PULMONOLOGY FORM 1

 A 45 y/o man comes to the office with his wife complaining of daytime sleepiness. He has been caught sleeping at work and his boss threatened to fire him next time. He complains of feeling like he hasn’t gotten any sleep when he wakes up. His wife mentions that he has been snoring a lot recently and often wakes up at night gasping for air. She also mentions that he is unable to perform as well as he used to in the bedroom. Based on this patient’s suspected diagnosis, what is the best initial treatment?

A 45 y/o man comes to the office complaining of falling asleep at work. He is a forklift operator and has noticed nodding off many times while at work. He also mentions that he has been feeling tired on awakening with headaches. His BMI is 38. Which of the following will best help confirm his diagnosis?

A 45 y/o man is brought to the ED after a MVA. He says he was driving then suddenly he hit an oncoming vehicle. He has sustained minor injuries but is in stable condition. He complains of minor neck soreness. He is a heavy set individual with a BMI of 32 kg/m2. His neck circumference is 44 cm and examination is limited. His wife is present and mentions that she has seen him wake up gasping for air at night. What is the likely diagnosis?

A 36 y/o man is brought to the ED with a sudden onset of difficulty breathing while eating dinner. A diagnosis of pulmonary embolism is made and IVC placement is considered. Which of the following is a complication of IVC filter placement?

A 45 y/o woman is brought to the ED with sudden onset of shortness of breath while eating dinner. A diagnosis of pulmonary embolism is made. Which of the following is an indication for IVC filter placement?

A 26 y/o man was brought to the ED by his roommate after he collapsed in their apartment. Further questioning reveals he was having difficulty breathing and suddenly passed out.  Investigations reveal a pulmonary embolism. The patient is put on anticoagulation and asked to follow up with a specialist. One month later the patient has another venous thromboembolism while on anticoagulation. What is the next best step in management of this patient?

A 26 y/o man was brought to the ED by his roommate after he collapsed in their apartment. Further questioning reveals he was having difficulty breathing and suddenly passed out.  A CT angiography reveals a pulmonary embolism. The patient’s parents are present in the ED and want to know about his treatment. Which of the following is the best response?

A 67 y/o man is brought to the ED complaining of difficulty breathing. He also mentions having chest pain. He was watching television at home when the symptoms suddenly started. His medical history is significant for a fractured pelvis after a fall 4 weeks ago. Since then he has had difficulty ambulating and remains in bed most of the day. What would be the best initial treatment for this patient’s likely diagnosis?

A 57 y/o man comes to the ED complaining of difficulty breathing. He also mentions having chest pain. He had undergone a hip replacement surgery last week. His PMH is significant for hypertension and allergy to contrast material. What would be the best investigation of choice to help confirm the diagnosis?

A 67 y/o man comes to the ED complaining of difficulty breathing. He also mentions having chest pain. He was watching television at home when the symptoms suddenly started. His medical history is significant for a hip replacement surgery last week. What would be the best initial investigation of choice to help confirm the diagnosis?

A 25 y/o man comes to the ED complaining of difficulty breathing. He also mentions having chest pain. He was watching television at home when the symptoms suddenly started. His brother had similar symptoms a couple of years ago. What would be the best initial investigation of choice to help confirm the diagnosis?

A 38 y/o man is brought to the ED after a MVA. He complains of severe abdominal pain. Investigations reveal penetrative abdominal trauma with possible organ rupture. He is taken to the OR for repair. He is admitted to the hospital for post-op evaluation. On post-op day 2 he suddenly complains of difficulty breathing and chest pain. Vital signs reveal BP = 110/75, HR = 100, RR = 22, T = 38.5C. Which of the following is the likely diagnosis in this patient?

A 38 y/o man is admitted to the hospital for observation after a left above the knee amputation. He is currently post-op day 2. Suddenly he develops shortness of breath and his RR is now 22. An immediate chest x-ray is done and is shown below. Which of the following would be likely seen on effusion analysis in this patient?

A 68 y/o woman comes to the clinic for a complaint of cough and shortness of breath for the last 5 weeks. She also mentions episodes of hemoptysis increasing in frequency. She is a chronic smoker. A diagnosis of small cell lung cancer is confirmed. Effusion analysis in this patient would likely reveal which of the following?

A 67 y/o man comes to the ED complaining of shortness of breath on exertion. He also complains of waking up in the middle of the night gasping for air and has to sleep on 3 pillows. A chest x-ray is shown below. Which of the following would be likely to be seen on further investigation of this patient?

