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1) Typical of an asthma exacerbation, in a patient taking no medication, are all of the following except:

a) reduced peak expiratory flow rate

b) reduced mid flow

c) blood or sputum eosinophilia

d) normal to increased diffusing capacity

e) reduced total lung capacity

2) Given the following arterial blood gas values:

pH 7.56

PaCO2 31 mm Hg

HCO3 27 mEq/l

PaO2 56 mm Hg

what is(are) the most likely acid-base state(s) in the patient?

a) acute respiratory alkalosis

b) chronic respiratory alkalosis

c) respiratory alkalosis and metabolic alkalosis

d) respiratory acidosis and metabolic acidosis

e) respiratory alkalosis and metabolic acidosis

Hint for #2

3) The principal difference between management of COPD and asthma exacerbations is:

a) types and doses of drugs used

b) degree of expected improvement in spirometry

c) utility of pulse oximetry

d) utility of sputum exam

e) patient symptoms by numerical scoring criteria

4) Which of the following rules out the diagnosis of pulmonary embolism?

a) normal PA and lateral chest x-ray

b) normal difference between alveolar and arterial PO2

c) normal D-dimer assay

d) normal electrocardiogram

e) none of above

5) A healthy young woman, toward the end of a mile run in the gym, has increased her heart rate by 50% over baseline. At that point, which one of the following statements is least likely to be true.

a) She is tachypneic and/or hyperpneic.

b) She is hyperventilating.

c) Her alveolar ventilation is increased above its resting baseline value.

d) Her CO2 production is increased above its resting baseline value.

e) Her PaO2 is normal.

Hint for #5

6) Which of the following is least likely to be present with obstructive apnea episodes occurring during REM sleep?

a) rapid eye movements

b) low voltage, mixed frequency EEG

c) active submental EMG

d) arousal after episode

e) dreaming

Hint for #6

7) Which of the following changes will most increase arterial oxygen delivery?

a) PaO2 from 50 to 95 mm Hg

b) cardiac output from 4 to 5 L/min

c) hemoglobin from 9 to 10 grams%

d) atmospheric pressure from 1 to 2 atmospheres

e) arterial pH from 7.30 to 7.50

8) Which one of the following statements about cystic fibrosis (CF) is not correct?

a) CF, an autosomal recessive disorder, is the most common genetic disease in the U.S.

b) Carriers of the CF gene are phenotypically normal

c) Pansinusitis with opacification of the paranasal sinuses is present in over 90% of CF patients.

d) The lungs are normal in CF at birth.

e) An abnormal sweat test is diagnostic of CF.

9) Which of the following statements about bronchiolitis obliterans organizing pneumonia (BOOP) is not correct?

a) the histology consists of intraluminal plugs of organizing connective tissue within distal airways, and in alveolar ducts and peribronchiolar alveolar spaces.

b) It may be idiopathic or due to a variety of clinical conditions, including drugs such as bleomycin, toxins such as NO2, infections, radiation, and connective tissue diseases.

c) BOOP is a manifestation of acute rejection seen after lung transplantation, with a typical time of presentation between 10 and 90 days after surgery.

d) BOOP can present in both lungs or just one lung or one lobe of one lung.

e) Either ESR or CRP is elevated in over half the cases of BOOP.

10) Considering latency period as time from first exposure to manifestation of disease, which asbestos-related condition can be observed after the shortest latency period?

a) pleural plaque

b) pleural effusion

c) malignant mesothelioma

d) asbestosis

e) lung cancer

Hint for #10

11) Given the following arterial blood gas values:

pH 7.40

PaCO2 20 mm Hg

HCO3 12 mEq/l

what is(are) the most likely acid-base state(s) in the patient?

a) metabolic acidosis with full compensation

b) respiratory alkalosis with full compensation

c) metabolic acidosis and respiratory alkalosis

d) metabolic acidosis and metabolic alkalosis

e) normal acid-base state

Hint for #11

12) All of the following are true about pulse oximetry reading of oxygen satuaration (SpO2) except:

a) In a patient receiving supplemental oxygen, SpO2 can be normal even when PaCO2 is >200 mm Hg.

b) It is not affected by anemia.

c) It reads most of the blood carboxyhemoglobin as oxyhemoglobin.

d) It is not affected by excess methemoglobin.

e) It requires a detectable pulse.

