1. Which of the following is/are true relative to the definition, diagnosis and prevalence of hypertension.
1. A BP cuff that is too small (i.e., encircles less than 80% of the upper arm) gives an erroneously low BP reading.
2. The upper normal BP value for a seven-year-old is 135/85.
3. African Americans experience a higher prevalence of hypertension than Caucasians, but appear to suffer less severe end-organ damage.
4. The prevalence of hypertension rises with age.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: D
2. Which of the following is/are true relative to the causes of high blood pressure:
1. Renal parenchymal disease is the single most common cause of persistent hypertension in the pre-adolescent population.
2. Environmental factors thought to raise BP include obesity, diabetes, high salt intake, physical inactivity and immoderate alcohol consumption.
3. Renal artery stenosis, renal parenchymal disease, endocrine disorders, pregnancy, and drugs, account for the majority of secondary hypertension.
4. A cause for hypertension can be identified in close to 95% of hypertensive adults, if diligently searched for.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: A
3. The work-up of a patient who is referred to you with established hypertension should include:
1. A thorough drug history.
2. Physical examination to include assessment of the skin.
3. Urinalysis, serum electrolytes and creatinine.
4. Assessment of left ventricular heart mass.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: E
4. The following is/are true regarding the treatment of essential hypertension:
1. The elderly usually require and tolerate larger doses of diuretics and beta blockers than younger adults.
2. Beta blockers should generally be avoided in those with reactive airway disease (asthma).
3. Beta blockers and angiotensin-converting enzyme (ACE) inhibitors should be avoided following myocardial infarction.
4. The slow reduction of medication (step-down therapy) can be attempted in those with essential hypertension who have been under good control for one year.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: C
5. Which statements are true regarding the increase in glomerular filtration rate (GFR) that occurs after birth?
1. Increased renal blood flow contributes to increased GFR in the neonate.
2. GFR increases immediately after birth, regardless of gestational age.
3. Redistribution of blood flow to the outer renal cortex increases GFR.
4. Renal vascular resistance increases while systemic vascular resistance falls after birth.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: B
6. Tubular reabsorption of _______________ increases with maturation.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: A
7. A three month old infant born at full term weights 5 kg and has a length of 50 cm. The serum creatinine is 1.0. Which statements are true?
1. This infant has normal renal function.
2. Glomerulogenesis is complete.
3. Tubular maturation is complete.
4. This infant's glomerular filtration rate is approximately 22 mL/1.73 m2/min.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: C
8. The following statements about congenital nephrotic syndrome of the Finnish type are true.
1. It is caused by a mutation in the nephrin gene on chromosome 19.
2. Maternal alpha feto protein is increased in the second trimester.
3. Steroid therapy is useless.
4. Proteinuria is present prior to age three months.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: E
9. Factors contributing to renal vein thrombosis include all of the following EXCEPT:
A. Hemoconcentration
B. Increased antithrombin Ill levels
C. Increased platelet activation
D. High molecular weight fibrinogen
Show answer
Correct Answer: B
10. Findings in atheroembolic renal disease include:
A. Renal failure
B. Eosinophilia
C. Hypocomplementemia
D. Livedo reticularis
E. All of the above
Show answer
Correct Answer: E
11. The most likely diagnosis in a patient presenting with signs and symptoms of small vessel vasculitis, antineutrophil cytoplasmic antibodies (ANCA) in the blood and no evidence of asthma, eosinophilia or necrotizing granulomas is which of the following:
A. Henoch-Schonlein purpura
B. Cryoglobulinemic vasculitis
C. Microscopic polyangiitis
D. Necrotizing granulomatosis (Wegener's)
E. Churg-Strauss syndrome
Show answer
Correct Answer: C
12. A 45-year-old physician has a long history of recurrent kidney stones. Because of his busy schedule as Chief of Medicine he has undergone 11 extracorporeal shock wave lithotripsy (ESWL) treatments to "get rid of the stones". He states that he can handle his stone problem quite well in this manner and that he has seen no reason to have a metabolic work-up. He noticed in recent months, however, that he has to urinate quite often, especially at night, that he has exertional dyspnea and that he is more fatigued than usual. All of the following statements apply to his situation, EXCEPT:
