Pulmonology: Practice Exam

A 62-year-old man has been smoking 2 packs of cigarettes a day for over 40 years, but 3 months ago, he reduced his consumption to 1 pack per day after experiencing shortness of breath during physical activities with his grandchildren. The patient also reports having a mild cough in the morning, and he experiences breathing difficulty even at rest. Already frail, he has lost 5 kilograms (approximately 11 pounds) in the past month, and he is brought to the hospital emergency room by paramedics after his anxious daughter found him in a restless and distressed state, unable to eat or sleep comfortably. The patient admits that he has experienced increasing shortness of breath for the last 3 or 4 years. Vital signs reported by the emergency medical technicians include: heart rate 115 - 120, respirations 28, and blood pressure 140/80. On admission to the emergency room, the patient is in acute respiratory distress. When the examining physician assesses him, it is noted that the patient has prominent kyphosis. The patient is sitting in a chair, tightly gripping the chair's arms as he breathes. He is still tachypneic and restless. Arterial blood gases are drawn and reveal the following: Pao2 = 40 mm Hg, Paco2 = 55 mm Hg, and pH = 7.31. He is placed on oxygen at 2 L/min, which is delivered by nasal cannula. A chest radiograph reveals hyperinflation of the lungs, narrow mediastinum, and low, flat diaphragms. Chest auscultation reveals quiet breath sounds and the presence of expiratory wheezes. The patient is admitted to the intensive care unit and maintained on oxygen. After a time, he becomes less anxious. Based on a combination of patient history, physical examination, and radiographic evidence, the patient is diagnosed with emphysema, a form of chronic obstructive pulmonary disease, which is also known as COPD. He is given a course of nebulizer treatments with bronchodilators and then reassessed. Chest auscultation reveals decreased expiratory wheeze. Respiratory rate is 20 breaths per minute. Arterial blood gases indicate: Pao2 = 62 mm Hg, Paco2 = 42 mm Hg, and pH = 7.37. After a few more days, he is sent home with an incentive spirometer to practice breathing exercises; he is given instructions regarding the use of pursed lip breathing, and is started on a smoking cessation program. After discharge, the patient is maintained at home on oxygen at a 1 L/min flow rate. What is responsible for the patient's weight loss? Answer Choices A.) Utilization of nutrients is prevented by COPD conditions B.) Cigarette smoking increases the body's basal metabolic rate (BMR) resulting in rapid consumption of calories C.) Chronic cigarette smoking progressively decreases the sensitivity of taste buds, thus decreasing appetite D.) Cigarette smoking stimulates the satiety center of the hypothalamus, producing an appetite suppression effect E.) Chronic obstructive pulmonary disease increases the body's caloric requirement

Correct answer: E Chronic obstructive pulmonary disease increases the body's caloric requirement Explanation The correct response is that chronic obstructive pulmonary disease increases the body's caloric requirement. In conditions of emphysema, destruction of elastic tissue results in decreased elastic recoil of the lung and destruction of alveolar septa. As a result of impaired expiration, hypoventilation and unequal ventilation-perfusion matching occurs. As alveolar carbon dioxide tension (PaCO2) increases, the partial pressure of arterial carbon dioxide (PaCO2) increases, resulting in hypercarbia. Hypoxemia has no effect on the retention of CO2 in patients with COPD. Relaxation of airway smooth muscle does not contribute to retention of carbon dioxide in the lung. In fact, airway relaxation is promoted through the use of bronchodilators to relieve the symptoms of airway obstruction. Similarly, tachypnea is not responsible for carbon dioxide retention but, instead, is one of the clinical signs often seen in patients with severe emphysema. Under normal conditions, the primary ventilatory control is the central hypercapnic drive mechanism, or carbon dioxide chemoreceptor mechanism. This ventilatory control is unusually sensitive because it depends on the detection of hydrogen ions (H+) in the cerebrospinal fluid (CSF). With PaCO2 levels in the normal range, CO2 slowly diffuses into the CSF and combines with H2O to form carbonic acid (H2CO3). As this weak acid ionizes, the liberated H+ lower the pH of the CSF and stimulate the medullary ventilatory center. The sensitivity of this central mechanism is due to the fact that CSF possesses a relatively minor buffering capability. Consequently, a small increase in PaCO2 translates into the release of H+ that are not adequately buffered and accounts for the exquisite sensitivity of this mechanism. In the case of emphysema, however, PaCO2 is chronically high and sodium bicarbonate (NaHCO3) has sufficient time to diffuse from the plasma into the CSF. The added buffering capacity of bicarbonate in the CSF neutralizes liberated H+ and dulls the sensitivity of the hypercapnic drive mechanism. As a result, the patient with COPD relies more heavily on the peripheral O2-chemoreceptors that comprise the hypoxic drive mechanism. This mechanism usually plays a minor role in the control of breathing, showing optimal sensitivity in the relatively low PaO2 range of 30 mm Hg to 60 mm Hg, but in the patient with emphysema, it becomes the primary control of ventilation. The peripheral aortic and carotid bodies respond to depressed PaO2 levels by triggering an increase in ventilation. For these reasons, when patients with emphysema require therapeutic oxygen, it is delivered at low flow rates of 1 - 2 L/min, and at relatively low concentrations (25% - 35%) in order to preserve the patients' critically important hypoxic drive mechanism. High concentrations of oxygen, high flow rates, or a combination of both, will raise the PaO2 above the sensitivity threshold of the peripheral O2-chemoreceptors. Acidic conditions in the bloodstream (e.g., pH = 7.31) and high PaCO2 levels (e.g., PaCO2 = 55 mm Hg) cause the hemoglobin dissociation curve to shift to the right. This indicates that hemoglobin has a decreased affinity for oxygen, thus more oxygen unloads at the tissues (the Bohr effect). A right shift of the oxygen dissociation curve represents decreased O2-loading in the lung because of a decrease in the affinity of hemoglobin for oxygen. In other words, less hemoglobin saturation occurs for a given change in PO2. In patients with acidosis and hypercarbia caused by emphysema, the right shift of the hemoglobin dissociation curve causes increased diffusion of O2 into the tissues for a given change in PaO2. If the disease progresses slowly, the kidney is able to reabsorb additional bicarbonate to buffer H+ in the blood and prevent pH changes (compensated respiratory acidosis), but if the PaCO2 rises suddenly as a result of impaired gas exchange at severely disrupted alveoli, acute respiratory acidosis may occur. Patients with COPD often benefit from nebulizer treatment with bronchodilators such as β2 -adrenergic agonists (e.g., albuterol, terbutaline) and anticholinergics (e.g., ipratropium). The smaller-diameter peripheral airways respond well to β2 -adrenergic agonists whereas the antimuscarinic bronchodilators are most effective on large-diameter central airways. Administered together, the 2 classes of bronchodilators produce an enhanced effect. The antimuscarinic drug opposes bronchoconstriction caused by cholinergic stimulation, whereas the β2 -agonist drug stimulates β2 -adrenergic receptors to promote bronchodilation. The xanthine bronchodilators, such as theophylline, and the glucocorticoids, such as prednisone, would be of limited value in treating acute respiratory distress. In advanced cases of emphysema, malnutrition is a common finding, but it is not related to a long history of smoking. Instead, the malnutrition and inevitable weight loss is due to a combination of increased energy needs and decreased caloric intake. The individual with COPD expends extra energy with the increased work of breathing required by the accessory muscles of ventilation. In addition, appetite is often depressed due to fatigue and dyspnea.

A 45-year-old man presents for a certification of disability. The man works in a nursery. He gives history of occasional breathlessness for which no medical record is present. Examination shows tachypnea, and scattered rhonchi are heard all over the chest. In what way is spirometry helpful in this case? Answer Choices A.) Done alone B.) Done once and repeated again with bronchodilator therapy C.) Done only with bronchodilator therapy D.) Spirometry is not important E.) Spirometry conducted alone or with bronchodilator therapy, does not matter

Correct answer: B Done once and repeated again with bronchodilator therapy Explanation Spirometry is the most useful assessment of impairment caused by airway obstruction. It is used to determine the impairment leading to disability. It should be done initially and then repeated with bronchodilator therapy because it proves that the 1st result was due to blockage of the airway.

A 57-year-old man presents with fever and productive cough. A brief history reveals a 60-pack per year smoking habit and worsening cough with occasional hemoptysis and dyspnea. He reports recent shoulder pain, which radiates down the right arm in the ulnar distribution. On physical exam, the patient is thin, moderately distressed, and short of breath with tachypnea and oxygen saturation at 84%. Wheezing is noted. Chest CT is rich with pulmonary findings, some of which are suggestive of lung carcinoma. The patient is admitted to the hospital for further evaluation. What would be most appropriate in the ensuing work-up for lung carcinoma? Answer Choices A.) Bronchoscopy and biopsy B.) Endocrine evaluation for paraneoplastic phenomenon C.) Genetic testing for p53 mutation D.) High resolution CT of chest E.) Transthoracic fine-needle aspiration biopsy

Correct answer: A Bronchoscopy and biopsy Explanation Bronchoscopy and biopsy is the most logical next step in the evaluation for lung cancer in this case. A fiber optic probe is inserted through the trachea and is used to obtain images as well as samples of suspicious tissue for biopsy. While many of the smaller airways can be artfully accessed in this way, there are still occasions where bronchoscopy fails to obtain a sample when the tumor is "out of reach". Transthoracic fine-needle aspiration biopsy is used to sample a tumor when bronchoscopy is not practical or has already yielded negative results. Peripheral lung tumors often fit this description. Endocrine evaluation for paraneoplastic phenomenon might be considered later, but at this point, bronchoscopy would be a more fruitful option for diagnosis and staging. The passage does not mention electrolyte abnormalities and offers little evidence of endocrine syndrome. Endocrine syndrome occurs in about 12% of lung cancer patients. One of the better-known syndromes is ectopic production of PTH, typically by squamous cell (epidermoid) tumors. Genetic testing for p53 mutation might be interesting, but it does not play a role in initial diagnosis and work-up of lung cancer. High resolution CT of chest would not be appropriate in this scenario. The patient has already had a chest CT. A sample of the tumor is now needed to evaluate the type of neoplasm (e.g., small cell or non-small cell), staging, and treatment options. Such a sample may be obtained via bronchoscopy. Additional points from this case: the incidence of lung cancer peaks between 55 and 60 years of age. The fever and productive cough in this case might be due to a post-obstructive pneumonia secondary to a neoplasm. Among the causes of this patient's dyspnea could be phrenic nerve paralysis with elevation of the hemidiaphragm; this would indicate regional spread of the tumor in the thorax. Likewise, if the tumor is associated with an apical (involvement of superior lung fields) spread, there may be involvement of the cervical and thoracic nerves (C8, T1, T2) resulting in shoulder pain, which radiates down the ulnar distribution (Pancoast's syndrome).

