CHEST自测-题目 (No.50)

A 26-year-old woman living in Los Angeles has injected heroin subcutaneously daily for the last 3 years. She presents to the emergency department with a 3-day history of dry mouth, dysarthria, and dysphagia. For the last 2 days she has nausea and vomited five times. Since the morning of admission, she has been increasingly short of breath at rest. Physical examination shows a thin woman in mild respiratory distress. Her temperature is 37.2℃, pulse 116 / min, blood pressure 120 / 75 mm Hg, and respirations 28 / min. She has numerous skin lesions at the sites of injections, some of which appear to be infected. She has bilateral ptosis, and is dysarthric but oriented. There is no jugular venous distention, the chest is clear, and heart and abdomen examinations are unremarkable. There is bilateral, symmetrical weakness of the arms and legs. The arterial blood gas measurements show PO2 60 mm Hg, PCO2 48 mm Hg, and pH 7.31. The chest roentgenogram is normal.After 2 hours of observation, she becomes increasingly tachypneic, oxygen saturation measured by pulse oximetry falls from 91% to 82%, and she is intubated, placed on a mechanical ventilator, and transferred to the intensive care unit. Which of the following tests in most likely to confirm the diagnosis of the cause of respiratory failure in this patient?

A. Serum acetylcholine receptor antibody level.

B. Magnetic resonance imaging (MRI) of the head.

C. Lumbar puncture.

D. Blood culture.

E. Culture of skin lesions.

此题相应的点评请参阅2007年7月期的第435页或 (No.50) 的《CHEST 自测-点评》。


CHEST自测-题目 (No.49)

All of the following statements about percutaneous dilational tracheostomy (PDT) are true EXCEPT:

A. Delayed complications are less common with PDT than with open tracheostomy.

B. Puncture of the thyroid isthmus occurs in less than 5% of properly performed PDT.

C. Placement of the tracheostomy tube between the second and third tracheal rings is an acceptable location.

D. Use of videobronchoscopic guidance during PDT can virtually eliminate paratracheal placement of the tracheostomy tube.

E. PDT results in fracture of one or more tracheal rings in most patients.

此题相应的点评请参阅 (No.49)的《CHEST自测-点评》。



CHEST自测-题目 (No.48)

Which one of the following statements concerning thromboembolic disease durging pregnancy is correct?

A. The majority of deep venous thromboses occur post-partum.

B. The majority of pulmonary thromboemboli occur ante-partum.

C. The majority of deep venous thromboses occur in the right leg.

D. Deplex ultrasonography of the legs has a negligible false-positive rate during pregnancy.

E. Diagnosis using a combination of chest radiography,ventilation-perfusion,and helical CT scanning of the chest with shielding,confers no significant risk of fetal injury.



CHEST自测-题目 (No.47)

A 68-year-old woman with a 42 pack-year smoking history is seen because of increasing dyspnea without cough or sputum production. She also has leg discomfort when walking uphill and shows mild leg edema. The patient is currently on inhaled bronchodilators and enalapril. She had a myocardial infarction 3 years before. Her temperature is 37 C,blood pressure 122 / 75 mmHg, heart rate 63 / min,and respiratory rate 22 / min. There is no jugular venous distention. The breath sounds are minimally decreased and the heart sounds are normal. There is no visceromegaly. Extremities show trace leg edema and poor pulses. Routine laboratory exams are normal except for a high cholesterol of 280 mg / dL (7.24 mmol / L). Baseline ECG shows an old inferior wall myocardial infarction. Chest roentgenogram reveals mild hyperinflation. You order pulmonary function tests and a cardiopulmonary exercise study, which return with these results:

These results are best explained as follows:

A. Ventilatory limitation.

B. Cardiac limitation.

C. Submaximal exercise test.

D. Deconditioning.

E. Peripheral vascular disease.




CHEST自测-题目 (No.46)

A 77-year-old man with severe COPD on supplemental oxygen at home presents to the emergency department with shortness of breath. His wife notes that he has had an upper respiratory infection for the past week and began wheezing last night. Upon arrival, he is mildly cyanotic and using accessory muscles to breathe. He is constantly removing his nasal cannula, arguing with the nurses and his wife, and won't allow the nurse to place an intravenous line. His initial blood gas measurements show an acute on chronic respiratory acidosis. Which of the following would be a contraindication to use of noninvasive ventilation in this setting?

A.Presence of a living will.

B.Nasal obstruction.

C.History of prior pneumothorax.


E.pH <7.30.



CHEST自测-题目 (No.45)

A 58-year-old woman had a right single-lung transplantation for emphysema 18 months ago. Postoperatively, she experienced two episodes of acute rejection at 6 and 12 weeks posttransplant that were treated with corticosteroids. She was a cytomegalovirus (CMV) mismatch and had an episode of CMV pneumonitis despite prophylaxis at 2 months following transplantation. Sebsequently, her course has been relatively uncomplicated. She is seen now for her routine visit. She notes the gradual onset of mild shortness of breath over the past 4 to 6 weeks. She denies fever, chills ,cough,or sputum production. She is on a stable immunosuppressive regimen of cyclosporine, azathioprine, and corticosteroids. Her weight has been stable. Vital signs are stable and she is afebrile. Her lung examination reveals decreased breath sounds on the left and clear breath sounds on the right.