A. ESWL reduces stone activity.
B. ESWL can increase stone activity.
C. Repeated ESWL can cause hypertension and 2o heart failure
D. Repeated ESWL can cause renal insufficiency.
E. Despite a good response to ESWL, a metabolic evaluation is essential.
Show answer
Correct Answer: A
13. Which therapeutic measures correlate best with the prevention of Calcium oxalate stones in patients with idiopathic hypercalciuria?
A. Extracorporeal Shock Wave Lithotripsy.
B. sustained alkalinization of the urine with bicarbonate.
C. a high sodium diet.
D. high dose vitamin C.
E. low sodium and normal protein intake, a high urine volume, thiazide diuretic.
Show answer
Correct Answer: E
14. Which one of the following factors contribute to edema formation in congestive heart failure?
A. Effective arterial blood volume is increased due to renal salt and water retention.
B. Decreased effective arterial blood volume leads to increased aldosterone, ADH, and sympathetic nerve activity.
C. Total peripheral resistance is decreased due to splanchnic vasodilatation.
D. Decreased actual blood volume leads to activation of baroreceptors.
E. The renin-angiotensin system is suppressed.
Show answer
Correct Answer: B
15. Which one of the following does not drive potassium into cells?
A. Insulin
B. Increased extracellular pH
C. Epinephrine
D. Increased extracellular sodium concentration
E. Aldosterone
Show answer
Correct Answer: D
16. The clinical manifestations of hyperkalemia include all of the following except:
A. Predisposes to digitalis toxicity
B. Predisposes to ventricular fibrillation
C. EKG shows flattened P wave, peaked T wave, and widened QRS complex
D. Weakness
E. Predisposes to cardiac arrest
Show answer
Correct Answer: A
17. Which one of the following statements is false?
A. The main cause of hypokalemia associated with vomiting is not loss of K+ in the vomitus.
B. Diuretics are one of the most common causes of hypokalemia.
C. Renal failure is a common cause of hyperkalemia.
D. Hyperkalemia in diabetes mellitus is at least partially due to inadequate aldosterone formation.
E. Copious watery diarrhea is frequently associated with hyperkalemia.
Show answer
Correct Answer: E
18. An elderly woman develops a urinary tract infection, becomes confused, and does not eat or drink for three days at her nursing home. She is found to have a blood pressure of 70/50 mmHg (very low). Which one of the following intravenous fluids would you recommend?
A. One-half normal saline
B. Normal saline
C. 5% dextrose and water
D. Hypertonic saline
E. One-quarter normal saline
Show answer
Correct Answer: B
19. Which one of the following statements about hypo- or hypernatremia is true?
A. A patient with frank symptoms of hypo- or hypernatremia should have his/her serum sodium concentrations rapidly (few hours) corrected back to normal levels.
B. The brain fully compensates for hypenatremia within 2-4 hours by making "idiogenic osmoles".
C. The symptoms of hyper- and hyponatremia are mainly due to central nervous system dysfunction.
D. Hyponatremia due to SIADH is most often due to underlying kidney or liver disease.
E. "Pseudohyponatremia" is as dangerous as true hyponatremia.
Show answer
Correct Answer: C
20. Which of the following is NOT commonly found in chronic urinary obstruction?
A. Nocturia
B. No symptoms
C. Renal failure
D. Microhematuria with dysmorphic red cells
E. Polyuria
Show answer
Correct Answer: D
21. A 23-year-old sexually active woman presents with urinary frequency and burning on micturition of 24 hours duration. Her urinalysis shows: Yellow, hazy urine. pH 6. No glucose. Protein trace, blood trace. 20-50 WBC/HPF, 10-20 RBC/HPF. 0-1 squamous epithelial cells and no bacteria. You prescribe trimethoprim/sulfamethoxazole tablets twice a day. The next day she feels much better but her urine culture report reads:"Staphylococcus saprophyticus 100,000 cfu/ml." Which of the following statements is true?
