Internal medicine - Pulmonology (123) Flashcards

Question

INT - 4.28 Symptoms of Goodpasture-syndrome, except: A) focal glomerulonephritis B) septic spleen C) pulmonary fibrosis, induration D) cutaneous purpura E) Prussian blue staining in lung parenchyma

Answer 1

ANSWER B) septic spleen EXPLANATION Goodpasture-syndrome is not an infectious disease, therefore septic spleen is not part of the sypmtoms.

Answer 2

ANSWER D) left ventricular dysfunction EXPLANATION COPD causes strain on the right side of the heart, not on the left. Altough polycythaemia caused by hypoxaemia increases blood viscosity, thus straining the left side of the heart, but that usually doesn’t lead to left ventricular failure all by itself.

Answer 3

ANSWER C) dyspnoea EXPLANATION Dyspnea caused by airway obstruction is typical for both obstructive emphysema and obstructive bronchitis. Polycythaemia, airflow improvement after using bronchodilators and chronic cough are not characteristic for emphysema. In emphysema alone, significant hypoxaemia doesn’t occur, and hypercapnia never happens because of hyperventilation. (Except for in very severe emphysema when exhaustion of the respiratory muscles cause hypoventilation.)

Answer 4

ANSWER B) Sympathetic nerves control the main mechanisms of bronchodilatation. EXPLANATION Sympathetic postganglionic neurons innervating the respiratory tract – which are mediated primary by noradrenaline – play a fundamental role only in regulating the bronchial blood flow. Airway smooth muscles don’t have sympathetic innervation, therefore sympathetic nerves don’t mediate bronchodilation. Bronchoconstriction is mainly regulated by respiratory parasympathetic nerves, which are primary mediated by acetlycholine. Acetylcholine activates the M3-receptors of bronchial smooth muscle cells, triggering bronchoconstriction. Tonic acetylcholine release from the parasympathetic nerves is responsible for the slightly increased, physiological resting bronchial tone.

Answer 5

ANSWER B) M2 EXPLANATION Activation of M2-receptors of parasympathetic postganglional nerves inhibits acetylcholine release. Pharmacological inhibition of postganglional nerve’s inhibitory M2-receptors leads to more acetylcholine release during cholinergic stimulation. This decreases the effect of the non-selective cholinergic antagonist or, paradoxically, can trigger bronchoconstriction. Bronchoconstriction caused by cholinergic antagonists is not related to the other listed receptors.

Answer 6

ANSWER D) by inhibiting parasympathetic neuromuscular transmission EXPLANATION Cholinergic antagonist bronchodilators are competitive antagonists of acetylcholin, which inhibit activation of the muscarinic cholinergic receptors by acetylcholin. This mechanism is responsible for inhibiting the parasympathetic neuromuscular transmission, therefore decreasing the bronchial smooth muscle’s tone, indirectly causing bronchodilation. Sympathetic innervation of the airways doesn’t play a considerable role in regulating bronchial tone.

Answer 7

ANSWER D) enhancing the colonisation of particular viruses and bacteria EXPLANATION Surfactant inhibits (and not enchances) bacterial and viral colonisation. The other answers are correct.

Answer 8

ANSWER E) Airways distal to the terminal bronchioles are called conductive airways. EXPLANATION The respiratory tract up to the respiratory bronchioles leads ("conducts") the air to the alveolar region where gas exchange occurs. The latter region contains respiratory bronchioles, the distal airways and alveoli. So E statement is not true, but the other statements are true.

Answer 9

ANSWER F) An acinus contains 8-10 lobules. EXPLANATION The difference between bronchioles and bronchi is that the bronchioles do not contain cartilage. Their average diameter is 0.6 mm. A lung unit belonging to the terminal bronchioles is the acinus and the diameter of the acinus is 0.5 to 1 cm at its base. The lung unit belonging to the 3rd generation of respiratory bronchioles is now called the "terminal respiratory unit". Lung acinus consists of 3-5 (and not 8-10) lobules. The airspace of the acinus is 0.2 ml. So all statements are true, except of F.

Answer 10

ANSWER C) Type I pneumocytes produce surfactant. EXPLANATION Surfactant is produced by type II pneumocytes and not type I pneumocytes. The other answers are true. Kulchinsky cells, also known as paracrine or APUD cells, are presented in relatively small numbers in the epithelium and the submucosal glands. They can produce biogenic amines (including 5-hydroxytryptamine, dopamin and noradrenaline) and peptide hormones (for example calcitonin). Endocrin tumours called „apudomas” can be formed from these cells.

Answer 11

ANSWER D) The normal alveolar ventilation is 8 l. EXPLANATION Alveolar ventilation is smaller than minute ventilation, because it is the amount of air that in terms of its gas tension is balanced with the gas tension of arterial blood. Thus, alveolar ventilation is the minute ventilation reduced with anatomical and functional dead space ventilation. It is not characterized by a fixed value. It depends primarily on body size but is also influenced by other factors (for example metabolic rate etc.). If the value of the minute ventilation (at rest) is 6-8 l, then the 8 l alveolar ventilation is unrealistically high. The other statements are true.

Answer 12

ANSWER F) Hypoxaemia-induced erythropoietin production EXPLANATION Hypoxaemia-induced erythropoietin production is located in the kidney and not in the lungs. The other statements are true.

Answer 13

ANSWER B) eosinophil granulocyte EXPLANATION Bronchial asthma is characterized by the chronic eosinophilic cell inflammation in bronchial airways. Almost all other types of inflammatory cells play role in the activation of eosinophilic cells.

