PULMONARY ROSH REVIEW EXAM WITH QUESTIONS AND ANSWER p p p p p p p
S (VERIFIED AND WELL DETAILED ANSWERS) LATESTUPDATE 2024/2
p p p p p p p p
025
A 25-year-
p
old man presents for evaluation of fever and cough. He reports last weekthat he was di
p p p p p p p p p p p p p p p p
agnosed with influenza. In the last 2 days he developed a worsening cough productive
p p p p p p p p p p p p p p
of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR 18, and 95
p p p p p p p p p p p p p p p p p
% oxygen saturation on room air. His chest X-ray
p p p p p p p p
demonstrates a lobar infiltrate in the left lower lobe. Which of the following wouldyou
p p p p p p p p p p p p p p p
most likely expect to see on the patient's Gram stain?
p p p p p p p p p
Gram negative bacilli Gra
p p p
m negative diplococciGra
p p p
m positive bacilli
p p
Gram positive cocci in clusters -
p p p p p
p CORRECT ANSWER Correct Answer ( D )Explanation: p p p p p p p
The patient had a recent influenza infection and now presents with a lobar
p p p p p p p p p p p p
infiltrate. Staphylococcus aureus pneumonia is classically associated with causingp
p p p p p p p p p
ost-
influenza bacterial pneumonia. On Gram stain this is seen as Gram positive cocci in
p p p p p p p p p p p p p
pclusters
Question: In which population is Klebsiella pneumonia most commonly seen in? -
p p p p p p p p p p p
CORRECT ANSWER COPD, Alcoholics and the elderly.
p p p p p p p
Bacterial Pneumonia Overview - CORRECT ANSWER Bacterial Pneumonia
p p p p p p p
S. pneumonia: most common, rusty colored sputum, rigors, gram+ paired lancets
p p p p p p p p p p
,Klebsiella: alcoholics, currant jelly sputum, bulging fissures,
p p p p p p
S. aureus: IVDA, postinfluenza, elderly, gram+ cocci in clusters
p p p p p p p p
H. influenzae: COPD, gram negative pleomorphic rods Pseudomon
p p p p p p p
as: cystic fibrosis, nursing home resident and cyanosisHealth care a
p p p p p p p p p p
ssociated pneumonia: pseudomonas, MRSA p p p
Outpatient, healthy: macrolide or doxycycline p p p p
Outpatient, comorbidity: respiratory tract fluoroquinolone (RTF)In
p p p p p p
patient: RTF p
ICU: antipneumococcal ß-
p p
lactam (ceftriaxone or cefotaxime) + either azithromycinor an RTF
p p p p p p p p p
You evaluate a 65-year-old patient for shortness of breath and note on exam
p p p p p p p p p p p p
decreased breath sounds at the left lung base. You are suspicious of a small pleuraleff
p p p p p p p p p p p p p p p
usion. In which of the following views on the chest radiograph is the small pleural eff
p p p p p p p p p p p p p p p
usion most likely to be detected?
p p p p p
Lateral
Lateral decubitus left side down L p p p p p
ateral decubitus right side down
p p p p
Posterior-anterior (PA) - p p
p CORRECT ANSWER Correct Answer ( B )Explanation: p p p p p p p
Classic physical signs of a pleural effusion include diminished breath sounds, dullness
p p p p p p p p p p p
pto percussion, decreased tactile fremitus, and occasionally a localized pleural friction
p p p p p p p p p p p
rub. Chest radiograph confirms the suspicion of pleural effusion.
p p p p p p p p
The classic radiographic appearance of a pleural effusion is blunting of thecostophreni
p p p p p p p p p p p p
c angle on the upright chest radiograph
p p p p p p
,Pleural Effusion p
Transudate: CHF (most common) Ex p p p p
udate: infection > malignancy, PE
p p p p
↓ Breath sounds + dull percussion + ↓ tactile fremitusCX
p p p p p p p p p p
R: blunting of the costophrenic angle
p p p p p
Question: A pleural effusion is most difficult to detect in which radiographicp
p p p p p p p p p p p p
osition? - CORRECT ANSWER Supine.
p p p p
Which of the following complications can be prevented by simultaneously
p p p p p p p p p
administering pyridoxine and isoniazid in a patient with tuberculosis exposure?
p p p p p p p p p
Color blindness p p
Hepatitis
Peripheral neuropathy p
Renal failure - p p
CORRECT ANSWER Correct Answer ( C )Explanation:
p p p p p p p p
Isoniazid (INH) inhibits the enzyme responsible for the conversion of pyridoxine(
p p p p p p p p p p p
vitamin B6) to one of its active metabolites, pyridoxal phosphate (PLP). This deple
p p p p p p p p p p p p
tion of vitamin B6 may lead to complications such as peripheral neuropathyand sei
p p p p p p p p p p p p p
zures. Therefore, vitamin B6 should be administered concomitantly to
p p p p p p p p
patients taking isoniazid. PLP is also a coenzyme required for the synthesis of ga
p p p p p p p p p p p p p
mma-
aminobutyric acid (GABA), an inhibitory neurotransmitter. Decreased GABA fo
p p p p p p p p
rmation in the setting of vitamin B6 deficiency may also contribute toseizures.
