1.

A 42- feniul£• pi•sertts for follows'-up atter lseing treated for

recurrent resJilratory
roblems at an urgent care facility. She is feelinE a lithe better afler a ort
course of oral
prednisone and use of nn albuterol (Proventil, Ventolin) inhaler. She has liud a
gradual increase
in shortness of breath, a chronic cnu '•h, ttlld a d0£'T0H5£• in her usual activity
level os er the
piist year. She tins brought a
copy of a recent chest rudi•E P • report for your review that describes pnn-
lobular basal
emph›'sema. She does not have « I FstoFy Itf Smoking, second hand
smnhe exposure, or occupational exposures. Spirometry in the office revesls an FEV
tfFVC rntio of
0.(i7 w4th no change after bronchodilator administration.

Which One o£ the £otl»=a>R >berlj5ng conditions is the must iikely cause for this
ie tat on?

< i-Antitrypsin deficiency

B. Bronchiectasis
C. Diffuse pnn-hronchiolit s
D. Interstitial lung disease Lett heart failure

This patient presents s ith symptoms of chronic obstructive lung disease, and
spirometry confirms
airflow limitation or obstruction with an FEV,fFVC <0.7. Her a₈l, the lack of
tobacco smoke or
occupational exposures, and the chest radiograph findings are typical of e
t•antitrypsin
deficiency. 3Yhile left heart failure, interstitisl lung disease, bronchieetasis,
rind diffuse
pan-bronchiolitis are all causes of chronic cough, they are not necessarily
associated with the
development of COPD and these spirometry findings. Furthermore, the radiologic
findings in this
patient are not consistent with these conditions. Left heart failure u'ould present
with pulmonary
edema on o chest radiograph and volume restriction on
pulmonary function testing. Bzonehiectasis would present with bronchial dilution
anfl bronchial
wall thickening on a chest rndiogr:iph. Interstitial lung disease would present
with reticular or
incrcasetl interstitial markings. Diffuse pan-broncliiolitis would present o itli
diffuse small
centrilobular nodiilar opacities along with hyperinflation.

15. A 69-year-old female presents to your office with a 5-day history of cough and
low-grade fever.
She has a past history of hypertension and obstructive sleep apnea. Her daughter
brought her in
this morning because of worsening symptoms. The patient's temperature is 37.4°C
99.3°F her blood
pressure is 110/74 mm Hg, her pulse rate is 88 beats/min, her respiratory rate is
36/min, and her
oxygen saturation is 95% on room air. She is alert and oriented to person, place,
and time. A CBC
and basic metabolic panel are normal except for an elevated WBC count of 12,500/mm"
(N
4300—10,800). A chest radiograph shows a right lower lobe infiltrate.

This patient has a higher risk of mortality and should be considered for inpatient
treatment due to
her

A. Female sex
B. Underlying hypertension
C. Respiratory rate
D. Elevated WBC count
E. Abnormal chest radiograph

ANSWER:C
There are several decision support tools to assist in predicting 30-day mortality
for patients with
community-acquired pneumonia. Calculating the number of high-risk markers can aid
in deciding
whether to admit the patient to the hospital. The risk of mortality increases with
a respiratory
rate 30/min, hypotension, confusion or disorientation, a BUN level 20 mg/dL, age
>65 years, male
sex, or the presence of heart failure or COPD.

lfi. A 78-year-old male is brought to your office by his daughter. She is

concerned that her
father is no loneer attending his weekly cribbaue and bingo has

23. A 6-month-old male is brought to the urgent care center with a 3-day Nstory of
rhinorrhea,
cough, and increased respiratory effort. His temperature is 37.5°C (99.5°F), his
heart rate is 120
beaG/min, ms respiratory rate is 42/min, and his oxygen saturation is 96% on room
air. On
examination the child appears well hydrated with clear secretions from his nasal
passages, there is
diffuse wheezing heard bilaterally, and %ere is no nasal Haring or retractions. The
mother states
that the child has a decreased appetite but is drinking a normal amount of fluids.

Which one of the following would be the most appropriate management for tms
patient?

A. Supportive therapy only

B. Dronchodilators
C. A corticosteroid taper
D. Epinephrine
E. Nebulized hypertonic saline
ANSWER: A

This patient's symptoms and the examination suggest viral bronchiolitis. Supportive
therapy,
including adequate hydration, is recommended for treatment. Treatment with
bronchodilators,
epinephrine, hypertonic saline, or corticosteroids is not indicated (SOR A)

44. A 38-year-old female with a 6-month history of mild shortness of breath

associated with some
intermittent wheezing during uppe respiratory infections presents for follow-up.
You previously
prescribed albuterol (Proventil, Veiitolin) via metered- dose inhaler, which she
says helps her
symptoms. You suspect asthma. Pulmonnry function testing reveals a normal FEVi/FVC
ratio for her
age.

Which one of the following would be the most appropriate next step?

A. Consider an alternative diagnosis

B. Assess her bronchodilator response
C. Perform a methacholine challenge
D. Prescribe an inhaled corticosteroid
E. Proceed with treatmenf for COPD

ANSWER: C

Spirometry is central to confirming the diagnosis of asthma, which is characterized

by a reversible
obstructive paftern of pulmonary funcfion. In this case the patient's FEVt/FVC
ratio is normal,
which neither confirms nor rules out asthma. A methacholine challenge is
recommended in this
scenario to assess for the airway hyperresponsiveness that is the hallmark of
asthma. Methacholine
is a cholinergic agonist. Bronchoconstriction (defined as a reduction in FEV 20%)
observed at low
levels of methacholine administration (<4 mg/mL) is consistent with asthma. If the
FEVi/FYC ratio
is reduced on initial spirometry, a bronchodilator response should be fesfed. A
fixed or partially
reversible obstructive pattern suggests an alternative diagnosis such as
COPD, and full
reversal after bronchodilator use is consistent with asthma. Inhaled
corticosteroids are not
appropriate for intermittent asthma.

^°• A aa-,",'.,'° ma
the to of th

re
again this year.

y ••i» i» n«i ,i„,ₑ ₐ, PM a headache, nausea, an he had $lty slee

recurrence of the probleni when he goes skijpg
before his ascent aod

A cefazolamide (Diamox Sequels)

B. Aspirin

E. Yo!pidem(Ambien}

ANSWER: A
nd he start the day

AcetasolarDide is the preferred agent for preventing acute mountain sickness

(AMS). Multiple
trials have demonstrated its efficacy In preventing AMS. Dexamethasoxe is o first-
line treatment
for acute mountaN sickness of any severity but is a second-line drug for preveo0on
because of its
side-effect profile. Tadalnl"d is advised as a second-line treatitiepl
aRez nifedipine for the prevention and treatment of high-altitude pulmonary
edema. Zolpidern
may help with sleep but not AMSL and aspirin is not recommended for
prevention of AJYIS-

91. A 58-year-old female with COPD asks what she can do to avoid hospitalization.
She does not have any other medical problems.

Which one of the following interventions has been shown to reduce related hospital
admissions in
patients such as this?
respiratory•

A. Written sek-management plans that include smoking cessation plans

B. Regular physical acfivity
C. Regular assessment of FEV
D. Nightly CPAP therapy
E. Daily oxygen therapy

ANSWER: A

Written seH-management plans have been shown to decrease respiratory-

related
hospitalizations in patients with COPD. Although regular physical activity has
clear health
benefits, the methods are so varied in studies of physical activity that there is
currently no
strong evidence to show it reduces hospitalizations in COPD patients. Although FEV,
is important
for predicting hospitalizations for a population, it is not accurate enough to be
useful in an
individual paGent. Daily oxygen therapy does not help to postpone the first
hospitalization.
Nightly CPAP therapy reduces hospitalizations in patients with COPD and sleep
apnea, but not those
with COPD alone.

ss. A 67-year-old male is admitted to the hospital for community-acquired

pneumonia. An examination reveals a temperature of 40.0°C (104.0°F), a respiratory
rate of 50fmin,
a pulse rate of 110 beats/min, a blood pressure o /50 mm Hg, and an oxygen
saturation of 88% on
room air. The patient is confused and requires aggressive fluid resuscitation for
hypotension and
lie is transferred to the intensive-care unit. He has no known additional risk
factors or
exposures.

In addition to treatment with ceftriaxone and azitbromycin (Zithromax), which one

of the following
medications is most likely to result in improved outcomes?

A. Clindamycin (Cleocin)
B. Levodoxacin (Levaquin)
€. Methylprednisolone (Medrol)
D. Oseltamivir (Tamiflu)

ANSWER:C
This patient has severe community acquired pneumonia based on clinical
criteria, including an
elevated respiratory rate, confusion, and hypotension requiring aggressive
fluid
resuscitation. Corticosteroids such as methylprednisolone have been shown to
improve clinical
outcomes such as length of stay, duration of antibiotic treatment, and the risk of
developing adult
respiratory distress syndrome. The preferred choice of antibiotic treatment for
patients in the
intensive-care unit is a -lactam antibiotic (ceftriaxone, cefotaxime) or
ampicilIin/sMIbactam, plus
n macrolide alone or a macrolide and a respiratory fluoroquinolone. The addition of
levofloxacin is
not necessarily preferred over just ceftriaxOOR H22d azilhromycin. Clindamycin is
not indicated in
the absence of risk factors for anaerobic infection such as aspiration or
alcoholism. Oseltamivir
is not indicated in the absence of known or suspected influenza infection.

i*3. A 7fi-year-old mule nursinRhome resident is T›rought tu the emergency

dcy9rtment •• itl› a
cn‹igli 9ncl fever. his yost me‹licol hi*tnry is significant for cornnary arlery
discuss, COPD,
hypertension, and osteoarthritis. On examination he has n blood pressure of 145/90
mm Hg,
u puLsc rote uf 84 bcuts/min, and un oxygen snturolion of 89% on mum air. A
physical examination is
remarkable for mildly labored breathing and crackles in his left lower lung field.
A chesl
radiogrnph confine lett loo'er lobe pneumonia. He is admilled to the hospital for
intravenous

lYhich one of the £ollo»ing would he the most appropriate antibiotic treatment?

A. Cefdinir ‹›xlY
B. Piyemcillin/taznhactam (Zw 'ri) nnly
C. Ceftriasorie Bnd nzithrom cin (Zithromnx)
D. Cer»i ie (Supex) and vancomycin (Vancocin)
K. ip2 3Cf Zt/t9ZO/aCfODt, 5'nncomycirt, nxd ciprofloxscin (Cipro)

Current rccommcndtifions stnte that nursinE hoHlc-^*9 ••d pneumonia sh0uld he

treated as
community-acquiretl pneumonia unless pnlients have severe illness, chronic
ii'ounds, foreign bodies
in the uirway, a history of antibiotic use in the last 90 da)s or recent
hospitolizalion,
colonization with multidrug-resistant
ytthogens, or very low functional status, or reside in a fitCility With a high
prevalence nf
niultld f’•-*(•Sislimt_Qatho@£us. Comn1unit)'-acquired pneumonia should be treated
with either
'respiratory hiioroquinolone or an advanced macrolide plus a -laEtam iintibiotic.
Lloxyc3clinc
could also be used in place of the macrolide.

151. A 28-year-old male presents to your office in January with a 1-day history
of cough and
nasal congestion. He has not had any fever, shortness of breath, or chest pain. An
examination
reveals some rhinorrhea and hoarseness. A lung examination is normal. The patient
asks you to
prescribe albuterol (Proventil, Ventolin) because it seemed to help a friend who
had similar
symptoms.

Which one of the following would be the most appropriate evidence-based response to
the patient's
request?

A. Do not prescribe albuterol

B. Prescribe albuterol alone
C. Prescribe albuterol and oral corticosteroids
D. Prescribe albuterol and inhaled corticosteroids

ANSWER: A

In a Cochrane review of five trials of 2-agonist therapy in adults, there was no

significant
dkference between 2 agonists and placebo in cough reduction. Based on reports of
adverse effects,
the number needed to harm is 2. It is important to set reasonable expectations for
cough duration
after an acute respiratory Illness.

j5n. A SB•ycor-oil female presents to your officr to discuss a ne«'

dJ BID •f COPD. Sbe bas a 40-pack-year siooklsg k£story. aad she quit
asInR‹• •- 18 Months ago. Splmmeiry performed Inst week sbooed nn FEVlfFYC retlo
of 0.ti2 w4th an
FEV1 thai is 75•Z• of predicted. the wee fint framed for an exaccrbntion Inst mouth
and has never
rcqulred
hospltnllz tion for nn. respiratory llnesn 1’ou administer a COPD
assessment itst and she raies erse f si i£/4o, z'klch is n itioder»teIy higb

87do!mooeofUbefoZooinglnbzIcdmndicslo*#**u4dbrsppropde{eto

B. Fiutlnistnie lFiovenil
C. FlaHmsmie/salmeierel fAdsoir)

D. lpratropiuin (Airoventl
E. Tlotroplum tspiriizl

ANS$TER: E

TbLs patient kas airflow obslructloo consistent wft}gj rliagoasis of C{3PD,

e•1denced by an WY1 fi ratio <'0.7. An exldeoce-ba.red standard approach to COPD
Ls found la tbe
aooual $uldeKaes published h¿ lhe Clobal InitiJsllvr for Cl n›ntc Obstructive Lung
Disease
(C'•OLD). Accordfisg To ihe 20f9 report, thLs patient’s FE\’1 nf 75’/• of predicted
puts her ia the
HOLD grade 2 (rr+oJcrxIe) category nf airflow fiaJtallon. fler symplortts und risk
of exacerbatiuos
places
ber In £•ULD group B. yotleots ia LhLe tatego kave symptoms tbat k‹•ther tlieza
regularly wilbout l›ax iog Irequeot COPD esacerbatIoas• Pallenfs In thL category
beoe5t from daily use ol'lang•actiog bronchodilators, eic6er long•acttag agonists
tLAltMl or
long•setlng emsoirinlc sgents (LAhtAsl. Long•aetlag agents such as uotrnplum ta
with)or salmeiernl
ta LAB.xl are preferred over
the short-eeting agems lprairopluin and albuterol fur patients hi tlils celepory of
dLscow
severity. P»t\ents Hitb persLslent simplex u'hile usizsg nnr of tbese agcnL a ay
benefit drool e
coml•lnatl«a of a L tBA aod a LAAIA.
hlonotberapy with l1al«d co•ticmteroids bas not beea sbown to jotpro 'c ninrtafity
or p -r•rnl a
Toog•terta decJlae io FEED. Tke comhlnajioo oj'att lh{iajed corticosteroid plus a
LAgA fate es
Ideoce ‹›£»upertorily o+’cr eilher agrnt aloae
*•• Improving!uajt ruoctioa and hmltA status. aad lor reducing esacerballons in
patients n'bo ka\'e
more ece disease. No lmproyewat In all -cause mortaIit*' bas been noted.

173. A 67-year-old female who recently moved to your city presents to your office
as a new patient.
Over the past year she has experienced wheezing and shortness of breath during her
morning walks.
She has a 35-pack-year smoking history and has been treated with antibiotics at
least four times in the past year fotre noanfections. You suspect
COPD and perform spirometry before and after a bronchodilator treatment.

Which one of the following pulmonary function test results would confirm COPD in
this patient?

A. A reversible FEVl/FVC ratio <55%

B. A reversible FEVI/FVC ratio >75%
C. An irreversible FEVl/FVC ratio <65%
D. An irreversible FEYl/FVC ratio >85%

ANSWER: C

A large cohort study indicated that the Global Initiative for Chronic Obstructive
Lung Disease
criterion (FEVI/FVC ratio <70%) is more sensitive for COPD in individuals 65 years
and older
compared to the American Thoracic Society criteria (SOR C). COPD is present if the
FEVI/FVC ratio
is reduced to <70% and is irreversible with bronchodilator therapy. A reversible
response to
bronchodilator therapy is more consistent with asthma.

17£. A 2-3'cur-old mule is brought to your office try his mother. The child has a
2-day history of
a runny nose and mild cougñ associated with a suhjective fever. The cough worsened
last night. The
patient has had a reduced appetite but a good intake of fluids.

On examin,ation the child has an nxillary temperature •f 37.4°C (99.3°F), a heart

rate of 120
heals/min, respiratory te of 26/min, n weight of 16 kg (35 lb), and an oxygen
saturation of »
on rrusm air. He appears mildly ill hut is alert and does not show nny signs of
distress, and has n
prominent high-pitched barking cough. You note thnt he has clear rhinorrhea, the
tympanic memhrnnes
are normal, Rnd the oropharynx is moist and cleRr. Auscultation reve.als
inspiratory stridor, but
there ure nu signs of respiratory distress. The patient's skin has good turgor
o'ith no rash.

Which one of the following would be the most appropriate next step in the
management of this child?

A. Administration of dexa iethasnne, 0.£ mg/kg orally in a single dose

D. Initiation of oral amoxicillin, 40 nig/kg twice daily
C. Administratinn of albuteml, 2.3 mg/3 mL via nebulizer
D. Administration of racemic epinephrine 2.2s% solution (Asthmanefrin), 0.5 mL via
nebulizer
E. Transfer to n hospital emergency department for stnbilizntion rind hospital
admission

ANSIYER: A

Tiiis patient hns mild croup based on the clinical findings. A single dose of
dexamethasone is
recommended in all cases of croup (SOR A). Hospitalization is not necessary if the
child is stable.
Rnccmie Epinephrine, ishicb has been shnom to reduce symptoms nt 30 minutes but not
at 2 hours or 6
hours, is recommended for the treatment of moderate to severe crnup when patients
are beinR
ohserved in a medical setting such as the eoiergenc3' department or hospital (SOR
A).
Amoxicillin and albuterol are not indicated in the management of croup.

195. A 2-year-old female is brought to your office for a well child check. She had
an episode of
coughing and mild bronchospasm 3 months ago lhnt was successfully treated with
albuterol
(Proveniil, Ventolin). The mother asks you if there are any factors that would
increase the
patient's risk of asthma.

Which one of the following factors would increase this patient's risk of asthma?

A. Living in a high niicrohial environment

B. Exposure t respiratory $yncytial virus

C. Recurrent otitis media

D. Persistent lactose intolerance

ANSWER: B

Immunologic profiles of patients with asthma are influenced by environmental

exposures. Those who
are exposed to respiratory syncytial virus as an infant have an increased risk,
whereas those who
are exposed to a high microbial environment have a looser risk than thnse without
such exposure.
Otitis media and lactose intolerance arc not known to he associated »'ith asthma
risk.

