TABLE IV-114 Risk Factors for Active Tuberculosis Among Persons Who Have Been Infected With Tubercle Bacilli 13 page

C. Mycobacterium avium-intracellulare infection

D. Mycobacterium tuberculosis infection

E. Rheumatoid arthritis

VI-29. A 54-year-old woman presents complaining of chronic cough that has worsened over a period of 6–12 months. She reports the cough to be present day and night, and productive of a thick green sputum. Over the course of the day, she estimates that she produces as much as 100 mL of sputum daily. Bilateral coarse crackles are heard in the lower lung zones. Pulmonary function tests demonstrate an FEV₁ of 1.68 L (53.3% predicted), FVC of 3.00 L (75% predicted), and FEV₁/FVC ratio of 56%. A chest radiograph is unremarkable. What would you recommend as the next step in the evaluation of this patient?

A. Bronchoscopy with bronchoalveolar lavage

B. Chest CT with intravenous contrast

C. High-resolution chest CT

D. Serum immunoglobulin levels

E. Treatment with a long-acting bronchodilator and inhaled corticosteroid

VI-30. A 48-year-old man is admitted to the hospital with fever and cough. He suffers from alcoholism and is homeless. He does not routinely obtain any health care. He reports that he has felt poorly for about 8 weeks. He has fatigue and generalized malaise. He states that he lost weight over this period as his clothing is very loose, but he cannot quantify the weight loss. He has felt feverish at times. During this period, he has been having increasing cough with malodorous sputum production. He coughs at least 3 tablespoons of dark sputum daily that has been blood streaked at times. He takes no medications, but drinks about 1 L of vodka daily. He also smokes one pack of cigarettes daily. On physical examination, the patient is disheveled and appears chronically ill. His vital signs are heart rate 98 beats/min, blood pressure 110/73, respiratory rate 20 breaths/min, temperature 38.2°C (100.8°F), and oxygen saturation of 94% on room air. He has evidence of temporal wasting with very poor dentition. A foul odor is present on his breath. Amphoric breath sounds are heard posteriorly in the right lower lung field. A chest x-ray shows a 4-cm cavitary lung lesion in the right lower lobe. The patient is admitted and placed on respiratory isolation. Sputum cultures for bacteria, mycobacteria, and fungus are ordered. What is the best initial choice for therapy in this patient?

A. Ampicillin-sulbactam 3 g intravenously every 6 hours

B. Isoniazid, rifampin, pyrazinamide, and ethambutol orally

C. Metronidazole 500 mg orally four times daily

D. Percutaneous drainage of the cavity

E. Piperacillin-tazobactam 2.25 g intravenously every 4 hours in combination with tobramycin 5
mg/kg intravenously daily

VI-31. A 35-year-old male is seen in the clinic for evaluation of infertility. He has never fathered any children, and after 2 years of unprotected intercourse his wife has not achieved pregnancy. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections, and the patient recently was told that he has bronchiectasis. Chest radiography is likely to show which of the following?

A. Bihilar lymphadenopathy

B. Bilateral upper lobe infiltrates

C. Normal findings

D. Situs inversus

E. Water balloon–shaped heart

VI-32. A 28-year-old woman is evaluated for recurrent lung and sinus infections. She recalls having at least yearly episodes of bronchitis beginning in her early teens. She states that for the past 5 years she has been on antibiotics at least three times yearly for respiratory or sinus infections. She also reports that she has had difficulty gaining weight and has always felt short compared to her peers. On physical examination, the patient has a body mass index of 18.5 kg/m². Her oxygen saturation is 94% on room air at rest. Nasal polyps are present. Coarse rhonchi and crackles are heard in the bilateral upper lung zones. Mild clubbing is seen. A chest radiograph shows bilateral upper lobe bronchiectasis with areas of mucous plugging. You are concerned about the possibility of undiagnosed cystic fibrosis (CF). Which of the following tests would provide the strongest support for the diagnosis of CF in this individual?

