Final Exam

Question 1

J.W. is a 35-year-old female patient who is going to be treated for active tuberculosis. J.W. wears soft contact lenses. Before starting treatment, you advise her to stop wearing the soft lenses because they may get a red-orange discoloration. This discoloration (as well as a similar discoloration of her urine) occurs because you will be administering:

A) Isoniazid (INH)
B) Pyrazinamide
C) Ethambutol
D) Amikacin
E) Rifampin

Answer 1

E) Rifampin

Rifampin is known to cause a red-orange discoloration of body fluids, including urine, sweat, tears, and saliva. This discoloration can also affect soft contact lenses. Other anti-tubercular drugs like isoniazid, pyrazinamide, and ethambutol do not cause this discoloration

Question 2

All of the following statements about the role of inhaled corticosteroids in the management of asthma are correct EXCEPT:

A) Due to the frequent side effects of inhaled corticosteroids (thrush, Cushingoid changes, growth retardation in children, acute adrenal insufficiency, etc.) their role is limited to prophylaxis of severe persistent asthma
B) Inhaled corticosteroids are not effective in the relief of acute bronchospasm
C) Long-term corticosteroid use results in the upregulation of β-receptors enhancing responsiveness to inhaled β-agonists
D) Corticosteroids inhibit the release of leukotrienes and decrease IgE synthesis to decrease airway inflammation
E) Inhaled corticosteroids can be combined with long-acting β-agonists to suppress airway inflammation and hyper-reactivity in moderate to severe persistent asthma

Answer 2

A) Due to the frequent side effects of inhaled corticosteroids (thrush, Cushingoid changes, growth retardation in children, acute adrenal insufficiency, etc.) their role is limited to prophylaxis of severe persistent asthma

Inhaled corticosteroids are commonly used in managing persistent asthma of all severities, not just severe cases. They are effective in reducing inflammation and preventing symptoms in both mild and moderate asthma, and the side effects listed are less common with inhaled forms than with systemic corticosteroids. Therefore, option A is incorrect.

Question 3

All of the following general principles of active tuberculosis treatment are correct EXCEPT:

A) Multi-drug therapy is utilized
B) Directly observed therapy (DOT) can be part of the treatment regimen
C) Some anti-tubercular drugs can reduce the half-life of other drugs, which may necessitate increasing the dosages of the affected drugs
D) If the patient is symptom-free after 4 weeks of treatment, drug administration can be halted
E) Some patients will have resistance to more than one anti-tubercular drug

Answer 3

D) If the patient is symptom-free after 4 weeks of treatment, drug administration can be halted

Tuberculosis treatment requires a long duration of therapy, typically 6-9 months, to ensure complete eradication of the bacteria and prevent relapse. Even if symptoms improve, the full course must be completed. Stopping treatment early can lead to drug resistance and treatment failure.

Question 4

Fine crackles on exam may indicate:

A) Interstitial lung disease such as IPF
B) Pulmonary edema due to congestive heart failure
C) Airway narrowing resulting in turbulent flow
D) A and B
E) All of the above

Answer 4

D) A and B

Fine crackles are commonly associated with interstitial lung diseases like idiopathic pulmonary fibrosis (IPF). These diseases affect the lung interstitium and lead to the formation of small, fluid-filled spaces, which result in crackling sounds during inhalation, typically heard in the base of the lungs.
Fine crackles can also be heard in pulmonary edema, often caused by congestive heart failure (CHF). This occurs when the left ventricle fails to pump efficiently, leading to fluid accumulation in the lungs, which produces crackling sounds, especially in the lower lung fields
Airway narrowing (option C) usually produces wheezing rather than fine crackles.

Question 5

Which of the following findings is not suggestive of consolidation, such as in pneumonia?

