A 79-year-old woman is hospitalized after a fall that resulted in a left femoral neck fracture.  She tripped over her dog while cleaning her home, hit her head on a bookshelf, and landed on her left side.  Prior to this she had been in her usual state of health; her other medical issues include obesity, type 2 diabetes mellitus, hypertension, chronic kidney disease, and hypothyroidism.  The patient lives at home by herself.  She has smoked a pack of cigarettes daily for 38 years.  She drinks alcohol every weekend.  Results of the patient’s initial workup in the emergency department demonstrated the left femoral neck fracture, creatinine of 2.0 mg/dL, and a negative noncontrast head CT.  She was admitted to the hospital and the following day underwent surgical repair.  The procedure was uncomplicated.  However, on postoperative day 3 the patient is noted to be uncomfortable and mildly agitated.  She is unable to coherently explain her symptoms.  Current medications include prophylactic subcutaneous heparin, insulin glargine, omeprazole, hydrocodone, and levothyroxine.  Temperature is 37.7 C (99.9 F), blood pressure is 104/68 mm Hg, pulse is 114/min, and respirations are 28/min.  Pulse oximetry is 86% on room air.  Examination shows equal round and reactive pupils.  Lung examination demonstrates decreased breath sounds at the bilateral bases.  Heart rhythm is regular with normal S1 and S2.  The surgical incision shows no surrounding erythema or purulent drainage.  The patient follows commands and moves all extremities except the left leg.  Laboratory results are as follows:

Troponin I is undetectable.  Chest x-ray shows slight bibasilar atelectasis without focal consolidation, pleural effusion, or pulmonary edema.  ECG shows sinus tachycardia but is otherwise unremarkable.

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2

Ventilation-perfusion scan shows high probability for pulmonary embolism.  The patient is started on intravenous heparin.  The next day, the nurse reports that the patient has a fever.  The patient still has some chest pain but her shortness of breath and mental status are improved.  There is no cough, abdominal pain, nausea, vomiting, diarrhea, dysuria, urinary frequency, or headache.  Temperature is 38.3 C (101 F), blood pressure is 121/73 mm Hg, pulse is 102/min, and respirations are 22/min.  Oxygen saturation is 92% on 2 L of oxygen by nasal cannula.  She does not appear ill.  The lungs are clear to auscultation.  The abdomen is soft and nontender.  Neurologic examination is nonfocal.  The operative site is healing well without erythema or purulence.  The patient’s 2 peripheral IV lines have no evidence of infection.  Indwelling urinary catheter is draining clear yellow urine.  Laboratory results are as follows:

Chest x-ray shows no new abnormalities.  Urinalysis is normal.  Blood cultures are sent.  Which of the following would be the most appropriate next step for this patient?

A 63-year-old woman is brought to the emergency department from a rehabilitation facility due to shortness of breath and global weakness.  After eating lunch today, her breath suddenly felt “heavy.”  She became lightheaded and too weak to stand, rendering her unable to engage with physical therapy.  The patient had been at the facility for 5 days following a long intensive care stay for pneumonia and septic shock.  Medical history includes hypertension and mild aortic stenosis seen on an echocardiogram 2 years ago.  The patient has a 30-pack-year history.  Temperature is 36.2 C (97.2 F), blood pressure is 73/58 mm Hg, pulse is 122/min and regular, and respirations are 36/min.  Pulse oximetry reading is 75% on room air and improves to 93% with supplemental oxygen by non-rebreather mask.  She appears restless but follows commands.  The lungs are clear on auscultation.  Cardiac examination demonstrates a regular tachycardic rhythm with an early-peaking grade 2/6 systolic ejection murmur.  The abdomen is soft.  The extremities are cool.  Chest x-ray is clear.  ECG is shown below.

After administration of a 500-mL bolus of crystalloid resuscitation fluid, blood pressure is 75/57 mm Hg.

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2

Emergency bedside echocardiography and lower extremity venous ultrasonography are performed as part of a rapid ultrasound assessment of shock and hypotension.  A noncompressible lumen-filling defect is seen in the left external iliac vein.  Cardiac telemetry continues to show sinus tachycardia.  Which of the following echocardiographic findings is most likely to be present?

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

Which of the following is the best next step in management of this patient?

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

Item 1 of 2

Which of the following is the most appropriate initial step in management of this patient?

Item 2 of 2

CT scan of the chest confirms a 2.2-cm, peripherally located nodule in the left lower lobe surrounded by lung parenchyma.  The nodule has spiculated borders and eccentric calcification on the periphery, and no lymphadenopathy is present.  CT scan of the abdomen reveals no abnormalities of the liver or adrenal glands.  Which of the following is the best next step in management of this patient’s lung lesion?

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

Which of the following is the best response to this patient’s concerns?

