Pulmonary ROSH Review exam Questions and Correct
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What is the most common cause of minor hemoptysis in the Emergency Department?
Acute bronchitis
Pneumonia
Pulmonary embolism
Tuberculosis - ANSWER-Correct Answer ( A )
Explanation:
Acute bronchitis is the most common cause of minor hemoptysis in the Emergency Department.
Hemoptysis describes the presence of blood in sputum expectorated from the respiratory tract. The
majority of episodes of hemoptysis are minor episodes with small amounts of blood. Less than 5% of
patients with hemoptysis have life-threatening hemorrhage. Bronchitis results from inflammation in the
bronchial tree and can lead to hemoptysis. Additionally, forceful coughing further irritates the inflamed
mucosal surfaces and can result in bleeding. Hemoptysis in bronchitis is typically self-limited.
Acute Bronchitis
Viruses > bacteria
Most common cause of minor hemoptysis
Hallmark: cough (usually productive), <1week
Symptomatic treatment, bronchodilators
Routine ABX therapy not indicated
Question: What are the most common sites of hemorrhage in massive hemoptysis? - ANSWER-Massive
hemoptysis typically involves the bronchial or pulmonary arteries.
A 58-year-old man presents to your office with complaints of chronic cough and difficulty breathing. He
has smoked approximately 2 packs of cigarettes per day since he was 14 years old and has not seen a
doctor in many years. You order spirometry testing, which shows airflow limitation (predicted FEV1
45%). Which of the following is the most appropriate therapy?
,Azithromycin
Guaifenesin
Prednisone
Tiotropium - ANSWER-Correct Answer ( D )
Explanation:
Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by airflow
limitation that causes an enhanced inflammatory response in the airways and lungs. Historically COPD
was divided into three subtypes: chronic bronchitis, emphysema and asthma. Asthma is no longer
grouped with COPD and current definitions of COPD do not differentiate between emphysema and
chronic bronchitis. Patients generally have a lengthy smoking history and are in their fifth decade of life.
They often have a chronic cough with sputum production. Diagnosis is by pulmonary function tests
including spirometry. Treatment is based on the severity of the disease. Long-acting anticholinergics
such as tiotropium are the mainstay of therapy.
Question: True or false: All patients with chronic obstructive pulmonary disease should be prescribed a
short-acting bronchodilator? - ANSWER-True.
A 35-year-old woman comes to the urgent care clinic complaining of a 3-week history of difficulty
seeing, blurred vision, eye pain, and cough. She describes the cough as being dry and nonproductive.
She has no past medical history and takes no medications. Her blood pressure is 140/85 mm Hg and her
temperature is 38.1°C (100.5°F). Ophthalmologic examination shows uveitis. Chest X-ray shows bilateral
hilar adenopathy. Which of the following additional findings would also most likely be found in this
patient?
Ferruginous bodies
Increased sweat chloride
Positive PPD skin test
Subcutaneous nodules - ANSWER-Correct Answer ( D )
Explanation:
Uveitis, bilateral hilar adenopathy, and a dry cough most likely indicate sarcoidosis. Sarcoidosis is
granulomatous disease that can form nodules in multiple organs. When these nodules form in the skin,
they are referred to as subcutaneous nodules (ie, erythema nodosum). Patients with sarcoidosis
typically present with fatigue, weight loss, arthritis, dry eyes, blurry vision, and respiratory symptoms
(eg, cough, dyspnea). Management usually involves the use of corticosteroids (eg, prednisone).
,Question: What is the preferred form of management in patients with sarcoidosis? - ANSWER-
Corticosteroids (eg, prednisone).
A 4-year-old patient is brought to the emergency department by his parents after a choking incident
that occurred one hour ago. The parents tell you that their son was eating steak, started to laugh and
then began choking. Since the incident, he has been coughing and wheezing. Physical exam reveals
unilateral diminished breath sounds with auscultation of the lungs. Which of the following is the most
appropriate next step in management?
Begin a course of antibiotics and steroids
Chest X-ray
Flexible bronchoscopy
Rigid bronchoscopy - ANSWER-Correct Answer ( D )
Explanation:
Foreign body aspiration (FBA) can be a life-threatening event and is a common cause of morbidity and
mortality in children. The majority of pediatric FBA incidents occur in children less than 3 years of age.
Types of foreign bodies that are commonly aspirated by children include peanuts, popcorn, other nuts
and seeds, food particles and pieces of toys. FBA is a true medical emergency if there is a complete
airway obstruction. Children with cyanosis, altered mental status and severe respiratory distress require
immediate medical intervention including life support and rigid bronchoscopy to remove the foreign
body. All cases of suspected FBA require that the tracheobronchial tree be examined. Rigid
bronchoscopy is used for this examination and is both a diagnostic and management tool for partial and
complete obstructions caused by FBA.
