Self Evaluation

Kevin Simpson M.D.
Assistant Professor of Medicine
Pulmonary Critical Care Medicine

Programmed By: Vince Kumar and A.J.Chandrasekhar

ONE BEST ANSWER:

Pulmonary Embolism

1. Which of the following statements is true regarding the majority of patients with pulmonary embolism:

(A) signs of DVT are present.

(B) hypercoagulability 2o to abnormalities of protein C/S and/or antithrombin III are present.

(D) hemoptysis is present.

2. Laboratory abnormalities that are present in greater than 50% of patients with documented acute pulmonary embolism include all of the following EXCEPT:

(A) increased A - a (alveolar to arterial) oxygen gradient

(B) respiratory alkalosis

(D) "S1 Q3 T3" pattern on electrocardiogram

3. Which of the following test results should be considered to be diagnostic of pulmonary embolism:

(A) a D-dimer of > 500 ug/L

(B) a high probability V/Q scan

(D) "Hampton's Hump" on chest x-ray

4. Accepted treatment options for pulmonary embolism include all of the following EXCEPT:

(A) intravenous heparin

(B) subcutaneous heparin

(D) oral aspirin

Acute Respiratory Failure

1. A 45 year old alcoholic aspirates and develops ARDS. Initial ventilatory settings are FIO2 of 100%, tidal volume of 500mL, assist/control rate of 12/min, and PEEP of 5 cm H2O. Arterial blood gases are PO2 = 54 mmHg, PCO2 = 38 mmHg, and pH = 7.38. Patient is agitated with a temperature of 39.0oC, with an observed respiratory rate of 32. WBC = 15,000 and hemoglobin of 8.2 g/dL. Strategies that could allow for a non-toxic FIO2 include all of the following EXCEPT:

(A) increasing PEEP

(B) treating fever

(D) increasing assist/control rate to 20

2. PEEP therapy reliably improves oxygenation in all of the following EXCEPT:

(A) congestive heart failure

(B) lobar pneumonia

(D) postictal pulmonary edema

3. A 67 year old patient with severe COPD (FEV1 = 600 cc) is admitted to the intensive care unit is acute respiratory failure and is immediately intubated and mechanically ventilated with initial settings of assist/control mode, tidal volume = 800 cc, respiratory rate = 24, PEEP = 0 cm H2O, FIO2 = 60%, and inspiratory time of 33%. On these settings, the patients observed respiratory rate is 24, peak pressure is 55 cm H2O, plateau pressure is 20 cm H2O, and PEEPi is estimated to be 12 cm H2O. Ventilator maneuvers which are likely to decrease PEEPi include all of the following EXCEPT:

(A) decreased tidal volume

(B) administration of bronchodilators

(D) application of PEEP

4. A 55 year old patient with COPD presents to the emergency room in acute on chronic respiratory failure in a state of obvious dyspnea, with poor air exchange, diffuse wheezing, and accessory muscle use. Arterial blood gases reveal a pO2 = 52 mmHg, pCO2 = 47 mmHg, and pH = 7.38 mmHg. Appropriate interventions at this point could include all of the following EXCEPT:

(A) administration of 100% FIO2 by face mask

(B) administration of oxygen, 2 lpm, by nasal cannula

(D) administration of nebulized bronchodilator

Pregnancy

1. Which of the following medications is NOT considered safe for use during pregnancy:

(A) coumadin

(B) B-agonists

(D) heparin

Asthma

1. For patients with mild asthma, who have only occasional symptoms, such as those with exercise-induced asthma, the most appropriate choice for therapy would be:

(A) Prednisone, 60mg tapering over two weeks to 10 mg QOD

(B) Theophylline 300mg BID

(D) B-agonist PRN and/or pre-exercise

2. A 26 year old man is referred to pulmonary clinic because of poorly controlled asthma. He has been admitted several times over the past five years for exacerbations of asthma associated with fever, chills, wheezing, and flame-shaped infiltrates located in various lung fields. Which of the following diagnostic procedures would you perform first:

(A) Bronchoscopy to identify any endobronchial obstructing mass

(B) Skin prick-test for Aspergillus fumigatus

(D) Nasal septum biopsy to rule out abnormal cilia syndrome

3. Which of the following statements about exercise in asthmatics is true?

(A) Most asthmatics will show increased airway resistance after exercise.

(B) The stimulus for the bronchial narrowing is the exercise itself.

(D) Simple hyperventilation of cold air of low humidity will not induce the bronchial narrowing.

