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Pulmonary ROSH Review | Questions & Answers (100 %Score) Latest Updated 2024/2025 Comprehensive Questions A+ Graded Answers | With Expert Solutions

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  • August 9, 2024
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Pulmonary ROSH Review | Questions & Answers (100 %Score) Latest Updated 2024/2025
Comprehensive Questions A+ Graded Answers | With Expert Solutions


A 25-year-old man presents for evaluation of fever and cough. He reports last week that
he was diagnosed with influenza. In the last 2 days he developed a worsening cough
productive of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR
18, and 95% oxygen saturation on room air. His chest X-ray demonstrates a lobar
infiltrate in the left lower lobe. Which of the following would you most likely expect to see
on the patient's Gram stain?

Gram negative bacilli
Gram negative diplococci
Gram positive bacilli
Gram positive cocci in clusters - Correct Answer ( D )
Explanation:
The patient had a recent influenza infection and now presents with a lobar infiltrate.
Staphylococcus aureus pneumonia is classically associated with causing post-influenza
bacterial pneumonia. On Gram stain this is seen as Gram positive cocci in clusters

Question: In which population is Klebsiella pneumonia most commonly seen in? -
COPD, Alcoholics and the elderly.

Bacterial Pneumonia Overview - Bacterial Pneumonia

S. pneumonia: most common, rusty colored sputum, rigors, gram+ paired lancets
Klebsiella: alcoholics, currant jelly sputum, bulging fissures,
S. aureus: IVDA, postinfluenza, elderly, gram+ cocci in clusters
H. influenzae: COPD, gram negative pleomorphic rods
Pseudomonas: cystic fibrosis, nursing home resident and cyanosis
Health care associated pneumonia: pseudomonas, MRSA
Outpatient, healthy: macrolide or doxycycline
Outpatient, comorbidity: respiratory tract fluoroquinolone (RTF)
Inpatient: RTF
ICU: antipneumococcal ß-lactam (ceftriaxone or cefotaxime) + either azithromycin or an
RTF

You evaluate a 65-year-old patient for shortness of breath and note on exam decreased
breath sounds at the left lung base. You are suspicious of a small pleural effusion. In
which of the following views on the chest radiograph is the small pleural effusion most
likely to be detected?

Lateral
Lateral decubitus left side down
Lateral decubitus right side down
Posterior-anterior (PA) - Correct Answer ( B )

,Explanation:
Classic physical signs of a pleural effusion include diminished breath sounds, dullness
to percussion, decreased tactile fremitus, and occasionally a localized pleural friction
rub. Chest radiograph confirms the suspicion of pleural effusion. The classic
radiographic appearance of a pleural effusion is blunting of the costophrenic angle on
the upright chest radiograph


Pleural Effusion
Transudate: CHF (most common)
Exudate: infection > malignancy, PE
↓ Breath sounds + dull percussion + ↓ tactile fremitus
CXR: blunting of the costophrenic angle

Question: A pleural effusion is most difficult to detect in which radiographic position? -
Supine.

Which of the following complications can be prevented by simultaneously administering
pyridoxine and isoniazid in a patient with tuberculosis exposure?

Color blindness
Hepatitis
Peripheral neuropathy
Renal failure - Correct Answer ( C )
Explanation:
Isoniazid (INH) inhibits the enzyme responsible for the conversion of pyridoxine (vitamin
B6) to one of its active metabolites, pyridoxal phosphate (PLP). This depletion of vitamin
B6 may lead to complications such as peripheral neuropathy and seizures. Therefore,
vitamin B6 should be administered concomitantly to patients taking isoniazid. PLP is
also a coenzyme required for the synthesis of gamma-aminobutyric acid (GABA), an
inhibitory neurotransmitter. Decreased GABA formation in the setting of vitamin B6
deficiency may also contribute to seizures.

Color blindness (A) is not a complication of INH. However, another commonly used drug
in TB, ethambutol, is associated with retrobulbar neuritis and red-green color blindness.
INH is metabolized by the liver and gets converted to an ammonium molecule that can
lead to hepatotoxicity (B). However, this is not affected by vitamin B6 supplementation.
Renal failure (D) is a complication of pyridoxine overdose.

Question: What is the most common location of extrapulmonary TB? - Lymph nodes.

