Kaplan Cumulative: Pulmonary

58. The oxygen-hemoglobin dissociation curve shifts to the left under which of the following circumstances? A. Carbon monoxide poisoning B. Decreased pH C. Increased 2,3-diphosphoglycerate (2,3-DPG) D. Increased PCO2 E. Increased temperature

A. Carbon monoxide poisoning

63. While relaxing on the beach, a health care provider hears a woman call out for help. Her husband was out swimming and got hit on the head by a surf board; he is now struggling for his life in the water. The lifeguards bring the man out of water. The health care provider volunteered to help and finds the man unconscious. He quickly secures the airway and administers rescue breaths. Paramedics arrive at the scene within ten minutes and begin basic life support measures. The patient gains consciousness but is still having difficulty breathing. Addition of which of the following is most likely to help this patient? A. Abdominal thrusts B. Continuous positive airway pressure C. Prophylactic antibiotics D. Steroid administration E. Tracheostomy

B. Continuous positive airway pressure

79. A 51-year-old man is complaining of shortness of breath. The patient describes a slowly progressive inability to perform physical activities over the past 2 years. He reports being able to start an activity, such as golf or tennis, but within a few minutes he feels like "he has lost his breath." There is no associated chest pain, pressure, or discomfort. More recently, he has had significant shortness of breath even at rest. The clinical picture, with the addition of a restrictive pattern on pulmonary function tests and interstitial infiltrates on the chest x-ray film, suggests the diagnosis of interstitial lung disease. Which of the following is the most appropriate next step in management? A. Follow-up in the clinic in 2 months, as most interstitial lung diseases are untreatable B. Referral to a pulmonologist for further evaluation and possible transbronchial biopsy C. An empiric course of prednisone for 6 weeks D. Immunosuppressive therapy with azathioprine E. Referral to a thoracic surgeon for further evaluation and possible open lung biopsy

B. Referral to a pulmonologist for further evaluation and possible transbronchial biopsy

64. A 76-year-old man presents to the clinic for his semiannual examination. The patient is well known to the clinic and has been having semiannual examinations for the past 3 years to follow up his chronic obstructive pulmonary disease (COPD). The patient is a long-time smoker, with a 200+ pack year history. He is status post a right upper wedge resection 2 years ago for adenocarcinoma, and at that time had severe obstructive disease. A recent chest CT showed apical bullae and severe emphysematous changes. The patient has moderate dyspnea on exertion and often has shortness of breath with minimal activity. On this visit, the patient relates that he is even more short of breath at rest and is almost unable to perform any physical activity as a result. Which of the following would most strongly suggest the need to initiate home oxygen therapy? A. Exercise-induced oxygen desaturations to less than 92% B. Resting arterial PaO2 showing an alveolar arterial gradient of more than 12 mm Hg C. Resting arterial PaO2 of less than 55 mm Hg D. Resting PaO2 of greater than 40 mm Hg E. Room air oxygen saturation of less than 92%

C. Resting arterial PaO2 of less than 55 mm Hg

33. A 54-year-old woman with a long history of emphysema comes to the emergency department because of an exacerbation of her cough and dyspnea. On physical examination her blood pressure is 126/64 mm Hg, pulse 82/min, and respirations 24/min. On lung examination there are loud expiratory wheezes and rhonchi. Cardiac examination is normal. Arterial blood gas is performed. Which of the following results would most likely be expected? A. pH of 7.20, pCO2 of 60, and pO2 of 46 B. pH of 7.30, pCO2 of 50, and pO2 of 94 C. pH of 7.35, pCO2 of 45, and pO2 of 60 D. pH of 7.46, pCO2 of 25, and pO2 of 76 E. pH of 7.52, pCO2 of 30, and pO2 of 82

C. pH of 7.35, pCO2 of 45, and pO2 of 60

78. A 24-year-old woman has fever, malaise, and a dry, nonproductive cough. She also complains of headache, muscle aches, and leg pain. Lab values are significant for elevated cold agglutinins. Which of the following microorganisms is responsible for her symptoms? A. Haemophilus influenzae B. Klebsiella pneumoniae C. Legionella pneumophila D. Mycoplasma pneumoniae E. Streptococcus pneumoniae

D. Mycoplasma pneumoniae

20. When watching a routine immunization injection being given to her 2-year-old brother, a teenage girl suddenly complains of feeling faint and starts hyperventilating. A nurse has her sit on the floor and gives her a paper bag. What is the rationale for this therapy? A. The higher CO2 content of the bag will correct the patient's compensated respiratory acidosis B. The higher CO2 content of the bag will correct the patient's compensated respiratory alkalosis C. The higher CO2 content of the bag will correct the patient's uncompensated respiratory acidosis D. The higher CO2 content of the bag will correct the patient's uncompensated respiratory alkalosis E. The paper bag is a placebo

D. The higher CO2 content of the bag will correct the patient's uncompensated respiratory alkalosis

21. A 26-year-old woman accidentally inhales a peanut while laughing hysterically. Examination in the emergency department reveals that the peanut is lodged in the right mainstem bronchus. Which of the following is true about the blood flowing through the area of lung distal to the peanut? A. The amount of dissolved oxygen is greater than normal B. The oxygen dissociation curve is left-shifted C. The PCO2 is lower than normal D. The pH is lower than normal E. The pO2 approaches that of arterial blood

D. The pH is lower than normal

62. A patient presents to his health care provider because of a chronic cough. He notes occasional streaks of blood in his sputum. Chest x-ray reveals multi-nodular, cavitating lesions in the apical posterior segments of both lungs, with evident satellite lesions. The condition described is likely to occur in the apices of the lungs because they A. are better perfused B. are more acidic C. contain more alveolar macrophages D. have a higher pO2 E. ventilate better

D. have a higher pO2

71. A 21-year-old woman attempts suicide by taking an overdose of barbiturates. On arrival in the emergency department, her blood pressure is 95/65 mm Hg and pulse 105/min. The health care provider orders arterial blood gases. Which of the following values would you expect in this patient? A. pO2 = 45, PCO2= 45, pH = 7.45 B. pO2 = 55, PCO2 = 70, pH = 7.50 C. pO2 = 65, PCO2 = 35, pH = 7.45 D. pO2 = 75, PCO2 = 60, pH = 7.30 E. pO2 = 98, PCO2 = 60, pH = 7.20

D. pO2 = 75, PCO2 = 60, pH = 7.30

82. The maximum expiratory flow-volume curve shown below was obtained from a normal, healthy volunteer. Which point on the curve represents residual volume? *look at curve on questions 82

answer E

14. A 64-year-old man smokes one or 2 cigarettes a day sporadically on weekends and he has been diagnosed with severe emphysema. Routine blood work reveals elevated serum transaminases. Hepatitis serologies reveal no evidence of viral hepatitis A, B, or C. A younger brother with no smoking history died of emphysema at age 50. Which of the following diseases should most likely be considered to explain this patient's liver abnormalities and his lung disease? A. Alpha-1-antitrypsin deficiency B. Primary hemochromatosis C. Primary sclerosing cholangitis D. Secondary hemochromatosis E. Wilson disease

