Question 1

A 72-year-old woman is found to be severely short of breath at her skilled nursing facility. The patient was recently hospitalized for vertebral osteomyelitis and discharged 2 weeks ago to complete a 6-week course of piperacillin-tazobactam via a peripherally inserted central venous catheter. Her dyspnea began only with exertion but is now also present at rest. Medical history includes coronary artery disease with ischemic cardiomyopathy, chronic obstructive pulmonary disease, and chronic kidney disease. She has had 2 hospitalizations for heart failure over the last year; noninvasive positive-pressure ventilation was required. Paramedics observe the patient to be obtunded with agonal respirations and rales throughout the bilateral lung fields. Oxygen saturation is 72% on room air. She is intubated and transferred to the emergency department. On arrival, the patient is minimally responsive to stimuli. Temperature is 36.7 C (98 F), blood pressure is 115/65 mm Hg, and pulse is 110/min and regular. The patient's oxygen saturation is 88% on 100% inspired oxygen. BMI is 19 kg/m². The trachea is midline. On physical examination, rales are heard on the right side and markedly decreased breath sounds on the left side of the chest. S3 is heard. There is 2+ bilateral peripheral edema. A chest x-ray reveals the following: After the intervention is performed, the patient's oxygenation improves. She is transferred to the medical intensive care unit and treated with diuretics and bronchodilators. Two days later, her ventilation requirements have improved to 50% inspired oxygen and 5 cm of positive end-expiratory pressure. The patient's respirations suddenly become dys-synchronous with the ventilator, and her oxygen saturation drops to 85%. Tidal volume spontaneously decreases from 350 to 200 mL. Temperature is 37.2 C (99 F), blood pressure is 125/60 mm Hg, pulse is 110/min, and respirations are 25/min. Physical examination shows that the trachea is midline and the endotracheal tube is in place. No jugular venous distension is present. Breath sounds are markedly decreased on the right side. A portable chest x-ray reveals the following: Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: Positive-pressure ventilation allows for improved oxygenation in patients with an alveolar-filling process (eg, pulmonary edema, pneumonia); however, it also poses the risk of pulmonary barotrauma, leading to alveolar rupture and subsequent air leakage into undesired parts of the body (eg, subcutaneous tissue, mediastinum, pleural space). This patient has developed a potentially serious complication of pulmonary barotrauma, a large pneumothorax. A large pneumothorax can quickly lead to tension physiology, resulting in compression of mediastinal structures and marked hypotension; however, the normal blood pressure and absence of jugular venous distension and tracheal deviation in this patient suggest that a tension pneumothorax has not yet developed. Patients with a large pneumothorax often demonstrate tachycardia, tachypnea, hypoxemia, and decreased or absent breath sounds on the affected side. In patients on mechanical ventilation, measured tidal volume markedly decreases due to an increase in airway resistance. Bedside ultrasound has become the diagnostic test of choice for pneumothorax in the critical care setting, but if performed, chest x-ray demonstrates a pleural line with an absence of distal lung markings. Management involves placement of a chest tube, which allows for definitive management of the pneumothorax with suction. chest x-ray (Choice A) Decreasing sedation is appropriate when attempting to wean a patient off the ventilator but is not appropriate in this patient. Sedation typically allows for optimal respiratory synchrony with the ventilator; decreasing sedation in a hypoxemic patient who is intubated and mechanically ventilated typically results in worsening hypoxemia. (Choice B) Temporarily disconnecting the ventilator and providing bag ventilation with long expiration time is the appropriate treatment for auto-positive end-expiratory pressure (auto-PEEP), a condition caused by insufficient duration of the expiratory phase resulting in accumulated air pressure in the lungs. However, large pneumothorax requires decompression of the pleural space (eg, chest tube). (Choice C) Increasing the PEEP is likely to cause further barotrauma and increased air pressure in the pleural space, resulting in worsening of the pneumothorax. (Choice D) Needle decompression is appropriate emergency treatment of a tension pneumothorax in a patient in whom cardiac arrest is imminent. However, needle decompression must always be followed by chest tube placement for definitive management; therefore, placement of a chest tube is more appropriate in this patient who has not yet developed tension physiology. Educational objective: Pulmonary barotrauma is a risk of mechanical ventilation and can lead to pneumothorax. Placement of a chest tube is the preferred initial treatment of a large pneumothorax in a patient who has not developed tension physiology. References: Pneumothorax: an update. (http://www.ncbi.nlm.nih.gov/pubmed/17621614)

Question 2

A 60-year-old man with a history of chronic obstructive pulmonary disease comes to the office due to hemoptysis.  For the past several days, he has had increasing cough with greenish-yellow sputum.  He also had 2 episodes of blood-streaked sputum, which prompted the clinic visit.  The patient has mild dyspnea but no fever or chest pain.  His other medical problems are peripheral vascular disease and osteoarthritis.  His current medications include aspirin, inhaled fluticasone and salmeterol, and ipratropium.  He continues to smoke 1/2 pack of cigarettes daily and drinks alcohol occasionally.  The patient had a screening CT scan 2 years ago that was negative for lung mass.  His father died of lung cancer.  Blood pressure is 140/95 mm Hg and heart rate is 100/min.  The patient's pulse oximetry shows 95% on room air.  Lung auscultation reveals bilateral expiratory wheezing. Soon after the patient leaves the office, his wife calls and requests information about her husband's condition.  She is also the treating physician's patient.  Which of the following is the most appropriate response to her request?

Accepted Answer

Explanation: Confidentiality is one of the basic tenets of medical ethics. It underscores patient privacy and autonomy. Information about a patient's condition, including that obtained by history taking and chart review, should not be discussed with family and friends unless the patient authorizes the physician to do so. The best response in this case is to inform the patient's wife that the information about the patient's condition cannot be shared without his consent because it is considered confidential. (Choices A, C, and D) In some situations, the risk of withholding information outweighs the principles of confidentiality. Examples are general public health issues (eg, public officials and people at risk should be informed about cases of reportable infectious diseases) or cases in which a third party could be harmed (eg, suicidal/homicidal patient or impaired driver). This patient's case is not an exception to confidentiality principles. (Choice E) This statement may sound offensive and does not explain why the physician is unable to share patient information. Educational objective: Information about a patient's condition, including that obtained by history taking and chart review, should not be discussed with family and friends unless authorized by the patient.

Question 3

A 40-year-old woman is brought to the emergency department by paramedics after a motor vehicle collision.  She was driving and wearing a seatbelt when her car was hit by another vehicle from the opposite direction.  Her car went off the road and hit a tree.  When paramedics arrived at the scene, the patient was noted to have an open femur fracture but was alert and oriented.  Her medical issues include hyperlipidemia and mitral valve prolapse with mild regurgitation.  She takes no medications.  The patient undergoes open reduction and internal fixation of the femur fracture.  She receives intravenous fluids and pain control postoperatively.  The next morning she experiences left-sided chest discomfort and shortness of breath.  Temperature is 37.6 C (99.7 F), blood pressure is 120/70 mm Hg, pulse is 100/min, and respirations are 30/min.  Pulse oximetry shows 84% on room air.  Physical examination reveals an area of tenderness over the left chest wall where the seatbelt was placed.  On pulmonary examination, the patient has rales over the left upper lung.  A 2/6 holosystolic murmur is present over the cardiac apex.  Laboratory results are as follows:
 ECG shows sinus tachycardia with no ST-segment or T-wave changes.  Chest x-ray shows irregular opacification predominantly of the left upper lung.
Adequate pain control and supplemental oxygen by nasal cannula is provided and the patient's respiratory distress improves.  Pulse oximetry shows 96% on 3 L/min supplemental oxygen.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: Patients in whom there is suspicion of significant pulmonary contusion should be admitted to the hospital and monitored for 24-48 hours. In those who develop respiratory symptoms, treatment involves adequate pain control to avoid hypoventilation, as well as supportive care to include pulmonary hygiene (eg, chest physiotherapy, suctioning) and supplemental oxygen and ventilatory support as needed. With adequate support and monitoring, most patients experience resolution of symptoms within 3-5 days. (Choice A) Fluid management goals in patients with pulmonary contusion are somewhat controversial; however, it is generally recommended to maintain patients at or near euvolemia. Diuresis and fluid restriction are not indicated in the absence of overt volume overload. (Choice B) Patients with pulmonary contusion are at increased risk of developing pneumonia; however, prophylactic antibiotics are not indicated. Supportive care, including pain control and pulmonary hygiene, is the best course of management for preventing pulmonary infection. (Choice C) Mechanical ventilation in the form of noninvasive positive pressure or endotracheal intubation is sometimes required for severe pulmonary contusion; however, this patient's symptoms have responded to pain control and supplemental oxygen, and mechanical ventilatory support is not currently indicated. (Choice E) Therapeutic dose heparin infusion is appropriate management for acute pulmonary embolism, but it is not indicated for the management of pulmonary contusion. Educational objective: Pulmonary contusion is best managed with adequate pain control and supportive care to include pulmonary hygiene and supplemental oxygen and ventilatory support as needed. References: Selective management of flail chest and pulmonary contusion. (http://www.ncbi.nlm.nih.gov/pubmed/7125734)