A 23-year-old man presents with a 5-day history of productive cough of blood-streaked sputum. Over the last several years, he had similar symptoms 3 to 4 times a year; they were successfully treated with antibiotics. He has had a cough since his childhood; recently, it has been productive of 1-2 cups of yellow-green sputum. The patient is a non-smoker. He takes lipase, protease, and amylase for malabsorption. Coarse rhonchi and wheeze are heard. Chest X-ray shows bilateral nodular tissues, hyperinflation with increased interstitial markings. What is the most likely diagnosis? Answer Choices A.) Cystic fibrosis B.) Pneumonia C.) COPD D.) Bronchiectasis E.) Tuberculosis

Correct Answer: A Cystic Fibrosis Explanation The clinical picture, X-ray, and malabsorption are diagnostic of cystic fibrosis. Cystic fibrosis is an autosomal recessive disease resulting from mutation of chromosome 7. Patients are infertile due to aspermia, secondary to disordered vas deferens and seminal vesicles, and they have bronchiectasis early in life. Repeated infection, inflammation, and scarring destroy the lung. Associated malabsorption is present in 80% of the cases due to pancreatic insufficiency. Delayed puberty amyloidosis, biliary cirrhosis, and increased frequency of gallstones are some of the associated features. An increased sweat chloride is present in 99% of the patients with cystic fibrosis and is diagnostic. The average life expectancy for cystic fibrosis is more than 30 years of age; life expectancy is progressively increasing to 40 years. The lung complications develop late, whereas the primary symptoms are gastrointestinal. The average life expectancy age for a child born in 2006 with cystic fibrosis is 36 years. COPD requires a history of smoking for at least 10 - 15 years to produce such gross symptoms. Neither tuberculosis nor pneumonia would have such a long history, and the X-ray would differentiate. Bronchiectasis would have a similar clinical picture; however, it would be at late age, and there would be no pancreatic insufficiency. Therefore, the patient would not be on treatment for malabsorption. X-ray would show a honeycomb appearance.

A 60-year-old man presents with cough and easy fatigability. His cough has been productive of yellow sputum for several months; however, over the past few days, he has developed hemoptysis. He also reports weakness in the muscles of both arms, such that is he is not able to raise objects above his head. On examination, his vital signs are normal. His systemic examination is essentially normal, except that his deep tendon reflexes are reduced. He has a 70-pack per year smoking history. What is the most likely diagnosis? Answer Choices A.) Eaton Lambert syndrome B.) Superior vena cava syndrome C.) Pancoast syndrome D.) Ectopic adrenocorticotropic hormone (ACTH) secretion) E.) Hypertrophic pulmonary osteoarthropathy

Correct Answer: A Eaton Lambert syndrome. The clinical picture is suggestive of bronchogenic carcinoma. The risk factors for lung cancer are smoking and occupational agents such as asbestos. The 4 common histological types of bronchogenic carcinoma are squamous cell, small cell, large cell, and adenocarcinoma. Patients usually present with symptoms associated with local tumor effects in the chest or with neoplastic syndromes due to tumor involvement of contiguous anatomic structures, or with symptoms due to paraneoplastic syndromes resulting from a tumor-produced hormone or hormone-like substance. Symptoms caused by local tumor effects include cough, chest pain, dyspnea, and hemoptysis. Bronchial narrowing may cause air trapping with localized new onset wheezing and atelectasis with ipsilateral mediastinal shift and loss of breath sounds. Neoplastic syndromes include Pancoast syndrome and the superior vena cava syndrome. Pancoast syndrome is caused by tumor infiltration of the brachial plexus, neighboring ribs, and vertebrae. These tumors are usually located in the superior sulcus of the lung. Patients usually present with pain in the shoulder or medial portion of the scapula, numbness, and weakness of the affected arm. The pain is radicular pain - along the ulnar nerve distribution. Continued tumor growth leads to sympathetic chain involvement with Horner's syndrome (enophthalmos, miosis, ptosis, and hemianhidrosis). Pulmonary symptoms are rare. The most common cell type causing Pancoast syndrome is squamous cell carcinoma. On examination, the patients may have muscle wasting in the T1 and C8 distribution. Radiographically, the tumor is often difficult to see and may only be visible as a vague cap at the lung apex, similar to pleural thickening. CT and MRI are helpful in determining the extent of involvement and invasion of adjacent structures. Superior vena cava (SVC) syndrome results from the partial or complete obstruction of the SVC and intraluminal venous thrombosis. It leads to dilation of collateral veins in the upper part of the chest and neck, edema and plethora of the face, neck, upper part of the chest, and upper extremities. The patients present with facial flushing, cough, breathlessness when supine, headache, visual disturbances, and syncope. On examination, they have prominent distended and tortuous veins in the face, neck and upper trunk, papilledema, facial cyanosis, and pleural effusions. A contrast enhanced CT scan is useful in making the diagnosis. Symptomatic relief can be obtained through supplemental oxygen, diuretics, and steroids. Chemotherapy and radiation therapy are used to treat the malignancy. Paraneoplastic syndromes of lung cancer include hypertrophic pulmonary osteoarthropathy, Eaton-Lambert syndrome, secretion of ectopic adrenocorticotropic hormone, and syndrome of inappropriate antidiuretic hormone secretion. Small cell carcinomas may secrete ectopic adrenocorticotropic hormone ACTH, resulting in hypokalemia, muscle wasting, and Cushing's syndrome. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) results in water retention, plasma hypotonicity, and hyponatremia. Symptoms include weakness, lethargy, abnormal mentation, coma, and seizures. Diagnosis is made by finding hyponatremia, low serum osmolality (<280mOsm/kg) with a high urine osmolality (greater than serum osmolality), and high urine sodium (>20 mEq/L) in a patient with normal intravascular volume. It is treated by limiting the total free water intake and by demeclocycline, as well as by treating the underlying tumor. Squamous cell carcinomas may secrete parathyroid hormone-like substances that produce hypercalcemia. Eaton Lambert myasthenic syndrome is an immune-mediated, myasthenia-like syndrome resulting from impaired release of acetylcholine from nerve terminals. Patients present with fatigability, dry mouth, proximal limb muscle, weakness, paresthesias, autonomic dysfunction, and decreased or absent deep tendon reflexes. Electromyography may show posttetanic potentiation. Unlike in myasthenia gravis, the Eaton-Lambert is associated with improved strength with repeated muscle activity. The diagnosis is confirmed by finding an incremental response to repetitive nerve stimulation. Small cell lung carcinoma is most often associated with this syndrome, and effective chemotherapy may result in improvement. Guanidine, corticosteroids, and plasmapheresis provide benefits for some patients. In hypertrophic pulmonary osteoarthropathy (HPO), there is formation of new subperiosteal cancellous bone at the distal ends of long bones such as the radius, ulna, tibia, and fibula. This results in periosteal elevation. Patients present with pain, swelling, erythema, localized tenderness, as well as clubbing of the fingers and toes. X-rays of long bones show new subperiosteal bone formation. A 99mTc bone scan assists in making the diagnosis of HPO because it demonstrates increased metabolic activity in long bones. The etiology for clubbing and HPO in lung cancer has been thought to occur through neurogenic and humoral mechanisms.

Eosinophils can bind to IgE because they express IgE Fc receptors. They also express Fc receptors to the Fc portion of IgG. Thus, both IgE- and IgG-bound antigen will bind to their respective Fc receptors on eosinophils, causing these cells to be activated. Once these receptors are triggered, the cells degranulate, releasing a variety of factors that can cause tissue damage. What is the cause of this disorder called? Answer Choices A.) Polyarteritis nodosa B.) Erythema elevatum diutinum C.) Polymyalgia rheumatica D.) Loeffler's syndrome E.) Hashimoto's thyroiditis

Correct Answer: D Loeffler's syndrome Explanation Loeffler's syndrome, or pulmonary eosinophilia, is an inflammation of the lungs associated with infiltration of eosinophils in the lungs and blood. It is characterized by lassitude, night cough, shortness of breath, and pulmonary infiltrates showing a large amount of eosinophils. Loeffler's syndrome is precipitated by a hypersensitivity response to food or medication, infection, or parasitic infestation (especially ascariasis in children) and is usually self-limited. Symptoms are related to the release of toxic eosinophil products. These products include major basic protein, eosinophil cationic protein, and eosinophil-derived neurotoxin, which damage the respiratory epithelium, induce ciliastasis, and influence mucus production. Tissue injury may also be caused by the release of reactive oxygen species. The release of platelet-activating factor and leukotrienes contributes to bronchospasm. Treatment depends on the cause. Polyarteritis nodosa is a disorder characterized by swelling of the muscle fibers within the media of arteries. This is followed by fibrinoid change and intense infiltration of polymorphonuclear cells. The process results in multiple aneurysm formation often with total occlusion of the vessel. The etiology of the vasculitis is unknown. Erythema elevatum diutinum is a rare disease characterized by infiltration of the dermis of the skin with neutrophils. Skin manifestations include chronic papules and nodules of the skin, particularly in areas overlying joints. The disease is often associated with HIV and/or abnormalities in antibody production that may be due to underlying cancer or infections. Treatment is accomplished with anti-inflammatory agents. Polymyalgia rheumatica is a relatively common disease of the elderly, particularly women. Most patients are over 70 at presentation and the disease is rare before the age of 55. The major presenting symptoms are acute onset of pain and morning stiffness in the muscles of the shoulders and pelvic girdle. Systemic symptoms include malaise, weight loss, and anorexia. The response of polymyalgia rheumatica to prednisolone is dramatic. Hashimoto's disease is an autoimmune disease of the thyroid most commonly found in middle-aged women, and leads to the formation of a goiter or to hypothyroidism and results in the destruction of thyroid function. Several target antigens are involved in the disease process, including thyroglobulin, which is the major hormone produced by the thyroid. Microsomal antigens from thyroid epithelial cells also have been implicated, and antibodies to all these antigens have been found in Hashimoto's disease patients.

You order respiratory tests on a patient with difficulties breathing. Which of the following would be the best indicator for airflow obstruction? Answer Choices A.) 1 second forced expiratory volume to forced vital capacity ratio (FEV1/FVC) B.) Residual volume C.) Diffusion capacity D.) Forced vital capacity (FVC) E.) 1 second forced expiratory volume (FEV1)

Correct answer: A 1 second forced expiratory volume to forced vital capacity ratio (FEV1/FVC) Explanation The decrease in the FEV1/FVC ratio is the best measure of airflow obstruction. FEV1 is the maximal volume that can be forcefully exhaled during the first second after maximal inhalation; FVC represents the total volume that can be exhaled after maximal inhalation. FEV1 is decreased in restrictive, as well as obstructive lung disease. Diffusion capacity and residual volume both do not identify airway obstruction. Diffusion capacity is a measure for the functioning of the alveolar-capillary membrane and residual volume, the volume remaining in the lungs after maximal exhalation.