p p p p p p p p p p p p
Color blindness (A) is not a complication of INH. However, another commonly use
p p p p p p p p p p p p
d drug in TB, ethambutol, is associated with retrobulbar neuritis and red-
p p p p p p p p p p p
greencolor blindness. INH is metabolized by the liver and gets converted to an
p p p p p p p p p p p p p
, ammonium molecule that can lead to hepatotoxicity (B). However, this is not affected
p p p p p p p p p p p p p
by vitamin B6 supplementation. Renal failure (D) is a complication ofpyridoxine over
p p p p p p p p p p p p
dose.
Question: What is the most common location of extrapulmonary TB? -
p p p p p p p p p p
CORRECT ANSWER Lymph nodes.
p p p p
Pulmonary Tuberculosis (TB) p p
RFs: immunodeficiency, immigrant, close contactLatent/
p p p p p
primary TB: asymptomatic p p
Active/reactivation TB: fever, night sweats, weight loss, productive cough,hemoptysis p p p p p p p p p
Erythema nodosum p
Primary TB CXR: Ghon focus p p p p
Active/reactivation TB: upper lobes, cavitary lesions p p p p p
Dx: sputum smears for acid-
p p p p
fast bacilli (AFB), sputum/tissue culture for AFB (goldstandard)
p p p p p p p p
PPD: gold standard for latent TB dx
p p p p p p p
Latent TB rx: 9 months of INH p p p p p p
Primary TB rx: rifampin, INH, pyraziniamide, ethambutol (RIPE)
p p p p p p p
A 45-year-
p
old patient with newly diagnosed diabetes mellitus type 2 presents to your office for h
p p p p p p p p p p p p p p
er annual exam. She has had her hepatitis B vaccination, but wantsto know if she need
p p p p p p p p p p p p p p p p
s any additional vaccinations because of her new diagnosis.
p p p p p p p p
Which of the following is the most appropriate next step in her management?
p p p p p p p p p p p p
Administer annual influenza vaccine only p p p p
S (VERIFIED AND WELL DETAILED ANSWERS) LATESTUPDATE 2024/2
p p p p p p p p
025
A 25-year-
p
old man presents for evaluation of fever and cough. He reports last weekthat he was di
p p p p p p p p p p p p p p p p
agnosed with influenza. In the last 2 days he developed a worsening cough productive
p p p p p p p p p p p p p p
of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR 18, and 95
p p p p p p p p p p p p p p p p p
% oxygen saturation on room air. His chest X-ray
p p p p p p p p
demonstrates a lobar infiltrate in the left lower lobe. Which of the following wouldyou
p p p p p p p p p p p p p p p
most likely expect to see on the patient's Gram stain?
p p p p p p p p p
Gram negative bacilli Gra
p p p
m negative diplococciGra
p p p
m positive bacilli
p p
Gram positive cocci in clusters -
p p p p p
p CORRECT ANSWER Correct Answer ( D )Explanation: p p p p p p p
The patient had a recent influenza infection and now presents with a lobar
p p p p p p p p p p p p
infiltrate. Staphylococcus aureus pneumonia is classically associated with causingp
p p p p p p p p p
ost-
influenza bacterial pneumonia. On Gram stain this is seen as Gram positive cocci in
p p p p p p p p p p p p p
pclusters
Question: In which population is Klebsiella pneumonia most commonly seen in? -
p p p p p p p p p p p
CORRECT ANSWER COPD, Alcoholics and the elderly.
p p p p p p p
Bacterial Pneumonia Overview - CORRECT ANSWER Bacterial Pneumonia
p p p p p p p
S. pneumonia: most common, rusty colored sputum, rigors, gram+ paired lancets
p p p p p p p p p p
,Klebsiella: alcoholics, currant jelly sputum, bulging fissures,
p p p p p p
S. aureus: IVDA, postinfluenza, elderly, gram+ cocci in clusters
p p p p p p p p
H. influenzae: COPD, gram negative pleomorphic rods Pseudomon
p p p p p p p
as: cystic fibrosis, nursing home resident and cyanosisHealth care a
p p p p p p p p p p
ssociated pneumonia: pseudomonas, MRSA p p p
Outpatient, healthy: macrolide or doxycycline p p p p
Outpatient, comorbidity: respiratory tract fluoroquinolone (RTF)In
p p p p p p
patient: RTF p
ICU: antipneumococcal ß-
p p
lactam (ceftriaxone or cefotaxime) + either azithromycinor an RTF
p p p p p p p p p
You evaluate a 65-year-old patient for shortness of breath and note on exam
p p p p p p p p p p p p
decreased breath sounds at the left lung base. You are suspicious of a small pleuraleff
p p p p p p p p p p p p p p p
usion. In which of the following views on the chest radiograph is the small pleural eff
p p p p p p p p p p p p p p p
usion most likely to be detected?