25. A 60-year-old male presents with a several-month history of a dry cough and
progressive
shortness of breath with exepion. On examination he has tachypnea and bibasilar
end-inspiratory dry
crackles, and a chest radiograph reveals interstitial opacities.
Which one of the following patient occupations would most likely support a
diagnosis of silicosis?
A) Baker
B) Firefighter
C) Stone cutter
D) Goat dairy farmer
E) High-tech eleCtronics fabricator

ANSWER: C
Family physicians should be aware of the environmental exposures associated with
pulmonary disease.
Stone cu2ing, sand blasting, mining, and quarrying expose patients to silica, which
is an inorganic
dust that causes pulmonary fibrosis (silicosis).
Occupational exposure to beryllium, which is also an inorganic dust, occurs in the
high-
tech electronics manufacturing industry and results in chronic beryllium lung
disease. Exposure to
organic agricultural dusts (fungal spores, vegetable products, insect fragments,
animal dander,
animal feces, microorganisms, and pollens) can result in “farmer's lung,” a
hypersensitivity
pneumonitis. Other organic dust exposures, suCh as exposures to grain dust in
bakers, can lead to
asthma, chronic bronchitis, and C 0 PD. Firefighters are at risk of smok nd
are exposed to
toXiC Chemicals that can cause many acute and chroni respiratoy ymptams.

131. A•» 18-month-old female is brought to your office in January for evaluation of
a cough and
fever. She has no ch.ronic medical conditions. She abruptly developed a barking
cough and
hoarseness with a low-grade fever 2 days ago. The cough is worse at night. She has
been drinking
normally b " " ested in eating. On examin•ation she is alert and resists the
examination. He
respiratory te and effox are normal. She has no stridor or wheezing.

Which one of the following would be most appropriate at this point?

A) A nasal swab for influenza testing
B) A chesl radiograph
C) A single dose of oral dexamethasone
D) Azithromycin (Zithromax)
E) Oseltamivir (Tamiflu)

ANSWER: C

This patient has symptoms consistent with croup, a lower respiratory infection that
is common in
the winter months in children ages 6 months to 3 years. The diagnosis is clinical
and should be
suspected in children with a history of a sudden onset of a deep cough, hoarseness,
and a low-grade
fever. Randomized studies have shown that even with mild croup (an occasional
barking cough with no
stridor at rest), oral corticosteroids provide some benefit.

154. A 35-year-old white female presents with recurrentwheezing and coughing over
Jhe past few
weeks, and recent production of brown sputum plugs. She is a rRguiar patient of
yours and has a
long history of asthma arid multiple allergies. She has been treated four times in
the last 3
months for asthma exacerbations and generally feels better the first day she takes
her
corticosteroid, but any attempt at tapering leads io a recurrence of symptoms. She
previously had
good EOntroI of her asthma, although shE? has required regular use of a high-dose
inhaled
corticosteroid and a long-acting -agonist. In spite of just completing a course of
tevo8oxacin
(Levaquin)for suspected pneumonia she returns
loday with a recunence of the same symptoms.
A physical examination is unremarkable with the exception of diffuse expiratory
wheezing. She has
no fever or other abnormal v'ñaI signs. A chest radiograph shows opac“ries in the
upper and middle
lobes and a CBC is concerning for eosinophiTia.

Which one of the following is the most likely diagnosis?

A) Allergic bronchopulmonary aspergillosis
B) COmmunity-aEquired pneumonia
C) Pulmonary embolism
D) Medication nonadherence
ANSWER: A
Allergic bronchopulmonary aspergillosis (ABPA) affects IS—12' of immunocompe\ent
palienfs with
asthma and is important to consider in patients with rRcurrent exacerbations
because it can cause
permanent lung damage il it Is undlztected and untreated. The symptoms alone are
insufficient for a
diagnosis. but this clinical presentation should prompt consideration of the
diagnosis, and some of
the symptoms and findings noted are included in the diagnostic criteria. The major
diagnostic
criteria include the presence of asthma or cystic fibrosis and immediate skin
reactivity to
Aspergâlus antigens, peripheral eosinophiiia, transient pulmonary infiltrates or
opacities, central
bfonChieclasis on a chest radiograph or CT, serum precipitating antibodies to
Aspergâlus fumigatus
, and elevated Aspergillus IgE- and/or IgG-specific antibodies.
Minor criteria that support the diagnosis include prodoctlon of brownish mucus
plugs,
identification of Aspergillus in 1he sputum, and delayed skin sensitivity to
Aspergillus.

Pneumonia is unlikely in this case given recent treatment with a respiratory

fluoroquinoTone and a
lack of c‹xnmon symptoms such as fever. ian iycafdia, tachypnea. and pleuritic
chest pain. along
with a cough productive of mucopurulent sputum. The most common symptoms of
pulmonary embolism
include dyspnea. chest pain, syncope. tachypnea. and a cough. WhTe medication
nonadherence may
increase asthma exacerbations and wheezing, it would be unlikely to be related to
the new brown
fI1MEus production.

168. A 42-year-old female presents with shortness of breath that has slowly
worsened over the past
s months. She can now walk only 10 feet without becoming short of breath. She does
not have a cough
or chest pain. Her history is significant only for obesity. She smoked one pack of
cigarettes per
day for 20 years and quit
years ago. Her blood pressure is 138/88 mm Hg, pulse rate 92 beats/min, respiratory
rate 18/min,
and oxygen saturation 92% on room air. Her BMC is 42.4 kg/i ».
Her heart has a regular rate and rhythm with no murmurs and her lungs are clear to
auscultation.
Her lower extremities have bilateral 1+ edema. A chest radiograph is normal.
Spirometry reveals a
decreased FVC with a normal FEV1/FVC ratio. A CBC, a TSH level, and a basic
metabolic panel are all
normal except for a serum bicarbonate level of 36 mEq/L (N 22—29).
These findings are most consistent with
A) asthma
B) COPD
C) obstructive sleep apnea
D) obesity hypoventilation syndrome
E) pulmonary fibrosis ANSW ER' D
This patient has obesity hypoventilation syndrome (OHS), a disorder in which
central obesity leads
to chronic hypoventilation due at least in part to restricted diaphragm excursion.
Current criteria
for this condition include hypoventilation leading to carbon dioxide retention
(PaC0› 45 mm Hg) in
an individual with a BMI • 30 kg/mzwhen other causes of chronic alveolar
hypoventilation have been
ruled out. These patients retain bicarbonate to compensate for the respiratory
acidosis. It has
been suggested that an increased serum bicarbonate level (>29 mEq/L) in the absence
of another
cause for metabolic alkalosis should be included in the definition of DHS.
OHS leads to a restrictive pattern on spirometry, which this patient has. Asthma
and COPD are
obstructive lung diseases and can therefore be ruled out in this patient who has no
signs of airway
obstruction on spirometry. Obstructive sleep apnea is ohen present in patients with
OHS, but sleep
apnea alone does not lead to daytime hypoventilation and carbon dioxide retention.
Pulmonary
fibrosis is a cause of restrictive lung disease and has not yet been completely
ruled out in this
patient, but a normal chest radiograph makes this less likely. Comprehensive
pulmonary function
testing,

179. A 29-year-old male smoker presents with a 10-day history of a cough. He also
had a low-grade
fever for 2 days that has resolved. He has had some mild rhinorrhea and has noted
that the cough
has become productive of greenish sputum over the past 3—4 days. He has not tried
any medication.
An examination reveals some mild rhinorrhea but his lungs are clear.
Which one of the following would be most appropriate at this point?
A) Supportive care only
B) A chest radiograph
C) Albuterol (Proventil, Ventolin)
D) Antibiotic therapy
E) An inhaled corticosteroid ANSWER: A
The defining symptom of acute bronchitis is cough. Even in smokers the etiologic
agent is viral at
least 90% of the time, so antibiotics are not indicated. Unless wheezing is noted,
albuterol is not
helpful. Inhaled corticosteroids are used in maintenance therapy for asthma.
Indications for an
adult patient with acute bronchitis to have a chest radiograph i y sputum,
rusty-colored
sputum, or dyspnea; a pulse rate 100 beats/min; respiratory te ›24/min; or a
temperature 37.8•C
(100.0•F). A chest radiograph is a so in ica ed if there are abnormal findings on a
chest
examination such as fremitus, egophony, or focal consolidation. Supportive care is
made easier by
informing the patient that symptoms are likely to last 2-3 weeks. Symptoms may be
managed with
measures such as dextromethorphan, guaifenesin, or honey.
Ref: Kinkade S, Long NA: Acute bronchitis. Am Fam Physician 2016;94(7):560-565.

185. A 34-year-old male has a 3-day history of a runny nose, postnasal drainage,
sinus
congestion, and left-sided facial pain. He also reports a mild cough and diffiEulty
sleeping due to
the congestion. He is afebrile and the examination reveals inflammation of the
nasal mucosa,
purulent rhinorrhea, and mild left maxillary sinus tenderness to percussion.

Which one of the following would be the most appropriate pharmacotherapy?

A) Amoxicillin/clavulanate (Augmentin)
B) Levofloxacin (Levaquin)
C) Loratadine (Claritin)
D) Mometasone (Nasonex)

ANSWER: D
This patient presents with symptoms of acute rhinosinusitis. In the first 3—4 days,
viral and
bacterial rhinosinusitis are indistinguishable. Guidelines from the American
Academy of
0tolaryngology—Head and Neck Surgery suggest that antibiotics should not be
routinely prescribed
for acute mild to moderate sinusxis unless symptoms persist for 7 days or worsen
after initial
improvement. Watchful waiting without antibiotic treatment is appropriate when
follow-up is
accessible (SOR A). In this scenario antibiotic therapy is not indicated.
Amoxicillin with or without clavulanate is appropriate for symptoms lasting 7 or
more days without
improvement and is the first-line antibiotic treatment for acute bacterial
(SO R A). Due to the risk of adverse effects and no benefit over -lactams,
respiratory f uoroquinolones are not considered first-line antibiotic therapy.
Symptomatic
recommended within the first 10 days of the onset of symptoms and may be
continued if antibiotics are started. Intranasal corticosteroid use has a modest
therapeutic
benefit for patients wilh acute rhinosinusitis. Decongestants and antihistamines
have not been
proven effective for the treatment of acute rhinosinusilis.

11/ //-year-old male smoker presents to your office in January with worsening
respiratory ‹
ymptoms over the past 24 hours, along with a rapid onset of fever and chills,
algias, and sore throat. He has a history of mild chronic bronchitis and
hypertension, and his
medications include tiotropium (Spiriva) inhaled daily;
lisinopril/hydrochlorothiazide
(Zestoretic), 20/12.5 mg daily; and albuterol (Proventil, Ventolin) as needed.
On examination the patient has a temperature of 38.8'C (101.8'F), a heart rate of
102 beats/min, a
respiratory rate of 24/min, and an oxygen saturation of 94% on room air. He is ill-
appearing and
pale. Examination of his throat reveals mild erythema, and chest auscultation
reveals bilateral
bronchovesicular breath sounds with no crackles or wheezing.
The examination is otherwise unremarkable. Laboratory and radiology services are
not
available.
Which one of the following would be most appropriate at this point?
A) Observation only, with follow-up in a few days
B) Azithromycin (Zithromax)
C) Oseltamivir (Tamiflu)
D) Penicillin VK
E) Prednisone

ANSW ER: C
This patient has findings consistent with influenza, including a rapid onset of
fever, nausea, and
sore throat, and negative pulmonary findings. Influenza is considered a clinical
diagnosis and
confirmation of the diagnosis with laboratory testing is not required. Treatment of
influenza is
recommended for individuals at a high risk of influenza-related complications.
High-risk
individuals include those with chronic lung disease; cardiovascular (excluding
hypenension), renal,
hepatic, hematologic, or neurologic disease; or age •65. Children on long-term
aspirin therapy, and
pregnant and postpartum women are also considered high risk. This patient should be
treated with
antiviral medication because of his chronic pulmonary disease. While pneumonia and
stfeptococcal
pharyngitis should be considered in the differential diagnosis, these are less
likely given the
examination findings, and antibiotics are not recommended.
Prednisone is not indicated for influenza-like illness and may cause harm.

199. A 7-month-old male is admitted to the hospital fo respiratory yncytial virus

bronchiolitis.
His temperature is 37.9•C (100.2•F), puls eats/min, respiratory rate 70/min,
and oxygen
saturation 92% on room air. Auscultation of the lungs reveals diffuse wheezing and
crackles
accompanied by nasal flaring and retractions.

Which one of the following interventions would most likely be beneficial?

A) Bronchodilators
B) Corticosteroids
C) Epinephrine
D) Nasogastric fluids
E) Oxygen supplementation to maintain Oa saturation above 95⁰a

ANSWER: D
The mainstay of therapy for acute respiratory syncytial virus bronchiolitis is
supportive care, and
maintaining hydration is important. Infants with respiratory rates »60/min may have
poor feeding
secondary to difficulty breathing and oral rehydration may increase the risk of
aspiration. In
these cases, nasogastric or intravenous fluids should be administered. Oxygen
saturation of 90+‹ or
more on room air is sufficient for infants with bronchiolitis, and using
supplemental oxygen to
maintain higher oxygen saturations only prolongs hospitalization because of an
assumed need for
oxygen. Bronchodilators should not be administered to infanls with bronchiolitis,
because they have
not been shown to have any effect on the need for hospitalization, oxygen
saturation, or disease
resolution. In addition, lhere is no evidence to support the use of epinephrine or
corticosteroids
in the inpatient setting.

205. A 46-year-old male presents with a persistent as been present for several
months and was
not preceded by an uppe respiratory i Section. He does not have a history of
asthma, does not
smoke, and tak tions. His symptoms consist of short bursts of coughing that
produce a small
amount of mucoid sputum during the day. He does not have emesis or nausea. The
cough sometimes
wakes him at night but does not seem to be specific to any particular posture. He
does not have a
fever, shortness of breath, wheezing, heartburn, or nasal symptoms. A thorough
physical examination
is normal and a chest radiograph appears normal.

Which one of the following would be the most appropriate next step in the
management of this
patient?
A) Amoxicillin/clavulanate (Augmentin)
B) An empiric trial of a proton pump inhibitor
C) CT of the chest
D) CT of the sinuses
E) Referral for bronchoscopy

ANSW ER: B

Chronic cough is defined as a cough lasting at least 8 weeks. If a thorough history

(with attention
to ACE inhibitor use), a physical examination, and a plain-film chest radiograph do
not suggest an
obvious cause for the cough, experts suggest that the three most common etiologies
are
gastroesophageal reflux, persistent postnasal drip, and unrecognized asthma.
Treating a chronic
cough empirically with a high-dose proton pump inhibitor for 2—3 months is
considered a reasonable
choice before further investigations are attempted. Ordering an esophageal pH probe
or
esophagogastroduodenoscopy would also be considered appropriate. Postnasal drip is

Ref: Eichenfield LF, Krakowski AC, Piggott C, et al: Evidence-based recommendations

for the
diagnosis and treatment of pediatric acne. Pediatrics 201 3;131(Suppl 3):5163-5186.

226. A 30-year-old white male presents to the emergency department with a 4-day
history of fever to
J 01°F, a sore throat, rhinorrhea, and cough. An examination reveals rhinorrhea and
a boggy nasal
mucosa, but is otherwise unremarkable. A chest radiograph shows a questionable
infiltrate.

Which one of the following would help determine if antibiotic treatment would be
appropriate?
A) A C-reactive protein level
B) A procalcitonin level
C) A WBC count with differential
D) An erythrocye sedimentation rate
E) CT of the chest

ANSWER: B

Using a procalcitonin-guided therapy algorithm reduces antibiotic ays

without increasing
either morbidity or morality in adults with acut respiratory i fections. If the
procalcitonin
level is «0.10 mg/dL, a bacterial infection is hig nd it is strongly
recommended that
antibiotics not be prescribed. If the procalcitonin level is 0.10—0.24 mg/dL a
bacterial infection
is stilt unlikely and it is recommended that antibiotics not be used. If the level
is 0.25—0.50
mg/dL a bacterial infection is likely and antibiotics are recommended. It is
strongly recommended
that antibiotics be given if the level is »0.50 mg/dL, because a bacterial
infection is very
likely.

Ref: Morris C, Paul K, Safranek S: Procalcitonin-guided antibiotic therapy for

acute respiratory
infections.
Am Fam Physician2016;94(1):53-58.

231. The drug class of choice for the management of breathlessness in end-of-life
care
IS
A) anticholinergics
B) antipsychotics
C) benzodiazepines
D) coñicosteroids
E) opiates

ANSWER: E

lerra6roinistered at appropriate doses, opiates do not reduce or compromise

respiratory tatus and
do not hasten dying. Opiates help to reduce the sense of air
unger in patients with dyspnea. The use of opiates for palliative therapy in
advanced pulmonary
disease is supported by clinical guidelines from the American Thoracic Society.

Ref: Albert RH: End-of-life care: Managing common symptoms. Am Fam Physician
2017;95(6):35b-36J.
62. A 52-year-old female sees 7oU because of concerns ahout developin ancer.
She reports that
she quit smoking last month after learning that her Father has stage IV lung
cancer. She had smoked
a pack oF cigarettes per day since she was
18 years old. She has no history of cough, shortness of breath, or weight loss. She
is worried
about developing lung cancer and wants to know' how’ to “catch it eariy.”

Based on the recommendations of the U.S. Preventive Services Task Force, in

addition to providing
ongoing smelting cessation support, which one of the following should you
recommend?

A. A chest radiograph today

B. Low-dose chest CT today
C. Low-dose chest CT at age 55
D. No imaging, since she has already quit smoking
E. No imaging, since she is female

ANSWER: C

The 2013 U.S. Preventive Services Task Force lung cancer screening guidelines
recommend annual
low-dose CT screening for all adults between the ages of 55 and 80 who have a 30-
pack-year smoking
history and either currently smoke or have smoked within the past 15 yeurs (B
recommendation).

b2. A 25-year-old female vas invols-ed in a motor vehicle accident 2 weeks ago. A
cliext
radiograph to assess for rih fractures revealed l›i1ateral hilar
ljniphadenopniliy. She
thinks that her mother had a similar finding when she svas younger. Records from
the emergency
department reveal that a CBC, compreheosis e metabolic panel, and urinalysis
were all normal.

The patient has never been scxuall)' uctive, docs not take any medications, rind
does not smoke or
use any illicit drugs. Her rih pain has since resolved and she has no other
symptoms. She docs not
hove a cough, dyspnea, ss eight loss, or skin lesions. Spirometry in the office
today is normal.
lVJiicli one of the following would lie flue most appropriate next step?

A. A follow’-up visit and a repeat chest radingrapli in 6 month

B. Oral prednisone, 40 nig daily for 4 weeks
C. CT of the chest, abdomen, and pelvis
D. Formal pulmonary function lests
E. Referral for bronclioscopy w5th a biopsy

ANS\VER:‘ A:

Given this patient's age, lack of symptoms, end possible family history, the
presence of
asymptoiniitie bilateral hilnr lymphadenoputhy most likely represents stnge 1
pulmonary
sarcnidosis. Because the patient does not have any s3wptnms and stage 1 sarcoidosks
resnls es in
most cases, the most prudent cnurse is tn reevaluate tier in b months with a
careful history, a
physical examination, and a chesl radiograph. Given the normal s ironietry results,
pulmonary
function tests nrc not needed nt flits time. Neither CT nor n

!sarcoidosis but would be merited if she developed increasing pulmonary symptoms or

any
extra-pulmonary symptoms.

