An 87-year-old man is brought to the emergency department with respiratory distress, confusion, and lethargy since this

morning.  The patient resides in a nursing home and is bedridden.  He fell out of bed last night.  He had no loss of
consciousness prior to the fall or associated trauma, and he was verbally responsive and oriented after the fall.  The
patient's past medical history is significant for severe osteoarthritis in the knees and hips, hypertension, hyperlipidemia,
and mild chronic obstructive pulmonary disease.  His medications include amlodipine, simvastatin, and tiotropium.
His temperature is 36.7 C (98 F), blood pressure is 148/90 mm Hg, pulse is 102/min, and respirations are 20/min. 
Oxygen saturation is 92% on room air.  Physical examination shows a frail, elderly man in mild respiratory distress with
accessory muscle usage.  He is oriented to self only.  Jugular venous pressure is estimated at 5 cm H O. 2

Cardiopulmonary examination reveals irregular tachycardia with bilateral crackles.  There are no murmurs or third heart
sound.  The patient has significant pain with internal rotation of the left lower extremity.  Skin examination shows many
small (1- to 3-mm) purplish discolorations on the chest that do not blanch with pressure.  The remainder of the
examination is normal.
Laboratory results are as follows:

Leukocytes 8,200/mm 3

    Neutrophils 70%
Blood urea nitrogen 14 mg/dL
Creatinine 0.6 mg/dL
International Normalized Ratio 1.1 (normal: 0.8-1.2)
B-type natriuretic peptide 82 pg/mL
Chest x-ray reveals bibasilar and peripheral haziness.  X-rays of the hip reveal left femoral neck fracture.
In addition to orthopedic evaluation, which of the following is the best next step in management of this patient?
A.
Aggressive diuresis
B.
Broad-spectrum antibiotics

C.
Supportive care
D.
Transesophageal echocardiogram
E.
Venous Doppler of the lower extremities
A 69-year-old man comes to the office with a 6-month history of dry cough and progressive exertional dyspnea.  The
patient smoked a pack of cigarettes a day for 40 years but quit 15 years ago.  He owns 2 parrots and a cat.  He feels that
his symptoms improved somewhat while on vacation 2 months ago.
On examination, blood pressure is 138/92 mm Hg, pulse is 84/min, and respirations are 18/min.  Pulse oximetry is 90% on
room air.  Chest auscultation shows bilateral crackles with mild end-expiratory wheeze and a 2/6 systolic murmur at the
left sternal border.  Digital clubbing is present.
Pulmonary function testing shows a restrictive defect with impaired gas exchange.  A CT scan of the chest reveals
bilateral patchy ground-glass opacities, mostly in the mid-upper lung fields.  There is no lymphadenopathy.
Which of the following is the most likely diagnosis?
A.
COPD

B.
Hypersensitivity pneumonitis
C.
Idiopathic pulmonary fibrosis
D.
Moderate persistent asthma
E.
Sarcoidosis
A 47-year-old man is hospitalized due to worsening shortness of breath over the last 2 days.  He complains of orthopnea
requiring 2 pillows to sleep.  The patient has a history of coronary artery disease and underwent coronary artery bypass
grafting 2 years ago.  He has been noncompliant with his medications.
His temperature is 98.6° F (37° C), blood pressure is 157/90 mm Hg, pulse is 113/min, and respirations are 34/min.  Pulse
oximetry shows 88% on 100% O2 non-rebreather face mask.  He appears to be in respiratory distress and is using
accessory muscles of respiration.  Jugular venous pressure is estimated at 12 mm H2O.  Examination shows a third heart
sound and bibasilar crackles.  There is 1+ pitting peripheral edema bilaterally to the shins.
The patient's chest-x ray is shown below.
ECG shows sinus tachycardia with nonspecific T-wave changes.
Which of the following best describes how noninvasive positive pressure would benefit this patient?
A.
Decrease in functional residual capacity
B.
Decrease in minute ventilation