Pulmonary Tuberculosis (TB)

RFs: immunodeficiency, immigrant, close contact
Latent/primary TB: asymptomatic
Active/reactivation TB: fever, night sweats, weight loss, productive cough, hemoptysis

,Erythema nodosum
Primary TB CXR: Ghon focus
Active/reactivation TB: upper lobes, cavitary lesions
Dx: sputum smears for acid-fast bacilli (AFB), sputum/tissue culture for AFB (gold
standard)
PPD: gold standard for latent TB dx
Latent TB rx: 9 months of INH
Primary TB rx: rifampin, INH, pyraziniamide, ethambutol (RIPE)

A 45-year-old patient with newly diagnosed diabetes mellitus type 2 presents to your
office for her annual exam. She has had her hepatitis B vaccination, but wants to know
if she needs any additional vaccinations because of her new diagnosis. Which of the
following is the most appropriate next step in her management?

Administer annual influenza vaccine only
Administer pneumococcus and annual influenza vaccines
Administer pneumonia prophylaxis with trimethoprim-sulfamethoxazole
The patient does not need any additional vaccines since she is up to date - Correct
Answer ( B )
Explanation:
Patients with diabetes mellitus require regular monitoring and health maintenance to
prevent diabetes-related complications. Health maintenance for these patients includes
three vaccinations: annual influenza, pneumococcus (repeated at age 65 if given prior
to that age) and the hepatitis B three dose series. Patients with diabetes mellitus require
annual foot, dental and dilated eye examinations, blood pressure monitoring, and
smoking cessation counseling. Upon diagnosis, a serum creatinine should be drawn.
Annual fasting serum lipids and urinary albumin-to-creatinine ratios should be
monitored. Hemoglobin A1C should be obtained every 3-6 months with a goal of <7%.

Question: What is the blood pressure goal for patients with diabetes mellitus type 2? - <
140/90.

A 36-year-old veterinarian presents with myalgias, dry cough, and severe headache.
His vital signs include blood pressure 138/74 mm Hg, heart rate 82 beats/minute,
temperature 39°C, and oxygen saturation 94% on room air. He has
hepatosplenomegaly on abdominal exam. His chest X-ray shows patchy perihilar
infiltrates. What of the following is the most appropriate antibiotic for this patient?

Amoxicillin-clavulanate
Doxycycline
Levofloxacin
Trimethoprim-sulfamethoxazole - Correct Answer ( B )
Explanation:
Psittacosis is caused by Chlamydia psittaci, an obligate intracellular gram-negative
organism. It is harbored in avian species making bird owners, veterinarians, and pet-
shop employees particularly susceptible to infection. Patients present with high fevers,

, severe headache, myalgias, nonproductive cough, and hepatosplenomegaly. Chest X-
rays show patchy perihilar or lower lobe infiltrates. Patients may have proteinuria and
elevated liver transaminases. Diagnosis should be considered in patients with
community acquired pneumonia and exposure to birds. The treatment of choice is a 14-
21 day course of doxycycline. Complications are uncommon in patients treated with
appropriate antibiotics.

Question: What is the antibiotic of choice for psittacosis in children and pregnant
women? - Erythromycin.

Psittacosis

Patient with a history of exposure to birds
Complaining of high fevers, severe headache, myalgias, nonproductive cough
PE will show hepatosplenomegaly
CXR will show patchy perihilar or lower lobe infiltrates
Most commonly caused by Chlamydia psittaci
Treatment is doxycycline

Which of the following physiologic responses would occur after application of
noninvasive positive pressure ventilation in a patient presenting with an acute
exacerbation of chronic obstructive pulmonary disease?

Increased afterload
Increased alveolar dead space
Increased tidal volumes
Increased venous return - Correct Answer ( C )
Explanation:
Noninvasive positive pressure ventilation applies a consistently positive airway pressure
to increase laminar flow. This leads to airway stenting, elimination of dead space
through alveolar recruitment, and an increase in tidal volumes and minute ventilation.
The beneficial effects of positive pressure ventilation are not only realized in the
pulmonary system but also in the cardiovascular system. Patients with pulmonary
edema from decompensated heart failure benefit from the increased intrathoracic
pressure which decreases venous return and increases left heart output and thus
decreases afterload.

Increased afterload (A) is incorrect because the increased intrathoracic pressure
increases left heart output which decreases afterload. Increased alveolar dead space
(B) is incorrect because airway stenting recruits alveoli and decreases the alveolar dead
space. Increased venous return (D) is incorrect because the increased intrathoracic
pressure actually decreases the venous return.

Question: What is a physiologic complication of noninvasive positive pressure
ventilation? - Barotrauma including pneumothorax.

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