Question 4

A 40-year-old woman is brought to the emergency department by paramedics after a motor vehicle collision.  She was driving and wearing a seatbelt when her car was hit by another vehicle from the opposite direction.  Her car went off the road and hit a tree.  When paramedics arrived at the scene, the patient was noted to have an open femur fracture but was alert and oriented.  Her medical issues include hyperlipidemia and mitral valve prolapse with mild regurgitation.  She takes no medications.  The patient undergoes open reduction and internal fixation of the femur fracture.  She receives intravenous fluids and pain control postoperatively.  The next morning she experiences left-sided chest discomfort and shortness of breath.  Temperature is 37.6 C (99.7 F), blood pressure is 120/70 mm Hg, pulse is 100/min, and respirations are 30/min.  Pulse oximetry shows 84% on room air.  Physical examination reveals an area of tenderness over the left chest wall where the seatbelt was placed.  On pulmonary examination, the patient has rales over the left upper lung.  A 2/6 holosystolic murmur is present over the cardiac apex.  Laboratory results are as follows:
 ECG shows sinus tachycardia with no ST-segment or T-wave changes.  Chest x-ray shows irregular opacification predominantly of the left upper lung.
What is the most likely cause of this patient's respiratory symptoms?

Accepted Answer

Explanation: This patient's respiratory symptoms are most likely due to a pulmonary contusion. Blunt trauma to the lungs results in accumulation of edema and blood in a localized area of the lung parenchyma. Patients typically have chest pain and may develop accompanying shortness of breath and hemoptysis, and chest x-ray characteristically shows an irregular, localized opacification at the site of injury. The onset of respiratory symptoms may be delayed for approximately 24 hours from the time of injury, and initial chest x-ray sometimes demonstrates no airspace disease. CT scan is more diagnostically sensitive; however, contusions that are apparent on CT scan but not on chest x-ray are often minor and may be of low clinical significance. Depending on the size of the contusion, respiratory distress and significant hypoxemia can develop. (Choice A) Acute respiratory distress syndrome describes noncardiogenic pulmonary edema that typically results from a systemic disease process (eg, sepsis, pancreatitis) or lung injury (eg, toxic inhalation). The pulmonary edema is typically diffuse and bilateral rather than localized as in this patient. (Choice B) Cardiogenic pulmonary edema most often results from left ventricular systolic dysfunction. Trauma patients may experience cardiac contusion resulting in impaired left ventricular contraction and resulting pulmonary edema; however, as in acute respiratory distress syndrome, the pulmonary edema is typically diffuse and bilateral. (Choice C) Fat embolism syndrome is a potential complication of long-bone (eg, femur) fracture and can result in respiratory distress with hypoxemia. However, accompanying neurologic symptoms (eg, confusion) and a petechial rash are often present, and chest x-ray typically shows no airspace disease. (Choice E) Femur fracture increases the risk of acute pulmonary embolism, and the typical presentation is with chest pain and shortness of breath. However, the irregular opacification in the left lung and corresponding chest tenderness at the site of seatbelt contact make pulmonary contusion more likely. Educational objective: Pulmonary contusion is a common injury resulting from blunt chest trauma. Patients typically have chest pain and may develop respiratory distress and hypoxemia that is delayed up to 24 hours from the time of injury. Chest x-ray characteristically shows an irregular, localized lung opacification. References: Pulmonary contusion in the pan-scan era. (http://www.ncbi.nlm.nih.gov/pubmed/26708426)

Question 5

A 61-year-old Caucasian female presents to her primary care physician complaining, "I feel terrible lately, coughing much worse than normal.  Just very nauseated and tired.  My head is pounding and my husband says I'm especially irritable."  She also attests to a gradual increase in thirst and a generalized weakness.  She has a history of mitral valve prolapse and well-controlled hypertension.  Her only medications at this time are atenolol and a multivitamin.  From the age of 19, she has smoked one pack of cigarettes per day.  She drinks socially on the weekends.  Physical examination reveals a thin, pale woman who is mildly wheezing but otherwise appears normal.  Chest x-ray shows a four centimeter perihilar mass and increased hilar opacity.  What is the most likely diagnosis?

Accepted Answer

Explanation: Syndrome of inappropriate antidiuretic hormone (SIADH) can be caused by a multitude of conditions, including tumors, drugs, and disorders of the chest and central nervous system. SIADH is associated with normovolemic hyponatremia and, in this case, is caused by small cell carcinoma (Choice D). In SIADH, the urine is concentrated but the patient is not volume depleted. Initially, the symptoms are mild and nonspecific, but as the serum sodium declines (especially <120 mEq/L), neurologic symptoms, seizures, and coma may ensue. Asbestosis (Choice A) occurs more often in construction and shipyard workers and generally occurs approximately 20 years after the initial exposure to asbestos. The condition is characterized by dyspnea on exertion, cough, chest tightness, and wheezing. Pulmonary fibrosis is evident on CXR or chest CT. Mesothelioma (Choice B) is linked to asbestos exposure. Mesothelioma is often characterized by dyspnea and chest pain, and CXR shows nodular thickening of the pleura and/or obscuring of the diaphragm. Large cell carcinoma (Choice C) accounts for 10-15% of all lung cancers and typically manifests on CXR as a large peripheral mass. Symptoms may include cough and dyspnea. Severe pain may be reported if the parietal pleura or chest wall are infiltrated. Squamous cell carcinoma (Choice E) accounts for 25-30% of all lung cancers and typically manifests on CXR as a cavitary lesion in a bronchus. Symptoms may include cough, dyspnea, wheezing, and hemoptysis. This type of lung cancer is sometimes associated with hypercalcemia due to parathyroid like hormone production. Educational Objective: Syndrome of inappropriate antidiuretic hormone (SIADH) is associated with normovolemic hyponatremia and can be caused by small cell carcinoma of the lung.

Question 6

A 59-year-old man comes to the office for a routine wellness examination.  The patient's medical history includes chronic bronchitis, hypertension, hypertriglyceridemia, and basal cell carcinoma.  He smokes a pack of cigarettes per day, with a total 40-pack-year history.  The patient typically consumes 1 or 2 cans of beer each night.  Family medical history is remarkable for heart disease and diabetes mellitus.  The patient had a normal screening colonoscopy 5 years ago.  A chest x-ray from a year ago shows changes consistent with chronic bronchitis. 
The patient asks if he is at increased risk for lung cancer because of his smoking history.  What is the most appropriate response by the physician?

