The correct answer is C. Patient confidentiality is one of the most important medical ethical issues facing physicians, and it certainly can pose dilemmas at times. This patient has just received horrible news and is likely just reacting without really thinking about the ramifications of his decision. However, there may be very important personal, social, or cultural reasons for his decision. It is important for you, as a physician, to explore these with him.

Calling his son (choice A) is inappropriate because it breaks confidentiality.

Although you will likely try to get the patient to reconsider his decision (choice B) telling him that therapy will likely be curative for stage IV lung cancer is not true. There is very little chance at a cure and palliative therapy is a much more reasonable expectation.

Giving him a referral to the oncologist because he is will “come to his senses” (choice D) is inappropriate. He obviously needs counseling, and the feelings as to why he does not want treatment and why he does not want his family to know, should be explored.

Although the patient may be in denial (choice E), patient confidentiality precludes you from unilaterally deciding to tell his wife. It is appropriate to try to understand the reasons why he does not want to tell his family, as opposed to trying to persuade him to tell his wife when he gets home.

The correct answer is E. This patient most likely has acute bronchitis. Acute bronchitis in a healthy patient with no other medical conditions is often due to viral infection that is usually self-limited. Given that this patient has only had 2 days of symptoms, an antibiotic is not necessary and is inappropriate. If the symptoms persist for longer than 1 week, a macrolide antibiotic may be given. A chest x-ray and a sputum culture are not indicated.

Admission to the hospital for medical management (choice A) is inappropriate for a healthy patient with acute bronchitis.

A sputum culture (choice B) is used to identify organisms, but should only be used in an elderly patients with chronic disease that fail antibiotic therapy. This patient’s acute bronchitis is most likely due to a self-limited viral infection.

A chest x-ray (choice C) has no role in the diagnosis of acute bronchitis in a healthy patient.

Send the patient home with antibiotic therapy (choice D) is appropriate management for acute bronchitis in an elderly patient with chronic disease. A macrolide (erythromycin, azithromycin, clarithromycin) is the treatment of choice. It is not part of the initial treatment in a previously healthy patient.

The correct answer is C. Aspiration of gastric contents causes severe lung inflammation. The traditional dogma that the acidic nature of the aspirate is critical has recently been reevaluated and it is now clear that large volumes of gastric contents of any pH are dangerous to the lung. Patients with severe reflux often regurgitate frequently throughout the day and at night will have small aspiration events, which will wake them from sleep by coughing. Once sedated, these people develop depressed cough reflexes and therefore are more likely to be unable to protect their airway during such regurgitations. This is most certainly what has occurred with this patient. The most common radiological finding is right lower lobe opacification (alveolar filling) or collapse.

Diffuse bilateral airspace disease (choice A) is characteristic of acute respiratory distress syndrome (ARDS) or very late stage aspiration which can lead to ARDS.

Diffuse bilateral interstitial infiltrates (choice B) are characteristic of pulmonary edema. This may be a late manifestation (a few days) of severe aspiration, but not an early one.

Pleural effusions (choice D) are not present in aspirations. A unilateral effusion can be found in cases of liver abscess or right sided diaphragmatic irritation or with Meigs syndrome (ovarian cancer and ipsilateral pleural effusion).

A widened mediastinum (choice E) is characteristic of an aortic arch dissection or of a pulmonary disease such as sarcoid.

The correct answer is C. The patient is in respiratory distress and needs intubation for airway control, better oxygenation, hemodynamic resuscitation, and to feel comfortable. Although every attempt should be made to respect the patient’s wishes and the family’s requests, in an emergency situation there is limited opportunity to check the validity of telephone messages and faxed documents. Medical emergency mandates appropriate action prior to legal concerns.

Calling the hospital administrator (choice A) and lawyer (choice B) are not advisable in an emergency situation for the reasons explained above.

A living will mandating “do not resuscitate or do not intubate” needs to be checked and certified by a hospital social worker or legal department for authenticity before implementation. In an emergency situation this is not practical. Even if this patient is intubated, once a valid living will is obtained the ventilator can be switched off. Hence, to respect the daughter’s wishes and keep the patient comfortable without intubation (choice D) is incorrect.

To try and trace the daughter’s phone number and request a fax of the living will (choice E) is not practical in an emergency situation, and the validity of the documents is questionable without being checked by hospital authorities.

The correct answer is B. The patient likely has tuberculosis. Virtually all M. tuberculosis is transmitted by airborne particles that are 1 to 5 µm in diameter. The symptoms of tuberculosis are protean and nonspecific and can be classified as either systemic or organ-specific. Classic systemic symptoms include fever, night sweats, anorexia, weight loss, and weakness. However, since tuberculosis is associated with other illnesses that have similar symptoms, this lack of specificity can result in a delayed diagnosis or even a misdiagnosis. Organ-specific symptoms of pulmonary tuberculosis include cough, pleuritic pain, and hemoptysis. The requirement for diagnosis is the presence of the organism that appears by acid-fast staining in a sputum sample.

In patients with primary tuberculosis, chest radiographs (choice A) often show infiltrates in the middle or lower lung zones, with ipsilateral hilar adenopathy. These findings are non-specific and are not used for confirmation of the diagnosis.

A sputum culture (choice C) is not useful in this case since the organism responsible for TB is fastidious and is difficult to culture, and certainly does not grow rapidly.

The organism responsible for TB does not stain with traditional Gram stain dyes (choice D) and therefore requires special staining such as acid-fast in order to detect it.

Although it is imperfect, the gold standard for diagnosing latent tuberculosis infection remains the intradermal injection (choice E) of purified protein derivative (5 TU) into the volar or dorsal surface of the forearm (Mantoux method). The test has no role in the diagnosis of active infection.

The correct answer is B. The chest x-ray demonstrates a right mid-lung nodule and emphysema. There is a lung nodule that is likely to be cancer in this patient with a smoking history and radiographic emphysema. The next step is a CT scan of the thorax with contrast, and before administering iodinated contrast, an allergy history must be elicited. Prior allergies to iodinated contrast material or shellfish will require further questioning. If the allergy is minor such as mild hives, pruritus, or flushing, a pre-medication regimen of prednisone and diphenhydramine is necessary. More serious allergies such as anaphylaxis preclude the administration of intravenous contrast.

Questions about death (choice A and D) are premature. This nodule may be an artifact, pneumonia, a granuloma, or cancer. Moreover, a localized cancer may be curable.

While quantification of the patient’s smoking (choice C) is necessary for a complete history, it does not change the management of this patient.

A lung biopsy (choice E) is premature. A CT scan and possibly PET scan are necessary to evaluate this lesion noninvasively before an invasive procedure is carried out.

Even though this nodule is likely to be cancer, questions about cancer treatment (choice F) are premature.

The correct answer is C. This patient has a chronic cough, which is usually considered chronic because it is lasting more than 3 weeks. It may be due to a variety of things. However, the important lesson in this question is that before you turn to diagnostic studies you need, to make sure that you have obtained a detailed history. The case history will provide the answer to almost every question that you will need to ask her, except what medications she takes. Since she is a new patient, you will need to find out if she is taking an ACE inhibitor, such as captopril or enalapril, which is a frequent cause of a chronic cough in hypertensive patients. They cause a cough in up to 20% of people taking them. The exact mechanism is unknown, but it is thought to somehow be related to bradykinin and substance P. The treatment for the cough is the discontinuation of the ACE inhibitor.

An electrocardiogram (choice A) is unnecessary at this time in this patient, complaining of a chronic cough. She is not complaining of chest pain and there is nothing in her history that suggests an arrhythmia. The most important next step, is to take a detailed history before you order diagnostic tests.

An x-ray of the chest (choice B) may be appropriate in the near future, but it is not the next step at this time. Before you order diagnostic studies, you need to make sure that you ask her any questions that might help you figure out the etiology of her cough. Asking her about medications is very important because ACE inhibitors cause a chronic cough in up to 20% of patients taking this medication.

A fiberoptic bronchoscopy (choice D) is used to obtain histologic and cytologic specimens and to visualize an endobronchial tumor. Before you turn to such a specialized study, you need to first obtain a detailed history. If the patient is not taking an ACE inhibitor, a chest x-ray should usually be performed, and if this is abnormal, sputum cytology, a high resolution CT scan, and fiberoptic bronchoscopy should be considered.

Pulmonary function tests (choice E) are used to assess airway hyperresponsiveness for patients in which you suspect asthma, and lung volumes and diffusion capacity in patients in which you suspect a diffuse interstitial lung disease. A detailed history is necessary before using any of these studies.

The correct answer is C. This patient has a living will, which states that if he was in a terminal condition he wants only comfort care. He has also clearly stated his wishes to you in the past. Intubation of this patient is clearly against his wishes. Starting morphine may cause respiratory suppression or worsen his hypotension which might hasten death. The potential to hasten death is an acceptable risk if the primary intention is to decrease patient suffering. Ideally, the patient’s wishes should be clearly explained early in his hospital course.

Injection of a “lethal dose” of morphine (choice A) is not acceptable management of this patient since its only purpose would be to hasten death. As stated above, it is acceptable to use a drug that may hasten death if the primary intention is to decrease suffering. Asking the family to leave and then injecting a lethal dose of medication is clearly not acceptable management.

Any time you start morphine on a patient you need to be aware of the possibility of worsening hypotension. Morphine is a mild vasodilator and therefore acts as a preload reducer. In this patient, hypotension already is prominent prior to starting morphine. Starting dopamine with the morphine (choice B) is not appropriate in this case since most physicians agree that, in this patient, starting vasopressors would constitute “heroic” measures.

Contacting the hospital ethics committee (choice D) is not appropriate in this patient. This patient needs immediate medical attention. There is no time for meetings now.

Intubation of this patient now (choice E) is clearly against the patient’s documented wishes. To ignore a patient living’s will and end of life issues is clearly wrong and would make completion of advance directives meaningless.

The correct answer is A. The patient is a smoker who presented with progressive shortness of breath. Physical examination found diffuse wheezing and chest X-ray noted emphysema. In addition, she had an elevated pCO₂ with acute respiratory acidosis and moderate hypoxia. These findings are consistent with an exacerbation of chronic obstructive lung disease. Such flares are treated with β₂-agonists, anticholinergics, and steroids. In addition, antibiotics have also been shown to improve clinical outcome, and so they are part of the treatment regimen for chronic obstructive lung disease flares.

