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* pulmonology
 #256437  
  rehellohie - 12/31/07 05:31
 
  1

A 50-year-old patient with long-standing chronic obstructive lung disease develops the insidious onset of aching in the distal extremities, particularly the wrists bilaterally. There is a 10-lb weight loss. The skin over the wrists is warm and erythematous. There is bilateral clubbing. Plain film is read as periosteal thickening, possible osteomyelitis. You should
A) Start ciprofloxacin
B) Obtain chest x-ray
C) Aspirate both wrists
D) Begin gold therapy
2

A patient with low-grade fever and weight loss has poor excursion on the right side of the chest with decreased fremitus, flatness to percussion, and decreased breath sounds all on the right. The trachea is deviated to the left. The most likely diagnosis is
A) Pneumothorax
B) Pleural effusion
C) Consolidated pneumonia
D) Atelectasis
3

A 60-year-old female with a history of urinary tract infection, steroid-dependent chronic obstructive lung disease, and asthma presents with bilateral infiltrates and an eosinophil count of 15%. The least likely diagnosis is
A) Bronchopulmonary aspergillosis
B) Hypersensitivity pneumonitis
C) Strongyloides hyperinfection syndrome
D) Drug effect of nitrofurantoin
4

A 40-year-old alcoholic develops cough and fever. Chest x-ray shows an air-fluid level in the superior segment of the right lower lobe. The most likely etiologic agent is
A) Streptococcus pneumoniae
B) Haemophilus influenzae
C) Legionella
D) Anaerobes
5

A 30-year-old male is admitted to the hospital after a motorcycle accident that resulted in a fracture of the right femur. The fracture is managed with traction. Three days later the patient becomes confused and tachypneic. A petechial rash is noted over the chest. Lungs are clear to auscultation. Arterial blood gases show PO2 of 50, PCO2 of 28, and pH of 7.49. The most likely diagnosis is
A) Unilateral pulmonary edema
B) Hematoma of the chest
C) Fat embolism
D) Pulmonary embolism
E) Early Staphylococcus aureus pneumonia
6

A 70-year-old patient with chronic obstructive lung disease requires 2 L of nasal O2 to treat his hypoxia, which is sometimes associated with angina. While receiving nasal O2, the patient develops pleuritic chest pain, fever, and purulent sputum. He becomes stuporous and develops a respiratory acidosis with CO2 retention and worsening hypoxia. The treatment of choice is
A) Stop oxygen
B) Begin medroxyprogesterone
C) Intubate the trachea and begin mechanical ventilation
D) Observe patient 24 hours before changing therapy
E) Begin sodium bicarbonate
7

A 34-year-old black female presents to your office with symptoms of cough, dyspnea, and lymphadenopathy. Physical exam shows cervical adenopathy and hepatomegaly. Her chest radiograph is shown below. How should you pursue diagnosis?
A) Open lung biopsy
B) Liver biopsy
C) Bronchoscopy and transbronchial lung biopsy
D) Scalene node biopsy
E) Serum angiotensin converting enzyme (ACE) level
8

A 64-year-old woman is found to have a left-sided pleural effusion on chest x-ray. Analysis of the pleural fluid reveals a ratio of concentration of total protein in pleural fluid to serum of 0.38, a lactate dehydrogenase (LDH) level of 125 IU, and a ratio of LDH concentration in pleural fluid to serum of 0.46. Which of the following disorders is most likely in this patient?
A) Uremia
B) Congestive heart failure
C) Pulmonary embolism
D) Sarcoidosis
E) Systemic lupus erythematosus
9

A 25-year-old male cigarette smoker has a history of respiratory infections and has also been found to have hematuria. A high value for diffusing capacity is noted during pulmonary function testing. This finding is consistent with which of the following disorders?
A) Anemia
B) Cystic fibrosis
C) Emphysema
D) Intrapulmonary hemorrhage
10

A 25-year-old male with a long history of severe asthma presents to the emergency room with shortness of breath. He has previously required admission to the hospital and was once intubated for asthma. Which of the following findings on physical exam would indicate a benign course?
A) Silent chest
B) Hypercapnia
C) Thoracoabdominal paradox (paradoxical respiration)
D) Pulsus paradoxus of 5 mmHg
E) Altered mental status
11

A 40-year-old man without a significant past medical history comes to the emergency room with a 3-day history of fever and shaking chills; a 15-minute episode of rigor; nonproductive cough; anorexia; and the development of right-sided pleuritic chest pain and shortness of breath over the last 12 hours. A chest x-ray reveals a consolidated right middle lobe infiltrate, and a CBC shows an elevated neutrophil count with many band forms present. Which of the following statements regarding pneumonia in this patient is correct?
A) Sputum culture is more helpful than sputum Gram stain in choosing empiric antibiotic therapy
B) If the Gram stain revealed numerous gram-positive diplococci, numerous white blood cells, and few epithelial cells, Streptococcus pneumoniae would be the most likely diagnosis
C) Although S. pneumoniae is the agent most likely to be the cause of this patient's pneumonia, this diagnosis would be very unlikely if blood cultures were negative
D) The absence of rigors would rule out a diagnosis of pneumococcal pneumonia
E) Penicillin is the drug of choice in all cases of pneumococcal pneumonia
12

An anxious young woman who is taking birth control pills presents to the emergency room with shortness of breath. The absence of which of the following would make the diagnosis of pulmonary embolus unlikely?
A) Wheezing
B) Pleuritic chest pain
C) Tachypnea
D) Hemoptysis
E) Right-sided S3 heart sound
13

