MKSAP 15 Pulmonary Pulmonary and an d Critical and Care Medicine Questions Answers & Critiques CD1
Question 1 A 28-year-old 28-year-old man is evaluated for a 6-month history of episodic episodic dyspnea, cough, and and wheezing. As a child, he had asthma and allergies, but he has been been asymptomatic since his early teenage years. His recent symptoms started after an upper respiratory tract infection, and they are often triggered by eercise or eposure to cold a ir. He is also awa!ened with asthma symptoms " or 6 nights a month. He is otherwise healthy and ta!es no medications. #n physical eamination, vital signs are normal. $here is scattered wheezing in both lung fields. %hest radiograph is normal. &pirometry shows an '() * of + of predicted with a *" improvement after inhaled albuterol. hich of the following is the most appropriate therapy for this patient/ 0A-Azithromycin 0B-Inhaled albuterol as needed 0C-Inhaled low-dose corticosteroids plus inhaled albuterol as needed 0D-Long-acting β-agonist 0E-Long-acting β-agonist plus inhaled albuterol as needed
Question 1 A 28-year-old 28-year-old man is evaluated for a 6-month history of episodic episodic dyspnea, cough, and and wheezing. As a child, he had asthma and allergies, but he has been been asymptomatic since his early teenage years. His recent symptoms started after an upper respiratory tract infection, and they are often triggered by eercise or eposure to cold a ir. He is also awa!ened with asthma symptoms " or 6 nights a month. He is otherwise healthy and ta!es no medications. #n physical eamination, vital signs are normal. $here is scattered wheezing in both lung fields. %hest radiograph is normal. &pirometry shows an '() * of + of predicted with a *" improvement after inhaled albuterol. hich of the following is the most appropriate therapy for this patient/ 0A-Azithromycin 0B-Inhaled albuterol as needed 0C-Inhaled low-dose corticosteroids plus inhaled albuterol as needed 0D-Long-acting β-agonist 0E-Long-acting β-agonist plus inhaled albuterol as needed
Answer and Critique Critique 1 (Correct Answer: C) (ducational #b1ective $reat persistent asthma. Key oint oint 03nhaled corticosteroids are the cornerstone of therapy for persistent asthma. 0 Asthma Asthma symptom s on 2 or more days a wee! 4or 2 or more nights a m onth5 is the defining characteris tic of persistent asthm a. 3nhaled corticosteroids are the cornerstone of therapy for persistent asthma. egular use of inhaled corticosteroids is associated with improved pulmonary function, reduced airway hyperresponsiveness, decreased asthma eacerbations, and reduced mortality. &ide effects of inhaled corticosteroids include oral candidiasis and dysphonia related to laryngeal muscle myopathy. &ystemic effects may occur with use of inhaled corticosteroids and are generally related to the dose and duration of use. 3n adults, these effects include osteopenia, s!in thinning, and increased ris! for cataracts or glaucoma. $herefore, the lowest dose consistent with disease control should be used. $he treatment should be reevaluated every 7 to 6 months in stable patients, and ad1ustments made to step-up or step-down therapy based on disease control and occurrence of eacerbations. 3n between visits, patients should use a written asthma management plan, devised by their physician, to guide potential changes to their treatment. 0 Albuterol Albuterol should be used as needed in all patients with asthma, but by itself is not ade uate therapy because it does not affect the underlying airway inflammation. 9ong-acting :-agonists 4salmeterol and formoterol5 provide bronchodilation for up to *2 hours and are effective in preventing eercise-induced asthma. $hese drugs do not have a clinically significant anti-inflammatory effect; therefore, their use without concomitant administration of corticosteroids may mas! worsening of asthma control and lead to increased asthma-related complications, including the possibility of increased asthma-related deaths. $herefore, long-acting :agonists are not appropriate as monotherapy or in place of inhaled corticosteroids. $he use of antibiotics for atypical infections 4
Question 2 0
A +7-year-old woman is evaluated in the em ergency department for a 2-wee! history of worsening dyspnea and a dry cough. &he has not had fever or any recent travel. 3diopathic pulmonary fibrosis was diagnosed 2 years ago by open l ung biopsy. &he also has a his tory of hypertension and gastroesophageal reflu disease. Her medications are prednisone, diltiazem, hydrochlorothiazide, and omeprazole.
0
#n physical eamination, she is afebrile; the blood pressure is *=2>86 mm Hg, the pulse rate is ?+>min, the respiration rate is 28>min, and the @<3 is 2+. #ygen saturation with the patient breathing oygen, * 9>min by face mas!, is ?. $here are dry crac!les at the lung bases etending half way up the chest bilaterally. %ardiac and abdominal eaminations are normal. ram stain of sputum is negative; culture is pending. %$ scan of the chest is negative for pulmonary embolism but shows new areas of alveolar infiltrates and consolidation superimposed on previous basilar, reticular, and honeycomb changes.
hich of the following is the most appropriate net test in the evaluation of this patient/ 0
A-Bronchoscopy with bronchoal!eolar la!age
0
B-"ungal serologies
0
C-#ight-heart catheterization
0
D-$wallowing e!aluation
Answer and Critique 2 (Correct Answer: A) Educational Objective: Evaluate an acute exacerbation of idiopathic pulmonary fibrosis. Key Point: 0@ronchoalveolar lavage is the diagnostic procedure to eclude opportunistic infection in an apparent acute eacerbation of idiopathic pulmonary fibrosis. 0$he two immediate diagnostic considerations in this patient are respiratory infection and an acute eacerbation of pulmonary fibrosis. @oth diagnostic possibilities may be evaluated by bronchoalveolar lavage with studies to detect bacterial organisms, opportunistic pathogens 4for eample, Pneumocystis jirovecii 5, and viral pathogens. outine sputum evaluation for ram stain and culture is not sensitive enough to detect opportunistic infectious organisms. Biagnostic criteria for an acute eacerbation of pulmonary fibrosis include eclusion of opportunistic respiratory infections via endotracheal aspiration or bronchoalveolar lavage as well as eclusion of pulmonary embolism, left ventricular failure, and other causes of acute lung in1ury. $he incidence of an acute eacerbation of idiopathic pulmonary fibrosis is not certain but li!ely ranges between " and =. 3n patients with pulmonary fibrosis admitted to the intensive care unit for respiratory failure, the incidence may be as high as 6 with a reported mortality rate between 8 and *. Co therapy has been shown to be beneficial. 0'ungal serologies may be helpful to diagnose opportunistic infection in this patient. However, bronchoalveolar lavage is more sensitive, and results more readily available for detecting other opportunistic pathogens that need to be ecluded in this immunosuppressed patient. ight-heart catheterization is not part of the initial evaluation of patients with a suspected acute eacerbation of idiopathic pulmonary fibrosis. Aspiration may cause acute lung in1ury and may trigger an acute eacerbation of idiopathic pulmonary fibrosis, but swallowing evaluation is unli!ely to be diagnostic in this patient with no history of aspiration.
Question 3 0
A 6"-year-old woman is evaluated in a follow-up eamination for dyspnea, chronic cough, and mucoid sputum; she was diagnosed with chronic obstructive pulmonary disease 7 years ago. $he patient has a =-pac!-year history of cigarette smo!ing, but uit smo!ing * year ago. &he is otherwise healthy, and her only medication is inhaled albuterol as needed.
0
#n physical eamination, vital signs are normal. @reath sounds are decreased, but there is no edema or 1ugular venous distention. &pirometry shows an '() * of 62 of predicted and an '()*>')% ratio of 6". %hest radiograph shows mild hyperinflation.
hich of the following is the most appropriate therapy for this patient/ A-Add a long-acting β %-agonist B-Add an inhaled corticosteroid C-Add an oral corticosteroid D-Add theophylline and montelu&ast E-Continue current albuterol therapy
Answer and Critique 3 (Correct Answer: A) Educational Objective: Manage moderate chronic obstructive pulmonary disease. Key Point: 0 3n patients with moderate chronic obstructive pulmonary disease, therapy with a long-acting : 2-agonist or a long-acting anticholinergic agent improves uality of life and pulmonary function compared with therapy with short-acting bronchodilators alone. 0$his patient has stage 33 chronic obstructive pulmonary disease 4%#DB5 as defined by the guidelines of the lobal 3nitiative for #bstructive 9ung Bisease 4#9B5. #9B stage 33 disease is defined by a postbronchodilator '() *>')% ratio less than + and an '() * less than 8 but more than " of predicted with or without chronic symptoms. 3n patients with #9B stage 33 disease, maintenance treatment with one or more long-acting bronchodilators such as a long-acting : 2-agonist 4salmeterol or formoterol5 is r ecommended, along with as-needed albuterol. Dulmonary rehabilitation can be considered in addition to medical treatment in symptomatic patients. &tarting or adding a long-acting anticholinergic agent would also be appropriate. 03nhaled corticosteroids, oral corticosteroids, theophylline, and montelu!ast would be inappropriate f or this patient. $heophyllineEs narrow therapeutic window and poor bronchodilator effect ma!e it a poor choice. #ral corticosteroids are not recommended routinely in %#DB because of their systemic side effects.
Question 4 0
0
A "2-year-old woman is evaluated after a screening %$ colonography detected a 7-mm nodule in the right lower lobe of the lung. A tortuous colon prevented complete screening colonoscopy. %$ scan of the chest showed no additional nodules and was otherwise normal. $he patient has never smo!ed; she wor!s in the home and has not been eposed to potential carcinogens. &he has not had a chest radiograph or other imaging procedure, ecept mammography. Her medical history includes only hyperlipidemia, and her only medication is simvastatin. Her family history is unremar!able. #n physical eamination, vital signs are normal. (amination of the s!in is normal; there is no lymphadenopathy, and the lungs are clear.
hich of the following is the most appropriate net step in the management of this patient/ A-Chest radiograph in ' months B-C( scan o) the chest in ' months C-C( scan o) the chest in * months D-C( scan o) the chest in +% months E-,o )ollow-up
Answer and Critique 4 (Correct Answer: E) Educational Objective: Evaluate a low-risk patient with a very small pulmonary nodule. Key Point: 03n a patient at low ris! for malignancy no follow-up is reuired for an incidentally noted pulmonary nodule = mm or smaller. 0&tudies of chest %$ screening have shown that 2" to " of patients have one or more pulmonary nodules detected on the initial %$ scan. (ven in patients at relatively high ris! for lung cancer, the li!elihood that a small nodule is malignant is low 4G*5. 'or eample, the ris! of malignancy is about .2 for nodules smaller than 7 mm and .? for nodules = to + mm. $he 'leischner &ociety recommendations include no follow-up for low-ris! patients with nodules = mm or smaller and follow-up %$ at *2 months for patients with such nodules who are at ris! for lung cancer.
Question 5 0
A 7-year-old man is eva luated for difficulty weaning from the ventilator. $he patient was intu bated + days ago for a severe eacerbation of asthma. Bespite receiving a high-dose inhaled :-agonist; methylprednisolone, 6 mg>d; and aggressive sedation, he had persistent severe auto-positive endepiratory pressure with elevated ventilator pressures. $herefore, a continuous infusion of vecuronium, a paralytic agent, was started and continued for 2= hours until his respiratory mechanics improved. $oday, he underwent a ventilator weaning trial but became tachycardic and diaphoretic with a rapid shallow breathing inde of *2.