Diffusion capacity (choice B) for this patient will likely be low given her emphysema and is an important measurement for diagnosis, but it is not required in the acute management of this condition.

The patient has a normal mental status and is able to protect her airway. Her symptoms and oxygenation also improve with treatment. Thus, there is no current indication for intubation (choice C). Intubation is required if the patient has severe CO₂ retention and/or hypoxia refractory to medical therapy. Intubation is also indicated if her condition is refractory to non-invasive ventilation, if she has severe acid-base disturbances, or if there is any change in her mental status that would compromise the airway.

Lung spirometry (choice D) will aid in the diagnosis of her disease but is not useful in management of her clinical course.

Non-invasive positive pressure ventilation (choice E) is indicated in patients with severe chronic obstructive pulmonary disease that is refractory to medical therapy. It is also useful in patients with increasing respiratory fatigue. A patient must be able to initiate breathing and tolerate the breathing mask. This patient has a normal mental status and her symptoms improve with treatment. Thus, she currently does not require any assistance in ventilation.

The correct answer is C. This patient has asthma, and the most crucial step in the management of asthma is avoidance of the triggering factors, e.g., allergens. Unfortunately, it is difficult to avoid specific types of allergens, such as pollens. Specific measures to eliminate or reduce exposure to dust mites and animal dander at home lead to a reduced frequency of attacks and hospitalization rates. Regardless of the allergens involved, elimination of respiratory irritants, especially cigarette smoke, is of crucial importance. The bronchial tree of asthmatic patients is highly reactive to any form of chemical or physical irritation. Thus the avoidance of passive smoke is important. The mother should ask her boyfriend to go smoke outside alone if he needs to, but he should not be allowed to smoke in the house.

It is not practical to administer immunotherapy against identified allergens (choice A) in this case because he is allergic to multiple airborne allergens, and it seems like he is especially responsive to cigarette smoke. Immunotherapy is of some benefit when a single allergen is identified. The most important step is to try to reduce exposure to avoidable allergens (smoke).

Avoidance of all exercise (choice B) is not appropriate because even though exercise triggers asthmatic attacks in some patients, this does not seem to be his main trigger.

Humidifiers and air cleaners (choice D) at home is not the appropriate management. Humidifiers favor the growth of dust mites, and air cleaners have not been shown to be uniformly effective in getting rid of dust mites.

It is inappropriate to prescribe inhaled sodium cromoglycate, oral corticosteroids, and oral theophylline (choice E) for this patient because the fewest number of drugs at the lowest effective doses should be used. Typically, a one drug regimen (a bronchodilator or an inhaled corticosteroid) for mild to moderate asthma or two drugs for more severe cases is sufficient to control asthma exacerbations. Oral corticosteroids are indicated in cases of severe asthma and are therefore, not for this patient.

The correct answer is D. This patient most likely has Mycoplasma pneumonia, which is a common cause of pneumonia in young adults and is typically treated with oral erythromycin as an outpatient. It is characterized by a dry cough, headache, myalgia, malaise, and fever. Physical examination is usually unremarkable except for diffuse rhonchi or fine rales. A chest x-ray shows diffuse interstitial or reticulonodular infiltrates, typically in the lower lobes. Given the patient’s age, history, physical examination, and chest x-ray findings, it is reasonable to assume that he has a community-acquired pneumonia. This is most likely due to Mycoplasma pneumoniae and empiric antimicrobial therapy with erythromycin should be prescribed. In these patients, a microbial diagnosis (with a sputum culture, transtracheal aspiration, bronchoscopy, or a blood culture) is often impractical and unnecessary. A cold agglutinin response is often associated with Mycoplasma pneumoniae. However, it is nonspecific and detected in less than 50% of cases.

Admitting him to the hospital and beginning administration of erythromycin, intravenously (choice A) is incorrect because a patient with Mycoplasma pneumonia, which is what this patient most likely has, is usually treated as an outpatient. The criteria for hospitalization of patients with pneumonia are ages >65, significant comorbidity, leukopenia, pneumonia due to Staphylococcus aureus, Gram-negative bacilli or anaerobes, suppurative complications, failure of outpatient management, inability to take oral medication, respirations >30/min, heart rate >140/min, hypotension, hypoxia, or acute alteration of mental status. The patient in this case does not meet any of these criteria.

Admitting him to the hospital and beginning administration of trimethoprim-sulfamethoxazole intravenously (choice B) is the management for patients with severe Pneumocystis carinii pneumonia (PCP), which is characterized by shortness of breath, a dry cough, fever, night sweats, rales or rhonchi, and bilateral patchy alveolar infiltrates. This is a common cause of pneumonia in immunocompromised patients, especially those with HIV and AIDS. The patient in this case does not appear to be immunocompromised, and he is not short of breath, which makes the diagnosis of PCP unlikely.

Admitting him to the hospital for a cold agglutinin test (choice C) is inappropriate because even though this patient most likely has Mycoplasma pneumonia, it can be treated with erythromycin as an outpatient, and a cold agglutinin test can be performed as an outpatient. A cold agglutinin response is often associated with Mycoplasma pneumoniae. However, it is nonspecific and detected in less than 50% of cases.

Recommending aspirin, fluids, and rest at home (choice E) is inappropriate treatment for this patient who most likely has Mycoplasma pneumonia, which needs to be treated with an antibiotic such as erythromycin.

The correct answer is D. This patient has a classic history for cough variant asthma. The diagnosis of asthma is helped by the history of atopy/eczema. His cough is predominant after exercising, but other allergens (e.g., cigarette smoke, dust, pollen) or cold weather could also induce asthma in many patients. Pulmonary function tests would reveal a decrease in the FEV1/FVC ratio, pathognomonic for obstructive lung disease.

There is no need for bronchoscopy (choice A) since in this patient there is low suspicion for an infectious process. His history of unprotected sexual intercourse does raise the suspicion for HIV, yet opportunistic pulmonary infections such as Pneumocystis Carinii pneumonia would be a late finding when the CD4 counts are less than 200.

A chest x-ray (choice B) would probably be unremarkable, since we have low suspicion for any pulmonic infection. Other causes of pulmonary wheezing and cough could include a foreign body, hypersensitivity pneumonitis, or intrathoracic lung mass. However, these are rarer etiologies and asthma is still primarily a clinical diagnosis.

Inhaled steroids (choice C) may be an appropriate treatment for mild or moderate persistent asthma. However, this patient only coughs roughly once or twice a week, and therefore would be considered to have mild intermittent asthma. An intermittent beta agonist would be the appropriate first line treatment for mild intermittent asthma.

There is no reason to suspect atypical pneumonia (choice E) in this afebrile patient with cough variant asthma.

The correct answer is E. Although once limited to very specialized care units, patients with ARDS are becoming more prevalent in general medical ICU settings, in part due to the increasing incidence and recognition of the disorder. ARDS is an inflammatory condition of the lungs of unknown etiology but is associated with many conditions such as pneumonia, trauma, sepsis, and blood transfusions. The common denominator of all ARDS is profound hypoxia defined as a PaO2/FiO2 ratio of less than 200. Because of the profound hypoxia, the patients require mechanical ventilation for improvement. Ironically, many of the strategies employed over the years have actually contributed to or significantly worsened the injury of ARDS. The only effective intervention to date was recently shown in an NIH clinical trial. The mortality benefit conferred from this maneuver is substantial. The limitation of tidal volume to 6cc/kg or less is now standard of care and is required knowledge of any physician caring for critically ill patients.

Although there have been case reports that prone positioning during mechanical ventilation (choice A) is useful for these patients, the randomized trials indicate that there is no mortality benefit associated with this intervention.

The traditional teaching of keeping tidal volumes greater than 15 cc/kg (choice B) and of limiting peak inspiratory pressure to 45 cm H2O or less (choice C) is now incorrect and in fact, has been shown to be very detrimental to these patients. Experimental data have shown that ventilatory strategies that overdistend parts of the lung or allow the lung to cycle repeatedly between a collapsed state and an open state can lead to injuryXso-called ventilator-induced lung injury. PIPs should be limited to 35 cm H2O or less.

Limiting PEEP levels to less than 10 cm H2O (choice D) is opposite of what is required to manage these patients. PEEP values often exceed 10 cm H2O so that repeated cycling between a collapsed state and an open state is prevented. This is the so-called “open-lung” approach to ARDS management.

The correct answer is C. This patient has erythema nodosum in the setting of bilateral hilar adenopathy. Given the fact that she has no other underlying symptoms of infection, and is a young African American female, the erythema nodosum is most likely in the setting of sarcoidosis. The treatment in this case will often involve the use of corticosteroids.

Erythema nodosum can also be associated with several other disease processes such as streptococcal infections, upper respiratory infections, and inflammatory bowel diseases. The less common associations include tuberculosis, histoplasmosis, coccidioidomycosis, and drugs such as oral contraceptives and sulfonamides. She is on none of these drugs and has no symptoms of tuberculosis (choice B), a systemic or regional fungal infection(choice A), or systemic bacterial infection (choice E).

Hilar adenopathy is always a concern for a malignancy (choice D). However, this clinical scenario is much more classic for sarcoidosis. Biopsy proof should nevertheless be obtained. Therefore, chemotherapy is not indicated at this time.

The correct answer is E. The management of patients with pulmonary hypertension focuses on three issues: is the disease secondary to primary pulmonary disease (secondary pulmonary hypertension), is the patient responsive to vasodilator therapy, and, can the pulmonary pressures be made normal with medication. For this patient, the assumption is, given her age and lack of medical history, that her pulmonary hypertension is primary. In addition to pulmonary function testing to help verify this assumption, vasodilator testing to determine whether the pulmonary vasculature is responsive or not is the first step in the management of such patients.

Calcium channel blockers (choice A), inhaled nitric oxide (choice B) or intravenous prostaglandin (choice C) are all agents used in the management of primary pulmonary hypertension. The choice of these agents depends on whether the patient is vasodilator responsive and the side effect profile. Systemic agents such as calcium antagonists and prostaglandins are associated with often profound systemic hypotension which limits their utility is normalizing pulmonary pressures.

Referring the patient for oxygen diffusion capacity testing (choice D) is not necessary. Standard spirometry as part of a full battery of pulmonary function tests are indicated to assess whether the hypertension is primary or secondary, but diffusion testing is only useful in cases where hypoxemia coexists with existing pulmonary disease.