A 65-year-old male with mild congestive heart failure is to receive total hip replacement. He has no other underlying diseases and no history of hypertension, recent surgery, or bleeding disorder. The best approach to prevention of pulmonary embolus in this patient is
A) Aspirin 75 mg/d
B) Aspirin 325 mg/d
C) Warfarin with INR of 2 to 3
D) Early ambulation
14

A 30-year-old athlete with asthma is also a cigarette smoker. Which of the following is characteristic of asthma but not other obstructive lung disease?
A) Hyperinflation is present on chest x-ray
B) Airway obstruction is reversible
C) Hypoxia occurs as a consequence of ventilation-perfusion mismatch
D) The FEV1/FVC ratio is reduced
E) Exacerbation often occurs as a result of an upper respiratory tract infection
15

A 60-year-old male has had a chronic cough for over 5 years with clear sputum production. He has smoked one pack of cigarettes per day for 20 years and continues to do so. X-ray of the chest shows hyperinflation without infiltrates. Arterial blood gases show a pH of 7.38, PCO2 of 40 mmHg, and PO2 of 65 mmHg. Spirometry shows an FEV1/FVC of 65%. The most important treatment modality for this patient is
A) Oral corticosteroids
B) Home oxygen
C) Broad-spectrum antibiotics
D) Smoking cessation program
16

A 50-year-old male with emphysema and a chest x-ray that has shown apical blebs develops the sudden onset of shortness of breath and left-sided pleuritic chest pain. Pneumothorax is suspected. Physical examination findings that would confirm the diagnosis are
A) Localized wheezes at the left base
B) Hyperresonance of the left chest with decreased breath sounds
C) Increased tactile fremitus on the left side
D) Decreased breath sounds on the left side with deviation of the trachea to the left
17

A 30-year-old paraplegic male has a long history of urinary tract infection secondary to an indwelling Foley catheter. He develops fever and hypotension requiring hospitalization, fluid therapy, and intravenous antibiotics. He improves, but over 1 week becomes increasingly short of breath and tachypneic. He develops frothy sputum, diffuse rales, and diffuse alveolar infiltrates. There is no fever, jugular venous distention, S3 gallop, or peripheral or sacral edema. The best approach to a definitive diagnosis in this patient is
A) Blood cultures
B) CT scan of the chest
C) Pulmonary capillary wedge pressure
D) Ventilation-perfusion scan
18

A 35-year-old female complains of slowly progressive dyspnea. Her history is otherwise unremarkable, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. On physical exam, there is jugular venous distention, a palpable right ventricular lift, and a loud P2 heart sound. Chest x-ray shows clear lung fields. ECG shows right axis deviation. A perfusion lung scan is normal with no segmental deficits. The most likely diagnosis in this patient is
A) Primary pulmonary hypertension
B) Recurrent pulmonary emboli
C) Cardiac shunt
D) Interstitial lung disease
19

In the evaluation of this patient, cardiac catheterization confirms the diagnosis. The next step in the management of the patient is
A) Acute drug testing with short-acting pulmonary vasodilators
B) High-dose nifedipine
C) Intravenous prostacyclin
D) Lung transplantation
20

A 60-year-old obese male complains of excessive daytime sleepiness. He has been in good health except for mild hypertension. He drinks alcohol in moderation. The patient's wife states that he snores at night and awakens frequently. Examination of the oropharynx is normal. Which of the following studies is most appropriate?
A) EEG to assess stage sleep patterns
B) Ventilation pattern to detect apnea
C) Arterial O2 saturation
D) Polysomnography to include all of the above
21

The patient above is found to have recurrent episodes of arterial desaturation-about 15 events per hour-with evidence of obstructive apnea. The treatment of choice for this patient is
A) Nasal continuous positive airway pressure
B) Uvulopalatopharyngoplasty
C) Weight reduction
D) Tracheostomy
 
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* Re:pulmonology
#1106838
  alveoli - 12/31/07 05:59
 
  1...
2.C
3....
4.C
5.C
6.C
7.
8.D
9.A
10.
11.
12..
13.D
14.B/E
15.B
16.C
17.
18.A
19.A
20.D
21.C

My pulmonology is hopeless : -((
 
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* Re:pulmonology
#1106900
  darkhorse - 12/31/07 09:25
 
  1

A 50-year-old patient with long-standing chronic obstructive lung disease develops the insidious onset of aching in the distal extremities, particularly the wrists bilaterally. There is a 10-lb weight loss. The skin over the wrists is warm and erythematous. There is bilateral clubbing. Plain film is read as periosteal thickening, possible osteomyelitis. You should
A) Start ciprofloxacin
B) Obtain chest x-ray
C) Aspirate both wrists
D) Begin gold therapy
...................................................................................................
I think this is typical of hypertrophic pulmonary osteopathy...likely to be lung cancer.....so BBBBBBB
....................................................................................................................



2

A patient with low-grade fever and weight loss has poor excursion on the right side of the chest with decreased fremitus, flatness to percussion, and decreased breath sounds all on the right. The trachea is deviated to the left. The most likely diagnosis is
A) Pneumothorax
B) Pleural effusion
C) Consolidated pneumonia
D) Atelectasis

.......................................................................................................................
dull to percuss...tvf reduced...trachea to the opposite side...sounds like BBBBBB
....................................................................................................................

