BNB - Pulmonary Quizzes

A 34 year old man is referred for PFT. He is able to produce three similar curves. FEV1 is 3 Liters FVC is 4 liters What is his FEV1:FVC ratio

0.75

A 57 year old patient presents to the ER with fever and productive cough for 3 days. BP: 110/76 Pulse: 100/min RR: 22/min Temperature: 101 Hb: 7.0 g/dL PO2: 65 mm Hg a PCO2: 36 mm Hg What is the patient's alveolar partial pressure of of oxygen (assume room air gives a partial inspired equal to 150 mm Hg).

105 mm Hg. 150 - 36/.8

A 35 year old man presents with fever and cough. He reports chills for the last two days along with mild shortness of breath and a productive cough. His PMH is significant for HIV for which he is compliant with multi-agent antiretroviral therapy. His last CD4 cell count was 550/mm3. BP is 1120/76, pulse is 92/min, RR is 18, temp is 101.8 and O2 sat is 93%. Pulmonary exam demonstrates crackles in right lung. Chest X ray shows a focal consolidation in the right middle lobe that obscures the right heart border. Which of the following organisms is the most likely cause? A. Streptococcus pneumoniae B. Haemophilus influenze C. Moraxella catarrhalis D. Pneumocystis jirovecii E. Legionella pneophila

Streptococcus pneumoniae HIV patients are immunocompromised and therefore susceptible to pneumonia form bacterial agents as well as certain fugni and viruses. Although the patient has HIV, he is presenting with a straightforward case of community acquired lobar pneumonia, which is most commonly caused by Streptococcus pneumoniae. Streptococcus pneumoniae is still the most common cause of pneumonia in HIV patients. Other less common causes are B and C. Lobar pneumonia typically presents with an acute onset of symptoms such as fever, chills, dyspnea, and productive cough. X ray classically shows a focal unilateral opacity. Pneumocystis jirovecii pneumonia causes pneumonia in HIV/AIDS patients. Clinical manifestations are a slower, more indolent onset with low grade fever, malaise, cough, and dyspnea. It is most common in patients with poor disease control. Chest X ray would show diffuse bilateral ground glass opacities rather than lobar consolidation.

A 13 year old boy presents for plethysmography for characterization of asthma. His functional residual capacity is 3 liters. Inspiratory capacity is 2.5 liters, and vital capacity is 3.5 liters. What is his residual volume?

2.0 L In the lungs, a capacity is the sum of two or more lung volumes. The FRC is equal to the ERV plus the RV. Base on this, residual volume can be calculated by subtracting the ERV from the FRC. FRC = ERV + RV RV = FRC - ERV The FRC is given as 3 L. To obtain the ERV, we can use the data given for the vital capacity and the IC. the VC is equal to the IC plus the ERV. VC = IC + ERV ERV = VC - IC = 3.5 -2.5 The ERV is 1 L. Therefore, the RV is the FRC minus the ERV. 3.5-2.5 = 1

A 58 year old man present to pulmonology clinic for follow up. He has a history of idiopathic interstitial fibrosis resulting in restrictive lung disease. Pulmonary function tests are performed showing FEV1 at 66% of predicted, FVC of 70% of predicted and DLCO (diffusion capacity of the lung for CO) at 55% of predicted. Which of the following describes the exchange of oxygen in this patient's lungs? A. Diffusion limited B. Perfusion limited C. Unable to determine D. Not diffusion or perfusion limited

A In normal lungs uptake of oxygen is perfusion limited meaning uptake is proportional to blood flow (more flow = more oxygen uptake). In pulmonary fibrosis, oxygen becomes diffusion limited. The main indication of diffusion limited oxygen uptake in this patient, is his reduced diffusing capacity of the lungs for carbon monoxide.

An 82 year old man presents for evaluation of weight gain. He has gained 10 pounds in one week with associated leg swelling and SOB. He has a history of CHF and this presentation is consistent with past exacerbations. Vitals include BP 112/68, pulse 92, RR 20, temp 97.9, O2 is 93%. Breath sounds are decreased in lower lung fields. CXR shows pulmonary congestion and bilateral pleural effusions in the lung bases. Which of the following is the best management of this patient's pleural effusions? A. Diuresis B. Thoracentesis C. Chest tube placement D. Observation E. Surgical intervention

A Patient is presenting with bilateral pleural effusions from an exacerbation of heart failure. HF exacerbations are treated with loop diuretics, which relieve pulmonary congestion leading to resorption of pleural fluid. Pleural effusions associated with respiratory distress can be drained via thoracentesis to improve symptoms and help with diagnosis. Chest tube placement can also be done. For bilateral pleural effusions associated with HF these are not necessary. The cause (heart failure) is obvious, so treat that.

A 17 year old girl presents to the clinic with four days of dry cough and malaise. She had a sore throat at initial onset of symptoms, but has since improved. A number of her high school classmates have a similar illness. On a daily inhaled corticosteroid for asthma. Temp of 100.4, everything else normal. Chest x ray shows diffuse, patchy interstitial opacities in both lungs. Which of the following medications is most appropriate? A. Azithromycin B. Amoxicillin-clavulanate C. Vancomycin D. Piperacillin-tazobactam E. Clindamycin

A The patient is presenting with an atypical pneumonia likely caused by Mycoplasma. This is typical in young patients with lots of exposure to other people. Mycoplasma pneumonia presents with the indolent onset of malaise, low grade fever, and cough. Other possible manifestations include pharyngitis, maculopapular rash, hemolytic anemia, and Stevens-Johnson syndrome. Xray will show diffuse interstitial opacities that often look worse than the symptoms. Antibiotics with the best coverage inlclude macrolides, fluoroquinolones, or tetracyclines. These agents with atypical coverage are effective against Mycoplasma, Legionella and Chlamydia pneumonia. Azithromycin is a commonly used macrolide that is part of the standard antimicrobial therapy for community acquired pneumonia. Amoxicillin-clavulanate is a broad spectrum antibiotic that may be used in some cases of lobar pneumonia. No coverage for atypical organisms. Vancomycin is primarily used to coer methicillin-resistant staph aureus. It does not cover atypicals. P-T is used to cover gram negative agents such as pseudomonas. It can also cover anaerobic coverage, but doesn't cover atypicals.

82 yo man presents to ER with muscle weakness. Diagnosed with small cell carcinoma three months ago. He is undergoing chmo with cisplatin and etoposide. His first cycle of therapy was completed 4 weeks ago. He has difficulty standing from a chair and also feels he cannot lift as much as usual. Vital signs are normal. Neurologic exam is significant for bilateral ptosis. Pupils are equal, round and reactive to light. Extraocular muscle movements are intact. CN tests shows no abnormalities. The patient has full range of motion in all extremities. 3/5 muscle strenght bilaterally. Deep tendon reflexes in the upper and lower extremities are 1+. Cerebellar testing is normal. The patient's creatine kinase and erythrocyte sedimentation rate are within normal limits. Which of the following is the most likely cause of the patient's symptoms? A Pre-synaptic autoantibodies B. Post synaptic autoantibodies C. Drug reaction D. Autoimmune muscle inflammation E. Nerve compression.

A The patient is presenting with subacute, progressive bilateral muscle wekaness in the setting of small cell lung carcinoma. This presentation is highly suggestive of Lambert-Eaton syndrome, a paraneoplastic condition n which autoantibodies are fomred against presynaptic calcium channels. Patients with L-E present with bilateral proximal muscle weakness. Ptosis and cranial nerve invovlement are other possible findings.

An 82 yo male presents with fatigue. Over the last week he has been sleeping for most of the day. He is lightheaded when standing up. He was diagnosed with squamous cell carcinoma of the lung one year ago and opted against surgery or chemotherapy. Vitals include BP 84/52 mm Hg, pulse 102/min, RR 14/min, temp 98.8 and O2 sat 98% on room air. Lab: Hb 12 (13.5-17.5), Hematocrit 36.2 (41-53), Leukocyte 4200 (4500-11000), Sodium slightly high, Potassium slightly low, Glucose low. Which of the following is the most likely cause of the patient's presentation? A. Organ dysfunction from metastatic disease B. Ectopic hormone production C. Pulmonary vascular obstruction D. Inadequate renal blood flow E. Lesion of the pituitary

A This patient has primary adrenal insufficiency. The key finding is the patient's lab results that indicate primary adrenal insufficiency are hypoglycemia, hyperkalemia, alkalosis, and hyponatremia. Clinical manifestations of adrenal insufficiency due to loss of the adrenal insufficiency occur due to loss of the adrenal hormones aldosterone and cortisol. Low cortisol leads to hypotension and hypoglycemia. Low aldosterone leads to volume loss, hyperkalemia and a non-anion gap metabolic acidosis. The most common causes of primary adrenal insufficiency are autoimmune disease and tuberculosis. Metastatic disease is a rare cause of adrenal insufficiency, but lung cancer is the most common cause of metastatic primary adrenal insufficiency.

