A 23-year-old man presents with coughing up blood and sputum. He gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is worse when lying down and in the morning. On physical examination, he appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is sometimes seen in this condition?
Kartagener’s syndrome consists of situs inversus (with dextrocardia), bronchiectasis, and nasal polyps. The bronchiectasis results from impaired ciliary function.
A 27-year-old man presents with chest pain and feeling unwell. He describes cough with blood-tinged sputum, chills, and fever of 2 days’ duration. Physical findings reveal dullness and moist rales in the left lower chest. His CXR is shown in Fig. 12–2. Which of the following is the most likely diagnosis?
The diagnosis is pneumonia. There is consolidation of the left lower lobe. The increased density, presence of air bronchogram, and the silhouetting of the left diaphragm point to a parenchymal lesion. Pneumococcal infection, as in this patient, is still the most common etiology, although other bacterial infections such as Klebsiella, Streptococcus, or, Staphylococcus is often encountered. Viral and arthropod-borne diseases are also seen.
A 40-year-old man is seen for an insurance assessment. He has no past medical history and feels well. His compete physical examination is normal. His biochemistry, complete blood count (CBC), ECG, and urinalysis are also normal. His CXR is abnormal and presented in Fig. 12–3. Which of the following is the most likely diagnosis?
There is a calcified nodule in the left apex. Obviously, a calcified tuberculous granuloma is the most common lesion. This may be from reinfection tuberculosis, where its preference for the apicoposterior segment is well-known. It is also possible that it may be a calcified Ghon’s lesion.
A 21-year-old man has a nonproductive cough, shortness of breath, and chest pain, which changes with breathing. He also has pain in the left arm. On examination, there is tenderness over the left shoulder, heart sounds are normal, and the lungs are clear. CXR reveals a lytic lesion in the left humerus and reticulonodular opacities in the upper and middles lobes (Fig. 12–4). The eosinophil count is normal. Which of the following is the most appropriate initial diagnostic test?
Primary pulmonary Langerhans cell histiocytosis (PLCH), also called eosinophilic granuloma of the lung, pulmonary Langerhans cell granulomatosis, and pulmonary histiocytosis X, is an uncommon interstitial lung disease that primarily affects young adults. There is a coarse, reticular pattern in the whole lung, somewhat more prominent in the upper lobes, suggesting a honeycomb appearance. It is the density here that is abnormal and not the lucency. The next most appropriate test would be a better definition of the lung findings with a high-resolution CT scan. The other more invasive investigations may be more appropriate after the CT.
The pulmonary function studies shown in Table 12–1 are of a 65-year-old man with severe dyspnea and cough. Which of the following is the most likely diagnosis?
Because of the maintained increase in minute volume and the maintenance of arterial PaO 2, patients with emphysema are referred to as pink puffers. The relatively high PaO2 and relatively low hemoglobin, as compared to chronic bronchitis, make cyanosis unusual in emphysema.
A 33-year-old woman, otherwise perfectly well, presents with recurrent episodes of hemoptysis. She has no fever, weight loss, cough, or sputum production. Her physical examination is entirely normal. Her CXR, biochemisty, CBC, and coagulation profile are also normal. Which of the following is the most appropriate initial diagnostic test?
This history suggests a benign bronchial adenoma. These are usually centrally located on CXR. The most appropriate next test would be a lung CT to demonstrate a lesion. The other tests are invasive and/or not appropriate for identifying the source of bleeding.
A 34-year-old woman is complaining of progressive and worsening shortness of breath. Her symptoms first started 3 years ago, and she now gets dyspneic and fatigued while doing her activities of daily living. Her past medical history is not significant and she not taking any medications. Physical examination reveals increased JVP and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and right-sided S3 and S 4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests are normal. Which of the following is the most likely diagnosis?