0
#n physical eamination, the patient is alert and responsive; vital signs are normal. $here is minimal epiratory wheezing and otherwise normal vesicular breath sounds. He has flaccid wea!ness involving all etremities, including decreased bilateral hand grip strength. $here is no rash. outine laboratory studies reveal normal liver enzyme tests and renal function.
hich of the following is the most li!ely cause for the patientEs difficulty weaning from the ventilator/ A-Acute in)lammatory demyelinating polyneuropathy .uillain-Barr/ syndrome0 B-Churg-$trauss syndrome C-Intensi!e care unit1ac2uired wea&ness D-rolonged neuromuscular bloc&ade
Answer and Critique 5 (Correct Answer: C) Educational Objective: Diagnose intensive care unitac!uired weakness. Key Point; 0Datients with intensive care unitacuired wea!ness have diffuse, flaccid wea!ness and often present with difficulty with ventilator weaning. 0Datients with intensive care unit 43%F5acuired wea!ness have diffuse wea!ness and decreased muscle tone. $he disorder may be first recognized in patients with uneplained difficulty weaning from the ventilator. "#$-ac!uired weakness is a term used to encompass critical-illness poly-neuropathy and critical-illness myopathy. $reatment with paralytic agents and systemic corticosteroids, as well as sepsis and immobilization, increase the ris! of developing 3%F-acuired wea!ness. $reatment is supportive, including discontinuation or reduction of corticosteroids, aggressive management of eisting disorders, and physical rehabilitation. 0 Acute inflammatory demyelinating polyneuropathy 4uillain-@arrI syndrome5 can also cause diffuse wea!ness, but in contrast to this patient, wea!ness is the presenting symptom. 'urthermore, wea!ness associated with acute inflammatory demyelinating polyneuropathy typically develops gradually over a longer time course 4* to 2 wee!s5 and typically is preceded by an inf ection. 0Drolonged neuromuscular bloc!ade is a condition in which the effect of paralytic agents, such as vecuronium, can persist f or days after discontinuing the medication. However, this is rarely encountered and is caused by altered drug metabolism due to liver and>or renal dysfunction, neither of which this patient has. 0%hurg-&trauss syndrome is associated with asthm a and, in the vasculitic stage, can cause wea!ness. However, the syndrome most often manifests as mononeuritis multiple rather than generalized wea!ness. 'urthermore, this patient does not have other manifestations of vasculitis such as rash or renal dysfunction.
Question 6 0
A "=-year-old man is evaluated in the emergency department f or a *-hour history of c hest pain with mild dyspnea. $he patient had been hospitalized * wee! ago for a colectomy for colon cancer. His medical history also includes hypertension and nephrotic syndrome secondary to membranous glomerulonephritis, and his medications are furosemide, ramipril, and pravastatin.
0
#n physical eamination the temperature is 7+." J% 4* J'5, the pulse rate is *2>min, the respiration rate is 2=>min, the blood pressure is **>6 mm Hg, and the @<3 is 7. #ygen saturation is 8? with the patient breathing ambient air and ?+ on oygen, = 9>min. %ardiac eamination shows tachycardia and an &=. @reath sounds are normal. %hest radiograph is negative for infiltrates, widened mediastinum, and pneumothora. &erum creatinine concentration is 2.* mg>d9 4*8".6 Kmol>95. (mpiric unfractionated heparin therapy is begun.
hich of the following is the best test to confirm the diagnosis in this patient/
A-Assay )or plasma D-dimer B-C( angiography C-Lower e3tremity ultrasonography D-4easurement o) antithrombin III E-5entilation6per)usion scan
Answer and Critique 6 (Correct Answer: E) Educational Objective: #onfirm the clinical diagnosis of acute pulmonary embolism. Key Point: 0(ither ventilation>perfusion scanning or contrast-enhanced %$ scanning 4if not contraindicated5 performed with a specific protocol to detect pulmonary embolism is an appropriate noninvasive test to diagnose acute pulmonary embolism. 0$his patient is at high ris! for pulmonary embolism because of his recent hospitalization, cancer, and nephrotic syndrome. A positive ventilation>perfusion scan would confirm the diagnosis of pulmonary embolism in this patient with a high pretest probability for the condition, especially in the absence of parenchymal lung defects on chest radiograph. 0$he probability of pulmonary embolism was very high based on this presentation that included chest pain, dyspnea, recent hospitalization and surgery, active cancer, and a protein-losing nephropathy. A negative B-dimer test would not be sufficient evidence to rule out a pulmonary embolism under these circumstances, and a high B -dimer level would add little to the diagnostic wor!-up. Becreased antithrombin 333 levels may result from nephrotic syndrome, and levels are lowered during acute thrombosis, especially during treatment with heparin. $herefore, measuring antithrombin 333 would add little to the accuracy of the diagnosis of pulmonary embolism or have any implication for immediate management decisions. 9ower etremity ultrasonography can disclose asymptomatic deep venous thrombosis in a small percentage of patients presenting with symptoms of pulmonary embolism. However, the yield is relatively low and ventilation>perfusion scanning would have a much higher degree of accuracy. %$ angiography is an acceptable modality to diagnose acute pulmonary embolism but reuires a significant amount of contrast infusion 4as much as a pulmonary angiogram5 which would be contraindicated in a patient with an elevated serum creatinine level.
Question 7 A An *8-year-old man is evaluated in the emergency department after his mother found him unconscious in his bed at home. &he reported that her son had gone to a party two nights ago, but she was not sure when he returned home. hen she chec!ed on him, he was unarousable. He has no significant medical history and ta!es no medications. 3n the emergency department, he is afebrile, bl ood pressure is **>+ mm Hg, the pulse rate is ">min, and respiration rate is 6>min; he is intubated for airway protection. Laboratory studies78emoglobin +%9% g6dL +%% g6L0 0Leu&ocyte count ':;;6
6L0 0latelet count ++;?;;;6 6L0 0Creatinin e
'9% mg6dL %@%9>
0Aspartate aminotrans)erase @; 6L 0Alanine aminotrans)erase
:* 6L
0Creatine &inase +@?:;; 6L 0I,#
+9%
0 Al!aline phosphatase, bilirubin, and albumin are normal. Frine dipstic! is =L positive for occult blood. @lood alcohol level is .8 g>d9 4*+= mmol>95. $oicology testing is positive for opiates and cocaine. @ladder catheterization reveals only 7 m9 of brown urine.
hich of the f ollowing is the most li!ely cause of the patientEs renal failure/ 0A-8emolytic anemia 0B-8emolytic-uremic syndrome 0C-8epatorenal syndrome 0D-#habdomyolysis 0E-$epsis
Answer and Critique 7 (Correct Answer: D) Educational Objective: Diagnose rhabdomyolysis secondary to narcotic overdose. Key Point: 0Contraumatic causes of rhabdomyolysis include drug use, metabolic disorders, and infections. 0$his patient most li!ely has rhabdomyolysis, which is caused by s!eletal muscle damage that leads to release of intracellular components into the circulation, such as creatine !inase and lactate dehydrogenase, the heme pigment myoglobin, purines, and potassium and phosphate. $he syndrome was first identified in patients with traumatic crush in1uries, but t here are nontraumatic causes, such as alcohol 4due to hypophosphatemia5, drug use, metabolic disorders, and infections. $he classic triad of findings includes muscle pain, wea!ness, and dar! urine. $he diagnosis is based on c linical findings and a history of predisposing factors 4such as prolonged immobilization or drug toicity5 and confirmed by the presence of myoglobinuria, an increased serum creatine !inase level, and, in some c ases, hyper!alemia. $he disorder usually resolves within days to wee!s. $reatment consists of aggressive fluid resuscitation; fluids should be ad1usted to maintain the hourly urine output at least 7 m9 until the urine is negative for myoglobin. Acute !idney in1ury resulting from acute tubular necrosis occurs in approimately one third of patients. Bialysis is sometimes necessary. 0 Although fulminant hepatic failure may result in coma, dar! urine, and renal failure, other tests of synthetic liver function in this patient are normal. $here are no clinical features to suggest sepsis. $he patient has mild anemia, but the proportionate reduction in the leu!ocyte and platelet counts suggests alcohol-induced bone marrow suppression. Hemolytic anemia would not eplain the patientEs elevated creatine !inase level and usually does not cause renal failure. Hemolytic uremic syndrome is not c onsistent with the clinical findings of polysubstance overdose or the laboratory finding of the elevated serum creatine !inase level.
Question 8 A +-year-old man is evaluated in the emergency department for a 2-day history of dyspnea with eertion, orthopnea, and paroysmal nocturnal dyspnea. He has ischemic heart disease with left ventricular dysfunction and had c oronary artery bypass graft surgery 6 wee!s ago. His medications include aspirin, nitroglycerin, metoprolol, lisinopril, and furosemide.#n physical eamination, the patient is sitting upright and breathing with difficulty; the temperature is 7+ J% 4?8.6 J'5, the blood pressure is *">8" mm Hg, the pulse rate is *">min and regular, and the respiration rate is 28>min. #ygen saturation is 8? on ambient air. $here are fine crac!les at the lung bases bilaterally, and breath sounds are diminished at the right b ase. $here is a regular tachycardia and an &7 at the ape. $here is no 1ugular venous distention or peripheral edema. Hemoglobin is *2." g>d9 4*2" g>95, and the leu!ocyte count is *,">K9 4*." M * ?>95. %hest radiograph shows cardiomegaly and small bilateral pleural effusions, greater on the right than the left. $horacentesis is performed, and pleural fluid analysis shows 0Cucleated cell count=">K9 with 7 neutrophils, + lymphocytes, * macrophages, *" mesothelial cells, and 2 eosinophils. 0Dleural fluid to serum total protein ratio 09actate dehydrogenase 49BH5
."=
*2" F>9
0Dleural fluid to upper limits of normal serum 9BH ratio 0lucose
8 mg>d9 4=.== mmol>95
0$otal protein
7.+ g>d9 47+ g>95
0Dh +.=" 0 Albumin
*." g>d9 4*" g>95
0%holesterol
7" mg>d9 4.? mmol>95
0$he serumpleural fluid albumin gradient is *.+.
hich of the following is the most li!ely diagnosis/ 0A- 8eart )ailure 0B- arapneumonic e))usion 0C- ost1cardiac inury syndrome 0D- ulmonary embolism
."2
Answer and Critique 8 (Correct Answer: A) Educational Objective: %ecogni&e the effect of diuretic therapy on the pleural fluid analysis in patients with heart failure. Key Point: 0Biuretic therapy for heart failure c an result in either a protein- or l actate dehydrogenasediscordant eudative pleural effusion and, rarely, a concordant eudate. 0$he patientEs pleural fluid analysis shows a protein discordant eudate 4an eudate by protein criterion only5 with a pleural fluid to serum total protein ratio of ."= and a pleural fluid l actate dehydrogenase 49BH5 to upper limits of normal serum 9BH ratio of ."2. Dleural fluid findings may have eudative characteristics in patients with heart failure who are receiving diuretics. A serumpleural fluid albumin gradient greater than *.2 suggests a transudate in cases where the pleural fluid to serum total protein ratio or pleural fluid to serum 9BH ratio and pleural fluid 9BH to upper limits of normal serum 9BH ratio suggest an eudate, but the clinical findings suggest a transudate. $he increased pleural fluid to serum total protein ratio is the result of a diuretic effect, with more efficient clearance of pleural liuid than pleural protein. 0Datients with postcardiac in1ury syndrome typically present 7 wee!s 4range 7 days to * year5 after coronary artery bypass graft surgery; they usually have pleuritic chest pain and typically dyspnea, pleural or pericardial friction rub, fever, left lower lobe infiltrates, leu!ocytosis, and an increased erythrocyte sedimentation rate. $his patientEs findings are not compatible with postcardiac in1ury syndrome. $he absence of chest pain would be highly unli!ely with a pulmonary embolisminduced pleural effusion. Co consolidation was detected on chest radiograph, ma!ing pneumonia unli!ely. 'urthermore, a parapneumonic effusion is typically a concordant eudate 4both protein and 9BH in the eudate range5 with a neutrophil predominance, and a low pleural fluid 9BH is typically not associated with an acute parapneumonic effusion.
