Exam 2004-5 (Pulmonary section)

1. Which of these diseases causes the greatest number of annual deaths in the USA?
A.
B.
C.
D.
E.

Pulmonary embolism
COPD
Acute Respiratory Distress Syndrome
Tuberculosis
Pneumococcal pneumonia

2. Emphysema and pulmonary fibrosis share all of the following pathophysiologic

abnormalities except:
A.
B.
C.
D.
E.

Arterial hypoxemia
Destruction of the pulmonary capillary bed
Ventilation-perfusion mismatch
Elevated residual volume
Inflammatory changes in the terminal airspaces

A 60 year old man complains of dyspnea on exertion. It has worsened over the past 5
years, and now he becomes short-winded when he walks between rooms of his house.
He has smoked 1.5 packs of cigarettes/day for 35 years. He denies frequent cough or
sputum production. He has lost 8 kilograms weight in the past 3 years. On physical
examination, his blood pressure is 120/80, pulse 95/min, respiratory rate = 20 (with
minimal use of accessory muscles at rest), and temp = 37. He has diminished muscle
mass in his extremities. He is not cyanotic. Auscultation of the lungs reveals very quiet
breath sounds with a prolonged expiratory phase; no crackles, rhonchi, or wheezes.
Cardiovascular examination is normal. Chest x-ray shows large, hyperlucent lungs,
decreased curvature of the diaphragms, and a narrow cardiac silhouette. Arterial blood
gas: PO2 = 45 mm Hg, PCO2 = 60 mm Hg, pH = 7.36.
3. Which of the following statements is true regarding this patient's dyspnea during
exercise?
A. He can't exhale fast enough because his expiratory muscles are mechanically
disadvantaged.
B. He can't exhale fast enough because his lungs are too stiff.
C. He can't ventilate enough because his airway resistance is too high and his
bronchi close too easily.
D. He can't ventilate enough because his lung recoil is diminished and his inspiratory
muscles are mechanically disadvantaged.
E. He could ventilate more, but there is a problem with his central nervous system
respiratory control center.
4. His arterial blood gas shows hypoxemia and:

A.
B.
C.
D.
E.

Metabolic acidosis
Combined respiratory and metabolic acidosis.
Acute respiratory acidosis
Compensated respiratory acidosis
Hyperventilation

5. Treatment for this disorder includes all of the following EXCEPT

A.
B.
C.
D.
E.

Bronchodilators
Influenza vaccination
Continuous oxygen
Surgery to resect parts of both lungs
Mucolytic therapy

6. The flow-volume curve of this patient is likely to look like which of the following:
B

Flow

Volume

A 35 year woman comes to the emergency department complaining of worsening

dyspnea of several days duration. She is coughing frequently, producing a little white
phlegm. She has had several episodes like this in the past year. They usually pass after a
day or two without treatment other than rest. Her vital signs are normal except for
respiratory rate = 24 with moderate use of accessory muscles at rest. She has wheezes
throughout both lungs. An x-ray of her chest is normal except that the lungs appear larger
than normal. Arterial blood gas on room air: PO2 = 54 mm Hg, PCO2 = 49 mm Hg, pH =
7.34. Her peak expiratory flow rate = 100 l/min (normal for her = 450 l/min).
7. Which of the following statements is true about this patient?
A. She is dyspneic primarily because of hypoxemia.
B. The main causes of her hypoxemia are reduced alveolar ventilation and excessive
oxygen consumption by her respiratory muscles.
C. Her expiratory flow rates are reduced because of increased airways resistance and
a greater tendency of her airways to close.
D. Bronchodilators are unhelpful in the acute setting.
E. Exercises to strengthen her diaphragm would improve her symptoms during
exacerbations.
8. Characteristics of this condition include:
A.
B.
C.
D.
E.

Aspergillus species are often recovered from bronchoalveolar lavage.

Bacterial infection of the lung, cold, and exercise are common triggers.
Airway inflammation and mucus secretion are reversed by inhaled beta-agonists.
A severe attack, as above, is indicated by mildly elevated PaCO2.
Associated with bronchial hyper-reactivity in about 50% of patients.