A 30 yo male is seen for follow up of a CXR finding. The patient was in a minor car accident and received a CXR in the ER. A 0.7 cm regular, round nodule was seen in the periphery of the right lung. He has no significant PMH. He is an occasional smoker and emigrated from Mexico eight years ago. Vital signs are within normal limits. Which of the following is the likely underlying cause of the nodule? A. Granuloma B. Hamartoma C. Malignancy D. Infection E. Traumatic lesion

A Young patients that present with pulmonary nodules are more likely to have benign etiologies than malignant. In addition, a person who presents with symptoms is more likely to have a benign lesions than a malignant one. The most common cause of a benign pulmonary nodule is a granuloma, which is typically formed after infection with fungi or tuberculosis. Management of pulmonary nodules is outside the scope of Step 1. However, pulmonary nodules are better visualized by CT. Lesions with low risk for malignancy are typically followed with serial imaging. Larger, higher ris lesions may require biopsy. The important take away is that small nodules in people under 40 are typically benign.

21 year old woman evaluated for lightheadedness. Exertion brings on this feeling. One episode of syncope with exertion. ROS shows mild dyspnea, but no cough. No PMH or medications. Her mother passed away at 25 after childbirth and her father has asthma. BP 108/68, pulse 102, RR of 20, temp 98. On exam, she is breathing comfortably without cyanosis. Lungs CTA and resonant to percussion. Loud P2 sound. Pulses 2+ throughout. ECG shows large R waves in V1 and right axis deviation. Which of the following is the most likely etiology for her condition? A. Genetic mutation B. Chronic thromboembolism C. Bronchial hyperreactivity D. Cardiomyopathy E. Lung inflammation

A. Patient has signs and symptoms of pulmonary HTN. Given her young age and family history, she most likely has pulmonary arterial hypertension secondary to a BMPR2 mutation. This results in smooth muscle hyperplasia and fibrosis in the the three layers of the pulmonary arterial vascular wall. PVR increases lead to RV hypertrophy and right heart failure. Pregnancy exacerbates pulmonary HTN and is frequently fatal. The loud P2 sound and parasternal heave are the biggest clinical signs. Late stage can result in findings of right heart failure. The ECG showing a right axis deviation is indicative of right heart failure. B - could, but unlikely in this patient, would see a history of hypercoaguable state. C - Asthma D - left sided heart failure signs like bibasilar crackles or LV hypertrophy on EKG would be seen. E - can cause pulmonary HTN. Presents as slowly progressive dyspnea and cough. Exposure to a toxin or use of amiodarone most likely cause. X ray would show honeycombing

A 65 year old man is referred for PFT. He takes a deep breath and forces out as much air as possible. A graph of time vs. volume shows that a steady slope between 1 and 4 seconds before it plateaus at 4 liters. A. Obstructive disease B. Restrictive disease C. Normal test D. No conclusion

A. The FVC and the FEV1 are the two important values. In this patient the FEV1 is around 1 liter. The FVC is around 4 L. FEV1/FVC = 25% (normally 80%). A decreased FEV1/FVC ratio is consistent with obstructive disease. Airway obstruction limits the air that can be expired in one second.

A 57 year old with a history of severe chronic asthma presents for a right heart cathertization to evaluate for pulmonary HTN. A catheter is inserted through her femoral vein and into her pulmonary artery to measure PVR. At what point in the respiratory cycle will her pulmonary vascular resistance be lowest? A. Maximum expiration B. After expiration of a normal tidal volume C. After inhalation of a normal tidal volume D. Maximum inspiration E. Maximum expiration with breath hold

B. PVR is lowest when the lungs are at FRC. This occurs after expiration of a normal tidal volume. At this point, resistance of the pulmonary arterioles and pulmonary alveolar capillaries is minimized. During inspiration (C and D) alveoli expand and compress the adjacent capillaries, raising resistance. During maximum expiration (A and E) pulmonary arterioles are collapsed which increases vascular resistance. FRC is the happy medium of least resistance.

A 35 year old African American women presents to pulmonary clinic with six months of dry cough and dyspnea. A CXR was ordered last month and showed prominent hila. On exam, the patient has lower lung rales bilaterally. Cervical lymphadenopahty is also present. The patient undergoes a cervical lymph node biopsy which reveals non-caseating granulomas. Which of the following are involved in the pathogenesis of this patient's condition? A. IL-1 B. IL-2, INF-gamma C. IL-4, IL-5 D. IL-6 E IL-10, TGF-beta

B Classic case of sarcoidosis based on patient demographic, presentation, and findings. The non-caseating granulomas are characterized by the presence of epithelioid histiocytes (lightly eosinophilic cells with flattened, elongated nuclei) and multi nucleated giant cells (large eosinophilic cells with multiple basophilic nuclei). The formation of non-caseating granulomas involve the interaction of CD4 helper T cells with macrophages. INF-gamma secretion from the helper T cells stimulates macrophages to undergo the changes seen in granulomas. IL-2 is also produced and maintains a robust T helper cell response.

A 75 year old man with a PMH of Hypertension, diabetes mellitus, COPD and gout presents for a health maintenance visit. He has been stable over the last year without hospitalizations. His most recent PFT shows an FEV1 of 45%. Vitals inclue BP 142/68, pulse 82, RR 14, and O2 sat of 92%. On exam, the patient breathes slowly with prolonged expiration. Which of the following is a potential complication of this patient's underlying pulmonary disease? A. Hypernatremia B. Polycythemia C. Anemia D. Neuropathy E. Arthritis

B Patients with COPD and chronic hypoxemia may develop polycythemia. Chronic hypoxemia results in the production of erythropoietin. As a result, RBC mass is increased as a physiologic response to chronic hypoxemia. Similar to response to high altitude or cyanotic congenital heart defects.

A 92 year old woman is admitted for sepsis secondary to right middle lobe pneumonia. One day after admission, she develops worsening hypoxemia. She is minimally responsive and requires 100% non-rebreather oxygen mask. Repeat CXR shows new fluffy opacities bilaterally. ECG demonstrates an ejection fraction of 60% (normal is >55). JVP and heart sounds are normal. Which of the following is the most likely cause of this patient's respiratory distress? A. Left heart failure B. Leakage of proteinaceous fluid into alveoli C. Progression of bacterial infection D. Propagation of a blood clot E. Iatrogenic fluid overload

B Patients with sepsis are at risk for acute respiratory distress syndrome (ARDS). Inflammatory mediators from sepsis cause endothelial dysfunction and damage. This allows proteinaceous fluid leakage into the alveoli leading to diffuse pulmonary edema and hypoxemia from shunt physiology. Edema also reduces lung compliance. The patient will require mechanical ventilation with high pressure to ventilate her poorly compliant lungs. Other causes of ARDS: trauma, pancreatitis, obstetric complications, and transfusion-associated acute lung injury. Criteria for the diagnosis include acute bilateral lung opacities with severe hypoxemia. Cardiac causes of pulmonary edema must be excluded. The patient had a normal ECG, JVP, heart sounds and ejection fraction so LHF is unlikely especially compared to ARDS.

A 28 year old man is seen by the trauma team after falling off a ladder. No internal bleeding is identified. Vitals include BP 78/48, pulse 108, RR 22, temp 98, O2 sat 94% on 16 L oxygen mask Jugular venous presure is elevated. CXR shows a large, left sided pneumothorax with tracheal deviation to the right. The diaphragm is flattened on the left side. Which of the following is the most likely cause of hypotension in this patient? A. Increased afterload B. Decreased preload C. Pulmonary arterial obstruction D. Decreased cardiac contractility E. Hypovolemia

B Tension pneumothorax develops when pleural air becomes trapped and exerts pressure on surrounding structures in the chest. X ray findings include tracheal deviation away from the affected side and depression of the diaphragm. Hemodynamic instability results from pressure on veins in the chest. This decreases venous return and cardiac preload. Decreased preload leads to a fall in cardiac output and findings of shock including hypotension and tachycardia. Jugular venous distension is present due to impaired venous return. A - aortic stenosis or hypertension C - occurs in pulmonary embolism and may result in low CO due to poor left heart preload D - occurs in cardiogenic shock associated with infarction E - Hemorrhagic shock. JVP wouldn't be decreased.

A 73 yo female is admitted to the hospital for respiratory failure. She has no significant PMH and takes only aspirin and a multivitamin. She does not smoke cigarettes or drink alcohol. A chest CT is obtained with a section through the lower lungs displayed below. It shows multiple lower lung nodules. Which of the following is the most likely diagnosis? A. Pulmonary adenocarcinoma B. Breast adenocarcinoma C. Squamous cell carcinoma D. Small cell carcinoma E. Large cell carcionoma.