A 55-year-old man is a known case of COPD; he presents with dyspnea. Patient is cyanotic, restless and confused. He has tachycardia, tachypnea and peripheral and conjunctival hyperemia. If you suspect respiratory failure, what is the most important thing you would use to aid the diagnosis? Answer Choices A.) ABG B.) Signs and symptoms of hypoxemia C.) Signs and symptoms of hypercapnia D.) Chest X-ray E.) History

Correct answer: A ABG Explanation Symptoms and signs of respiratory failure are those of underlying disease combined with hypercapnia and hypoxemia. The signs and symptoms are insensitive and nonspecific, hence the physician must maintain a high level of suspicion and request an arterial blood gas (ABG) analysis if respiratory failure is suspected. Chest X-ray does not have any significance in the diagnosis of respiratory failure. It helps in the diagnosis of the underlying disease. History plays a role in the diagnosis of respiratory failure by giving an idea of any illness present, which can lead to respiratory failure. Signs and symptoms of both hypoxemia and hypercapnia are important but alone they cannot help to diagnose respiratory failure, though they arouse the suspicion. These can be present in ARDS, pulmonary edema etc. Signs and symptoms of hypoxemia include dyspnea, anxiety, restlessness, delirium, tachypnea, tachycardia, hypertension and cardiac arrhythmias. Signs and symptoms of hypercapnia include headache and dyspnea, peripheral and conjunctival hyperemia, tachycardia, tachypnea, papilledema, and asterixis.

A 60-year-old man gives a characteristic history of carcinoma of the lung. The patient is a non-smoker. Because the patient a non-smoker, what cancer does he probably have? Answer Choices A.) Adenocarcinoma of the lung B.) Squamous cell carcinoma of the lung C.) Squamous cell carcinoma of the larynx D.) Mesothelioma of the pleura E.) Small cell anaplastic carcinoma of the lung

Correct answer: A Adenocarcinoma of the lung Explanation Adenocarcinoma is one of the peripheral carcinomas affecting the lungs. Peripheral carcinomas (adenocarcinoma and large cell carcinomas) show less association with smoking than central cancers (squamous cell and small cell carcinomas). Considering that the patient is a non-smoker, he is most likely to be suffering from adenocarcinoma of the lung. Squamous cell carcinoma is one of the most common cancers seen in smokers. It has a close association with smoking, and it is less common in non-smokers. Laryngeal carcinomas as well as squamous cell carcinomas of the pharynx are more common in smokers. Mesothelioma of the pleura is seen with asbestos exposure. Although asbestos exposure is a necessary cause, history of smoking increases the risk ten-fold. Small cell carcinoma (or oat cell carcinoma) is the second most common cancer associated with smoking. It is rare amongst non-smokers.

A 2-year-old boy presents with chronic respiratory infections, foul-smelling pale stools, weight loss, and wheezing. His mother reports using moist mist treatments repeatedly, and they offer some relief. A clinical exam shows delayed growth, an enlarged spleen upon palpation, and clubbing of fingers and toes. Auscultation of the lungs demonstrates pulmonary congestion. Lab results report a positive fecal fat test and sweat chloride test. What is the most likely diagnosis?? Answer Choices A.) Cystic fibrosis B.) Pulmonary tuberculosis C.) Pulmonary histiocytosis D.) Pulmonary aspergilloma E.) Pulmonary nocardiosis

Correct answer: A Cystic fibrosis Explanation Cystic fibrosis is an inherited disease that affects the respiratory and digestive systems. It affects the exocrine (mucus and sweat) glands of the body and is caused by a defective gene. It is the most common cause of chronic lung disease in children and young adults. Thick mucus is formed in the bronchial tree, which predisposes the person to chronic lung infections. Symptoms include no meconium stool in the first 24 hours of life, stools (pale or clay colored, foul-smelling, and floating), skin may taste salty (infants), persistent respiratory infections, coughing or wheezing, weight loss, clubbing of the fingers or toes, diarrhea, delayed growth, easy fatigue, and splenomegaly. Tests should include sweat chloride test, a fecal fat test (positive), bone X-ray, chemistry panel, upper GI, small bowel series, as well as immunoreactive trypsinogen. Treatments include antibiotics for respiratory infections and pancreatic enzymes to replace the missing enzymes. Mucomyst may be used on occasion to thin secretions. The use of ibuprofen has been shown to slow lung deterioration in some children. Other treatments include postural drainage, chest percussion, and other breathing treatments. Lung transplant may be considered in some cases. About 50% of patients with cystic fibrosis live beyond age 20. Few patients live beyond 35. Death occurs from pulmonary (lung) complications. Pulmonary tuberculosis is a contagious bacterial infection caused by Mycobacterium tuberculosis (TB). The lungs are primarily involved, but the infection can spread to other organs. The disease is characterized by the development of granulomas (granular tumors) in the infected tissues. Primary infection is usually asymptomatic. Symptoms may include initially but are not limited to minor cough and mild fever, fatigue, weight loss, coughing up blood, slight fever and night sweats, wheezing, rales, excessive sweating, joint pain, hearing loss, diarrhea, chest pain, breathing difficulty, positive Babinski's reflex, and clubbing of the fingers or toes. Pulmonary histiocytosis is characterized by inflammation of the small airways (bronchioles) and the small blood vessels in the lungs. This inflammation leads to stiffening (fibrosis) and destruction of the walls of the alveoli. Systemic involvement may cause rashes, pulmonary problems, enlargement of the spleen and liver, anemia, and death. In children, symptoms can include failure to thrive, weight loss, irritability, fever, seborrheic dermatitis of the scalp, generalized rash (petechiae or purpura), and chronically draining ears; bone pain may or may not be present. Pulmonary aspergilloma is a fungal mass that grows in pre-existing lung cavities (or can cause new lung cavities). The preexisting cavities may have been caused by a previous infection of histoplasmosis, tuberculosis, sarcoidosis, lung abscess, cystic fibrosis, or previous lung cancer. Symptoms include cough, coughing up blood, weight loss, and fever. Tests include bronchoscopy or bronchoscopy with lavage (BAL), chest X-ray, and sputum culture. The most effective therapy is a surgical resection (cutting out the fungus growth). If life-threatening bleeding occurs, emergency surgery may be the only choice of treatment. Pulmonary nocardiosis is an infection of the lung (pneumonia that is caused by a fungus-like bacterium). The causative organism is present throughout the world, and the infection is acquired through inhalation, causing a pneumonia-like illness. The disease can spread to any part of the body, but brain lesions and subcutaneous (under the skin) lesions are most common. Symptoms include cough with sputum production, progressive difficulty breathing, general discomfort, uneasiness or ill feeling (malaise), weight loss, fever (intermittent), night sweats, chest and joint pain, as well as liver and spleen enlargement (hepatosplenomegaly).

Pulmonary function studies generally show in chronic obstructive lung disease (COPD): Answer Choices A.) Decreased VC and increased RV, FRC, and TLC. B.) Increased VC and decreased RV, FRC, and TLC. C.) Increased RV and decreased VC, FRC, and TLC. D.) Increased TLC and decreased RV, FRC, and VC. E.) Decreased TLC and increased RV, FRC, and VC.

Correct answer: A Decreased VC and increased RV, FRC, and TLC. Explanation Unlike asthma, COPD is not characterized by marked temporal variability in the degree of airway obstruction. Airway obstruction leads to characteristic changes in lung volume with a decrease in vital capacity (VC), and expiratory flow rates and an increased total lung capacity (TLC), functional residual capacity (FRC) and residual volume (RV).

Which of the following may be the first sign of a lung cancer of the superior sulcus? Answer Choices A.) Horner's syndrome B.) Anisocoria C.) Holmes-Adie pupil D.) Argyll Robertson pupils

Correct answer: A Horner's syndrome Explanation Cerebral herniation leads to pupillary dilatation if it affects the third nerve, or it leads to bilaterally mid-positioned and fixed pupils if it affects midbrain. Tonic (Adie's) pupil is a somewhat larger than normal pupil that constricts little or not at all to light and shrinks slowly on accomodation. It constricts more than normal when dilute pilocarpine is instilled, suggesting that the pupil is parasympathetically denervated (denervation hypersensitivity). The disorder may be unilateral or bilateral. In some patients, the disorder is associated with absent deep tendon reflexes (Adie's syndrome), but neither the pupillary nor the reflex disorder causes serious disability. Argyll Robertson pupils are small (1 to 2 mm), unequal, irregular, fixed to light, and they constrict briskly on accomodation. Their principal cause is neurosyphilis, although partial Argyll Robertson pupils occur with diabetes and certain autonomic neuropathies. Essential anisocoria (lifelong difference in the size of the pupils with a normal light reaction) occurs in about 15% of normal people. Horner's syndrome may be caused by vascular damage to the hypothalamus or brain stem, but then associated with other neurological signs that point to the disorder. An isolated Horner's syndrome may be the first sign of a lung cancer of the superior sulcus or may occur with tumors or other diseases involving the carotid artery. When sympathetic fibers are damaged, the pupil narrows (the light reaction is still normal), and the palpebral fissure becomes smaller as the upper lid descends and the lower lid elevates (Horner's syndrome).

In a hospitalized patient at risk for the development of venous thromboembolism after surgery, which of the following would be the best choice for prevention in terms of safety, efficacy, and cost-effectiveness? Answer Choices A.) Low-molecular-weight heparin B.) Unfractionated heparin C.) Aspirin D.) Warfarin E.) Dextran

Correct answer: A Low-molecular-weight heparin Explanation Standard or unfractionated heparin, aspirin, warfarin, and dextran have all been used to prevent venous thromboembolism in the high-risk patient in the postoperative period. Aspirin and dextran tend to have fewer bleeding complications than the anticoagulant drugs, but some studies have suggested that they are less effective in the prevention of deep venous thrombosis and pulmonary embolism. Both warfarin and standard heparin are effective, but are associated with bleeding complications in a substantial number of patients. In addition, both unfractionated heparin and warfarin require careful monitoring of blood tests (partial thromboplastin time, prothrombin time) to maintain the dosage within a therapeutic range. Unfractionated heparin must be given several times daily. Low-molecular-weight heparin has the advantages of once-daily dosing, no monitoring requirement, and a lower risk of bleeding complications, while demonstrating efficacy comparable to standard heparin.

Pneumomediastinum is most likely to be associated with which one of the following? Answer Choices A.) Mechanical ventilation B.) Viral pneumonia C.) Pulmonary embolism D.) Congestive heart failure E.) Bronchiectasis

Correct answer: A Mechanical ventilation Explanation Pneumomediastinum is one manifestation of the "barotrauma" that may result from mechanical ventilation, especially when associated with high pressures or positive end-expiratory pressure ventilation. It represents extrapulmonary leakage of air through similar mechanisms as pneumothorax. The other conditions listed are not commonly associated with pneumomediastinum unless other complications supervene to create a circumstance that favors rupture of lung tissue and air leakage.