A. DNA analysis demonstrating one copy of the delta F508 allele

B. Decreased baseline nasal potential difference

C. Presence of Pseudomonas aeruginosa on repeated sputum cultures

D. Sweat chloride values greater than 35 meq/L

E. Sweat chloride values greater than 70 meq/L

VI-33. A 22-year-old man with cystic fibrosis is seen for a routine follow-up exam. He is currently treated with recombinant human DNAse and albuterol by nebulization twice daily. His primary sputum clearance technique is aerobic exercise five times weekly and autogenic drainage. He is feeling well overall, and his examination is normal. Pulmonary function testing demonstrates an FEV₁ of 4.48 L

(97% predicted), an FVC of 5.70 L (103% predicted), and an FEV₁/FVC ratio of 79%. A routine sputum culture grows Pseudomonas aeruginosa. The only organism isolated on prior cultures has been Staphylococcus aureus. What do you recommend for this patient?

A. High-frequency chest wall oscillation

B. Hypertonic saline (7%) nebulized twice daily

C. Inhaled tobramycin 300 mg twice daily every other month

D. Intravenous cefepime and tobramycin for 14 days

E. Return visit in 3 months with repeat sputum cultures and treatment only if there is persistent P.
aeruginosa

VI-34. Which of the following organisms is unlikely to be found in the sputum of a patient with cystic fibrosis?

A. Haemophilus influenzae

B. Acinetobacter baumannii

C. Burkholderia cepacia

D. Aspergillus fumigatus

E. Staphylococcus aureus

VI-35. All of the following are risk factors for chronic obstructive pulmonary disease EXCEPT:

A. Airway hyperresponsiveness

B. Coal dust exposure

C. Passive cigarette smoke exposure

D. Recurrent respiratory infections

E. Use of biomass fuels in poorly ventilated areas

VI-36. A 65-year-old woman is evaluated for dyspnea on exertion and chronic cough. She has a long history of tobacco use, smoking 1.5 packs of cigarettes daily since the age of 20. She is a thin woman in no obvious distress. Her oxygen saturation on room air is 93% with a respiratory rate of 22/min. The lungs are hyperexpanded on percussion with decreased breath sounds in the upper lung fields. You suspect chronic obstructive pulmonary disease. What are the expected findings on pulmonary function testing (see Table VI-36)?

TABLE VI-36

VI-37. A 70-year-old man with known chronic obstructive pulmonary disease is seen for follow-up. He has been clinically stable without an exacerbation for the past 6 months. However, he generally feels in poor health and is limited in what he can do. He reports dyspnea with usual activities. He is currently being managed with an albuterol metered-dose inhaler twice daily and as needed. He has a 50 pack-year history of smoking and quit 5 years previously. His other medical problems include peripheral vascular disease, hypertension, and benign prostatic hyperplasia. He is managed with aspirin, lisinopril, hydrochlorothiazide, and tamsulosin. On examination, the patient has a resting oxygen saturation of 93% on room air. He is hyperinflated to percussion with decreased breath sounds at the apices and faint expiratory wheezing. His pulmonary function tests demonstrate an FEV₁ of 55%

predicted, an FVC of 80% predicted, and an FEV₁/FVC ratio of 50%. What is the next best step in the

management of this patient?

A. Initiate a trial of oral glucocorticoids for a period of 4 weeks and initiate inhaled fluticasone if
there is a significant improvement in pulmonary function.

B. Initiate treatment with inhaled fluticasone 110 μg/puff twice daily.

C. Initiate treatment with inhaled fluticasone 250 μg/puff in combination with inhaled salmeterol 50
mg/puff twice daily.

