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Match the disease entity with the type of pleural effusion.

b. Right-sided effusion, protein 2.5 g/dL

c. Pleural fluid glucose less than 15 mg/dL

d. Exudate, 100% lymphocytes e. Bloody effusion f. Milky appearance g. Low cholesterol

108. Congestive heart failure (CHOOSE 1 EFFUSION)

109. Tuberculosis (CHOOSE 1 EFFUSION)

110. Empyema (CHOOSE 1 EFFUSION)

111. Rheumatoid arthritis (CHOOSE 1 EFFUSION)

112. Mesothelioma (CHOOSE 1 EFFUSION) Items 113-116

Match the chest x-ray letter with the most likely clinical description.

Pleural Effusion With Gram CocciHistoplasmosis Ray Images
D

113. Fever, shaking chills; sputum Gram stain showing gram-positive cocci in clusters (CHOOSE 1 X-RAY)

114. Shortness of breath, awakens gasping for breath at night (CHOOSE 1 X-RAY)

115. Fever, night sweats for 1 year (CHOOSE 1 X-RAY)

116. Long-standing hypertension (CHOOSE 1 X-RAY)

117. A 30-year-old male is admitted to the hospital after a motorcycle accident that resulted in a fracture of the right femur. The fracture is managed with traction. Three days later the patient becomes confused and tachypneic. A petechial rash is noted over the chest. Lungs are clear to auscultation. Arterial blood gases show Po2 of 50, Pco2 of 28, and pH of 7.49. The most likely diagnosis is a. Unilateral pulmonary edema b. Hematoma of the chest c. Fat embolism d. Pulmonary embolism e. Early Staphylococcus aureus pneumonia

118. A 70-year-old patient with chronic obstructive lung disease requires 2 L of nasal O2 to treat his hypoxia, which is sometimes associated with angina. While receiving nasal O2, the patient develops pleuritic chest pain, fever, and purulent sputum. He becomes stuporous and develops a respiratory acidosis with CO2 retention and worsening hypoxia. The treatment of choice is a. Stop oxygen b. Begin medroxyprogesterone c. Intubate the trachea and begin mechanical ventilation d. Observe patient 24 hours before changing therapy e. Begin sodium bicarbonate

119. A 34-year-old black female presents to your office with symptoms of cough, dyspnea, and lymphadenopathy. Physical exam shows cervical adenopathy and hepatomegaly. Her chest radiograph is shown below. How should you pursue diagnosis?

Hilar Adenopathy Treatment

a. Open lung biopsy b. Liver biopsy c. Bronchoscopy and transbronchial lung biopsy d. Scalene node biopsy e. Serum angiotensin converting enzyme (ACE) level a. Open lung biopsy b. Liver biopsy c. Bronchoscopy and transbronchial lung biopsy d. Scalene node biopsy e. Serum angiotensin converting enzyme (ACE) level

120. A 64-year-old woman is found to have a left-sided pleural effusion on chest x-ray. Analysis of the pleural fluid reveals a ratio of concentration of total protein in pleural fluid to serum of 0.38, a lactate dehydrogenase (LDH) level of 125 IU, and a ratio of LDH concentration in pleural fluid to serum of 0.46. Which of the following disorders is most likely in this patient?

a. Uremia b. Congestive heart failure c. Pulmonary embolism d. Sarcoidosis e. Systemic lupus erythematosus

121. A 25-year-old male cigarette smoker has a history of respiratory infections and has also been found to have hematuria. A high value for diffusing capacity is noted during pulmonary function testing. This finding is consistent with which of the following disorders?

a. Anemia b. Cystic fibrosis c. Emphysema d. Intrapulmonary hemorrhage

122. A 25-year-old male with a long history of severe asthma presents to the emergency room with shortness of breath. He has previously required admission to the hospital and was once intubated for asthma. Which of the following findings on physical exam would indicate a benign course?

a. Silent chest b. Hypercapnia c. Thoracoabdominal paradox (paradoxical respiration)

d. Pulsus paradoxus of 5 mmHg e. Altered mental status

123. A 40-year-old man without a significant past medical history comes to the emergency room with a 3-day history of fever and shaking chills; a 15-minute episode of rigor; nonproductive cough; anorexia; and the development of right-sided pleuritic chest pain and shortness of breath over the last 12 hours. A chest x-ray reveals a consolidated right middle lobe infiltrate, and a CBC shows an elevated neutrophil count with many band forms present. Which of the following statements regarding pneumonia in this patient is correct?

a. Sputum culture is more helpful than sputum Gram stain in choosing empiric antibiotic therapy b. If the Gram stain revealed numerous gram-positive diplococci, numerous white blood cells, and few epithelial cells, Streptococcus pneumoniae would be the most likely diagnosis c. Although S. pneumoniae is the agent most likely to be the cause of this patient's pneumonia, this diagnosis would be very unlikely if blood cultures were negative d. The absence of rigors would rule out a diagnosis of pneumococcal pneumonia e. Penicillin is the drug of choice in all cases of pneumococcal pneumonia

Items 124-125

124. A 57-year-old man develops acute shortness of breath shortly after a 12-hour automobile ride. The patient consults his internist, and findings on physical examination are normal except for tachypnea and tachycardia. An electrocardiogram reveals sinus tachycardia but is otherwise normal. Which of the following is correct?

a. A definitive diagnosis can be made by history alone b. The patient should be admitted to the hospital, and, if there is no contraindication to anticoagulation, intravenous heparin should be started pending further testing c. Normal findings on examination of the lower extremities are extremely unusual in this clinical setting d. Early treatment has little effect on overall mortality

125. The most important next step in the diagnosis of this patient is a. Pulmonary angiogram b. Ventilation-perfusion scan c. D-dimer assay d. Venous ultrasound