A 35 y/o man comes to the office with a cough. The cough is associated with rust coloured sputum. His vital signs are BP = 120/75, HR = 90, RR = 20, T = 39C. Which of the following would best confirm this patient’s likely diagnosis?

A 40 y/o woman comes to the clinic complaining of a cough for the last 1 month. She also mentions fatigue and weight loss during this period. She denies ever smoking tobacco or drinking alcohol. Which of the following is the likely diagnosis in this patient?

 A 59 y/o woman comes to the clinic complaining of shortness of breath and cough for the last 1 month. She has also noticed fatigue and weight loss during this period. She is a chronic smoker and has smoked 2 ppd for the last 35 years. A chest x-ray reveals a centrally located mass. Which of the following is the likely diagnosis?

A 55 y/o African American woman comes to the office complaining of shortness of breath on exertion. A chest x-ray is done and is shown below. Which of the following is a common finding associated with this patient’s diagnosis?

A 52 y/o woman is brought to the ED complaining of chest pain after falling from a small hill while jogging this morning. Physical examination shows localized bruising on the chest wall. A chest x-ray is done and shown below. Lab tests reveal elevated calcium levels. What is the best explanation for her hypercalcemia?

A 51 y/o African American woman comes to the office complaining of shortness of breath on exertion. A diagnosis of sarcoidosis is suspected. Which of the following is essential in diagnosing sarcoidosis?

A 55 y/o African American woman comes to the office complaining of shortness of breath on exertion. A chest x-ray is done and is shown below.

Which of the following is the best treatment option in this patient?

A 55 y/o African American woman comes to the office complaining of shortness of breath on exertion. A chest x-ray is done and is significant for bilateral hilar lymphadenopathy. Which of the following is likely to be seen in this patient?

A 45 y/o African American woman comes to the office complaining of shortness of breath on exertion. A chest x-ray is done and is shown below.

What is the likely diagnosis?

A 38 y/o man presents to the office complaining of difficulty breathing and pain. The pain worsens when he lies down and breathes. He has also noticed weight loss within the past 6 weeks. Chest radiography shows 1cm nodules in the upper lobes bilaterally. What is the likely association with this patient’s likely diagnosis?

A 43 y/o shipyard worker comes to the office complaining of difficulty breathing when he exerts himself. He also mentions some chest pain with fever and weight loss. An imaging study is shown below.

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What is the likely diagnosis?

 A 48 y/o shipyard worker comes to the office complaining of difficulty breathing when he exerts himself. He also mentions a non-productive cough. Which of the following is a likely complication that he should be made aware of?

A 49 y/o man comes to the clinic complaining of difficulty breathing on exertion. This started over a month ago and has since progressed. He also mentions a non-productive cough. He works at a mine and his symptoms have impaired his work. A chest x-ray is performed and shows a honeycombing appearance in the lung fields. Which of the following is the likely diagnosis?

A 56 y/o coal mine worker comes to the office complaining of difficulty breathing for the last couple of weeks. He notices difficulty in breathing whenever he exerts himself and it is impairing his work. He also mentions a dry cough. Which of the following would be expected to be seen on further investigation?

A 39 y/o woman comes to the ED for dyspnea and cough. A decision to perform spirometry is established. Her FEV1/FVC ratio is lower than normal. Which of the following is the likely diagnosis in this patient?

A 50 y/o woman comes to the ED for dyspnea and cough. She has a history of drug abuse and smoking 1 ppd for the last 18 years. A decision to perform spirometry is established. Her FEV1/FVC ratio is 0.68. Which of the following is the likely diagnosis in this patient?

A 33 y/o man is brought to the ED after he was involved in a MVA. He complains of chest pain which intensifies with breathing. A chest x-ray reveals multiple fractured ribs and a 2 cm spiculated nodule in the right upper lobe. There are no previous chest x-rays done. What would be the best next step in managing the nodule?

A 50 y/o man undergoes a chest x-ray for chest pain after he was involved in a MVA. The chest x-ray reveals a suspicious lesion in the left upper lobe. The image is shown below.

Which of the following features would raise suspicion of malignancy?

A 45 y/o woman comes to the office for evaluation of chronic cough for the last 2 months. She has tried multiple treatment methods which were unsuccessful. A chest x-ray is done which shows a pulmonary nodule in the right middle lobe. What is the next best step in management of this patient?