3

A 60-year-old female with a history of urinary tract infection, steroid-dependent chronic obstructive lung disease, and asthma presents with bilateral infiltrates and an eosinophil count of 15%. The least likely diagnosis is
A) Bronchopulmonary aspergillosis
B) Hypersensitivity pneumonitis
C) Strongyloides hyperinfection syndrome
D) Drug effect of nitrofurantoin

........................................................................................
sounds ABPA to me...with b/l pulm infiltrate and eosinophilia...AAAAAAAAAAAAA
............................................................................................
4

A 40-year-old alcoholic develops cough and fever. Chest x-ray shows an air-fluid level in the superior segment of the right lower lobe. The most likely etiologic agent is
A) Streptococcus pneumoniae
B) Haemophilus influenzae
C) Legionella
D) Anaerobes

...........................................................................................................................
looks like he has aspirated while drunk and asleep....so DDDDDDD
............................................................................................................................
5

A 30-year-old male is admitted to the hospital after a motorcycle accident that resulted in a fracture of the right femur. The fracture is managed with traction. Three days later the patient becomes confused and tachypneic. A petechial rash is noted over the chest. Lungs are clear to auscultation. Arterial blood gases show PO2 of 50, PCO2 of 28, and pH of 7.49. The most likely diagnosis is
A) Unilateral pulmonary edema
B) Hematoma of the chest
C) Fat embolism
D) Pulmonary embolism
E) Early Staphylococcus aureus pneumonia

...................................................................................................................
hypoxic patient...3rd day...fracture femur with a rash...typical of FES....CCCCCCCCC
............................................................................................................
6

A 70-year-old patient with chronic obstructive lung disease requires 2 L of nasal O2 to treat his hypoxia, which is sometimes associated with angina. While receiving nasal O2, the patient develops pleuritic chest pain, fever, and purulent sputum. He becomes stuporous and develops a respiratory acidosis with CO2 retention and worsening hypoxia. The treatment of choice is
A) Stop oxygen
B) Begin medroxyprogesterone
C) Intubate the trachea and begin mechanical ventilation
D) Observe patient 24 hours before changing therapy
E) Begin sodium bicarbonate

...............................................................................................................
patient is having co2 narcosis...obviously...stuporus patient will need air way sorting out..CCC
............................................................................................................
7

A 34-year-old black female presents to your office with symptoms of cough, dyspnea, and lymphadenopathy. Physical exam shows cervical adenopathy and hepatomegaly. Her chest radiograph is shown below. How should you pursue diagnosis?
A) Open lung biopsy
B) Liver biopsy
C) Bronchoscopy and transbronchial lung biopsy
D) Scalene node biopsy
E) Serum angiotensin converting enzyme (ACE) level

................................................................................................................
adenopathy, cervical in sarcoidosis...i m not very sure....but i think biopsy of lymph node..DDDD
...................................................................................................................
8

A 64-year-old woman is found to have a left-sided pleural effusion on chest x-ray. Analysis of the pleural fluid reveals a ratio of concentration of total protein in pleural fluid to serum of 0.38, a lactate dehydrogenase (LDH) level of 125 IU, and a ratio of LDH concentration in pleural fluid to serum of 0.46. Which of the following disorders is most likely in this patient?
A) Uremia
B) Congestive heart failure
C) Pulmonary embolism
D) Sarcoidosis
E) Systemic lupus erythematosus

................................................................................................
sounds like a transudate to me...CCF...BBBBBBBBBBB
...............................................................................................
9

A 25-year-old male cigarette smoker has a history of respiratory infections and has also been found to have hematuria. A high value for diffusing capacity is noted during pulmonary function testing. This finding is consistent with which of the following disorders?
A) Anemia
B) Cystic fibrosis
C) Emphysema
D) Intrapulmonary hemorrhage

...............................................................................................................................
veHigh DLco: congestive heart failure, atrial septal defect, intrapulmonary hemorrhage.
Low DLco: emphysema, infiltrative lung disease, pulmonary htn, PE, scleroderma, sarcoidosis, talc granulomatosis.
Falsely Low DLco: anemia, low TLC; often DLco is already corrected for hemoglobin and TLC.
very good question....DDDDDDDDDDDDDDDDDDDD
.............................................................................................................................
10

A 25-year-old male with a long history of severe asthma presents to the emergency room with shortness of breath. He has previously required admission to the hospital and was once intubated for asthma. Which of the following findings on physical exam would indicate a benign course?
A) Silent chest
B) Hypercapnia
C) Thoracoabdominal paradox (paradoxical respiration)
D) Pulsus paradoxus of 5 mmHg
E) Altered mental status

............................................................................................................................
hmmm...i m unsure...whats PP of 5mm...normally it should be more than 10.....i think less than 10 should be normal...probably DDDDD
...............................................................................................................
11

A 40-year-old man without a significant past medical history comes to the emergency room with a 3-day history of fever and shaking chills; a 15-minute episode of rigor; nonproductive cough; anorexia; and the development of right-sided pleuritic chest pain and shortness of breath over the last 12 hours. A chest x-ray reveals a consolidated right middle lobe infiltrate, and a CBC shows an elevated neutrophil count with many band forms present. Which of the following statements regarding pneumonia in this patient is correct?
A) Sputum culture is more helpful than sputum Gram stain in choosing empiric antibiotic therapy
B) If the Gram stain revealed numerous gram-positive diplococci, numerous white blood cells, and few epithelial cells, Streptococcus pneumoniae would be the most likely diagnosis
C) Although S. pneumoniae is the agent most likely to be the cause of this patient's pneumonia, this diagnosis would be very unlikely if blood cultures were negative
D) The absence of rigors would rule out a diagnosis of pneumococcal pneumonia
E) Penicillin is the drug of choice in all cases of pneumococcal pneumonia

...............................................................................................................................

