1. A major difference between bronchiolitis obliterans (BO) and bronchiolitis obliterans

   A. BO responds to glucocorticoids better than BOOP
   B. BOOP responds to glucocorticoid better than BO
   C. BO is not associated with infectious agents; BOOP is
   D. BOOP is often found after toxic fume exposure; BO is not
   E. The prognosis of BO is generally better than that of BOOP

2. A 23 year old woman presents with a 3 month history of increased difficulty breathing.

• The patient in Question 2 is a non-smoker with no family history of malignancy. The most

• Which of the following appears to contribute most to the carbon dioxide retention in chronic obstructive pulmonary disease (COPD) [4] ?

  A. Reduced central respiratory drive in presence of oxygen
  B. Reset acid-base balance sensors
  C. Mucous plugging with ventilation-perfusion (V/Q) mismatch
  D. Renal overcompensation for respiratory acidosis
  E. Pulmonary parenchymal damage with failed gas exchange

• All of the following may be effective in treating central sleep apnea EXCEPT [5]:

  A. Tricyclic Antidepressants
  B. Progesterones
  C. Theophylline
  D. Pseudoephedrine
  E. Nocturnal oxygen therapy

• All of the following cell types are typically found in alveolar lavage and pathological specimens in patients with Idiopathic Pulmonary Fibrosis EXCEPT [6]:

  A. Eosinophils
  B. Neutrophils
  C. Alveolar Macrophages
  D. T Lymphocytes
  E. Type II Pneumocytes

• Which of the following pleural fluid results is most often found with an empyema [7] ?

  A. Protein >3g/dL or >50% of serum
  B. LDH > 200 or >60% of serum LDH
  C. White Blood Cell Count >10,000/µL
  D. Glucose <80mg/dL or <60% of serum
  E. pH <7.2

• A 48 year old man with a 45 pack-year smoking history presents with three days of fevers to 102°F, cough, and greenish-brown sputum. He denies chills, rigors, hemoptysis, gastrointestinal symptoms, and takes no medications. His pulse is 110 per minute, blood pressure 150/88mm, temperature 101° tympanic, respiratory rate 18 per minute. There is no diaphoresis. Physical examination reveals wet crackles in the left mid lung field with evidence of consolidation. A chest radiograph confirms a left sided consolidation in the lower lobe.
• The most appropriate course of action is [8]:

  A. Obtain a complete blood count (CBC), sputum sample, and begin erythromycin
  B. Obtain a CBC, two or three sets of blood cultures, sputum sample, and begin amoxicillin
  C. Obtain a CBC, sputum sample, and begin trimethoprim-sulfamethoxazole (TMP/SMX)
  D. Obtain a sputum sample and begin penicillin
  E. Obtain a CBC and begin clarithromycin (Biaxin®)

• The patient's symptoms initially improve, but then worsen over the 2 weeks. The initial sputum sample showed large numbers of neutrophils and both gram positive cocci and gram negative rods. The patient returns to the emergency room with left sided flank pain, rigors, anorexia and vomiting. Examination is notable for a middle aged man in moderate respiratory distress breathing at 26 per minute, a pulse of 118 per minute, and a tympanic temperature of 102.5°F. He has anicteric sclera, diffuse left sided crackles with mid lung zone egophany, normal cardiac exam, hyperactive normal-pitched bowel sounds, and normal skin. The CBC shows a leukocyte count of 18K/µL with 81% neutrophils, 7% immature forms (bands), 6% lymphocytes, and 6% monocytes. The sodium is 132mM (normal 135-145mM), BUN 28mg/dL (normal 6-18mg/dL), aspartate aminotransferase (AST, SGOT) 56U/L (normal <30U/L), alanine aminotransferase (ALT, SGPT) 80U/L (normal <35U/L), and the bilirubin is 1.3mg/dL. The potassium, chloride, bicarbonate, anion gap, glucose, alkaline phosphatase, and gamma glutamyltransferase are normal. The prothrombin time (PT) is 1.1X control; the activated partial thromboplastin time is normal. A repeat sputum specimen stained at the time of admission shows large numbers of neutrophils, occasional macrophages, and very rare organisms.
• Assuming that the patient was compliant with the initial therapy, these findings are most consistent with infection with which organism [9]?

  A. Chlamydia pneumoniae
  B. Streptococcus pneumoniae
  C. Staphylococcus aureus
  D. Mycoplasma pneumoniae
  E. Legionella pneumophilia

• The patient is admitted to the hospital. Blood cultures are obtained and the patient is started on empiric antibiotic therapy. Which of the following regimens is most appropriate in this patient [10] ?

  A. Ampicillin-sulbactam combination
  B. Cefuroxime and high dose erythromycin
  C. Penicillin and high dose erythromycin
  D. Vancomycin and high dose erythromycin
  E. Vancomycin and ceftazidime

Answers

1. B
2. D
3. E
4. C
5. D
6. A
7. E
8. C (Must obtain a sputum sample and must cover Haemophilis ssp.)
9. E
10. B