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CD1
Question 1
A 28-year-old man is evaluated for a 6-month history of episodic dyspnea, cough, and wheezing.
As a child, he had asthma and allergies, but he has been asymptomatic since his early teenage
years. His recent symptoms started after an upper respiratory tract infection, and they are often
triggered by exercise or exposure to cold air. He is also awakened with asthma symptoms 5 or 6
nights a month. He is otherwise healthy and takes no medications.
On physical examination, vital signs are normal. There is scattered wheezing in both lung fields.
Chest radiograph is normal. Spirometry shows an FEV 1 of 70% of predicted with a 15%
improvement after inhaled albuterol.
Which of the following is the most appropriate therapy for this patient?
A-Azithromycin
B-Inhaled albuterol as needed
C-Inhaled low-dose corticosteroids plus inhaled albuterol as needed
D-Long-acting -agonist
E-Long-acting -agonist plus inhaled albuterol as needed
Question 2
A 73-year-old woman is evaluated in the emergency department for a 2-week history of worsening
dyspnea and a dry cough. She has not had fever or any recent travel. Idiopathic pulmonary fibrosis was
diagnosed 2 years ago by open lung biopsy. She also has a history of hypertension and
gastroesophageal reflux disease. Her medications are prednisone, diltiazem, hydrochlorothiazide, and
omeprazole.
On physical examination, she is afebrile; the blood pressure is 142/86 mm Hg, the pulse rate is 97/min,
the respiration rate is 28/min, and the BMI is 27. Oxygen saturation with the patient breathing oxygen, 10
L/min by face mask, is 90%. There are dry crackles at the lung bases extending half way up the chest
bilaterally. Cardiac and abdominal examinations are normal. Gram stain of sputum is negative; culture is
pending. CT scan of the chest is negative for pulmonary embolism but shows new areas of alveolar
infiltrates and consolidation superimposed on previous basilar, reticular, and honeycomb changes.
Which of the following is the most appropriate next test in the evaluation of this patient?
B-Fungal serologies
C-Right-heart catheterization
D-Swallowing evaluation
Question3
A 65-year-old woman is evaluated in a follow-up examination for dyspnea, chronic cough, and
mucoid sputum; she was diagnosed with chronic obstructive pulmonary disease 3 years ago.
The patient has a 40-pack-year history of cigarette smoking, but quit smoking 1 year ago. She is
otherwise healthy, and her only medication is inhaled albuterol as needed.
On physical examination, vital signs are normal. Breath sounds are decreased, but there is no
edema or jugular venous distention. Spirometry shows an FEV 1 of 62% of predicted and an
FEV1/FVC ratio of 65%. Chest radiograph shows mild hyperinflation.
Which of the following is the most appropriate therapy for this patient?
A-Add a long-acting 2-agonist
B-Add an inhaled corticosteroid
C-Add an oral corticosteroid
D-Add theophylline and montelukast
E-Continue current albuterol therapy
Question 4
A 52-year-old woman is evaluated after a screening CT colonography detected a 3-mm nodule in the
right lower lobe of the lung. A tortuous colon prevented complete screening colonoscopy. CT scan of
the chest showed no additional nodules and was otherwise normal. The patient has never smoked; she
works in the home and has not been exposed to potential carcinogens. She has not had a chest
radiograph or other imaging procedure, except mammography. Her medical history includes only
hyperlipidemia, and her only medication is simvastatin. Her family history is unremarkable.
On physical examination, vital signs are normal. Examination of the skin is normal; there is no
lymphadenopathy, and the lungs are clear.
Which of the following is the most appropriate next step in the management of this patient?
A-Chest radiograph in 3 months
B-CT scan of the chest in 3 months
C-CT scan of the chest in 6 months
D-CT scan of the chest in 12 months
E-No follow-up
Question 5
A 30-year-old man is evaluated for difficulty weaning from the ventilator. The patient was intubated 7 days
ago for a severe exacerbation of asthma. Despite receiving a high-dose inhaled -agonist;
methylprednisolone, 60 mg/d; and aggressive sedation, he had persistent severe auto-positive endexpiratory pressure with elevated ventilator pressures. Therefore, a continuous infusion of vecuronium, a
paralytic agent, was started and continued for 24 hours until his respiratory mechanics improved. Today, he
underwent a ventilator weaning trial but became tachycardic and diaphoretic with a rapid shallow breathing
index of 120.
On physical examination, the patient is alert and responsive; vital signs are normal. There is minimal
expiratory wheezing and otherwise normal vesicular breath sounds. He has flaccid weakness involving all
extremities, including decreased bilateral hand grip strength. There is no rash. Routine laboratory studies
reveal normal liver enzyme tests and renal function.