Question 9 A 2-year-old woman is ev aluated in the emergency department for an acute episode of wheezing and dyspnea without cough or sputum production. &he has had previous freuent evaluations in emergency departments and urgent care centers for similar episodes. 3n between these episodes, findings on physical eamination and pulmonary function testing, including methacholine challenge, have been normal. &he is otherwise healthy and ta!es no medications. #n physical eamination, the patient has inspiratory and epiratory wheezing and is in moderate discomfort. $he temperature is 7+.* J% 4?8.8 J'5, pulse rate is *>min, and the respiration rate is 2=>min; oygen saturation on ambient air is ?6. After receiving albuterol and intravenous corticosteroids, she continues to wheeze and is in moderate respiratory distress. #ygen saturation on ambient air remains at ?6. %hest radiograph shows decreased lung volumes.
hich of the following is the most appropriate management for this patient/ 0A-Chest C( scan 0B-Intra!enous aminophylline 0C-Intra!enous azithromycin 0D-Intra!enous terbutaline 0E-Laryngoscopy
Answer and Critique 9 (Correct Answer: E) Educational Objective: Evaluate vocal cord dysfunction. Key Point: 09aryngoscopy during an eacerbation of vocal cord dysfunction shows adduction of the vocal cords during inspiration. 0$his patient li!ely has vocal cord dysfunction 4)%B5. Datients with )%B can have throat or nec! discomfort, wheezing, stridor, and aniety. $he disorder can be difficult to differentiate from asthma; however, affected patients do not respond to the usual asthma therapy. Biagnosing )%B is made more difficult by the fact that many of these patients also have asthma. $he chest radiograph in this patient showed decreased lung volumes, which is in contrast to hyperinflation that would be epected in acute asthma. #ygen saturation is typically normal in patients with )%B. 09aryngoscopy, especially when done while the patient is symptomatic, can reveal characteristic adduction of the vocal cords during inspiration. Another test that helps ma!e the diagnosis is flow volume loops, in which the inspiratory and epiratory flow rates are recorded while a patient is as!ed to ta!e a deep breath and then to ehale. 3n patients with )%B, the inspiratory limb of the flow volume loop is NflattenedO owing to narrowing of the etrathoracic airway 4at the level of the vocal cords5 during inspiration. ecognition of )%B is essential to prevent lengthy courses of corticosteroids and to initiate therapies targeted at )%B, which include speech therapy, relaation techniues, and treating such underlying causes as aniety, postnasal drip, and gastroesophageal reflu disease. 03ntravenous aminophylline is not recommended for treating either acute asthma or )%B. $herapy with intravenous terbutaline or other :-agonists for asthma eacerbations is associated with an unacceptably high rate of side effects. Azithromycin is a reasonable choice for acute bronchitis, but there is little evidence that this patient has acute bronchitis, which would manifest with cough, sputum production, and fever. $he chest %$ scan can be used to eclude parenchymal lung disease or evaluate the possibility of a pulmonary embolism; however, these disorders are unli!ely in this patient with previous normal pulmonary eaminations and radiographs and ecellent oygenation, and chest %$ scan is unli!ely to yield useful information.
Question 10 0
A +2-year-old woman is evaluated for fatigue and decreased eercise capacity. $he patient has severe chronic obstructive pulmonary disease, which was first diagnosed * years ago, and was hospitalized for her second eacerbation * month ago. &he is a former smo!er, having stopped smo!ing " years ago. &he has no other significant medical problems, and her medications are albuterol as needed, an inhaled corticosteroid, a long-acting bronchodilator, and oygen, 2 9>min by nasal cannula.
0
#n physical eamination, vital signs are normal. @reath sounds are decreased, and there is *L bilateral pitting edema. &pirometry done * month ago showed an '() * of 28 of predicted, and blood gases measured at that time 4on supplemental oygen5 showed pH +.=*, D%# 2 =7 mm Hg, and D# 2 6= mm Hg; B9%o is 7 of predicted. $here is no nocturnal oygen desaturation. %hest radiograph at this time shows hyperinflation. %$ scan of the chest shows homogeneous distribution of emphysema.
hich of the following would be the most appropriate management for this patient/ 0
A-ung transplantation
0
B-Lung !olume reduction surgery
0
C-,octurnal assisted !entilation
0
D-ulmonary rehabilitation
Answer and Critique 10 (Correct Answer: D) Educational Objective: Prescribe pulmonary rehabilitation for a patient with severe chronic obstructive pulmonary disease. Key Point: 0Dulmonary rehabilitation in patients with advanced lung disease can increase eercise capacity, decrease dyspnea, improve uality of life, and decrease health care utilization. 0$his patient who is on maimum medical treatment for chronic obstructive pulmonary disease 4%#DB5 and is still symptomatic would benefit from pulmonary rehabilitation. %omprehensive pulmonary rehabilitation includes patient education, eercise training, psychosocial support, and nutritional intervention as well as the evaluation for oygen supplementation. eferral should be considered for any patient with chronic respiratory disease who remains symptomatic or has decreased functional status despite otherwise optimal medical therapy. 0Dulmonary rehabilitation increases eercise capacity, reduces dyspnea, improves uality of life, and decreases health care utilization. eimbursement for pulmonary rehabilitation treatment remains an impediment to its widespread use. 0$he effect of lung volume reduction surgery is larger in patients with predominantly nonhomogeneous upper-lobe disease and limited eercise performance after rehabilitation. $he ideal candidate should have an '() *between 2 and 7" of predicted, the B9%# no lower than 2 of predicted, hyperinflation, and limited comorbidities. $here is no indication for nocturnal assisted ventilation because she does not have daytime hypercapnia and worsening oygen desaturation during sleep. 9ung transplantation should be considered in patients hospitalized with %#DB eacerbation complicated by hypercapnia 4D%#2 greater than " mm Hg5 and patients with '() * not eceeding 2 of predicted and either homogeneous disease on high-resolution %$ scan or B9%# less than 2 of predicted who are at high ris! of death after lung volume reduction surgery. 9ung transplantation is, therefore, not an option for this patient.
Question 11 0
A +*-year-old woman is evaluated for a 7-wee! history of mild pain in the shoulders and thighs and wea!ness when rising from a seated position and getting out of bed. &he also has a new rash on her hands. (ight m onths ago she was evaluated for dyspnea and new interstitial infiltrates that resulted in a lung biopsy and a diagnosis of idiopathic nonspecific interstitial pneumonia. &he was treated with prednisone, 6 m g>d, for * month; the dose was then tapered to * mg>d. Her symptoms had been st able on that dose until her new complaints.
0
#n physical eamination, there are swelling and discoloration of the eyelids and an erythematous scaly rash over the etensor surfaces of interphalangeal 1oints of both hands. $here is symmetric wea!ness of the proimal hip fleors and shoulder girdle muscles; hand s trength is normal. 9aboratory studies show antinuclear antibodies positive at a titer of **28 4previously negative5, serum creatine !inase *2+ F>9, and erythrocyte sedimentation rate 6 mm>h; serum electrolytes and complete blood count are normal. %hest radiograph shows bilateral reticular and alveolar abnormalities in the lower- and mid-lung zones.
hich of the following is the most appropriate management for this patient/ 0
A-Electromyography and muscle biopsy
0
B-#epeat lung biopsy
0
C-$&in biopsy
0
D-(aper prednisone dosage
Answer and Critique 11 (Correct Answer: A) Educational Objective: Diagnose and manage dermatomyositis presenting as interstitial lung disease. Key Point: 0Fp to 7 of patients with dermatomyositis and polymyositis present with single-organ involvement of the lungs indistinguishable from idiopathic interstitial lung disease. 0$his patientEs symmetric proimal muscle wea!ness and pain with an erythematous, scaly rash over the interphalangeal 1oints 4ottron sign5, coupled with a positive antinuclea r antibody titer and elevated creatine !ina se level, suggest dermatomyositis. (lectromyography and muscle biopsy will establish the diagnosis of inflammatory myopathy. 3nflammatory myopathy must be distinguished from corticosteroid-induced myopathy because treatment of dermatomyositis reuires increased corticosteroids, whereas corticosteroid-induced myopathy is treated with withdrawal of prednisone. %orticosteroidinduced myopathy is not associated with elevated antinuclear antibodies, creatine !inase, or erythrocyte sedimentation rate. Fp to 7 of patients with dermatomyositis and polymyositis present without muscle, s!in, or 1oint involvement and have single-organ involvement of the lungs indistinguishable from idiopathic interstitial lung disease. 3nterstitial lung disease associated with inflammatory myopathy often occurs in the contet of antisynthetase antibodies 4for eample, anti-Po-*5 and the antisynthetase syndrome 4acute onset, constitutional symptoms, aynaud phenomenon, NmechanicEs hands,O arthritis, and interstitial lung disease5. 0epeat lung biopsy is unli!ely to yield new diagnostic information in this patient with stable chest radiograph and no new respiratory symptoms. A s!in biopsy is li!ely to reveal non specific findings that will not h elp diagnose the muscle symptoms.
Question 12 A +=-year-old man is evaluated for a "-year history of gradually progressive dyspnea and dry cough without wheezing or hemoptysis. 'or the past 2 years he has had pain and occasional swelling in both !nees. He has not had fever or lost weight. He smo!ed one pac! of cigarettes a day from the age of *8 to 6 years. He wor!ed as an insulator for = years. Dhysical eamination shows no digital clubbing or cyanosis. Auscultation of the lungs reveals bilateral end-inspiratory crac!les. Dulmonary function testing shows 0$otal lung capacity 0esidual volume 0')% 0'()*
6+ of predicted +2 of predicted
6" of predicted +" of predicted
0'()*>')% ratio 8? 0B9%# "2 of predicted 0His chest radiograph is shown
hich of the following is the most li!ely diagnosis/ 0A-Asbestosis 0B-Idiopathic pulmonary )ibrosis 0C-#heumatoid interstitial lung disease 0D-ulmonary sarcoidosis
Answer and Critique 12 (Correct Answer: A) Educational Objective: Diagnose asbestosis. Key Point 0Dleural plaues are focal, often partially calcified, fibrous tissue collections on the parietal pleura and are a mar!er of asbestos eposure. 0$he diagnosis of asbestosis is based on a convincing history of asbestos eposure with an appropriately long latent period 4* to *" years5 and definite evidence of interstitial fibrosis without other li!ely causes. $his patient wor!ed as an insulator when asbestos eposure was still widespread and is at ris! for asbestos-related lung disease. $he most specific finding on chest radiograph is bilateral partially calcified pleural plaues. Dleural plaues are focal, often partially calcified, fibrous tissue collections on the parietal pleura and are considered a mar!er of asbestos eposure. 0heumatoid lung disease has many manifestations, including an interstitial lung disease, which is most common in patients with severe rheumatoid arthritis. $his patientEs occasional swelling in both !nees is not compatible with the diagnosis of rheumatoid arthritis. 0&arcoidosis occurs most commonly in young and middle-aged adults, with a pea! incidence in the third decade.
Question 13 0
A +"-year-old woman with a history of chronic obstructive pulmonary disease is evaluated in the intensive care unit for delirium. &he had a median sternotomy and repair of an aortic dissection and was etubated uneventfully on postoperative day =. $wo days later she developed fluctuations in her mental status and inattention. hile still in the intensive care unit, she became agitated, pulling at her lines, attempting to climb out of bed, and as!ing to leave the hospital. Her arterial blood gas values are normal. $he patient has no history of alcohol abuse. $he use of freuent orientation cues, calm reassurance, and presence of family members has done little to reduce the patientEs agitated behavior.
hich of the following is the most appropriate therapy for this patientEs delirium/ 0
A-Diphenhydramine
0
B-8aloperidol
0
C-Lorazepam
0
D-ropo)ol
Answer and Critique 13 (Correct Answer: B) Educational Objective: 'reat delirium in the intensive care unit. Key Point 0Co drug is F.&. 'ood and Brug Administrationapproved for the treatment of delirium, but clinical practice guidelines recommend antipsychotic agents, such as haloperidol. 0hen supportive care is insufficient for prevention or treatment of delirium, symptom control with medication is occasionally necessary to prevent harm or to allow evaluation and treatment in the intensive care unit. $he appropriate treatment for this patient is haloperidol. $he recommended therapy for delirium is antipsychotic agents, although no drugs are F.&. 'ood and Brug Administrationapproved for this indication. #ngoing randomized, placebo-controlled trials are investigating different management strategies for intensive care unit delirium. A recent systematic evidence review found that the eisting limited data indicate no superiority for second-generation antipsychotics compared with haloperidol for delirium. Haloperidol does not cause respiratory suppression, which is one reason that it is often used in patients with hypoventilatory respiratory failure who reuire sedation. All antipsychotic agents, and especially NtypicalO agents such as haloperidol, pose a ris! of torsades de pointes and etrapyramidal side effects as well as the neuroleptic malignant syndrome. 0Biphenhydramine and other antihistamines are a ma1or ris! factor for delirium, especially in older patients. 9orazepam is actually deliriogenic, and its use in a delirious patient should be carefully re-evaluated, other than perhaps in patients eperiencing benzodiazepine withdrawal or delirium tremens. $here is no evidence that propofol has any role in treating delirium.
