Respiratory
An adult has upper respiratory symptoms and cough for the past 14 days. What should be
considered? (Pertussis)
Pertussis should always be considered in adults who present with acute cough of greater than
5 days’ duration. The incubation period for pertussis is about 7-10 days. Patients present with
URI symptoms for 1-2 weeks. The classic paroxysmal cough usually begins in the second week
of the illness. The duration of symptoms and cough are about 3 months even when treated
with antibiotics. This is highly infectious and is a reportable disease.
Mycoplasma pneumoniae is: (a disease with extrapulmonary manifestations)
Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to
diagnose because symptoms can be varied and involve multiple body systems
(extrapulmonary manifestations). Infection with Mycoplasma may present with a normal
white blood cell count, maculopapular rash, GI symptoms, tender joints and aches, and,
though rare, cardiac rhythm disturbances. Respiratory symptoms may not be pronounced. On
chest X-ray there are some unique findings (peribronchial pattern) with Mycoplasma. These
include thickened bronchial shadow, streaks of interstitial infiltration, and atelectasis. These
are more likely to occur in the lower lobes.
Which medication below is contraindicated in an asthma patient because it may increase
risk of sudden death if used alone? (Long-acting bronchodilator)
A long-acting bronchodilator can be used to treat asthma when it is used in combination with
an inhaled steroid. Otherwise, using a long-acting bronchodilator like salmeterol is
contraindicated. There is an increased risk of sudden death with asthma exacerbations when
this class is used solo to treat asthma. The other choices can be used to treat asthma. Choices
vary depending on the patient.
A 75-year-old female with emphysema who has been treated with inhaled steroids for
many years should: (should be screened for osteoporosis)
Older females are at higher risk than others for osteoporosis. This female patient, who has
used inhaled steroids and smokes, has multiple risk factors for osteoporosis. Additionally,
she probably has emphysema because she smoked (or still smokes). If she is Asian or
Caucasian, she has still another risk factor. Screening for osteoporosis should be considered
,when managing patients with multiple risk factors.
A patient received the pneumonia immunization at age 60 years. He is 65 years old and
presents to your clinic today. What recommendation should be made about the
pneumococcal immunization? (He should receive another one today)
This patient should receive another one today because he is 65 years old and at least 5 years
has elapsed since his last one. The CDC does not recommend immunizing this patient every 5
years. Two immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should
be administered today. PPSV23 should be administered at least 1 year later.
Which of the following medications should be used cautiously in a patient who has asthma?
(Timolol ophthalmic drops)
Timolol is a beta blocker. This class of medications can precipitate bronchoconstriction in
patients who have asthma. Even though timolol is being administered in the eye, it is
absorbed through mucous membranes and can exert systemic effects. Beta blockers should
be avoided in patients with asthma and used cautiously in patients with COPD. The other
medications listed have no specific contraindications for patients with asthma.
The most common symptom associated with acute bronchitis is: (Cough)
Fever (temp > 101°F) is an unusual symptom associated with acute bronchitis. Cough is the
most common symptom associated with acute bronchitis. Purulent sputum is identified in
more than 50% of patients with acute bronchitis. The color imparted to the sputum is usually
due to sloughing of epithelial cells, not bacterial infection. Concurrent upper respiratory
symptoms are typical of acute bronchitis.
Pharyngitis is common.
Mild persistent asthma is characterized by: (symptoms occurring more than twice weekly)
Mild persistent asthma is characterized by symptoms that occur more than twice weekly but
not daily; or 3-4 nocturnal awakenings per month due to asthma. It is treated with an inhaled
steroid daily, and a bronchodilator PRN for exacerbations. If symptoms occur more than twice
weekly, therapy should be stepped up. Generally, a long-acting bronchodilator is added to the
steroid when therapy is stepped up.
