Upper Respiratory Infections

ANSWER: B

This patient has seasonal allergic rhinitis. A joint guideline statement from the American Academy of

Allergy, Asthma, and Immunology/American College of Allergy, Asthma, and Immunology Joint Task

Force on Practice Parameters recommends that monotherapy with intranasal corticosteroids should be

prescribed initially in patients 12 years of age rather than combined treatment with oral antihistamines

because data has not shown an additional benefit to adding the antihistamine. Higher patient adherence and

tolerance and fewer side effects were seen with the monotherapy regimen. High-quality evidence indicates

that intranasal corticosteroids were more effective than leukotriene receptor antagonists. Inhaled

corticosteroids and triamcinolone injections are not appropriate first-line options for the treatment of

seasonal allergic rhinitis.

Ref: Hauk L: Treatment of seasonal allergic rhinitis: A guideline from the AAAAI/ACAAI Joint Task Force on Practice

Parameters. Am Fam Physician 2018;97(11):756-757.

ANSWER: A

This patient has bacterial tracheitis, which includes a high fever, barking cough, respiratory distress, and

rapid deterioration. Epiglottitis has an acute onset of dysphagia, drooling, and high fever, along with

anxiety and a muffled cough, and typically occurs in children 3–10 years of age. Foreign body aspiration

is associated with an acute onset of choking and drooling. A peritonsillar abscess would cause a sore

throat, fever, and “hot potato” voice.

Ref: Kuo CY, Parikh SR: Bacterial tracheitis. Pediatrics in Review 2014;35(11):497-499. 2) Smith DK, McDermott AJ, Sullivan

JF: Croup: Diagnosis and management. Am Fam Physician 2018;97(9):575-580.

ANSWER: D

Upper respiratory tract infections are the most common acute illness in the United States. Symptoms are

self-limited and can include nasal congestion, rhinorrhea, sore throat, cough, general malaise, and a

low-grade fever. According to a Cochrane review of 10 trials without a meta-analysis, antitussives and

expectorants are no more effective than placebo for cough. Intranasal ipratropium is the only medication

that improves persistent cough related to upper respiratory infection in adults. Intranasal antibiotics,

antihistamines, corticosteroids, and saline would not improve this patient’s cough.

Ref: DeGeorge KC, Ring DJ, Dalrymple SN: Treatment of the common cold. Am Fam Physician 2019;100(5):281-289.

ANSWER: D

Of the choices listed, an adverse effect of medication, specifically lisinopril, is the most likely cause of this

patient’s persistent cough. ACE inhibitors are among the most common causes of chronic cough, with an

estimated incidence of 5%–35% of patients. The onset of an ACE inhibitor–induced cough may occur

within hours to months after the first dose. A proper evaluation of patients presenting with a chronic

cough, which is defined in adults as a persistent cough lasting >8 weeks, begins with a careful history,

with attention to smoking status, environmental exposures, and medication use. Identifying ACE inhibitor

use is particularly important for a patient with hypertension and diabetes mellitus presenting with a

persistent dry cough. If ACE inhibitor use is identified, consideration should be given to a trial of

medication elimination, which is the only way to determine if the medication is the cause. If so, the cough

should resolve within days, although resolution may take up to 3 months to occur.

Chronic lung disease, although a common cause of cough, would be less likely in a patient of this age with

symptoms only for the past several months, particularly without a smoking history or associated dyspnea.

Similarly, the absence of a tobacco history or alarm symptoms such as unintended weight loss or

hemoptysis, coupled with a normal chest radiograph, makes malignancy less likely. Infection is also less

likely, given the absence of constitutional symptoms coupled with a normal physical examination and

recent normal chest imaging. Psychogenic cough is a rare cause of cough in adults and children, and would

be much less likely in this situation.

Ref: Michaudet C, Malaty J: Chronic cough: Evaluation and management. Am Fam Physician 2017;96(9):575–580.

ANSWER: D

The U.S. Preventive Services Task Force and the American College of Chest Physicians support screening

for lung cancer with annual low-dose CT in patients 50–80 years of age who have a 20-pack-year smoking

history and who currently smoke or have smoked within the past 15 years. There is no evidence to support

an annual history and physical examination or annual chest radiography as screening tools for lung cancer.