Answer 14

ANSWER A) running in cold air EXPLANATION Practical experiences have shown that running in cold air most commonly provokes asthmatic attack in exercise-induced asthma. Swimming is a well-tolerated sport for asthmatics. Noteworthy, sulfuric or heavily chlorinated water can increase BHR (bronchial hyperresponsiveness) and cause asthma attacks.

Answer 15

ANSWER C) dendritic cell EXPLANATION Bone marrow dendritic cell is the most important antigen presenting cell in asthma.

Answer 16

ANSWER D) CRP EXPLANATION The decrease of CRP, it occurs 1-3 days after. The other parameters will be normalized in 3-4 days.

Answer 17

ANSWER A) CMV EXPLANATION Immunsuppressive treatment is predisposed to CMV-infection after the transplantation. The mostly endangered patients are CMV seronegative patients, who gets their organ from a CMV positive donor.

Answer 18

ANSWER B) The clinical manifestation includes pneumonitis, necrotising bronchopneumonia and pulmonary abscess. EXPLANATION The aspiration pneumonia is mostly caused by mixed aerob and anaerob bacterias. The clinical manifestation depends on the invasivity and patogenicity of the bacterias.

Answer 19

ANSWER C) Mycobacterium marinum EXPLANATION The most common causes of pulmonary gangrene are Klebsiella pneumoniae, then S. aureus, S. pneumoniae, H. influenzae and anaerobic bacteria.

Answer 20

ANSWER B) confused psychical status, unsettled severe social status EXPLANATION The indications of lung transplantation are untreatable end-stage pulmonary diseases of known or unknown etiology including progressive severe pulmonary arterial hypertension. The surgery is indicated if the life expectancy without transplantation is worse. The conditions of the surgery are the acceptable nutritional, emotional and psychical status.

Answer 21

ANSWER B) pulmonary sepsis EXPLANATION (A kérdésben nincs szó egyoldali tüdőtranszplantációról. PAH-ban kétoldali transzplantáció indokolt. Így nem jó) The indications of single lung transplantation are: end-stage pulmonary fibrosis, severe emphysema, severe pulmonary arterial hypertension, various pulmonary diseases, including eosinophil granuloma, sarcoidosis. Pulmonary sepsis is against lung transplantation until the signs of sepsis exist.

Answer 22

ANSWER A) Eisenmenger-syndrome EXPLANATION The indication of lung transplantation are: severe emphysema (including alfa-1-antitrypsin deficiency), pulmonary arterial hypertension, various diseases including eosinophil granuloma, sarcoidosis. In Eisenmenger-syndrome the initial left-to-right shunt may result in elevated pulmonary vascular resistance and right-to-left/bidirectional shunt causing cyanosis. This is a point at which the pulmonary vascular disease is irreversible with contraindication against closure of the shunt lesion. Transplantation, either combined heart–lung transplantation or lung transplantation with concomitant cardiac repair, remain the only definitive treatment options.

Answer 23

ANSWER A) congenital heart defect combined with Eisenmenger-syndrome EXPLANATION The indications of heart-lung transplantation are: parenchymal lung disorder with severe independent heart disease, congenital heart disease with Eisenmenger-syndrome, so the answer A is the correct. In case of tuberculosis transplantation is not indicated. In case of end-stage pulmonary fibrosis, single lung transplantation is indicated. In case of emphysema caused by severe α-1 antitrypsin deficiency single or dual lung transplantation is indicated.

Answer 24

ANSWER C) 50% EXPLANATION CMV infection is the second most common infection in lung-transplanted patients, after bacterial infections. It starts 2-12 weeks after the transplantation. The most severe infection develops in case if a seronegative recipient gets a seropositive graft. The diagnosis is made by BAL, if positive, a transbronchial biopsy is also needed. After heart or heart-lung transplantation the prevalence of CMV infection can reach 50 % without specific drug treatment.

Answer 25

ANSWER A) 0–3 months EXPLANATION The most common disease after lung transplantation is the bacterial pneumonia, which occurs usually in the first 3 months. Among Gram-negative bacteria Enterobacter and Pseudomonas infection, fro other bacteria Haemophilus influenzae and Staphylococcus aureus are the most common causes of the disease.

Answer 26

ANSWER B) 10–22% EXPLANATION Fungal infections are frequent as a consequence of the immunosupressive therapy. They usually occur in the first two months after the transplantation, with an incidence of approx. 10-22%. They're caused by Candida and Aspergillus spp. Candida infections usually occur right after the transplantation, because the colonisation takes place from the donor's airways. Aspergillus spp. can lead to invasive, acute, fulminant infections. Fungal infections have a high mortality, around 40-70%. They're mostly successfully treatable with amphotericin B, although Aspergillus spp. are hard to eradicate, and often could lead to lethal infections.

Answer 27

ANSWER C) increased lung compliance EXPLANATION Most common symptoms of thyreotoxicosis are dyspnea, increased oxygen consumption and carbon-dioxide production - due to increased metabolism -, and increased minute ventilation with tachypnea and tachycardia. The increased circulatory load leads to left ventricular failure and dilation, mitral valve insufficiency and pulmonary hypertension. The enlarged thyroid puts pressure on the trachea. The pulmonary hypertension causes interstitial congestion, extends the diffusion route and reduces (not increases!) the compliance of the lungs and the vital capacity. Either the increased respiratory work - caused by the former mechanism -, the pressure on the trachea or the cardiac abnormalities can cause dyspnea. (Tachypnea, and rarely tachycardia also can be experienced as dyspnea by the patients.)