C.
Decrease in preload
D.
Increase in afterload
E.
Increase in dead space ventilation
A 34-year-old woman comes to the emergency department with sharp, right-sided chest pain that worsens with
inspiration, movement, coughing, and sneezing.  She developed dry cough, malaise, fever, and rhinorrhea 3 days ago. 
The patient has pain when sitting up; she lies on her right side and sits with her torso hunched during the interview.  She
has a 15-pack-year smoking history and takes an estrogen-progestin oral contraceptive.
Temperature is 37.4 C (99.4 F), pulse is 78/min, and respirations are 16/min.  Pulse oximetry shows oxygen saturation of
97% on room air.  BMI is 22 kg/m .2

Lung examination reveals a scratching sound in the right base.  There is no lower extremity edema.
Chest x-ray and ECG are unremarkable.  D-dimer is within normal limits.
Which of the following is the best next step in management of this patient?
A.
Azithromycin
B.
CT chest without contrast
C.
CT pulmonary angiogram
D.
Echocardiogram

E.
Indomethacin
A 65-year-old woman comes to the emergency department because of fever, chills, productive cough, and shortness of
breath for the past 2 days.  Today she felt very weak and had a pre-syncopal episode while trying to get out of bed.  Her
other medical problems include hypertension, paroxysmal atrial fibrillation, cystocele, pituitary tumor resection 3 years
ago, and hypothyroidism.  Her medications include 3 antihypertensive agents, levothyroxine, warfarin, and multivitamins.
She has smoked 1 pack of cigarettes per day for the past 45 years.
Her temperature is 39.4 C (103 F), blood pressure is 110/70 mm Hg, pulse is 116/min and irregular, and respirations are
18/min.  Examination reveals crackles and bronchial breath sounds at the left lung base.
Her leukocyte count is 18,000 cells/µL with 87% neutrophils.  Her chest x-ray shows left lower lobe pneumonia.
Intravenous fluids, intravenous ceftriaxone, and azithromycin are initiated.  Her blood cultures two days later
grow Streptococcus pneumoniae susceptible to ceftriaxone, levofloxacin, and moxifloxacin.  On day 3, her temperature is
36.1 C (97°F), blood pressure is 156/90 mm Hg, pulse is 78/min and regular, and respirations are 14/min.  Her WBC
count is 9,000 cells/µL.  She tolerates her diet well without nausea or vomiting.
Which of the following is the best next step in management?
A.
Change to oral Levofloxacin for total 7 days
B.
Change to oral Levofloxacin for total 14 days
C.
Continue IV ceftriaxone for total 7 days
D.
Continue IV ceftriaxone for total 14 days
E.
Obtain CXR to adjust antibiotic therapy
A 68-year-old man with a past medical history of hypertension and active smoking comes to the physician with complaints
of daily sputum production, cough, and dyspnea.  His dyspnea has progressed over the past 2 years so that he becomes
dyspneic walking 2 blocks and up 1 flight of stairs.  The patient uses albuterol/ipratropium 4 times daily.  He has a 40-
pack-year smoking history.
His blood pressure is 140/80 mm Hg, pulse is 100/min, and respirations are 18/min.  Pulse oximetry shows 88% on room
air.  Estimated jugular venous pressure is 9 cm H2O.  Examination shows a barrel-shaped chest.  There is a split S2 with a
holosystolic murmur heard at the left sternal border.  Lung examination shows decreased air entry and slow expiratory
phase in all lung fields.  There is 1+ bilateral pitting edema in the lower extremities midway to the knees.
Pulmonary function testing shows the following:

Forced expiratory volume in 1 second 33% of predicted

Forced vital capacity 54% of predicted
FEV1/FVC 54%
Diffusion capacity 37% of predicted
Chest x-ray shows hyperinflation of the lungs.
Pulmonary rehabilitation is most likely to result in which of the following in this patient?
A.
Decreased lung hyperinflation
B.
Decreased need for oxygen therapy
C.
Improved health related quality of life
D.
Increased health care costs
E.
Increased overall survival
A 45-year-old man comes to the physician at his wife’s insistence for evaluation of his snoring.  The patient reports that he
feels fine and denies any symptoms.  Specifically, he has no daytime sleepiness, morning headaches, lack of
concentration, fatigue, or nocturnal waking.  He does not smoke cigarettes, but he drinks 1-2 glasses of wine every day. 
He last saw a physician two years ago, and he denies any chronic medical problems.
His blood pressure is 150/95 mm Hg, pulse is 76/min, and respirations are 14/min.  His BMI is 30 kg/m .  Examination
2

shows a neck circumference of 17 inches (43 cm).  Lungs are clear to auscultation.  Heart sounds are normal.  There is
no peripheral edema.
Complete blood count, serum chemistries, and thyroid stimulating hormone (TSH) are within normal limits.
Which of the following is the most appropriate recommendation for this patient?
A.
Alcohol avoidance and sleeping in lateral position