B The CT scan shows multiple lower lung nodules consistent with lung metastases. Common sources of metastatic lung cancer are breast, colon and prostate cancers. As a rule of thumb, multiple lesions suggests metastatic rather than primary lung cancer. Metastases typically occur in the lung periphery. Lower lobes are more commonly affected due to higher blood flow.

A 75 year old man is admitted to the ICU with septic shock. Lab testing shows elevated serum lactate Arterial blood pH is 7.12 (normal is 7.45). This man's condition will alter the oxyhemoglobin via which of the following mechanisms? A. Decreasing oxygen release in peripheral tissue B. Promotion of hemoglobin in the taut form C. Shifting the oxyhemoglobin curve down and left D. Promoting the formation of methemoglobin. E. Increased 2,3 BPG production

B The man has lactic acidosis caused by septic shock. Acidemic conditions promote the release of oxygen from hemoglobin by inducing the taut protein configuation which has a decreased affinity for oxygen compared to the relaxed state. Hb is either taut or relaxed. The taut state is formed when protons bind specific histidine groups in Hb and shift the protein configuration. This causes a right shift meaning less Hb binding at a give PaO2. Increased temp, increased CO2, and increased 2,3-BPG can also shift the curve. The mechanism behind these shifts is a switch to the taut configuration.

A 62 year old is seen for follow up 3 months after inpatient treatment for community acquired pneumonia. The patient has been well since discharge. CXR shows clear lung fields bilaterally, an improvement from the consolidation seen during hosptialization. Which of the following cell types is most responsible for the recovery of normal lung tissue in this patient? A. Type 1 pneumocytes B. Type 2 pneumocytes C. Goblet Cells D. Club cells E. Neutrophils

B The patient had lobar pneumonia which has resolved. After the stages of lobar pneumonia (congestion, re hepatization, white hepatization) comes resolution. Enzymes digest the exudate and Type II pneumoncytes regenerate normal lung tissue. Type 2 - stem cells and surfactant secretion Type 1 - predominant cells in the alveoli. Allow for gas exchange.

A 14 yo male presents to ER for blood streaked sputum. For the last week, he has had fever, fatigue and cough productive of cupfuls of purulent sputum. He has a history of recurrent bacterial pulmonary and sinus infections that require antibiiotics. These episodes have become more frequent and severe over the last few years. BP: 106/60 Pulse: 96/min RR: 22/min Temp: 102.6 Pulmonary exam demonstrates rales and wheezing throughout the upper and middle lung fields. Mild clubbing is present. Chest x ray shows prominent bronchovascular makrings Which of the following is the most likely cause of presentation? A. Asthma B. Bronchiectasis C. Chronic bronchitis D. Emphysema E. Interstitial lung disease

B The patient has an exacerbation of bronchiectasis, a disease of chronic bacterial inflammation and damage to bronchi resulting in airway dilation. Patients typically present with recurrent episodes of fever, dyspnea, and production of purulent sputum. Hemoptysis can be present. Although this patient is presenting with an exacerbation, the disease is chronic and often symptomatic between episodes. Nail clubbing is indicative of the chronicity of this patient's pulmonary disease. Patients typically suffer from a disorder that permits bacterial proliferation required to damage airways. Underlying etiologies include cystic fibrosis, ciliary dysmotility and immunodeficiencies.

A 65 year old presents with nausea, vomiting, and epigastric pain radiating to the back. His PMH shows alcohol abuse, HTN, and emphysema. Serum lipase is ten times the normal limit and a diagnosis of acute pancreatitis is made. The patient is admitted and treated supportively. On day two of hospitalization the patient develops respiratory distress. Blood pressure is 152/78, pulse is 110/min, RR is 28/min, and O2 saturation of 84%. Lung exam demonstrates rhonchi and rales throughout the lung fields. The patient is transferred to the ICU and placed on mechanical intubation. Which of the following findings would be expected upon mechanical ventilation of this patient in his current state? A. Increased compliance B. Increased pulmonary pressures C. Increased residual volume D. Increased work of breathing

B This patient has acute respiratory distress syndrome characteried by diffuse non-cardiogenic pulmonary edema and hypoxemia. ARDS has many etiologies including sepsis, pancreatitis, obstetric complications and trauma. Patients with ARDS have decreased lung compliace from pulmonary edema. As a result, lung volumes are decreased as stiff lungs cannot be inflated to normal volumes. In addition, airway pressures are elevated as stiff lungs require high pressures for expansion. Compliance is defined as the change in volume over change in pressure. In this patient with decreased lung compliance, decreased lung volumes and increased pulmonary pressures are expected. A is seen with emphysema C is seen with COPD D would be seen in this patient if he weren't mechanically ventilated.

A 58 year old woman presents for follow up of asthma. She has had persistent asthma since 7 years of age and has been noncompliant with therapy. She suffers from 1-2 exacerations a year that require hospitalization. She also has hypertension, hyperlipidemia, diabetes mellitus and eczema. PFT has FEV1 at 55% and and a FEV1/FVC ration of .60. There is improvement in FEV1 to 70% after bronchodilator administration. This has been the case the last three visits. Which of the following best explains the patient's low FEV1? A. Reversible bronchoconstriction B. Irreversible airway remodeling C. Interstitial fibrosis D. Neuromuscular weakness E. Alveolar destruction

B This patient's PFTs are indicative of obstructive process with reversibility on administration of a bronchodilator (improvement greater than 12%). However, the patient's FEV1 is still abnormal after bronchodilator administration, and has been for multiple visits. This is indicative of chronic irreversible change. Patients with chronic asthma can develop irreversible airway obstruction due to inflammation and airway remodeling. Major complicaiton of severe, poorly contolled asthma in adults.

A 32 year old man presents for worsening cough over the last year. He reports a dry cough throughout the day that is associated with dyspnea. He has never had this before and has no history of asthma. PMH is unremarkable and he takes no medications He smokes one pack a day for the last 9 years. Vitals include BP 132/78, pulse 82, RR 16, O2 sat 95% on room air. Examination shows normal heart sounds with physiologic splitting of the S2. Lung sounds are quiet throughout with no wheezes, rhonchi or rales. Lab tests show elevated AST and ALT levels. PFT is performed which shows and FEV1 60% of predicted and an FVC 85% of predicted. There is minimal imporvement with bronchodilator administration. What is the location of this proces in the Lung and in the acini?

B - Lungs: lower Acini: Panacinar This is a young patient with COPD. Any time someone under the age of 40 presents with signs of COPD, alpha-1 antitrypsin deficiency should be considered. The onset of pulmonary disease in AATD can be accelerated by smoking as seen in this patient. The elevated liver enzymes are commonly found in patients with AATD due to accumulation of abnormal antitrypsin in the liver. The pattern of disease seen in AATD is panacinar emphysema more frequently in the lower lobes.

A 26 yo woman is evaluated during labor. She has had a routine pregnancy with appropriate prenatal care. After a slightly prolonged active phase of labor, the patient delivers a healthy baby boy. Following delivery, the woman becomes unresponsive. Vitals show BP 70/42 mm Hg, pulse 115/min, RR 24, temp 99.8 and O2 of 86%. Bedside chest x ray shows diffuse, patchy lung opacities bilaterally. Which of the following is most likely to develop as a complication of this woman's condition? A. Deep venous thrombosis B. Disseminated intravascular coagulation C. Hemolytic uremic syndrome D. Idiopathic thrombocytopenic purpura E. Heparin-induced thrombocytopenia.

B. Amniotic fluid embolism is a catastrophic peripartum event. It is characterized by shock, hypoxemia, and acute respiratory distress syndrome. This constellation of findings shortly after delivery is highly suggestive of amniotic fluid embolism. The X-ray is consistent with non-cardiogenic pulmonary edema as occurs in ARDS. Hypoxemia from ARDS in amniotic fluid embolism is a common mode of death. Hemorrhage develops within hours of amniotic fluid embolism due to disseminated intravascular coagulation (DIC). An amniotic fluid embolism occurs when amniotic fluid and fetal debris enter the maternal circulation via uterine veins. This activates tissue factor, innappropriately triggering the clotting cascade and consuming platelets and clotting factors.

