3 with 67
% lymphocytes. If the tissue sample from the neck mass was sent for biopsy, what
would be the most likely finding?

Choices:

1. Granulation tissue
2. Reed–Sternberg cells
3. Atypical T lymphocytes with coagulative necrosis
4. Caseating necrosis with giant cells
Answer: 4 - Caseating necrosis with giant cells

Explanations:

The presence of fever, frequent night sweats, and hemoptysis in an immigrant from a
high-risk country with lymphadenopathy should raise suspicion of tuberculosis (TB)
and underlying scrofula.
Microscopically, characteristics of TB lymphadenopathy include granuloma
formation, the same as in pulmonary TB. Central caseous necrosis surrounded by
multinucleated giant cells, epithelioid cells, and a rim of sensitized T-cells mixed
with fibrous connective tissue on later stages when healing occurs. The primary
cause of scrofula in the immunocompromised patients is mycobacterium
tuberculosis (95%), atypical and nontuberculous mycobacteria cause rest (5%). On
the other hand, atypical and nontuberculous mycobacteria are mainly responsible
Page 915 of 955
 for scrofula in immunocompetent children.
Diagnosis of tuberculous lymphadenopathy is provided by histopathology along
with a smear of acid-fast bacilli and culture of lymph nodes. Fine needle aspiration is
the gold standard for the diagnosis of peripheral lymphadenopathy, including
tuberculous cervical lymphadenitis.
Research Concepts: Scrofula

Question 963: A 45-year-old patient presents to the emergency department with three
days of worsening fever and dry cough. He also complains of dyspnea on exertion. He
has a history of renal transplant for which he takes immunosuppressants, including
glucocorticoids. He does not have a sore throat or running nose.
Temperature is 39 C (102.2 F), pulse is 98/min, blood pressure is 130/80 mm Hg, and
respirations are 28/min. Oxygen saturation is 84% in ambient room air. Chest auscultation
reveals bilateral diffuse crackles. Chest x-ray reveals bilateral diffuse ground-glass
opacities. A sample obtained from bronchoalveolar lavage reveals eosinophilic foamy
alveolar material and numerous cup-shaped cyst-like organisms in the methenamine silver
stain. Which of the following is the most likely to be present in this patient?

Choices:

1. Soap bubble lesions on brain imaging

2. Elevated serum lactate dehydrogenase
3. Lung granuloma
4. Hemolytic anemia
Answer: 2 - Elevated serum lactate dehydrogenase

Explanations:

This patient on chronic glucocorticoid therapy presents with fever, dry cough, and
signs of acute respiratory failure (dyspnea, hypoxia). Methenamine silver staining of
the sample obtained from bronchoalveolar lavage shows numerous cup-shaped
organisms that are suggestive of Pneumocystis jiroveci. Lab findings include
elevated serum lactate dehydrogenase and leukocytosis. Pneumocystis jiroveci can
cause pneumonia in patients on immunosuppression, which can manifest as an
acute respiratory failure. The course is more indolent in patients with HIV/AIDS.
Complications like pneumothorax and respiratory failure are signs of poor
prognosis.
Pneumocystis jiroveci pneumonia (PCP) is very difficult to culture and thus silver
stains are used to identify the cyst. Bronchoscopy lavage is required to obtain a
lung specimen. When stained, it reveals the cyst wall or the trophozoite.
Page 916 of 955
 Numerous disc-shaped or cup-shaped yeasts are visible along with the eosinophilic
foamy alveolar materials.
The treatment of choice is trimethoprim-sulfamethoxazole (TMP- SMX).
Corticosteroids should be added for severely impaired oxygenation. Prophylaxis with
TMP-SMX is indicated in patients with HIV/AIDS when the CD4 count is less than
200/mm3.
Silver staining can be used to detect various other fungi like Cryptococcus or
Histoplasma and Legionella. Cryptococcus usually causes meningoencephalitis
("soap bubble" lesions on brain imaging) in immunocompromised patients. It is an
encapsulated yeast with narrow budding. It is usually stained with Indian ink, which
shows a clear halo around the yeast (transparent capsule). Histoplasma can cause
focal or perihilar lung infiltrates. Histopathology will reveal granulomas with
narrow-based budding yeasts inside macrophages. Mycoplasma pneumonia can
present with cough, fever, and interstitial infiltrate. It can cause subclinical
hemolytic anemia.

Research Concepts:

Pneumocystis Jirovecii Pneumonia

Question 964: A 45-year-old female with no significant past medical history presents with
weakness, which increases with activity. She reports fatigue, orthopnea, and dysphagia
that worsen throughout the day. Laboratory investigations reveal a hemoglobin level of 12
g/L and a white blood cell count of 8000 cells/mL. Electrolytes are normal except for a
bicarbonate level of 33 meq/L. Vital signs indicate a blood pressure of 120/80 mmHg, a
heart rate of 94 beats per minute, and oxygen saturation of 92% on room air.
Further examination reveals poor inspiratory effort. Arterial blood gas values are pH of 7.31,
PO2 of 67 mmHg, and PCO2 of 58 mmHg.
What is the next best step to be performed in managing this patient?
Choices:

1. Transesophageal echocardiography
2. Plethysmography
3. Pulmonary function tests
4. Transthoracic echocardiography
Answer: 3 - Pulmonary function tests

Explanations:

Page 917 of 955

 The patient most likely has a diaphragmatic weakness that would be evident in pulmonary
function testing by a reduced forced vital capacity that is worse when supine.
Diaphragmatic palsy or paresis can be a result of either direct diaphragmatic muscle weakness
and atrophy or damage to the phrenic nerves. The unilateral weakness of one of the
hemidiaphragm is more common than bilateral weakness.
Depending on the cause, the weakness can be either temporary or permanent.
Positive-pressure and bilevel positive-pressure ventilation show success in diaphragmatic
weakness. This noninvasive pressure ventilation creates a dynamic pressure splint in the
airways and prevents paradoxical diaphragmatic movements. It also augments the minute
ventilation working in coordination with intercostal muscles. This therapy is frequently used
overnight as respiration is compromised in the supine position.
In severe cases, intermittent daytime therapy can be used. For more severe cases requiring
high-pressure settings and the inability to tolerate oral or nasal masks, a tracheostomy is an
option. Advancement in noninvasive technology has enabled noninvasive therapy with a
tracheostomy interface. If the patient cannot tolerate this setting, then a mechanical
ventilator can be used. Diaphragmatic paralysis following surgeries is usually temporary and
can be treated with this noninvasive, positive- pressure ventilation until the diaphragm or
phrenic nerve regains function.

Research Concepts: Diaphragm Disorders

Question 965: A 40-year-old man is being evaluated in the ICU. He has been extubated 10
minutes ago and is complaining of progressive difficulty in breathing with a slowly
increasing swelling in the lower neck. He had a road traffic accident with blunt trauma of
head/neck and chest 2 days ago. His initial evaluation at the emergency was normal, with
unremarkable CT scans of the head, chest, and neck. He was intubated at admission due
to a low GCS and has regained consciousness 24 hours ago. He was hemodynamically
stable with optimal ventilatory parameters before extubation. On evaluation, he is
conscious, oriented, and hemodynamically stable with mild breathing difficulty with a
saturation of 92% on 5 L/min of mask oxygen. Examination shows bruises over the
anterior neck and chest with moderate subcutaneous emphysema. An urgent
bronchoscopic evaluation reveals a 4.5 cm laceration in the mid trachea. Which of the
following is the next best step in the management of this patient?

Choices:

1. Surgical repair
2. Conservative management
3. Fibreoptic bronchoscopy and stenting
4. Local glue injection
Answer: 1 - Surgical repair

Page 918 of 955

Explanations:

The clinical vignette describes a classic presentation of a tracheobronchial tear that

has presented with post-extubation respiratory failure & subcutaneous
emphysema. The endotracheal tube cuff must have sealed the tear initially, but the
tear has again opened up following extubation. This tear, which is more than 4 cms
in length with the patient clinically deteriorating, needs a surgical repair.
Surgical repair is indicated in tracheal tears more than 4 cms in length and patients
who deteriorate clinically. Those who have a length between 2 to 4 cm are
managed on a case to case basis based on anatomy, clinical situation,
comorbidities, and available expertise. Tracheobronchial tears less than 2 cm could
be managed conservatively with bronchoscopic follow up.
Cardilo et al. proposed a morphologic classification for intubation related posterior
tracheal wall injuries to identify patients who could be managed conservatively.
Level I is mucosal or submucosal injury, Level II represents further extension with
muscular wall involvement with subcutaneous or mediastinal emphysema, Level
IIIA represents complete laceration with herniation of oesophageal or mediastinal
soft tissue, and IIIB represents all above plus oesophageal injury or mediastinitis.
Level IIIA & IIIB represents a definite indication for surgery. Level I could undergo
conservative management with Level II management on a case to case basis. All
conservatively managed patients need bronchoscopic follow-ups.
Emergency surgery is indicated if there is a prolapse of the oesophageal wall into
the tracheal lumen, and also those patients who fail to get ventilated due to the
injury. Surgical repair would be done on any tear which is found during exploration.
Surgical repair has traditionally been the choice in tracheobronchial injuries.
However, a select group of patients with iatrogenic posterior wall tears could be
managed
conservatively if there is minimal subcutaneous emphysema without an increase in
size, absence of mediastinitis, pneumothorax evacuable with an intercostal tube
without large air leak, no associated esophageal injury, ability to maintain
ventilation with minimal positive end-expiratory pressure, and ability to keep the
endotracheal tube cuff distal to the injury site even if intubation is needed. Many
clinicians follow Cardilo's morphologic classification for planning management
strategies in such patients. There is another select number of patients who are unfit
for initial surgical repair (either transiently or permanently) who could be managed
with a trial of endobronchial stent placement. Stents are removed after 4-6 weeks,
and patients monitored. They could either get better with stenting or may need
surgery at a later stage (if they become fit for surgical repair).

