Pulmonology 1: The Audio PANCE and PANRE Podcast Topic Specific Review Episode 29

Welcome to episode 29 of the FREE Audio PANCE and PANRE Physician Assistant Board Review Podcast.

Over the next few episodes, I will be covering topic specific PANCE and PANRE review from the Academy course content following the NCCPA content blueprint.

This week we will be covering 10 topic specific Pulmonology board review questions.

Below you will find an interactive exam to complement the podcast.

I hope you enjoy this free audio component to the examination portion of this site. The full pulmonology review includes over 142 pulmonology specific questions and is available to all members of the PANCE and PANRE Academy.

You can download and listen to past FREE episodes here, on iTunes or Stitcher Radio.
You can listen to the latest episode, take an interactive quiz and download your results below.

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Pulmonology PANCE and PANRE Podcast Quiz

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Question 1

A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient?

A	spoken "ee" heard as "ay"
B	hyperresonant percussion note Hint: Consolidation from bacterial pneumonia causes findings of dullness to percussion, late inspiratory crackles and bronchial breath sounds over the involved area.
C	wheezes over the involved area Hint: See answer for explanation.
D	vesicular breath sounds over involved area Hint: Consolidation from bacterial pneumonia causes bronchial breath sounds over the involved area.

Question 1 Explanation:

This patient most likely has a bacterial pneumonia with consolidation, which would produce egophony, where a spoken "ee" is heard as "ay."

Question 2

A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding?

A	stridor
B	aphonia Hint: Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.
C	inability to cough Hint: Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.
D	progressive cyanosis Hint: Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.

Question 2 Explanation:

An inspiratory wheeze is called stridor, which indicates a partial obstruction of the trachea or larynx.

Question 3

On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause?

A	asthma Hint: Asthma is characterized by decreased tactile fremitus, but would have resonant to hyperresonant percussion, not dullness.
B	consolidation Hint: Consolidation from pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus.
C	pneumothorax Hint: pneumothorax is characterized by decreased to absent tactile fremitus, but would have a hyperresonant percussion note, not dullness.
D	pleural effusion

Question 3 Explanation:

A decreased tactile fremitus and dullness to percussion would be found in a pleural effusion. No answers yet

Question 4

Which of the following is essential to make a diagnosis of cystic fibrosis?

A	Positive family history Hint: Cystic fibrosis is a genetic disease, but a positive family history in and of itself is not enough to diagnose the condition.
B	Elevated sweat chloride
C	Recurrent respiratory infections Hint: While recurrent respiratory infections are a classic presentation of cystic fibrosis, the diagnosis relies on confirmation.
D	Elevated trypsinogen levels Hint: Trypsinogen levels are used as a neonatal screening test and if elevated should be followed by more definitive testing to confirm the diagnosis.

Question 4 Explanation:

The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test or demonstration of a genotype consistent with cystic fibrosis.

Question 5

An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. Which of the following is the most appropriate interpretation of this test result?

A	positive
B	negative Hint: See answer for explanation
C	active infection Hint: A positive PPD identifies patients that have been infected with Mycobacterium tuberculosis, but does not indicate whether the disease is currently active or inactive.
D	falsely negative Hint: See answer for explanation

Question 5 Explanation:

A reaction size of greater than or equal to 5 mm in a HIV positive patient is considered a positive tuberculin skin test reaction. CDC PPD Interpretation Guidelines

Question 6

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment?

A	chest x-ray Hint: A chest x-ray should be ordered in an asthmatic patient only if you are concerned about the presence of pneumonia or pneumothorax, neither of which is supported by the H&P findings noted above.
B	sputum gram stain Hint: A sputum gram stain is performed in patients who you suspect have an infectious process, such as pneumonia.
C	peak flow
D	ventilation - perfusion scan Hint: A ventilation-perfusion scan (V/Q scan) is indicated in cases of suspected pulmonary embolism. The patient above does not have any risk factors that would lead you to suspect such a diagnosis.

Question 6 Explanation:

A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.

Question 7

A patient presents with a history of progressive worsening of dyspnea over the past several years. He gives a history of having worked as a ship builder for over 50 years. He denies any alcohol or tobacco use. On examination you note clubbing and inspiratory crackles. Which of the following chest x-ray findings support your suspected diagnosis?