A) Dullness to percussion over the involved area of the chest
B) Egophony over the involved area of the chest
C) Bronchial breath sounds over the involved area of the chest
D) Decreased tactile fremitus over the involved area of the chest
E) They are all suggestive of consolidation

Answer 5

D) Decreased tactile fremitus over the involved area of the chest

In consolidation, tactile fremitus is usually increased due to the denser lung tissue, which transmits vibrations from speech more effectively. Decreased tactile fremitus is more commonly seen with pleural effusion or obstruction, where the transmission of vibrations is reduced.

Consolidation = lung tissue filled with something solid or fluid instead of air (like in pneumonia).
Dullness = tapping on the chest makes a less hollow sound because the lungs are full of something dense.
Egophony = the voice sounds change, like hearing “A” instead of “ee,” because sound behaves differently in consolidated lungs

Dullness occurs when there is solidification of the lung tissue, such as in pneumonia, where air is replaced by fluid or pus

Egophony is a change in the voice sound heard through the stethoscope, typically described as a nasal “A” sound. This occurs when there is consolidation or increased lung tissue density

Normally, breath sounds are vesicular (soft and low-pitched) in the periphery of the lungs. Bronchial breath sounds over the peripheral lung area indicate consolidation, where the air spaces are replaced by solid or liquid material.

Question 6

Bronchiectasis may be the end result of which of the following:

A) Defective ciliary function
B) IgG deficiency
C) Sleep-disordered breathing
D) Prior severe infection
E) A, B, and D

Answer 6

e) A, B and D

Bronchiectasis is a condition where the airways (bronchi) in the lungs become damaged and enlarged due to chronic inflammation. This leads to a cycle of mucus buildup, infection, and further damage to the airways.

Defective ciliary function leads to impaired mucociliary clearance, allowing bacteria and mucus to accumulate in the airways. This can result in chronic inflammation and damage to the airways, ultimately causing bronchiectasis.

Question 7

A 68-year-old male cigar smoker presents with a cough productive of blood-streaked sputum and weakness. His chest X-ray reveals a left-sided hilar lung mass. His serum electrolytes demonstrate a low sodium (122), normal renal function, normal liver function tests, and normal serum calcium and phosphate. Which of the following is/are true?

A) Paraneoplastic syndromes are most frequently associated with squamous cell carcinoma
B) This patient may have SIADH (syndrome of inappropriate anti-diuretic hormone)
C) His chest film suggests he may have either adenocarcinoma or small cell carcinoma
D) If his pulmonary function studies are good, surgery would be the next step for him
E) A, B, and C

Answer 7

B) This patient may have SIADH (syndrome of inappropriate anti-diuretic hormone)

Patient’s low sodium (122) is a key indicator of SIADH, which is a paraneoplastic syndrome often seen in small cell lung cancer

Question 8

Which of the following is essential to make a diagnosis of cystic fibrosis?

A) Positive family history
B) Elevated sweat chloride
C) Recurrent respiratory infections
D) Elevated trypsinogen levels
E) Bronchiectasis in CT scans

Answer 8

B) Elevated sweat chloride

Diagnosis of cystic fibrosis (CF) is primarily confirmed by detecting elevated chloride levels in sweat, which is characteristic of CF due to a defect in chloride transport. While recurrent respiratory infections and positive family history are common in CF, elevated sweat chloride is definitive and essential for diagnosis

Question 9

A solitary pulmonary nodule is found on a pre-employment screening chest x-ray in a 34-year-old nonsmoking male. There are no old chest x-rays to compare. Which of the following is the most appropriate next step in the evaluation?

A) CT scan of the chest
B) Needle biopsy of the lesion
C) Positron emission tomography of the chest
D) Fiberoptic bronchoscopy
E) Video-assisted thoracoscopy

Answer 9

A) CT scan of the chest

For a solitary pulmonary nodule detected on an X-ray, a CT scan of the chest is the next best step to further characterize the nodule, assess its size, shape, and likelihood of being benign or malignant. Other options like biopsy and PET scans may be considered based on CT findings.