BBBB should be the answer....u dont went for culture to start empiric therapy
.........................................................................................................................
12

An anxious young woman who is taking birth control pills presents to the emergency room with shortness of breath. The absence of which of the following would make the diagnosis of pulmonary embolus unlikely?
A) Wheezing
B) Pleuritic chest pain
C) Tachypnea
D) Hemoptysis
E) Right-sided S3 heart sound

................................................................................................................................
this is a straightforward q....CCCCCCCCCCCCCCCCCC
..................................................................................................................
13

A 65-year-old male with mild congestive heart failure is to receive total hip replacement. He has no other underlying diseases and no history of hypertension, recent surgery, or bleeding disorder. The best approach to prevention of pulmonary embolus in this patient is
A) Aspirin 75 mg/d
B) Aspirin 325 mg/d
C) Warfarin with INR of 2 to 3
D) Early ambulation

..................................................................................................................
u got to anticoagulate her...CCCCCCCCC
..........................................................................................................
14

A 30-year-old athlete with asthma is also a cigarette smoker. Which of the following is characteristic of asthma but not other obstructive lung disease?
A) Hyperinflation is present on chest x-ray
B) Airway obstruction is reversible
C) Hypoxia occurs as a consequence of ventilation-perfusion mismatch
D) The FEV1/FVC ratio is reduced
E) Exacerbation often occurs as a result of an upper respiratory tract infection

.............................................................................................................
asthma definition wise is a reversible airway obstruction
BBBBBBBBBBBBBBB
.........................................................................................................
15

A 60-year-old male has had a chronic cough for over 5 years with clear sputum production. He has smoked one pack of cigarettes per day for 20 years and continues to do so. X-ray of the chest shows hyperinflation without infiltrates. Arterial blood gases show a pH of 7.38, PCO2 of 40 mmHg, and PO2 of 65 mmHg. Spirometry shows an FEV1/FVC of 65%. The most important treatment modality for this patient is
A) Oral corticosteroids
B) Home oxygen
C) Broad-spectrum antibiotics
D) Smoking cessation program

.............................................................................................................
not yet for home oxygen...for than stats has to be below 88% and pao2 less than 55 at rest
DDDDDDDDDDDDDDDDD
.................................................................................................................
16

A 50-year-old male with emphysema and a chest x-ray that has shown apical blebs develops the sudden onset of shortness of breath and left-sided pleuritic chest pain. Pneumothorax is suspected. Physical examination findings that would confirm the diagnosis are
A) Localized wheezes at the left base
B) Hyperresonance of the left chest with decreased breath sounds
C) Increased tactile fremitus on the left side
D) Decreased breath sounds on the left side with deviation of the trachea to the left


..................................................................................................
typical...BBBBBBBBBBBBB
.......................................................................................................
17

A 30-year-old paraplegic male has a long history of urinary tract infection secondary to an indwelling Foley catheter. He develops fever and hypotension requiring hospitalization, fluid therapy, and intravenous antibiotics. He improves, but over 1 week becomes increasingly short of breath and tachypneic. He develops frothy sputum, diffuse rales, and diffuse alveolar infiltrates. There is no fever, jugular venous distention, S3 gallop, or peripheral or sacral edema. The best approach to a definitive diagnosis in this patient is
A) Blood cultures
B) CT scan of the chest
C) Pulmonary capillary wedge pressure
D) Ventilation-perfusion scan
..............................................................................................................
the most imp thing is to know PCWP.....CCCCCCCCCCCCCCCC
..................................................................................................................
18

A 35-year-old female complains of slowly progressive dyspnea. Her history is otherwise unremarkable, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. On physical exam, there is jugular venous distention, a palpable right ventricular lift, and a loud P2 heart sound. Chest x-ray shows clear lung fields. ECG shows right axis deviation. A perfusion lung scan is normal with no segmental deficits. The most likely diagnosis in this patient is
A) Primary pulmonary hypertension
B) Recurrent pulmonary emboli
C) Cardiac shunt
D) Interstitial lung disease
....................................................................................................
young lady...loud p2..rvh...sob...typical pph..AAAAAAAAAA
.............................................................................................
19

In the evaluation of this patient, cardiac catheterization confirms the diagnosis. The next step in the management of the patient is
A) Acute drug testing with short-acting pulmonary vasodilators
B) High-dose nifedipine
C) Intravenous prostacyclin
D) Lung transplantation
.......................................................................................
all of the above are used...but first step is AAAAAAAAAAAAA
.....................................................................................
20

A 60-year-old obese male complains of excessive daytime sleepiness. He has been in good health except for mild hypertension. He drinks alcohol in moderation. The patient's wife states that he snores at night and awakens frequently. Examination of the oropharynx is normal. Which of the following studies is most appropriate?
A) EEG to assess stage sleep patterns
B) Ventilation pattern to detect apnea
C) Arterial O2 saturation
D) Polysomnography to include all of the above

............................................................................................
sleep apnea...DDDDDDDDDDDDD
.............................................................................................
21

The patient above is found to have recurrent episodes of arterial desaturation-about 15 events per hour-with evidence of obstructive apnea. The treatment of choice for this patient is
A) Nasal continuous positive airway pressure
B) Uvulopalatopharyngoplasty
C) Weight reduction
D) Tracheostomy
.....................................................................................
CPAP is the treatment of choice....AAAAAAAAAAAAAAAAAAAA
......................................................................................
 