The correct answer is A. Determining serum angiotensin-converting enzyme (ACE) and serum calcium is the correct management for this patient with suspected sarcoidosis. Although a bronchoscopy (choice D) and a lung biopsy (choice E) will also help with diagnosis of sarcoidosis, serum ACE and calcium levels are less invasive tests to obtain for diagnosis. Sarcoidosis involves multisystems including lungs, eyes, peripheral lymph nodes, spleen, gastrointestinal tract, hearing, and musculoskeletal systems. Hypercalcemia may occur in any stage of sarcoidosis. Corticosteroids lower the raised calcium level to normal by inhibiting the peripheral action of 1,25(OH)2D3 and by metabolizing the compound to an inactive metabolite. The serum ACE level is also raised in 60% of patients. ACE activity is higher in patients with hilar adenopathy and pulmonary infiltration.

A complete blood count (choice C) is incorrect, because hemolytic anemia is rare in sarcoid and leukopenia alone is too non-specific for diagnosis of sarcoid.

Serum CEA level (choice B) is incorrect, because this is a non-specific tumor marker used to monitor for colon carcinoma recurrence, as well as some lung adenocarcinoma responses to chemotherapy.

The correct answer is C. This patient has interstitial fibrosis. Clues to the diagnosis include a history of mildly progressive shortness of breath with a non-productive cough. Physical exam findings of late crackles with inspiration, and the lack of signs of CHF or reactive airway disease such as wheezing suggest interstitial fibrosis. A chest x-ray revealing a ground glass pattern or a reticular nodular pattern also suggests the diagnosis. Pulmonary function tests reveal decreased lung volume with decreased forced vital capacity and FEV1. The ratio of FEV1/FVC might be normal or increased. Diffusion capacity should be decreased.

Patients with asthma have a similar PFT pattern to patients with other obstructive lung disease such as emphysema or bronchitis (choice A) but should have a good bronchodilator response since the pathology of asthma involves bronchospasm. Patients with COPD with bronchospasm will have similar PFTs.

Patients with restriction secondary to obesity or kyphosis have PFTs which show a restrictive pattern (choice B) similar to a patient with interstitial lung disease. The two etiologies can be differentiated by either history or physical exam findings or by examination of the diffusion capacity. In obesity/kyphosis, the diffusion capacity is normal while in interstitial lung disease, the diffusion capacity is decreased.

Emphysema (choice D) patterns on PFT look identical to other obstructive patterns (e.g., asthma, chronic bronchitis) with two exceptions. First, the diffusion capacity in emphysema is decreased. Second, there should not be a significant bronchodilator response in pure emphysema. The caveat of this is that very often chronic bronchitis and emphysema coexist so that some bronchodilator response is possible.

This patient does have underlying lung disease so it would be unlikely for her to have normal PFTs (choice E).

The correct answer is D. The principle of individual autonomy is central to medicine. The only exceptions are if the patient has no clearly expressed wishes documented and is unable to make a decision or if the patient is deemed incompetent to make a decision. This patient is clearly competent to refuse treatment despite the wishes of his physician or neighbor. It is important to make the consequences of his decision clear to the patient before discharge and to tell him that he should return immediately should he change his mind.

Hospital care with or without intravenous antibiotics (choices A and B) is inappropriate as this patient is refusing hospital care.

This patient is clearly competent to refuse treatment, so he should not be admitted to the psychiatry ward (choice C) or given antidepressant therapy (choice F).

Consultation with an attorney (choice E) is not necessary as the patient is clearly competent to refuse medical care.

The correct answer is D. This child’s clinical picture is most consistent with infectious croup (laryngotracheobronchitis), commonly caused by parainfluenza viruses. The prodrome of upper respiratory illness with fever followed by a spasmodic, barking cough, is typical of this diagnosis. The classic sign on chest x-ray is the subglottic swelling ( “steeple sign,”), which is the result of viral-induced swelling of the subglottic tissue. This swelling can cause an incomplete airway obstruction, leading to stridor either at rest or during crying. Stridor at rest is an indication for treatment with steroids to decrease inflammation.

Dyspnea in a child can be the result of congenital heart disease and resulting congestive heart failure, manifested as cardiomegaly and pulmonary venous congestion on x-ray (choice A), but given the absence of prior symptoms, the normal oxygen saturation, and the lack of rales on lung examination, this is unlikely.

Fever and cough in a child also raises the possibility of pneumonia as a diagnosis. A lobar pneumonia (choice B) would be a surprising x-ray finding in this case given the child’s clear lung fields on examination and the presence of stridor, which indicates upper airway involvement.

Pneumothorax (choice C) can be a cause of sudden dyspnea in a child, especially in tall, male adolescents who may be predisposed to spontaneous pneumothoraces. This child’s prodrome and stridor on examination make this diagnosis unlikely.

Prior to the introduction of the vaccine against Haemophilus influenzae type b, epiglottitis was a common and much-feared diagnosis in pediatrics. Infection of the epiglottis by this organism led to rapidly progressive airway obstruction and potentially death. A lateral neck radiograph would demonstrate a thumb-shaped epiglottis (choice E) in these cases. This sign is not seen on frontal views of the chest.

The correct answer is B. The two interventions that have been shown to affect mortality, smoking cessation and oxygen therapy, should be foremost in the minds of all caregivers who manage patients with COPD. At any stage of the disease, smoking cessation is the most important intervention that can be taken to improve lifestyle and longevity. Other management strategies such as medications, rehabilitation, and even surgery are less effective, sometimes ineffective, when smoking is still practiced.

Changing ACE inhibitors from captopril to lisinopril, a 3 times per day drug to a once daily drug (choice A) is not required for this patient. Since this is a compliance/lifestyle issue, it should not take priority of a critical medical intervention. There is no difference in efficacy between the two drugs.

This patient has reasonably controlled blood pressure so that increasing his thiazide diuretic dose (choice C) may improve his blood pressure slightly, but its benefits are minimal when compared to those obtained with smoking cessation.

The decision to initiate home oxygen therapy (choice D) is based upon arterial oxygen pressures of less than 55 mm Hg (saturations less than 88%) and therefore a resting arterial blood gas is required before a decision to initiate long-term oxygen therapy is made.

Pulmonary function testing (choice E) is an important tool to stratify patients with COPD and to determine if they have an element of reversible bronchoconstriction. Since they are not therapeutic however, they do not take precedence over immediate medical interventions that have life-prolonging consequences.

The correct answer is A. This patient has long-standing pulmonary disease and is suffering from some acute respiratory event, either infection or a COPD flare. His past medical history is enlightening because it can be appreciated that this patient has required ventilatory support for his pulmonary disease in the past. In the office, he is clearly in some distress. With his history and known lung disease, this patient should be admitted to the hospital for further care and observation.

Similar reasoning holds for obtaining a chest radiograph and prescribing antibiotics if an infiltrate is present (choice B). Knowing that his distress is due to pneumonia does not alter the fact that he needs to be treated in the hospital.

Prescribing oral cefuroxime and oral steroids (choice C), although a reasonable regimen for a COPD flare, fails to address how this patient’s acute respiratory compromise will be addressed. He has been intubated in the past for flares such as this and discharging the patient out of your care could result in serious harm or even death to this patient.

Prescribing oral cefuroxime and see the patient in seven days (choice D) is clearly inappropriate since the patient is presently in mild to moderate distress and the cause for this is unknown. Even if he does have an infection, the antibiotics will take days to be of any assistance.

It would be inappropriate to refer the patient to a local emergency department (choice E) where he may sit unobserved in triage or may be discharged home if another physician had a different impression of the patient.

The correct answer is E. Based upon the classic Virchow triad of stasis, hypercoagulability, and endothelial damage, it had been widely speculated that prolonged air travel can be associated with an increased incidence of deep venous thrombosis and pulmonary embolism. Infact, this risk increases with increasing duration of the flight and for a flight this long, the relative risk is 4.7 fold. In general, any trip longer than 5,000 miles confers at least a 2-fold greater risk. The risk is not increased for trips less than 3,500 miles (choice D).

The pressurization of the cabin, which is required for modern-day air flight can cause damage to the middle ear if people fail to equalize the ambient pressure with the middle ear pressure. However, since this patient has no evidence of a middle ear infection that would cause her eustachian tubes to fail to offer this equalization (choice A), she has no increased risk.

At altitude, airliners routinely have ambient PaO₂ of much less than sea level since cabins are not pressurized to one atmosphere. For this reason, arterial PaO₂ is around 70 mm Hg. In persons with known coronary disease(choice B), this decrease in supply cannot be met with an increased flow and myocardial ischemia can occur.

Although the ambient air in airliners is recirculated and therefore exposes passengers to “common” pathogens, there is no epidemiological evidence that states that the risk of acquiring tuberculosis (choice C) is any greater than breathing ground level, non-recirculated air.

The correct answer is E. This patient is presenting with signs and symptoms of pulmonary embolism (PE). His risk factors for PE include prior history of cancer and immobility. A ventilation/perfusion scan is a nuclear medicine study that is most often used for the diagnosis of PE. The demonstration of segments of lung that are ventilated, but not perfused is called a “V/Q” mismatch (V stands for ventilation and Q stands for perfusion). This is highly specific for PE. A ventilation/perfusion scan is the most appropriate diagnostic step in this patient particularly since he has a non-diagnostic chest x-ray. Patients with infiltrates or other parenchymal abnormalities are not ideal candidates for this type of imaging because these abnormalities can limit interpretation of the scan. Helical CT pulmonary angiography is a relatively new diagnostic study which is now commonly used for patients suspected of PE and have abnormal chest x-rays.

Bronchoscopy (choice A) is used for the evaluation of airways. Common indications for bronchoscopy include hemoptysis, chronic cough, and evaluation of central lung lesions identified on chest x-ray or CT of the chest. Bronchoscopy has no role in the evaluation of the pulmonary arteries.

Contrast venography (choice B) is an invasive method of evaluating the veins for thrombosis. This examination has been largely replaced by ultrasonography.

Pulmonary angiography (choice C) is the gold standard in the diagnosis of pulmonary embolism. The most common indication is a patient with an indeterminate or intermediate probability ventilation/perfusion (V/Q) scan who requires a definitive diagnosis. Due to the risks and complications associated with angiography, it is not a study that is performed in the initial work up. It is usually only performed when a definitive diagnosis is not achieved by either V/Q lung scan or helical CT pulmonary angiography.

