08-15-2008, 08:11 AM
1)A 24-year-old Caucasian woman comes to the clinic complaining of progressive shortness of breath over the last 4 weeks. There is no particular pattern to the dyspnea and it seems to be getting worse. She denies any associated symptoms of pain or fever, and although she admits to œsmoking like a chimney, she has not had a cough. She has had multiple respiratory problems in the past, having suffered two spontaneous pneumothoraces over the last 3 years, as well as intermittent dyspnea. Although no one has been able to determine why she suffers these respiratory problems, she has been told she likely has adult onset asthma. She has tried an albuterol inhaler, the only medication she takes other than birth control pills, but has had little improvement. Other than her respiratory complaints, review of systems and past medical history is unremarkable. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 138/88 mm Hg, pulse 72/min, and respirations 24/min. Chest examination reveals diminished breath sounds and dullness to percussion over the right side of the chest and faint end-expiratory wheezes. A chest radiograph reveals a large right side effusion, together with flattened diaphragms and bilateral reticulonodular interstitial opacities. Reviewing her chart, you see that a previous workup has included a ventilation perfusion scan, read as œlow probability, and a set of pulmonary function tests that were read as œmixed obstructive/restrictive pattern with a markedly reduced DLCO. A diagnostic thoracentesis reveals a milky white effusion. Shortly after the specimen is sent, the laboratory calls to report a triglyceride level of 120 mg/dL and the presence of numerous chylomicrons in the sample. Which of the following primary pathologic abnormalities explains this woman™s lung disease?
A. Congenital reduction in antiprotease production in the lungs
B. Interstitial lung disease related to undiagnosed HIV infection
C. Pan-acinar destruction of alveoli from tobacco use
D. Proliferation of atypical smooth muscle cells, compressing surrounding tissue
E. Stage IV cystic/nodular sarcoidosis resulting in obstructive granuloma formation
2) A 71-year-old man comes to the emergency department complaining of progressive shortness of breath over the last 2 weeks. He also reports an increase in his baseline cough with purulent sputum production. He denies fever, chills, or chest pain. He reports his diet has been poor lately and he has been eating large amounts of salty foods. He believes this is contributing to his breathing problems. His past medical history is significant for hypertension and a chronic œsmoker™s cough. He takes verapamil for blood pressure control and he occasionally uses an inhaler when he feels short of breath but cannot remember what the inhaler is called. He tells you that he formerly smoked two packs of cigarettes per day for 35 years but now is down to three cigarettes each day. He has several drinks of vodka each day but denies any drug use. His temperature is 38.1 C (100.6 F), blood pressure is 190/70 mm Hg, pulse is 113/min, and respirations are 28/min. His oxygen saturation is 81% on room air and improves to 92% on 6 L of oxygen by way of nasal cannula. Physical examination reveals a thin man in mild to moderate respiratory distress, breathing rapidly. His pulse is regular but tachycardic. His breath sounds are coarse and decreased bilaterally with occasional wheezes. His abdomen is benign and his lower extremities have no edema. An electrocardiogram shows sinus tachycardia, left ventricular hypertrophy, and diffuse nonspecific T-wave changes
Which of the following statements is true concerning this patient™s management?
A. On the basis of the information given, this patient needs to be intubated immediately
B. Empiric antibiotics, systemic steroids, oxygen, and nebulized ipratropium bromide and albuterol are indicated
C. He will likely improve with diuresis and a low salt diet
D. Inhaled steroids, ipratropium bromide, and albuterol by way of metered dose inhaler (MDI) are indicated
E. Supplemental oxygen should be avoided because it may cause respiratory depression
A. Congenital reduction in antiprotease production in the lungs
B. Interstitial lung disease related to undiagnosed HIV infection
C. Pan-acinar destruction of alveoli from tobacco use
D. Proliferation of atypical smooth muscle cells, compressing surrounding tissue
E. Stage IV cystic/nodular sarcoidosis resulting in obstructive granuloma formation
2) A 71-year-old man comes to the emergency department complaining of progressive shortness of breath over the last 2 weeks. He also reports an increase in his baseline cough with purulent sputum production. He denies fever, chills, or chest pain. He reports his diet has been poor lately and he has been eating large amounts of salty foods. He believes this is contributing to his breathing problems. His past medical history is significant for hypertension and a chronic œsmoker™s cough. He takes verapamil for blood pressure control and he occasionally uses an inhaler when he feels short of breath but cannot remember what the inhaler is called. He tells you that he formerly smoked two packs of cigarettes per day for 35 years but now is down to three cigarettes each day. He has several drinks of vodka each day but denies any drug use. His temperature is 38.1 C (100.6 F), blood pressure is 190/70 mm Hg, pulse is 113/min, and respirations are 28/min. His oxygen saturation is 81% on room air and improves to 92% on 6 L of oxygen by way of nasal cannula. Physical examination reveals a thin man in mild to moderate respiratory distress, breathing rapidly. His pulse is regular but tachycardic. His breath sounds are coarse and decreased bilaterally with occasional wheezes. His abdomen is benign and his lower extremities have no edema. An electrocardiogram shows sinus tachycardia, left ventricular hypertrophy, and diffuse nonspecific T-wave changes
Which of the following statements is true concerning this patient™s management?
A. On the basis of the information given, this patient needs to be intubated immediately
B. Empiric antibiotics, systemic steroids, oxygen, and nebulized ipratropium bromide and albuterol are indicated
C. He will likely improve with diuresis and a low salt diet
D. Inhaled steroids, ipratropium bromide, and albuterol by way of metered dose inhaler (MDI) are indicated
E. Supplemental oxygen should be avoided because it may cause respiratory depression