DIRECTIONS: Choose the one best response to each question.
VI-1. Which of the following statements regarding auscultation of the chest is TRUE?
A. Absence of breath sounds in a hemithorax is almost always associated with a pneumothorax.
B. An astute clinician should be able to differentiate “wet” from “dry” crackles.
C. “Cardiac asthma” refers to wheezing associated with alveolar edema in congestive heart failure.
D. Rhonchi are a manifestation of obstruction of mediumsized airways.
E. The presence of egophony can be used to distinguish pulmonary fibrosis from alveolar filling.
VI-2. A 72-year-old male with a long history of tobacco use is seen in the clinic for 3 weeks of progressive dyspnea on exertion. He has had a mild nonproductive cough and anorexia but denies fevers, chills, or sweats. On physical examination, he has normal vital signs and normal oxygen saturation on room air. Jugular venous pressure is normal, and cardiac examination shows decreased heart sounds but no other abnormality. The trachea is midline, and there is no associated lymphadenopathy. On pulmonary examination, the patient has dullness over the left lower lung field, decreased tactile fremitus, decreased breath sounds, and no voice transmission. The right lung examination is normal. After obtaining chest plain film, appropriate initial management at this point would include which of the following?
A. Intravenous antibiotics
D. Deep suctioning
E. Bronchodilator therapy
VI-3. At what lung volume does the outward recoil of the chest wall equal the inward elastic recoil of the lung?
A. Expiratory reserve volume
B. Functional residual capacity
C. Residual volume
D. Tidal volume
E. Total lung capacity
VI-4. A 65-year-old man is evaluated for progressive dyspnea on exertion that has occurred over the course of the past 3 months. His medical history is significant for an episode of necrotizing pancreatitis that resulted in multiorgan failure and acute respiratory distress syndrome. He required mechanical ventilation for 6 weeks prior to his recovery. He also has a history of 30 pack-years of tobacco, quitting 15 years previously. He is not known to have chronic obstructive pulmonary disease. On physical examination, a low-pitched inspiratory and expiratory wheeze is heard that is loudest over the mid-chest area. On pulmonary function testing, the forced expiratory volume in 1 second is 2.5 L (78% predicted), forced vital capacity is 4.00 L (94% predicted), and the FEV1/FVC ratio is 62.5%. The flow volume curve is shown in Figure VI-4. What is the most likely cause of the patient’s symptoms?
A. Aspirated foreign body
B. Chronic obstructive pulmonary disease
C. Idiopathic pulmonary fibrosis
D. Subglottic stenosis
E. Unilateral vocal cord paralysis
VI-5. A 32-year-old woman presents to the emergency department in her 36th week of pregnancy complaining of acute dyspnea. She has had an uncomplicated pregnancy and has no other medical problems. She is taking no medications other than prenatal vitamins. On examination, she appears dyspneic. Her vital signs are as follows: blood pressure 128/78, heart rate 126 beats/min, respiratory rate 28 breaths/min, and oxygen saturation is 96% on room air. She is afebrile. Her lung and cardiac examinations are normal. There is trace bilateral pitting pedal edema. A chest x-ray performed with abdominal shielding is normal, and the ECG demonstrates sinus tachycardia. An arterial blood gas is performed. The pH is 7.52, PaCO2 is 26 mmHg, and PaO2 is 85 mmHg. What is the next best step in the diagnosis and management of this patient?
A. Initiate therapy with amoxicillin for acute bronchitis.
B. Perform a CT pulmonary angiogram.
C. Perform an echocardiogram.
D. Reassure the patient that dyspnea is normal during this stage of pregnancy and no abnormalities are seen on testing.
E. Treat with clonazepam for a panic attack.
VI-6. Match each of the following pulmonary function test results with the respiratory disorder for which they are the most likely findings.
A. Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio
B. Decreased TLC, decreased VC, decreased residual volume (RV), increased FEV1/FVC ratio, normal maximum inspiratory pressure (MIP)
C. Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP
D. Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP
1. Myasthenia gravis
2. Idiopathic pulmonary fibrosis
3. Familial pulmonary hypertension
4. Chronic obstructive pulmonary disease
VI-7. A 78-year-old woman is admitted to the medical intensive care unit with multilobar pneumonia. On initial presentation to the emergency room, her initial oxygen saturation was 60% on room air and only increased to 82% on a non-rebreather face mask. She was in marked respiratory distress and intubated in the emergency room. Upon admission to the intensive care unit, she was sedated and paralyzed. The ventilator is set in the assist-control mode with a respiratory rate of 24, tidal volume of 6 mL/kg, FiO2 of 1.0, and positive end-expiratory pressure of 12 cmH2O. An arterial blood gas measurement is performed on these settings; the results are pH 7.20, PCO2 of 32 mmHg, and PO2of 54 mmHg. What is the cause of the hypoxemia?
A. Hypoventilation alone
B. Hypoventilation and ventilation-perfusion mismatch
D. Ventilation-perfusion mismatch
VI-8. A 65-year-old man is evaluated for progressive dyspnea on exertion and dry cough that have worsened over the course of 6 months. He has not had dyspnea at rest and denies wheezing. He has not experienced chest pain. He has a history of coronary artery disease and atrial fibrillation, and underwent coronary artery bypass surgery 12 years ago. His medications include metoprolol, aspirin, warfarin, and enalapril. He previously smoked one pack of cigarettes daily for 40 years, quitting 5 years previously. His vital signs are blood pressure 122/68, heart rate 68 beats/min, respiratory rate 18 breaths/min, and oxygen saturation 92% on room air. His chest examination demonstrates bibasilar crackles present about one-third of the way up bilaterally. No wheezing is heard. He has an irregularly irregular rhythm with a II/VI holosystolic murmur at the apex. The jugular venous pressure is not elevated. No edema is present, but clubbing is noted. Pulmonary function testing reveals a forced expiratory volume in 1 second 65% predicted, forced vital capacity of 67% predicted, FEV1/FVC ratio of 74%, total lung capacity 68% predicted, and diffusion capacity for carbon monoxide of 62% predicted. Which test is most likely to determine the etiology of the patient’s dyspnea?