A. Alpha-1-antitrypsin deficiency

4. A 27-year-old pharmacist comes to her health care provider for her annual physical examination. She describes that over the past several months she has awoken from sleep on several occasions with cough, wheezing, and shortness of breath, but denies having these symptoms during the day. The symptoms generally last for up to 2 hours before gradually subsiding. She has no previous history of asthma and exercises regularly without difficulty. She is on no medications, except for the frequent use of over-the-counter histamine-2 receptor antagonists for daily episodes of heartburn. She is afebrile and has normal vital signs. Her lungs are clear to auscultation and percussion. Which of the following is the most likely explanation for her nocturnal symptoms? A. Acid reflux B. Laryngospasm C. Mast cell release D. Mucus plugs E. Upper airway obstruction

A. Acid reflux

52. A 20-month-old is brought to the office with a 2-day history of a harsh cough. His mother states that the cough sounds like a seal. She also states he has not had any fever, although he had a runny nose earlier in the week. His current temperature is 36.7 °C (98 °F). On examination, he is notably hoarse with inspiratory stridor. He is not drooling and is sitting on his mother's lap comfortably. The rest of his examination is within normal limits. Which of the following is the most likely diagnosis? A. Acute laryngotracheobronchitis B. Aspiration of foreign body in the upper respiratory tract C. Epiglottitis D. Laryngomalacia E. Subglottic stenosis

A. Acute laryngotracheobronchitis

18. A 20-year-old man comes to his health care provider because of a 3-month history of occasional chest tightness with exertion and with cold exposure. On average he experiences symptoms less than 2 times weekly and never experiences symptoms at night. He has no medical history except eczema and mild seasonal allergies. He takes no medications. His temperature is 37.0°C (98.6°F), blood pressure is 120/70 mm Hg, pulse is 73/min, and respirations are 13/min. Physical examination shows scattered wheezes bilaterally and a prolonged expiratory phase. Which of the following is the most appropriate medical management at this time? A. Albuterol (Proventil) B. Cromolyn sodium (Intal) C. Inhaled steroids D. Ipratropium bromide (Atrovent) E. Zafirlukast (Accolate)

A. Albuterol (Proventil)

13. A 35-year-old man comes to the emergency department with shortness of breath, which has worsened over the past 3 days and is associated with a cough productive of yellow sputum. His past medical history is significant for asthma, and his medications include an albuterol inhaler. He has a 20-pack-year history of tobacco use, and currently smokes 2 packs per day. On physical examination his temperature is 37.8°C (100°F), blood pressure 160/87 mm Hg, pulse 69/min, and respirations 24/min. Lung examination is significant for diminished breath sounds, with diffuse wheezing but no evidence of consolidation. Chest radiograph is significant for hyperexpansion. Pulse oximetry shows 90% oxygen saturation on room air. Which of the following is the most appropriate next step in therapy? A. Albuterol nebulizer B. Ipratropium nebulizer (Atrovent) C. Helium-oxygen mixture D. IV beta adrenergic blocker E. Racemic epinephrine

A. Albuterol nebulizer

5-year-old boy suddenly begins coughing while eating peanuts. He is choking and gagging. When he is brought to the emergency department, but he is awake and is able to give his name. On physical examination his vital signs are stable. On examination of the chest, inspiratory stridor and intercostal and suprasternal retractions are apparent. Which of the following is the most appropriate initial step in management? A. Allow patient to clear foreign object by spontaneous coughing B. Clear oropharynx with multiple blind sweeps with finger C. Position patient and perform back blows D. Stand behind patient and perform abdominal thrusts E. Perform emergency tracheostomy and take to surgery

A. Allow patient to clear foreign object by spontaneous coughing

75. A 41-year-old man comes to the clinic complaining of a chronic cough over the past 4 months, which has now been accompanied by hemoptysis. He denies smoking or any past medical history. On physical examination his head and neck examination is normal. His lungs have diffuse bilateral rales. Cardiac examination is normal. Laboratory findings reveal a sodium of 142 mEq/L, a potassium of 4.3 mEq/L, a chloride of 110 mEq/L, a bicarbonate of 24 mEq/L, a BUN of 39 mg/dL, and a creatinine of 2.9 mg/dL. Urinalysis reveals microscopic hematuria and 4+ proteinuria. Which of the following serologic blood tests would most help confirm the suspected diagnosis? A. Anti-glomerular basement membrane antibodies B. Anti-mitochondrial antibodies C. Anti-neutrophilic antibodies D. Anti-parietal cell antibodies E. Anti-smooth muscle antibodies

A. Anti-glomerular basement membrane antibodies

47. A 21-year-old college senior comes to the university health clinic complaining of shortness of breath and cough for the past 2 weeks. He has just transferred to this university in Chicago from his hometown in Arizona, where he had studied for the past 3 years. Each evening, on returning from classes to his dormitory room, he develops a dry nonproductive cough that typically lasts for several hours before he falls asleep. He is awakened from sleep with shortness of breath, cough, and wheezing. He denies cigarette smoking, but drinks several beers on weekends and has occasionally smoked marijuana. Symptoms often occur on weekends, when he spends time studying in his dormitory room. On physical examination he denies any respiratory symptoms, and his lung examination is normal. Which of the following is the most likely mechanism for his symptoms? A. Bronchospasm B. Laryngeal spasm C. Pleural effusion D. Pulmonary congestion E. Ventilation-perfusion mismatch

A. Bronchospasm

11. A 67-year-old man with emphysema comes to his health care provider for a routine checkup. He reports that his symptoms have remained stable, with frequent coughing and dyspnea, despite compliance to his medications, which include oral prednisone, aminophylline, inhaled beta 2 agonists, and rotating courses of antibiotics. On physical examination he has a barrel-chest and distant breath sounds in both lung fields with soft expiratory wheezes. An arterial blood gas reveals an arterial pH of 7.32, a pCO2 of 47 mm Hg, and a pO2 of 53 mm Hg. Which of the following would most likely prolong his survival? A. Continuous home oxygen therapy B. High-dose oral prednisone C. Influenza vaccine D. Pneumococcal vaccine E. Tracheostomy

A. Continuous home oxygen therapy

43. An alcoholic man is brought to the emergency department in respiratory distress. Chest x-ray demonstrates lobar consolidation of the right upper lung. Which of the following organisms is the most likely diagnosis? A. Klebsiella pneumoniae B. Legionella spp. C. Mycoplasma pneumoniae D. Pneumocystic jirovecii E. Staphylococcus aureus