Question 14 A A 6-year-old woman is evaluated 7 wee!s after starting continuous positive airway pressure 4%DAD5 therapy for obstructive sleep apnea. $he patient was initially evaluated for ecessive sleepiness, and obstructive sleep apnea was diagnosed based on results of polysomnography. 3t was determined that %DAD at a pressure of *= cm H 2# normalized respiration and oygen saturation during sleep. &he was prescribed %DAD at this pressure along with heated humidification administered via a nasal mas!. &he has been using %DAD, but she is still often sleepy during the day. &he has a history of hypertension and osteoarthritis, and her medications are hydrochlorothiazide and ibuprofen. &he does not smo!e or drin! alcohol. #n physical eamination, she is afebrile; the blood pressure is *=">8" mm Hg, and the @<3 is 76.". &he has a slightly receding 1aw; otherwise, physical features are unremar!able.
hich of the following is the most appropriate net step in the management of this patient/ 0A-rder a multiple sleep latency test 0B-rescribe hormone replacement therapy 0C-rescribe moda)inil 0D-#e!iew CA compliance
Answer and Critique 14 (Correct Answer: D) Educational Objective: Manage obstructive sleep apnea. Key Point 0(cessive sleepiness that persists despite positive airway pressure therapy may be due to poor adherence with treatment. 0#bstructive sleep apnea is associated with significant, even life-threatening complications, and %DAD is effective therapy. %DAD therapy reduces the number of apneas and hypopneas and improves sleep architecture, hypertension, and uality of life. (cessive sleepiness that per sists despite %DAD therapy may be due to poo r adherence with treatment, insufficient sleep duration, presence of coeisting sleep disorders, surreptitious use of sedating medications, or mood disorders. Adherence to %DAD therapy is often suboptimal, and many patients remain symptomatic and report either not being able to tolerate the device or using it intermittently. )erifying proper use and adherence is important before %DAD therapy is discontinued or additional studies are ordered or therapy prescribed.
Question 15 A 28-year-old man is evaluated for a ?-month history of daily cough productive of yellow sputum and intermittent low-grade fever. He has had three episodes of pneumonia during that time; the symptoms improve with antibiotic therapy but return when therapy is disc ontinued. $he patient does not have a history of aspiration, asthma, or sinusitis, and he ta!es no medications. He has never smo!ed. #n physical eamination, the temperature is 7+.= J% 4??.7 J'5, the pulse rate is 88>min, the respiration rate is *8>min, the blood pressure is **6>"8 mm Hg, and the @<3 is 2=. @reath sounds are reduced in the ri ght base; the lungs are otherwise clear. 9aboratory tests are normal. $wo chest radiographs 7 months apart have shown an infiltrate in the ri ght lower lobe. %ontrast-enhanced %$ scan of the chest shows right lower lobe bronchiectasis and partial volume loss of this lobe; endobronchial obstruction is suggested. $here is no lymphadenopathy.
hich of the following is the most li!ely diagnosis/ 0A-Adenocarcinoma 0B-Carcinoid tumor 0C-$mall cell carcinoma 0D-$2uamous cell carcinoma
Answer and Critique 15 (Correct Answer: B) Educational Objective:%ecogni&e a typical presentation of a carcinoid tumor. Key Point 0%arcinoid tumors are neuroendocrine tumors with an indolent growth pattern that often present w ith endobronchial obstruction. 0 A carcinoid tumor is the most li!ely tumor in a young person who has never smo!ed and who has evidence of endobronchial obstruction. @ronchial carcinoid is a slow growing tumor that originally was classified as an adenoma but has been reclassified as a malignant neoplasm because of its ability to metastasize.
Question 16 A 28-year-old man is A 7-year-old medical resident is evaluated for cough, right-sided chest pain, and fever of 2* daysE duration. He has no significant medical history or family history, and he ta!es no medications. 0Hemoglobin is *= g>d9 4*= g>95, and the leu!ocyte count is 8 >K9 48 M * ?>95. %hest radiograph shows a right pleural effusion occupying approimately " of the hemithora without other abnormalities. $horacentesis yields turbid, yellow fluid, and analysis shows 0(rythrocyte count ">K9 0Cucleated cell count eosinophils 0$otal protein
7">K9 47." M * ?>95 with 2 neutrophils, 6 lymphocytes, * macrophages, = mesothelial cells, and 6
=.2 g>d9 4=2 g>95
09actate dehydrogenase 2= F>9 0Dh
+.7"
0lucose
68 mg>d9 47.8 mmol>95
0&erum total protein is +. g>d9 4+ g>95 and serum lactate dehydrogenase is * F>9. ram stain shows no organisms and culture is pending.
hich of the following is the most appropriate net step in management/ 0A-Chest C( scan 0B-"le3ible bronchoscopy 0C-leural biopsy 0D-#epeat chest radiograph a)ter a -day course o) azithromycin
Answer and Critique 16 (Correct Answer: C) Educational Objective: Evaluate a tuberculous pleural effusion. Key Point 0 A patient with tuberculous pleural effusion typically presents with a lymphocyte-predominant eudative effusion; however, within the first * to 2 wee!s, neutrophils can predominate as the cellular response evolves from neutrophils to lymphocytes. 0$he patient li!ely has a tuberculous pleural effusion based on the subacute 47-wee!5 duration of symptoms and the characteristics of the pleural effusion. @ecause of the patientEs age and the presentation with an isolated pleural effusion, primary tuberculosis is most li!ely. A tuberculous effusion is typically eudative by both protein 4pleural fluid to serum protein ratio greater than ."5 and lactate dehydrogenase 49BH5 criteria 4pleural fluid to serum 9BH ratio greater than .6 and pleural fluid to serum upper limits of normal 9BH ratio greater than .6+5. $he cellular response in the pleural fluid is classically lymphocytic 4greater than 8 mature lymphocytes5. However, it can be neutrophilic within the first 2 wee!s, after which it typically evolves into the classic lymphocyte-predominant eudate. hereas pleural fluid cultures for Mycobacterium are positive in less than one third of cases, the combination of pleural biopsy for histologic evaluation and culture is typically positive in more than two thirds of cases. 0$he 7-wee! history of symptoms is too long for a typical bacterial pneumonia, no definite infiltrate was present on the chest radiograph, and the cellular response in the pleural fluid was primarily lymphocytic rather than neutrophilic. $herefore, a bacterial pneumonia with a parapneumonic effusion is unli!ely, and an empiric course of azithromycin would not be appropriate. %hest %$ scan might be helpful to assess whether there is an underlying parenchymal infiltrate that was not visible on plain chest radiograph, but it would not help in determining the underlying cause of the pleural effusion. 'leible bronchoscopy, with collection of samples for histology and culture, is useful for diagnosing pulmonary tuberculosis in the setting of pulmonary parenchymal disease. However, the yield from culture of bronchopulmonary secretions 4obtained either as sputum or bronchoscopic samples5 is low, especially in the absence of pulmonary parenchymal abnormalities on chest radiograph.
Question 17 A 28-year-old man is eva luated in the emergency department for a 2-day history of worsening dyspnea a nd wheezing in con1unction with an up per respiratory tract infection. $he patient has a history of asthma, and his medications are inhaled mometasone and albuterol. 3n the emergency department, the patient is anious and is using accessory muscles to breathe; he cannot spea! in full sentences. $he oygen saturation is ? while he is breathing ambient air. @reath sounds are reduced bilaterally, with faint diffuse epiratory wheezes. He is given albuterol by nebulizer, and use of accessory muscles is reduced. @edside spirometry shows an '() * of 7" of predicted; he is given two more treatments of nebulized albuterol. After treatmen t, the patient is alert with slight use of a ccessory muscles; he can spea! in sho rt full sentences. )ital signs are stable; oygen saturation is ?8 with the patient receiving oygen, 2 9>min. @reath sounds are louder than on initial eamination, and wheezing is more intense. &pirometry shows an '() * of " of predicted.
hich of the following is the most appropriate net step in the management of this patient/ 0A-Admit the patient to a regular medicine ward 0B-Discharge the patient on his baseline asthma treatment regimen 0C-Intubate and admit the patient to the intensi!e care unit 0D-4onitor the patient in the intensi!e care unit
Answer and Critique 17 (Correct Answer: A) Educational Objective: Manage a patient with an exacer bation of asthma. Key Point 0$he response to inhaled bronchodilators is more predictive of the clinical course in a patient with asthma than initial physical eamination and findings. 0$his patient presented with signs of a severe asthma eacerbation. Becreased breath sounds, accessory muscle use, sternocleidomastoid or suprasternal retractions, inability to spea! in full sentences, and paradoical pulse greater than *" mm Hg are associated with severe airflow obstruction, although the absence of these findings does not necessarily eclude the presence of a high-ris! eacerbation. However, the initial physical eamination and findings are less predictive of the clinical course in a patient with asthma than the response to bronchodilators. $his patient has responded well to bronchodilators, with improved ability to spea! and reduced accessory muscle use. heezing may become more prominent in the early stages of recovery owing to improved airflow through narrowed airways. According to the newest Cational Asthma (ducation and Drevention DrogramEs guidelines, admission to the intensive care unit is recommended for symptomatic patients with even mild carbon dioide retention 4D%#2 greater than =2 mm Hg5 or severely decreased lung function despite aggressive bronchodilator treatment 4persistent '()* or pea! epiratory flow less than = of predicted5. $his patient does not meet the criteria for admission to the intensive care unit or intubation and mechanical ventilation at this time. $he best disposition for this patient would be admission to the hospital ward; his '()* has not improved enough to warrant discharge.
