The answer is a Fauci 14e pp 14511455 Massive lifethreatening hemoptysis is 100 cc of blood in 24 h The most common

cause for nonmassive hemoptysis (<30 cc/day) in smokers and nonsmoking patients with a normal chest radiograph is bronchitis. Chronic bronchitis is characterized by excessive secretions manifested by a productive cough, often purulent or bloody, for 3 mo or more for 2 consecutive years in the absence of any other disease to explain the symptoms. Patients are often obese and cyanotic ("blue bloater"). The mnemonic is BBB = Bronchitis/Blue Bloater.

117. The answer is a. (Fauci, 14/e, pp 1451-1455.) COPD is defined as a condition where there is chronic obstruction to airflow due to chronic bronchitis or emphysema. An exacerbation of COPD occurs when the patient develops the acute onset of marked dyspnea and tachypnea requiring the use of accessory muscles that is unresponsive to medications. a antitrypsin deficiency should be suspected in nonsmokers who present with COPD of the lung bases in their fifties without any predisposing history, such as occupational exposure to support the diagnosis. a1 antitrypsin deficiency is rare in African Americans and Asian-Pacific islanders.

118. The answer is e. (Seidel, 4/e, pp 377-383.) Egophony is characterized by increased intensity of the spoken word upon auscultation and occurs with lung consolidation. Whispered pectoriloquy is a whispered voice that can be heard loudly and clearly through the stethoscope and occurs in areas of pulmonary consolidation. Bronchophony is increased loudness of spoken sounds in peripheral areas of consolidation. Bronchial breath sounds are normally heard over the trachea, bronchovesicular breath sounds over the main bronchi, and vesicular breath sounds over the lobes.

119. The answer is d. (Fauci, 14/e, pp 1474-1475.) The patient has a tension pneumothorax, which is evidenced by the trachea deviating away from the side of the traumatized lung. This occurs secondary to trauma or during mechanical ventilation. Breath sounds will be faint or distant, percussion will be hyperresonant, and fremitus will be decreased. The increased air on the affected side is in the pleural space, not in the lung. As an attempt is made to inflate the lung, air moves into the pleural space from the puncture site, resulting in a collapsed lung with a large pleural space. The contralateral lung is also at risk for collapse. Anytime the trachea is deviated from the involved side, it is considered a medical emergency and the tension pneumtothorax must be relieved or the patient will die from hypoxemia or inadequate cardiac output.

120. The answer is d. (Fauci, 14/e, pp 1474-1475.) The patient most likely has a spontaneous pneumothorax. This disorder affects tall, thin men and may be recurrent. It is thought to be due to the rupture of subpleural blebs in response to high negative intrapleural pressures. Physical examination often reveals unilateral chest expansion, decreased fremitus, hyperresonance, and diminished breath sounds. Patients with COPD, cystic fibrosis, Pneumocystis carinii pneumonia (PCP), and tuberculosis may have blebs and are at risk for secondary pneumothoraces.

121. The answer is a. (Goldman, 21/e, p 1003. Sapira, p 81.) Platypnea is the opposite of orthopnea. Platypnea is difficulty breathing when sitting up that is relieved in the recumbent position. This is often accompanied by orthodeoxia, which is a decrease in oxygen saturation in the erect position. Several disorders may rarely cause platypnea (pneumonia, multiple pulmonary emboli, pleural effusion, tuberculosis, and cirrhosis), but the physical finding is most associated with Rendu-Osler-Weber disease. This is a hereditary disorder that causes telangiectasias in the face, tongue, nose (patients often present with epistaxis), lip, gastrointestinal tract, lungs, and central nervous system. Patients have platypnea due to formation of pulmonary arteriovenous fistulas.