Which of the following is the most likely cause for the patients difficulty weaning from the ventilator?
A-Acute inflammatory demyelinating polyneuropathy (Guillain-Barr syndrome)
B-Churg-Strauss syndrome
C-Intensive care unitacquired weakness
D-Prolonged neuromuscular blockade
Question 6
A 54-year-old man is evaluated in the emergency department for a 1-hour history of chest pain with mild dyspnea.
The patient had been hospitalized 1 week ago for a colectomy for colon cancer. His medical history also includes
hypertension and nephrotic syndrome secondary to membranous glomerulonephritis, and his medications are
furosemide, ramipril, and pravastatin.
On physical examination the temperature is 37.5 C (100 F), the pulse rate is 120/min, the respiration rate is
24/min, the blood pressure is 110/60 mm Hg, and the BMI is 30. Oxygen saturation is 89% with the patient
breathing ambient air and 97% on oxygen, 4 L/min. Cardiac examination shows tachycardia and an S4. Breath
sounds are normal. Chest radiograph is negative for infiltrates, widened mediastinum, and pneumothorax. Serum
creatinine concentration is 2.1 mg/dL (185.6 mol/L). Empiric unfractionated heparin therapy is begun.
Which of the following is the best test to confirm the diagnosis in this patient?
Question 7
A An 18-year-old man is evaluated in the emergency department after his mother found him unconscious in his bed at home. She reported that her son had gone to a
party two nights ago, but she was not sure when he returned home. When she checked on him, he was unarousable. He has no significant medical history and takes no
medications.
In the emergency department, he is afebrile, blood pressure is 110/70 mm Hg, the pulse rate is 50/min, and respiration rate is 6/min; he is intubated for airway protection.
Laboratory studies:Hemoglobin 12.2 g/dL (122 g/L)
Leukocyte count 3400/L (3.4 109/L)
Platelet count 110,000/L (110 109/L)
Creatinine
46 U/L
1.2
Alkaline phosphatase, bilirubin, and albumin are normal. Urine dipstick is 4+ positive for occult blood. Blood alcohol level is 0.8 g/dL (174 mmol/L). Toxicology testing is
positive for opiates and cocaine. Bladder catheterization reveals only 30 mL of brown urine.
Which of the following is the most likely cause of the patients renal failure?
A-Hemolytic anemia
B-Hemolytic-uremic syndrome
C-Hepatorenal syndrome
D-Rhabdomyolysis
E-Sepsis
Question 8
A 70-year-old man is evaluated in the emergency department for a 2-day history of dyspnea with exertion, orthopnea, and paroxysmal nocturnal dyspnea. He has ischemic
heart disease with left ventricular dysfunction and had coronary artery bypass graft surgery 6 weeks ago. His medications include aspirin, nitroglycerin, metoprolol, lisinopril,
and furosemide.On physical examination, the patient is sitting upright and breathing with difficulty; the temperature is 37 C (98.6 F), the blood pressure is 150/85 mm Hg, the
pulse rate is 105/min and regular, and the respiration rate is 28/min. Oxygen saturation is 89% on ambient air. There are fine crackles at the lung bases bilaterally, and breath
sounds are diminished at the right base. There is a regular tachycardia and an S 3 at the apex. There is no jugular venous distention or peripheral edema. Hemoglobin is 12.5
g/dL (125 g/L), and the leukocyte count is 10,500/L (10.5 10 9/L). Chest radiograph shows cardiomegaly and small bilateral pleural effusions, greater on the right than the
left. Thoracentesis is performed, and pleural fluid analysis shows:
Nucleated cell count450/L with 3% neutrophils, 70% lymphocytes, 10% macrophages, 15% mesothelial cells, and 2% eosinophils.
Pleural fluid to serum total protein ratio
Lactate dehydrogenase (LDH)
0.54
125 U/L
Total protein
Ph 7.45
Albumin
Cholesterol
0.52
Question 9
A 20-year-old woman is evaluated in the emergency department for an acute episode of wheezing and dyspnea
without cough or sputum production. She has had previous frequent evaluations in emergency departments and
urgent care centers for similar episodes. In between these episodes, findings on physical examination and
pulmonary function testing, including methacholine challenge, have been normal. She is otherwise healthy and
takes no medications.
On physical examination, the patient has inspiratory and expiratory wheezing and is in moderate discomfort. The
temperature is 37.1 C (98.8 F), pulse rate is 100/min, and the respiration rate is 24/min; oxygen saturation on
ambient air is 96%. After receiving albuterol and intravenous corticosteroids, she continues to wheeze and is in
moderate respiratory distress. Oxygen saturation on ambient air remains at 96%. Chest radiograph shows
decreased lung volumes.
