FM Board Review Questions

Lung infections

Academic Committee
1. You see a 67-year-old woman in the
emergency department. She reports 2 days of
fever and productive cough. The physical
examination results reveal rales in the right
lower lobe of the lung and the white blood cell
count is elevated. You obtain chest x-rays,
which show no infiltrates. Based on current
practice guidelines, which one of the following is
the recommended approach to antibiotic therapy
for this patient?
A. Compute a CURB-65 score and start
antibiotics if the score is greater than 2.
B. Obtain a computed tomography (CT) scan of
the chest and treat with antibiotics if the CT
scan reveals pneumonia.
C. Repeat the chest x-ray in the morning and
start antibiotics if pneumonia is revealed on the
repeat x-ray results.
D. Start antibiotics.
E. Treat symptoms without antibiotics.
The correct answer is D.
Lack of an infiltrate on chest x-ray should not prevent a
presumptive diagnosis of pneumonia or treatment
initiation if clinical suspicion of pneumonia is high.
Current guidelines from the Infectious Diseases Society
of America and the American Thoracic Society state
that although a chest x-ray should be obtained in all
patients with suspected pneumonia, a negative chest
x-ray result should not preclude treatment initiation for
patients with symptoms that are consistent with
community-acquired pneumonia.
Confusion of new onset (defined as an AMTS of 8 or less)
Blood Urea nitrogen >19 mg/dL
Respiratory rate >30 breaths per minute
Blood pressure<90 mmHg systolic or diastolic <60
mmHg
Age 65 or older
0-1 Points: Low risk
2-5 Points: Higher risk

CURB-65 Pneumonia Severity Score

2. You are evaluating an otherwise healthy 72-year-old man.
He has cough and fever, but is alert and oriented. He has
never smoked cigarettes. The pulse is 95 beats/min,
respiratory rate is 23 breaths/min, and the blood pressure
level is 146/84 mm Hg. Pulse oximetry on room air shows
an oxygen saturation level of 92%. Lung examination
results reveal rales and rhonchi in the posterior left lower
lung. You suspect community-acquired pneumonia and
obtain a chest x-ray, which shows an infiltrate. Results of
basic laboratory tests show a white blood cell count of
11,000 mcL with 9,000 neutrophils, normal electrolyte
levels, creatinine level of 0.9 mg/dL, and blood urea
nitrogen level of 18 mg/dL. Which one of the following is
the recommended approach to management of this
patient?
A. Admit to general medical ward for intravenous
antibiotics.
B. Admit to general medical ward and delay antibiotics
pending blood cultures.
C. Admit to intensive care unit (ICU) for intravenous
antibiotics.
D. Admit to ICU for likely intubation and mechanical
ventilation.
E. Provide outpatient therapy with oral antibiotics,
assuming home care and followup are adequate.
The correct answer is E.
Outpatient therapy with oral antibiotics is the appropriate
management. This patient has a CURB-65 score of 1
(0 points for new-onset confusion, 0 points for blood
urea nitrogen of 20 mg/dL or greater, 0 points for
respiratory rate of 30 or more breaths/min, 0 points for
blood pressure level below 90/60 mm Hg, and 1 point
for 65 years or older). Patients with a CURB-65 score
of 0 or 1 can be treated with outpatient antibiotics if
home care and followup are adequate.
3. You have just diagnosed community-acquired
pneumonia in a 56-year-old man with type 2
diabetes. His condition and CURB-65 score
indicate that he is a candidate for outpatient
therapy. Assuming he has no allergies to drugs,
which one of the following antibiotics is most
appropriate for this patient?
A. Fluoroquinolone.
B. High-dose amoxicillin.
C. Macrolide.
D. Tetracycline.
E. Third-generation cephalosporin.
The correct answer is A.
For outpatient treatment of community-acquired
pneumonia in a patient with comorbidities such
as diabetes, the recommended treatment is a
respiratory fluoroquinolone.
4. You are providing care for an HIV-negative 19-
year-old man who recently moved to the United
States from South Africa, the country with the
highest prevalence of tuberculosis in the world.
You perform a tuberculin skin test (TST), and 48
hours later there is an 8 mm area of induration.
Which one of the following is the appropriate
response to this patient's TST result?
A. Nothing further is needed because the TST
result is negative.
B. Obtain a chest x-ray, and if results are
negative, prescribe isoniazid for 6 months.
C. Obtain a chest x-ray, and if results are
negative, prescribe isoniazid for 9 months.
D. Order a QuantiFERON TB gold test to confirm
the diagnosis.
The correct answer is A.
Nothing further is needed, as the tuberculin skin
test (TST) result is negative. An HIV-negative
individual who immigrates to the United States
from a country with a high prevalence of
tuberculosis is considered to be at moderate
risk. Such individuals must exhibit an induration
area of 10 mm or greater for TST results to be
considered positive.
5. Which one of the following is an advantage of
the enzyme-linked immunosorbent assay
QuantiFERON (QFT-G) TB gold test over the
standard tuberculin skin test (TST)?
A. It can distinguish active tuberculosis (TB) from
latent TB infection.
B. It can predict whether patients with latent TB
infection are likely to progress to active disease.
C. It is less expensive than TST.
D. It is much more sensitive than TST.
E. BCG vaccine does not cause a positive QFT-G
test result.
The correct answer is E.
Test results from the QuantiFERON TB gold
(QFT-G) test are specific to Mycobacterium
tuberculosis infection. Although BCG vaccine
can cause a positive result using standard
tuberculin skin testing, BCG vaccine does not
cause a positive QFT-G test result.