PNEUMOLOGY USMLE (1-100)

1. A 67-year-old male presents with a one-month history of dyspnea on exertion and chest pain. He denies hemoptysis, cough, fever, night sweats or weight loss. His past medical history is significant for hypertension and chronic obstructive pulmonary disease. He has a 48 pack-year smoking history but quit six years ago. He works as a salesman. On physical examination, the patient has a temperature of 38.2C (100.8.F), blood pressure of 128/72 mm Hg, pulse of 92/minute, and respirations of 20 breaths/minute. His complete blood count, chemistry panel, and hepatic function tests are all within normal limits. A chest x-ray and computed tomography scan of the chest reveal a right-sided pleural effusion and calcified nodules in both upper lobes. The patient undergoes thoracentesis. Characteristics of the pleural fluid are given below: Total protein 5.2 g/dl Glucose 83 mg/dl Adenosine deaminase 98.5 U/L Cytologic examination reveals 600 white blood cells/mm3, 1% macrophages and 99% leukocytes. Of the leukocytes, 45% are neutrophils, 50% are lymphocytes, and 5% are monocytes, with no basophils or eosinophils. No neoplastic cells are found. Which of the following is the most likely mechanism underlying development of this pleural effusion?

2. A 33-year-old white female complains of repeated episodes of fever, malaise, chills, breathlessness and dry cough over the past 6 months. She says that each episode starts suddenly and lasts for several days. She otherwise has no significant past medical history and does not take any medications. There is no family history of lung disorders. She does not smoke cigarettes or drink alcohol. She has never been abroad, and has had no sick contacts. She breeds budgerigars (a small Australian parrot) as a hobby. Chest x-ray shows diffuse generalized haziness in both lower lung fields. Pulmonary function tests reveal reduced lung volumes and an FEV1/FVC ratio of 87%. PPD test is negative. Serology shows antibodies to budgerigar antigens. What is the best treatment for this disease?

4. A 44-year-old male is involved in a serious motor vehicle accident. He is admitted to the intensive care unit with multiple fractures and internal bleeding, and is placed on mechanical ventilation. Over the next two days, his oxygen saturation repeatedly drops below 90%, requiring gradual increases in the FiO2. On day three of his admission, the patient's chest x-ray, which was initially clear, shows bilateral fluffy infiltrates. He has no prior medical problems and does not take any medications. Skin examination reveals no rashes. Lab studies show: Hemoglobin 10.1 g/L Platelets 160,000/mm3 Leukocyte count 13,500/mm3 Sputum cultures are negative. The ventilator settings are: Fi02 90% Tidal volume 400 ml (body weight 60 kg) Respiratory rate 12/min PEEP 5cmH2O The patient's oxygenation continues to drop below 90%. Which of the following interventions would be best for improving the patient's oxygenation?

5. A 65-year-old white man comes to the Emergency Room complaining of headache, insomnia, palpitations, and vomiting. His past medical history is significant for chronic obstructive pulmonary disease (COPD) treated with theophylline, ipratropium, and occasional albuterol. He had a puncture wound of the foot one week ago, and it is being treated effectively with amoxicillin-clavulanate and ciprofloxacin. For the past three days, his shortness of breath is worsening, and his primary care physician gave oral prednisone. His blood pressure is 150/80 mmHg and heart rate is 105/min with frequent ectopic beats. You suspect that drug toxicity may be responsible for this patient's complaints. Which of the following drugs is most likely responsible for his condition?

6. A 67-year-old woman with a past medical history significant for hypertension, hypercholesterolemia, and type 2 diabetes calls 911 for severe shortness of breath. Her symptoms started 2 hours ago with chest pain and progressed rapidly to orthopnea and shortness of breath. Her blood pressure is 170/100 mmHg and heart rate is 120/min and regular. A third heart sound is present. Bilateral crackles are heard on chest auscultation. Her oxygen saturation is 78% with 40% inspired oxygen. She is intubated in the field by paramedics for progressive respiratory failure and is treated with nitrates and diuretics. After the initial resuscitation, breath sounds on the left side are markedly decreased. Which of the following is most likely to restore breath sounds to this hemithorax?

7. A 65-year-old man presents to your office complaining of progressive breathing difficulty. His past medical history is significant for hypertension, diabetes mellitus, type 2, and myocardial infarction experienced two years ago. His current medications are hydrochlorothiazide, atenolol, glipizide, and aspirin. He does not smoke or consume alcohol. His vital signs are BP 156/96 mmHg, PR 65/min, RR 18/min, T 36.7C (98F). Physical examination shows mild symmetric edema of the lower extremities. Hepatojugular reflex is positive. Point of maximal impulse is displaced downward and to the left. Soft blowing systolic murmur is heard on the apex. Breath sounds are diminished on the right side. Serum protein level is 6.5 g/dl and serum LDH is 200 mg/ml. After taking a chest radiograph, you suspect pleural effusion on the right and decide to perform diagnostic thoracocentesis. Which of the following findings, on pleural fluid analysis, is most consistent with this patient's condition?

10. A 66-year-old male presents to the emergency department with acute onset of severe chest pain and dyspnea. He localizes the pain to the right upper chest, and says that it is aggravated by deep breathing and coughing. On physical examination, his pulse is 116/min and regular, blood pressure is 110/70 mmHg, and respirations are 22/min. His lungs are clear to auscultation. Chest x-ray is unremarkable. EKG shows sinus tachycardia. CT angiogram of the chest shows a thrombus in the right pulmonary artery. Which of the following is the most likely source of his pulmonary thrombus?

11. A 55-year-old chronic smoker comes to you because of worsening shortness of breath. He says that he has had lung problems due to smoking for the past five years. He has hypertension controlled with hydrochlorothiazide, and type 2 diabetes mellitus, controlled with diet. He has smoked two packs of cigarettes daily for 25 years. Physical examination shows bilateral decrease in breath sounds with prolonged expiration and wheezing in both the lung fields. He is hypoxic on room air. An x-ray film of the chest shows hyperinflation of both lung fields. His pulmonary function tests showed moderate obstructive disease, with very little bronchodilator response. The patient is started on bronchodilators. He is being considered for home oxygen therapy. Which of the following is a criterion for initiating home oxygen in such patients?