126. An anxious young woman who is taking birth control pills presents to the emergency room with shortness of breath. The absence of which of the following would make the diagnosis of pulmonary embolus unlikely?

a. Wheezing b. Pleuritic chest pain c. Tachypnea d. Hemoptysis e. Right-sided S3 heart sound

127. A 65-year-old male with mild congestive heart failure is to receive total hip replacement. He has no other underlying diseases and no history of hypertension, recent surgery, or bleeding disorder. The best approach to prevention of pulmonary embolus in this patient is a. Aspirin 75 mg/d b. Aspirin 325 mg/d c. Warfarin with INR of 2 to 3

d. Early ambulation

128. A 30-year-old athlete with asthma is also a cigarette smoker. Which of the following is characteristic of asthma but not other obstructive lung disease?

a. Hyperinflation is present on chest x-ray b. Airway obstruction is reversible c. Hypoxia occurs as a consequence of ventilation-perfusion mismatch d. The FEV1/FVC ratio is reduced e. Exacerbation often occurs as a result of an upper respiratory tract infection

Items 129-133

For each clinical situation, select the arterial blood gas and pH values with which it is most likely to be associated.

129. A 30-year-old obese female bus driver develops sudden pleuritic left-sided chest pain and dyspnea. (CHOOSE 1 SET OF VALUES)

130. A 60-year-old heavy smoker has severe chronic bronchitis and peripheral edema and cyanosis. (CHOOSE 1 SET OF VALUES)

131. A 22-year-old drug-addicted man is brought to the emergency room by friends who were unable to awaken him. (CHOOSE 1 SET OF VALUES)

132. A 62-year-old man who has chronic bronchitis and chest pain is given oxygen via mask in the ambulance en route to the hospital and becomes lethargic in the emergency room. (CHOOSE 1 SET OF VALUES)

133. A 20-year-old man with diabetes mellitus comes to the emergency room with diffuse abdominal pain, tachypnea, and fever. (CHOOSE 1 SET OF VALUES)

Items I34-I38

For each set of findings below, select the disease with which it is most likely to be associated.

a. Asthma b. Rheumatoid arthritis c. a1 antitrypsin deficiency d. Cystic fibrosis e. Sarcoidosis

134. Low levels of glucose in pleural effusions (SELECT 1 DISEASE)

135. Bronchiectasis and severe hemoptysis as frequent complications of clinical course (SELECT 1 DISEASE)

136. Presence of the mucoid strain of Pseudomonas aeruginosa (SELECT 1 DISEASE)

137. Development of severe liver disease that is usually associated with, but may be independent of, lung disease (SELECT 1 DISEASE)

138. Development of symptoms after ingestion of tartrazine yellow or aspirin (SELECT 1 DISEASE)

139. A 60-year-old male has had a chronic cough for over 5 years with clear sputum production. He has smoked one pack of cigarettes per day for 20 years and continues to do so. X-ray of the chest shows hyperinflation without infiltrates. Arterial blood gases show a pH of 7.38, Pco2 of 40 mmHg, and Po2 of 65 mmHg. Spirometry shows an FEV1/FVC of 65%. The most important treatment modality for this patient is a. Oral corticosteroids b. Home oxygen c. Broad-spectrum antibiotics d. Smoking cessation program

140. A 50-year-old male with emphysema and a chest x-ray that has shown apical blebs develops the sudden onset of shortness of breath and left-sided pleuritic chest pain. Pneumothorax is suspected. Physical examination findings that would confirm the diagnosis are a. Localized wheezes at the left base b. Hyperresonance of the left chest with decreased breath sounds c. Increased tactile fremitus on the left side d. Decreased breath sounds on the left side with deviation of the trachea to the left

141. A 30-year-old paraplegic male has a long history of urinary tract infection secondary to an indwelling Foley catheter. He develops fever and hypotension requiring hospitalization, fluid therapy, and intravenous antibiotics. He improves, but over 1 week becomes increasingly short of breath and tachypneic. He develops frothy sputum, diffuse rales, and diffuse alveolar infiltrates. There is no fever, jugular venous distention, S3 gallop, or peripheral or sacral edema. The best approach to a definitive diagnosis in this patient is a. Blood cultures b. CT scan of the chest c. Pulmonary capillary wedge pressure d. Ventilation-perfusion scan

142. A 35-year-old female complains of slowly progressive dyspnea. Her history is otherwise unremarkable, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. On physical exam, there is jugular venous distention, a palpable right ventricular lift, and a loud P2 heart sound. Chest x-ray shows clear lung fields. ECG shows right axis deviation. A perfusion lung scan is normal with no segmental deficits. The most likely diagnosis in this patient is a. Primary pulmonary hypertension b. Recurrent pulmonary emboli c. Cardiac shunt d. Interstitial lung disease

143. In the evaluation of this patient, cardiac catheterization confirms the diagnosis. The next step in the management of the patient is a. Acute drug testing with short-acting pulmonary vasodilators b. High-dose nifedipine c. Intravenous prostacyclin d. Lung transplantation

144. A 60-year-old obese male complains of excessive daytime sleepiness. He has been in good health except for mild hypertension. He drinks alcohol in moderation. The patient's wife states that he snores at night and awakens frequently. Examination of the oropharynx is normal. Which of the following studies is most appropriate?

a. EEG to assess stage sleep patterns b. Ventilation pattern to detect apnea c. Arterial O2 saturation d. Polysomnography to include all of the above

145. The patient above is found to have recurrent episodes of arterial desaturation—about 15 events per hour—with evidence of obstructive apnea. The treatment of choice for this patient is a. Nasal continuous positive airway pressure b. Uvulopalatopharyngoplasty c. Weight reduction d. Tracheostomy

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