Ultrasound of the lower extremities (choice D) is an indirect way of evaluating for pulmonary embolism. 90% of PE arise from deep vein thrombosis (DVT) in the lower extremities. Since the treatment of PE and proximal DVT is the same, many clinicians feel that the diagnosis of DVT is an adequate endpoint to decide on treatment. An important criterion in deciding whether or not to perform a lung scan or ultrasound depends on the stability of the patient. This patient is hypotensive, tachycardic, and will benefit from a ventilation/perfusion scan which may show a lack of perfusion to one or both lungs. In the case of a saddle embolus, anticoagulation is not adequate therapy and further intervention with possible thrombectomy is indicated. Ultrasound can be used when a ventilation/perfusion scan is intermediate or indeterminate probability.

The correct answer is B. Any patient that has eaten solids or liquids within 8 hours prior to an intubation, or is a trauma patient that has eaten within 12 hours, is considered a high risk patient for aspiration. These patients require, in addition to any other intervention, cricoid pressure to minimize the risk of aspiration. The cricoid pressure must be applied by an assistant since the operator has no free hands with which to perform the maneuver.

Aggressive oral suctioning during laryngoscopy (choice A) is important to assist with visualization of the pharyngeal and laryngeal structures but in fact does little to minimize the risk of aspiration of gastric contents.

For a patient such as this, giving the patient oral anti-acid therapy prior to intubation (choice C) is not practical since she is in distress and will be unable to take oral medications without likely aspirating those.

Placement of a nasogastric tube (choice D) or orogastric tube (choice E) for evacuation of the stomach is a reasonable choice in non-emergent situations. For this patient, having her cooperate in order to place either one of these tubes is not going to be possible and would delay an urgent, if not emergent, intubation. These tubes are often used in the operating room by anesthesiologists to evacuate the stomach once the patient has been sedated.

The correct answer is A. By history, exam, and chest radiography, this patient has pneumonia. In someone with a pneumonic process, it is advisable to send sputum for Gram stain and culture prior to the initiation of antibiotics in order to ensure that the choice of antibiotic agent will be appropriate. Empiric antibiotics are often started anyway, but it is good to know if the organism that is present is covered by the chosen antibiotic.

An open lung biopsy (choice B) is not used in the routine diagnosis of a lobar pneumonia. It is instead used in the diagnosis of more complex pulmonary pathologies such as the idiopathic interstitial pneumonias that are not amenable to diagnosis using routine methods.

A chest CT (choice C) will not add any additional information at this juncture since a chest radiograph is sufficient to confirm the presence of pneumonia in this patient.

A ventilation-perfusion scan (choice D) is used to diagnose the presence of a pulmonary embolus, which is not a part of the differential diagnosis with this patient. This type of scan is often uninterpretable in the setting of a lobar pneumonia.

A bronchoalveolar lavage (choice E) is not used in the diagnosis of a lobar pneumonia associated with a productive cough.

The correct answer is C. This patient has non-massive hemoptysis, which is defined as less that 100 mL of expectorated blood over 24 hours. The work-up begins with history and physical examination. A chest x-ray and laboratory studies should be ordered initially. If the chest x-ray is normal and the patient has risk factors for cancer, like smoking 2 pack of cigarettes a day for the past 30 years, a bronchoscopy should be ordered to localize the bleeding site and look for an endobronchial mass. If none is found, a high resolution CT scan should be considered. If a mass is found on a study, referral to a thoracic surgeon is necessary.

It is inappropriate to admit him to the hospital for immediate thoracic surgery (choice A) at this time. He has non-massive hemoptysis and needs a bronchoscopy to be ordered to localize the bleeding site and look for an endobronchial mass. Surgery may be indicated in the future, but now, since he is hemodynamically stable, he needs further evaluation for his hemoptysis.

It is unnecessary to order another chest x-ray (choice B) at this time. Since his physical examination has not changed, it is unlikely that a chest x ray would have changed in 2 weeks. He has no symptoms that suggest pneumonia which may appear on a later x-ray. He requires a bronchoscopy to look for a mass that cannot be visualized on the x-ray.

A high-resolution CT scan (choice D) is usually only indicated after a chest x-ray and a bronchoscopy. An exception is when the chest x-ray suggests parenchymal disease, then the HCRT is usually performed before the bronchoscopy.

In this patient with hemoptysis and a significant smoking history, reassuring him that all of the tests were normal (choice E) is inappropriate. You need to find the cause of his symptoms by continuing with the diagnostic evaluation. A bronchoscopy is indicated at this time.

The correct answer is C. This patient appears to be in moderate respiratory distress and is hypoxic. As part of a pediatric advanced life support protocol, the most important initial interventions should pertain to airway, breathing, and circulation, the “ABCs”. The first intervention for this patient should be to provide oxygen because her room air saturation is below 95%.

As you are providing oxygen, you may prepare to give the patient albuterol, a beta-2 agonist, via nebulizer for early management of her bronchospasm. Albuterol via metered dose inhaler (choice A) is not appropriate in this patient because of the child’s age. Four-year-olds do not have the skill to master a metered dose inhaler in a way that will administer the medication correctly.

Prednisolone (choice B) is a steroid commonly used to treat reactive airway disease. It helps to decrease inflammation. Children having a significant asthma attack should be started on prednisolone early in the course of their management, but not prior to being started on oxygen if hypoxemic.

Obtaining a chest x-ray (choice D) is important in the evaluation of a child with cough and fever. This patient may have a pneumonia, which is exacerbating her reactive airway disease. Classic chest x-ray findings in children with asthma include hyperinflation and peribronchial cuffing. However, a chest x-ray is not an immediate priority in the patient in this vignette.

Preparing to do an arterial blood gas (choice E) is not appropriate in the initial management of the patient in the vignette. This patient is in moderate respiratory distress but has not received any medications or interventions to improve her bronchoconstriction. If this patient does not improve, or begins to become tired, she may require an arterial blood gas to evaluate her pCO₂, which looks for carbon dioxide retention.

The correct answer is A. This patient likely has COPD based upon his social history and symptoms. All patients who present complaining of shortness of breath, are over the age of 40, and have a smoking history or environmental exposure history to asbestos, beryllium, or dust, should have screening spirometry. Spirometry measures forced inspiratory and expiratory effort. The hallmark of COPD is decreased forced expiratory effort. The tests are noninvasive and can be performed in fully clothed patients.

A chest CT scan (choice B) is of minimal value in this case since the chest radiograph revealed no evidence of any abnormality except hyperinflation, which is to be expected in a case of COPD.

Therapeutic interventions such as albuterol inhalers (choice C), steroids (choice D), or home oxygen (choice E) are options to be considered once a diagnosis of COPD is established and its severity is quantified. Inhalers are excellent first-line drugs for patients that have reversible airflow obstruction demonstrated by full pulmonary function testing. Home oxygen is usually given for late-stage COPD in patients who have room air arterial oxygen pressures of less than 60 mm Hg. Steroids are very useful agents in acute exacerbations of COPD.

The correct answer is D. The key to this question is to recognize that this patient remains acidotic and hypercarbic despite intubation. In order to “blow off” more carbon dioxide and normalize the blood pH, you must increase minute ventilation (MV). If you remember that MV=TV X RR, you can quickly recognize that the two ways to decrease carbon dioxide is to increase the RR or increase the TV.

Decreasing RR (choice A) will increase carbon dioxide because we are decreasing minute ventilation as described above. This will result in worsening acidosis. In addition, our set respiratory rate is lower than the patient’s actual rate. If we decreased the respiratory rate, our patient would continue to breathe at a high rate and receive the same tidal volume (thereby not even changing the MV).

Increasing FiO₂ (choice B) will not be beneficial. First, the patient already has a paO₂ of greater than 60 mm Hg. If you remember the hemoglobin binding curve, you should remember oxygen saturations remain above 90% for paO₂>60 mm Hg. Therefore, our goal is to keep paO₂>60 mm Hg for most patients. Second, maintaining patients on greater than 60% oxygen may have some associated lung toxicity. Therefore, if possible, keeping the inspired oxygen less than 60% is an important part of management. Of course, if high levels of inspired oxygen are necessary, you should not hesitate to use them. Please remember that patients on ventilators need not (and should not) have oxygen saturations of 100% or paO₂ much greater than 60 mm Hg.

PEEP (choice C) is the use of positive airway pressures at the end of expiration. PEEP is useful in hypoxic respiratory failure such as ARDS or cardiogenic pulmonary edema. Low levels of PEEP can be used in COPD to keep airways open. Our patient’s oxygenation is acceptable so increasing PEEP would not be beneficial now. In addition, our patients blood pressure is only borderline acceptable. Increasing PEEP will decrease venous return to the heart and might lead to further reductions in blood pressures. High levels of PEEP might also predispose patients to barotrauma which is a form of ventilator induced lung damage.

Making no adjustments (choice E) is not acceptable. This patient is severely acidotic and hypercarbic and should not be left in this state.

The correct answer is D. This patient has a classic history for cough variant asthma. The diagnosis of asthma is helped by the history of atopy/eczema. His cough is predominant after exercising, but other allergens (e.g., cigarette smoke, dust, pollen) or cold weather could also induce asthma in many patients. Pulmonary function tests would reveal a decrease in the FEV1/FVC ratio, pathognomonic for obstructive lung disease.

There is no need for bronchoscopy (choice A) since in this patient there is low suspicion for an infectious process. His history of unprotected sexual intercourse does raise the suspicion for HIV, yet opportunistic pulmonary infections such as Pneumocystis Carinii pneumonia would be a late finding when the CD4 counts are less than 200.

A chest x-ray (choice B) would probably be unremarkable, since we have low suspicion for any pulmonic infection. Other causes of pulmonary wheezing and cough could include a foreign body, hypersensitivity pneumonitis, or intrathoracic lung mass. However, these are rarer etiologies and asthma is still primarily a clinical diagnosis.

Inhaled steroids (choice C) may be an appropriate treatment for mild or moderate persistent asthma. However, this patient only coughs roughly once or twice a week, and therefore would be considered to have mild intermittent asthma. An intermittent beta agonist would be the appropriate first line treatment for mild intermittent asthma.

There is no reason to suspect atypical pneumonia (choice E) in this afebrile patient with cough variant asthma.