A. Klebsiella pneumoniae

74. A 71-year-old man with a 70-pack-year smoking history comes to his health care provider after he notes that his right eye has a lagging lid. The health care provider has been seeing this patient for more than 10 years for management of his symptoms of chronic obstructive pulmonary disease (COPD). On physical examination he has ptosis of the right eye with a constricted right pupil. The remainder of the ophthalmologic examination is normal. Cranial nerve function is otherwise normal. Which of the following would most likely be expected on a chest x-ray film? A. Normal chest x-ray film B. Irregularly shaped mass at the apex of the right lung C. Calcified granuloma in the left mid-lung field D. Left-sided pleural effusion E. Right upper lobe pneumonia

B. Irregularly shaped mass at the apex of the right lung

51. A patient develops an acute febrile illness with shivers, nonproductive cough, and pleuritic chest pain. He does not seek treatment and 5 days later, he presents to the emergency department after abruptly having coughed up nearly a cup of bloodstained sputum. He appears acutely ill and septic. Which of the following is most likely to be seen on a chest x-ray film? A. Blunting of diaphragmatic costal angles B. A cavity with a fluid level C. Complete opacification of one lobe with no additional findings D. Patchy consolidation centered on bronchi E. Prominent bronchi that can be followed far out into the lung fields

B. A cavity with a fluid level

40. A 35-year-old roofer presents to his health care provider complaining of dyspnea and chronic dry cough. For the past few years, he has been replacing old roofs. Chest x-ray film reveals pulmonary hyperinflation with honeycombing and calcified parietal pleural plaques. Which of the following is the most likely diagnosis? A. Anthracosis B. Asbestosis C. Berylliosis D. Byssinosis E. Silicosis

B. Asbestosis

19. A 32-year-old man has had asthma for the past 9 years. The symptoms are frequently exacerbated by changes in the weather and household allergens. He has had 2 emergency department visits over the past year, where he was started on oral corticosteroids, but he has not required hospitalization. He uses an albuterol inhaler about 4 times per week for symptom relief and he has symptoms at night about 3 times a month. Which of the following would be the most appropriate therapy to maintain remission between his asthmatic attacks? A. Aminophylline B. Beclomethasone inhaler C. Cromolyn nasal spray D. Metaproterenol inhaler E. Oral prednisone

B. Beclomethasone inhaler

67. Which of the following is the most common type of lung cancer in nonsmokers? A. Bronchioloalveolar carcinoma B. Bronchogenic adenocarcinoma C. Large cell anaplastic carcinoma D. Small cell (oat cell) carcinoma E. Squamous cell carcinoma

B. Bronchogenic adenocarcinoma

54. A 59-year-old construction worker has a history of asbestos exposure. Which of the following malignancies is most likely to occur in this man? A. Bladder carcinoma B. Bronchogenic carcinoma C. Lymphoma D. Malignant mesothelioma E. Scrotal carcinoma

B. Bronchogenic carcinoma

55. A 59-year-old man comes to his primary care provider with fever and chills. His past medical history is significant for osteoarthritis for many years. He has a long smoking history of >150 pack-years. He routinely takes non-steroidal anti-inflammatory agents for pain. He presents with 5 days of fever and chills associated with a productive cough. He has not been hospitalized recently and has no sick contacts at home, where he lives with his wife. On physical examination he is comfortable, his temperature is 38.9° C (102° F) and has bibasilar crackles heard best at the left base. Which of the following is the most appropriate next step in diagnosis? A. Arterial blood gas B. Chest radiograph C. Complete blood count D. Oxygen saturation check E. Sputum gram stain

B. Chest radiograph

60. A 72-year-old woman comes to the emergency department complaining of severe shortness of breath, fevers, chills, and left-sided pleuritic chest pain. She was recently hospitalized for similar symptoms and was just discharged from another hospital 1 week ago. Her temperature is 39.0º C (102.2º F), blood pressure is 100/60 mm Hg, pulse is 133/min, and respirations are 24/min. Her oxygen saturation is 90% on room air. Physical examination reveals an elderly woman in mild respiratory distress. Her heart sounds are tachycardic and regular. Lung examination is significant for decreased breath sounds at the left base. There is no lower extremity edema. Chest radiograph shows a large left-sided pleural effusion. A thoracocentesis is performed which reveals frank pus on aspiration. Effusion pH 6.9 Color: white Lactate dehydrogenase effusion: 400 U/L Effusion to serum lactate deyhyr. ration: 1.1 Effuison serum protein ratio: .9 At this time, which of the following is the most appropriate management? A. Antibiotics alone B. Chest tube placement and antibiotics C. CT scan of chest D. Heparin administration E. Periodic thoracocentesis The correct answer is B. This patient has

B. Chest tube placement and antibiotics

69. A 70-year-old man with an 88 pack-year smoking history and hypertension has slowly progressive shortness of breath over the last 1 to 2 years. Physical examination reveals a cachectic man who is in mild respiratory distress using accessory muscles and "pursed lip" breathing. He is not cyanotic. His breath sounds are decreased without wheezing or rhonchi. His heart sounds are distant. He has no edema. A chest x-ray shows hyperinflation of lung fields with a small heart, flattened diaphragm, and no infiltrates or edema. Pulmonary function testing is most likely to reveal which of the following findings? A. Bronchodilator response of approximately 15 to 20% B. Decreased diffusion capacity of the lung for carbon monoxide C. Decreased residual volume D. Decreased total lung capacity E. Increased FEV1/FVC ratio

B. Decreased diffusion capacity of the lung for carbon monoxide

56. A 24-year-old woman presents to her health care provider with a rasping cough. She is given a sample of an antitussive drug that is neither addicting nor constipating. Which of the following drugs was she most likely given? A. Codeine B. Dextromethorphan (Robitussin) C. Diphenoxylate (Lomotil) D. Levorphanol (Levo-Dromoran) E. Oxycodone (OxyContin, Roxicodone)

B. Dextromethorphan (Robitussin)

30. An infant is delivered at full term by a spontaneous vaginal delivery to a 29-year-old primigravida. At delivery, the infant is noted to have subcostal retractions and cyanosis despite good respiratory effort. The abdomen is scaphoid. On bag and mask ventilation, auscultation of the lungs reveals decreased breath sounds on the left, with heart sounds louder on the right. Which of the following is the most likely diagnosis? A. Dextrocardia with situs inversus B. Diaphragmatic hernia C. Pneumonia D. Pulmonary hypoplasia E. Spontaneous pneumothorax