Ref: Armstrong C: Lung cancer screening recommendations from the ACCP. Am Fam Physician 2018;98(11):688-689. 2)

Mazzone PJ, Silvestri GA, Patel S, et al: Screening for lung cancer: CHEST guideline and expert panel report. Chest

2018;153(4):954-985. 3) Final Recommendation Statement: Lung Cancer: Screening. US Preventive Services Task Force,

2021.

ANSWER: A

This patient has symptoms typical for respiratory syncytial virus (RSV) bronchiolitis. Since the patient

shows no signs of distress and is well hydrated, no specific treatment is necessary. Neither testing for RSV

nor obtaining a chest radiograph would change management, and therefore would not be indicated.

Albuterol is ineffective for the wheezing associated with RSV since the mechanism of wheezing is not due

to bronchospasm. Antibiotics are not indicated without evidence of a secondary bacterial infection.

Ref: Smith DK, Seales S, Budzik C: Respiratory syncytial virus bronchiolitis in children. Am Fam Physician 2017;95(2):94-99.

ANSWER: B

Obstructive sleep apnea (OSA) is the repetitive partial or complete collapse of the upper airway during

sleep, resulting in episodic apnea or hypopnea lasting at least 10 seconds. OSA is common and affects 17%

of women and 34% of men. Risk factors include increased BMI, male sex, postmenopausal state in

women, enlarged upper airway soft tissue, and craniofacial abnormalities. The most common presenting

symptom is excessive sleepiness; patients may also present with fatigue and lack of energy. Cough, leg

swelling, palpitations, and weight gain are not among the most common presenting symptoms of OSA.

OSA increases the incidence of heart failure, type 2 diabetes, hypertension, coronary heart disease, stroke,

atrial fibrillation, and death. OSA severity is quantified using the apnea-hypopnea index. The diagnostic

test of choice is laboratory-based polysomnography. Treatments include behavioral measures (alcohol

avoidance, weight loss, exercise, and not sleeping in the supine position), medical devices (CPAP, oral

devices), and surgery.

Ref: Gottlieb DK, Punjabi NM: Diagnosis and management of obstructive sleep apnea: A review. JAMA

2020;323(14):1389-1400.

ANSWER: B

This patient’s presentation is typical for idiopathic pulmonary fibrosis (IPF), a chronic and progressive

subtype of fibrotic interstitial lung disease (ILD) with an unknown cause, which affects older men more

than other individuals. Many patients who are ultimately diagnosed with ILD initially receive a diagnosis

of COPD or heart failure. Some patients experience dyspnea and dry cough up to 5 years before ILD is

recognized. Although IPF is associated with a high mortality rate, recent advances have been made in drug

therapies that slow the rate of disease progression, so early recognition and diagnosis of this condition in

the primary care setting is key to improving patient outcomes.

Nearly all patients with IPF experience chronic exertional dyspnea. Other common symptoms include

chronic nonproductive cough and fatigue. Bilateral “Velcro-like” crackles are nearly universal. Other

common examination findings include digital clubbing, acrocyanosis, and resting hypoxemia. Chest

radiographs are often normal or show nonspecific findings early in the disease course. Common findings

later in the disease include bilateral reticular infiltrates in the lower lung zones, hazy opacities, and low

inspiratory lung volumes.

Once ILD is suspected, further evaluation is indicated to determine a more specific diagnosis, as

management and prognosis differ by type. Of the options listed, only high-resolution chest CT has the

potential to provide a specific diagnosis of IPF, which usually has a characteristic pattern of bilateral

reticulation and honeycombing in the lung periphery and in the lower lobes termed usual interstitial

pneumonia. Spirometry usually shows a restrictive pattern, although it may be normal in early disease or

with comorbid emphysema. The presence of restrictive physiology is not specific to IPF but is seen more

generally with other forms of ILD as well. Polysomnography may identify an associated sleep disorder,

such as obstructive sleep apnea, but does not factor into making the diagnosis of IPF. Echocardiography

and right heart catheterization may help to identify associated pulmonary hypertension, although neither

would provide a specific diagnosis of IPF.