The chest circumference of a 12 month-old is: (equal to head circumference)
The chest circumference is not routinely measured at well-child visits, but is assessed if there is
,concern about the circumference of either the head or the chest. An exception to this
observation can occur in premature infants where the head grows very rapidly. Normally, the
head exceeds the chest circumference by 1-2 cm from birth until 6 months. Between 6 and 24
months the head and chest circumference should be about equal and by 2 years of age the
chest should be larger than the head. The chest circumference is measured at the nipple line.
A patient with cough and fever is found to have infiltrates on chest x-ray. What is his likely
diagnosis? (Pneumonia)
The finding of infiltrates on chest x-ray, in conjunction with clinical findings of fever and
cough, should direct the examiner to consider pneumonia as the diagnosis. Other common
clinical findings with pneumonia include chest pain, dyspnea, and sputum production. Though
not common, some patients with pneumonia exhibit gastrointestinal symptoms like nausea,
vomiting, and diarrhea.
An uncommon symptom associated with acute bronchitis is: (temperature > 101°F)
Fever is an unusual symptom associated with acute bronchitis. Cough is the most common
symptom associated with acute bronchitis. Purulent sputum is identified in more than 50% of
patients with acute bronchitis. The color imparted to the sputum is usually due to sloughing
of epithelial cells, not bacterial infection. Concurrent upper respiratory symptoms are typical
of acute bronchitis. Pharyngitis is common within the first 3 days of the illness.
Patients who have cough-variant asthma: (all exhibit cough)
One of the most common causes of cough in adults is asthma. Cough due to asthma is often
accompanied by episodic wheezing or dyspnea, though some patients who have asthma only
cough. This is termed “cough-variant asthma.” The clinical presentation of asthma varies but
hyper-responsiveness of the airways is a typical finding.
The most common cause of atypical pneumonia in adults is: (Mycoplasma pneumonia)
In patients who have atypical pneumonia, Mycoplasma is the most common pathogen. M.
pneumoniae is so named because of its atypical appearance on chest X-ray. This organism is
responsible for “walking pneumonia” that is prevalent in a young adult population. This
accounts for about 15% of pneumonia and is transmitted via respiratory droplet.
Which patient might be expected to have the worst FEV1? (A 65-year-old with emphysema)
FEV 1 stands for “forced expiratory volume in 1 second.” This is the volume of air that is
, forcefully exhaled in the first second of exhalation after a deep breath. Patients with
emphysema are not able to do this efficiently because their alveoli are stretched, and mostly
contain trapped air. FEV 1 is used to assess airway obstruction. An asthma patient in the
green zone would be expected to have a normal (compared to himself) FEV1. An FEV1
measurement or pulmonary function tests would not be performed on a patient with
pneumonia or bronchiectasis because he would have diminished respiratory capacity related
to his infection.
A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He
has wheezing and diminished breath sounds in the upper right lobe. His cough is
nonproductive, and he denies nasal symptoms. Which symptom is not likely related to his
asthma? (Fever)
Wheezing is typical of asthma, but one must consider pneumonia in any patient who presents
with diminished breath sounds in only one lobe. Fever is not typical of asthma or an
exacerbation.
Ipratropium is very widely used in the treatment of COPD. Which of the following
statements about ipratropium is correct? (It decreases parasympathetic tone and produces
bronchodilation)
Ipratropium is the most widely studied anticholinergic medication used to treat patients with
COPD. It produces its helpful effects by reducing cholinergic tone in the lungs. It may be used
with a beta agonist if shortness of breath is present. However, beta agonists increase side
effects like tachycardia and tremor and do not improve efficacy.
An 80-year-old has Stage 3 COPD. He is most likely to have concomitant: (anxiety or
depression)
About 40% of older patients who have COPD have concomitant anxiety and/or depression. It
should be treated because it affects the overall management of COPD. COPD is
characterized by airflow limitation and dyspnea. This may contribute to feelings of chronic
anxiety. Additionally, many chronic diseases are associated with depression. This is the case
with COPD.