Accepted Answer

Explanation: 11ec2b69_c080_5929_8f63_312f8913b56a_MD0005_00 Long-term smokers are estimated to be at a 10- to 30-fold increased risk of developing lung cancer, with the cumulative cancer risk approaching 30% in heavy smokers versus 1% in nonsmokers. Screening chest x-ray has not been shown to be effective in diagnosing lung cancer or reducing morbidity or mortality rates. However, screening current and former smokers with annual low-dose helical CT scan reduces the number of lung cancer deaths. Current guidelines recommend screening beginning at age 50 for patients with a significant smoking history (ie, those with ≥20 pack-years who currently smoke or quit within the past 15 years) (Choice D). The risk for lung cancer declines with cessation of smoking, and screening can be discontinued once a patient has not smoked for 15 years. Screening generally should continue through age 80. However, it may be discontinued in patients who develop other conditions that significantly limit life expectancy or the ability to tolerate aggressive therapy, especially surgery, for lung cancer. (Choice A) Basal cell carcinoma is a common skin malignancy. It typically has an indolent course and is easily resectable. Basal cell carcinoma is linked primarily to sunlight exposure and does not appreciably increase the risk of lung cancer. (Choice B) Lung cancer and chronic bronchitis are associated with smoking, and the risk for lung cancer is significantly higher in patients with chronic bronchitis than it is in the general population. However, recommendations for lung cancer screening are based primarily on smoking history. Also, CT scan is the recommended screening modality, not chest x-ray. (Choice E) Sputum cytology has low sensitivity for lung cancer screening and is not recommended. Educational objective: Lung cancer screening by annual low-dose helical CT scan is recommended for patients age 50-80 who have a ≥20-pack-year smoking history and are current smokers or quit within the past 15 years. References: Screening for lung cancer: US Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/33687470)

Question 7

A 79-year-old woman is hospitalized after a fall that resulted in a left femoral neck fracture.  She tripped over her dog while cleaning her home, hit her head on a bookshelf, and landed on her left side.  Prior to this she had been in her usual state of health; her other medical issues include obesity, type 2 diabetes mellitus, hypertension, chronic kidney disease, and hypothyroidism.  The patient lives at home by herself.  She has smoked a pack of cigarettes daily for 38 years.  She drinks alcohol every weekend.  Results of the patient's initial workup in the emergency department demonstrated the left femoral neck fracture, creatinine of 2.0 mg/dL, and a negative noncontrast head CT.  She was admitted to the hospital and the following day underwent surgical repair.  The procedure was uncomplicated.  However, on postoperative day 3 the patient is noted to be uncomfortable and mildly agitated.  She is unable to coherently explain her symptoms.  Current medications include prophylactic subcutaneous heparin, insulin glargine, omeprazole, hydrocodone, and levothyroxine.  Temperature is 37.7 C (99.9 F), blood pressure is 104/68 mm Hg, pulse is 114/min, and respirations are 28/min.  Pulse oximetry is 86% on room air.  Examination shows equal round and reactive pupils.  Lung examination demonstrates decreased breath sounds at the bilateral bases.  Heart rhythm is regular with normal S1 and S2.  The surgical incision shows no surrounding erythema or purulent drainage.  The patient follows commands and moves all extremities except the left leg.  Laboratory results are as follows:
 Troponin I is undetectable.  Chest x-ray shows slight bibasilar atelectasis without focal consolidation, pleural effusion, or pulmonary edema.  ECG shows sinus tachycardia but is otherwise unremarkable.
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient likely has an acute pulmonary embolism (PE). Recent surgery and immobilization, tachycardia, and absence of a more likely alternate diagnosis give her a modified Wells score >4, which indicates likely pretest probability of PE. Hypoxemia that is out of proportion to chest x-ray findings and active smoking further increases the probability of an acute PE. Although receipt of prophylactic heparin reduces the risk of acute PE, it does not preclude the diagnosis. modified Wells score CT angiogram of the chest is typically preferred for diagnostic confirmation of acute PE; however, due to impaired renal function, intravenous contrast should be avoided. Therefore, ventilation-perfusion scan is most appropriate. In the setting of likely pretest probability for acute PE, a high-probability ventilation-perfusion scan confirms the diagnosis. (Choice A) Intravenous antibiotics, preceded by the collection of appropriate cultures, are appropriate for management of suspected sepsis. This patient's lack of fever, absence of consolidation on chest x-ray, and several risk factors for PE make sepsis less likely. (Choice B) Benzodiazepines (eg, lorazepam) are appropriate treatment for suspected alcohol withdrawal. Patients typically have a history of heavy alcohol use and present with signs of sympathetic nervous system activation (eg, agitation, tachycardia, hypertension) 48-96 hours following hospital admission. This patient's risk factors for PE and lack of hypertension make alcohol withdrawal less likely. (Choice C) Naloxone is an opiate receptor antagonist used to reverse the effects of opioid (eg, hydrocodone) overdose. Opioid overdose can cause hypoxemia due to hypoventilation; however, patients should be somnolent with decreased respiratory rate and pinpoint pupils. This patient's tachypnea and round and reactive pupils are not consistent with opioid overdose. (Choice D) CT scan of the head would be appropriate if intracranial hemorrhage were suspected. This elderly patient is at risk for developing a subdural hematoma following her fall; however, subdural hematoma would not explain her hypoxemia and tachycardia, and the initial negative head CT makes the diagnosis less likely. Educational objective: Hip fracture, recent surgery or immobilization, and smoking increase the risk of acute pulmonary embolism (PE), and PE can occur despite treatment with prophylactic heparin. In patients with impaired renal function, ventilation-perfusion scan is most appropriate to evaluate for acute PE; in the setting of likely pretest probability, a high-probability ventilation-perfusion scan confirms the diagnosis. References: Radionuclide diagnosis of pulmonary embolism. (http://www.ncbi.nlm.nih.gov/pubmed/27620309)

Question 8

A 20-month-old girl is brought to the emergency department due to cough and fever.  She had nasal congestion and a dry cough yesterday, but the symptoms are worse today.  The patient developed a fever overnight and the cough is now more forceful.  Her father says, "She was coughing so hard that it sounded like she couldn't breathe."  Her appetite is mildly decreased, but she has been drinking water and juice frequently throughout the day.  The patient's immunizations are up to date, and she takes no medications.  Temperature is 38.1 C (100.6 F), pulse is 100/min, and respirations are 28/min.  Physical examination demonstrates an awake, alert patient playing with a toy on her father's lap.  When the examiner approaches her, she cries and has an episode of harsh, brassy coughing followed by mild inspiratory stridor.  The nares are patent with clear rhinorrhea, the pharynx has no erythema or exudate, and the tympanic membranes are clear.  S1 and S2 are present without murmurs.  The lungs are clear to auscultation, but there are mild intercostal retractions.  The abdomen is soft and nontender without organomegaly.  There are no rashes or lesions.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c07f_6ec5_8f63_0dadd8e71a18_MD0005_00 Croup (laryngotracheitis) is a parainfluenza viral infection of the larynx and trachea that peaks in the fall and early winter. Croup usually affects children age <3. Clinical manifestations include rhinorrhea, cough, and fever, which progress to the sudden onset of a harsh, barking cough; inspiratory stridor; and hoarseness. Stridor in mild croup occurs with agitation and activity, whereas children with moderate/severe croup have stridor, retractions, and distress at rest.Croup is usually diagnosed clinically. Viral testing and x-rays are not indicated when the presentation and examination are characteristic. A posterior-anterior neck x-ray can be ordered for uncertain cases and may reveal the steeple sign due to subglottic narrowing (Choice D). x-ray Croup is generally a self-limited illness and usually resolves within a week. Treatment for mild croup consists of humidified air to soften secretions and decrease drying of inflamed mucosal surfaces. A single dose of corticosteroids (either as an oral liquid or intramuscular injection) can be given to reduce stridor, which often worsens at night. Corticosteroids plus nebulized epinephrine should be administered for moderate/severe croup to relieve upper airway obstruction. Moderate/severe croup often improves significantly after treatment. Patients who are hypoxic and whose condition worsens or does not improve should be hospitalized for repeated doses of nebulized epinephrine. (Choice B) Nebulized beta agonists, such as albuterol, are the first-line treatment for asthma exacerbations as they relax smooth muscle to relieve lower airway bronchoconstriction. Asthma presents with wheezing rather than stridor, and beta agonists are ineffective for croup as it is an upper airway disease. (Choice C) Intravenous antibiotics are the treatment for bacterial pneumonia, which also presents with fever, cough, and tachypnea. However, stridor is not characteristic, and rales or crackles would be expected on auscultation. Antibiotics have no role in the treatment of croup, as it is a viral illness. (Choice E) Endotracheal intubation is critical in a child with epiglottitis, which also presents with fever and stridor. However, cough is absent in epiglottitis, and patients appear toxic (high fever, drooling, leaning forward, severe respiratory distress). Educational objective: Croup is a parainfluenza viral infection characterized by a barking cough and stridor. Mild croup is treated with humidified air and corticosteroids; moderate/severe croup is treated with corticosteroids plus nebulized epinephrine. References: Viral croup: diagnosis and a treatment algorithm. (http://www.ncbi.nlm.nih.gov/pubmed/24596395) Nebulized epinephrine for croup in children. (http://www.ncbi.nlm.nih.gov/pubmed/24114291) Glucocorticoids for croup. (http://www.ncbi.nlm.nih.gov/pubmed/21249651)