B. Diaphragmatic hernia

50. A 74-year-old woman, who has been followed for the past 25 years for chronic obstructive pulmonary disease (COPD) comes to the emergency department complaining of 48 hours of temperatures to 38.6°C (101.4°F) and worsening shortness of breath. She has a chronic productive cough, which has become more copious. She has a long-standing history of smoking. On physical examination she has rhonchi and increased fremitus in the posterior mid-lung field. A Gram's stain reveals many epithelial cells and multiple gram-positive and gram-negative organisms; no neutrophils are seen. Which of the following is the most likely organism causing the symptoms? A. Escherichia coli B. Haemophilus influenzae C. Klebsiella pneumoniae D. Mycobacterium tuberculosis E. Mycoplasma pneumoniae

B. Haemophilus influenzae

49. A 52-year-old man with a history of emphysema spends a 2-week vacation on a cruise ship. Shortly after returning home, he develops high fevers and becomes lethargic and disoriented. His wife describes that he has been coughing and short of breath since returning home. She also describes that he has vomited several times over the past 48 hours and has had diarrhea. On physical examination he appears lethargic but arousable. He is disoriented to the current date. He has loud, coarse, rhonchi in both lung fields, palpation revealed. Abdominal examination reveals mild tenderness over the liver edge. There is no splenomegaly or ascites present. His neurologic examination is nonfocal. Lab results are notable for an aspartate aminotransferase (AST) of 112 U/L and an alanine aminotransferase (ALT) of 157 U/L. Which of the following is the most appropriate treatment for this patient? A. IV ceftazidime (Fortaz) B. IV azithromycin (Zithromax) C. IV gentamicin D. IV nafcillin E. IV vancomycin

B. IV azithromycin (Zithromax)

66. A 63-year-old man is admitted to the hospital for fever and a productive cough. The patient reports that, over the past few days, he has had a worsening cough that has become productive of greenish-crimson sputum. The patient reports temperatures to 39.5° C (103° F) over the past 24 hours. The patient has had nothing to eat or drink for the past 36 hours. On further questioning the man describes a prodromal period 7 days prior to the onset of the cough that was remarkable for rhinorrhea and general malaise. On physical examination the patient appears acutely ill. His blood pressure is 130/80 mm Hg, and his pulse is 110/min and regular. Examination is remarkable for diminished breath sounds on the right lung-base with "a to e" egophony and whispered pectoriloquy. Which of the following is required for the diagnosis of pneumonia? A. Hypoxemia on pulse oximetry B. Infiltrates present on chest radiograph C. Sputum Gram stain showing gram-positive diplococci D. Sputum Gram stain showing neutrophils E. Temperature up to 38.6°C (101.4°F)

B. Infiltrates present on chest radiograph

35. A 68-year-old man comes to his health care provider for follow-up. Two weeks ago he was diagnosed with COPD and underwent pulmonary function tests (PFTs) to assess reversibility of his obstruction. He has smoked 3 packs/day for 50 years and has hypercholesterolemia. In the 23 years that he has been a patient in this practice, he has had poor compliance and only sees a health care provider if he is very ill. His PFTs document moderate obstructive lung defects. His quality of life is currently good and he has not had to curtail his daily activities significantly. Which of the following immunizations is most important for this patient? A. Haemophilus influenzae type B vaccine B. Influenza vaccine C. Measles booster D. Pertussis booster E. Varicella vaccine

B. Influenza vaccine

1. A 10-year-old asthmatic is prescribed a cromolyn sodium inhaler (Intal) to be administered prior to vigorous activity to prevent an attack. Which of the following is the mechanism of action of this drug? A. It blocks muscarinic receptors B. It inhibits the degranulation of mast cells C. It reduces bronchial inflammation and edema D. It selectively stimulates beta-2 receptors E. It stimulates all beta-receptors

B. It inhibits the degranulation of mast cells

5. A 41-year-old health care provider attends an annual national conference in San Francisco. On his return home, he develops fevers, with temperatures as high as 39.4°C (102.9°F) over the past 5 days. He has also developed a severe, nonproductive cough with associated shortness of breath at rest. In addition, he complains of headache and fatigue, and his wife reports that he has become slightly confused at home. He has also had nausea and frequent loose stools. On physical examination his temperature is 39.1°C (102.3°F), blood pressure 116/84 mm Hg, pulse 96/min, and respirations 28/min. On lung examination there are scattered loud rhonchi in both lung fields. Abdominal examination is normal. Which of the following is the most likely diagnosis? A. Cytomegalovirus pneumonia B. Legionnaires' disease C. Mycobacterium tuberculosis D. Pneumocystis jiroveci pneumonia E. Staphylococcal pneumonia

B. Legionnaires' disease

28. A 12-year-old girl with a history of asthma has been admitted to intensive care units 2 times in the past and has had 3 emergency department visits during the past 12 months. Her only medication is inhaled albuterol as needed, and she uses it 2 to 3 times a day. She has nocturnal symptoms about 2 times a week. She is free of symptoms now but reports that she gets short of breath easily. Which of the following pharmacologic interventions is most appropriate? A. Anticholinergic agent B. Cromolyn sodium (Intal) C. Inhaled corticosteroid D. Long-term bronchodilator E. Nedocromil sodium (Alocril)

C. Inhaled corticosteroid

9. A 24-year-old tire salesman complains of a low-grade fever and a nonproductive cough for 1 week. His girlfriend had similar symptoms 1 week earlier. He denies any shortness of breath or pleuritic chest pain. On physical examination his temperature is 37.9°C (100.2°F). A lung examination reveals coarse bilateral inspiratory and expiratory crackles. His laboratory results reveal a white blood cell count of 6300/mm3, a hemoglobin of 10.2 g/dL, and a hematocrit of 32%. A cold agglutinin assay of his red blood cells is positive. Which of the following is the most appropriate treatment for this patient? A. Ampicillin B. Cephalexin (Keflex) C. Azithromycin (Zithromax) D. Ceftriaxone (Rocephin) E. Trimethoprim/sulfamethoxazole (Bactrim)

C. Azithromycin (Zithromax)

32. A patient is observed to have an abnormal breathing pattern characterized by cyclical changes in tidal volume. The tidal volume first increases and then decreases to the point of apnea. What term best describes this breathing pattern? A. Apneustic B. Biot's C. Cheyne-Stokes D. Hysterical E. Kussmaul