A. She has a bacterial UTI.
B. The urine sample was contaminated and the results from it are unreliable.
C. The hematuria likely signifies the presence of a stone or tumor.
D. The Staphylococcus saprophyticus is likely a skin contaminant.
E. The urinalysis is a laboratory error.
Show answer
Correct Answer: A
22. A 58-year-old woman presents with hematuria and left flank pain. Renal ultrasound shows marked left hydronephrosis. Serum creatinine and CBC are normal. Which of the following is the most relevant diagnostic aid?
A. Renal biopsy
B. Renal arteriogram
C. Palpation for inguinal lymph nodes
D. Antinuclear antibody test
E. Pelvic examination and IVP
Show answer
Correct Answer: E
23. A 26 year-old diabetic woman is seen in the ER for sore throat. Rapid strep test is positive for streptococcal pharyngitis and she was started on ampicillin 500 mg four times a day. Three days later, she develops hematuria associated with a low grade fever. On physical examination, she has a maculopapular rash and a temperature of 101oF. Laboratory studies show: serum creatinine 3.6 mg/dl, WBC 8,700 with 56% PMN, 25% lymphs, 3% monos and 15% eosinophils. Urinalysis: pH 6.2, protein 2+, blood 3+, 65 RBCs/HPF, 20-30 WBCs/HPF, 3-4 WBC casts/HPF. Hansel's stain is positive for eosinophils. The most likely diagnosis would be:
A. Diabetic nephropathy
B. IgA nephropathy
C. Acute interstitial nephritis
D. Acute pyelonephritis
E. Acute post-streptococcal glomerulonephritis
Show answer
Correct Answer: C
24. Analgesic nephropathy can be associated with all of the following except:
A. Small kidney size by renal ultrasound
B. Nephritic sediment with RBC casts
C. Increased risk of transitional cell carcinoma
D. Tubulointerstitial fibrosis on renal biopsy
E. Urinary tract obstruction due to papillary necrosis on IVP
Show answer
Correct Answer: B
25. Autosomal dominant polycystic kidney disease is associated with all of the following except:
A. Hypertension is very common
B. Ultrasound is very useful in establishing the diagnosis
C. Renal failure progresses slowly
D. The majority of the patients (>80%) have cerebral aneurysms
E. Lipid soluble antibiotics should be used when the cysts become infected
Show answer
Correct Answer: D
26. A 10-month-old boy presents with status epilepticus. His intoxicated mother was unable to provide a history. The child quit seizing after being treated with diazepam. Exam revealed an obtunded child with tachypnea. Screening labs showed Na 140 mEq/L, K 5.5 mEq/L, total CO2 6 mEq/L, Cl 104 mEq/L, BUN 15 mg/dl, creatinine 0.6 mg/dl, glucose 40 mg/dl, Ca 9.5 mg/dl, Mg 1.4 mg/dl, PO4 5 mg/dl, serum osmolality 350 mosm/L. The arterial blood gas showed a pH of 7.0, PCO2 25 mmHg. The patient has a:
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Show answer
Correct Answer: A
27. The anion gap in the infant above is:
A. 25
B. 30
C. 36
D. None of the above
Show answer
Correct Answer: B
28. What is his possible diagnosis:
A. Septic shock with lactic acidosis
B. Intoxication with methanol
C. Diabetic ketoacidosis
D. Bartter's syndrome
Show answer
Correct Answer: B
29. An infant presents to a pediatrician for recurrent vomiting and failure to thrive. The child has been hospitalized by another primary care physician for recurrent dehydration. However, data are not available. Weight and length are below the fifth percentile. Exam shows a normal blood pressure with signs of mild dehydration. Reflexes are markedly increased. The child is hypotonic. Chemistry panel showed Na 140 mEq/L, K 2.2 mEq/L, CO2 50 mEq/L, Cl 78 mEq/L, BUN 20 mg/dl, creatinine 1.0 mg/dI, Ca 9.5 mg/dl, Mg 1.7 mg/dl, PO4 2.8 mg/dl. Arterial blood gas showed pH 7.54, pCO2 60 mmHg, urine chloride was 40 mEq/L and urinary calcium excretion was elevated. What is the nature of the acid-base disorder?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Metabolic acidosis
Show answer
Correct Answer: B
30. The most likely diagnosis in this infant is:
A. Gitleman's syndrome
B. Bartter's syndrome
C. Renal tubular acidosis
D. Contraction alkalosis
1. A 33 year old woman develops fever, chills, cough, shortness of breath and chest pain a few days after returning home from delivering her fourth child. A chest x-ray obtained by her primary care physician demonstrates a sizeable left lower lobe opacity, and she is admitted to your team for care. You are assigned to her.
