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Select the ONE answer that is BEST in each case.
A 33-year-old farmer complains of recurrent episodes of wheezing after working in a barn where hay is stored. On auscultation, there are bibasilar crackles and heart sounds are normal. His laboratory work is normal with no increase in eosinophils and the chest x-ray (CXR) reveals patchy lower lobe infiltrates. Which of the following is the most likely diagnosis?
Hypersensitivity pneumonitis is an inflammatory disorder of the lungs involving alveolar walls and terminal airways that is caused by repeated exposure to organic agents. In this example of “farmer’s lung,” the inhalation of antigens present in moldy hay such as thermophilic actinomyces or Aspergillus species are the causative agents. When exposure to moldy hay is stopped, symptoms and signs of farmer’s lung all tend to abate and complete recovery usually follows. In acute syndromes, the presentation is 4–8 hours after exposure. Symptoms include fever, chills, malaise, cough, and dyspnea without wheezing. The rate of disease depends on rainfall (which promotes fungal growth) and agricultural practices related to turning and stacking hay. In acute and subacute presentations, removing exposure to the antigen will result in complete recovery.
See all quizzes of the Diseases of the Respiratory System at here:
|1. A 33-year-old farmer complains of recurrent episodes of wheezing after working in a barn
where hay is stored. On auscultation, there are bibasilar crackles and heart sounds are normal.
His laboratory work is normal with no increase in eosinophils and the chest x-ray (CXR) reveals patchy lower lobe infiltrates. Which of the following is the most likely diagnosis?
(B) chronic obstructive lung disease
(C) hypersensitivity pneumonitis
|2. A 57-year-old man with a 40-pack-per-year history of smoking experiences symptoms of
shortness of breath on exertion. He has bilateral wheezes on expiration and increased resonance to percussion of the chest. Pulmonary function tests confirm the diagnosis of chronic obstructive lung disease (COPD). Which of the following is the best definition of this condition?
(A) it is caused by bronchial asthma
(B) it is preceded by chronic bronchitis
(C) it is airflow limitation that is not fullyreversible
(D) it is due to destruction and dilatation of lung alveoli
(E) is due to small airways disease only
|3. An agitated and nervous 24-year-old woman has had severe wheezing and shortness of
breath for 2 days. After receiving oxygen, steroids, and salbutamol (Ventolin) in the emergency room, her breathing improves. She is still wheezing and now feels tremulous and anxious with a pulse of 110/min and respirations 30/min. Arterial blood gases on oxygen reveal a pH of 7.40, PO2 340 mm Hg, PCO2 40 mm Hg, and bicarbonate of 24 mEq/L. She is hospitalized for further treatment. Which of the following treatments or medications should be avoided in her?
(D) sympathomimetic amines
(E) intravenous (IV) fluids
|4. A 29-year-old woman has a long history of mild asthma. She now has a flare and experiences recurrent episodes of bronchial obstruction, fever, malaise, and expectoration of brownish mucous plugs. On examination, there is bilateral wheezing. Infection is suspected
and a CXR reveals upper lobe pulmonary infiltrates. The eosinophil count is 2000/mL, and
serum precipitating antibodies to Aspergillus are positive. Which of the following is the most
appropriate next step in management?
(A) antihelminthic therapy
(B) a short course of systemic glucocorticoid therapy
(C) desensitization treatment
(D) high-dose glucocorticoids by puffer
(E) long-term systemic glucocorticoid therapy
|5. A 31-year-old African American man presents with dyspnea on exertion. He also has fever
and red tender rash on his shins. Physical examination reveals fine inspiratory crackles
in both lower lung lobes and tender erythematous nodules on his legs. CXR shows bilateral
hilar adenopathy and reticulonodular changes in both lungs. Transbronchial biopsy reveals
noncaseating granulomas. Which of the following is the most appropriate next step in management?