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* Re:pulmonology
#1106940
  darkhorse - 12/31/07 10:43
 
  for 333...it is asking least likely diag ...sry..didnt read it properly...should be BBBBB...hypersensitivity pneumonitis...u get neutrophilia in it....  
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* Re:pulmonology
#1106970
  rehellohie - 12/31/07 11:26
 
  A 50-year-old patient with long-standing chronic obstructive lung disease develops the insidious onset of aching in the distal extremities, particularly the wrists bilaterally. There is a 10-lb weight loss. The skin over the wrists is warm and erythematous. There is bilateral clubbing. Plain film is read as periosteal thickening, possible osteomyelitis. You should

A) Start ciprofloxacin
This is the correct answer.
B) Obtain chest x-ray

C) Aspirate both wrists

D) Begin gold therapy
Feedback: The answer is b. The clinical picture suggests hypertrophic osteoarthropathy. This process, the pathogenesis of which is unknown, is characterized by clubbing of digits, periosteal new bone formation, and arthritis. Hypertrophic osteoarthropathy is associated with intrathoracic malignancy, suppurative lung disease, and congenital heart problems. Treatment is directed at the underlying disease process. While x-rays may suggest osteomyelitis, the process is usually bilateral and easily distinguishable from osteomyelitis. The first step in evaluation of this patient is to obtain a chest x-ray looking for lung infection and carcinoma.
2 CORRECT A patient with low-grade fever and weight loss has poor excursion on the right side of the chest with decreased fremitus, flatness to percussion, and decreased breath sounds all on the right. The trachea is deviated to the left. The most likely diagnosis is

A) Pneumothorax
This is the correct answer.
B) Pleural effusion

C) Consolidated pneumonia

D) Atelectasis
Feedback: The answer is b. The diagnosis in this patient is suggested by the physical exam findings. The findings of poor excursion, flatness of percussion, and decreased fremitus on the right side are all consistent with a right-sided pleural effusion. A large right-sided effusion may shift the trachea to the left. Histoplasmosis would be one possible cause of such an effusion. A pneumothorax should result in hyperresonance of the affected side. Atelectasis on the right side would shift the trachea to the right. A consolidated pneumonia would characteristically result in increased fremitus, flatness to percussion, and bronchial breath sounds, and would not cause tracheal deviation.
3 CORRECT A 60-year-old female with a history of urinary tract infection, steroid-dependent chronic obstructive lung disease, and asthma presents with bilateral infiltrates and an eosinophil count of 15%. The least likely diagnosis is

A) Bronchopulmonary aspergillosis
This is the correct answer.
B) Hypersensitivity pneumonitis

C) Strongyloides hyperinfection syndrome

D) Drug effect of nitrofurantoin
Feedback: The answer is b. This 60-year-old woman has peripheral eosinophilia in association with pulmonary infiltrates. The differential diagnosis for eosinophilic pneumonia includes allergic bronchopulmonary aspergillosis, parasitic infections, drug reactions, and a category of idiopathic disease. Nitrofurdantoin and sulfonamides are among the drugs most likely to cause eosinophilic pneumonia. Hypersensitivity pneumonitis may cause bilateral infiltrates, but does not of itself cause eosinophilia.
4 CORRECT A 40-year-old alcoholic develops cough and fever. Chest x-ray shows an air-fluid level in the superior segment of the right lower lobe. The most likely etiologic agent is

A) Streptococcus pneumoniae

B) Haemophilus influenzae

C) Legionella
This is the correct answer.
D) Anaerobes
Feedback: The answer is d. Of the organisms listed, only anaerobic infection is likely to cause a necrotizing process. Type III pneumococci have been reported to cause cavitary disease, but this is unusual. The location of the infiltrate suggests aspiration, also making anaerobic infection most likely. The superior segment of the right lower lobe is the one most likely to develop an aspiration pneumonia.
5 CORRECT A 30-year-old male is admitted to the hospital after a motorcycle accident that resulted in a fracture of the right femur. The fracture is managed with traction. Three days later the patient becomes confused and tachypneic. A petechial rash is noted over the chest. Lungs are clear to auscultation. Arterial blood gases show PO2 of 50, PCO2 of 28, and pH of 7.49. The most likely diagnosis is

A) Unilateral pulmonary edema

B) Hematoma of the chest
This is the correct answer.
C) Fat embolism

D) Pulmonary embolism

E) Early Staphylococcus aureus pneumonia
Feedback: The answer is c. Because the clinical signs of neurologic deterioration and a petechial rash have occurred in the setting of fracture and hypoxia, fat embolism is the most likely diagnosis. This process occurs when neutral fat is introduced into the venous circulation after bone trauma or fracture. The latent period is 12 to 36 hours, usually earlier than a pulmonary embolus would occur after trauma.
6 CORRECT A 70-year-old patient with chronic obstructive lung disease requires 2 L of nasal O2 to treat his hypoxia, which is sometimes associated with angina. While receiving nasal O2, the patient develops pleuritic chest pain, fever, and purulent sputum. He becomes stuporous and develops a respiratory acidosis with CO2 retention and worsening hypoxia. The treatment of choice is

A) Stop oxygen

B) Begin medroxyprogesterone
This is the correct answer.
C) Intubate the trachea and begin mechanical ventilation

D) Observe patient 24 hours before changing therapy

E) Begin sodium bicarbonate
Feedback: The answer is c. stupor and coma supervene in CO2 retention, fatal arrhythmias, seizures, and death are likely to follow. Stopping oxygen is the worst course of action, as it will exacerbate life-threatening hypoxia. Intubation is the only good alternative. Bicarbonate plays no role in this acidosis, which is respiratory and caused by hypoventilation.
7 CORRECT A 34-year-old black female presents to your office with symptoms of cough, dyspnea, and lymphadenopathy. Physical exam shows cervical adenopathy and hepatomegaly. Her chest radiograph is shown below. How should you pursue diagnosis?

