PULMONARY ROSH EXAM REVIEW WITH QUESTIONS AND
Pulmonary ROSH Review
ANSWERS (VERIFIED AND DETAILED ANSWERS) LATEST 2024/2025
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1. A 25-year-old man Correct Answer ( D )
presents for eval- Explanation:
uation of fever The patient had a recent influenza infection and now presents with a lobar
and cough. He re- infiltrate. Staphylococcus aureus pneumonia is classically associated with caus-
ports last week that ing post-influenza bacterial pneumonia. On Gram stain this is seen as Gram
he was diagnosed positive cocci in clusters
with influenza. In
the last 2 days he
developed a wors-
ening cough pro-
ductive of large
amounts of spu-
tum. Vital signs
are T 101°F, HR
98, BP 120/60, RR
18, and 95% oxy-
gen saturation on
room air. His chest
X-ray demonstrates
a lobar infiltrate in
the left lower lobe.
Which of the fol-
lowing would you
most likely expect
to see on the pa-
tient's Gram stain?
Gram negative
bacilli
Gram negative
diplococci
Gram positive bacil-
, Pulmonary ROSH Review
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li
Gram positive cocci
in clusters
2. Question: In which COPD, Alcoholics and the elderly.
population is Kleb-
siella pneumonia
most commonly
seen in?
3. Bacterial Pneumo- Bacterial Pneumonia
nia Overview
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
4. You evaluate a Correct Answer ( B )
65-year-old patient Explanation:
for shortness of Classic physical signs of a pleural effusion include diminished breath sounds,
breath and note dullness to percussion, decreased tactile fremitus, and occasionally a localized
on exam decreased pleural friction rub. Chest radiograph confirms the suspicion of pleural effu-
breath sounds at sion. The classic radiographic appearance of a pleural effusion is blunting of
the left lung base. the costophrenic angle on the upright chest radiograph
You are suspicious
, Pulmonary ROSH Review
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of a small pleural
effusion. In which Pleural Effusion
of the following Transudate: CHF (most common)
views on the chest Exudate: infection > malignancy, PE
radiograph is the “Breath sounds + dull percussion + “tactile fremitus
small pleural effu- CXR: blunting of the costophrenic angle
sion most likely to
be detected?
Lateral
Lateral decubitus
left side down
Lateral decubitus
right side down
Posterior-anterior
(PA)
5. Question: A pleural Supine.
effusion is most dif-
ficult to detect in
which radiographic
position?
6. Which of the follow- Correct Answer ( C )
ing complications Explanation:
can be prevented Isoniazid (INH) inhibits the enzyme responsible for the conversion of pyridox-
by simultaneously ine (vitamin B6) to one of its active metabolites, pyridoxal phosphate (PLP).
administering pyri- This depletion of vitamin B6 may lead to complications such as peripheral
doxine and iso- neuropathy and seizures. Therefore, vitamin B6 should be administered con-
niazid in a pa- comitantly to patients taking isoniazid. PLP is also a coenzyme required for the
tient with tubercu- synthesis of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter.
losis exposure? Decreased GABA formation in the setting of vitamin B6 deficiency may also
, Pulmonary ROSH Review
Study online at https://quizlet.com/_8z16qz
contribute to seizures.
Color blindness
Hepatitis Color blindness (A) is not a complication of INH. However, another commonly
Peripheral neu- used drug in TB, ethambutol, is associated with retrobulbar neuritis and
ropathy red-green color blindness. INH is metabolized by the liver and gets converted
Renal failure 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.
7. Question: What is Lymph nodes.
the most common
location of extra- Pulmonary Tuberculosis (TB)
pulmonary TB?