Question 18 A 6"-year-old man is admitted to the intensive care unit for gram-negative sepsis. $he patientEs medical history is significant only for hyperthyroidism for which he ta!es methimazole. #n day 2 in the intensive care unit, he undergoes rapid seuence intubation with propofol and succinylcholine for worsening hypoemic respiratory failure resulting from the acute respiratory distress syndrome. $he patient receives intermittent lorazepam and fentanyl boluses intravenously for sedation. &everal hours later, the patient becomes febrile 4temperature = J% Q*= J'R5, hypertensive, and tachycardic. #n eamination, he is diaphore tic and has muscular rigidity. Arterial blood gas analysis shows a metabolic and respiratory acidosis, and laboratory results are significant for an elevated serum creatine !inase level.
hich of the following is the most li!ely cause of the patientEs clinical deterioration/ 0A-4alignant hyperthermia 0B-,euroleptic malignant syndrome 0C-$erotonin syndrome 0D-(hyroid storm
Answer and Critique 18 (Correct Answer: A) Educational Objective:Diagnose malignant hyperthermia. Key Point 0
Question 19 A 2=-year-old woman with persistent asthma, which is well controlled on low-dose fluticasone and albuterol as needed, became pregnant 2 months ago and as!s for advice about asthma therapy during her pregnancy. @efore she started fluticasone therapy, she had freuent asthma symptoms and occasional eacerbations reuiring emergency department treatment. &ince she became pregnant, her asthma has remained under good control. $he physical eamination is unremar!able, and spirometry is normal.
hich of the following is the most appropriate management for this patient/ 0A-Continue the current regimen 0B-$top )luticasone add theophylline 0C-$top )luticasone add salmeterol 0D-$top )luticasone add inhaled cromolyn
Answer and Critique 19 (Correct Answer: A) Educational Objective: Manage asthma during pregnancy. Key Point 0%linical eperience has shown that inhaled corticosteroids are safe and effective in pregnant patients with asthma. 0 Asthma during pregnancy follows the rule of thirds the cond ition improves in one third of patien ts, worsens in one third, and remains unchanged in one third. Fncontrolled asthma has significantly worse impact on pregnancy outcome than the potential ris! of medications during pregnancy. &hort-acting :-agonists are regarded as safe during pregnancy. @udesonide has been studied in pregnancy and been shown to be safe. $here are fewer data on other inhaled corticosteroids, such as fluticasone, which is a F.&. 'ood and Brug Administration pregnancy ris! category % drug 4studies of safety in pregnancy are lac!ing but the poten tial benefit of the drug may 1ustify the potential ris!5. $he inhaled corticosteroids are, however, believed from clinical eperience to be safe during pregnancy, and, therefore, it is generally recommended to !eep the patient on the regimen that has been effective for control of asthma. 0$heophylline and aminophylline are pregnancy ris! category % drugs also, but etensive clinical eperience suggests that they are safe during pregnancy. However, the metabolism of t hese agents may be altered in pregnan cy, reuiring increased drug level monitoring. Also, inhaled corticosteroids are as effective as th eophylline with fewer side effects in pregnant patients. %romolyn is also considered safe in pregnancy but no safer than inhaled corticosteroids and less effective in persistent asthma. $he Cational Asthma (ducation and Drevention Drogram 4CA(DD5 epert panel guidelines in 2+ affirmed the recommendation of adding long-acting :-agonists to patients whose asthma is not controlled with an inhaled corticosteroid but advised against using long-acting :-agonists as a single controller therapy. $here is no need to add a long-acting :-agonist to this patientEs asthma regimen because her symptoms are well controlled and substituting the long-acting :-agonist for inhaled fluticasone may result in loss of symptom control and possible increased ris! of asthmarelated death.
Question 20 A 6=-year-old woman is eval uated for a 6-wee! history of dyspnea, d ry cough, fever, chills, night sweats, a nd fatigue, which have not responded to treatment with azithromycin and levofloacin; she has lost 2.2 !g 4" lb5 during that time. $he patient had a thorough eamination 6 months ago while she was asymptomatic that included routine laboratory studies, age- and se-appropriate cancer screening, and a chest radiograph; all results were normal. $he patient has never smo!ed, has had no !nown environmental eposures, and has not traveled recently or been eposed to anyone with a similar illness. Her only medications are aspirin and a multivitamin. #n physical eamination, temperature is 7+.8 J% 4*. J'5; other vital signs are normal. %ardiac eamination is normal. $here are scattered crac!les in the mid-lung zones with associated rare epiratory wheezes. $here is no digital clubbing.
hich of the following is the most li!ely diagnosis/ 0 A-Cryptogenic organizing pneumonia 0B-Idiopathic pulmonary )ibrosis 0C-Lymphocytic interstitial pneumonia 0D-,onspeci)ic interstitial pneumonia
Answer and C Critique ritique 20 (Correct Answer: A) Educational Objective: Diagnose cryptogenic organi&ing pneumonia. Key Point 0%ryptogenic organizing organizing pneumonia most often presents with subacute disease progression and bilateral opacities on chest radiograph. 0$his nonsmo!er without any eposure history has acute to s ubacute development of nonspecific systemic and r espiratory symptoms with a dominant alveolar 4opacification5 process on chest radiograph. $he tempo of the disease process is the !ey to differentiating cryptogenic cryptogenic organizing pneumonia 4%#D5 from other i nterstitial lung diseases. %#D 4formerly called idiopathic bronchiolitis obliterans organizing pneumonia5 pneumonia5 is often acute or subacute, with symptom onset occurring within 2 months of presentation in three fourths of patients. $he presentation is so suggestive of an acute or subacute lower respiratory tract infection that patients have almost always been treated with and failed to respond to one or more courses of antibiotics before diagnosis. 03diopathic pulmonary fibrosis 43D'5, nonspecific i nterstitial pneumonia 4C&3D5, or lymphocytic interstitial pneumonia 493D5 typically follows a prolonged course with evidence of respiratory symptoms and radiographic findings that progress slowly over months or years. adiographic findings in %#D are also distinct from those in 3D', C&3D, and 93D. A dominant alveolar opacification process is typically present in patients with %#D %#D.. $he opacities are almost always bilateral with varied distribution. #ne of the !ey radiographic features of %#D is the tendency for %#D opacities to NmigrateO or involve different areas of the lung on serial eaminations. Although the radiographic findings of 3D', C&3D, C&3D, and 93D are varied, they all have a dominant interstitial 4 reticular5 pattern with or w ithout opacities. 93D 4which is very rare5 is one of the few interstitial lung diseases that can present with cystic changes on high-resolution %$.
Question 21 A 7"-year-old woman is evalua ted in the hospital hos pital for chest ches t pain and dyspnea dyspn ea * day after vaginal vagi nal delivery of her second child. &he had an uncomplicated pregnancy but a prolonged labor. #n physical eamination, the temperature is 7+. J% 4?8.6 J'5, the blood pressure is *>6 mm Hg, the pulse rate is **">min, and the respiration rate is 22>min. $he lungs are clear, heart sounds are normal, and there is no evidence of bleeding on pelvic eamination. %omplete blood count on admission revealed a h ematocrit of 7= and a platelet count of *",>K9 4*" M *?>95. %hest radiograph is normal. )e )entilation>pe ntilation>perfusion rfusion scan shows mismatched perfusion defects in 2 of her lung volume.
hich of the following would be an acceptable therapy for this patient/ 0A-n)erior !ena ca!a )ilter 0@@-Intra!enous Intra!enous argatroban 0C-Intra!enous low-molecular-weight heparin 0D-$ubcutaneous un)ractionated heparin
Answer and C Critique ritique 21 (Correct Answer: D) Educational Objective: 'reat stable acute pulmonary embolism. Key Point 0 Acute Acute pulm onary embolism can be treated initially with subcutaneous unfrac tionated heparin, low-m olecular-weight heparins, or fondaparinu without the need for dosage ad1ustment. 0$his patient has had an acute pulmonary embolism * day post partum. $he patient has no evidence of active bleeding, and there is no increased ris! for bleeding from anticoagulation. &ubcutaneous administration of unfractionated heparin, low-molecular-weight heparins, and fondaparinu are all safe and effective for the treatment of acute pulmonary embolism. A recent clinical trial showed that high-dose subcutaneous unfractionated heparin, administered without dose ad1ustment guided by the activated partial thromboplastin time, was as safe and effective as low-molecular-weight heparin administered in the same fashion. 03ntravenous argatroban, a direct thrombin inhibitor, might be useful in the setting of heparin-induced thrombocytopenia. However, the patientEs platelet count is normal.
Question 22 A 6-year-old man is evaluated during routine follow-up in Covember. $he patient has severe chronic obstructive pulmonary disease, with dyspnea on minim al eertion and a chronic cough. He has a =-pac!-year history of cigarette smo!ing, but he uit smo!ing 7 years ago. His medications are albuterol as needed, inhaled corticosteroids, and tiotropium. #n physical eamination, the patient is afebrile, blood pressure is *=>88 mm Hg, pulse rate is ?>min, and respiration rate is 2>min. # ygen saturation with the patient at rest and breathing am bient air is 86. Pugular venous distention and a loud D 2 are present. $he chest is hyperinflated and breath sounds are dim inished. $here is *L pedal edema. Hemoglobin concentration is *6." g>d9 4*6" g>95. Arterial blood gases show pH +.7", D%# 2 "" mm Hg, and D# 2 "" mm Hg on ambient air. &pirometry shows an '() * of 2" of predicted. %hest radiograph shows hyperinflation but no infiltrates.
hich of the following is the most appropriate therapy for this patient/ 0A-Continuous o3ygen 0B-,octurnal o3ygen 0C-3ygen as needed 0D-3ygen during e3ercise
Answer and Critique 22 (Correct Answer: A) Educational Objective:%ecogni&e indications for continuous oxygen therapy in patients with chronic obstructive pulmonary disease. Key Point 03n a patient with severe chronic obstructive pulmonary disease, at-rest oygen saturation less than or eual to 88 is an indication for long-term continuous oygen therapy. 0$he long-term administration of oygen for more than *" hours per day to patients with chronic obstructive pulmonary disease 4%#DB5 increases survival, and may also improve hemodynamics, hematologic characteristics, eercise capacity, lung mechanics, and mental status. 3ndications for continuous long-term oygen therapy for patients with %#DB include 0D#2 less than or eual to "" mm Hg or oygen saturation less than or eual to 88 0Do2 less than or eual to "? mm Hg or oygen saturation less than or eual to 8? if there is evidence of cor pulmonale, right heart failure, or erythrocytosis 4hematocrit greater than ""5. 0$his patientEs resting oygen saturation is 86 and his D# 2 is "" mm Hg, and, therefore, continuous long-term oygen therapy is indicated. 0%hronic hypoemia leading to the development of cor pulmonale portends a poor prognosis. Cocturnal oygen therapy is better than no oygen therapy at all, but continuous therapy is better than nocturnal therapy in severely hypoemic patients with erythrocytosis, elevated pulmonary artery pressures, and respiratory acidosis. Co study has shown a survival benefit when oygen is prescribed for eercise-induced oygen desaturation or when used as needed for symptoms of breathlessness.
Question 23 A 27-year-old man see!s medical advice for an upcoming mountain epedition. A year earlier, a planned ="-day tre! to 9hotse in Cepal 4elevation 8"*6 m Q2+,?= ftR5 was cut short when he developed severe dyspnea and cough productive of blood-tinged, frothy sputum shortly after leaving the base camp 4elevation =?7 m Q*6,*+= ftR5. hen his symptoms persisted despite oygen therapy, he was aided down the mountain. He plans to return to the high Himalayas for another attempt to climb the 9hotse summit.
hich of the following would be appropriate prophylais for this patient/ 0A-Acetazolamide 0B-De3amethasone 0C-8ydrochlorothiazide 0D-4etoprolol 0E-,i)edipine
Answer and Critique 23 (Correct Answer: E) Educational Objective: %ecogni&e prophylaxis for high-altitude pulmonary edema. Key Point 0Cifedipine is used both to prevent and to treat high-altitude pulmonary edema. 0@oth the occurrence and severity of respiratory symptoms at high altitude are affected by the degree of elevation, rapidity of ascent, altitude during sleep, comorbid cardiovascular and respiratory disorders, physical eertion at altitude, and individual variations in tolerance to altitude 4for eample, altitude illness is more common in those with inadeuate hypoic ventilatory drive, prior history of altitude illness, and residence below an altitude of ?*" m Q7 ftR5. 0High-altitude pulmonary edema 4HAD(5 is a form of noncardiogenic pulmonary edema due to lea!age of fluid and hemorrhage into the alveolar spaces. $he most effective preventive measure for HAD( is an appropriately gradual ascent to altitude 4not greater than 7 to " m Q?8= to *6= ftR daily above an altitude of 2 m Q6"62 ftR, with scheduled rest days every 7 or = days5. Cifedipine is used to prevent and to treat HAD(. 0 Acetazolamide is used as prophylais for periodic breathing related to high altitude and acute m ountain sic!ness 4A<&5 but is not indicated for HAD(. Beamethasone is used for the prevention and treatment of A<&; it is not generally considered as a prophylactic agent for HAD(. Biuretics have been used for HAD(, but their role is not clearly established and there is no compelling evidence for their use. :-@loc!ers are not indicated for either the prevention or treatment of HAD(. #ther agents that might be potentially useful for preventing HAD( include the phosphodiesterase inhibitors tadalafil and sildenafil, as well as salmeterol, but additional studies are reuired to ascertain their precise role for this indication.