Match the patients below to the following pulmonary function test results (Each may be
used once, more than once, or not at all. All values except FEV1/FVC are given as the
percent of the predicted normal value. The normal FEV1/FVC ratio is about 0.80, or 80%)

A
B
C
D

FEV1
45
102
56
55

FVC
80
103
58
50

FEV1/FVC
61%
79%
91%
81%

TLC
114
104
54
70

FRC
123
100
50
95

RV
185
104
45
105

DCO
74
46
35
93

9. 33 year old woman with progressive diffuse muscle weakness over several days,
beginning after a gastrointestinal illness.
10. A 55 year old woman with gradually increasing dyspnea on exertion, pedal edema,
and a loud pulmonic heart sound.
11. 63 year old Cardiologist smoking away in a Fells Point gin joint.
12. 70 year old man with bilateral, reticular infiltrates on chest x-ray.
13. Unilateral phrenic nerve dysfunction:
A.
B.
C.
D.
E.

Often follows cardiac surgery.

Usually requires mechanical ventilation until resolution.
Typically causes pulsus paradoxus.
Causes severe orthopnea (dyspnea with recumbency)
Increases residual volume.

14. The main cause of pulmonary hypertension in COPD is:

A.
B.
C.
D.
E.

Arterial hypercapnia
Alveolar hypoxia
Altered chemoreceptor sensitivity
Increased dead space
Reduced diffusing capacity

15. A 29 year-old man presents to your emergency room dyspneic and coughing up
bloody secretions. He gasps that he has pulmonary veno-occlusive disease. You
remember nothing about this rare disease, except its name. Unfortunately, the
hospital network is down, so you cant Google it. However, you remember your
pathophysiology of the pulmonary vasculature and immediately administer:
A.
B.
C.
D.
E.

Thrombolytics to dissolve the embolic clot.

Diuretics to reduce pulmonary congestion.
Prostacyclin to relieve pulmonary constriction and muscular hypertrophy.
Bronchodilators to reduce hyperinflation.
Last rites.

16. Crisis averted, you admit the patient to the ICU and return to Scrubs. You are
interrupted by a 29 year-old Jamaican woman who is dyspneic and coughing up bloody
secretions. She gasps that she drinks bush tea, brewed from a leaf that can rarely cause
pulmonary arterial hypertension similar to primary pulmonary hypertension. You
remember your pathophysiology and admit her to the ICU to be tested for her response
to:

A.
B.
C.
D.
E.

The 29 year-old man you admitted earlier.

Thrombolytics to dissolve the embolic clot.
Diuretics to reduce pulmonary congestion.
Prostacyclin to relieve pulmonary constriction and muscular hypertrophy.
Bronchodilators to reduce hyperinflation.

17. Which one of the following statements is true regarding obstructive sleep apnea?
A.
B.
C.
D.
F.

Most patients are male.

Prevalence in females decreases after menopause.
Arterial blood gases while awake typically show hypoventilation.
Flow-volume curves show the pattern of extrathoracic obstruction.
Most patients are morbidly obese.

18. Which one of the following statements regarding acute respiratory distress syndrome
(ARDS) is true?
A.
B.
C.
D.
E.

The three most common causes are sepsis, pancreatitis, and aspiration.
The hypoxemia is due primarily to V/Q mismatch.
Mild hypoventilation is typical on arterial blood gases before intubation.
Mechanical ventilation should include the use of PEEP and small tidal volumes.
Chest wall compliance is decreased due to edema.

19. A patient with ARDS is being mechanically ventilated while heavily sedated, and the
following parameters are measured:
Tidal volume is 600 ml.
Airway pressure during a pause at peak inspiration is 35 cm H2O.
Airway pressure at end-expiration is 5 cmH2O.
Inspired oxygen concentration is 60%.
PaO2 is 65 mmHg and PaCO2 is 50 mmHg.
Which one of the following is correct:
A.
B.
C.
D.
E.

Lung compliance must be increased above normal.

The A-a gradient is 23 mmHg.
Respiratory system compliance is 20 mL/cm H2O.
The patient is not on enough positive end-expiratory pressure.
The patient is likely obese.

20. Which one of the following statements is TRUE:

A.
B.
C.
D.

Respiratory syncytial virus (RSV) is an uncommon cause of bronchiolitis

Bronchiolitis usually occurs in the summer
Metapneumovirus is a common cause of bronchiolitis
Influenza A does not cause respiratory problems in young children

E. Bronchiolitis is not a cause of apnea in infants.

21. Which of the following IS NOT a risk factor for severe bronchiolitis:
A. Prematurity
B. Preexisting cardiac disease
C. Male sex
D. Passive smoke exposure
E. Obesity
22. Which one of the following characterizes new BPD (bronchopulmonary dysplasia
in contemporary practice) but not classic BPD (BPD as seen 25 years ago)
A.
B.
C.
D.
E.

Major pathophysiologic cause is hypoplastic alveoli.