D. Initiate treatment with inhaled tiotropium 18 μg/daily.

E. Perform exercise and nocturnal oximetry, and initiate oxygen therapy if these demonstrate
significant hypoxemia.

VI-38. A 56-year-old woman is admitted to the intensive care unit with a 4-day history of increasing shortness of breath and cough with copious sputum production. She has known severe COPD with an FEV₁ of 42% predicted. On presentation, she has a room air blood gas with a pH 7.26, PaCO₂ 78 mmHg, and PaO₂ 50 mmHg. She is in obvious respiratory distress with the use of accessory muscles

and retractions. Breath sounds are quiet with diffuse expiratory wheezing and rhonchi. No infiltrates are present on chest radiograph. Which of the following therapies has been demonstrated to have the greatest reduction in mortality for patients with these findings?

A. Administration of inhaled bronchodilators

B. Administration of intravenous glucocorticoids

C. Early administration of broad-spectrum antibiotics with coverage of Pseudomonas aeruginosa

D. Early intubation with mechanical ventilation

E. Use of noninvasive positive pressure ventilation

VI-39. A 63-year-old male with a long history of cigarette smoking comes to see you for a 4-month history of progressive shortness of breath and dyspnea on exertion. The symptoms have been indolent, with no recent worsening. He denies fever, chest pain, or hemoptysis. He has a daily cough of 3–6 tablespoons of yellow phlegm. The patient says he has not seen a physician for over 10 years. Physical examination is notable for normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated jugular venous pulsation, and moderate pedal edema. Hematocrit is 49%. Which of the following therapies is most likely to prolong his survival?

A. Atenolol

B. Enalapril

C. Oxygen

D. Prednisone

E. Theophylline

VI-40. A 62-year-old man is evaluated for dyspnea on exertion that has progressively worsened over a period of 10 months. He has a 50 pack-year history of tobacco, quitting 10 years ago. His physiologic and radiologic evaluation demonstrates a restrictive ventilatory defect with diffuse fibrosis that is worse in the subpleural region and at the bases. A surgical lung biopsy is performed, which is consistent with usual interstitial pneumonia. No autoimmune or drug-related cause is found. What is the recommended treatment for this patient?

A. Azathioprine 125 mg daily plus prednisone 60 mg daily

B. Cyclophosphamide 100 mg daily

C. N-acetylcysteine 600 mg twice daily plus prednisone 60 mg daily

D. Prednisone 60 mg daily

E. Referral for lung transplantation

VI-41. What would be the expected finding on bronchoalveolar lavage in a patient with diffuse alveolar hemorrhage?

A. Atypical hyperplastic type II pneumocytes

B. Ferruginous bodies

C. Hemosiderin laden macrophages

D. Lymphocytosis with an elevated CD4:CD8 ratio

E. Milky appearance with foamy macrophages

VI-42. A 42-year-old male presents with progressive dyspnea on exertion, low-grade fevers, and weight loss over 6 months. He also is complaining of a primarily dry cough, although occasionally he coughs up thick mucoid sputum. There is no past medical history. He does not smoke cigarettes. On physical examination, the patient appears dyspneic with minimal exertion. The patient’s temperature is 37.9°C

(100.3°F). Oxygen saturation is 91% on room air at rest. Faint basilar crackles are heard. On laboratory studies, the patient has polyclonal hypergammaglobulinemia and a hematocrit of 52%. A CT scan reveals bilateral alveolar infiltrates that are primarily perihilar in nature with a mosaic pattern. The patient undergoes bronchoscopy with bronchoalveolar lavage. The effluent appears milky. The cytopathology shows amorphous debris with periodic acid–Schiff (PAS)-positive macrophages. What is the diagnosis?

A. Bronchiolitis obliterans organizing pneumonia

B. Desquamative interstitial pneumonitis

C. Nocardiosis

D. Pneumocystis carinii pneumonia

E. Pulmonary alveolar proteinosis

VI-43. What treatment is most appropriate at this time for the patient in question VI-42?