C. Cheyne-Stokes

25. A 26-year-old African American woman comes to the emergency department complaining of severe shortness of breath that began while jogging earlier today and has not improved despite the repeated use of her inhaler, which she has been instructed to always carry with her. Her past medical history is significant for asthma and seasonal allergies. Her medications include oral contraceptive pills and 3 respiratory medications, 2 of which are inhaled and, she says, are closely managed and adjusted by her allergist. Her respiratory rate is 44/min and she is exhibiting supraclavicular retractions. She has difficulty completing her sentences while speaking. On auscultation the lungs have expiratory and inspiratory wheezes. Her nail beds and oral mucosa are pink. In addition to instituting prompt therapy with nebulized beta-agonists, IV steroids, and oxygen, a STAT arterial blood gas (ABG) shows pH 7.46, pO2 86 mm Hg, and pCO2 32 mm Hg. Thirty minutes later the patient's respiratory rate is 25/min. Wheezing is not as audible on auscultation and retractions have diminished. The lips appear blue, however. A second STAT ABG reveals pH 7.38, pO2 84 mm Hg, and pCO2 41 mm Hg. Which of the following is the most appropriate next step in management A. Check the chest x-ray and discharge the patient if it is normal B. Continue treatment and check on the patient in 30 minutes C. Explain the meaning of respiratory failure to the patient, then intubate her D. Give another dose of beta-agonists and add racemic epinephrine to the regimen E. Obtain a prompt pulmonary/critical care consultation and await recommendations

C. Explain the meaning of respiratory failure to the patient, then intubate her

53. A 3-year-old boy has sudden onset of dry cough with a small amount of bright red blood produced when he coughs. He has had no fevers, runny nose, or vomiting. In the Emergency Department physical examination reveals generalized inspiratory wheezing and decreased breath sounds on the right. A chest x-ray shows hyperexpansion of the right lung and clear lung fields. He attends daycare 5 days a week and interacts with many other children. Which of the following is the most likely etiology of this child's symptoms? A. Bacterial pneumonia B. Cystic fibrosis C. Foreign body aspiration D. Pulmonary arteriovenous malformation E. Tuberculosis

C. Foreign body aspiration

8. The wife of an elderly patient with chronic obstructive pulmonary disease (COPD) calls his health care provider because her husband is extremely short of breath and appears "blue," but is responsive. The patient has a long history of COPD and has been compliant with his medications of albuterol inhalers, rotating antibiotics, and theophylline. His wife reports that, over the past several days, he has developed an increasingly productive cough. The patient is brought to the hospital by ambulance. At the hospital, the patient is barely responsive. He is breathing 100% oxygen via a tight-fitting face mask and no longer appears cyanotic. Which of the following is the most likely explanation for his change in mental status A. Aspiration B. Hyperventilation C. Hypoventilation D. Myocardial ischemia E. Pulmonary embolus

C. Hypoventilation

7. A 23-year-old man is admitted to the medical services with a severe asthma attack. He is also nauseous, having diarrhea, and has vomited twice today. The patient has a long history of severe asthma with multiple hospitalizations and one intubation 3 years ago. 2 days prior to admission, he was exposed to dust while moving a file cabinet in his basement. Since that time, he has had progressively worsening shortness of breath. He had tried home albuterol and ipratropium (Atrovent) nebulizers, as well as his standard cromolyn (Intal) therapy, but none of these interventions relieved his symptoms. In the hospital, the man's peak flow rates are decreased by nearly 50% from baseline. Which of the following agents should most likely be added to the patient's therapy to alleviate his current symptoms? A. Inhaled beclomethasone (QVAR) B. Zafirlukast (Accolate) C. IV hydrocortisone D. Oral prednisone E. Aminophylline (Theophylline)

C. IV hydrocortisone

24. A man who was an unrestrained front-seat passenger in a car which crashed at a high speed arrives at the emergency department with signs of moderate respiratory distress. Physical examination shows no breath sounds at all on the left hemithorax. Percussion is tympanic on the left, and vital signs are normal. Chest x-ray shows a collapsed left lung and multiple air-fluid levels filling the left pleural cavity. A nasogastric tube that had been placed prior to taking the x-ray shows the tube reaching the upper abdomen and then curling up into the left chest. Which of the following is the most likely diagnosis? A. Blow out of pulmonary blebs B. Esophageal rupture or perforation C. Left diaphragmatic rupture D. Left hemopneumothorax E. Major injury to the tracheobronchial tree

C. Left diaphragmatic rupture

3. A 71-year-old woman is being treated for a severe chronic obstructive pulmonary disease (COPD) flare. She presented to the hospital 3 days ago with cough, fever, and pleuritic chest pain, having been feeling fatigued and, on the day of admission, persistently febrile. She has had more severe shortness of breath, often at rest and with mild exertion, and moderate dyspnea. Chest radiograph revealed a left lower lobe infiltrate and she was started on antibiotics. The patient has a long smoking history with forced expiration in 1 second (FEV1) of 1.1 L (avg FEV1 3.6 L). Which of the following therapies is most beneficial with respect to long-term morbidity and mortality in this patient? A. Beta-agonists B. Inhaled corticosteroids C. Long-term oxygen therapy D. Systemic corticosteroids E. Theophylline

C. Long-term oxygen therapy

16. A 19-year-old college freshman comes to the university health clinic because of recurrent episodes of wheezing during basketball practices. He has been a starting shooting guard for this team and has typically been hampered by shortness of breath shortly after beginning practice and during games. The symptoms are accompanied by a nonproductive cough and chest tightness. He denies any symptoms at rest. The symptoms occur whether the practices are indoors or outdoors. On physical examination he is comfortable and denies any symptoms. His physical examination is unremarkable. Which of the following cells are most likely to mediate his symptoms? A. Eosinophils B. Lymphocytes C. Mast cells D. Monocytes E. Neutrophils

C. Mast cells

27. A 33-year-old woman with a history of asthma is being treated for symptoms of hyperthyroidism that is causing intolerable heart palpitations. Which of the following beta-blockers would be an appropriate therapy? A. Isoproterenol (Isuprel) B. Labetalol (Trandate) C. Metoprolol (Lopressor) D. Propranolol (Inderal) E. Timolol (Timoptic)

C. Metoprolol (Lopressor)

31. A 27-year-old ski instructor complains of a nonproductive cough for 10 days. He has also developed a low-grade fever and diffuse muscle aches. He has been able to work 6 hours per day but has become increasingly dyspneic on long ski runs. He has no prior medical history and does not smoke or drink. He has a temperature of 38.3°C (100.9°F) and has scattered bilateral crackles. He has a regular heart rhythm. The remainder of his physical examination is normal. A chest x-ray film reveals a faint bilateral interstitial infiltrate. Which of the following is the most likely diagnosis? A. Legionella pneumonia B. Mycobacterium tuberculosis C. Mycoplasma pneumonia D. Pneumocystis carinii pneumonia E. Staphylococcal pneumonia

C. Mycoplasma pneumonia

29. A 22-year-old gang member arrives in the emergency department with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. He is wide awake, and in a normal tone of voice tells everyone that he is going to die. An initial survey reveals blood pressure 60/40 mm Hg. Pulse is 150/min and barely perceptible. He is in obvious respiratory distress and has large distended veins in his neck and forehead. His trachea is deviated to the left, and the right side of his chest is hyper-resonant to percussion, with no breath sounds. Which of the following is the most appropriate initial step in management? A. Drawing blood gases B. Immediate chest x-ray films C. Awake endotracheal intubation D. A 16-gauge needle inserted in the second right intercostal space E. Pericardiocentesis