A 50-year-old man presents with dyspnea. The chest radiograph shows a large right pleural effusion. A thoracentesis is performed; 700 cc of chylous (milky white) fluid is obtained. What is the most probable cause of this finding? Answer Choices A.) Mediastinal malignant lymphoma B.) Penetrating chest trauma C.) Tuberculosis D.) Congestive cardiac failure E.) Systemic lupus erythematosus

Correct answer: A Mediastinal malignant lymphoma Explanation Presence of a chylothorax suggests that there is obstruction of the thoracic duct and/or major lymph channels in the chest cavity, with leakage of chylous fluid. Chylothorax is the most rare form of pleural effusion. Of the listed causes, malignant lymphoma is the most probable cause; due to its large size and presence in the mediastinum, it can cause obstruction of the thoracic duct. Penetrating chest trauma would rarely cause a chylothorax. It would take a good aim to cut the thoracic duct; even then, the hemorrhage would be more as compared to the lymph spilled out. In general, tuberculosis would not produce lymphatic obstruction. Congestive cardiac failure (CCF) alone cannot lead to lymphatic obstruction. CCF can lead to serous pleural effusions. SLE is often associated with serous pleural effusion because of the inflammation of the serosal surfaces.

A 15-year-old African-American boy presents follow-up of asthma. He has had symptoms since age 2 and was hospitalized once when he was 3. His symptoms have decreased over the years, but he still complains about wheezing most of the year, particularly in the winter. His peak-flow readings are in the 450 range when he is feeling well, but a mild respiratory infection can bring this number down to 300. He feels well at the moment and does not report any cough, wheeze, fever, or shortness of breath. Past medical history is significant for sickle cell trait. He has never undergone surgery. Current medications include an albuterol-metered dose inhaler and a triamcinolone 100 mcg inhaler that he uses for 4 puffs, 2 times a day. When questioned about his albuterol inhaler, he answers that he uses it at least 1 or 2 times each day. He reports that he is allergic to sulfur based medicines, which caused rash and itching. Family history is significant for asthma and eczema, as well as sickle cell disease in his birth father. Social history reveals that he lives with his mother and stepfather, along with 2 half brothers. There are no smokers in the house. They have no pets. Review of systems is negative for chest pain, numbness, tingling, or pleuritic discomfort. He reports excellent exercise tolerance when his asthma is not active. On exam, he is well developed and well nourished. His head, ears, eyes, nose, and throat appear normal. Chest is clear to auscultation bilaterally today, with no evidence of wheezing or rales. Heart examination is normal, with no evidence of murmur. Abdomen is soft, nontender, and bowel sounds are normal. His extremities show mild clubbing but no cyanosis. Pulse oximetry is 99% on room air. How is the patient's clinical status best summarized? A.) Moderate, but uncontrolled asthma B.) Mild, adequately controlled asthma C.) Severe, but well-controlled asthma D.) Impaired oxygen-carrying capacity E.) Susceptible to hemolytic sickle crisis

Correct answer: A Moderate, but uncontrolled asthma Explanation Most experts agree that use of a short-acting bronchodilator (such as albuterol) more than 2 times a week during the daytime (or more than 1 time per week during the night) indicates inadequately controlled asthma. This patient is using albuterol on a daily basis, which classifies him as having uncontrolled asthma. In addition, he is already using a fair amount of inhaled steroid. The goal for this patient would be to add adjuvant therapy until the short acting bronchodilator, or 'rescue' inhaler, is only being used 1 or 2 times a week. Inhaled ipratropium (Atrovent) could be considered, as should an oral leukotriene inhibitor. Long-acting bronchodilators, such as salmeterol, could also be considered. If the patient continues to have uncontrolled asthma, theophylline might also be an option. Having the sickle cell trait does not put the patient at a significantly increased risk of hemolytic sickle cell crisis, which is much more likely to occur with homogenous sickle cell SS disease. The hemoglobin oxygen-carrying capacity would not be significantly less by having the sickle cell trait.

A 50-year-old man who has smoked 1 pack-a-day of cigarettes since age 23 presents with a history of cough and dyspnea on exertion that has progressively worsened over the past several months. Chest x-ray reveals flattening of the diaphragms but no consolidations. Spirometry was performed and the results are as follows: FEV1 60% predicted FVC 84% predicted FEV1/FVC 71% predicted Based on these findings, what is the most likely diagnosis? Answer Choices A.) Obstructive lung disease B.) Restrictive lung disease C.) Silicosis D.) Upper airway disease E.) Pneumonia

Correct answer: A Obstructive lung disease Explanation The spirometry results and chest x-ray are consistent with the diagnosis of chronic obstructive pulmonary disease (COPD). COPD is a disease marked by chronic obstructive to airflow. Common symptoms include cough and dyspnea on exertion. The most common risk factor for the development of COPD is cigarette smoking. On spirometry, patients with COPD exhibit both a decrease in FEV1 (forced expiratory volume in the first second of expiration) and FVC (forced vital capacity); but the decrease in FEV1 is generally greater than the decrease in FVC, which results in a decrease in the FEV1/FVC ratio, which is a hallmark of the diagnosis. Difficulty in expiring leads to air trapping and hyperinflation. On chest x-ray, this is noted as flattening of the diaphragm. Patients with restrictive lung disease exhibit reduced lung volumes and a normal or increased FEV1/FVC ratio. The most common cause is interstitial lung damage. Examples of restrictive lung diseases include acute respiratory distress syndrome (ARDS), asbestosis, silicosis. Upper airway disease can be diagnosed with spirometry only if the flow graphs are shown. There will be flattening of the inspiratory curve in upper airway disease. Pneumonia is a lower respiratory tract infection that would most likely produce x-ray findings such as a consolidation in a particular lobe or increased interstitial markings. Silicosis is a restrictive disorder of the lung caused by exposure to silica (silicon dioxide) dust or quartz particles. Spirometry readings will be consistent with a restrictive disorder (reduced lung volumes and normal or increased FEV/FVC1 ratio). Nodular opacities in the upper lung zones and hilar calcifications may also be present on chest x-ray.

A 44-year-old healthy man, who is a non-smoker, has a 3-cm coin lesion in the right upper lobe. The lesion was revealed on his chest radiograph. The patient did not have any clinical symptoms. The fine-needle aspiration did not reveal any cells. What is the most likely tumor in this case? Answer Choices A.) Pulmonary hamartoma B.) Bronchial carcinoid C.) Mesothelioma D.) Metastatic adenocarcinoma E.) Large cell undifferentiated carcinoma

Correct answer: A Pulmonary hamartoma Explanation A peripheral 'coin lesion' could be a granuloma, carcinoma, or a hamartoma. The most likely malignancy in a non-smoker would be adenocarcinoma. Pulmonary hamartoma is the most common benign lung tumor, although it is a relatively uncommon lesion. It is likely an acquired lesion from peribronchial mesenchyme. The patients are generally asymptomatic. The lesion is almost always solitary and is usually peripheral; hence, it does not reveal any cells on fine-needle aspiration. Histologically, hamartomas are composed of both mesenchymal and epithelial elements. A bronchial carcinoid is (usually) a central benign tumor with some of the properties of malignant growth. Mesothelioma is a bulky pleural mass. It is rare, even in smokers with asbestos exposure. Metastatic adenocarcinoma usually produces multiple lung nodules. Large cell undifferentiated carcinoma is a large peripheral mass.

A 55-year-old man is a known case of COPD; he presents with dyspnea. The patient is cyanotic, restless, and confused. He has tachycardia, tachypnea, as well as peripheral and conjunctival hyperemia. Ophthalmoscopy shows papilledema. ABG shows PaO2 - 54mmHg, PaCO2 57mmHg and SaO2 76%. Chest X-ray shows the changes only due to COPD. What is the most likely diagnosis? Answer Choices A.) Pulmonary edema B.) Acute respiratory failure C.) Pneumothorax D.) Pneumonia E.) Asthma

Correct answer: B Acute respiratory failure Explanation The ABG with PaO2<60% and PaCO2>50% is the important factor in the diagnosis of respiratory failure. All the signs and symptoms along with the ABG lead to the diagnosis. Pneumothorax will be diagnosed on X-ray. It shows a deflated lung with the visceral pleural line, with complete translucency between this and the chest wall. Pneumonia will not be missed on X-ray, with mostly a lobular consolidation, and it would not have so severe signs and symptoms at presentation. Asthma presents with wheezing and mostly has a previous history. Pulmonary edema will have the causatory factors of increased interstitial fluid in the lung that leads to alveolar flooding like drowning, acute glomerulonephritis, allergic reaction, aspiration, inhalational injury. Chest X-ray will show bilateral perihilar pulmonary edema.

A 40-year-old man has a several-year history of chronic cough; it is sometimes accompanied by fever and sputum production. Patient is a nonsmoker. The chest X-ray shows consolidation of the left lung field. A bronchogram shows bronchial dilatation and sacculation involving the first segmental bronchus and branches extending to the left lingular region. What is the most likely diagnosis? Answer Choices A.) Pulmonary hamartoma B.) Bronchial carcinoid C.) Mesothelioma D.) Metastatic adenocarcinoma E.) Large cell undifferentiated carcinoma

Correct answer: B Bronchial carcinoid Explanation The chest X-ray with the consolidation and the bronchogram showing localized bronchiectasis, suggesting a picture of pulmonary collapse, could possibly be due to a tumor. A bronchial adenoma, of which a carcinoid tumor is a form, could produce localized bronchial obstruction leading to localized bronchiectasis. A pulmonary hamartoma has a classical 'coin lesion' radiological feature. The lesion is usually peripheral. Mesothelioma is a bulky pleural mass. It is rare, even in smokers with asbestos exposure, but it is still rarer in anyone else. Metastatic adenocarcinoma usually produces multiple lung nodules. Large cell undifferentiated carcinoma is a large peripheral mass.

A 56-year-old man presents with dyspnea on exertion. He also describes a chronic cough with sputum production, which he estimates has been present for 3 - 4 months of the year for the last 2 years. He is a heavy smoker. He works in a plastics plant where he is exposed to toluene diisocyanate. Examination of the chest reveals scattered crackles and some low-pitched wheezes on forced expiration. Chest radiograph is unremarkable, except for increased lung markings. Spirometry shows a normal forced vital capacity and a forced expiratory volume in 1 second that is 62%of normal, increasing 9% after bronchodilator administration. What is the most likely diagnosis? Answer Choices A.) Asthma B.) Chronic bronchitis C.) Emphysema D.) Interstitial fibrosis E.) Pneumoconiosis

Correct answer: B Chronic bronchitis Explanation The clinical description fits the diagnosis of chronic bronchitis well. Cigarette smoking is by far the most common etiologic factor. The 6th decade is a typical time for the appearance of symptoms in a heavy smoker. Occupational exposure to dusts or chemicals, such as toluene diisocyanate, is known to contribute to the inflammatory process in the airways. A standard definition for chronic bronchitis is the presence of cough and sputum production for at least 3 months of the year for the preceding 2 years. The physical findings are nonspecific and contribute little to the diagnosis. The radiographic findings are also nonspecific, but help to eliminate the diagnoses of emphysema (no hyperinflation, bullae, etc.) and interstitial fibrosis (no interstitial infiltrates). The spirometry results are typical of chronic bronchitis, with a moderate obstructive defect, no evidence of restrictive defect, indicative of interstitial fibrosis, and a small response to bronchodilator, eliminating asthma as a causative factor, defined by many pulmonologists to have at least a 15 percent response. The lack of exposure to organic or inorganic dust, such as asbestos or silica, and the lack of a restrictive defect, eliminates a possible diagnosis of pneumoconiosis.