Chest X-ray (B) may detect FBA if the aspirated object is radioopaque or depending on the severity of
the obstruction. Normal findings on a chest X-ray do not rule out FBA since foods are not radioopaque
and are commonly aspirated by pediatric patients. Flexible bronchoscopy (C) is often used in children
with pneumonia or other respiratory symptoms. Use of flexible bronchoscopy for diagnosis of FBA may
dislodge the object and cause a partial obstruction to become complete.
Where are most aspirated foreign bodies located? - ANSWER-Right main bronchus.
Foreign Body Aspiration
, Patient will be a child
Complaining of a sudden episode of coughing, wheezing, or stridor
Comments: most common is the right main bronchus
An obese 34-year-old woman is brought to the Emergency Department with respiratory distress. Two
months ago she was in the hospital for knee surgery. Paramedics report an acute onset of dyspnea and
pleuritic chest pain. She also complains of a tender thigh on the same side of her knee surgery. She is
tachycardic and tachypneic, and mildly hypotensive. Examination reveals decreased breath sounds but
no hyperresonance. An emergent chest radiograph is relatively normal except for some mild atelectasis.
Which of the following is the most likely diagnosis?
Acute bronchitis
Pleural effusion
Pneumothorax
Pulmonary embolism - ANSWER-Correct Answer ( D )
Explanation:
Pulmonary embolism refers to the obstruction of a pulmonary artery by thrombus, tumor, air or fat that
originated elsewhere in the body, mostly from the deep veins of the lower extremities. It is classified as
acute or chronic, and massive or submassive. It is often a fatal disease, leading to a mortality rate of 30%
without treatment. Risk factors include immobilization, surgery or central venous instrumentation
within the last three months, stroke/paresis/paralysis, cancer, chronic cardiac disease, autoimmune
disease, obesity, >1 pack per day tobacco use, hypertension and a history of deep vein thrombosis. Most
patients experience dyspnea with or without wheezing, cough, pleuritic chest pain, orthopnea, lower
extremity pain or swelling, tachypnea, tachycardia, jugular venous distension, decreased breath sounds
and an accentuated pulmonic component of S2. These signs and symptoms are variable and nonspecific.
Furthermore, up to 32% of patients present asymptomatically. As such, the diagnosis can be difficult.
The mainstay of treatment is anticoagulation.
Question: What is a saddle pulmonary embolism? - ANSWER-An embolus that lodges in the bifurcation
formed by the main pulmonary artery and right and left pulmonary arteries.
Pulmonary Embolism
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What is the most common cause of minor hemoptysis in the Emergency Department?
Acute bronchitis
Pneumonia
Pulmonary embolism
Tuberculosis - ANSWER-Correct Answer ( A )
Explanation:
Acute bronchitis is the most common cause of minor hemoptysis in the Emergency Department.
Hemoptysis describes the presence of blood in sputum expectorated from the respiratory tract. The
majority of episodes of hemoptysis are minor episodes with small amounts of blood. Less than 5% of
patients with hemoptysis have life-threatening hemorrhage. Bronchitis results from inflammation in the
bronchial tree and can lead to hemoptysis. Additionally, forceful coughing further irritates the inflamed
mucosal surfaces and can result in bleeding. Hemoptysis in bronchitis is typically self-limited.
Acute Bronchitis
Viruses > bacteria
Most common cause of minor hemoptysis
Hallmark: cough (usually productive), <1week
Symptomatic treatment, bronchodilators
Routine ABX therapy not indicated
Question: What are the most common sites of hemorrhage in massive hemoptysis? - ANSWER-Massive
hemoptysis typically involves the bronchial or pulmonary arteries.
A 58-year-old man presents to your office with complaints of chronic cough and difficulty breathing. He
has smoked approximately 2 packs of cigarettes per day since he was 14 years old and has not seen a
doctor in many years. You order spirometry testing, which shows airflow limitation (predicted FEV1
45%). Which of the following is the most appropriate therapy?
,Azithromycin
Guaifenesin
Prednisone
Tiotropium - ANSWER-Correct Answer ( D )
Explanation:
Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by airflow
limitation that causes an enhanced inflammatory response in the airways and lungs. Historically COPD
was divided into three subtypes: chronic bronchitis, emphysema and asthma. Asthma is no longer
grouped with COPD and current definitions of COPD do not differentiate between emphysema and
chronic bronchitis. Patients generally have a lengthy smoking history and are in their fifth decade of life.
They often have a chronic cough with sputum production. Diagnosis is by pulmonary function tests
including spirometry. Treatment is based on the severity of the disease. Long-acting anticholinergics
such as tiotropium are the mainstay of therapy.
Question: True or false: All patients with chronic obstructive pulmonary disease should be prescribed a
short-acting bronchodilator? - ANSWER-True.
A 35-year-old woman comes to the urgent care clinic complaining of a 3-week history of difficulty
seeing, blurred vision, eye pain, and cough. She describes the cough as being dry and nonproductive.
