Clinical_Vignettes_Pulmonary Exam_Full.pptx

Pulmonary physical exam

1. Lung Abscess A 45-year-old man with a history of alcoholism presents with a 2-week history of productive cough with foul-smelling sputum, fever, and night sweats. Chest X-ray reveals a cavitary lesion with an air-fluid level in the right upper lobe. Which of the following is the most appropriate initial management? A) Start broad-spectrum antibiotics with anaerobic coverage B) Schedule surgical resection of the affected lobe C) Initiate corticosteroid therapy D) Advise smoking cessation and monitor Correct Answer: A) Start broad-spectrum antibiotics with anaerobic coverage Explanation: Lung abscesses often result from aspiration, especially in individuals with risk factors like alcoholism. Anaerobic bacteria are commonly involved, necessitating antibiotics that cover anaerobes.

2. Mitral Stenosis A 35-year-old woman from Southeast Asia presents with progressive dyspnea on exertion and palpitations. On examination, she has a low-pitched diastolic murmur best heard at the apex. Echocardiography shows thickened mitral valve leaflets with restricted motion. What is the most likely underlying cause of her condition? A) Congenital heart disease B) Rheumatic fever C) Infective endocarditis D) Degenerative valve disease Correct Answer: B) Rheumatic fever Explanation: In developing countries, rheumatic fever remains a leading cause of mitral stenosis due to post-inflammatory scarring of the valve.

3. ARDS A 60-year-old man develops severe shortness of breath 48 hours after being admitted for pancreatitis. He is hypoxic despite supplemental oxygen. Chest X-ray shows bilateral infiltrates. Which of the following best describes the pathophysiology of his condition? A) Cardiogenic pulmonary edema due to left heart failure B) Increased alveolar-capillary permeability leading to non-cardiogenic pulmonary edema C) Obstruction of the pulmonary arteries D) Bronchospasm causing airway obstruction Correct Answer: B) Increased alveolar-capillary permeability leading to non-cardiogenic pulmonary edema Explanation: ARDS is characterized by increased permeability of the alveolar-capillary barrier, leading to fluid accumulation in the alveoli independent of cardiac function.

4. Cushing Syndrome A 40-year-old woman presents with weight gain, facial rounding, and purple striae on her abdomen. Laboratory tests reveal elevated cortisol levels that do not suppress with low-dose dexamethasone. What is the next best step in evaluating the cause of her condition? A) Measure ACTH levels B) Perform a high-dose dexamethasone suppression test C) Order a CT scan of the abdomen D) Initiate metyrapone therapy Correct Answer: A) Measure ACTH levels Explanation: Determining ACTH levels helps differentiate between ACTH-dependent and ACTH-independent causes of Cushing syndrome.

5. Diabetes Mellitus - Neuropathy A 55-year-old man with type 2 diabetes presents with numbness and tingling in his feet. Examination reveals decreased vibration sense and absent ankle reflexes. Which of the following is the most likely cause of his symptoms? A) Peripheral arterial disease B) Diabetic peripheral neuropathy C) Vitamin B12 deficiency D) Chronic kidney disease Correct Answer: B) Diabetic peripheral neuropathy Explanation: Chronic hyperglycemia can lead to nerve damage, resulting in peripheral neuropathy, commonly presenting as numbness and tingling in the extremities.

6. Liver Cirrhosis A 60-year-old man with a history of chronic alcohol use presents with abdominal distension and confusion. Physical examination reveals ascites, jaundice, and asterixis. Which of the following laboratory findings is most consistent with his condition? A) Elevated serum albumin B) Prolonged prothrombin time C) Decreased bilirubin levels D) Elevated platelet count Correct Answer: B) Prolonged prothrombin time Explanation: Liver dysfunction impairs synthesis of clotting factors, leading to a prolonged prothrombin time.

7. Acute Pancreatitis A 47-year-old man presents to the emergency department with severe epigastric pain radiating to the back, nausea, and vomiting. He has a history of alcohol use. Serum lipase is elevated to 4 times the normal limit. Which of the following is the most appropriate initial management step? A) Immediate ERCP B) Start antibiotics C) Aggressive IV fluid resuscitation D) Surgical debridement Correct Answer: C) Aggressive IV fluid resuscitation Explanation: The cornerstone of early management in acute pancreatitis is aggressive fluid replacement to maintain pancreatic perfusion and prevent complications like necrosis.

8. Aplastic Anemia A 19-year-old female presents with fatigue, frequent infections, and easy bruising. CBC shows pancytopenia. Bone marrow biopsy reveals a hypocellular marrow with fatty infiltration. What is the most likely diagnosis? A) Acute myeloid leukemia B) Aplastic anemia C) Myelodysplastic syndrome D) Iron deficiency anemia Correct Answer: B) Aplastic anemia Explanation: Aplastic anemia is characterized by pancytopenia and hypocellular marrow, often triggered by autoimmune, drug, or viral causes.

9. Diabetes Mellitus - Foot Ulcer A 62-year-old man with long-standing diabetes presents with sudden onset of left foot ulceration. On examination, the ulcer is surrounded by callus, and he has diminished sensation to monofilament testing. What is the primary pathophysiologic factor contributing to his ulcer? A) Venous insufficiency B) Arterial thrombosis C) Peripheral neuropathy D) Deep vein thrombosis Correct Answer: C) Peripheral neuropathy Explanation: Diabetic foot ulcers are typically due to sensory loss from peripheral neuropathy, leading to unnoticed trauma.

10. Cushing Syndrome - Imaging A 30-year-old woman is diagnosed with ACTH-independent Cushing syndrome after testing. She has no signs of pituitary disease. She undergoes imaging. Which of the following imaging findings is most likely? A) Pituitary microadenoma B) Adrenal adenoma C) Bilateral adrenal hyperplasia D) Pancreatic insulinoma Correct Answer: B) Adrenal adenoma Explanation: ACTH-independent Cushing syndrome is often due to an adrenal source, most commonly an adrenal adenoma.