Question 10

A 53-year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals sinus tachycardia. Which of the following is the most likely diagnosis?

A) Atelectasis
B) Pneumothorax
C) Pulmonary embolism
D) Pleural effusion
E) Myocardial infarction

Answer 10

C) Pulmonary embolism

Patient has pleuritic chest pain (pain that worsens with breathing), dyspnea (difficulty breathing), tachycardia, and rales (abnormal heart sounds) , all of which are concerning for pulmonary embolism (PE), especially following recent surgery (abdominal hysterectomy). PE is a common complication after surgery due to immobility, venous stasis, and hypercoagulability. The chest x-ray may be unremarkable in PE, and the sinus tachycardia seen on the EKG is also commonly associated with PE.

Question 11

List the most common indications for bronchoscopy procedures

Answer 11

Suspected lung cancer or tumor
Unexplained hemoptysis
Foreign body aspiration
Chronic cough

Question 12

List the probable causes of transudate

Answer 12

Congestive heart failure (CHF)
Nephrotic syndrome
Cirrhosis
Hypoalbuminemia

Question 13

Sus

List the most common obstructive diseases

Answer 13

COPD - Chronic Pulmonary Obstructive Disorder
Asthma
Cystic Fibrosis
Chronic Bronchitis
Emphysema

Question 14

List the most common symptoms of COPD and name the test needed to confirm the disease

Answer 14

Chronic cough, dyspnea, chest tightness, chronic sputum production
Spirometry : reduced FEV1, FEV1/FVC ratio less than 70%

Question 15

Recommendations for treatment of severe asthma

Answer 15

Inhaled corticosteroids
Short acting beta agonists (albuterol)
Anticholinergics
Oral corticosteroids (prednisone)
Theophylline

Question 16

For COPD typical is
a) concerns children and adults
b) chronic airflow limitation is a mainstay
c) Usually is reversible
d) Nearly all patients need long term oxygen therapy
e) the most effective treatment are steroids

Answer 16

b) chronic airflow limitation is a mainstay

Question 17

A 21 year-old male presents to the ED with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Examination reveals moderate respiratory distress with absence of breath sounds and hyperresonance to percussion on the left, with trachea deviation to the right. Which of the following is the most appropriate next step?
a) Order a V/Q scan
b) Order chest x-ray
c) Administer a sclersoing agent
d) insert large bore needle into left second intercostal space
e) oxygen therapy

Answer 17

d) insert large bore needle into left second intercostal space

Question 18

A 50-year-old woman has lived in Oslo, Norway all her life and worked as a seamstress. She is a non-smoker, but she has had increasing shortness of breath, fever, weight loss and night sweats for the past 4 months. On physical examination, her temperature is 37.6°C. There are fine rails auscultated in all lung fields. A chest radiograph reveals hilar lymphadenopathy and a reticulonodular pattern in all lung fields. She demonstrates anergy by skin testing to mumps and Candida antigens. A transbronchial biopsy is performed, and microscopically demonstrates numerous small pulmonary interstitial non-caseating granulomas. Which of the following is the most likely diagnosis
a) Histoplasmosis
b) Adenocarcinoma
c) Sarcoidosis
d) Usual interstitial pneumonitis
e) Tuberculosis

Answer 18

c) Sarcoidosis

Question 19

A 36 year-old woman has had increasing dyspnea for 8 years. She has no cough or increased sputum production. On physical examination, there is hyperresonance to percussion. A chest radiograph reveals increased lung volumes with flattening of the diaphragmatic leaves bilaterally. The right heart border is more prominent than usual. A chest CT scan demonstrates emphysematous changes in all lung fields. Which of the following laboratory findings is she most likely to have?
a) decreased serum plasma
b) increased sweat chloride
c) elevated blood ethanol
d) decreased serum alpha-1 antitrypsin
e) positive urine opiates

Answer 19

d) decreased serum alpha-1 antitrypsin