122. The answer is b. (Fauci, 14/e, pp 950-952.) The clinical presentation is most consistent with Legionnaires' disease. Patients are usually elderly, immunocompromised, or with chronic lung disease. Air conditioners, whirlpools, water-using machinery, and cooling towers have been linked to outbreaks of the disease. Clinical signs of the disease include fever, relative bradycardia, abdominal complaints, scanty cough, and laboratory abnormalities. Pontiac fever is an acute, self-limited, flulike illness due to Legionella, but it does not cause pneumonia. Psittacosis (Chlamydia) is pneumonia associated with the handling of birds.

123. The answer is d. (Tintinalli, 5/e, p 1568.) Tracheal stenosis may occur days after intubation and is a sequela of the balloon cuff of the tracheal tube pressing against the tracheal wall causing necrosis and scar tissue formation. Patients are typically hoarse and dyspneic.

124. The answer is d. (Seidel, 4/e, pp 353-358, 363.) The trachea is 2 cm in diameter and 10-11 cm long. It lies anterior to the esophagus and posterior to the isthmus of the thyroid gland. The trachea is a midline structure and divides into the right and left main stem bronchi at the level of T4 or T5 below the manubriosternal joint (angle of Louis).

125. The answer is c. (Fauci, 14/e, p 994.) The right main stem bronchus is wider, shorter, and vertically placed, and therefore the posterior segment of the right upper lobe (if the patient aspirated while supine) is anatomically susceptible to aspiration. The superior segments of the right lower and left lower lobes (if the patient is supine) are also susceptible to aspiration pneumonia. These three segments are often referred to as the aspiration segments of the lung. The basilar segments of both lungs are susceptible to aspiration if the patient aspirates while erect or sitting up.

126. The answer is d. (Fauci, 14/e, pp 1429-1436.) Persons in certain occupations, such as asbestos mining, shipbuilding, construction, insulation, automobile brake repair, pipe fitting, plumbing, electrical repair, and railroad engine repair are at risk for asbestos exposure. Even persons handling the clothes of the person exposed to asbestos are at risk for asbesto-sis (bystander exposure). Asbestosis means that the patient has developed pulmonary fibrosis, scarring (plaques), and calcification. Asbestosis is a bilateral disease that starts from the bottom of the thorax and works upward, so it is not uncommon for the diaphragm to be involved early on in the disease process. Patients with asbestosis are at risk not only for lung cancer and mesothelioma but also for pharyngeal, gastric, and colon cancers. This patient has clubbing and malignancy must be considered. Farmer's lung results from exposure to moldy hay containing spores. Berylliosis causes bilateral hilar adenopathy; patients have a history of occupational exposure to nuclear weapons, fluorescent lights, and ceramics. Patients who work as miners, sandblasters, stonecutters, or foundry or quarry workers are at risk for exposure to silica. The chest x-ray typically reveals the "eggshell" calcification of the hilar nodes. Byssinosis occurs with exposure to cotton, flax, and hemp.

127. The answer is b. (Seidel, 4/e, p 385.) The Apgar score has no predictive value regarding long-term outcome but tells you a great deal about the newborn's respiratory efforts. It is repeated a third time at 10 min only if the score is poor at 5 min. The Apgar scoring system (a score of 0-10 is possible) is based on APGAR = Appearance, Pulse, Grimace, Activity, and Respirations:

0

1

2

Heart rate

Absent

<100/min

>100/min

Respiratory effort

Absent

Slow or irregular

Good

Muscle tone

Limp

Some flexion

Active motion

Response to catheter

None

Grimace

Cough/

in nostril

sneeze

Color

Blue/Pale

Body pink/

All pink

extremities blue

128. The answer is b. (Fauci, 14/e, pp 1427, 1923-1928.) Sarcoidosis is a multisystemic disease of unknown cause. The histologic hallmark of the disease is noncaseating granulomas and the most common chest radiograph finding is that of bilateral hilar adenopathy. Lymphadenopathy is found in 70-90% of all patients with sarcoidosis. Hamman-Rich syndrome is also called idiopathic pulmonary fibrosis (IPF). It is as common as sarcoidosis but is found more in males than females; the usual age of onset is the fifth or sixth decade of life. Chest radiograph usually reveals fibrosis. Bagassosis is a hypersensitivity pneumonitis (HP) due exposure to sugar cane. Loeffler syndrome is a disorder of unknown etiology that causes an acute pneumonia with peripheral blood eosinophilia.