A 48-year-old man presents with history of breathlessness. The chest X-ray shows diaphragmatic fibrous pleural plaques and interstitial fibrosis. What is the most likely histopathological finding possible in this case? Answer Choices A.) Noncaseating granulomas with asteroid bodies B.) Ferruginous bodies in the lung C.) Neutrophilic infiltrate D.) Dystrophic calcification E.) Necrotizing granulomas in bronchovascular distribution

Correct answer: B Ferruginous bodies in the lung Explanation From the history of breathlessness and the chest X-ray with characteristic pleural plaques and interstitial fibrosis, it suggests that the patient has asbestosis. Hence the most probable histopathological description is the presence of ferruginous bodies in the lung, which fits the picture. Noncaseating granulomas with asteroid bodies suggest the findings of sarcoidosis. Though lung involvement is the commonest, it affects the other systems too and hence breathlessness would not be the only symptom present. A neutrophilic infiltrate suggests a bacterial pneumonia. A bacterial pneumonia can be superimposed over a restrictive disease but it is not the underlying disease. Dystrophic calcification is seen in areas of the lung injury, which are recent. Necrotizing granulomas in bronchovascular distribution suggests Wegener's granulomatosis.

A secretary working temporarily in an office building presents with acute onset of fever, cough and dyspnea. Over the past 6 months, she has had the same problem every time she works in the office building. She is hospitalized for respiratory distress, and a transbronchial biopsy is performed. The histological findings include focal peribronchial mononuclear interstitial infiltrates with some macrophages. What condition is she most likely infected with? Answer Choices A.) Influenza A pneumonia B.) Hypersensitivity pneumonitis C.) Diffuse alveolar damage D.) Pneumocystis carinii pneumonia E.) Extrinsic asthma

Correct answer: B Hypersensitivity pneumonitis Explanation Hypersensitivity pneumonitis should be suspected when a person exposed to a heavy concentration of organic dust experiences, with the re-exposure of the same dust, flu-like symptoms, such as acute onset of fever, cough, headaches, and breathlessness without wheeze. The inhaled allergen (e.g., thermophilic actinomycetes) sets up a localized antigen-antibody reaction. This is the "farmer's lung". Most cases occur today as a result of some indoor allergen. An air conditioner is one of the important sources. Influenza A pneumonia, like viral pneumonia, should not have a sudden onset or an intermittent course. Here are mononuclear infiltrates, but they are not usually focal. Diffuse alveolar damage occurs in response to severe lung injury; generally, it is so severe that the patient will require intubation. Pneumocystis occurs in immunocompromised patients. Bronchial asthma is episodic and produces bronchoconstriction, but there are many eosinophils, not chronic inflammatory cells.

A 12-year-old boy presents with sudden onset of dyspnea with wheezing. The patient had a similar appearance a month ago. An arterial blood gas shows hypoxemia, hypercapnia, and acidosis. The chest X-ray shows clear lung fields. What is the most likely accompanying laboratory finding in this case? Answer Choices A.) Elevated sweat chloride B.) Numerous sputum eosinophils C.) Decrease CD4 lymphocyte count D.) Increased serum alkaline phosphatase E.) Positive tuberculin skin test

Correct answer: B Numerous sputum eosinophils Explanation The characteristic dyspnea with wheezing suggests that it is an acute attack of asthma. In children, exposure to an allergen is often the inciting event for extrinsic asthma. This form of obstructive lung disease is episodic and limited, and so chronic lung changes are uncommon; therefore, the classical finding will be the raised eosinophil count, which is due to exposure to an allergen. Elevated sweat chloride is classical for cystic fibrosis. The chronic infections of cystic fibrosis are likely to produce pulmonary consolidations. A decreased CD4 count would suggest that he has HIV infection. He is unlikely that he has complications of AIDS, which are primarily infections in the lung; the X-ray shows clear lung fields. Increased serum alkaline phosphatase suggests paraneoplastic syndrome. A malignancy with metastasis is unlikely to yield an appearance of clear lung fields. Tuberculosis can often be primary and subclinical in children, but there may be hilar adenopathy that could produce wheezing though not in an episodic pattern.

A thoracocentesis is performed on a 55-year-old woman who has multiple lung masses. The pleural fluid obtained is serosanguinous. What would the cytological examination of the pleural fluid most likely show? Answer Choices A.) Ferruginous bodies B.) Cytomegalovirus infection C.) Adenocarcinoma D.) Lymphocytosis E.) Polarizable crystals

Correct answer: C Adenocarcinoma Explanation The presence of bloody pleural effusion suggests the presence of a neoplasm, metastatic more often than primary. Infectious agents such as Mycobacterium tuberculosis may produce serosanguinous effusions. Ferruginous bodies may appear in the lung parenchyma of a person with asbestos exposure. They do not appear in the pleural fluid. Cytomegalovirus can produce pneumonia in immunocompromised individuals and in neonates as a congenital infection, but the parenchymal involvement rarely leads to significant effusion. Lymphocytosis can be seen in the interstitium of viral pneumonias and inflammatory conditions that produce fibrosis. Polarizable crystals can appear in the parenchyma of persons with dust exposure; it is also found in persons with a history of intravenous drug use. They do not appear in the pleural fluid.

A 60-year-old man is operated on for a nephrectomy. On the 10th postoperative day, the patient ambulates and goes to the bathroom. Upon returning to the bed, he suddenly becomes extremely dyspneic and diaphoretic. What do you suspect has happened? Answer Choices A.) Pleural effusion B.) Pulmonary embolism C.) Postoperative atelectasis D.) ARDS E.) Pulmonary edema

Correct answer: B Pulmonary embolism Explanation The ambulation resulted in the movement of a thrombus from the leg or pelvic veins; the sudden symptoms of dyspnea in a postoperative patient after ambulation strongly suggest the diagnosis of pulmonary embolism. The sudden severe dyspnea suggests that the patient has an acute massive embolism. The chest X-ray will show oligemic lung fields, with an increase in the hilar shadows. Blood gas analysis will show decreased PaO2 and decreased PaCO2 due to disordered ventilation-perfusion, because massive areas of the lung are ventilated but not perfused. Ventilation-perfusion scan will show many areas that are ventilated, but not perfused. The definitive diagnostic procedure is pulmonary angiography. Pulmonary angiography, with the catheter in situ, can also be used to measure hemodynamic effects as well as deliver thrombolytic agents. A pleural effusion presents with dyspnea; however, pleural effusions take days to weeks to develop. Postoperative atelectasis does not have a sudden onset. The changes resolve after a week or so, and it would have a course of gradual improvement. ARDS occurs as the result of a severe lung injury following an accident or septicemia. It does not occur in patients who are up and ambulating. Pulmonary edema does not have a sudden onset. The edema could result in dyspnea and cough with frothy sputum. Orthopnea is a significant finding with pulmonary edema.

A 52-year-old Caucasian man is brought to the ER by paramedics; the patient's wife called the paramedics. He experienced an acute episode of sharp chest pain and difficulty breathing; it started 1 hour ago after getting up from a nap. His last sickness, an upper respiratory tract infection, was about 4 months ago. He has had orthopedic surgery for a broken ankle on the left side 15 years ago and sclerotherapy for varicose veins on his right side 7 years ago. He has smoked 20 cigarettes per day for the last 30 years and drinks alcohol only when going out on the weekend. The patient works as an accountant and has been traveling excessively within the last 6 months. There are no allergies known. He is in distress, tachycardic, and the ECG shows an incomplete right bundle branch block. Blood pressure is 100/70, heart rate is 100, temperature is 36.9° C, and pO2 is 60 mmHg. What is the most likely diagnosis? Answer Choices A.) Myocardial infarction B.) Pulmonary embolism C.) Intercostal neuralgia D.) Exacerbation of pneumonia E.) Pleuritis

Correct answer: B Pulmonary embolism Explanation Varicose veins, in combination with sitting occupation and traveling, is a risk factor for phlebothrombosis and can lead to pulmonary embolism. The symptoms described above are typical for lung embolism. The pain, dyspnea, distress, tachycardia, hypotonia as well as the history of nicotine abuse would fit for myocardial infarction. The ECG however would show Q waves and T inversion in leads depending on the localization of the infarction. Intercostal neuralgia can imitate the picture of pulmonal embolism, but there are no ECG changes. An exacerbation of pneumonia is very unlikely as there is no real proof the patient had pneumonia in the first place; the URI was too long ago. Furthermore, you would expect fever, and there would be no ECG changes. Pleuritis, an inflammation of the pleura with exudation, would present with the same kind of pain and dyspnea. There would be no ECG changes, and there could be fever.

A thin 26-year-old woman presents with sudden onset of dyspnea, non-productive cough, and vague chest pain radiating to the left shoulder. She is a soccer player, and her symptoms initially occurred 24 hours ago during her usual 5-mile training run. PMH is unremarkable. EKG shows sinus tachycardia, 105 bpm. Respiratory rate equals 30 breaths per minute. Decreased breath sounds and hyperresonance are noted on the left thorax; otherwise, the physical exam is unremarkable. What is the most likely diagnosis? Answer Choices A.) Myocardial infarction B.) Spontaneous pneumothorax C.) Exercise-induced asthma D.) Dissecting aortic aneurysm E.) Atypical pneumonia

Correct answer: B Spontaneous pneumothorax Explanation Spontaneous pneumothorax is more likely to occur in young, tall, thin individuals; a history of smoking is commonly present. Initial symptoms include sudden onset of chest pain, dyspnea, and cough; symptoms are usually associated with exertion. Chest X-rays will show air in the pleural space along the lung border on the affected side, without evidence of pleural effusion. Myocardial infarction is less likely in this age group, but it cannot be ignored and must be ruled out. In addition to the symptoms mentioned in this case, exercise-induced asthma typically presents with diffuse expiratory wheezing and prolonged expiratory phase. Dissecting aortic aneurysm may occur in individuals with Marfan's syndrome, which is also seen in tall, thin individuals. However, the classic presentation is that of sudden onset of severe chest pain, radiating to the back, with or without symptoms of hypovolemic shock. The lack of fever, prodromal period, fatigue, malaise, or other constitutional symptoms makes an infectious agent unlikely.

Refer to the information below. The findings in the chart are of the findings of spirometry in a 65-year-old woman who is a chronic smoker with a history of breathlessness on any exertion, productive cough, and frequent wheeze. TLC is 103. What is the most likely diagnosis? Pre-Bronchodilator: FVC=45, FEV1=33, FEV1/FVC=58 Post-Bronchodilator FVC=49, FEV1=41, FEV1/FVC=65 A.) Asthma B.) COPD C.) Sarcoidosis D.) Pneumonia E.) Asbestosis

Correct answer: B COPD Explanation Both FVC and FEV1 are reduced but FEV1 is more affected as compared to FVC. So the ratio is below the predicted level. The TLC is also increased, indicating it is an obstructive disease. There is a slight change with bronchodilators, which excludes asthma. Sarcoidosis is a multi-system granulomatous disease and shows findings of a restrictive disease. Asbestosis is also a restrictive disease that is cause by a prolonged exposure to asbestos (inorganic dust).