Laboratory examination is unremarkable. Her pulmonary function tests reveal an FEV1 of 1.2L. Her prior baseline had been 1.6L. Her chest radiograph is unchanged from her baseline film. She undergoes a bronchoscopy with transbronchial biopsy. Preliminary culture results are negative and the histopathology is pending. Her CMV antigen studies are negative. All the following statements about the most likely diagnosis in this patient are correct EXCEPT:

A.It develops in up to 50% of lung transplant recipients.

B.High-resolution CT scanning may show air trapping on end expiration.

C.Augmented immunosuppression rarely results in improvement.

D.Pathologic diagnosis is required.

E.Acute rejection is the most important risk factor.



CHEST自测-题目 (No.44)

Major diagnostic features of allergic bronchopulmonary aspergillosis (ABPA) include all of the following, EXCEPT:

A.Recurrent pulmonary infiltrates.

B.Elevated Aspergillus-specific IgG.

C.Immediate reaction to Aspergillus antigen on skin testing.

D.Elevated total serum IgE.

E.Culture of Aspergillus from respiratory secretions.



CHEST自测-题目 (No.43)

A 68-year-old man is referred to you for progressive dyspnea on exertion. He had smoked two packs of cigarettes per day from the age of 19 to the age of 65. At the age of 58, because of a chronic cough, he was told he had chronic bronchitis and was begun on a short-acting inhaled beta-agonist for relief of symptoms. At the age of 65, he stopped smoking and a long-acting inhaled beta-agonist was added for control of nocturnal cough and daytime dyspnea. He had never received oral or inhaled corticosteroids. Despite using his long-acting inhaled beta-agonist as prescribed,he has had to use his short-acting inhaled beta-agonist increasingly more often during the day because of dyspnea on exertion. He denies worsening cough, wheeze, or nocturnal symptoms and has had no back pain or falls. Serial spirometry results reveal the following:

Which of the following diagnostic tests would most likely explain the patient's progressive dyspnea and the spirometric findings?

A. Chest CT scan.

B. Lateral chest radiograph.

C. Diffusing capacity of the lung for carbon monoxide.

D. Ventilation-perfusion lung scan.

E.. Trial of oral corticosteroids.



CHEST自测-题目 (No.42)

A 20-year-old man with hemoglobin sickle cell disease is seen in the emergency department for new onset of severe bilateral upper arm pain. Examination shows an uncomfortable young man. Blood pressure is 120 / 90 mmHg, heart rate 100 / min, respiratory rate 20 / min, temperature 38℃, and oxygen saturation is 92% with the patient breathing room air. There are no crackles on auscultation and there is pain on deep palpation of both upper arms.

Neurological examination is within normal limits. Hemoglobin is 95 g / L (9.5 g / dL) and the last known hemoglobin 2 weeks ago in the office was 130 g / L (13 g / dL). His WBC count is 4 000 / mm3 (4 x 109 / L) and platelets 100 000 / mm3 (100 x 109 / L). Chest radiograph shows no new infiltrates. Reticulocyte count is 2 000 / mm3 (2 x 109 / L). Two blood cultures are drawn, and ceftriaxone 1.0 g twice daily is started and the patient is admitted to the hospital. Additional therapy should include all of the following EXCEPT:

A. Blood transfusions to raise hemoglobin to previous level.

B. Bronchodilator therapy.

C. Supplemental oxygen.

D. Change the current ceftriaxone therapy to piperacillin / tazobactam.

E. Add a macrolide to the current ceftriaxone therapy.




CHEST自测-题目 (No.41)

A 68-year-old man is referred to you for progressive dyspnea on exertion. He had smoked two packs of cigarettes per day from the age of 19 to the age of 65. At the age of 58, because of a chronic cough, he was told he had chronic bronchitis and was begun on a short-acting inhaled beta-agonist for relief of symptoms. At the age of 65, he stopped smoking and a long-acting inhaled beta-agonist was added for control of nocturnal cough and daytime dyspnea. He had never received oral or inhaled corticosteroids. Despite using his long-acting inhaled beta-agonist as prescribed,he has had to use his short-acting inhaled beta-agonist increasingly more often during the day because of dyspnea on exertion. He denies worsening cough, wheeze, or nocturnal symptoms and has had no back pain or falls. Serial spirometry results reveal the following:

Age, years 58 65 68
Height, inches 71 69 67
Weight, lbs 188 187 189
FEV1 actual / predicted (percent predicted) 2.51 / 3.76 (67%) 2.09 / 3.22 (65%) 1.76 / 2.80 (63%)
FVC actual / predicted (percent predicted) 3.88 / 4.68 (83%) 3.32 / 4.05 (82%) 2.90 / 3.54 (82%)
FEV1 / FVC / % 65 63 61

Which of the following diagnostic tests would most likely explain the patient's progressive dyspnea and the spirometric findings?

A. Chest CT scan.

B. Lateral chest radiograph.

C. Diffusing capacity of the lung for carbon monoxide.

D. Ventilation-perfusion lung scan.

E.. Trial of oral corticosteroids.