Answer 28

ANSWER B) It decreases the central reaction to hypoxaemia and hypercapnia. EXPLANATION While hyperthyreosis increases, hypothyreosis decreases the reaction to hypoxaemia and hypercapnia. With the possible pressure on the larynx, the trachea and the respiratiory functions (upper airway obstruction, that can cause stridor), obstructive sleep apnea can develop, or less often their effect develops through uni-, or bilateral pleural effusion.

Answer 29

ANSWER B) isolation of the patient from the environment EXPLANATION In case of extrinsic asthma, avoidance of allergens is the most important aspect, if it is possible (eg. dust mite, fur, infections). With pollen allergy this is a difficult question, because at certain times the pollen is in the air. Adequate medication - bronchodilator and inhaled steroid - is needed, based on the severity of asthma. Home surveillance of patients is possible with a peak flow meter, which gives information about the PEF (peak exspiratory flow) and can be used to control the effectivness of the treatment. The asthmatic patients should be under regular and close pulmonological control. Isolation of the patients is not needed at all. The above findings not only apply to asthmatic pregnancy but to asthma bronchiale in general.

Answer 30

ANSWER C) succinyilcholine EXPLANATION In case of status asthmaticus or acute severe asthma parenteral hydration, treatment of hypoxaemia with oxygen supplementation (usually with a 4-6L/min dosage) and intravenous cannulation are essential. Besides that, intravenous methylprednisolone and inhaled short acting beta-agonist - preferably with nebulizer (it's more effective than simple inhalation) - should be administered. The muscle relaxing agent, succinylcholine isn't part of the treatment of status asthmaticus. The former management protocol can be followed in status asthmaticus, irregardless whether the patient is pregnant.

Answer 31

ANSWER C) only the 1. and 3. answers are correct EXPLANATION Calcification is typical in tuberculoma, "healed" post-tuberculotic nodules and hamartomas. Metastases of ovarian cancer, bronchopneumonia and cysts (except echinococcus) rarely shows signs of caclification, the latter is eggshell-like.

Answer 32

ANSWER C) only the 1. and 3. answers are correct EXPLANATION Metastatic colorectal cancer mostly appears in the form of multiple nodules in the lungs, without any cavitation. Lung cysts rarely occur in the top of the lower lobe, and while they can look like a cavity with a thin wall, they often consist fliud and rather appear like a nodule or a cavity with an air-fluid level inside. Aspergilloma develops from a preformed cavity with the invasion of fungi, and it is usually in the upper lobe. The top of the lower lobe is the predilection site for tuberculosis, but disintegrating lung cancer can also occur there.

Answer 33

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Many diseases can cause unilateral hilar widening on the x-ray, such as central lung cancer, mediastinal tumours, malignant lymphoma, tuberculosis, silicosis etc. X-rays in histiocytosis X mostly shows focal lesions in the upper lobes. In LAM (lymphangioleiomyomatosis) fine reticulonodular lesions, pleural effusion and sometimes pneumothorax can be observed.

Answer 34

ANSWER D) only the 2. and 4. answers are correct EXPLANATION Bilateral widening of hilum can have several possible reasons, eg. Boeck-sarcoidosis, bronchial cancer, mediastinal tumours, lymphoma etc. In the early stages of idiopathic pulmonary fibrosis, reticular lesions are present primarily in the lower lobes, and in the later stages "honeycomb lung" is seen. You can see nodular lesions on the X-ray in Wegener-granulomatosis, typically with cavitation. Alveolar microlithiasis causes small intense foci on the X-ray, mainly in the lower lobes.

Answer 35

ANSWER C) only the 1. and 3. answers are correct EXPLANATION Long-term steroid therapy is indicated in COPD in cases where either significant increase of FEV1 can be observed after a high dose short-term (two week) steroid therapy, or the patient's overall state is unsatisfactory without steroids. Nor irreversible airway obstruction despite beta-agonist, nor theophyllin-intolerace are indications for long-term steroid therapy. The persistent airway obstruction in itself is also not an indication for steroid, as airway obstruction is in the definition of COPD and it can be fully irreversible even if the patient takes steroids.

Answer 36

ANSWER D) only the 2. and 4. answers are correct EXPLANATION In COPD, the progression of the diasease – and mainly the FEV1 reduction - is highly determined by the smoking. Improvement in prognosis is to await from smoking cessation and from long-term O2 therapy.

Answer 37

ANSWER E) only the 4. answer is correct EXPLANATION The only correct answer is exercise-induced dyspnea, since emphysema is not a reversible airway obstruction. Only exercise-induced asthma is characterized by dyspnea 6 to 10 minutes after cessation of exercise, while exercise-induced asthma does not increase flow restriction during the exercise (provided that the patient had not had previously difficulty of breathing)

Answer 38

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Statement 1 is the definition of COPD, which implies that the obstruction indicator FEV1 is also reduced. Approximately one third to half of COPD cases are accompanied by bronchial hyperresponsiveness. FIV1 is generally not reduced, especially when emphysema and not bronchitis is dominant. In the rare cases when bronchitis is the leading condition, "fixed" constrictions may occur, which can rarely cause a moderate decrease in FIV1. In COPD, dyspnea does not show rapid alterations and asthma-like attack does not characterize the disease.