A 25-year-old man presents with sharp left chest pain, increased by deep breathing, and coughing. He has been a heavy smoker (30 - 40 cigarettes per day) for almost 10 years. Physical examination, chest X-ray, and ECG are normal. What is the most likely diagnosis? Answer Choices A.) Bacterial pneumonia B.) Myocardial infarction C.) Acute viral pleuritis D.) Pneumothorax

Correct answer: C Acute viral pleuritis Explanation Differential diagnosis of pleuritic chest pain include acute pleuritis (coxsackie virus A, B), acute pericarditis (coxsackie virus B), pneumonia (viral, bacterial), pulmonary embolus or infarction, and pneumothorax. In this case, the most likely cause of pleuritic chest pain (in the presence of normal physical examination, chest X-ray, and ECG) is acute viral pleuritis.

A 25-year-old man presents with sudden onset of sharp left chest pain, increased by deep breathing and coughing. He has been a heavy smoker (30 - 40 cigarettes per day) for almost 10 years. Physical examination, chest X-ray, and ECG are normal. What is the most likely diagnosis? Answer Choices A.) Bacterial pneumonia B.) Myocardial infarction C.) Acute viral pleuritis D.) Pneumothorax E.) Bronchitis

Correct answer: C Acute viral pleuritis Explanation In this patient, the most likely clinical diagnosis causing pleuritis chest pain in the presence of normal physical examination, chest X-ray and ECG is acute viral pleuritis. Differential diagnosis of pleuritic chest pain include; acute pleuritis (Coxsackie virus A, B), acute pericarditis (Coxsackie virus B), pneumonia (viral, bacterial), pulmonary embolus or infarction, and pneumothorax.

A 45-year-old chronic smoker presents with increasing exertional breathlessness. The patient has a productive cough. The patient is diagnosed with panacinar emphysema. He is also found to have cirrhosis of the liver. What underlying disease could relate panacinar pulmonary emphysema to cirrhosis of the liver? Answer Choices A.) Wilson's disease B.) Cystic fibrosis C.) Alpha-1 anti-trypsin deficiency D.) IV drug use E.) Alcoholism

Correct answer: C Alpha-1 anti-trypsin deficiency Explanation Alpha-1 anti-trypsin deficiency leads to fibrosis in the liver; the lack of this anti-protease leads to the development of emphysema. Wilson's disease affects the liver and the CNS, but there is no respiratory involvement. Cystic fibrosis affects the lungs, but it usually does not lead to liver disease. Cystic fibrosis causes bronchiectasis in the lungs. IV drug users are at greater risk for infections and abscess in the lungs. The injected drugs may form foreign body granulomas in the lungs. Alcoholism is not a cause for development of emphysema. However, it can cause alcoholic liver cirrhosis.

A 56-year-old Caucasian woman presents for a follow up visit. She was seen 1 week prior with fever and productive cough; she was placed on clarithromycin (Biaxin). Past medical history is significant for hypertension. Medications include amlodipine (Norvasc) and hydrochlorothiazide. She is allergic to penicillin. She is married with 2 children, and she is a homemaker. She has no known history of alcohol abuse, but she admits to a 30 pack-year history of smoking. She has no significant family history. She currently reports feeling better, and that the cough is less productive. However, she reports fever of 99 to 100 degrees Fahrenheit each night. She denies any chest pain or shortness of breath. She has a good appetite, and she has been able to sleep well. Physical examination reveals a woman who is nontoxic in appearance, with an oral temperature of 99.5 degrees Fahrenheit, blood pressure of 140/90, pulse 85, and regular respirations 15 per minute. Head, ears, eyes, nose, and throat examination are normal. Heart is regular rate and rhythm with a grade II/VI systolic murmur at the left upper sternal border. Lung fields reveal decreased breath sounds at the right base but are otherwise clear bilaterally. What diagnostic study should you order to confirm your diagnosis? Answer Choices A.) Sputum and blood cultures B.) 2-dimensional echocardiogram C.) Chest X-ray, PA and lateral D.) Complete blood count E.) Arterial blood gas

Correct answer: C Chest X-ray, PA and lateral Explanation This patient initially presented with pulmonary complaints, which were appropriately treated. However, after a week of antibiotics, she continued to have a fever, raising suspicion that either the original diagnosis was incorrect or that this was not a simple pneumonia. Decreased breath sounds on examination suggest pulmonary pathology. A chest X-ray can quickly and accurately guide the diagnosis. Sputum cultures would be difficult to obtain, as the cough is not productive, and blood culture results would take 48 hours to obtain. An echocardiogram may determine the valvular etiology of the murmur, but the murmur would not be related to decreased breath sounds and would not be related to a pulmonary process. A complete blood count may help confirm the presence of an infectious process but would not help narrow the differential diagnosis. An arterial blood gas would not be helpful because the patient is not in respiratory distress, and normal results would not eliminate the possibility of pulmonary pathology.

Dornase alpha (Pulmozyme) is a marketed form of deoxyribonuclease I that is approved for treatment of which of the following? Answer Choices A.) Chronic bronchitis B.) Bronchiectasis C.) Cystic fibrosis D.) Bacterial pneumonia

Correct answer: C Cystic fibrosis Explanation The United States Food and Drug Administration has approved the use of dornase alpha only for the treatment of cystic fibrosis. The manufacturer of the drug, Genentech, Inc., intended to apply for marketing approval for chronic bronchitis, but the clinical trials in this indication did not show significant effectiveness. The use of dornase alpha in bronchiectasis and bacterial pneumonia has not been established to be effective, and the drug has not been approved for these indications.

A 60-year-old man presents with hemoptysis for several weeks. He is a nonsmoker. The CT scan reveals a 5 cm cavitary mass in the hilar region. Sputum cytological examination reveals atypical cells present consistent with squamous cell carcinoma. A mediastinoscopy reveals that the mass extends into the mediastinum but not to the opposite lung. Sampling of the enlarged hilar lymph and scalene lymph nodes reveals metastatic squamous cell carcinoma. What does he most likely have? Answer Choices A.) Resectable lesion B.) Probable survival of 80% C.) History of radon exposure D.) Positive antinuclear antibody test E.) Stage of T1

Correct answer: C History of radon exposure Explanation The diagnosis of squamous cell carcinoma with metastasis is revealed. This is a large unresectable cancer with a poor prognosis because distant nodes are involved. The most common cause of squamous cell carcinoma is smoking, which is absent in the above patient. The 2nd most common cause of squamous cell carcinoma is history of radon exposure; therefore, it is the answer. It is not a resectable lesion because the mass is not localized enough for successful resection. T1 cancers are generally smaller than 2 - 3 cm, and they are present wholly in the organs in which they arise. The survival for lung cancer in general is poor, particularly for large infiltrative unresectable masses. Carcinomas of the lung are not related to autoimmune diseases.

A 60-year-old man presents with shortness of breath, wheezing, and a feeling of tightness in the chest. He is a non-smoker with no past history of asthma. ECG reveals myocardial ischemia. The patient is anxious and tachypneic. Blood pressure is elevated. Chest sounds reveal rales and rhonchi. There is wheezing and pink frothy sputum. Heart sounds reveal S3 gallop. Chest X-ray shows increased vascularity bilaterally and distended pulmonary artery. On the basis of the above clinical picture, what is the most likely diagnosis? Answer Choices A.) Pneumonia B.) Asthma C.) Pulmonary edema D.) Pleural effusion E.) COPD

Correct answer: C Pulmonary edema Explanation The clinical picture and the findings are characteristic of pulmonary edema. Pulmonary edema is a state of increased interstitial fluid in the lung that leads to flooding of alveoli, with fluid resulting in a severe disturbance of gas exchange across the alveolar surface. Pneumonia is described as inflammation of the lung with lower respiratory tract infection, and it would show consolidation on chest X-ray. There will be a history of fever and cough along with the symptoms in this case. Pleural effusion is the presence of fluid in the pleural space between the pleural membranes. There will be diminished breath sounds on the side of effusion. Pleural rub will be heard on auscultation in some cases. Chest X-ray will show opacity at the site of effusion. Patients with asthma will likely have a previous history breathing problems. The chest X-ray would not have the characteristics mentioned in this case. COPD will have history of smoking or weight loss, and the X-ray findings would be normal in bronchitis, or with loss of peripheral vascular markings with large bullae in emphysema.

A 60-year-old man is in the hospital for the last 3 weeks following a left cerebral infarction. Patient has a history of congestive cardiac failure. He has a sudden episode of pleuritic chest pain on the left. He had shown a steady improvement and remained afebrile. What is the most likely cause? Answer Choices A.) Cytomegalovirus pneumonitis B.) Lobar pneumococcal pneumonia C.) Pulmonary infarction D.) Upper lobe abscess E.) Bronchiectasis

Correct answer: C Pulmonary infarction Explanation Hospitalized immobile patients are at risk for deep vein thrombosis and pulmonary embolism. Patients with pre-existing heart or lung diseases are at risk for pulmonary infarction with a medium-sized embolus. The noted patient is at risk for both and hence the answer. Cytomegalovirus infection is typically seen in immunocompromised patients. Patients with lobar pneumonia should be febrile. Most of such pneumonias are community-acquired and due to pneumococcus bacteria. An abscess usually follows aspiration in patients who are neurologically compromised. An abscess of the left upper lobe is uncommon because the aspirated material tends to flow to the right lower lobe. Bronchiectasis with inflammation and infection would make the patient febrile.

A 50-year-old African-American woman presents with a history of fever, weight loss, and dyspnea. The chest X-ray shows prominent hilar adenopathy and diffuse pulmonary interstitial disease. The microscopic examination of lung biopsy does not show bacteria, viral inclusions, or any fungi. What is the most likely diagnosis? Answer Choices A.) Silicosis B.) Tuberculosis C.) Sarcoidosis D.) Asbestosis E.) Usual interstitial pneumonitis

Correct answer: C Sarcoidosis Explanation Sarcoidosis usually produces a granulomatous pattern, with enlargement of the hilar lymph nodes. The symptoms in this patient are classic, with the chest X-ray showing diffuse interstitial disease with hilar enlargement. Silicosis produces an interstitial lung disease; a reticulonodular pattern with silicotic nodules can be seen on the X-ray. With special stains, tuberculosis would have shown acid-fast bacilli on the lung biopsy. Asbestosis is characterized by the development of pleural plaques, which can be demonstrated on the X-ray. Usual interstitial pneumonitis is a form of restrictive lung disease with interstitial fibrosis; it does not show any of the characteristics described in the X-ray of this patient.

