(BQ) Part 2 book Principles of internal medicine - Self assessment board review presents the following contents: Disorders of the respiratory system, disorders of the urinary and kidney tract, disorders of the gastrointestinal system, rheumatology and immunology, endocrinology and metabolism, neurologic disorders, dermatology.
VI DISORDERS OF THE RESPIRATORY SYSTEM QUESTIONS DIRECTIONS: Choose the one best response to each question VI-1 A patient is evaluated in the emergency department for peripheral cyanosis Which of the following is not a potential etiology? A B C D E Cold exposure Deep venous thrombosis Methemoglobinemia Peripheral vascular disease Raynaud’s phenomenon VI-2 Which of the following associations correctly pairs clinical scenarios and community-acquired pneumonia (CAP) pathogens? A B C D E Aspiration pneumonia: Streptococcus pyogenes Heavy alcohol use: atypical pathogens and Staphylococcus aureus Poor dental hygiene: Chlamydia pneumoniae, Klebsiella pneumoniae Structural lung disease: Pseudomonas aeruginosa, S aureus Travel to southwestern United States: Aspergillus spp VI-3 A 54-year-old female presents to the hospital because of hemoptysis She has coughed up approximately teaspoon of blood for the last days She has a history of cigarette smoking A chest radiogram shows diffuse bilateral infiltrates predominantly in the lower lobes The hematocrit is 30%, and the serum creatinine is 4.0 mg/dL Both were normal previously Urinalysis shows 2+ protein and red blood cell casts The presence of autoantibodies directed against which of the following is most likely to yield a definitive diagnosis? A B C D E Glomerular basement membrane Glutamic acid decarboxylase Phospholipids Smooth muscle U1 ribonucleoprotein (RNP) VI-4 All the following drugs can cause eosinophilic pneumonia except A B nitrofurantoin sulfonamides VI-4 (Continued) C nonsteroidal anti-inflammatory drugs (NSAIDs) D isoniazid E amiodarone VI-5 A 26-year-old man presents to the clinic with days of severe sore throat and fever All of the following support the diagnosis of streptococcal pharyngitis except A B C D E cough fever pharyngeal exudates positive rapid streptococcal throat antigen test tender cervical lymphadenopathy VI-6 Which of the following has been shown to decrease duration of nonspecific upper respiratory tract symptoms? A B C D E F Azithromycin Echinacea Vitamin C Zinc None of the above All of the above VI-7 A 24-year-old man presents to the emergency room complaining of shortness of breath and right-sided chest pain The symptoms began abruptly about hours previously The pain is worse with inspiration He denies fevers or chills and has not had any leg swelling He has no past medical history but smokes pack of cigarettes daily On physical examination, he is tachypneic with a respiratory rate of 24 breaths/min His oxygen saturation is 94% on room air Breath sounds are decreased in the right lung, and there is hyperresonance to percussion A chest radiograph confirms a 50% pneumothorax of the right lung What is the best approach for treatment of this patient? A B C D Needle aspiration of the pneumothorax Observation and administration of 100% oxygen Placement of a large-bore chest tube Referral for thoracoscopy with stapling of blebs and pleural abrasion 237 Copyright © 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc Click here for terms of use 238 VI DISORDERS OF THE RESPIRATORY SYSTEM — QUESTIONS VI-8 A 23-year-old female complains of dyspnea and substernal chest pain on exertion Evaluation for this complaint months ago included arterial blood gas testing, which revealed pH 7.48, PO2 79 mmHg, and PCO2 31 mmHg Electrocardiography then showed a right axis deviation Chest x-ray now shows enlarged pulmonary arteries but no parenchymal infiltrates, and a lung perfusion scan reveals subsegmental defects that are thought to have a “low probability for pulmonary thromboembolism.” Echocardiography demonstrates right heart strain but no evidence of primary cardiac disease The most appropriate diagnostic test now would be A B C D E open lung biopsy Holter monitoring right-heart catheterization transbronchial biopsy serum α1-antitrypsin level VI-9 A 53-year-old woman presents to the hospital following