A. Bronchoscopy with transbronchial lung biopsy
B. CT pulmonary angiography
D. High-resolution CT scan of the chest
E. Nuclear medicine stress test
VI-9. A 24-year-old woman is seen for a complaint of shortness of breath and wheezing. She reports the symptoms to be worse when she has exercised outdoors and is around cats. She has had allergic rhinitis in the spring and summer for many years and suffered from eczema as a child. On physical examination, she is noted to have expiratory wheezing. Her pulmonary function tests demonstrate a forced expiratory volume in 1 second (FEV1) of 2.67 (79% predicted), forced vital capacity of 3.81 L (97% predicted), and an FEV1/FVC ratio of 70% (predicted value 86%). Following administration of albuterol, the FEV1 increases to 3.0 L (12.4%). Which of the following statements regarding the patient’s disease process is TRUE?
A. Confirmation of the diagnosis will require methacholine challenge testing.
B. Mortality due to the disease has been increasing over the past decade.
C. The most common risk factor in individuals with the disorder is genetic predisposition.
D. The prevalence of the disorder has not changed in the last several decades.
E. The severity of the disease does not vary significantly within a given patient with the disease.
VI-10. A 38-year-old woman is brought to the emergency room for status asthmaticus. She rapidly deteriorates and dies of her disease. All of the following pathologic findings would likely be seen in this individual EXCEPT:
A. Infiltration of the airway mucosa with eosinophils and activated T-lymphocytes
B. Infiltration of the alveolar spaces with eosinophils and neutrophils
C. Occlusion of the airway lumen by mucous plugs
D. Thickening and edema of the airway wall
E. Thickening of the basement membrane of the airways with subepithelial collagen deposition
VI-11. A 25-year-old woman is seen for follow-up of persistent asthma symptoms despite treatment with inhaled fluticasone 88 μg twice daily for the past 3 months. According to the National Asthma Education and Prevention Program guidelines endorsed by the National Institutes of Health, which of the following changes in therapy can be considered?
A. Addition of a leukotriene antagonist.
B. Addition of a long-acting beta-agonist.
C. Addition of low-dose theophylline.
D. Increase the dosage of inhaled corticosteroid.
E. Any of the above can be considered.
VI-12. Which of the following patients is appropriately diagnosed with asthma?
A. A 24-year-old woman treated with inhaled corticosteroids for cough and wheezing that has persisted for 6 weeks following a viral upper respiratory infection.
B. A 26-year-old man who coughs and occasionally wheezes following exercise in cold weather.
C. A 34-year-old woman evaluated for chronic cough with an FEV1/FVC ratio of 68% with an FEV1 that increases from 1.68 L (52% predicted) to 1.98 L (61% predicted) after albuterol (18% change in FEV1).
D. A 44-year-old man who works as a technician caring for the mice in a medical research laboratory complains of wheezing, shortness of breath, and cough that are most severe at the end of the week.
E. A 60-year-old man who has smoked two packs of cigarettes per day for 40 years who has dyspnea and cough, and airway hyperreactivity in response to methacholine.
VI-13. A 40-year-old woman with moderate persistent asthma has been under good control for 3 months and is currently using her albuterol MDI for symptomatic control once weekly. She awakens at night twice monthly with asthma symptoms, but continues to exercise regularly without difficulties. Her other medications include fluticasone inhaled 88 μg/puff twice daily and salmeterol 50 μg twice daily. Her FEV1 is currently at 83% of her personal best. Which action is most appropriate at the present time?
A. Add montelukast 10 mg once daily, as the current albuterol usage suggests poor asthma control.
B. Decrease the fluticasone to 44 μg/puff twice daily.
C. Discontinue the fluticasone.
D. Discontinue the salmeterol.
E. Do nothing, as the current albuterol usage suggests poor asthma control.
VI-14. You are considering omalizumab therapy for a patient with severe persistent asthma who is requiring oral prednisone at 5–10 mg daily in addition to high-dose inhaled corticosteroids, long-acting bronchodilators, and montelukast to control her symptoms. Which of the following is necessary prior to initiating omalizumab?
A. Discontinuation of oral prednisone
B. Demonstrated elevation in immunoglobulin E levels to greater than 1000 IU/L
C. Normalization of FEV1 or peak expiratory flow rates
D. Presence of sensitivity to a perennial aeroallergen
E. Switch oral prednisone to intravenous prednisolone
VI-15. A 76-year-old woman is evaluated for acute onset of shortness of breath and dry cough for the past 2 days. She also has had a fever to as high as 102.5°F (39.2°C). Her past medical history includes hypothyroidism and diabetes mellitus. She currently is taking metformin 1000 mg twice daily. Her levothyroxine dose was increased to 100 μg daily 1 month ago, and she was prescribed nitrofurantoin 100 mg twice daily 3 days ago for a urinary tract infection. Her vital signs show a blood pressure of 115/82, heart rate of 96 beats per minute, respiratory rate of 24 breaths per minute, temperature of 101.3°F (38.5°C), and oxygen saturation of 94% on room air. There is dullness to percussion and decreased breath sounds at the right lung base. Crackles are heard bilaterally as well. A chest radiograph shows a moderate right-sided pleural effusion, and patchy bilateral lung infiltrates are seen. The patient is admitted to the hospital. A thoracentesis is performed demonstrating an exudative effusion. The fluid has a white cell count of 3500/mm3 with a differential of 60% polymorphonuclear cells, 30% eosinophils, and 10% lymphocytes. A bronchoscopy is performed that shows a differential of 50% polymorphonuclear cells, 15% eosinophils, and 35% alveolar macrophages. Which of the following would be the most important next step in the treatment of this patient?