82. A 25-year-old female was involved in a motor vehicle accident 2 weeks ngo. A
chest radiograph
to assess for rib fractures re -cated hilsteral hilar lJ'mpliadcnopntIiy.
She thinks that
her mother had n similar finding »’licn she ivns younger. Records from the
emergency
deparlaient reveal that n CBC, comprehensive metabolic panel, and urinalysis
were all normal.

The pnlient h*s never been sexually nctlve, docs mil lnkc nny mcdicullons, rind
does not smoke or
use any illicit drugs. Her rib pain has since resolved rind she has no other
symptom. She does not
have a cough, dyspnea, weight loss, or skin lmions. S9lronieiry in the office todny
is normnl.

Which one of the follovt'ing would be the most appropriate next step?

A. A follow'-up visit and n repeat chest radiograph in 6 months

B. Oral prednisnne, 40 Brig daily for 4 weeks
C. CT of the chest, abdomen, and pelvis
D. Formal pulmonary function tests
E. Referral for bronchoscopy with a biopsy

ANSWER: A

Gi 'eo this patient's age, lacb of syzaptoras, aod possible faozily bistory, tke
presence of
asymptomatic bilateral hilar lymphadenopathy most likely represents stage I
pulmonary sorcoidosis.
Because the polient does not hnve rim)' symptoms and sloge 1 sarcoidosis resolves
in most eases,
Uie most prudent course is to reevaluate her in 6 months witb s coreftil history, n
physical
examination, and a chest radiograph. Given the normal s irometry rmults, pulmonary
function tests
are not needed at this time. Neither CT nor a lung iopsy would chitllge
fHilflagement at this
time. Treatment is not indicated in stage 1 sarcoidosis hut o ould be merited if
she developed
increasing pulmonary symptoms or any extro•pulaionary symptoms.

weight iirld vital signs, clear, a mildly erythematuus orophoryna,

rind pnlc, edematous nasnl mucosa. There is no lymphndcnopathy.

Which one of the follo»1ng is the most likely cause of this patient's chronic

A. Bronchogenic carcinoma
B. Chronic aspiration
C. Obstructive sleep apnea
D. Tuberculosis
E. Upper airway cough syndrome

The most common causes of chronic cough in ndults include upper nirway cough
syndrome, tobi2eCo
USe, GERD, asthma, and TCE lnhibitDF U8R. Th° P 7sical examination of this pnticnt
is most
consistent with upper nirway cough
syndrome, previously referred to as postnosal drip syndrome. Giren the patient's
lRck of tobacco
use and normal blood pressure, bronchngenic carcinoma and obstructire sleep apnea
are less likely.
There are no risk factors in this patient's history to suggest chronic aspiration
or tuberculosis.

A I ear-old female presents to your office to discuss the results of a recen

appropriate communication strategies include

A. Limiting the number of family members that are present

while delivering the bad news
B. Making your test educated guess for how much time the
patient has left to live
C. Using layman's terms to describe detailed trestment options and the prognosis
D. Allowing adequ:ite time to deliver the diagnosis in a private setting with
limited
interruptions

ANSWER:D
Physicians should respect the patient's individual preferences for receiving bad
news and allow
adequate time to deliver the diagnosis in a private setting with limited
interruptions. After
delivering the news it is best to avoid extensive treatment details and making
estimates of the
patient's survii•al, and to focus instend on patient-directed questions and
providing empathy.
Patients should be allowed to have as few or as many family meml›ers and friends
present as they
desire at the time of commimication, and this often varies depending on the
patient’s cultural
background.

95. A 58-year-old male sees you for a routine health maintenance visit. He has a
20- pack-year
smoking history and proudly tells you that he quit "for good" 1 year ago. You
congratulate him on
this accomplishment and encourage him to continue to abstain from tobacco. He has
not seen a
physician for 20 years.
U.S. Preventive Services Task Force recommendations for this patient include which
one of the
following?
A) Abdominal aortic aneurysm screening
B) Fall prevention screening

C) itis C screening
D) Lung ancer screening with low-dose CT

ANSWER: C
The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for
hepatitis C
virus infection for adults born between 1945 and 1965. Abdominal aortic aneurysm
screening with
ultrasonography is recommended for men 65—75 years of age who have any history of
smoking. The
USPSTF recommends annual screening for lung cancer with low-dose CT in adults 5W80
years of age who
have a 30-pack-year smoking history and currently smoke or have quit within the
past 15 years. Fall
risk screening is recommended in community-dwelling adults 65 years of age or
older.

u. u. r'reventivu aerviuuu i uue ruiuu Ieuui;mmi iudHui iS iui i us to tit-u i

ii iuiuuo wi ii i
i
one of the following?
A) Abdominal aortic aneurysm screening
B) Fall prevention screening

) itis C screening
) g with low dose CT

ANSWER: C
The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for
hepatitis C
virus infection for adults born between 1945 and 1965. Abdominal aortic aneurysm
screening with
ultrasonography is recommended for men 6W75 years of age who have any history of
smoking. The
USPSTF recommends annual screening for lung cancer with low-dose CT in adults 5W80
years of age who
have a 30-pack-year smoking history and currently smoke or have quit within the
past 15 years. Call
risk screening is recommended in community-dwelling adults 65 years of age or
older.

i zo. a as-year-oio temaie presents wan oyspnea wnn exenion. one nas never smoKeo.
A physical examination is normal, including vital signs and pulse oximetry. A chest
radiograph
reveals mild hyperexpansion of the chest, and pulmonary function testing reveals an
FEV1/FVC ratio
of 0.67, unchanged after bronchodilator use. An EKG and stress echocardiogram are
normal. You
suspect C 0 PD.
Which one of the following is the most likely underlying cause of this patient's
pulmonary
disease?
A) Allergic bronchopulmonary aspergillosis
B) -Antitrypsin deficiency
C) Hemochromatosis
D) Primary pulmonary hypertension
E) Hypertrophic obstructive cardiomyopathy
ANSW ER: B

This patient is a nonsmoker but has typical symptoms and findings of COPD. alfal-
Antitrypsin
deficiency should be considered in patients with very premature COPD or in patients
without risk
factors for COPD such as smoking, hand smoke exposure, or other smoke exposure.
Dyspnea would
be present and lung unction would be normal in patients with primary pulmonary
hypertension or
hypert obstructive cardiomyopathy. Hemochromatosis may cause liver function
abnormalities but
not abnormal lung function. Allergic bronchopulmonary aspergiilosis is associated
with asthma, not
COPD

156. Which one of the following is the leading cause of cancer death in men in the
United States?
A) Colorectal cancer
B) ancer
C) Lung ancer
D) melanoma skin cancer
E) Prostate cancer
ANSWER: C

According to the CDC, the leading causes of cancer death in men from 20J1—2015 were
lung cancer
(53.8 deaths per 100,000 per year), prostate cancer (19.5 deaths per
1 00,000 per year), colorectal cancer (17.3 deaths per 1 00,000 per year), and
pancreatic
cancer (J 2.6 deaths per 1 00,000 per year).

Ref: US Cancer Statistics Working Group: US cancer statistics data visualization

tool, based on
November 20J7 submission data (J 999—20J 5). Centers for Disease Control and
Prevention and
National Cancer Institute, 20J 8.

164. In a 60-year-old patient who has not previously received prieumococcal

vaccine, which one of
the following would be an indication for both 13-vaIent pneumococcal conjugate
vaccine (PCV13,
Prevnar 13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax
23)?
A) Alcoholism
B) Chronic re.naI failure
C) Cigarette smoking
D) COPD
E) Diabetes mellitus

ANSWER: B

Both 13-valent pneumococcal conjugate vaccine (PCVJ3) and 23-valent pneumococcal

polysaccharide
vaccine (PPSV23) are recommended for patients with chronic renal failure. Indicati
r PPSV23
alone in immunocompetent persons younger than 65 include chroni lung isease,
diabetes mellitus,
chronic heart disease, smoking, and alcoholism.
Re1: Kobayashi M, BennetS NM, Gierke R, et al: Intervals between PCV13 and PPSV23
vaccines:
Recommendations of the Advisory Committee on ImraJnization Practices (ACIP). MMW R
Morb Mortal Wkly
Rep 2015;64(34):944-947.

165. A 36-year-old male presents with a 2-day history of painless right-sided

facial

216. A 45-year-old male with a 30-pack-year smoking history reports a chronic cough
with a small
amount of phlegm production and dyspnea with strenuous exercise. You order
spirometry, which shows
a pre- and postbronchodilator FEV1/FVC ratio of 0.6 and an FEV of 85b of predicted.

Which one of the following agents would be the best initial pharmacologic
management?
A) An inhaled corticosteroid
B) A short-acting anticholinergic
C) A long-acting anticholinergic
D) A long-acting 2-agonist
E) Theophylline

ANSW ER: B

This patient has COPD and is in a risk catego (low risk, fewer symptoms) based
on the Global
Initiative for Chronic Obstructiv Lung Disease (GAOL D) combined assessment of C
OPD. As a result,
either a sh ng anticholinergic or a short-acting

2-agonist should be selected as the initial pharmacologic management. Long-acting

2- agonists or
long-acting anticholinergics are indicated for patients with a GOLD combined
assessment category of
B or worse. Long-acting inhaled corticosteroids are indicated for patients with a
GOLD combined
assessment category of C or worse. Due to its narrow therapeutic window, modest
benefit, and need
for monitoring, theophylline is not recommended as an initial agent and should be
considered as an
alternative only for patients with severe refractory symptoms.

17. A 67-year-old female sees you because nf a cough she has had for the past few'
days and a
fever thnt starred tc›day. She is shnrt of breath and generally does not feel well.
She has no
history of lung disease
and is n nonsmoker. Iter medical hist in i or‹ t r• hypertension
hyperlipidemia, and type 2
diabetes mellitus, all of which are well managed with medications and diet.
A physiml examination reveal ‘11-appearing female with a temperature of 38.2°C
(100.R°F), It
pulse rntc nf 90 beaiNmin, respirntory te of 2 I/rnin, a blood pressure of I
10/60 mm Hg, and an
oxygen saturation of 9896 on room air. Her heart has a regular rhythm and her
respiratinns appear
nlabored. She has rhonchi in the left Iow'er lung field but has good air movement
overall. A chest
mdiogrnph reveals a left lower lobs infiltmte.

Which one or the foI\o»1ng is the most appropriate setting for ihe management nd !
his patient's
pneuznoaid?

A) tlome with close monitoring

B) An inpatient medical bed without telcmeoy monitoring
C) An inyaticnt medical bed with telemetry raonitoring D} An inpalicni intensive
cafe bed

t2

Hem 17
ANSIYER: A
For cammunity•acquircd pneumonia, an important decision point is the severity of
illness that
inrficates the need for inpatient care. There am muliip!c tools for evaluation of
pneumonia
severity. including SMART-COP (predicts the likelihood of the need for invasive
ventilation or
vzsopressor suppori), the Pneumonia Severity Index (predicts the risk of 30-day
mortality and the
need for admission to the intensive-care unit), and CURB-65 or CRB-65. In an
outpatient setting.
CURB-65 and CRB-65 are easy In use, although they have weaker predictive vatues for
30-day
mortality, ln additinn, clinical judgment finuld iways be used. In this scennrin,
the patient does
not clinically appear markedly ill, and her vital siyn.s anJ physical examination
dn nnt fit any
criieric fnr increased risk in any of ihc scoring systems. her only’ risk facrcr is
age 6S years,
and lhose »ith zero or owe criteria for CURD-65 or CRB-6S can he managed as
outpatients.

2l,
A SP-year-old femalg crime.s io your office for evaluation nf fatigue and
shortnes.s nf bream She
As a history of type 2 diabetes mellitus, hyprrierLsinrt. hyperlipiilrmia. ar I
nh*•xiiy. Her
diabries lus been well controlled, and a our bcmoglobin A lc nos 6.7%.
She reports Hi etc has been mv tired than usual for the past scszral montks and
that walking morr
rhao a blwk or going up a Flight of slairs has now t›ccomc difficult. She has no
chest [ain,
y04yi\a\iorrs, dizziness. nr cnugh. She kas had mi)d, suh)e lnwcr extremity eJeina
fnr yean, and
lhis is unchanged. She like fIoza• orxt i* not sure if she snores. She hrs kad
difficulties with
sleep for y'cazs anJ dv ‹x UM refreshed upun ass'aLening. She d‹w. n‹›t use
«›hccco ur drink
alcohol.

pressure of 128.^78 mm Hg, a pulse rate of° 76 beals/min, piz

ralr of l4/mirt, a temperature of 37. l°C ‹98 am. an •xygen saturation of 95?6 rim
rmm air, at
oF 38.2 Lg/rn2 Auscultation of tfw hewn ccswls a regular mte and rhythm wiLh no
murmw, I(w lungs
are clear to auscultptinn hiintctplly. the is I + pitying edema of hn\h Io'a°cr
cxtzcmi\ies.

A chest mdiogmph is normal and an EKG reveals normal sinus rhythm. Echmordiography
xhows a left
ventricular ejection fraction cif £ % without impaired dinstoiic function.
Wffich onc n£ tic lollouing evaluations is mt [ikely to mmol the cause oF her
fatigTic?

A) 2-I-kour ambulatory blocxâ pressure monitoring

By Spimmetiy
Cj A sleep study
D) CT angingraphy of the chat
E) Lnft heart caiheterizntion

Item 21
ANUVER: C

This patient inns pulmonary hypertension thot, feed on her history, is most likely
related in
obstructi e sleep aprrco {OSA). Most patients «ath pulmonary hypcrtenxinn have an
underlying
disease uf the heart or lungs ilut leads to elevated pulmonary artery pressures.
Common underlying
conditions include

lung dina'< such as COPO. OSS rind lcfi heat failure (»-iih a reduced or prcscr cd
ejection
faction}. Addilionzl cnixsiderations include chronic thmm oemfxilic disease and
primary pulmonary
arterial hypertension.
This patient’s obesity and iinirfrcshing sleep make OSA the likely imderlying cnuse
nf her
pulmoruiry hypertension. the does not hn+'e clinical features nf thmmMmbulic
disease nr a histnry
of COPD. Her ecWardiogmm As not Sluiw heart failure, all she h,zx no symptoms io
suggw obstructive
cnmnary disease. Ambulniory blood pressure monitnring can aid in the diagnosis and
npnmal treatmeni
of
but this z ouid be unlikely to relate directly to her

75. A 30-year-old male presents to your office with a 10-day history of rhinorrhea,
nasai
congestion, cough, and headache. He initially had a low-grade fever that resolved,
bui over the
past 2 days all of his symptoms have gonen worse. His past medical history is
unremnrknble and he
does not smoke.
On examination there is a puiulent secretion noted from the rip•ht nasa) cavity and
tenderness over
the right maxillary sinus region.

The most ayyroyriatc tF02tment is

A) amoxicillin/clavulanate (Augmentin)
B) azithromycin (Zithroiriax)
C) cefuroxime (Ceftin)
D) levofloxacin (Levaquin)
E) trimethoprim/sulfamethoxazole (Bactrim)

Item 75
ANSWER: A

\n the first 3 to 4 dnys of illness, viral rhinosinusitis cannot be distinguished

from early acule
bacterial rhinosinusitis. If the patient seems to be improving and then symptoms
start to worsen on
days 5-10 of the illness (double sicLening), acuie bacterial rhinosinusiti.s should
be suspected.
The color of the nasal discharge should not be used as the sole indication for
antibiotic thempy.
One study showed that unilateral predominance with nurulent rhinorrhea had ovemll
reliability of
8586 for diagnosing
.sinusi\is. After 10 days of uyyet respimtory •ymytoms, thc prohcbiiiry of acute
bacterial
rhinosinusitis is 60%. Antibiotic therapy should De considered if the patient does
not improve
after 7-10 days from the onset of symptoms or if the symptoms worsen at my time.
According to mosl
guidelines, lhe first-line antibiotic for treatment of adults with sinusiiis is
arnoxicillin/clavulanate. Respiratory fluoroquinolones are not recommended as
first-line
medications, as they offer no additional benefits and have significant side
effects. Second- and
third-genemiion cephalosporins, trimethoprim/sulfamethoxazole, and macrolide
antibiotics are no
longer recommended for initial therapy. This is due to high rates of resistance in
Streptococcus
pncumoniae and Haemophilus infiuenzne.

75. A 30-year-old male presents to your office with a 10-day history of rhinorrhea,
nasal
congestion, cough, and headache. He initially had a low-grade fever that resolved,
but over the
past 2 days all of his symptoms have goxen worse. His past medical history is
unremarkable and he
does not smoke.
On examination there is a purulent secretion noted from the right nasal cavity nnd
tenderness over
the
right mnxillary minus region.

The most appropriate treatment is

A) nmoxicillin/clovulanate (Augmentin)
B)aziTxmycin(Dfxomx)
C) cefuroxime (Ceftin)
D) levofloxacin (Levaquin)
E) trimethoprim/sulfarncthoxozolc (Bactrim)

Item 75
ANSWER: A

In the first 3 to 4 days of illness, viral rhinosinusitis cannot be distinguished

from early ncule
bncleriol rhinosinusitis. If the patient seems to be improving and then symptoms
start to worsen on
days 5—10 of the illness (double sickening), acute bacterial rhinosinusitis should
be suspected.
The color of the nasal discharge should not be used us the sole indication for
antibiotic thernpy.
One study showed thnt unilateral predominance with purulent rhinorrhea had an
overall reliability
of 85% for diagnosing sinusitis. After 10 days of uppe respiratory symptoms, the
probability of
acute bacterial rhinosinusitis is 60a. Antibiotic therapy should be considered if
the patient does
not improve after 7—10 days from the onset of symptoms or if the s ptoms worsen at
any time.
According to most guidelines, the first-line antibiotic for treatment of adults
with sinusitis is
amoxicillin/clavulannte. Respiratory fluoroquinolones are not recommended as first-
line
medications, as they offer no additional benefils and have significant side
effects. Second- and
third-genenition cephalosporins, trimethoprim/sulfamethoxazole, and macrolide
antibiotics are no
longer recommended for initial therapy. This is due to high rates of resistance in
Streptococcus
pneumoniae and Haemophilus infiuenzne.

