Pulmonary Disease Pre test

Pulmonary Disease
Questions
DIRECTIONS: Each item below contains a question or incomplete
statement followed by suggested responses. Select the one best response to
each question.

104. A 50-year-old patient with long-standing chronic obstructive lung
disease develops the insidious onset of aching in the distal extremities, particularly
the wrists bilaterally. There is a 10-lb weight loss. The skin over
the wrists is warm and erythematous. There is bilateral clubbing. Plain film
is read as periosteal thickening, possible osteomyelitis. You should
a. Start ciprofloxacin
b. Obtain chest x-ray
c. Aspirate both wrists
d. Begin gold therapy

105. A patient with low-grade fever and weight loss has poor excursion on
the right side of the chest with decreased fremitus, flatness to percussion,
and decreased breath sounds all on the right. The trachea is deviated to the
left. The most likely diagnosis is
a. Pneumothorax
b. Pleural effusion
c. Consolidated pneumonia
d. Atelectasis

106. A 60-year-old female with a history of urinary tract infection, steroiddependent
chronic obstructive lung disease, and asthma presents with bilateral
infiltrates and an eosinophil count of 15%. The least likely diagnosis is
a. Bronchopulmonary aspergillosis
b. Hypersensitivity pneumonitis
c. Strongyloides hyperinfection syndrome
d. Drug effect of nitrofurantoin

107. A 40-year-old alcoholic develops cough and fever. Chest x-ray shows
an air-fluid level in the superior segment of the right lower lobe. The most
likely etiologic agent is
a. Streptococcus pneumoniae
b. Haemophilus influenzae
c. Legionella
d. Anaerobes

104. The answer is b. (Braunwald, 15/e, pp 2008–2010.) The clinical picture
suggests hypertrophic osteoarthropathy. This process, the pathogenesis
of which is unknown, is characterized by clubbing of digits, periosteal
new bone formation, and arthritis. Hypertrophic osteoarthropathy is associated
with intrathoracic malignancy, suppurative lung disease, and congenital
heart problems. Treatment is directed at the underlying disease
process. While x-rays may suggest osteomyelitis, the process is usually
bilateral and easily distinguishable from osteomyelitis. The first step in
evaluation of this patient is to obtain a chest x-ray looking for lung infection
and carcinoma.
105. The answer is b. (Braunwald, 15/e, pp 1444–1445.) The diagnosis in
this patient is suggested by the physical exam findings. The findings of
poor excursion, flatness of percussion, and decreased fremitus on the right
side are all consistent with a right-sided pleural effusion. A large rightsided
effusion may shift the trachea to the left. Histoplasmosis would be
one possible cause of such an effusion. A pneumothorax should result in
hyperresonance of the affected side. Atelectasis on the right side would
shift the trachea to the right. A consolidated pneumonia would characteristically
result in increased fremitus, flatness to percussion, and bronchial
breath sounds, and would not cause tracheal deviation.
106. The answer is b. (Braunwald, 15/e, pp 1460, 1465.) This 60-year-old
woman has peripheral eosinophilia in association with pulmonary infiltrates.
The differential diagnosis for eosinophilic pneumonia includes allergic
bronchopulmonary aspergillosis, parasitic infections, drug reactions,
and a category of idiopathic disease. Nitrofurdantoin and sulfonamides are
among the drugs most likely to cause eosinophilic pneumonia. Hypersensitivity
pneumonitis may cause bilateral infiltrates, but does not of itself
cause eosinophilia.
107. The answer is d. (Braunwald, 15/e, p 1478.) Of the organisms listed,
only anaerobic infection is likely to cause a necrotizing process. Type III
pneumococci have been reported to cause cavitary disease, but this is
unusual. The location of the infiltrate suggests aspiration, also making
anaerobic infection most likely. The superior segment of the right lower
lobe is the one most likely to develop an aspiration pneumonia.

Items 108–112
Match the disease entity with the type of pleural effusion.
a. pH less than 7.0
b. Right-sided effusion, protein 2.5 g/dL
c. Pleural fluid glucose less than 15 mg/dL
d. Exudate, 100% lymphocytes
e. Bloody effusion
f. Milky appearance
g. Low cholesterol
108. Congestive heart failure (CHOOSE 1 EFFUSION)
109. Tuberculosis (CHOOSE 1 EFFUSION)
110. Empyema (CHOOSE 1 EFFUSION)
111. Rheumatoid arthritis (CHOOSE 1 EFFUSION)
112. Mesothelioma (CHOOSE 1 EFFUSION)

108–112. The answers are 108-b, 109-d, 110-a, 111-c, 112-e.
(Braunwald, 15/e, pp 1513–1515.) The first step in determining the cause of
a pleural effusion is to categorize it as either a transudate or exudate. Transudative
effusions occur when factors alter the formation or absorption of
pleural fluid; exudative effusions occur when local factors produce an
inflammatory process. Exudative effusions have one of the following characteristics:
pleural fluid protein–to–serum protein ratio greater than 0.5,
pleural fluid LDH–to–serum LDH ratio greater than 0.6, or pleural fluid
LDH more than two-thirds the normal upper limit for serum. Congestive
heart failure usually produces a right-sided pleural effusion. Of all the disease
processes listed, it is the only one that usually results in a transudative
effusion.
Tuberculosis causes a hypersensitivity reaction to tuberculous protein
in the pleural fluid. It produces an exudative effusion with small lymphocytes.
The diagnosis is now established by demonstrating high levels of TB
markers such as adenosine deaminase or positive PCR for tuberculous DNA.
Empyema may be defined by the very low pH value. It is an exudative
effusion with a polymorphonuclear leukocyte predominance. A drainage
procedure is usually necessary when the pleural fluid pH is below 7.20,
when there is gross pus, or when the fluid shows a positive gram stain or
culture.
Rheumatoid effusions are often exudative and may be lymphocytic,
but they are best characterized by their very low glucose levels. Pleural
fluid glucose levels below 60 mg/dL also occur in malignancy and bacterial
infections.
Mesotheliomas are primary tumors that arise from mesothelial cells
that line the pleural cavity. They produce a very bloody effusion. Thoracoscopy
or open pleural biopsy are often necessary to make a definitive
diagnosis.

117. A 30-year-old male is admitted to the hospital after a motorcycle
accident that resulted in a fracture of the right femur. The fracture is managed
with traction. Three days later the patient becomes confused and
tachypneic. A petechial rash is noted over the chest. Lungs are clear to auscultation.
Arterial blood gases show PO2 of 50, PCO2 of 28, and pH of 7.49.
The most likely diagnosis is
a. Unilateral pulmonary edema
b. Hematoma of the chest
c. Fat embolism
d. Pulmonary embolism
e. Early Staphylococcus aureus pneumonia

117. The answer is c. (Braunwald, 15/e, p 329.) Because the clinical signs
of neurologic deterioration and a petechial rash have occurred in the setting
of fracture and hypoxia, fat embolism is the most likely diagnosis. This
process occurs when neutral fat is introduced into the venous circulation
after bone trauma or fracture. The latent period is 12 to 36 hours, usually
earlier than a pulmonary embolus would occur after trauma.