A) Open lung biopsy

B) Liver biopsy
This is the correct answer.
C) Bronchoscopy and transbronchial lung biopsy

D) Scalene node biopsy

E) Serum angiotensin converting enzyme (ACE) level
Feedback: The answer is c. Sarcoidosis is a systemic illness of unknown etiology. Many patients have respiratory symptoms, including cough and dyspnea. Hilar and peripheral lymphadenopathy is common, and 20 to 30% of patients have hepatomegaly. The chest x-ray shows symmetrical hilar lymphadenopathy. The diagnostic method of choice is transbronchial biopsy, which will show a mononuclear cell granulomatous inflammatory process. While liver and scalene node biopsies are often positive, noncaseating granulomas are so frequent in these sites that they are not considered acceptable for primary diagnosis. ACE levels are elevated in two-thirds of patients, but false-positive values are common in other granulomatous disease processes.
8 CORRECT A 64-year-old woman is found to have a left-sided pleural effusion on chest x-ray. Analysis of the pleural fluid reveals a ratio of concentration of total protein in pleural fluid to serum of 0.38, a lactate dehydrogenase (LDH) level of 125 IU, and a ratio of LDH concentration in pleural fluid to serum of 0.46. Which of the following disorders is most likely in this patient?

A) Uremia
This is the correct answer.
B) Congestive heart failure

C) Pulmonary embolism

D) Sarcoidosis

E) Systemic lupus erythematosus
Feedback: The answer is b. Classifying a pleural effusion as either a transudate or an exudate is useful in identifying the underlying disorder. Pleural fluid is exudative if it has any one of the following three properties: a ratio of concentration of total protein in pleural fluid to serum greater than 0.5, an absolute value of LDH greater than 200 IU, or a ratio of LDH concentration in pleural fluid to serum greater than 0.6. Causes of exudative effusions include malignancy, pulmonary embolism, pneumonia, tuberculosis, abdominal disease, collagen vascular diseases, uremia, Dressler syndrome, and chylothorax. Exudative effusions may also be drug-induced. If none of the aforementioned properties are met, the effusion is a transudate. Differential diagnosis includes congestive heart failure, nephrotic syndrome, cirrhosis, Meigs syndrome (benign ovarian neoplasm with effusion), and hydronephrosis.
9 CORRECT A 25-year-old male cigarette smoker has a history of respiratory infections and has also been found to have hematuria. A high value for diffusing capacity is noted during pulmonary function testing. This finding is consistent with which of the following disorders?

A) Anemia

B) Cystic fibrosis

C) Emphysema
This is the correct answer.
D) Intrapulmonary hemorrhage
Feedback: The answer is d. Carbon monoxide (CO) diffusing capacity provides an estimate of the rate at which oxygen moves by diffusion from alveolar gas to combine with hemoglobin in the red blood cells. It is interpreted as an index of the surface area engaged in alveolar-capillary diffusion. Measurement of diffusing capacity of the lung is done by having the person inspire a low concentration of carbon monoxide. The rate of uptake of the gas by the blood is calculated from the difference between the inspired and expired concentrations. The test can be performed during a single 10-second breath holding or during 1 minute of steady-state breathing. The diffusing capacity is defined as the amount of carbon monoxide transferred per minute per millimeter of mercury of driving pressure and correlates with oxygen transport from the alveolus into the capillaries. Primary parenchymal disorders, anemia, and removal of lung tissue decrease the diffusing capacity. Conversely, polycythemia, congestive heart failure, and intrapulmonary hemorrhage tend to increase the value for diffusing capacity. In this patient, the possibility of Goodpasture syndrome would be considered.
10 CORRECT A 25-year-old male with a long history of severe asthma presents to the emergency room with shortness of breath. He has previously required admission to the hospital and was once intubated for asthma. Which of the following findings on physical exam would indicate a benign course?

A) Silent chest

B) Hypercapnia

C) Thoracoabdominal paradox (paradoxical respiration)
This is the correct answer.
D) Pulsus paradoxus of 5 mmHg

E) Altered mental status
Feedback: The answer is d. It is extremely important to accurately determine the severity of an exacerbation of asthma, since the major cause of death from asthma is the underestimation of the severity of a particular episode by either the patient or the physician. Silent chest is a particularly ominous finding, because the airway constriction is so great that airflow is insufficient to generate wheezing. Hypercapnia and thoracoabdominal paradox are almost always indicative of exhaustion and respiratory muscle failure or fatigue and generally need to be aggressively treated with mechanical ventilation. Altered mental status is frequently seen with severe hypoxia or hypercapnia, and ventilatory support is usually required. An increased pulsus paradoxus may also be a sign of severe asthma, as it increases with greater respiratory effort and generation of more negative intrathoracic pressures during inspiration. However, a pulsus paradoxus of up to 8 to 10 mmHg is considered normal; thus, a value of 5 mmHg would not be indicative of a severe episode of asthma.
11 CORRECT A 40-year-old man without a significant past medical history comes to the emergency room with a 3-day history of fever and shaking chills; a 15-minute episode of rigor; nonproductive cough; anorexia; and the development of right-sided pleuritic chest pain and shortness of breath over the last 12 hours. A chest x-ray reveals a consolidated right middle lobe infiltrate, and a CBC shows an elevated neutrophil count with many band forms present. Which of the following statements regarding pneumonia in this patient is correct?

A) Sputum culture is more helpful than sputum Gram stain in choosing empiric antibiotic therapy
This is the correct answer.
B) If the Gram stain revealed numerous gram-positive diplococci, numerous white blood cells, and few epithelial cells, Streptococcus pneumoniae would be the most likely diagnosis

C) Although S. pneumoniae is the agent most likely to be the cause of this patient's pneumonia, this diagnosis would be very unlikely if blood cultures were negative