..... ..... .. . ........... .. I03 hcats/m n

Respiratory rate 20.'min
I emp<ra\urc J7.B°C' ( 100.0°F)
^y8 WittMTiOD. 89% on room air
A rhest radiograph shov•-s corusoTida\irin in Ihe right lou<r l‹›he.

pain gg pg v,Wch one of the following is important to include in the patient’s

trnuneni

A)AudMmmyin( ihmmv) B)Dz@omycnlCuWmn

D) Gentmicin
F) Vancomycin tVnricr›cin)

Thix pafienl has acute chest syndmrne (ACS). a Yous cnrnplicatinn of sickle
cell lines
fSCD›. lv cause may be muhif•c‹orial, but infw1i‹›n• arc mr«mon and wrirnimhi«ls
crc irK]ic;ucd.
Houxver, the clinical murxe of ACS is si'fiefiEcanGy different hmm infections
pneumonia in pat•cnis
uñthout SCD, due to the damaged microvwsculnrure tbal occurx in ACS. Studies have
sho»m ion
atypical pathogens predominate in ACT and ii is lhcrefoze important to ae•‹ all
patients s-iih ACS
v. ifl1 sntihio\irs rhat cower 5lycopl:»ma and Chlamydophilx Virnl infection»
nre aLso con\rnnn.
erpecicJly in chi]dlwi ulth ACS. Orher poxrible {xtlhngcns inciu+Ie
Sfaphylocxxx-us
aurru*. SU-eplocuccws pncum‹iniar. sruJ Hnemophilus influenzae Therefore, lhc use
of a
third-genemtion cephalosporin alung with milhmmycin ix the recommended antibiotic
ca+-crnge.

In addition to aiuimicrobiais, tmztrnent includes supporti*'e care wnth

supplemental oxygen,
ininixenous fiuidx, pain control, and incen0ve spin›metry. Lkpendlng on the degree
of anemia seem a
simple blood tmasfu.sion or e.schany transfusion is often irnlicatetl as w ell.
Consullal i‹›8 w
iih z hemntologist is recnmwrided in the c:me of patients with ACS. Es-en with
appropriate care,
m‹irta1ity mtce in AC.8 are

J02. A I 2-year-old male has a I -week history of fever. headache. sore throat, and
a mildly
productive cough. He also began having ear pain yesterday. On examination he does
not appear in he
tox ic. He has a tcmpcratum of 37.8°C (100.0°F). Examination of his c.we shows a
bulla on the
rij;ht tympanic mcmbmnc, as well as mild to moderate crythcma of the posterior
pharynx.
The neck is supple. The lungs have a few scattered crackles. The remainder of the
examination is
unremarkable. A chest radiogmph reveals thickened bronchial shadows, as well as
interstitial
infiltmtes in the lower lobes.
The most appropriate treatment at this time w'ould be

A) amoxicillin
B) az.ilhromycin (Zilhromax)
C) ceflriaxone (Rocephin)
D) cefuroxime (ZinaccfJ
E) v2ncomycin

ltem 102 ANS\VER: B

Community-acquired pneumonia in children is created based on age. The most likely

etioJngic agents
in a schnol-cge child are Mycoplasma yneumoniae, Chlamydia pneumonize, and
Streptococcus
pncumoniac. Group A Streptococcus and Hacmopliilus inFlucnzac arc less
common causes.
Staphylococcus aureus that is methicillin-resistant has hccnme increasingly common.
The prefered
treatment for community-acquired pneumonia is a macrolide antibiotic such as
azithzomycin.
63

In chil — 6. Mycoplasma pneumonia tends to have a gradual onset of symptoms and

seldom causes
respimiory distress. Signs and symptoms may vary. The patient may develnp a msh,
mu.zulu.s c c a
symptoms, or ga.stroinicstinal symptoms. Radiogniphs may reveal bronchopncumonia.
modular
infiltmtcs, hilar iidcnop:ithy, pleuml cffusions, or plate-litre atclcctnsis. Ear
pain may he due
to bullous myringitis, although this may be viral as well. Lnborntory findings may
not be helpful,
as the WBC count may be normal or slightly elevated. There may be thrombocyiosis.
an elevated
erythrocyte sedimentation rate, an elevation of cold a•_glutinins, or an elevated
reticulocye
count. A Coombs test is seldom needed, although it might be helpful i3t times. The
diap=nosis is
genemlly made on a clinical basis.

189. Opioid therapies provide the greatest analgesic relief for most patients with
a terminal
illness. However, concerns about which one of the following can inappropriately
limit the use of
opioids in these patients?

A) Angina
B) Dementia
C) Gastritis
D) Renal failure
E) Respiratory depression

Item 188 ANSWFR: E

Concerns about addiction and respiratory depression often limit the use of opioids
or lead to
inadequate dosages in patients with a terminal illness who ve experiencing pain at
the end of life
(SOR C).
nging from fuP consciousness to complete loss of consciousness) usually
precedes
respiratory epression. Opioid use and dosages can therefore be effectively
managed wit close
mom oring for sedation, allowing patients to receive adequate medication to
control pain.
Close monitoring allows clinicians to identify advancing sedation before it is
compounded by
continued opioid administration that could lead to clinically significant
respiratory depression
(SOR C).

189. You see a 37-year-old asymptomatic male for the fést time for a health
maintenance visit. He
underwent a splenectomy 6 years ago following a motor vehicle accident.
Which one of the following would be appropriate in the eve of this paiient?

215. A 22-year-old female who was diagnosed with bronchitis at an urgent care
clinic 3 days ago
sees you because her cough is still present. She is very annoyed by the cough and
is concerned
because she read online that she could have pneumonia. She asks if she should have
a chest
radiograph.

Which one of the following would be an indication for a chest radiograph in tNs
patient?

more than 14 days

b. A. respiratory {ate >24/min
c. A temperature >37.5°C (99.5°F)
d. Wheezing on the lung examination
e. Cigcette smoking

Item 215
ANSWER: B

Adult patients with acute bronchitis rarely requée a chest radiograph to rule out
pne'amonia.
Indications for a chest radiograph include dyspnea, tachypnea, tachycardia,
temperat‹are >100.0OF,
bloody sputum, or signs of focal consolidation on lung auscultation. In patients
with bronchitis
the cough lasts an average of 18 days, so a chest radiograph would not be indicated
after only 14
days. Smoking does not influence ie need for a chest radiograph, and wheezing is
common in
uncomplicated acute bronchitis.

219. You see a 4-month-old male in your office with a 2-day history of cough,
runny nose, fever,
poor feeding, and difficulty breathing. He was born at 38 weeks gestation via a
normal spontaneous
vaginal delivery after an uncomplicated pregnancy. He did well after birth and went
home with his
mother after a 48-hour hospital stay. He is breastfed and had been doing well until
now. He has
breastfed much less than usual today and has had no wet diapers in the last 8
hours.
On examination you note a temperature of 38.9°C (102.0°F), a pulse rate of 176
beats/min, rate of
66/min, and an oxygen saturation of 92% on room air. The patient generally appears
respiratory
iacnypneic
and clingy, is fussy during the examination, and has notable subcostal retractions
and nasal
flaring. A nasai examination reveals crusted mucus at the nares bilateraily.
Examination of the
mouth reveals no oral lesions. A cardiovascular examination reveals tachycardia
with a regular
rhythm and no murmur. Auscultation of the lungs revenls diffuse crackle.s and
wheezes without focal
findings. His extrcmities are warm, with a capillary refill time of <3 sec.

In addition to oral or intravenous rehydration, which one of the following

treatment plans is most
appropriate for this patient at this time?

a. Send the child home and follow up tomorrow

b. Admit to the hospital for supportive care only
c. Admit to the hospital for inhaled bronchodilators
d. Admit to the hospital for inhaled bronchodilators and oral dexamethasone
e. Admit to the hospital for inhaled bronchodilators, oral dexamethasone, and
intravenous
antibiotics

Item 219 ANSWER: B

This patient has classic signs and symptoms of Vlfal bronchiolitis, likely due to
respiratory
syncytial virus (RSV). A chest radiograph is not indicated in a patient with a
classic presentation
and no focal findings on examination. Most concerning is his history of low urine
output,
suggesting inadequate oral intake. This is often related to a high respiratory rate
and copious
nasal secretions. The patient requires hospitalization for monitoring of his
respiratory status and
supportive care, including intravenous or nasogastric rehydration. At this time the
infant does not
require supplemental oxygen, as his oxygen saturation is above 90%. Many
medications have been
studied for the treatment of bronchiolitis in children and most have been fotind to
not provide
benefit with regard to the need for hospitalization, length of hospitalization, or
disease
resolution. Medications that are NOT recommended include inhaled bronchodilators,
inhaled
epincphrine, inhaled or systemic corticosteroids, and antibiotics.

229. A 56-yev-old male presents with a 2-day history of a fever and productive
cough. He has mild
dyspnea with exertion and has pain in h’ ’• Lsi hen he takes a deep breath. On
examination his
temperature is 38.4°C (101.1°F), hi respiratory te is 24/min, his pulse rate is 92
beats/min, and his oxygen saturation is o on room air. He has cracHes in the right
lower lung
posteriorly. The remainder of the examination is normal.

The most likely diagnosis is

A) upper respiratory infection
B) community-acquired pneumonia
C) heart failure
D) pulmonary embolus
E) acute leukemia

Item 229
ANSWER: B

This patient has pneumonia based on the clinical presentation and the physical
findings of fever,
cough, and abnormal lung findings. A fever would not be a typical finding in
pulmonary embolus or
heart failure. An upper respiratory infection is unlikelygiven the abnormal lung
findings that
suggest a lower respiratory tract infection. This would not be a typical
presentation for acute
leukemia.

230. A 17-year-old seasonal farm worker presents with a 7-day history of left-sided
facial weakness
that

238. A 2-year-old female is brought to your office with a 3-day history of

rhinorrhea, fever,
cough, and

increasing dyspnea. Her p«›

immunizations. She has a respiratory
history is unremarkable and she is up to date on her of 40/min, a pulse rate of 120
beats/min, a
temperature of
37.8°C (100.0°P), and an oxygen saturation of 93a on room air. She is alert and
irritable, and has
clear rhinorrhea and expiratory wheezing, but good airflow overall. The remainder
of the
examination is normal.

Which one of the following would be most appropriate at this time?

A) Supportive treatment only
B) Nebulized racemic epinephrine (Asthmanefrin)
C) Nebulized albuterol
D) A single dose of dexamethasone
E) A 5-day course of methylprednisolone (Medrol)

134
Item 238 ANSWER: A

No pharmacologic treatment shortens the course of viral bronchiolitis in

a young child.
SupplementaJoxygen is indicated if the oxygen saturation falls below 90%, but
otherwise the most
effective treatment is simply supportive care (fluids, antipyretics, nasal bulb
suction, etc.).
None of the pharmacologic options listed arc recommended in the treatment of
broncliiolitis in this
scenario.

13. A 65-year-old male with a 40-pack-year history of smoking presents with

shortness of breath on
exertion.
Spirometry reveals the following:
FEV /FVC I , /! I, I l I l 65% of predicted
DC , !! !! ! ! !! ! .! s !! ' ! ! n rBd

Which one of the following is suggested by these results?

A) Normal spirometry
B) Reversible obstructiv lung disease
C) Irreversible obstructive ung disease
D) Restrictive lung disease
E) Mixed obstructive and restrictive lung disease
9

Item 13 ANSWER: C
These spirometry results indicate an irreversible obstructive pattern. Patients
with a restrictive
component to their lung disease have a decreased FVC. Reversible obstruction
improves with
bronchodilator therapy.

48. A 64-year-old male presents with increasing dyspnea on exertion. He feels well
otherwise and
has no chronic medical problems. A physical examination is normal. Pulmonary
function testing r
normal spirDmetry, with no evidence of an obstructive or restrictive pattern.
However, his lung
carbon monoxide diffusing capacity (DLCO) is low. Based on these results, which one
of the fo owing
is the most likely diagnosis?
32

A) Asthma
B) Bronchiectasis
C) Chronic pulmonary emboli
D) COPD
E) Pulmonary fibrosis

Item 48
ANSWER: C

Low diffusing capacity of the lungs for carbon monoxide (DLCO) with normal
spirometry indicates a
disease process that disrupts gas transfer in the lungs without causing lung
restriction or airflow
obstruction. CDmmon causes include chronic pulmonary emboli, heart failure,
connective tissue
disease with pulmonary invDlvement, and primary pulmonary hypertension. Asthma,
bronchiectasis,
COPD, and pulmonary fibrosis are associated with abnormalities on spirometry.

60. A 24-yearmld asymptomatic female has a chest radiograph that incidentally shows
bilateral hilar
adenopathy. Additional evnluation supports a diagnosis of sarcoidosis.
Which one of the following n'ould be most appropriate at this point?
A)Montoñngony
B) Treatment with corlicoseroids
C) Treatment with xate
D) A transbronchi hing iopsy

Item 60
ANSWER: A

According to an international consensu.s statement. there are thme criteria for

diagnosing
sarcoidosis: (1)
a compatible clutch nnd radiologic presentation, (2) pathologic evidence of
noncaseating
anJ (3) exclusion or other diseases with similar findings. The main exceptions to
the neeJ for
histologic confirmation are the presence of bilateral hilar adenopnthy in an
asymptomatic patient
(stage I) and thc presentation of sarcoid-specific Lofgren syndrom with fever,
erythema nodosum,
and bilateral hilar adenopathy that can be diagnosed based on clinical presentation
alone. An
asymptomatic patient with

stage I sarcoidosis (bilaieml hilar lymphadenopathy on chest radiography) without

suspected
infection or fTlaltgnzncy does not require an invasive tissue biopsy because the
resulLs would not
affect the recommcncled management, which is monitoring only. Treatment is nnl
intlicatcd because
syontaneeus resolution of stage I sarcoidosis is common.
Reliable biomarkers for diagnosing sarcoidosis do not exist. Although the serum
angiotensin
converting enzyme level may be elevated in up to 75a of unseated patients, this
lacks sufficient
specificity, has large interindividual variability, and fails to consistently
correlate with
disease severity, all of which limit its clinical utility.
Pathologic of noncaseating gmnulonias from the most accessible and safest
biopsy site should be
pursued only if there is an indication for treatment, such as significant
symptomatic or
progressive stage d or Ill pulmonary disease or serious extmpulmonary disease. If
treatment is
indicated, corticosteroids nrc the first-line treatment for sarcoidosis. Second-
and third-line
treatments include methotrexnle, azathioprine, leflunomide, and biologic agents.

70. A 77-year-old female with widely metastati lung ancer is seen in her home with
increase
confusion, hallucinations, and combative behavio or the past 2 days. She has not
slept and has a
very poor appetite.
Which one of the following should be the first step in the management of this
patient?

A) Place her in gentle restraints for safety

B) Determine and treat the underlying cause of the behavior change
C) Start diphenhydramine (Benadryl) at bedtime for sleep
D) Start mirtazapine (Remeron) at bedtime for sleep and appetite
E) Start lorazepam (Ativan) as needed for agitation
Item 70
ANSWER: B

This patient has hyperactive delirium. The first step in mana₌einent is to

determine and treat the
underlying cause if possible. There are multiple causes of delirium such as
medications,
infections, metabolic abnormalities, and underlying diseases. The first step in
treatment is
behavioral management with strategies to orient the patient. Haloperidol or
antipsychotics may be
used if the patient is at risk of harm. Lorazepam and anticholinergics should both
be avoided, as
they can worsen delirium. Restraints can also worsen the agitation and should not
be used.
Mioazapine is an antidepressant and is not used in the treatment of delirium.

71. You are called to a rapid response on the inpatient medical ward at your local
hospital. A

90. A 6c•-year-old male hospitalized for treatment of metastatic lung cancer

develops a proximal
deep vein thrombosis of the leg. Which one of the following anticoagu an s should
be prescribed
when he is discharged from the hospital?

A) Apixaban (Eliquis)
B) Dabigatran (Pradaxa)
C) Enoxaparin (Lovenox)
D) Rivaroxaban (Xarelto)
E) Warfarin (Coumadin)

Item 90
ANSWER: C

In a patient with cancer, deep vein thrombosis of the leg or a pulmonary embolus is
considered to
be cancer-associated thrombosis. Low molecular weight heparin (LMWH), such as
enoxaparin, should be
chosen over the other anticoagulant options listed. (LMWH over warfarin
is a Grade 2B
recommendation; LMWH over dabigatran is a Grade 2C recommendation; LMWH over
rivaroxaban is a Grade
2C recommendation; and LMWH over apixaban or edoxaban is a Grade 2C
recommendation).

96. A 5B-year-old male comes to your office for a routine health maintenance
examination. He has
smoked 1 pack of cigarettes per day for the last 35 yenrs.

Thc U.S. Prcvcntivc Service.s Task Force recommends which one of thc followin lung
ancer
screening strategies for this patient?

59

A) A chest radiograph annually

B) Low-dose CT annually
C) Sputum cytology every 3 years
D) BronchO5copy every 5 years

Item 96
ANSWER: B

Lung cancer is the leading cause of cancer-related deaths in the United States and
the third most
common cause of death ovemll. Smoking causes approximately 85% of aIl U.S. lung
cancer deaths.
Thirty-seven percent of U.S. adults are current or former smokers. While nearly 90%
of people
diagnosed with hung cancer will die from the disease, early-stage non—small cell
lung cancer has 8
betier prognosis and can be treated with surgical resection. The largest
randomized, controlled
trial of low-dose CT (LDCT) for lung cancer detection, the National Lung Screening
Trial. enrolled
50.000 people age 55—74 with at least a 30-pack-year smoking history and showed a
reduction in lung
cancer mortality of 16% and a reduction in all-cause mortality of 6.7%. Based on
this study and
several other nindomized, controlled trials, the U.S. Preventive Services Task
Force has concluded
that LDCT has 8 hlgh sen.sitivity and an acceptable specificity for the detection
of lung cancer in
high-risk persons. The other tc.smug modalities listed have not been validated zs
acceptable
scrccning strntcgies for lung cancer.

96. A 5B-year-old male comes to your office for a routine health maintenance
examination. He has
smoked 1 pack of cigarettes per day for the last 35 yenrs.
Thc U.S. Prcvcntivc Service.s Task Force recommends which one of thc followin lung
ancer
screening strategies for this patient?

59

A) A chest radiograph annually

B) Low-dose CT annually
C) Sputum cytology every 3 years
D) BronchO5copy every 5 years

Item 96
ANSWER: B

Lung cancer is the leading cause of cancer-related deaths in the United States and
the third most
common cause of death ovemll. Smoking causes approximately 85% of aIl U.S. lung
cancer deaths.
Thirty-seven percent of U.S. adults are current or former smokers. While nearly 90%
of people
diagnosed with hung cancer will die from the disease, early-stage non—small cell
lung cancer has 8
betier prognosis and can be treated with surgical resection. The largest
randomized, controlled
trial of low-dose CT (LDCT) for lung cancer detection, the National Lung Screening
Trial. enrolled
50.000 people age 55—74 with at least a 30-pack-year smoking history and showed a
reduction in lung
cancer mortality of 16% and a reduction in all-cause mortality of 6.7%. Based on
this study and
several other nindomized, controlled trials, the U.S. Preventive Services Task
Force has concluded
that LDCT has 8 hlgh sen.sitivity and an acceptable specificity for the detection
of lung cancer in
high-risk persons. The other tc.smug modalities listed have not been validated zs
acceptable
scrccning strntcgies for lung cancer.