CHEST 自测—题目 (No.40)

A 37-year-old woman presented with a 3-day history of dark urine that, on evaluation, was found to contain red blood cells,red blood cell casts, and 3+ protein. Her blood urea nitrogen was 40 mg/dL(14 mmol/L) and her serum creatinine was 4.2 mg/dL(400 mmol/L). You are consulted to assist in establishing the diagnosis because a history of sparse hemoptypsis was elicited on the review of symptoms, bilateral alveolar infiltrates were found on her initial chest radiography, and the indirect immunofluorescence test for an antiglomerular basement membrane antibody was negative. Whichi of the following diagnostic tests should be done first?

A.A transbronchial lung biopsy.

B.A video-assisted open lung biopsy.

C.A kidney biopsy.

D.A direct enzyme-linked immunosorbent assay for antiglomerular basement membrane antibody.

E.A serum test for an antineurophil cytoplasmic antibody.

此题相应的点评请参阅No.40的《CHEST 自测—点评》。


CHEST 自测-题目 (No.39)

A 34-year-old man received a second renal transplantation 2 years ago complicated by an episode of rejection 6 months prior to admission. He now presents complaining of a sore throat, back pain, weakness, and recent reduction in urinary output. Current medications are minoxidil, diltiazem, torsemide, metoprolol, tacrolimus, and prednisone.

His vital signs are normal except for blood pressure of 190 / 95 mm Hg. Physical examination reveals a well-developed, well-nourished man in no respiratory distress. A loud S4 is present at the apex. There is no edema. The laboratory results reveal a hemoglobin of 12 g / dL (120 g / L), WBC count 9 000 / mm3 (9 x 109 / L), blood urea nitrogen of 49 mg / dL (17.2 mm ol / L), and a serum creatinine of 4.1 mg / dL (312 um ol / L). The chest radiograph reveals mild cardiomegaly but is otherwise normal. On the sixth hospital day the patient develops an upper GI bleed with an episode of hypotension. Endoscopy shows moderate gastritis. The patient becomes oliguric with a further rise in blood urea nitrogen and creatinine requiring hemodialysis on the 8th and 9th hospital days. On the 10th hospital day, the patient is acutely short of breath. Upon transfer to the ICU, he requires immediate intubation and assisted ventilation. Vital signs and statistics on admission to the ICU reveal a weight of 80 kg (admission weight 76.6 kg), pulse 120 / min, temperature 36.8°C, blood pressure 130 / 60 mm Hg, and respirations 36 / min. Arterial blood gas analysis with the patient breathing 60% 02 showed PO2 54 mm Hg, PCO2 23 mm Hg, and pH 7.32 with an HCO3 of 17 mEq/L. The chest radiograph shows widespread alveolar infiltrates consistent with pulmonary edema and mild cardiomegaly. A pulmonary artery balloon catheter is inserted and the following pressures are obtained:

Right atrial, mean 12 mm Hg

Pulmonary artery, systolic / diastolic / mean 68 / 22 / 38 mm Hg

Pulmonary artery occlusion, mean 19 mm Hg

Cardiac output 8.24 L / min

Pulmonary vascular resistance 185

Systemic vascular resistance 680

The most likely cause of this patient's worsening respiratory distress is:

A. ARDS secondary to sepsis.

B. Hydrostatic pulmonary edema due to volume overload.

C. An opportunistic pulmonary infection.

D. Drug induced lung disease.

E. Aspiration of gastric contents.

此题相应的点评请参阅本期第463页的《CHEST 自测-点评》。


CHEST 自测-题目 (No.38)

The use of inhaled corticosteroids over 6 months to 3 years in patients with moderate to severe COPD (FEV1/FVC< 70%, FEV1< 80%) has improved all of the following outcomes EXCEPT:

A. Respiratory symptoms.

B. Rate of exacerbations.

C. 6 minute walking distance.

D. Rate of decline of lung function.

E. Rate of decline of health-related quality of life.

此题相应的点评请参阅No.38的《CHEST 自测-点评》。



CHEST 自测-题目 (No.37)

All of the following choices are statistically significant patient-related risk factors for the development of postoperative pulmonary complications EXCEPT:

A. Cigarette smoking.

B. General health status (ASA class >Ⅱ).

C. Age > 70.

D. Obesity.

E. Chronic obstructive pulmonary disease (COPD).

此题相应的点评请参阅No.37的《CHEST 自测-点评》。



CHEST 自测-题目 (No.36)

You are asked to see a 65-year-old man in consultation. Eighteen days ago the patient underwent his 5th course of nitrogen mustard, vincristine (Oncovin), procarbazine, and prednisone (MOPP) therapy for recurrent Hodgkin's disease. Five days ago, when the absolute neutrophil count (ANC) was 350/mm3 (0.35 x 109/L), he became febrile. Ceftazidime, ciprofloxacin, and vancomycin were started. He remained febrile and 2 days later (2 days prior to you seeing the patient) your partner performed bronchoscopy and BAL for aiding in the diagnosis of his fever. ANC was then 150/mm3 (0.15 x 109/L) and the chest radiograph and chest CT were clear with no evidence of an infiltrate. Fluconazole was started.