12. A 35-year-old male presents to the emergency room complaining of increasing shortness of breath, fever and malaise for several days. His past medical history is significant for two years of recurrent sinusitis. He is a former smoker and has an occasional glass of wine. His temperature today is 38.4°C (101.1F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. Examination reveals an illappearing male in mild respiratory distress. Patchy rales are appreciated on lung auscultation. Chest x-ray reveals multiple nodular densities bilaterally. His serum creatinine is 2.7 mg/dl and urinalysis shows red blood cell casts. Which of the following would be most helpful in diagnosing his condition?

13. A 64-year-old male presents to the ER with a one-week history of progressive exertional dyspnea. Each of the past two nights he has awakened with a choking sensation and has had to sit up to catch his breath. His past medical history is significant for hypertension and a myocardial infarction two years ago. He takes a baby aspirin and lisinopril daily. His blood pressure is 140/90 mmHg, and his heart rate is 110/min, irregularly irregular. His temperature is 98F (36.7C) and his respiratory rate is 24/min. His oxygen saturation is 91% on room air. There is moderate jugular venous distention. Markedly reduced breath sounds are heard over the right lung base. Which of the following most likely underlies this patient's physical findings?

15. A 62-year-old male is brought to the ER after passing out at work. He reports having had difficulty walking over the past couple of days due to an infected wound on his right foot. His past medical history is significant for diabetes mellitus. On physical examination, his blood pressure is 80/40 mm Hg and his heart rate is 120/min, regular. His skin is cold and clammy. Right heart catheterization is performed, and the following readings are obtained: Right atrial pressure 18 mmHg Pulmonary artery pressure 40/20 mmHg Pulmonary capillary wedge pressure 9 mmHg Which of the following is the most likely diagnosis?

16. You are asked to evaluate four different patients, all who have presented with cough and progressive dyspnea. Each has a chest x-ray showing diffuse pulmonary infiltrates. In which of the following patients would bronchoscopy with bronchoalveolar lavage be most likely to yield a diagnosis?

17. A 68-year-old female is admitted with a broken hip after a fall. She undergoes a left hip replacement, which was uneventful. After spending two days in bed, she undergoes partial non-weight bearing physiotherapy. Five days later, she has developed shortness of breath and a swollen leg. A deep vein thrombosis is discovered. An arterial blood gas evaluation is done for suspected pulmonary embolism. What is the most consistent finding of pulmonary embolism?

20. A 45-year-old man presents with two days of bilateral hand pain that is most severe in his wrists. Physical examination reveals bilateral wrist tenderness, thickening of the distal fingers, and convex nail beds. There is nicotine staining of the right index and middle fingers. He states that he has been smoking 2 packs of cigarettes a day for the past 25 years. Chest examination reveals decreased breath sounds and a prolonged expiratory phase. The patient relates the pain's onset to a data entry job he recently started. He notes that his boss believes he is fabricating his pain to get off work. His job records reveal numerous sick leaves. Which of the following is the most appropriate course of action?

21. A 45-year-old man presents to the emergency department with a two-day history of fever, chills and productive cough. He reports having had two episodes of pneumonia over the past six months, both of which resolved completely with levofloxacin therapy. He smoked cigarettes for twenty years, but quit recently with the second bout of pneumonia. Today, his temperature is 38.9°C (102.F), pulse is 98/minute, blood pressure is 110/80 mm Hg, and respirations are 18/min. On physical examination, there are crackles and bronchial breath sounds over the right lower lobe of the lung. Chest x-ray shows right lower lobe consolidation; previous x-rays also show consolidation in this area. What is the most appropriate next step in the management of this patient?

22. A 76-year-old male nursing home resident is hospitalized with confusion, fever and decreased oral intake. His past medical history is significant for type 2 diabetes mellitus, hypertension, osteoarthritis and gout. Blood cultures are positive for E coli. Despite antibiotic therapy, he slips into respiratory failure. He is intubated and placed on mechanical ventilation with an FiO2 of 70%, tidal volume of 500 ml and respiratory rate of 14/min. His current arterial blood gases are: pH 7.45 pO2 59 mmHg pCO2 30 mmHg HCO3 21 mEq/L Which of the following is the best next step in managing this patient?

24. A 65-year-old man complains of two years of persistent cough. He says that he coughs up whitish sputum almost every morning on waking, and then continues coughing throughout the day. He also complains of exertional shortness of breath that becomes disabling if he gets an upper respiratory infection. He has smoked one pack of cigarettes daily for the past 40 years. Pulmonary function testing reveals a vital capacity that is 65% of his predicted. Which of the following best explains this finding?

26. A 45-year-old female with a past medical history of rheumatoid arthritis presents to the emergency department with right calf pain and swelling of sudden onset. She denies fever, chills, dyspnea, chest pain, or history of trauma to the leg. She has smoked a half pack of cigarettes daily for 20 years. Her only medicine is methotrexate for her rheumatoid arthritis. On physical examination, her temperature is 37.0°C (98.6.F), pulse is 70/min, blood pressure is 140/80 mmHg, and respirations are 14/min. Her BMI is 30 kg/m2. Examination of the right calf reveals mild redness, warmth and tenderness. Which of the following is the most appropriate next step in the management of this patient?

27. A 54-year-old man is being evaluated for shortness of breath. Examination shows dullness to percussion and increased breath sounds, particularly during expiration, in the right lower lobe. Cardiac examination reveals regular rate and rhythm with normal S1 and S2. There is no murmur. Moderate peripheral edema is present. Which of the following is the most likely cause of his shortness of breath?

28. A 15-year-old male comes to your office with a one-week history of fever, non-productive cough, sore throat and headaches. Today he noticed a skin rash. His temperature is 38.5°C (101.3.F), pulse is 90/min, blood pressure is 115/78 mm Hg and respirations are 16/min. His throat is hyperemic, but there is no cervical lymphadenopathy. Chest auscultation and percussion reveal no abnormalities. You note dusky red, target shaped skin lesions over all four extremities. Chest x-ray reveals interstitial infiltrates in the left lower lobe. Sputum gram stain reveals polymorphonuclear cells but no organisms. Which of the following organisms is most likely responsible for this presentation?

29. A 53-year-old man presents with two episodes of hemoptysis over the last week. He describes a preceding two-year history of morning cough productive of approximately one tablespoon of yellowish sputum. During the last week his morning cough was accompanied by a small amount of blood on two occasions. He denies any dyspnea, fever, chest pain, or weight loss. He has been smoking for 30 years but has tried to cut down recently. He works in construction. His only medication is ranitidine for occasional heartburn. Which of the following is the most likely cause of his hemoptysis?