Causes a restrictive defect on pulmonary function testing.
Is associated with deficient endogenous surfactant.
Affects 50% of premature infants weighing more than 1250 gms.
Worsened by lung distension during mechanical ventilation.

23. Differences between the infant and adult respiratory system include all of the
following EXCEPT:
A.
B.
C.
D.
E.

Infants have a more compliant chest wall.

Infants are more prone to atelectasis with viral lung infections.
Infants have more active vagal reflexes.
Infants are obligate nose-breathers.
Infants do not wheeze with lower respiratory infections.

24. A sweat test should be ordered in a child who develops:

A.
B.
C.
D.
E.

Wheezing
Stridor
Recurrent RSV infection
Rectal prolapse
Metabolic acidosis

25. Extrapulmonary manifestations of cystic fibrosis include all of the following

EXCEPT:
A.
B.
C.
D.
E.

Biliary cirrhosis
Meconium ileus
Male infertility
Addisons disease
Pancreatic insufficiency

26. The most common cause of lobar pneumonia is:

A.
B.
C.
D.
E.

M. Tuberculosis
S. Pneumoniae
B. Anthracis
L. Pneumophila
Mycoplasma

27. A 66 year old man presents for evaluation of worsening shortness of breath and
dry cough developing over 6 months. He has a 7 year history of rheumatoid arthritis,
treated with methotrexate over the last 2 years. He also has a history of paroxysmal
atrial fibrillation managed with amiodarone and warfarin. He was a steelworker for
35 years at Bethlehem Steel. Prior to that, he held a series of odd jobs, polishing
beryllium missile casings for the Defense Department, opening bales of sugar cane at
the Domino plant, dismantling old ships for steel recycling, and stripping logs at a
sawmill. Since retiring, he works part-time as a docent at the Mushroom Museum in
Kennett Square, PA. As a hobby, he has been an avid breeder of Afghan hounds and
has had 4-6 of these dogs at any one time over the past 15 years. Two of his
grandchildren are allergic to the dogs, but he has never had any allergic symptoms.
He takes mineral oil for constipation. He smokes a hookah. On lung exam he has
crackles over both lung bases. Chest X-ray reveals diffusely increased interstitial
markings with honeycombing. Pulmonary function tests show the following:
FEV1
FVC
FEV1/FVC
TLC
FRC
RV
DCO

Measured
% Predicted
1.64 L
71%
2.09 L
70%
78%
3.40 L
72%
1.78 L
69%
1.10 L
68%
10.2 mL/min/mmHg 48%

Which of the following is the least likely cause of this patients lung disease?
A.
B.
C.
D.
E.

Rheumatoid arthritis
Drugs (Methotrexate or amiodarone)
Mushroom or fungal spore exposure
Work exposure at Bethlehem Steel
Dog-breeder hobby

28. Which organism is never recovered in expectorated sputum in the absence of

pneumonia:
A. Pneumococcus
B. Methicillin- resistant S. aureus

C. Respiratory syncytial virus (RSV)

D. Legionella
E. Anaerobes
In a patient with clinical symptoms of pneumonia, match the chest x-ray finding with the
most likely infectious organism; each choice may be used once, more than once, or not at
all.
Organism:
29.
30.
31.
32.
33.

Klebsiella pneumoniae
Pneumocystis jiroveci (carinii)
Mixed anaerobes
Mycoplasma pneumoniae
Tuberculosis

Chest x-ray finding

A.
B.
C.
D.
E.
F.
G.

Normal film
Mediastinal adenopathy
Lobar consolidation
Patchy, bilateral alveolar infiltrates
Lower lobe cavity
Upper lobe cavity
Hyperinflation

34. Obstructive sleep apnea is commonly associated with:

A.
B.
C.
D.
E.

Excessive daytime sleepiness

Decreased critical closing pressure of the upper airway
Leptin deficiency
Decreased FEV1/FVC ratio
Hypoxemia during wakefulness

35. An arterial blood gas drawn on room air shows pH 7.30, PaCO2 42 mmHg, PaO2 55
mmHg. The hypoxia cannot be due to:
A.
B.
C.
D.
E.

Shunt
V/Q mismatch
High altitude
Hypoventilation
Shock

Answer Key
1. B
2. D
3. D
4. D
5. E
6. A
7. C
8. D
9. D
10. B
11. A
12. C
13. A
14. B
15. B
16. D
17. A
18. D
19. C
20. C
21. E
22. A
23. E
24. D
25. D
26. B
27. E
28. D
29. C
30. A
31. E
32. D
33. F
34. A
35. D