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What is the most appropriate next step in management for a 61-year-old woman with an 8 mm left pulmonary nodule discovered incidentally? A) PET/CT scan B) Bronchoalveolar lavage C) Transthoracic lung biopsy D) Observation and regular follow-up
D) Observation and regular follow-up Explanation: Given that the patient is asymptomatic and the nodule is small (8 mm), the most appropriate management is observation and regular follow-up, as this is a common approach for incidental pulmonary nodules.
What is the most appropriate next step in management for a 33-year-old man with shortness of breath and fatigue associated with his work in a car repair shop? A) High-resolution chest CT B) Inhaled glucocorticoid daily C) Referral to a pulmonologist D) Occupational health evaluation E) Immediate bronchodilator therapy
A) High-resolution chest CT Explanation: Given the occupational exposure and respiratory symptoms, a high-resolution chest CT is appropriate to evaluate for potential work-related lung disease.
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p.3
Pulmonary Nodule Evaluation

What is the most appropriate next step in management for a 61-year-old woman with an 8 mm left pulmonary nodule discovered incidentally?
A) PET/CT scan
B) Bronchoalveolar lavage
C) Transthoracic lung biopsy
D) Observation and regular follow-up

D) Observation and regular follow-up
Explanation: Given that the patient is asymptomatic and the nodule is small (8 mm), the most appropriate management is observation and regular follow-up, as this is a common approach for incidental pulmonary nodules.

p.4
Chronic Cough Evaluation

What is the most appropriate next step in management for a 33-year-old man with shortness of breath and fatigue associated with his work in a car repair shop?
A) High-resolution chest CT
B) Inhaled glucocorticoid daily
C) Referral to a pulmonologist
D) Occupational health evaluation
E) Immediate bronchodilator therapy

A) High-resolution chest CT
Explanation: Given the occupational exposure and respiratory symptoms, a high-resolution chest CT is appropriate to evaluate for potential work-related lung disease.

p.6
Asthma Exacerbation Management

In a 17-year-old with severe asthma exacerbation and respiratory distress, what is the most appropriate next step in management after 1 hour of systemic glucocorticoids and B2 agonist nebulizer?
A) Admit to the ICU
B) Reassure him and discharge home
C) Admit to the general medical floor
D) Discharge home the next day with follow-up
E) Start a new inhaler

A) Admit to the ICU
Explanation: Given the patient's severe respiratory distress and lack of improvement after treatment, admitting him to the ICU is the most appropriate next step to ensure close monitoring and intensive management.

p.10
Chronic Cough Evaluation

What is the most important initial diagnostic procedure for a 29-year-old pregnant woman with progressive dyspnea and a swollen right lower limb?
A) D-dimer
B) CT pulmonary angiography
C) Lung perfusion scintigraphy
D) Doppler ultrasonography of the legs
E) Chest X-ray

D) Doppler ultrasonography of the legs
Explanation: Doppler ultrasonography of the legs is crucial for assessing potential deep vein thrombosis (DVT), especially in a pregnant patient presenting with leg swelling and dyspnea.

p.2
Systemic Lupus Erythematosus Management

For a 30-year-old woman with systemic lupus erythematosus planning to get pregnant, what is the most appropriate action regarding her medication?
A) Discontinue prednisone and start cyclosporine
B) Continue all current medications
C) Discontinue hydroxychloroquine
D) Increase the dose of mycophenolate mofetil
E) Switch to a different immunosuppressant

A) Discontinue prednisone and start cyclosporine
Explanation: In preparation for pregnancy, it is often recommended to adjust medications to minimize risks to the fetus, which may include discontinuing certain medications like prednisone.

p.8
Chronic Cough Evaluation

A 55-year-old man with a history of smoking presents with chronic cough and dyspnea. What is the most appropriate next step in management?
A) Chest X-ray
B) Spirometry
C) CT scan of the chest
D) Referral to a pulmonologist
E) Start inhaled corticosteroids

B) Spirometry
Explanation: Spirometry is the most appropriate next step in management to assess lung function and diagnose potential obstructive airway disease, especially in a patient with a significant smoking history.

p.7
Asthma Exacerbation Management

For a 34-year-old woman with asthma reporting poor control and nighttime cough, what is the most appropriate addition to her current therapy?
A) Increase salbutamol dosage
B) Add long-acting B2 agonist (Salmeterol)
C) Add long-acting anticholinergic bronchodilator (Tiotropium)
D) Add oral corticosteroids
E) Increase beclometasone dosage