Ref: Lederer DJ, Martinez FJ: Idiopathic pulmonary fibrosis. N Engl J Med 2018;378(19):1811-1823. 2) Wijsenbeek M, Cottin

V: Spectrum of fibrotic lung diseases. N Engl J Med 2020;383(10):958-968.

Item 70

ANSWER: C

Family physicians are often required to manage dyspnea and evaluate common office spirometry results.

The American Thoracic Society recommends full pulmonary function testing when office spirometry

suggests a restrictive pattern, which is the case with this patient’s normal FEV1/FVC ratio and decreased

FVC. Full laboratory pulmonary function testing gives further information about gas exchange and lung

volumes, which allows a more definitive diagnosis.

The 6-minute walk test is used to evaluate treatment response for known cardiopulmonary disease.

Bronchoprovocation testing helps identify asthma triggered by allergens or exercise when office spirometry

is normal. Bronchoscopy is an invasive test that is not indicated at this point in the evaluation. A

ventilation-perfusion scan is not appropriate because pulmonary embolus is not strongly suspected.

Ref: Budhwar N, Syed Z: Chronic dyspnea: Diagnosis and evaluation. Am Fam Physician 2020;101(9):542-548. 2) Langan RC,

Goodbred AJ: Office spirometry: Indications and interpretation. Am Fam Physician 2020;101(6):362-368.

ANSWER: B

SARS-CoV-2 is a respiratory coronavirus that is responsible for COVID-19. Knowledge of the natural

history of the viral infection will inform testing strategies and many other aspects of counseling of patients.

The incubation period measures the time from exposure to symptom onset. The typical incubation period

for COVID-19 is approximately 4–5 days, though it can range from 1–14 days.

Ref: COVID-19: Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). Centers

for Disease Control and Prevention, updated 2021.

ANSWER: E

Opiates are the most effective agents for treating dyspnea and the resultant anxiety in patients with terminal

cancer. Higher levels of oxygen are indicated if the patient’s oxygen saturation is <92% and with caution

in patients with COPD so as not to suppress respiratory drive. Dexamethasone, hyoscyamine, and

lorazepam have a frequent role in patients such as this one, but morphine sulfate or a similar fast-acting

opiate is the drug of choice (SOR B).

Ref: Albert RH: End-of-life care: Managing common symptoms. Am Fam Physician 2017;95(6):356-361.

ANSWER: B

For patients with mild asthma, recent evidence has shown that an inhaled corticosteroid (ICS)/long-acting

β-agonist (LABA), such as budesonide/formoterol, as needed was as effective at preventing exacerbations

as a daily maintenance ICS plus a short-acting β-agonist (SABA) at one-fifth of the total corticosteroid

dose. In addition, it was more effective at preventing exacerbations than continued use of a SABA alone

as needed. A daily maintenance ICS inhaler plus either a LABA or a leukotriene receptor antagonist are

management strategies for persistent asthma.

Ref: Bateman ED, Reddel HK, O’Byrne PM, et al: As-needed budesonide-formoterol versus maintenance budesonide in mild

asthma. N Engl J Med 2018;378(20):1877-1887. 2) Beasley R, Holliday M, Reddel HK, et al: Controlled trial of

budesonide-formoterol as needed for mild asthma. N Engl J Med 2019;380(21):2020-2030. 3) Grad R, Ebell MH: Top

POEMS of 2018 consistent with the principles of the Choosing Wisely campaign. Am Fam Physician 2019;100(5):290-294.

ANSWER: A

The American Thoracic Society, Infectious Diseases Society of America, and CDC recommend testing for

tuberculosis with an interferon-gamma release assay (IGRA) rather than a tuberculin skin test (TST) in

individuals >5 years of age who have received the bacillus Calmette-Guérin (BCG) vaccine. Since BCG

immunization will not cause false positives with an IGRA but does with a TST, an IGRA is preferred.