A 40-year-old man presents with a 5-day history of cough and purulent sputum. The patient has had recurrent attacks of cough with sputum production since his childhood. There are no other systemic complaints. The patient is febrile and has grade III finger clubbing. Rales are present all over the chest on auscultation. The chest X-ray shows a characteristic honeycomb appearance. What is the most likely diagnosis? Answer Choices A.) COPD B.) Tuberculosis C.) Bronchiectasis D.) Pneumonia E.) Cystic fibrosis

Correct answer: C Bronchiectasis Explanation The clinical picture along with clubbing and the honeycomb appearance on chest X-ray is diagnostic of bronchiectasis. Bronchiectasis is a disease caused by irreversible dilatation of the bronchial tree. Pathogenesis can be obstruction, congenital disorder, and infection. It can develop as a result of severe bacterial infections in childhood, often as a complication of whooping cough or measles. It can be cylindrical, varicose, or cystic, and it corresponds to the severity of degree of bronchiectasis. Typically, the patient has recurrent respiratory infections, usually cough with lots of sputum production. There will be clubbing of fingers and cyanosis (depending on the severity), and it presents at a later age compared to cystic fibrosis. Chest X-ray shows a typical honeycomb appearance. Diagnosis can be confirmed by CT scan or bronchography. Treatment is by antibiotics and assisting postural drainage. Cystic fibrosis presents with associated symptoms of malabsorption and infertility. COPD is associated with a history of smoking. It will usually have a normal X-ray, as in bronchitis, or be seen with associated features of emphysema (e.g., bullae and hyper-translucent lung field with loss of peripheral vascular markings). Pneumonia will have an acute history, and recurring infections are not characteristic. X-ray will be diagnostic. Tuberculosis will also be diagnosed on the X-ray. Bronchiectasis may develop secondary to a tuberculous hilar lymph node obstructing a major bronchus.

A 55-year-old woman has a sudden episode of pleuritic chest pain on the left side. The patient spent 20 days in the hospital after a laparotomy for a perforated gall bladder complicated by peritonitis. The patient gives a history of congestive cardiac failure. You suspect the patient has pulmonary infarction. Pulmonary infarction is most likely to occur under what condition(s)? Answer Choices A.) Bronchial arteries are occluded B.) A large saddle embolus occludes both right and left pulmonary arteries C.) Cor pulmonale is present D.) A medium-sized pulmonary artery is occluded E.) Multiple small emboli occur over a period of several weeks to months

Correct answer: D A medium-sized pulmonary artery is occluded Explanation An embolus in a medium-sized arterial branch is not large enough to kill the patient but is large enough to cause an infarction. Pulmonary infarction is a hemorrhagic consolidation of lung parenchyma resulting from thromboembolic pulmonary arterial occlusion. The causes of pulmonary infarction are stasis, vein injury, hypercoagulable state, phlebitis, deep vein thrombosis, surgery, burns, oral contraceptives, hip fracture, immobilization, subacute bacterial endocarditis, CCF, cardiomyopathy, atrial myxoma, polycythemia rubra vera, sickle cell anemia, pancreatic carcinoma. Bronchial arteries, although are a part of the systemic circulation, supply little blood to the lungs. Their lack of occlusion with thromboemboli leads to hemorrhage into the infarcts. A large saddle shaped embolus occluding both right and left pulmonary arteries would kill the patient before any infarction would occur. Cor pulmonale would make infarction more likely if pulmonary arterial occlusion has occurred. Multiple small emboli would be too small to cause an infarction. They would, however, lead to pulmonary hypertension.

Which of the following methods is best for detecting early, subclinical interstitial lung disease? Answer Choices A.) Spirometry B.) Arterial blood gas analysis C.) Body plethysmography D.) Diffusing capacity measurement E.) Measurement of blood oxygen-carrying capacity

Correct answer: D Diffusing capacity measurement Explanation The diffusing capacity of the lung is the most sensitive determination for detecting early interstitial lung disease. At the stage when physiologic gas exchange still appears to be normal, the rate at which carbon dioxide or other inert gases diffuse across the alveolo-capillary membrane can often be shown to be abnormally slow. In this way, the consequences of infiltration of interstitial lung tissue, often referred to as an "alveolo-capillary block", can be demonstrated in an asymptomatic patient. Early in the course of interstitial lung disease, lung volumes are usually normal, so spirometry and body plethysmography are generally not helpful diagnostically. Since gas exchange of oxygen and carbon dioxide are often relatively well maintained in the early stages, arterial blood gas determinations are also likely to be within normal limits. The measurement of blood oxygen-carrying capacity is informative in defining the quantity of hemoglobin and its affinity for oxygen, neither of which is affected by interstitial lung disease in its early stages.

A 55-year-old man presents with dyspnea that has been increasing over several years. He has a history of exposure to asbestos during construction projects. What is the most likely finding in this case? Answer Choices A.) Pulmonary atherosclerosis B.) Necrotizing vasculitis C.) Bronchiolitis obliterans D.) Fibrous pleural plaques E.) Bronchoconstriction

Correct answer: D Fibrous pleural plaques Explanation The exposure to asbestos with the symptom of increasing dyspnea suggests that the patient has asbestosis. Asbestosis, as other pneumoconioses, produces fibrous pleural plaques. With asbestosis the fibrous plaques are mainly diaphragmatic. Interstitial fibrosis may also be present. Pulmonary atherosclerosis is a feature of any disease that leads to pulmonary hypertension. Necrotizing vasculitis involves various organs and is seen in polyarteritis nodosa, microscopic polyarteritis, Churg-Strauss vasculitis and Wegener's granulomatosis. Bronchiolitis obliterans is a fatal airway disorder seen in connective tissue disorder like rheumatoid arthritis. Bronchoconstriction will produce severe dyspnea with sudden onset. It will not generally have an increasing dyspnea over many years.

A 22-year-old woman presents with shortness of breath. She has a history of intermittent wheezing while exercising. On examination, you find that her pulse rate is increased; there are diffuse wheezes on pulmonary auscultation. Her oxygen saturation is 95%. What would be the most effective therapy in this patient? Answer Choices A.) I.V Aminophylline B) I.M Theophylline C.) Inhaled cromolyn sodium D.) Inhaled albuterol E.) Inhaled beclomethasone

Correct answer: D Inhaled albuterol Explanation In the case of an acute attack, asthmatic patients who lack signs of impending ventilatory collapse should be treated with inhaled aerosolized β2 agonist (albuterol) every 20 minutes by nebulizer for 3 doses, with reduced frequency thereafter. Inhaled steroids (beclomethasone) have a delayed action as compared to the α2 agonist; therefore, they are not the first choice in case of an acute attack. Intramuscular therapy also shows a delayed response as compared to inhalation of β2 drugs. Cromolyn sodium is not effective in an emergency. It is used to prevent attacks. Cromolyn sodium is an anti-inflammatory medication. It works by preventing the release of substances in the body that cause inflammation. I.V aminophylline is also less effective as compared to inhaled albuterol. Aminophylline is a bronchodilator. Aminophylline works in several ways; it relaxes muscles in the lungs and chest to allow more air in, decreases the sensitivity of the lungs to allergens and other substances that cause inflammation, and increases the contractions of the diaphragm to draw more air into the lungs.

A 42-year-old male runner undergoes spirometry testing. Gas analysis finds the concentration of carbon dioxide is 0% in room air, 4% in expired air and 6% in mixed venous blood. Vital capacity equals 5000 ml. Tidal volume is 600 ml. How would you best describe the dead space volume? Answer Choices A.) Increased due to bronchospasm B.) Decreased due to bronchospasm C.) Normal; approximately 50 ml D.) Normal; approximately 200 ml E.) Equal to residual volume

Correct answer: D Normal; approximately 200 ml Explanation Anatomical dead space volume equals approximately 30% of tidal volume and represents air in the trachea and large bronchi where gas exchange does not occur. Bronchospasm occurs at the terminal bronchioles resulting in partially or non-functional alveoli, thereby increasing physiological dead space. Anatomical and physiological dead space are equal in healthy individuals. Residual volume is the volume of air remaining in the lungs after a forceful expiration. Although anatomical dead space is a small portion of this volume, most residual volume is due to elastic forces and surface tension maintaining alveolar spaces. The gas concentrations listed are normal values.

A 55-year-old man is a chronic smoker; he has recently noticed blood-tinged sputum with increasing breathlessness. After thorough investigations, the patient is diagnosed with bronchoalveolar carcinoma. What feature would most likely be present in this patient? Answer Choices A.) Early and widespread metastases B.) Coin lesion C.) Polarized crystals D.) Pneumonia-like consolidation E.) Parathyroid hormone-like activity

Correct answer: D Pneumonia-like consolidation Explanation Bronchoalveolar carcinoma may mimic pneumonia. Bronchoalveolar carcinoma is an unusual primary tumor that arises in the lung periphery. The most common form appears as a slow growing solitary peripheral nodule, which rarely progresses to diffuse disease. The other form presents aggressively, with multiple nodules or a dense consolidation involving single lobes or entire lungs mimicking acquired pneumonia or pulmonary edema in radiographic appearance. As the disease advances, typical symptoms include cough, chest pain, dyspnea, weight loss, and hemoptysis. The diagnostic criteria for bronchoalveolar carcinoma are primarily histologic. As it is difficult to differentiate bronchoalveolar carcinoma from metastatic disease, extrathoracic adenocarcinoma must be ruled out. Early and widespread metastasis is most typical for oat cell carcinoma of the lung. A coin lesion is typical for a solitary tumor, such as hamartoma, granuloma, and neoplasm Polarized crystals are seen with silicosis. They also appear in those with a history of intravenous drug use. Parathyroid hormone-like activity is most often seen in squamous cell carcinoma of lung, amongst the other lung cancers.

A 30-year-old man is a known COPD patient; he wakes at night with a sudden feeling of tightness on the left side of the chest, which is aggravated on deep breathing. Patient feels breathless and is cyanotic. On examination in the ER, there is expansion of only the right side of the chest. There is decrease in the breath sounds on the affected side. Chest X-ray shows mediastinal shift and deflated lung with translucency between this and the chest wall with no lung markings. What is the most likely diagnosis? Answer Choices A.) Myocardial infarction B.) Left lobar pneumonia C.) Tuberculosis D.) Pneumothorax E.) Emphysema

Correct answer: D Pneumothorax Explanation Pneumothorax is air in the pleural cavity. It is caused by: Rupture of a subpleural emphysematous bulla, pleural bleb, or a pulmonary end of pleural adhesion. Rupture of a subpleural tuberculous focus into the pleural space. Pneumothorax can be closed, open, or tension pneumothorax. The signs and symptoms in this patient, presented along with the chest X-ray, confirm the diagnosis. Left side pneumothorax can produce QRS axis and precordial T wave changes on ECG. Loculated pneumothorax is difficult to diagnose from emphysematous bullae. Myocardial infarction is caused due to cessation of coronary artery supply to the myocardium. Atherosclerotic changes in the coronary arteries are the main causative factor, though there are other factors. Chest pain in myocardial infarction is located at the center of the chest and is usually dull and heavy. There is no asymmetry of airway entry and the X-ray will not show the changes described as in pneumothorax but may show pulmonary edema. The ECG changes in a recent infarction are ST elevation and an abnormal Q wave. A 2D Echo is the diagnostic tool when there is doubt with the ECG changes. The blood CK MB starts to rise within 4 - 6 hours of infarction and peaks at 12 hours, falling back to normal within 48 - 72 hours is of diagnostic value. Tuberculosis is an airway disease caused by Mycobacterium tuberculosis. The onset is gradual, with features of anorexia, weight loss, evening pyrexia, cough with sputum, and hemoptysis. Chest X-ray will show ill-defined opacities usually in the upper lobes. Emphysema is a chronic obstructive pulmonary disease caused by deficiency of alpha-1-antiproteinase. Cigarette smoking attracts inflammatory cells and stimulates the release of anti-proteinase, but it also inactivates the anti-proteinases that are responsible for the damage of interstitial proteins (elastin). This causes irreparable damage to the alveolar septa. The patient has gradual onset of the symptoms like dry cough, weight loss, and breathlessness. Chest X-ray shows bullae and hyper-translucent lung fields with peripheral vascular markings. A subpleural bulla may rupture and cause pneumothorax.