To date all cultures have remained sterile, the fever continued, reaching 39C, and the ANC is now 100/mm3 (0.1 x109/L). Electrolytes and serum chemistries remain unchanged except the creatinine has now risen to 3.0 mg/dL (240 μmol/L). Urine culture remains sterile and there are no white blood cells seen in the urine sediment. Repeat chest radiograph was unchanged and still clear. Physical examination, except for the fever and tachycardia, is entirdy within normal limits. Which of the following would you recommend?

A.Repeat bronchoscopy and BAL for cultures.

B.Recommend changing antibiotics to include gentamicin and imipenem and add itraconazole by mouth.

C.initiate itraconazole 200 mg twice daily by mouth.

D.Start amphotericin B infusions at 1.5 mg/kg/d.

E.Start liposomal amphotericin B at 6 mg/kg/d.

此题相应的点评请参阅No.36的《CHEST 自测-点评》。


CHEST 自测-题目 (No.35)

All of the following choices are statistically significant patient-related risk factors for the development of postoperative pulmonary complications EXCEPT:

A. Cigarette smoking.

B. General health status (ASA class >Ⅱ).

C. Age > 70.

D. Obesity.

E. Chronic obstructive pulmonary disease (COPD).

此题相应的点评请参阅No.35的《CHEST 自测-点评》。


CHEST 自测-题目 (No.34)

You are asked to evaluate an 85-year-old retired hospital executive whose chief complaint is exertional near-syncope with dyspnea of 3 months?duration, occurring after walking less than 1/3 block. He had coronary bypass 11 years ago, and left carotid endarterectomy 6 years ago. Despite excellent control of long-standing hypertension using a calcium channel blocking agent, progressive renal failure had been attributed to elevated blood pressure. Last year he required initiation of continuous ambulatory peritoneal dialysis.

Examination reveals a thin, frail, elderly man who is afebrile. Blood pressure is 132/70 mm Hg seated, pulse 84/min, respirations 19/min. Raised whorls of firm shiny pale white tissue replace the expected linear scars of endarterectomy and median sternotomy. Periungual telangiectasias are present and severe nail pitting is noted. A soft basal systolic murmur radiating to the carotids is present, with normal carotid upstroke. Coarse crackles are present at both lung bases. P2 is accentuated and clearly palpable in the second left intercostal space. The abdomen is distended by dialysis fluid and a catheter is in place. On further questioning you discover that the patient is troubled by frequent "heartburn" and for many years he has suffered from painful blanching of his hands on exposure to cold. The chest roentgenogram reveals sternotomy wires and bibasal interstitial infiltrates. Left ventricular ejection fraction by 2D echocardiography is approximately 50%; there is no pericardial effusion. Pulmonary function tests and right heart catheterization are scheduled.

While awaiting results of these studies, which of the following will be most helpful in determining the etiology of this patient's acute problem?

A.Rheumatoid latex agglutination test.

B.Anti-topoisomerase 1 (SCL-70).

C.Biopsy of skin from non-sun-exposed area.

D.Renal biopsy.

E.Open lung biopsy.

此题相应的点评请参阅No.34的《CHEST 自测-点评》。


CHEST 自测一题目 (No.33)

Which of the following statements regarding outcomes from pulmonary rehabilitation (PR) has the strongest supporting strength of evidence?

A. Lower extremity exercise improves exercise capacity.

B. Formal psychosocial interventions improve psychosocial function.

C. PR programs improve survival.

D. PR programs reduce hospitalizations.

E. PR programs improve health related quality of life (HRQL).

此题相应的点评请参阅No.33的《CHEST 自测一点评》。


CHEST自测-题目 (No.32)

All of the following in interventions have been demonstrated to reduce the incidence of ventilator-associated pneumonia in clinical trials EXCEPT:

A. Semirecumbent patient positioning.

B. Continuous suction of subglottic secretions.

C. Daily changes of heat and moisture exchanger.

D. Noninvasive face mask ventilation.

E. Multidisciplinary educational program.




A patient with normal spirometry takes a submaximal inspiratory volume (less than the known vital capacity) during the single-breath measurement of carbon monoxide diffusing capacity (DLCO). Which of the following statements regarding the subsequent measurement of DLCO is correct?

A. The measured DLCO will be reduced by the lung volume reduction but can be corrected by dividing the observed DLCO by the measured alveolar volume (DLCO/VA).

B. The measured DLCO will be reduced by the lung volume reduction but can be corrected by dividing the observed DLCO by the measured total lung capacity (DLCO/TLC).

C. The measured DLCO will be reduced by the lung volume reduction but can be corrected by dividing the observed DLCO by the inspired volume (DLCO/VI).

D. The measured DLCO requires no adjustments as it is unaffected by the inspired volume.

E. The measured DLCO will be reduced by the lung volume reduction but the reduction will be much less than a 1: 1 relationship with any measured lung volume.




Which of the following statements is correct regarding the American Thoracic Society standards for spirometry?