She has no past medical history and takes no medications. Her blood pressure is 140/85 mm Hg and her
temperature is 38.1°C (100.5°F). Ophthalmologic examination shows uveitis. Chest X-ray shows bilateral
hilar adenopathy. Which of the following additional findings would also most likely be found in this
patient?
Ferruginous bodies
Increased sweat chloride
Positive PPD skin test
Subcutaneous nodules - ANSWER-Correct Answer ( D )
Explanation:
Uveitis, bilateral hilar adenopathy, and a dry cough most likely indicate sarcoidosis. Sarcoidosis is
granulomatous disease that can form nodules in multiple organs. When these nodules form in the skin,
they are referred to as subcutaneous nodules (ie, erythema nodosum). Patients with sarcoidosis
typically present with fatigue, weight loss, arthritis, dry eyes, blurry vision, and respiratory symptoms
(eg, cough, dyspnea). Management usually involves the use of corticosteroids (eg, prednisone).
,Question: What is the preferred form of management in patients with sarcoidosis? - ANSWER-
Corticosteroids (eg, prednisone).
A 4-year-old patient is brought to the emergency department by his parents after a choking incident
that occurred one hour ago. The parents tell you that their son was eating steak, started to laugh and
then began choking. Since the incident, he has been coughing and wheezing. Physical exam reveals
unilateral diminished breath sounds with auscultation of the lungs. Which of the following is the most
appropriate next step in management?
Begin a course of antibiotics and steroids
Chest X-ray
Flexible bronchoscopy
Rigid bronchoscopy - ANSWER-Correct Answer ( D )
Explanation:
Foreign body aspiration (FBA) can be a life-threatening event and is a common cause of morbidity and
mortality in children. The majority of pediatric FBA incidents occur in children less than 3 years of age.
Types of foreign bodies that are commonly aspirated by children include peanuts, popcorn, other nuts
and seeds, food particles and pieces of toys. FBA is a true medical emergency if there is a complete
airway obstruction. Children with cyanosis, altered mental status and severe respiratory distress require
immediate medical intervention including life support and rigid bronchoscopy to remove the foreign
body. All cases of suspected FBA require that the tracheobronchial tree be examined. Rigid
bronchoscopy is used for this examination and is both a diagnostic and management tool for partial and
complete obstructions caused by FBA.
Chest X-ray (B) may detect FBA if the aspirated object is radioopaque or depending on the severity of
the obstruction. Normal findings on a chest X-ray do not rule out FBA since foods are not radioopaque
and are commonly aspirated by pediatric patients. Flexible bronchoscopy (C) is often used in children
with pneumonia or other respiratory symptoms. Use of flexible bronchoscopy for diagnosis of FBA may
dislodge the object and cause a partial obstruction to become complete.
Where are most aspirated foreign bodies located? - ANSWER-Right main bronchus.
Foreign Body Aspiration
, Patient will be a child
Complaining of a sudden episode of coughing, wheezing, or stridor
Comments: most common is the right main bronchus
An obese 34-year-old woman is brought to the Emergency Department with respiratory distress. Two
months ago she was in the hospital for knee surgery. Paramedics report an acute onset of dyspnea and
pleuritic chest pain. She also complains of a tender thigh on the same side of her knee surgery. She is
tachycardic and tachypneic, and mildly hypotensive. Examination reveals decreased breath sounds but
no hyperresonance. An emergent chest radiograph is relatively normal except for some mild atelectasis.
Which of the following is the most likely diagnosis?
Acute bronchitis
Pleural effusion
Pneumothorax
Pulmonary embolism - ANSWER-Correct Answer ( D )
Explanation:
Pulmonary embolism refers to the obstruction of a pulmonary artery by thrombus, tumor, air or fat that
originated elsewhere in the body, mostly from the deep veins of the lower extremities. It is classified as
acute or chronic, and massive or submassive. It is often a fatal disease, leading to a mortality rate of 30%
without treatment. Risk factors include immobilization, surgery or central venous instrumentation
within the last three months, stroke/paresis/paralysis, cancer, chronic cardiac disease, autoimmune
disease, obesity, >1 pack per day tobacco use, hypertension and a history of deep vein thrombosis. Most
patients experience dyspnea with or without wheezing, cough, pleuritic chest pain, orthopnea, lower
extremity pain or swelling, tachypnea, tachycardia, jugular venous distension, decreased breath sounds
and an accentuated pulmonic component of S2. These signs and symptoms are variable and nonspecific.
Furthermore, up to 32% of patients present asymptomatically. As such, the diagnosis can be difficult.
The mainstay of treatment is anticoagulation.
Question: What is a saddle pulmonary embolism? - ANSWER-An embolus that lodges in the bifurcation
formed by the main pulmonary artery and right and left pulmonary arteries.
Pulmonary Embolism