B.
Full-night polysomnography
C.
Nocturnal pulse oximetry
D.
Reassurance and blood pressure check in 2-4 weeks
E.
Sleep diary over the next two weeks
A 76-year-old man with chronic obstructive pulmonary disease is admitted to the intensive care unit for pneumonia.  On
presentation in the emergency department, he had hypercapnia and hypoxic respiratory failure.  He was intubated and
sedated.  After intubation, the patient's blood pressure dropped to 85/58 mm Hg and did not recover with intravenous fluid
resuscitation.  A central venous catheter was placed and he was started on pressors.
Which of the following procedures is most likely to improve outcome in this patient?
A.
Daily ABGs

B.
Daily assessment of central line
C.
Daily chemistry profile
D.
Daily CBC
E.
Start enteral nutrition within 6 hours of admission
A 32-year-old primigravida at 24 weeks gestation is evaluated for excessive tiredness.  The patient feels sleepy
throughout the day and keeps dozing off at work.  Her overnight sleep is poor and she does not feel refreshed on
awakening in the morning.  She also reports occasional morning headaches.  The patient had mild nausea during the first
trimester but her pregnancy has otherwise been uneventful.  She has no known medical issues and her only medication is
prenatal vitamins.  The patient drinks alcohol occasionally but stopped after conception and does not use tobacco or illicit
drugs.
Blood pressure is 142/90 mm Hg, pulse is 98/min, respirations are 18/min, and SaO  is 96% on room air.  The patient's
2

pre-pregnancy weight was 76 kg (167.6 lb) with BMI of 28 kg/m ; she has gained 7 kg (15.4 lb) during the pregnancy. 
2

Examination shows normal thyroid gland, prominent jugular venous pulse estimated at 2 cm above the sternal angle, clear
lungs, grade 2/6 systolic ejection murmur, and gravid uterus appropriate for gestation.  There is mild ankle edema.  Fetal
heart rate is within normal limits.
Laboratory studies are significant for hemoglobin of 11.4 g/dL and trace protein in urine.
Which of the following is the most appropriate next step in management of this patient?
A.
Begin antihypertensive therapy
B.
Obtain comprehensive iron studies

C.
Perform overnight polysomnography
D.
Perform resting echocardiography
E.
Reassure that these are normal pregnancy symptoms
A 70-year-old man with mild chronic obstructive lung disease and type 2 diabetes mellitus comes to the emergency
department in November with a 2-day history of fever, cough, and shortness of breath.  He was previously well and has
no other medical problems.  His medications include metformin, lisinopril, and an albuterol inhaler as needed.  He has a
50-pack-year smoking history and drinks alcohol occasionally.
His temperature is 38 C (100.4 F), blood pressure is 120/70 mm Hg, and pulse is 92/min.  Pulse oximetry shows an
oxygen saturation of 90% on room air.  Lung examination shows crackles over the right lower lung field with egophony
and bronchophony.
Chest x-ray reveals a right lower lobe infiltrate.  The patient is hospitalized with community-acquired pneumonia.  Blood
cultures grow Streptococcus pneumoniae and he improves rapidly with intravenous antibiotics.  The patient becomes afebrile
and is ready for discharge from the hospital.  He has not received any vaccines in the past 10 years.  Which of the
following is the most appropriate course of action?
A.
Give influenza and 13-valent pneumococcal vaccine (PCV13) now
B.
Give influenza and 23-valent pneumococcal polysaccharide (PPSV23) vaccine in 2 weeks
C.
Give influenza vaccination in 2 weeks
D.
Give influenza vaccination now
E.
Give PCV13 and PPSV23 vaccine now
A 63-year-old hospitalized woman develops severe shortness of breath that awakens her from sleep.  She underwent
elective right hip replacement for severe osteoarthritis 5 days ago.  She has no history of coronary artery disease.  She
has received enoxaparin subcutaneously for deep vein thrombosis prophylaxis.
Her blood pressure is 78/50 mm Hg, pulse is 130/min, respirations are 34/min, and oxygen saturation is 70% on room air. 
Jugular venous distension is present.  Her lungs are clear to auscultation.  There are no murmurs.  Her extremities are
cold and clammy.
A 12-lead ECG shows sinus tachycardia.  Portable chest x-ray is ordered and preparations are made for endotracheal
intubation.
Which of the following is the most appropriate next step in management?
A.
Cardiac enzymes and D-Dimer levels
B.
CT-angiogram of the chest