Question 24 A =-year-old man is evaluated for shortness of breath and left-sided chest discomfort without cough, fever, or hemoptysis. He had a contusion to the left side of his chest and bac! * wee! ago in an automobile accident. %hest radiograph immediately after the accident showed no fracture of the spine or ribs, but he had severe contusions on his bac! and on the left side of the chest. $he patient has a history of lymphoma. (amination of the chest shows dullness to percussion and decreased breath sounds on the left side. %hest radiograph shows a moderate-sized, left-sided pleural effusion without a pneumothora. &erum protein is ".8 g>d9 4"8 g>95, cholesterol 2 mg>d9 4".2 mmol>95, and triglycerides * mg>d9 4*.*7 mmol>95. $horacentesis yields " m9 of pleural fluid, and analysis shows 0%ell count (rythrocytes 7>K9; leu!ocytes 8?>K9 4.8? M *?>95 with 6" lymphocytes, 22 neutrophils, 8 mesothelial cells, and = eosinophils 0$otal protein
7." g>d9 47" g>95
09actate dehydrogenase 2" F>9 0Dh +." 0 Amylase 2" F>9 0$riglycerides
*=" mg>d9 4*.6 mmol>95
0%holesterol
78 mg>d9 4.?8 mmol>95
0%ytology, ram stain, acid-fast bacilli stain, and bacterial culture are negative.
hich of the following is the most li!ely diagnosis/ 0A-Chylothora3 0B-Lymphomatous pleural e))usion 0C-arapneumonic e))usion 0D-(uberculous pleural e))usion
Answer and Critique 24 (Correct Answer: A) Educational Objective:Diagnose chylothorax. Key Point 0$he most common causes of chylothora are cancer and trauma; other causes are pulmonary tuberculosis, chronic mediastinal infections, sarcoidosis, lymphangioleiomyomatosis, and radiation fibrosis. 0%hylothora is drainage of lymphatic fluid into the pleural space secondary to disruption or bloc!age of the thoracic duct or one of its lymphatic tributaries. d9 4*.2= mmol>95 and occurs in association with a low pleural fluid cholesterol concentration. 3f the triglyceride level is less than " mg>d9 4."6 mmol>95, chylothora is unli!ely. hen the pleural fluid triglyceride concentration is between " and ** mg>d9 4."6 and *.2= mmol>95, a lipoprotein analysis should be done and the presence of chylomicrons would confirm the diagnosis in such cases. 0%hylothora can also occur in association with pulmonary tuberculosis and chronic mediastinal infections, sarcoidosis, lymphangioleiomyomatosis, and radiation fibrosis. 0 A lymphomatous pleural eff usion is always a consideration in p atients with a history of lymph oma; however, a lymphomat ous pleural effusion typically has an elevated lactate dehydrogenase level 4often greater than * F>95. Darapneumonic effusion is usually associated with a neutrophilic pleocytosis. Datients with tuberculous pleural effusion usually present with a nonproductive cough, chest pain, and fever. %hest radiograph usually shows a small to moderate effusion.
Question 25 A "6-year-old woman is evaluated for a 2-month history of a drooping eyelid, difficulty chewing food and swallowing, and slurred speech. $he symptoms are worse when she is tired. $he patient has a *"-pac!-year history of cigarette smo!ing but uit smo!ing * years ago. &he is otherwise healthy and ta!es no medications. #n physical eamination, the temperature is 7+. J% 4?8.6 J'5, the blood pressure is **8>6 mm Hg, the pulse rate is +2>min, the respiration rate is *6>min, and the @<3 is 2 =.". $here is right-sided ptosis; pupils are eual in size and reactive, and eye movements are normal. @rief neurologic eamination is normal, and there is no lymphadenopathy. outine laboratory studies are normal; acetylcholine receptor binding antibody level is =6.8 nmol>9 4normal range, less than .2 nm ol>95. %hest radiograph shows a 7-cm anterior-superior mediastinal mass. %$ scan of the chest is shown .
hich of the following is the most li!ely diagnosis/ 0A-Esophageal leiomyoma 0B-,eurolemmoma 0C-$arcoidosis 0D-$mall cell lung cancer 0E-(hymoma
Answer and Critique 25 (Correct Answer: E) Educational Objective: Diagnose thymoma. Key Point 0$hymomas may be associated with a paraneoplastic syndrome such as myasthenia gravis. 0Fp to +" of patients with myasthenia gravis have thymic abnormalities, such as hyperplasia or tumor. $herefore, evaluation of patients with suspected myasthenia gravis should include %$ scan of the chest. $he %$ image shows an anterior mediastinal mass, and the diagnosis of myasthenia gravis is supported by the findings of ptosis and the elevated acetylcholine receptor binding antibody 4A%h-Ab5.
Question 26 A "?-year-old man is evaluated for tachycardia and hypertension 6 hours after undergoing an uncomplicated open cholecystectomy under general anesthesia. $he patient had intraoperative high blood pressure and was treated postoperatively with metoprolol, " mg every = hours by intravenous bolus. $he patient underwent repair of a laceration of the liver " years ago and had an uncomplicated intraoperative and postoperative course. He has a history of essential hypertension, and his medications are hydrochlorothiazide and metoprolol. #n physical eamination, the temperature is 7?.2 J% 4*2." J'5, the blood pressure is *?>** mm Hg, and the pulse rate is **">min. $here is significant rigidity of all his etremities.
hich of the following is the most appropriate therapy for this patient/ 0A-Alcohol sponge baths 0B-Ampicillin-sulbactam 0C-Corticosteroids 0D-Dantrolene 0E-$odium nitroprusside
Answer and Critique 26 (Correct Answer: D) Educational Objective:%ecogni&e and treat malignant hyperthermia. Key Point 0!g intravenously and then 2 mg>!g every " to * minutes until the symptoms resolve. esponse to dantrolene is not diagnostic of the disorder but is supportive if signs and symptoms resolve uic!ly. 'or those patients with a !nown history, pretreatment with dantrolene before the anesthetic agent is administered prevents the dev elopment of symptoms. 0 Alcohol sponge baths are generally not recommended as an augmentation of evaporative cooling in any hyperthermic patient, including malignant hyperthermia, owing to the possibility of substantial alcohol absorption through the s!in. 'urthermore, augmented coo ling 4typically accomplished with water misting and forced air circulation by fans5 may result in shivering which can increase body temperature unless it is s uppressed with benzodiazepine administration. Ampicillin-sulbactam might be a consideration if acute ascending cho langitis were suspected; however, this is unli!ely only hours after an elective cholecystectomy. 'urthermore, an infection cannot account for the patientEs muscular rigidity. %orticosteroids would be effective treatment f or an allergic reaction, but there are no symptoms suggesting an allergic reaction such as rash, urticaria, angioedema, or wheezing. &odium nitroprusside is indicated in patients with hypertensive emergencies. However, this patientEs blood pressure is elevated secondary to malignant hyperthermia, and treatment of the underlying disorder is the preferred therapy.
Question 27 A "6-year-old woman is evaluated for a 2-year history of episodic cough and chest tightness. Her symptoms began after a severe respiratory tract infection. &ince then, she has had cough and chest discomfort after similar infections, typically lasting several wee!s before resolving. &he feels well between episodes. &he is otherwise healthy and t a!es no medications. Dhysical eamination reveals no abnormalities, and spirometry is normal.
hich of the following is the most appropriate net step in the evaluation of this patient/ 0A-Bronchoscopy 0@-C( scan o) the sinuses 0C-E3ercise echocardiography 0D-4ethacholine challenge testing
Answer and Critique 27 (Correct Answer: D) Educational Objective:%ecogni&e indications for methacholine challenge testing in cases of suspected asthma. Key Point 0m9 is consistent with asthma. A D% 2 between = and *6 mg>m9 suggests some bronchial hyperreactivity and is less specific for asthma. A D% 2 above *6 mg>m9 is considered normal. $he sensitivity of a positive methacholine challenge test in asthma is in the range of 8" to ?". 'alse-positive results can occur in patients with allergic rhinitis, chronic obstructive pulmonary disease, heart failure, cystic fibrosis, or bronchitis. 0@ronchoscopy to evaluate the trachea could be helpful if an anatomic lesion is suspected. However, the symptoms in patients with such lesions are persistent or progressive rather than intermittent. &ince this patient has intermittent symptoms, bronchoscopy is not indicated. (ercise echocardiography could help determine the presence of cardiac ischemia or myocardial dysfunction, the typical symptoms of which are dyspnea on eertion, chest tightness, or pain. %ough and wheezing can occur in coronary artery disease, particularly when associated with acute decompensation of the left ventricle, but this patientEs intermittent episodes of cough and wheezing are provo!ed by an upper respiratory tract infection, ma!ing the diagnosis of coronary artery disease unli!ely. Datients with rhinosinusitis have symptoms consisting of nasal congestion, purulent nasal secretions, sinus tenderness, and facial pain. adiography, including sinus %$ scan, is not indicated in the initial evaluation of acute sinusitis.
Question 28 A ""-year-old man with a +-year history of severe chronic obstructive pulm onary disease is evaluated after being discharged from the hospital following an acute eacerbation; he has had three eacerbations over the previous *8 months. He is a long-term smo!er who stopped smo!ing * year ago. He adheres to therapy with albuterol as needed and inhaled salmeterol and tiotropium and has demonstrated proper inhaler techniue. #n physical eamination, vital signs are normal. @reath sounds are decreased bilaterally; there is no edema or cyanosis. #ygen saturation after eertion is ?2 on ambient air. &pirometry shows an '()* of 72 of predicted and an '() *>')% ratio of =. %hest radiograph done in the hospital 7 wee!s ago showed no active disease.
hich of the following should be added to this patientEs therapeutic regimen/ 0A-An inhaled corticosteroid 0B-Ipratropium 0C-N -acetylcysteine 0D-ral prednisone
Answer and Critique 28 (Correct Answer: A) Educational Objective: %ecogni&e the role of inhaled corticosteroids i n severe chronic obstructive pulmonary disease. Key Point 03nhaled corticosteroids may offer significant benefit in patients with severe chronic obstructive pulmonary disease, with the benefit generally greater when an inhaled corticosteroid is com bined with a long-acting : 2-agonist. 0egular use of inhaled corticosteroids in patients with chronic obstructive pulmonary disease 4%#DB5 is associated with a reduction in the rate of eacerbations from *.7 to .? per year, and patients who have freuent eacerbations with more severe %#DB benefit most. 3n si placebo-controlled trials in *+=* patients over 6 months, inhaled corticosteroids reduced eacerbations by 2=. $herefore, the #9B guidelines recommend consideration of inhaled corticosteroids i n patients whose lung function is less than " and those who have eacerbations. hen inhaled corticosteroids are combined with a long-acting : 2-agonist, the rate of decline in uality of life and health status is significantly reduced and acute eacerbations are reduced by 2"; lung function is also improved and dyspnea is alleviated. $here does not appear to be a dose response to inhaled corticosteroids in %#DB, and the effects of combination therapy on mortality are uncertain. 0 Anticholinergic agents in %#DB are especially useful when combined with short-acting or long-acting : 2-agonists. $iotropium is effective in patients with stable %#DB for up to 2= hours and should not be combined with short-acting anticholinergic agents, such as ipratropium.