The correct answer is D. Aspiration of gastric contents causes severe lung inflammation. The traditional dogma that the acidic nature of the aspirate is critical has recently been reevaluated and it is now clear that large volumes of gastric contents of any pH are dangerous to the lung. A witnessed aspiration event has the best chances for airway lavage so in these cases an endotracheal tube should be placed, ventilation should be held for a moment, and a flexible suction catheter should be passed so that the airway can be evacuated of gastric contents. By ventilating (choice E) with a tube in the trachea, a 100% effective mechanism for dispersion and aerosolizing the material to the distal airways is occurring. This is to be avoided.

To cease mask ventilation and suction the mouth (choice A) would not address the material that is distal to the larynx that would become aerosolized to the distal airways upon resumption of mask ventilation.

To continue masking the patient (choice B) is the least desirable course of action to take with this patient. Continuing to bellow the material on the pharynx into the larynx and lungs will almost certainly result in severe aspiration disease and death for this patient.

The insertion of a nasogastric tube (choice C) has no role in the management of acute aspiration. The goals are securing the airway and evacuation of the material from the airway prior to any delivery of the aspirate to the distal airways.

The correct answer is E. Although the task of performing laryngoscopy and intubation of the trachea is a skill that requires practice to perfect, the steps immediately after placement of the tube are in fact more critical to the success of the procedure. Once a tube is placed, unless in an infant or small child where cuffless tubes are used, the balloon on the tube must be inflated with at least 3-4cc of air. This completes the protection of the airway from aspiration and seals the airway so that delivered tidal volumes do not “leak” around the tube.

Auscultation for air in the stomach (choice A) or breath sounds (choice B) are appropriate interventions once the cuff is inflated. Ensuring no air is heard in the stomach during delivery of tidal volume (first place to auscultate), followed by bilateral breath sounds, is standard procedure for tube placement verification.

At many institutions, checking for end-tidal carbon dioxide (choice C) with a portable monitor that is placed inline with the ambu-bag is now standard. These detect the presence of carbon dioxide by a color change. These devices are now packaged as part of standard emergency airway trays at many hospitals. However, the tube must be inflated first to seal the airway.

Once the tube is secured and determined to be in the trachea, delivery of 100% inspired oxygen and initiation of mechanical ventilation (choice D) is appropriate.

The correct answer is C. Placement of an endotracheal tube via laryngoscopy can be a life-saving intervention. Ensuring proper placement of the tube however is critical to the success of the intervention. The most sensitive method of ensuring appropriate placement is colorimetric detection of end-tidal carbon dioxide. These devices are now packaged as part of standard emergency airway trays at many hospitals. A false-positive result can be obtained if a significant amount of air has been insufflated into the stomach and a false negative if the patient has no circulation (no delivery of carbon dioxide to the lungs) or has suffered a massive pulmonary embolism (large dead space).

The absence of air heard in the stomach (choice A) is reassuring, but auscultation is wholly unreliable in ascertaining whether a tube is placed in the esophagus. This is especially true in obese persons.

The presence of bilateral breath sounds (choice B) is reassuring as well, but transmitted breath sounds across the midline are a common cause for a false-positive result.

The restoration of 100% saturation by pulse oximetry (choice D) in no way offers any insight into appropriate placement of an endotracheal tube. If a patient has a large shunt, as for example with a large pneumonia, then the saturation of oxygen may not approach 100%, even with endotracheal intubation and mechanical ventilation. Also, patients can maintain 100% saturations via apneic oxygenation.

The rise and fall of the chest with positive pressure respirations (choice E) is not a good indicator of placement since patients with restrictive disorders of the lung or chest wall or with poor pulmonary compliance may not manifest any chest wall changes during ventilation.

The correct answer is A. Determining serum angiotensin-converting enzyme (ACE) and serum calcium is the correct management for this patient with suspected sarcoidosis. Although a bronchoscopy (choice D) and a lung biopsy (choice E) will also help with diagnosis of sarcoidosis, serum ACE and calcium levels are less invasive tests to obtain for diagnosis. Sarcoidosis involves multisystems including lungs, eyes, peripheral lymph nodes, spleen, gastrointestinal tract, hearing, and musculoskeletal systems. Hypercalcemia may occur in any stage of sarcoidosis. Corticosteroids lower the raised calcium level to normal by inhibiting the peripheral action of 1,25(OH)2D3 and by metabolizing the compound to an inactive metabolite. The serum ACE level is also raised in 60% of patients. ACE activity is higher in patients with hilar adenopathy and pulmonary infiltration.

A complete blood count (choice C) is incorrect, because hemolytic anemia is rare in sarcoid and leukopenia alone is too non-specific for diagnosis of sarcoid.

Serum CEA level (choice B) is incorrect, because this is a non-specific tumor marker used to monitor for colon carcinoma recurrence, as well as some lung adenocarcinoma responses to chemotherapy.

The correct answer is D. This patient has developed a tension pneumothorax, which is an emergency that requires immediate intervention with a needle on the side of the pneumothorax. He presented with a spontaneous pneumothorax, that progressed to a tension pneumothorax, and decompression to relieve the increased intrathoracic pressure is the first step in management. Young, thin men are at an increased risk for developing a spontaneous pneumothorax, and the exact cause is unknown.

Blood gases (choice A) are not the most important next step in management of this case. He requires a needle into the left 2^nd intercostal space, which is a life-saving intervention in a patient with a tension pneumothorax. Blood gases may be drawn later on, after the needle and then the chest tube are inserted.

Endotracheal intubation (choice B) is the treatment for a flail chest, which presents with paradoxical chest wall motion, splinting, and crepitus of rib fragments. The patient in this case has a tension pneumothorax, not a flail chest.

A chest tube (choice C) is inserted after the needle is placed into the left 2^nd intercostal space. By the time all of the required chest tube equipment is put together, a patient with a tension pneumothorax may die. Therefore, a needle insertion is the quickest life-saving procedure for this patient.

A chest x-ray (choice E) is not required to make the diagnosis of a tension pneumothorax. The diagnosis is clinical and a chest x-ray will only waste precious time.

The correct answer is B. In the setting of a high pretest probability for pulmonary embolism (as in this case with a patient who is known to be hypercoagulable and presents with classic symptoms), a high probability ventilation/perfusion scan is sufficient to make the diagnosis. Ventilation/perfusion scans may be read as negative, but are otherwise described in terms of the probabilities (low, intermediate, or high) of pulmonary embolism. The patient should be immediately anticoagulated with heparin to prevent further progression of thrombosis. Studies have demonstrated that low molecular weight heparin and unfractionated heparin have similar efficacies in this setting. Given the severity of his symptoms and abnormal vital signs, the patient should not be sent home until he has been monitored in the hospital and his condition stabilizes. This patient should be started on intravenous unfractionated heparin and warfarin and the heparin should be discontinued 2 days after a therapeutic INR is achieved.

Start intravenous unfractionated heparin and warfarin; discontinue the heparin as soon as the INR is therapeutic (choice A) is incorrect because the heparin must overlap with the warfarin for at least 2 days after the INR is therapeutic. Warfarin inhibits the synthesis of factors II, VII, IX, and X. The initial increase in INR seen with warfarin is due to inhibition of the factor with the shortest half-life, factor VII (the half life is approximately 7 hours). The antithrombotic effect of warfarin is thought to rely mainly on inhibition of factor II. Due to its longer half life, it can take up to 2 days for factor II levels to sufficiently decline. Therefore, if the heparin is discontinued as soon as the INR is therapeutic, the patient will be left essentially un-anticoagulated for 1-2 days.

Beginning subcutaneous low molecular weight heparin and warfarin and sending the patient home to follow up in anticoagulation clinic in 1 week (choice C) is incorrect due to the reasons described above. While low molecular weight heparin has similar efficacy to unfractionated heparin in this setting, there is no data to suggest nor any consensus that patients with pulmonary embolism can safely be treated as outpatients. This patient’s tachycardia, low blood pressure, high respiratory rate, and low oxygen saturation warrants cardiac monitoring and an inpatient stay.

Obtaining an ultrasound of his right lower extremity to rule out deep venous thrombosis (choice D) is incorrect. The patient already has a known history of deep venous thrombosis. While the physical finding of asymmetric lower extremity edema is strongly suggestive of a deep venous thrombosis in the right lower extremity, knowing this for certain would not change management. The patient will receive anticoagulation for his pulmonary embolism regardless of any findings on lower extremity ultrasound.

Performing a CT angiogram to confirm the diagnosis of pulmonary embolism (choice E) is incorrect because a CT angiogram is neither more sensitive nor more specific than ventilation/perfusion lung scan. Pulmonary angiogram (via fluoroscopy, not computed tomography) is the gold standard to make the diagnosis of pulmonary embolism. As noted above, a high probability scan is sufficient to make the diagnosis of pulmonary embolism in this setting. The PIOPED study provides data on ventilation/perfusion lung scanning for the diagnosis of pulmonary embolism, validating its use. While a CT angiogram is commonly used in practice, its routine use has not yet been validated in large trials.

The correct answer is C. This patient has septic shock. Septic shock is characterized by decreased blood pressure despite euvolemia and is often seen with severe infection, especially with Gram-negative organisms. Release of inflammatory mediators is responsible for decreasing SVR. Patients are thought to be in a hyperdynamic state with increased cardiac output. Volume status is reflected by PAWP and is classically normal but can be normal, low, or high depending on the aggressiveness of hydration.

Decreased CI, increased SVR, and normal PAWP (choice A) is an example of cardiogenic shock. This is common with cardiac tamponade or myocardial infarction. It should be thought of as pump failure. The cardiac index is low because the heart is not pumping well. The SVR is increased in an effort to maintain blood pressure. The PAWP is normal in these patients since volume is typically not the primary problem.

Hypovolemic shock (choice B) is demonstrated by a low cardiac index, an increased SVR, and a decreased PAWP. Simply, CI and PAWP are low because there isn’t enough blood volume to be pumped by the heart (low volume = low pre-load). SVR is elevated to attempt to increase blood pressure.

Obstructive shock, characterized decreased CI and normal SVR and PAWP (choice D), is typically caused by massive pulmonary embolus. Supportive care with IV fluids and vasoconstrictors along with possible embolectomy is indicated. Note: The only indication for embolectomy is hemodynamic instability.

Increased CI and SVR, and decreased PAWP (choice E) is not likely to be seen since Starling principles would suggest that it would be difficult to increase your cardiac output against a high pressure system (increased SVR) and a low intravascular volume (decreased SVR).

The correct answer is E. The patient has a classic case of superior vena cava syndrome (SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of SVCS are caused by malignancies, with lung cancer being the most common. The most feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment of choice for most patients with SVCS.