A 6-year-old child who has moderate persistent asthma is diagnosed with pneumonia after
An adult has upper respiratory symptoms and cough for the past 14 days. What should be
considered? (Pertussis)
Pertussis should always be considered in adults who present with acute cough of greater than
5 days’ duration. The incubation period for pertussis is about 7-10 days. Patients present with
URI symptoms for 1-2 weeks. The classic paroxysmal cough usually begins in the second week
of the illness. The duration of symptoms and cough are about 3 months even when treated
with antibiotics. This is highly infectious and is a reportable disease.
Mycoplasma pneumoniae is: (a disease with extrapulmonary manifestations)
Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to
diagnose because symptoms can be varied and involve multiple body systems
(extrapulmonary manifestations). Infection with Mycoplasma may present with a normal
white blood cell count, maculopapular rash, GI symptoms, tender joints and aches, and,
though rare, cardiac rhythm disturbances. Respiratory symptoms may not be pronounced. On
chest X-ray there are some unique findings (peribronchial pattern) with Mycoplasma. These
include thickened bronchial shadow, streaks of interstitial infiltration, and atelectasis. These
are more likely to occur in the lower lobes.
Which medication below is contraindicated in an asthma patient because it may increase
risk of sudden death if used alone? (Long-acting bronchodilator)
A long-acting bronchodilator can be used to treat asthma when it is used in combination with
an inhaled steroid. Otherwise, using a long-acting bronchodilator like salmeterol is
contraindicated. There is an increased risk of sudden death with asthma exacerbations when
this class is used solo to treat asthma. The other choices can be used to treat asthma. Choices
vary depending on the patient.
A 75-year-old female with emphysema who has been treated with inhaled steroids for
many years should: (should be screened for osteoporosis)
Older females are at higher risk than others for osteoporosis. This female patient, who has
used inhaled steroids and smokes, has multiple risk factors for osteoporosis. Additionally,
she probably has emphysema because she smoked (or still smokes). If she is Asian or
Caucasian, she has still another risk factor. Screening for osteoporosis should be considered
,when managing patients with multiple risk factors.
A patient received the pneumonia immunization at age 60 years. He is 65 years old and
presents to your clinic today. What recommendation should be made about the
pneumococcal immunization? (He should receive another one today)
This patient should receive another one today because he is 65 years old and at least 5 years
has elapsed since his last one. The CDC does not recommend immunizing this patient every 5
years. Two immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should
be administered today. PPSV23 should be administered at least 1 year later.
Which of the following medications should be used cautiously in a patient who has asthma?
(Timolol ophthalmic drops)
Timolol is a beta blocker. This class of medications can precipitate bronchoconstriction in
patients who have asthma. Even though timolol is being administered in the eye, it is
absorbed through mucous membranes and can exert systemic effects. Beta blockers should
be avoided in patients with asthma and used cautiously in patients with COPD. The other
medications listed have no specific contraindications for patients with asthma.
The most common symptom associated with acute bronchitis is: (Cough)
Fever (temp > 101°F) is an unusual symptom associated with acute bronchitis. Cough is the
most common symptom associated with acute bronchitis. Purulent sputum is identified in
more than 50% of patients with acute bronchitis. The color imparted to the sputum is usually
due to sloughing of epithelial cells, not bacterial infection. Concurrent upper respiratory
symptoms are typical of acute bronchitis.
Pharyngitis is common.
Mild persistent asthma is characterized by: (symptoms occurring more than twice weekly)
Mild persistent asthma is characterized by symptoms that occur more than twice weekly but
not daily; or 3-4 nocturnal awakenings per month due to asthma. It is treated with an inhaled
steroid daily, and a bronchodilator PRN for exacerbations. If symptoms occur more than twice
weekly, therapy should be stepped up. Generally, a long-acting bronchodilator is added to the
steroid when therapy is stepped up.