IGRA also would be ideal when the likelihood of the patient returning for follow-up is low. In this case,

the patient has received the BCG vaccine and she is new to the office and may not return since there is not

an established primary care provider relationship, so a TST requiring a 48- to 72-hour follow-up visit may

not be a reliable testing method. Performing a nucleic acid amplification test or obtaining acid-fast bacilli

specimens would be premature as there is no indication of active tuberculosis infection at this time.

Ordering a chest radiograph for an asymptomatic child without a positive test is also premature and exposes

the child to unnecessary radiation.

Ref: Hauk L: Tuberculosis: Guidelines for diagnosis from the ATS, IDSA, and CDC. Am Fam Physician 2018;97(1):56-58.

ANSWER: C

Community-acquired pneumonia (CAP) is an infection of the lung parenchyma that is not acquired in a

hospital, long-term care facility, or other health care setting, and it is a significant cause of morbidity and

mortality in adults. This patient has CAP in the presence of a significant comorbidity (diabetes mellitus).

After CAP is diagnosed the first decision to make is whether hospitalization is needed. In all patients with

CAP, mortality and severity prediction scores should be used to determine inpatient versus outpatient care

(SOR A). This patient has a CURB-65 score of 1 (age 65 years), so she can be treated as an outpatient.

For outpatients with comorbidities, amoxicillin/clavulanate is a possible treatment option, but it should be

paired with a macrolide. Macrolides such as azithromycin are the treatment of choice for previously

healthy outpatients with no history of antibiotic use within the past 3 months. Azithromycin monotherapy,

amoxicillin plus metronidazole, azithromycin plus levofloxacin, or clindamycin plus doxycycline would

not be appropriate treatment strategies for this patient with a significant comorbidity.

Ref: Metlay JP, Waterer GW, Long AC, et al: Diagnosis and treatment of adults with community-acquired pneumonia. An

official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J

Respir Crit Care Med 2019;200(7):e45-e67.

ANSWER: C

In addition to the presence of relevant factors and chronic respiratory symptoms, a postbronchodilator

FEV1/FVC ratio <0.70 is required for the diagnosis of COPD. COPD is classified as mild (FEV1 >80%

of predicted), moderate (FEV1 50%–79% of predicted), severe (FEV1 30%–49% of predicted), or very

severe (FEV1 <30% of predicted). Further pulmonary function testing may support the diagnosis, but it

is not required. For instance, a high total lung capacity indicating hyperinflation, a high residual volume

indicating air trapping, and a low diffusing capacity for carbon monoxide indicating impaired gas exchange

all suggest emphysema.

Ref: Labaki WW, Rosenberg SR: Chronic obstructive pulmonary disease. Ann Intern Med 2020;173(3):ITC17-ITC32.

ANSWER: C

COPD is currently the third leading cause of death in the United States and is commonly treated by

primary care providers. In patients on monotherapy with a long-acting bronchodilator such as a long-acting

muscarinic agonist (LAMA) or long-acting -agonist (LABA) who have continued dyspnea, the Global

Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend escalating therapy to two

bronchodilators. This patient has persistent dyspnea and is being treated with a single agent, a LAMA, so

his regimen needs to be escalated to include a LABA such as salmeterol. Once the symptoms are stabilized,

treatment can be de-escalated to a single agent. For patients with frequent COPD exacerbations or with

a diagnosis of asthma and COPD, the guidelines recommend adding an inhaled corticosteroid (ICS) such

as fluticasone to a LABA, LAMA, or both. Triple therapy with a LABA, a LAMA, and an ICS is not

indicated at this time as the patient has not yet been treated with a combination of a LAMA and LABA and

has not had any recent exacerbations. The addition of azithromycin may be considered in patients who are

already on triple therapy with a LABA, a LAMA, and an ICS and still having exacerbations. Monotherapy

with an ICS is not indicated in COPD and has been shown to increase the risk of developing pneumonia.

Ref: Gentry S, Gentry B: Chronic obstructive pulmonary disease: Diagnosis and management. Am Fam Physician

2017;95(7):433-441. 2) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary

Disease. Global Initiative for Chronic Obstructive Lung Disease, 2019. 3) Nici L, Mammen MJ, Charbek E, et al:

Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical

practice guideline. Am J Respir Crit Care Med 2020;201(9):e56-e69.