A. A minimum of two separte, acceptable spirometry trials should be performed.

B. The two largest FVC and FEV1 maneuvers should agree within 0.2 L.

C. The patient should exhale for a minimum of 5 seconds during the flow-volume loop measurement.

D. The FVC maneuver should continue until there is no volume change for 2 seconds.

E. The two largest peak expired flow (PEF) rates should agree within 20%.




All of the following statements regarding chronic hypoxemia and long-term oxygen therapy are correct EXCEPT:

A. Similar to the lung, systemic vascular beds vasoconstrict in the face of hypoxemia.

B. Chronic use of oxygen therapy in hypoxemic COPD patients will lower pulmonary artery pressures.

C. The delivery of supplemental oxygen to the alveoli occurs during the first third of inspiration.

D. The frequency of neuropsychological deficits is proportional to the degree of hypoxemia.

E. The hypoxemia that occurs during REM sleep in COPD patients is a result of hypotonia of the accessory muscles of

respiration and subsequent decrease in functional residual capacity (FRC) with ventilation-perfusion mismatch.




A 32-year-old man presents with recurrent episodes of “the flu.” He describes feelings of fatigue, malaise, mild cough, myalgias, rigors, and profuse sweating. He knows when he will become ill when he notes a sudden onset of thirst and a metallic taste in his mouth. He is an electric arc welder working with galvanized steel. The occupational medicine physician at the shipyard has given him multiple courses of antibiotics which have alleviated the symptoms by the next day, but the symptoms recur upon returning to work. He is otherwise healthy. Which of the following is the most likely cause of his problem?

A. IgE response to inhaled copper salts.

B. Arthus reaction to inhaled magnesium oxide.

C. Direct toxic effect of zinc oxide.

D. Direct toxic effect of inhaled antimony salts.

E. Direct activation of the alternate complement pathway by mycotoxins.




A 35-year-old woman is admitted to the ICU for respiratory distress due to acute lung injury. She is severely hypoxemic and has been sedated and intubated. Mechanical ventilation has been initiated and the patient continues to be restless and agitated. The nurse asks you whether she should start an infusion of midazolam. All of the following statements about starting an infusion of midazolam in this patient are true EXCEPT:

A. The duration of mechanical ventilation could be prolonged.

B. The length of the hospitalization could be prolonged.

C. The need for a tracheostomy may be increased.

D. The patient will become tolerant to midazolam.

E. Infusions are associated with metabolic acidosis.




All of the following lung diseases develop primarily in tobacco users EXCEPT:

A. Bronchogenic adenocarcinoma.

B. Eosinophilic granuloma.

C. Desquamative interstitial pneumonitis (DIP).

D. Hypersensitivity pneumonitis.

E. Goodpasture's syndrome.




All of the following are risk factors for the development of the first episode of pneumonia in residents of long-term care facilities EXCEPT:

A. Age.

B. Failure to receive influenza vaccination.

C. Male gender.

D. Swallowing difficulty.




In performing a cardiopulmonary exercise test for dyspnea evaluation, which parameter requires an arterial blood gas?

A. Dead space to tidal volume ratio.

B. Oxygen pulse.

C. Ventilatory equivalent for CO2.

D. CO2 output.

E. Peak oxygen uptake.




In which of the following patients would PET scanning yield the most useful clinical information in order to make a decision about proceeding to surgical resection?

A. A 52-year-old man with poorly controlled diabetes and a 60 pack-year smoking history with an undiagnosed 3-cm right lower lobe nodule.

B. A 55-year-old man with a 2.5-cm left lower lobe adenocarcinoma with a chest CT scan revealing normal sized mediastinal nodes.

C. A 50-year-old woman with a 4-cm right middle lobe adenocarcinoma with new neurologic findings.

D. A 46-year-old woman with a new 0.9-cm left lower lobe nodule with enlarged mediastinal nodes on chest CT and a history of bronchoalveolar cell carcinoma resected 1 year ago.

E. A 60-year-old never-smoking woman from Indiana with a history of histoplasmosis in the past now found to have a 2-cm pulmonary nodule on chest CT. No prior radiographs are available.




A holding chamber (spacer) for use with a pressurized metered dose inhaler (pMDI) consists of a cylindrical (or sometimes other geometric configuration) device placed between the pMDI and the patient. These devices perform which of the following functions?

A. Keeps the freon propellant in liquid form.

B. Allows pMDI activation to occur in mid inspiration.

C. Slows the velocity of the aerosol particles.

D. Decreases the electrostatic charge on the aerosol particles.

E. Permits exhalation into the chamber when a one-way valve is added.




Which one of the following statements concerning the effects of late pregnancy (third trimester) on lung function testing in healthy subjects is correct?

A. Vital capacity is reduced.

B. Functional residual capacity is unchanged.

C. Tidal volume is reduced.

D. Arterial PCO2 is reduced.

E. Arterial PO2 is reduced.




A 45-year-old man present to your office accompanied by his wife. They have agreed that he must stop smoking. He is committed and his wife is supportive. He has attempted to stop multiple times. He has ut back and currently smokes one half to one pack of cigarettes per day. He is otherwise healthy but has been using Wellbutrin (bupropion) 150 mg twice daily for mild depression for approximately 6 months. Which of the following initial therapies is most appropriate?