134. A 62-yec-old male sees you the day after returning from a 4- day cruise. He
says he developed
a fever and a productive cough on the day before the ship returned to Los Angeles
following a trip
down the coast of Baja California. He tePs you Tat several other passengers
imilv symptoms. The
examinations is remarkable for tachypnea and you hey cracHes in both lung . This
patient's history
should raise concerns about infection with which one of the following pathogens.
A) Asian avian influenza A virus
B) Coxiella burnetii
C) Hantavirus
D) Histoplasma capsulatum
E) Legionella species

Item 134 ANSWER: E

Legionella should be considered as a pathogen for community- acquired pneumonia

when the patient
has a history of a hotel stay or cruise ship travel within the past couple of
weeks. Travel to or
residence in Southeast Asia or East Asia is a risk factor for avian influenza,
exposure to fain
animals or parturient cats is a risk factor for Coxiella burnetii infection,
exposure to bird or
bat droppings is a risk factor for Histoplasma capsulatum infection, and travel to
or residence in
desert Southwest states with deer mouse exposure is a risk factor for Hantavirus
infection.

153. A 54-year-old femaie with systemic sclerosis sees you for a follow-up visit.
She is afebrile,
with n blood pressure of l32/7d mm Hg. a heart rate or a2 b«Ls/min, and an oxygen
satumtion or
94a on room air. On examination you note thai the patient is thin and has fibrotic
skin changes
proximal io the elbows and knees, and facial tightening. She doRS nOt have
increasing shortness of
breath but does have ongoing chronic musculoskeletal pain. She is currently taking
cyclophosphamide
prescribed by eumatologist. Pulmonary function tests reveal an FVC
<50%, consistent with restrictiv Jung isease. CT of the chest shows ground-glass
opacities and
honeycombing of the lower o es of the lungs.

Which one of the foIlowing do these findings suggest?

A) Emphysema
B) Idiopathic pulmonary fibrosis
Cl Inicrstiiial lung disease
D) Pulmonary edema
E) Sarcoidosis

89
Item 153
ANSWER: C

Patients with systemic sclerosis (SS) in its final stages ofien develop a
restrictive lung disease
(SOR C). Interstitial lung disease and pulmonary artery hypertension are common.
While the
restrictive pattern is similar lo idiopathic pulmonary fibrosis, this condition is
characteristic
of SS and is not idiopathic.
Emphysema presents with an obstructive pattern on pulmonary function test.s.
Pulmonary edema con
develop from cardiac malfunction and has failure. but ii is not present in ihis
paiient.
Sarcoidosis is not related to SS. There is a 10-year mortality of 42a in patients
with SS who have
an FVC <50'n .
Cyclophosphamide may be helpful in some cases to improve lung function. decrease
dyspnea. and
improve the patient's quality of life (SOR B).

160. A 54-year-old male presents to your office with a 2-day history of mild right
interior chest
pain with deep breathing. He reports that it has been sharp and constant and is
preventing him from
sleeping. He also describes shortness of breath and a cough productive of whiie
sputum. He
reports that prior io this episode he had been in good health, and he has not
experienced the.se

.symptoms in the past.

On examination his blood pmssure is 140/88 mm Hg, his temperature is 37.1
eC (98.8°F). his
pulse rnie is 88 beats/min. and his oxygen sat is 95% on room air. Henrt
auscultation reveals a
regular rhythm wiih no murmur. Hi lung are clear. Examination of the lower
extremities reveals no
edema or tenderness. A e es radiograph is normal. An EKG reveals right bundle
branch block.

Which one of the following would you order next?

A) A D-timer level
B) Compression ultrasonography
C) Echocardiogmphy
D) A ventilation-perfusion scan of the lungs
E) CT angiogmphy of the lungs

Item 160 ANSiVER: A

Validated clinical prediction rules can be used to estimate the protest probability
of deep vein
thrombosis (DVT) and pulmonary embolism in a patient with dyspnea and chesi pain,
and to guide
further evaluation (SOR C). Factors used for calculating the protest probabiEty
include elevated
heart rate without hemopiysis. a diagnosis of cancer, recent
surgery/immobilization. previous
thromboembolism. and signs and symptoms of DVT. Based on these rules the patient
described in ihe
scenario has a low score and therefore a low probability of pulmonary embolism.
A D-dimer level is the next most appropriate test for this low-prnbability
scenario. Compression
ultmsonogmphy would be the next iesi for a patient wiih an intermediate or high
protest probability
for DVT. CT angiography would be the next test for a clinically stable paiient with
an intermediate
or high ptetest probability of pulmonary embolism. A ventilation-perfusion scan
would be the next
test if a CT nngiogram were indicated in a patient with a contrnindicotion such aS
KORirnsi
allergy, renal discuss, or pregnancy. Echocardiogmphy would be the next test for a
critically ill
patient with a high protest probability of pulmonary embolism.

93

179. A 63-year-old male presents to your office because his COPD is worsening. He
indicates that
his exercise tolerance is steadily decreasing but he can still walk approximately
100 yards on flat
ground. His medications include fDfTRDterol (Perforomist) twice daily and albuterol
(Proventil,
Ventolin) as needed, which he requires only occasionally. He had an exacerbation
requiring
prednisone 7 months ago. He quit smoking 6 years ago. His oxygen saturation is 93%
on room
air and 89% after walking briskly for 8 minutes. His FEV 1 is 1.91 L (62% of
predicted) and his
FEV I/FVC ratio is 0.57.

Which one of the following is most likely to improve his progressive dyspnea?
A) Stop formoterol and start fluticasone/salmeterol (Advair)
B) Stop formoterol and start tiotropium
C) Add tiotropium
D) Start oxygen at 2 Amin with exertion
E) Refer for pulmonary rehabilitation

Item 179 Anssrer :E

Pulmonary rehabilitation has multidimensional benefits in COPD management,

including improved
exercise tolerance, quality of life, and mood. Aerobic exercise improves muscle
mass, with high-
intensity exerc ying more efficacious than low-intensity exercise. Accordlng to
Global
Initiative for Obstructiv Lung isease (GOLD) guidelines, an inhaled
corticosteroid should be
added for frequent exacerbations an an FEV 1 <50% . Although it is possible that a
combined
long-acting -agonist (LABA)/corticosteroid would improve dyspnea more than a LABA
alone, the
benefit would not likely be more than a pulmonary rehabilitation program. Switching
from formoterol
to tiotropium would not be expected to provide a significant benefit, and the
benefits of adding a
LABA to tiotropium have not been studied. Third-party payers restrict payment fOr
oKygen therapy to
those with an SaO2 <89%, a PaO2
<55 mm Hg, a hematocrit >55%, or documented cor pulmonale.

14. A 25- mold male presents with pleuritic chest pain. He has not had a fever or
symptoms of
respiratory infection. He has no risk factors for thromboembolism, and no past
medical or family
history of thromboembolism. His vital signs and examination are normal, including
clear lungs on
auscultation and no chest wall tenderness. Laboratory findings include a normal CBC
and a normal
D-dimer level. A chest radiograph is also normal.
Which one of the following is the most appropriate next step in this patient's
management?
A) An NSAID
B) An anticoagulant pending further imaging
C) C-reactive protein and antinuclear antibody levels, and corticosteroids
D) A rib belt

ANSWER: A
Causes of pleuritic chest pain include pneumonia, chest wall trauma, pulmonary
embolus, and
vasculitis. If these conditions are deemed unlikely based on the history, physical
examination, and
limited laboratory studies, a chest radiograph is obtained. If this is within
normal limits then
viral pleuritic pain is most likely, and can be treated with an NSAID. Given that
the history and
physical findings are not suspicious for thromboembolism and a D-dimer is negative,
anticoagulation
is inappropriate. With no other systemic symptoms or findings of collagen-vascular
disease,
corticosteroids are not indicated. Since there is no rib tenderness and no
radiographic findings of
an acute rib fracture, a rib belt is not indicated.

33. Which one of the following is the recommended initial treatment for allergic
rhinitis in a
patient whose symptoms are affecting his quality of life?
A) An oral corticosteroid
B) An intranasal corticosteroid
C) An intranasal antihistamine
D) Subcutaneous immunotherapy injection
E) Sublingual immunotherapy

ANSWER: B
An intranasal corticosteroid alone should be the initial treatment for allergic
rhinitis with
symptoms affecting quality of life (SOR A). Intranasal corticosteroids act by
decreasing the influx
of inflammatory cells and inhibiting the release of cytokines, thereby reducing
inflammation of
the nasal mucosa. Intranasal corticosteroids are more effective than oral and
intranasal
antihistamines in the treatment of persistent or more severe allergic rhinitis (SOR
A). Intranasal
antihistamines also have more adverse effects than intranasal corticosteroids (SOR
C).
Subcutaneous and sublingual immunotherapy are not considered first-line
treatments but
should be considered for moderate or severe persistent allergic rhinitis that is
not responsive to
usual treatments (SOR A).
Ref: Price D, Bond C, Bouchard J, et al: International Primary Car Respirntory
roup (IPCRG)
guidelines: Management of allergic rhinitis. Prim Care Respir I 2006;15(1):58-70.
2) Sur DK, esa
reatment of allergic rhinitis. Am Fam Physician 2015:92(11):985-992.

Ref: Final Recninmendntion fitntemero: Camtid Ariery fiiennsis Screening, US

Preventive Sen ices
7asL Fnrre, 2fll4.

59. A 52-year-old female presents with a 5-day history of nasal congestion, facial
pressure, heavy
nasal discharge, and decreased sense of smell. She has not had a fever and says her
symptoms have
not started to improve. She is mildly tender over both maxillary sinuses. Even
though you have
reassured her that this is most likely a vira) illness, she would like antibiotics
because she is
going on vocation in 2 days and she wants to be better for her trip. Which one of
ihe following
strategies has been shown to improve the acceptance of symptomatic care only and
reduce the use of
antibiotics in this situation?
A) Using medical terminology for the condition, such as acute bronchitis or acute
lracheilis
B) Providing a “pocket” prescription with advice to fill it afier a defined period
without
improvement
C) Ordering sinus rildiographs
D) Referml to a specialist

ANSWER: B
In spite of good evidence that antibiotics are inerr*ctive for the treatment of
acute bronchitis,
and that 90% of cases are caused by viruses, rates of antibiotic prescription for
acute bronchitis
remaiR in the 60%—80% range. Several strategies have been shown to reduce the rare
of antibiotic
prescribing for this condition. These include careful use of nonmcdical terminology
such as
referring to the problem as a “chest cold,” providing “pocket” prescription.s with
advice to fill
the prescription only if the patient does not improve in a defined period of time,
and educating
patients about the natural history of bronchitis, informing them that symptoms may
persi*i ror 3
weeks. Specialists are not less likely than primary care physicians to prescribe
antibiotics. Sinus
films would not provide evidence to confirm thnt the infection is viral.

68. A 75-year-old male has a past medical history significant for atrial
fibrillation, ischemic
eardiomyopathy, diabetes mellitus, and hyperlipidemia. He is admitted to the
hospital with
bronchiolitis obliterans organizing pneumonia (cryptogenie organizing pneumonia).
Which one of the medications he takes is the most likely cause of this problem?
A) Amiodarone (Cordarone)
B) Carvedilol (Coreg)
C) Digoxin (Lanoxin)
D) Lisinopril (Prinivil, Zestril)
E) Pioglitazone (Actos)

ANSWER: A
Many drugs can cause lung disease. Amiodarone has been known to cause both
bronchiolitis obliterans
organizing pneumonia (BOOP) and interstitial pneumonitis. BOOP, also known as
eryptogenic
organizing pneumonia, is characterized by interstitial inflammation
superimposed on the
dominant background of alveolar and ductal fibrosis. This is a very distinctive
pattern of lung
response to exposure to several drugs, including amiodarone, bleomycin, gold,
penicillamine,
sulfasalazine, radiation, interferons, methotrexate, mitomycin C,
cyclophosphamide, and cocaine.
Interstitial pneumonitis is the most common manifestation of drug-induced lung
disease.
Drugs that can cause lis include amiodarone, azathioprine, bleomycin,
chlorambucil, methotrexate,
phenpoin, statins, and sulfasalazine.

Ref Broaddus VC, Mason R-1, Ernst JD, et al (eds): Murray & Nadcl's Textbook o
2016, pp 7 l,
1275-1294.
Respirntory Medicine, cd 6. Elsevier Saunders,

82. A 5-year-old male has a 10-day history of re pir tory symptoms, including nasal
congestion. He
seemed to improve around day S but acutely worsened on day 7 with a new onset of
fever, daytimc
cough, and persistent nasal dminage. On examination his oral temperature is 38.1°C
(100.6°F), heart
rate 100 beats/min, respinitory rate 24/min, and blood pressure 90/68 mm Hg. He has
no sinus
tenderness or cervical lymphadenopathy, and normal tympanic membranes bilaterally.
You note nasal
mucosal swelling and erythema, and mild pharyngeal erythema. Cardiac and lung
examinations are
normal.
Which one of the following would you recommend?
A) Saline nasal rinses, decongestants, fluids, and rest
B) A laboratory workup including a CBC, an erythrocyte sedimentation rate, and a C-
reactive
protein level
C) Sinus CT
D) Amoxicillin
E) Azithromycin (Zithromax)

ANSWER: D
This child meets the criteria for acute bacterial sinusitis (ABS) and should be
treated with
antibiotics. He exemplifies the concept of “double sickening,” in which a child
initially has
typical symptoms of a viral upper respiratory infection and improves initially only
to worsen
later, with daytime cough, persistent nasal discharge, and/or new fever. Other
criteria for ABS
include persistence of URI symptoms without improvement after 7—10 days and “severe
onset” ABS with
a high fever and purulent nasal discharge for at least 3 days. Evidence shows that
treatment with
antibiotics in these situations improves outcomes (SOR B). The first-line
antibiotic is amoxicillin
with or without clavulanate. The length of treatment can rnnge from 10 to 28 days.
Depending on
risks, patients may be treated with either high-dose amoxicillin or
amoxicillin/clavulanate, with
an amoxicillin dosage of 90 mg/kg/day. Many of the bacteria causing ABS have
been shown to be
resistant to azithromycin and trimethoprirri/sulfamethoxazole and these
antibiotics should be
avoided. For patients allergic to penicillins, cephalosporins should be used.
The diagnosis of ABS is based on the history (SOR C). The physical examination is
not
particularly helpful and findings such as sinus tenderness, mucosal
swelling, rind
transillumination of the sinuses do not help differentiate ABS from a viral URI.
Laboratory

111. A 35-year-old male has a 5-day history of cough and has had one episode of
blood- streaked
sputum. He is otherwise healthy and has never smoked. He is afebrile and has normal
findings on
examination. A chest radiograph is normal.
Which one of the following would be most appropriate at this point?
A) Observation
B) CT of the chest
C) Pulmonary function studies
D) Bronchoscopy
E) A trial of antibiotics

ANSWER: A
This patient has a low risk of cancer, based upon his age and medical history, and
no suggestion of
a lowers respiratory infection. With this presentation, a chest radiograph is
recommended as the
first step in the workup, and if findings are normal he should be observed for 2-6
weeks (SOR A).
If there is a recurrence of hemoptysis further evaluation is indicated, which
should include an
interval history, a repeat examination, and CT of the chest.
If the initial presentation had suggested a lower respiratory infection, treatment
with oral
antibiotics rather than observation would have been appropriate.
Ref: Earwood JS, Thompson TD: Hemoptysis: Evaluation and management. Am Fam
Physician
2015;91(4):243-249.

136. An 86-year-old female is in the emergency department with community-acquired

pneumonia
confirmed on n chest radiogrnph. Physicnl findings include n temperature of 38.4°C
( i0l . I °F). a
yulse mte of 101 hlood pressure of i0l/50 mm Hg, an oxygen satumtion of 9096
on room air, and
dateof 32/min. The Salient is nwake, alert, and oriented times three. The physical
examination is
otherwise unremarkable except ror coarse breath sounds in the lefi lung base.
Labomtory findings
include a BUN level of 14 mg/dL (N 8—25), a senim creatinine level of 0.7 mg/dL (N
0.6r-1.5). a
blood glucose level of 144 mg/dL, and a WBC count of 15,000/mm3 (N 4300—10,800).
Which one of the following would be most appropriate?
A) Discharge to home and treatment with azithromycin (Zithrnmax)
B) Discharge to home and treatment with amoxicillin/clavulanate (Augmcntin)
C) Discharge to home and treatment with amoxicillin/clavulanate plus azithromycin
D) Hospital admission rind imaiment with amoxicillin/clavulanate
E) Hospital admission and treatment with eeftriaxone (Rocephin) plus azithromycin

ANS\VER: E
This patient requires hospitalization based on her CURB-65 score of 3 (age >65,
diastolic blood
pressure <60 mm Hg, respiratory rnte >30/min, BUN < 19 mg/dL, no confusion), which

places her mortality risk at 14%. Although azithromycin has been associated with an
increased risk
of myocardlal infarction in elderly patients hospitalized with community-acquired
pneumonia, the
combination of azithromycin with a §-lactam has been associated with decreased
mortality in this
population. Azithromycin alone is acceptable treatment in the outpatient setting,
but not when the
patient requires hospitalization. A macrolide plus a §- lactam antibiotic has been
shown to have a
lower 30-day mortality rate than a §-lactam alone. This combination also results in
a greater
proportion of hospitalized patients achieving clinical stability at 7 days (defined
as stable vital
signs and oxygen saturation >90% on room air) when compared with §-lactam thempy
alone.

137. A 55-year-old female who works at a local day cure center presents with a
severe cough. Her
illness began 10 days ago with malaise, a low-grade fever, rhinorrhea, rearing, and
a mild cough.
Over the past 3 days the cough has becnme much mnre severe and she coughs to the
point that
vomiting ix induced.
Which one of the following is most likely to lead to a definitive diagnosis?
A) A Gram stain rind culium of sputum
B) Serologic studies
C) Polymemse chain reaction resting
D) A chest radiograph
E) Office pre- and post-bronchodilator spirometry

ANS\VER: C
Periussis has been increasing in incidence. The initial presentation usually
involves nonspecific
symptoms including malaise, lacrirnation, and rhinorrhea, which is referred to as
the catarrhal
stage. The following stage, known as the paroxysmal stage, is manifested by severe
coughing that
may lead to the characteristic high-pitched whooping sound when the patient tries
to catch his or
her breath. Coughing io the pnint of emesis is also characteristic of pertussis,
and the cough can
be severe enough to actually result in rib fmctures. The cough may last several
weeks before it
hegins to wane during the convalescent phase, which usually lasts 2-3 weeks.
Pcrtussis cnn be diagnosed clinically if there is n coughing illness of 2 weeks'
duration with one
of the classic signs of pertussis (post-tussive emesis$ respiratory whoop, or
pemxysmal cough) rind
there is no other apparent cnusc. The CDC nlso recommends the use of both cultures
and pol erase
chain reaction testing io confirm the diagnosis. Culture is nor the best choice,
however, ns it is
often done improperly, nnd culture results may not be nvniloblc
for severer dnys. Polymerase chain reaction hos the ndvantngc of providing results
in 1 —2 dnys. It
hax good specificity rind the sensitivity is much higher than that of a culture;
itx sensitivity is
highest during the firsi 2 weeks of symptoms.
Treatment with antibiotics usually does not improve clinical symptoms, although it
does decrease
transmission. The COC continucs io recommend antibiotics for pcrtussis. Either
azithromycin or
clarithromycin is currently recommended.