Research Concepts: Tracheobronchial Tear

Page 919 of 955
Question 966: A 32-year-old man is brought to the emergency department after his car
engine explodes in a motor vehicle collision. The total body burn area is estimated to be
around 18%. On presentation, the patient is in pain and somewhat disoriented. The Glasgow
Coma Scale (GCS) score is 14/15. Nasoendoscopy shows swollen upper respiratory tract and
slightly edematous vocal cords.
Bronchoscopy shows mild erythema throughout and a normal lower airway. After this type
of injury, which long-term complication is most likely to develop in this patient?

Choices:

1. Pneumonia
2. Atelectasis
3. Bronchiectasis
4. Pulmonary edema

Answer: 3 - Bronchiectasis

Explanations:

Long-term complications from smoke inhalation injury are much less common than
short-term complications. They include subglottic stenosis, bronchiectasis,
bronchiolitis obliterans, interstitial fibrosis, and reactive airways dysfunction
syndrome (RADS).
Short-term complications are seen in more severe injuries within 4 to 5 days, and
the most common complication is pneumonia.
Acute respiratory distress syndrome and pulmonary edema are also seen in the short
term.
These patients will often demonstrate changes in pulmonary function testing and may
require ventilatory support.
Complication rates are higher in patients with a history of an underlying lung disease,
such as chronic obstructive pulmonary disease (COPD) or asthma.

Research Concepts:

Inhalation Injury

Page 920 of 955

Question 967: A 76-year-old man presents with fever, chills, and myalgias. He has a history
of hypertension and congestive heart failure. Vitals are blood pressure 150/100 mmHg,
temperature
38.1°C (100.5°F), heart rate 88/min, and oxygen saturation 99% on room air. Rapid SARS
CoV-2 test is positive. His local area is known to have the Omicron variant as the
predominant circulating variant of concern for SARS-CoV-2. What is the best initial therapy
for this patient?

Choices:

1. Dexamethasone
2. Bamlanivimab-etesevimab
3. Casirivimab-imdevimab
4. Sotrovimab

Answer: 4 - Sotrovimab

Explanations:

This clinical vignette demonstrates a patient with mild-moderate COVID-19

infection. He does not require hospitalization and is not hypoxic; however, he has
multiple risk factors for progression to severe disease. Monoclonal antibodies are
authorized for treatment of COVID-19 in nonhospitalized patients with risk factors
for progression to severe disease and is indicated for use in this patient.
The Omicron variant of SARS-CoV-2 is now the predominant circulating variant in
the United States. Of the previously approved monoclonal antibodies, only
sotrovimab retains efficacy against this variant.
It neutralizes the spike protein of the virus and prevents viral entry into the host
cell. It should be administered as soon as possible and within 10 days of
symptom onset.
Bamlanivimab-etesevimab and casirivimab-imdevimab do not retain efficacy
against the Omicron variant. In January of 2022, the FDA revoked their emergency
use authorization due to the predominance of Omicron in the community.

Research Concepts:

Benefits And Risks Of Administering Monoclonal Antibody Therapy For Coronavirus (COVID-
19)

Page 921 of 955

Question 968: A 26 year-old-man is being evaluated in the intensive care unit. He was
admitted after a motor vehicle collision due to chest trauma after acceleration-
deceleration injury; he was not wearing a seatbelt. The patient complains of right side
chest pain, dyspnea. Physical examination is remarkable for chest tenderness, decreased
breath sounds, and rales on the right side. CT chest is remarkable for focal, non-
segmental areas of peripheral parenchymal opacification, with subpleural sparing,
confirming the diagnosis. The patient is started on bilevel positive airway pressure
(BiPAP) due to significant respiratory distress and desaturation.
Which of the following best explains the benefit of ventilation for the management of
this type of lung injury?

Choices:

1. High positive end-expiratory pressure to keep alveoli open and high tidal volume
2. High positive end-expiratory pressure to keep alveoli open and low tidal volume
3. Minimum positive end-expiratory pressure to keep alveoli open and recruit
maximum alveoli without barotrauma and high tidal volume
4. Minimum positive end-expiratory pressure to keep alveoli open and recruit
maximum alveoli without barotrauma and low tidal volume
Answer: 4 - Minimum positive end-expiratory pressure to keep alveoli open and recruit
maximum alveoli without barotrauma and low tidal volume

Explanations:

Two important components for a patient with pulmonary contusion requiring

mechanical ventilation are positive end- expiratory pressure (PEEP) and tidal
volume.
Most important is appropriate minimum PEEP to keep the lungs open, recruit
maximum alveoli, and prevent barotrauma.
Large tidal volume can have adverse effects; the use of low tidal volume is suggested.
If positive pressure ventilation fails, invasive ventilation is required.

Research Concepts:

Pulmonary Contusion

Page 922 of 955

Question 969: An African American female comes to the emergency room with facial
weakness. The right side started yesterday and the left side today. She has had no
constitutional symptoms or rashes. She lives in Chicago and has no pets. She is employed
in an office and has no hobbies with exposure to chemicals. She has hypertension and is
on hydrochlorothiazide. Her blood pressure is 130/85 mm Hg, the pulse is 85, respirations
16, and she is afebrile. The right side of the face is paralyzed, but she can raise her
eyebrow on the left. The chest radiograph has bilateral hilar lymphadenopathy. MRI with
gadolinium shows enhancement of the seventh cranial nerve and meninges bilaterally.
Lumbar puncture yields CSF with an opening pressure of 12 cm H2O, with no red cells, 21
white cells with 82% lymphocytes and 28 percent neutrophils, protein 72 mg/dL, and
glucose 62 mg/dL. Gram stain is negative. Select the most likely diagnosis.

Choices:

1. Multiple sclerosis
2. Sarcoidosis
3. Lyme disease
4. Tuberculosis
Answer: 2 - Sarcoidosis

Explanations:

5 to 10 percent of patients with sarcoidosis have neurologic manifestations.

The presenting complaint of sarcoidosis is neurologic symptoms half the time.
The most common neurologic findings are cranial nerve involvement, basilar
meningitis, myelopathy, and anterior hypothalamic disease.
Treatment initially would be prednisone 0.5 mg/kg daily.

Research Concepts:

Sarcoidosis

Page 923 of 955

Question 970: An 80-year-old male presents with nausea, intractable vomiting, and a
headache since last night. He reports that he was unable to sleep at night and made
frequent trips to the bathroom due to an increased urinary frequency. He has a history of
COPD, diabetes mellitus type 2, ischemic heart disease and congestive heart failure. His
current medications are inhaled albuterol, lisinopril, metoprolol, spironolactone,
atorvastatin, aminophylline, metformin, glyburide, and low-dose aspirin. He doesn't use
tobacco, alcohol or illicit drugs. His blood pressure is 110/90 mmHg, the pulse is 120/min
and irregular. On examination, he appears restless and agitated. There is a tremor in the
outstretched hand. Auscultation of the heart is within normal limits but the point of
maximal impulse is displaced laterally. ECG shows no p waves and the absence of
isoelectric baseline. What is the mechanism of action of the drug that caused this
patient's current symptoms?

Choices:

1. HMG-CoA reductase inhibitor

2. Phosphodiesterase inhibitor
3. Aldosterone antagonist
4. Angiotensin-converting enzyme inhibitor
Answer: 2 - Phosphodiesterase inhibitor

Explanations:

After entering the body, aminophylline releases theophylline. Theophylline causes

non-selective inhibition of type III and type IV isoenzymes of phosphodiesterase
which leads to increased tissue cyclic adenine monophosphate (cAMP) and cyclic
3',5' guanosine monophosphate concentrations, resulting in smooth muscle
relaxation in the lungs and pulmonary vessels, diuresis, CNS and cardiac
stimulation.
Theophylline clearance varies by age and concurrent illnesses. Congestive heart failure
decreases its clearance leading to increased serum concentrations.
Theophylline has a narrow therapeutic index. When the serum concentration rises
above 20mcg/ml, the signs of toxicity like nausea, intractable vomiting, cardiac
arrhythmias, seizures, increased urination, insomnia, and restlessness start
manifesting.
Atorvastatin is an HMG-CoA reductase inhibitor and it's adverse effects include liver
dysfunction, myositis, and rhabdomyolysis.