ANSWER: A

Patients with acute bacterial sinusitis who do not improve while taking the usual dose of amoxicillin, who

have recently been treated with an antimicrobial (within the past 90 days), who have an illness that is

moderate or more severe, or who attend day care should be treated with high-dose amoxicillin/clavulanate

in two divided doses. Alternate therapies include cefdinir, cefuroxime, or cefpodoxime. A single dose of

ceftriaxone, 50 mg/kg daily, either intravenously or intramuscularly, can be used in children who are

vomiting. Once there is clinical improvement, usually within about 24 hours, an oral antibiotic can be

started. Cephalexin is not recommended for treating acute bacterial sinusitis because of inadequate

antimicrobial coverage of the major organisms. Clarithromycin is not recommended as empiric therapy

because of high rates of resistance in Streptococcus pneumoniae. The use of doxycycline is not appropriate

in children. Levofloxacin would be appropriate if the patient had a history of type I hypersensitivity to

penicillin.

Ref: DeMuri GP, Wald ER: Acute bacterial sinusitis in children. N Engl J Med 2012;367(12):1128-1134. 2) Chow AW,

Benninger MS, Brook I, et al: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin

Infect Dis 2012;54(8):e72-e112. 3) Kliegman RM, St Geme JW III, Blum NJ, et al (eds): Nelson Textbook of Pediatrics,

ed 21. Elsevier Saunders, 2020, pp 2188-2191.

ANSWER: C

Acute respiratory distress syndrome (ARDS) will often present similarly to pneumonia and heart failure

with dyspnea, hypoxemia, and tachypnea. ARDS typically does not respond to supplemental oxygen or

diuretic therapy. Patients decompensate quickly and usually require mechanical ventilation. Chest

radiographic findings include bilateral airspace opacities but not a localized infiltrate as with pneumonia,

venous congestion or cardiac enlargement as with heart failure, or a flattened diaphragm (associated with

COPD).

Ref: Saguil A, Fargo MV: Acute respiratory distress syndrome: Diagnosis and management. Am Fam Physician

2020;101(12):730-738.

ANSWER: B

Office spirometry can be very helpful in the development of a differential diagnosis. The differential can

be narrowed with the use of office spirometry, as many conditions create either an obstructive or restrictive

pattern. Of the options listed, only cystic fibrosis can cause an obstructive pattern. Other causes of an

obstructive pattern include asthma, COPD, α1-antitrypsin deficiency, and bronchiectasis, among others.

Common diseases or conditions causing restrictive patterns include adverse reactions to nitrofurantoin,

methotrexate, and amiodarone. Chest wall conditions such as kyphosis, scoliosis, and morbid obesity can

also cause restrictive patterns. Interstitial lung disease, including idiopathic pulmonary fibrosis,

sarcoidosis, and asbestosis, also causes a restrictive pattern (SOR A).

Ref: Langan RC, Goodbred AJ: Office spirometry: Indications and interpretation. Am Fam Physician 2020;101(6):362-368.

ANSWER: A

Clinicians should consider measuring the α 1-antitrypsin level in all symptomatic COPD patients with fixed

airflow obstruction, particularly with a COPD onset as early as the fifth decade of life; a family history

of α 1-antitrypsin deficiency; and emphysema, bronchiectasis, liver disease, or panniculitis in the absence

of a recognized risk factor. Identifying this condition is particularly important because current smokers

should be urged to quit, given that they are at high risk for accelerated lung function decline, and also to

consider intravenous pooled human α 1-antitrypsin, which has been shown to reduce declines in lung

function and lung density measured on chest CT. In this patient, testing for cystic fibrosis,

hemochromatosis, Williams syndrome, or Wilson’s disease would not be indicated.

Ref: Labaki WW, Rosenberg SR: Chronic obstructive pulmonary disease. Ann Intern Med 2020;173(3):ITC17-ITC32.