Question 29 A "=-year-old woman is evaluated after a *."-cm nodule was detected in the right lower lobe of the lung on a chest radiograph done to evaluate new-onset dyspnea on eertion. $he nodule was not present on a chest radiograph done 8 years ago. $he patient lives in +2 mm Hg, the pulse rate is 6=>min, and the respiration rate is *=>min. $he lungs are clear, the s!in is normal, and there is no lymphadenopathy. Dulmonary function testing shows mild airway obstruction and no acute r esponse to a bronchodilator. %ontrastenhanced %$ scan of the chest shows the nodule to be uncalcified on thin-section images, and there was no significant enhancement 4* Hounsfield units5 on dynamic contrast study.)istoplasma serology is negative.
hich of the following is the most appropriate management for this patient/ 0A-Bronchoscopy and biopsy o) the lesion 0B-C(-guided transthoracic biopsy o) th e lesion 0C-#epeat C( scan in ' months 0D-5ideo-assisted thoracoscopic surgery to remo!e the nodule 0E-,o )urther e!aluation
Answer and Critique 29 (Correct Answer: C) Educational Objective:Manage a pulmonary nodule that is negative on #' enhancement s tudy. Key Point 0 A nodule that is nonenhancing on dynamic %$ contrast study is li!ely benign, and observation is appropriate. 0$he attenuation coefficient of a pulmonary nodule is a m easure of its density and is epressed in Hounsfield units. (nhancement after contrast reflects nodule vascularity and is an indicator of malignancy or active inflammation. A nodule that shows less than *" Hounsfield units of enhancement on dynamic contrast study is h ighly li!ely to be benign; a multicenter study showed a ?+ negative predictive value at a cutoff of *" Hounsfield units. 0eevaluation of the nodule at 7 months would be appropriate given the low li!elihood that this is a malignant nodule. 3mmediate evaluation with biopsy or surgical removal can be avoided because of the low li!elihood that this is a malignant nodule. 9ac! of enhancement is not the same as a tissue diagnosis, and follow-up is appropriate whether or not the patient has ris! factors for lung cancer.
Question 30 A previously healthy 62-year-old man w as intubated 7 days ag o for the acute resp iratory distress syndrom e complicating communityacuired pneumonia. His condition improved with antibiotic therapy and supportive care. He was etubated 2 hours ago after tolerating a trial of spontaneous breathing, but he has subseuently developed respiratory distress. $he patient is alert, cooperative, and spea!ing in short sentences. $he temperature is 76.? J% 4?8.= J'5, blood pressure is *">? mm Hg, pulse rate is **>min, and respiration rate is 7=>min. #ygen saturation is 86 on 'i# 2 .+ by face mas!. $here are inspiratory crac!les bilaterally, and the patient is using nec! and abdominal muscles to breathe. %ardiac eamination reveals regular tachycardia without etra sounds or murmurs; the 1ugular venous pressure could not be assessed because of the patientEs respiratory effort. Arterial blood gases at the end of the brea thing trial on 'i#2 .= included pH +.78, D%# 2 7" mm Hg, and D#2 68 mm Hg. His current blood gases following etubation on 'i# 2 .+ are pH +.7, D%#2 =" mm Hg, and D#2 "6 mm Hg. %hest radiograph after etubation shows reduced lung volumes but otherwise no change in bilateral alveolar infiltrates from his previous radiograph.
hich of the following is the most appropriate management for this patient/ 0A-Administer intra!enous )urosemide 0B-Administer intra!enous nalo3one 0C-Increase "i% to +9; 0D-#eintubate and resume mechanical !entilation 0E-$tart nonin!asi!e positi!e-pressure !entilation
Answer and Critique 30 (Correct Answer: D) Educational Objective:Manage a patient on mechanical ventilation who fails a trial of extubation. Key Point 0Coninvasive positive-pressure ventilation is potentially harmful in patients with hypoemic respiratory failure who are failing a trial of etubation. 0$his patient has acute hypoemic ventilatory failure and should be electively reintubated. $he respiratory eamination, large supplemental oygen needs, and rising D%# 2 suggest that he is at high ris! for respiratory arrest. $he most li!ely eplanation for his failing a trial of etubation is insufficient recovery from his initial lung in1ury. esidual elevated dead space and poor lung compliance, coupled with loss of positive end-epiratory pressure after etubation, account for his deterioration in gas echange. 0'urosemide would not be indicated because there is little to suggest new-onset heart failure. 3ncreasing supplemental oygen is unli!ely to reduce the patientEs wor! of breathing or reverse the upward trend in Dco 2. &hunt is the primary cause of hypoemia in patients with the acute respiratory distress syndrome 4AB&5, and placing the patient on * oygen will li!ely only modestly improve hypoemia. 0Coninvasive positive-pressure ventilation 4CDD)5 may prevent postetubation respiratory failure if initiated immediately after etubation. ecent randomized studies have found no benefit, or even increased mortality, with the use of CDD) for patients failing a trial of etubation. Also, routine use of CDD) in patients with AB& is not recommended. 0$he patient is alert and ma!ing vigorous respiratory efforts. $herefore, respiratory failure is unli!ely to be the result of ecessive sedation, and a trial of naloone is unli!ely to be efficacious.
Question 31 A "2-year-old man is evaluated for a +-month history of progressive dyspnea, initially with vigorous eertion; now, even wal!ing slowly causes immediate severe dyspnea and dizziness. $he symptoms subside when he is at rest. He has had two syncopal episodes, both while he was wal!ing at a bris! pace. He does not have cough, chest pain, or wheezing. He has no other significant medical history and ta!es no medications. #n physical eamination, the temperature is 7+. J% 4?8.6 J'5, the blood pressure is *">6 mm Hg, the pulse rate is *2>min at rest and *2>min after the patient wal!s across the room, the respiration rate is 2>min, and the @<3 is 72. 9ung epansion is normal during deep breathing. Pugular venous distention is present. 9ungs are clear to auscultation with no wheezes or crac!les. $here is fied splitting of & 2 with an increased pulmonic component. $here is a grade *-2>6 holosystolic murmur at the left sternal border near the fourth rib that increases with inspiration. $he lower etremities are edematous. $here is no cyanosis or clubbing. %omplete blood count and resting arterial blood gases are normal. (lectrocardiography shows a rightward S& ais and large waves in ) *. &pirometry and plethysmography are normal. $he chest radiograph shows no infiltrates or masses.
hich of the following is the best net step in the evaluation of this patient/ 0A-Bronchoscopy and transbronchial lung biopsy 0B-4ethacholine challenge test 0C-#ight-heart catheterization and pulmonary angiography 0D-(ransthoracic echocardiography
Answer and Critique 31 (Correct Answer: D) Educational Objective:Evaluate pulmonary hypertension. Key Point 03n patients with suspected pulmonary hypertension, transthoracic echocardiography can suggest the presence of pulmonary hypertension and evaluate cardiac causes of elevated pulmonary artery pressure. 0$he patientEs progressive dyspnea, hemodynamic symptoms during eercise, and physical findings suggest right ventricular dysfunction and pulmonary hypertension. $ransthoracic echocardiography can confirm the presence of pulmonary hypertension and right ventricular dysfunction. (chocardiography is also useful to rule out left-sided heart disease and congenital heart disease as a cause of pulmonary hypertension. A ventilation>perfusion scan can also rule out potential causes. $ypically, the ventilation>perfusion scan in pulmonary arterial hypertension is either normal or shows a scattered, Nmoth-eatenO perfusion pattern in the peripheral lung zones. 0$he patient has no evidence of bronchospasm. (ercise-induced asthma is unli!ely because the symptoms begin immediately during mild eertion and subside rapidly upon rest. 'urthermore, eercise-induced bronchospasm cannot eplain the patientEs clinical findings of pulmonary hypertension. $herefore, a methacholine challenge test is not indicated. ightheart catheterization and pulmonary angiography might be necessary to confirm the diagnosis of pulmonary arterial hypertension but are not indicated before less invasive screening tests for pulmonary hypertension are done. @ronchoscopy and transbronchial lung biopsy may be indicated in patients with diffuse parenchymal lung disease, but this patientEs chest radiograph is normal, ma!ing parenchymal lung disease unli!ely.
Question 32 A 2-year-old male college student is evaluated for a 7-year history of persistent daytime sleepiness. He snores loudly but h as had no witnessed apneas or catapley. He has occasional episodes of sleep paralysis in which he cannot move for about a minute after awa!ening from sleep. He typically goes to bed at **7 D< on wee!days and at * A< on wee!ends. He falls asleep easily, sleeps uneventfully, and awa!ens at about 6 A< on wee!days and ** A
hich of the following is the most appropriate management for this patient/ 0A-rder thyroid )unction tests 0B-er)orm a multiple sleep latency test 0C-rescribe moda)inil 0D-#ecommend longer nighttime sleep 0E-#e)er )or polysomnography
Answer and Critique 32 (Correct Answer: D) Educational Objective:Manage excessive daytime sleepiness caused by insufficient sleep. Key Point 0(cessive daytime sleepiness is defined by a persistent or recurrent inability to both achieve and sustain alertness reuired to accomplish the tas!s of daily living and is most commonly secondary to insufficient sleep. 0(valuation of ecessive daytime sleepiness consists of a careful history with inuiries into sleep duration and uality, daytime conseuences of sleepiness, medical disorders, and medication or substance use. 03nadeuate sleep duration is the most common cause of ecessive daytime sleepiness and it can cause sleep paralysis. &leep paralysis is a complete inability to move for * or 2 minutes immediately after awa!ening. Although sleep paralysis is one of the clinical characteristics of narcolepsy, it can occur in other conditions, including sleep deprivation. Although the adeuate duration of sleep varies, most persons reuire about 8 hours of sleep each night. Datients with sleep deprivation generally describe a habitual sleep duration that is shorter than normal for most age-matched persons, and there may be a significant difference in nighttime sleep duration during wee!ends, with a longer NrescueO sleep. A trial of longer nighttime sleep duration is often all that is necessary to improve ecessive daytime sleepiness. 0$hyroid disease can cause central sleep apnea, which is more common in older persons and is very unli!ely in this young man. $herefore, thyroid function tests would be unli!ely to help in the management of his daytime sleepiness. &timulant agents, such as modafinil, should not be used as a substitute for getting sufficient sleep. &leep latency is the duration from getting into bed to the onset of sleep and is an ob1ective measure of sleepiness. Dolysomnography involves the measurement of several physiologic variables during sleep and is useful in the evaluation of ecessive sleepiness. Ceither polysomnography nor a multiple sleep latency test is reuired for the diagnosis of insufficient sleep syndrome.
Question 33 A 7+-year-old man with asthma is evaluated for freuent episodes of wheezing and dyspnea unrelieved by short-acting :-agonist therapy. He uses his controller medications regularly, including an inhaled long-acting :-agonist and inhaled high-dose corticosteroids. He has symptoms daily and freuent nocturnal symptoms. #n physical eamination, the patient is in mild respiratory distress. $he temperature is 7+. J% 4?8.6 J'5, blood pressure is *=>8" mm Hg, pulse rate is ?>min, and respiration rate is *8>min. He has bilateral wheezing. &pirometry shows an '() * of 6" of predicted. After the supervised use of a bronchodilator in the office, there was some relief of symptoms, and repeat spirometry * minutes after the administration of the bronchodilator showed that the '() *increased to 8" of predicted.
hich of the following is the appropriate net step in this patientEs management/ 0A-Add a leu&otriene modi)ying drug 0B-8a!e the patient demonstrate his inhaler techni2ue 0C-8a!e the patient &eep a symptom and treatment log 0D-$tart oral prednisone therapy
Answer and Critique 33 (Correct Answer: B) Educational Objective:%ecogni&e poor inhaler techni!ue as a possible cause of medication failure in asthma. Key Point 0Door inhaler techniue is a ma1or reason why patients with asthma do not respond well to specific asthma therapy. 0$he best initial management approach for this patient is to have him demonstrate his inhaler techniue. Datient education is a !ey component in asthma care. &tudies have shown that patient education by the physician decreases the number of visits to the emergency department and improves asthma control. 3mproper techniue in the use of inhalers is a ma1or reason that patients do not respond well to medications. A clue suggesting poor inhaler techniue includes the patientEs rapid improvement in '() * after the supervised use of a bronchodilator. Although there used to be one type of inhalation device 4the metered-dose inhaler5 with one techniue that could be taught to the patient, there are now several new and different devices with significant differences in the techniue needed for their use. Dhysicians should learn the proper techniue for use of these inhalers before prescribing them to patients in order to ensure proper techniue to optimize drug delivery and effectiveness and to reduce side effects. 0 Adding a leu!otriene modifying agent would be appropriate if the patient is effectively using the current medic ations. #ral prednisone would be appropriate for an eacerbation of poorly controlled severe persistent asthma. 3t would improve asthma control, but without proper education in the use of the inhaler, symptoms would most li!ely return when the corticosteroid dosage is tapered. 'urthermore, oral corticosteroids have increased adverse effects. &imply having the patient return with a symptom and treatment log would not be epected to identify poor inhaler techniue, although it would be helpful to assess compliance and symptom pattern.
