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Select the ONE answer that is BEST in each case.
A 66-year-old man with chronic alcoholism has had a low grade fever and cough for several weeks. His heart sounds are normal and there are crackles in the left lower base. A CXR reveals a left lower lobe lung abscess. Which of the following is the most appropriate therapy?
Traditionally, penicillin was the treatment of choice for anaerobic lung disease. However, metronidazole plus either third-generation cephalosporin (ceftriaxone) or fluoroquinolone (levofloxacin) has a better spectrum of activity against oral anaerobes, Gram negatives, and Streptococcus pneumoniae.
See all quizzes of the Diseases of the Respiratory System at here:
|21. A 66-year-old man with chronic alcoholism has had a low grade fever and cough for several weeks. His heart sounds are normal and there are crackles in the left lower base. A CXR reveals a left lower lobe lung abscess. Which of the following is the most appropriate therapy?
|22. A 44-year-old woman presents with increased shortness of breath, cough, and sputum production. She has had asthma since childhood and uses her medications as directed. Recently, she noticed that her peak flow readings were decreasing after the symptoms started. On examination, she is in moderate respiratory distress, respirations 25/min, there are bilateral wheezes and oxygen saturation is 90% on room air. On her blood gas, the PCO2 is 50 mm Hg. Which of the following is the most likely mechanism for her carbon dioxide retention?
(A) impaired diffusion syndromes
(B) right-to-left shunt
(D) ventilation-perfusion ratio inequality
(E) mechanical ventilation at fixed volume
|23. A previously well 53-year-old man develops progressive shortness of breath. Pulmonary
function tests reveal a restrictive defect and a high-resolution CT suggests pulmonary fibrosis. Which of the following is the most likely role of transbronchial biopsy in this condition?
(A) assess disease severity
(B) assess possible bronchiolar narrowing
(C) diagnose specific causes of interstitial lung disease
(D) determine degree of inflammation
(E) diagnose possible cancer
|24. A 28-year-old man presents with coughing up blood and sputum. He gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. He has no other past medical history and is a lifetime nonsmoker. On physical examination, there are no oral lesions, heart sounds are normal, and wet inspiratory crackles are heard at the lung
bases posteriorly. He also has clubbing of his fingers, but there is no hepatosplenomegaly or
any palpable lymph nodes. CXR show fibrosis and pulmonary infiltrates in the right lower lung. Which of the following is the most appropriate initial diagnostic test?
(A) chest CT scan
(D) open thoracotomy
(E) bronchoalveolar lavage
|25. A 38-year-old woman has been complaining of a 2-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 P2, 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. Primary pulmonary hypertension is diagnosed. Which of the following treatments is helpful in this
(C) alpha-adrenergic blockers
(D) calcium channel blockers
(E) angiotensin-converting enzyme (ACE) inhibitors
|26. A 64-year-old woman is admitted to the hospital with right lobar pneumonia and sepsis syndrome. She becomes progressively more short of breath and hypoxemic requiring intubation and mechanical ventilation. Her repeat CXR in the intensive care unit now shows diffuse pulmonary infiltrates and a diagnosis of acute respiratory distress syndrome (ARDS) is made. Which of the following mechanisms is the most likely cause for the early “exudative” phase of ARDS?
(A) increased lung compliance
(B) increased interstitial fibrosis
(C) increased vascular permeability to fluid and proteins
(D) decreased pulmonary perfusion
(E) decreased ventilatory dead space
|27. A 23-year-old man is experiencing a flare of his asthma. He is using his salbutamol inhaler
more frequently than usual and despite increasing his inhaled steroids he is still short of breath. Previously his asthma was considered mild with no severe exacerbations requiring oral steroids or hospitalization. With his flare, he has recurrent episodes of bronchial obstruction, fever, malaise, and expectoration of brownish mucous plugs. On examination, there is bilateral wheezing. The heart, abdomen, neurologic, and skin exams are normal. CXR reveals upper lobe pulmonary infiltrates; the eosinophil count is 3000/mL, and serum precipitating antibodies to Aspergillus are positive. Which of the following is the most likely diagnosis?
(A) ascaris infestation
(B) allergic bronchopulmonary aspergillosis
(C) Churg-Strauss allergic granulomatosis
(D) Löeffler’s syndrome
(E) hypereosinophilic syndrome
|28. A 34-year-old African American man presents with mild dyspnea on exertion and joint discomfort in his knees, wrists, and ankles. He also has a fever and red tender rash on his shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, and tender erythematous nodules on his legs. CXR shows bilateral symmetric hilar adenopathy. Which of the following laboratory findings is not characteristic of this condition?
(B) elevated ACE level
(C) elevated sedimentation rate (ESR)
(D) elevated serum calcium
(E) normal gallium scan
|29. A 66-year-old man has progressive shortness of breath due to COPD. He is currently able to do his activities of daily living, but has trouble walking more than one block. His physical
examination reveals hyperinflation, increased resonance to percussion, and bilateral expiratory wheezes. He is on appropriate medical therapy for his stage of COPD. Which of the following is also indicated in the management of this condition?