A. Await pleural fluid cultures before making a treatment recommendation.
B. Decrease levothyroxine dose.
C. Discontinue nitrofurantoin.
D. Increase levothyroxine dose.
E. Initiate treatment with high-dose steroid therapy (methylprednisolone 1 g daily).
VI-16. A 34-year-old female seeks evaluation for a complaint of cough and dyspnea on exertion that has gradually worsened over 3 months. The patient has no past history of pulmonary complaints and has never had asthma. She started working in a pet store approximately 6 months ago. Her duties there include cleaning the reptile and bird cages. She reports occasional low-grade fevers but has had no wheezing. The cough is dry and nonproductive. Before 3 months ago the patient had no limitation of exercise tolerance, but now she reports that she gets dyspneic climbing two flights of stairs. On physical examination the patient appears well. She has an oxygen saturation of 95% on room air at rest but desaturates to 89% with ambulation. Temperature is 37.7°C (99.8°F). The pulmonary examination is unremarkable. No clubbing or cyanosis is present. The patient has a normal chest radiogram. A high-resolution chest CT shows diffuse ground-glass infiltrates in the lower lobes with the presence of centrilobular nodules. A trans-bronchial biopsy shows an interstitial alveolar infiltrate of plasma cells, lymphocytes, and occasional eosinophils. There are also several loose noncaseating granulomas. All cultures are negative for bacterial, viral, and fungal pathogens. What is the diagnosis?
B. Hypersensitivity pneumonitis
C. Nonspecific interstitial pneumonitis related to collagen vascular disease
VI-17. What treatment do you recommend for the patient in question VI-16?
D. Glucocorticoids plus azathioprine
E. Glucocorticoids plus removal of antigen
VI-18. A 75-year-old man is evaluated for a new left-sided pleural effusion and shortness of breath. He worked as an insulation worker at a shipyard for more than 30 years and did not wear protective respiratory equipment. He has a 50 pack-year history of tobacco with known moderate COPD (FEV1 55% predicted) and prior history of myocardial infarction 10 years previously. His current medications include aspirin, atenolol, benazepril, tiotropium, and albuterol. His physical examination is consistent with a left-sided effusion with dullness to percussion and decreased breath sounds occurring over one-half of the hemithorax. On chest x-ray, there is a moderate left-sided pleural effusion with bilateral pleural calcifications and left apical pleural thickening. No lung mass is seen. A chest CT confirms the findings on chest x-ray and also fails to show a mass. There is compressive atelectasis of the left lower lobe. A thoracentesis is performed that demonstrates an exudative effusion with 65% lymphocytes, 25% mesothelial cells, and 10% neutrophils. Cytology does not demonstrate any malignancy. Which of the following statements regarding the most likely cause of the patient’s effusion is TRUE?
A. Cigarette smoking increases the likelihood of developing the condition.
B. Death in this disease is usually related to diffuse metastatic disease.
C. Exposure to the causative agent can be as little as 1–2 years, and latency to expression of disease may be as great as 40 years.
D. Repeated pleural fluid cytology will most likely lead to a definitive diagnosis.
E. Therapy with a combination of surgical resection and adjuvant chemotherapy significantly improves long-term survival.
VI-19. Chronic silicosis is related to an increased risk of which of the following conditions?
A. Infection with invasive Aspergillus
B. Infection with Mycobacterium tuberculosis
C. Lung cancer
D. Rheumatoid arthritis
E. All of the above
VI-20. All of the following occupational lung diseases are correctly matched with their exposure EXCEPT:
A. Berylliosis—High-technology electronics
B. Byssinosis—Cotton milling
C. Farmer’s lung—Moldy hay
D. Progressive massive fibrosis—Shipyard workers
E. Metal fume fever—Welding
VI-21. A 45-year-old male is evaluated in the clinic for asthma. His symptoms began 2 years ago and are characterized by an episodic cough and wheezing that responded initially to inhaled bronchodilators and inhaled corticosteroids but now require nearly constant prednisone tapers. He notes that the symptoms are worst on weekdays but cannot pinpoint specific triggers. His medications are an albuterol MDI, a fluticasone MDI, and prednisone 10 mg po daily. The patient has no habits and works as a textile worker. Physical examination is notable for mild diffuse polyphonic expiratory wheezing but no other abnormality. Which of the following is the most appropriate next step?
A. Exercise physiology testing
B. Measurement of FEV1 before and after work
C. Methacholine challenge testing
D. Skin testing for allergies
E. Sputum culture for Aspergillus fumigatus
VI-22. A 53-year-old male is seen in the emergency department with sudden-onset fever, chills, malaise, and shortness of breath, but no wheezing. He has no significant past medical history and is a farmer. Of note, he worked earlier in the day stacking hay. PA and lateral chest radiography show bilateral upper lobe infiltrates. Which organism is most likely to be responsible for this presentation?
A. Nocardia asteroides
B. Histoplasma capsulatum
C. Cryptococcus neoformans
E. Aspergillus fumigatus
VI-23. All of the following conditions are associated with an increased risk of methicillin-resistant Staphylococcus aureus as a cause of health care–associated pneumonia EXCEPT:
A. Antibiotic therapy in the preceding 3 months
B. Chronic dialysis
C. Home wound care
D. Hospitalization for more than 2 days in the preceding 3 months
E. Nursing home residence
VI-24. Which of the following statements regarding the diagnosis of community-acquired pneumonia is TRUE?