The chest circumference of a 12 month-old is: (equal to head circumference)
The chest circumference is not routinely measured at well-child visits, but is assessed if there is
,concern about the circumference of either the head or the chest. An exception to this
observation can occur in premature infants where the head grows very rapidly. Normally, the
head exceeds the chest circumference by 1-2 cm from birth until 6 months. Between 6 and 24
months the head and chest circumference should be about equal and by 2 years of age the
chest should be larger than the head. The chest circumference is measured at the nipple line.
A patient with cough and fever is found to have infiltrates on chest x-ray. What is his likely
diagnosis? (Pneumonia)
The finding of infiltrates on chest x-ray, in conjunction with clinical findings of fever and
cough, should direct the examiner to consider pneumonia as the diagnosis. Other common
clinical findings with pneumonia include chest pain, dyspnea, and sputum production. Though
not common, some patients with pneumonia exhibit gastrointestinal symptoms like nausea,
vomiting, and diarrhea.
An uncommon symptom associated with acute bronchitis is: (temperature > 101°F)
Fever is an unusual symptom associated with acute bronchitis. Cough is the most common
symptom associated with acute bronchitis. Purulent sputum is identified in more than 50% of
patients with acute bronchitis. The color imparted to the sputum is usually due to sloughing
of epithelial cells, not bacterial infection. Concurrent upper respiratory symptoms are typical
of acute bronchitis. Pharyngitis is common within the first 3 days of the illness.
Patients who have cough-variant asthma: (all exhibit cough)
One of the most common causes of cough in adults is asthma. Cough due to asthma is often
accompanied by episodic wheezing or dyspnea, though some patients who have asthma only
cough. This is termed “cough-variant asthma.” The clinical presentation of asthma varies but
hyper-responsiveness of the airways is a typical finding.
The most common cause of atypical pneumonia in adults is: (Mycoplasma pneumonia)
In patients who have atypical pneumonia, Mycoplasma is the most common pathogen. M.
pneumoniae is so named because of its atypical appearance on chest X-ray. This organism is
responsible for “walking pneumonia” that is prevalent in a young adult population. This
accounts for about 15% of pneumonia and is transmitted via respiratory droplet.
Which patient might be expected to have the worst FEV1? (A 65-year-old with emphysema)
FEV 1 stands for “forced expiratory volume in 1 second.” This is the volume of air that is
, forcefully exhaled in the first second of exhalation after a deep breath. Patients with
emphysema are not able to do this efficiently because their alveoli are stretched, and mostly
contain trapped air. FEV 1 is used to assess airway obstruction. An asthma patient in the
green zone would be expected to have a normal (compared to himself) FEV1. An FEV1
measurement or pulmonary function tests would not be performed on a patient with
pneumonia or bronchiectasis because he would have diminished respiratory capacity related
to his infection.
A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He
has wheezing and diminished breath sounds in the upper right lobe. His cough is
nonproductive, and he denies nasal symptoms. Which symptom is not likely related to his
asthma? (Fever)
Wheezing is typical of asthma, but one must consider pneumonia in any patient who presents
with diminished breath sounds in only one lobe. Fever is not typical of asthma or an
exacerbation.
Ipratropium is very widely used in the treatment of COPD. Which of the following
statements about ipratropium is correct? (It decreases parasympathetic tone and produces
bronchodilation)
Ipratropium is the most widely studied anticholinergic medication used to treat patients with
COPD. It produces its helpful effects by reducing cholinergic tone in the lungs. It may be used
with a beta agonist if shortness of breath is present. However, beta agonists increase side
effects like tachycardia and tremor and do not improve efficacy.
An 80-year-old has Stage 3 COPD. He is most likely to have concomitant: (anxiety or
depression)
About 40% of older patients who have COPD have concomitant anxiety and/or depression. It
should be treated because it affects the overall management of COPD. COPD is
characterized by airflow limitation and dyspnea. This may contribute to feelings of chronic
anxiety. Additionally, many chronic diseases are associated with depression. This is the case
with COPD.
A 6-year-old child who has moderate persistent asthma is diagnosed with pneumonia after