A 57 year old male presents to the ER with fever and productive cough for 3 days. Vitals include BP 110/76 mm Hg, pusle 100/min, RR 22/min, temperature 101.1 F, O2 sat 92%. Hematocrit is 21.4@ and hemoglobin is 7.0 g/dL. Blood gas shows 7.34/65/36 CO is 6 L/min. which of the following vlaues is the best estimate of this patient's O2 delivery to tissues? 200 mL/min 600 750 1100 Can't be determined

B. O2 content equation gives you 9.15 mL/dL. When multiplied by the cardiac output and 10 that is 548 ml/min, which is closest to 600.

a 55 year old woman is evaluated for 6 months of cough and dyspnea She reports dry cough that has woken her from sleep. In addition, she develops dyspnea with moderate exertion such as climbing stairs or long walks. No PMH. She had mild intermittent asthma as a child but grew out of it. She has smoke 1/2 pack per day for fifteen years. Vital signs are within normal limits. Exam is notable for trace wheezes heard throughout the lung fields. PFT is performedand shows mild to moderate airway obstruction. Which of the following is best next step in management? A. Methacholine challenge B. Repear spirometry with bronchodilator C. Prescribe albuterol D. Reassurance E. Order chest CT

B. This patient has obstructive pulmonary function testing consistent with any of the four major obstructive diseases: asthma, chronic bronchitis, emphysema and bronciectasis. The next step in someone with airway obstruction is the administration of a bronchodilator and repeat of PFT. This test can be used to differntiate asthma from the other processes. If the FEV1 improves by 12% or 200 mL with the administration, obstruction is considered reversible and asthma is the likely diagnosis. Methacholine is used in patients with normal PFT, but a high suspicion of asthma. Albuterol is prescribed in both asthma and COPD, but only after better characterization of the underlying disease.

An 8 year old girl presents for follow up evaluation for asthma. For the past two years, her symptoms have been well controlled on inhaled albuterol and moderate doses of inhaled fluticasone. She is asked to perform a peak flow test. Which of the following correctly describes the pulmonary pressures in this girl with a maximal forced exhalation? Intrapleural pressure - Pos/Neg Alveolar pressure - Pos/Neg

Both positive During a forced exhalation, positive intrapleural pressure develops. This results in a positive alveolar pressure which forces air out of the lungs. In quiet breathing, intrapleural pressure is always negative which balances the natural elasticity of the lungs and the chest wall.

A 65 year old man presents with a severe ripping chest pain that radiates between his scapula. His PMH includes lifestyle controlled hypertension and hyperlipidemia. He takes no medications. He appears in distress and diaphoretic. A CT angiogram is performed. The aorta appears to be involved. At what level does this pass through the diaphragm? A. T8 B. T10 C. T12 D. L2

T12 This patient's presentation has classical features of aortic dissection. The CT scan in the question demonstrates an aortic flap, a linear structure in the lumen of the aorta formed by the intimal layers of the aortic wall that has separated from the medial and adventitial layers. The aorta passes through the diaphragm at T12. The inferior vena cava passes though at T8. The esophagus passes through the diaphragm at T10.

A 78 year old man is admitted for exacerbation of COPD. Before admission, he had two days of increased dyspnea and sputum production. He has required two admissions fro COPD in the last year. Vitals include BP 132/62 mm Hg, pulse of 92, RR of 20, temp of 98, and O2 sat of 92%. He is started on inhaled albuterol/ipratropium and corticosteroids. Which of the following is also appropriate in the management of this patient? A. Long acting beta agonist B. Long acting cholinergic antagonists C. Antibiotics D. Magnesium sulfate E. Nebulized epinephrine F. No further treatment

C Antibiotics are used in the management of COPD exacerbations in certain circumstances. The main indication is moderate to severe exacerbations defined by having at least two of the following features: 1. increased dyspnea 2. increased sputum volume and 3. increased sputum purulence. Inpatient intravenous antibiotic choices include ceftriaxone, lvolfloxacin or piperacillin-tazobactam. LABAs and cholinergic antagonists are used for chronic management, not acute exacerbations. Magnesium sulfate is used in severe asthma exacerbations not COPD. If the patient had mild COPD exacerbation (only 1/3) no further management would be necessary.

A 32 year old male presents with hemoptysis. For the last month he has had fevers, chills, and night sweats. Over the last week, he has developed a progressively worsening cough. He immigrated to the US two years and has no health insurance and has never seen a physician. Workup confirms active pulmonary tuberculosis and he is admitted to the hospital for treatment. What type of precautionary measures are necessary for this patient? A. Standard B. Contact C. Airborne D. Droplet

C Patients with active pulmonary tuberculosis require airborne precautions on admission to the hospital. Airborne precautions include placement in a negative pressure room. In addition, medical staff must wear certified respirators. Other infections that require airborne precautions include varicella, measles, smallpox and Ebola virus. Standard should be taken for every patient - proper hand hygiene, cleaning of instruments and linen, gown/gloves. Contact - gown and gloves for medical staff that will be in contact with the patient. Indications include infection with multidrug resistant organism, enteric infections, certain skin infections, and some viral infections. Droplet - similar to contact precautions but with the addition of a mask. Indications include known or suspected infection with Neisseria meningitidis, Haemophilus influenzae type B, Pertussis, Diptheria, and influenza.

A 32 year old female presents with a persistent runny nose. For many years, she has had persistent rhinitis with clear drainage. This drainage occurs throughout the day and has not improved with nasal glucocortiocids. She also reports cough that occurs with exercise and at night. She has no PMH. She takes ibuprofen during menses. On exam, bilateral nasal polyps are noted. The oropharynx has pink mucosa without significant erythema. Cardiac exam shows RRR without murmurs or rubs. Lungs are CTA. Which of the following therapies is most appropriate medical therapy for this patient? A. Oral antibiotics B. Oral antihistamines C. Leukotriene antagonist D. Phosphodiesterase inhibitor E. Mast cell stabilizer

C Patients with aspirin exacerbated respiratory disease present with a triad of rhinosinusitis, asthma, and nasal polyposis. These pateints have exacerbations of symptoms when given drugs that block cyclooxygenase such as aspirin, ibuprofen, or other non-steroidal anti-inflammatory drugs. By blocking the COX pathway, these drugs increase production of leukotrienes from arachidonic acid. Increased leukotriene levels lead to symptoms of the disorder. In addition to avoidance of drugs that inhibit the COX pathway, treatment is with leukotriene antagonsists such as Montelukast.

A 56 yo male presents for a health maintenance visit. He has a history of HIV managed with multi-agent antiretroviral therapy. His most recent CD4+ cell count was 425. A PPD test is placed and shows 7 mm induration after 48 hours. Which of the following is correct concerning this patient? A. He has active TB B. He has latent TB C. He has exposure to TB D. His TB status can't be determined E. He has not been exposed to TB

C Patients with immunosuppression have positive PPD tests with induration greater than 5 mm. A positive PPD test is a sign that the individual's immune system has a prior exposure to mycobacterium. The next step in this patient's management should be CXR to rule out active pulmonary disease. Active TB and latent TB can't be established with PPD alone. These conditions require a positive PPD in conjunction with X ray and clinical findings.

A 45 year old man presents for a health maintenance visit. He has a history of hypertension and sarcoidosis. Medications include lisinopril and methotrexate. Routine screening chemistries are shown below.: Na - normal K - normal Cl - normal Bicarbonate - normal BUN - slightly high Creatinine - slightly high Glucose - normal Calcium - high Which of the following is the most likely underlying cause for the patient's hypercalcemia? A. Primary hyperparathyroidism B. Secondary hyperparathyroidism C. Excessive calcitriol. D. Excessive calcium intake E. Malignancy

C The patient has asymptomatic hypercalcemia. Sarcoidosis is associated with non-caseating granulomas which contain macrophages. These macrophages over express the enzyme 1-alpha hydroxylase which converts 25-hydroxyvitamin D into the active form of vitamin D. Excessive amounts of active vitamin D (aka calcitriol) can result in hypercalcemia.

An 85 year old patient is hospitalized in the ICU for massive pulmonary embolism. He is placed on mechanical ventilation and administered heparin. On hospital day 5, he develops worsening oxygen saturations and a new fever. X ray shows a developing pneumonia. Which of the following is the most appropriate treatment? A. Levofloxacin B. Azithomycin and ceftriaxone C. Vancomycin and cefepime D. Ampicillin-Sulbactam E. Metronidazole and penicillin

C The patient has nosocomial (originating in a hospital) pneumonia. Current terminology for this patient's condition is ventilator associated pneumonia (VAP), a form of hospital acquired pneumonia. This is differentiated form community acquired pneumonia as the infection develops greater than 48 hours after admission. Hospital acquired pneumonia involves multi-drug resistan nosocomial pathogens such as pseudomonas and MRSA. Proper treatment requires a MRSA agent like vancomycin, plus coverage for pseudomonas with an agent such as cefepime. Levofloxacin - used for community acquired pneumonia. It does not cover MRSA. Azithromycin and ceftriaxone are common drugs used in treatment of community acquired pneumonias. They do not cover MRSA or pseudomonas. Ampicillin sulbactam provides coverage for common gram positive organisms as well as anerobes. Metronidazole and penicillin is a regimen for aspirational pneumonia due to anerobic and gram positive organisms.