A. Directed therapy specific to the causative organism is more effective than empirical therapy in hospitalized patients who are not in intensive care.
B. Five percent to 15% of patients hospitalized with community-acquired pneumonia will have positive blood cultures.
C. In patients who have bacteremia caused by Streptococcus pneumoniae, sputum cultures are positive in more than 80% of cases.
D. Polymerase chain reaction tests for identification of Legionella pneumophila and Mycoplasma pneumoniae are widely available and should be utilized for diagnosis in patients hospitalized with community-acquired pneumonia.
E. The etiology of community-acquired pneumonia is typically identified in about 70% of cases.
VI-25. A 55-year-old man presents to his primary care physician with a 2-day history of cough and fever. His cough is productive of thick, dark green sputum. His past medical history is significant for hypercholesterolemia treated with rosuvastatin. He does not smoke cigarettes and is generally quite healthy, exercising several times weekly. He has no ill contacts and cannot recall the last time he was treated with any antibiotics. On presentation, his vital signs are as follows: temperature 102.1°F (38.9°C), blood pressure 132/78, heart rate 87 beats/min, respiratory rate 20 breaths/min, and oxygen saturation 95% on room air. Crackles are present in the right lung base with egophony. A chest radiograph demonstrates segmental consolidation of the right lower lobe with air bronchograms. What is the most appropriate approach to the ongoing care of this patient?
A. Obtain a sputum culture and await results prior to initiating treatment.
B. Perform a chest CT to rule out postobstructive pneumonia.
C. Refer to the emergency department for admission and treatment with intravenous antibiotics.
D. Treat with doxycycline 100 mg twice daily.
E. Treat with moxifloxacin 400 mg daily.
VI-26. A 65-year-old woman is admitted to the intensive care unit for management of septic shock associated with an infected hemodialysis catheter. She was initially intubated on hospital day 1 for acute respiratory distress syndrome. She has slowly been improving such that her FIO2 was weaned to 0.40, and she was no longer febrile or requiring vasopressors. On hospital day 7, she develops a new fever to 39.4°C (102.9°F) with increased thick, yellow-green sputum from her endotracheal tube. You suspect the patient has ventilator-associated pneumonia. What is the best way to make a definitive diagnosis in this patient?
A. Endotracheal aspirate yielding a new organism typical of a ventilator-associated pneumonia.
B. Presence of a new infiltrate on chest radiograph.
C. Quantitative cultures from an endotracheal aspirate yielding more than 106 organisms typical of ventilator-associated pneumonia.
D. Quantitative culture from a protected brush specimen yielding more than 103 organisms typical of ventilator-associated pneumonia.
E. There is no single set of criteria that is reliably diagnostic of pneumonia in a ventilated patient.
VI-27. Which of the following associations correctly pairs clinical scenarios and community-acquired pneumonia (CAP) pathogens?
A. Aspiration pneumonia: Streptococcus pyogenes
B. Heavy alcohol use: Atypical pathogens and Staphylococcus aureus
C. Poor dental hygiene: Chlamydia pneumoniae, Klebsiella pneumoniae
D. Structural lung disease: Pseudomonas aeruginosa, S. aureus
E. Travel to southwestern United States: Aspergillus spp.
VI-28. Which of the following is the most common cause of diffuse bronchiectasis worldwide?
A. Cystic fibrosis
B. Immunoglobulin deficiency
C. Mycobacterium avium-intracellulare infection
D. Mycobacterium tuberculosis infection
E. Rheumatoid arthritis
VI-29. A 54-year-old woman presents complaining of chronic cough that has worsened over a period of 6–12 months. She reports the cough to be present day and night, and productive of a thick green sputum. Over the course of the day, she estimates that she produces as much as 100 mL of sputum daily. Bilateral coarse crackles are heard in the lower lung zones. Pulmonary function tests demonstrate an FEV1 of 1.68 L (53.3% predicted), FVC of 3.00 L (75% predicted), and FEV1/FVC ratio of 56%. A chest radiograph is unremarkable. What would you recommend as the next step in the evaluation of this patient?
A. Bronchoscopy with bronchoalveolar lavage
B. Chest CT with intravenous contrast
C. High-resolution chest CT
D. Serum immunoglobulin levels
E. Treatment with a long-acting bronchodilator and inhaled corticosteroid
VI-30. A 48-year-old man is admitted to the hospital with fever and cough. He suffers from alcoholism and is homeless. He does not routinely obtain any health care. He reports that he has felt poorly for about 8 weeks. He has fatigue and generalized malaise. He states that he lost weight over this period as his clothing is very loose, but he cannot quantify the weight loss. He has felt feverish at times. During this period, he has been having increasing cough with malodorous sputum production. He coughs at least 3 tablespoons of dark sputum daily that has been blood streaked at times. He takes no medications, but drinks about 1 L of vodka daily. He also smokes one pack of cigarettes daily. On physical examination, the patient is disheveled and appears chronically ill. His vital signs are heart rate 98 beats/min, blood pressure 110/73, respiratory rate 20 breaths/min, temperature 38.2°C (100.8°F), and oxygen saturation of 94% on room air. He has evidence of temporal wasting with very poor dentition. A foul odor is present on his breath. Amphoric breath sounds are heard posteriorly in the right lower lung field. A chest x-ray shows a 4-cm cavitary lung lesion in the right lower lobe. The patient is admitted and placed on respiratory isolation. Sputum cultures for bacteria, mycobacteria, and fungus are ordered. What is the best initial choice for therapy in this patient?