B) Add long-acting B2 agonist (Salmeterol)
Explanation: Adding a long-acting beta-agonist like salmeterol can help improve asthma control, especially for patients experiencing nighttime symptoms and exertional wheeze.

p.4
Asthma Exacerbation Management

For a 20-year-old man with asthma who experiences chest and throat tightness during basketball practice, what is the most appropriate next step in management?
A) Echocardiography
B) Allergen immunotherapy
C) Otolaryngology evaluation
D) Switch to a medium-dose inhaled glucocorticoid
E) Increase short-acting B2 agonist use

C) Otolaryngology evaluation
Explanation: Given the symptoms of stridor and prolonged wheeze, an evaluation by an otolaryngologist is warranted to rule out any upper airway obstruction or other non-asthmatic causes.

p.6
Asthma Exacerbation Management

What is the most appropriate management for a patient with a dry cough and throat clearing, with a clear chest and no wheezing?
A) Add a long-acting B2-agonist
B) Add a proton pump inhibitor
C) Start nocturnal antitussive therapy
D) Repeat methacholine challenge testing
E) Prescribe an antibiotic

B) Add a proton pump inhibitor
Explanation: The presence of a dry cough and throat clearing, especially in the morning, suggests a possible association with gastroesophageal reflux disease (GERD), making a proton pump inhibitor the most appropriate management option.

p.3
Systemic Lupus Erythematosus Management

What should be done for a patient who has been taking mycophenolate mofetil but needs a change in medication?
A) Discontinue hydroxychloroquine and start quinacrine
B) Discontinue mycophenolate mofetil and start azathioprine
C) Discontinue mycophenolate mofetil and start methotrexate
D) Continue mycophenolate mofetil

B) Discontinue mycophenolate mofetil and start azathioprine
Explanation: The answer indicates that switching from mycophenolate mofetil to azathioprine is the most appropriate next step in management for the patient.

p.8
Asthma Exacerbation Management

Which of the following is the most appropriate next step in outpatient management for asthma?
A) Ipratropium inhaler
B) Low-dose oral prednisolone
C) Leukotriene receptor antagonist
D) Modified-release theophylline
E) Short-acting beta-agonist

C) Leukotriene receptor antagonist
Explanation: The leukotriene receptor antagonist is indicated as the most appropriate next step in outpatient management for asthma, as it helps in controlling asthma symptoms effectively.

p.3
COPD Management and Treatment

For a 63-year-old woman with COPD and exertional dyspnea, what is the most appropriate treatment?
A) Daily prednisone
B) Long-term oxygen therapy
C) Overnight pulse oximetry
D) Repeat pulmonary rehabilitation

B) Long-term oxygen therapy
Explanation: The patient's symptoms and echocardiogram findings suggest significant pulmonary hypertension, making long-term oxygen therapy the most appropriate treatment to improve her quality of life and manage her condition.

p.5
Chronic Cough Evaluation

What is the most appropriate next diagnostic test for a 49-year-old woman with a 4-month history of dry cough and a slightly reduced FEV/FVC ratio?
A) Allergy skin testing
B) High-resolution chest CT
C) Measurement of serum IgE levels
D) Methacholine challenge testing
E) Chest ultrasound

D) Methacholine challenge testing
Explanation: Given the patient's history of dry cough and the spirometry results indicating a slight reduction in the FEV/FVC ratio, a methacholine challenge test is appropriate to assess for asthma or bronchial hyperreactivity.

p.2
Rheumatoid Arthritis Treatment Options

In a 52-year-old man with rheumatoid arthritis presenting with fever and shortness of breath, what is the most appropriate action?
A) Hold adalimumab and start antibiotics
B) Hold methotrexate and start antibiotics
C) Hold his current treatment and start antibiotics
D) Continue his current treatment and start antibiotics
E) Refer to a specialist

C) Hold his current treatment and start antibiotics
Explanation: Given the patient's symptoms and the potential for infection, it is prudent to hold all immunosuppressive treatments and start antibiotics.

p.1
Systemic Lupus Erythematosus Management

In a 30-year-old woman with systemic lupus erythematosus experiencing right hip pain, which is the most likely cause given her normal lab results and pain on internal rotation?
A) Active lupus arthritis
B) Osteoarthritis
C) Avascular necrosis
D) Psoriatic arthritis
E) Rheumatoid arthritis

C) Avascular necrosis
Explanation: The patient's hip pain, especially with normal lab results and pain on internal rotation, raises suspicion for avascular necrosis, a potential complication in patients with systemic lupus erythematosus.

