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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.
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?
Carbon dioxide retention is seen in right-toleft shunt only with exercise and is uncommon in impaired diffusion syndromes. Disorders of the chest wall, lower airways, and lungs can cause an increased PaCO 2 because of severe ventilation-perfusion mismatching despite normal or increased minute volume of ventilation.
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?
Transbronchial biopsy helps differentiate idiopathic pulmonary fibrosis (IPF) from similar syndromes with specific treatments. These include chronic hypersensitivity pneumonitis, cryptogenic organizing pneumonia, and sarcoidosis.
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?
Bronchography has been superseded by a CT scan in defining the extent of bronchiectasis. Occasionally, advanced cases of saccular bronchiectasis can be diagnosed by routine CXR. The use of high-resolution CT scanning, in which the images are 1.5 mm thick, has resulted in excellent diagnostic accuracy
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 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. Primary pulmonary hypertension is diagnosed. Which of the following treatments is helpful in this condition?
Patients frequently are subjected to test doses of short-acting vasodilators such as IV prostacyclin or adenosine, or inhaled nitric oxide. About half of these responders will then respond to high oral doses of nifedipine or diltiazem. Prostacyclin is also available as a treatment, but its applicability is limited by the necessity to administer it as a continuous IV infusion.
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?
The increased vascular permeability is the hallmark of the disease. Diagnostic criteria include acute onset, PaO2/FiO2 = 200 mm Hg (regardless of positive end-expiratory pressure [PEEP] level), bilateral infiltrate on frontal CXR, and pulmonary artery occlusion pressure = 18 mm Hg (or if not measured, no evidence of left atrial hypertension).
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?
Allergic bronchopulmonary aspergillosis (in asthmatics), parasitic reactions, and drugs are known causes of pulmonary eosinophilia. Idiopathic causes include Löeffler’s syndrome (benign, acute eosinophilic pneumonia), chronic eosinophilic pneumonia, hypereosinophilic syndrome, and Churg-Strauss allergic granulomatosis.
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?
There is no diagnostic blood test, but twothirds of patients with sarcoidosis will have an elevated level of ACE. Also there is an elevated ESR, hyperglobulinemia, and occasionally hypercalcemia, which are all nonspecific findings. A false-positive rheumatoid factor (RF) and antinuclear antibodies (ANA) antibodies can also be seen. The gallium scan is positive in patients with sarcoidosis.
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?
Yearly influenza vaccination is indicated for patients with COPD. Evidence for pneumococcal vaccination is not definitive but some advocate giving it as well. There is no role for vaccination with H. influenzae B or meningococcus in patients with COPD. Dietary support to prevent malnutrition and improve muscle strength can be helpful. Exercise programs seem to provide subjective improvement as well. Obviously, stopping smoking is crucial.
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?
Acute mediastinitis is a rare complication of upper endoscopy. It can also result from trauma to the trachea or esophagus, or dissection of the retroperitoneum. Clinical presentation may include substernal chest pain, subcutaneous emphysema, and Hamman’s signs, a crunching or clicking noise synchronous with the heartbeat.
Which of the following is most likely associated with cystic fibrosis in an adult patient?
Hemoptysis suggests infection in a patient with advanced lung disease. Pancreatic exocrine function is poor. Nasal polyps are common, but not rectal polyps. About 7% of cases of cystic fibrosis are diagnosed after age 18. Because of improved therapy, cystic fibrosis is no longer just a pediatric disease. Median survival is now 32 years for men and 29 years for women.
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?
Hypoxemia while receiving 100% oxygen indicates right-to-left shunt. Shunts permit circulation of blood that never passes through the ventilated lung. Shunting can occur within the lung (atelectasis, vascular abnormalities) or outside the lung (congenital cardiac malformations). The hypoxemia of ventilation-perfusion mismatch is more easily correctable by 100% oxygen.
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?
Bony deformities of the chest can lead to respiratory failure with raised PCO2, as well as recurrent pulmonary infection. Most patients develop a restrictive lung disease pattern with decreased compliance, reduced TLC and VC. In addition, because of the reduced compliance, the resting position of the lung changes such that FRC is reduced. Finally, the net effect is an increase in the work of breathing. The pattern on pulmonary function testing is usually that of a restrictive pattern.
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?
The VC is reduced in emphysema, but the FEV1 is grossly reduced because of high airway resistance. In predominant emphysema, diffusing capacity is more profoundly decreased than in predominant bronchitis.
Which of the following statements concerning asbestosis is correct?
All forms of asbestos fiber have been associated with lung disease. Restrictive, not obstructive, disease is characteristic. Lung cancer, either squamous cell or adenocarcinoma, is the most common malignancy and the risk is greatly increased by smoking. Benign pleural effusions can occur in both symptomatic and asymptomatic individuals. Reports of mesothelioma 30–35 years after brief exposure to asbestos emphasize the importance of a complete occupational/environmental history
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 37.8C, 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?
PE is an important postoperative complication, which requires urgent treatment. This man is hemodynamically stable and treatment consists of anticoagulation to prevent another PE or propagation of the clot. Thrombolytics are not indicated unless there is severe hemodynamic compromise, and especially in him since he has had recent surgery. The efficacy of IV heparin and LMWH is the same, and can be used with caution in the postoperative setting if there is no ongoing bleeding from the operative site. IVC filter would only be indicated if the patient could not be anticoagulated for some absolute contraindication. The thrust of management is therefore prevention.
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?
In the preantibiotic era, bacterial bronchopneumonia was the most common cause of bronchiectasis. Now it is felt that influenza and adenoviruses are the most common causes. Of the bacterial causes, S. aureus, Klebsiella, and anaerobes are the most common. Besides infection impaired drainage of the involved segment by bronchial obstruction (foreign body) or poorly functioning cilia is required. Other causes in some individual include poor host humeral immunity such as hypogammaglobulinemia.
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 condition?
The description of a middle-aged man with daytime sleepiness, obesity, hypertension, and snoring suggests obstructive sleep apnea. Although nasal continuous positive airway pressure is effective treatment, simple oxygen therapy is not. Stopping sedative medications and avoiding alcohol improves symptoms. Restless sleep and sudden death have been described as part of the syndrome and surgery (uvulopalatopharyngoplasty or tracheostomy) has been used in severe cases. A wide variety of symptoms can occur, but neuropsychiatric and behavioral manifestations secondary to sleep disturbance are the most common.
Which of the following statements concerning hypoxemia in COPD is correct?
Nocturnal oxygen supplementation improves symptoms but is not as effective as continuous supplementation in prolonging life and decreasing hospitalization. Some symptoms of erythrocytosis, headaches, and fullness can be relieved by phlebotomy. In prolonged air travel, even those with PO2 in the mid 70s should be considered for oxygen therapy. A PO2 below 55 mm Hg is an indication for oxygen therapy, but between 55 and 60 mm Hg, associated evidence of right heart dysfunction should also be present before therapy is commenced.
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. Which of the following is the most likely diagnosis?
In asbestosis, there is moderate pleural thickening, with scalloped margins from apex to base. There is a similar finding in the mediastinal and diaphragmatic pleura. Furthermore, there is a plaque of pleural calcification in the base. The association of asbestosis with mesothelioma has long been known. As the neoplasm progresses, it may envelop the thorax.
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