Question 9

A 60-year-old man with a history of chronic obstructive pulmonary disease comes to the office due to hemoptysis.  For the past several days, he has had increasing cough with greenish-yellow sputum.  He also had 2 episodes of blood-streaked sputum, which prompted the clinic visit.  The patient has mild dyspnea but no fever or chest pain.  His other medical problems are peripheral vascular disease and osteoarthritis.  His current medications include aspirin, inhaled fluticasone and salmeterol, and ipratropium.  He continues to smoke 1/2 pack of cigarettes daily and drinks alcohol occasionally.  The patient had a screening CT scan 2 years ago that was negative for lung mass.  His father died of lung cancer.  Blood pressure is 140/95 mm Hg and heart rate is 100/min.  The patient's pulse oximetry shows 95% on room air.  Lung auscultation reveals bilateral expiratory wheezing. 
Which of the following is the best initial step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c07e_f994_8f63_877e199f3bb1_MD0005_00 This patient's worsening cough with sputum production suggests acute bronchitis causing an exacerbation of underlying chronic obstructive pulmonary disease (COPD). Airway inflammation in acute bronchitis can cause erosion of the superficial vessels, leading to hemoptysis, which is usually scant or small in volume. Plain chest radiograph remains the initial test of choice as it may identify the site and cause of bleeding (eg, cavitary lesion, lung mass, or stigmata of mitral stenosis) in over one-third of patients. In combination with the clinical picture, a chest radiograph may also help direct further management (bronchoscopy versus CT scan). mitral stenosis (Choice A) Further evaluation, such as fiberoptic bronchoscopy to reveal endobronchial carcinoma, should be based on initial chest x-ray findings and the degree of clinical suspicion of a specific cause. (Choice C) Patients at high risk for lung cancer should have a CT scan to rule out malignancy. This patient's acute presentation and absence of alarming symptoms (eg, chronic cough, weight loss) argue against development of malignancy since his CT scan 2 years ago. Chest CT should be considered only if the hemoptysis persists despite treatment of COPD exacerbation. (Choices D and E) Sputum cytology and culture are of little significance in demonstrating the cause of hemoptysis. They also have little diagnostic significance in patients with COPD. Educational objective: Chest x-ray abnormalities may suggest a variety of specific causes in patients with hemoptysis, including malignancy, focal infection (eg, pulmonary tuberculosis), or heart disease (eg, mitral disease). References: ACR appropriateness criteria® hemoptysis. (http://www.ncbi.nlm.nih.gov/pubmed/24717602)

Question 10

A 59-year-old man comes to the office due to cough and mild dyspnea.  His symptoms began 10 days ago with nasal congestion and a sore throat, which improved spontaneously after a few days.  However, the cough, productive of white sputum, has persisted.  He has also had an episode of blood-streaked sputum.  The patient has a history of hypertension and stable coronary artery disease.  He is a current smoker with a 20-pack-year history.  The patient is a car salesman and has not traveled recently.  Temperature is 36.7 C (98.1 F), blood pressure is 110/72 mm Hg, and respirations are 18/min.  Lung examination shows scattered wheezes bilaterally.  Chest x-ray demonstrates no parenchymal infiltrate or consolidation, but a 2-cm peripherally located nodule is present in the left lower lobe.  No prior chest imaging is available. 
Which of the following is the most appropriate initial step in management of this patient?

Accepted Answer

Explanation: This patient has a solitary pulmonary nodule (SPN), which is defined by the following features: Rounded opacity ≤3 cm in diameter (>3 cm is considered a "mass") Surrounded by pulmonary parenchyma No associated lymph node enlargement The first step in evaluating an SPN is to compare previous x-rays or CT scans; a nodule with stable size and appearance over 2-3 years has a low risk for malignancy and requires no further workup. If the SPN has changed in size or appearance from previous imaging or if no previous imaging is available, the next step is to obtain a CT scan of the chest. CT scan has high sensitivity and may identify other SPNs that either are too small to detect on x-ray or are located in areas obscured on x-ray (eg, costophrenic angles). CT scan also allows for better characterization of the appearance of an SPN. An SPN that is partially solid (heterogenous) or has a spiculated (spikes radiating from the surface), rather than rounded, surface is more likely to be malignant. In contrast, an SPN with a ground-glass appearance is less likely to be malignant. (Choices B and E) This patient's cough, initially accompanied by a sore throat and nasal congestion, is likely due to a resolving viral upper respiratory infection unrelated to the SPN. Antibiotics are not indicated and are unlikely to be helpful. Sputum analysis for acid-fast bacteria is also not indicated, as active mycobacterial infection is unlikely in the absence of chronic symptoms (eg, fever, weight loss). (Choice C) Reassurance and symptomatic treatment are appropriate for this patient's viral upper respiratory infection; however, the SPN may represent malignancy and needs to be further investigated. (Choice D) Repeat chest x-ray in 2-3 months is unlikely to be helpful in evaluating this SPN, and it would allow time for a malignant SPN to further progress. Educational objective: A solitary pulmonary nodule (SPN) is defined as a round opacity ≤3 cm in diameter and surrounded by pulmonary parenchyma. Because an SPN can be malignant, its appearance should be compared to that on previous imaging. Patients with no previous imaging or an SPN that has grown or changed in appearance should undergo CT scan of the chest for further investigation. References: Diagnosis and management of solitary pulmonary nodules. (http://www.ncbi.nlm.nih.gov/pubmed/20477238) The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy. (http://www.ncbi.nlm.nih.gov/pubmed/19484354)

Question 11

A 4-year-old boy is brought to the office due to snoring.  For the past 5 months, his mother has heard loud snoring at night, with pauses in his breathing followed by gasping for air.  Medical history is significant for 2 episodes of otitis media that resolved with antibiotic therapy.  The patient is up to date with vaccinations.  He attends day care 5 days a week.  His father smokes outside the home.  The family has a cat.  Height is at the 40th percentile and weight is at the 15th percentile.  On physical examination, the patient appears well.  The tympanic membranes are clear with no middle ear effusion.  The nose is clear with no rhinorrhea.  Oral examination shows good dentition and tonsillar hypertrophy.  The lungs are clear to auscultation and heart sounds are normal.  Which of the following is the best next step in management?

