Question of the Week # 470

470) An 11-year-old with a history of asthma and seasonal allergies is currently using albuterol to manage asthma symptoms. Recently his use of albuterol has increased from 1-2 days per week to 4 times per week for several weeks, though does not experience his symptoms daily. On physical examination, you find that his vital signs are within normal limits. Auscultation of his lungs reveals mild end expiratory wheezing. Given his persistent symptoms, what change should be made to his current treatment regimen?

A. Add salmeterol twice daily

B. Add montelukast 10mg daily

C. Add fluticasone daily

D. Add formoterol + budesonide twice daily

E. Add tiotropium

Question of the Week # 425

425) A 80 day old african american woman with advanced dementia is admitted to the intensive care unit for overwhelming sepsis secondary to a urinary tract infection. At presentation she was hypoxemic and was subsequently, intubated and placed on a ventilator. Blood and urine cultures are obtained and she is started on antibiotics A chest x-ray post-intubation shows endotracheal tube in place and bilateral diffuse alveolar infiltrates. On examination, his pulse is 110/min, Blood pressure is 110/80 mm Hg and respiratory rate is 18/min with the patient on Assist-Control mode on the ventilator. Pulse oximetry reveals 88% on Fio2 90%. Chest examination reveals diffuse crackles. Cardiac examination reveals tachycardia, there is no S3 gallop. Brain natriuretic peptide level is 50 pg/ml . A 2D echocardiogram shows normal left ventricular function with an ejection fraction of 60%. His ventilator settings are as follows : Assist-Control mode; Fio2 ( Fraction of inspired oxygen) : 90%, Respiratory rate : 18/minute, Tidal Volume : 500 ml, PEEP ( Positive End expiatory Pressure) : 5 cm H20 . Arterial blood gas analysis reveals ( on Fio2 70%): pH : 7.36, pCo2 : 45 mmHg, pO2 : 55 mm Hg, Bicarbonate : 23 Meq/L

Which of the following is indicated at this time?

A) Intravenous Furosemide

B) Swan-Ganz Catheter Placement

C) Increase PEEP by 3 cm H20

D) Increase Tidal Volume to 650 ml

E) Increase Fio2 to 100%

Question of the Week # 334

334) A 50 year old male nurse is evaluated in your office for a recently discovered lung nodule. About 1 month ago, he had whole body CT scans because he read over the internet that these can be helpful in early detection of cancer. A high resolution CT scan of chest revealed a 7 mm nodule with very smooth edges. The margins are well-defined and there is no calcification. The patient has never smoked in his life and he has no family history of cancer. He has no other risk factors for lung cancer.  He denies any night sweats, weightloss or chronic cough. His recent Tuberculin skin test was negative. Laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits.

Which of the following is the most appropriate management option?

A) Obtain a Positron Emission Tomography scan ( PET/CT scan)

B) No further follow-up

C) CT guided biopsy of the nodule

D) Follow-up CT scan at 6-12 months and then at 2 years if no change

E) Refer to Cardiothoracic surgery for Wedge Resection

Question of the Week # 329

329) A 62 year old man presents to your office complaining of dry cough for past several months. Recently, he also noticed shortness of breath on exertion. He denies any fever, hemoptysis or weight loss. He has no history of infections. He does not smoke. He worked as a soft-ware consultant for past 40 years. He has no other medical problems and has never been hospitalized.  On examination, he is afebrile, blood pressure 120/80 mm Hg, RR 18/min and Pulse 82/min. There are no palpable chest-wall masses or lymphadenopathy. On auscultation, fine crackles are heard at bilateral lung bases. A high resolution CT scan of the lungs shows sub-pleural cyst formation with honey combing. The patient undergoes an open lung biopsy for confirmation of diagnosis. Which of the following histo-pathological patterns is likely to be found in this condition?

A) Non-specific Interstitial Pneumonia ( NSIP)

B) Desquamative Interstitial Pneumonia (DIP)

C) Usual Interstitial Pneumonia (UIP)

D) Bronchiolitis Obliterans Organizing Pneumonia (BOOP)

E) Acute Interstitial Pneumonia (AIP)

Question of the Week # 328

328) A 66 year old man is seen in your office for progressive shortness of breath on exertion for the past one year. He also reports dry cough. He denies any fever, hemoptysis or weight loss. He has no history of infections. He denies smoking. He has no other medical problems and has never been hospitalized.  On examination, he is afebrile, blood pressure 120/80 mm Hg, RR 18/min and Pulse 82/min. There are no palpable chest-wall masses or lymphadenopathy. On auscultation, crackles are heard all over the lung fields, more pronounced at lung bases. Extremities show mild digital clubbing.

A chest x-ray is shown below:

 

Which of the following is expected to be seen with this disease?

A) Young age at onset

B) Rapid progression

C) High Resolution CT scans showing ill-defined cysts and pleural plaques

D) Poor or no response to steroids

E) Obstructive pattern on Pulmonary function tests

Question of the Week # 326

326)  A 55 year old african-american man presents to your office with complaints of shortness of breath that has slowly progressed over the past several months. He also reports chest pain which in non-pleuritic in nature. He has lost about 10lbs weight in the past three months. He has changed several jobs but he currently works as a sales representative for a drug company. On examination, his temperature is 100F, Pulse 98/min, RR 20/min and Blood Pressure 100/60 mm HG.  He is in mild distress due to shortness of breath. On chest examination, there is dullness to percussion over the right side of the chest. No masses are palpable. Laboratory investigations reveal WBC 8k/μl with normal differential, Hgb 10.5gm%, Platelets 550k/μl, Calcium 11.2gm% ( (Normal 8.9 to 10.5 mg%)

A chest-x-ray is shown below:

Which of the following element in the history would be most helpful in making a presumptive diagnosis of his presentation?

A) Smoking

B) Family history of Cancer

C) Bone pain

D) Flank pain and Hematuria

E) Previous Occupation

Question of the Week # 270

270 )  A 62 year old man presents with complaints of chronic cough for the past two years. Cough occurs mostly in the morning and is associated with mild sputum production. Lately, he has noticed mild shortness of breath on exertion. He denies any chest pain or weightloss. He has a 50 pack year history of smoking. He has been counselled against smoking several times in the past but he believes it is quite difficult for him to quit smoking. He is concerned about lung cancer and requests if he can placed on an annual screening protocol. A chest x-ray and a CT scan of the chest show changes consistent with chronic obstructive pulmonary disease. There is no evidence of malignancy. Which of the following is the most appropriate screening recommendation for this patient?

A) Sputum Cytology every 6 months

B) Chest X-ray annually

C) No Screening

D) Spiral CT scan annually

E) PET scan annually

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