(B) isoniazid (INH) and streptomycin
(D) nitrogen mustard
(E) no therapy
|6. A 53-year-old man with a long respiratory history is admitted to the hospital because of increasing shortness of breath and sputum production. He is started on antibiotics and
inhaled bronchodilators and anticholinergic agents. The next day he is found in his room
confused and sleepy. A PCO2 determination reveals severe hypercarbia (PCO2 70 mmHg).
Which of the following explanations regarding his elevated PCO2 is correct?
(A) occurs only with CO2 inhalation
(B) does not occur in obstructive lung disease
(C) does not occur in restrictive lung disease
(D) may worsen with oxygen administration
(E) occurs with chronic hypocapnia
|7. A 63-year-old woman is seen in the emergency room with acute shortness of breath. There is no history of heart or lung problems in the past. She was recently diagnosed with breast cancer and is undergoing active treatment. On examination, her blood pressure is 120/80 mm Hg, pulse 100/min, and heart and lungs are normal. There are no clinical signs of deep venous thrombosis (DVT). Which of the following investigations is most likely to rule out a pulmonary embolism (PE)?
(A) normal CXR
|8. A40-year-old woman has been complaining of a 3-year history of increasing dyspnea and fatigue. She has no other medical illness. Physical examination reveals increased jugular venous pressure (JVP) with prominent c-v wave, and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and rightsided S 3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests show a slight restrictive pattern. Primary pulmonary hypertension is suspected. Which of the following is the most appropriate test to confirm the diagnosis?
(A) open lung biopsy
(B) pulmonary angiography
(C) cardiac catheterization
(D) noninvasive exercise testing
(E) electrophysiologic testing
9. A 63-year-old man is having symptoms of shortness of breath. As part of his workup, an arterial blood gas is done and the PCO2 is 60 mm Hg. Which of the following is the most likely cause for the elevated PCO 2?
(A) ventilation-perfusion ratio inequality
(B) right-to-left shunt
(C) impaired diffusion
(D) hypoventilation(E) carbon monoxide poisoning10. A 56-year-old man is evaluated for chronic cough. It is present most of the time and is progressively getting worse over the past 3 years. With the cough he usually has white to yellow sputum that he has to expectorate. There is no history of wheezing, asthma, congestive heart failure (CHF), or acid reflux disease. He currently smokes one pack a day for the past 25 years. On examination, his chest is clear. CXR is normal and his forced expiratory volume in 1 second (FEV1) and forced vital capacit (FVC) on spirometry are normal. Which of the following is the most likely diagnosis?
(A) chronic obstructive pulmonary disease (COPD)
(B) early cor pulmonale
(C) chronic bronchitis
(E) emphysema11. A 58-year-old man is recently diagnosed with bowel cancer. He now complains of vague chest discomfort and shortness of breath. On examination, he is unwell, blood pressure 90/50 mm Hg, pulse 110/min, respirations 26/min, and oxygen saturation 88%. His lungs are normal on auscultation, the JVP is 8 cm, and P 2 is loud. There is no edema or leg tenderness on palpation. A quantitative (ELISA) D-dimer assay is positive, ECG reveals sinus tachycardia, and cardiac enzymes are negative. The lung scan is read as high probability for PE. Which of the following tests is most likely to help in guiding emergent therapy?
(B) CT scan
(C) venous ultrasound of the legs
(D) contrast phlebography
(E) pulmonary function tests12. A 40-year-old man has a routine CXR, which reveals a posterior mediastinal mass. Which of the following is the most likely diagnosis?
(B) neurogenic tumor
(C) esophageal cyst
(E) bronchogenic cyst13. A 35-year-old man is evaluated for symptoms of shortness of breath. He reports no other lung or heart disease. He smokes half pack a day for the past 10 years. On examination, his JVP is 2 cm, heart sounds normal, and lungs are clear. A CXR shows hyperinflation and increased lucency of the lung fields. A chest CT reveals bullae and emphysematous changes, while pulmonary function tests show an FEV1/FVC ratio of <70%. Evaluation of his family reveals other affected individuals. Which of the following is the most likely diagnosis?