189. A 2-year-old male is brought to the emergency department by his frightened

mother following
the sudden onset of nasal stuffiness and a harsh, barking, nonproductive cough. The
child does not
appear significantly distressed. His temperature is 37.9°C (100.2OF) orally. Mild
nasal flaring is
present. The nasopharyngeal mucus appears mildly edematous and injected, and upper
airway noises
are heard, but good air movement is evident on auscultation of his chest.
Which one of the following is the most appropriate treatment for this patient?
A) A bedside humidifier
B) A single dose of oral dexamethasone
C) Amoxicillin for 7 days
D) Nebulized treatment with racemic epinephrine
E) Tracheal intubation and oxygen administration

ANSWER: B
Croup is a common, self-limited illness caused by viral infection of the upper
respiratory tract.
The diagnosis is based primarily on the clinical history and examination findings.
A history of the
abrupt onset of a barking cough, inspirutory stridor, and hoarseness in a 2-year-
old child is
typical of croup, although it can present at any age between 6 months and 12 years.
Low- grade
fever, a barking cough, and varying degrees of respiratory distress (nasal flaring,
retractions, or
stridor) are typically present on examination. Findings such as a toxic appearance,
wheezing,
dfooling, and difficulty swallowing are not consistent with the diagnosis.
Treatment of mild disease with a corticosteroid has proven benefit (SOR A) even
when administered
as a single oral dose (SOR B). Nebulized epinephrine has been shown to improve
outcomes in children
with moderate to severe croup (SOR A). Humidification therapy in the emergency
department setting
provides no benefit (SORA). This child has mild croup and a single dose of
dexamethasone (0.15—0.60
mg/kg, usually given omlly) followed by close observation is the most appropriate
treatment.
Ref: Znnmh R. SiJani M. Murray J: Cmuy: An overview. Am Fom Physician 201 I:ft1\9):
Ifi57 •I073.
216. You see a 5-week-old female for a well child visit in December. She was
delivered at 28 weeks
gestation because of severe preeclampsia in the mother. Her parents state that she
is doing well,
feeding well, and growing. The physical examination is normal.
At this time, you recommend immunoprophylaxis with
A) influenza vaccine
B) palivizumab (Synagis)
C) pertussis vaccine
D) rotavirus vaccine
E) intravenous immunoglobulin

ANSWER: B
For all infants born before 29 weeks gestation, palivizumab is recommended for the
first year of
life during respiratory yncytial virus season to reduce the likelihood of
hospitalization.
Immunization against pertussis and rotavirus is not recommended until the 2-month
visit. Influenza
vaccine is not recommended for any infant until 6 months of age. There is no
indication for
immunoglobulin in this infant.
Ref: Joffe S, Escobar GJ, Black SB, et al: Rehospitalization for respiratory
syncytial virus among
premature infants. Pediatrics 1999;104(4 Pt 1):894-899. 2) American Academy of
Pediatrics Committee
on Infectious Diseases, Ameriran Academy of Pediatrics Bronchiolitis Guidelines
Committee: Updated
guidance for palivizumab prophylaxis among infants and young children at increased
risk of
hospitalization for respiratory syucytial vinis infection. Pediatrics
2014;134(2):415-420. 3) Gauer
RL, Burkct I, Horowitz E: Common questions about outpatient care of premature
infants. Am Fans
Physician 2014;90(4):244-251.

229. A full-term newborn female develops respiratory ‹distress 1 hour after an

uncomplicated
caesarean delivery. She has a respiratory rate of 70/min, and mild grunting and
intercostal
retractions are noted on examination. The remainder of the examination is within
normal limits. A
chest radiograph shows some hyperexpansion and fluid in the fissures.
Which one of the following is the most likely cause of her symptoms?
A) Respiratory distress syndrome of the newborn
B) Transient tachypnea of the newborn
C) Pneumothorax
D)Meconium aspiration syndrome

ANSWER: B
This patient has transient tachypnea of the newborn, which typically occurs within
2 hours of
birth. The chest radiograph usually shows hyperexpansion with perihilar densities
and fluid
within the fissures. Respiratory distress syndrome of the newborn is most often
seen in premature
infants, and the chest radiograph shows a classic diffuse ground-glass appearance.
With
pneumothorax a chest radiograph would typically show a partial or complete lung
collapse. Meconium
aspiration syndrome occurs in the setting of meconium-stained fluid and is usually
apparent
immediately after delivery. The chest radiograph typically shows fluffy densities
with
hyperinflation.

32. A 66-year-old female with a history of shortness of breath returns to your

office to review her
pulmonary function test results. Her FEV I/FVC ratio is 76%. You calculate that her
FVC is below
the normal range for an adult. Her DLCO is also low.
Which one of the following is most consistent with her pulmonary function test
results?
A) COPD
B) Asthma
C) Idiopathic pulmonary fibrosis
D) Chronic pulmonary emboli
E) Morbid obesity

ANS\VER: C
This patient's pulmonary function test (PFT) findings are consistent with a
restrictive defect with
a low DLCO. Idiopathic ulmonary fibrosis, asbestosis, hypersensitivity
pneumonitis, and
sarcoidosis are restrictive lung diseases with a low diffusion capacity due to
alveolar damage.
COPD and asthma are both obstructive lung diseases, but can be associated with an
abnormal DLCO.
Morbid obesity causes a restrictive lung disease associated with a normal DLCO. The
presence of
chronic pulmonary emboli is associated with a low DLCO due tD pulmonary vascular
disease, but PFTs
are normal.
Ref: Johnson JD. Tiieurer KVM: A stepivise approach to the interpretation of
pulmonary function
tests. Am Fain Physician 2014;d9(5):359-366.

79. A 90-year-old male with a history of metastatic ancer is admitted to

hospice. You agree to
follow the patient. The following week the hospice nurse calls you because the
patient is
complaining of significant dyspnea. His oxygen saturation is 91% on room air. A
physical
examination reveals diminished but otherwise clear breath sounds.
Which one of the following is the treatment of choice for this patient's dyspnea?
A) Oxygen
B) Albuterol in normal saline by nebulizer
C) Prednisone orally
D) Morphine sulfate sublingually
E) Lorazepam (Ativan) orally

ANSWER: D
Opioids, given either orally or intravenously, are the treatment of choice for
dyspnea and have
been studied thoroughly in patients with COPD and patients with cancer. They have
been found to be
effective in alleviating dyspnea and, when used carefully, do not have serious side
effects such as
respiratory depression. When the patient is experiencing anxiety, which regularly
occurs in
association with breathlessness, benzodiazepines can be added, although there is no
evidence that
they improve the dyspnea. Patients are regularly given supplemental oxygen for
dyspnea, but
systematic reviews have found no benefit for patients with cancer or heart failure
who do not have
hypoxemia. However, oxygen may provide some relief for patients with COPD who do
not have
hypoxemia. Prednisone and albuterol are not indicated
for this patient.

Ref: Blinderman CD, Billings JA: Comfort care for patients dying in the hospital. N
Engl 1 Med
2015:373(26):2549-2561.

2015;91(12):856-863.

182. A 62-year-old male with a history of smoking comes to your office for
evaluation of a solitary
2-cm right upper lobe pulmonary nodule noted on CT. Which one of the following
radiologic features
is most predictive of malignancy?
A) Smooth borders
B) A ground-glass appearance
C) Central calcification of the nodule
D) A solid density

ANSWER: B
In the evaluation of a solitary pulmonary nodule, a risk assessment is useri to
determine the
diagnostic evaluation of the nodule. Clinical risk factors for malignancy include
older age, a
history of smoking, and a previous history of cancer. Radiologic features
indicative of malignancy
include a nodule diameter >10 mm, an uppeilloeation, irregular or spiculated
borders, no
calcifications, a ground-glass appearance, and increasing size over time.
Radiologic
characteristics suggesting berngn disease include a size <5 mm, central
calcifications,
smooth borders, a solid appearance, and a stable size over 1 year.
Ref: Kikano CiE, Fabien A, Schilz R: Evaluation of the solitary pulmonary nodule.
Am Fam Physician
2015;92(12): 1084-1091.

214. A 54-year-old male smoker with a family history of coronary artery disease
tells you that he
takes §-carotene and vitamin E regularly to help prevent cancer and heart disease.
In counseling
this patient, you discuss smoking cessation and advise him that
A) he should continue both supplements
B) he should continue 9 -carotene and discontinue vitamin E
C) he should discontinue § -carotene and continue vitamin E
D) he should discontinue both supplements
E) evidence is insufficient to assess the risk and benefit of these supplements

ANSWER: D
The U.S. Preventive Services Task Force recommends against the use of $-carotene or
vitamin E
supplementation for the prevention of cardiovascular disease or cancer. This is a
class D
recommendation (do not recommend). Overall there is no beneficial effect on cancer
or heart disease
from these vitamin supplements. In one study vitamin E appeared to increase the
risk of hemorrhagic
stroke, and $-carotene has been found to increase the risk o lung cancer in persons
already at
higher risk for lung cancer.
Ref: Moyer VA; US Preventire Services Task Force: Vitamin, mineral, and
multivitamin supplements
for the primary prevention of

xo. A nonverbal zz-year-old male with intellectual disability is brought to your

office by the
staff of the group home where he lives. They report that the patient has been
functioning at his
baseline until this morning when he was found to have loud breathing. No other
history is available
at the time of this visit.
On examination he has a temperature of 37.3°C(gg.i°F), a blood pressure of izd/82
mm Hg, a pulse
rate of ioo beats/min, and a tory rate ofi6/min. The patient appears to bein
mild distress and
a high-pitched whistling, crowing sound on inspiration is heard as you walk in the
room.

Which one of the following would be the most appropriate next step for this
patient?
A) Oral antibiotics
B) Oral corticosteroids
C) Nebulized albuterol
D) Nebulized epinephrine
E) Urgent evaluation in the emergency department
RN5 JER: E
Stridor is a high-pitched whistling, crowing sound on inspiration. It can be caused
by obstruction
of the larynx or trachea by a foreign body, vocal cord edema, a neoplasm, or a
pharyngeal abscess.
Acute stridor requires urgent evaluation for obstruction. This patient may have a
foreign body or
other obstruction in his airway and requires urgent assessment. Oral antibiotics,
oral
corticosteroids, nebulized albuterol, or nebulized epinephrine would not be
appropriate at this
time.

zo. An 18-month-o1dfemde is brought to your oNce by her mother for evaluation of a

cough. The
patient has had low-gradefeversand a runnynose for 2 days. She now has a cough that
is worse at
night. On examination she has a temperature of 37.5°C
(99 5°F), a pulse rate of lzo beats/min, a gQi3ii3Mi%rate of 3oJmin, and an oxygen
saturation of g2!ié on room air. She is noted to have hoarseness, mild inspiratory
stridor, and
abarking cough. She does not have drooling or a mumed voice.
Which one of the following should be ordered to confirm the diagnosis?
A) No further testing
B) A CBC
C) A viral culture
D) Rapid antigen testing
E) A radiograph of the neck

ñHSlxlER: R
This patient has croup, which is diagnosed clinically and no further testing is
usually indicated.
A CBC is nonspecific and is usually only indicated if a bacterial cause of stridor
is suspected,
such as bacterial tracheitis, epiglottitis, retropharyngeal abscess, or
peritonsillar abscess.
Viral cultures and rapid antigen testing should be reserved for instances in which
the patient
fails to respond as expected to initial treatment. A neck radiograph is not
indicated in the
absence of findings that suggest possible epiglottitis, such as drooling or a
muffled voice.

g£›. A42-year-o1dma1eseesjouforfollo»-upafterhisthirdepisodeofpneumonia.He has

noother
significantmedicalhistoq.Hehasneversmoked,drinksalcoholoccasionally, andhasnoother
drug use or
known exposures. A physical examination is normal.
Pulmonaq function tests demonstrate an FEV of B of predicted and an
FEV /FVC ratio of o.68, which does not normaliieiñthbronchodilatDr
administration.Achestradiogrzphshowshjjnrinflationbutno other signiCcant findings.
Laboratory
Findings:
Platelets........................... 102,0oo/mm3(**iso,ooo- o,ooo)
Creatinine O.7mg/dL(N o.6—1.2)
AST. ..... ... .. .. s6 U/L (N 8—48)
ALT................ . 43 U/L (N 7—S5)
Albumin .... ........... 338/dL(+3-5-5.O)
Which one of the following conditions best explains this patient's abnO£TRal
findings?
A) e,-Antitrypsin deficiency
B) Cystic fibrosis
C) Goodpasture syndrome
D) Hereditary hemochmmatosis
E) Sarcoidosis

This patient is in his Sorties without clear risk factors and has both an
irreversible obstructive
pulmonary defect consistent with COPD (FEVi <8oB of predicted and an FEVi/FVC ratio
€O 7o) and liver abnormalities associated with advanced fibrosis. These combined
findings are the
hallmark of al hai-anti psin deficiency. This patient has a high likelihood of
advanced liver
fibrosis based on the low albumin level and noninvasive scoring using the fibroSiS-
4 (FIB-
4 index (age « ASTM(platelets [in mm3) x ALTVz • 3 5h> i• s patient). Further
evaluation
with transient elastography should be performed to confirm cirrhosis.
Cystic fibrosis is less likely to cause a typical obstructive picture on pulmonary
function tests
(PFTs) and does not /'pically cause liver fibrosis. Goodpasture ymdmme is a
vasculitis that
classically involves the lungs and the kidneys and is more likely to cause a
restrictis•e pattern
on PFTs. Hereditary hernochromatosis can cause early liver disease, including
cirrhosis, but is not
a significant cause of joy disease. Sarcoidosis may involve both the lung and
the li er, and
can cause obstructive or restrictive patterns on PFTs. However, this patient's
radiograph did not
show the characteristic hilar adenopathy and granulomatous disease of sarcoidosis.

go. A 62-year-old male with hypertension presents to your office with substernal
chest pain
radiafing intohis leñ armfor the past zo minutes. He alsohas diaphoresis andnausea.
Hehasablood
pressure of is6/96 mm Hg, a pulse rate of 84 beats/min, and an oxygen saturation of
93% On room
air.An EKG shows ST-segment elevations inleads Vi and Vz. Your medical assistant
calls
9liforimmediatetranspoG to the local hospital's emergency depaGment. While awaiting
the ambulance's
arrival you give the patient low-dose aspirin and sublingual nitroglycerin.
Which one of the following would be most appropriate regarding oxygen therapy at
this time?
A) No oxygen therapy
B) Oxygen via nasal cannula at 2 L/min
C) Oxygen via nasal cannula at 6 L/min
D) 1007» oxygen with a regular mask
E) 100% oxygen with a nonrebreathing mask

RNSWER: R
While oxygen supplementation is routinely initiated for patients who are suspected
of having acute
coronary syndrome, evidence does not suppoG a benefit from this unless ie patient
is hypoxic.
Oxygen supplementation is recommended if the patient has an oxygen saturation
<9OO , if the patient is at risk for hypoxemia, or if the patient is in respiratory
distress.

GO • A s5-year-old male with a 4o-pack-

ear smoking history comes to your office with
the results OfspirometryhehadataheaIthfair.Hequitsmoking l year ago. Hedoes nothave
any cough, dys
nea, wheezing,orsputumproduction,but he is concerned that
FEVy/ ratio of o.6
whlC}l indicates mild to moderate airflow obstrucDon.
Basedonthe best available evidence, whichoneofthe followingshould you recommend in
order to prevent
the development of symptomatic airflow obstruction?
A) No treatment
B) A long-acting anticholinergic
C) A long-acting b-agonist
D) An inhaled corticosteroid
E) Combination therapy with a corticosteroid and long-acting §-agonise

There is no evidence from randomized, controlled trials to show that treating

asymptomatic
individuals, with or without risk factors for airflow obstrucfion, prevents future
i trio
symptoms ot reduces subsequent declines in lung function. Partly for this reason,
the U.S.
Preventive Services Task Force and joint guidelines issued by the American College
of Physicians,
American College of Chest Physicians, American Thoracic Society, and European
Respiratory Society
recommend against screening for COPD in asymptomatic adults.
Regardless of the results of this patient's spirometry testing, treatment should
not be initiated
in the absence of symptoms. A long-acting anticholinergic, a long-acting beta-
agonist, an inhaled
corticosteroid, and combination therapy with a corticosteroid and long acting beta-
agonist would
not be recommended for this patient.

has type* diabetes and persistent budesenide/fomioterol (/-rnbi‹orij and

montelukast(Si was lrea

ago.the
She has not
sbe bas a tea}›ct”xtuze oldy 7"F*-{99-9"j:r}, y pulmonary examination is
significant for diffuse
expirat q «tty gbehest
38
radiograph shout arne intemitial thickening arid is reed as concerning for
bronchiectasis
AcDC’us’gnl'f rantfozmnnophilts u4lh an eesinaphilcount ot 9#*/*m'(N2o-85o).!!
G’tertinpineptve.

Thing foru'hich one of the following o nisms is most likely to meal a contrimtin
to her illness?

Ptilmonaq aspergillosis comprises a spectrum of clinical disease, from inst.sive,

often caviq--
termini disease in critically ill rind profoltndi immunosuppressed pstients to
allergic
bronchopulmonary aspetgillosis. This case of poorly controEed asihma associated
is4th eosinophilia
and bmnchieetasis is topical nf allergic brouchopulmonay aspergillosis.
Aspergillus IgE liters are recommended as initial testing in patients with
suspected allergic
bronchopulmonary aspergillosis. Antifungal treatment can imprme outcomes in these
cases.

Cortidioides immitis rind Histoplasiria typicnlll cause more ystemic s\nptoms such
as mustle and
joint pain, rather than wheezing. Coecidioides immitis is present in the desefi
regions of the U.S.
sniithwest nrtd Histoplasma is endemic tn the btissLssippi and Ohin Riser valley-s
of the hlidwest
and the South. Stjxxibacterium tuberculosis is less mmmon in the United States, and
this patient's
yznptoms ar‹d findings are not byical of active tuberculosis. Pneum stis jiroveci
causes
pneumonifi btit is tare in patients «ho src not overlh'iinmunosuppreLsed.