Accepted Answer

Explanation: 11ec2b69_c083_db9f_8f63_f3ed5877461a_MD0005_00 This child with loud snoring, pauses in breathing, and gasping for breath during sleep likely has obstructive sleep apnea (OSA). As in adults, OSA in children is a sleep disorder in which episodic upper airway obstruction results in difficulty breathing and disrupted sleep. This often manifests as restless sleep, loud snoring, periods of apnea, and gasping for breath at night. Other symptoms in children may include enuresis and parasomnias. In adults, OSA is often associated with obesity, so weight loss is usually recommended. In contrast, young children with OSA are often underweight, and severe cases may result in failure to thrive. In these patients, adenotonsillar hypertrophy contributes to a significant narrowing of the upper airway, resulting in intermittent obstruction. Therefore, first-line management for pediatric OSA is tonsillectomy and adenoidectomy. (Choice A) Recurrent infections early in life may contribute to adenotonsillar hypertrophy, but this patient has no symptoms of a bacterial infection that would require antibiotics. Although antibiotics sometimes temporarily decrease tonsil size, they would not result in permanent improvement in the airway caliber. (Choices B and C) Changing sleep position and continuous positive airway pressure may be recommended as therapy for OSA in adults. In young children, adenotonsillectomy is often curative, obviating the need for an intervention unlikely to be successful due to significant difficulty with adherence. (Choice D) Some children with OSA may benefit from avoiding environmental allergens (eg, cat) or irritants (eg, tobacco smoke), but it is unlikely that this alone would resolve OSA symptoms. Therefore, this is recommended as adjuvant, rather than initial, therapy. Educational objective: In contrast to the treatment for obstructive sleep apnea (OSA) in adults, first-line therapy for OSA in children is tonsillectomy and adenoidectomy. References: Clinical practice guideline: Tonsillectomy in children (update). (http://www.ncbi.nlm.nih.gov/pubmed/30798778) Detection of common respiratory viruses in tonsillar tissue of children with obstructive sleep apnea. (http://www.ncbi.nlm.nih.gov/pubmed/24574078)

Question 12

A 43-year-old man comes to the office with his wife for evaluation of his snoring. His wife reports that he snores loudly most nights and keeps her awake, but she has not observed him choke, gasp, or stop breathing while asleep. The patient is unaware of his snoring and reports no morning headaches, memory loss, or poor concentration. He occasionally falls asleep after lunch while seated at his desk. He reports no fatigue, weight gain, or constipation. His medical problems include seasonal allergies and hypothyroidism. The patient's medications include intranasal fluticasone and levothyroxine. He drinks 12-24 ounces of beer daily, usually 1-2 hours before going to bed. He does not use tobacco or illicit drugs. Both his parents have hypertension. Temperature is 36.8 C (98.2 F), blood pressure is 125/75 mm Hg, pulse is 65/min, and respirations are 16/min. BMI is 26 kg/m² and neck circumference is 39.4 cm (15.5 in). Physical examination reveals an alert, oriented, and cooperative man in no distress. Oropharyngeal examination is normal. No nasal polyps or septal deviation is seen, and the nares are normal in appearance. Cardiac examination reveals normal first and second heart sounds and no jugular venous distension. The lung fields are clear bilaterally. No edema or rashes are present. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: Snoring is a common phenomenon caused by respiration-induced soft tissue vibrations in the setting of a relaxed upper airway during sleep; it can be an isolated finding or a sign of more serious upper airway pathology such as obstructive sleep apnea (OSA). This patient is most likely experiencing habitual snoring in the absence of OSA; although snoring is usually present in patients with OSA (high sensitivity), >50% of patients who snore do not have OSA (low specificity). Surveys, such as the STOP-Bang questionnaire, have poor positive predictive value but high negative predictive value for OSA; patients with a score <3 are unlikely to have OSA and do not require diagnostic testing. Other than habitual snoring and male sex, this patient does not have other characteristics suggestive of OSA, including observed apneas, elevated blood pressure, BMI >35 kg/m², age >50, and neck circumference >43 cm (17 in). Occasionally falling asleep while sitting quietly after lunch is not unusual and does not meet criteria for excessive daytime sleepiness. Although not included in the STOP-Bang survey, absence of either morning headaches or poor concentration during the day also makes OSA less likely. STOP-Bang questionnaire Both smoking (due to an unknown mechanism) and alcohol consumption before bedtime (likely due to relaxation of pharyngeal muscles) are associated with increased snoring. The best initial management of this patient's isolated habitual snoring is to eliminate alcohol intake prior to bedtime. When appropriate, smoking cessation and weight loss are also suitable initial management strategies. (Choices B and C) Monitoring of nocturnal oxygen saturation is a preliminary diagnostic test for OSA, and polysomnography is the gold standard diagnostic test for OSA. Diagnostic testing is not needed in this patient with low clinical probability of OSA. (Choices D and E) Oral appliances are effective at reducing snoring by physical manipulation of the upper airway (eg, mandible advancement, tongue retraction), and uvulopalatopharyngoplasty may reduce snoring through surgical removal of upper airway tissue. However, lifestyle changes to reduce snoring should be pursued prior to these more invasive and costly therapies. Educational objective: Many patients who snore do not have obstructive sleep apnea (OSA); in the absence of other evidence suggesting OSA (eg, hypertension, excessive daytime sleepiness), snoring is not an indication for diagnostic testing for OSA. Smoking cessation and elimination of alcohol intake before bedtime are preferred initial management strategies for snoring. References: Does this patient have obstructive sleep apnea?: The Rational Clinical Examination systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23989984) Bedtime ethanol increases resistance of upper airways and produces sleep apneas in asymptomatic snorers. (http://www.ncbi.nlm.nih.gov/pubmed/3064641)

Question 13

A 38-year-old woman in the intensive care unit is evaluated for worsening hypoxia. The patient was admitted a week ago due to dyspnea and nonproductive cough. At that time, diffuse crackles were found on lung examination, and chest x-ray revealed bilateral infiltrates. The patient smoked crack cocaine and used intravenous heroin prior to symptom onset. She required endotracheal intubation due to hypoxic respiratory failure and has been mechanically ventilated. Her respiratory condition has gradually improved over the past week, but in the last 2 days she has required a higher fraction of inspired oxygen. The patient has also had increased tracheobronchial secretions. Temperature is 38.9 C (102 F), blood pressure is 112/71 mm Hg, pulse is 114/min, and respirations are 22/min. Central venous pressure is 8 cm H₂O. Lung auscultation reveals bilateral crackles. Heart sounds are normal with no murmur or gallop. The abdomen is soft and nondistended with normoactive bowel sounds. She has no dependent edema or skin rash. Ventilator settings, arterial blood gases, and laboratory results are as follows: Repeat chest x-ray reveals asymmetric worsening of the lung infiltrate. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c07e_5d53_8f63_57d3642203b7_MD0005_00 This patient initially had acute respiratory distress syndrome (ARDS), likely due to crack cocaine inhalation. The new onset of fever, increased secretions, worsening pulmonary infiltrates, and increased requirement for ventilatory support are consistent with ventilator-associated pneumonia (VAP), a common complication of ARDS. VAP can develop after ≥48 hours of mechanical ventilation and is most commonly caused by microaspiration of virulent oropharyngeal organisms (eg, Escherichia coli, Streptococcus species). Other signs of VAP include leukocytosis, tachypnea, and decreased oxygenation. Due to the nonspecific nature of its presentation and the increasing prevalence of drug-resistant organisms, respiratory sampling is necessary to confirm the diagnosis and appropriately tailor antibiotic therapy. Options include bronchoalveolar lavage or tracheobronchial aspiration. Once sampling has been performed, empiric antibiotics can be initiated while awaiting culture data. The specific regimen depends on individual risk factors for multidrug-resistant organisms and typically includes gram-positive and gram-negative coverage. Patients with risk factors for resistant pathogens should receive coverage for methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. (Choice A) CT pulmonary angiography would be the next step to diagnose acute pulmonary embolism, which more commonly presents with tachycardia, tachypnea, and hypoxia. However, this patient's high fever, leukocytosis, increased tracheobronchial secretions, and worsening pulmonary infiltrates are better explained by VAP. (Choice B) Although negative fluid balance is associated with improved mortality in ARDS, the current decompensation is consistent with sepsis due to VAP, for which diuresis with furosemide is relatively contraindicated. Moreover, this patient does not have elevated central venous pressure, extra heart sounds, or dependent edema, making volume overload unlikely. (Choice C) Mechanical ventilation with patients in prone position may have mortality benefits in severe ARDS, likely due to enhanced gas exchange (through improvements in lung perfusion and transpulmonary pressure differences). However, it is generally reserved for those in whom ventilator settings have been maximized (eg, fraction of inspired oxygen of 100%) and is associated with complications (eg, nerve compression, tube dislodgment). (Choice D) Systemic corticosteroids for the treatment of ARDS remain controversial, but they have no role in the treatment of VAP. Educational objective: Ventilator-associated pneumonia is associated with fever, increased secretions, worsening pulmonary infiltrates, and increased requirements for ventilatory support occurring ≥48 hours after mechanical ventilation. Respiratory sampling is necessary to confirm the diagnosis and appropriately tailor an antibiotic regimen. References: Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. (http://www.ncbi.nlm.nih.gov/pubmed/27418577) Ventilator-associated pneumonia. (http://www.ncbi.nlm.nih.gov/pubmed/25279009)