p.9
Pleural Effusion Analysis

What is the most appropriate next step for a 69-year-old man with a large left-sided pleural effusion and bloody fluid from thoracentesis?
A) Empirical broad-spectrum antibiotics
B) Observation
C) Repeat thoracentesis
D) Chest tube placement
E) Referral for surgery

A) Empirical broad-spectrum antibiotics
Explanation: The presence of a large pleural effusion with bloody fluid suggests possible infection or malignancy, and empirical broad-spectrum antibiotics are warranted while further evaluation is conducted.

p.4
Pleural Effusion Analysis

What is the most appropriate management for a 71-year-old man with a moderate right-sided pleural effusion after pneumonia?
A) Ceftriaxone and azithromycin
B) Chest tube and levofloxacin
C) Repeat chest radiograph in 2 weeks
D) Small-bore pleural drain and piperacillin-tazobactam
E) Oral antibiotics only

D) Small-bore pleural drain and piperacillin-tazobactam
Explanation: The presence of a moderate pleural effusion and ongoing symptoms after pneumonia indicates the need for drainage and appropriate antibiotic coverage, making this option the most suitable.

p.8
Asthma Exacerbation Management

Which feature is most likely to indicate a life-threatening asthma attack?
A) Failure to improve after nebulized salbutamol 5 mg
B) Oxygen saturations of 94% on room air
C) Peak flow of 30% best or predicted
D) Respiratory rate of 28/min
E) Mild wheezing

C) Peak flow of 30% best or predicted
Explanation: A peak flow of 30% best or predicted indicates severe airway obstruction and is a critical sign of a life-threatening asthma attack.

p.6
Pleural Effusion Analysis

What is the most likely cause of a clear transudative pleural effusion in a 63-year-old man with progressive shortness of breath?
A) Pancreatitis
B) Pneumonia
C) Heart failure
D) Malignancy
E) Tuberculosis

C) Heart failure
Explanation: A clear transudative pleural effusion is most commonly associated with heart failure, making it the most likely cause in this clinical scenario.

p.5
Chronic Cough Evaluation

What symptom is most likely to worsen a chronic cough in a 42-year-old woman diagnosed with cough-variant asthma?
A) Lying down
B) Physical activity
C) Cold weather
D) Eating spicy food
E) Exposure to dust

A) Lying down
Explanation: The patient's cough worsens when she lies down, which is a common symptom in cough-variant asthma, indicating potential postnasal drip or other factors related to position.

p.1
Rheumatoid Arthritis Treatment Options

What is the most appropriate treatment for a 50-year-old man with active arthritis in multiple joints?
A) Methotrexate
B) Methotrexate and sulfasalazine
C) Methotrexate and hydroxychloroquine
D) Methotrexate, hydroxychloroquine, and prednisone
E) Prednisone alone

D) Methotrexate, hydroxychloroquine, and prednisone
Explanation: The combination of methotrexate, hydroxychloroquine, and prednisone is appropriate for managing active arthritis in this patient, addressing both inflammation and disease-modifying effects.

p.9
Pulmonary Nodule Evaluation

What is the most appropriate next step for a 68-year-old woman with a 10.5 mm pulmonary nodule that has increased in size?
A) Perform blind transthoracic needle aspiration
B) Repeat chest CT imaging in 6 months
C) Refer for thoracic surgery
D) Perform bronchoscopy
E) Start chemotherapy

C) Refer for thoracic surgery
Explanation: Given the increase in size of the nodule and the patient's significant smoking history, referral for thoracic surgery is the most appropriate next step for potential malignancy.

p.5
Chronic Cough Evaluation

What spirometry finding is indicative of a significant response to bronchodilator therapy in a patient with respiratory symptoms?
A) FEV1/FVC ratio decreases
B) FEV1 increases by 20% or more
C) FVC decreases
D) FEV1 remains unchanged
E) FEV1/FVC ratio remains the same

B) FEV1 increases by 20% or more
Explanation: An increase in FEV1 by 20% or more after bronchodilator administration indicates significant reversibility, which is often seen in asthma or other obstructive airway diseases.

p.10
Pleural Effusion Analysis

In a 71-year-old man with high fever, dyspnea, and a pleural effusion, which pleural fluid analysis indicates the need for chest-tube drainage?
A) pH < 7.2
B) Glucose > 60 mmol/L
C) Negative Gram stain
D) Serosanguineous appearance
E) Clear fluid appearance