Which of the following is the most appropriate management for this patient?
A-Chest CT scan
B-Intravenous aminophylline
C-Intravenous azithromycin
D-Intravenous terbutaline
E-Laryngoscopy
Question 10
A 72-year-old woman is evaluated for fatigue and decreased exercise capacity. The patient has severe
chronic obstructive pulmonary disease, which was first diagnosed 10 years ago, and was hospitalized for
her second exacerbation 1 month ago. She is a former smoker, having stopped smoking 5 years ago. She
has no other significant medical problems, and her medications are albuterol as needed, an inhaled
corticosteroid, a long-acting bronchodilator, and oxygen, 2 L/min by nasal cannula.
On physical examination, vital signs are normal. Breath sounds are decreased, and there is 1+ bilateral
pitting edema. Spirometry done 1 month ago showed an FEV 1 of 28% of predicted, and blood gases
measured at that time (on supplemental oxygen) showed pH 7.41, PCO 2 43 mm Hg, and PO2 64 mm Hg;
DLCo is 30% of predicted. There is no nocturnal oxygen desaturation. Chest radiograph at this time shows
hyperinflation. CT scan of the chest shows homogeneous distribution of emphysema.
Which of the following would be the most appropriate management for this patient?
A-ung transplantation
D-Pulmonary rehabilitation
Question 11
A 71-year-old woman is evaluated for a 3-week history of mild pain in the shoulders and thighs and weakness
when rising from a seated position and getting out of bed. She also has a new rash on her hands. Eight months
ago she was evaluated for dyspnea and new interstitial infiltrates that resulted in a lung biopsy and a diagnosis
of idiopathic nonspecific interstitial pneumonia. She was treated with prednisone, 60 mg/d, for 1 month; the dose
was then tapered to 10 mg/d. Her symptoms had been stable on that dose until her new complaints.
On physical examination, there are swelling and discoloration of the eyelids and an erythematous scaly rash
over the extensor surfaces of interphalangeal joints of both hands. There is symmetric weakness of the proximal
hip flexors and shoulder girdle muscles; hand strength is normal. Laboratory studies show antinuclear antibodies
positive at a titer of 1:1280 (previously negative), serum creatine kinase 1270 U/L, and erythrocyte
sedimentation rate 60 mm/h; serum electrolytes and complete blood count are normal. Chest radiograph shows
bilateral reticular and alveolar abnormalities in the lower- and mid-lung zones.
Which of the following is the most appropriate management for this patient?
C-Skin biopsy
Question 12
A 74-year-old man is evaluated for a 5-year history of gradually progressive dyspnea and dry cough without wheezing or hemoptysis. For the
past 2 years he has had pain and occasional swelling in both knees. He has not had fever or lost weight. He smoked one pack of cigarettes a
day from the age of 18 to 60 years. He worked as an insulator for 40 years.
Physical examination shows no digital clubbing or cyanosis. Auscultation of the lungs reveals bilateral end-inspiratory crackles. Pulmonary
function testing shows:
Total lung capacity
Residual volume
67% of predicted
72% of predicted
FVC
65% of predicted
FEV1
75% of predicted
Question 13
Which of the following is the most appropriate therapy for this patients delirium?
A-Diphenhydramine
B-Haloperidol
C-Lorazepam
D-Propofol
Question 14
A A 60-year-old woman is evaluated 3 weeks after starting continuous positive airway pressure (CPAP)
therapy for obstructive sleep apnea. The patient was initially evaluated for excessive sleepiness, and
obstructive sleep apnea was diagnosed based on results of polysomnography. It was determined that CPAP
at a pressure of 14 cm H2O normalized respiration and oxygen saturation during sleep. She was prescribed
CPAP at this pressure along with heated humidification administered via a nasal mask. She has been using
CPAP, but she is still often sleepy during the day. She has a history of hypertension and osteoarthritis, and
her medications are hydrochlorothiazide and ibuprofen. She does not smoke or drink alcohol.
On physical examination, she is afebrile; the blood pressure is 145/85 mm Hg, and the BMI is 36.5. She
has a slightly receding jaw; otherwise, physical features are unremarkable.
Which of the following is the most appropriate next step in the management of this patient?
A-Order a multiple sleep latency test
B-Prescribe hormone replacement therapy
C-Prescribe modafinil
D-Review CPAP compliance
Question 15
A 28-year-old man is evaluated for a 9-month history of daily cough productive of yellow sputum and
intermittent low-grade fever. He has had three episodes of pneumonia during that time; the symptoms
improve with antibiotic therapy but return when therapy is discontinued. The patient does not have a history
of aspiration, asthma, or sinusitis, and he takes no medications. He has never smoked.
