1. A 20 year old man with a history of asthma for 12 years has moved and switched doctors. His asthma is currently fairly well controlled on 4 puffs of albuterol (a short acting ß2-adrenergic agonist) three times per day. He sometimes wakes up in the middle of the night coughing (1-2 times per week). Which is the most appropriate recommendation for therapy [1] ?

   A. No change in current treatment
   B. Add an anti-histamine and change albuterol inhaler to prn (as needed) only
   C. Change last dose of albuterol to longer acting ß-adrenergic agonist
   D. Add a glucocorticoid inhaler and a longer acting ß-agonist, use albuterol prn
   E. Add ipatropium bromide (Atrovent®) to the regimen, use albuterol prn

2. A 52 year old man who worked on a farm for twenty years presents with dyspnea on exertion. He takes no medications. Evidence of right sided heart failure is present on examination. Pulmonary function tests (PFT's) show a Forced Expiratory Volume in 1 second of 1.5L (40% of predicted), a Forced Vital Capacity (FVC) of 2.0L (50%) of predicted. These finds are most compatible with [2]:

   A. Pure restrictive pulmonary defect
   B. Pure obstructive pulmonary defect
   C. Mixed restrictive and obstructive defects
   D. Normal Lung Volumes for the patient's age
   E. Inflammatory Lung Disease

3. A 28 year old black woman presents with a cough for two weeks, no better after 1 week of erythromycin. Examination reveals mild bilateral mid-lung rales (crackles) which do not clear with cough. A chest radiograph shows hilar lymphadenopathy and mild interstitial infiltrates bilaterally. The most likely diagnosis is [3]:

   A. Hodgkin's Lymphoma
   B. Sarcoidosis
   C. Tuberculosis
   D. Histoplasmosis
   E. Breast Cancer with lymphangitic spread

4. A 38 year old woman is referred to you for evaluation of pulmonary hypertension. She has had 14 years of Raynaud's Syndrome, and was recently diagnosed with localized scleroderma (CREST syndrome). Which of the following is very UNLIKELY to improve the pulmonary hypertension [4] ?

   A. Glucocorticoids
   B. Calcium Channel Blockers
   C. Oxygen
   D. Nitric Oxide
   E. Prostaglandins

5. A 30 year old man with cystic fibrosis presents with fevers and sputum production. A chest radiograph shows diffuse interstitial infiltrates (chronic) with no new focal abnormalities. Pulmonary function tests show mixed obstructive and restrictive patterns. A gram stain of the sputum shows many neutrophils and many gram negative rods. The most likely diagnosis is [5]:

   A. Bronchiolitis obliterans with organizing pneumonia (BOOP)
   B. Bronchiolitis with pseudomonas infection
   C. Bronchitolitis obliterans
   D. Chronic Bronchitis with exacerbation
   E. Interstitial Lung Disease and with exacerbation

6. Which of the following is NOT indicated for the treatment of chronic obstructive pulmonary disease (COPD) [6] ?

   A. Low dose oral glucocorticoids
   B. Chronic antibiotic therapy
   C. Inhaled anti-cholinergic Agents
   D. Theophylline
   E. ß-2 Adrenergic Antagonists

7. Which of the following is specifically associated with a decreased diffusion capacity [7] ?

   A. Asthma
   B. Chronic Bronchitis
   C. Emphysema
   D. Sarcoidosis
   E. Pulmonary Hypertension

8. A 32 year old woman presents with shortness of breath, hemoptysis, and chest pain which is worse when she breaths in. She has a 20 pack-year history of smoking. She takes no medications and uses no recreational drugs. She drinks alcohol occasionally. On examination she is an acutely ill appearing young woman in moderate distress. Her blood pressure is 150/90, pulse 120 and regular, respirations 32, temperature 99.5°F (tympanic). Her oropharynx is dry, neck without lymphadenopathy, lungs clear without rubs, cardiac is tachycardic with a regular rate and rhythm with no murmers, rubs, or gallops. A chest radiograph is unremarkable. An electrocardiogram shows a rate of 124 bpm, right axis deviation, and non-specific ST-T changes. The appropriate next steps are [8]:

   A. Obtain an arterial blood gas and start heparin therapy
   B. Start heparin therapy, then obtain a V/Q scan
   C. Obtain a V/Q scan; if positive, then start heparin therapy
   D. Obtain arterial blood gas, then start heparin therapy, then obtain V/Q scan
   E. Obtain arterial blood gas and V/Q scan; if positive V/Q scan, start therapy

9. The patient is started on heparin therapy. On day two, she becomes increased tachypnic. An echocardiogram is done and shows right ventricular dilatation with akinesis; estimated right ventricular and pulmonary artery pressures are 60/20mm and 60/30mm respectively. The left ventrical is functioning normally. The next step is [9]:

A. Perform V/Q Scan
B. Perform pulmonary arteriography
C. Transfer the patient to an intensive care unit and administer thrombolytic therapy
D. Continue heparin therapy maintaining a high activated partial thromboplastin time
E. Transfer the patient to an intensive care unit, administer thrombolytic therapy, and obtain a surgical consult for possible embolectomy

10. The patient recovers well over the next several days. She is discharged on warfarin and strongly encouraged not to smoke. The most appropriate duration of warfarin therapy is [10]:

    A. 1-2 months
    B. 3-6 months
    C. 6-12 months
    D. 2 years
    E. Indefinitely

Answers

1. D
2. C
3. B
4. A
5. B
6. B
7. C
8. D
9. E
10. C