Emergency calls only 4•

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79- A4s-yearo]dfemale returns to your clinic efterpnlmonaq• Sanction testing for

dyspnea. Her
prebronchodilatorFEV,/FVCrafioivaso.6y, which improvedtoo. g postbronchodilator.
These findings are most consistent iñth which one of the folloiñng?
A) Asthma
B) COPD
C) Interstitial lung disease
D) Pulmonary hypertension

A diagnosis of COPD is established by an FEVI/FVC that is consistent with

obstruction and is not
significantly reversible with bronchodilator treatment. The American Thomcic
Society/European Q
liâtoiy_SocieJ guidelines define reversibility as an impzoi•ement of more than iz%
in adults. This
patient's FEVi/FVC increased by more than thaf with bronchodilation, so her results
are most
consistent with asthma. Spirorneoy is not used fo diagnose interstitial lung
disease or pulmonary
hypertension. Interst‹tial lung disease ‹s
45

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*37- In patients hospitalized with acute qQQg3M3Iginfections, procalcitonin levels

are
useful for:
A) nutritional status assessment
B) reducing inappropriate use of antibiotics
C) ruling out pulmonary embolism
D) early identificatlon of the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH)
E) identifying acute respiratory distress syndrome

RNSIxlER: 8

Procalcitonin is a biomarker for the presence of severe bacterial infections such

as pneumonia and
sepsis. Its utility in clinical decision-making is reducing unnecessary antibiotic
use, which
reduces antibiotic resistance. Its use in guiding treatment is associated wit
reduced modality
(SORA) and wit fewer antibiotic treatment days and fewer antibiotic complications
(SOR B).
Procalcitonin levels are not useful in assessing nutritional status, ruling out
pulmonary embolism,
early identification of the syndrome of inappropriate secretion of antidiuretic
hormone, or
identifying acute respñatory distress syndrome.

4 O

IGG. Ahealthy18-year-oldAfrican-Americanfeina1ecomesto youroffceisñthessay

historyof
sharpchestpainthatworsens uitbbotbinspiration aodexpiration.Shehas also noticed
thatthe pain
worsens ss5th laughing or coughing. She had symptoms of an upper puaWo infection
aweek ago with
nofever or shortness of breath. Shehasno histo of trauma and no significant past
medical history,
and takes no regular
9>

medicntions. Her fatal signs are normal, includingop'gen sxtutation, an‹laphysiml

examination is unremarknble. A chest radiograph is Nso normal.

iYhich one of the follo»5ng would be the most appropriate next step?
A) A D6imcr leyeI
B) An EKG
C) Spiral chest CT
D) Diclofenac, 75 eg tn'ice daily
E) Prednisone. 50 mg daily for 5 days

Ruling out life-threatening causes of pleuritic chest pain is the most important
consideration in a
pleurisy evaluation. A full histoq' and complete physical examination with vital
be performs tSORC). Tachycilfdla, tachypnea, hypotension, fever, or respiTatory
distress
should raise concerns. Chest radiography should be pedormₑd if the cause o( the
pain is unclear(SOR
C). If no red flags are raised on urination tend a chest ta6iogmp'h ›s clear, a
trial of NSAIDs
should be started (SOR B). NSAIDs are preferred to narcotic medications as they do
not suppress
respirator' drive and do not have the risk of addiction and abuse. If a life-
threatening cause is
suspected from the histoq' and physical examination,they further diagnostic testing
is indicated.

*70. A 6-month-old female is brought to the emergency department by her parents

with a
4-dayhistoryoffever,congestion,cough,shortnessofbreath,anddecreasedappetite.
Onexamination of the
lungs you note wheezes and crackles throughout. You also note subcostalretractions,
an
oygensaturationof gif on room air, anda respiratory rate of4=/min.A chest
radiograph reveals
pert-bronchial markings iñth no infiltrates.
The parents say that the patient's teenage cousin visited recently and was having
“cold symptoms.”You suspect bronchiolitis.
Which one of the following would you recommend next?
A) Maintaining hydration and keeping oxygen saturation n 90a
B) Deep nasal sectioning
C) Albuterol via nebulizer
D) Broad-spectrum antibiotics
E) Systemic coaicosterol0S

Bronchiolitis is a common lower sha itract infection in young children and

infants.
Respiratory syncytial virus (RSV) is the most common cause. Supportive care with
hydration and
maintenance of oxygen saturation is important in the treatment of RSV
bronchiolitis.
Infants with respiratory rates >6o/min are often unable to manage oral hydration
due to the risk of
aspiration. In these cases, intravenous or nasogastric feeds are acceptable. An
oxygen saturation
›9o%is sufficient in RSV bronchiolitis and use of supplemental ohygen to achieve
higher levels of
oxygen saturation may prolong hospital stays. There is no clear advantage to deep
nasal suctioning,
which may also be associated with prolonged hospital stays. Routine nasal
suctioning is indicated,
however. Bronchodilators are not recommended in the treatment of RSV (level of
evidence A).
Antibiotics are only indicated with a confirmed bacterial co-infection (level of
evidence B).
Systemic corticosteroids have shown no benefit in the treatment of bronchiolitis.

ago. A fully immunized 7-month-Oldmaleis brought urgently to your office after his
parents noted a
possible seizure. The mother says that the infant began to“shake all over” for
about 3—4
"'inutesand then prompUy fell asleep for about 20 minutes.
When he awoke he was alert but fussy and crying. He has been ill for the last few
days
with a cough, congestion, decreased oral intake, and fevers up to ioi°F. On
examination he has an
oraltemperatureof 38.3°c(1oo.9°F), aheart rate of 170 beat5/min, a oy rate
of so/min,and an
oxygen saturation of 97%on room air. The infant is fussy but consolable. His mucous
membranes are
moist, his tympanic membranes are clear, and he has a normal oropharynx. He has
clear rhinorrhea.
Examination of the heart is normal, and examination of the lungs reveals rhonchi
and wheezes. He is moving all of his extremities normally.
Which one of the following would be the most appropriate initial step in the
evaluation of this
child?
A) A basic metabolic panel
B) Radiography of the chest
C) of the brain
D) Electroencephalography
E) A lumbar puncture

Children who have a simple febrile seizure and appear neurologically intact do not
require routine
testing except to determine the source of their fever (SOR C). This child has signs
of possible
pneumonia so a chest radiograph would be warranted to look for the source of
infection that
triggered the fever.
Routine laboratory testing is not indicated in the workup of simple febrile
seizures. There is a
low risk that these children will have low sodium or glucose levels, and this would
not predict
seizure recurrence. Routine neuroimaging such as MRI is not recommended for
febrile seizures.
Electroencephalography is not useful for predicting the recurrence of simple
febrile seizures and
would not be indicated in the workup of these seizures. A lumbar puncture is
indicated only in
cases where the child has neurologic findings suggestive of meningitis, but that is
not the case
for this child.

zoo. Aprevious1yhea1thy62-year-o1dfemalepresentstoyourofficewit* a3-day

historyoffeverand a
cough productive of purulent sputum. On examination she has a temperature of 3s z°C
(1O2.6°F), a
blood pressure of no/yo mm Hg, a pulse rate of
9= beats/min, a @spir%i¥d•ateof 25/min, and an oxygensaturation of 4%on room
air. She shows no signs of confusion. An examination is significant for crackles at
the right lower
lung base and a chest radiograph confirms an infiltrate in the same location.
Which one of the following treatment settings would be most appropriate at this
time for this
patient's community-acquired pneumonia?
A) Outpatient
B) The emergency department
C) A regular hospital inpatient floor
D) The intensive-care unit

The CRB-6s tconfusion, respiratory rate, blood pressure, 6s years of age) rule is a
validated tool
for risk stratification in the primary care setting. It can be used to determine
who is a good
candidate for outpatient treatment of community-acquired pneumonia. Patients are
given 1 point for
each of the following signs or symptoms: new-onset confusion, a respiratory rate
*30/min, a blood pressure <qo rum Hg systolic or
<6o mm Hg diastolic, and an age of 6$ years or older. Patients with o points, such
as this patient,
are at low risk and can be managed in the outpatient setting unless there are other
significant
comorbidities or social factors that make outpatient treatment contraindicated.
Patents with a
score of i—z are at moderate risk and should be hospitalized in most cases.
Patients with a score
of 3—4are at high risk and should be considered for hospitalization in an
intensive-care unit.

in;3. A 6o-year-old male presents with dyspnea on exertion, occasional wheeling,

and a chronic
cough that is producti 'e. tfe has nex'erbeenhospitoIizeJ. He has smoked one pack
ofcigarettes per
day since the age of zo. An examination reveals diminishedbreaih sounds but no
Cackles, jugular
venotis distention, gallop. oredema. Spimmetryshosss n postbronchodilatnrFM , that
is4S fthe
predicted sane, and the seszrityofhis dise0se is rated asGl0bal Initiatix'e for
Chronic Obstructive
Disease (GOLD) group C.

In addition to albuterol as needed for symptomatic relief and smolung cessation,

the initial
treatment should include:
s8

A) bccl‹›mctfiasone
B) hudesonidc/f‹›rmotcrnl (Symbicort)
C) r‹›flumilast (Daliresy)
D) thc‹›ghyIIine
E) tiotn›yium tSyirivaT

The goals for treatment of this pnlient's COPD Should include prevention of or a
reduction in

hnspitalfzztions, o
in dyspnea, slowing; progression rthe disease, and a decrease in
mortality. Disease sex'erig' is categorized by spirometry results, ihe severity of
qwptows Such us
cough end tlJ'spnea, and the number of exacerbations, including those requiring
hnspit;t]tZ;ttion.
CJassiJ5np p0tlt•ttls into Global Initiative for Chronic Obstructive Lung Disease
(GOLD) groups A
ihrnugh D helps guide treatment initiation and modification over t'^^-
The initial treatment for patients in GOLD group A is o short- or ]pflg-fitting
bronchodil;rtoF.
Patients in COLD group B shouTtl begin treatment Cth a single long-actinC
muscarinic

antagonist (LAI\tA) or a long-acting beta-agonist (WADA). A tA is the initial

recommendation for patients in GOLD group C, although a combination inhaled
corticosteroid
plus n LABA can be considered for treating persiSl8pt exacerbations. tn4ividMgls
Cla18lfied in
COLD group D can begin treatment with a LABA or a combination of an inhaled
corticosteroid

›=7• Ataroutinevisit,a6s-year-oldmaleformersmokerreportsshortnessofbreathanda cough

that
hasbeenworseningslowlyover%e1ast6months.0nexaminationyouhear bibasilarinspiratory
cracUes. An EKG,
chest radiograph, and echocardiogramare normal. CT of the chest shows multiple
bilateral patchy
areas of consolidation.
The most appropriate next step is to:

A) take a detailed history

B) start an antibiotic
of medication use and lifetime environmental exposures
C) start furosemide (Lasix)
D) stan an inhaled short-acting §-agonist as needed
E) refer for pulmonary rehabilitation

RNSISER: 7t
Idiopathic pulmonary fibrosis occurs most oflen in male fomier smokers over the age
of 6o. For
patients with newly diagnosed interstitialQung disease (ILD) wit suspected
idiopathic pulmonary
fibrosis, the American Thoracic Society recommends taking a detailed history of
medication use and
environmental exposures over the patient's lifetime. In an observational study of
1O84 patients.
47% were identified as having hypersensitivity pneumonitis on a detailed assessment
of new-onset
ILD with an unknown cause. Laboratory testing for connective tissue disease is also
recommended.
Antibiotics would be appropriate to treat a bacterial infection. Furosemide is used
to treat heart
failure. An inhaled short-acting -agonist
and pulmonary rehabilitation would not bR appropriate at this time.

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•74- A 46-year-old male who injects heroin daily presents with a 6-month history of
progressive
dyspnea on exertion, a productive cough, and fatigue. He does not have any fever,
chills, malaise,
or hemoptysis. He has not had any sick contacts and has never smoked. On physical
examination he
shows nosignsofdistress,hasa normal oxygensaturationonroomair, and has normal
breath sounds. A
chest radiograph reveals bilateral perihilar shadowing.
A subsequent biopsy will most likely show
A) adenocarcinoma
B) branching hyphae
C) foreign body granulomas
D) caseating granulomas
E) noncaseating granulomas

RNSMER: €
Although persons who inject drugs are at high risk for a variety of pulmonary
infectious diseases,
this patient's presentation, including the relatively slow development of symptoms,
is most
consistent with pulmonary foreign bDdy granulomas. These result from the injection
of crushed
pills, tale, or other foreign substances, which are then deposited in the
vasculature of the lungs.
Adenocarcinoma is not as likely given the patient's age and nonsmoking history.
Branching hyphae would be seen in aspergillosis but this patient does not have
fevers or malaise.
Caseating granulomas are seen in tuberculosis, which is less likely given the
absence of fever and
hemoptysis. Noncaseating granulomas, seen in sarcoidosis, would not be more likely
in this patient
than in the general population.

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14. A 2-year-old female is brought to the urgent care clinic because of a fever.
0n examination
she has a temperature of 39.7°C (103.5°F). Within a short period of time while at
the clinic
shedevelops a barking cough and %@gjg%;gj distress, and you note rapid
deterioration of her
condition.

Which one of the following is the most likely diagnosis?

A. Bacterial tracheitis
B. Epiglottitis
C. Foreign body aspiration
D. Peritonsillar abscess

ANSWER: A

This patient has bacterial tracheitis, which includes a high fever, barking cough,
respiratory
distress, and rapid deterioration. Epiglottitis has an acute onset of dysphagia,
drooling, and high
fever, along with anxiety and a muffled cough, and typically occurs in children 3—
10 years of age.
Foreign body aspiration is associated with an acute onset of choking and drooling.
A peritonsillar
abscess would cause a sore throat, fever, and “hot potato” voice.

25. After a thorough history and examination, you determine that a

30-year-old male has an
upper 11a infection with a persistent cough, He is arebrile and is otherwise
healthy. The best
treatment for symptomatic relief of his persistent cough would be intranasal:
A. Antibiotics
B. Antihistamines
C. Corticosteroids
D. lpratrop um (Atrovent) 14
E. Saline
ANSWER: D

Upper resplratory tract infections are the most common acute illness in the tfnited
States.
Symptoms are self-limited and can include nasal congestion, rhinorrhea, sore
throat, cough, general
malaise, and a low-grade fever. According to a Cochrane review of 10 trim1s without
a
meta-analysis, antitussives and expectorants are no more effective than placebo for
cough.
Intranasal ipratropium 1s the only medication that improves persistent cough
related to upper
respiratory infection in adults. I ntranasal antibiotics, antihistamines,
corticosteroids, and
saline would not improve this patient's cough.

4 9. A 2-year-old female is brought to your office by her mother because or a

cough and fever The
mother also tells you that the chlld has had a reduced appetite but she is drinking
fluids
normally. The child was born at term and has previously been healthy.

On examination the child appears alert and happy. She has a temperature of 37.2•C
(99.0•F], a pulse
rate of 100 beams/min, a raFe of 30/min, and an oxygen saturation of 9B9t
on room air. An
HEENT eaamination reveals clear rhinorrhea. Auscultation of tbe lungs reveals mild
expTmtory
wheezing throughout wirh no crackles, and you note no signs of resplratory distress
such as
retractions or use of accessory muscles of respiration.

Which one of the following would be the most appropriate next step?

Reassurance only
B. A nasal swab for resplratory syncytlal virus
C. A chest radiographs
D. Nebulized albuterol 28
E. Oral amoxlclllln
AbiSWER: A

This patient has symptoms typica] for resptfatoFy syncytiâl virzis (RSV]
bronchiolitis. Since the
patient shows no signs of distress and is well hydrated, no specific Deatment is
necessary. Neither
testing for RSV nor Obtaining a chest radiograph would change management, and
therefore would not
be indicated. Albuterol Is ineffective for the wheezing associated with RSV since
the mechanism of
wheezing Is not due to bronchospasm. Antibiotics are not indicated without evidence
ora secondary
bacterial Infection.

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76. A 30-year-old female who is an established patient calls your office to request
a test for
COVID-19. The patient spent several hours inside the home of another individual who
just received a
positive COVID-19 test result. She states that her sense of taste seems diminished,
but she has no
r@3g%ya symptoms and otherwise feels well.

Which one of the following is the typical incubation period for COVID-19?

A. 1 day
B. 5 days
C. 14 days
D. 30 days

SARS-CoV-2 is a respiratory coronavirus that is responsible for COVID-19. Knowledge

of the natural
history of the viral infection will inform testing strategies and many other
aspects of counseling
of patients. The incubation period measures the time from exposure to symptom
onset. The typical
incubation period for COVID-19 is approximately 4—5 days, though it can range from
1—14 days.

fi O

83. A 78-year-old male with terminal lung cancer and long-standing COPD is
admitted to a regular
medical-surgical care unit pending transfer to the hospice unit within the next
day. You are called
about worsening anxiety and dyspnea. The patient is alert and anxious. He has a
blood pressure of
150/94 mm Hg, a pulse rate of 96 beats/min, a $@jFs rate of 24/min, and an
oxygen saturation of
93% on 2 L/min of oxygen via nasal cannula.

Which one of the following would be most effective in this situation?

A. 40% oxygen by venti-mask

B. Dexamethasone
C. Hyoscyamine (Anaspaz)
D. Lorazepam (Ativan)
E. Morphine sulfate

ANSWER: E

Opiates are the most effective agents for treating dyspnea and the resultant
anxiety in patients
with terminal cancer. Higher levels of oxygen are indicated if the patient's oxygen
saturation is
<92% and with caution in patients with COPD so as not to suppress respimtory drive.
Dexamethasone,
hyoscyamine, and lorazepam have a frequent role in patients such as this one, but
morphine sulfate
or a similar fast-acting opiate is the drug of choice (SOR B).

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108. In a patient with persistent ggQi.ag3giT"1y symptoms, which one of the

following pulmonary
function abnormalities añer bronchodilator administration is required for the
diagnosis of COPD?
A. Low residual volume
B. Low total lung capacity
C. An FEVI/FVC ratio <0.70
D. An FEVi <85% of predicted
E. A peak flow <90% of predicted

ANSWER: C

In addition to the presence of relevant factors and chronic respiratory symptoms, a

postbronchodilator FEVI/FVC ratio <0.70 is required for the diagnosis of COPD. COPD
is classified
as mild (FEV1 >80% of predicted), moderate (FEV1 50%—79% of predicted), severe
(FEV1 30%—49% of
predicted), or very severe (FEV1 <30% of predicted). Further pulmonary function
testing may support
the diagnosis, but it is not required. For instance, a high total lung capacity
indicating
hyperinflation, a high residual volume indicating air trapping, and a low diffusing
capacity for
carbon monoxide indicating impaired gas exchange all suggest emphysema.
117. A 68-year-old male \v1rh a history of COPD, hypertension. and hyperlipidemia
presents wif t a
worsening cough and dyspnea with exertion over the past 3 months. His symptoms were
previously well
controlled with tiotropium (Spiriva) daily and albuterol (ProventiL Ventolin) as
needed, and he has
not had any COPD exacerbations ill thR SSt ear until these symptoms began. He has
not had any
change in sputum production Recently he has been using his albuterol inhaler
several times a day to
help relieve his shortness of breath wirh exertion.