On physical examination, the temperature is 37.4 C (99.3 F), the pulse rate is 88/min, the respiration rate
is 18/min, the blood pressure is 116/58 mm Hg, and the BMI is 24. Breath sounds are reduced in the right
base; the lungs are otherwise clear. Laboratory tests are normal. Two chest radiographs 3 months apart
have shown an infiltrate in the right lower lobe. Contrast-enhanced CT scan of the chest shows right lower
lobe bronchiectasis and partial volume loss of this lobe; endobronchial obstruction is suggested. There is no
lymphadenopathy.
Question 16
A 28-year-old man is A 30-year-old medical resident is evaluated for cough, right-sided chest pain, and fever of 21 days duration. He has no
significant medical history or family history, and he takes no medications.
Hemoglobin is 14 g/dL (140 g/L), and the leukocyte count is 8000/L (8 10 9/L). Chest radiograph shows a right pleural effusion occupying
approximately 50% of the hemithorax without other abnormalities. Thoracentesis yields turbid, yellow fluid, and analysis shows:
Erythrocyte count 500/L
Nucleated cell count
eosinophils
Total protein
3500/L (3.5 10 9/L) with 20% neutrophils, 60% lymphocytes, 10% macrophages, 4% mesothelial cells, and 6%
7.35
Glucose
Serum total protein is 7.0 g/dL (70 g/L) and serum lactate dehydrogenase is 100 U/L. Gram stain shows no organisms and culture is pending.
Question 17
A 28-year-old man is evaluated in the emergency department for a 2-day history of worsening dyspnea and
wheezing in conjunction with an upper respiratory tract infection. The patient has a history of asthma, and his
medications are inhaled mometasone and albuterol. In the emergency department, the patient is anxious and is
using accessory muscles to breathe; he cannot speak in full sentences. The oxygen saturation is 90% while he
is breathing ambient air. Breath sounds are reduced bilaterally, with faint diffuse expiratory wheezes. He is given
albuterol by nebulizer, and use of accessory muscles is reduced. Bedside spirometry shows an FEV 1 of 35% of
predicted; he is given two more treatments of nebulized albuterol.
After treatment, the patient is alert with slight use of accessory muscles; he can speak in short full sentences.
Vital signs are stable; oxygen saturation is 98% with the patient receiving oxygen, 2 L/min. Breath sounds are
louder than on initial examination, and wheezing is more intense. Spirometry shows an FEV 1 of 50% of
predicted.
Which of the following is the most appropriate next step in the management of this patient?
A-Admit the patient to a regular medicine ward
B-Discharge the patient on his baseline asthma treatment regimen
C-Intubate and admit the patient to the intensive care unit
D-Monitor the patient in the intensive care unit
Question 18
A 65-year-old man is admitted to the intensive care unit for gram-negative sepsis. The patients
medical history is significant only for hyperthyroidism for which he takes methimazole. On day 2 in
the intensive care unit, he undergoes rapid sequence intubation with propofol and succinylcholine
for worsening hypoxemic respiratory failure resulting from the acute respiratory distress syndrome.
The patient receives intermittent lorazepam and fentanyl boluses intravenously for sedation.
Several hours later, the patient becomes febrile (temperature 40 C [104 F]), hypertensive, and
tachycardic. On examination, he is diaphoretic and has muscular rigidity. Arterial blood gas analysis
shows a metabolic and respiratory acidosis, and laboratory results are significant for an elevated
serum creatine kinase level.
Which of the following is the most likely cause of the patients clinical deterioration?
A-Malignant hyperthermia
B-Neuroleptic malignant syndrome
C-Serotonin syndrome
D-Thyroid storm
Question 19
A 24-year-old woman with persistent asthma, which is well controlled on low-dose fluticasone
and albuterol as needed, became pregnant 2 months ago and asks for advice about asthma
therapy during her pregnancy. Before she started fluticasone therapy, she had frequent asthma
symptoms and occasional exacerbations requiring emergency department treatment. Since she
became pregnant, her asthma has remained under good control. The physical examination is
unremarkable, and spirometry is normal.
Which of the following is the most appropriate management for this patient?
A-Continue the current regimen
B-Stop fluticasone; add theophylline
C-Stop fluticasone; add salmeterol
D-Stop fluticasone; add inhaled cromolyn
Question 20
A 64-year-old woman is evaluated for a 6-week history of dyspnea, dry cough, fever, chills, night sweats, and
fatigue, which have not responded to treatment with azithromycin and levofloxacin; she has lost 2.2 kg (5 lb)
during that time. The patient had a thorough examination 6 months ago while she was asymptomatic that
included routine laboratory studies, age- and sex-appropriate cancer screening, and a chest radiograph; all
results were normal. The patient has never smoked, has had no known environmental exposures, and has not
traveled recently or been exposed to anyone with a similar illness. Her only medications are aspirin and a
multivitamin.