30. A 60-year-old Caucasian man comes to the physician because of a productive cough and dyspnea on exertion. He denies hemoptysis, chest pain, and leg swelling. He has smoked one-and-a-half packs of cigarettes daily for 40 years and drinks 2-ounces of alcohol daily. He has worked in a shipyard for 10 years. His temperature is 37.2 C (99 F), blood pressure is 140/80 mmHg, pulse is 80/min, and respirations are 20/min. His chest x-ray shows prominent bronchovascular markings and mild diaphragmatic flattening. His pulmonary function testing shows decreased FEV1/FVC ratio and normal DLCO. Which of the following is the most likely diagnosis?

31. A 47-year-old smoker presents to the emergency room with a three-day history of shortness of breath and cough. His past medical history is significant for tuberculosis ten years ago, treated with six months of a multidrug regimen. On exam today, his blood pressure is 140/90 mmHg and his heart rate is 110/min. Breath sounds are decreased over the right lung base. Over the same area there is dullness to percussion and increased fremitus. The patient also has trace ankle edema. Which of the following most likely accounts for these findings?

32. A 51-year-old man develops acute respiratory distress syndrome (ARDS) while hospitalized for acute pancreatitis. On his third day in the intensive care unit, he is sedated, intubated, and ventilated with a PEEP (positive end-expiratory pressure) of 15 cm water and Fi0 2 of 0.6 (60%). Suddenly his pulse increases from 100 to 140/min, systolic blood pressure drops from 120 to 90 mm Hg, and central venous pressure increases from 10 to 15 cm water. On chest auscultation, breath sounds are absent on the left side. Which of the following is the most likely explanation for this sudden deterioration?

33. A 53-year-old white male comes to your office with long history of cough, periodic shortness of breath, and wheezing. His family history is significant for asthma in his mother and hypertension and diabetes in his father. He is not taking any medications. He smokes two packs a day ever since he was 16 years of age and consumes alcohol occasionally. Physical examination reveals bilateral scattered expiratory wheezes. Which of the following tests can help you most in differentiating asthma from emphysema in this patient?

34. A 71-year-old man is brought to the ER after a witnessed tonic-clonic seizure. He is somnolent and intermittently combative on exam. No past medical history is available. His arterial blood gas (ABG) at room air is given below. pH 7.23 pCO2 69 mmHg pO2 57 mmHg HCO3 28 mmHg Which of the following best explains the acid-base disturbances in this patient?

35. A 60-year-old white male presents to the Emergency Room with sudden onset of dyspnea. He is a truck driver and just returned from a long trip. His past medical history is insignificant. He is not taking any medications. His blood pressure is 110/70 mmHg and heart rate is 110/min. Physical examination reveals a moderately overweight man with tachypnea. Lungs are clear on auscultation. ECG shows right axis deviation. You order ventilation/perfusion scanning. Which of the following findings will help you the most to confirm the diagnosis?

36. A 65-year-old female undergoes total right hip replacement after fracturing the neck of her femur. There are no surgical complications, and afterwards she is started on enoxaparin (low molecular weight heparin) for deep venous thrombosis prophylaxis. On the third postoperative day, she suddenly becomes anxious and complains of right sided chest pain and shortness of breath. She has a history of hypertension, diabetes and hyperlipidemia. She has a 20 pack-year smoking history, but quit 10 years ago. On exam, her temperature is 37.2°C (98.9. F), blood pressure is 126/76 mm Hg, pulse is 110/min and respirations are 30/min. Her oxygen saturation is 88% on room air. She is diaphoretic but her chest is clear to auscultation. A portable chest x-ray shows no abnormalities. EKG reveals sinus tachycardia and non-specific ST/T-wave changes. Which of the following studies would most likely reveal the diagnosis?

37. A 29-year-old woman presents with chest pain and exertional dyspnea of 10days duration. Her medical history is significant for a normal spontaneous vaginal delivery three months ago, after which she has had frequent episodes of dark bloody vaginal discharge. The most recent bleeding episode was 6 days ago. The patient denies fever, chills, hemoptysis, orthopnea, or leg pain. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Her temperature is 37.7C (98.9.F), pulse is 80/min, blood pressure is 110/68 mmHg and respirations are 16/min. Examination shows clear lungs. Pelvic examination shows an enlarged uterus. Complete blood count and serum electrolytes are within normal limits. Chest radiographs reveal multiple bilateral infiltrates of various shapes. Which of the following investigations will be most helpful in establishing the diagnosis?

38. A 45-year-old male with mild persistent asthma comes to you for a routine checkup. He is taking a low-dose beclomethasone inhaler daily and inhaled albuterol, as needed, for the last year. His past medical history is otherwise not significant. His family history is significant for diabetes mellitus type 2, hypertension and obesity. His blood pressure is 136/90 mmHg and his heart rate is 80/min. His BMI is 26 kg/m2. Which of the following is the most likely complication of chronic beclomethasone use in this patient?

39. A 56-year-old morbidly obese man twisted his ankle five days ago and has been bed-ridden since. Today he presents to the emergency department with acute-onset shortness of breath and chest tightness. His past medical history is significant for diabetes mellitus, hypertension, right knee osteoarthritis, and a deep venous thrombosis. His current medications are lisinopril, metoprolol, and metformin. His blood pressure is 110/60 mmHg and his heart rate is 110/min. A CT scan of the chest with contrast is consistent with pulmonary thromboembolism. Which of the following is the best treatment for this patient?

40. A 35-year old male presents to your office complaining of nocturnal wheezing and chest tightness for the past three months. He has also noticed new hoarseness, particularly in the morning. He has no history of bronchial asthma, hypertension or diabetes. He is a non-smoker but occasionally drinks alcohol. On examination, he is an obese male in no acute distress. His pulse is 84/min, blood pressure is 130/80 mmHg, and respirations are 16/min. His chest is clear to auscultation and percussion. Laryngoscopy reveals a red and inflamed posterior pharynx and larynx. Which of the following pharmacotherapies would be most helpful for this patient?