Your history reveals that she has always been healthy and that the recent labor and delivery were uncomplicated. The baby is doing well. She has never smoked and does not work outside the home. Review of systems is unrevealing.
Physical exam demonstrates a drowsy and uncomfortable woman. Temperature is 103.1( F., respiratory rate is 32, blood pressure is 130/70, pulse is 110. She has percussion dullness over the left base posteriorly and crackles on auscultation of the same area. The rest of the exam is unremarkable.
Laboratory obtained by the primary care physician includes a CBC (WBC 17,000, Hgb 6.0, Hct 18, platelets 200,000), electrolytes (Na 135, K 3.7, Cl 105, HCO3 25) and coagulation studies (PT 14.2, APTT 36). A pulse oximeter reading on room air shows a hemoglobin saturation of 91%. Her hemoglobin saturation during her delivery was 97%.
Your team starts antibiotics for the pneumonia. Which one of the following should also be given to this patient?
A. Oxygen
B. Potassium
C. Blood
D. Cooling blanket
Show answer
Correct Answer: C
FEEDBACK
C: With a hemoglobin of 6.0, her CaO2 will be low, despite saturation of 91%
2. Interpret the following blood gas report: FiO2 0.21, Temp. [snip].7 F, PB 640 mmHg, PaO2 99, PaCO2 36, pH 7.45, HCO3 22, saturation 99%
A. Lab error
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Normal
Show answer
Correct Answer: A
FEEDBACK
A: The A-a gradient is a negative number, which indicates either that the patient was receiving supplemental oxygen (contrary to the report) or that there was some other foul-up. A negative A-a gradient is a physiologic impossibility
3. Interpret the following blood gas report: FiO2 0.21, Temp. 96.7 F, PB 760 mmHg, PaO2 99, PaCO2 36, pH 7.45, HCO3 22, saturation 99%
A. Lab error
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Normal blood gases
4. An 18 year old male is brought to the University of Utah Emergency Room after being found unconscious in his dorm room in a pool of his own vomit. He has a history of depression and recently expressed feelings of despondency to some of his friends. An empty pill bottle is found on the floor beside him. A blood gas obtained on room air at the start of his resuscitation is as follows: PaO2 44, PaCO2 60, pH 7.36, HCO3 24. Which one of the following diagnoses is most consistent with these values?
A. Aspiration of gastric contents from obvious vomiting
B. Pulmonary embolism from prolonged immobility
C. Hypoventilation from drug induced ventilatory suppression
D. Pneumonitis in response to drug overdose
Show answer
Correct Answer: C
FEEDBACK
C: A-a gradient is normal, ruling out the other choices.
5. After a hard day of holding retractors on the Orthopedic Surgery service, you are called to admit an 80-year-old woman who fell out of bed at a local nursing home and broke her hip. She has a history of stroke and does not talk. Her nursing home chart reveals that she has a history of chronic congestive heart failure and borderline renal insufficiency. She has a productive cough.