Research Concepts:Aminophylline

Page 924 of 955

Question 971: A 45-year-old woman presents for the evaluation of painful swelling and
skin changes of the fingers in both hands.
She reports long-standing cold intolerance with bluish color changes and swelling of her
fingers to cold exposure, returning to her usual color with warming. Recently the changes
have been enduring longer and are associated with pain. Her past medical history is
significant for gastroesophageal reflux disease, for which she takes ranitidine. Her vital
signs are within normal limits. Examination demonstrates sclerodactyly and digital pitting
of the fingertips bilaterally, neck skin tightening, clear lungs, and normal heart sounds.
Laboratory studies are significant for a positive antinuclear antibody titer in a centromere
pattern. Anti-centromere B antibody is strongly positive. Considering the potential
pulmonary complications of her disease, which of the following investigations is indicated
at this time?
Choices:

1. Pulmonary function testing

2. CT angiography of the chest
3. Ventilation perfusion scan
4. No further testing is indicated at this time
Answer: 1 - Pulmonary function testing
Explanations:

This patient has systemic sclerosis (SSc) of limited cutaneous subtype and is at risk
for pulmonary arterial hypertension (PAH). The lack of reliable risk factors for PAH
in SSc highlights the importance of routine and early screening and evidence
suggests that patients diagnosed and treated as a result of screening have better
outcomes. It is recommended that patients undergo an initial screening for PAH at
the time of diagnosis of SSc and then annually thereafter.
All patients diagnosed with SSc should undergo pulmonary function testing to
exclude or characterize any underlying airway or parenchymal disease. Decreased
diffusing capacity of the lungs for carbon monoxide (DLCO) and mild to moderate
reduction in lung volumes are common in PAH.
A reduction in DLCO in a patient with scleroderma with normal lung volumes is
suggestive of PAH and will warrant further testing to diagnose PAH with a right
heart catheterization.
Although echocardiography is frequently obtained at the time of diagnosis and
annually thereafter as a screening method for PAH, it has poor specificity and
sensitivity for the disease, especially in the absence of symptoms.
Research Concepts:Scleroderma-Associated Pulmonary Arterial Hypertension: Early
Detection For Better Outcomes

Page 925 of 955

Question 972: A 42-year-old male presents to the emergency department with altered
mental status. The family reports that the patient had recently gone through a divorce
and was found with a bottle of pink-colored pills next to him. His past medical history is
significant for hypertension, allergic rhinitis, and insomnia. His home prescription
medications include lisinopril. His blood pressure is 125/87 mmHg, heart rate is 186
beats/min, respiratory rate is 37 breaths/min, and oxygen saturation (SpO2) is 96% on
room air.
Physical exam reveals respiratory distress and dry mucous membranes.
Electrocardiogram (ECG) demonstrates a QTc interval of 525 milliseconds. Ingestion took
place approximately 85 minutes ago. He starts seizing on the gurney, and his SpO2 falls
to 79%.
What is the best step in the management of this patient?

Choices:

1. Lorazepam bolus and ICU admission for emergent hemodialysis

2. Lorazepam bolus and emergent intubation for airway protection
3. Diazepam bolus and albuterol nebulizer
4. Intravenous naloxone
Answer: 2 - Lorazepam bolus and emergent intubation for airway protection

Explanations:

Benzodiazepines, such as lorazepam, can be used for symptomatic management of

seizures secondary to diphenhydramine toxicity.
Given that this patient’s SpO2 is declining, continued respiratory distress can be fatal.
Emergent intubation is warranted in this situation to protect the patient’s airway and
to provide respiratory support.
Naloxone is used for opioid reversal and thus, would be ineffective in reversing the
effects of diphenhydramine.

Research Concepts: Diphenhydramine Toxicity

Page 926 of 955

Question 973: A 54-year-old male is brought to the emergency department by his family.
They report that several days ago, the patient began complaining of arthralgias,
myalgias, and subjective fevers. He thought that he had the flu and remained home from
work. Yesterday he developed swelling and a rash on his legs.
According to his family, yesterday evening the patient started acting strange, and today
he has been somewhat confused. On physical examination, the patient's temperature is
99.5 F (37.5 C), his heart rate is 93 beats per minute, and his blood pressure is 154/85
mmHg. He is able to answer questions but is easily distracted during the examination.
Pulmonary, cardiovascular, and abdominal examinations are normal. On musculoskeletal
examination, petechiae and purpura are noted on the upper and lower extremities, with
1+ pitting edema in the lower extremities. Laboratory values reveal a white blood cell
count of 24,000, a platelet count of 550,000, and a hematocrit of 35%. Blood urea
nitrogen and creatinine levels are 120 mg/dl and 4.5 mg/dl, respectively. Renal biopsy
reveals pauci-immune glomerulonephritis. A serum test for perinuclear antineutrophil
cytoplasmic antibodies (p-ANCAs) with anti myeloperoxidase specificity is positive. Once
induction of remission has been achieved, what should be used for maintenance therapy?

Choices:

1. Cyclosporine
2. Cyclophosphamide
3. Azathioprine
4. Prednisolone

Answer: 3 - Azathioprine

Explanations:

Microscopic polyangiitis is a small vessel necrotizing vasculitis, a part of a large

spectrum of disorders termed anti-neutrophil- cytoplasmic-antibody (ANCA)-
associated vasculitides (AAV).
Maintenance therapy is started after induction of remission and typically involves the
use of azathioprine compared to cyclophosphamide, as demonstrated by the
Cyclophosphamide versus Azathioprine for Early Remission Phase of Vasculitis trial
(CYCAZAREM trial).
Azathioprine is given in a dose of 2 mg/kg/day for 12 months. After one year, the
dose of azathioprine is decreased to 1.5 mg/kg/day.
If methotrexate is used in maintenance therapy, it can be started at 0.3 mg/kg once
a week, with the maximum dose of 15 mg/week. This is increased by 2.5 mg/wk
(maximum 20 mg/wk). This phase lasts for 12-24 months. Prednisone can be
continued at 10 mg/day or every other day. Low-dose cyclosporine has also been
Page 927 of 955
 used for maintenance therapy. But azathioprine is the safest option.

Research Concepts:

Microscopic Polyangiitis

Question 974: A 17-year-old male patient presents with complaints of a persistent night-
time cough and wheezing. He has had asthma since childhood. His last visit was three
months ago, and his symptoms were well-controlled on medium-dose inhaled
corticosteroid and long-acting beta 2 agonist plus as-needed short- acting beta 2 agonists.
However, now he is more short of breath with morning dipping of his peak flow readings.
On examination, he is mildly dyspneic but able to complete sentences. On auscultation,
there are scattered wheezes in his chest. His peak expiratory flow rate is 65% of
predicted. What is the most appropriate next step in the management of this patient?

Choices:

1. Add oral theophylline and oral corticosteroid

2. Add a long-acting muscarinic antagonist to the current regimen
3. High dose inhaled corticosteroid and long-acting beta 2 agonist plus a long-acting
muscarinic antagonist or anti-IgE
4. Admit to the hospital for continuous nebulized albuterol and intravenous
corticosteroids

Answer: 3 - High dose inhaled corticosteroid and long-acting beta 2 agonist plus a long-
acting muscarinic antagonist or anti-IgE

Explanations:

Initially, the patient may also require oral corticosteroids. High- dose inhaled
corticosteroids with long-acting and short-acting beta-agonists would be
appropriate. This can be followed by muscarinic antagonists such as ipratropium
bromide if needed. There are five steps in the management of chronic asthma,
treatment is started depending on the severity and then escalated or de-
escalated depending on the response to treatment.
This patient is at step 4 of asthma management which comprises of medium-dose
inhaled corticosteroid and long- acting beta 2 agonist plus as-needed short-acting
beta 2 agonists.
Page 928 of 955
 His medications need to be escalated to step 5 which includes high dose inhaled
corticosteroid and long-acting beta 2 agonist plus a long-acting muscarinic
antagonist or anti-IgE.

Research Concepts:Asthma

Question 975: A 24-year-old man presents to the clinic with complaints of a cough and
fever for one day. His blood pressure is 110/70 mmHg, heart rate 68/min, temperature
100.8 F, respiratory rate 16/min, and oxygen saturation 98%. His physical examination
reveals mild crackles at the lung bases bilaterally. The remainder of the physical
examination is unremarkable. A chest x-ray shows an elevation of the anterior portion of
the left hemidiaphragm without effusions or infiltrates. Reverse-transcriptase polymerase
chain reaction testing confirms influenza A infection. He is treated with oseltamivir and
symptoms resolve. He returns one month later for a follow-up without respiratory
symptoms. What is the next best step in the management of his chest x-ray findings?