Answer 39

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Antihistamines should not be given for asthma. This group of drugs has an indication in the potential associated allergic rhinitis. Its effect on asthma is very moderate. Continuous oral steroid administration in moderate asthma (stage 3) is contraindicated. At this stage, administration of an inhaled steroid, a long acting bronchodilator and, if necessary, a short acting β2-agonist will provide adequate control of asthma.

Answer 40

ANSWER B) only the 1., 2., 4. and 5. answers are correct EXPLANATION Oral theophyllin has not been recommended in mild asthma until the test questions have appeared. So the correct answer is B.

Answer 41

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Macrolides, fluoroquinolones and oxytetracycline are effective antibiotics in the treatment of atypical pneumonia.

Answer 42

ANSWER F) all of the answers are correct EXPLANATION In the case of pulmonary tuberculosis, any of these symptoms can occur, but none are specific. However, the coexistence of symptoms greatly raises the possibility of tuberculosis.

Answer 43

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION The TBC bacterium can be detected from the punctate by a PCR technique within 24 hours. Thoracoscopy - ZN staining of the optically representative image and even more of the pleural effusion biopsy and histological image (thoracoscopic or blind pleurabiopsy) - can also give a diagnosis within 3 days. In the case of pleuritis exsudativa, there is often no specific lesion seen in the lungs, so a positive result with ZN staining in the sputum is not expected.

Answer 44

ANSWER C) only the 1. and 3. answers are correct EXPLANATION In addition to toxic pulmonary tuberculosis, corticosteroid treatment is required in all cases where scarring or adhesions causing severe dysfunction is expected. Thus, among those listed, miliary tuberculosis, all tuberculous exudative serous inflammation, including pleuritis exsudativa. Administration of steroid for primary complex and cervical lymph node TB is not indicated.

Answer 45

ANSWER B) only the 1., 2., 4. and 5. answers are correct EXPLANATION In TB associated with HIV infection, the proportion of new (exogenous) TB infection dominates (70%) and only 30% is endogenous exacerbation (activation of dormant bacteria). This was determined by genetic engineering methods. The rest of the statements are facts based on observations.

Answer 46

ANSWER F) all of the answers are correct EXPLANATION Bronchocentric granuloma is also a fungal disease usually caused by Aspergillus. Tissue and peripheral eosinophilia can be detected in about one third and are therefore classified as eosinophilic diseases of the lungs. In most cases, in sputum or biopsy fungal filaments can be present. The other diseases listed include the name of the fungus, so there is no doubt that it is caused by Aspergillus.

Answer 47

ANSWER E) only the 4. answer is correct EXPLANATION Invasive aspergillosis is a multi-segmental lesion that cannot be treated with segmental resection. Caverna is generally not typical for invasive bronchopulmonary aspergillosis. Significant reductions in oxygen tension are rarely accompanied, at most, by healing with extensive scarring (in the absence of steroid therapy). O2 treatment is not a causal therapy and is indicated for respiratory failure. Treatment is carried out with Amphotericin B and given by infusion.

Answer 48

ANSWER B) only the 1., 2., 4. and 5. answers are correct EXPLANATION In acute massive pulmonary embolism, severe resting dyspnea-cyanosis-central chest pain syndrome is almost always present and syncope is common. Cough is not a common symptom of the disease.

Answer 49

ANSWER C) only the 1. and 3. answers are correct EXPLANATION Pneumothorax is characterized by chest pain on the same side, which can be pronounced mainly when the PTX occurs and may eventually disappear. The same applies to dyspnea, which occurs only initially in the case of smaller amounts of air in the pleural space. However, as the PTX gradually increases, shortness of breath increases. In a smaller PTX, after initial resting dyspnea exertional dyspnea may persist. Cyanosis occurs mainly in extensive or tension PTX. In a smaller PTX, only if the lung is already severely damaged by other diseases. Wheezing is not typical for PTX. The mediastinum, when pushed, is due to increased intrapleural pressure on the ipsilateral side of the PTX relative to the contralateral side.

Answer 50

ANSWER A) only the 1., 2. and 3. answers are correct

Answer 51

ANSWER B) only the 1., 2., 4. and 5. answers are correct EXPLANATION The indication of mechanical ventilation is not primarily influenced by the size of vital capacity. Anyway, the vital capacity of 65-70 ml/kg, or even slightly lower, falls within the normal range. The other 4 statements are correct.

Answer 52

ANSWER D) only the 2. and 4. answers are correct EXPLANATION There are two forms of respiratory failure, including acute respiratory failure. In the case of Type I, only PaO2 is reduced and does not result in CO2 retention. It can also be a consequence of extensive pneumonia. Regardless of its cause, especially in the case of CO2 retention, acid-base imbalances are common. Acute exacerbation of chronic lung disease is a common cause. O2 therapy does not eliminate the cause and does not always affect hypoxemia (eg ARDS).

Answer 53

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Chronic respiratory failure develops over months to years. A common consequence of COPD. Initially, this disease develops only hypoxaemia, which is accompanied by CO2 retention via further worsening of the ventilation/perfusion rate, and an increase in alveolar hypoventilation. In fibrosis, type I (hypoxaemia only) respiratory failure is typical because diffusion is the main cause but CO2 diffuses well. Compensation mechanisms increase the level of buffer bases.