A 53 y/o man comes to the clinic with progressive difficulty breathing on exertion. His vital signs in the clinic are BP = 110/78, HR = 100, RR = 22, T = 39 C. He complains of weight loss over the last 6 weeks. Physical exam reveals diffuse rales and rhonchi bilaterally. A chest x-ray is done and shown below.

Which of the following would be vital to ask about while determining the likely diagnosis in this patient?

A 70 y/o woman has been admitted to the hospital from the nursing home for a fever. She has become a comatose patient after sustaining injury in a MVA. A diagnosis of aspiration pneumonia is made and she is treated accordingly. 2 weeks later her fever continues to rise. Her current temperature is 39 C. What is the best next step in management?

A 68 y/o woman was brought to the ED after suffering a stroke. After this she has lost function in her right upper and lower extremity and lost her gag reflex. Four weeks later she is brought to the ED by her son for difficulty breathing and fever. On examination she is alert to person but not to place and time. Percussion of the chest wall reveals dullness at the right middle lobe and breath sounds are decreased over this region. What is the likely diagnosis in this patient?

A 33 y/o man is brought to the office after he had episodes of coughing up sputum. He has been having these episodes for the past 1 week. He describes the sputum as smelling foul. His temp in the office is 39 C. Three weeks ago he was brought to the ED after he passed out while on an alcohol binge. He has a history of alcohol abuse. A chest X-ray is shown below.

What is the most likely diagnosis?

A 28 y/o woman comes to the office with complaints of cough and fever for the last 3 days. Her vital signs are: BP 110/75, HR = 100, RR = 32, T = 39 C. A chest x-ray is done and shown below.

What is the best management for this patient?

A 38 y/o man comes to the clinic complaining of difficulty breathing with cough and fever. He recently returned from a business convention 2 days ago. Since then he has been having these symptoms. He also mentions episodes of diarrhea. Vital signs in the office show BP = 118/80, HR = 92, RR = 22, T = 38.5 C. A chest x-ray is shown below.

What is the likely causative organism?

A 35 y/o man comes to the clinic complaining of difficulty breathing for the last 2 days. He also complains of fever and coughs with sputum since then. The sputum is thick with jelly-like consistency. Vital signs in office are BP = 120/80, HR = 90, RR = 20, T = 38.5 C. He is a chronic alcoholic and normally binge drinks on the weekends. A chest x-ray is shown below.

What is the likely causative organism for this patient’s presentation?

A 22 y/o man comes to the office complaining of dyspnea and cough for the last 2 days. Vitals signs are BP = 120/80, HR = 105, RR = 20, T = 38.5 C. Physical exam reveals decreased breath sounds and crackles in the left lower lobe. Which of the following criteria determines the management of this patient’s illness?

A 48 y/o man comes to the clinic complaining of chronic cough and copious amounts of purulent sputum. He became increasingly concerned when she saw streaks of blood in the sputum this morning. He also mentions some weight loss during this time. Radiologic investigation is done and is shown below.

What is the most likely diagnosis?

A 44 y/o woman comes to the clinic complaining of chronic cough and copious amounts of purulent sputum. She became increasingly concerned when she saw blood in her sputum this morning. She also complains of some weight loss recently. Radiologic investigations are being considered. Which specific finding would be likely seen on chest x-ray in this patient with the suspected diagnosis?

A 44 y/o woman comes to the clinic complaining of chronic cough and copious amounts of purulent sputum. She became increasingly concerned when she saw blood in her sputum this morning. She also complains of some weight loss recently. A chest x-ray is done which shows dilated bronchi with tram tracking. Which of the following is the most likely diagnosis in this patient?

A 34 y/o man comes to the clinic complaining of chronic cough and copious amounts of purulent sputum. A chest x-ray is done which shows dilated bronchi with tram tracking. Which of the following is the most common cause of this patient’s most likely diagnosis?

A 49 y/o woman comes to the ED complaining of chronic worsening cough with sputum production. She also mentions that she becomes breathless with minimal exertion. She has smoked 2 ppd for the last 20 years. Physical exam is significant for a thin woman with muscle wasting and a prominent chest. ABG reveals a PaO2 of 45 mmHg. Which of the following is best to reduce mortality in this patient?

A 49 y/o man comes to the office complaining of chronic worsening cough with sputum production. He also mentions that he becomes breathless with minimal exertion. Physical exam reveals wheezing on auscultation of the chest and hyperresonance to percussion. Which of the following is best to reduce mortality in this patient?

