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31) Arterial oxygen content will theoretically be reduced by all of the following except:

a) Carboxyhemoglobin

b) Methemoglobin

c) Ventilation-perfusion imbalance

d) Anemia

e) A leftward shift of the oxygen dissociation curve

Hint for #31

32) Acute respiratory distress syndrome is characterized by all of the following except:

a) bilateral pulmonary infiltrates

b) PaO2/FIO2 ratio less than 200

c) decreased pulmonary compliance

d) reduced surfactant activity

e) reduced diffusing capacity in over 2/3 of survivors

33) Which of the following conditions would not be expected to give a restrictive pattern of pulmonary impairment?

a) chronic eosinophilic pneumonia

b) berylliosis

c) lymphangioleiomyomatosis

d) pulmonary alveolar proteinosis

e) idiopathic pulmonary fibrosis

34) A 58-year-old, 60 kg. man with chronic obstructive pulmonary disease is seen for acute respiratory failure. His pH is 7.22, PCO2 89 mm Hg, PaO2 47 mm Hg, on supplemental oxygen. Blood pressure is 142/78 mm Hg, pulse 110/minute. Because of somnolence he is intubated. Just prior to intubation he is given 2 mgm of IV midazolam. Initial ventilator settings include:

tidal volume 800 ml
inspiratory flow rate 60 L/min
respiratory rate 14/minute
PEEP 5 cm H20

Within 15 minutes of intubation his blood pressure falls to 70/40 mm Hg. You disconnect him from the ventilator and during manual bagging with 100% O2 his blood pressure increases to 110/74 mm Hg. Exam reveals distant breath sounds bilaterally. Oxygen saturation is 99%. What should you do next?

a) Bag him until chext x-ray can determine if there is pneumothorax or atelectasis.

b) Re-start mechanical ventilation without PEEP.

c) Re-start mechanical ventilation with a lower tidal volume.

d) Re-start mechanical ventilation with a lower inspiratory flow rate.

e) Push IV fluids and give a benzodiazipine reversal agent.

35) The following arterial blood gas values are measured while the patient is breathing room air (FIO2 = .21):

pH 7.42

PaCO2 38 mm Hg

HCO3 24 mEq/l

PaO2 85 mm Hg

SaO2 80%

What is(are) the most likely explanation for these blood gas results?

a) Patient recently removed from supplemental oxygen

b) Ventilation-perfusion imbalance

c) Carbon monoxide poisoning

d) Pulmonary embolism

e) Test done at high altitude

36) "Pickwickian syndrome" refers to:

a) central sleep apnea associated with hypercapnia and pulmonary hypertension

b) narcolepsy associated with obesity

c) obesity associated with hypoventilation and daytime hypersomnolence

d) a condition other than a, b or c, and is named after the fat man Hosiah Pickwick in an early Charles Dickens' novel

e) a condition other than a, b or c, and is named after Robert Almond Pickwick, an English physician who first described it.

Hint for #36

37) All of the following are true about hyperbaric oxygen therapy except one:

a) can cause seizures

b) can be given with any concentration of inspired oxygen, from 21% to 100%

c) is recommended for arterial gas embolism

d) is recommended for decompression sickness

e) has been shown superior to normobaric oxygen for most cases of CO poisoning

38) All of the following are true about hypersensitivity pneumonitis (HS), except one:

a) HS is an immunologially-induced, non-IgE-mediated inflammatory lung disease that results from sensitization and subsequent recurrent exposure to organic dust.

b) The large airways are generally not affected.

c) Pathology shows granulomas and in late stages may show fibrosis.

d) Silo Filler's disease, one example of HS, is due to inhalation of molds that grow in poorly-ventilated silos.

d) HS is distinguished from "Organic Dust Toxic Syndrome", also known as "inhalation fever," by the fact that ODTS is simply due to high dust burden and does not require prior sensitization.

39) All of the following are true about upper airway obstruction except:

a) Fixed tracheal obstruction will cause flattening of both the inspiratory and expiratory limbs of the flow volume loop.

b) "Vocal cord dysfunction syndrome" manifests as variable extrathoracic obstruction, with flattening of the inspiratory flow volume curve.

c) Variable intrathoracic obstruction manifests as flattening of the expiratory flow volume cuve.

d) An index that can be used to help identify extrathoracic UAO is an FEF50/FIF50 > 1.

e) The expiratory flow volume curve in severe COPD (FEV-1 < 50% predicted) is similar to that in variable intrathoracic obstruction, the difference being the former's response to inhaled bronchodilator.