Corticosteroids, such as dexamethasone, (choice A) are not the primary treatment of SVCS. In some malignancies which are steroid responsive or if there is significant inflammation, steroids can be started as an adjunct to radiation therapy.

Chemotherapy (choice B) is not the initial treatment of choice for patients with non-small lung cancer who present with SVCS. After the patient has been started on radiation, a chemotherapeutic regimen can be offered to the patient if it is appropriate.

In patients with known lung cancer, a biopsy of the mass (choice C) causing the SVCS is usually not necessary and treatment can commence once the clinical diagnosis is made. In patients without a history of cancer, every effort should be made to obtain a diagnosis before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement, thrombosis).

Narcotics (choice D) are not direct therapy for SVCS. Of course if the patient has any significant pain due to their cancer then narcotics should be prescribed to help alleviate it. This patient is not complaining of any pain by history but like any cancer patient she should be asked directly whether she is experiencing any pain or discomfort.

The correct answer is A. This patient likely has COPD based upon his social history and symptoms. All patients who present complaining of shortness of breath, are over the age of 40, and have a smoking history or environmental exposure history to asbestos, beryllium, or dust, should have screening spirometry. Spirometry measures forced inspiratory and expiratory effort. The hallmark of COPD is decreased forced expiratory effort. The tests are noninvasive and can be performed in fully clothed patients.

A chest CT scan (choice B) is of minimal value in this case since the chest radiograph revealed no evidence of any abnormality except hyperinflation, which is to be expected in a case of COPD.

Therapeutic interventions such as albuterol inhalers (choice C), steroids (choice D), or home oxygen (choice E) are options to be considered once a diagnosis of COPD is established and its severity is quantified. Inhalers are excellent first-line drugs for patients that have reversible airflow obstruction demonstrated by full pulmonary function testing. Home oxygen is usually given for late-stage COPD in patients who have room air arterial oxygen pressures of less than 60 mm Hg. Steroids are very useful agents in acute exacerbations of COPD.

The correct answer is D. Although the details of the emergency airway algorithm are not required for either ACLS or ATLS certification, the basics of airway management are required for both. The first rule of resuscitation is “A” for airway. This patient has not had their airway secured so that they can be ventilated and oxygenated. A surgeon should be called to immediately attempt a surgical airway.

Trying to attempt a surgical airway (choice A) is not wise in a situation where there is surgical backup personnel available. These procedures are difficult and, if not done properly, will result in no chance of survival for a patient with a difficult airway.

Any attempt to re-intubate the patient with a new laryngoscope (choice B) should be undertaken only after a surgical airway has been called for. Three attempts at laryngoscopy by experienced operators is reasonable evidence that this approach will be unsuccessful at securing the airway rapidly.

To begin chest compressions and the ACLS algorithm for ventricular fibrillation (choice C) is incorrect for two reasons. First, the “A” airway has not been secured. Secondly, there is no evidence that this patient is in VF. In order to determine which ACLS algorithm to follow, a rhythm or must be determined.

To deliver 100% oxygen by face mask (choice E) is incorrect since there is no way to deliver the oxygen to the lungs without positive-pressure mask ventilation. Face mask oxygen is only useful for patients who are spontaneously breathing.

The correct answer is D. The patient’s history, exam, and x-ray are all consistent with a diagnosis of community acquired pneumonia (CAP). CAP can be safely treated as an outpatient in most circumstances. Exceptions to this rule are when the patient has an underlying medical condition (cardiac disease, pulmonary disease, diabetes, HIV, cirrhosis, renal disease, or malignancy), advanced age, or presents with a severe pneumonia manifested by unstable vital signs or bilobar pneumonia. The appropriate treatment for this patient is either a macrolide antibiotic or an extended spectrum fluoroquinolone as they will cover typical and atypical organisms.

As discussed previously this patient does not require intravenous therapy or hospital admission (choice A) unless his condition deteriorates. In addition ceftriaxone would not be adequate coverage as it does not cover the atypical organisms.

In the management of routine cases of CAP, a CT scan (choice B) is not necessary. A CT scan might be appropriate in situations where there is a concern for malignancy, underlying pulmonary disease, or non-resolving pneumonia. None of these conditions are present in this case.

This patient does not require a bronchoscopy (choice C). Potential indications for bronchoscopy are when there is a concern for an obstructive lesion on imaging studies, recurrent lobar pneumonia, or significant hemoptysis.

Ciprofloxacin (choice E) is not the antibiotic of choice for CAP. It does not provide adequate coverage against streptococcal pneumonia, which is the most common cause of CAP.

The correct answer is A. Cystic fibrosis is a pulmonary/gastric disorder caused by mutation in a protein responsible for maintaining salt and water gradients across cell membranes. The clinical manifestations of the disease stem from the presence of thick, copious secretions in the airways and ducts of the pancreas. The pulmonary manifestations are frequent infection such as pneumonia and eventually bronchiectasis. In addition to antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is critical to clearing hyper-acute infections.

Inhaled beta agonists (choice B) offer no benefit for these patients since they have no element of bronchoconstriction to their disease. All of the airway issues in these patients relates to the thick mucous plugs that they are unable to clear.

Despite some of the early successes in gene therapy for CF, early enrollment in gene therapy trials (choice C) is still not considered a standard of care and does not replace in any way the most basic management principles of caring for patients with CF which is antibiotics and chest physical therapy.

It is appropriate to begin evaluation for lung transplantation (choice D) at any time during the course of CF. However, such an evaluation does not in any way assist in managing the acute infection that the patient is currently suffering.

Most patients with CF have defined pathogenic flora such as pseudomonas. For this reason, a sputum culture for directed antibiotic therapy (choice E) to direct therapy is not critical and antibiotic coverage can be initiated prior to any definitive culture data being returned.

The correct answer is C. Patient confidentiality is one of the most important medical ethical issues facing physicians, and it certainly can pose dilemmas at times. This patient has just received horrible news and is likely just reacting without really thinking about the ramifications of his decision. However, there may be very important personal, social, or cultural reasons for his decision. It is important for you, as a physician, to explore these with him.

Calling his son (choice A) is inappropriate because it breaks confidentiality.

Although you will likely try to get the patient to reconsider his decision (choice B) telling him that therapy will likely be curative for stage IV lung cancer is not true. There is very little chance at a cure and palliative therapy is a much more reasonable expectation.

Giving him a referral to the oncologist because he is will “come to his senses” (choice D) is inappropriate. He obviously needs counseling, and the feelings as to why he does not want treatment and why he does not want his family to know, should be explored.

Although the patient may be in denial (choice E), patient confidentiality precludes you from unilaterally deciding to tell his wife. It is appropriate to try to understand the reasons why he does not want to tell his family, as opposed to trying to persuade him to tell his wife when he gets home.

The correct answer is C. This patient has asthma, and the most crucial step in the management of asthma is avoidance of the triggering factors, e.g., allergens. Unfortunately, it is difficult to avoid specific types of allergens, such as pollens. Specific measures to eliminate or reduce exposure to dust mites and animal dander at home lead to a reduced frequency of attacks and hospitalization rates. Regardless of the allergens involved, elimination of respiratory irritants, especially cigarette smoke, is of crucial importance. The bronchial tree of asthmatic patients is highly reactive to any form of chemical or physical irritation. Thus the avoidance of passive smoke is important. The mother should ask her boyfriend to go smoke outside alone if he needs to, but he should not be allowed to smoke in the house.

It is not practical to administer immunotherapy against identified allergens (choice A) in this case because he is allergic to multiple airborne allergens, and it seems like he is especially responsive to cigarette smoke. Immunotherapy is of some benefit when a single allergen is identified. The most important step is to try to reduce exposure to avoidable allergens (smoke).

Avoidance of all exercise (choice B) is not appropriate because even though exercise triggers asthmatic attacks in some patients, this does not seem to be his main trigger.

Humidifiers and air cleaners (choice D) at home is not the appropriate management. Humidifiers favor the growth of dust mites, and air cleaners have not been shown to be uniformly effective in getting rid of dust mites.

It is inappropriate to prescribe inhaled sodium cromoglycate, oral corticosteroids, and oral theophylline (choice E) for this patient because the fewest number of drugs at the lowest effective doses should be used. Typically, a one drug regimen (a bronchodilator or an inhaled corticosteroid) for mild to moderate asthma or two drugs for more severe cases is sufficient to control asthma exacerbations. Oral corticosteroids are indicated in cases of severe asthma and are therefore, not for this patient.

The correct answer is C. This patient has non-massive hemoptysis, which is defined as less that 100 mL of expectorated blood over 24 hours. The work-up begins with history and physical examination. A chest x-ray and laboratory studies should be ordered initially. If the chest x-ray is normal and the patient has risk factors for cancer, like smoking 2 pack of cigarettes a day for the past 30 years, a bronchoscopy should be ordered to localize the bleeding site and look for an endobronchial mass. If none is found, a high resolution CT scan should be considered. If a mass is found on a study, referral to a thoracic surgeon is necessary.

It is inappropriate to admit him to the hospital for immediate thoracic surgery (choice A) at this time. He has non-massive hemoptysis and needs a bronchoscopy to be ordered to localize the bleeding site and look for an endobronchial mass. Surgery may be indicated in the future, but now, since he is hemodynamically stable, he needs further evaluation for his hemoptysis.

It is unnecessary to order another chest x-ray (choice B) at this time. Since his physical examination has not changed, it is unlikely that a chest x ray would have changed in 2 weeks. He has no symptoms that suggest pneumonia which may appear on a later x-ray. He requires a bronchoscopy to look for a mass that cannot be visualized on the x-ray.

A high-resolution CT scan (choice D) is usually only indicated after a chest x-ray and a bronchoscopy. An exception is when the chest x-ray suggests parenchymal disease, then the HCRT is usually performed before the bronchoscopy.

In this patient with hemoptysis and a significant smoking history, reassuring him that all of the tests were normal (choice E) is inappropriate. You need to find the cause of his symptoms by continuing with the diagnostic evaluation. A bronchoscopy is indicated at this time.