A) pH < 7.2
Explanation: A pleural fluid pH of less than 7.2 typically indicates an infected or complicated effusion, necessitating chest-tube drainage.

p.2
Gout and Psoriatic Arthritis

What type of crystals are most likely seen in a patient diagnosed with gout?
A) Needle-shaped, negatively birefringent
B) Needle-shaped, weakly positively birefringent
C) Rhomboidal-shaped, negatively birefringent
D) Rhomboidal-shaped, weakly positively birefringent
E) Cubic-shaped, negatively birefringent

A) Needle-shaped, negatively birefringent
Explanation: Gout is characterized by the presence of needle-shaped, negatively birefringent crystals in the synovial fluid.

p.8
COPD Management and Treatment

Which intervention is most associated with increased survival in a patient with COPD and cor pulmonale?
A) Heart-lung transplant
B) Corticosteroid therapy
C) Pulmonary rehabilitation
D) Long-term oxygen therapy
E) Antibiotic therapy

D) Long-term oxygen therapy
Explanation: Long-term oxygen therapy is associated with increased survival in patients with COPD and cor pulmonale, as it improves oxygenation and reduces the risk of complications.

p.7
Pleural Effusion Analysis

In a 69-year-old smoker with a large left-sided pleural effusion, which finding would most likely indicate that it is an exudative effusion?
A) Pleural fluid LDH / Serum LDH < 0.6
B) Pleural fluid protein / Serum protein < 0.5
C) Effusion LDH level greater than 1/3rd the upper limit of serum LDH
D) Effusion LDH level greater than 2/3rds the upper limit of serum LDH
E) Pleural fluid glucose level < 60 mg/dL

D) Effusion LDH level greater than 2/3rds the upper limit of serum LDH
Explanation: An effusion is classified as exudative if the pleural fluid LDH level is greater than 2/3rds the upper limit of normal serum LDH, indicating a pathological process.

p.10
Pulmonary Nodule Evaluation

What is the most appropriate next step for a 55-year-old woman with a 1 cm solitary nodule in the right lung?
A) Follow-up CT in 3-6 months
B) No follow-up needed
C) Transbronchial biopsy
D) Surgical resection
E) Immediate chemotherapy

A) Follow-up CT in 3-6 months
Explanation: Given the characteristics of the nodule and the patient's smoking history, a follow-up CT in 3-6 months is the most appropriate next step to monitor any changes in the nodule.

p.1
Systemic Lupus Erythematosus Management

In a 28-year-old woman with systemic lupus erythematosus presenting with sudden lower limb weakness and urinary incontinence, which test should be done immediately?
A) Lumbar puncture, MRI brain
B) Lumbar puncture, CT brain
C) Lumbar puncture, MRI spinal cord
D) Lumbar puncture, MRI, MRA, and MRV of the brain
E) CT scan of the abdomen

C) Lumbar puncture, MRI spinal cord
Explanation: Given the symptoms of paraplegia and hyperreflexia, a lumbar puncture and MRI of the spinal cord are crucial to assess for possible neurological complications.

p.9
Pulmonary Nodule Evaluation

For a 79-year-old man with a stable 2 mm solitary pulmonary nodule, what is the most appropriate recommendation?
A) Repeat chest CT in 1 year
B) Repeat chest CT in 2 years
C) Repeat chest CT in 5 years
D) No further imaging is necessary
E) Refer for surgery

D) No further imaging is necessary
Explanation: The nodule has remained unchanged over several years, and given the patient's stable condition, no further imaging is necessary.

p.5
COPD Management and Treatment

For a 57-year-old man with chronic cough and a smoking history, what is the most appropriate long-term management plan?
A) Combination inhaled glucocorticoid and a long-acting bronchodilator
B) Phosphodiesterase-4 inhibitor and combination inhaled glucocorticoid and long-acting bronchodilator
C) Short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation
D) Short-acting bronchodilator as needed and an inhaled glucocorticoid
E) Oral corticosteroids

C) Short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation
Explanation: The patient’s symptoms and spirometry results suggest COPD, and the recommended management includes a short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation.

p.2
Osteoarthritis Diagnosis and Management

What is the most appropriate action to confirm a diagnosis of osteoarthritis in a 60-year-old man with knee pain?
A) Bilateral knee X-rays
B) MRI of the right knee
C) No further investigation
D) Arthroscopy for the right knee
E) Physical therapy

C) No further investigation
Explanation: In cases of suspected osteoarthritis, especially with a typical presentation, no further investigation is often needed if the clinical diagnosis is clear.