D. A 16-gauge needle inserted in the second right intercostal space

41. A 45-year-old man presents to the emergency department with severe pneumonia. He recently returned from a business trip, and he has a history of smoking and alcohol use. An x-ray film shows extensive consolidation affecting portions of each lung lobe. Culture on charcoal yeast extract medium grows out a small gram-negative bacterium. Urine antigen test is positive for this organism. Which of the following antibiotics is the most appropriate treatment for this patient? A. Ceftriaxone (Rocephin) B. Chloramphenicol C. Clindamycin (Cleocin) D. Azithromycin (Zithromax) E. Metronidazole (Flagyl)

D. Azithromycin (Zithromax)

12. A 14-year-old boy is hit by an automobile while walking across the street and is immediately taken to the emergency department. On arrival, he is conscious and complains of shortness of breath and chest pain. Physical examination reveals an ecchymotic area over his right chest and subcutaneous emphysema. Breath sounds are absent on the right side. His trachea is deviated to the left, and his right hemithorax is tympanic to percussion. Which of the following is the most appropriate initial step in management of this patient? A. 12-lead ECG B. CT of the chest C. Plain radiography of the chest D. Chest tube thoracostomy E. Pericardiocentesis

D. Chest tube thoracostomy

45. A 15-year-old girl is brought to the pediatric health care provider's office because of sudden deterioration of school performance. Over the past month, her mother has noticed an occasional paint stain on the girl's hands. Her mother also noticed 6 bottles of typewriter correction fluid in her bedroom about a week ago. She raised the concern of inhalant abuse. Which of the following is the most likely consequence of chronic inhalant abuse? A. Arrhythmia B. Bronchial asthma C. Cerebral hemorrhage D. Encephalopathy E. Respiratory depression

D. Encephalopathy

83. A 57-year-old man comes to his health care provider for a semi-annual visit. He has a medical history significant for long-standing COPD. He has smoked 2-3 packs of cigarettes/day for the past 40 years and drinks a glass of whisky every night. He also has hypertension and diet-controlled type 2 diabetes mellitus. His medications include lisinopril (Prinivil, Zestril) and a thiazide diuretic. He has no allergies. He seems to be compliant with his medications. He walks 1/2 mile every day at a fairly brisk pace but is limited by fatigue and shortness of breath. His home blood glucose log shows a range of values from 108-201 mg/dL. On physical examination he is a fairly obese man with a large barrel chest. He is breathing comfortably. His blood pressure is 152/88 mm Hg, and pulse 82/min and regular. His lungs are hyperresonant to percussion with scant bibasilar crackles. He has an S4 gallop and a grade 1 systolic ejection murmur radiating to the carotids bilaterally. The extremities are without edema or clubbing. Which of the following is the most appropriate preventive measure for this patient? A. Add an oral glucose control agent B. Encourage additional exercise C. Encourage rapid cessation of alcohol use D. Encourage rapid cessation of tobacco use E. Increase his dose of thiazide

D. Encourage rapid cessation of tobacco use

34. A 69-year-old man comes to the hospital for a follow-up physical examination and chest CT scan. He has known long-standing lung disease secondary to amiodarone (Cordarone) therapy for arrhythmia related to atrial fibrillation, and this requires annual examinations and CT scans to document progression of his disease. He first took amiodarone 6 years ago and has continued to use the drug to control his arrhythmia and atrial fibrillation. His last pulmonary function tests showed a moderate restrictive defect. Which finding on physical examination is most consistent with advanced restrictive lung disease? A. Increased anterior-posterior (AP) diameter on inspection of the chest B. Diffuse expiratory wheezes on auscultation of the chest C. Dullness to percussion at the bases of the posterior thorax D. Fine inspiratory crackles at the bases on auscultation of the chest E. Hyperresonance to percussion of the chest

D. Fine inspiratory crackles at the bases on auscultation of the chest

59. Which of the following would most likely be observed in the lungs during an autopsy of a 2-week-old infant who died of neonatal respiratory distress syndrome? A. Alveoli filled with neutrophils B. Dense fibrosis of the alveolar walls C. Enlarged air spaces D. Hyaline membranes and collapsed alveoli E. Normal lung histology for age

D. Hyaline membranes and collapsed alveoli

48. A 25-year-old man is stabbed in the right chest. He comes into the emergency department fully awake and alert, and, in a normal tone of voice, he states that he feels short of breath. His vital signs are normal and stable. On physical examination he has no breath sounds at the right base, and only faint breath sounds at the apex. He is dull to percussion over the right base. A chest x-ray film confirms that he has a hemothorax on that side. Which of the following is the most appropriate next step in management? A. Oxygen by mask, analgesics, and no specific intervention B. Intubation and use of a respirator C. Insertion of a chest tube in the right second intercostal space D. Insertion of a chest tube at the right base E. Exploratory thoracotomy

D. Insertion of a chest tube at the right base

6. During a bitterly cold winter, an elderly couple is found dead in their apartment. All of their windows are closed, and their dated furnace is on full throttle and is heating the home. Which of the following is the primary mechanism by which the toxin involved led to the death of this couple? A. Decreasing intracellular calcium B. Inhibition of cytochrome oxidase C. Inhibition of Na+/K+ ATPase D. Irreversible binding to hemoglobin E. Stimulation of cellular apoptosis

D. Irreversible binding to hemoglobin

61. A 54-year-old woman is admitted to the hospital for pneumonia. The patient presented to the hospital 2 days ago for cough and fever. She reported temperatures to 38.9° C (102° F) and a cough productive of green, copious sputum. She also reported pleuritic chest pain with deep inspiration. The initial examination revealed diminished breath sounds in the left lower lobe with dullness to percussion, and a chest radiograph revealed a dense left lower lobe infiltrate. Which of the following organisms is most likely responsible for her pneumonia? A. Bordetella pertussis B. Klebsiella pneumoniae C. Mycoplasma pneumoniae D. Pneumococcus E. Staphylococcus aureus

D. Pneumococcus

38. A 56-year-old man is been admitted to the medical intensive care unit (MICU) in respiratory distress. An endotracheal tube is placed for mechanical ventilation at tidal volume 900 mL, rate 12 breaths/min, and fraction of inspired oxygen 50%. The positive end expiratory pressure is 10 cm of water. Medications include subcutaneous heparin and aspirin. Forty-eight hours into his MICU stay he develops tachycardia and a blood pressure 70 mm Hg. Cardiac examination at this time reveals multiple premature contractions. His arterial blood gas reveals PO2 40 mm Hg. Which of the following is the most likely cause of this condition? A. Cardiac arrhythmia B. Bronchial secretions C. Myocardial infarction D. Pneumothorax E. Pulmonary embolus