ANSWER: C

Most anaphylactic reactions occur outside of the hospital setting, and early treatment decreases both

hospitalizations and mortality. This patient presents with respiratory, dermatologic, cardiovascular, and

gastrointestinal symptoms, which are common in anaphylaxis. Tree nut and peanut allergies are risk factors

for severe reactions. Early treatment with intramuscular epinephrine and attention to airway, breathing,

and circulation are the first steps for treatment. Adjunct medications can be considered after epinephrine,

but antihistamines have an onset of action of 1 hour and corticosteroids have an onset of action of 6

hours. Albuterol may be considered as an adjunct but its use does not address the urgent need to resolve

anaphylaxis symptoms first.

Ref: Pflipsen MC, Vega Colon KM: Anaphylaxis recognition and management. Am Fam Physician 2020;102(6):355-362.

ANSWER: A

The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) guideline

recommends use of a validated clinical prediction rule, preferably the Pneumonia Severity Index (PSI),

to determine the need for hospitalization in adults diagnosed with community-acquired pneumonia (CAP)

(strong recommendation). The yield of blood cultures is around 2% (outpatients) to 9% (inpatients) in

adults with non-severe CAP. A sputum culture and a Gram stain of respiratory secretions are

recommended in patients classified as having severe CAP, or in those with strong risk factors for

methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa . Randomized trials have

failed to show a benefit for urinary antigen testing for Streptococcus pneumoniae and Legionella.

ATS/IDSA guidelines recommend empiric antibiotic therapy for adults with clinically suspected and

radiographically confirmed CAP regardless of the initial serum procalcitonin level (strong

recommendation). Coverage for MRSA is not recommended in patients without risk factors for MRSA

pneumonia.

Ref: Kaysin A, Viera AJ: Community-acquired pneumonia in adults: Diagnosis and management. Am Fam Physician

2016;94(9):698-706. 2) Metlay JP, Waterer GW, Long AC, et al: Diagnosis and treatment of adults with

community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious

Diseases Society of America. Am J Respir Crit Care Med 2019;200(7):e45-e67.

ANSWER: B

Pulmonary embolus is reliably diagnosed with CT pulmonary angiography (CTA), but there is now a

simple diagnostic algorithm to reduce the reliance on CTA. The simplified recommendations for ordering

CTA are a D-dimer 1000 ng/mL, or a D-dimer that is >500 ng/mL and hemoptysis, signs of deep vein

thrombosis, or a suspicion that pulmonary embolism is the most likely diagnosis.

A BNP level would be useful in detecting heart failure, and an EKG would be more helpful if ischemic

heart disease were suspected. Pulmonary arteriography is invasive and carries a higher risk. A

ventilation-perfusion scan has less risk but is not as accurate.

Ref: van der Hulle T, Cheung WY, Kooij S, et al: Simplified diagnostic management of suspected pulmonary embolism (the

YEARS study): A prospective, multicentre, cohort study. Lancet 2017;390(10091):289-297. 2) Slattengren AH, Prasad S,

Bury C, et al: PURL: A better approach to the diagnosis of PE. J Fam Pract 2019;68(6):286, 287, 295.

ANSWER: B

This patient is at risk for aspiration pneumonia due to his neurologic disease and impaired cough reflex.

A swallow evaluation is appropriate. A mechanical soft diet with thickened liquids is recommended rather

than pureed foods and thin liquids. Addressing oral hygiene has shown no clear benefit, and the use of

chlorhexidine mouthwashes is controversial due to the risk of toxicity if aspirated. The effect of swallowing

exercises requires more study at this time. Prophylactic antibiotic therapy can be considered in comatose

patients following emergency intubation but is not appropriate in this scenario. Antibiotic therapy is

appropriate for signs and symptoms of aspiration pneumonia with or without chest radiograph findings and

depending on illness severity. The effect of nasogastric tube placement in preventing aspiration is unclear.

Ref: Mandell LA, Niederman MS: Aspiration pneumonia. N Engl J Med 2019;380(7):651-663.