41. A 38-year-old female comes to your office with a recent episode of hemoptysis. The symptoms started one week ago with malaise, throat pain and dry cough. The cough progressed becoming productive of yellowish sputum. She started noticing speckles of red blood in her sputum as of yesterday. Her past medical history is significant for peptic ulcer disease. She has a 5 pack-year smoking history, but she quit 10 years ago. Her temperature is 98F (36.7C), blood pressure is 130/80 mmHg and heart rate is 87/min. Physical examination reveals scattered bilateral wheezes. Chest X- ray shows clear lung fields. Which of the following is the most appropriate next step in management?

42. A 27-year-old male presents to you with complaints of cough, chest discomfort and dyspnea on exertion. He says that he has lost 10 pounds over the past 2 months. He has been smoking 1 pack per day for the past 10 years. He drinks 2 beers every weekend. He denies illegal drug use and has not had multiple sexual partners. Physical examination is unremarkable. Chest-x ray reveals a large anterior mediastinal mass. Blood work reveals that he has elevated levels of HCG and alpha- fetoprotein (AFP). What is the most likely diagnosis?

43. A 74-year-old nursing home resident is brought to the ER with a low-grade fever, cough and shortness of breath for the last two days. The cough is productive of small amounts of greenish sputum. His past medical history is significant for hypertension, diabetes mellitus type 2, COPD, hypercholesterolemia and mild dementia. His blood pressure is 152/78 mmHg and his heart rate is 89/min, regular. Physical examination reveals decreased breath sounds, coarse rhonchi, and increased fremitus over the lower left lung field. His oxygen saturation is 92% on room air when lying on his right side but drops to 84% when he lies on his left. Which of the following best explains this finding?

44. A 55-year-old male presents with face and arm swelling that he says is worst when he wakes in the morning. He also notes a 10-pound unintentional weight loss over the past three months, plus new- onset exertional dyspnea. His past medical history is significant for hypertension, for which he takes hydrochlorothiazide. He has smoked cigarettes for the past 40 years and drinks alcohol occasionally. On physical examination, he is afebrile and his vital signs are within normal limits. His face is plethoric and darkappearing. The veins on the anterior chest wall appear engorged. His abdomen is soft, non-tender, and nondistended, and there is no organomegaly. The lower extremities are non- edematous. What is the most appropriate next step in the management of this patient?

45. A 34-year-old male presents to his physician's office for a routine health maintenance examination. He has a five-year history of bronchial asthma for which he uses an albuterol inhaler. He says that he uses the inhaler an average of two times per week during the day. In addition, he states that his asthma symptoms wake him from sleep approximately 3-4 times per month. He does not use tobacco, alcohol or illicit drugs. His family history is significant for asthma in his grandfather. Physical examination is unremarkable. Which of the following is the most appropriate next step in his management?

46. A 34-year-old male is recovering from head trauma sustained in a motor vehicle accident. He is currently in the intensive care unit on mechanical ventilation. His most recent arterial blood gas analysis shows: pH 7.54 PaO2 124 mmHg PaCO2 20 mmHg Bicarbonate 17 mEq/L Which of the following additional findings do you most expect in this patient?

48. A 33-year-old male was involved in a motor vehicle accident with numerous rib fractures. His course in the hospital was complicated by difficulty with deep breathing and later developed pneumonia. The chest x-ray later confirmed that the patient had developed a parapneumonic effusion. Which one of the following laboratory tests on the pleural fluid is currently thought to be most helpful in determining the need for chest tube placement in parapneumonic effusion?

49. A 4 2-year-old man presents to his primary care physician complaining of daytime sleepiness. He says that he often falls asleep during meetings, watching TV, and even while driving his car. He does not feel refreshed after his daytime naps, and has not experienced vivid hallucinations when falling asleep or upon awakening. He has occasional morning headaches and his wife complains that he sometimes keeps her up at night. Physical exam reveals a body mass index (BMI) of 31.3 kg/m2. An arterial blood gas is normal What is this patient's most likely diagnosis?

50. A 24-year-old Caucasian man is brought to the emergency room with acute asthma exacerbation. His current medications include inhaled fluticasone and salmeterol. The attack started 10 hours ago and did not respond to numerous albuterol inhalations and systemic steroids. His blood pressure is 120/70 mmHg and heart rate is 110/min. The patient is tachypneic and speaks with difficulty. Lung auscultation reveals decreased breath sounds, prolonged expiration, and bilateral wheezing. Pulse oximetry showed 86% at room air. ABG at room air are: pH 7.43, Po2 68 mmHg, PCO2 40mmHg. The chest x-ray demonstrates hyperinflated lungs. Which of the following findings indicates that the patient is getting worse?

51. A 19-year woman presents to her physician's office for a routine health maintenance examination. She notes experiencing occasional wheezing and breathlessness following aerobic exercise, but has no symptoms at other times of the day or night. Her medical history is otherwise significant for allergic rhinitis and acne, for which she uses topical benzoyl peroxide and erythromycin cream. She does not use tobacco, alcohol or illicit drugs. On physical examination, her vital signs are within normal limits and chest auscultation is unremarkable. Which of the following is the most appropriate next step in her management?

52. A 34-year-old male is rushed to the emergency room with severe respiratory distress. He is agitated and gasping for breath. He has been seen in the ER several times before for difficulty breathing, food intolerances and skin allergies. Physical examination is notable for excessive accessory respiratory muscle use, retraction of the subclavicular fossae during inspiration, and scattered urticaria over the upper body. What is the most likely diagnosis?

53. A 57-year-old male was involved in a motor vehicle accident and was immediately brought to the Emergency Room. He suffered minor head and neck injury, but was found to have a broken tibia. He underwent repair of the tibial fracture the following day. Five days later, he suddenly develops tachycardia and is tachypneic. He complains of increasing chest discomfort and has a syncopal episode. His blood pressure is 80/55 mmHg, pulse is 130/min, and respirations are 24/min. Pulse oximetry showed 82% on room air. Stat echocardiogram reveals obstruction in the main pulmonary artery. Which of the following choices is the most appropriate course of action?