A. Doxycycline

B. Prednisone

C. Prednisone and cyclophosphamide

D. Trimethoprim-sulfamethoxazole

E. Whole-lung saline lavage

VI-44. A 68-year-old man presents for evaluation of dyspnea on exertion. He states that he first noticed the symptoms about 2 years ago. At that time, he had to stop walking the golf course and began to use a cart, but he was still able to complete a full 18 holes. Over the past year, he has stopped golfing altogether because of breathlessness and states that he has difficulty walking to and from his mailbox, which is about 50 yards from his house. He also has a dry cough that occurs on most days. It is not worse at night, and he can identify no triggers. He denies wheezing. He has had no fevers, chills, or weight loss. He denies any joint symptoms. He is a former smoker of about 50 pack-years, but quit 8 years previously after being diagnosed with coronary artery disease. On physical examination, he appears breathless after walking down the hallway to the examination room, but quickly recovers upon resting. Vital signs are as follows: blood pressure 118/67 mmHg, heart rate 88 beats/min, respiratory rate 20 breaths/min. His SaO₂ is 94% at rest and decreases to 86% after ambulating 300 ft. His lung

examination shows normal percussion and expansion. There are Velcro-like crackles at both bases, and they are distributed halfway through both lung fields. No wheezing is noted. Cardiovascular examination is normal. Digital clubbing is present. A chest CT is performed and is shown in Figure VI-44. He is referred for surgical lung biopsy. Which pathologic description is most likely to be seen in this patient’s disease?

FIGURE VI-44

A. Dense amorphous fluid within the alveoli diffusely that stains positive with periodic acid–Schiff
stain

B. Destruction of alveoli with resultant emphysematous areas, predominantly in the upper lobes

C. Diffuse alveolar damage

D. Formation of noncaseating granulomas

E. Heterogeneous collagen deposition with fibroblast foci and honeycombing

VI-45. All the following are pulmonary manifestations of systemic lupus erythematosus EXCEPT:

A. Cavitary lung nodules

B. Diaphragmatic dysfunction with loss of lung volumes

C. Pleuritis

D. Pulmonary hemorrhage

E. Pulmonary vascular disease

VI-46. A 56-year-old woman presents for evaluation of dyspnea and cough for 2 months. During this time, she has also had intermittent fevers, malaise, and a 5.5-kg (12-lb) weight loss. She denies having any ill contacts and has not recently traveled. She works as a nurse, and a yearly PPD test performed 3 months ago was negative. She denies any exposure to organic dusts and does not have any birds as pets. She has a history of rheumatoid arthritis and is currently taking hydroxychloroquine, 200 mg twice daily. There has been no worsening in her joint symptoms. On physical examination, diffuse inspiratory crackles and squeaks are heard. A CT scan of the chest reveals patchy alveolar infiltrates and bronchial wall thickening. Pulmonary function testing reveals mild restriction. She undergoes a surgical lung biopsy. The pathology shows granulation tissue filling the small airways, alveolar ducts, and alveoli. The alveolar interstitium has chronic inflammation and organizing pneumonia. What is the most appropriate therapy for this patient?

A. Azathioprine 100 mg daily

B. Discontinuation of hydroxychloroquine and observation

C. Infliximab IV once monthly

D. Methotrexate 15 mg weekly

E. Prednisone 1 mg/kg daily

VI-47. In which of the following patients presenting with acute dyspnea would a positive D-dimer prompt additional testing for a pulmonary embolus?

A. A 24-year-old woman who is 32 weeks pregnant.

B. A 48-year-old man with no medical history who presents with calf pain following prolonged air
travel. The alveolar-arterial oxygen gradient is normal.