A 7 year old girl is admitted to the pediatric intensive care unit for a severe asthma exacerbation. In the ER she receives nebulized albuterol, IV methylprednisolone and O2. In the ICU, she demonstrates accessory muscle use while breathing. Loud wheezes are heard throughout the lung fields. In addition to current medial therapy, which of the following interventions would improve this patient's condition? A. Montelukast B. Cromolyn C. Magnesium sulfate D. Antibiotic therapy E. Theophylline

C. Patients with asthma exacerbation are typically treated with oxygen, steroids, and inhaled beta agonists as in this case. If the patients remain symptomatic after initial therapy, magnesium sulfate can be added. The mechanism is not well understood, but it is thought to interfere with calcium uptake in the smooth muscle cells leading to bronchodilation. Monelukast - Leukotriene antagonist; chronic therapy Cromolyn - Mast cell stabilizer; chronic therapy Theophylline - methylxanthine that acts like a beta agonist; chronic therapy Antibiotics - no signs of infection

A 40 year old woman presents to the primary care clinic for eye burning and blurry vision in her right eye. The patient has noticed these symptoms worsening over the last week and notes that her eye has looked red. She does not remember any trauma to the area and has no risk factors for foreign body exposure to they eye. PMH includes hypothyroidism and sarcoiosis. Vitals are within normal limits. Visuals fields and extraocular movements are within normal limits. Fundoscopic exam shows no retinal abnormalities. The right pupil is asymmetric. Inflammation in which of the following structures is most likely responsible? A. Conjunctiva B. Cornea C. Iris D. Retina E. Optic Nerve

C. Sarcoidosis and other autoimmune conditions are associated with uveitis, inflammation of the structures of the uvea: iris, ciliary body, retina. Patients with anterior uveitis (iris and ciliary body( present with erythema, burning, blurred vision and photophobia. Pupillary irregularity is often noted.

A hospitalized 72 year old male is evaluated for the acute onset of hypoxemia. He was admitted for an upper GI bleed two days ago. The patient has a history of hypertension, chronic kidney disease, and recently diagnosed colon cancer. Prophylaxis for deep vein thrombosis has been administered with arterial compression stockings. Vitals include BP of 116/82, pulse 102, RR of 40, temp 99.0, and O2 sat of 88%. PE and X-ray unremarkable. Sinus tachycarida on EKG. Very elevated BUN levels. Creatinine high as well. Which test is the most appropriate diagnostic test in this patient? A. CT angiography B. Pulmonary angiography C. Ventrilation-perfusion scan D. CT chest without contrast E. D-dimer

C. This patient has multiple risk factors for pulmonary embolism including bed bound status and known malignancy. He has tachypnea and hypoxemia and needs a definitive test for pulmonary embolism that can be performed quickly. The standard test in this situation is a CT angiogram. Unfortunately, CT angiography requires intravenous nephrotoxic dye to image the pulmonary arteries. In a man with chronic kidney disease (as indicated by his history and his BUN and creatinine levels) this might result in renal failure and need for dialysiss When CT angiography cannot be performed, a ventilation-perfusion (V/Q) scan is the next best test. A V/Q scan is a nuclear imaging procedure where radioactive substances are used to image areas of perfusion and ventilation. The diagnostic hallmark of pulmonary embolism is a lung segment with ventilation in the absence of perfusion.

An 87 year old presents to the ER with SOB and increasing weight for the last four days. He has a history of systolic heart failure, HTN, hyperlipidemia, and type II diabetes mellitus. Vitals include BP of 122/68, pulse of 82, RR 20, O2 sat 92%. Exam shows bibasilar crackles and 2+ lower extremity pitting edema. Which of the following changes would be expected in Cardiac output O2 delivery A-a gradient

CO - Decreased o2 delivery - Decreased A-a gradient - Increased This patient is suffering from acute exacerbation of congestive heart failure. He has decreased CO and decreased oxygen delivery due to poor left ventricular function. His A-a gradient will be increased due to the pulmonary edema impairing gas exchange.

An 85 year old woman presents to the primary care clinic with shortness of breath on exertion. She can only walk one block before developing shortness of breath. She also reports a cough productive of grey sputum which has been present for many years. Medical history is significant for hypertension, hyperlipidemia, and left knee arthroplasty three years ago. She has a 60 pack year smoking history. Examination shows a thin woman in no acute distress. Pulmonary examination demonstrates decreased breath sounds in all lung fields with a prolonged expiratory phase. There are no significant wheezes, rales, or rhonchi. Compared to a healthy patient, what changes are epxected in compliance, functional residual capacity and forced expiratory volume 1.

Compliance - increased FRC - increased FEV1 - decreased This woman has COPD. In COPD, destruction of alveoli results in increased compliance. Alveolar destruction also decreases elastic recoil and moves the equal pressure point into the non-cartilaginous airways. This causes airflow obstruction that results in air trapping. As a result, both the residual volume and the functional residual capacity are increased. Airway obstruction also results in decreased maximum forced expiratory volume.

A 56 yo male presents for a health maintenance visit. He has a history of HIV managed with multi-agent antiretroviral therapy. A PPD test shows 7 mm of induration after 48 hours. Which of the following is responsible for the development of induration in this patient? A. Type I hypersensitivity B. Type II C. Type III D. Type IV

D A PPD test is an example of type IV hypersensitivity. Type IV reactions involve a cell mediated immune response to a specific antigen. Antigen is presented to T cells which trigger a cytokine cascade that activates the response of T cell and macrophages. This process takes approximately 48 hours and is the reason for the delayed time to interpretation necessary with PPD testing.

A 45 yo male prisoner is referred for interpretation of a PPD test. He has 12 mm of induration 48 hours after PPD placement. He has no significant past medical history and takes no medications. He denies cough or dyspnea. He also denies being treated for tuberculosis in the past. A CXR is unremarkable. Which of the following is the most appropriate step in management? A. Repeat PPD B. Prescribe four drug antibiotic therapy C. Chest computed tomography D. Prescribe a drug that inhibits mycolic acid synthesis E. Reassurance that the patient is negative for tuberculosis

D A patient at high risk for tuberculosis such as a prisoner that has a positive PPD test if > 10 mm of induration is present after 48 hours. The next step in management after a positive PPD is a chest X ray. This patient's negative chest x ray rules out active pulmonary disease and indicates latent tuberculosis infection. Latent tuberculosis is treated with isoniazid therapy for 6-9 months. This drug acts by inhibiting the synthesis of mycolic acids, a key component of the cell membrane of mycobacterium. Four agent antimicrobial therapy is first line therapy for active pulmonary tuberculosis, and includes rifampin, isoniazid, ethambutol, and pyrazinamide. CT of the chest without contrast is used to evaluate nodules and to better characterize interstitial lung disease or bronchiectasis. Repeat PPD is not necessary as the initial test is positive. Reassurance would not be appropriate as this patient is at increased risk for re-activation of latent tuberculosis.

A 62 year old woman is seen for a left sided pleural effusion. She has a PMH of poorly controlled type II diabetes. complicated by chronic kidney disease. She has HTN, hypothyroidism, and gout. She is a pack a day smoker. Vital signs are within normal limits. Thoracentesis is performed which shows protein of 2.0 g/L (5.5 serum) and LDH of 105 (240 serum). Which of the following processes is most likely causing this patient's pleural effusion? A. Malignancy B. Autoimmune inflammation C. Infection D. Hypoalbuminemia E. Trauma

D Light's criteria - Exudative if: Pleural protein/serum protein greater than 0.5. Pleural LDH/serum LDH greater than 0.6 Pleural LDH greater than 2/3 upper limits of normal The ratio to serum protein and LDH are .36 and .44 respectively. Application of Light's criteria, classifies this as transudative effusion. Low hypoalbumine can cause this. Low serum albumin leads to low capillary oncotic pressure. This increases fluid movement out of the pulmonary capillaries and into lung tissue leading to effusion. Hypoalbuminemia can be seen in nephrotic syndrome and cirrhosis. Patients with diabetic kidney disease may develop diabetic nephropathy which can cause nephrotic syndrome. Malignancy, autoimmune disease, and infection would cause transudative effusion.

A 62 yo male presents to the opthalmologist with complaints of vision change. Over the last week his central vision seems blurry. He has a history of poorly controlled diabetes mellitus, hypertension, hyperlipidemia, and asthma. Two months ago, he was diagnosed with active pulmonary tuberculosis and started on standard multi-agent therapy. Funduscopic examination demonstrates micro-aneurysms, several small hemorrhages, and cotton wool spots. Visual acuity testing shows a decline compared with a visit three months ago. Which of the following is the most likely cause of this patient's presentation? A. Ischemia B. Hypertension C. Hyperglycemia D. Drug reaction E. Age related changes

D This patient has an acute loss of visual acuity. Considering his recent diagnosis of active tuberculosis, this presentation is suggestive of ethambutol toxicity. Active TB is treated with a four drug regimen of rifampin, isoniazid, ethambutol, and pyrazinamide. Each drug is associated with important side effects that are commonly tested on Step 1. Ethambutol causes optic neuropathy that presents after two months of use. The most common presentations are decreased visual acuity and red-green color blindness.