13) All of the following are true about carbon monoxide poisoning except:

a) shifts O2-dissociation curve to left

b) lowers SaO2 by binding to hemoglobin and displacing oxygen

c) alters the affinity of O2 molecules that do bind to hemoglobin

d) lowers PaO2

e) is treated with high concentrations of inspired oxygen

14) One or more of the following statements about PaO2 may be correct. Choose the single letter answer that reflects which statement(s) is(are) correct.

1) If the lungs and heart are normal, then PaO2 is affected only by factors that affect alveolar PO2.
2) In a person with normal heart and lungs, anemia should not affect PaO2.
3) PaO2 will go up in a patient with active hemolysis of red blood cells, as oxygen is given off when the cells lyse.
4) As the oxygen dissociation curve shifts to the left, PaO2 falls since more oxygen becomes bound to hemoglobin.
5) The reason PaO2 falls with increasing altitude is because the FIO2 falls.

a) only 1) is correct.

b) 1) and 2) are correct.

c) 1), 2), and 5) are correct.

d) 1) and 5) are correct.

e) 2) and 5) are correct.

Hint for #14

15) A patient has the following lung function test results:

decreased FEV-1
normal FVC
decreased DLCO
increased static compliance
increased TLC

The most likely diagnosis is:

a) emphysema

b) chronic bronchitis

c) asthma

d) pulmonary fibrosis

e) neuromuscular weakness affecting the chest wall and diaphragm

16) A patient is found to have interstitial lung disease on chest x-ray. Which one of the following tests will likely be least helpful in making a diagnosis?

a) perfusion lung scan

b) spiral CT scan of the chest

c) bronchoalveolar lavage

d) old chest x-rays going back over 5 years

e) transbronchial lung biopsy

17) Regarding ventilation/perfusion (V/Q) imbalance, all are true except one:

a) It is the most common physiologic cause of hypoxemia.

b) It is the most common physiologic cause of hypercapnia.

c) It means that some alveolar-capillary V/Q ratios are greater than 1, and some are less than 1.

d) It can cause hypoxemia without hypercapnia because the O2 dissociation curve is shaped differently than the CO2 dissociation curve.

e) In normal lungs there is no V/Q imbalance.

18) A patient with respiratory failure has the following room air (FIO2 = .21) arterial blood gases:

pH 7.20

PCO2 70 mm Hg

PO2 60 mm Hg

SaO2 86%

Which of the following is the least likely cause of these abnormal blood gases?

a) narcotic overdose

b) myasthenia gravis

c) flail chest

d) congestive heart failure

e) Guillain Barre' Syndrome

19) A 42-year-old man is admitted to the hospital with dehydration and hypotension. Electrolytes show Na+ 165 mEq/L, K+ 4.0 mEq/L, CO2 32 mEq/L, Cl- 112 mEq/L. No arterial blood gas is obtained. Which statement best applies about this patient's acid-base status?

a) Electrolytes indicate the presence of metabolic acidosis.

b) Electrolytes indicate the presence of metabolic alkalosis.

c) Electrolytes indicate the presence of both metabolic acidosis and metabolic alkalosis.

d) Need arterial blood gases to make any clinically useful assessment of his metabolic acid-base disorders.

e) Need serum lactate to make any clinically useful assessment of his metabolic acid-base disorders.

Hint for #19

20) All of the following statements regarding obstructive sleep apnea syndrome are true, except one:

a) Increased prevalence in men with neck size > 17 inches.

b) Standard medical treatment is nasal continuous positive airway pressure.

c) The higher the respiratory distrurbance index (RDI), the worse the problem and the more likely treatment will be beneficial.

d) Episodes of apnea may occur in REM and nonREM sleep.

e) The multiple sleep latency test will show early onset of REM sleep.

Hint for #20

21) A 32-year-old woman, 28 weeks pregnant, presents with chickenpox. She reports some shortness of breath with movement, and has a resting respiratory rate of 30/minute. You hear a few crackles over her right lower lung. Arterial blood gas shows pH 7.47, PCO2 32 mm Hg, PO2 71 mm Hg (FIO2 = .21). She is a non-smoker. Chest x-ray shows no infiltrate. The next step should be:

a) ventilation-perfusion lung scan

b) spiral CT scan of the chest

c) admit to the ICU, start nasal oxygen, and repeat chest x-ray in 12 hours

d) start Acyclovir therapy

e) start Amantadine therapy

22) Which one of the following statements about pneumonconiosis is not correct?

a) Asbestosis is manifested by parietal pleural plaques, which may or may not be calcified.