On physical examination, temperature is 37.8 C (100.0 F); other vital signs are normal. Cardiac examination
is normal. There are scattered crackles in the mid-lung zones with associated rare expiratory wheezes. There
is no digital clubbing. Musculoskeletal and skin examinations are normal. Chest radiograph is shown .
Question 21
A 35-year-old woman is evaluated in the hospital for chest pain and dyspnea 1 day after vaginal
delivery of her second child. She had an uncomplicated pregnancy but a prolonged labor.
On physical examination, the temperature is 37.0 C (98.6 F), the blood pressure is 100/60 mm
Hg, the pulse rate is 115/min, and the respiration rate is 22/min. The lungs are clear, heart
sounds are normal, and there is no evidence of bleeding on pelvic examination. Complete blood
count on admission revealed a hematocrit of 34% and a platelet count of 150,000/L (150
109/L). Chest radiograph is normal. Ventilation/perfusion scan shows mismatched perfusion
defects in 20% of her lung volume.
Question 22
A 60-year-old man is evaluated during routine follow-up in November. The patient has severe chronic obstructive
pulmonary disease, with dyspnea on minimal exertion and a chronic cough. He has a 40-pack-year history of
cigarette smoking, but he quit smoking 3 years ago. His medications are albuterol as needed, inhaled corticosteroids,
and tiotropium.
On physical examination, the patient is afebrile, blood pressure is 140/88 mm Hg, pulse rate is 90/min, and
respiration rate is 20/min. Oxygen saturation with the patient at rest and breathing ambient air is 86%. Jugular venous
distention and a loud P 2 are present. The chest is hyperinflated and breath sounds are diminished. There is 1+ pedal
edema.
Hemoglobin concentration is 16.5 g/dL (165 g/L). Arterial blood gases show pH 7.35, PCO 2 55 mm Hg, and PO 2 55
mm Hg on ambient air. Spirometry shows an FEV 1 of 25% of predicted. Chest radiograph shows hyperinflation but no
infiltrates.
Which of the following is the most appropriate therapy for this patient?
A-Continuous oxygen
B-Nocturnal oxygen
C-Oxygen as needed
D-Oxygen during exercise
Question 23
A 23-year-old man seeks medical advice for an upcoming mountain expedition. A year earlier, a
planned 45-day trek to Lhotse in Nepal (elevation 8516 m [27,940 ft]) was cut short when he
developed severe dyspnea and cough productive of blood-tinged, frothy sputum shortly after
leaving the base camp (elevation 4930 m [16,174 ft]). When his symptoms persisted despite
oxygen therapy, he was aided down the mountain. He plans to return to the high Himalayas for
another attempt to climb the Lhotse summit.
Question 24
A 40-year-old man is evaluated for shortness of breath and left-sided chest discomfort without cough, fever, or hemoptysis. He had a contusion to the left
side of his chest and back 1 week ago in an automobile accident. Chest radiograph immediately after the accident showed no fracture of the spine or ribs,
but he had severe contusions on his back and on the left side of the chest. The patient has a history of lymphoma.
Examination of the chest shows dullness to percussion and decreased breath sounds on the left side. Chest radiograph shows a moderate-sized, left-sided
pleural effusion without a pneumothorax. Serum protein is 5.8 g/dL (58 g/L), cholesterol 200 mg/dL (5.2 mmol/L), and triglycerides 100 mg/dL (1.13 mmol/L).
Thoracentesis yields 500 mL of pleural fluid, and analysis shows:
Cell count Erythrocytes 300/L; leukocytes 890/L (0.89 10 9/L) with 65% lymphocytes, 22% neutrophils, 8% mesothelial cells, and 4% eosinophils
Total protein
Cholesterol
Cytology, Gram stain, acid-fast bacilli stain, and bacterial culture are negative.
Question 25
A 56-year-old woman is evaluated for a 2-month history of a drooping eyelid, difficulty chewing food and
swallowing, and slurred speech. The symptoms are worse when she is tired. The patient has a 15-pack-year
history of cigarette smoking but quit smoking 10 years ago. She is otherwise healthy and takes no medications.