54. A 60-year-old man comes to the office with worsening shortness of breath over the last 5 months. He has had two episodes of bronchitis over the last 12 months. He now has a mild nonproductive cough. He denies any fever, chills, hemoptysis, chest pain, or difficulty breathing while lying on his back. His medications include an ipratropium inhaler, aspirin, and amlodipine. He was hospitalized twice in the last 3 years due to an exacerbation of his chronic obstructive pulmonary disease. He has been smoking 1 pack of cigarettes per day for the last 40 years. His temperature is 99 F (37.2 C), blood pressure is 130/86 mm Hg, pulse is 98/min, and respirations are 18/min. Examination shows a thin man in mild respiratory distress with increased anteroposterior chest diameter, diffuse expiratory wheeze and loud S2. Chest X-ray shows hyperinflation of bilateral lung fields with diaphragm flattening and small heart size. Which of the following is the most effective measure to decrease mortality in this patient?

55. A 68-year-old female comes to the Emergency Room with increased shortness of breath and cough for 12 hours. She has a history of chronic obstructive pulmonary disease for the past 14 years and has been oxygen dependent for two years. Twelve hours ago, she felt unable to get her breath. She took two extra nebulizer treatments and used her as-needed inhaler with no relief of symptoms. She denies any fever, chills, sweating, nausea or vomiting, and hemoptysis. She rarely uses alcohol, but had smoked two packs/day for 45 years. She quit smoking about six years ago. Her medications include ipratropium, albuterol, multivitamins, and oxygen 2 liters/min by nasal cannula. She is a thin, frail female in moderate distress. Her temperature is 36.7C (98F), blood pressure is 110/65 mmHg, pulse is 110/min, and respirations are 28/min. Pulse oximetry shows 84% on 2 liters oxygen by nasal cannula. The patient is given oxygen, methyl prednisolone, aerosolized ipratropium, and albuterol; however, the patient remains dyspneic and bedridden. ABGs are ordered and the results show: pH 7.32, PCO2 60 mmHg, and PO2 52 mmHg on 4-liters O2. What is the next best step in the management of this patient?

57. A healthy 36-year-old Caucasian woman comes to the physician because of dyspnea on exertion. She has no other medical problems. She does not use tobacco, alcohol, or drugs. Her father has prostate cancer and her mother had a stroke. She takes no medication and has no known drug allergies. Her temperature is 36.7C (98 F), blood pressure is 140/90 mmHg, pulse is 84/min, and respirations are 22/min. Examination shows clear lung fields. Her chest x-ray shows prominent pulmonary arteries and an enlarged right heart border. EKG shows right axis deviation. Which of the following is the most likely diagnosis?

58. A 65-year-old male comes to the physician because of fever, chills, and productive cough. The symptoms started four days ago. He also complains of chest pain, which increases with inspiration. He has smoked one pack of cigarettes daily for 45 years. He drinks 3-4 ounces of alcohol daily. His chest x-ray showed an infiltrate in the right upper lobe. The sputum examination of the patient reveals capsulated gram-negative bacilli. Sputum culture is growing mucoid colonies. Which of the following is the most likely causative organism in this patient?

59. A 26-year-old Caucasian male comes to the physician because of severe productive cough for the past two months. He also complains of occasional blood in sputum, and dyspnea for the last three weeks. His past medical history is significant for otitis media, two episodes of pneumonia, and sinusitis. He and his wife were recently worked up for infertility. Physical examination shows crackles in the left upper lobe. Chest x-ray shows dilated and thickened airways and irregular peripheral opacities in the left upper lobe. Which of the following is the most appropriate test to make the diagnosis of his condition?

60. A 68-year-old male is hospitalized following an intracerebral hemorrhage. On hospital day 3, he develops redness, swelling, and tenderness of the left calf. There is no fever. Compression ultrasonography reveals a thrombus in the popliteal vein. Which of the following is the most appropriate next step in the management of this patient?

62. A 59-year-old male is brought to the emergency department with severe dyspnea and left-sided chest discomfort. He says that he was driving to work when he began to feel suddenly weak and short of breath. He has a long history of chronic obstructive pulmonary disease, esophageal reflux and chronic pyelonephritis. He smokes one pack of cigarettes per day. His current medications include ranitidine and inhaled ipratropium and albuterol as needed. Physical examination reveals trace ankle edema, decreased breath sounds over the left chest and scattered wheezes over the right chest. ECG shows sinus tachycardia. Arterial blood gas analysis is given below: pH 7.42 pO2 59 mmHg pCO2 41 mmHg Which of the following most likely underlies this patient's current condition?

63. A 31-year-old woman presents to the emergency department complaining of shortness of breath. She denies associated chest pain or palpitations. She tells you that she recently returned from a trip to Thailand. She smokes one pack of cigarettes per day and drinks alcohol occasionally. She is married and uses oral contraceptives. She has no significant past medical history. On physical examination, her blood pressure is 110/70 mmHg and her heart rate is 120/min. A negative result on which of the following tests would best exclude pulmonary venous thromboembolism in this patient?

64. A 32-year-old man with a known history of recreational drug abuse is found by a friend on the floor of his apartment. There is a pool of urine around him. He is confused, not oriented to time or place, and does not recall recent events. His blood pressure is 110/70 mmHg and his heart rate is 120/min. He talks and moves all his extremities. His laboratory findings are the following: Hemoglobin 15.2 mg/dl WBC 12,500/mm3 Platelets 160,000/mm3 Sodium 136 mEq/L Potassium 5.1 mEq/L Creatinine 1.1 mg/dl AST 35 units/L AL T 40 units/L Alkaline phosphatase 70 units/L CPK 26,000 units/L His urine toxicology screen is positive for cocaine and cannabinoids. The patient is at the greatest risk of which of the following?

65. A 66-year-old man complains of exertional dyspnea that has progressed over the last two years. As a result, he has had to limit his physical activities to avoid becoming short of breath. He denies any significant chest pain, but does note having a recurrent cough productive of whitish sputum. His past medical history is significant for hypertension controlled with hydrochlorothiazide. He has a 40 pack- year smoking history. His family history is significant for a stroke in his mother. His blood pressure is 160/90 mmHg and his heart rate is 80/min. Physical examination reveals a mildly overweight patient in no acute distress. His anteroposterior chest diameter is markedly increased. Breath sounds are decreased bilaterally with scattered expiratory wheezes. Which of the following agents is most likely to reduce this patient's symptoms?