b) Absent a biopsy, diagnosis of berylliosis requires a positive lymphocyte transformation test, which can be done on the patient's blood or bronchial washings.

c) Silicosis increases the risk of developing lung cancer.

d) Asbestosis increases the risk of developing lung cancer.

e) Coal worker's pneumoconiosis is radiologically and clinically indistinguishable from silicosis

23) A 30-year-old man, previously healthy, is brought to the ER after suffering smoke inhalation. He has a measured COHb level of 20%; arterial blood gas shows a PaO2 of 95 mm Hg on room air (sea level), PaCO2 34 mm Hg, pH 7.34. The calculated oxygen saturation (based on PO2 and pH) is 96%. Measured hemoglobin content is 15 gm%. Exam shows clear lungs to auscultation and his chest x-ray is normal. From this information alone, you can determine that:

a) His actual SaO2 is much lower than the calculated value.

b) There is no lung abnormality present, though pulmonary disease could develop in the ensuing 24 hours.

c) He has a mild metabolic acidosis associated with an increased anion gap.

d) His arterial oxygen content is in the normal range.

e) None of the above.

Hint for #23

24) The most accurate statement about airway pressures during normal quiet breathing (as measured in the upper airway) is:

a) At the end of expiration there is a slight amount of positive airway pressure, between 3 and 5 cm H20 above atmospheric.

b) At the end of expiration airway pressure is the same as atmospheric.

c) At the end of inspiration there is a slight negative airway pressure, between -3 and -5 cm H20.

d) Airway pressure is atmospheric throughout the breathing cycle.

e) Airway pressure is below atmospheric throughout the breathing cycle.

25) All of the following are true about the history of oxygen and oxygen therapy, except:

a) Oxygen was discovered independently in the 1770s by Joseph Priestly in England and Carl Wilhelm Scheele in Sweden.

b) The first institute for respiratory therapy -- England's "Pneumatic Institute" -- was set up by Thomas Beddoes (1760-1808) in the late 18th century.

c) The first arterial blood gas measurements were performed by Dr. Alvan Barach in the 1920s.

d) The largest hyperbaric chamber ever built opened for business in Cleveland, Ohio in the 1920s.

e) The modern era of oxygen therapy (i.e., on a scientific basis) began with studies by J.S. Haldane during and shortly after World War I.

Hint for #25

26) All of the following speed up the metabolism of theophylline except:

a) phenytoin

b) rifampin

c) erythromycin

d) hyperthyroidism

e) high protein, low carbohydrate diet

27) Of the known associations of disease with pleural fluid eosinophilia (PF eosinophils/total nucleated PF cells > 10%), the rarest association is with:

a) pneumothorax with pleural effusion

b) benign asbestos pleural effusion

c) parasitic-related effusions

d) fungal-related effusions

e) tuberculous pleurisy

28) The syndrome whereby patients fake an illness that requires hospitalization, has achieved publicity of some sort (e.g., by characterizing the syndrome and/or the person it's named after) in print and film, including all of the following except:

a) The Adventures of Baron Munchausen, a book by Rudolph Erich Raspe.

b) "The Red Baron", a story by Lawrence Martin, M.D.

c) A poem by William Bean, M.D. that concludes: "So be alert for this great nonesuchman/Munchausen syndrome's flying Dutchman."

d) The Adventures of Baron Munchausen, a 1988 feature-length film directed by Terry Gilliam, with Robin Williams as King of the Moon.

e) The Baron and Me, an historical novel by Italo Calvino.

Hint for #28

29) Which of the following statements about asbestos and asbestos-related diseases is not true?

a) Malignant mesothelioma is commonly related to remote asbestos exposure and is not statistically associated with smoking history.

b) Asbestosis greatly increases the risk of developing lung cancer in smokers.

c) For patients with calcified pleural plaques, there is a lifetime 20-30% chance of developing pleural or lung cancer.

d) Lung cancer related to asbestos has no particular histologic predilection.

e) Patients can have asbestosis on pathologic exam of tissue that doesn't show up on chest x-ray.

Hint for #29

30) "N2" in the TNM classification of lung tumors describes metastasis to:

a) ipsilateral hilar lymph nodes.

b) ipsilateral and contralateral hilar lymph nodes.

c) ipsilateral mediastinal and subcarinal lymph nodes.

d) ipsilateral and contralateral mediastinal lymph nodes.

e) ipsilateral and supraclavicular lymph nodes.


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