Pulmonary Practice Exam
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Question 1 |
Which of the following is essential to make a diagnosis of cystic fibrosis?
Positive family history Hint: Cystic fibrosis is a genetic disease, but a positive family history in and of itself is not enough to diagnose the condition. | |
Elevated sweat chloride | |
Recurrent respiratory infections Hint: While recurrent respiratory infections are a classic presentation of cystic fibrosis, the diagnosis relies on confirmation.The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test or demonstration of a genotype consistent with cystic fibrosis. | |
Elevated trypsinogen levels Hint: Trypsinogen levels are used as a neonatal screening test and if elevated should be followed by more definitive testing to confirm the diagnosis. |
Question 1 Explanation:
The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test or demonstration of a genotype consistent with cystic fibrosis.
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Question 2 |
A patient presents with a history of progressive worsening of dyspnea over the past several years. He gives a history of having worked as a ship builder for over 50 years. He denies any alcohol or tobacco use. On examination you note clubbing and inspiratory crackles. Which of the following chest x-ray findings support your suspected diagnosis?
hyperinflation and flat diaphragms Hint: Chest x-ray findings of hyperinflation and flat diaphragms suggest long-standing chronic obstructive lung disease. | |
interstitial fibrosis and pleural thickening | |
cavitary lesions involving the upper lobes Hint: Chest x-ray findings of cavitary lesions involving the upper lobes suggest pulmonary tuberculosis. | |
"eggshell" calcification of hilar lymph nodes Hint: Chest x-ray findings of "eggshell" calcification of hilar lymph nodes strongly supports the diagnosis of silicosis. |
Question 2 Explanation:
This patient most likely has asbestosis, which is supported by his occupation as a ship builder and clinical presentation as noted above. Chest x-ray findings include interstitial fibrosis, pleural thickening and calcified pleural plaques on the diaphragm or lateral chest wall.
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Question 3 |
A 15 year-old male presents with a 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. Examination is unremarkable except for a few scattered rhonchi and rales upon auscultation of the chest. The chest x-ray reveals interstitial infiltrates and a cold agglutinin titer was negative. Which of the following is the most likely diagnosis?
acute bronchitis Hint: While the patient's clinical symptoms of dry cough and rhonchi support this diagnosis, the chest x-ray would be normal or only show a mild increase in bronchovascular markings, not infiltrates. | |
viral pneumonia | |
mycoplasma pneumonia Hint: While the gradual onset of symptoms suggest mycoplasma, the negative cold agglutinin titer makes this less likely. | |
pneumococcal pneumonia Hint: In older children the signs and symptoms of pneumococcal pneumonia are similar to an adult and consist of an abrupt onset of cough, fever and chills. The chest x-ray would reveal a lobar consolidation, not interstitial, picture. |
Question 3 Explanation:
The patient's clinical symptoms as well as chest x-ray findings and negative cold agglutinin titer are most consistent with viral pneumonia.
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Question 4 |
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 tracheal deviation to the right. Which of the following is the most appropriate next step?
order a V/Q scan Hint: A V/Q scan is indicated in suspected cases of pulmonary embolism. | |
order a chest x-ray Hint: Patients in respiratory distress and evidence of a tension pneumothorax, such as tracheal deviation, should have treatment initiated without waiting on a chest x-ray to be taken. | |
administer a sclerosing agent Hint: Pleurodesis by administration of a sclerosing agent is indicated in treatment of recurrent, not traumatic, pneumothorax. | |
insert large bore needle into left second intercostal space stat |
Question 4 Explanation:
Simple aspiration by insertion of a needle into the involved side will decompress the tension pneumothorax until a chest tube can be inserted. Read more about this blueprint topic: Click Here
Question 5 |
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?