Her physical examination is as follows:
Vitals: BP 80/50, Heart rate 120, respirations 32, temperature 94.5 F.
Head/neck: normal
Chest: bilateral crackles and percussion dullness at right base
Heart: S3 gallop present
Abdomen: soft, bowel sounds normal in character
Extremities: 2+ pitting edema bilaterally
Other data include:
BUN 40, Hgb 12.5, WBC 16,000, platelets 50,000
ABG: (room air) PaO2 50, PaCO2 32, pH 7.48, HCO3 24
CXR: "consolidation of the right middle and lower lobes, with some airspace disease in the left lower lobe as well."
Sputum and blood cultures - pending
The most important determinant of her prognosis is:
A. Her advanced age
B. The bacteria causing her pneumonia
C. Her comorbid illness(es)
D. The time interval between diagnosis and institution of antibiotic therapy
Show answer
Correct Answer: C
FEEDBACK
C: We discussed in class, small groups and in the syllabus that comorbid illness is a more important prognosticator than either the patient's age or the etiologic bacteria.
6. Your next door neighbor calls you over to look at his wife. She has had a productive cough for about three days, and is feeling poorly. She does not have a fever, but does complain of pleuritic chest pain. He is sure she has pneumonia. After some coaxing, you get your stethoscope and examine her. (Boy, is this embarrassing or what?) Her respiratory rate is 24, and her pulse is 100. Her chest is clear. What should you tell your neighbor at this point?
A. "I don't think she has pneumonia, but you should take her to the doctor for a CBC. That will tell us for sure."
B. "I don't think she has pneumonia, but you should take her to the doctor for a blood gas measurement. That will tell us for sure."
C. "I don't think she has pneumonia, but you should take her to the doctor for a chest x-ray. That will tell us for sure."
D. "I don't think she has pneumonia, but you should take her to the doctor for a sputum gram stain. That will tell us for sure."
Show answer
Correct Answer: C
FEEDBACK
C: Pneumonia is a diagnosis made by chest x-ray.
7. A middle-aged African-American male has advanced sarcoidosis. His PaO2 is 55 on room air. The FEV1/FVC ratio is higher than normal. The diffusion capacity (DLCO) is only 20% of that which is predicted for his age, height, weight and sex. Why is the diffusion capacity so low?
A. Enlarged lymph nodes from sarcoidosis compress the pulmonary arteries
B. Airway obstruction prevents normal distribution of inhaled gases
C. The pulmonary capillary bed is destroyed by the disease process
D. Sarcoid causes interstitial thickening
Show answer
Correct Answer: C
FEEDBACK
C: Remember that the DLCO measures how much carbon monoxide binds to pulmonary capillary blood, and that the thickened interstitium is not nearly the barrier to CO that it would be to oxygen. It is the loss of pulmonary capillary bed that lowers the DLCO. Lymph nodes and pulmonary artery compression is a bogus choice. The solubility of CO makes maldistribution of ventilation a non-issue.
8. You administer oxygen to an elderly woman with a PaO2 of 40, PaCO2 of 40, pH of 7.43 and HCO3 of 24. Repeat blood gas measurements after 30 minutes of therapy are as follows: PaO2 42, PaCO2 of 39, pH of 7.43 and HCO3 of 25. How do you explain these results?
A. Ventilation-perfusion inequality
B. Hypoventilation
C. Diffusion limitation
D. Shunt
Show answer
Correct Answer: D
FEEDBACK
D: PaO2 didn't change with administration of oxygen. This is the identifying feature of a shunt.
9. A 19 year old man develops weakness in his legs a few days after recovering from a cold. This progresses daily and he soon has difficulty rising from a chair. He is almost completely paralyzed by the time his parents bring him to University of Utah Hospital where he is diagnosed with Guillain-Barre syndrome. A blood gas is obtained just as he is intubated:
PaO2 40, PaCO2 60, pH 7.24 and HCO3 28. A chest x-ray is normal. How do you explain the low PaO2?