A. Ampicillin-sulbactam 3 g intravenously every 6 hours
B. Isoniazid, rifampin, pyrazinamide, and ethambutol orally
C. Metronidazole 500 mg orally four times daily
D. Percutaneous drainage of the cavity
E. Piperacillin-tazobactam 2.25 g intravenously every 4 hours in combination with tobramycin 5 mg/kg intravenously daily
VI-31. A 35-year-old male is seen in the clinic for evaluation of infertility. He has never fathered any children, and after 2 years of unprotected intercourse his wife has not achieved pregnancy. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections, and the patient recently was told that he has bronchiectasis. Chest radiography is likely to show which of the following?
A. Bihilar lymphadenopathy
B. Bilateral upper lobe infiltrates
C. Normal findings
D. Situs inversus
E. Water balloon–shaped heart
VI-32. A 28-year-old woman is evaluated for recurrent lung and sinus infections. She recalls having at least yearly episodes of bronchitis beginning in her early teens. She states that for the past 5 years she has been on antibiotics at least three times yearly for respiratory or sinus infections. She also reports that she has had difficulty gaining weight and has always felt short compared to her peers. On physical examination, the patient has a body mass index of 18.5 kg/m2. Her oxygen saturation is 94% on room air at rest. Nasal polyps are present. Coarse rhonchi and crackles are heard in the bilateral upper lung zones. Mild clubbing is seen. A chest radiograph shows bilateral upper lobe bronchiectasis with areas of mucous plugging. You are concerned about the possibility of undiagnosed cystic fibrosis (CF). Which of the following tests would provide the strongest support for the diagnosis of CF in this individual?
A. DNA analysis demonstrating one copy of the delta F508 allele
B. Decreased baseline nasal potential difference
C. Presence of Pseudomonas aeruginosa on repeated sputum cultures
D. Sweat chloride values greater than 35 meq/L
E. Sweat chloride values greater than 70 meq/L
VI-33. A 22-year-old man with cystic fibrosis is seen for a routine follow-up exam. He is currently treated with recombinant human DNAse and albuterol by nebulization twice daily. His primary sputum clearance technique is aerobic exercise five times weekly and autogenic drainage. He is feeling well overall, and his examination is normal. Pulmonary function testing demonstrates an FEV1 of 4.48 L (97% predicted), an FVC of 5.70 L (103% predicted), and an FEV1/FVC ratio of 79%. A routine sputum culture grows Pseudomonas aeruginosa. The only organism isolated on prior cultures has been Staphylococcus aureus. What do you recommend for this patient?
A. High-frequency chest wall oscillation
B. Hypertonic saline (7%) nebulized twice daily
C. Inhaled tobramycin 300 mg twice daily every other month
D. Intravenous cefepime and tobramycin for 14 days
E. Return visit in 3 months with repeat sputum cultures and treatment only if there is persistent P. aeruginosa
VI-34. Which of the following organisms is unlikely to be found in the sputum of a patient with cystic fibrosis?
A. Haemophilus influenzae
B. Acinetobacter baumannii
C. Burkholderia cepacia
D. Aspergillus fumigatus
E. Staphylococcus aureus
VI-35. All of the following are risk factors for chronic obstructive pulmonary disease EXCEPT:
A. Airway hyperresponsiveness
B. Coal dust exposure
C. Passive cigarette smoke exposure
D. Recurrent respiratory infections
E. Use of biomass fuels in poorly ventilated areas
VI-36. A 65-year-old woman is evaluated for dyspnea on exertion and chronic cough. She has a long history of tobacco use, smoking 1.5 packs of cigarettes daily since the age of 20. She is a thin woman in no obvious distress. Her oxygen saturation on room air is 93% with a respiratory rate of 22/min. The lungs are hyperexpanded on percussion with decreased breath sounds in the upper lung fields. You suspect chronic obstructive pulmonary disease. What are the expected findings on pulmonary function testing (see Table VI-36)?
VI-37. A 70-year-old man with known chronic obstructive pulmonary disease is seen for follow-up. He has been clinically stable without an exacerbation for the past 6 months. However, he generally feels in poor health and is limited in what he can do. He reports dyspnea with usual activities. He is currently being managed with an albuterol metered-dose inhaler twice daily and as needed. He has a 50 pack-year history of smoking and quit 5 years previously. His other medical problems include peripheral vascular disease, hypertension, and benign prostatic hyperplasia. He is managed with aspirin, lisinopril, hydrochlorothiazide, and tamsulosin. On examination, the patient has a resting oxygen saturation of 93% on room air. He is hyperinflated to percussion with decreased breath sounds at the apices and faint expiratory wheezing. His pulmonary function tests demonstrate an FEV1 of 55% predicted, an FVC of 80% predicted, and an FEV1/FVC ratio of 50%. What is the next best step in the management of this patient?
A. Initiate a trial of oral glucocorticoids for a period of 4 weeks and initiate inhaled fluticasone if there is a significant improvement in pulmonary function.
B. Initiate treatment with inhaled fluticasone 110 μg/puff twice daily.
C. Initiate treatment with inhaled fluticasone 250 μg/puff in combination with inhaled salmeterol 50 mg/puff twice daily.
D. Initiate treatment with inhaled tiotropium 18 μg/daily.
E. Perform exercise and nocturnal oximetry, and initiate oxygen therapy if these demonstrate significant hypoxemia.
VI-38. A 56-year-old woman is admitted to the intensive care unit with a 4-day history of increasing shortness of breath and cough with copious sputum production. She has known severe COPD with an FEV1 of 42% predicted. On presentation, she has a room air blood gas with a pH 7.26, PaCO2 78 mmHg, and PaO2 50 mmHg. She is in obvious respiratory distress with the use of accessory muscles and retractions. Breath sounds are quiet with diffuse expiratory wheezing and rhonchi. No infiltrates are present on chest radiograph. Which of the following therapies has been demonstrated to have the greatest reduction in mortality for patients with these findings?