A physical examinadon reveals a temperature of 37.0°C (9B.6•F), a heart rate of 7B

beats/ min. a
rate of 16/min, a blood pressure of 144/82 mm llg, and an nxygen saW rahas of 9S
% on room air. A
cardiac evaluation reveals a regular rate and rhythm and he has no peripheral edema
or cyanosts.
His lungs are clear with no wheezes or crackles. and there 1s a mild prolnnged
expiratory phase.

ACcording to curreNt GOLD guidelines, which » r the following would be the most
appropriate next
step in che management of rhis patient's symptoms?
A. Add azi1romycin {Zirhromax)
B. Add inhaled fluticasone (Fiovent) Add inhaled salmeterol [Serevent}
D. Add inhaled fluticasone/salmeterol (Advair}
E. Discontinue tioDopium and start inhaled fluticasone

ANSWER: C

COPD ts currently the third leading cause of death In the United States and is
commonly created by
primary care providers. In patients on monotherapy with a long-acting
bronchodilator such as a
lortg acting muscarinic agonist [LAMA) or long-acting bera-agonist {LABA) who have
continued
dyspnea, rhe Cfobal /nit›adve for Chronic Obstructive LMng Disease {COLD}
guidelines recommend
escalating therapy to two bronchodilators. This patient has persistent dyspnea and
is being treated
with a single agent, a LAMA, SO hls regimen needs to be escalated to include a LABA
such as
salmeterol. Once the symptoms are stabilized. treatment can be de-escalated to a
single agent. For
patients with frequent COPD exacerbations or with a diagnosis of asthma and COPD.
the guidelines
recommend adding an inhale4 corticosteroid (ICS) such as flutlcasone to a LABA,
LAMA, or both.
Trfple therapy wfth a LABA. a LAMA, and an ICS Is not indicated at this time as the
patient has not
yet been treated Mth a combination ofa LAMA and LABA and has not had any recent
exacerbations. The
addition of azithromycin may be considered in patients who are already on triple
therapy with a
LABA, a LAMA, and an tCfi and still t›avlng exacerbations. Monothezapy with an lcs
Ts not Indicated
in COPD and has been shown to increase the risk of developing pneumonia.
134. A 64-year-old female presents to the emergency department with a 10-day
history of increasing
shortness of breath and mild tachycardia. On examination she has an oxygen
saturation of 75%on room
air.

Whlch one of the following additional findings would suggest a diagnosis of acute
$@@%@$ distress syndrome (ARDS)?

A. Improved oxygen saturation with supplemental oxygen

B. Improvement of lter symptoms with diuretic therapy
C. Bilateral air space opacities seen on a chest radiograph
D. A flattened diaphragm seen on a chest radiograph
E. A right lower lobe infiltrate seen on a chest radiograph

ANSWER: C

Acute respiratory distress syndrome (ARDS) will often present similarly to

pneumonia and heart
failure with dyspnea, hypoxemia, and tachypnea. ARDS typically does not respond to
supplemental
oxygen or diuretic therapy. Patients decompensate quickly and usually require
mechanical
ventilation. Chest radiographic findings include bilateral airspace opacities but
not a localized
infiltrate as with pneumonia, venous congestion or cardiac enlargement as with
heart railure, or a
flattened diaphragm (associated with COPD).

fi O

155. The American Thoracic Society/Infectious Diseases Society of America

guidelines recommend
which one of the following for the diagnosis and initial management of non- severe
community-acquired pneumonia in adults?
A. Use of a validated clinical prediction rule to determine the need for
hospitalization
B. Urine antigen testing for Legionella
C. Blood and sputum cultures to guide therapy
D. Procalcitonin to determine the need for antibacterial therapy
E. Coverage for methicillin-resistant Staphylococcus aureus (MRSA)

ANSWER: A

The American Thoracic Society (ATS) and the Infectious Diseases Society nf America
(IDSA) guideline
recommends use of a validated clinical prediction rule, preferably the Pneumonia
Severity Index
(PSI), to determine the need for hospitalization in adults diagnosed with
community-acquired
pneumonia (CAP) (strong recommendation). The yield of blood cultures is around 2%
(outpatients) to
9% (inpatients) in adults with non-severe CAP. A sputum culture and a Gram stain of
story
secretions are recommended in patients classified as having severe CAP, or in those
with strong
risk factors for methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas
aeruginosa.
Randomized trials have railed to show a benefit for urinary antigen testing for
Streptococcus
pneumoniae and Legionella. ATS/IDSA guidelines recommend empiric antibiotic therapy
for adults with
clinically suspected and radiographically confirmed CAP regardless of the initial
serum
procalcitonin level (strong recommendation). Coverage for MRSA is not recommended
in patients with
nut risk factors for MRSA pneumonia.

173. A 2-year-old male with a barking cough is brought to the urgent care clinic by
his parents. He
is noted to have stridor when agitated and mild retractions. He has a normal level
of
consciousness, good air entry, and no evidence of cyanosis.

Which one of the following treatment modalities would be most appropriate?

A. Dexamethasone
B. Heliox
C. Humidified air inhalation
D. Nebulized epinephrine
E. Oxygen

ANSWER: A

Based on the Westley Croup Score, this patient has mild croup. Corticosteroids
should be used in
the treatment of croup regardless of the degree of severity. Dexamethasone is
preferred because it
can be given in a single dose and administered either orally, parentally, nr
intravenously. Heliox
is a helium and oxygen mixture that theoretically decreases airflow resistance but
there is no
clear evidence to support its use at this time. Humidified air inhalation has not
been shnwn to
have a clinical benefit in terms of croup scores or hospital admissions. Nebulized
epinephrine
should be reserved for patients with moderate to severe croup. Oxygen should be
administered if
there are signs of hypoxemia or severe i'dto distress.

180. A 25-year-old primigravida presents to your office in her second trimester

with a 24- hour
history of fever, cough, and myalgias. A nasal swab is positive for influenza A.
She has a
temperature of 38.6°C (101.5°F), a heart rate of 100 beats/min, a rate of
15/min, a blood
pressure of 100/64 mm Hg, and an oxygen saturation of 98% on room air. On
examination the patient
is warm to the touch with mild cervical lymphadenopathy and moist mucous membranes.
Her lungs are
clear to auscultation bilaterally without wheezes, crackles, or rhonchi. A
cardiovascular
examination reveals a regular rate and rhythm without murmurs, rubs, or gallops. An
abdominal
examination is normal.
Which one of the following would be the medication of choice for this patient?

A. Baloxavir marboxil (Xofluza)

B. Oseltamivir (Tamifiu)
C. Peramivir (Rapivab)
D. Zanamivir (Relenza)

ANSWER: B

Antiviral medications are recommended for the treatment of influenza only within 48
hours of
symptom onset (SOR A). However, in high-risk patient populations and in severe
cases of disease,
antivirals should be provided regardless of the duration of symptoms (SOR B).
According to the CDC,
oseltamivir remains the drug of choice for the treatment of influenza during
pregnancy because it
has good safety data. Baloxavir marboxil is indicated for patients »12 years of age
but should be
avoided during pregnancy. There is less safety data for peramivir and zanamivir.

19G. Which one of the following psychoactive medications would create the greatest
risk of
@@sIaF”70'?"ry depression if used in combination wlth an opiold?

A. Amitriptyline
B. Bupropion (Wellbutrin)
C. Escitalopram (Lexapro)
D. Lorazepam (Ativan)
E. Trazodone

ANSWER: D

The FDA has issued a safety communication about combining benzodiazepines with
either opioids or
cough medications. The FDA expressed its strongest warning due to the risk of
central nervous
system (CNS) depression and respiratory depression. Also, the 2016 CDC guideline
for prescribing
oploids for chronic pain recommended specifically that clinicians should avoid
prescribing opioid
pain medication and benzodiazepines concurrently whenever possible.

While caution should be exercised with all medication combinations, there has not
been a specific
FDA warning about the risks of combining opioids with amitriptyline, bupropion,
escitalopram, or
trazodone. Antipsychotics, barbiturates, benzodiazepines, hypnotics, muscle
relaxants, and opioid
analgesics are associated with an increased risk of CNS depression.

32. A SS-year-old female with diabetes mellitus and hypertension sees you because
or a I- month
history of a persistent nonproductive cough. Two weeks after the cough began she
presented to a
local urgent care center with additional symptoms of sinus pressure, rhinorrhea,
and subjective
wheezing. A lung examination and chest radiograph performed at that visit were
unremarkable.She was
diagnosed with acute bronchitis and prescribed benzonatate (Tessalon). Since then,
her
sinus-related symptoms have abated, although her cough has not improved. Her
current medications
include metformin (Glucophage), lisinopril (Prinivil, Zestril), and
hydrochlorothiazide, all of
which were initiated 6 months ago. She has no known allergies and has never smoked.
A physical
examination today is unremarkable.

Which one of the following is the most likely cause of her cough?

A. Chronic (iiij disease

B. Infection
C. Malignancy
D. A medication side effect
E. A psychogenic habit

ANSWER: D

Of the choices listed, an adverse effect of medication, specifically lisinopril, is

the most likely
cause of this patient's persistent cough. ACE inhibitors are among the most common
causes of
chronic cough, with an estimated incidence of 5%-35% of patients. The onset of an
ACE
inhibitor—induced cough may occur within hours to months after the first d e. A
proper evaluation
of patients presenting with a chronic cough, which is defined in adults as a
persistent cough
lasting >8 weeks, begins with a careful history, with attention to smoking status,
environmental
exposures, and medication use.

4 1. A 69-year-old male sees you for a routine examination and asks about }ong
cancer screening. He
smoked one pack of cigarettes per day for about 35 years but quit 11 years ago.

According to the U.S. Prevenfive Services Task Force and the American College of
Chest Physicians,
which one of the following should you recommend?
A. No screening
B. An annual history and examination focusing on lung symptoms
C. Annual chest radiography
D. Annual low-dose chest CT

ANSWER: D

The U.S. Preventive Services Task Force and the American College of Chest
Physicians support
screening for lung cancer with annual low-dose CT in patients 50—80 years of age
who have a
20-pack- year smoking history and who currently smoke or have smoked within the
past 15 years.
There is no evidence to support an annLlal history and physical examination or
annual chest
radiography as screening tools for lung cancer.

8›f›. A 70-yoar-old mate presents wtth a 2•year history or gr•duaI\y progressive

ezertional
dyspnea associated with a dry cough and fatigue. A physical examination reveals
bilateral basll2r
One inspiratory cracMes on {ñfjg ausrulcatton and acroryanos\a A chest radlograph
demonstrates hazy
opactdes and rctlcular infiltrates of both lower lung fields. You suspect
Interstitial lung
disease.

Sflmlng that no underlying connective tissue disease is identified on serologic

testing, which one
o£ tote following additional studies could confirm a diagnosis of irfiopathiE
pulmonary fibrosis
for this parent, potentially preventing the need for a subsequent lung

A. Spirometry
B. tltgh-resolution chest CT
C. Po]ysomnography
D. EChocardiograyhy
E. Right heart catheterlzation

Thus patient's presentation Is ryplcal (0r idiopathfr pulmonary fibresls{lPFj, a

chronk-and
progressive subtype of ftbrotic intersbtla\ hung disease (OLD) wlth an unknown
c•use, which affects
oldrr men more than other Individuals. f•1nny patients who arc ultimately diagnosed
wtth ILD
initially receive a diagnosis rcopD ••h‹ rt failure. Somr patients experience
dyspnea and dry
cough up to 5 years before ILD Is recognized. Although IPF Is associated with a
hlgh morta\iiy
rate, ment advances have been made in drug therapies that slow the mte or disease
progrtss\on, so
eor\y recognition and diagnosis of this condition In the primary care setting Ts
key to improving
paNent outcomes.

Nearly all patients wlth IPF experience chronlc exertlonaT dyspnea. Other common
symptoms include
chronic nonpr0duCtive cough and (at fgue. BfTateraf Wt•fcro•flke“ rracMer are
nearly universal.
Ofher common exam\natIox findings Include digital clubbing, ocrocyanosls. and
resting hypoxemlz
Chest radiographs are ofter‹ nor¥rla] or show nonspecific findings early In the
disease course.
Common find\ng$ later in the disease include bilateral rctjcular Infiltrates In the
Power lung
zones, hazy opacities, anb how insplratory lung volumes.
Once ILD is suspected, further evaluation Is Indicated to deteoolne a more spec4f)c
dlagnosls, as
man2gement and prognosis differ by type. or‹h‹ options listed, on\Y high-
resolutlon chest CT has
the potentlal to provide a specific diagnosis of IPF, whlch usually has a
chamcterlsnc pattern of
btlatera\ reticulatlon and honeycombing In the lung periphery and In the lower
lobes trrmed uruaJ
/ntcrstJt/aJ pneumonia. Spirometry usually shows a restrlrbve pattern, although It
may be normal \n
easy disease or with comorbid emphysema. The presence of reactive physiology Is not
specific to IPF
but Is seen more generally wtth other forms of ILD as welL PoTysomnography may
Identify an
aNocJated sleep dlsorde», surf› as obstructive sleep apnea, but does not factor
into maMng the
diagnosis of IPF.

70. A 60-year-old male comes to your office with a 1-year history of the gradual
onset of mlld r
tigue and dyspnea. There are nn symptom trlggers. He has a 20-pack•year hlstnry nf
cigarettesmoking
but stopped at age 35. In examination is significant only for a BMI of 30 kg/m*.
Office splrometry
reveals a decreased FVC and a normal FEVi/FVC ratlo, and there are no changes after
bronchodilator
administration.

Which one of the following would §0u recommend at tttis point?

A. The 6-ml nute walk test

B. Brnnchoprovocatlon testlng such as a methacholine challenge test
c. Full pulmonary function testlng
D. BronchOSCO y
E. A ventilation-perfusion scan

ANSWER: C

Family physicians are often required t0 manage dyspnea and evaluate common Imre
spirometry results.
The American Thoracic Sociel:y recommends full pulmonary function testing when
office spirometry
suggests a restrtctive pattern, which Is the case with this patient's normal
FEV1/FVC ratio and
decreased FVC. Full laboratory puimonary function testing glves further information
ab0ut gas
exchange and volumes, which allows a more definitive diagnosis

The 6-minute walk test Is used to evaluate treatmdft response for known
cardiopulmonary disease.
Bronchoprovocation testing helps identify asthma triggered by allergens or exercise
whRft Office
spirometry is normal. Bronchoscopy is an invasive test that is not indicated at
this point in the
evaluation. A ventilation-perfusion scan Is not appropriate because pulmonary
embolus Is not
strnngly suspected.

osteoporosis pmenu Mth a 2-day history of fmr. chtMa and a gnxtucc rv r•uBIt She
I1vcs at homr wtth
her husband, who has not noted any conI'udon but czys ahe has been

On examination the patient has a temperature of 3B.2'C (I006”F}, a blnod juessure

of 1t0/68 rem
llg, unluboced respirations at c mte of 22/min, and an oxygen safuracion of 91% on
room air. You
note that she has good air entry, there are I+e abnormd breath

WBCS

platelets prtailnlne BUfi

Labocalory Findings

14 /r•m* (N 4500- 11.000)

IM $/dL (N 14 0- I J'S) 250,000/mm' (Ft ISo,000-250.000)
I.0 mg/dL (N 06-I.2) Ie mg/dL (N 8-73)

posiereanteñor and lateral chest radlo$rapiu show an lnfiltnie la the rti;;hi

mlddle lobe.
Wltlch one of the follovñng would be Lhe most approprtau cre*tmr't ! !
patlent7

A Azlthrom In thromax)

L A moxtclllln/rIavuLsnate (ñu€monUn) plus cdt hromyrtn

D, Aelthrornycln plus levofI•zacI•
E ClIndamj«1n (CIe‹ In) P! °^^

ANSWER- C
pneumonLs

mellitus).

\zeated as an outpAtTenC

sLould be p
fifiie

t4 she M n be

Ion. but It
mlthron›yci« n onotherapy. •mexirtlliwplus metzonkLzzolc. '*

141. A patient's office spirometry results demonstrate an obstructive pattern.

This would be seen
with which one of the following?

A. Asbestosis exposure
B. Cystic fibrosis
C. Idiopathic pulmonary fibrosis
D. Nitrofurantoin exposure
E. Sarcoidosis

ANSWER: B

Office spirometry can be very helpful in the development of a differential

diagnosis. The
differential can be narrowed with the use of office spirometry, as many conditions
create either an
obstructive or restrictive pattern. 0f the optlons listed, only cystic fibrosis can
cause an
obstructive pattern. Other causes of an obstructive pattern include asthma, COPD,
alpha1-antitrypsin deficiency, and bronchiectasis, among others. Common diseases or
conditions
causing restrictive patterns include adverse reactions to nitrofurantoin,
methotrexate, and
amiodarone. Chest wall conditions such as kyphosis, scoliosis, and morbid obesity
can also cause
restrictive patterns. Interstitial Jung disease, including idiopathic pulmonary
fibrosis,
sarcoidosis, and asbestosis, also causes a restrictive pattern (SORA).

1411. In patients diagnosed with COPD, testing should be considered for which one
of the following
underlying conditions?

A. ‹Alpha i-Antitrypsin deficiency

B. Cystic fibrosis 84
C. Hemochromatosis

D. Williams syndrome
E. Wi\son's disease

ANSWER: A

Clinicians should consider measuring the alpha 1-antitrypsin level in all

symptomatic COPD patients
with fixed airflow obstruction, particularly with a COPD onset as early as the
fifth decade «r
rife; a ramily history or alpha l-antitrypsin deficiency; and emphysema,
bronchiectasis, liver
disease, or panniculitis in the absence of a recognized risk factor. Identifying
this condition is
particularly important because current smokers should be urged to quit, given that
they are at high
risk for accelerated uang function decline, and also to consider intravenous pDoled
human alpha
1-antitrypsin, which has been shown to reduce declines in lung function and lung
density measured
on chest CT. In this patient, testing for cystic fibrosis, hemochromatosis,
Williams syndrome, or
Wilson's disease would not be indicated.

194. A 56-year-old female with a history of stage III non—small cell !ung cancer
who is currently
receiving radiation treatment and chemotherapy sees you because of a poor appetite
and a 4.5-kg
(10-lb) weight loss in the past month. She requests medication to improve her
appetite and
youconslder prescribing megestrol (Megace).

Which one of the following is a possible side effect associated with the use of
megestrol in this
patient?

A. Hirsutism
B. Hypoglycemia
C. Improved libido
D. Thrombocytopenia
E. A venous thromboembolic event

ANSWER: E

Megestrol increases the risk of venous thromboembolic events in patients with

cancer who are
receiving chRmotherapy (SOR C). Megestrol can also cause adrenal suppression,
diabetes mellitus,
and cardiomyopathy, and it is associated with alopecia, hyperglycemia, decreased
libido, and sexual
dysfunction. Megestrol is nut associated with hirsutism, hypoglycemia, improved
libido, or
thrombocytopenia.