C.
Emergent bedside transthoracic echocardiogram
D.
Right heart cathetrization
E.
Ventilation/perfusion (V/Q) scan
 65-year-old woman with a history of chronic obstructive pulmonary disease (COPD) is brought to the intensive care unit
after being intubated for respiratory failure.  She initially presented to the emergency department with severe respiratory
distress, fever, chills, and productive cough.  She smokes 1 pack of cigarettes per day and has been intubated in the past
for COPD exacerbation.  Her other medical problems include hypertension, coronary artery disease, congestive heart
failure, and colonic diverticulosis.  She has no history of diabetes mellitus.
Her leukocyte count is 15,000 cells/µL and her serum creatinine is 1.2 mg/dL.  Liver function tests are within normal limits.
Chest x-ray shows bilateral lower lobe infiltrates.  She is started on high-dose methylprednisolone, inhaled
bronchodilators, and antibiotics.  Over the following 12 hours, her fingerstick blood glucose levels ranged from 210 to 280
mg/dL.
Which of the following is the most appropriate next step in management?
A.
Insulin infusion with target blood glucose level of 80-110 mg/dL

B.
Insulin infusion with target blood glucose level of 140-180 mg/dL
C.
Insulin infusion with target blood glucose level of 180-200 mg/dL
D.
Metformin via nasogastric tube and rapid weaning of corticosteroids
E.
Sliding scale of subcutaneous insulin for blood glucose levels exceeding 150mg/dL
A 67-year-old woman with moderate chronic obstructive pulmonary disease comes to the physician to discuss plans for
upcoming air travel from Boston to California.  She leads a sedentary lifestyle and has mild occasional cough but no
significant dyspnea with household activities.  One year ago, she was hospitalized with exacerbation of chronic
obstructive pulmonary disease and was treated with noninvasive ventilation, corticosteroids, and antibiotics.  The patient's
other medical problems include coronary artery disease with stent placement 2 years ago.  Her left ventricular ejection
fraction is normal.  Current medications include tiotropium, salmeterol, albuterol as needed, aspirin, clopidogrel,
atorvastatin, metoprolol, and losartan.
Her blood pressure is 122/70 mm Hg, pulse is 75/min, and respirations are 16/min.  Pulse oximetry is 96% on room air at
rest.  Pulmonary examination shows minimal bilateral end-expiratory wheezes.  Cardiac examination is within normal
limits.  There is no peripheral edema.  Forced expiratory volume in 1 second on spirometry 6 months ago was 55% of
predicted.
Which of the following is the best next step in management of this patient?
A.
Cardiopulmonary exercise testing
B.
Hypoxia altitude simulation test

C.
No further evaluation is needed
D.
Six-minute walk test
E.
Supplemental oxygen at 2 L/min for flight
 42-year-old man comes to the physician with complaints of daytime sleepiness, dyspnea on exertion, and impaired
concentration.  His other medical problems include hypertension and type 2 diabetes mellitus.
His temperature is 36.1° C (97° F), blood pressure is 162/85 mm Hg, pulse is 92/min, and respirations are 14/min.  His
BMI is 40 kg/m2.  The patient's pulse oximetry is 94% on room air.  Examination shows jugular venous distention, clear
lung fields, loud second heart sound, and 2+ pretibial edema bilaterally.
Laboratory results are as follows:

Complete blood count

    Hemoglobin 15.6 g/dL
    Platelets 279,000/µL
    Leukocytes 7,800/µL
 
Serum chemistry
    Sodium 143 mEq/L
    Potassium 4.3 mEq/L
    Chloride 99 mEq/L
    Bicarbonate 35 mEq/L
    Blood urea nitrogen 26 mg/dL
    Creatinine 1.0 mg/dL
    Calcium 9.0 mg/dL
    Glucose 104 mg/dL
 