A. Administration of inhaled bronchodilators
B. Administration of intravenous glucocorticoids
C. Early administration of broad-spectrum antibiotics with coverage of Pseudomonas aeruginosa
D. Early intubation with mechanical ventilation
E. Use of noninvasive positive pressure ventilation
VI-39. A 63-year-old male with a long history of cigarette smoking comes to see you for a 4-month history of progressive shortness of breath and dyspnea on exertion. The symptoms have been indolent, with no recent worsening. He denies fever, chest pain, or hemoptysis. He has a daily cough of 3–6 tablespoons of yellow phlegm. The patient says he has not seen a physician for over 10 years. Physical examination is notable for normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated jugular venous pulsation, and moderate pedal edema. Hematocrit is 49%. Which of the following therapies is most likely to prolong his survival?
VI-40. A 62-year-old man is evaluated for dyspnea on exertion that has progressively worsened over a period of 10 months. He has a 50 pack-year history of tobacco, quitting 10 years ago. His physiologic and radiologic evaluation demonstrates a restrictive ventilatory defect with diffuse fibrosis that is worse in the subpleural region and at the bases. A surgical lung biopsy is performed, which is consistent with usual interstitial pneumonia. No autoimmune or drug-related cause is found. What is the recommended treatment for this patient?
A. Azathioprine 125 mg daily plus prednisone 60 mg daily
B. Cyclophosphamide 100 mg daily
C. N-acetylcysteine 600 mg twice daily plus prednisone 60 mg daily
D. Prednisone 60 mg daily
E. Referral for lung transplantation
VI-41. What would be the expected finding on bronchoalveolar lavage in a patient with diffuse alveolar hemorrhage?
A. Atypical hyperplastic type II pneumocytes
B. Ferruginous bodies
C. Hemosiderin laden macrophages
D. Lymphocytosis with an elevated CD4:CD8 ratio
E. Milky appearance with foamy macrophages
VI-42. A 42-year-old male presents with progressive dyspnea on exertion, low-grade fevers, and weight loss over 6 months. He also is complaining of a primarily dry cough, although occasionally he coughs up thick mucoid sputum. There is no past medical history. He does not smoke cigarettes. On physical examination, the patient appears dyspneic with minimal exertion. The patient’s temperature is 37.9°C (100.3°F). Oxygen saturation is 91% on room air at rest. Faint basilar crackles are heard. On laboratory studies, the patient has polyclonal hypergammaglobulinemia and a hematocrit of 52%. A CT scan reveals bilateral alveolar infiltrates that are primarily perihilar in nature with a mosaic pattern. The patient undergoes bronchoscopy with bronchoalveolar lavage. The effluent appears milky. The cytopathology shows amorphous debris with periodic acid–Schiff (PAS)-positive macrophages. What is the diagnosis?
A. Bronchiolitis obliterans organizing pneumonia
B. Desquamative interstitial pneumonitis
D. Pneumocystis carinii pneumonia
E. Pulmonary alveolar proteinosis
VI-43. What treatment is most appropriate at this time for the patient in question VI-42?
C. Prednisone and cyclophosphamide
E. Whole-lung saline lavage
VI-44. A 68-year-old man presents for evaluation of dyspnea on exertion. He states that he first noticed the symptoms about 2 years ago. At that time, he had to stop walking the golf course and began to use a cart, but he was still able to complete a full 18 holes. Over the past year, he has stopped golfing altogether because of breathlessness and states that he has difficulty walking to and from his mailbox, which is about 50 yards from his house. He also has a dry cough that occurs on most days. It is not worse at night, and he can identify no triggers. He denies wheezing. He has had no fevers, chills, or weight loss. He denies any joint symptoms. He is a former smoker of about 50 pack-years, but quit 8 years previously after being diagnosed with coronary artery disease. On physical examination, he appears breathless after walking down the hallway to the examination room, but quickly recovers upon resting. Vital signs are as follows: blood pressure 118/67 mmHg, heart rate 88 beats/min, respiratory rate 20 breaths/min. His SaO2 is 94% at rest and decreases to 86% after ambulating 300 ft. His lung examination shows normal percussion and expansion. There are Velcro-like crackles at both bases, and they are distributed halfway through both lung fields. No wheezing is noted. Cardiovascular examination is normal. Digital clubbing is present. A chest CT is performed and is shown in Figure VI-44. He is referred for surgical lung biopsy. Which pathologic description is most likely to be seen in this patient’s disease?
A. Dense amorphous fluid within the alveoli diffusely that stains positive with periodic acid–Schiff stain
B. Destruction of alveoli with resultant emphysematous areas, predominantly in the upper lobes
C. Diffuse alveolar damage
D. Formation of noncaseating granulomas
E. Heterogeneous collagen deposition with fibroblast foci and honeycombing
VI-45. All the following are pulmonary manifestations of systemic lupus erythematosus EXCEPT:
A. Cavitary lung nodules
B. Diaphragmatic dysfunction with loss of lung volumes
D. Pulmonary hemorrhage
E. Pulmonary vascular disease
VI-46. A 56-year-old woman presents for evaluation of dyspnea and cough for 2 months. During this time, she has also had intermittent fevers, malaise, and a 5.5-kg (12-lb) weight loss. She denies having any ill contacts and has not recently traveled. She works as a nurse, and a yearly PPD test performed 3 months ago was negative. She denies any exposure to organic dusts and does not have any birds as pets. She has a history of rheumatoid arthritis and is currently taking hydroxychloroquine, 200 mg twice daily. There has been no worsening in her joint symptoms. On physical examination, diffuse inspiratory crackles and squeaks are heard. A CT scan of the chest reveals patchy alveolar infiltrates and bronchial wall thickening. Pulmonary function testing reveals mild restriction. She undergoes a surgical lung biopsy. The pathology shows granulation tissue filling the small airways, alveolar ducts, and alveoli. The alveolar interstitium has chronic inflammation and organizing pneumonia. What is the most appropriate therapy for this patient?