Question 14

A 74-year-old man with a history of hypertension comes to the clinic asking advice about his recent memory problems. He is accompanied by his wife. The patient says, "I have always been very sharp but over the last year I have had difficulty remembering things. I missed a number of appointments and sometimes I feel embarrassed because I forget names of the people I meet." His wife says he has been moody and irritable and that he complains of headaches; "He doesn't sleep well at nights and we rarely have sex now. I don't know if it's old age or what." The patient reports no nausea, vomiting, falls, weakness, weight loss, fevers, chills, vision changes, or incontinence. Other issues include obesity, diet-controlled type 2 diabetes mellitus, and coronary artery disease. Current medications include lisinopril, atorvastatin, aspirin, and carvedilol. He does not use alcohol, tobacco, or recreational drugs. Family history is unremarkable. Temperature is 36.7 C (98 F), blood pressure is 155/95 mm Hg, pulse is 62/min, and respirations are 14/min. BMI is 34 kg/m² and neck circumference is 45.7 cm (18 in). Examination shows normal jugular venous pressure and no lymphadenopathy. Lung fields are clear, and S1 and S2 are normal. The abdomen is soft and nontender. Examination shows no edema. Mental status examination shows poor concentration and 3-object recall, while other aspects are normal. Cranial nerves are within normal limits. Muscle strength is 5/5 in both upper and lower extremities, and upper and lower limb deep tendon reflexes are 2+. Gait is normal. The patient's complete blood count and metabolic panel are normal. Other laboratory results are as follows: Which of the following is the best response to this patient's concerns?

Accepted Answer

Explanation: This patient's memory problems are most likely due to undiagnosed obstructive sleep apnea (OSA). The nocturnal hypoxia caused by OSA has been linked to cognitive impairment in the elderly, including irritability, poor concentration, and decreased short-term memory. The STOP-Bang questionnaire outlines a number of features suggestive of OSA. This patient's age >50, male sex, neck circumference >43.2 cm (17 in), and elevated blood pressure place him at intermediate risk of having OSA (score of 4). BMI >30 kg/m², chronic headaches, and poor sleep provide further suggestion of OSA. STOP-Bang questionnaire Given this patient's numerous signs and symptoms suggestive of OSA, and his mild cognitive impairment that can be reasonably attributed to OSA, evaluation for OSA with polysomnography (sleep study) is the most appropriate next step in management. (Choice A) It is likely that this patient's memory impairment is related to undiagnosed OSA, and is potentially correctable with appropriate treatment. Advising the patient that his symptoms are related to normal aging, and implying that there is no treatment available, would be inappropriate. (Choice B) Although this patient demonstrates poor concentration and poor 3-object recall, these symptoms can be attributed to OSA. His mental status examination is otherwise normal, making dementia unlikely. (Choice C) Polypharmacy is not of great concern in this patient, who is taking just 4 medications that constitute appropriate treatment for diabetes and coronary artery disease. Beta blockers (eg, carvedilol) are associated with generalized fatigue and irritability in some patients, but OSA is a more likely cause of his presentation given the multiple signs and symptoms suggestive of OSA. (Choice D) MRI of the brain to rule out a brain lesion is of very low diagnostic yield in the absence of any focal neurologic deficits on physical examination. Normal pressure hydrocephalus is a potential cause of cognitive impairment in the elderly and can be diagnosed by MRI, but it is unlikely in the setting of normal gait. Educational objective: Obstructive sleep apnea (OSA) is associated with mild cognitive impairment (eg, irritability, poor concentration, decreased memory) in the elderly. Elderly patients with mild cognitive impairment and signs and symptoms suggestive of OSA (eg, neck circumference >43.2 cm, elevated blood pressure) should be evaluated with polysomnography. References: Evidence of neurodegeneration in obstructive sleep apnea: Relationship between obstructive sleep apnea and cognitive dysfunction in the elderly. (http://www.ncbi.nlm.nih.gov/pubmed/26301370) Nocturnal hypoxia and neuropsychological variables. (http://www.ncbi.nlm.nih.gov/pubmed/3722349) Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. (http://www.ncbi.nlm.nih.gov/pubmed/21828324)

Question 15

A 56-year-old obese female comes to the emergency department (ED) for evaluation of sudden-onset left-sided lower chest pain and shortness of breath. Her past medical history includes cholelithiasis, hypertension, hypothyroidism, and hyperlipidemia. Her medications are hydrochlorothiazide, amlodipine, aspirin, and levothyroxine. She has a 35-pack-year smoking history and continues to smoke one pack of cigarettes daily. Initial work-up in the ED reveals a large left-sided pulmonary embolism, left lower lobe pulmonary infarction, and right popliteal vein thrombosis. She is admitted to the hospital and started on subcutaneous enoxaparin and warfarin. On the third hospital day, she develops weakness and dizziness and produces 500 ml of coffee grounds emesis. Physical examination reveals a temperature of 36.7 C (98 F), heart rate of 110/min, blood pressure of 98/54 mmHg, and respiratory rate of 26/min. Her hemoglobin level is 9.8 g/dL (12.6 g/dL on admission) and platelet count is 320,000/mm³ (210,000/mm³ on admission). Upper gastrointestinal endoscopy shows multiple stomach ulcers and erosions. She is started on high-dose pantoprazole. Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: This patient received appropriate initial management of her pulmonary embolism (PE) including anticoagulation with subcutaneous enoxaparin and warfarin. However, she has now had a complication of anticoagulation in the form of upper gastrointestinal bleeding from previously undiagnosed stomach ulcers. The large drop in her hemoglobin, plus the accompanying tachycardia and borderline blood pressure, tell us that this bleed was substantial. The patient should be resuscitated with fluids and her anticoagulation stopped. Placement of an inferior vena cava (IVC) filter would be appropriate at this time. Indications for IVC filter placement include: complications of anticoagulation, contraindications to anticoagulation, or failure of anticoagulation in the setting of a known DVT or PE. (Choice A) Continuing both the enoxaparin and warfarin would place the patient at risk for continued gastrointestinal hemorrhage and would not be appropriate. (Choice B) Continuing the enoxaparin alone would also place the patient at risk for future gastrointestinal hemorrhage. (Choice C) Continuing only the warfarin would leave the patient inadequately anticoagulated in the short term and would risk recurrent gastrointestinal hemorrhage once the patient's INR becomes therapeutic. (Choice E) Aspirin is not adequate anticoagulation for a patient with a pulmonary embolism. Educational objective: Anticoagulation with heparin or a low molecular weight heparin followed by oral warfarin is the treatment of choice for a patient with pulmonary embolism. An IVC filter is recommended in patients with complications of anticoagulation, contraindications to anticoagulation, or failure of anticoagulation.