D. Pneumothorax

2. A 79-year-old man weighing 75 kg with emphysema is intubated in the intensive care unit because of respiratory failure after developing adult respiratory distress syndrome secondary to an Escherichia coli bacteremia. This event followed an untreated urinary tract infection. The ventilator is set to a respiratory rate 20/min, tidal volume 450 mL/breath, and pO2 100%. If these settings are continued for long-term use, the patient has increased risk for developing which of the following complications? A. Congestive heart failure B. Jugular venous distention C. Pulmonary embolus D. Pulmonary fibrosis E. Tension pneumothorax

D. Pulmonary fibrosis

70. A 34-year-old waiter with a known history of asthma has severe shortness of breath, cough, and wheezing. He arrives at the emergency department and appears extremely dyspneic. His blood pressure is 154/84 mm Hg, pulse 104/min, and respirations 32/min. With inspiration blood pressure falls to 112/70 mm Hg. On lung examination there are loud, high-pitched wheezes and a prolonged expiratory phase. Which of the following physical examination findings is of most significance while evaluating this patient? A. Hypertension B. Loud wheezing C. Prolonged expiratory phase D. Pulsus paradoxus E. Tachycardia

D. Pulsus paradoxus

26. A 33-year-old woman is undergoing a diagnostic work-up because she appears to have Cushing syndrome. She has elevated levels of cortisol, which are not suppressed when she is given high-dose dexamethasone. ACTH levels are greater than 200 pg/ mL. A chest x-ray film shows a central, 3-cm round mass on the hilum of the right lung. Bronchoscopy and biopsies confirm a diagnosis of small cell carcinoma of the lung. Which of the following is the preferred treatment for this woman? A. Bilateral adrenalectomy B. General support only C. Pneumonectomy D. Radiation and chemotherapy directed at the lung cancer E. Trans-sphenoidal hypophysectomy and pulmonary lobectomy

D. Radiation and chemotherapy directed at the lung cancer

81. A 65-year-old man with long-standing COPD develops extreme shortness of breath over a period of about 15 minutes. A chest x-ray film shows shift of the mediastinum to the right, and the lung field on the left appears hyperlucent. Chest film also shows a white shadow near the heart border. Which of the following is the most probable cause of the patient's current problem? A. Bronchogenic carcinoma B. Pleural effusion C. Pulmonary embolism D. Rupture of an emphysematous bulla E. Tuberculosis

D. Rupture of an emphysematous bulla

68. A 10-year-old boy with hereditary spherocytosis falls while riding his scooter down a steep hill. In the emergency department his injuries include a fractured wrist and lacerated spleen, which require surgical removal. Two years later the boy is diagnosed with bacterial pneumonia. Which of the following bacterial agents is the most likely pathogen for this patient's pneumonia? A. Escherichia coli B. Klebsiella pneumoniae C. Neisseria meningitidis D. Streptococcus pneumoniae E. Staphylococcus aureus

D. Streptococcus pneumoniae

37. A 27-year-old homeless man comes to the emergency department complaining of fever, rigors, and a productive cough for the past 24 hours. He admits to having last used IV heroin 24 hours earlier. He has rhonchi in both lower lung fields posteriorly. A chest x-ray reveals bilateral lobar consolidations, with an air-fluid level in the left lower lobe. A sputum Gram stain reveals gram-positive cocci in clusters in association with many polymorphonuclear leukocytes. Which of the following would be the most appropriate next step in management? A. Begin therapy with oral dicloxacillin B. Begin therapy with ampicillin 4 times daily C. Initiate therapy with oral erythromycin D. Initiate therapy with IV erythromycin E. Initiate therapy with IV Vancomycin

E. Initiate therapy with IV Vancomycin

65. A 24-year-old man with a known history of asthma comes to the emergency department complaining of 5 hours of severe wheezing and shortness of breath. He has used his bronchodilator inhaler 6 times during the past 5 hours but with only minimal relief. On physical examination he appears dyspneic; his temperature is 37.4°C (99.3°F), blood pressure is 118/64 mm Hg, pulse is 106/min, and respirations are 32/min. There is visible use of the sternocleidomastoid muscles with each inspiration. A lung examination reveals bilateral diffuse inspiratory and expiratory wheezing with poor air movement and a prolonged expiratory phase. Which of the following will most likely be found on a chest x-ray film? A. Bilateral interstitial infiltrate B. Lobar consolidation C. Pleural effusion D. Pneumothorax E. Normal findings

E. Normal findings

17. A 7-month-old child presents with a 4-day history of fever, deepening cough, and dyspnea. Chest x-ray shows multiple interstitial infiltrates and hyperinflation of the lungs. Multinucleated giant cells with cytoplasmic inclusion bodies are seen when a nasal wash is inoculated into tissue culture. The most appropriate therapy includes administration of which of the following drugs? A. Augmentin B. Prednisolone C. Ribavirin D. Albuterol E. Oxygen

E. Oxygen

22. A 6-month-old boy is brought to the emergency department because of a 3-day history of cough, congestion and low grade fever. The mother states that the baby has not been feeding well and has only 2 wet diapers over the past 24 hours. Physical examination reveals a pale infant with a temperature of 37.8ºC (100.1ºF), pulse of 170/min, respirations of 60/min and oxygen saturation of 88% on room air. The patient exhibits nasal flaring, subcostal and intercostal retractions. Lung examination reveals diffuse wheezing. Cardiac examination reveals a regular but tachycardic rhythm with no murmur. Central capillary refill is 4 seconds. The remainder of the examination is normal. Which of the following is the most appropriate initial step in management? A. Albuterol nebulizer treatment B. Bolus of IV fluids C. Chest x-ray film D. IV steroids E. Oxygen therapy

E. Oxygen therapy

10. A 65-year-old man presents with a productive cough and difficulty breathing. His sputum culture is positive for encapsulated gram-positive cocci, which are often seen in pairs. The patient's dyspnea is primarily due to which of the following mechanisms A. Inadequate perfusion B. Inadequate ventilation C. Increased airway resistance D. Increased lung compliance E. Poor oxygen diffusion

E. Poor oxygen diffusion

42. A 49-year-old Vietnamese man is diagnosed with tuberculosis. On physical examination large flocculent masses are noted over the lateral lumbar back, and a similar mass is located in the ipsilateral groin. This pattern of involvement strongly suggests an abscess tracking along which of the following muscles? A. Adductor longus B. Gluteus maximus C. Gluteus minimus D. Piriformis E. Psoas major