129. The answer is d. (Fauci, 14/e, pp 194-197.) The most common cause of chronic cough in adults is postnasal drip due to sinusitis or rhinitis (allergic, vasomotor, irritant, perennial nonallergic). Patients typically complain of having to clear their throats or a feeling of something dripping in the back of their throats. Physical examination reveals muco-purulent secretions and a cobblestone appearance to the mucosa. Asthma is more of an episodic disease with wheezing, but occasionally patients complain of only cough. Gastroesophageal reflux disease (GERD) must be considered in patients who complain of heartburn or regurgitation. Other causes of chronic cough include bronchitis, congestive heart failure, and use of angiotensin converting enzyme (ACE) inhibitors.

130. The answer is c. (Seidel, 4/e, pp 382, 392-393.) This patient has a pleural effusion most likely due to tuberculosis. Chest examination of a pleural effusion reveals distant or absent breath sounds, a pleural friction rub, decreased fremitus, and flatness to percussion. A pleural friction rub is a raspy, grating sound heard in both inspiration and expiration due to inflamed surfaces rubbing against each other. Occasionally, exaggerated bronchial breath sounds are audible at the area of the effusion.

131. The answer is b. (Seidel, 4/e, pp 396-398.) Based on the patient's risk factors for human immunodeficiency virus (HIV), Pneumocystis carinii pneumonia (PCP) is the most likely diagnosis in this patient, but PCP rarely presents with any physical examination findings that distinguish it from other pneumonias. The chest radiograph may reveal bilateral interstitial infiltrates, and patients are often hypoxemic. Congestive heart failure may present with a similar chest radiograph, but patients will have jugular venous distension (JVD) and an S

3 gallop. Cytomegalovirus (CMV), varicella zoster, and Kaposi's sarcoma (due to herpes virus 8) are opportunistic infections seen in immunocompromised patients.

132. The answer is b. (Fauci, 14/e, pp 1437-1439.) Pneumococcal pneumonia is abrupt in onset, with fever, pleuritic chest pain, and purulent sputum production. In young, otherwise healthy patients who present with a localized pneumonia (in this case right middle lobe) of gradual onset accompanied by dry cough and a predominance of extrapulmonary symptoms (i.e., malaise, headache, diarrhea), the most likely diagnosis is atypical pneumonia due to Chlamydia pneumoniae or Mycoplasma pneumoniae. Patients often complain of a sore throat at the beginning of the illness and a protracted course of symptoms. Physical examination is often unimpressive compared to the radiograph findings. Legionella pneumoniae is an atypical organism, but patients usually have renal and hepatic abnormalities, hyponatremia, and mental status changes.

133. The answer is d. (Seidel, 14/e, pp 368-369.) In emphysema, there is destruction of alveolar septa and reduced elastic recoil. This causes collapse of the small airways and prolongs the expiratory phase of respiration. During the prolonged expiration, patients will "purse" their lips to avoid collapse of the small airways. The respiratory rate is increased by having a markedly shortened inspiratory interval. Kussmaul respirations are slow and deep respirations to increase the tidal volume in patients with diabetic ketoacidosis. Biot respirations are seen in patients with increased intracra-nial pressure. These are irregular, unpredictable periods of apnea alternating with periods of noisy hyperventilation. Cheynes-Stokes respiration is a rhythmic, gradually changing pattern of apnea and hyperpnea that is cardiac or neurologic in origin. Apneustic breathing is characterized by a long period of inspiration or gasping with almost no expiratory phase.