Question 34 A *?-year-old woman is evaluated in the emergency department f or low-grade fever, muscle aches, cough, and progressively severe shortness of breath of * wee!Es duration. &he reuires intubation and mechanical ventilation. $he patient recently moved to the Fnited &tates from Papan. &he started smo!ing cigarettes 7 wee!s ago and smo!es a pac! a day. #n physical eamination, the temperature is 7+.2 J% 4??. J'5, the blood pressure is *28>6 mm Hg, the pulse rate is **>min, and the respiration rate is 22>min on mechanical ventilation. %ardiac eamination is normal. $here are bilateral crac!les posteriorly. $he rest of the general physical eamination is normal. $he hemoglobin is *=.7 g>d9 4*=7 g>95; the leu!ocyte count is *6,888>K9 4*6.? M *?>95 with "2 neutrophils, = monocytes, 2 lymphocytes, and 2= eosinophils; and the platelet count is 7=",>K9 47=" M *?>95. %hest %$ scan with intravenous contrast shows bilateral focal areas of consolidation with scattered ground-glass opacification, small bilateral pleural effusions, and no evidence of pulmonary embolism. @ronchoscopy with bronchoalveolar lavage shows no organisms on ram stain or fungal stain; cell count is elevated, and the differential shows 7 neutrophils, 6 macrophages, = lymphocytes, and 6 eosinophils. @lood and sputum cultures are negative after 2 days.
hich of the following is the most li!ely diagnosis/ 0A-Acute eosinophilic pneumonia 0B-Churg-$trauss syndrome 0C-Idiopathic acute interstitial pneumonia 0D-Mycoplasma pneumonia
Answer and Critique 34 (Correct Answer: A) Educational Objective:Diagnose acute eosinophilic pneumonia. Key Point 0 Acute eosinophilic pneumonia may present as hypoemic respiratory fa ilure after * to 2 wee!s of low-grade fever and systemic symptoms. 0$his patientEs dramatic presentation is typical of acute eosinophilic pneumonia, which must be differentiated from other causes of idiopathic acute respiratory distress syndrome. $reatment of respiratory failure due to acute eosinophilic pneumonia with intravenous corticosteroids is efficacious, with clinical improvement over *2 to 2= hours. 3f a patient does not respond to corticosteroid therapy, another diagnosis should be considered. Acute eosinophilic pneumonia is idiopathic, but it has been associated with inhaled environmental antigens. ecently, initiation of cigarette smo!ing has been lin!ed to acute eosinophilic pneumonia in a Papanese population and in military recruits. 0$his patient does not have asthma or evidence of systemic vasculitis, ma!ing %hurg-&trauss syndrome unli!ely. Acute interstitial pneumonia, which occurs over * to 7 wee!s, progresses to hypoemic respiratory failure and is associated with fever, nonproductive cough, headache, myalgia, and a flu-li!e malaise. %hest radiograph shows diffuse, bilateral air-space infiltrates. Dathologically, a pattern of organizing diffuse alveolar damage is seen. $reatment is usually supportive, with intravenous pulse corticosteroids freuently used but of unproven benefit. 3diopathic acute interstitial pneumonia is a diagnosis of eclusion and would not be appropriate for this patient with eosinophilic pneumonia. Mycoplasmapneumonia may be culture-negative and present with respiratory symptoms. However, these symptoms rarely progress to respiratory failure and would not eplain this patientEs eosinophilia.
Question 35 A =2-year-old man is evaluated in the hospital for dyspnea and pleuritic chest pain. $he patient had a fracture of the right femur 7 wee!s ago. He has hypertension, and his only medication is hydrochlorothiazide. #n physical eamination, the temperature is 78.* J% 4*.6 J'5, the pulse rate is **>min, the respiration rate is 22>min, the blood pressure is *7>+8 mm Hg, and the @<3 is 2=. outine laboratory studies are normal; serum troponins are undetectable. (lectrocardiography shows increased height of waves in leads )=-)6; the S& comple has a leftward ais. %ontrast-enhanced %$ scan s hows pulmonary emboli in the arteries perfusing the lingula and the posterior basal segment of the left lower lobe.
hich of the following is the most appropriate treatment for this patient/ 0A-In)erior !ena ca!a )ilter 0B-Intra!enous un)ractionated heparin 0C-Intra!enous tissue plasminogen acti!ator 0D-4echanical clot dissolution 0E-$urgical embolectomy
Answer and Critique 35 (Correct Answer: B) Educational Objective: 'reat pulmonary embolism. Key Point 0Fnfractionated heparin, low-molecular-weight heparin, or fondaparinu is generally sufficient initial therapy for acute pulmonary embolism. 0$he patient has an acute pulmonary embolism. 3n the absence of contraindications, the patient should be treated initially with intravenous or subcutaneous unfractionated heparin, low-molecular-weight heparin, or fondaparinu. (lectrocardiographic abnormalities are present in + of patients with pulmonary embolism. strain, most li!ely because of his essential hypertension. 0Datients with hemodynamically unstable pulmonary embolism have a high mortality rate. $he role of thrombolytic agents in pulmonary embolism is unclear. $here are no clinical trials comparing thrombolytic agents with other forms of therapy for massive pulmonary embolism, and management decisions must therefore be made by inference from studies in stable patients. $he Fro!inase in Dulmonary (mbolism $rial reported a short-term improvement in cardiac output and pulmonary pressure with thrombolytic therapy but no improvement in morbidity or mortality and increased bleeding. Acute pulmonary embolectomy is rarely warranted because medical therapy is successful, patient selection difficult, and the results of acute embolectomy unimpressive. However, if eperienced surgical intervention is possible, embolectomy may be considered for a confirmed, massive embolism that fails to respond promptly to medical therapy.
Question 36 A "?-year-old man with chronic obstructive pulmonary disease is evaluated before planned air travel from Benver, %olorado, to @ei1ing, %hina. He is physically active but has episodic wheezing and a NracingO heartbeat with eertion. His current therapy consists of inhaled bronchodilators and supplemental continuous oygen at 2 9>min. #n eamination, the pulse rate is 68>min, respiration rate is *8>min, and oygen saturation is ? with the patient breathing oygen, 2 9>min. %ardiac eamination is normal. @reath sounds are distant without wheezes or crac!les. %hest radiograph shows hyperepanded lungs but no infiltrates or bullae.
hich of the following is the most appropriate net step in this patientEs management/ 0A-Calculate o3ygen needs using a prediction algorithm 0B-rder a hypo3ia inhalation test 0C-rescribe in-)light supplemental o3ygen le!el at ' L6min 0D-#ecommend that the patient not )ly
Answer and Critique 36 (Correct Answer: B) Educational Objective:Evaluate an oxygen-dependent patient with obstructive lung disease before air travel. Key Point 0Datients who reuire continuous oygen therapy owing to chronic respiratory or cardiovascular disorders may not tolerate commercial air travel and should be assessed for the need for possible additional in-flight supplemental oygen. 0 Air travel is generally safe for patients with stabl e chronic respiratory disorders but can pos e significant hazards for those who reuire continuous oygen therapy for hypoemia. %abin air pressure for most commercial airplanes is maintained at about =" to 8 ft above sea level, but the pressure can change significantly from flight to flight and from one airplane model to another. At a cabin pressure euivalent to 8 ft above sea level, D# 2 is epected to fall, potentially leading to hypoemia and cardiac events in persons who reuire supplemental oygen for hypoemia. $herefore, using the same level of oygen supplementation used at sea level may be inappropriate for many patients. Additional supplemental oygen is recommended for patients whose predicted D#2 during flight is less than " to "" mm Hg or oygen saturation less than 8". 03n-flight D#2 can be predicted using published algorithms or determined by performing a hypoia inhalation test. Drediction algorithms may fail to identify patients who will develop significant hypoemia during air travel and, unli!e the hypoia inhalation test, cannot predict the development of cardiac events related to low oygen levels. &imply increasing the level of oygen supplementation runs the ris! of underestimating the reuired oygen demands during flight. $he hypoia inhalation test involves placing the patient in either a hypobaric chamber or having the patient breath a *" oygen miture at sea level for at least *" minutes with continuous pulse oimetry and electrocardiographic monitoring.
Question 37 A 76-year-old man is evaluated for a *-year history of progressive shortnes s of breath; his wife has noticed that he has a dry cough and wheezing when he returns from wor!. $he patient has wor!ed as an automobile painter for the past = years. He has a "-pac!-year history of cigarette smo!ing, but uit smo!ing 8 years ago. He has no history of allergic disease. 0#n physical eamination, vital signs and review of systems are normal. %hest radiograph is normal. Dulmonary function testing shows 0'()* "2 of predicted 0')% 87 of predicted 0'()*>')% ratio =+ 0B9%# 8" of predicted 0&pirometry after a bronchodilator shows 0'()* 87 of predicted 0')%
* of predicted
0'()*>')% ratio 62
hich of the following would be an appropriate net step in the evaluation of this patient/ 0A-Chest C( scan 0B-4ethacholine challenge test 0C-btaining a detailed description o) his current ob tas&s 0D-$&in testing to common aeroallergens
Answer and Critique 37 (Correct Answer: C) Educational Objective: Evaluate a patient for occupational asthma. Key Point 0eviewing a patientEs occupational eposures, the 1ob process and tas!s, and substances involved in the patientEs activities is necessary for an evaluation for possible occupational asthma. 0$his patient li!ely has isocyanate-induced asthma caused by eposure to isocyanate-containing automobile paints. $he most helpful piece of information to support the diagnosis of occupational asthma in this patient is an occupational history that substantiates direct or bystander eposure to isocyanate-containing paints with associated symptoms development. Although this manEs 1ob title may suggest such eposure , it is important to review the patientEs daily 1ob tas!s to ascertain whether he is actually at ris! for direct or bystander eposure to an isocyanate-containing product. 0$he significant reversible airflow limitation on spirometry in this patient is already compatible with a diagnosis of asthma, and a confirmatory methacholine challenge test is not necessary and potentially dangerous by provo!ing bronchospasm. %$ scan of the chest would be indicated in a patient with possible parenchymal disease; this patient has obstructive airways disease. &!in pric! testing to common aeroallergens would determine whether the patient is atopic; however, atopy is not a ris! factor for the development of asthma from eposure to low-molecular-weight substances such as isocyanates. eview of
Question 38 A 2-year-old man with a history of severe asthma is brought to the emergency department obtunded and in severe respiratory acidosis from an acute eacerbation of his asthma. He is intubated in the emergency department, and 7 minutes later he is evaluated in the intensive care unit. #n physical eamination, the patient is sedated and unresponsive; he is afebrile, and the blood pressure is 8>= mm Hg, pulse rate is *=>min, and respiration rate is 2=>min. #ygen saturation is ?8. $here are diffusely decreased breath sounds with faint bilateral epiratory wheezes. %ardiac eamination reveals distant regular tachycardic rhythm but is otherwise normal. )entilator settings include volume control mode with a set rate of 2=, tidal volume 8 m9 4*2 m9>!g ideal body weight5, positive end-epiratory pressure " cm H 2#, and 'i#2 .6. Arterial blood gases are pH +.7, D%# 2 = mm Hg, and D# 2 *8 mm Hg. %hest radiograph shows hyperinflation and a properly placed endotracheal tube.
hich of the following would most rapidly improve the patientEs hypotension/ 0A-Administer thrombolytic therapy 0B-Disconnect the patient )rom the !entilator )or '; seconds 0C-er)orm pericardiocentesis 0D-lace chest tubes bilaterally