Choices:

1. Oxygen therapy via nasal cannula

2. Nasal continuous positive airway pressure therapy (nasal CPAP)
3. Surgical plication
4. Conservative management
Answer: 4 - Conservative management

Explanations:

This patient's chest x-ray findings are consistent with eventration of the left
hemidiaphragm. Eventration of the diaphragm is often an incidental finding on
imaging.
Diaphragm eventration can be managed conservatively to treat symptoms as needed.
Conservative management may include oxygen therapy in hypoxemic patients,
nutritional support, physical therapy, and pulmonary rehabilitation.
This patient is asymptomatic on his follow-up visit. Oxygen therapy via nasal
cannula and nasal CPAP is not indicated as this patient is not hypoxemic and is
asymptomatic. Surgical plication is invasive and is reserved for patients with severe
symptoms that fail conservative management.

Research Concepts:Diaphragm Eventration

Page 929 of 955

Question 976: A 40-year-old man with a history of alcohol use disorder is admitted to the
hospital due to epigastric abdominal pain radiating to his back. Laboratory evaluation is
significant for a leukocyte count of 13,000/mm3 and lipase 2,000 U/L. Three days into the
patient's hospitalization, he develops hypoxia refractory to supplemental oxygen support
and is intubated. The patient has an ideal body weight of 80 kg and is initiated on
ventilator settings of tidal volume 600 cc, respiratory rate 20/min, FiO2 40%, and positive
end-expiratory pressure of 8 mmHg. A chest x-ray is obtained bilateral, predominantly
peripheral, somewhat asymmetrical consolidation with air bronchograms. An
echocardiogram demonstrates a left ventricular ejection fraction of 40% with global left
ventricular hypokinesis. The patient develops hypotension refractory to crystalloid
intravenous fluid support, and norepinephrine infusion is initiated. Despite continued
fluid support, pressor requirements continue to escalate along with increased oxygen
ventilator requirements. For further hemodynamic evaluation, a right heart
catheterization is performed. Mean right atrial pressure is 3 mmHg (normal 5 mmHg),
mean pulmonary arterial pressure 25 mmHg (normal 16 mmHg), and pulmonary capillary
wedge pressure 8 mmHg (normal 10 mmHg). Systemic vascular resistance is calculated at
1200 dynes/second. Which of the following is the next best step in the management of
this patient?

Choices:

1. Decrease the tidal volume to 6 cc/kg and up titrate positive end- expiratory
pressure
2. Initiate dobutamine
3. Intravenous furosemide
4. Intravenous nitroglycerin

Answer: 1 - Decrease the tidal volume to 6 cc/kg and up titrate positive end-expiratory
pressure

Explanations:

The patient presents with a clinical insult of acute pancreatitis and, within seven
days, developed worsening respiratory status. The chest x-ray is consistent with
bilateral opacities that are not explained by effusions, lung collapse, or nodules.
Clinically, the patient has developed ARDS (acute respiratory distress syndrome). The
origin of the pulmonary edema is not consistent with a cardiogenic etiology given
pulmonary capillary wedge pressure (PCWP) below 18 mmHg.
Given the clinical diagnosis of ARDS, the patient requires a low tidal volume and to
up titrate the positive end-expiratory pressure (PEEP). The tidal volume is
calculated as 6 cubic centimeters per kilogram of ideal body weight.

Page 930 of 955

 As the patient does not have elevated left-sided heart pressures given the PCWP of
8 mmHg, diuresis is not indicated at this time. Systemic vascular resistance is not
elevated, and there is not a cardiogenic etiology of the patient's pulmonary edema.
Thus dobutamine could further worsen hypotension. Intravenous nitroglycerin,
which diminishes preload, would not assist in this scenario as the right-sided heart
pressures are already within the normal range.

Research Concepts: Pulmonary Edema

Question 977: A 45-year-old female presents with recurrent cough, chest discomfort, and
increasing shortness of breath. The patient has no smoking history. She has been
evaluated multiple times for the same symptoms over the past 2 years with consistently
normal laboratory workups and chest x-rays. She had a past medical history of
Histoplasma infection a few years ago. A CT scan of the chest shows small calcifications
within a soft tissue mass in the hila of the right lung, which obscures the mediastinal fat
planes. What is a potential complication of this disease process?

Choices:

1. Malignant transformation
2. Left sided heart failure
3. Superior vena cava syndrome
4. Adrenal Insufficiency
Answer: 3 - Superior vena cava syndrome

Explanations:

The patient likely has fibrosing mediastinitis secondary to her previous Histoplasmosis
infection. Fibrosing mediastinitis is associated with complications that are caused by
obstruction or compression of structures within the mediastinum.
Superior vena cava syndrome is a potential complication of fibrosing mediastinitis.
Fibrosis involving the superior vena cava causes a venous backup. Thus symptoms are
related to venous congestion in the upper body.
Patients with superior vena cava syndrome may present with swelling of the neck,
face, or upper extremity, distended veins in the neck, shortness of breath, cough, and
orthopnea.
Research Concepts:

Mediastinitis
Page 931 of 955
Question 978: A 65-year-old male patient with a past medical history of chronic alcohol
use disorder presents with a blood-tinged cough for the last several days. The chest
radiograph shows infiltrates in the posterior aspect of the right upper lung, and a sputum
culture shows gram-negative, encapsulated, and non-motile bacterium. The patient
reports that he has anaphylaxis to penicillin and cephalosporins. Which of the following
is the best antibiotic to treat the patient's condition?

Choices:

1. Piperacillin/tazobactam
2. Fosfomycin
3. Levofloxacin
4. Tigecycline
Answer: 3 - Levofloxacin

Explanations:

If the patient is penicillin-allergic, then a course of aztreonam or a respiratory

quinolone should be advised to treat Klebsiella pneumonia.
Current regimens for community-acquired K. pneumoniae pneumonia include a 14-
day treatment with either a third or fourth generation cephalosporin as
monotherapy or a respiratory quinolone as monotherapy or either of the previous
regimes in conjunction with an aminoglycoside.
Several antibiotic options to treat Carbapenem-resistant Enterobacteriaceae (CRE)
Klebsiella pneumonia include antibiotics from the polymyxin class, tigecycline,
fosfomycin, aminoglycosides, or dual therapy carbapenems.
Piperacillin/tazobactam is a penicillin derivative and may incite a reaction in the
patient.

Research Concepts:

Klebsiella Pneumonia

Page 932 of 955

Question 979: A 65-year-old male complains of low-grade fever, cough, and foul-smelling
sputum for the past three weeks. The patient has a history of periodontal disease for
which he has not sought treatment for the past year. On physical examination, the
patient has a temperature of 100.1 F (37.8 C), blood pressure of 124/85 mmHg, heart
rate of 99 beats per minute, and respiratory rate of 22 breaths per minute. He has
dullness to percussion at the right lower base. Lab values reveal a white blood cell count
of 16,500 per mm3. Chest x-ray reveals extensive right lower lobe opacity. The patient is
allergic to penicillin. Which of the following antibiotics is best suited to treat this
patient's condition?

Choices:

1. Amoxicillin plus clavulanic acid

2. Clindamycin plus levofloxacin
3. Azithromycin plus meropenem
4. Levofloxacin plus aztreonam

Answer: 4 - Levofloxacin plus aztreonam

Explanations:

Risk factors for the development of anaerobic abscess include alcohol use disorder,
periodontal disease, and altered mental status (seizure, stroke, drug intoxication).
In the supine position, superior segments of the lower lobes are affected.
Azithromycin and meropenem are generally the first-line treatment without
penicillin allergy. In the absence of any risk factors for methicillin-resistant
Staphylococcal aureus or Pseudomonas aeruginosa and penicillin allergy, the
empiric therapy would be respiratory fluoroquinolone and aztreonam. Clindamycin
is not generally used in empiric therapy due to growing resistance.

Research Concepts:

Aspiration Pneumonia

Page 933 of 955

Question 980: A 60-year-old male presented with dyspnea, weight loss, and non-
productive cough six months ago. He was later found to have a 15 cm solid pleural-based
mass in the right lung on a CT scan of the chest. Pleural effusion was visible on imaging.
The tumor was completely resected via thoracotomy with negative surgical margins (R0)
confirmed intra-operatively. On gross appearance, the tumor is smooth with a
vascularized peduncle and originates from the visceral pleura. On microscopic
examination, a haphazard arrangement of spindle cells interspersed with collagen fibers
with several areas of necrosis is noted. High mitotic activity with 15 mitoses per high-
power field is observed. Immunochemistry reveals positive CD34, bcl2, and CD99 positive
spindle cells. His symptoms improved after the procedure. What is the next best step in
management?

Choices:

1. Adjuvant chemotherapy
2. Repeat CT scan in 3 months
3. Repeat CT scan in 16 months
4. Adjuvant radiation therapy
Answer: 2 - Repeat CT scan in 3 months

Explanations:

Adjuvant chemotherapy has a limited role after the complete resection of solitary
fibrous tumors of the pleura. Adjuvant chemotherapy does not improve survival in
these patients.
This tumor exhibits several characteristics concerning for malignancy. Some high-
risk features, in this case, include the presence of tumor necrosis, high mitotic
activity, pleural effusion, and large tumor size (diameter greater than 10). Complete
surgical resection (R0) significantly decreases the risk for recurrence. However,
intermediate to high-risk solitary fibrous tumors of the pleura require frequent CT
surveillance. A repeat CT scan is recommended every three months in the first two
years post-surgery.
Tumors with a high potential for recurrence should be monitored more frequently.
Adjuvant radiation therapy is not indicated after complete surgical resection of
low-risk tumors. In high-risk tumors with negative surgical margins, this is utilized
on a case-by-case basis after multidisciplinary discussion. Adjuvant radiation
therapy is recommended in high-risk patients with positive surgical margins.