ANSWER: A

Based on the Westley Croup Score, this patient has mild croup. Corticosteroids should be used in the

treatment of croup regardless of the degree of severity. Dexamethasone is preferred because it can be given

in a single dose and administered either orally, parentally, or intravenously. Heliox is a helium and oxygen

mixture that theoretically decreases airflow resistance but there is no clear evidence to support its use at

this time. Humidified air inhalation has not been shown to have a clinical benefit in terms of croup scores

or hospital admissions. Nebulized epinephrine should be reserved for patients with moderate to severe

croup. Oxygen should be administered if there are signs of hypoxemia or severe respiratory distress.

Ref: Johnson DW: Croup. BMJ Clin Evid 2014;2014:0321. 2) Smith DK, McDermott AJ, Sullivan JF: Croup: Diagnosis and

management. Am Fam Physician 2018;97(9):575-580.

ANSWER: B

Antiviral medications are recommended for the treatment of influenza only within 48 hours of symptom

onset (SOR A). However, in high-risk patient populations and in severe cases of disease, antivirals should

be provided regardless of the duration of symptoms (SOR B). According to the CDC, oseltamivir remains

the drug of choice for the treatment of influenza during pregnancy because it has good safety data.

Baloxavir marboxil is indicated for patients >12 years of age but should be avoided during pregnancy.

There is less safety data for peramivir and zanamivir.

Ref: Cayley WE Jr: Vaccines for preventing influenza in healthy children, healthy adults, and older adults. Am Fam Physician

2019;100(3):143-146. 2) Armstrong C: Influenza vaccination: Updated recommendations from ACIP. Am Fam Physician

2019;100(8):505-507. 3) Gaitonde DY, Moore FC, Morgan MK: Influenza: Diagnosis and treatment. Am Fam Physician

2019;100(12):751-758. 4) Erlich DR: Baloxavir marboxil (Xofluza) for influenza. Am Fam Physician

2019;100(12):776-777. 5) Influenza (flu): Recommendations for obstetric health care providers related to use of antiviral

medications in the treatment and prevention of influenza. Centers for Disease Control and Prevention, reviewed 2020.

ANSWER: D

This patient has signs and symptoms of pulmonary hypertension. Diagnostic tests, particularly

echocardiography, can confirm this diagnosis. It is important to determine the etiology since addressing

the underlying condition is the preferred treatment for most cases of non-severe pulmonary hypertension.

Left heart disease, including both preserved and reduced systolic function, is the most common cause of

pulmonary hypertension, while chronic thromboembolism, COPD, and sleep-disordered breathing are

other possible but less common causes. Idiopathic pulmonary arterial hypertension is a rare cause.

Ref: Rich JD, Rich S: Clinical diagnosis of pulmonary hypertension. Circulation 2014;130(20):1820-1830. 2) Rakel RE, Rakel

DP (eds): Textbook of Family Medicine, ed 9. Elsevier Saunders, 2016, p 264.

ANSWER: C

Inhaling airborne spores of the fungus Coccidioides immitis or Coccidioides posadasii causes primary

pulmonary coccidioidomycosis (valley fever). Traveling to or residing in areas endemic for Coccidioides

is required for the diagnosis, since no zoonotic contagion or person-to-person contagion occurs.

Coccidioides has been identified as the cause of 17%–29% of all cases of community-acquired pneumonia

in endemic areas. This patient traveled to an endemic area and engaged in dusty outdoor activities, which

puts him at a higher risk for infection, and he presents with common symptoms of primary pulmonary

coccidioidomycosis. A chest radiograph often appears normal on the initial evaluation. Eosinophilia should

raise suspicion for coccidioidomycosis but laboratory detection of Coccidioides is required for a definitive

diagnosis. In symptomatic patients who have a clinically significant disease or an elevated risk of

dissemination, antifungals are recommended for treatment. Although Aspergillus, Blastomyces,

Cryptococcus, and Histoplasma may cause similar symptoms, the test findings and travel history make

Coccidioides the most likely pathogen in this case.

Ref: Herrick KR, Trondle ME, Febles TT: Coccidioidomycosis (valley fever) in primary care. Am Fam Physician

2020;101(4):221-228.