Answers

106. The answer is e. (Fauci, 14/e, pp 1445-1447. Goldman, 21/e, pp 405-406.) Bronchiectasis is an acquired disease that causes abnormal dilatation of the bronchi leading to pooling of secretions in the airways and recurrent infections. Patients typically present with cough and with the production of purulent sputum. Lung auscultation may be normal or remarkable for wheezes, rhonchi, or crackles. Chest radiograph may be normal, but occasionally the damaged, dilated airways will appear as "tram tracks" or "ring shadows." Bronchiectasis may be a sequela of foreign body aspiration, cystic fibrosis, rheumatic diseases (rheumatoid arthritis and Sjogren's disease), pulmonary infections (tuberculosis, pertussis, Mycoplasma), AIDS, and allergic bronchopulmonary aspergillosis (ABPA).

107. The answer is b. (Seidel, 4/e, pp 370-378.) The proper sequence for examination of the lungs is:

Inspection for chest wall abnormalities, symmetry, and retractions Palpation for fremitus and crepitus ("crinkly" sensation) Percussion for dullness and diaphragmatic excursion Auscultation of breath sounds

108. The answer is b. (Sapira, p 81.) The rule for the comfortable recumbent position in lung disease is "good side down." This patient with right-sided lung disease will be lying in the left lateral decubitus position to maximize gas exchange in the good lung.

109. The answer is a. (Fauci, 14/e, pp 1428, 1460-1465.) Idiopathic bronchiolitis obliterans with organizing pneumonia (BOOP) is also called cryptogenic organizing pneumonia. It is a disorder of granulation tissue proliferation within the small ducts and airways. Usually, patients present with an acute illness followed by exertional dyspnea. Patients with allergic bronchopulmonary aspergillosis (ABPA) have asthma with wheezes on physical examination. Chest radiographs usually reveal transient, recurrent infiltrates. Wegener's granulomatosis typically involves the upper airways (i.e., nasal ulcers, sinus infections), lungs, joints, and kidneys, and c-ANCA (antineutrophil cytoplasmic antibodies) is positive. Goodpasture syndrome causes glomerulonephritis and pulmonary hemorrhage, and patients have antibodies to renal and lung alveolar basement membranes.

110. The answer is e. (Seidel, 4/e, p 845.) The tongue may fall posteriorly to obstruct the oropharynx and is the major cause of airway obstruction. This may occur in patients with a decreased level of consciousness and may be corrected by utilizing the head tilt-chin lift maneuver.

111. The answer is d. (Fauci, 14/e, pp 1469-1472. Tierney, 39/e, pp 323-326.) The most frequent presenting clinical sign of pulmonary embolus (PE) is shortness of breath. Patients may also present with pleuritic chest pain, hemoptysis, and tachycardia. An excellent clue to the diagnosis of PE is deep venous thrombosis (DVT), but absence of signs of DVT does not exclude the diagnosis of PE. Embolus from a thrombus in the lower extremities (DVT) is the most common cause of PE. Common settings for PE include prolonged immobilization, use of oral contraceptives, obesity, recent surgery, burns, severe trauma, congestive heart failure, malignancy, pregnancy, sickle cell anemia, polycythemias, inherited deficiencies of the antico-agulating proteins (protein C, protein S, antithrombin III), and the Leiden factor V mutation. Chest radiograph in PE may be normal but may demonstrate a peripheral wedge-shaped density above the diaphragm (Hampton's hump), focal oligemia (Westermark sign), or abrupt occlusion of a vessel (cutoff sign). A loud S

2 is often heard in disorders that cause pulmonary hypertension, such as pulmonary embolism. The next best step in making the diagnosis would be to order a ventilation/perfusion (V/Q) scan. If the V/Q scan results are of low or indeterminate probability, the patient may need further studies, such as pulmonary arteriogram or venous ultrasonography of the lower extremity. D-dimer assays will result in future changes to existing diagnostic strategies for pulmonary embolism, but the marker is still in the investigative stages (the absence of this product is evidence against throm-boembolism). Helical (spiral) CT scans are comparable to V/Q scans and may be the first step in diagnosing pulmonary embolus.

112. The answer is b. (Fauci, 14/e, pp 1408,1439.) The patient described most likely has community-acquired pneumonia (CAP) due to Streptococcus pneumoniae. Other pathogens responsible for CAP include

Mycoplasma pneumoniae, viruses, and Chlamydia pneumoniae. In smokers even without documented chronic lung disease, Haemophilus influenzae must be considered. Fremitus refers to vibrations that are perceived in a tactile manner; these are increased in patients with consolidation from pneumonia. Vocal fremitus (bronchophony, egophony, bronchial breath sounds, and pectoriloquy), increased dullness to percussion, and fine crackles may be evident in patients with pneumonia. Areas of atelectasis have decreased fremitus, decreased breath sounds, and dullness to percussion. The trachea is shifted to the side of the atelectasis. A limited area of egophony is heard above the area of atelectasis.

113. The answer is d. (Seidel, 4/e, p 357.) The best areas to listen for right middle lobe findings would be: (1) the right anterior midclavicular line between the fifth and sixth ribs and (2) the right midaxillary line between the fourth and sixth ribs. The right middle lobe is not heard posteriorly, and the lung examination is incomplete if physicians do not listen anteriorly or medially.

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