(A) alpha1-antitrypsin deficiency
(B) beta-glycosidase deficiency
(C) glucose-6-phosphatase deficiency
(D) glucocerebrosides deficiency
(E) growth hormone deficiency14. A 23-year-old man notices a gradual but progressive increase in breathing difficulty. He has a long history of back pain with prolonged morning stiffness. He has also had an episode
of iritis in the past. On examination, there is reduced range of motion in the lumbar spine
with forward flexion and pain on palpation of the sacroiliac joint and surrounding soft tissue.
X-rays of the pelvis show erosions and sclerosis of the sacroiliac joint. Which of the following is the most likely pulmonary complication of this condition?
(A) fibrocavitary disease
(B) airflow obstruction
(C) bilateral lower lobe involvement
(D) pleural effusions
(E) hilar adenopathy15. A 44-year-old woman has been complaining of a 4-year history of increasing dyspnea and
fatigue. Physical examination reveals increased JVP and a reduced carotid pulse. Precordial
examination reveals a left parasternal lift, loud P 2, and right-sided S3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests show a slight restrictive pattern. A diagnosis of primary pulmonary hypertension is made. Which of the following is the most likely cause of death in this condition?
(A) intractable left ventricular failure
(B) intractable respiratory failure
(C) massive PE
(D) intractable right ventricular failure or sudden death
16. A patient with hypoxemia, hypercapnia, and polycythemia is able to restore his blood gases
to normal by voluntary hyperventilation. Which of the following is the most likely location for the abnormalities seen on his blood gases?
(A) cerebral cortex
(B) bone marrow
(C) ventricular septum
(D) respiratory center
17. A 63-year-old woman presents with dyspnea and coughing up foul smelling purulent
sputum. She has had many similar episodes in the past. There are no other constitutional
symptoms and she denies excessive alcohol intake. On physical examination, she appears chronically ill with clubbing of the fingers. Heart sounds are normal, JVP is measured at 4 cm, and there are inspiratory crackles heard at the lung bases posteriorly. There is no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the left lower lobe, which on chest CT scan is identified as cystic changes with airway dilatation and bronchial wall thickening. Which of the following is the most appropriate initial next step in management?
(A) antibiotics and postural drainage
(E) INH18. A 32-year-old man develops symptoms of wheezing, cough, and shortness of breath. He
has bilateral expiratory wheezes, and the rest of the examination is normal. Further evaluation
with pulmonary function tests reveals a reduced FEV1/FVC ratio that corrects with
bronchodilators. Which of the following statements about a diagnosis of idiosyncratic
asthma (also called nonatopic) is correct?
(A) known antigenic stimulus
(B) adult onset
(C) history of atopy
(D) positive skin tests
(E) high immunoglobulin E (IgE) levels19. A 20-year-old African American woman presents with mild dyspnea on exertion and joint discomfort in her knees, wrists, and ankles. She also has a fever and red tender rash on her shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, corneal opacities, and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy. Transbronchial biopsy reveals noncaseating granulomas. Which of the following is the most likely cause for the eye lesion?
(B) diabetic complications
(D) congenital origin
(E) infectious infiltration20. A 74-year-old man with a history of smoking notices blood in his chronic daily sputum production. He has no fever or chills, but has lost 10 lb in the past 6 months. On examination, he has bilateral expiratory wheezes, and his fingers are clubbed. There are no lymph nodes
and the remaining examination is normal. CXR reveals a left hilar mass. Which of the following suggests that the tumor is a small cell lung cancer?
(A) syndrome of inappropriate antidiuretic hormone (SIADH) secretion
(B) acanthosis nigricans
(C) Cushing’s syndrome
(D) leukemoid reaction
(E) Stevens-Johnson syndrome