Answer 54

ANSWER B) only the 1., 2., 4. and 5. answers are correct EXPLANATION In ARDS, pulmonary artery pressure is high while pulmonary wedge pressure is not, because the disease - and pulmonary edema as a part of it - is not caused by left-sided heart failure.

Answer 55

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Smoke inhalation is characterized by edema of the respiratory tract (including the upper respiratory tract) and symptoms caused by intoxication caused by substances in the smoke. Respiratory dysfunction may develop up to 2 days after the exposure, but this is no longer primarily a causal effect of the main gas exchange inhibiting component (CO) of smoke, since CO cannot be detected in the blood 8 hours after exposure. Immediate respiratory arrest is not a feature; many chemical and physical factors (eg. heat) in smoke are responsible for the symptoms.

Answer 56

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Foreign body aspiration, which is more common in children than in adults, is a bronchoscopic indication even when it is just suspected. Failure to diagnose or remove the foreign body in time can result in endobronchial granulation. Detection and removal can be done with a bronchoscope. With chest CT it is not always detectable.

Answer 57

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Pulmonary infiltrate and pleural effusion are not part of Löfgren's syndrome.

Answer 58

ANSWER F) all of the answers are correct EXPLANATION In lung cancer, any of these symptoms (including Cushing's syndrome) can occur.

Answer 59

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Atrovent and colchicine do not cause pulmonary fibrosis, unlike amiodorone, bleomycin or nitrofurantoin.

Answer 60

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION Spontaneous regression in sarcoidosis is common and tuberculin test is mostly negative. Hilar lymphadenopathy can be unilateral in about 5-10% of cases. In its active form, hypergammaglobulinaemia occurs often with elevated β-macroglobulin levels. However, testing for these has not become a part of routine diagnosis of the disease. Pathologically, the disease is characterized by formation of epitheloid cellular granuloma, without caseous necrosis.

Answer 61

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION If FEV1 is below 1 liter, not only pulmonectomy but also segmentectomy is not possible due to the high risk of postoperative mortality. The same applies to respiratory failure and severe pulmonary hypertension. Decreased CO-transfer coefficient and high TLC, which is characteristic of emphysema, are not a contraindication for surgical removal of the tumor. Volume reduction following resection may, in some cases, result in an increase in tension in the remaining lung sections (increase in elastic contractile force), which may reduce airway dynamic compression and thus improve the patient’s physical performance.

Answer 62

ANSWER C) The first one is correct in itself, but the second one is incorrect EXPLANATION The cessation of wheezing during an asthmatic attack (silent lungs) always indicates very severe airway obstruction caused by severe inflammation and edema of the respiratory tract, and extensive obstruction of the small airways by mucus plugs.

Answer 63

ANSWER A) Both are correct, and there is a causal relationship between them EXPLANATION In case of suspected pulmonary embolism, the sooner the low-radiation lung scintigraphy is performed, the greater its information value.

Answer 64

ANSWER A) Both are correct, and there is a causal relationship between them EXPLANATION When diagnosing a peripheral nodule bronchoscopy and transbronchial biopsy is less efficient than transthoracic fine needle biopsy. The area of the bronchioles can not be examined with bronchoscopy.

Answer 65

ANSWER E) Both are incorrect EXPLANATION In shock arterialized blood from earlobe or fingertip would significantly undervalue PaO2, thus it is unreliable. Instead of it arterial blood (e.g. drawn from a. radialis) should be used for blood gas analysis.

Answer 66

ANSWER C) The first one is correct in itself, but the second one is incorrect EXPLANATION The definition is correct, however the patient in severe acute asthma (status asthmaticus) only needs mechanical ventilation when the following criteria are met: - the patient has severe respiratory insufficiency, that does not improve to further therapy than usual bronchodilators - e.g. high dose intravenous corticosteroids, - the patient’s respiratory muscles show signs of fatigue - hypoxaemia is not improving despite oxygen-therapy, hypercapnia is worsening. 90% of the acute severe asthma cases can be managed without ventilation therapy.

Answer 67

ANSWER D) The first one is incorrect, the second one is correct in itself EXPLANATION The explanation itself is true, because amoxicillin is effective against the most common bacteria causing community-acquired pneumonia (CAP). Although pneumonia caused by atypical pathogens is becoming more and more frequent, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the most common bacteria in CAP.

Answer 68

ANSWER E) Both are incorrect EXPLANATION Hyperergic reaction to tuberculin test can mean previous (already healed) tuberculosis, because the reaction is based on the immunity against mycobacteria. The size of the reaction does not correlate neither with the activity, nor the extension of the disease

Answer 69

ANSWER B) Both are correct but there is no causal relationship between them EXPLANATION Alveolar hypoxaemia triggers pulmonary vasoconstriction, which elevates the pulmonary vascular resistance. If the pressure in the pulmonary artery exceeds 30 mmHg, there is pulmonary hypertension. There is no causality between the two statements because not only alveolar hypoxaemia can cause pulmonary hypertension (e.g. primary pulmonary hypertension), and hypoxaemia that is present for only a short amount of time does not necessarily cause pulmonary pressure above 30 mmHg.

Answer 70

ANSWER B) Both are correct but there is no causal relationship between them EXPLANATION Both statements are true, but there is no causality because hypoxaemia can be managed with oxygen therapy, although in that case PCO2 level can rise. The indication for mechanical ventilation in type II respiratory insufficiency is primarily the CO2 retention. To reduce the hypercapnia intubation is not always needed.