an episode of syncope, with ongoing lightheadedness and shortness of breath She had a history of antiphospholipid syndrome with prior pulmonary embolism and has been nonadherent to her anticoagulation recently She has been prescribed warfarin, 7.5 mg daily, but reports taking it only intermittently She does not know her most recent INR On presentation to the emergency room, she appears diaphoretic and tachypneic Her vital signs are: blood pressure 86/44 mmHg, heart rate 130 beats/min, respiratory rate 30 breaths/min, SaO2 85% on room air Cardiovascular examination shows a regular tachycardia without murmurs, rubs, or gallops The lungs are clear to auscultation On extremity examination, there is swelling of her left thigh with a positive Homan’s sign Chest CT angiography confirms a saddle pulmonary embolus with ongoing clot seen in the pelvic veins on the left Anticoagulation with unfractionated heparin is administered After a fluid bolus of L, the patient’s blood pressure remains low at 88/50 mmHg Echocardiogram demonstrates hypokinesis of the right ventricle On 100% non-rebreather mask, the SaO2 is 92% What is the next best step in management of this patient? A B C D E Continue current management Continue IV fluids at 500 mL/hr for a total of L of fluid resuscitation Refer for inferior vena cava filter placement and continue current management Refer for surgical embolectomy Treat with dopamine and recombinant tissue plasminogen activator, 100 mg IV VI-10 to VI-13 Among the following pulmonary function test results, pick those which are the most likely finding in each of the following respiratory disorders: A Increased total lung capacity (TLC), decreased vital capacity (VC), decreased FEV1/FVC ratio VI-10 to VI-13 (Continued) B Decreased TLC, decreased VC, decreased residual volume (RV), increased FEV1/FVC ratio, normal maximum inspiratory pressure (MIP) C Decreased TLC, increased RV, normal FEV1/FVC ratio, decreased MIP D Normal TLC, normal RV, normal FEV1/FVC ratio, normal MIP VI-10 Myasthenia gravis VI-11 Idiopathic pulmonary fibrosis VI-12 Familial pulmonary hypertension VI-13 Chronic obstructive pulmonary disease VI-14 A 52-year-old female presents with a communityacquired pneumonia complicated by pleural effusion A thoracentesis 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 B C D E Presence of more than 90% polymorphonucleocytes (PMNs) Glucose less than 100 mg/dL Presence of more than 1000 white blood cells pH less than 7.20 Lactate dehydrogenase (LDH) more than two-thirds of the normal upper limit for serum VI-15 A 63-year-old male with a long history of cigarette smoking comes to see you for a 4-month history of progressive shortness of breath and dyspnea on exertion The symptoms have been indolent, with no recent worsening He denies fever, chest pain, or hemoptysis He has a daily cough of to tablespoons of yellow phlegm The patient says he has not seen a physician for over 10 years Physical examination is notable for normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated jugular venous pulsation, and moderate pedal edema Hematocrit is 49% Which of the following therapies is most likely to prolong his survival? A B C D E Atenolol Enalapril Oxygen Prednisone Theophylline VI DISORDERS OF THE RESPIRATORY SYSTEM — QUESTIONS VI-16 A 23-year-old male is climbing Mount Kilimanjaro He has no medical problems and takes no medications Shortly after beginning the climb, he develops severe shortness of breath Physical examination shows diffuse bilateral inspiratory crackles Which of the following is the most likely etiology? A B C D E Acute interstitial pneumonitis Acute respiratory distress syndrome Cardiogenic shock Community-acquired pneumonia High-altitude pulmonary edema VI-17 Which of the following statements about this condition is true? A B C D E Acetazolamide is indicated for the treatment of this disorder Older patients are more at risk for this disorder than are younger patients because hypoxic vasoconstriction is more pronounced as patients age Oxygen is an ineffective therapy for this disorder Persons who live at high altitudes are not at risk for this disorder even when they return to a high altitude after time spent at sea level Prevention can be achieved