66. A 52-year-old nursing home worker presents with a four-week history of non-productive cough and night-time sweating. She also reports having unintentionally lost five pounds over the last month. Her medical history is significant for a mastectomy for left-sided breast cancer five years ago and hepatitis C for which she does not take treatment. She says she was last tested for HIV 6 months ago and the test was negative. She takes no medications currently. She emigrated from Mexico two years ago. She smokes one pack of cigarettes daily and consumes two bottles of beer every weekend. Chest x-ray shows a right upper lobe cavity with surrounding infiltration. Which of the following is the most important epidemiologic clue to the etiology of this patient's disease?

67. A 44-year-old obese Asian immigrant presents to the ER complaining of a persistent cough for about 3 months. He denies any fever, chills, runny nose or sputum production. He does complain of dyspnea on exertion, which also has been of a short duration. He says that over the last year, he has become progressively short of breath and is unable to sleep lying down. He denies any chest pain or diaphoresis, but has had palpitations in the past. He does not smoke or drink alcohol. On examination, he is alert and in mild distress. He has a BP of 110/70 mmHg, pulse 100/min and is afebrile. Auscultation is difficult. The chest-x ray reveals an enlarged cardiac silhouette. It appears that the left main stem bronchus is elevated. There is no other lung pathology visible. The ECG shows irregularly irregular rhythm. The pathophysiology of this condition is related to which of the following?

68. A 72-year-old white male with a past medical history of hypertension, hypothyroidism, and coronary artery disease presented to the physician's office because of fever, malaise, nonproductive cough, and shortness of breath. His temperature was 38.3C (101 F). His chest x-ray showed a patchy right lower lobe infiltrate. He was sent home on oral amoxicillin. Four days later, the patient was brought to the emergency room because he was having continuous fevers, headache, pleuritic chest pain, and abdominal pain. He appears confused. His blood pressure is 120/70 mmHg, pulse rate is 100 per minute, respiratory rate is 24 per minute, and temperature is 38.9C (102 F). His chest x-ray showed consolidation of the right lower lobe. Which of the following is the most likely cause of this patient's pneumonia?

69. A 64-year-old man presents to the emergency department with progressive exertional dyspnea that worsened after he contracted an upper respiratory infection. He also complains of bilateral ankle swelling. He has a 40 pack-year history of smoking. Physical examination reveals a mildly overweight patient in mild respiratory distress. Lung auscultation reveals bilateral wheezes and a prolonged expiratory phase. His white blood cell count is 14,500/mm3 and his hemoglobin level is 16 mg/dl. Arterial blood gas analysis reveals the following: pH 7.37 pO2 65mmHg pCO2 60mmHg Absence of marked acidosis in this patient is best explained by which of the following?

70. A 43-year-old woman with congestive heart failure, rheumatoid arthritis and chronic hepatitis C complains of abdominal discomfort and difficulty breathing. Physical examination shows dullness to percussion at the right lung base. Chest x-ray reveals a large right-sided pleural effusion. Thoracentesis yields pleural fluid with a glucose content of 30 mg/dl and an LDH of 192units/L. Which of the following explains the pleural fluid glucose concentration?

73. A 4 2-year-old morbidly obese man is being evaluated for poor sleep. He complains of frequent awakenings due to a choking sensation and says that the resulting tiredness severely limits his physical activity. He also complains of chronic leg swelling. He denies cigarette, alcohol, or drug use. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 110/min. Which of the following additional findings is most likely to be present in this patient?

74. A 32-year-old Caucasian female presents to your office with persistent cough and shortness of breath. She has had three episodes of pneumonia over the last year. She had severe sinusitis one year ago, and an episode of bloody diarrhea that required hospitalization and IV antibiotic therapy six months ago. She does not smoke or consume alcohol. She denies any illicit drug use. She is currently not taking any medications. All her immunizations are up-to-date. Her blood pressure is 130/80 mmHg and heart rate is 90/min. Physical examination reveals fine crackles over the right lower lung lobe. No lower extremity edema is present. Neck palpation does not reveal any lymph node enlargement. The chest x-ray shows right lower lobe infiltrates and left upper lobe fibrosis. The ECG reveals non- specific ST segment and T wave changes. What is the best next step in the management of this patient?

75. A 32-year-old man presented to the emergency department five hours ago with an acute asthma exacerbation. He has been receiving continuous albuterol nebulizer treatments since that time. He has a 20-year history of asthma but notes that recently the frequency of his attacks has increased. Presently, his blood pressure is 110/70 mmHg and heart rate is 120 and regular. On physical exam, the patient appears drowsy. Breath sounds are diminished bilaterally but there are no wheezes. The most recent ABG reveals: pH 7.32 pO2 65mmHg pCO2 50mmHg Which of the following is the best next step in managing this patient?

76. A 25-year-old male presents with progressive shortness of breath over the past 6 months. His past medical history is significant only for neonatal hepatitis that resolved spontaneously when he was 6 months of age. The man has never smoked. On lung auscultation today, there are decreased breath sounds over both lower lobes. Chest x-ray demonstrates emphysematous changes in the bilateral lower lobes. Routine blood work is normal. Which of the following analyses would be most helpful in establishing this patient's diagnosis?

78. A 64-year-old male presents to the physician's office with increasing shortness of breath. He denies orthopnoea, paroxysmal nocturnal dyspnea, or chest pain. He was hospitalized for pneumonia four years ago but has otherwise been healthy. He has smoked one pack of cigarettes daily for the past 30 years. He does not take any medications. His temperature is 37.2°C (98.9.F), blood pressure is 124/76 mm Hg, pulse is 82/min and respirations are 16/min. Pulse oximetry reveals an oxygen saturation of 88%. On chest auscultation, breath sounds are diminished throughout, and the expiratory phase is prolonged. Heart sounds are regular and there are no murmurs or gallops. There is no peripheral edema or jugular venous distention. Laboratory studies show a hematocrit of 56% and WBC count of 6,700/mm3. Which of the following interventions will have the maximum impact on this patient's survival?

79. A 47-year-old male who has just returned from a cruise to the Bahamas presents to the hospital with a high-grade fever, productive cough and shortness of breath for the past two days. He also complains of frequent vomiting and diarrhea. He has no prior medical problems, does not take any medications, and denies using tobacco, alcohol or drugs. His temperature is 40°C (104 °F), blood pressure is 110/65 mm Hg, pulse is 80/min, and respirations are 18/min. Lung examination reveals right lower lobe crackles. The abdomen is soft and non-tender. Chest x-ray demonstrates right lower lobe consolidation. Sputum Gram stain contains many neutrophils with no organisms. Which of the following antibiotics must be given to this patient?

