Family Medicine Pulmonary Clinical Vignettes

Listen to the podcast for why each multiple choice answer is right or wrong!

1. A 21 YO F who is taking OCPs presents to the ED with increasing SOB starting 4 hours ago. On PE she’s tachycardic and has tachypnea at 23 breaths a minute. Her BP is 120/80. She has wheezing to all lung fields and appears to be in moderate distress. Both calves are mildly edematous and somewhat tender. What will you do next?
A. CT chest  
B. Chest x-ray 
C. Ventilation to perfusion scan 
D. Pulmonary arteriography 
E. MRI chest

2. A 33 YO M presents for an evaluation of a chronic cough for the past 6 months. He does not smoke and does not report any seasonal allergies. He denies any systemic complaints such as fever or weight loss, and does not have any symptoms of heartburn or regurgitation or runny nose. He does not take any medications. Lungs are clear to auscultation and a chest x-ray shows no acute disease. He reports having tried bronchodilators and Claritin recently with no symptomatic improvement. What is the next step?
A. A trial of a proton pump inhibitor 
B. Pulmonary function tests to r/o COPD
C. 24-hour pH monitoring
D. Start z-pack for subclinical URI
E. Methacholine inhalation test

3. An 18-year-old F presents complaining of a very sore throat, swollen lymph nodes in her neck, fever, and general malaise for the past 2 days. She’s febrile at 102.2°F, has enlarged exudative tonsils, tender cervical lymphadenopathy, rapid strep screen is negative. What additional PE findings will you most likely find? 
A. Increased monocytes on white cell differential 
B. Enlarged spleen
C. IgA antibodies for Epstein-Barr virus
D. Decreased atypical lymphocytes on white blood cell differential

1. D. Pulmonary arteriography
2. A. A trial of a proton pump inhibitor
3. B. Enlarged spleen

Wells' Criteria for Pulmonary Embolism: 

PERC Rule for Pulmonary Embolism: 

Lung sounds:

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