p.4
Asthma Exacerbation Management

What is the recommended addition to the treatment regimen for a patient with asthma who is not adequately controlled with a low-dose inhaled glucocorticoid and a long-acting B2 agonist?
A) Add a leukotriene antagonist
B) Add a low-dose inhaled glucocorticoid
C) Recommend daily oral antihistamine use
D) Add a low-dose inhaled glucocorticoid and long-acting B2 agonist
E) Increase the frequency of short-acting B2 agonist use

D) Add a low-dose inhaled glucocorticoid and long-acting B2 agonist
Explanation: For patients with moderate persistent asthma, adding a low-dose inhaled glucocorticoid and a long-acting B2 agonist can help achieve better control of symptoms.

p.3
Asthma Exacerbation Management

What is the most appropriate treatment for a 58-year-old woman experiencing daily wheezing and breathlessness during allergy season?
A) Increase loratadine dosage
B) Start a long-acting bronchodilator
C) Use a rescue inhaler as needed
D) Initiate inhaled corticosteroids

D) Initiate inhaled corticosteroids
Explanation: Given the frequency of her wheezing and the impact on her activities, initiating inhaled corticosteroids would be the most appropriate treatment to manage her asthma symptoms effectively.

p.7
Asthma Exacerbation Management

What is the most appropriate management for a 33-year-old man with severe asthma who is deteriorating despite treatment?
A) Non-invasive ventilation
B) Add intravenous aminophylline
C) Add nebulized ipratropium bromide
D) Intubation and mechanical ventilation
E) Increase nebulized salbutamol frequency

D) Intubation and mechanical ventilation
Explanation: In cases of severe asthma where the patient is deteriorating despite aggressive treatment, intubation and mechanical ventilation may be necessary to secure the airway and provide adequate ventilation.

p.1
Gout and Psoriatic Arthritis

What is the most likely cause of joint pain in a 40-year-old man with a history of gout and psoriasis, who is on allopurinol but has no improvement in his joint pain?
A) Active pseudogout arthritis
B) Active gout arthritis
C) Psoriatic arthritis
D) Osteoarthritis
E) Rheumatoid arthritis

C) Psoriatic arthritis
Explanation: The patient's history of psoriasis and the presentation of recurrent joint pain affecting multiple joints suggest that psoriatic arthritis is the most likely cause of his joint pain, despite being on allopurinol for gout.

p.9
Pulmonary Nodule Evaluation

What is the most appropriate next diagnostic test for a patient with normal examination findings and no medications?
A) Sleep study
B) Spirometry
C) Chest CT scan
D) Bronchoscopy
E) MRI

B) Spirometry
Explanation: Given the patient's normal examination findings and the absence of respiratory symptoms, spirometry is the most appropriate next diagnostic test to assess lung function.

p.8
Asthma Exacerbation Management

What is the most appropriate IV emergency treatment for a patient with acute severe asthma who is in respiratory distress?
A) Magnesium sulfate
B) Aminophylline
C) Salbutamol
D) Adrenaline
E) Corticosteroids

A) Magnesium sulfate
Explanation: Magnesium sulfate is the most appropriate IV emergency treatment for acute severe asthma, as it helps to relax bronchial smooth muscle and improve airflow.

p.6
Asthma Exacerbation Management

For a 24-year-old woman with frequent asthma exacerbations despite using salbutamol and beclometasone, what is the most appropriate next step in management?
A) Switch beclometasone to fluticasone
B) Start to take the salbutamol regularly
C) Increase the dose of beclometasone
D) Add a long-acting B2-agonist
E) Refer to a specialist

A) Switch beclometasone to fluticasone
Explanation: Switching to a more potent inhaled corticosteroid like fluticasone may help better control her asthma symptoms and reduce the frequency of exacerbations.

p.7
COPD Management and Treatment

What is the most appropriate next step in the management of a 63-year-old woman with COPD experiencing frequent exacerbations?
A) Salmeterol inhaler
B) Betamethasone inhaler
C) Long-term oxygen therapy
D) Combined salmeterol + fluticasone inhaler
E) Increase tiotropium dosage

D) Combined salmeterol + fluticasone inhaler
Explanation: For a patient with COPD experiencing frequent exacerbations, the addition of a combined inhaler containing a long-acting beta-agonist (salmeterol) and a corticosteroid (fluticasone) is recommended to improve control and reduce exacerbations.

Study Smarter, Not Harder
Study Smarter, Not Harder