The correct answer is D. This patient most likely has Mycoplasma pneumonia, which is a common cause of pneumonia in young adults and is typically treated with oral erythromycin as an outpatient. It is characterized by a dry cough, headache, myalgia, malaise, and fever. Physical examination is usually unremarkable except for diffuse rhonchi or fine rales. A chest x-ray shows diffuse interstitial or reticulonodular infiltrates, typically in the lower lobes. Given the patient’s age, history, physical examination, and chest x-ray findings, it is reasonable to assume that he has a community-acquired pneumonia. This is most likely due to Mycoplasma pneumoniae and empiric antimicrobial therapy with erythromycin should be prescribed. In these patients, a microbial diagnosis (with a sputum culture, transtracheal aspiration, bronchoscopy, or a blood culture) is often impractical and unnecessary. A cold agglutinin response is often associated with Mycoplasma pneumoniae. However, it is nonspecific and detected in less than 50% of cases.

Admitting him to the hospital and beginning administration of erythromycin, intravenously (choice A) is incorrect because a patient with Mycoplasma pneumonia, which is what this patient most likely has, is usually treated as an outpatient. The criteria for hospitalization of patients with pneumonia are ages >65, significant comorbidity, leukopenia, pneumonia due to Staphylococcus aureus, Gram-negative bacilli or anaerobes, suppurative complications, failure of outpatient management, inability to take oral medication, respirations >30/min, heart rate >140/min, hypotension, hypoxia, or acute alteration of mental status. The patient in this case does not meet any of these criteria.

Admitting him to the hospital and beginning administration of trimethoprim-sulfamethoxazole intravenously (choice B) is the management for patients with severe Pneumocystis carinii pneumonia (PCP), which is characterized by shortness of breath, a dry cough, fever, night sweats, rales or rhonchi, and bilateral patchy alveolar infiltrates. This is a common cause of pneumonia in immunocompromised patients, especially those with HIV and AIDS. The patient in this case does not appear to be immunocompromised, and he is not short of breath, which makes the diagnosis of PCP unlikely.

Admitting him to the hospital for a cold agglutinin test (choice C) is inappropriate because even though this patient most likely has Mycoplasma pneumonia, it can be treated with erythromycin as an outpatient, and a cold agglutinin test can be performed as an outpatient. A cold agglutinin response is often associated with Mycoplasma pneumoniae. However, it is nonspecific and detected in less than 50% of cases.

Recommending aspirin, fluids, and rest at home (choice E) is inappropriate treatment for this patient who most likely has Mycoplasma pneumonia, which needs to be treated with an antibiotic such as erythromycin.

The correct answer is A. The patient is a smoker who presented with progressive shortness of breath. Physical examination found diffuse wheezing and chest X-ray noted emphysema. In addition, she had an elevated pCO₂ with acute respiratory acidosis and moderate hypoxia. These findings are consistent with an exacerbation of chronic obstructive lung disease. Such flares are treated with β₂-agonists, anticholinergics, and steroids. In addition, antibiotics have also been shown to improve clinical outcome, and so they are part of the treatment regimen for chronic obstructive lung disease flares.

Diffusion capacity (choice B) for this patient will likely be low given her emphysema and is an important measurement for diagnosis, but it is not required in the acute management of this condition.

The patient has a normal mental status and is able to protect her airway. Her symptoms and oxygenation also improve with treatment. Thus, there is no current indication for intubation (choice C). Intubation is required if the patient has severe CO₂ retention and/or hypoxia refractory to medical therapy. Intubation is also indicated if her condition is refractory to non-invasive ventilation, if she has severe acid-base disturbances, or if there is any change in her mental status that would compromise the airway.

Lung spirometry (choice D) will aid in the diagnosis of her disease but is not useful in management of her clinical course.

Non-invasive positive pressure ventilation (choice E) is indicated in patients with severe chronic obstructive pulmonary disease that is refractory to medical therapy. It is also useful in patients with increasing respiratory fatigue. A patient must be able to initiate breathing and tolerate the breathing mask. This patient has a normal mental status and her symptoms improve with treatment. Thus, she currently does not require any assistance in ventilation.

The correct answer is B. This patient comes in for a routine examination but tells you something that could possibly be serious—that she has nonmassive (less than 100mL) hemoptysis (“expectorated blood”). Since she is a smoker and travels very frequently, you should not ignore this symptom. Since it is likely that the blood-streaked sputum is from the respiratory tract, a chest x-ray is the first diagnostic procedure that should be ordered.

Obtaining a sputum sample (choice A) by transtracheal aspiration is not indicated at this time because it is too invasive. Expectorated sputum should first try to be obtained. Blood in the sputum may occur in cases of bronchitis, pneumonia, bronchiectasis, a lung abscess, or an endobronchial tumor. Gram, fungal, and acid-fast stains will help diagnose an infectious cause, while cytology may be helpful to diagnose a tumor.

Fiberoptic bronchoscopy (choice C) is part of the evaluation of a patient with hemoptysis, but it is typically performed after a chest x-ray. It is the next step if a chest x-ray shows a mass, if the chest x-ray is normal and there are major risk factors for cancer, or if the chest x-ray is normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after weeks to months of observation.

A high-resolution CT scan (choice D) is usually only indicated after a chest x-ray is performed. If the chest x-ray shows a mass and a bronchoscopy fails to suggest a specific diagnosis, a HRCT is ordered. Also, if a chest x-ray shows parenchymal disease, a HRCT may be indicated for further evaluation.

It is inappropriate to reassure her that it is most likely nothing but to come back if she continues to have blood-streaked sputum (choice E) because hemoptysis can be the sign of serious disease, especially because she is a smoker and a “world traveler.” Even though she came to the office for a routine physical examination, a chest x-ray should be ordered at this time. Keep in mind that a chest x-ray is not part of a routine physical examination of an asymptomatic smoker.

The correct answer is B. This patient has a history of aggressive lung cancer with recurrence that presented with bronchial obstruction. Her symptoms at present, cough, shortness of breath, and stridor, suggest that again the patient has a bronchial obstruction. Stridor is caused by the inflow of air across a narrow obstruction in the airway. It signifies that some part of the trachea or main stem bronchi are quite narrow and portends an airway disaster if the disease process is allowed to progress. This patient requires a CT scan to delineate the extent of her lung malignancy and to assess the extent of her airway obstruction.

A chest radiograph (choice A) will offer no critical information for management of this patient. The resolution of the image is such that it will allow visualization of tumor recurrence and of any infiltration such as a pneumonia, but offers no details of the airways or mediastinum; the structures likely to be involved in this disease process.

A flexible bronchoscopy (choice C) is a tool that allows relatively easy visualization of the airways. It is however not useful for defining the extent to which an extrinsic mass impinges upon the airway. Flexible bronchoscopy is often used to ensure that a tumor has not invaded the bronchial structure prior to performing a lung resection of a patient with cancer of the lung.

Since there is no evidence as of yet, that there is a pleural effusion, pleural drainage (choice D) is not indicated.

A transtracheal biopsy (choice E) is used as a minimally invasive method to sample lung parenchyma when a diagnosis of a lung mass is needed. In this case, the patient has a clear diagnosis so there is no need for a tissue sample.

The correct answer is D. This child’s clinical picture is most consistent with infectious croup (laryngotracheobronchitis), commonly caused by parainfluenza viruses. The prodrome of upper respiratory illness with fever followed by a spasmodic, barking cough, is typical of this diagnosis. The classic sign on chest x-ray is the subglottic swelling ( “steeple sign,”), which is the result of viral-induced swelling of the subglottic tissue. This swelling can cause an incomplete airway obstruction, leading to stridor either at rest or during crying. Stridor at rest is an indication for treatment with steroids to decrease inflammation.

Dyspnea in a child can be the result of congenital heart disease and resulting congestive heart failure, manifested as cardiomegaly and pulmonary venous congestion on x-ray (choice A), but given the absence of prior symptoms, the normal oxygen saturation, and the lack of rales on lung examination, this is unlikely.

Fever and cough in a child also raises the possibility of pneumonia as a diagnosis. A lobar pneumonia (choice B) would be a surprising x-ray finding in this case given the child’s clear lung fields on examination and the presence of stridor, which indicates upper airway involvement.

Pneumothorax (choice C) can be a cause of sudden dyspnea in a child, especially in tall, male adolescents who may be predisposed to spontaneous pneumothoraces. This child’s prodrome and stridor on examination make this diagnosis unlikely.

Prior to the introduction of the vaccine against Haemophilus influenzae type b, epiglottitis was a common and much-feared diagnosis in pediatrics. Infection of the epiglottis by this organism led to rapidly progressive airway obstruction and potentially death. A lateral neck radiograph would demonstrate a thumb-shaped epiglottis (choice E) in these cases. This sign is not seen on frontal views of the chest.

The correct answer is B. The patient likely has tuberculosis. Virtually all M. tuberculosis is transmitted by airborne particles that are 1 to 5 µm in diameter. The symptoms of tuberculosis are protean and nonspecific and can be classified as either systemic or organ-specific. Classic systemic symptoms include fever, night sweats, anorexia, weight loss, and weakness. However, since tuberculosis is associated with other illnesses that have similar symptoms, this lack of specificity can result in a delayed diagnosis or even a misdiagnosis. Organ-specific symptoms of pulmonary tuberculosis include cough, pleuritic pain, and hemoptysis. The requirement for diagnosis is the presence of the organism that appears by acid-fast staining in a sputum sample.

In patients with primary tuberculosis, chest radiographs (choice A) often show infiltrates in the middle or lower lung zones, with ipsilateral hilar adenopathy. These findings are non-specific and are not used for confirmation of the diagnosis.

A sputum culture (choice C) is not useful in this case since the organism responsible for TB is fastidious and is difficult to culture, and certainly does not grow rapidly.

The organism responsible for TB does not stain with traditional Gram stain dyes (choice D) and therefore requires special staining such as acid-fast in order to detect it.

Although it is imperfect, the gold standard for diagnosing latent tuberculosis infection remains the intradermal injection (choice E) of purified protein derivative (5 TU) into the volar or dorsal surface of the forearm (Mantoux method). The test has no role in the diagnosis of active infection.

The correct answer is B. It is important to remember that anemia can present with dyspnea on exertion and a complete blood count should always be part of this work up. This elderly patient has an iron deficiency anemia with hemoccult positive stool. A GI malignancy needs to be ruled out and colon cancer is the most likely etiology in this patient population. Therefore, a colonaoscopy is imperative.

Although ischemic cardiomyopathy or silent ischemia can certainly present with progressive dyspnea on exertion, there are other things in the patient’s history to suggest the cause of his symptoms. A cardiac workup (choice A) at this time is not the most pressing issue.