A 75 year old man is referred for pulmonary function testing to evaluate new onset exertional dyspnea. He has not seen a physician in 10 years and has not been treated for any pulmonary conditions previously. He has a 30 pack-year smoking history and drinks three beers daily. A flow-volume curve is generated and displayed in red below. Compared to the normal, it has a scooped slope, lower PEF and higher lung volumes. Which of the following best explains the shape of the expiratory flow curve in this patient? A. Reversible bronchoconstriction B. Interstitial fibrosis C. Fixed extrathoracic airway obstruction D. Loss of alveolar elasticity

D This patient has an obstructive pattern on pulmonary function testing. This is indicated by the scooped expiratory flow volume curve in addition to higher lung volumes consistent with chronic air trapping. Obstruction, elevated lung volumes and a smoking hisotry are classic for COPD. With emphysema, destruction of alveolar tissue results in the loss of alveolar elasticity. This moves the equal pressure point into the non-cartilaginous airways, resulting in an intrathoracic airway obstruction.

A 45 yo correctional officer is seen by his primary care physician for routine car. He is treated for psoriasis, which had previously been under control with topical medications alone. He inquires about potential oral medications. Which of the following medications has the highest risk for potential reactivation of tuberculosis? A. Methotrexate B. Acitretin C. Cyclosporine D. Adalimumab

D Tumor necrosis factor alpha (TNF-alpha) inhibitors have a high risk of reactivation tuberculosis as a major side effect. These drugs include adlimumab, infliximab, certolizumab, and etanercept. Patients considering TNF-alpha inhibitors should be screened for latent tuberculosis prior to initiation of therapy. Patients are also at risk for other opportunistic infections such as fungal infections like histoplasmosis and blastomycosis. Methotrexate is an immunosuppressant associated with hepatitis, stomatitis, pulmonary fibrosis, and bone marrow suppression. Risk for tuberculosis will be increased due immunosuppresssion, but studies have shown the risk is not as significant as TNF-alpha inhibitors.

A 55 year old man present with acute onset of respiratory distress. The patient reports that he had lung, took a one-hour nap and then awoke feeling short of breath and diaphoretic. He reports no chest or abdominal pain. PMH includes hypertension, hyperlipidemia, obstructive sleep apnea, and achalasia. Vital signs are pulse 105/min, BP 146/86, temp 99.5, RR 22/min and O2 saturation 90%. Lung exam demonstrates rales and rhonchi in the right lower lobe. Which of the following processes is most likely responsible for the patient's respiratory distress? A. Pulmonary edema B. Latent infection C. Coronary thrombus D. Aspiration E. Clot embolization

D. Patient is suggestive of aspiration. He has achalasia, an esophageal disorder that often leads to regurgitation of stomach contents. Lying flat after eating increases the risk of aspiration into the respiratory tract. Aspiration results in pneumonitis, an inflammatory reaction caused by acidic material in the respiratory tract. Clinical features include sudden onset respiratory distress, low grade fever, hypoxemia, rales, and patchy infiltrates on lung imagin. When supine like the man in the question, aspiration typically occurs in the posterior segment of the right upper lobe or the superior segment of the right lower lobe. Treatment is usually supportive, however patients can develop bacterial infections related to aspiration that require antibiotic coverage for anaerobic bacteria.

A 28 year old G1PO presents to labor and delivery at 33 weeks gestation with abdominal cramps and a gush of fluid. Prior to presentation, her pregnancy had been uncomplicated with appropriate prenatal care. Examination reveals evidence of active labor. In addition to tocolytic therapy and penicillin, betamethasone is administered. The target of the betamethasone is increased fetal production of what? A. Insulin B. Glucose C. Sphingomyelin D. Dipalmitolylphosphatidylcholine E. Globtriaosylceramide

D. Steroids induce the production of surfactant, which is composed of the phospholipid phosphatidylcholine also known as lecithin. Corticosteroids such as betamethasone are administered in preterm labor to increase fetal surfactant production and prevent the development of neonatal respiratory distress syndrome. Sphingomyelin is also a phospholipid that functions as a surfactant. It is found in amniotic fluid where its level can be measured and compared to the amniotic fluid lecithin level to estimate fetal lung maturity. L-S levels are approximately equal in amniotic fluid until about 33 weeks gestation. Around this time, a rise in amniotic fluid lecithin occurs. A L-S ration greater than 2:1 indicates a mature fetal lung.

A 21 year old female presents with a 3 day history of rhinitis and sore throat. She also reports cough productive of yellow-green sputum. ROS is negative for chest pain, dyspnea, or GI symptoms She has no significant past medical history and takes no medication. Temp is 99.5, BP is 114/72, pulse is 92, and RR is 16/min. On PE there is an erythematous oropharynx. Heart and lungs are unremarkable. A diagnosis of respiratory infection is made. This patient's infection is most likely located at which level of the respiratory tract? A. Alveoli B. Bronchioles C. Bronchi D. Upper respiratory tract.

D. The URT includes the nasal passages, pharynx, and larynx above the vocal cords. URIs are common viral illnesses caused by a variety of pathogens such as rhinovirus, coronavirus, adenovirus, and coxsackievirus. Typical symptoms include nasal congestion, rhinitis, cough, fever and malaise. Lung exam is normal as the lower respiratory tract is not involved. A: Pneumonia - a lower respiratory tract infection that involves the alveoli. Presents with fever, productive cough, and dyspnea. Pulmonary exam may demonstrate rales and increased tactile fremitus. B: Bronchiolitis - a disease common in younger children caused by the respiratory syncytial virus. It presents as wheezing and respiratory distress in a child less than 2. C: Bronchitis - can occur during or after URI's, resulting in a productive cough. Wheezing and rhonchi may be present. Symptoms can last up to six weeks. E: Pleuritis

A 6 year old girl presents with a complaint of nighttime cough. She has been waking with a dry cough at least two nights a week for three months. She has not otherwise been sick during this time period and has no fevers. There are no new pets in the house On exam, the girl is breathing comfortably. Her lung sounds are clear with no wheezes, rhonchi or rales. PFT is ordered. Volume to time curve shows a slope that rises steadily to 3 L in 2 seconds. From there the slope decreases and reaches 4 liters at the 3 second mark and then ends. What is the next step? A. Bronchodilator therapy B. Hostpital admission for asthma exacerbation C. Evaluate for pulmonary mass D. Repeat pulmonary function test E. Corticosteroid and bronchodilator therapy

D. The graph obatinsed is not a good quality PFT and needs to be repeated. 1. Early rise 2. sustained plateau 3. At least 6 seconds in duration 4. Reproducible 5. Free from artifact. This patient's test lasts only three seconds and does not plateau. The test needs to be repeated with encouragement for the patient to provide a stronger and sustained effort.

A 29 year old female present to ER with altered mental status. Her BF found her unconscious on the floor. Vitals are BP: 100/62 Pulse: 118 Temp: 96 RR: 14 O2 sat: 86% on room air Her arterial blood is 7.26/45/66 Which of the following is the most likely cause of the hypoxemia?

D. The patient has hypoxemia with an increased A-a gradient. PaO2 = 45 mm Hg PAO2 = 150 mm Hg - 66/0.8 = 68 mm Hg. A-a = 68 - 45 = 23 mm Hg. Hypoxemia with an increased A-a gradient may occur in massive pulmonary embolism due to V/Q mismatch. Only pulmonary embolism of the listed options would result in an increased A-a gradient.

A35 year old female presents to the ER for left posterior knee swelling. For the past day she has had swelling, redness and pain behind the knee. She has a known factor V Leiden mutation with multiple episodes of deep venous thrombosis in the past. She was prescribed warfarin but has been having difficulty complying with therapy. Vital signs are within normal limits including oxygen saturation of 99% on room air. Telemetry shows normal sinus rhythm. Besides lower extremity ultrasound confirms the presence of thrombus in her popliteal vein. She is started onlow molecular weight heparin. One hour later, she is seen for sudden onset right side hemiparesis and expressive aphasia. The presence of which of the following most likely explains the following most likely explains this patient's neurologic deficit. A. Atherosclerosis B. Arrhythmia C. Hypertension D. Congenital defect E. Medication adverse effect

D. This patient has a DVT and subsequently develops signs of acute left sided cerebral artery stroke. Clots from the lower extremities can cause pulmonary emboli, but cannot embolize systemically unless there is a patent foramen ovale is present. Stroke in the presence of a DVT is highly suspicious for PFO. PFO is a congenital defect in which the septum primum and secundum fail to fuse after birth. These defects are found in approximately 25% of the population. Most patients with PFO have no symptoms from the defect but rarely paradoxical thromboembolism occurs in which venous clot travels to the right atrium, across the PFO and into arterial circulation.