80. A 56-year-old woman is brought to the emergency room with shortness of breath, which she says began suddenly two hours ago while she was enjoying her favorite television show. She also reports the simultaneous onset of sharp, left-sided chest pain. Her previous medical history includes diabetes mellitus for the past 10 years and hypertension for the past 6 years. Her family history is significant for heart disease in her father, who died at age 40. Her medications include enteric-coated aspirin, captopril and glipizide. She has a 30 pack-year smoking history, but does not smoke currently. On physical examination, she is in acute distress and is sweating profusely. Her temperature is 38.0°C (100.5.F), pulse is 140/min and irregular, respiratory rate is 30/min, and blood pressure is 110/60 mm Hg. Her oxygen saturation is 84% on room air by pulse oximetry. Jugular venous pressure is within normal limits and her lungs are clear to auscultation. Serum analysis reveals the following: Hematocrit 40% WBC count 11,600/mm3 Platelet count 190,000/mm3 Chest x-ray is unremarkable. ECG reveals irregular RR intervals, with no definite P waves and narrow QRS complexes. Which of the following is the most likely cause of her current symptoms?

81. A 36-year-old female presented to the emergency room with fever and a productive cough. The physician on call suspected community acquired pneumonia and prescribed azithromycin for 5 days. After 5 days of treatment, she comes to your office with no improvement of her symptoms and complains of worsening foul smelling sputum. Further inquiry reveals that she had undergone an upper GI endoscopy 8 days ago for a long history of heartburn and suspected peptic ulcer disease. She also reports a history of manic-type bipolar disorder. In your office she has a blood pressure of 130/80 mm Hg, her pulse is 108/min, temperature is 38.7C (101.6F) and respirations are 26/min. Chest x-ray showed a right upper lobe infiltrate. Which of the following additional therapies would be most helpful for this patient's condition?

83. A 55-year-old man presents to your office with a six-month history of non-productive cough, especially at night. He denies postnasal drip, chest pain, difficulty breathing, or wheezing. His only other complaint is water brash. His past medical history is insignificant, and he is not taking any medications. He does not smoke or consume alcohol. Physical examination is insignificant. Chest x- ray and pulmonary function testing are normal. Esophagoscopy is also normal. What is the next best step in the management of this patient?

84. A 53-year-old homosexual man comes to the ER with shortness of breath and dry cough over the past week. You note that he was hospitalized for Candida esophagitis one month ago, but left against medical advice. On physical examination, his blood pressure is 120/70 mmHg, heart rate is 120/min and regular, oxygen saturation is 89% on 2Umin of oxygen by nasal cannula, and temperature is 38.3° (101°F). There are extensive white plaques over the oral mucosa and there is a soft 2/6 systolic murmur over the cardiac apex. Lung auscultation is remarkable for faint bilateral crackles. Which of the following is most likely responsible?

85. A 65-year-old Caucasian male comes to the physician because of shortness of breath, fever, and a productive cough for the last four days. He is a chronic smoker and alcoholic. He quit smoking two years ago. His medical problems include hypertension, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, and coronary artery disease. He is taking daily-inhaled ipratropium bromide, albuterol, metformin, metoprolol, warfarin, and diltiazem. His temperature is 38.9 C (102 F), blood pressure is 140/88 mmHg, pulse is 110/min, and respirations are 28/min. Pulse oximetry showed 88% on room air. Examination shows decreased breath sounds and crackles over the right lower lobe of the lung. Which of the following is the most appropriate next step in his management?

86. A 42-year-old white male presents to your office complaining of periodic breathing difficulty and wheezing. He visited an otolaryngologist for persistent nasal blockage recently. His past medical history is significant for unstable angina experienced five months ago. His current treatment includes aspirin, diltiazem, and pravastatin. He does not use tobacco, alcohol, or drugs. His vital signs are within limits. What is the most probable cause of this patient's respiratory complaints?

87. A 45-year-old male comes to the emergency room complaining of shortness of breath that began 3 hours ago. He also has a nonproductive cough, a low-grade fever and right-sided chest pain that worsen with inspiration. He denies coughing up blood, wheezing, palpitations, leg pain or swelling of his lower extremities. He recently returned home from a trip to Singapore. He has a history of hypertension and diabetes mellitus. His takes fosinopril, metformin and glyburide. He doesn't use tobacco, alcohol or illicit drugs. His temperature is 98.0 F (36.6C), blood pressure is 115/70 mmHg, pulse is 128/min, respirations are 32/min, and O2 saturation is 84% on room air. Physical examination shows a slightly obese man in acute respiratory distress. He is alert and cooperative without any cyanosis or jaundice. He has a slightly displaced apical impulse with a S4. Chest-x ray shows mild cardiomegaly with no infiltrates. EKG shows sinus tachycardia and left ventricular hypertrophy without ST-T wave changes. His arterial blood gas analysis shows pH 7.52, pCO2 30, pO2 55, HC03 22. What is the next best step in the management of this patient?

89. A 56-year-old male presents with progressively worsening dyspnea over a 4-month period. He denies fever, chest pain, cough or ankle swelling and does not use tobacco, alcohol or drugs. He works for a home insulation and plumbing company. He has never been abroad and does not own any pets. His only medications are hydrochlorothiazide and metoprolol for blood pressure control. On physical examination, his temperature is 36.8°C (98.2.F), pulse is 76/min, blood pressure is 130/78 mmHg, and respirations are 15/min. Examination shows digital clubbing and fine bibasilar end-inspiratory crackles. Jugular venous pressure is 7 cm and there is no peripheral edema. Which of the following additional findings is most likely in this patient?

90. A 43-year-old moderately overweight woman presents to the emergency department complaining of two days of shortness of breath. Today, while climbing stairs, she had an episode of severe lightheadedness and near syncope. Her medical history is significant for a right calf deep venous thrombosis one year ago. She takes no medications currently. On physical examination, her blood pressure is 90/50 mmHg and her heart rate is 120/min and regular Imaging studies are most likely to reveal which of the following?