134. The answer is d. (Tintinally, 5/e, pp 1278-1280.) The definition of drowning is death from suffocation after submersion. Freshwater drowning in swimming pools is actually more common than saltwater drowning. The patient described has noncardiogenic pulmonary edema, which is a complication of near-drowning (a survivor after suffocation from submersion). This is a result of direct pulmonary injury, loss of surfactant, and contaminants in the water. Respiratory failure, severe hypothermia, and neurologic injury are the three most common threats to life after submersion.

135. The answer is e. (Seidel, 4/e, p 184, 371.) Clubbing is associated with cystic fibrosis, lung cancer, congenital heart disease, cirrhosis, colitis, and thyroid disease. Clubbing is due to the formation of new periosteal bone and the development of synovial effusions. Emphysema and asthma do not cause clubbing.

136. The answer is c. (Fauci, 14/e, pp 1451-1455.) The increased antero-posterior thickness of the thorax indicates the presence of a "barrel" chest, which in association with a smoking history and exertional dyspnea is a typical presentation of emphysema. Pursed-lip breathing is often a learned behavior that occurs with emphysema to prolong the expiratory phase of respiration and prevent sudden collapse of the small airways. Patients have an asthenic body habitus since energy expenditure is in excess of calorie intake. There is often hypertrophy of the accessory muscles of respiration. Breath sounds in emphysema are usually diminished and there is hyperresonance with percussion. Emphysema begins as a cen-triacinar process but eventually becomes panacinar, involving both the central and peripheral tissues.

137. The answer is c. (Fauci, 14/e, pp 1437-1440.) The signs and symptoms of lung abscess include a history of loss of consciousness due to seizure, alcoholism, or illicit drug use. Patients complain of several days or weeks of malaise and fever while the abscess develops. Patients eventually complain of chills, cough, pleuritic chest pain, and cough productive of putrid sputum. Due to position at the time of loss of consciousness and to the anatomy of the lung, the lung segments most often involved in lung abscesses include the posterior segment of the right upper lobe (wide, short, and vertically placed) and the superior segments of both lower lobes. Patients with poor dental hygiene are prone to developing anaerobic infections if aspiration occurs.

138. The answer is a. (Fauci, 14/e, pp 1483-1485.) Acute respiratory distress syndrome (ARDS) can occur due to conditions unrelated to pulmonary disease, such as burns, transfusion, or trauma, but may also be due to sepsis and shock. ARDS is due to severe and widespread increased alveolar capillary permeability secondary to injury of the alveolar and capillary epithelium. This leads to the accumulation of protein-rich edematous fluid within the septal walls, followed by escape of the fluid into the alveolar spaces, where it coagulates to form hyaline membranes lining the alveoli. There is marked impairment of gas exchange that causes severe dyspnea, diffuse crackles, tachypnea, hypoxemia, and cyanosis. The cyanosis may be refractory to oxygen therapy. Chest radiograph reveals bilateral infiltrates.

139. The answer is b. (Seidel, 4/e, pp 378-380.) Vesicular breath sounds are low-pitched sounds (described as "breezy") that are heard over the bronchioles and lesser bronchi. Bronchovesicular breath sounds (described as "air passing through a tube") are medium-pitched sounds heard over the main bronchi. Bronchial (tubular) breath sounds are high-pitched, coarse, loud sounds heard over the trachea. Bronchial and bron-chovesicular breath sounds should not be heard over peripheral lung tissue.

140. The answer is b. (Fauci, 14/e, pp 1422-1423.) Asthma is an airway disease characterized by a hyperreactive tracheobronchial tree that manifests physiologically as narrowing of the airway passages. The classic triad of symptoms is dyspnea, cough, and wheezing. Attacks are usually episodic and nocturnal and often follow exposure to specific allergens, exertion, viral infection, or emotional excitement. Wheezing is described as "whistling" and is typically heard in both inspiration and expiration. The expiratory phase becomes prolonged and the patient develops tachypnea, tachycardia, and mild systolic hypertension. Accessory muscles of respiration (sternocleidomastoid and intercostals) may be used to improve breathing. If the asthma attack is severe, the patient will develop a pulsus paradoxus (an inspiratory drop in systolic blood pressure of more than 10 mm Hg). Patients with epiglottitis present with fever, drooling, and dysphagia; lung examination will be normal. Children with croup or laryngo-tracheobronchitis present with labored breathing and stridor, and use accessory muscles to assist breathing.