Answer 71

ANSWER D) The first one is incorrect, the second one is correct in itself EXPLANATION Chronic respiratory insufficiency is often type II, especially in COPD. Due to the slow progression of the disease there is time for compensatory mechanisms to evolve, thus pH can be within normal range despite the hypercapnia. First part is incorrect, second part is true.

Answer 72

ANSWER E) Both are incorrect EXPLANATION Tumor markers can show an elevated level in other diseases as well, they are neither specific, nor diagnostic.

Answer 73

ANSWER C) The first one is correct in itself, but the second one is incorrect EXPLANATION Smoking does cause chronic bronchitis, but only a subset of smokers will have lung cancer.

Answer 74

ANSWER E) Both are incorrect EXPLANATION SCLC (small cell lung cancer) is treated in any case, because the combination therapy can improve quality of life and overall survival.

Answer 75

ANSWER D) The first one is incorrect, the second one is correct in itself EXPLANATION Haemoptysis is a common symptom in lung cancer. A negative X-ray does not exclude the presence of lung cancer. In case of haemoptysis, bronchoscopy is mandatory. In case bronchoscopy is negative, a CT scan is needed.

Answer 76

ANSWER A) Both are correct, and there is a causal relationship between them EXPLANATION Pleuritis carcinomatosa can occur in patients years after operation of breast cancer, even without a visible local recurrance.

Answer 77

ANSWER B) only the 2. and 4. answers are correct EXPLANATION Chest X-ray is indicated in case of long-lasting (e.g. 3 weeks) non-productive cough and fever. Family members presenting the same symptoms implies the probability of infection even without a chest X-ray. In case the possibility of tuberculosis emerges, radiomorphology and lesions in the sites of predilection should be considered. However, it is not likely that more family members get infected by Mycobacterium at the same time. The radiological manifestations of invasive aspergillosis may be similar to that seen in atypical pneumonia, however tha fact that this is a relatively rare disease with low infectious rate and most cases occur in people with severely compromised immune systems, it is very unlikely to be present in 3 people at the same time. When the symptoms and radiological findings imply the presence of atypicial pneumonia, serological tests can confirm the diagnosis, and the infection can be treated with antibiotics of proper spectrum.

Answer 78

ANSWER D) atypical pneumonia EXPLANATION Chest X-ray is indicated in case of long-lasting (e.g. 3 weeks) non-productive cough and fever. Family members presenting the same symptoms implies the probability of infection even without a chest X-ray. In case the possibility of tuberculosis emerges, radiomorphology and lesions in the sites of predilection should be considered. However, it is not likely that more family members get infected by Mycobacterium at the same time. The radiological manifestations of invasive aspergillosis may be similar to that seen in atypical pneumonia, however tha fact that this is a relatively rare disease with low infectious rate and most cases occur in people with severely compromised immune systems, it is very unlikely to be present in 3 people at the same time. When the symptoms and radiological findings imply the presence of atypicial pneumonia, serological tests can confirm the diagnosis, and the infection can be treated with antibiotics of proper spectrum.

Answer 79

ANSWER B) antibiotic therapy EXPLANATION Chest X-ray is indicated in case of long-lasting (e.g. 3 weeks) non-productive cough and fever. Family members presenting the same symptoms implies the probability of infection even without a chest X-ray. In case the possibility of tuberculosis emerges, radiomorphology and lesions in the sites of predilection should be considered. However, it is not likely that more family members get infected by Mycobacterium at the same time. The radiological manifestations of invasive aspergillosis may be similar to that seen in atypical pneumonia, however tha fact that this is a relatively rare disease with low infectious rate and most cases occur in people with severely compromised immune systems, it is very unlikely to be present in 3 people at the same time. When the symptoms and radiological findings imply the presence of atypicial pneumonia, serological tests can confirm the diagnosis, and the infection can be treated with antibiotics of proper spectrum.

Answer 80

ANSWER A) aspergilloma EXPLANATION Aspergillus fumigatus tends to colonize the surface of preformed lung cavities (e.g. an empty cyst, a ’healed’ tuberculous cavern, cavity of a haematoma) and grows freely within the cavity. It tipically appears as an intracavitary mass outlined by a crescent of air on chest X-ray. This lesion is called an aspergilloma. Diagnosis relies on radiographic findings, the presence of Aspergillus fumigatus in sputum, tomography and positive serum Aspergillus antibody. The gold standard of therapy is surgical removal of the aspergilloma.

Answer 81

ANSWER C) only the 1. and 3. answers are correct EXPLANATION Aspergillus fumigatus tends to colonize the surface of preformed lung cavities (e.g. an empty cyst, a ’healed’ tuberculous cavern, cavity of a haematoma) and grows freely within the cavity. It tipically appears as an intracavitary mass outlined by a crescent of air on chest X-ray. This lesion is called an aspergilloma. Diagnosis relies on radiographic findings, the presence of Aspergillus fumigatus in sputum, tomography and positive serum Aspergillus antibody. The gold standard of therapy is surgical removal of the aspergilloma

Answer 82

ANSWER D) pulmonary resection EXPLANATION Aspergillus fumigatus tends to colonize the surface of preformed lung cavities (e.g. an empty cyst, a ’healed’ tuberculous cavern, cavity of a haematoma) and grows freely within the cavity. It tipically appears as an intracavitary mass outlined by a crescent of air on chest X-ray. This lesion is called an aspergilloma. Diagnosis relies on radiographic findings, the presence of Aspergillus fumigatus in sputum, tomography and positive serum Aspergillus antibody. The gold standard of therapy is surgical removal of the aspergilloma