A. Nicotine gum in the 4-mg dose.

B. Nicotine patch at 7 mg per day.

C. Nicotine patch at 22 mg per day.

D. Zyban(bupropion) at 150 mg once daily for 3 days followed by 150 mg twice daily.

E. Nicotine patch 14 mg twice daily.




A 69-year-old retired physician presents to you for evaluation of persistent cough. The cough began about 3 months ago, was nonproductive, and began with a sore throat. Examination at that time showed a normal oropharynx and a temperature of 38.2 ℃, and he was given a 10-day course of levofloxacin. At the conclusion of the therapy the cough remained. Under the assumption that the cough was related to reactive airway disease, pulmonary function studies were ordered which were entirely normal. The sore throat and cough increased in severity and did not respond to two more courses of antibiotics and albuterol inhalers. Chest radiograph was normal and a thin-cut CT showed no abnormalities.

Physical examination in your office reveals an anxious man who is coughing every time he speaks. Vital signs are noraml except for temperature of 38.2 ℃. The oropharynx is normal, but the tongue is painful to touch. Except for minimal proximal thigh weakness, physical examination is within normal limits. Hemoglobin is 12 g/dL (120 g/L). WBC and platelet counts are within normal limits. Serum Chemistries and serum electrolytes are within normal limits. Urinalysis is also normal. Erythrocyte sedimentation rate is 110 mm/h. ECG is normal and a repeat chest radiograph reveals no abnormalities. Which diagnostic test will lead to the correct diagnosis?

A. Transthoracic echocardiogram.

B. Sputum culture for routine pathogens, fungi, and acid-fast bacilli.

C. A therapeutic trial of glucocorticoids for 2 weeks for cough.

D. Temporal artery biopsy.

E. Serum total and hemolytic complement levels.




You are asked to evaluate a 52-year-old woman who is admitted with 2 days of fever and cough productive of purulent sputum. On admission, the pulse is 120/min, blood pressure 80/60 mm Hg, and respirations 28/min. The following laboratory studies are reported: sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 99 mEq/L, and bicarbonate 16 mEq/L. Arterial blood gas measurements with the patient breathing room air show PO2 68 mm Hg, PCO2 24 mm Hg, and pH 7.44. What is the correct interpretation of this acid-base disorder?

A. Inconsistent and uninterpretable data.

B. Chronic respiratory alkalosis.

C. Respiratory alkalosis and anion gap metabolic acidosis.

D. Respiratory alkalosis, anion gap metabolic acidosis, and metabolic alkalosis.

E. Anion gap metabolic acidosis and hyperchloremic metabolic acidosis.




A 71-year-old man presents with nasal congestion, muscle aches, fevers to 39.4 ℃, cough, and increasing shortness of breath. He denies nausea, vomiting, or diarrhea. He has a history of insulin-requiring diabetes mellitus and chronic renal insufficiency. A nasopharyngeal swab is performed and a bedside rapid flu test is positive for influenza A. An infiltrate is seen in the left lower lobe on chest radiograph. He is hospitalized and therapy with oseltamivir is initiated. After 72 hours in the hospital the patient continues to have daily fevers to 39.4 ℃ and his shortness of breath and cough are worse. A repeat chest radiograph shows new infiltrates in the right lung and the left upper lobe. The most important next step would be to:

A. Add amantadine.

B. Begin corticosteroids.

C. Perform bronchoscopy with bronchoalveolar lavage.

D. Add effective antimicrobial therapy for Pseudomonas aeruginosa.

E. Add effective antimicrobial therapy for Staphylococcus aureus.



A 16-year-old adolescent presents with recurrent lower respiratory tract infections and high sweat chlorides. A diagnosis of cystic fibrosis is established. Repeat sputum cultures demonstrate Staphylococcus aureus sensitive to cephalosporins. Treatment with cephalexin three times per day would be expected to lead to:

A. Higher colonization rate of Pseudomonas aeruginosa.
B. Fewer hospitalizations.
C. Improved lung function.
D. Fewer respiratory symptoms.
E. Higher isolation rate of Staphylococcus aureus.




The health department of a large city received several reports of cases of a flu-like illness that often had a fulminant course leading to respiratory failure, shock, and death. A previously healthy 29-year-old office worker now presents with 3 days of fever, nonproductive cough, and myalgia. He denies risk factors for HIV infection. Physical examination is remarkable only for a pulse of 100/min, blood pressure 80/50 mm Hg, and reduced breath sounds at the lung bases. A chest radiograph shows clear lungs, mediastinal widening, and bilateral pleural effusions. Which test is mostly likely to confirm the correct diagnosis?

A. Sputum induction for Gram's stain and culture.

B. Sputum induction for acid-fast smear and culture.

C. Nasal swabs for viral culture.

D. Blood culture.

E. Pleural biopsy.




A 53-year-old woman with a chronic cough productive of yellow-green sputum is referred to you. She has had an intermittent cough for the past several years. In addition to the cough, she complains of significant postnasal drip, throat clearing, and mild intermittent dyspnea. There is no associated hemoptysis. A previous allergy work-up is reported as negative. She is allergic to erythromycin and penicillin. She has been treated with numerous antibiotics over the past year with some temporary improvement in the cough. She was diagnosed with non-Hodgkin's B-cell lymphoma 10 months ago and is on chemotherapy. She has no history of asthma, is a life-long nonsmoker, and is the mother of two children.