RFs: immunodeficiency, immigrant, close contact
Latent/primary TB: asymptomatic
Active/reactivation TB: fever, night sweats, weight loss, productive cough, he-
moptysis
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)
8. A 45-year-old pa- Correct Answer ( B )
tient with newly di- Explanation:
agnosed diabetes Patients with diabetes mellitus require regular monitoring and health main-
mellitus type 2 pre- tenance to prevent diabetes-related complications. Health maintenance for
sents to your of- these patients includes three vaccinations: annual influenza, pneumococcus
fice for her annu- (repeated at age 65 if given prior to that age) and the hepatitis B three dose
al exam. She has series. Patients with diabetes mellitus require annual foot, dental and dilated
Pulmonary ROSH Review
ANSWERS (VERIFIED AND DETAILED ANSWERS) LATEST 2024/2025
Study online at https://quizlet.com/_8z16qz
1. A 25-year-old man Correct Answer ( D )
presents for eval- Explanation:
uation of fever The patient had a recent influenza infection and now presents with a lobar
and cough. He re- infiltrate. Staphylococcus aureus pneumonia is classically associated with caus-
ports last week that ing post-influenza bacterial pneumonia. On Gram stain this is seen as Gram
he was diagnosed positive cocci in clusters
with influenza. In
the last 2 days he
developed a wors-
ening cough pro-
ductive of large
amounts of spu-
tum. Vital signs
are T 101°F, HR
98, BP 120/60, RR
18, and 95% oxy-
gen saturation on
room air. His chest
X-ray demonstrates
a lobar infiltrate in
the left lower lobe.
Which of the fol-
lowing would you
most likely expect
to see on the pa-
tient's Gram stain?
Gram negative
bacilli
Gram negative
diplococci
Gram positive bacil-
, Pulmonary ROSH Review
Study online at https://quizlet.com/_8z16qz
li
Gram positive cocci
in clusters
2. Question: In which COPD, Alcoholics and the elderly.
population is Kleb-
siella pneumonia
most commonly
seen in?
3. Bacterial Pneumo- Bacterial Pneumonia
nia Overview
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
4. You evaluate a Correct Answer ( B )
65-year-old patient Explanation:
for shortness of Classic physical signs of a pleural effusion include diminished breath sounds,
breath and note dullness to percussion, decreased tactile fremitus, and occasionally a localized
on exam decreased pleural friction rub. Chest radiograph confirms the suspicion of pleural effu-
breath sounds at sion. The classic radiographic appearance of a pleural effusion is blunting of
the left lung base. the costophrenic angle on the upright chest radiograph
You are suspicious
, Pulmonary ROSH Review
Study online at https://quizlet.com/_8z16qz
of a small pleural
effusion. In which Pleural Effusion
of the following Transudate: CHF (most common)
views on the chest Exudate: infection > malignancy, PE
radiograph is the “Breath sounds + dull percussion + “tactile fremitus
small pleural effu- CXR: blunting of the costophrenic angle
sion most likely to
be detected?
Lateral
Lateral decubitus
left side down
Lateral decubitus
right side down
Posterior-anterior
(PA)
5. Question: A pleural Supine.
effusion is most dif-
ficult to detect in
which radiographic
position?
6. Which of the follow- Correct Answer ( C )
ing complications Explanation:
can be prevented Isoniazid (INH) inhibits the enzyme responsible for the conversion of pyridox-
by simultaneously ine (vitamin B6) to one of its active metabolites, pyridoxal phosphate (PLP).
administering pyri- This depletion of vitamin B6 may lead to complications such as peripheral
doxine and iso- neuropathy and seizures. Therefore, vitamin B6 should be administered con-
niazid in a pa- comitantly to patients taking isoniazid. PLP is also a coenzyme required for the
tient with tubercu- synthesis of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter.
losis exposure? Decreased GABA formation in the setting of vitamin B6 deficiency may also
, Pulmonary ROSH Review
Study online at https://quizlet.com/_8z16qz
contribute to seizures.
Color blindness
Hepatitis Color blindness (A) is not a complication of INH. However, another commonly
Peripheral neu- used drug in TB, ethambutol, is associated with retrobulbar neuritis and
ropathy red-green color blindness. INH is metabolized by the liver and gets converted
Renal failure 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.
7. Question: What is Lymph nodes.
the most common
location of extra- Pulmonary Tuberculosis (TB)
pulmonary TB?
RFs: immunodeficiency, immigrant, close contact
Latent/primary TB: asymptomatic
Active/reactivation TB: fever, night sweats, weight loss, productive cough, he-
moptysis
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)
8. A 45-year-old pa- Correct Answer ( B )
tient with newly di- Explanation:
agnosed diabetes Patients with diabetes mellitus require regular monitoring and health main-
mellitus type 2 pre- tenance to prevent diabetes-related complications. Health maintenance for
sents to your of- these patients includes three vaccinations: annual influenza, pneumococcus
fice for her annu- (repeated at age 65 if given prior to that age) and the hepatitis B three dose
al exam. She has series. Patients with diabetes mellitus require annual foot, dental and dilated