4. A 46 year old woman is brought by ambulance to the ER unconscious and already intubated. The patient is mechanically ventilated on assist control mode with a TV = 500 cc and RR = 16. On these settings the peak airway pressure is measured to be 60 cm H2O while the plateau (pause) pressure is determined to be 10 cm H2O. These peak and plateau pressures are most consistent with which of the following:

(A) right mainstem intubation

(B) pneumothorax

(D) acute bronchospasm

COPD

1. The first line medication for the treatment of COPD is:

(A) Ipatropium bromide (@Atrovent)

(B) Theophylline

(D) Inhaled corticosteroids

2. Which of the following has been demonstrated to prolong life in patients with COPD:

(A) Pulmonary rehabilitation programs

(B) Ipatropium bromide (@Atrovent)

(D) Supplemental oxygen

3. The most reliable clinical feature distinguishing asthma from Emphysema is:

(A) Age of patient

(B) Reversibility and intermittent nature of symptoms

(D) Male sex

4. The primary mechanism resulting in hypoxia in patients with both asthma and COPD is:

(A) Shunt

(B) Abnormal diffusion

(D) Decreased mixed venous oxygen saturation

5. Which of the following is NOT an indication for supplemental oxygen in patients with COPD:

(A)PaO2 < 55 mmHg or SaO2 < 89% at rest

(B) PaO2 < 55 mmHg or SaO2 < 89% during sleep

(D) Evidence of cor pulmonale or polycythemia in association with a PaO2 56 to 59 mmHg

6. When a patient is intubated and mechanically ventilated as treatment of acute on chronic respiratory failure (i.e. during an acute exacerbation of COPD), minute ventilation should be titrated according to the patient's:

(A) PaO2

(B) O2 saturation

(D) pH

Cystic Fibrosis

1. The predominant pathologic finding of the lung in cystic fibrosis is:

(A) bronchiectasis

(B) atelectasis

(D) dystrophic calcification

2. The predominant microorganism affecting the airways in adult patients with cystic fibrosis is:

(A) A. fumigatus

(B) S. pneumonia

(D) C. albicans

3. Cystic Fibrosis is transmitted by which of the following genetic mechanisms:

(A) autosomal dominant

(B) autosomal recessive

(D) X-linked recessive

Pulmonary Function Testing

1. Which of the following statements regarding the elastic recoil of the lung is correct:

(A) In normal individuals, total lung capacity (TLC) is determined (i.e. limited) primarily by the elastic recoil of the lung.

(B) The elastic recoil of the lung is less than normal in patients with idiopathic pulmonary fibrosis.

(D) Increased elastic recoil leads to diminished expiratory flow.

2. A 46 year old male undergoes pulmonary function testing and if found to have a TLC which is 72% of predicted, a FRC which is 96% of predicted, and a RV which is 132% of predicted. Which of the following diseases would best explain these lung volumes:

(A) Obesity

(B) Emphysema

(D) Pulmonary Embolism

3. A 26 year old female is sent for pulmonary function testing as part of a work up for chronic cough. FVC, FEV1, FEV1/FVC, TLC, and DLCO are all within normal limits. Which of the following statements are accurate.

(A) Methacholine challenge is not indicated since baseline spirometry is normal.

(B) The patient may have asthma.

(D) The patient most likely has psychogenic cough since baseline spirometry is normal.

4. A 55 year old shipyard worker with a 45 pack year smoking history undergoes pulmonary function testing which reveals the following results: FVC = 62% predicted, FEV1 = 46% predicted, FEV1/FVC = .62, TLC = 92% predicted, and DLCO = 44% predicted. These PFT's are most compatible with:

(A) Asbestosis

(B) Mesothelioma

(D) Emphysema

Interstitial Lung Disease

1. Which of the following statements regarding amiodarone lung toxicity is NOT true:

(A) Pulmonary disease most commonly occurs after 5 to 6 months of treatment.

(B) Symptoms most commonly include chest pain.

(D) Pulmonary function testing most commonly reveals a decrease in DLCO.

2. Which of the following statements regarding Idiopathic Pulmonary Fibrosis (IPF) is NOT true:

(A) IPF is fatal an average of 3 to 6 years after the onset of symptoms.

(B) Patients with active IPF have an increased percentage of neutrophils in bronchoalveolar lavage.

(D) Patients with IPF typically demonstrate reduced lung volumes and DLCO.

3. Which of the following statements regarding sarcoidosis is NOT true:

(A) In patients with intrathoracic lymphadenopathy secondary to sarcoidosis but normal appearing parenchyma on chest x-ray, the yield of transbronchial biopsy for obtaining non-caseating granulomas is >85%.

(B) ACE levels are neither sensitive nor specific for sarcoidosis.

(D) Even if a patient with sarcoidosis is asymptomatic and has normal pulmonary function tests, steroids should be administered for at least 3 months to prevent rapid deterioration.

4. Which of the following statements regarding interstitial lung disease is NOT true:

(A) Histiocytosis X (eosinophilic granuloma) is associated with pituitary and bone abnormalities.

(B) Lymphangioleiomyomatosis (LAM) rarely affects women.

(D) Idiopathic pulmonary fibrosis (IPF) is rarely associated with pleural effusions.