An 18 yo male presents with pleuritic chest pain and mild dyspnea. The patient was doing chores in the house when he noticed these symptoms occur suddenly. He has no significant PMH and takes no medications. Vitals include BP 120/78 mm Hg, pulse 78, RR 20, temp 98.7 and O2 sat 97%. He is breathing without significant distress. CXR shows small left sided pneumothorax estimates 5-10% of lung volume. No tracheal deviation. Which of the following is the most appropriate management of this patient? A. Needle thoracotomy B. Chest tube placement C. Further diagnostic imaging D. Supplemental O2 E. Bronchoscopy

D. This patient has a small, spontaneous pneumothorax likely secondary to a ruptured bleb. Blebs are common in taller individuals and can occur in patients with any underlying lung disease. Small pneumothoraces are treated with 100% O2. Oxygen levels will rise in the blood, displacing nitrogen gas. Low blood nitrogen facilitates the absorption of nitrogen gas from the pleural space into surrounding capillaries. Needle thoracotomy - used for decompression of tension pneumothoraces in patients with hemodynamic instability. Chest tube - Same as needle thoracotomy, except it allows continuous air drainage. These interventions are for tension pneumothoraces or large spontaneous pneumothoraces that don't respond to O2. Bronchosopy - evaluation of lung masses or hemoptysis

A 78 year old man presents to the ER with lower extremity edema. His legs have been swollen for the last week to the point where his shoes no longer fit. He reports dyspnea and fatigue. 60 pack year smoking history. Long standing COPD requiring chronic oxygen therapy. HTN, hyperlipidemia, peripheral vascular disease and gout. Medicines: lisinopril, atorvastatin, albuterol, tiotropium and rofluminslast. BP: 102/60 Pulse: 78 RR: 16 O2 sat: 95 on 2L Breathing without apparent distress. JVD is 10 cm H2O (normal is <8). Lung sounds are decreased diffusely. Trace wheezes are noted, but no rales or dullness to percussion. Heart auscultation reveals a II/VI holosytolic murmur at the left lower sternal border and a S3 in the same area. Firm pressure to abdomen results in an elevation of JVP. 2+ pitting edema on LE. Dorsalis pedis and posterior tibial pulses are difficult to palpate. Which of the following mechanisms is most likely responsible for this patient's condition? A. Smooth muscle proliferation B. Chronic thrombi formation C. Hypokinesis of the LV D. Chronic hypoxic pulmonary vasoconstriction E. Autoimmune fibrosis

D. This patient with long standing COPD is presenting with cor pulmonale (right heart failure from lung disease). Chronic hypoxemia from COPD results in pulmonary arterial vasoconstriction causing elevated PVR. Elevated pulmonary pressures strain the right heart and can lead to low right sided cardiac output. Classic findings of right heart failure: Elevated JVP, peripheral edema, abdominal distension. Firm pressure to RUQ can induce hepatojugular reflux. Heart examination is variable, but can include right sided heave, right sided S3 and tricuspid regurgitation murmur.

A 65 yo man presents to the primary care clinic for worsening dyspnea over the last year. He has a PMH of hypertension but has been noncompliant. Pack a day smoker. Vitals include BP 158/86, pulse 72, RR 16, temp 99, O2 sat 95% on room air. He has an increased chest diameter. Breath sounds are quiet with trace rhonchi. In additon to albuterol, the patient is started on tiotropium. This drug acts through what mechanism? A. Increased cAMP levels B. Decreased cAMP levels C. Increased intracellular calcium D. Decreased intracellular calcium E. alteration in DNA expression

D. Tiotropium is an antagonist of muscarinic cholinergic receptors. M3 type receptros cause bronchoconstriction in the lung. These membrane receptors act through G1 proteins which triggers the produciton of inositol trisphospherate (IP3) from PIP2 via the enzyme phospholipase C. IP3 triggers calcium release fro the SR and ultimately increases intracellular calcium levels. As an antagonist tiotropium effectively decreases inracellular calcium.

A 74 year old presents for an evaluation of dypnea. He describes a productive cough for the last five years. He reports increasing shortness of breath with exertion for the past week. On the day of evaluation, he was outside burning large amounts of wood when his symptoms became unbearable. He has a 40 pack year smoking history and drinks 2-3 beers a day. Vital signs include BP 168/92, pulse 105/min, RR 24/min, temp 100.2 and O2 saturation of 91% on room air. He appears slightly diaphoretic with flushed red skin. CV exam reveals a regular rate and rhythm with no murmurs. An S4 is present. Pulmonary exam reveals slightly decreased breath sounds throughout all lung fields. No wheezes, rales or rhonchi. Co-oximetry is significant for a carboxyhemoglobin level of 10%. Which of the following is the most likely diagnosis? A. Pneumonia B. Pulmonary embolus C. Carbon monoxide poisoning D. Cyanide poisoning E. COPD exacerbation F. Heart failure

E This patient's presentation is consistent with a chronic obstructive pulmonary disease exacerbation. He has a long smoking history and chronic productive cough. His exam, including hypoxemia and decreased lung sounds, is consistent with emphysema. In addition, his pink skin hue suggests the presentation of a pink puffer. Carboxyhemoglobin levels can be as high as 10-15% in smokers. In carbon monoxide poisoning, carboxyhemoglobin levels are greater than 15%. His shortness of breath and chronic cough suggest a chronic process rather than an acute poisoning. Pneumonia would include rales, fever, and a focal infiltrate on chest x ray. Pulmonary emboli would present with acute onset hypoxemia and pleuretic chest pain.

An 85 year old man is admitted to the hospital for an acute heart failure exacerbation. LVEF is 15% (normal >55%). He requires dobutamine to increase CO. A pulmonary artery catheter is placed to titrate doubutamine therapy. RAP: 15 mm Hg (normal 1-5) PA: 62/32 (normal 24/12) Pulmonary capillary wedge pressure: 20 mm Hg (normal 4-12) What is the most likely reason for his elevated pulmonary arterial systolic pressure? A. Primary pulmonary arterial hypertension B. Chronic pulmonary disease C. Pulmonary embolus D. Right ventricular infarction E. Pulmonary venous hypertension

E. Left sided heart failure is the most common cause of pulmonary arterial hypertension. When the LV fails, LVEDP rises. This pressure is transmitted backwards, through the LA and the pulmonary veins and ultimately the pulmonary arteries causing pulmonary arterial HTN. Left heart failure causing pulmonary hypertension is referred to as pulmonary venous hypertension, because pressure is first elevated in the pulmonary veins which connect to the left heart. High PCWP indicates high left atrial and pulmonary venous pressure. Pulmonary embolus would not cause elevated PCWP.

A 56 year old woman presents with fever, malaise and cough for three days. She reports abdominal pain and diarrhea. PMH includes hypothyroidism, type II diabetes. Vital include 132/78, pulse 80, RR 20, temp 101.6 and O2 sat 96. Pulmonary examination demonstrates diffuse rales and rhonchi. CXR shows interstitial pneumonia. Lab tests reveal hyponatremia. Which of the following organisms is most likely responsible? A. Streptococcus B. Staphylococcus C. Klebsiella D. Mycoplasma E. Legionella

E. The patient is suffering from atypical pneumonia. The constellation is seen in Legionnaires' disease caused by Legionella infection. These spread by contaminated water droplets. In atypical pneumonia, symptoms are milder with a slower onset compared to lobar. CXR often shows an interstitial pattern rather than lobar consolidation. Clinical presentation for Legionella pneumonia includes fever, pulmonary symptoms, and GI symptoms (the diarrhea). Neurologic symptoms including altered mental status and ataxia are also possible. Hyponatremia is a common electrolyte abnormality. The mechanism is not well understood, but may involve inflammation of justaglomerular apparatus.

A 70 year old woman presents for follow up of a lung biopsy. The patient was recently hospitalized for pneumonia after a right middle lobe infiltrate was seen on CXR After she did not improve on antibiotic therapy, a lung biopsy was performed. Pathology shows a single layer of malignant columnar cells growing along the alveolar septa. Which of the following is the most likely type of cancer? A. Small cell carcinoma B. Squamous cell carcinoma C. Large cell carcinoma D. Bronchial carcinoid E. Bronchoalveolar carcinoma

E. This patient's clinical presentation and pathology are consistent with bronchoalveolar carcinoma, a subtype of adenocarcinoma. This cancer typically presents in smokers with a lobar consolidation on X ray that mimics lobar pneumonia. The malignancy is derived from goblet cells, clara cells, or type II pneumocytes. The characteristic pathology is a single layer of malignant columnar cells growing along the alveolar septa There is no invasion, so this type of malignancy is considered adenocarcinoma in situ. With proper treatment, prognosis is generally excellent because invasion has not occurred.