On physical examination she is a healthy appearing woman who coughs intermittently during the exam. Blood pressure is 125/70 mm Hg, pulse 90/min, respirations 16/min, and O2 saturation 94% on room air. Chest examination reveals scattered crackles and rhonchi bilaterally. The chest radiograph suggests bilateral lower lobe bronchiectasis, which is confirmed on high-resolution, thin-cut chest CT scan. Total IgE and total eosinophil count are both normal. A bronchoscopy is performed to obtain quantitative bacterial cultures before treatment is begun. Bronchoscopy reveals purulent material coming from both lower lobes. BAL is performed and quantitative culture results show > 105 cfu/mL of Streptococcus pneumoniae with intermediate resistant to penicillin (minimal inhibitory concentration of 1.0 mg/mL). She is treated with moxifloxacin for 2 weeks with an excellent response. Within a few days of stopping it the productive cough reoccurs. What laboratory test should be done next to evaluate the possible underlying cause of her bronchiectasis?

A. Quantitative serum immunoglobulins.

B. Sweat chloride test.

C. Measure subclass levels of IgG.

D. Aspergillus skin test.

E. Evaluation of T-cell function.




The recently completed National Emphysema Treatment Trial (NETT) compared outcomes in patients with severe emphysema who were randomized to either lung volume reduction surgery (LVRS) or optimal medical therapy. Compared to optimal medical therapy, the results showed that LVRS:

A. Produced no functional benefit and a higher overall mortality, primarily from early surgical mortality.

B. Was effective for improving functional status (but not survival) overall and provided a survival benefit in a prospectively identified subgroup with upper lobe predominance and poor functional status.

C. Was effective for improving functional status (but not survival) in those with homogeneous disease by chest CT scan, FEV1 < 20% predicted and DLCO < 20% predicted.

D. Was effective for improving functional status (but not survival) only in those with preoperative resting hypoxemia.

E. Produced an overall survival advantage but had no effect on functional status.




All of the following individuals with a tuberculin skin test of ≥ 5 mm of induration should receive treatment, EXCEPT:

A. HIV-positive individuals.

B. Recent contacts of a TB case.

C. Recent arrivals from a high prevalence country.

D. Fibrotic changes on a chest radiograph consistent with old TB.

E. Patients with organ transplants.




A 49-year-old man presents with acute, severe shortness of breath. He denies chest pain and hemoptysis. Two weeks prior to presentation, he had developed painless hematuria. An abdominal ultrasound suggested a renal cell carcinoma and nephrectomy was planned. He is in severe respiratory distress with a respiratory rate of 36 / min and an oxygen saturation of 83% while breathing supplemental oxygen with an FIO2 of 1.0. The patient is intubated and placed on mechanical ventilation. Initially, his pulse is 112 / min and his blood pressure is 136 / 76 mm Hg, but soon after admission his blood pressure falls to 76 / 42 mm Hg and vasopressors are started. A chest CT scan with contrast shows extensive clots filling the main right pulmonary artery and the left lower lobe pulmonary artery. An abdominal CT scan confirms a right renal tumor with encasement of both the renal vein and the inferior vena cava. What therapeutic intervention would you suggest?

A. Systemic heparin therapy.
B. Surgical resection of the pulmonary emboli.
C. Systemic thrombolytic therapy.
D. Local infusion of thrombolytic therapy into the pulmonary artery.
E. Combined chemotherapy and immunotherapy.




Which of the following statements concerning the therapeutic use of intravenous bicarbonate is supported by experimental evidence?

A. In hypoxia-related lactic acidosis, bicarbonate therapy reduces net lactate production and plasma lactate concentration.

B. Buffering of hypercapnic acidosis with bicarbonate worsens acute lung injury.

C. Bicarbonate administration to patients with ketoacidosis decreases ketone generation.

D. The administration of bicarbonate to hypercapnic patients with blood pH < 7.20 improves clinical outcome.

E. The intravenous administration of bicarbonate reduces systemic oxygen demand.




All of the following statements concerning the natural history of asthma are true EXCEPT:

A. The age-related decline in FEV1 is greater for asthmatic than nonasthmatic adults.

B. Most adult asthmatics do not experience complete asthma remission.

C. Regular use of inhaled corticosteroids is associated with reduced asthma mortality.

D. Delayed introduction of inhaled corticosteroids reduces the likelihood that FEV1 will normalize with therapy.

E. The risk of a fatal asthma episode is greatest for asthmatics with severe disease and fixed airflow obstruction.




All of the following statements regarding exercise-induced bronchoconstriction (EIB) are true EXCEPT:

A. EIB usually occurs shortly after exercise.

B. Most asthmatics experience bronchodilation during exercise.

C. Compared to mouth breathing, nasal breathing during exercise can reduce the magnitude of EIB.

D. Repeated bouts of exercise worsen the degree of EIB.

E. Exercise does not cause asthma.




In COPD patients with adequate awake oxygenation values but who are shown to have oxyhemoglobin desaturation with sleep, supplemental oxygen during sleep has been shown to:

A. Reduce pulmonary vascular pressure elevations associated with nocturnal oxyhemoglobin desaturation.

B. Reduce hospitalizations for COPD exacerbations.

C. Improve survival in a prospective trial.

D. Improve daytime functional status.

E. Improve daytime FEV1.




Which of the following statements is true regarding most episodes of acute lung rejection that occur more than 3 months after heart-lung transplantation?