This presentation is characteristic of primary pulmonary hypertension. Pulmonary veno-occlusive disease is much less common. The predominant pathology, plexogenic arteriopathy, is characterized by medial hypertrophy associated with laminar intimal fibrosis and plexiform lesions. The thrombotic arteriopathy is characterized by eccentric intimal fibrosis with medial hypertrophy, fibroelastic intimal pads in the arteries and arterioles, and evidence of old recanalized thrombi. There is a female predominance, and the third or fourth decade is the most common age at presentation. By the time of diagnosis, the pulmonary hypertension is usually severe.
An 83-year-old man with Parkinson’s disease presents with low-grade fever and cough for several weeks. Lately, he has been experiencing more rigidity and difficulty with his walking. He is on a levodopa/carbidopa combination for treatment for the past 5 years. On examination, his gait is shuffling and slow. He has a tremor in his left hand at rest, and there is cogwheel rigidity of the forearm. There are crackles in the left lower lung field. CXR reveals a lung abscess in the left lower lobe. Which of the following is the most likely bacteriologic diagnosis for the lung abscess?
Most lung abscesses and all anaerobic abscesses involve the normal flora of the oropharynx. Septic embolic usually contain S. aureus. Factors that predispose to Gramnegative colonization of the oropharynx include hospitalization, debility, severe underlying diseases, alcoholism, diabetes, and advanced age. Impaired consciousness, neurologic disease, swallowing disorders, and nasogastric or endotracheal tubes all increase the likelihood of aspiration.
A 28-year-old African American woman presents with mild dyspnea on exertion. She reports no coughing, sputum production, or wheezing symptoms, but has noticed a red tender rash on her shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy. Her pulmonary function tests reveal a mild restrictive pattern. Which of the following tests will most likely make a definitive diagnosis?
Transbronchial biopsy, looking for noncaseating granulomas, is required to confirm the diagnosis of sarcoidosis in someone with the right clinical context. The other investigations are supportive of a diagnosis of sarcoidosis but not diagnostic of it, since many other conditions can cause an elevated ACE level or positive gallium scan.
A 69-year-old woman has recently returned on an overnight flight from Europe. She now complains of vague chest discomfort and shortness of breath. On examination, she is comfortable, blood pressure 130/80 mm Hg, pulse 90/min, respirations 18/min, and oxygen saturation 97%. Her heart and lungs are normal on auscultation, and there is no edema or leg tenderness on palpation. A quantitative (ELISA) D-dimer assay is positive. Which of the following statements regarding the D-dimer assay is correct?
A negative D-dimer level rules out thromboembolic disease in patients with intermediate or low pretest probability for DVT/PE. When done by the enzyme-linked immunosorbent assay (ELISA) technique, it is relatively sensitive (i.e., a negative result helps rule out DVT or PE). When done by the latex agglutination method (qualitative assay), it is neither specific nor sensitive enough to guide therapy.
A 24-year-old African American woman presents with mild dyspnea on exertion, fever, and a rash on her legs. Her symptoms have come on gradually and she reports no pleuritic chest pain, hemoptysis or sputum production. She has no significant past medical history, smokes 10 cigarettes/day and is not taking any medications. Physical examination reveals generalized lymphadenopathy and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy and reticulonodular changes in both lungs. She has a restrictive lung disease pattern on pulmonary function testing. Which of the following is the most likely diagnosis?
Sarcoidosis is the most likely diagnosis. Granulomatous inflammatory changes of sarcoidosis may occur in almost any organ. About 90% of patients with sarcoid will have an abnormal CXR at some point.
A 30-year-old man presents with coughing up blood and sputum. There is no associated dyspnea, fever, or pleuritic chest pain. His past medical history is significant for recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is usually worse when lying down and in the morning. He quit smoking 5 years ago and started when he was 18 years old. On physical examination, he appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is the most likely diagnosis?
Bronchiectasis is defined as a permanent abnormal dilatation of large bronchi due to destruction of the wall. It is a consequence of inflammation, usually an infection. Other causes include toxins or immune response. Persistent cough and purulent sputum production are the hallmark symptoms.