On physical examination, the temperature is 37.0 C (98.6 F), the blood pressure is 118/60 mm Hg, the pulse
rate is 72/min, the respiration rate is 16/min, and the BMI is 24.5. There is right-sided ptosis; pupils are equal in
size and reactive, and eye movements are normal. Brief neurologic examination is normal, and there is no
lymphadenopathy. Routine laboratory studies are normal; acetylcholine receptor binding antibody level is 46.8
nmol/L (normal range, less than 0.2 nmol/L). Chest radiograph shows a 3-cm anterior-superior mediastinal
mass. CT scan of the chest is shown .
Question 26
A 59-year-old man is evaluated for tachycardia and hypertension 6 hours after undergoing an
uncomplicated open cholecystectomy under general anesthesia. The patient had intraoperative high blood
pressure and was treated postoperatively with metoprolol, 5 mg every 4 hours by intravenous bolus. The
patient underwent repair of a laceration of the liver 5 years ago and had an uncomplicated intraoperative
and postoperative course. He has a history of essential hypertension, and his medications are
hydrochlorothiazide and metoprolol.
On physical examination, the temperature is 39.2 C (102.5 F), the blood pressure is 190/110 mm Hg,
and the pulse rate is 115/min. There is significant rigidity of all his extremities.
Which of the following is the most appropriate therapy for this patient?
A-Alcohol sponge baths
B-Ampicillin-sulbactam
C-Corticosteroids
D-Dantrolene
E-Sodium nitroprusside
Question 27
A 56-year-old woman is evaluated for a 2-year history of episodic cough and chest tightness.
Her symptoms began after a severe respiratory tract infection. Since then, she has had cough
and chest discomfort after similar infections, typically lasting several weeks before resolving.
She feels well between episodes. She is otherwise healthy and takes no medications. Physical
examination reveals no abnormalities, and spirometry is normal.
Which of the following is the most appropriate next step in the evaluation of this patient?
A-Bronchoscopy
B-CT scan of the sinuses
C-Exercise echocardiography
D-Methacholine challenge testing
Question 28
A 55-year-old man with a 7-year history of severe chronic obstructive pulmonary disease is evaluated
after being discharged from the hospital following an acute exacerbation; he has had three
exacerbations over the previous 18 months. He is a long-term smoker who stopped smoking 1 year
ago. He adheres to therapy with albuterol as needed and inhaled salmeterol and tiotropium and has
demonstrated proper inhaler technique.
On physical examination, vital signs are normal. Breath sounds are decreased bilaterally; there is no
edema or cyanosis. Oxygen saturation after exertion is 92% on ambient air. Spirometry shows an
FEV1 of 32% of predicted and an FEV 1/FVC ratio of 40%. Chest radiograph done in the hospital 3
weeks ago showed no active disease.
Question 29
A 54-year-old woman is evaluated after a 1.5-cm nodule was detected in the right lower lobe of the lung on a chest
radiograph done to evaluate new-onset dyspnea on exertion. The nodule was not present on a chest radiograph done
8 years ago. The patient lives in Missouri and has not traveled recently. She has a 30-pack-year history of cigarette
smoking but quit smoking 3 years ago. Her medical history includes hypertension and hyperlipidemia, and her
medications are hydrochlorothiazide and atorvastatin. There is no family history of lung cancer.
On physical examination, the temperature is 36.8 C (98.0 F), the blood pressure is 124/72 mm Hg, the pulse rate is
64/min, and the respiration rate is 14/min. The lungs are clear, the skin is normal, and there is no lymphadenopathy.
Pulmonary function testing shows mild airway obstruction and no acute response to a bronchodilator. Contrastenhanced CT scan of the chest shows the nodule to be uncalcified on thin-section images, and there was no
significant enhancement (10 Hounsfield units) on dynamic contrast study.Histoplasma serology is negative.
Which of the following is the most appropriate management for this patient?
A-Bronchoscopy and biopsy of the lesion
B-CT-guided transthoracic biopsy of the lesion
C-Repeat CT scan in 3 months
D-Video-assisted thoracoscopic surgery to remove the nodule
E-No further evaluation
Question 30
A previously healthy 62-year-old man was intubated 3 days ago for the acute respiratory distress syndrome complicating communityacquired pneumonia. His condition improved with antibiotic therapy and supportive care. He was extubated 2 hours ago after
tolerating a trial of spontaneous breathing, but he has subsequently developed respiratory distress.
The patient is alert, cooperative, and speaking in short sentences. The temperature is 36.9 C (98.4 F), blood pressure is 150/90 mm
Hg, pulse rate is 110/min, and respiration rate is 34/min. Oxygen saturation is 86% on FiO 2 0.7 by face mask. There are inspiratory
crackles bilaterally, and the patient is using neck and abdominal muscles to breathe. Cardiac examination reveals regular tachycardia
without extra sounds or murmurs; the jugular venous pressure could not be assessed because of the patients respiratory effort.