by means of gradual ascent VI-18 Which of the following organisms is unlikely to be found in the sputum of a patient with cystic fibrosis? A B C D E Haemophilus influenzae Acinetobacter baumannii Burkholderia cepacia Aspergillus fumigatus Staphylococcus aureus VI-19 A 63-year-old female is seen in the pulmonary clinic for evaluation of progressive dyspnea She underwent single-lung transplantation years ago for idiopathic pulmonary fibrosis and did well until the last months, when she noted that her exercise tolerance had decreased as a result of shortness of breath She denies fevers, chills, weight loss, or medication noncompliance The patient does have an occasional dry cough Her current medications include tacrolimus, prednisone, trimethoprim-sulfamethoxazole (TMP-SMX), pantoprazole, diltiazem, and mycophenolate mofetil She denies any current habits but has a remote history of tobacco use Physical examination is notable for dry crackles on the side of the native lung and decreased breath sounds on the side of the transplanted lung but no adventitious sounds Review of pulmonary function testing shows an FEV1/FVC ratio of 50% of the predicted value and an FEV1 of 0.91 L Additionally, FEV1 has fallen by 30% progressively over the last year Which of the following can ameliorate the fall in FEV1 in this patient? 239 VI-19 A B C D E F (Continued) Augmented immunosuppression Reduced immunosuppression Antifungal therapy Antiviral therapy Administration of α1 antitrypsin None of the above VI-20 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 takes 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 is 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 patient? A B C D E He must quit smoking immediately as his risk of emphysema is higher than that of other smokers because of asbestos exposure He does not have asbestosis His risk of mesothelioma is higher than that of other patients with asbestos exposure because he has a history of tobacco use He has no evidence of asbestos exposure on chest radiography He should undergo biannual chest radiography screening for lung cancer VI-21 Which of the following patients with communityacquired pneumonia meet the CURB-65 criteria for hospital admission? A B C D E A 23-year-old man with normal mental status, blood urea nitrogen (BUN) = 17 mg/dL, respiratory rate 25 breaths/min, and blood pressure 110/70 mmHg A 35-year-old woman with normal mental status, BUN = 13 mg/dL, respiratory rate 35 breaths/min, and systolic blood pressure 140/80 mmHg A 48-year-old man with normal mental status, BUN = 25 mg/dL, respiratory rate 32 breaths/min, blood pressure 110/75 mmHg A 62-year-old woman who is confused, BUN = 15 mg/dL, respiratory rate 25 breaths/min, blood pressure 115/65 mmHg A 73-year-old woman with normal mental status, BUN = 10 mg/dL, respiratory rate 18 breaths/min, blood pressure 145/70 mmHg 240 VI DISORDERS OF THE RESPIRATORY SYSTEM — QUESTIONS VI-22 What mode of ventilation is depicted in the graphic below? VI-25 (Continued) room Upon admission to the intensive care unit, she was sedated and paralyzed The ventilator is set in the assistcontrol mode with a respiratory rate of 24, tidal volume of mL/kg, FIO2 of 1.0, and positive end-expiratory pressure of 12 cmH2O An arterial blood gas measurement is performed on these settings; the results are pH 7.20, PaCO2 of 32 mmHg, and PaO2 54 mmHg What is the cause of the hypoxemia? A B C D FIGURE VI-22 A B C D E Assist control Continuous positive airway pressure Pressure control Pressure support Synchronized intermittent mandatory ventilation VI-23 A 67-year-old female is admitted to the hospital with a hip fracture after a fall Which of the following regimens constitutes appropriate venous thromboembolism prophylaxis for this patient? A B C D E Intermittent pneumatic compression devices Subcutaneous unfractionated heparin Subcutaneous low-molecular-weight heparin Warfarin, with a target international normalized ratio (INR) of 1.5 to 2.0 A and B VI-24 A 35-year-old male is seen in the clinic for evaluation of infertility He has never fathered any children, and after years of unprotected intercourse his wife has not achieved pregnancy Sperm analysis shows a normal number of sperm, but they are