CT scan of the chest | |
Needle biopsy of the lesion Hint: A needle biopsy would be indicated for a person greater than 35 years old and/or with a history of smoking to evaluate a solitary pulmonary nodule. | |
Positron emission tomography of the chest Hint: Positron emission tomography (PET scan) would be indicated if the CT scan was nonconclusive. | |
Fiberoptic bronchoscopy Hint: Fiberoptic bronchoscopy would be indicated only in the presence of a history of tobacco use or if the lesion was suggestive of malignancy. |
Question 5 Explanation:
In the absence of old x-rays in a nonsmoking individual less than 35 years old, CT scan of the chest is the next step in the evaluation of a solitary pulmonary nodule. Read more about this blueprint topic: Click Here
Question 6 |
Which of the following best describes the pathophysiology of emphysema?
Interstitial inflammation and fibrosis Hint: Interstitial inflammation and fibrosis are seen with restrictive causes of lung disease, such as asbestosis. | |
Alveolar enlargement and loss of septa | |
Mucosal edema and inflammatory response Hint: Mucosal edema and inflammatory response are seen with asthma. | |
Excessive mucus secretion and chronic cough Hint: Excessive mucus secretion and chronic cough are characteristic of chronic bronchitis. |
Question 6 Explanation:
Emphysema results from alveolar enlargement with loss of septal wall integrity without any evidence of fibrosis. Read more about this blueprint topic: Click Here
Question 7 |
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?
Atelectasis Hint: Small atelectasis is commonly asymptomatic, while large atelectasis may produce signs of dyspnea and cough. Exam reveals absence of breath sounds in the area involved and dullness to percussion. A chest x-ray would reveal various findings dependent on the location of the atelectasis, but would not be normal. | |
Pneumothorax Hint: While a pneumothorax commonly presents with pleuritic chest pain and dyspnea, exam would reveal the presence of diminished breath sounds and hyperresonance on the involved side. A chest x-ray would reveal presence of a pleural line on the expiratory chest x-ray. | |
Pulmonary embolism | |
Myocardial infarction Hint: While a myocardial infarction usually presents with dyspnea, the chest pain is not usually pleuritic in nature. An EKG would commonly reveal ST segment changes which would be consistent with ischemia or infarct. |
Question 7 Explanation:
This patient's risk factors for pulmonary embolism include advanced age, surgery, and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult to make due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal. Read more about this blueprint topic: Click Here
Question 8 |
A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is
tuberculosis Hint: Most children with pulmonary tuberculosis are asymptomatic with few physical examination findings. The results of the diagnostic studies do not support tuberculosis as the most likely diagnosis. | |
mycoplasma pneumonia | |
pneumococcal pneumonia Hint: The clinical presentation of bacterial pneumonias in children is variable, but usually involves fever of acute onset. The WBC count is also usually elevated, making this a less likely diagnosis. | |
staphylococcal pneumonia Hint: See C for explanation. |
Question 8 Explanation:
The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely.
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Question 9 |
Which of the following conditions will produce a transudative pleural effusion?
Kaposi's sarcoma Hint: Kaposi's sarcoma, pneumonia, or mesothelioma will produce an exudative pleural effusion. | |
Pneumonia Hint: Kaposi's sarcoma, pneumonia, or mesothelioma will produce an exudative pleural effusion. | |
Cirrhosis | |
Mesothelioma Hint: Kaposi's sarcoma, pneumonia, or mesothelioma will produce an exudative pleural effusion. |
Question 9 Explanation:
Transudative pleural effusions result from alteration in the formation of pleural fluid, the absorption of pleural
fluid, or both, by systemic factors. Local factors affecting pleural fluid absorption and/or formation produce exudative pleural effusions. Read more about this blueprint topic: Click Here
Question 10 |
A patient should be tested for tuberculosis prior to being treated with
etanercept (Enbrel) | |
cyclosporine (Neoral) Hint: Cyclosporine, methotrexate, and prednisone do not have the requirement to check for tuberculosis prior to initiating treatment. | |
methotrexate (Rheumatrex) Hint: See B for explanation. | |
prednisone (Deltasone) Hint: See B for explanation. |
Question 10 Explanation:
Etanercept is an anti-cytokine agent used in the treatment of rheumatoid arthritis and has as a side effect the potential for serious infections. One of these side effects includes reactivation of dormant tuberculosis. Read more about this blueprint topic: Click Here
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