Arterial blood gases at the end of the breathing trial on FiO 2 0.4 included pH 7.38, PCO 2 35 mm Hg, and PO2 68 mm Hg. His current
blood gases following extubation on FiO 2 0.7 are pH 7.30, PCO2 45 mm Hg, and PO2 56 mm Hg.
Chest radiograph after extubation shows reduced lung volumes but otherwise no change in bilateral alveolar infiltrates from his
previous radiograph.
Which of the following is the most appropriate management for this patient?
A-Administer intravenous furosemide
B-Administer intravenous naloxone
C-Increase FiO2 to 1.0
D-Reintubate and resume mechanical ventilation
E-Start noninvasive positive-pressure ventilation
Question 31
A 52-year-old man is evaluated for a 7-month history of progressive dyspnea, initially with vigorous exertion; now, even
walking slowly causes immediate severe dyspnea and dizziness. The symptoms subside when he is at rest. He has had
two syncopal episodes, both while he was walking at a brisk pace. He does not have cough, chest pain, or wheezing. He
has no other significant medical history and takes no medications.
On physical examination, the temperature is 37.0 C (98.6 F), the blood pressure is 105/60 mm Hg, the pulse rate is
102/min at rest and 120/min after the patient walks across the room, the respiration rate is 20/min, and the BMI is 32. Lung
expansion is normal during deep breathing. Jugular venous distention is present. Lungs are clear to auscultation with no
wheezes or crackles. There is fixed splitting of S 2 with an increased pulmonic component. There is a grade 1-2/6
holosystolic murmur at the left sternal border near the fourth rib that increases with inspiration. The lower extremities are
edematous. There is no cyanosis or clubbing.
Complete blood count and resting arterial blood gases are normal. Electrocardiography shows a rightward QRS axis and
large R waves in V1. Spirometry and plethysmography are normal. The chest radiograph shows no infiltrates or masses.
Which of the following is the best next step in the evaluation of this patient?
A-Bronchoscopy and transbronchial lung biopsy
B-Methacholine challenge test
C-Right-heart catheterization and pulmonary angiography
D-Transthoracic echocardiography
Question 32
A 20-year-old male college student is evaluated for a 3-year history of persistent daytime
sleepiness. He snores loudly but has had no witnessed apneas or cataplexy. He has occasional
episodes of sleep paralysis in which he cannot move for about a minute after awakening from
sleep. He typically goes to bed at 11:30 PM on weekdays and at 1:00 AM on weekends. He falls
asleep easily, sleeps uneventfully, and awakens at about 6:00 AM on weekdays and 11:00 AMon
weekends. His medical history includes depression diagnosed 1 year ago for which he takes a
selective serotonin reuptake inhibitor. He drinks three or four caffeinated drinks a day.
Which of the following is the most appropriate management for this patient?
A-Order thyroid function tests
B-Perform a multiple sleep latency test
C-Prescribe modafinil
D-Recommend longer nighttime sleep
E-Refer for polysomnography
Question 33
A 37-year-old man with asthma is evaluated for frequent episodes of wheezing and dyspnea
unrelieved by short-acting -agonist therapy. He uses his controller medications regularly, including an
inhaled long-acting -agonist and inhaled high-dose corticosteroids. He has symptoms daily and
frequent nocturnal symptoms.
On physical examination, the patient is in mild respiratory distress. The temperature is 37.0 C (98.6
F), blood pressure is 140/85 mm Hg, pulse rate is 90/min, and respiration rate is 18/min. He has
bilateral wheezing. Spirometry shows an FEV 1 of 65% of predicted. After the supervised use of a
bronchodilator in the office, there was some relief of symptoms, and repeat spirometry 10 minutes
after the administration of the bronchodilator showed that the FEV 1increased to 85% of predicted.
Which of the following is the appropriate next step in this patients management?
A-Add a leukotriene modifying drug
B-Have the patient demonstrate his inhaler technique
C-Have the patient keep a symptom and treatment log
D-Start oral prednisone therapy
Question 34
A 19-year-old woman is evaluated in the emergency department for low-grade fever, muscle aches, cough, and
progressively severe shortness of breath of 1 weeks duration. She requires intubation and mechanical ventilation. The
patient recently moved to the United States from Japan. She started smoking cigarettes 3 weeks ago and smokes a pack
a day.