D) The absence of rigors would rule out a diagnosis of pneumococcal pneumonia

E) Penicillin is the drug of choice in all cases of pneumococcal pneumonia
Feedback: The answer is b. Pneumonia is a common disorder and is a major cause of death, particularly in hospitalized elderly patients. Before choosing empiric therapy for presumed pneumonia, it is necessary to know the age of the patient, whether the infection is community-acquired or nosocomial, and whether there are any underlying debilitating illnesses. Community-acquired pneumonias in patients over the age of 35 are most likely due to S. pneumoniae, Legionella species (e.g., pneumophila), and Haemophilus influenzae. In the case outlined, the history is strongly consistent with pneumococcal pneumonia, manifested by a short prodrome, shaking chills with rigor, fever, chest pain, sparse sputum production associated with cough, and a consolidated lobar infiltrate on chest x-ray. The most reliable method of diagnosing pneumococcal pneumonia is seeing gram-positive diplococci on an adequate sputum (many white cells, few epithelial cells). Sputum culture is also important in the era of penicillin-resistant pneumococci, but is not helpful in initial diagnosis. Blood cultures are positive in only about 20% of patients, and, when positive, are indicative of a more severe case. Although rigors may suggest pneumococcal bacteremia, the absence of rigors does not rule out the diagnosis. About 25% of pneumococci in the United States are partially or completely resistant to penicillin due to chromosomal mutations resulting in penicillin-binding protein changes. Penicillin is no longer the regimen of choice for pneumococcal pneumonia pending the results of sensitivity testing. The fluoroquinolones or ceftriaxone are widely used as initial therapy for pneumococcal pneumonia.
12 CORRECT An anxious young woman who is taking birth control pills presents to the emergency room with shortness of breath. The absence of which of the following would make the diagnosis of pulmonary embolus unlikely?

A) Wheezing

B) Pleuritic chest pain
This is the correct answer.
C) Tachypnea

D) Hemoptysis

E) Right-sided S3 heart sound
Feedback: The answer is c. While all of these signs and symptoms can occur in acute pulmonary embolus, tachypnea is by far the most common. Tachypnea occurs in more than 90% of patients with pulmonary embolus. Pleuritic chest pain occurs in about half of patients and is less common in the elderly and those with underlying heart disease. Hemoptysis and wheezing occur in less than half of patients. A right-sided S3 is associated with large emboli that result in acute pulmonary hypertension.
13 CORRECT A 65-year-old male with mild congestive heart failure is to receive total hip replacement. He has no other underlying diseases and no history of hypertension, recent surgery, or bleeding disorder. The best approach to prevention of pulmonary embolus in this patient is

A) Aspirin 75 mg/d

B) Aspirin 325 mg/d
This is the correct answer.
C) Warfarin with INR of 2 to 3

D) Early ambulation
Feedback: The answer is c. Warfarin is the principal agent recommended for the prophylaxis of acute pulmonary embolus in patients who receive total hip replacement. Warfarin is started preoperatively, and the daily dose is adjusted to maintain an international normalized ratio (INR) of 2 to 2.5. Low-molecular-weight heparin given twice daily subcutaneously is also a recommended regimen. The value of aspirin in this setting is unclear. Early ambulation and elastic stockings are also important in preventing thromboembolism, but are not adequate in themselves in this high-risk situation.
14 CORRECT A 30-year-old athlete with asthma is also a cigarette smoker. Which of the following is characteristic of asthma but not other obstructive lung disease?

A) Hyperinflation is present on chest x-ray
This is the correct answer.
B) Airway obstruction is reversible

C) Hypoxia occurs as a consequence of ventilation-perfusion mismatch

D) The FEV1/FVC ratio is reduced

E) Exacerbation often occurs as a result of an upper respiratory tract infection
Feedback: The answer is b. Asthma is an incompletely understood inflammatory process that involves the lower airways and results in bronchoconstriction and excess production of mucus, which in turn lead to increased airway resistance and occasionally respiratory failure and death. During acute exacerbations of asthma, and in other obstructive lung diseases such as chronic obstructive pulmonary disease, hyperinflation may be present on chest x-ray. Hypoxia is common and usually a result of ventilation-perfusion mismatch. The FEV1/FVC is reduced, and exacerbations are frequently precipitated by upper airway infections. Only in asthma is the airway obstruction reversible.
15 CORRECT A 60-year-old male has had a chronic cough for over 5 years with clear sputum production. He has smoked one pack of cigarettes per day for 20 years and continues to do so. X-ray of the chest shows hyperinflation without infiltrates. Arterial blood gases show a pH of 7.38, PCO2 of 40 mmHg, and PO2 of 65 mmHg. Spirometry shows an FEV1/FVC of 65%. The most important treatment modality for this patient is

A) Oral corticosteroids

B) Home oxygen

C) Broad-spectrum antibiotics
This is the correct answer.
D) Smoking cessation program
Feedback: The answer is d. This patient's chronic cough, hyperinflated lung fields, abnormal pulmonary function tests, and smoking history are all consistent with chronic bronchitis. A smoking cessation program can decrease the rate of lung deterioration and is successful in as many as 40% of patients, particularly when the physician gives a strong antismoking message and uses both counseling and nicotine replacement. Continuous low-flow oxygen becomes beneficial when arterial oxygen concentration falls below 55 mmHg. Antibiotics are indicated only for acute exacerbations of chronic lung disease, which might present with fever, change in color of sputum, and increasing shortness of breath. Oral corticosteroids are helpful in some patients, but are reserved for those who have failed inhaled bronchodilator treatments.
16 CORRECT A 50-year-old male with emphysema and a chest x-ray that has shown apical blebs develops the sudden onset of shortness of breath and left-sided pleuritic chest pain. Pneumothorax is suspected. Physical examination findings that would confirm the diagnosis are

A) Localized wheezes at the left base
This is the correct answer.
B) Hyperresonance of the left chest with decreased breath sounds