Answer 83

ANSWER B) only the 4., 6. and 7. answers are correct EXPLANATION Chest X-ray is indicated since the patient is cyanotic, has a restrictive ventilatory defect, decrease in diffusion capacity (DLCO) and respiratory symptoms. A simple posteroanterior chest X-ray can be informative, even in early stages of diffuse interstial lung disease, which can be confirmed with HRCT imaging. The diagnosis is verified by histology of a bioptatum. Regarding the possible answers of sub-question B, silicosis and asbestosis are incorrect, given that the case report mentions rapid progression. The same stands for Boeck sarcoidosis, since it does not show such rapid progression, even with concomittant bronchopneumonia. Though the chest X-ray can be similar to that seen in interstitial lung disease. Which makes the diagnosis unlikely is that the patient does not have fever in this specific case. In conclusion, the most possible diagnosis, even without histology, is fibrosing alveolitis, which can be treated by corticosteroids and immunosupressive therapy after histological verification.

Answer 84

ANSWER C) only the 1., 2. and 3. answers are correct EXPLANATION In today’s TB epidemiological situation in Hungary tuberculous pleuritis exsudativa is frequent again. Often it appears without any visible pulmonary tuberculous infiltration. To confirm the diagnosis mycobacterial culture from the pleural fluid (lately PCR analysis can give results in 24 hours), pleural needle biopsy can be the primary proof. Mantoux test in such cases is usually highly hiperreactive. Dominance of lymphocytes in the pleural fluid is also an evidence of tuberculotic pleuritis. It can be treated with a combination of antituberculotic drugs, to which adding low dose steroid is recommended to avoid pleural scarring. Administering steroids without antituberculotics leads to rapid progression (“burst”) of the disease, which puts the patient’s life in great danger.

Answer 85

ANSWER D) Pleuritis exsudativa tuberculosa EXPLANATION In today’s TB epidemiological situation in Hungary tuberculous pleuritis exsudativa is frequent again. Often it appears without any visible pulmonary tuberculous infiltration. To confirm the diagnosis mycobacterial culture from the pleural fluid (lately PCR analysis can give results in 24 hours), pleural needle biopsy can be the primary proof. Mantoux test in such cases is usually highly hiperreactive. Dominance of lymphocytes in the pleural fluid is also an evidence of tuberculotic pleuritis. It can be treated with a combination of antituberculotic drugs, to which adding low dose steroid is recommended to avoid pleural scarring. Administering steroids without antituberculotics leads to rapid progression (“burst”) of the disease, which puts the patient’s life in great danger.

Answer 86

ANSWER A) Combination of antituberculotic drugs EXPLANATION In today’s TB epidemiological situation in Hungary tuberculous pleuritis exsudativa is frequent again. Often it appears without any visible pulmonary tuberculous infiltration. To confirm the diagnosis mycobacterial culture from the pleural fluid (lately PCR analysis can give results in 24 hours), pleural needle biopsy can be the primary proof. Mantoux test in such cases is usually highly hiperreactive. Dominance of lymphocytes in the pleural fluid is also an evidence of tuberculotic pleuritis. It can be treated with a combination of antituberculotic drugs, to which adding low dose steroid is recommended to avoid pleural scarring. Administering steroids without antituberculotics leads to rapid progression (“burst”) of the disease, which puts the patient’s life in great danger.

Answer 87

ANSWER A) only the 2., 4., 6. and 7. answers are correct EXPLANATION The patient’s anamnesis and asymmetric tumescence of mediastinal lymph nodes on the chest x-ray indicate chest CT, bronchoscopy, haematological testing and mediastinoscopy. Histology of the lymph node sample acquired with mediastinoscopy leads to diagnosis. Before haematological testing and mediastinoscopy the probable diagnoses surely exclude COPD, asthma and pneumonia. All the other diseases show or can possibly show tumescence of mediastinal lymph nodes. Sarcoidosis can occur in the form of unilateral tumescence of mediastinal lymph nodes.

Answer 88

ANSWER A) only the 2., 4., 6. and 7. answers are correct EXPLANATION The patient’s anamnesis and asymmetric tumescence of mediastinal lymph nodes on the chest x-ray indicate chest CT, bronchoscopy, haematological testing and mediastinoscopy. Histology of the lymph node sample acquired with mediastinoscopy leads to diagnosis. Before haematological testing and mediastinoscopy the probable diagnoses surely exclude COPD, asthma and pneumonia. All the other diseases show or can possibly show tumescence of mediastinal lymph nodes. Sarcoidosis can occur in the form of unilateral tumescence of mediastinal lymph nodes.

Answer 89

ANSWER A) Histology of the lymph node EXPLANATION The patient’s anamnesis and asymmetric tumescence of mediastinal lymph nodes on the chest x-ray indicate chest CT, bronchoscopy, haematological testing and mediastinoscopy. Histology of the lymph node sample acquired with mediastinoscopy leads to diagnosis. Before haematological testing and mediastinoscopy the probable diagnoses surely exclude COPD, asthma and pneumonia. All the other diseases show or can possibly show tumescence of mediastinal lymph nodes. Sarcoidosis can occur in the form of unilateral tumescence of mediastinal lymph nodes.