Arterial blood gases
    pH 7.36
     PaO2 72 mm Hg
    PaCO2 55 mm Hg
Chest x-ray shows low lung volumes but is otherwise unremarkable.  Spirometry shows a FEV1 of 70% of predicted and a
FEV1/FVC ratio of 90%.  Transthoracic echocardiography is limited by body habitus but shows mild right ventricular
enlargement.
Which of the following is the best initial therapy for this patient?
A.
Acetazolamide
B.
Appetite suppressant 
C.
Chronic Oxygen therapy

D.
Positive pressure ventilation
E.
Structured exercise program
A 60-year-old man comes to the emergency department due to a 3-day history of fever and productive cough.  The patient
has had shortness of breath and mild nausea but no vomiting.  His other medical problems include type 2 diabetes,
hypertension, and hyperlipidemia.  The patient's medications include long-acting insulin, a statin, an antihypertensive,
metformin, and a daily multivitamin.  He has no known drug allergies.  He does not use tobacco or alcohol.  He is a lawyer
and lives with his wife.
The patient's temperature is 38.9 C (102 F), blood pressure is 134/86 mm Hg, pulse is 88/min, and respirations are
16/min.  Pulse oximetry shows 95% on room air.  Examination reveals bronchial breath sounds and crackles at the right
lung base.
Laboratory results are as follows:

Complete blood count

    Hemoglobin 13.0 g/dL
    Platelets 240,000/mm 3

    Leukocytes 11,000/mm 3

    Differential
        Neutrophils 80%
        Lymphocytes 20%
 
Serum chemistry
    Sodium 135 mEq/L
    Potassium 4.2 mEq/L
    Chloride 100 mEq/L
    Bicarbonate 24 mEq/L
    Blood urea nitrogen 18 mg/dL
    Creatinine 1.0 mg/dL
Chest x-ray reveals right lower lobe consolidation.
Which of the following is the most appropriate next step in management?
A.
Inpatient ceftriaxone and azithromycin
B.
Inpatient piperacillin/tazobactam
C.
Outpatient azithromycin
D.
Outpatient doxycycline

E.
Outpatient levofloxacin
A 53-year-old man comes to the emergency department in moderate respiratory distress.
On examination, blood pressure is 90/58 mm Hg, pulse is 100/min, and SaO  is 82%-85% on FiO  100% via nonrebreather
2 2

mask.  Lung examination reveals crackles and reduced breath sounds in the left base.
The patient undergoes rapid-sequence intubation due to respiratory distress.  The endotracheal tube is 26 cm at the lip. 
The colorimetric end-tidal CO  device displays a color change, and normal waveform is noted on capnography.  Chest
2

auscultation reveals reduced breath sounds in the entire left lung field.  Several minutes after intubation, SaO  remains
2

82%-85% and blood pressure is 94/56 mm Hg.

Which of the following is the best next step in management of this patient?
A.
Immediate needle decompression of the left chest
B.
Mechanical ventilation with high, positive, end expiatory pressure
C.
Nebulized albuterol/ipratropium

D.
Retraction of endotracheal tube by 3 cm
E.
Urgent extubation and reintubation
A 63-year-old man is hospitalized with dyspnea due to right lower lobe pneumonia.  On the third day of hospitalization, he
develops progressive respiratory failure and bilateral lung infiltrates.  His trachea was intubated and mechanical
ventilation is initiated.
His blood pressure is 146/80 mm Hg, and pulse is 97/min.  The patient’s pulse oximetry shows 89% on assist-control
mode with tidal volumes of 450 mL, respiratory rate of 30/min, fraction of inspired oxygen of 100%, and positive end-
expiratory pressure of 12 cm H O.  Examination shows diffuse crackles all over the lung fields, normal first and second
2

heart sounds, and capillary refill of < 2 seconds.  There is trace pre-sacral edema.
Laboratory results are as follows:

Complete blood count

    Hemoglobin 12.5 g/dL
    Platelets 196,000/µL
    Leukocytes 17,000/µL
 
Serum chemistry
    Sodium 135 mEq/L
    Potassium 3.8 mEq/L
    Chloride 98 mEq/L
    Bicarbonate 20 mEq/L
    Blood urea nitrogen 10 mg/dL
    Creatinine 0.7 mg/dL
    Calcium 9.6 mg/dL
    Glucose 148 mg/dL
 
Arterial blood gases
     pH 7.27
    PaO 2 57 mm Hg
    PaCO 2 43 mm Hg
His chest-x ray reveals dense bilateral alveolar opacities.  Bedside echocardiogram shows left ventricular ejection fraction
of 65%.  A central line is placed and the central venous pressure is 10 mm Hg.
Conservative fluid management using diuretic therapy in this patient is most likely to positively affect which of the
following?
A.
In Hospital mortality
B.
Oxygen desaturation in mixed venous blood
C.
Residual lung function
D.
Risk of acute kidney injury

E.
Ventilator free days
A 78-year-old woman is admitted to the intensive care unit (ICU) with confusion, fever, hypotension, and tachypnea.  She
is intubated and started on antibiotics for septic shock caused by a urinary tract infection.  Norepinephrine infusion is
started via an internal jugular venous catheter.  The ventilator is set on continuous mandatory ventilation (CMV) mode and
the patient is sedated with midazolam and fentanyl infusions.  Chest x-ray shows mild subsegmental atelectasis and
appropriate positioning of endotracheal and orogastric tubes.
Which of the following is likely to decrease this patient's length of stay in the ICU and reduce the number of days she
requires mechanical ventilation?
A.
daily interruptions in sedation
B.
early tracheostomy
C.
Low tidal volume ventilation with higher positive end expiatory pressure levels 
D.
Neuromuscular blockade
E.
Synchronized intermittent mandatory ventilation
A 56-year-old man with a history of alcohol abuse is hospitalized due to aspiration pneumonia of the right lower lung. 
While being treated, he develops severe hypoxemia requiring transfer to the intensive care unit for initiation of mechanical
ventilation.  Temperature is 37.1 C (98.8 F), blood pressure is 120/62 mm Hg, and pulse is 95/min.  Pulmonary
examination is significant for bilateral crackles.  There is no jugular venous distension or peripheral edema.  Repeat chest
x-ray demonstrates diffuse, bilateral alveolar opacities.
Initial ventilator settings demonstrate a tidal volume of 510 mL (8 mL/kg of predicted body weight), positive end-expiratory
pressure of 10 cm H O, respiratory rate of 35/min, and FiO  of 80%.  Tidal volume is reduced to 380 mL (6 mL/kg of ideal
2 2

body weight) over several hours; the other ventilator parameters are unchanged.  Plateau pressure is 27 cm H O.  Arterial
2

blood gas results are as follows:

   
  Initial 4 hours later 6 hours later
pH 7.35 7.23 7.23
PaO 2 65 mm Hg 61 mm Hg 60 mm Hg
PaCO 44 mm Hg 62 mm Hg 63 mm Hg
2

A.
Continue ventilation at same settings
B.
Decrease the positive end expiratory pressure 
C.
Increase the fraction of inspired oxygen
D.
Increase respiratory rate
E.
Increase tidal volume to 8 ml/Kg of ideal body weight
A 57-year-old man comes to the physician with 3 months of cough, night sweats, and subjective fevers.  He has been
feeling "run down."  The patient emigrated from India 26 years ago and has not travelled recently.  He had a negative
tuberculin skin test 6 months ago performed at work.
Lung examination is significant for reduced breath sounds with dullness to percussion on the left.
Chest imaging reveals a moderate left-sided pleural effusion with bulky mediastinal lymphadenopathy.  A thoracentesis
shows turbid white fluid.  Laboratory results are as follows:

Pleural fluid
    pH 7.43
    Total protein 4.2 g/dL
    Lactate dehydrogenase 107 U/L (60-100 U/L)
    Leukocytes 1075/mL
    Lymphocytes 97%
 
Serum
    Total protein 7.4 g/dL
    Lactate dehydrogenase 177 U/L
Which of the following tests performed on pleural fluid would help identify the cause of the effusion?
A.
Amylase
B.
Bacterial culture
C.
Brain Natriuretic peptide
D.
Total cholesterol

E.
Triglycerides