(A) meningococcal vaccination
(B) yearly influenza vaccination
(C) weight reduction if obese
(D) Haemophilus influenzae B vaccination
(E) pneumococcal vaccination
|30. A 45-year-old woman has severe symptoms of epigastric and abdominal pain after eating. A trial of acid suppression therapy with proton pump inhibitors (PPI) only partially improved
her symptoms. She undergoes elective outpatient upper endoscopy, which is positive for a
small duodenal ulcer. Two hours later, she is short of breath and complaining of severe anterior chest pain, which is made worse with deep inspiration. On examination, she looks unwell, blood pressure is 150/90 mm Hg, pulse 110/min, and lungs are clear. Heart sounds are
normal but an extra “crunching” type sound is intermittently heard. CXR demonstrates air surrounding the heart. Which of the following is the most likely diagnosis?
(A) acute pericarditis
(B) acute cardiac ischemia
(C) acute mediastinitis
(D) aortic dissection
|31. Which of the following is most likely associated with cystic fibrosis in an adult patient?
(A) spontaneous remission
(B) good pancreatic exocrine function
(D) rectal polyps
(E) normal sweat chloride
| 32. A 55-year-old woman is in the intensive care unit on a ventilator for hypoxemia following
“flash” pulmonary edema. Her PO2 on the blood gas prior to intubation was 44 mm Hg, and now while breathing 100% oxygen on the ventilator her repeat blood gas reveals a PO2
of 80 mm Hg. Hypoxemia while receiving 100% oxygen indicates which of the following problems?
(A) ventilation-perfusion ratio inequality
(B) right-to-left shunt
(D) impaired diffusion
(E) interstitial lung disease
|33. A 31-year-old man with severe kyphoscoliosis due to cerebral palsy is experiencing worsening shortness of breath with exertion. On examination, he has a severe scoliosis to the left and decreased air entry to that side. His right lung is clear, JVP is 3 cm, and heart sounds are normal. Pulmonary function tests are performed. Which of the following is the most
likely abnormality to be seen on the pulmonary function tests?
(A) increased total lung capacity (TLC)
(B) increased functional residual capacity (FRC)
(C) decreased TLC
(D) increased compliance
(E) increased vital capacity (VC)
|34. A 67-year-old woman has pulmonary function tests performed to evaluate symptoms of dyspnea. The most prominent finding is a reduction of the ratio of FEV1/FVC. Which of the
following is the most likely diagnosis?
(B) ankylosing spondylitis
(C) pickwickian syndrome
(D) scleroderma of the chest wall
(E) lobar pneumonia
|35. Which of the following statements concerning asbestosis is correct?
(A) the type of asbestos fiber is crucial in determining whether asbestos-related lung disease occurs
(B) moderate rather than severe obstruction to airflow is characteristic of asbestosis
(C) mesothelioma is the common malignancy associated with asbestosis
(D) pleural effusions are invariably associated with malignancy in asbestosis
|36. A 52-year-old man develops sudden-onset shortness of breath on postoperative day 4 after
a hemicolectomy for colon cancer. His surgery went well with no operative complications. He
reports no cough, sputum, or pleuritic chest pain. His blood pressure is 155/90 mm Hg,
pulse 100/min, temperature 37.8°C, lungs are clear, and heart sounds normal. He has bilateral
pedal edema, but no discomfort in his legs. His CXR and ECG are normal. A chest CT with contrast reveals a thrombus in his right upper lobe artery. Which of the following statements concerning the management of this condition is most likely correct?
(A) continuous IV heparin or subcutaneous low-molecular-weight heparin (LMWH)
therapy is indicated
(B) urgent thrombolytic therapy is indicated
(C) urgent inferior vena cava (IVC)
(D) filter insertion is indicated
(E) confirmation of the diagnosis with bilateral ultrasound leg Dopplers
|37. A 55-year-old woman presents with coughing up blood and sputum. She gives a history of
recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum.
The sputum production is worse on lying down and in the morning. On physical examination,
she appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard
at the lung bases posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is a recognized precursor to this patient’s condition?
(A) bronchial asthma
(B) cigarette smoking
(C) lung infection and impairment of drainage
(D) lung cancer
|38. A 50-year-old man presents with excessive daytime sleepiness and a history of snoring. One week ago, he fell asleep while driving his car and got into a minor accident. On examination, he is obese (body mass index [BMI] >30) and his blood pressure is 160/90 mm Hg. His lungs are clear and heart sounds are distant.
Which of the following is the most likely explanation for the symptoms associated with this
(A) related to cardiac dysfunction
(B) neuropsychiatric and behavioral
(D) gastrointestinal (GI)
|39. Which of the following statements concerning hypoxemia in COPD is correct?
(A) erythrocytosis is an appropriate
compensation for hypoxemia, and
phlebotomy will worsen symptoms
(B) nocturnal oxygen therapy is effective in producing symptomatic and hemodynamic improvement in severe hypoxia
(C) a PO2 of 58 mm Hg is an indication for continuous oxygen therapy
(D) a PO2 of 65 mm Hg or below is an indication for supplemental oxygen during air travel
(E) continuous supplemental oxygen improves functional ability but does not alter the natural history of obstructive airways disease with severe hypoxemia
|40. A 58-year-old steam pipe worker presents with a vague ache in the left chest and mild dyspnea of several months’ duration. There is dullness on percussion of the left chest associated with diminished breath sounds. His CXR is shown in Fig. 12–1. Which of the following is the most likely diagnosis?
(A) pleural metastases
(B) Paget’s disease
(C) mesothelioma and asbestosis
(D) pleural effusion
(E) multiple myeloma