Answer 90

ANSWER D) only the 2. and 5. answers are correct EXPLANATION Progressive dyspnoea and cyanosis together are clear indications for a blood gas assessment and chest x-ray. Typical radiographic appearance and severe hypoxaemia confirm ARDS, which occurs often in patients with pancreatitis. In this case hypoxaemia cannot be managed by simple (nasal) oxygen therapy, only with increased FiO2 administered with mechanical ventilation. To avoid pulmonary oedema continuous positive airway pressure ventilation is needed.

Answer 91

ANSWER C) ARDS EXPLANATION Progressive dyspnoea and cyanosis together are clear indications for a blood gas assessment and chest x-ray. Typical radiographic appearance and severe hypoxaemia confirm ARDS, which occurs often in patients with pancreatitis. In this case hypoxaemia cannot be managed by simple (nasal) oxygen therapy, only with increased FiO2 administered with mechanical ventilation. To avoid pulmonary oedema continuous positive airway pressure ventilation is needed.

Answer 92

ANSWER D) Continuous positive airway pressure ventilation EXPLANATION The coexistence of progressive suffocation and cyanosis is clearly an indication of blood gas test and chest x-ray. Typical x-ray result and severe hypoxemia confirms the diagnosis of ARDS, which is not rare together with the diagnosis of pancreatitis. Hypoxemia cannot be corrected by simple (nasal) O2 administration, only correctable with elevated FiO2 delivered by respiratory ventilation. Continuous positive pressure ventilation should be used to reduce the formation of pulmonary edema.

Answer 93

ANSWER C) only the 1. and 3. answers are correct EXPLANATION Inspiratoric stridor is characterized by upper respiratory tract constriction - especially extrathoracic - which is well indicated by inspiratory lung function parameters. Clear evidence of stenosis, size and probable cause is provided by bronchoscopy (possibly laryngoscopy). In this case, the probable diagnosis is postintubatic tracheastenosis, with tracheal resection as a therapeutic option.

Answer 94

ANSWER B) Postintubatic stenosis EXPLANATION Inspiratory stridor is characterized by upper respiratory tract constriction - especially extrathoracic - which is well indicated by inspiratory lung function parameters. Clear evidence of stenosis, size and probable cause is provided by bronchoscopy (possibly laryngoscopy). In this case, the probable diagnosis is stenosis after intubation, with tracheal resection as a therapeutic option.

Answer 95

ANSWER C) Trachea resection EXPLANATION Inspiratory stridor is characterized by upper respiratory tract constriction - especially extrathoracic - which is well indicated by inspiratory lung function parameters. Clear evidence of stenosis, size and probable cause is provided by bronchoscopy (possibly laryngoscopy). In this case, the probable diagnosis is stenosis after intubation, with tracheal resection as a therapeutic option.

Answer 96

ANSWER C) respiratoric acidosis EXPLANATION In COPD, with high pCO2 levels, low pH and elevated st. bicarbonate indicates respiratory acidosis. If the O2 therapy - to achieve sufficient arterial O2 tension - significantly increases pCO2 tension, then mechanical ventilation or respiratory therapy is required.

Answer 97

ANSWER C) Mechanical ventilation, respirator treatment EXPLANATION In COPD, with high pCO2 levels, low pH and elevated st. bicarbonate indicates respiratory acidosis. If the O2 therapy to achieve sufficient arterial O2 tension significantly increases pCO2 tension, then mechanical ventilation or respiratory therapy is required

Answer 98

ANSWER A) only the 1., 2., 4. and 7. answers are correct EXPLANATION The history of the young patient clearly shows possibility of allergic rhinitis and bronchial asthma. To verify or exclude the diagnosis, it is recommended to perform an allergy test using a cutan test, a serum IgE test, PEF monitoring to detect significant fluctuations in airway caliber in asthma bronchiale. If PEF monitoring shows negative result, an inhalation provocation test is recommended with inhalating hypertonic KCl in the asymptomatic state. If the provocation test shows positive result, asthma bronchiale is likely verified. If the provocation test is negative, diagnosis of asthma bronchiale is excluded. For allergic rhinitis, oral antihistamines can be used or local Na-cromoglycate may be given locally (nasally), or inhaled steroid can be used. Depending on the severity of the patient's asthma bronchiale - in our case a mild intermittent asthma (stage 2) - oral inhaled steroid or Na-chromoglycate are the best choice among the drugs listed. (Other alternatives that are not listed here are also possible.) Cough suppressants are prohibited in asthma bronchiale and digoxin is not a remedy for asthma bronchiale.

Answer 99

ANSWER A) only the 1., 2. and 3. answers are correct EXPLANATION The history of the young patient clearly shows possibility of allergic rhinitis and bronchial asthma. To verify or exclude this, it is recommended to perform an allergy test using a cutan test, a serum IgE test, PEF monitoring to detect significant fluctuations in airway caliber in asthma. If PEF monitoring shows negative result, an inhalation provocation test is recommended with hypertonic KCl in the asymptomatic state. If the provocation test shows positive result, astha is likely verified. If the provocation test is negative, diagnosis of asthma bronchiale is excluded. For allergic rhinitis, oral antihistamines can be used or local Na-cromoglycate may be given locally (nasally), or inhaled steroid can be used. Depending on the severity of the patient's asthma - in our case a mild intermittent asthma (stage 2) - oral inhaled steroid or Na-chromoglycate are the best choice among the drugs listed. (Other alternatives that are not listed here are also possible.) Cough suppressants are prohibited in asthma bronchiale and digoxin is not a remedy for asthma bronchiale.