Question 16

A 1-month-old boy is brought to clinic by his mother due to concerns about his breathing.  The mother states that over the past week she has noticed several episodes in which "he just stops breathing and then takes a lot of quick breaths."  She adds, "He does it many times within a minute and then seems to breathe normally again.  It really scares me."  The infant has had no cyanosis, coughing, choking, fevers, or abnormal eye or limb movements.  He is exclusively breastfed and is given vitamin D daily.  The infant was born at 36 weeks gestation via normal spontaneous vaginal delivery after preterm premature rupture of membranes.  He spent a week in the neonatal intensive care unit for temperature instability and feeding difficulties, and was discharged with no remaining medical issues.  Family history is notable for a maternal cousin with epilepsy.  Temperature is 36.7 C (98 F), blood pressure is 80/50 mm Hg, pulse is 132/min, and respirations are 44/min.  Pulse oximetry is 99% on room air.  The patient is tracking along the 30th percentiles for weight, length, and head circumference.  Physical examination shows a well-nourished infant sleeping in his mother's arms.  The heart has a regular rate and rhythm without murmurs, and the lungs are clear to auscultation without apnea, tachypnea, or increased work of breathing.  He has appropriate tone and intact suck, grasp, and Moro reflexes.  Plantar reflexes show upgoing toes bilaterally.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: Periodic breathing is a physiologic breathing pattern characterized by pauses of 5-10 seconds in breathing followed by rapid, shallow breaths. Without stimulation or intervention, a regular rhythm of breathing resumes after several cycles of periodic breathing, as in this patient. Periodic breathing This benign breathing pattern is thought to be secondary to recurrent central apnea due to immaturity of the nervous system in infants up to age 6 months. There is no associated cyanosis, change in tone, or abnormal limb/eye movements. In addition, signs of respiratory distress, such as retractions, nasal flaring, and persistent tachypnea, are not present in infants with periodic breathing. The irregular breathing pattern and brief pauses in breathing may cause alarm in caregivers; reassurance is indicated. (Choice A) Apnea of prematurity is characterized by true apnea and pauses in breathing lasting ≥20 seconds; it typically resolves by a corrected gestational age of 37 weeks (ie, at 1 week of life for a 36-week gestation infant). This infant's pauses in breathing are brief (occurring several times per minute), and his age makes apnea of prematurity unlikely. (Choice C) Seizures are often associated with alterations of consciousness, abnormal limb or eye movements, or cyanosis, none of which are present in this patient. (Choice D) Supraventricular tachycardia can present with episodes of tachycardia and diaphoresis; prolonged tachycardia often presents with symptoms of heart failure (eg, cough, cyanosis, poor feeding). This infant has a breathing pattern consistent with periodic breathing and is otherwise asymptomatic. (Choice E) Tetralogy of Fallot often presents with "tet" spells, episodes of severe cyanosis due to right ventricular outflow obstruction, triggered by agitation. Patients also typically have a systolic ejection murmur. This patient has no murmur or cyanosis. Educational objective: Periodic breathing is a physiologic pattern of breathing in young infants characterized by episodes of alternating pauses (5-10 seconds) in breathing and rapid breathing. These benign episodes can be frightening for caregivers, and anticipatory guidance and reassurance are indicated. References: Apnea, Infant. (http://www.ncbi.nlm.nih.gov/pubmed/28722998) Developmental changes in sleep and breathing across infancy and childhood. (http://www.ncbi.nlm.nih.gov/pubmed/26364005)

Question 17

A 62-year-old woman comes to the office for a preoperative evaluation 3 days before undergoing elective cholecystectomy.  Over the past few months, she has had transient episodes of postprandial abdominal pain after large meals.  Abdominal ultrasound confirms multiple gallstones.  The patient feels well overall but has had 3 days of cough productive of green sputum and worsened dyspnea.  She has a history of chronic obstructive pulmonary disease, myocardial infarction with stenting of the right coronary artery, hypertension, and obesity.  She currently takes aspirin, lisinopril, rosuvastatin, amlodipine, albuterol, and ipratropium.  She has had no previous surgeries.  The patient has smoked a pack of cigarettes daily for 35 years but does not use alcohol or illicit drugs.  Vital signs are within normal limits.  Physical examination reveals moist mucous membranes and normal jugular venous pressure.  Pulmonary auscultation indicates wheezing over the bilateral lung fields and prolonged expiration.  There are no heart murmurs.  No edema is present, and the remainder of the examination is normal.  Which of the following interventions is most likely to reduce the incidence of postoperative pulmonary complications in this patient?

Accepted Answer

Explanation: This patient is scheduled for an elective cholecystectomy in 3 days but has clear symptoms (dyspnea, productive cough) and signs (wheezing, prolonged expiration) of a chronic obstructive pulmonary disease (COPD) exacerbation. To reduce her risk of postoperative pulmonary complications (PPCs), this elective procedure should be delayed until her respiratory status returns to a stable baseline. PPCs are most common after thoracic and upper abdominal surgery due to reduced lung volumes from diaphragmatic dysfunction and splinting (reduction in inspiration depth due to pain). Common PPCs include atelectasis, infection, hypoxia, and respiratory failure. Patients with the following underlying medical conditions are at the greatest risk for developing PPC: COPD Cigarette smoking Sleep apnea Heart failure Prior to undergoing an elective procedure, these conditions should be optimized. This typically includes smoking cessation (ideally >4 weeks prior to the procedure) and the treatment of any heart failure or COPD exacerbation. (Choice A) Nicotine patches can aid in smoking cessation. Patients who stop smoking >4 weeks prior to surgery have lower rates of PPCs and better wound healing. Three days of smoking cessation are unlikely to have a significant impact on the risk of PPCs. (Choices B and D) Incentive spirometry and deep breathing exercises are often prescribed postoperatively with the intent to increase lung volume and minimize atelectasis. However, meta-analysis shows that these therapies have little or no benefit. Incentive spirometry and breathing exercises are not typically prescribed preoperatively and would not likely improve this patient's COPD exacerbation. (Choice C) This patient with a COPD exacerbation will likely receive antibiotics and bronchodilators. However, proceeding with surgery in 3 days will put her at greater risk of PPC. This elective surgery should be delayed until her respiratory function returns to a stable baseline. Educational objective: Postoperative pulmonary complications occur most often in those undergoing thoracic or upper abdominal surgery. Risk is greatest when patients have a history of chronic obstructive pulmonary disease (COPD), cigarette smoking, congestive heart failure, or sleep apnea. Patients with a preoperative COPD or heart failure exacerbation should have surgery delayed until pulmonary and cardiac function is optimized. References: Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25930169) Impact of COPD on postoperative outcomes: results from a national database. (http://www.ncbi.nlm.nih.gov/pubmed/23287892) Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23799418)

Question 18

A 59-year-old man comes to the office due to cough and mild dyspnea.  His symptoms began 10 days ago with nasal congestion and a sore throat, which improved spontaneously after a few days.  However, the cough, productive of white sputum, has persisted.  He has also had an episode of blood-streaked sputum.  The patient has a history of hypertension and stable coronary artery disease.  He is a current smoker with a 20-pack-year history.  The patient is a car salesman and has not traveled recently.  Temperature is 36.7 C (98.1 F), blood pressure is 110/72 mm Hg, and respirations are 18/min.  Lung examination shows scattered wheezes bilaterally.  Chest x-ray demonstrates no parenchymal infiltrate or consolidation, but a 2-cm peripherally located nodule is present in the left lower lobe.  No prior chest imaging is available. CT scan of the chest confirms a 2.2-cm, peripherally located nodule in the left lower lobe surrounded by lung parenchyma.  The nodule has spiculated borders and eccentric calcification on the periphery, and no lymphadenopathy is present.  CT scan of the abdomen reveals no abnormalities of the liver or adrenal glands.  Which of the following is the best next step in management of this patient's lung lesion?