Research Concepts:Pleural Solitary Fibrous Tumors

Page 934 of 955

Question 981: A 45-year-old man is brought to the emergency department after being found
in the middle of a snowstorm. He has a GCS of 10/15, and there appears to be no trauma.
After initial evaluation and stabilization measures have been initiated, bilateral chest tubes
are placed. Which of the following best describes the differences in the management of the
patient's bilateral chest tubes compared to commonly placed chest tubes?

Choices:

1. A large air leak from the patient's injury may be expected

2. One chest tube will be placed anteriorly and the contralateral side will have a
posteriorly placed chest tube
3. The chest tubes can be used to both instill and remove fluid from the thorax
4. Both chest tubes should initially be placed directly to wall suction without a chamber
Answer: 3 - The chest tubes can be used to both instill and remove fluid from the thorax

Explanations:

A method for internal rewarming of hypothermic patients is to place chest tubes to

introduce warmed fluids to the thorax.
With a single chest tube placed per side, the fluid is instilled and then removed.
Instillation of warm fluid into the thorax has the benefit of directly warming a large
amount of the patient's circulating volume through both the pulmonary vasculature
as well as the cardia that also occupies the thorax.
This atraumatic patient did not present with a history that leads one to believe
there is a pneumothorax with an injury to the lung parenchyma (answer 1).
Remembering that the mediastinum separates the left and right thorax, there is no
benefit to an anterior and posterior chest tube in separate sides of the thorax
because there should be no communication (answer 3). Few circumstances call for
placing a chest tube to wall suction immediately and most chest tubes should be
placed to a vacuum canister for monitoring and management (answer 4).

Research Concepts:

Care Of A Chest Tube

Page 935 of 955

Question 982: A 22-year-old woman presents to the emergency department for chest pain
after a motor vehicle collision. She reports a speed of approximately 25 MPH when she
rear-ended a stationary vehicle. She was a restrained driver. She denies loss of
consciousness or head trauma. She has no significant past medical history. Physical
examination demonstrates a small bruise across the anterior chest wall. A mobile chest x-
ray is ordered and reveals a right hilar opacity. A subsequent computed tomography of
the chest demonstrates a “finger-in-glove” appearance projecting from the hilum with
surrounding hyperlucent lung parenchyma. Which of the following is the next best step in
the management of this patient?

Choices:

1. Ibuprofen
2. Oral co-amoxiclav
3. Video-assisted thoracotomy
4. Magnetic resonance imaging
Answer: 1 - Ibuprofen

Explanations:

The patient has a musculoskeletal injury, and pain management is required. The
patient is incidentally diagnosed with bronchial atresia. This involves hyperinflation
of the involved segment.
The hyperinflation segment is excluded from the central airway and connected to
collateral air pathways, including; the intraalveolar pores of Kohn, the
bronchoalveolar channels of Lambert, and the interbronchiolar pores of Martin,
which act as one-way valves.
People diagnosed with bronchial atresia are most likely to be asymptomatic.
Bronchial atresia usually requires no surgical intervention. A select few patients may
experience persistent cough, respiratory distress, or recurrent infections. This may
require surgical intervention, such as partial lung resection, if severe.
If an individual with bronchial atresia is diagnosed with pneumonia, antibiotic
therapy should be started promptly. Bronchial atresia is most commonly diagnosed
with a chest radiograph and computed tomography.

Research Concepts:Bronchial Atresia

Page 936 of 955

Question 983: A 43-year-old female patient presents with a two- month history of fever,
nonproductive cough, and dyspnea. The chest CT scan evidenced a 9-mm intraluminal
lesion in the left main bronchus, in correspondence to the origin of the lingular segmental
bronchus. Histological examination showed tumor islands containing both cystic and solid
patterns. Cystic components consisted of cytologically bland columnar cells with mucin
and rare mitoses. Solid components consisted of squamoid and intermediate cells
surrounding the cystic areas. Mitoses were limited, and there was no necrosis. A left
upper lobectomy was performed. The histopathological examination confirmed the
preoperative diagnosis and stage (pT1N1M0). What is the most common location of this
type of tumor?

Choices:

1. Lung
2. Breast
3. Salivary gland
4. Bone

Answer: 3 - Salivary gland

Explanations:

Low-grade mucoepidermoid carcinomas are composed of three cell types: mucin

secreting, squamous, and intermediate cells, and often show cystic patterns with
solid areas. Tumor islands contain both cystic and solid patterns. Necrosis is rare.
Mucoepidermoid carcinomas are the most common type of salivary gland
cancer. Most of them originate in the parotid glands.
The prognosis of low-grade mucoepidermoid carcinomas is excellent. However, high-
grade mucoepidermoid carcinomas are more aggressive.
The treatment of mucoepidermoid carcinomas is generally surgical, which includes
traditional, or sleeve lobectomy.

Research Concepts: Mucoepidermoid Lung Tumor

Page 937 of 955

Question 984: A 65-year-old female presents to the office with exertional dyspnea, low-
grade fever, and productive cough. The patient states cough is associated with white
color sputum. Her past medical history is significant for hypertension, diabetes mellitus,
and osteoarthritis of her knees. Her vitals show a blood pressure of 140/85 mmHg, pulse
rate of 106/min, respiratory rate of 26/min, the temperature of 99 F, and oxygen
saturation is 89% on room air.
There has been no exposure to pets, birds, or other animals. Physical examination
reveals bilateral inspiratory crackles at lung bases. What is the classic high-resolution CT
scan finding in this patient's condition?

Choices:

1. Cheerios sign
2. Head cheese sign
3. Water lily sign
4. Atoll sign
Answer: 4 - Atoll sign

Explanations:

A central ground-glass opacity surrounded by a circumferential rim of dense

consolidation, known as the atoll sign, is the classically described high-resolution
CT finding in cryptogenic organizing pneumonia (COP).
The central ground-glass opacity is likely due to alveolar inflammation and cellular
debris, while the dense consolidation corresponds to the granulation tissue plug
within the alveolar ducts.
This sign, seen in about 20% of patients with COP and is non- specific as it can be seen
in various other infectious and inflammatory conditions.
A similar appearance has been reported in several other pulmonary conditions
such as fungal infections, granulomatosis with polyangiitis, lipoid pneumonia,
sarcoidosis, and adenocarcinoma-in-situ of the lung.

Research Concepts:

Cryptogenic Organizing Pneumonia

Page 938 of 955

Question 985:

A 59-year-old lady presented complaining of progressively worsening shortness of breath.

A review of systems was positive for dizziness and being lightheaded with exertion. Her
past medical history is significant for tobacco use and idiopathic pulmonary fibrosis (IPF).
In the emergency department, her vital signs were HR 112 beats per minute, blood
pressure 110/75 mmHg, and SpO2 86% on non-rebreather. On examination, there was
elevated JVD and lower extremity pitting edema in both legs. A pulmonary function test
one month ago showed a DLCO of 15% predicted, which dropped by 20% compared to one
year ago. She was admitted to the hospital for treatment of right heart failure. A
transthoracic echocardiogram showed dilated right ventricle and severely reduced systolic
function. Right heart catheterization showed mean pulmonary artery pressure of 88
mmHg and pulmonary wedge pressure of 12 mmHg.
Pulmonary vascular resistance (PVR) was calculated to be 8 woods unit. What would be the
appropriate next step in management?
Choices:

1. Inhaled treprostinil
2. Inpatient lung transplant evaluation
3. Intravenous epoprostenol therapy
4. Oral sildenafil

Answer: 2 - Inpatient lung transplant evaluation

Explanations:

Inpatient Lung transplant evaluation will be the appropriate next step. This patient has
severe pulmonary hypertension with right heart failure and requires a very high
amount of supplemental oxygen.
The international society for heart and lung transplant Guidelines recommends that
patients with IPF should be referred to the transplant center when FVC 80% and
DLCO 40% predicted or progressive decline in FVC and DLCO of 10% and 15% of
predicted, respectively.
Inhaled treprostinil in the INCREASE trial showed improvement in a six-minute walk
distance only. Patients with severe PH, right heart failure, and NYHA functional class
4 may not benefit from this treatment.
Oral sildenafil and other systemic vasodilators are not approved for treatment in
patients with PH due to lung disease or hypoxia.
Research Concepts:Pulmonary Hypertension Due To Lung Disease Or Hypoxia

Page 939 of 955

Question 986: A 45-year-old man presents to the emergency department with a
complaint of breathlessness and dry cough. This is his third admission this year with
similar complaints. On arrival, his vitals are blood pressure 100/70 mmHg, pulse 90/min,
respiratory rate 18/min and a temperature of 99 F. His spO2 is 86%. Laboratory
evaluation reveals an LDH level of 750 IU/L, CD4 count 140/microL and the chest x-ray
shows bilateral interstitial infiltrates. What is the best initial therapy for this patient?