On physical examination, the temperature is 37.2 C (99.0 F), the blood pressure is 128/60 mm Hg, the pulse rate is
110/min, and the respiration rate is 22/min on mechanical ventilation. Cardiac examination is normal. There are bilateral
crackles posteriorly. The rest of the general physical examination is normal. The hemoglobin is 14.3 g/dL (143 g/L); the
leukocyte count is 16,888/L (16.9 10 9/L) with 52% neutrophils, 4% monocytes, 20% lymphocytes, and 24% eosinophils;
and the platelet count is 345,000/L (345 10 9/L). Chest CT scan with intravenous contrast shows bilateral focal areas of
consolidation with scattered ground-glass opacification, small bilateral pleural effusions, and no evidence of pulmonary
embolism. Bronchoscopy with bronchoalveolar lavage shows no organisms on Gram stain or fungal stain; cell count is
elevated, and the differential shows 30% neutrophils, 6% macrophages, 4% lymphocytes, and 60% eosinophils. Blood and
sputum cultures are negative after 2 days.
Question 35
A 42-year-old man is evaluated in the hospital for dyspnea and pleuritic chest pain. The patient had a
fracture of the right femur 3 weeks ago. He has hypertension, and his only medication is
hydrochlorothiazide.
On physical examination, the temperature is 38.1 C (100.6 F), the pulse rate is 110/min, the respiration
rate is 22/min, the blood pressure is 130/78 mm Hg, and the BMI is 24. Routine laboratory studies are
normal; serum troponins are undetectable. Electrocardiography shows increased height of R waves in leads
V4-V6; the QRS complex has a leftward axis. Contrast-enhanced CT scan shows pulmonary emboli in the
arteries perfusing the lingula and the posterior basal segment of the left lower lobe.
Which of the following is the most appropriate treatment for this patient?
A-Inferior vena cava filter
B-Intravenous unfractionated heparin
C-Intravenous tissue plasminogen activator
D-Mechanical clot dissolution
E-Surgical embolectomy
Question 36
A 59-year-old man with chronic obstructive pulmonary disease is evaluated before planned air
travel from Denver, Colorado, to Beijing, China. He is physically active but has episodic
wheezing and a racing heartbeat with exertion. His current therapy consists of inhaled
bronchodilators and supplemental continuous oxygen at 2 L/min.
On examination, the pulse rate is 68/min, respiration rate is 18/min, and oxygen saturation is
90% with the patient breathing oxygen, 2 L/min. Cardiac examination is normal. Breath sounds
are distant without wheezes or crackles. Chest radiograph shows hyperexpanded lungs but no
infiltrates or bullae.
Which of the following is the most appropriate next step in this patients management?
A-Calculate oxygen needs using a prediction algorithm
B-Order a hypoxia inhalation test
C-Prescribe in-flight supplemental oxygen level at 3 L/min
D-Recommend that the patient not fly
Question37
A 36-year-old man is evaluated for a 1-year history of progressive shortness of breath; his wife has noticed that he has a dry cough and wheezing
when he returns from work. The patient has worked as an automobile painter for the past 4 years. He has a 5-pack-year history of cigarette
smoking, but quit smoking 8 years ago. He has no history of allergic disease.
On physical examination, vital signs and review of systems are normal. Chest radiograph is normal. Pulmonary function testing shows:
FEV1 52% of predicted
FVC 83% of predicted
FEV1/FVC ratio 47%
DLCO 85% of predicted
Spirometry after a bronchodilator shows:
FEV1 83% of predicted
FVC
100% of predicted
Which of the following would be an appropriate next step in the evaluation of this patient?
A-Chest CT scan
B-Methacholine challenge test
C-Obtaining a detailed description of his current job tasks
D-Skin testing to common aeroallergens
Question 38
A 20-year-old man with a history of severe asthma is brought to the emergency department obtunded and in
severe respiratory acidosis from an acute exacerbation of his asthma. He is intubated in the emergency
department, and 30 minutes later he is evaluated in the intensive care unit.
On physical examination, the patient is sedated and unresponsive; he is afebrile, and the blood pressure is
80/40 mm Hg, pulse rate is 140/min, and respiration rate is 24/min. Oxygen saturation is 98%. There are
diffusely decreased breath sounds with faint bilateral expiratory wheezes. Cardiac examination reveals distant
regular tachycardic rhythm but is otherwise normal. Ventilator settings include volume control mode with a set
rate of 24, tidal volume 800 mL (12 mL/kg ideal body weight), positive end-expiratory pressure 5 cm H 2O, and
FiO2 0.6. Arterial blood gases are pH 7.30, PCO 2 40 mm Hg, and PO2 180 mm Hg. Chest radiograph shows
hyperinflation and a properly placed endotracheal tube.
Which of the following would most rapidly improve the patients hypotension?
A-Administer thrombolytic therapy
B-Disconnect the patient from the ventilator for 30 seconds
C-Perform pericardiocentesis
D-Place chest tubes bilaterally