40) Which of the following statements about asthma is not true?

a) Eosinophilia is a marker for asthma exacerbations of allergic and non-allergic origin.

b) Airway inflammation is a major cause of morbidity.

c) Viral upper respiratory infection is a common trigger of asthma exacerbation in adults.

d) Chronic cough may be the only clinical manifestation of an asthma exacerbation.

e) Below a threshold peak flow of 50% of predicted, there is an inverse and almost linear relationship between PaCO2 and peak flow.

41) You admit a 77-year-old man with advanced Alzheimer's to the ICU. He developed respiratory failure and was intubated in the emergency department prior to ICU transfer. He has dehydration and right lower lobe pneumonia, plus a percutaneous feeding tube placed 6 months earlier. At the completion of your workup the son and daughter come to visit their father. They are his only children and closest surviving relatives; the patient's wife and and sole sibling died years earlier. You ask to meet with them in order to find out about advance directives, and the three of you go into a private area outside the patient's room. You learn there are no advance directives, and that DNR issues have not been previously raised. After you explain the clinical situation and the need for advance directives, the son and daughter ask, "What should we do?" In this setting your response should be predicated on which of the following?

a) As there are no advance directives, the son and daughter have to discern on their own what the patient would want if he could communicate.

b) You should make clear recommendations based on your values and medical knowledge, so the family can be guided about what decisions to make.

c) Since any advice you give could be misconstrued, it is best to stay totally objective, providing only medical information about his condition and no ethical advice.

d) In this type of situation a committee approach is best, and the hospital's Ethics Committee should be consulted before reaching a decision.

e) You should ask them to execute a legally-binding 'health power of attorney', so they can properly make decisions about his advance directives.

Hint for #41

42) Normal values and units for arterial oxygen content are:

a) 15-20 ml O2/100 ml blood

b) 10-15 ml O2/liter blood

c) 15-20 ml O2/liter blood

d) 10-15 mgm O2/liter blood

e) 15-20 mgm O2/liter blood

Hint for #42

43) A patient with tachypnea has the following room air arterial blood gases (FIO2 = .21):

pH 7.55

PCO2 20 mm Hg

PO2 58 mm Hg

Which of the following is the most likely cause of the abnormal blood gases?

a) carbon monoxide poisoning

b) acute pulmonary embolism

c) anxiety from blood gas puncture

d) unilateral pleural effusion

e) pontine hemorrhage

Hint for #43

44) A 60-year-old patient connected to the ventilator is receiving a tidal volume of 500 ml, rate of 10 breaths/minute. She is clinically stable, and has the following blood gas values while inhaling 40% oxygen.

pH 7.50

PCO2 48 mm Hg

PO2 70 mm Hg

SaO2 92%

Of the following therapies, which one might be the most helpful at this point?

a) give methylene blue

b) give acetazolamide

c) give bicarbonate

d) increase the ventilator tidal volume

e) add positive end-expiratory pressure (PEEP)

45. A 28-year-old man who is HIV positive develops left-sided pleuritic chest pain. In the emergency room you learn he has had cough, dyspnea and low grade fever for a week. Chest x-ray shows a 50% pneumothorax on the left, and his SpO2 is 91% on room air. The most likely cause is:

a) Mycobacterial tuberculosis infection

b) Atypical mycobacterial infection

c) Pneumocystis carinii infection

d) Kaposi's sarcoma

e) Chlamydia infection

46) The fact that people have summited Mt. Everest without supplemental oxygen (and survived) is:

a) possible because of anaerobic metabolism

b) possible because of extreme hyperventilation

c) due to body hypothermia and decreased tissue metabolism

d) due to fact that Mt. Everest is not as high in elevation as was originally thought

e) not explained by current understanding of human physiology

47) Based on historical records, which one of the following composers was thought to have died from tuberculosis?

a) Bartok

b) Beethoven

c) Brahms

d) Chopin

e) Mahler

48) You are climbing Pike's Peak in Colorado. As you ascend in altitude, all of the following will decrease except:

a) barometric pressure

b) arterial PO2

c) alveolar PO2

d) fraction of inspired oxygen

e) arterial hydrogen ion concentration

49) All of the following statements about low molecular weight heparin (LMWH) are true except:

a) LMWH is at least as effective as unfractionated heparin for the treatment and prevention of venous thromboembolism.

b) LMWH has a greater bioavailability than unfractionated heparin when given by subcutaneous injection.

c) The anticoagulant response (anti-Xa activity) to LMWH is highly correlated with body weight, permitting administration of a fixed dose.

d) Laboratory monitoring is not necessary when LMWH heparin is used in nonpregnant patients.

e) LMWH is somewhat more likely to induce immune-mediated thrombocytopenia compared to unfractionated heparin.