A. Azathioprine 100 mg daily
B. Discontinuation of hydroxychloroquine and observation
C. Infliximab IV once monthly
D. Methotrexate 15 mg weekly
E. Prednisone 1 mg/kg daily
VI-47. In which of the following patients presenting with acute dyspnea would a positive D-dimer prompt additional testing for a pulmonary embolus?
A. A 24-year-old woman who is 32 weeks pregnant.
B. A 48-year-old man with no medical history who presents with calf pain following prolonged air travel. The alveolar-arterial oxygen gradient is normal.
C. A 56-year-old woman undergoing chemotherapy for breast cancer.
D. A 62-year-old man who underwent hip replacement surgery 4 weeks previously.
E. A 72-year-old man who had an acute myocardial infarction 2 weeks ago.
VI-48. A 62-year-old woman is hospitalized following an acute pulmonary embolism. All of the following would typically indicate a massive pulmonary embolism EXCEPT:
A. Elevated serum troponin levels
B. Initial presentation with hemoptysis
C. Initial presentation with syncope
D. Presence of right ventricular enlargement on CT scan of the chest
E. Presence of right ventricular hypokinesis on echocardiogram
VI-49. Which of the following statements regarding diagnostic imaging in pulmonary embolism is TRUE?
A. A high probability ventilation-perfusion scan is one that has at least one segmental perfusion defect in the setting of normal ventilation.
B. If a patient has a high probability ventilation-perfusion scan, there is a 90% likelihood that the patient does indeed have a pulmonary embolism.
C. Magnetic resonance angiography provides excellent resolution for both large proximal and smaller segmental pulmonary emboli.
D. Multidetector-row spiral CT imaging is suboptimal for detecting small peripheral emboli, necessitating the use of invasive pulmonary angiography.
E. None of the routinely used imaging techniques provide adequate evaluation of the right ventricle to assist in risk stratification of the patient.
VI-50. A 53-year-old woman presents to the hospital following an episode of syncope, with ongoing lightheadedness and shortness of breath. She had a history of antiphospholipid syndrome with prior pulmonary embolism and has been nonadherent to her anticoagulation medication recently. She has been prescribed warfarin, 7.5 mg daily, but reports taking it only intermittently. She does not know her most recent INR. On presentation to the emergency room, she appears diaphoretic and tachypneic. Her vital signs are as follows: blood pressure 86/44 mmHg, heart rate 130 beats/min, respiratory rate 30 breaths/min, and oxygen saturation of 85% on room air. Cardiovascular examination shows a regular tachycardia without murmurs, rubs, or gallops. The lungs are clear to auscultation. On extremity examination, there is swelling of her left thigh with a positive Homan’s sign. Chest CT angiography confirms a saddle pulmonary embolus with ongoing clot seen in the pelvic veins on the left. Anticoagulation with unfractionated heparin is administered. After a fluid bolus of 1 L, the patient’s blood pressure remains low at 88/50 mmHg. Echocardiogram demonstrates hypokinesis of the right ventricle. On 100% non-rebreather mask, the oxygen saturation is 92%. What is the next best step in the management of this patient?
A. Continue current management.
B. Continue IV fluids at 500 mL/h for a total of 4 L of fluid resuscitation.
C. Refer for inferior vena cava filter placement and continue current management.
D. Refer for surgical embolectomy.
E. Treat with dopamine and recombinant tissue plasminogen activator, 100 mg IV.
VI-51. A 42-year-old woman presents to the emergency room with acute onset of shortness of breath. She recently had been to visit her parents out of state and rode in a car for about 9 hours each way. Two days ago, she developed mild calf pain and swelling, but she thought that this was not unusual after having been sitting with her legs dependent for the recent trip. On arrival to the emergency room, she is noted to be tachypneic. The vital signs are as follows: blood pressure 98/60 mmHg, heart rate 114 beats/min, respiratory rate 28 breaths/min, oxygen saturation of 92% on room air, weight 89 kg. The lungs are clear bilaterally. There is pain in the right calf with dorsiflexion of the foot, and the right leg is more swollen when compared to the left. An arterial blood gas measurement shows a pH of 7.52, PCO2 25 mmHg, and PO2 68 mmHg. Kidney and liver function are normal. A helical CT scan confirms a pulmonary embolus. All of the following agents can be used alone as initial therapy in this patient EXCEPT:
A. Enoxaparin 1 mg/kg SC twice daily
B. Fondaparinux 7.5 mg SC once daily
C. Tinzaparin 175 U/kg SC once daily
D. Unfractionated heparin IV adjusted to maintain activated partial thromboplastin time (aPTT) two to three times the upper limit of normal
E. Warfarin 7.5 mg po once daily to maintain INR at 2–3
VI-52. A 62-year-old woman is admitted to the hospital with a community-acquired pneumonia with a 4-day history of fever, cough, and right-sided pleuritic chest pain. The admission chest x-ray identifies a right lower and middle lobe infiltrate with an associated effusion. All of the following characteristics of the pleural effusion indicate a complicated effusion that may require tube thoracostomy EXCEPT:
A. Loculated fluid
B. Pleural fluid pH less than 7.20
C. Pleural fluid glucose less than 60 mg/dL
D. Positive Gram stain or culture of the pleural fluid
E. Recurrence of fluid following the initial thoracentesis
VI-53. A 58-year-old man is evaluated for dyspnea and is found to have a moderate right-sided pleural effusion. He undergoes thoracentesis with the following characteristics:
Which of the following is an unlikely cause of the pleural effusion in this patient?