Choices:

1. Trimethoprim/ sulfamethoxazole
2. Zidovudine (AZT)
3. Pentamidine isethionate
4. Ceftriaxone/azithromycin

Answer: 1 - Trimethoprim/ sulfamethoxazole

Explanations:

Trimethoprim/sulfamethoxazole is the first-line therapy for Pneumocystis jiroveci

pneumonia (PCP). This drug is an anti- infective/amebicide/antiprotozoal. The
organism responsible for PCP is the P jiroveci protozoon.
PCP is normally present in the lungs of humans and various animals. However, it
becomes an aggressive pathogen in the immunocompromised patient.
Pentamidine is among the drugs of choice for treating pneumocystis carinii and
used for patients with sulfa allergies. PCP does not respond to antifungal
treatment. Second-line drugs include dapsone, pentamidine, or atovaquone. In
HIV patients, the treatment duration is for 21 days.

Research Concepts:

Pneumocystis Jirovecii Pneumonia

Page 940 of 955

Question 987: A 16-year-old male patient is brought in by his mother with a one-month
history of progressive breathing difficulty. He has a past medical history of multiple
courses of antibiotics for sinus infections and pneumonia, for which he was hospitalized.
His vital signs show oxygen saturation of 94% on room air, respiratory rate of 24 breaths
per minute, heart rate of 109 beats per minute, blood pressure of 100/70 mmHg, and
temperature of 102 F (38.8 C). On examination, there is audible nasal breathing and
bilateral nasal polyps. Lung auscultation reveals diffuse coarse rales bilaterally.
Digital clubbing is present. His weight and height are normal for his age. Which of the
following could help in differentiating his likely condition from cystic fibrosis?

Choices:

1. Bronchiectasis
2. Biotin deficiency
3. Otitis media
4. Intestinal obstruction
Answer: 3 - Otitis media

Explanations:

Diagnosing primary ciliary dysfunction is challenging as it results from a variety of

defects in cilia, and no single diagnostic test can detect all defects. However, otitis
media, a typical feature in a patient with primary ciliary dysfunction, is not a feature
of cystic fibrosis.
Diagnosis is typically achieved with a combination of clinical features as described
above in conjunction with diagnostic testing, which may include procedures such
as nasal or bronchial brush biopsy to demonstrate abnormal ciliary ultrastructure
and ciliary motility.
Primary ciliary dysfunction is a disorder of mucociliary clearance. The affected
patients have recurrent sinopulmonary infections, nasal polyposis, and digital
clubbing but no signs of pancreatic insufficiency.
The patient with primary ciliary dysfunction has normal growth. However, about
half of patients with primary ciliary dysfunction also have situs inversus totalis,
including transposition of the right and left lung.

Research Concepts:Ciliary Dysfunction

Page 941 of 955

Question 988: A 65-year-old male presents complaining of shortness of breath and
frequent cough. The cough is not associated with sputum production. The patient states
that his symptoms get better when he is not at work. Chest examination reveals the
presence of fine bibasilar crackles predominantly in the lower lung fields. He previously
smoked a pack of cigarettes every week but stopped smoking 16 years ago. The patient
works in the textile industry. Diffuse, ill-defined haziness, mainly in the lower lung fields, is
observed on a chest radiograph. Which of the following is the next best step to establish a
diagnosis in this patient?
Choices:

1. High-resolution computed tomography

2. Inhalational challenge
3. Surgical lung biopsy
4. Bronchoalveolar lavage
Answer: 1 - High-resolution computed tomography

Explanations:

Byssinosis, an occupational lung disease, is a collection of respiratory symptoms elicited by

exposure to raw non-synthetic textiles during their manufacturing process. Byssinosis is
more common in people who work in the textile industry where cotton fabrics are made.
Classically, exposure to cotton dust during the spinning and manufacturing process causes
byssinosis.
In the initial stages, symptoms manifest as frequent coughing, chest tightness, dyspnea,
and at times, wheezing, particularly within a few hours of exposure or reexposure to the
workplace. Hence, patients usually report symptoms towards the beginning of their
workweek and thus the term Monday fever. This is in contrast to patients with
occupational asthma who experience symptoms towards the end of their workweek. Once
exposure and lung irritation becomes persistent, patients will no longer have cyclical
symptoms and progress to the chronic byssinosis state.
The diagnosis is often difficult because the condition can mimic asthma and many other
pneumoconioses. The biggest clue to the disease is that the patient will usually complain
that the symptoms get worse when they come to work on Monday (hence the name
Monday disease) and gets better when off work.
High-resolution computed tomography (HRCT) is the best tool to establish the diagnosis.
Bronchoalveolar lavage and surgical biopsy are not required if the diagnosis is established
by HRCT and history. An inhalational challenge may induce the progression of the disease
and is not performed.

Research Concepts:Byssinosis

Page 942 of 955

Question 989: A 78-year-old female presents with pleuritic chest pain and worsening
dyspnea for two days. She has a history of breast cancer and diabetes mellitus. She has a
40-pack-year history of cigarette use and quit smoking one year ago after being
diagnosed with multiple myeloma. Her home medications include metformin, insulin
glargine, and a daily tiotropium inhaler. On arrival, her blood pressure 125/82 mm Hg, the
temperature is 98 F, heart rate is 115 beats/min, and respiratory rate is 16 breaths/min,
and spO2 is 87% on room air. On physical examination, she has normal heart sounds and
decreased breath sounds to the right inferior lung fields. The patient has no clinical
findings consistent with deep venous thrombosis. EKG shows sinus tachycardia and
nonspecific ST and T wave changes. A chest X-ray shows no abnormal changes. Her
laboratory values show D dimer 1267 ng/mL, BNP 80 pg/mL, troponin 0.03 ng/mL,
creatinine 3.2 mg/dL, and GFR 14.9 mL/min/1.73 m². A ventilation-perfusion scan(V/Q ) is
ordered. What is the rationale behind the testing?
Choices:

1. V/Q scan is the diagnostic imaging of choice to rule out pulmonary embolism
2. V/Q scan is an alternative as the patient has worsening renal function
3. V/Q scan is the imaging of choice in patients with no abnormal chest X-ray
findings
4. V/Q scan is the test of choice in elderly patients
Answer: 2 - V/Q scan is an alternative as the patient has worsening renal function
Explanations:

This patient presents with sudden onset of atypical chest pain and dyspnea. According to
Well's criteria and a positive D dimer, she has a moderate probability of pulmonary
embolism that warrants further imaging to rule out pulmonary embolism. The patient's GFR
is 14.9 mL/min/1.73 m²; thus, chronic kidney disease stage V. Computed tomography
angiogram is contraindicated with renal insufficiency. For this reason, the imaging of choice
in the above scenario is a V/Q scan.
Computed tomography pulmonary angiogram has a sensitivity and specificity of 83% and
96%, respectively. This is comparable to the V/Q scan, which has a sensitivity and
specificity of 85% and 93%, respectively, using the PIOPED II criteria. Thus V/Q scan is an
alternative to computed tomography pulmonary angiogram when a patient has chronic
renal disease, allergy to iodine contrast, or pregnancy.
V/Q scan requires the presence of a normal chest X-ray as a pre-requisite. The presence
of abnormal chest X-ray findings, including infiltration, pulmonary edema, and pleural
effusions, can affect V/Q scans' interpretation.
Computed tomography angiogram is the diagnostic imaging of choice to rule out pulmonary
embolism. It can be used in elderly patients in the absence of contraindications such as renal
insufficiency and iodinated contrast allergy.
Research Concepts: Lung Perfusion
Scan

Page 943 of 955

Question 990: A 74-year-old man with a past medical history of chronic kidney disease
and diabetes mellitus presents to the emergency department at the direction of his
primary care provider. He was seen 24 hours ago at a telehealth visit for flu-like
symptoms and was advised to be tested for SARS-CoV-2, which returned positive. The
patient denies shortness of breath, and vital signs are within normal limits. He has not
been vaccinated against COVID-19, and he has had symptoms for six days. After
discussion, a one-time dose of a monoclonal antibody that binds to the spike protein of
the virus is given in the emergency department, and the patient is discharged home.
Which of the following is the most appropriate justification for monoclonal antibody
therapy in this patient?

