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  • 1. A 35 year old man presents to your office for treatment of asthma. He states asthma has been present since age 8. He is using an Albuterol inhaler 1 – 2 times daily for wheezing and mild dyspnea and is on no other medication. He denies any nocturnal symptoms. He is sedentary but denies any symptom limitation to exertion. On physical examination, he is in no respiratory distress and has clear and normal breath sounds bilaterally. Office spirometry shows his FEV1 to be 85% of predicted.<br />Based on the above, how would you classify his asthma?<br />Mild intermittent<br />Mild persistent<br />Moderate persistent<br />Severe persistent<br />What would be an appropriate medication regimen, based on severity?<br />Low dose inhaled corticosteroid, salmeterol (long acting inhaled beta-agonist), plus Albuterol inhaler (short acting inhaled beta-agonist) as needed<br />Albuterol inhaler taken as needed.<br />Oral prednisone (corticosteroid) plus salmeterol (long acting inhaled beta-agonist) plus oral theophylline.<br />Low dose inhaled corticosteroids plus inhaled short-acting β-agonist as needed.<br />________________________________________________________________________<br />You institute the above regimen but he returns 1 month later using his Albuterol inhaler 6 times daily, often without relief, nightly nocturnal exacerbations, and an inability to walk 100 feet to his mailbox due to dyspnea. His FEV1 is now 50% of predicted.<br />Based on the above, how would you classify his asthma?<br />Mild intermittent<br />Mild persistent<br />Moderate persistent<br />Severe persistent<br />What would be an appropriate medication regimen, based on severity?<br />Low dose inhaled corticosteroid, salmeterol (long acting inhaled beta-agonist), plus albuterol inhaler (short acting inhaled beta-agonist) as needed<br />Albuterol inhaler taken as needed.<br />Oral prednisone (corticosteroid) plus salmeterol (long acting inhaled beta-agonist) plus high dose inhaled corticosteroid plus albuterol inhaler taken as needed.<br />Low dose inhaled corticosteroids plus inhaled short-acting β-agonist as needed.<br />_______________________________________________________________________<br />Your patient calls you at 1 a.m. that night with worsening wheezing, cough and dyspnea. He now has a low grade fever and purulent sputum. You send him to the emergency room. They call you 2 hours later and tell you he is in severe respiratory distress. They have placed him on oxygen and given him 2 hand held nebulizer treatments with Albuterol. He is somewhat better but still wheezing and dyspneic at rest.<br />What is the most appropriate treatment regimen, based on his current severity?<br />Start him on intravenous corticosteroids.<br />Send him home with a prescription for antibiotics.<br />Add a leukotriene inhibitor to his regimen.<br />Give him another nebulizer treatment.<br />____________________________________________________________________<br />A 58 year old man, smoker of 2 packs of cigarettes daily for 50 years presents with dyspnea on exertion, cough, and wheezing. He denies purulent sputum production or hemoptysis. On examination he is in no respiratory distress but is audibly wheezing. Spirometry shows an FEV1/FVC ratio of 50%, his FEV1 is 61% of predicted. CXR shows hyperlucent lung fields but no infiltrates or parenchymal abnormalities. You diagnose COPD and counsel him aon smoking cessation.<br />Choose the correct stage of COPD based on the above.<br />A. Mild (I) COPD<br />B. Moderate (II) COPD<br />C. Severe (III) COPD<br />D. Very Severe (IV) COPD<br />What is the most appropriate therapy for this man, based on the above stage?<br />A. A course of oral antibiotics and a mucolytic (guaifenesin).<br />B. Oral prednisone (corticosteroid) & a course of oral antibiotics<br />C. As needed use of a beta-agonist inhaler<br />D. As needed use of a beta-agonist inhaler with regular use of a long acting bronchodilator<br />_______________________________________________________________________<br />He returns 1 year later, still smoking and complaining of worsening dyspnea on exertion and cough. He states he’s been compliant with your treatment regimen. O2 saturation on room air is acceptable at 93% but his spirometry shows a decline, with an FEV1/FVC ratio of 40% and an FEV1 of 43% predicted.