141. The answer is c. (Fauci, 14/e, p 1013. Tierney, 39/e, pp 302-303.) Patients with a positive PPD require isoniazid chemoprophylaxis. A positive PPD may mean that the patient currently has tuberculosis or may have had tuberculosis in the past. A PPD may be a false positive due to nontu-berculosis mycobacterium. A booster PPD is placed in patients (typically over the age of 55) 1 wk after a negative PPD to "boost" a response. A negative "boost" implies the patient is anergic or uninfected. A PPD skin test is classified as positive by the American Thoracic Society and the Centers for Disease Control and Prevention (1994) according to the reaction size and patient population:

>5 mm = HIV patients or HIV at-risk patients; close contacts of patients with active TB; persons with CXR showing healed TB >10 mm = Immigrants; intravenous drug abusers; medically underserved;

residents of nursing homes, prisons, and mental institutions; persons with underlying disease >15 mm = All other persons

142-144. The answers are 142-a, b, c, d, 143-e, f, 144-g, h. (Fauci, 14/e, p 1475.) The area between the pleural sacs—the mediastinum—is divided anatomically into the anterior mediastinum, middle mediastinum, and posterior mediastinum. The most common masses found in the anterior mediastinum are the four Ts = Thymomas, Teratomas, Thyroid masses, and paraThyroid masses. Lymphomas may also be found in the anterior mediastinum. Masses in the middle mediastinum include enlarged lymph nodes, lymphomas, vascular masses, pleuropericardial cysts, and bronchogenic cysts. The posterior mediastinum is the likely area for neurogenic tumors, lymphomas, pheochromocytomas, myelomas, meningoceles, meningomyeloceles, gastroenteric cysts, and diverticula.

145-146. The answers are 145-a 146-d. (Sapira, p 245.) Pectus exca-vatum or funnel breast is a congenital, hereditary malformation characterized by depression of the sternum below the clavicular-manubrial junction with symmetric inward bending of the costal cartilages. This may affect pulmonary and heart function. Pectus carinatum or pigeon breast is a deformity where the sternum protrudes from the narrowed thorax. Kyphosis is posterior deviation of the spine. Scoliosis is lateral deviation of the spine. Lordosis is an exaggerated convex curvature of the lumbar spine.

147-148. The answers are 147-c 148-d. (Fauci, 14/e, pp 1476-1483.)

The patient with obstructive sleep apnea syndrome (OSAS) presents complaining of disruptive snoring and daytime hypersomnolence. Obesity is a risk factor for OSAS, but many patients with OSAS are not obese. Patients have upper airway narrowing from enlarged soft tissues, and good respiratory effort occurs against the airway obstruction. Diagnosis is best made by overnight polysomnography to document the apneic periods (10-15 events per hour of sleep, each event > 10 s in duration). Obesity represents a mechanical load to the respiratory system, since excess weight reduces chest wall compliance. Patients with obesity hypoventilation syndrome demonstrate a decrease in central respiratory drive (no respiratory effort), especially during sleep (sleep-induced hypoventilation), since vital capacity is further reduced in the recumbent position. Narcolepsy is excessive daytime sleepiness associated with abnormalities in REM sleep. Narcoleptic sleep attacks are brief and may occur during sedentary periods or when the patient is driving, eating, or conversing. Cataplexy occurs when strong emotion (i.e., laughing or crying) precipitates sudden loss of muscle tone. Somnambulism is sleepwalking.

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