Download Pulmonary Blueprint

Pulmonary Blueprint
Questions, Answers and Explanations
Question 1
1. Your patient is a 12 month old male that presents with stridor, drooling, and
respiratory distress. This started suddenly. Chest x ray reveals a thumb print
sign. Patients vital signs are as follows: HR 172, Temp 102, SaO2 91% RR
64. Which of the following is the best management plan?
A.
B.
C.
D.
Racemic Epinephrine Aerosol and supplemental oxygen
Decadron 4 mg IM
Heated aerosolized mist
Intubation
Answer 1
1. Choice D is the correct answer. Given the thumb print
sign on x ray, drooling, and stridor this patient has epiglottis
clinically. This patient is not stable and needs his airway
protected, intubation is the correct answer. Aerosols and
intramuscular injections should be avoided so the child
does not get agitated and get more upper airway edema.
Heated aerosolized mist may actually make the child
worse.
Question 2
2. A 28 year old female who is healthy presents with a productive cough and
fever. He has had shaking episodes and chills. Her sputum has been rusty
colored. Her chest x ray shows a RML pneumonia. Gram stain is positive for
gram positive shaped diplococci. Which of the following is the most likely
diagnosis?
A.
B.
C.
D.
Tuberculosis
Pneumococcal pneumonia
Legionella
Pulmonary Embolus
Answer 2
2. Choice B is the correct answer. Pneumococcal
pneumonia presents usually in young, healthy individuals
with a lobar pneumonia. Patients frequently will have chills
and shakes. Tuberculosis presents with hemoptysis, night
sweats, weight loss, and cavitary lesions in the upper lobes
on chest x-ray. Pulmonary emboli typically will not have a
lobar pneumonia with it.
Question 3
3. A 34 year old with multiple comorbidities presents with "flu like" symptoms
that resolved 48 hours ago. He has a high fever and cough still. His chest
exam reveals rales and rhonchi throughout. His gram stain reveals large gram
positive cocci occurring in pairs. Which of the following is the most likely
diagnosis?
A.
B.
C.
D.
Influenza pneumonia
Mycoplasma Pneumonia
Haemophilus Influenzae
Staphylococcal Pneumonia
Answer 3
3. Choice D is the correct answer.
Staphylococcus on gram stain are cocci that
occur in pairs. Influenza would not grow on
gram stain. Mycoplasma can be confirmed by
sputum culture or cold agglutinin titer.
Haemophilus is usual in vaccinated individuals.
Question 4
4. Which of the following is true regarding influenza
pneumonia?
A. It presents with as a lobar pneumonia
B. It is the most common cause of viral pneumonia in
children
C. Ceftriaxone is the drug of choice
D. It causes significant morbidity and mortality
Answer 4
4. Choice D is the correct answer. Influenza pneumonia
causes significant morbidity and mortality in children. It
usually presents as more of an interstitial pneumonia. The
most common viral pneumonia in children is RSV.
Ceftriaxone is a third generation cephalosporin and is not
effective against influenza. Tamiflu is the drug of choice in
the appropriate age group and if started in the first 48 hours
of onset of symptoms.
Question 5
5. Which of the following is not a characteristic of bacterial
pneumonias?
A.
B.
C.
D.
Usually lobar pneumonias
Usually accompanied by a pleural effusion
Usually have bulging fissures
Usually are in the upper lobes
Answer 5
5. Choice D is the correct answer. Bacterial
pneumonias are usually found in the middle
and lower lobes. They are usually lobar.
Upper lobes pneumonia should make the
clinician suspicious for tuberculosis.
Question 6
6. Your patient is a 54 year old that just underwent a thoracentesis. His results
are as follows: serum protein < 0.5, LDH 100 IU/mL, specific gravity of <
1.016, ratio of pleural fluid LDH to serum LDH of < 0.6, and pleural fluid protein
of 2 gram/dL. Which of the following is the most likely diagnosis?
A.
B.
C.
D.
Infection
Pulmonary Embolism
CHF
Infarction
Answer 6
6. Choice C is the correct answer. These are
transudate findings with pleural fluid. The low
serum protein, the low low LDH, and the low
pleural fluid to serum LDH ratio. CHF is the
most common cause of transudative pleural
effusions.
Question 7
7. Your patient is a 24 year old healthy male that presents
with hemoptysis. The remainder of his past medical history,
exam, and vital signs are normal. Which of the following is
the most likely diagnosis?
A. Pneumonia
B. Tuberculosis
C. Bronchogenic Carcinoma
D. Bronchitis
Answer 7
7. Choice D is the correct answer. Bronchitis is
the most common cause of hemoptysis in the
US. With pneumonia and tuberculosis you
would expect some abnormal history or
physical findings. It would be unusual for a
healthy 24 year old to develop bronchogenic
carcinoma.
Question 8
8. Your patient is a 24 year old male that presents with left sided chest pain and shortness of breath.
His vitals are as follows HR 112, RR 24, Temp 98.7, SaO2 94%. His chest x ray is below. Which of the
following is the best management plan?
A. Arrange for immediate bronchoscopy and biopsy
B. Start on Levaquin 750 mg IV daily
C. Insert a 28 French chest tube on the left side at the 4th or 5th interspace
D. Observation and oxygen supplementation
Answer 8
8. Choice C is the correct answer. This patient has over a
15 percent pneumothorax on the left side. So observation
is not appropriate. This pneumothorax does not appear to
have any blood so a 28 or 32 french is appropriate. If there
is a hemothorax a 36 or 40 French would be
appropriate so it can drain effectively. This finding on the
left side is not a pneumonia or mass. There is missing lung
markings consistent with a pneumothorax.
Question 9
9. Your patient is a 50 year old that presents with blood in his
mouth. The blood is frothy, red with a normal pH. Which of the
following is the most likely source of the blood?
A. Pulmonary
B. Upper GI
C. Stomach
D. Duodenum
Answer 9
9. Choice A is the correct answer. Frothy red
sputum tends to be pulmonary in origin
because it mixes with edema. In addition the
pH is normal so this essentially excludes a GI
etiology. Another possibility but not likely is a
nosebleed. Blood from a nosebleed typically is
not frothy.
Question 10
10. Your patient is a 34 year old male that presents with an acute asthma
attack. He has had Solumedrol 125 mg IV, and a two hour continuous aerosol
of albuterol and is feeling better. His lungs are clear, his vital signs are normal
and he wants to go home. Which of the following things to consider in his
history before you discharge him home that may make you consider him high
risk for discharge?
A. He cannot pay for his medicine
B. He is a smoker
C. He was intubated 2 months ago
D. All of the following make him high risk for discharge and should be observed
Answer 10
10. Choice D is the correct answer. This patient should
likely be observed given he is a smoker, and had a recent
intubation. These make him high risk for relapse and
morbidity and mortality. In addition if he cannot afford his
medications, this would make him high risk for discharge.
Social services should be involved in his care.