A 64-year-old woman is admitted to the hospital after the acute onset of left-sided weakness. She has had a large right cerebral stroke and is confined to bed. On the fifth hospital day, her oxygen saturation is noted to be reduced to 90% on room air. She feels fine, the neurologic weakness is unchanged, blood pressure is 130/90 mm Hg, and pulse 80/min. Examination of the chest reveals decreased fremitus, dullness to percussion, and absent breath sounds in the left lower lung. There is also a tracheal shift towards the left side.
A 72-year-old man with COPD develops acute shortness of breath and presents to the hospital. He appears uncomfortable: blood pressure is 120/90 mm Hg, pulse 100/min, oxygen saturation 85% on room air. On examination of the chest, there is absent fremitus, absent breath sounds, and hyperresonant percussion of the right lung. The trachea is shifted to the left.
A 45-year-old woman comes to the emergency department because of increased shortness of breath. Examination of the chest reveals decreased fremitus, low diaphragms, and prolonged expiration phase.
A 24-year old woman notices increasing shortness of breath after recent treatment for right lower lobe pneumonia. She has no fever, cough, or sputum production. On examination, the pertinent findings are decreased fremitus, dullness on percussion, and absent breath sounds of the right lower lung. In addition, the trachea has shifted to the left.
A 61-year-old man is not feeling well because of shortness of breath and left-sided chest pains that increase with breathing. His examination reveals increased fremitus, dull to percussion, and bronchophony on the left side. His heart sounds are normal.
A 66-year-old man with a 40-pack-per-year history of smoking is investigated for hemoptysis. CXR reveals a central 3-cm mass near the left bronchus. His serum biochemistry is abnormal for elevated calcium, but there is no boney metastasis on the bone scan. Biopsy of the mass is positive for a type of lung cancer associated with paraneoplastic hypercalcemia.
Hypercalcemia may be due to metastatic destruction of bone, ectopic formation of parathyroid hormone, or formation of other osteolytic substances.
A 55-year-old woman presents with symptoms of fever, chills, and colored sputum production. She is a former 40-pack-per-year smoker. Her CXR is abnormal for a 2-cm right hilar mass and right lower lobe infiltrate. She is started on antibiotics and a biopsy of the hilar mass is positive for a type of lung cancer responsive to cytotoxic chemotherapy.
Combination chemotherapy has produced promising results in lung cancer, particularly of the small cell anaplastic type. Alkylating agents and anthracyclines are active among other agents.
A 58-year-old woman has a witnessed generalized seizure. She has no prior history of seizures, and her only new symptoms are weight loss and anorexia. She looks unwell and cachectic, and the remaining examination is normal. Her serum sodium is 112 mEq/L, osmolality 260 mOsm/kg, and urine osmolality 420 mOsm/kg. Her CXR is abnormal for a large left hilar mass. She has a 30-pack-peryear history of smoking. Biopsy of the mass is positive for a lung cancer most commonly associated with ectopic endocrine syndromes.
The most commonly encountered syndromes are SIADH, Cushing’s syndrome, and gynecomastia.
A 58-year-old man comes to the emergency department because of left shoulder pain radiating down his left arm. His only risk factor for cardiac disease is hypertension and a 30-packper-year smoking history. On examination, his blood pressure is 150/90 mm Hg in both arms, pulse 100/min, and heart sounds are normal. He also has ptosis of his left eyelid and a left pupil that is smaller than the right. ECG is normal, and a CXR shows a large left apical mass with 1st and 2nd rib destruction. A biopsy of the mass is consistent with lung cancer most commonly associated with Pancoast’s syndrome.
Pancoast’s syndrome (or superior sulcus syndrome) is found in apical lung tumors, usually epidermoid. Shoulder pain secondary to involvement of the eighth cervical and first and second thoracic nerves is characteristic. Horner syndrome frequently coexists.
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