HRCT (choice C) is a very good test to evaluate for pulmonary fibrosis. It is likely that the CXR would show more abnormalities. The minimal scarring mentioned at the right lower lobe is likely from his prior pneumonia mentioned in the past medical history, and is not causing the patient any symptoms.

The patient is presenting with a microcytic anemia. The most likely cause is iron deficiency. However, it must always be remembered that the finding of a microcytic anemia should always prompt the immediate search for an underlying cause. So although the patient will likely require iron supplementation (choice D), follow up in 3 months with no other diagnostic test is not appropriate.

A V/Q scan (choice E) can rule out chronic pulmonary emboli, which is certainly a cause of progressive DOE, but as mentioned previously, there are other things in the patient’s history to suggest the cause of his symptoms.

The correct answer is A. This is a case of pulmonary aspergillosis in a neutropenic patient after she underwent chemotherapy. The treatment of choice in neutropenic or immunosuppressed patients is amphotericin B intravenously.

Fluconazole (choices B and C) and itraconazole (choice D) are antifungal agents that have limited activity or no activity against aspergillus infections. Also, she should get intravenous therapy at this time.

Rifampin plus isoniazid (choice E) is a combination used to treat mycobacterial infections.

The correct answer is A. By history, exam, and chest radiography, this patient has pneumonia. In someone with a pneumonic process, it is advisable to send sputum for Gram stain and culture prior to the initiation of antibiotics in order to ensure that the choice of antibiotic agent will be appropriate. Empiric antibiotics are often started anyway, but it is good to know if the organism that is present is covered by the chosen antibiotic.

An open lung biopsy (choice B) is not used in the routine diagnosis of a lobar pneumonia. It is instead used in the diagnosis of more complex pulmonary pathologies such as the idiopathic interstitial pneumonias that are not amenable to diagnosis using routine methods.

A chest CT (choice C) will not add any additional information at this juncture since a chest radiograph is sufficient to confirm the presence of pneumonia in this patient.

A ventilation-perfusion scan (choice D) is used to diagnose the presence of a pulmonary embolus, which is not a part of the differential diagnosis with this patient. This type of scan is often uninterpretable in the setting of a lobar pneumonia.

A bronchoalveolar lavage (choice E) is not used in the diagnosis of a lobar pneumonia associated with a productive cough.

The correct answer is B. It is known that patients who are allergic to penicillins have a higher rate of allergy to cephalosporins. While the true rate of cephalosporin allergy under these circumstances is controversial, most authorities believe it is about 7-8%. However, it has been established that if a patient with a penicillin allergy has a negative penicillin skin test, he/she is at no increased risk of an allergy to a cephalosporin.

Starting the patient on a regimen of intravenous ampicillin-sulbactam (choice A) is not appropriate given the patient’s history of allergy to penicillin.

Starting the patient on intravenous cefuroxime if a penicillin skin test is positive (choice C) is inappropriate since a positive skin test to penicillin indicates an elevated risk of a coexistent allergy to cephalosporins. Under these conditions, based upon the available data, a quinolone agent would be reasonable.

Starting the patient on intravenous gentamicin (choice D) is not appropriate since the laboratory data specifies an organism sensitive to cephalosporins.

Starting the patient on oral vancomycin (choice E) is inappropriate since oral vancomycin has poor systemic absorption and as a rule, it is also best to avoid broad- spectrum antibiotics if a more specific agent (such as a cephalosporin with this patient) is available.

The correct answer is E. This patient most likely has acute bronchitis. Acute bronchitis in a healthy patient with no other medical conditions is often due to viral infection that is usually self-limited. Given that this patient has only had 2 days of symptoms, an antibiotic is not necessary and is inappropriate. If the symptoms persist for longer than 1 week, a macrolide antibiotic may be given. A chest x-ray and a sputum culture are not indicated.

Admission to the hospital for medical management (choice A) is inappropriate for a healthy patient with acute bronchitis.

A sputum culture (choice B) is used to identify organisms, but should only be used in an elderly patients with chronic disease that fail antibiotic therapy. This patient’s acute bronchitis is most likely due to a self-limited viral infection.

A chest x-ray (choice C) has no role in the diagnosis of acute bronchitis in a healthy patient.

Send the patient home with antibiotic therapy (choice D) is appropriate management for acute bronchitis in an elderly patient with chronic disease. A macrolide (erythromycin, azithromycin, clarithromycin) is the treatment of choice. It is not part of the initial treatment in a previously healthy patient.

The correct answer is D. The principle of individual autonomy is central to medicine. The only exceptions are if the patient has no clearly expressed wishes documented and is unable to make a decision or if the patient is deemed incompetent to make a decision. This patient is clearly competent to refuse treatment despite the wishes of his physician or neighbor. It is important to make the consequences of his decision clear to the patient before discharge and to tell him that he should return immediately should he change his mind.

Hospital care with or without intravenous antibiotics (choices A and B) is inappropriate as this patient is refusing hospital care.

This patient is clearly competent to refuse treatment, so he should not be admitted to the psychiatry ward (choice C) or given antidepressant therapy (choice F).

Consultation with an attorney (choice E) is not necessary as the patient is clearly competent to refuse medical care.

The correct answer is D. The key to this question is to recognize that this patient remains acidotic and hypercarbic despite intubation. In order to “blow off” more carbon dioxide and normalize the blood pH, you must increase minute ventilation (MV). If you remember that MV=TV X RR, you can quickly recognize that the two ways to decrease carbon dioxide is to increase the RR or increase the TV.

Decreasing RR (choice A) will increase carbon dioxide because we are decreasing minute ventilation as described above. This will result in worsening acidosis. In addition, our set respiratory rate is lower than the patient’s actual rate. If we decreased the respiratory rate, our patient would continue to breathe at a high rate and receive the same tidal volume (thereby not even changing the MV).

Increasing FiO₂ (choice B) will not be beneficial. First, the patient already has a paO₂ of greater than 60 mm Hg. If you remember the hemoglobin binding curve, you should remember oxygen saturations remain above 90% for paO₂>60 mm Hg. Therefore, our goal is to keep paO₂>60 mm Hg for most patients. Second, maintaining patients on greater than 60% oxygen may have some associated lung toxicity. Therefore, if possible, keeping the inspired oxygen less than 60% is an important part of management. Of course, if high levels of inspired oxygen are necessary, you should not hesitate to use them. Please remember that patients on ventilators need not (and should not) have oxygen saturations of 100% or paO₂ much greater than 60 mm Hg.

PEEP (choice C) is the use of positive airway pressures at the end of expiration. PEEP is useful in hypoxic respiratory failure such as ARDS or cardiogenic pulmonary edema. Low levels of PEEP can be used in COPD to keep airways open. Our patient’s oxygenation is acceptable so increasing PEEP would not be beneficial now. In addition, our patients blood pressure is only borderline acceptable. Increasing PEEP will decrease venous return to the heart and might lead to further reductions in blood pressures. High levels of PEEP might also predispose patients to barotrauma which is a form of ventilator induced lung damage.

Making no adjustments (choice E) is not acceptable. This patient is severely acidotic and hypercarbic and should not be left in this state.

The correct answer is C. Hoarseness of the voice is a symptom of vocal cord paralysis. Vocal cord paralysis is a result of injury to the ipsilateral recurrent laryngeal nerve, which is a branch of the vagus nerve supplying all the intrinsic muscles of the larynx. Unilateral vocal cord paralysis is much more common than bilateral disease by a factor of 3 to 1 and the left side is more commonly affected than the right side due to the longer course of the left recurrent laryngeal nerve. The most common cause of unilateral vocal cord paralysis is lung cancer. This patient’s history of smoking puts him at high risk for developing lung cancer.

Laryngeal carcinoma (choice A) can also present very early with symptoms of hoarseness. The most common laryngeal cancer is a glottic tumor arising from the true vocal cords. 90% of these tumors are squamous cell carcinomas. This is not a likely cause of this patient’s hoarseness because the laryngoscopy did not demonstrate a laryngeal mass or lesion. Laryngoscopy very readily detects lesions and is a good means for obtaining biopsies for further cytologic studies.

Diabetic neuropathy (choice B) is not the cause of this patient’s symptoms. Most diabetics over time will develop some neurologic involvement due to peripheral vascular disease. Classic signs and symptoms of diabetic neuropathy include numbness and loss of sensation in the distal extremities, particularly in the feet. Diabetic neuropathy is not known to cause damage to the recurrent laryngeal nerve and is thus not a cause of vocal cord paralysis.

Pneumonia (choice D) is not a cause of vocal cord paralysis. Primary lung cancers that occur in the lung apices are the most common cause of injury to the recurrent laryngeal nerve and thus vocal cord paralysis. Pneumonia is an infectious process that does not cause mass effect or damage to the nerve.

Stroke (choice E) can be a cause of vocal cord paralysis when an infarct occurs in the nucleus ambiguus of the medulla. The nucleus ambiguus is the origin of the vagus nerve in the brain. However, if a stroke were to occur in the medulla, there would be many more deficits than a focal vocal cord injury. This patient is presenting with isolated unilateral vocal cord paralysis which means the injury occurred somewhere after the left recurrent laryngeal nerve branched off the vagus nerve.

The correct answer is C. This patient has severe COPD and is suffering from a COPD flare. She is in severe respiratory distress, hypoxic, and almost certainly hypercarbic. Once her airway is secured, 100% oxygen should be delivered via slow breaths (8-12 per minute) with smaller tidal volumes than most patients would receive. Larger tidal volumes are associated with a risk of volu-trauma such as bursting of a bleb or bulla. Slow breaths minimize the risk of air trapping and so called “intrinsic-PEEP” or “auto-PEEP.”

Allowing the patient to breathe spontaneously (choice A) is inappropriate. She was unable to ventilate and oxygenate well prior to insertion of the endotracheal tube. Now, with it present, and the increased resistance to breathing it confers, there is minimal chance that her success with ventilation would be any greater.

Using rapid, shallow breaths to increase oxygen delivery (choice B) will almost certainly be harmful. These patients require prolonged expiratory time to exhale completely. Each rapid breath essentially “stacks” on top of an unfinished exhalation and therefore augments the end expiratory volume (therefore pressure) in the lungs. This is known as auto-PEEP and can become so severe that it impedes venous return to the heart and precipitates in circulatory collapse.

As discussed above, slow breaths with 15-20cc/kg tidal volumes (choice D) are associated with a significant risk of volu-trauma in these patients so traditional tidal volumes are not to be used.