A 55 y/o woman comes in with a productive cough for the last 2 months. The patient has also been having episodes of dyspnea after walking one block. She has a 2 ppd smoking history for the last 30 years. A diagnosis of COPD is suspected. Three different flow-volume loops are shown below. The graphs are labeled 1-3, with 1 on the far left and 3 on the far right.

Which of the following is likely to be seen in this patient based on the suspected diagnosis?

Two patients with respiratory disease are undergoing pulmonary investigation. A flow-volume loop is done for both and the results are shown below. Results for patient A are on the left and results for patient B are on the right.

Which form of respiratory disease does patient B have?

Two patients are being compared. Their flow-volume loops are shown below. Patient A’s results are on the left and patient B’s results are on the right.

 Which of the two have an obstructive lung disease?

A 55 y/o woman comes to the office complaining of a productive cough which is worse in the mornings. He also mentions that he becomes breathless with minimal exertion. A diagnosis of emphysema is suspected. Which of the following would be seen on pulmonary function testing if the patient has emphysema?

A 50 y/o man comes to the office complaining of chronic worsening cough with sputum production. He also mentions that he becomes breathless with minimal exertion. A chest x-ray is done and shown below.

What is the likely diagnosis?

A 52 y/o man comes to the office complaining of a productive cough. He has had a mild cough for months but it has been getting worse. He also mentions that he becomes breathless with minimal exertion. He has a history of smoking 1 ppd for the last 26 years. Radiologic examination is being considered. Based on this patient’s suspected diagnosis, what would be expected to be seen on chest x-ray?

A 50 y/o man comes to the office complaining of chronic worsening cough with sputum production. He has had a mild cough for months but it has been getting worse. He also mentions that he becomes breathless with minimal exertion. He has a history of smoking 1 ppd for the last 26 years. Physical exam reveals a thin patient with muscle wasting and a prominent chest. There is hyperresonance to palpation of the chest wall and expiratory wheeze on auscultation. Which of the following are characteristic of his disease?

A 50 y/o man comes to the office complaining of a chronic worsening cough. He has had a mild cough for months but it has been getting worse. The cough is usually worse in the morning and produces clear sputum. He also mentions that he becomes breathless with minimal exertion. Physical exam reveals a thin patient with muscle wasting and a big chest. There is hyperresonance to palpation of the chest wall and expiratory wheeze on auscultation. He is a chronic smoker. What is the likely diagnosis?

A 48 y/o man comes to the office complaining of a chronic worsening cough. He has had a mild cough for years but it has been progressing. The cough is usually worse in the morning and produces clear sputum. He also mentions that he becomes breathless walking around one block. Diffuse forced expiratory wheezing is heard on auscultation. He has a smoking history of 2 ppd for the last 20 years. Which of the following would best describe the disease process of this patient’s suspected diagnosis?

A 7 y/o boy is brought to the ED by his mother after he began having difficulty breathing while playing at the park. The mother says that he was running around when he suddenly began experiencing shortness of breath. Vital signs reveal BP = 112/80, HR = 90, RR = 24, T = 37 C. Physical examination reveals moderate wheezing during expiration bilaterally. A diagnosis of asthma is suspected. Which of the following would be seen with pulmonary function testing?

A 9 y/o girl is brought to the ED by her parents after she began having difficulty breathing while studying for her upcoming test. The mother says that she was fine but suddenly he began experiencing shortness of breath. The girl has been brought to the ED many times in the past for similar complaints while studying for tests. Vital signs reveal BP = 112/80, HR = 90, RR = 24, T = 37 C. Physical examination reveals moderate wheezing during expiration bilaterally. Which of the following is best to diagnose this patient’s condition?

A 7 y/o boy is brought to the ED by his mother after he began having difficulty breathing while playing at the park. The mother says that he was running around when he suddenly began experiencing shortness of breath. Vital signs reveal BP = 112/80, HR = 90, RR = 24, T = 37 C. Physical examination reveals moderate wheezing during expiration bilaterally. What is the likely pathogenesis for this patient’s presentation?

A 7 y/o boy is brought to the ED by his mother after he began having difficulty breathing while playing at the park. The mother says that he was fine but suddenly he began experiencing shortness of breath. Vital signs reveal BP = 112/80, HR = 90, RR = 24, T = 37 C. Physical examination reveals moderate wheezing during expiration bilaterally. Which of the following is the likely diagnosis?