E. Psoas major

76. A 71-year-old man comes to the emergency department with fever and cough. He has known hypercholesterolemia and is status post a recent right hemicolectomy for colon cancer. The patient states that he has had 3 days of fever to 38.9 °C (102 °F), cough productive of green sputum, as well as general malaise and weakness. His physical examination is remarkable for decreased breath sounds at the left base, left basilar egophony and dullness to percussion. A complete blood count reveals a leukocyte count of 15,000/mm3 (normal 5,000-10,000). A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most important part of the history to ascertain prior to initiating therapy? A. Influenza immunization status B. Plasma lipid profile C. Stage of the colon cancer D. Social support structure for home therapy E. Recent hospitalizations

E. Recent hospitalizations

44. A 33-year-old man comes to his health care provider for a physical examination and chest x-ray that is required by his new employer, an asbestos removal company. He is feeling well and has no complaints. He takes no medications. He does not smoke cigarettes or use drugs. He has no history of previous potentially toxic exposures. His temperature is 37.0°C (98.6°F), blood pressure is 100/70 mm Hg, pulse is 63/min, and respirations are 18/min. His lungs are clear to auscultation. He has no clubbing of his fingers. The remainder of the examination is unremarkable. Chest x-ray shows a 1.9-cm nodule in the left lower lobe with large, coarse, and dense calcifications. Which of the following is the most appropriate management regarding evaluation of this mass? A. Bronchoscopy with biopsy B. No further workup indicated because of benign nodule appearance C. Open lung biopsy D. PPD placement E. Repeat chest x-ray in 3 months

E. Repeat chest x-ray in 3 months

36. A previously healthy 27-year-old man comes to his health care provider complaining of a cough with whitish sputum production for the past 3 days. The cough has been keeping him up at night and it is affecting his job performance. He has no prior history of respiratory disease. His temperature is 37 °C (98.6 °F), blood pressure 130/80, pulse 70/min, and respirations 18/min. Physical examination is unremarkable. Which of the following is the most appropriate next step in management? A. Admit to the hospital for medical management B. Perform a chest x-ray film C. Perform a sputum culture D. Send home with antibiotic therapy E. Send home with a short-acting beta agonist

E. Send home with a short-acting beta agonist

23. A 45-year-old woman comes to her health care provider because she often feels tired throughout the course of the day. She claims that she sleeps for about 7 hours each night, but wakes up frequently. Her husband complains that she snores very loudly while sleeping. She has no significant medical history and denies substance use. Vital signs are within normal limits. Physical examination appears normal except for obesity. She is 165 cm (5 ft 5 in) tall and weighs approximately 77 kg (170 lb). Which of the following is the most likely diagnosis? A. Catalepsy B. Kleine-Levin syndrome C. Narcolepsy D. Primary hypersomnia E. Sleep apnea

E. Sleep apnea

73. A Gram stain of the sputum from a patient with lobar pneumonia involving the left lower lobe demonstrates gram-positive, encapsulated, lancet-shaped diplococci. Which of the following is the most probable causative organism? A. Haemophilus influenzae B. Neisseria gonorrhoeae C. Pneumocystis jirovecii D. Staphylococcus aureus E. Streptococcus pneumoniae

E. Streptococcus pneumoniae

72. A 33-year-old woman is involved in a high-speed automobile collision. She arrives at the emergency department gasping for breath. Her lips are cyanotic and she has flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple rib fractures. Her blood pressure is 60/45 mm Hg, pulse is 160/min and faint, and central venous pressure is 25 cm H2O. Her neck and forehead veins are distended. She is diaphoretic and has a hint of subcutaneous emphysema in the lower neck and upper chest. Her left hemithorax has no breath sounds and is hyperresonant to percussion. The trachea is deviated to the right. Which of the following is the most likely diagnosis? A. Tension pneumothorax caused by right lung being punctured by broken ribs. B. Flail chest due to multiple rib fractures C. Massive intrapleural bleeding from torn intercostal vessels D. Massive mediastinal bleeding from ruptured aorta E. Tension pneumothorax caused by left lung being punctured by broken ribs

E. Tension pneumothorax caused by left lung being punctured by broken ribs

39. A 69-year-old woman comes to her health care provider of 3 years with progressive shortness of breath. The dyspnea was initially limited to exertion but has progressed to shortness of breath at rest. She has had intermittent cough but no fever. Her past medical history is significant for mild hypertension and seropositive rheumatoid arthritis. Which of the following aspect of her social history is the most important consideration to review at this point? A. Alcohol history B. Drugs of abuse history C. Marital status D. Occupation E. Tobacco history

E. Tobacco history

57. A 69-year-old woman with a history of diabetes type 2, chronic kidney disease (baseline creatinine of 2.3 mg/dL), and hypertension presents with shortness of breath and right-sided pleuritic chest pain. She denies fevers, chills, or cough. Her temperature is 38.1° C (100.6° F), blood pressure 130/70 mm Hg, pulse 123/min, and respirations 29/min. Physical examination shows a swollen and tender right calf. Lung examination is normal. Chest x-ray reveals no active disease. Which of the following is the diagnostic test of choice? A. D-dimer studies B. Lower extremity venogram C. MR angiogram D. Spiral CT scan E. Ventilation perfusion scan

E. Ventilation perfusion scan

77. On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management? A. Aortogram and emergency surgical repair B. Electrocardiogram and cardiac enzymes C. Intubation and respirator, with hyperventilation and PEEP D. Retinal examination looking for fat droplets E. Ventilation-perfusion lung scan, or spiral CT scan of the chest

E. Ventilation-perfusion lung scan, or spiral CT scan of the chest

80. A 59-year-old man comes to the hospital complaining of cough. The patient describes a cough that has progressively worsened over the past 3 days, becoming more productive of yellowish sputum. He also reports one episode of shaking chills 2 days ago. His past medical history is remarkable for rheumatoid arthritis, for which he takes a nonsteroidal agent for pain control. On examination, his blood pressure is 140/90 mm Hg, and his pulse is 100/min. He has coarse breath sounds over his right base and a normal cardiac examination. Which of the following is the most appropriate diagnostic test for this patient? A. High-resolution chest CT B. Positron emission tomography (PET) scan of the lungs C. MRI of the chest D. Ventilation-perfusion scan E. X-ray films of the chest, posterior-anterior (PA) and lateral views

E. X-ray films of the chest, posterior-anterior (PA) and lateral views

15. A child with a history of meconium ileus is brought to a clinic because of a chronic cough. The mother notes a history of respiratory tract infections and bulky, foul-smelling stools. After assessment of the respiratory tract illness, the health care provider should also look for signs of: A. cystinuria B. hypoglycemia C. iron deficiency anemia D. sphingomyelin accumulation E. vitamin A deficiency

E. vitamin A deficiency