A. Concordant cardiac rejection is present.

B. The chest radiograph is normal or unchanged.

C. The diagnosis can be made by bronchoalveolar lavage fluid analysis.

D. A surgical lung biopsy (open or video-assisted) is necessary for diagnosis.

E. Transbronchial lung biopsies show bronchiolitis obliterans.




Which of the following statements about obstructive sleep apnea syndrome (OSA) is true?

A. There is a 6-to 8-fold greater risk for adult men compared to adult women.

B. The prevalence is significantly higher in middle age (40 to 60 years old) compared to older age (> 60 years old).

C. The development of hypertension over a 4 to 5 year period is only associated with a moderate to high level elevation of apnea-hypopnea index (AHI > 15 per hour) at baseline.

D. Insulin resistance is more common in OSA patients, even after adjustment for body mass index (BMI).

E. Treatment of OSA consistently lowers both daytime and nocturnal blood pressure in the majority of hypertensive patients.



All of the following improve bronchodilator delivery from a metered-dose inhaler during mechanical ventilation EXCEPT:

A. Humidification.

B. Use of a spacer device.

C. Use with an inspiratory pause.

D. Use with a decelerating waveform (vs square flow waveform).

E. Positioning in the inspiratory limb (vs at the end of the endotracheal tube).




A 28-year-old man with sickle cell anemia presents to the emergency department with complaints of excruciating substernal chest pain increasing in severity over the past 6 hours with associated dyspnea. He describes the pain as constant and increased with inspiration. He also reports diffuse arm and leg pain. He reports a cough minimally productive of white sputum for the past 3 days. On physical examination he appears in pain. His temperature is 38.2 ℃, blood pressure 110/70 mm Hg, pulse 102 beats/min, and respiratory rate 32 beats/min. His mucosa is pale, and scattered crackles and wheezes are present on lung auscultation. He is diffusely tender to touch on his chest and extremities. Laboratory examination is notable for a leukocyte count of 15 000/mm3 (15*109/L) and hematocrit 28% (0.28) with hemoglobin 10 g/dL (100 g/L). Lactate dehydrogenase is 400 IU/L (400 U/L). The remainder of the examination is normal. Oxygen saturation while the patient is breathing room air is 88%. His chest radiograph reveals scattered basilar infiltrates. In addition to beginning supplemental oxygen, hydration, cefotaxime, azithromycin, and narcotic analgesia, the next best step in his initial management is:

A. Corticosteroids.

B. Heparin anticoagulation.

C. Packed red cell transfusion.

D. Change antibiotic regimen to cefepime and ciprofloxacin.

E. Hydroxyurea.



A 46-year-old man with nephrotic syndrome has dyspnea walking up a flight of stairs. One month ago, he had no difficulty walking four flights of stairs. He is a nonsmoker and does not have a history of trauma or dust exposure. He is scheduled for a renal biopsy for evaluation of his nephrotic syndrome next week. His serum creatinine is 3.5 mg/dL (309 mmol/L). Chest radiograph shows a right pleural effusion occupying approximately 25% of his hemithorax. Diagnostic thoracentesis shows a pH of 7.34, RBC count 120,000/mm3 (120 109/L), WBC count 25,000/mm3 (25*109/L) with lymphocytic predominance, glucose 90 mg/dL (5.0 mmol/L), and pleural fluid LDH to serum LDH ratio of 0.7. Pleural fluid cytology is negative for malignant cells.

With these findings, which of the following should you do next?

A. Order a contrast chest CT scan.

B. Begin oral corticosteroids.

C. Perform a therapeutic thoracentesis.

D. Place a thoracostomy tube.

E. Order a ventilation-perfusion scan.




A 65-year-old woman presents for pulmonary function testing to evaluate a nonproductive cough lasting several months. She denies heartburn or acid indigestion, but does note that the coughing is worse after she drinks liquids. She also complains of drooling after eating. There is no history of asthma or other respiratory disease, smoking, or occupational exposures. She is otherwise in good health and is using no medications. She reports that a recent chest radiograph obtained by her internist was normal. Spirometry show an FEV1 63% of predicted, FVC 63% of predicted, and FEV1/FVC ratio 93%. Total lung capacity is 91% of predicted and residual volume is 127% of predicted. The pulmonary function technician asks if you want additional testing. Which of the following diagnostic tests would you suggest?

A. Maximal voluntary ventilation.

B. FEV1 response to inhaled beta-adrenergic agonist.

C. Methacholine challenge.

D. Diffusing capacity.

E. No further testing.