Choices:

1. Mild illness in an unvaccinated patient without hypoxia

2. Mild illness in a patient with multiple risk factors for progression to severe disease
3. Mild illness in a patient with symptoms for more than five days
4. Mild illness in a patient being discharged home from the emergency
department

Answer: 2 - Mild illness in a patient with multiple risk factors for progression to severe
disease

Explanations:

The patient described in the above clinical vignette has mild COVID-19 illness
and is at high risk of progressing to severe illness due to his underlying risk
factors.
Multiple monoclonal antibodies have received emergency use authorizations
(EUAs) by the FDA for use in nonhospitalized patients with mild to moderate
COVID-19 who are at high risk for developing severe illness.
According to the Centers for Disease Control (CDC) comorbidities that increase the
risk of progression to severe COVID-19 illness include the presence of cancer,
cerebrovascular disease, chronic kidney disease, interstitial lung disease, pulmonary
hypertension, chronic obstructive pulmonary disease, cirrhosis, diabetes mellitus,
congestive heart failure, coronary artery disease, schizophrenia, obesity with a body
mass index of greater than or equal to 30 kg/m2, pregnancy, smoking, and
tuberculosis.
Currently, only sotrovimab retained its EUA, as others were shown to be ineffective
against the Omicron variant.
Research Concepts:Evaluating And Referring Patients For Outpatient Monoclonal Antibody
Therapy For Coronavirus (COVID-19) In The Emergency Department
Page 944 of 955
Question 991: A 52-year-old man is brought to the emergency department with acute
exacerbation ofchronic obstructive pulmonary disease. He was in his normal health 2
weeks ago and had a fever beginning last week. It lasted for 2 days, and then he began to
have progressive dyspnoea. He had worsening of cough, which became uncontrollable
with his usual cough syrup. In the past 2 days, the use of his at-home oxygenation did not
suffice to maintain appropriate ventilation. His vital signs show pulse rate 108/min,
respiratory rate 34/min, and temperature 100 F. PaO2/FiO2 is 83 mmHg despite being on
a mobile ventilator, which uses volume-controlled ventilation having a PEEP of 8 mmHg.
The patient is transferred to the ICU and does not survive the period due to worsening
severity. A medical autopsy demonstrates soggy lungs with bleeding spots distributed all
over the lungs. Which of the following possible complications due to high-pressure
settings of the ventilator most likely contributed to the demise of the patient?
Choices:

1. Traumatic retroperitoneal fistula

2. Inactivation of the surfactant
3. Pneumothorax due to barotrauma
4. Pneumonia leading to sepsis
Answer: 2 - Inactivation of the surfactant
Explanations:

Adult respiratory distress syndrome (ARDS) was clearly found in this patient with the given
values according to the Berlin Criteria; severe ARDS to be specific with 100 mmHg PaO2
despite ventilator use with PEEP of 8 mmHg.
Consequentially, there happened to be pulmonary edema, which adds to the patient's ARDS.
In this setting, there occurs recruitment of leukocytes into the lung and alveolar flooding,
leading to worsening of the sogginess of the lung, which was exhibited in the autopsy.
High pressure can cause barotrauma to the pulmonary tree. High volume leads to
volutrauma, which is seen to increase microvascular permeability and surfactant
inactivation.
Increased pressure or Tidal volume can lead to the release of pro-inflammatory markers
and better alveolar fluid clearance through activation of epithelial Na-K ATPase.
Ventilation pressures and volumes play a large role in the stability of alveolar epithelial
cells. This patient had supposedly had an infection, which resulted in ARDS and worsened
with the inappropriate ventilator settings, which would have caused barotrauma or
volutrauma.

Research Concepts: Adaptive Support

Ventilation

Page 945 of 955

Question 992: A 16-year-old female with no significant past medical history presents to
the emergency department with complaints of progressively worsening dyspnea on
exertion. His vitals are stable. On physical exam, there are several tiny visible blood
vessels on the lips and oral mucosa. Computed tomography of the chest demonstrates a 2
cm pulmonary nodule. What is the next best step in the management of this patient?

Choices:

1. Pulmonary angiography
2. MRI of the chest
3. CT scan of the brain
4. Chest x-ray

Answer: 1 - Pulmonary angiography

Explanations:

The patient's complaint of dyspnea and the presence of multiple telangiectasias

should be concerning for hereditary hemorrhagic telangiectasia.
She has already undergone a CT scan of the chest, which showed a pulmonary
lesion, which is suggestive of a pulmonary arteriovenous malformation.
Pulmonary angiography is the gold standard in the diagnosis of a pulmonary
arteriovenous malformation.
This procedure helps to define the vascular anatomy of the lesion and assess if the
patient is a candidate for embolization therapy.

Research Concepts:

Pulmonary Arteriovenous Malformation

Page 946 of 955

Question 993: A 60-year-old man with a 30 pack-year smoking history presents to the clinic
for fatigue and cough. His symptoms started ten months ago and have progressively
worsened. He has noticed a couple of episodes of blood-tinged sputum while coughing. He
has lost 10 pounds (4.5 kg) in the last four months. Grade 2 clubbing is present on the
general examination. A CT scan of the thorax shows a 10 mm eccentric pulmonary nodule
located peripherally. Which of the following is the next step in management according to
the malignancy risk category of this patient?

Choices:

1. Low risk - lung biopsy

2. Intermediate risk - lung biopsy
3. Low risk - serial CT scan
4. High risk - surgical excision
Answer: 2 - Intermediate risk - lung biopsy

Explanations:

With an age of 40-60, a current smoker, and nodule size in the range of 0.8- 2.0 mm,
the patient falls in the intermediate-risk category.
The next best step in management would be a lung biopsy. A PET CT may also be
considered if available.
An initial CT will help determine if percutaneous CT can be attempted without the risk
of pneumothorax.
A bronchoscopic biopsy is preferred for central lesions.

Research Concepts:

Lung Biopsy Techniques And Clinical Significance

Question 994: A 65-year-old male from Ohio, presents with complaints of worsening of
shortness of breath and cough for six days. He reports that he has been having these
symptoms for almost 5 months but since he has returned from a bird-watching trip in the
UK the symptoms have aggravated. He took some antibiotics and cough suppressants, but
nothing seems to work. He has three parrots and two cats. He is a baker by profession. His
tobacco use is 35-pack-years. On examination, the blood pressure is 125/80 mmHg, pulse
88/min regular, respiratory rate 22/min and oxygen saturation on room air is 91%. On
auscultation of the chest, you find rales all over. Pulmonary is involved, the patient
undergoes bronchoscopy, and dimorphic budding yeast is identified on microscopy. What
is the most likely outcome of this illness?

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Choices:

1. Complete resolution
2. Death in 6 months
3. Death in 12 months
4. Death in 24 months

Answer: 1 - Complete resolution

Explanations:

If not treated appropriately in a timely fashion, Histoplasmosis can be fatal, and

complications will arise including recurrent pneumonia leading to respiratory
failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel
obstruction leading to pulmonary hypertension and right-sided heart failure, and
progressive fibrosis of lymph nodes.
Acute pulmonary histoplasmosis is associated with a good outcome on
symptomatic therapy alone with 90% of patients being asymptomatic.
Disseminated histoplasmosis, if untreated, results in death within 2 to 24
months.
Overall, there is a relapse rate of 50% in acute disseminated histoplasmosis. In chronic
treatment, however, this relapse rate decreases to 10% to 20%. Death is imminent
without treatment.

Research Concepts:Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough

Question 995: A 65-year-old male patient who just moved to the area and is setting up a
primary care facility presents to the hospital with complaints of low-grade fever, cough,
and shortness of breath. The patient's previous medical record shows that he was
diagnosed with HIV more than five years ago; however, the patient has been only
intermittently compliant with the treatment. The examination of the chest reveals
bilateral crepitations. The patient is evaluated with a chest X-ray, which shows bilateral
lower lobe pneumonia, and is treated. After recovery, what is the threshold CD4 count to
start him on cotrimoxazole for prophylaxis?

Choices:

1. 50
2. 100
3. 200
Page 948 of 955
4. 500
Answer: 3 - 200

Explanations:

Pneumocystis Carinii Pneumonia (PCP), now referred to as Pneumocystis Jirovecii

Pneumonia is a fungal infection that most commonly affects the
immunocompromised and, in some cases, can be severely life-threatening.
Typically, patients at risk are those with any underlying disease states that alter
host immunity, such as those with cancer, HIV, transplant recipients, or patients on
immunosuppressive therapies and medications.
Individuals with HIV infection whose CD4 count falls below 200 and who are not on
Pneumocystis jiroveci (PCP) prophylaxis are at increased risk for opportunistic
infections.
Other patients prone to PCP include those with an immunosuppressive disorder like
severe combined immunodeficiency syndrome. Individuals who are malnourished are
also susceptible to PCP.
Finally, patients receiving long-term immunosuppressive therapy following a
transplant are also prone to PCP.

Research Concepts:

Pneumocystis Jirovecii Pneumonia

Question 996: A 65-year-old woman is brought to the emergency department with a

history of slowly progressive breathlessness for the past two weeks. She admits to being
an occasional smoker for the past 40 years without any COPD-related symptoms. She has
had diabetes and hypertension controlled on medications for the last three years. She has
been having symptoms of frequent urination in the past nine months, and was diagnosed
to have carcinoma uterus with metastasis to liver and bones about four months ago and
is currently under treatment. Examination reveals a conscious patient with a blood
pressure of 160/90 mmHg, heart rate 122/min, and respiratory rate 32/min. An urgent X-
ray chest shows bilateral reticulonodular opacities predominantly on the right side, and a
12 lead ECG reveals sinus tachycardia. A bedside echo done by the emergency team is
within normal limits. What is the most common association of the underlying pathology?