50) A 58-year-old man is being treated with a six-drug regimen for multidrug-resistant tuberculosis. A month after starting treatment, he complains of inability to distinguish between red and green traffic lights. Which drug is likely responsible?

a) Capreomycin

b) Ciprofloxacin

c) Ethambutol

d) Ethionamide

e) Streptomycin

51) All of the following statements about pleural effusions are true except one.

a) 5-10% of malignant pleural effusions are transudates.

b) In malignant effusions, a low pleural fluid (PF) pH predicts a shorter survival time than a normal PF pH.

c) Tuberculous effusions are usually bloody.

d) Pleural effusion eosinophilia usually indicates a non-malignant process.

e) The majority of chylothorax effusions are caused by lymphoma.

52) Regarding a healthy recreational scuba diver at a depth of 66 feet in the Caribbean Sea, which statement is true?

a) her lungs are smaller than normal

b) she has an elevated PaO2 and a normal PaCO2

c) all gas partial pressures in her blood (oxygen, nitrogen, carbon dioxide and water vapor) are elevated to some degree

d) there are increases in both fraction of inspired oxygen (FIO2) and inspired nitrogen (FIN2)

e) The alveolar gas equation can't be used to calculate PAO2 because of changes in inhaled gas pressures

Hint for #52

53) According to currently-accepted guidlines, induration from a PPD skin test = or > than 5 mm is considered positive in all of the following groups except one.

a) people in recent close contact with someone with active TB

b) patients with HIV infection

c) patients with risk factors for HIV infection but unknown HIV status

d) people with fibrosis on chest x-ray consistent with healed TB

e) foreign-born persons recently arrived (within last 5 years) from countries having a high prevalence or incidence of TB

54) All of the following statements about the Nobel Prize are true except:

a) The medical student who co-discovered insulin did not receive the Prize.

b) Neither Jonas Salk nor Albert Sabin received the Prize.

c) It was awarded for development of the CT scan.

d) It was awarded for discovery of x-rays.

e) It was awarded for discovery of ether anesthesia.

Hint for #54

55) Which of the following orders for a patient's ventilator settings is in error?

a) A/C (assist-control) mode at rate of 12 breaths/minute, PEEP (positive end-expiratory pressure) at 5 cm H20.

b) IMV (intermittent mandatory ventilation) mode at rate of 12 breaths/minute, PEEP 7 cm H20.

c) A/C mode at 10/minute, PSV (pressure support ventilation) at 5 cm H20.

d) IMV mode 8/minute, PSV 10 cm H20

e) PSV mode at 10 cm H20

56) A patient is connected to the ventilator with the following pressures: Peak inspiratory pressure 30 cm H20, plateau pressure (pressure at end of inspiration during no flow) 25 cm H20. The patient then develops respiratory distress at which time the respective pressures are 50 cm H20 and 45 cm H20. What is the most likely cause of the patient's distress?

a) pneumothorax

b) diffuse bronchospasm

c) an air leak in the ventilator circuit

d) biting of the endotracheal tube

e) low exhaled tidal volume

57) Place the following events in proper chronologic order, beginning with the earliest.

1. first paper reporting catheterization of human heart
2. use of penicillin for treating infections
3. discovery of x-rays
4. use isoniazid for treating tuberculosis
5. use insulin for treating diabetes

a) 1-3-2-4-5

b) 3-1-2-5-4

c) 3-5-1-2-4

d) 5-1-3-4-2

e) 1-3-5-2-4

Hint for #54

58) You are covering the ICU and writing orders for intravenous agents. For patient A you write "Start dopamine at 2", and for patient B you write "Start IV nitroglycerine at 10". A nurse asks you to clarify the units. Assuming your goal is to infuse a low dose of each drugs, choose the correct units from the list below. (ugm = microgram; mgm = milligram; kgm = kilogram)

1) ugm/min
2) mgm/kgm/min
3) ugm/kgm/min
4) ugm/hr

(For each letter answer, dopamine units first, followed by nitroglycerine units)

a) 1,1

b) 3,3

c) 3,1

d) 4,3

e) 2,3

59) You see a 35-year-old man in the clinic who is HIV positive; his PPD shows 6 mm of induration. He feels well and is currently on no medications, and his chest x-ray is normal. Proper management is:

a) isoniazid for 6 months

b) isoniazid for 12 months

c) standard therapy for treatment of tuberculosis disease in non-HIV-positive patients

d) isoniazid and rifampin for 6 months

e) no treatment; ask patient to return for any respiratory symptoms

60) A 60-year-old patient has been connected to a mechanical ventilator for 3 days. He is improved clinically and you wish to extubate him. Which of the following weaning parameters would be most predictive of weaning success?

a) negative inspiratory force of -25 cm H20

b) adequate oxygenation and ventilation on PSV (pressure support ventilation) of 12 cm H20

c) a ratio of respiratory rate/tidal volume (in liters) of 75

d) spontaneous minute ventilation of 10 liters/minute

e) an SpO2 of 95% on room air


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