Accepted Answer

Explanation: 11ec2b69_c081_438c_8f63_cbfb960b2648_MD0005_00 The size of a solitary pulmonary nodule (SPN) strongly correlates with the chances of it being malignant. Nodules <0.6 cm are unlikely to be malignant and generally do not require follow-up; however, nodules >0.8 cm require additional management or surveillance. In addition to size, other factors that influence the probability of an SPN being malignant include patient age, sex, smoking history, family history, location of the nodule in the lung, and radiographic appearance of the nodule. Nodules >0.8 cm that are intermediate or high probability for malignancy (ie, ≥5% probability) based on these factors require tissue diagnosis with biopsy or surgical excision. Based solely on its large size (>2 cm), this patient's SPN has >50% probability of being malignant (far exceeding 5%). This probability is further increased by the patient's smoking history and the spiculated appearance of the nodule. For a nodule with such high malignant probability, timely surgical excision is most appropriate; thoracotomy or video-assisted thoracoscopy (VATS) can be both diagnostic and curative. For patients in whom the need for tissue diagnosis is unclear, positron emission tomography (PET) scan can be helpful. Nodules demonstrating high metabolic activity on PET scan are more likely malignant than benign and warrant biopsy or surgical excision. (Choice A) Fiberoptic bronchoscopy with transbronchial biopsy can be appropriate for obtaining tissue diagnosis prior to surgery; however, it is typically useful only for centrally located nodules. This peripherally located nodule would require percutaneous biopsy. (Choice B) Induced sputum cytology has a low sensitivity for detecting malignancy and is generally not helpful in evaluating an SPN. (Choice C) This SPN requires additional intervention, as it has a high chance of being malignant. (Choice E) Surveillance with repeat CT scan in 3, rather than 6, months is appropriate for nodules >0.8 cm that are low probability for malignancy (eg, 1-cm nodule in a 50 year old man with no smoking history). However, expedient tissue diagnosis is needed for the relatively large, spiculated nodule in this man with a significant smoking history. Educational objective: Solitary pulmonary nodules <0.6 cm are unlikely to be malignant, whereas those >0.8 cm require additional management or surveillance. Nodules that are intermediate or high probability for malignancy (ie, ≥5% probability) based on clinical factors (eg, nodule size, patient age, smoking history) should be biopsied or surgically excised. References: Diagnosis and management of solitary pulmonary nodules. (http://www.ncbi.nlm.nih.gov/pubmed/20477238) The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy. (http://www.ncbi.nlm.nih.gov/pubmed/19484354)

Question 19

A 32-year-old man is brought to the emergency department after a motor vehicle accident that resulted in severe head injuries.  The patient was unresponsive and hypotensive when paramedics arrived at the scene.  He was intubated on-site and given aggressive intravenous fluids.  Neurologic imaging reveals multiple cortical contusions, brain hemorrhage, and diffuse axonal injury.  The patient is admitted to the intensive care unit.  Three days later, he continues to require mechanical ventilation.  Temperature is 36.7 C (98 F), blood pressure is 100/45 mm Hg, and pulse is 62/min.  Sedation is held, and the patient is examined.  There is no response to stimuli of any type.  Brainstem reflexes are absent.  The ventilator is temporally disconnected to assess for spontaneous respiration.  No spontaneous breathing movements are visualized, and arterial blood gas results after 10 minutes are consistent with a positive apnea test, confirming brainstem failure.  The patient is declared brain-dead.  His wife informs the medical team that the patient always wanted to donate his organs in the event of unexpected death.  Which of the following is an important component of care to maximize the viability of this patient's organs for donation?

Accepted Answer

Explanation: Most transplanted organs come from donors who meet criteria for brain death. Brain death is associated with several physiologic changes that upset homeostasis and threaten the viability of potential donated organs, including: Central diabetes insipidus, which can increase urine output to >1000 mL/hr and cause volume depletion Systemic hypotension due to loss of sympathetic tone (and volume depletion) Hypothermia To prevent damage to organs, potential donors require aggressive intensive care unit treatment to maintain a euvolemic, normotensive, and normothermic (or mildly hypothermic) state. This is typically achieved by administering intravenous fluids and desmopressin to reduce the diuretic impact of central diabetes insipidus, ionotropic or pressor support to maintain blood pressure, and warm air blankets to maintain temperature. (Choice A) Administering anticoagulation is not indicated as most patients who meet criteria for brain death proceed to organ procurement rapidly to avoid organ damage. (Choice B) Hypercapnia has not been shown to improve organ viability and can damage organs by causing acidosis. (Choices C and D) Keeping the heart rate <60/min and the systolic blood pressure <100 mm Hg by administering medications has not been shown to improve organ viability. It is important to keep the patient normotensive to ensure adequate organ perfusion until procurement occurs. Educational objective: The primary goal of managing a brain-dead organ donor is to maintain a euvolemic, normotensive, and normothermic (or mildly hypothermic) state. Patients often receive intravenous fluids, desmopressin, and pressor support. References: ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation. (http://www.ncbi.nlm.nih.gov/pubmed/19624569) Physiologic changes during brain stem death-lessons for management of the organ donor. (http://www.ncbi.nlm.nih.gov/pubmed/15381167)

Question 20

A physician receives a call from a parent about a 3-year-old boy who started choking and gagging suddenly while playing with a small toy just a moment ago.  The boy is conscious but appears "blue" and is unable to speak.  In addition to advising an immediate call to 911, which of the following is the best recommendation?

Accepted Answer

Explanation: 11ec2b69_c07d_c111_8f63_f343f68d8796_MD0005_00 This child's history is consistent with a complete airway obstruction secondary to foreign body aspiration. Children age >1 with complete airway obstruction are initially conscious but may be cyanotic and unable to speak, cough, or breathe. The American Heart Association recommends that abdominal thrusts (ie, Heimlich maneuver) be administered immediately to conscious children with complete obstruction to dislodge the aspirated object. The rescuer should stand behind the child and lean the child forward; abdominal thrusts should be repeated until the object is dislodged or the patient becomes unconscious. As an alternative, the American Red Cross advises 5 back blows alternating with 5 abdominal thrusts with the child leaning forward in front of the rescuer. Children with partial or complete airway obstruction should be given nothing by mouth as this may result in further airway compromise. Heimlich maneuver (Choices A and E) Children with partial obstruction are able to speak but may be coughing or gagging. They should be allowed to cough up the object on their own and taken to a hospital for further evaluation. All children with suspected aspiration should undergo bronchoscopic evaluation of the tracheobronchial tree to assess for retained foreign bodies. This child requires first aid prior to hospital transport. (Choice B) If the patient becomes unconscious, CPR should be started immediately. Before rescue breaths are administered, the mouth should be opened and inspected for foreign bodies that may have become dislodged. CPR should not be initiated as this patient is currently conscious. (Choice C) Infants age <1 with complete airway obstruction should be placed face down on the rescuer's arm with the head down and receive alternating back blows and chest thrusts. This process should be repeated until the obstruction is relieved or until the patient becomes unconscious, when cardiopulmonary resuscitation (CPR) should be initiated. Educational objective: Abdominal thrusts should be performed immediately in conscious children age >1 with complete airway obstruction. Infants age <1 with complete airway obstruction should be placed face down/head down on the rescuer's arm and receive alternating back blows and chest thrusts. Cardiopulmonary resuscitation should be initiated immediately in unconscious patients. References: Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. (http://www.ncbi.nlm.nih.gov/pubmed/20956229) Diagnostic evaluation of foreign body aspiration in children: a prospective study. (http://www.ncbi.nlm.nih.gov/pubmed/16034756)

Exam 1: Advanced Clinical Medicine