A 76-year-old man comes to the emergency department due to shortness of breath, fatigue, cough, and fever over the last 2 days.  The patient’s medical problems include chronic obstructive pulmonary disease, osteoarthritis, and hypertension.  Temperature is 38.6 C (101.5 F), blood pressure is 110/60 mm Hg, pulse is 110/min, and respirations are 20/min.  Oxygen saturation is 87% on ambient air.  Chest x-ray reveals left lower lobe and right middle lobe consolidation.  The patient is admitted to the hospital for community-acquired pneumonia and treated with azithromycin and ceftriaxone.  His dyspnea is relieved by bronchodilator therapy.  The patient’s condition improves after 2 days of treatment.  Temperature is now 37.8 C (100.0 F), blood pressure is 125/70 mm Hg, pulse is 85/min, and oxygen saturation is 91% on ambient air.  No jugular venous distension is present, and mucous membranes are moist.  Newly decreased breath sounds are noted over the left lower lung field.  Heart rate is regular and without murmurs.  No edema is present.  A repeat chest x-ray reveals the following:

A bedside ultrasound shows the pleural effusion to be free-flowing and without loculations.  The patient undergoes a left-sided diagnostic thoracentesis with approximately 100 mL of pale yellow fluid removed.  Subsequent fluid analysis reveals a protein level of 4.0 mg/dL (serum level 6.6 mg/dL), lactate dehydrogenase (LDH) of 120 U/L (serum level 160 U/L), and pH of 7.31.  Gram stain of the pleural fluid is negative; culture is pending.  The patient asks what is going to be done about the “fluid on his lung.”  Which of the following is the most appropriate response to the patient?

A 66-year-old man comes to the office for follow-up of chronic obstructive pulmonary disease.  He reports breathlessness with daily activities such as unloading groceries and showering, and rarely leaves the house due to dyspnea.  The patient also experiences frightening moments of panic, struggling to regain his breath after overexerting himself.  He has stopped volunteering at his church due to concern about “losing control” of his breathing in public.  Over the previous year, the patient had 3 acute exacerbations treated with outpatient oral corticosteroids and one hospitalization for acute hypercapnic respiratory failure that resolved after several days of noninvasive ventilation.  He is on long-term oxygen therapy.  The patient smoked about 1 pack of cigarettes daily for 40 years and quit 10 years ago.  Additional medical history includes atrial fibrillation, coronary artery disease, and a stable 4.5-cm abdominal aortic aneurysm.  Temperature is 36.7 C (98.1 F), blood pressure is 140/96 mm Hg, pulse is 82/min, and respirations are 20/min.  Oxygen saturation is 86% on room air and 93% on 2 L/min oxygen via nasal cannula.  BMI is 31.5 kg/m².  Results of pulmonary function testing are shown below.

Which of the following features most strongly indicates an increased risk of mortality for this patient?

A 59-year-old man comes to the office for a routine wellness examination.  The patient’s medical history includes chronic bronchitis, hypertension, hypertriglyceridemia, and basal cell carcinoma.  He smokes a pack of cigarettes per day, with a total 40-pack-year history.  The patient typically consumes 1 or 2 cans of beer each night.  Family medical history is remarkable for heart disease and diabetes mellitus.  The patient had a normal screening colonoscopy 5 years ago.  A chest x-ray from a year ago shows changes consistent with chronic bronchitis.

Item 1 of 2
The patient asks if he is at increased risk for lung cancer because of his smoking history.  What is the most appropriate response by the physician?

Item 2 of 2
The patient says he enjoys smoking very much and is reluctant to stop because he has smoked since age 19.  He asks about the benefits of smoking cessation.  What is the most appropriate response by the physician?

A 38-year-old woman comes to the office due to worsening asthma symptoms for 2-3 days.  She has shortness of breath, wheezing, and productive cough.  The patient describes thick sputum that was blood-tinged yesterday.  She was diagnosed with asthma 12 years ago but says that it had not been this bad until last year.  For the past year the patient has had 2 hospitalizations for asthma exacerbations but has never been intubated.  She completed a course of oral prednisone and azithromycin 2 months ago.  Current medications include a daily fluticasone inhaler and as-needed albuterol inhaler.  The patient reports no decrease in appetite or weight loss and has not travelled outside of her home state of New Jersey in the past 2 years.  She works as a school teacher and does not use tobacco, alcohol, or illicit drugs.  The patient has no second-hand tobacco exposure and no known allergies.  Her grandmother also has asthma.  Temperature is 37 C (98.6 F), blood pressure is 123/80 mm Hg, pulse is 94/min, and respirations are 16/min.  Pulse oximetry shows 95% on room air.  Pulmonary examination reveals scattered wheezes.  Heart sounds are normal.  There is no clubbing, peripheral edema, or skin rashes.  Complete blood count shows the following:

Item 1 of 2

Chest x-ray reveals patchy bilateral upper lobe infiltrates and prominent bronchial markings.  Which of the following is the best next step in diagnosing the cause of this patient’s worsening symptoms?