<br />Choose the correct stage of COPD based on the above.<br />A. Mild (I) COPD<br />B. Moderate (II) COPD<br />C. Severe (III) COPD<br />D. Very Severe (IV) COPD<br />9. The most appropriate therapy for this patient is:<br />Continue the current medical regimen<br />Send him to the emergency room for O2 therapy, nebulized bronchodilators, corticosteroids, and probable admission.<br />C. Consider adding an inhaled corticosteroid and counsel him again on smoking cessation<br />D. Set him up with home oxygen and pulmonary rehabilitation.<br />He returns 3 weeks later, feeling much better on your prescribed regimen, stating “Doc, I haven’t felt so well in years.” On questioning, he denies any symptoms, including cough, sputum or dyspnea but is still smoking (“I don’t inhale, I just burn them up”). He agrees to spirometry, which shows his FEV1 to be 55% of predicted.<br />10. Of the following, which is the most appropriate therapy for this man, based on the above?<br />A. Albuterol inhaler on as needed basis only and smoking cessation counselling<br />B. Oral prednisone taken every other day and pulmonary rehabilitation<br />C. Cyclic antibiotics, as needed to control symptoms of bronchitis<br />D. No change in his current medications and smoking cessation counselling<br />11. Which of the following is a risk factor for asthma?<br />cockroach allergen exposure<br />outdoor pet exposure<br />pet birds indoors<br />frequent colds as an infant<br />indoor pet exposure<br />12. Which of the following is a mediator in progression of an asthma episode?<br />mucous production<br />mast cells releasing histamine<br />bronchospasm<br />white cell recruitment<br />red blood cells<br />13. Which of the following statements is true regarding asthma in general?<br />it has the same clinical appearance in everyone<br />activity is not affected<br />it is described by a classification system<br />young children are not affected<br />asthma is more severe in older children<br />14. When completing the structural examination of a child affected by asthma, which areas may be affected in addition to the lungs?<br />no other areas are affected<br />the thorax only is affected<br />only the cervical spine is affected<br />many areas distant from the lungs are affected<br />only the lumbar area is affected<br />32. A 25 y/o male presents to the emergency department with pleuritic chest pain and shortness of breath. His physical exam is unremarkable. Vitals are HR 78, BP 120/80, RR 16 and pulse ox 99% on room air. He has no prior medical history. Which of the following is true?<br />PE can be excluded from the differential diagnosis as he has no risk factors for pulmonary embolus.<br />History and physical exam have been found to be accurate and reliable in the work up and confirmation of pulmonary embolus<br />He would be expected to be in a “high risk” for PE using the Well’s Criteria.<br />While a chest x-ray is usually abnormal in patients with a pulmonary embolus, there is no chest x-ray findings that can confirm or exclude a pulmonary embolus<br />The presence of an S1Q3T3 finding on his ECG is both sensitive and specific for the presence of a pulmonary embolus.<br />33. The patient in question 6 above had a D-dimer (ELISA) performed which had a negative result. Which of the following is true regarding this patient?<br />The next appropriate step is to order a venous duplex of his lower extremities<br />A CTA (CT angiogram) of his chest should be ordered<br />PE can be excluded and a search for other causes of his symptoms should be undertaken<br />Administer enoxaparin (Lovenox) 1mg/kg subcutaneously and then obtain the CTA<br />If a CT is unavailable, a V/Q scan should be ordered to exclude PE in this patient. <br />34. A 30 y/o female presents to the emergency department complaining of chest pain and shortness of breath. She is 10 weeks pregnant by dates and by ultrasound done in her obstetrician’s office this week. She has no medical problems, takes no medicines and does not smoke, drink or use illicit drugs. Her vitals show a BP of 110/60, pulse 100, respirations 20 and pulse ox 96% on room air. Her lungs are clear, heart is regular without murmurs. She has trace edema to both lower legs but no obvious swelling. Which of the following is true?