A	hyperinflation and flat diaphragms Hint: Chest x-ray findings of hyperinflation and flat diaphragms suggest long-standing chronic obstructive lung disease.
B	interstitial fibrosis and pleural thickening
C	cavitary lesions involving the upper lobes Hint: Chest x-ray findings of cavitary lesions involving the upper lobes suggest pulmonary tuberculosis.
D	"eggshell" calcification of hilar lymph nodes Hint: Chest x-ray findings of "eggshell" calcification of hilar lymph nodes strongly supports the diagnosis of silicosis. It occurs in workers from mines, foundries, sandblasting, and glass manufacturing.

Question 7 Explanation:

This patient most likely has asbestosis, which is supported by his occupation as a ship builder and clinical presentation as noted above. Some occupations are associated with an elevated risk of asbestos exposure. Historically, naval shipyard workers are among the most frequently exposed. It is likely that workers who served between World War II and the Korean War came in contact with dangerous levels of asbestos, increasing their chances of developing diseases like asbestos-related lung cancer and mesothelioma. Chest x-ray findings include interstitial fibrosis, pleural thickening and calcified pleural plaques on the diaphragm or lateral chest wall.

Question 8

You are called to the nursery to see a male infant, born by uncomplicated vaginal delivery. He weighs 2,600 grams and has one deep crease on the anterior third of each foot. Respirations are 88 breaths/minute with expiratory grunting and intercostals retractions. He is cyanotic on room air and becomes pink when placed in 60% oxygen. Chest x-ray shows atelectasis with air bronchograms. Which of the following is the most likely diagnosis?

A	neonatal pneumonia Hint: While tachypnea, grunting, retractions and cyanosis may be signs of neonatal pneumonia, they are primarily late findings of progressive respiratory distress and would not be seen immediately at the time of delivery. A chest x-ray in pneumonia would also most commonly reveal an infiltrate or effusion.
B	congenital heart disease Hint: While congenital heart disease may present with cyanosis, the chest x-ray will reveal a cardiac abnormality, such as cardiomegaly.
C	hyaline membrane disease
D	chronic lung disease of prematurity Hint: Chronic lung disease of prematurity is a complication in about 20% of infants with hyaline membrane disease. It is defined as respiratory symptoms, oxygen requirement and chest x-ray abnormalities at 1 month of age so it cannot be diagnosed at this time in this newborn.

Question 8 Explanation:

Hyaline membrane disease is the most common cause of respiratory distress in the premature infant. The infant typically presents with tachypnea, cyanosis and expiratory grunting. A chest x-ray reveals hypoexpansion and air bronchograms.

Question 9

A 15 year-old male presents with a 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. Examination is unremarkable except for a few scattered rhonchi and rales upon auscultation of the chest. The chest x-ray reveals interstitial infiltrates and a cold agglutinin titer was negative. Which of the following is the most likely diagnosis?

A	acute bronchitis Hint: While the patient's clinical symptoms of dry cough and rhonchi support this diagnosis, the chest x-ray would be normal or only show a mild increase in bronchovascular markings, not infiltrates.
B	viral pneumonia
C	mycoplasma pneumonia Hint: While the gradual onset of symptoms suggest mycoplasma, the negative cold agglutinin titer makes this less likely.
D	pneumococcal pneumonia Hint: In older children the signs and symptoms of pneumococcal pneumonia are similar to an adult and consist of an abrupt onset of cough, fever and chills. The chest x-ray would reveal a lobar consolidation, not interstitial, picture.

Question 9 Explanation:

The patient's clinical symptoms as well as chest x-ray findings and negative cold agglutinin titer are most consistent with viral pneumonia. Cold agglutinin would likely be positive in a patient with mycoplasma pneumonia.

Question 10

A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals tachycardia. Which of the following is the most likely diagnosis?

A	atelectasis Hint: Small atelectasis is commonly asymptomatic, while large atelectasis may produce signs of dyspnea and cough. Exam reveals absence of breath sounds in the area involved and dullness to percussion. A chest x-ray would reveal various findings dependent on the location of the atelectasis, but would not be normal.
B	pneumothorax Hint: While a pneumothorax commonly presents with pleuritic chest pain and dyspnea, exam would reveal the presence of diminished breath sounds and hyperresonance on the involved side. A chest x-ray would reveal presence of a pleural line on the expiratory chest x-ray.
C	pulmonary embolism
D	myocardial infarction Hint: While a myocardial infarction usually presents with dyspnea, the chest pain is not usually pleuritic in nature. An EKG would commonly reveal ST segment changes, which would be consistent with ischemia or infarct.

Question 10 Explanation:

Risk factors for pulmonary embolism include advanced age, surgery and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal.

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