Lung Cancer

1. During a routine physical examination, a 22-year-old man with no past medical history is noted to have a noncalcified 1.5 cm solitary pulmonary nodule. The patient is otherwise asymptomatic, and results of the rest of the examination are normal. The next step in the management should be:

(A) thoracotomy

(B) fiberoptic bronchoscopy

(D) percutaneous-needle aspiration

2. Which of the following statements about the TNM staging system for lung cancer is true?

(A) A superior sulcus lung cancer with direct extension into the chest wall without nodal involvement or distal metastases is best classified as stage IIIa.

(B) Metastases to any lymph nodes, including ipsilateral hilar, clasifies a tumor as stage III or IV.

(D) All patients with stage III lung cancer are considered inoperable.

3. Which of the following statements about small cell carcinoma is true?

(A) Approximately 80% of patients with limited small cell carcinoma respond to treatment by showing clinical regression of symptoms and radiologic regression of tumor size.

(B) Whole-brain irradiation administered prophylactically has been shown to increase the survival rate.

(D) Hypercalcemia from production of ectopic parathyroid hormone is the most common paraneoplastic syndrome.

4. A 72 year old man is to undergo transurethral resection of the prostate for benign prostatic hypertrophy. A preoperative chest x-ray reveals a 1.5 cm pulmonary nodule (left midlung zone, smooth border, no apparent calcification). His health has been good, and he denies any complaints. He smoked one pack per day for 30 years but stopped 20 years ago. The patient had a chest x-ray 18 months ago and was told results were normal. Results of physical exam, CBC, urinalysis, and routine labs are normal. The next step in management is to request:

(A) a CT scan of the chest

(B) ask if the patient had a CXR obtained previously

(D) bronchoscopy

Pleural Effusions

1. Which of the following pleural fluid characteristics does NOT qualify the effusion as an exudate:

(A) Pleural fluid WBC > 1000

(B) Pleural fluid LDH > 200

(D) Pleural/Serum Protein ratio > 0.5

2. Which of the following statements regarding pleural effusions associated with pulmonary emboli is NOT true:

(A) Small pleural effusions, associated with platelike atelectasis, are consistent with the diagnosis of PE.

(B) Pleural fluid may be transudative in 10 - 15% of PE.

(D) If thoracentesis reveals an uncomplicated exudate, the patient may be observed without chest tube placement.

3. A 63 year old alcoholic is admitted with cough, fever, sputum production, and an infiltrate in chest x-ray associated with a moderate pleural effusion. Thoracentesis reveals the following: WBC = 2600, protein = 2.6 (serum = 4.5), LDH = 185 (serum = 246), pH = 7.24, glucose = 57 (serum = 97), gram stain revealed scattered WBC's and no organisms. Which of the following statements is accurate:

(A) The effusion can best be described as being a parapneumonic effusion.

(B) Since the pleural fluid LDH is less than 200, the effusion is a transudate.

(D) Since the pH of the pleural fluid is <7.35, a chest tube should be inserted.

4. Which of the following statements regarding pleural effusions is NOT true:

(A) Pleural fluid glucose may be low in cases of rheumatoid arthritis.

(B) In effusions associated with tuberculosis, there are typically large numbers of mesothelial cells noted on the WBC differential.

(D) Pleural fluid amylase may be high in esophageal rupture.

Sleep Apnea

1. Which of the following symptoms is NOT associated with sleep apnea:

(A) enuresis

(B) daytime hypersomnolence

(D) morning headaches

2. Which of the following conditions is NOT associated with sleep apnea:

(A) Pulmonary hypertension

(B) Obesity

(D) Acromegaly

HIV/AIDS

1. Which of the following statements about the use of steroids in HIV positive patients suspected of having PCP pneumonia is true:

(A) The risk of developing overt multi-drug resistant tuberculosis is between 20 and 30%.

(B) No decrease in 30-day mortality has been shown.

(C) No decrease in the rate of deterioration to the point of respiratory failure requiring mechanical ventilation has been shown.

(D) Indications include an A-a gradient of > 35 mmHg or a pO2 < 70 mmHg.

2. When features of PCP pneumonia in patients with acquired immunodeficiency syndrome (AIDS) are compared with those of patients who have other immunocompromised states, the patients with AIDS are found to have all of the following EXCEPT:

(A) a higher incidence of adverse reactions to trimethoprim-sulfamethoxazole

(B) longer duration of symptoms before diagnosis

(D) more neutrophils found during bronchoalveolar lavage

Lung Transplantation

1. Which of the following statements about lung transplantation is true:

(A) In the majority of circumstances, distinguishing rejection from infection in lung transplant patients can be done on the basis of symptoms, physical examination, chest x-ray, and routine laboratory evaluation.

(B) Operative 30-day mortality for the transplant itself is approximately 50%.

(D) Most patients post lung transplant require indefinite ongoing immunosuppression including a combination of immuran, cyclosporin, and prednisone.