91. A healthy 33-year-old man comes for a pre-employment examination. He has no complaints and has no medical problems. He does not use tobacco, alcohol, or drugs and takes no medications. He has no occupational exposures and has lived his entire life in suburban Mississippi. His temperature is 36.7 C (98.0F), blood pressure is 120/80 mmHg, pulse is 78/min, and respirations are 16/min. Examination shows no abnormalities. His chest x-ray shows a 1.5 cm nodule in his right mid-lung field. Other labs are unremarkable. Which of the following is the most likely diagnosis?

92. A 30-year-old African American female presents with a two-month history of shortness of breath and nonproductive cough. She has never had symptoms like these before. Her past medical history is significant for an episode of uveitis six months ago. She does not take any medications. She works as a secretary in a local office building. She does not use tobacco and drinks alcohol only on special occasions. She has no pets and has been monogamous with a single partner for the last three years. On physical examination, her temperature is 37.2°C (98.9.F), blood pressure is 126/76 mm Hg, pulse is 76/min and respirations are 16/min. Lung auscultation reveals patchy rales. The remainder of her examination is unremarkable. Chest x-ray shows diffuse interstitial infiltrates. Which of the following is the most likely cause of her shortness of breath?

93. A 63-year-old male complains of cough and nocturnal wheezing. The cough is mostly non-productive but can sometimes relieve chest tightness if a small amount of yellow sputum is produced. His past medical history is significant for a hospitalization for a 'chest infection' two years ago. His appetite is good but he lost 5 pounds over the last several months. He has smoked one pack of cigarettes per day for the past 40 years. He drinks 2-3 cans of beer per day on the weekends. His mother suffered from diabetes mellitus and his father died of a stroke. On physical examination, his blood pressure is 140/80 mmHg and his heart rate is 80/min. There is chest hyperinflation and scattered expiratory wheezes on auscultation. The patient expires through pursed lips. His fingers demonstrate prominent clubbing. This patient's clubbing is most likely related to:

94. A 65-year-old male with oxygen-dependent chronic obstructive pulmonary disease, chronic atrial fibrillation, and depression comes into the Emergency Room, with symptoms of increased dyspnea and worsening cough pattern. His recent history had been significant for a gradual worsening of his baseline lung disease over the past month, which had been treated by his outpatient doctor with increased frequency of inhaled beta-agonist and azithromycin. This morning he had a severe shortness of breath that was unresponsive to "stacked" home nebulizer treatments. The ER physician notes that the patient is in moderate severe respiratory distress. His temperature is 37.2C (99F), blood pressure is 150/90 mmHg, pulse is 110/min, and respirations are 28/min. Accessory muscle use was noted. Lung exam shows diffuse rhonchi and wheezing. A pulse oximetry revealed an oxygen saturation of 80% on room air. His chest x-ray showed no new infiltrates. His WBC count is 7,000/cmm with normal differential. The ER physician had given nebulization, and the patient is on 5-liters of oxygen. Which of the following should also be considered in this patient?

95. An 80-year-old Caucasian female is brought to the emergency room by her son with a three-day history of fever and a foul-smelling, productive cough. Her past medical history is significant for advanced dementia, diabetes, and hypertension. She takes aspirin, metformin, insulin, and atenolol. She was admitted two times with pneumonia during the past two months. Her temperature is 38.3 C (101 F), blood pressure is 100/70mmHg, pulse is 105/min, and respirations are 20/min. The patient is not oriented in time and place. Physical examination reveals dry mucus membranes and decreased skin turgor. Breath sounds are decreased to the right. A chest x-ray revealed right, lower lobe infiltrate. Which of the following is the most important predisposing factor for this condition in this patient?

96. A 40-year-old Caucasian man comes to the emergency department because of fever, dry cough, and shortness of breath. Symptoms started 24 hours ago. He denies hemoptysis. He was recently discharged from the hospital after a second cycle of chemotherapy for acute myeloid leukemia. He does not use tobacco, alcohol, or drugs. His temperature is 38.9 C (102.0 F), blood pressure is 120/70 mmHg, pulse is 112/min and respirations are 28/min. The patient's pulse oximetry showed 86% at room air. Examination shows diffuse crackles all over the lung fields. His chest x-ray shows diffuse interstitial infiltrates. Which of the following is the most likely cause of his condition?

97. A 65-year-old female presents with 6 months of worsening dyspnea and dry cough. Whereas she had previously enjoyed an active lifestyle, she now becomes breathless after walking just a few steps. The patient denies fever or chest pain and does not use tobacco, alcohol or illicit drugs. Her only medicine is hydrochlorothiazide for hypertension. She is retired and lives with her husband. She has never travelled abroad and denies any history of exposure to pets. On physical examination, her temperature is 37.2°C (98.9.F), blood pressure is 140/86 mm Hg, pulse is 84/min and respirations are 18/min. Examination shows dry, late inspiratory crackles and finger clubbing. Her chest x-ray is shown below: Which of the following abnormalities is most likely to be present in this patient?

98. A 45-year-old woman comes to your office with a three-month history of fatigue, exertional dyspnea, and non-productive cough. She has also been having difficulty swallowing. Her only other medical problems are Raynaud's phenomenon, heartburn, and high blood pressure. On examination, diffuse thickening of the skin with telangiectasia is noted. Her current medications include amlodipine, enalapril, and ranitidine. What is the most probable pathologic mechanism of her pulmonary complaints?

99. A 65-year-old man with chronic obstructive pulmonary disease, chronic atrial fibrillation, hypertension, and diabetes mellitus presents with a three-day history of shortness of breath. His condition began with runny nose, itchy eyes, and sore throat, but his symptoms progressed to productive cough, wheeze, and dyspnea. Physical examination reveals a mildly overweight man in moderate respiratory distress. His blood pressure is 150/90 mmHg and his heart rate is 110/min and irregular. On chest auscultation, expirations are prolonged and there are bilateral wheezes. You administer bronchodilators, facial mask oxygen, and lorazepam for agitation. Thirty minutes later, he is lethargic and confused. While you discuss the case with your attending, the patient experiences a generalized tonic-clonic seizure. Which of the following most likely underlies his neurologic symptoms?

100. A 32-year-old man presents to the emergency department with pain and swelling in the right leg. He was recently hospitalized for a right lower extremity deep venous thrombosis and discharged on warfarin. Today his INR is 1.12. Ultrasound reveals a right popliteal vein thrombosis extending into the deep femoral vein. What is the best initial management step for this patient?