B. Lung cancer
D. Pulmonary embolism
VI-54. A 66-year-old woman is evaluated for dyspnea. One month previously, she had undergone an esophagectomy for adenocarcinoma of the esophagus. On physical examination, the patient appears tachypneic with difficulty speaking in full sentences. She has a respiratory rate of 28/min and an oxygen saturation of 88% on room air. There is dullness to percussion with absent breath sounds in the left hemithorax. A chest radiograph confirms a large left-sided pleural effusion with mediastinal shift to the right. A thoracentesis removes 1.5 L of a milky-appearing fluid. The protein of the fluid is 6.2 mg/dL, LDH is 368 IU/L, and the WBC count is 1500/μL (20% PMNs, 80% lymphocytes). The triglyceride level is 168 mg/dL. Cultures and cytology are negative. Which of the following is the best management for this patient?
A. Placement of a chest tube plus octreotide
B. Placement of a chest tube to wall suction until drainage decreases to less than 100 mL daily
C. Reexploration of the chest with surgical correction of the likely defect
D. Referral for palliative care
E. Repeat thoracentesis for cytologic examination
VI-55. A 28-year-old man presents to the emergency room with acute-onset shortness of breath and pleuritic chest pain on the right that began 2 hours previously. He is generally healthy and has no medical history. He has smoked one pack of cigarettes daily since the age of 18. On physical examination, he is tall and thin with a body mass index of 19.2 kg/m2. He has a respiratory rate of 24/min with an oxygen saturation of 95% on room air. He has slightly decreased breath sounds at the right lung apex. A chest x-ray demonstrates a 20% pneumothorax on the right side. Which of the following is TRUE regarding pneumothorax in this patient?
A. A CT scan is likely to show emphysematous changes.
B. If the patient were to develop recurrent pneumotho-races, thorascopy with pleural abrasion has a success rate of nearly 100% for prevention of recurrence.
C. Most patients with this presentation require tube thoracostomy to resolve the pneumothorax.
D. The likelihood of recurrent pneumothorax is about 25%.
E. The primary risk factor for the development of spontaneous pneumothorax is a tall and thin body habitus.
VI-56. The most common cause of a pleural effusion is:
B. Left ventricular failure
E. Pulmonary embolism
VI-57. A patient with mild amyotrophic lateral sclerosis is followed by a pulmonologist for respiratory dysfunction associated with his neuromuscular disease. Which of the following symptoms in addition to PaCO2 of 45 mmHg or greater would necessitate therapy with noninvasive positive pressure ventilation for hypoventilation?
B. Poor quality sleep
C. Impaired cough
D. Dyspnea in activities of daily living
E. All of the above
VI-58. A 27-year-old man with muscular dystrophy is evaluated by his primary care physician for hypoxemia. He reports feeling at his baseline and is not short of breath. On physical examination, finger pulse oximetry is 86% on room air, his lungs are clear, and aside from stigmata of muscular dystrophy, is normal. Chest radiograph shows low lung volumes. Which of the following is most likely the source of his low oxygen saturation?
B. Mucous plug
C. Elevated PaCO2
VI-59. Patients with chronic hypoventilation disorders often complain of a headache upon wakening. What is the cause of this symptom?
A. Arousals from sleep
B. Cerebral vasodilation
C. Cerebral vasoconstriction
E. Nocturnal microaspiration and cough
VI-60. A 47-year-old woman with idiopathic pulmonary arterial hypertension has failed medical therapy including intravenous epoprostenol. She has advanced right heart failure with severe right ventricular dysfunction on echocardiography and a cardiac index of 1.7 L/min per m2. She is referred for lung transplantation. Which of the following statements is true?
A. She will require heart-lung transplantation for her advanced right heart failure.
B. Idiopathic pulmonary arterial hypertension patients have worse 5-year survival than other transplant recipients.
C. Single-lung transplantation is the preferred surgical procedure for idiopathic pulmonary arterial hypertension.
D. Her own right ventricular function will recover after lung transplantation.
E. She is at risk for recurrent pulmonary arterial hypertension after lung transplantation.
VI-61. A 25-year-old woman with cystic fibrosis is referred for lung transplantation. She is concerned about her long-term outcomes. Which of the following is the main impediment to long-term survival after lung transplantation?
A. Bronchiolitis obliterans syndrome
B. Cytomegalovirus infection
C. Chronic kidney disease
D. Primary graft dysfunction
E. Post-transplant lymphoproliferative disorder
VI-62. A 30-year-old man with end-stage cystic fibrosis undergoes lung transplantation. Three years later, he has a 6-month progressive decline in his renal function. Which of the following medications is the most likely etiology of this?
D. Mycophenolate mofetil
E. None of the above
VI-63. A 22-year-old man has cystic fibrosis. He currently is hospitalized about three times yearly for infectious exacerbations. He is colonized with Pseudomonas aeruginosa and Staphylococcus aureus, but has never had Burkholderia cepacia complex. He remains active and is in college studying architecture. He requires 2 L of oxygen with exertion. The most recent pulmonary function tests demonstrate an FEV1 that is 28% of the predicted value and an FEV1/FVC ratio of 44%. Measurement of his arterial blood gas or room air is pH 7.38, PCO2 36 mmHg, and PO2 62 mmHg. Which of these characteristics is an indication for referral for lung transplantation?
A. Colonization with Pseudomonas aeruginosa
B. FEV1 less than 30% predicted
C. FEV1/FVC ratio less than 50%
D. PCO2 less than 40 mmHg
E. Use of oxygen with exertion