p p p p p
Lateral
Lateral decubitus left side down L p p p p p
ateral decubitus right side down
p p p p
Posterior-anterior (PA) - p p
p CORRECT ANSWER Correct Answer ( B )Explanation: p p p p p p p
Classic physical signs of a pleural effusion include diminished breath sounds, dullness
p p p p p p p p p p p
pto percussion, decreased tactile fremitus, and occasionally a localized pleural friction
p p p p p p p p p p p
rub. Chest radiograph confirms the suspicion of pleural effusion.
p p p p p p p p
The classic radiographic appearance of a pleural effusion is blunting of thecostophreni
p p p p p p p p p p p p
c angle on the upright chest radiograph
p p p p p p
,Pleural Effusion p
Transudate: CHF (most common) Ex p p p p
udate: infection > malignancy, PE
p p p p
↓ Breath sounds + dull percussion + ↓ tactile fremitusCX
p p p p p p p p p p
R: blunting of the costophrenic angle
p p p p p
Question: A pleural effusion is most difficult to detect in which radiographicp
p p p p p p p p p p p p
osition? - CORRECT ANSWER Supine.
p p p p
Which of the following complications can be prevented by simultaneously
p p p p p p p p p
administering pyridoxine and isoniazid in a patient with tuberculosis exposure?
p p p p p p p p p
Color blindness p p
Hepatitis
Peripheral neuropathy p
Renal failure - p p
CORRECT ANSWER Correct Answer ( C )Explanation:
p p p p p p p p
Isoniazid (INH) inhibits the enzyme responsible for the conversion of pyridoxine(
p p p p p p p p p p p
vitamin B6) to one of its active metabolites, pyridoxal phosphate (PLP). This deple
p p p p p p p p p p p p
tion of vitamin B6 may lead to complications such as peripheral neuropathyand sei
p p p p p p p p p p p p p
zures. Therefore, vitamin B6 should be administered concomitantly to
p p p p p p p p
patients taking isoniazid. PLP is also a coenzyme required for the synthesis of ga
p p p p p p p p p p p p p
mma-
aminobutyric acid (GABA), an inhibitory neurotransmitter. Decreased GABA fo
p p p p p p p p
rmation in the setting of vitamin B6 deficiency may also contribute toseizures.
p p p p p p p p p p p p
Color blindness (A) is not a complication of INH. However, another commonly use
p p p p p p p p p p p p
d drug in TB, ethambutol, is associated with retrobulbar neuritis and red-
p p p p p p p p p p p
greencolor blindness. INH is metabolized by the liver and gets converted to an
p p p p p p p p p p p p p
, ammonium molecule that can lead to hepatotoxicity (B). However, this is not affected
p p p p p p p p p p p p p
by vitamin B6 supplementation. Renal failure (D) is a complication ofpyridoxine over
p p p p p p p p p p p p
dose.
Question: What is the most common location of extrapulmonary TB? -
p p p p p p p p p p
CORRECT ANSWER Lymph nodes.
p p p p
Pulmonary Tuberculosis (TB) p p
RFs: immunodeficiency, immigrant, close contactLatent/
p p p p p
primary TB: asymptomatic p p
Active/reactivation TB: fever, night sweats, weight loss, productive cough,hemoptysis p p p p p p p p p
Erythema nodosum p
Primary TB CXR: Ghon focus p p p p
Active/reactivation TB: upper lobes, cavitary lesions p p p p p
Dx: sputum smears for acid-
p p p p
fast bacilli (AFB), sputum/tissue culture for AFB (goldstandard)
p p p p p p p p
PPD: gold standard for latent TB dx
p p p p p p p
Latent TB rx: 9 months of INH p p p p p p
Primary TB rx: rifampin, INH, pyraziniamide, ethambutol (RIPE)
p p p p p p p
A 45-year-
p
old patient with newly diagnosed diabetes mellitus type 2 presents to your office for h
p p p p p p p p p p p p p p
er annual exam. She has had her hepatitis B vaccination, but wantsto know if she need
p p p p p p p p p p p p p p p p
s any additional vaccinations because of her new diagnosis.
p p p p p p p p
Which of the following is the most appropriate next step in her management?
p p p p p p p p p p p p
Administer annual influenza vaccine only p p p p