immotile Past medical history is notable for recurrent sinopulmonary infections, and the patient recently was told that he has bronchiectasis Chest radiography is likely to show which of the following? A B C D E Bihilar lymphadenopathy Bilateral upper lobe infiltrates Normal findings Situs inversus Water balloon–shaped heart VI-25 A 78-year-old woman is admitted to the medical intensive care unit with multilobar pneumonia On initial presentation to the emergency room, her initial oxygen saturation was 60% on room air and only increased to 82% on a non-rebreather face mask She was in marked respiratory distress and intubated in the emergency Hypoventilation alone Hypoventilation and ventilation-perfusion mismatch Shunt Ventilation-perfusion mismatch VI-26 A 17-year-old boy is admitted to the intensive care unit with fever, jaundice, renal failure, and respiratory failure Ten days ago he was part of a community service group from his school that cleaned up a rat-infested alley Two of his colleagues developed a flulike illness with headache, fever, myalgias, and nausea that has begun to resolve He developed similar symptoms with the addition of jaundice On the day of admission he developed shortness of breath The physical examination is notable for a temperature of 38.4°C (101.1°F), blood pressure of 95/65 mmHg, heart rate of 110/min, respiratory rate of 25/min, and oxygen saturation of 92% on 100% face mask He has notable jaundice and icterus as well as bilateral conjunctival suffusion A chest radiogram shows bilateral diffuse infiltrates Laboratory studies are notable for creatinine 2.5 mg/dL, total bilirubin 12.3 mg/dL, and normal aspartate aminotransferase (AST), alanine aminotransferase (ALT), and prothrombin time Which of the following antibiotics should be included in his therapy? A B C D E Cefipime Ciprofloxacin Clindamycin Penicillin Vancomycin VI-27 A 68-year-old woman presents to the emergency room complaining of dyspnea She has developed progressive shortness of breath over the past weeks She has a slight dry cough and a right-sided pleuritic chest pain There have been no associated fevers or chills She smokes a pack of cigarettes daily and has done so since the age of 18 On physical examination, she appears dyspneic at rest Her vital signs are: blood pressure 138/86 mmHg, heart rate 92 beats/min, temperature 37.1°C, respiratory rate 24 breaths/min, and SaO2 94% on room air There is dullness to percussion halfway up her right lung field with decreased tactile fremitus Breath sounds are decreased without egophony The examination is otherwise normal A chest radiograph shows a large free-flowing pleural effusion on the right and also suggests mediastinal lymphadenopathy The patient undergoes VI DISORDERS OF THE RESPIRATORY SYSTEM — QUESTIONS VI-27 (Continued) thoracentesis, and 1500 mL of bloody-appearing fluid is removed The results of the pleural fluid are: pH 7.46, red blood cell count too numerous to count, hematocrit 3%, white blood cell count 230/µL (85% lymphocytes, 10% neutrophils, 5% mesothelial cells), protein 4.6 g/dL, lactate dehydrogenase (LDH) 340 U/L, and glucose 35 mg/ dL The corresponding values in the serum are: protein 6.8 g/dL, LDH 360 U/L, and glucose 115 mg/dL A chest CT performed after the thoracentesis shows residual moderate pleural effusion with collapse of the right lower lobe and enlarged mediastinal lymph nodes Which of the following tests is most likely to yield the cause of the pleural effusion? A B C D E E Aspiration of the maxillary sinus Nasal fluticasone Oral amoxicillin Serum antineutrophil cytoplasmic antibodies (ANCA) Sinus CT scan VI-29 Which of the following conditions would be expected to increase the residual volume of the lung? A B C D E VI-30 (Continued) diograph which shows signs of bilateral pneumonitis and mediastinal lymphadenopathy An induced sputum silver stain is shown in the figure (see also Figure VI-30, Color Atlas) What is the preferred treatment for this patient? Mammography Mediastinoscopy Pleural fluid cytology Pleural fluid culture Thoracoscopic biopsy of the pleura VI-28 A 36-year-old male comes to his primary care physician complaining of days of worsening headache, left frontal facial pain, and yellow nasal discharge