Item 2 of 2

Further laboratory evaluation of the patient shows a serum total IgE level of >1,000 ng/mL.  High-resolution CT scan of the lungs confirms the presence of bilateral upper lobe infiltrates and central bronchiectasis.  Which of the following is the best next step in management of this patient?

A 58-year-old woman comes to the emergency department due to fever, confusion, and malaise beginning 24 hours ago.  The patient has an 8-year history of rheumatoid arthritis.  Current medications include methotrexate, low-dose prednisone, as well as indomethacin as needed.  Temperature is 38.9 C (102 F), pulse is 109/min, blood pressure is 73/40 mm Hg, respirations are 24/min, and oxygen saturation is 92% on 6 L/min oxygen.  Weight is 80 kg (176 lb).  Physical examination shows an ill-appearing woman with dorsocervical and central fat deposition but slim extremities.  Mucous membranes appear moist.  Laboratory studies reveal a leukocyte count of 22,000/mm³, serum creatinine of 1.7 mg/dL, and blood glucose level of 228 mg/dL.  Chest x-ray is shown in the image below:

Broad spectrum antibiotics are initiated.  The patient remains hypotensive after rapid administration of 2.5 L crystalloid fluid and continuous infusions of norepinephrine.  A second vasopressor agent is added.  Which of the following is the most appropriate recommendation regarding glucocorticoid therapy for this patient?

A 66-year-old woman is evaluated at the bedside for shortness of breath and anxiety that began suddenly in the early morning.  The patient was admitted to the hospital 4 days ago after she slipped and fell on her icy driveway, resulting in a displaced femoral neck fracture.  She underwent immediate orthopedic repair.  The patient has no chest pain, cough, or hemoptysis.  Medical history is significant for hypertension and dyslipidemia.  Blood pressure is 118/62 mm Hg, pulse is 122/min, and respirations are 28/min.  Pulse oximetry readings are 88% on room air and 93% on 2 L/min of oxygen.  Cardiopulmonary examination reveals regular tachycardia and tachypnea but is otherwise unremarkable.  Portable chest x-ray is shown in the exhibit.  ECG demonstrates sinus tachycardia with an incomplete right bundle-branch block and T-wave inversions in leads III and V₁ through V₄.  Serum chemistry values are within normal limits, and cardiac troponin I level is 2.78 ng/mL (normal: <0.01).

Item 1 of 3

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 3

CT angiography reveals bilateral segmental pulmonary emboli, a small right-sided pleural effusion, and a wedge-shaped consolidation in the right lower lobe.  Therapeutic anticoagulation is initiated with intravenous unfractionated heparin.  Blood pressure is 121/79 mm Hg and pulse is 118/min and regular.  In addition to the elevated cardiac troponin I level, the patient’s plasma B-type natriuretic peptide level is 524 pg/mL (normal: <100).  Arterial blood gas analysis reveals pH 7.49, PaCO₂ 26 mm Hg, and an elevated alveolar-arterial oxygen gradient.  Echocardiography shows moderate hypokinesis and dilation of the right ventricle, normal left ventricular ejection fraction, and no regional wall motion abnormalities.  The estimated pulmonary artery systolic pressure is 50 mm Hg.  Which of the following best signifies an increased risk of clinical deterioration in this patient?

Item 3 of 3

The following day, the patient’s shortness of breath is improved.  She continues to receive the heparin infusion, and the activated PTT is in a therapeutic range.  The surgical site is healing appropriately.  Plans for oral anticoagulation after discharge are being discussed.  The patient reports no chest pain or dizziness.  Prior to morning rounds, however, she expectorates approximately 1 teaspoon of dark blood.  Temperature is 37.6 C (99.7 F), blood pressure is 136/79 mm Hg, pulse is 82/min, and respirations are 20/min.  Pulse oximetry reading is 94% on 2 L/min oxygen.  Chest x-ray is unchanged.  Which of the following is the most appropriate next step in management of this patient?