C. A 56-year-old woman undergoing chemotherapy for breast cancer.

D. A 62-year-old man who underwent hip replacement surgery 4 weeks previously.

E. A 72-year-old man who had an acute myocardial infarction 2 weeks ago.

VI-48. A 62-year-old woman is hospitalized following an acute pulmonary embolism. All of the following would typically indicate a massive pulmonary embolism EXCEPT:

A. Elevated serum troponin levels

B. Initial presentation with hemoptysis

C. Initial presentation with syncope

D. Presence of right ventricular enlargement on CT scan of the chest

E. Presence of right ventricular hypokinesis on echocardiogram

VI-49. Which of the following statements regarding diagnostic imaging in pulmonary embolism is TRUE?

A. A high probability ventilation-perfusion scan is one that has at least one segmental perfusion
defect in the setting of normal ventilation.

B. If a patient has a high probability ventilation-perfusion scan, there is a 90% likelihood that the
patient does indeed have a pulmonary embolism.

C. Magnetic resonance angiography provides excellent resolution for both large proximal and
smaller segmental pulmonary emboli.

D. Multidetector-row spiral CT imaging is suboptimal for detecting small peripheral emboli,
necessitating the use of invasive pulmonary angiography.

E. None of the routinely used imaging techniques provide adequate evaluation of the right ventricle
to assist in risk stratification of the patient.

VI-50. A 53-year-old woman presents to the hospital following an episode of syncope, with ongoing lightheadedness and shortness of breath. She had a history of antiphospholipid syndrome with prior pulmonary embolism and has been nonadherent to her anticoagulation medication recently. She has been prescribed warfarin, 7.5 mg daily, but reports taking it only intermittently. She does not know her most recent INR. On presentation to the emergency room, she appears diaphoretic and tachypneic. Her vital signs are as follows: blood pressure 86/44 mmHg, heart rate 130 beats/min, respiratory rate 30 breaths/min, and oxygen saturation of 85% on room air. Cardiovascular examination shows a regular tachycardia without murmurs, rubs, or gallops. The lungs are clear to auscultation. On extremity examination, there is swelling of her left thigh with a positive Homan’s sign. Chest CT angiography confirms a saddle pulmonary embolus with ongoing clot seen in the pelvic veins on the left. Anticoagulation with unfractionated heparin is administered. After a fluid bolus of 1 L, the patient’s blood pressure remains low at 88/50 mmHg. Echocardiogram demonstrates hypokinesis of the right ventricle. On 100% non-rebreather mask, the oxygen saturation is 92%. What is the next best step in the management of this patient?

A. Continue current management.

B. Continue IV fluids at 500 mL/h for a total of 4 L of fluid resuscitation.

C. Refer for inferior vena cava filter placement and continue current management.

D. Refer for surgical embolectomy.

E. Treat with dopamine and recombinant tissue plasminogen activator, 100 mg IV.

VI-51. A 42-year-old woman presents to the emergency room with acute onset of shortness of breath. She recently had been to visit her parents out of state and rode in a car for about 9 hours each way. Two days ago, she developed mild calf pain and swelling, but she thought that this was not unusual after having been sitting with her legs dependent for the recent trip. On arrival to the emergency room, she is noted to be tachypneic. The vital signs are as follows: blood pressure 98/60 mmHg, heart rate 114 beats/min, respiratory rate 28 breaths/min, oxygen saturation of 92% on room air, weight 89 kg. The lungs are clear bilaterally. There is pain in the right calf with dorsiflexion of the foot, and the right leg is more swollen when compared to the left. An arterial blood gas measurement shows a pH of 7.52, PCO₂ 25 mmHg, and PO₂ 68 mmHg. Kidney and liver function are normal. A helical CT scan confirms a pulmonary embolus. All of the following agents can be used alone as initial therapy in this patient EXCEPT:

A. Enoxaparin 1 mg/kg SC twice daily

B. Fondaparinux 7.5 mg SC once daily

C. Tinzaparin 175 U/kg SC once daily

D. Unfractionated heparin IV adjusted to maintain activated partial thromboplastin time (aPTT) two
to three times the upper limit of normal