C) Increased tactile fremitus on the left side

D) Decreased breath sounds on the left side with deviation of the trachea to the left
Feedback: The answer is b. The most characteristic findings of pneumothorax are hyperresonance and decreased breath sounds. A tension pneumothorax may displace the mediastinum to the unaffected side. Tactile fremitus would be decreased in the patient with a pneumothorax, but would be increased in conditions in which consolidation of the lung has developed.
17 CORRECT A 30-year-old paraplegic male has a long history of urinary tract infection secondary to an indwelling Foley catheter. He develops fever and hypotension requiring hospitalization, fluid therapy, and intravenous antibiotics. He improves, but over 1 week becomes increasingly short of breath and tachypneic. He develops frothy sputum, diffuse rales, and diffuse alveolar infiltrates. There is no fever, jugular venous distention, S3 gallop, or peripheral or sacral edema. The best approach to a definitive diagnosis in this patient is

A) Blood cultures

B) CT scan of the chest
This is the correct answer.
C) Pulmonary capillary wedge pressure

D) Ventilation-perfusion scan
Feedback: The answer is c. Sepsis is the most important single cause of adult respiratory distress syndrome. Early in the course of ARDS, patients may appear stable without respiratory symptoms. Tachypnea, hypoxemia, and diffuse infiltrates gradually develop. It may be difficult to distinguish the process from cardiogenic pulmonary edema, especially in patients who have been given large quantities of fluid. This young patient with no evidence of volume overload would be strongly suspected of having ARDS. The pulmonary capillary wedge pressure would be normal or low in ARDS, but elevated in left ventricular failure. ARDS is a complication of sepsis, but blood cultures may or may not be positive. Neither CT of the chest nor ventilation-perfusion scan would be specific enough to help in diagnosis of ARDS.
18 CORRECT A 35-year-old female complains of slowly progressive dyspnea. Her history is otherwise unremarkable, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. On physical exam, there is jugular venous distention, a palpable right ventricular lift, and a loud P2 heart sound. Chest x-ray shows clear lung fields. ECG shows right axis deviation. A perfusion lung scan is normal with no segmental deficits. The most likely diagnosis in this patient is
This is the correct answer.
A) Primary pulmonary hypertension

B) Recurrent pulmonary emboli

C) Cardiac shunt

D) Interstitial lung disease
Feedback: The answer is a. Although a difficult diagnosis to make, primary pulmonary hypertension is the most likely diagnosis in this young woman who has used appetite suppressants. There has been a recent increase in primary pulmonary hypertension in the United States associated with fenfluramines. The predominant symptom is dyspnea, which is usually not apparent in the previously healthy young woman until the disease has advanced. When signs of pulmonary hypertension are apparent from physical findings, chest x-ray, or echocardiography, the diagnosis of recurrent pulmonary embolus must be ruled out. In this case, a normal perfusion lung scan makes pulmonary angiography unnecessary. Restrictive lung disease should be ruled out with pulmonary function testing. An echocardiogram will show right ventricular enlargement and a reduction in the left ventricle size consistent with right ventricular pressure overload.
19 CORRECT In the evaluation of this patient, cardiac catheterization confirms the diagnosis. The next step in the management of the patient is
This is the correct answer.
A) Acute drug testing with short-acting pulmonary vasodilators

B) High-dose nifedipine

C) Intravenous prostacyclin

D) Lung transplantation
Feedback: The answer is a. In all patients in whom primary pulmonary hypertension is confirmed, acute drug testing with a pulmonary vasodilator is necessary to assess the extent of pulmonary vascular reactivity. Inhaled nitric oxide, intravenous adenosine, or intravenous prostacyclin have all been used. Patients who have a good response to the short-acting vasodilator are tried on a long-acting calcium channel antagonist under direct hemodynamic monitoring. Prostacyclin has been approved for patients who are functional class III or IV and have not responded to calcium channel antagonists. Lung transplantation is reserved for late stages of the disease when patients are unresponsive to prostacyclin. The disease does not appear to recur after transplantation.
20 CORRECT A 60-year-old obese male complains of excessive daytime sleepiness. He has been in good health except for mild hypertension. He drinks alcohol in moderation. The patient's wife states that he snores at night and awakens frequently. Examination of the oropharynx is normal. Which of the following studies is most appropriate?

A) EEG to assess stage sleep patterns

B) Ventilation pattern to detect apnea

C) Arterial O2 saturation
This is the correct answer.
D) Polysomnography to include all of the above
Feedback: The answer is d. With the history of daytime sleepiness and snoring at night, the patient requires evaluation for obstructive sleep apnea syndrome. Frequent awakenings are actually more suggestive of central sleep apnea. Polysomnography is required to assess which type of sleep apnea syndrome is present. EEG variables are recorded that identify various stages of sleep. Arterial oxygen saturation is monitored by finger or ear oximetry. Heart rate is monitored. The respiratory pattern is monitored to detect apnea and whether it is central or obstructive. Ambulatory sleep monitoring with oxygen saturation studies alone might identify multiple episodes of desaturation, but negative results would not rule out a sleep apnea syndrome. Overnight oximetry alone can be used in some patients when the index of suspicion for obstructive sleep apnea is high.
21 CORRECT The patient above is found to have recurrent episodes of arterial desaturation-about 15 events per hour-with evidence of obstructive apnea. The treatment of choice for this patient is
This is the correct answer.
A) Nasal continuous positive airway pressure

B) Uvulopalatopharyngoplasty

C) Weight reduction

D) Tracheostomy
Feedback: The answer is a. In this patient with multiple episodes of desaturation, continuous positive airway pressure would be the recommended therapy. Weight loss is often helpful and should be recommended as well, but would probably not be sufficient. Uvulopalatopharyngoplasty has also been used in obstructive sleep apnea, but when applied to unselected patients is effective in less than 50%. Tracheostomy is a course of last resort that does provide immediate relief.
 
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  mysam - 06/16/08 15:13
 
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