Choices:

1. Hepatocellular carcinoma

Page 949 of 955

2. Breast carcinoma
3. Prostate carcinoma
4. Malignant melanoma

Answer: 2 - Breast carcinoma

Explanations:

This patient who has been diagnosed to have metastatic uterine malignancy four
months ago is presenting with progressive dyspnoea with asymmetric reticulonodular
shadows on an X-ray chest. The closest differential diagnosis is between pulmonary
lymphangitic carcinomatosis versus pulmonary tumor embolism. The absence of
pulmonary hypertension or right heart strain on echo is much more in favor of
pulmonary lymphangitic carcinomatosis rather than pulmonary tumor embolism.
Most series have identified carcinoma breast as the commonest cause for
lymphangitic carcinomatosis. Common causes also include cancers of the lung,
stomach, pancreas, prostate, liver & kidney.
The closest differential diagnosis of pulmonary lymphangitic carcinomatosis is
pulmonary tumor embolism, which could be confirmed only by histopathology. The
presence of tumor emboli in the pulmonary vein is highly consistent with
pulmonary tumor embolism,& the confinement of tumor cells predominantly to
interstitium favors the diagnosis of lymphangitic carcinomatosis. Features of right
heart strain & pulmonary hypertension are more in favor of pulmonary tumor
embolism. Despite being separate pathologic entities, it is not uncommon to have
both pathologic features in the same tissue sample.
The nearest differential diagnoses to lymphangitic carcinomatosis (apart from
pulmonary tumor embolism) are pulmonary embolism (thrombotic as well as non-
thrombotic), pulmonary hypertension & interstitial lung pathologies.

Research Concepts:

Lymphangitic Carcinomatosis

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Question 997: A 72-year-old man with no known medical history has been intubated and
transferred from the emergency department to the ICU. On arrival, the patient has a peak
airway pressure of 58 cmH2O. On examination, the patient has clear breath sounds
bilaterally, is expanding the chest normally with delivered breaths, is fully sedated, and is
not triggering any ventilator breaths. He is 180 cm in height. The patient has a size 8
endotracheal tube in place that, on plain film radiography, is 2 cm away from the carina.
The patient is currently on volume control with assist control with a set respiratory rate of
18/min and a tidal volume of 600 mL. An inspiratory hold demonstrates a plateau
pressure of 28 cmH2O. The patient’s peak inspiratory flow rate is adjusted from 90 L/min
to 45 L/min. Which of the following changes is most likely to occur as a result of this new
setting?

Choices:

1. Elevated PaO2
2. Decreased PaCO2
3. No change in measured peak pressures
4. Spontaneous assist-controlled breathing
Answer: 4 - Spontaneous assist-controlled breathing

Explanations:

A decrease in the peak inspiratory flow rate can decrease overall alveolar
ventilation and cause a rise in PaCO2. It will, however, decrease peak inspiratory
pressures but may not change the plateau pressures.
An elevation in PaCO2 may cause a patient to start triggering spontaneous breaths on
the ventilator if not over-sedated or paralyzed.
Ventilator dyssynchrony can occur if the PaCO2 rises too dramatically from the
changes to a ventilator and may rapidly worsen the patient's overall status.
Patients with obstructive lung disease or other pulmonary pathology may not
tolerate a peak inspiratory flow rate of less than 60 L/min due to the increased
airway pressures and the requirement for an increased flow rate to compensate
for them.

Research Concepts:

Partial Pressure of Carbon Dioxide

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Question 998: A 65-year-old male patient presents to the hospital with a 6-month history
of skin flushing, nausea, diarrhea, and wheezing. The patient has a past medical history
of hypertension and takes lisinopril. The patient’s blood pressure is 130/90 mmHg, pulse
80/min, respirations 16/min, and temperature
98.0 F (36.7 C). On pulmonary examination, wheezing is present bilaterally. Abdominal
examination is significant for diffuse tenderness to palpation. The patient’s skin is
erythematous and warm. The provider orders a 5-Hydroxyindoleacetic acid (5-HIAA)
24-hour urine collection, which is elevated. What vitamin is likely to be deficient in this
patient because of his condition?

Choices:

1. Niacin
2. Riboflavin
3. Folic acid
4. Biotin

Answer: 1 - Niacin

Explanations:

Carcinoid tumors are neuroendocrine tumors most commonly seen in the

gastrointestinal tract, which may cause a carcinoid syndrome of cutaneous flushing,
diarrhea, wheezing, peripheral edema due to the production of serotonin. The
syndrome is usually associated with liver metastasis from carcinoid tumors of the
small bowel or primary carcinoid tumors of the lung or stomach.
Patients may have tricuspid insufficiency or pulmonic stenosis. Diagnosis is by 24-
hour urine collection for 5- hydroxyindoleacetic acid (5-HIAA), a breakdown
product of serotonin.
Carcinoids are neuroendocrine tumors releasing serotonin. Additionally, carcinoid
tumors can release many other substances like amylin, gastrin, glucagon,
histamine, insulin, kinins, secretin, tachykinins, and substance P.
Carcinoid tumors use tryptophan and niacin to produce serotonin. Tryptophan is
normally required to produce niacin in the body. Therefore, patients with carcinoid
syndrome are at risk for developing a niacin deficiency.

Research Concepts: Carcinoid Syndrome

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Question 999: A 79-year-old man is found to have a 2.5 cm nodule in the right upper lobe
on chest CT. CT guided biopsy demonstrates moderately differentiated adenocarcinoma.
The lung nodule is PET-avid, with an SUV of 22. PET-CT is negative for distant metastatic
disease. Pulmonary function test reveals an FEV1 of 50% predicted and DLCO of 30%
predicted. What is the most appropriate management strategy for this patient?

Choices:

1. Lobectomy
2. Chemotherapy
3. Radiation therapy with concurrent chemotherapy
4. Stereotactic body radiation therapy

Answer: 4 - Stereotactic body radiation therapy

Explanations:

Stereotactic body radiation therapy (SBRT) or stereotactic ablative body radiation

(SABR) is an alternative option for patients who are not surgical candidates due to
high operative risk from poor cardiopulmonary function, comorbid conditions,
advanced age, or if patients refuse surgery.
The 5-year survival for stage IA (T1N0M0) is 60-80%. Radiation therapy with
concurrent chemotherapy is recommended for Stage IIIA-B non-small cell lung
cancer. Radiation therapy is delivered over 6-7 weeks to a total dose of 60-70 Gy.
If the patient is a surgical candidate, lobectomy is preferred over pneumonectomy,
if anatomically feasible. Wedge resection is not considered oncologic surgery and is
only considered if the patient is physiologically compromised.

Research Concepts:

Radiation Therapy For Early Stage Non-Small Cell Lung Cancer

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Question 1000: A 74-year-old male was recently discharged from the hospital for what
he describes as an episode of cough attacks and shortness of breath. In the last 14
months, the patient has had two admissions to the hospital for related complaints in
which he required treatment with inhaled corticosteroids and short- acting beta-agonist.
He has a social history significant for 55 pack- years of tobacco smoking and recently quit
smoking three months ago. He has been prescribed a long-acting bronchodilator, which
is used as first-line therapy in such patients. Which of the following is the most likely
side-effect to be found after the use of the prescribed drug in such patients?

Choices:

1. Cataract
2. Pharyngitis
3. Rhinitis
4. Chest pain
Answer: 2 - Pharyngitis

Explanations:

This patient most likely has a severe chronic obstructive pulmonary disease (COPD), with
hospital admissions for COPD exacerbations. Tiotropium, a long-acting bronchodilator, has
become first-line therapy in chronic obstructive pulmonary disease (COPD) with persistent
symptoms. Tiotropium has the following FDA approved mediation uses and indications for
the maintenance therapy of COPD, bronchitis, and emphysema.
Approved indications include use for the reduction of COPD exacerbations and pediatric
asthma. A non-FDA approved use (off label use) of tiotropium includes the use of
tiotropium as add-on therapy to inhaled corticosteroids and other maintenance therapies
for pediatric patients greater than 6 years old to 11 years old. Tiotropium is more effective
than salmeterol, another long-acting anticholinergic bronchodilator, in preventing
exacerbations.
The most frequently encountered adverse effects of tiotropium include pharyngitis,
bronchitis, sinusitis, dry mouth, cough, and headaches.
Less common side effects of tiotropium include insomnia, cataract, blurry vision, epistaxis,
rhinitis, laryngitis, dysphagia, gingivitis, chest pain and palpitations, joint swelling,
abdominal pain, gastroesophageal reflux disease, paralytic ileus of the intestine, abnormal
liver function test, dysuria, urinary retention, angioedema, dry skin, herpes zoster, and
dehydration.

Research Concepts: Tiotropium

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