<br />Start her workup with a duplex ultrasound of her lower extremities. If her duplex is positive for DVT no further studies are needed – begin treatment for PE.<br />A CTA with a CT Venogram is the preferred workup<br />If a PE is discovered, her treatment would include heparin and Coumadin until her INR is >2.0 and then Coumadin only until delivery<br />In pregnancy a conventional angiogram is the preferred diagnostic study<br />A transthoracic echo is the diagnostic study of choice for pregnant women with suspected PE<br />35. A 28 y/o male presents to the emergency department complaining of sudden onset of right chest pain and shortness of breath. You are concerned for a possible spontaneous pneumothorax. Which of the following is NOT TRUE?<br />Chest x-ray is the initial study of choice in suspected Pneumothorax<br />The diagnosis is confirmed with the finding of a thin visceral pleural line lying parallel to the chest wall separated by a radiolucent band containing no lung markings<br />A full inspiratory chest x-ray can often help identify a small pneumothorax, especially a small apical pneumothorax.<br />Routine arterial blood gas studies are generally not indicated or helpful in the evaluation of pneumothorax.<br />EKG is generally not helpful in establishing the diagnosis of pneumothorax. <br />36. The patient above (question 9) is found to have a small, approximately 10% right sided pneumothorax. His heart rate is 70, blood pressure 120/80, respiratory rate 16 and oxygen saturation of 100% on room air. Which of the following is true regarding his management?<br />No further evaluation or treatment is needed and the patient can be discharged.<br />This patient can be discharged if a repeat chest x-ray in 6 hours shows no progression of his pneumothorax and he remains clinically stable.<br />The appropriate treatment involves placing a 28-36F chest tube in the right 5th intercostal space in the anterior axillary line.<br />The appropriate treatment involves placing a small pigtail catheter in the left 2nd intercostal space in the midclavicular line.<br />None of the above are correct.<br />A 44 year old woman presents with the sudden onset of chest pain and shortness of breath. Chest pain is sharp and pleuritic; there is no hemoptysis. She gives no history of chest wall trauma. She is a cigarette smoker. She is on Tamoxifen for breast cancer. She flew into Roanoke yesterday from London. She is otherwise healthy and denies lower extremity pain. Vital signs: P 110, RR 28, afebrile, normal BP. Her physical exam is normal except for edema of the left leg.<br />31. Based on the above history, her risk for pulmonary embolism (Well’s criteria) would be:<br />No risk<br />Low risk<br />Moderate risk<br />High risk<br />32. Of the following, which is the most appropriate next diagnostic test?<br />Arterial blood gasses<br />Chest x-ray<br />Pulmonary angiography<br />CT angiogram<br />Arterial blood gasses (ABG’s) return showing a normal PO2 with a very mild acute respiratory alkalosis. Chest x-ray is normal. The cardiac cath lab is unavailable for 6 hours due to other emergent cases. You call for CT angiography but the scanner is down for repair.<br />33. Based on the following, which is the one best course of action?<br />Admit her for anticoagulation with heparin and warfarin<br />Send her home on Valium and aspirin<br />Send her home on warfarin<br />Order a ventilation-perfusion lung scan.<br />34. Assuming you order ventilation-perfusion lung scan and this test returns high probability for pulmonary embolism, which is the best course of action?<br />Further testing with pulmonary angiography or CT angiography, as pulmonary embolism is not ruled out<br />Pulmonary embolism is unlikely and she can be discharged<br />Pulmonary embolism is unlikely but further workup of her chest pain should be initiated.