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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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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