The patient reports that he has had nasal stuffiness and coryza for about days Past medical history is notable only for seasonal rhinitis The physical examination is notable for a temperature of 37.9°C (100.2°F) and tenderness to palpation over the left maxillary sinus The oropharynx has no exudates, and there is no lymphadenopathy Which of the following is the most appropriate next intervention? A B C D 241 Bacterial pneumonia Cryptogenic organizing pneumonia Emphysema Idiopathic pulmonary fibrosis Obesity VI-30 A 24-year-old man from Cincinnati, OH, comes into your clinic requesting treatment for “the flu.” He is in your town for a business trip He reports day of chills, sweats, headaches, myalgias, and a nonproductive cough He has no known occupational exposures but has just recently finished doing structural repairs on his old house His blood pressure is 106/72 mmHg, heart rate 98 beats/ min, temperature 39.5°C, respiratory rate 24 breaths/ min, and SaO2 is 88% on room air You obtain a chest ra- FIGURE VI-30 A B C D E Amphotericin Caspofungin Ciprofloxacin Glucocorticoids Piperacillin/tazobactam VI-31 Match the following vasopressors with the statement that best describes their action on the cardiovascular system Dobutamine Low-dose dopamine (2–4 µg/kg per min) Norepinephrine Phenylephrine A Acts solely at α-adrenergic receptors to cause vasoconstriction Acts at β1-adrenergic receptors and dopaminergic receptors to increase cardiac contractility and heart rate It also causes vasodilatation and increased splanchnic and renal blood flow Acts at β1- and, to a lesser extent, β2-adrenergic receptors to increase cardiac contractility, heart rate, and vasodilatation Acts at α and β1-adrenergic receptors to increase heart rate, cardiac contractility, and vasoconstriction B C D 242 VI DISORDERS OF THE RESPIRATORY SYSTEM — QUESTIONS VI-32 What sleep disorder is depicted in the graphic below (see also Figure VI-32, Color Atlas)? A Cheyne-Stokes respiration VI-32 B C D (Continued) Central sleep apnea Obstructive sleep apnea Periodic limb movement disorder of sleep FIGURE VI-32 VI-33 A 42-year-old male presents with progressive dyspnea on exertion, low-grade fevers, and weight loss over 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 dyspneic with minimal exertion The patient’s temperature is 37.9°C (100.3°F) 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 cytopathology shows amorphous debris with periodic acidSchiff (PAS)-positive macrophages What is the diagnosis? A B C D E Bronchiolitis obliterans organizing pneumonia Desquamative interstitial pneumonitis Nocardiosis Pneumocystis carinii pneumonia Pulmonary alveolar proteinosis VI-34 What treatment is most appropriate at this time? A B C D E Prednisone and cyclophosphamide Trimethoprim-sulfamethoxazole Prednisone Whole-lung saline lavage Doxycycline VI-35 An 86-year-old nursing home resident is brought by ambulance to the local emergency room He was found unresponsive in his bed and 911 was called Apparently he had been coughing and complaining of chills for the past few days; no further history is available from the nursing home staff His past medical history is remarkable for Alzheimer’s dementia and treated prostate cancer The emergency responders were able to appreciate a faint pulse and obtained a blood pressure of 91/49 mmHg and a heart rate of 120 beats/min In the emergency room his pressure is 88/51 mmHg and heart rate is 131 beats/min He is moan- ing and obtunded, localizes to pain, and has flat neck veins Skin tenting is noted A peripheral IV is placed, specimens for initial laboratory testing sent off, and electrocardiogram and chest x-ray are obtained Anesthesiology has been called to the bedside and is assessing the patient’s airway What is the best immediate step in management? A B C D E Infuse hypertonic saline to increase the rate of vascular filling Infuse isotonic crystalloid solution via IV wide open Initiate IV pressors starting with levophed Infuse a colloidal solution rapidly Transfuse packed red blood cells until hemoglobin is >10 g/dL VI-36 Which of the following is true regarding hypovolemic shock? A B C D E Loss of 20–40% of the blood volume leads to shock physiology Loss of 105 SaO2 >90% on FIO2