A 68-year-old man with chronic obstructive pulmonary disease (COPD) comes to the clinic due to a 9-kg (20-lb) weight loss over the last 2 years.  He describes his appetite as “all right” but does say that he is eating less.  The patient reports poor taste, fatigue, chronic dyspnea, productive cough, and occasional nausea.  He also reports insomnia most nights of the week with poor concentration during the day.  He has no night sweats, fevers, chills, dysphagia, change in bowel habits, blood in the stool, or dysphoria.  He has had 3 hospitalizations for COPD exacerbation over the past 2 years during which he was treated with short courses of prednisone.  The patient has smoked 2 packs of cigarettes daily for 42 years.  He reports feeling “bad” for smoking all these years and is trying to quit but says, “It’s just very hard.”  The patient lives alone and often feels lonely.  His other medical problems include hypertension and hyperlipidemia.  His last colonoscopy was 5 years ago and included removal of 2 hyperplastic polyps.  He does not use alcohol or recreational drugs.  Family history is not significant.  Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 18/min.  BMI is 17 kg/m².  Pulse oximetry shows 91% on ambient air.  Physical examination reveals moist mucous membranes, normal jugular venous pressure, and distant S1 and S2.  Lung examination reveals prolonged expiration, increased resonance to percussion bilaterally, and increased anterior-to-posterior diameter of the chest.  The abdomen is soft and nontender.  There is no hepatomegaly, splenomegaly, or masses.  Testing of the stool for occult blood is negative.  No edema or lymphadenopathy is present.  Neurologic examination is within normal limits.  The patient’s affect is normal.  Laboratory results are as follows:

Chest x-ray reveals hyperexpansion of bilateral lung fields with diaphragmatic flattening.  Which of the following is the most likely cause of this patient’s weight loss?

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

Repeat chest x-ray reveals asymmetric worsening of the lung infiltrate.  Which of the following is the best next step in management of this patient?

A 60-year-old Caucasian man is admitted to the hospital with an episode of bacterial pneumonia.  Upon review of his past medical history, you notice that he has had three recent admissions within the past seven months for bacterial pneumonia.  All the episodes were successfully treated with intravenous antibiotics.  Previous chest x-ray comparisons reveal that the infiltrate always occurs at the right middle lobe and leaves a persistent scar.  The scar was not noted on the chest x-ray prior to the episodes of pneumonia.  He has a 50-pack year history of smoking.  He quit smoking 10 years ago.

Item 1 of 2

Which of the following is the most likely cause of the patient’s recurrent pneumonia?

Item 2 of 2

Which of the following is the most likely to definitively confirm the diagnosis in this patient?

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

Item 1 of 2

What is the most likely diagnosis?

Item 2 of 2

What is the most appropriate means of correcting this patient’s hyponatremia?

A 66-year-old man comes to the office due to 3 months of slowly worsening nonproductive cough and shortness of breath.  He has also had night sweats, excessive fatigue, and sharp, episodic right-sided chest pain.  The patient has lost approximately 5 kg (11 lb) during this period.  He has a history of hypertension and takes chlorthalidone.  He has smoked a half-pack of cigarettes daily for the past 50 years.  The patient worked in a shipbuilding factory until his early 40s and then began working in the automobile industry.  Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 84/min, and respirations are 14/min.  No jugular venous distension or lymphadenopathy is present.  There is dullness to percussion and decreased breath sounds over the right lower chest.  Heart sounds are normal with no murmur.  The abdomen is soft and nontender with no hepatosplenomegaly.  No edema is present.  Chest imaging reveals a moderate right-sided pleural effusion with irregular pleural thickening and calcifications, but no lung parenchymal abnormalities.  A thoracentesis is performed and yields serosanguineous pleural fluid; pleural fluid analysis reveals the following:

Which of the following is the most likely cause of this patient’s pleural effusion?

A 40-year-old woman is brought to the emergency department by paramedics after a motor vehicle collision.  She was driving and wearing a seatbelt when her car was hit by another vehicle from the opposite direction.  Her car went off the road and hit a tree.  When paramedics arrived at the scene, the patient was noted to have an open femur fracture but was alert and oriented.  Her medical issues include hyperlipidemia and mitral valve prolapse with mild regurgitation.  She takes no medications.  The patient undergoes open reduction and internal fixation of the femur fracture.  She receives intravenous fluids and pain control postoperatively.  The next morning she experiences left-sided chest discomfort and shortness of breath.  Temperature is 37.6 C (99.7 F), blood pressure is 120/70 mm Hg, pulse is 100/min, and respirations are 30/min.  Pulse oximetry shows 84% on room air.  Physical examination reveals an area of tenderness over the left chest wall where the seatbelt was placed.  On pulmonary examination, the patient has rales over the left upper lung.  A 2/6 holosystolic murmur is present over the cardiac apex.  Laboratory results are as follows:

ECG shows sinus tachycardia with no ST-segment or T-wave changes.  Chest x-ray shows irregular opacification predominantly of the left upper lung.

Item 1 of 2

What is the most likely cause of this patient’s respiratory symptoms?

Item 2 of 2

Adequate pain control and supplemental oxygen by nasal cannula is provided and the patient’s respiratory distress improves.  Pulse oximetry shows 96% on 3 L/min supplemental oxygen.  Which of the following is the best next step in management of this patient?