A 44-year-old male is brought into the emergency department by paramedics. He is complaining of marked shortness of breath. He has a past medical history of diabetes and hypertension. His wife states that he has not been well for the last week, with decreased energy and fatigue. In addition, he has had a productive cough, which has worsened during the last 3 days. Physical exam reveals a quiet male in moderate to severe respiratory distress. Vital signs show: pulse 115; BP 90/50; respiration 18; Temp 38.2° C (100.7° F). HEENT shows dry mucous membranes. Lungs show decreased breath sounds and crackles on the left; cardiac exam is significant for tachycardia. Abdominal exam is nonspecific. No abnormal reflexes are noted. Initial laboratory studies show: Na 132; K 4.2; Cl 97; HCO3 25; Glucose 265. ABG reveals pH 7.26, pCO2 55; pO2 79; O2 saturation 90%. CBC shows a normal H/H with WBC count of 14K, the serum is reported as very lipemic. Chest X-ray shows an LLL consolidation. The patient has a Answer Choices A.) Respiratory alkalosis B.) Metabolic alkalosis C.) Mixed respiratory acidosis and metabolic alkalosis D.) Respiratory acidosis E.) Metabolic acidosis

Correct answer: D Respiratory acidosis Explanation Respiratory acidosis is characterized by an elevation of the PaCO2 and a decrease in pH. In the acute state, the HCO3 concentration is normal. When renal compensation occurs, the plasma HCO3 increases. Metabolic acidosis is an acid base disturbance that is created by a primary increase in H+ concentration or a reduction in HCO3 concentration and is compensated by a reduction in PaCO2. Respiratory alkalosis is characterized by a primary decrease in PaCO2 (hypocapnia) and an elevated pH. Patients with uncompensated respiratory alkalosis have normal plasma HCO3 concentration. Renal compensation results in a decrease in plasma HCO3 concentration. Metabolic alkalosis is created by factors that increase the HCO3 concentration or reduce H+ concentration. Patients with uncompensated metabolic alkalosis have an increased pH and an increased HCO3 concentration. A mixed respiratory acidosis and metabolic alkalosis is characterized by normal pH, HCO3 elevated above 30, increased PaCO2 greater than 60, and a normal anion gap.

A 55-year-old man presents with a nonproductive cough that has worsened over the last 2 months. He recently noted the appearance of blood-streaked sputum. Sputum cytology reveals the small cluster of hyperchromatic pleomorphic cells with very scanty cytoplasm. What is the predisposing factor to the development of these findings? Answer Choices A.) Silicosis B.) Urban dwelling C.) Asbestosis D.) Smoking E.) Passive smoking

Correct answer: D Smoking Explanation From the features described in the patient, along with the cytological examination of the sputum, it can be concluded that the patient suffers from lung carcinoma. Cigarette smoking is by far the most important single factor in the causation of lung cancer. It is probably directly responsible for at least 90% of lung carcinomas, the risk being directly proportional to the amount smoked and the tar content of cigarettes. Lung cancer does also occur in non-smokers. Radon gas exposure is the 2nd leading cause of lung cancer; however, along with the exposure, smoking is also present in most cases. Silicosis increases the risk for lung cancer about twofold. The incidence of lung cancer is slightly higher in urban dwellers than in rural dwellers, presumably as a result of atmospheric pollution. Asbestos exposure increases the incidence of lung cancer; it increases the incidence more in smokers. Passive smoking is one of the leading causes of lung cancer.

A 56-year-old man with no significant past medical history presents with weight loss and dyspnea on exertion. He has a 40 pack-year history of cigarette use. He is employed as a construction worker and says that he had exposure to asbestos when he was working on a project last year. The project lasted 6 months, and he reports taking the appropriate respiratory precautions. His chest X-ray reveals a hilar cavitary mass 4 centimeters in diameter. What type of neoplasm is this man most likely to have? Answer Choices A.) Hamartoma B.) Bronchoalveolar carcinoma C.) Mesothelioma D.) Squamous cell carcinoma E.) Small cell carcinoma

Correct answer: D Squamous cell carcinoma Explanation This patient presents with a central cavitary lung mass. He has a significant smoking history, which puts him at an increased risk for bronchogenic carcinoma. Squamous cell carcinoma is usually centrally located and can cavitate, making this the most likely choice. Large cell bronchogenic carcinoma (choice not given) can cavitate but are usually peripheral in origin. Hamartoma is a benign neoplasm characterized by diffuse "popcorn" calcifications. It does not cavitate and is usually less than 3 centimeters. Bronchoalveolar carcinoma can present as a single mass or diffuse infiltrate of the lung. It also typically does not cavitate. Mesothelioma is associated with asbestos exposure of prolonged duration. It typically takes years to develop. Mesothelioma presents as a pleural-based mass, so it is unlikely to be hilar in origin. Small cell carcinoma is usually centrally located, but it does not typically form cavities.

A 50-year-old man presents with a 1-week history of hemoptysis. He is a chronic smoker. A chest X-ray shows a hilar mass. What is the least likely pathologic finding in this setting? Answer Choices A.) Endogenous lipid pneumonia B.) Bronchiectasis C.) Squamous cell carcinoma D.) Hypercalcemia E.) Bronchoalveolar carcinoma

Correct answer: E Bronchoalveolar carcinoma Explanation Bronchoalveolar carcinomas are usually peripheral in location. Hemoptysis is seen only in neoplasms that are central in location or due to tuberculosis infection or conditions that are caused due to destruction of the bronchus. Endogenous lipid pneumonia usually develops distally, due to obstruction of a bronchus by a neoplasm, so it is usually central in location and can give rise to blood tinged sputum. Bronchiectasis can result from obstruction and the subsequent inflammation and destruction with dilation of bronchi with a neoplasm. Squamous cell carcinoma usually presents as a hilar mass lesion and gives rise to hemoptysis. Hypercalcemia results from a paraneoplastic syndrome that, among the lung cancers, is most often due to squamous cell carcinoma.

A 40-year-old woman presents with flu-like symptoms, including headache, fever, dry cough and breathlessness without wheezing, after attending an office meeting. She experiences this every time she attends meetings in that particular office. From the symptoms, it can be concluded that she has hypersensitivity pneumonitis. What best represents hypersensitivity pneumonitis? Answer Choices A.) Coal mining B.) Chronic necrotizing infection C.) Long term persistent cough with sputum production D.) Aspirin sensitivity E.) Farmer's lung

Correct answer: E Farmer's lung Explanation Moldy hay contains thermophilic actinomycetes, which produce allergic alveolitis or farmer's lung. Hypersensitivity pneumonitis should be suspected when a person exposed to a heavy concentration of organic dust presents, with the re-exposure of the same dust of flu-like symptoms, with acute onset of fever, cough, headaches, and breathlessness without wheeze. The inhaled allergen such as thermophilic actinomycetes sets up a localized antigen-antibody reaction. This is the 'farmer's lung;. Most cases occur today as a result of some indoor allergen. Air conditioning is one of the primary sources. Coal mining can lead to coal worker's pneumoconiosis with fibrosis. Chronic necrotizing infection is more typical of bronchiectasis. Long term cough with sputum production is clinical presentation of chronic bronchitis. Aspirin sensitivity is most likely to lead to asthma. These patients may also have nasal polyps and recurrent rhinitis.

A 45-year-old man presents with shortness of breath on exertion. The patient also notes an occasional dry cough. The spirometry findings reveal a normal FEV1/FVC ratio, decreased FVC and decreased TLC. What is the pathologic finding most likely to be present in this setting? Answer Choices A.) Bronchial destruction with dilatation B.) Increased bronchial submucosal glands C.) Apical bullae D.) Peripheral blood eosinophilia E.) Honeycomb fibrosis

Correct answer: E Honeycomb fibrosis Explanation The spirometry findings (with a normal FEV1/ FVC ratio, decreased FVC, and decreased TLC) suggest that it is a restrictive lung disease. To read the spirometry chart, the following things should be considered: FEV1 up to 80% predicted is normal. FEV1< 80% is abnormal. FEV1/FVC ratio <80% predicted is due to Obstructive Lung Disease. FEV1/FVC ratio normal or >80% predicted is due to Restrictive Lung Disease. FVC >80% is pure obstruction. FVC<80% may be due to concurrent restrictive disorder. Total lung capacity (TLC) is increased above the normal in obstructive disorders. TLC is >100% predicted in pure obstruction. TLC < 80% of predicted value is restriction. TLC > 120% is hyperinflation. Of the listed causes, only honeycomb fibrosis is a restrictive lung disease. The end stage of fibrosing disease will show honeycomb appearance. Bronchial destruction with dilatation will not show a restrictive pattern. Increased mucus production, with mucus gland hyperplasia is, a feature of asthma (acutely) or chronic bronchitis (chronically), both are obstructive lung diseases. Apical bullae are likely to be seen with centrilobar emphysema, an obstructive lung disease. Eosinophilia is a feature seen with extrinsic asthma, an obstructive lung disease.

A 60-year-old man presents with worsening cough for several months; he has also experienced blood-tinged sputum for the past several weeks. He has been a chronic smoker for the past 40 years. Otherwise, he has no major health problems. In order to initiate the management of his disease, what should be done first? Answer Choices A.) Bronchoalveolar lavage B.) Fine-needle aspiration cytology C.) Pleural fluid cytology D.) Arterial blood gas analysis E.) Sputum cytology

Correct answer: E Sputum cytology Explanation The history of chronic smoking, along with the cough with blood-tinged sputum, suggests the possibility of lung cancer. The easiest and the most cost-effective means of determining the presence of malignant cells is by sputum cytology. Bronchoalveolar lavage could detect malignant cells, but it is not simple, and it is usually used when an infection is also suspected. The fine-needle aspiration is also associated with some morbidity (pneumothorax). It is not as simple or as safe as sputum cytology. If a pleural disease was suspected, or if a large effusion was present, perhaps, thoracentesis would be done. However, it is still important to know if malignant cells are present in the sputum. Arterial blood gas analysis is useful for following the course of a hospitalized patient who is being treated for decreased pulmonary function with intubation. ABG will not suggest the presence of malignancy.