E. Warfarin 7.5 mg po once daily to maintain INR at 2–3

VI-52. A 62-year-old woman is admitted to the hospital with a community-acquired pneumonia with a 4-day history of fever, cough, and right-sided pleuritic chest pain. The admission chest x-ray identifies a right lower and middle lobe infiltrate with an associated effusion. All of the following characteristics of the pleural effusion indicate a complicated effusion that may require tube thoracostomy EXCEPT:

A. Loculated fluid

B. Pleural fluid pH less than 7.20

C. Pleural fluid glucose less than 60 mg/dL

D. Positive Gram stain or culture of the pleural fluid

E. Recurrence of fluid following the initial thoracentesis

VI-53. A 58-year-old man is evaluated for dyspnea and is found to have a moderate right-sided pleural effusion. He undergoes thoracentesis with the following characteristics:

Which of the following is an unlikely cause of the pleural effusion in this patient?

A. Cirrhosis

B. Lung cancer

C. Mesothelioma

D. Pulmonary embolism

E. Tuberculosis

VI-54. A 66-year-old woman is evaluated for dyspnea. One month previously, she had undergone an esophagectomy for adenocarcinoma of the esophagus. On physical examination, the patient appears tachypneic with difficulty speaking in full sentences. She has a respiratory rate of 28/min and an oxygen saturation of 88% on room air. There is dullness to percussion with absent breath sounds in the left hemithorax. A chest radiograph confirms a large left-sided pleural effusion with mediastinal shift to the right. A thoracentesis removes 1.5 L of a milky-appearing fluid. The protein of the fluid is 6.2 mg/dL, LDH is 368 IU/L, and the WBC count is 1500/μL (20% PMNs, 80% lymphocytes). The triglyceride level is 168 mg/dL. Cultures and cytology are negative. Which of the following is the best management for this patient?

A. Placement of a chest tube plus octreotide

B. Placement of a chest tube to wall suction until drainage decreases to less than 100 mL daily

C. Reexploration of the chest with surgical correction of the likely defect

D. Referral for palliative care

E. Repeat thoracentesis for cytologic examination

VI-55. A 28-year-old man presents to the emergency room with acute-onset shortness of breath and pleuritic chest pain on the right that began 2 hours previously. He is generally healthy and has no medical history. He has smoked one pack of cigarettes daily since the age of 18. On physical examination, he is tall and thin with a body mass index of 19.2 kg/m². He has a respiratory rate of 24/min with an oxygen saturation of 95% on room air. He has slightly decreased breath sounds at the right lung apex. A chest x-ray demonstrates a 20% pneumothorax on the right side. Which of the following is TRUE regarding pneumothorax in this patient?

A. A CT scan is likely to show emphysematous changes.

B. If the patient were to develop recurrent pneumotho-races, thorascopy with pleural abrasion has a
success rate of nearly 100% for prevention of recurrence.

C. Most patients with this presentation require tube thoracostomy to resolve the pneumothorax.

D. The likelihood of recurrent pneumothorax is about 25%.

E. The primary risk factor for the development of spontaneous pneumothorax is a tall and thin body
habitus.

VI-56. The most common cause of a pleural effusion is:

A. Cirrhosis

B. Left ventricular failure

C. Malignancy

D. Pneumonia

E. Pulmonary embolism

VI-57. A patient with mild amyotrophic lateral sclerosis is followed by a pulmonologist for respiratory dysfunction associated with his neuromuscular disease. Which of the following symptoms in addition to PaCO₂ of 45 mmHg or greater would necessitate therapy with noninvasive positive pressure ventilation

for hypoventilation?

A. Orthopnea

B. Poor quality sleep

C. Impaired cough

D. Dyspnea in activities of daily living

E. All of the above

VI-58. A 27-year-old man with muscular dystrophy is evaluated by his primary care physician for hypoxemia. He reports feeling at his baseline and is not short of breath. On physical examination, finger pulse oximetry is 86% on room air, his lungs are clear, and aside from stigmata of muscular dystrophy, is normal. Chest radiograph shows low lung volumes. Which of the following is most likely the source of his low oxygen saturation?