A 22 yo comes to ER complaining of dyspnea for one day. Last week she was recovering after her wisdom teeth were removed. She notes moderate amounts of jaw pain well controlled with oxycodone and a topical numbing gel. Her only PMH is childhood asthma, but she has "grown out of it." Vitals are BP 110/72, pulse of 110/min, RR of 22/min, temp of 98 and O2 saturation of 88% on room air. She is placed on 4 liters of nasal cannula oxygen but her O2 saturation does not improve. Physical exam shows no abnormalites. Her blood is noted to be dark red when drawn for lab testing. Which of the following therapies would be most effective? A. Hydroxycobalamin B. Dimercaperol C. Epinephrine D. Sodium Thiosulfate E. Methylene blue

E. Methylene blue The patient is suffering from methemoglobinemia which is treated with intravenous methylene blue. Methemoglobinemia occurs when ferrous groups in hemoglobin are oxidized into the ferric form (Fe3+) which has a lower affinity for oxygen. The topical anesthetic might be benzocaine or lidocaine which are common culprits for induce methemoglobinemia. Dapsone and nitrate and sulfa drugs have also been implicated. Patients with emthemoglobinemia present with dyspnea and cyanosis that does not respond to oxygen therapy. Classically blood will be dark red or chocolate brown in color. Methylene blue is the first line agent. Vitamin C is a second line agent. Both serve as reducing agents to convert the iron in hemoglobin back into its ferrous form. A,D - cyanide poisoning B - heavy metal toxicity C - anaphylaxis

A 57 yo male with a history of COPD and heart failure presents with hematemesis. Urgent endoscopy is performed and a bleeding peptic ulcer is identified. Vitalson ICU admission: BP: 110/70 Pulse: 120/min Temp: 99.1 RR: 18/min O2 sat: 90% on room air Arterial blood gas shows: 7.25/60/50 HCO3: 21 mEq/L. Hb: 10 gm/dL , hematocrit 30%, leukocytes 5,200/mm3 and platelets 155,000/mm3 Cardiac output: 3 L/min Which of the following interventions would result in the largest increase in tissue oxygen delivery in this patient? A. Increasing pO2 to 90 mm Hg. B. Increasing Hb to 12 gm/dL C. Increasing CO to 4 L/min D. Increase O2 sat to 95 E. Increasing BP to 140/90

Each one: Current: 367. 2 mL/min A. 369.9 B. 439. 6 C. 489.6 D. 387.3 E. Counterproductive Answer then is C This one will produce an increase of 33% in oxygen delivery. Increasing PaO2 has a very small effect, as it has to be multiplied by .003. Increasing Hb. by 20% will have a smaller effect on oxygen content compared with a rise is cardiac output. The same is true for a 5% increase in oxygen saturation. Oxygen delivery is proportional to CO, hemoglobin, and O2 saturation. Whichever of these is increased by the greatest amount will have the greatest amount in one of these variables.

An 85 year old woman is admitted to the hospital for an exacerbation of emphysema. She has had multiple hopitalizations in the last year for chronic pulmonary disease (COPD). She requires 4 liters of oxygen at home. Her other PMH includes HTN, CAD, and polymyalgia rheumatica. Which of the following sets of pulmonary function data would be expected in this patient compared to normal? FEV1/FVC Vital capacity DLCO

FEV1/FVC - decreased Vital capacity - decreased DLCO - decreased Patients with emphysema have a decreased FEV1/FVC ratio, decreased forced vital capacity, and decreased DLCO. Due to an expiratory airway obstruction, both the FEV1 and FVC decrease the but the FEV1 decreases more. The vital capacity, which is made up of the ERV, TV, and IRV is decreased The DLCO is decreased as destruction of alveoli reduces surface area for gas exchange.

A 65 year old woman is evaluated for left sided pleuritic chest pain. She has a history of breast cancer and is currently undergoing chemotherapy. Oxygen saturation is 89% on room air. CT angiography identifies a thrombus in the pulmonary artery. Where did the thrombus most likely come from? A. Superficial lower extremity vein B. Femoral Vein C. Posterior tibial vein D. Right atrium

Femoral Vein Pulmonary emboli most commonly originate from the deep venous system of the proximal lower extremity. The proximal veins include: the iliac, femoral and popliteal veins.

A 2 week old is seen for a well child visit. Mom is a sickle-cell carrier. Hemoglobin electrophoresis is performed and shows that the girls is not a carrier for the sickle cell gene. Compared to her mother, which of the following findings are expected related to these molecules. HgbA HgbA2 HgbF

HgbA - decreased HgbA2 - decreased HgbF - increased At birth, 75-80% of total hemoglobin is in the fetal form which has a higher affinity for oxygen than adult hemoglobin. During the first year, this is gradually replaced with adult hemoglobin. The mother with the sickle cell trait can synthesize adult hemoglobin (A and A2) and HbS. Sickle cell carriers have slightly less than 50% HbS and more than 50% HbA. The two week old girl will still have elevated amounts of fetal hemoglobin. She will also have only about 20-25% adult hemoglobin compared to her mom's 50%.

A 22 year old female presents fro evaluation of chest pain. For the last 12 hours she has had sharp left sided chest pain below her breast. The pain is worse with deep breaths. She describes mild dyspnea on exertion, but denies dyspnea at rest or cough. Her vital signs and Physical exam are normal. A D-dimer measurement is obtained. Which attribute of the D-dimer test makes it useful? A. High sensitivity B. Low sensitivity C. High specificity D. Low specificity

High sensitivity The D-dimer is used to rule out the diagnosis of Pulmonary embolism in patients with a low or moderate pre-test probability. The test has high sensitivity for PE meaning it is abnormal in the majority of true positive cases. The D-dimer test is not specific for PE. It in fact has a low specificity.

A 78 year old man is about to be discharged from the hospital after admission for a COPD exacerbation. He was treated with nebulized bronchodilatorys steroids and supplemental O2. His O2 sat is 87% on room air. Which of the following therapies is most likely to improve mortality in this patient? A. SABDs B. LABDs C. Inhaled steroids D. Oral steroids E. Supplemental O2

In patients with COPD, oxygen is the only therapy shown to improve mortality. Oxygen is prescribed for patients with an oxygen saturation equal to or below 88% to maintain oxygen saturation 89-92%. Oxygen levels higher than this may result in the accumulation of CO2 through the removal of the hypoxemic stimulus for respiration. Bronchodilators improve symptoms and reduce risk of exacerbation, but they do not improve mortality. Steroids can be added to LABDs in patients with more severe symptoms. Oral steroids are not used as a chronic therapy, but for acute exacerbations.

A 67 year old man presents to the ER with a headache. It began 10 hours ago and has become increasingly severe. PMH includes HTN and chronic renal disease. He takes several anti-hypertensive drugs but ran out of medication three days ago. BP is 212/108. Treatment with nitroprusside is started. Ten hours after starting therapy he develops and acute change in mental status. He is minimally responsive. Skin is flushed. Vitals include a BP of 175/100. Pulse is 110/min, RR is 24/min, and temp is 99.0 F. Examination is otherwise unremarkable. ECG shows sinus tachycardia. CT scan of the head shows no acute process. HB and Hematocrit are low. Bicarbonate is low. BUN is high. Creatinine is high. Lactate is severely elevated. What is the condition he is undergoing? What should you give him? A. Methylene Blue B. Dimercaprol C. Hydroxycobalamin D. N-acetylcysteine E. Neurosurgery

Nitroprusside is a rapid-active vasodilator with effects on arterioles and veins. It is used in the treatment of hypertensive emergency as described in the question. A potentially life threatening adverse effect is cyanide toxicity which may occur since nitroprusside contains cyanide moieties. Cyanide is an inhibitor of electron transport. When the electron transport chain shuts down, glucose metabolism is directed toward formation of lactate. As a result lactic acidosis develops. The hallmarks of cyanide toxicity from nitroprusside are delerium and lactic acidosis. This patient was at greater risk for cyanide toxicity due to his history of renal problems. Treatment should be withdrawal of nitroprusside and use of an antidote. Hydroxycobalamin is the first line and acts by directly binding cyanide molecules. If this agent isn't available nitrites an be used to induce methemoglobinemia, which has a high affinity for CO2.

An 85 year old man. History of HTN, hyperlipiemia, and COPD. His medications include lisinopril, atrovastatin albuterol, and tiotropium. On exam, he breathes at a rate of 10/min (normal is 15-20). His expiratory phase lasts three times as long as his inspiratory phase. Which of the following best explains this pattern? A. Central respiratory depression B. Neuromuscular weakness C. Optimized work of breathing D. Underlying pulmonary infection E. Pulmonary arterial obstruction.

This patient has COPD and is thus breathing at a slower rate to optimize his work of breathing. Due to increased airway resistance, COPD patients breathe more slowly and deeply to minimize their work of breathing. Work is minimized at lower respiratory rates than normal. In general, slow breathing reduces airway resistance, while faster breathing reduces alveolar elastic resistance. These two forces are balanced at a lower rate among patients with COPD due to higher airway resistance with normal elastic resistance