DISORDERS OF THE RESPIRATORY SYSTEM

1. A 52-year-old female presents with a community-aquired pneumonia complicated by pleural effusion. A thoracentensis is performed, with the following results:

Appearance pH Protein LDH Glucose WBC RBC PMNs Gram stain

Viscous, cloudy 7.11 5.8 g/dL 285 IU/L 66 mg/dL 3800/mm3 24,000/mm3 93% Many pMNs; no organism seen

Bacterial cultures are sent, but the results are not currently available. Which characteristic of the pleural fluid is most suggestive that the patient will require tube thoracostomy? a. Presence of more than 90% polymorphonucleocytes (PMNs) b. Glucose less than 100 mg/dL c. Presence of more than 1000 white blood cells d. pH less than 7.20 e. Lactate dehydrogenase (LDH) more than two-thirds of the normal upper limit for serum

2. A 60-year-old male is seen in the clinic for counseling about asbestos exposure. He is well and has no symptoms. He also has hypertension, for which he take hydrochlorothiazide. The patient smokes one pack of cigarettes a day but has no other habits. He is currently retired but worked for 30 years as a pipefitter and says he was around lots of asbestos, often without wearing a mask or other protective devices. Physical examination in normal except for nicotine stains on the left second and third fingers. Chest radiography shows pleural plaques but no

other changes. Pulmonary function tests, including lung volumes, are normal. Which of the following statements should be made to this patients? a. He must quit smoking immediately as his risk of emphysema is higher than that of other smokers because of asbestos exposure. b. He does not have asbestosis. c. He risk of mesothelioma is higher than that of other patients with asbestos exposure because he has a history of tobacco use. d. He has no evidence of asbestos exposure on chest radiography. e. He should undergo biannual chest radiography screening for lung cancer.

3. A 42-year-old male presents with progressive dyspnea on exertion, low-grade fevers, and weight loss over 6 months. He also is complaining of a primarily dry cough, although occasionally he coughs up a thick mucoid sputum. There is no past medical history. He does not smoke cigarettes. On physical examination, the patient appears dypsneic with minimal exertion. The patients temperature is 37.90C (100.30F). Oxygen saturation is 91% on room air at rest. Faint basilar crackles are heard. On laboratory studies, the patient has polyclonal hypergammaglobulinemia and a hematocrit of 52%. A CT scan reveals bilateral alveolar infiltrates that are primarily perihilar in nature with a mosaic pattern. The patient undergoes bronchoscopy with bronchoalveolar lavage. The effluent appears milky. The cystopathology shows amorphous debris with periodic acid Schiff (PAS)-positive macrophages. What is diagnosis? a. Bronchiolitis obliterans organizing pneumonia b. Desquamative interstitial pneumonitis c. Nocardiosis d. Pneumocystis carinii pneumonia e. Pulmonary alveolar proteinosis

4. A 49-year-old woman is admitted for an evaluation of weakness. She complains of fatigue with repetitive muscle use, with significant fatigue and dysphagia by the end of the day. Her activities have been significantly limited due to her fatigue, and there is significant orthopnea. During her evaluation, laboratory analysis reveals; Sodium 137 meq/L, potassium 3.8 meq/L, chloride 94 meq/L, bicarbonate 31 meq/L. An arterial blood gas shows a pH of 7.33, PaCO2 60 mmHg, and PaO2 65 2

mmHg. A chest x-ray is interpreted as poor inspiratory effort. The oxygen saturation is 92% on room air. A ventilation-perfusion scan has normal perfusion. Which of the following tests will most likely identify the cause of this patients respiratory acidosis? a. CT scan of the brain b. Diffusing capacity for carbon monoxide c. Esophagoscopy d. Forced vital capacity (supine and upright) e. Pulmonary angiogram

5. The most common cause of a pleural effusion is a. Cirrhosis b. Left ventricular failure c. Malignancy d. Pneumonia e. Pulmonary embolism

6. A 32-year-old male is brought to the emergency department after developing sudden-onset shortness of breath and chest pain while chouging. He reports a 3month history of increasing dyspnea on exertion, non-productive cough, and anorexia with 15 lb of weight loss. He has no past medical history and takes no medications. The patient smokes one or two packs of cigarettes a day, use alcohol socially, and has no risk factors of HIV infection. A chest radiogram shows a right 80% pneumothorax, and there are nodular infiltrates in the left base that spare the costophrenic angle. After placement of a chest tube, a chest CT shows bilateral small nodular opacities in the lung bases and multiple small cystic spaces in the lung apex. Which of the following interventions is most likely to improve the symptoms and radiograms? a. Intravenous 1 antitrypsin b. Isoniazid, rifampin, ethambutol, and pyrazinamide c. Prednisone and cyclophosphamide d. Smoking cessation e. Trimethoprim-sulfamethoxazole

7. All of the following statements about the physiology of mechanical ventilation are true except a. Application of positive end-expiratory pressure decreases preload and afterload. b. High inspired tidal volumes contribute to the develoment of acute lung injury due to overdistention of alveoli with resultant alveolar damage. c. Increasing the inspiratory flow rate will increase the ratio of inspiration to expiration (I:E) and allow more time for expiration. d. Mechanical ventilation provides assistance with inspiration and expiration. e. Positive end-expiratory pressure helps prevent alveolar collapse at endexpiration.

8. A 64-year-old man requires endotracheal intubation and mechanical ventilation for chronic obstructive pulmonary disease. He was paralyzed with rocuronium for intubation. His initial ventilator settings were AC mode, respiratory rate 10 breaths/min, FIO2 1.0, Vt (tidal volume) 550mL, and PEEP 0 cmH2O. On admission to the intensive care unit, the patient remains paralyzed; arterial bloos gas is pH 7.22, PaCO2 78 mmHg, PaO2 394 mmHg. The FIO2 decrease to 0.6. Thirty minutes later, you are called to the bedsite to evaluate the patient for hypotension. Current vital sign are: blood pressure 80/40 mmHg, heart rate 133 beats/min, respiratory rate 24 breaths/min, and SaO2 92%. Physical examination shows prolonged expiration with wheezing continuing until the initiation of the next breath. Breath sounds are heard in both lung fields. The high-pressure alarm on the ventilator is triggering. What should be done first in treating this patients hypotension? a. Administer a fluid bolus of 500 mL b. Disconnect the patient from the ventilator c. Initiate a continuous IV infusion of midazolam d. Initiate a continuous IV infusion of norepinephrine e. Perform tube thoracostomy on the right side