A. Atelectasis

B. Mucous plug

C. Elevated PaCO₂

D. Pneumonia

E. Methemoglobinemia

VI-59. Patients with chronic hypoventilation disorders often complain of a headache upon wakening. What is the cause of this symptom?

A. Arousals from sleep

B. Cerebral vasodilation

C. Cerebral vasoconstriction

D. Polycythemia

E. Nocturnal microaspiration and cough

VI-60. A 47-year-old woman with idiopathic pulmonary arterial hypertension has failed medical therapy including intravenous epoprostenol. She has advanced right heart failure with severe right ventricular dysfunction on echocardiography and a cardiac index of 1.7 L/min per m². She is referred for lung transplantation. Which of the following statements is true?

A. She will require heart-lung transplantation for her advanced right heart failure.

B. Idiopathic pulmonary arterial hypertension patients have worse 5-year survival than other
transplant recipients.

C. Single-lung transplantation is the preferred surgical procedure for idiopathic pulmonary arterial
hypertension.

D. Her own right ventricular function will recover after lung transplantation.

E. She is at risk for recurrent pulmonary arterial hypertension after lung transplantation.

VI-61. A 25-year-old woman with cystic fibrosis is referred for lung transplantation. She is concerned about her long-term outcomes. Which of the following is the main impediment to long-term survival after lung transplantation?

A. Bronchiolitis obliterans syndrome

B. Cytomegalovirus infection

C. Chronic kidney disease

D. Primary graft dysfunction

E. Post-transplant lymphoproliferative disorder

VI-62. A 30-year-old man with end-stage cystic fibrosis undergoes lung transplantation. Three years later, he has a 6-month progressive decline in his renal function. Which of the following medications is the most likely etiology of this?

A. Prednisone

B. Tacrolimus

C. Albuterol

D. Mycophenolate mofetil

E. None of the above

VI-63. A 22-year-old man has cystic fibrosis. He currently is hospitalized about three times yearly for infectious exacerbations. He is colonized with Pseudomonas aeruginosa and Staphylococcus aureus, but has never had Burkholderia cepacia complex. He remains active and is in college studying architecture. He requires 2 L of oxygen with exertion. The most recent pulmonary function tests demonstrate an FEV₁ that is 28% of the predicted value and an FEV₁/FVC ratio of 44%. Measurement of his arterial blood gas or room air is pH 7.38, PCO₂ 36 mmHg, and PO₂ 62 mmHg. Which of these characteristics is an indication for referral for lung transplantation?

A. Colonization with Pseudomonas aeruginosa

B. FEV₁ less than 30% predicted

C. FEV₁/FVC ratio less than 50%

D. PCO₂ less than 40 mmHg

E. Use of oxygen with exertion

ANSWERS

VI-1. The answer is E. (Chap. 251) An experienced clinician should be able to gain significant insight into the cause of dyspnea or cough in a patient by a thorough pulmonary examination. Wheezes are most commonly high-pitched sounds heard predominantly on expiration and are indicative of obstruction of small airways. The most frequent cause of wheezing is asthma, which results in polyphonic wheezing due to the dynamic variability in airway obstruction throughout the lung fields. However, many other diseases cause wheezing, including congestive heart failure. This so-called “cardiac asthma” is due to peribronchiolar edema that results in narrowing of the adjacent airways. In contrast, rhonchi are caused by obstruction of medium-sized airways and are associated with a lower pitch and more coarse sound. The most common cause of rhonchi is secretions in the airways. Stridor is another breath sound that is commonly labeled as wheezing, but is indicative of upper airway obstruction. When compared to wheezing associated with small airway disease, stridor is loudest during inspiration, although it can be heard during expiration as well.

Date: 2016-04-22; view: 1090