<br />Admit her for anticoagulation with heparin and warfarin<br />36. Treatment in cases of uncomplicated laryngits, tracheitis, and bronchitis may include which of the following<br />Rest<br />Hydration<br />OMT<br />Mucolytics<br />All of the above<br />22. An embolus is:<br />a clinically insignificant post mortem clot<br />a “dose”given intravenously and abbreviated “bolus”<br />a blood clot that has broken loose and travels in the body<br />a blood clot that never causes a stroke<br />23. Choose the correct statement regarding hydrostatic pressure:<br />keeps plasma fluid inside blood vessels<br />decreases in congestive heart failure<br />increases in congestive heart failure<br />measured accurately by dowsing<br />24. Risk factors for the “formation” of DVT include all of the following EXCEPT:<br />a family history of a hypercoaguable state<br />exercise<br />pregnancy<br />cancer<br />25. Virchow’s Triad is:<br />increased leg circumference, cellulitis, and calf tenderness<br />hypertension, hyperpigmentation and a hypercoaguable state<br />stasis, endothelial injury and a hypercoaguable state<br />edema, erythema and endothelial injury<br />26. A pneumothorax in a HIV positive patient is almost always associated with<br />P. Carnii pneumonia<br />S. Aureous pneumonia<br />Mycoplasma pneumonia<br />E. Coli pneumonia<br />27. The symptom of chest pain associated with secondary spontaneous pneumothorax usually<br />is seen more often than seen in PSP.<br />is more severe than in PSP.<br />resolves even though the pneumothorax remains.<br />occurs on the contra-lateral side.<br />28. The signs of secondary spontaneous pneumothorax may<br />be subtle and masked by underlying disease.<br />produce life-threatening hypoxemia.<br />produce hypercapnia.<br />All of the above<br />29. All of the following procedures may reduce the risk of recurrence of pneumothorax, EXCEPT<br />Thoracotomy<br />Pleurodesis<br />Video-assisted thorascopy<br />Tube thoracostomy<br />30. A patient who has presented with a complaint of chest pain and dyspnea suddenly becomes agitated. He is now dusky in appearance and is noted to have a drop in blood pressure and a worsening tachycardia. We must consider that he<br />has developed pneumonia.<br />has an underlying pneumonia.<br />has developed a tension pneumothorax.<br />has developed a pneumopericardium. <br />31. A 54 year old woman, lifelong heavy smoker, presents with cough, excessive sputum production, low blood oxygen level and lower extremity edema of 3 years duration. Which of the following findings characterize her disease?<br />A. A low hemoglobin level <br />B. A rapid respiratory rate.<br />C. Pink nailbeds.<br />D. Complicating cor pulmonale (right heart failure).<br />32. Which of the following is NOT a cause of airway narrowing and obstruction in obstructive lung disease?<br />A. Increased elastic recoil.<br />B. Bronchial wall thickening.<br />C. Mucous plugging.<br />D. Bronchospasm.<br />33. A 72 year old man presents to you with complaints of progressive shortness of breath, unassociated with wheezing or cough. He has smoked 3 packs of cigarettes daily for 45 years. His CXR shows hyperlucent lung fields. On his physical exam you find hyperexpanded, very quiet lungs. Which of the following best characterize his disease?<br />A. Complicating cor pulmonale (right heart failure).<br />B. Progressive edema <br />C. Cyanotic nailbeds<br />D. A lung biopsy would show loss of alveolar septae.<br />34. A 22 year old woman presents to the emergency room with severe shortness of breath, cough and wheezing. She denies smoking but states she had asthma as a child. Based on your presumptive diagnosis, you would expect the following:<br />A. She feels her chest is “too full” and she has trouble with inspiration.<br />B. She has a disorder characterized by chest wall stiffness.<br />C. A lung biopsy would show bronchial wall swelling.<br />D. A lung biopsy would show thickening of alveolar septae.<br />35. Obstructive lung disease is best characterized by which of the following:<br />A. Symptoms of shortness of breath and inspiratory wheezing<br />B. Reversible or irreversible airway narrowing<br />C. Reduced lung volumes <br />D. Chest wall stiffness<br />