A. Ventilation-perfusion inequality
B. Hypoventilation
C. Diffusion limitation
D. Shunt
Show answer
Correct Answer: B
FEEDBACK
B: Hopefully you identified an acute respiratory acidosis (low pH, high PaCO2, the cause of which is hypoventilation due to his muscle weakness.
10. Your Medicine team is on call at the VA Hospital and has just taken yet another admission. It's an elderly homeless man who was found seizing under an I-15 overpass. A chest x-ray obtained after the seizure is controlled shows a large right lower lobe opacity consistent with aspiration pneumonia. A blood gas on admission is as follows:
PaO2 40, PaCO2 32, pH 7.48, HCO3 28
Oxygen is administered for 30 minutes, after which another blood gas is obtained.
PaO2 60, PaCO2 40, pH 7.40, HCO3 26
What is the most likely explanation for his hypoxemia?
A. Ventilation-perfusion inequality
B. Hypoventilation
C. Diffusion limitation
D. Shunt
Show answer
Correct Answer: A
FEEDBACK
A: Hypoxemic, widened A-a gradient, responded to oxygen therapy. This rules out hypoventilation and shunt. Ventilation-perfusion mismatching is a feature of pneumonia. Diffusion limitation is unusual
11. A 55 year old woman falls victim to the "all you can eat for $2.49" offer at the local greasy spoon eatery and vomits all night. At 10:00 a.m. she presents for evaluation complaining of weakness and lightheadedness. Her violent emesis has been replaced by profound anorexia and she has some abdominal soreness. She has the following physical exam:
BP 105/70, Pulse 100, Resp 15, Temp [snip].7 F.
Head/neck: normal
Chest: clear
Heart: normal
Abdomen: soft, rare bowel sounds, sore to palpation
Extremities: no cyanosis or edema
CXR: clear
ABG on room air: PaO2 61 mm Hg, PaCO2 35 mm Hg, pH 7.52, HCO3 32 and SaO2 of 91%
Basic metabolic panel: Na 134, K 2.8, Cl 90, CO2 35, BUN 22, creatinine 1.2, glucose 105
How do you explain this picture?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis, compensated
D. Respiratory acidosis, compensated
Show answer
Correct Answer: A
FEEDBACK
A: pH is 7.52, so it is an alkalosis. PaCO2 is low-normal, and HCO3 is high.
12. A 33 year old HIV positive man undergoes bronchoscopy and bronchoalveolar lavage at the U. of U. because of new onset cough and dyspnea. Technical difficulties with the bronchoscope prolong the procedure unexpectedly. At its conclusion, the nurse notes that the patient is "barely responsive to painful stimuli" and turns off the sedative drip. A blood gas sent on room air is as follows: PaO2 45 mm Hg, PaCO2 60 mm Hg, pH 7.24, HCO3 20 and SaO2 of 81%. The blood gas can be explained by:
A. An acute change in ventilation
B. An acute change in perfusion
C. A chronic change in ventilation
D. A chronic change in perfusion
Show answer
Correct Answer: A
FEEDBACK
A: A-a gradient is normal, PaCO2 is high, pH is 0.16 lower than normal, consistent with an acute respiratory acidosis. This is caused by an acute change in ventilation resulting from oversedation at bronchoscopy.
13. At the annual family Christmas dinner, you notice that Grandma has a dry cough, and seems to be feeling ill. Your mother corners her and she admits that she gets short of breath with even mild exertion. She attributes this to the fact that she has not slept well recently. Every time she lays down she coughs and has to sit up to breathe. You're the family's doctor now, and everyone looks to you for an answer. She doesn't have a fever, but she is breathing about 28 times a minute.
You persuade Grandma to go to the Emergency Room. The resident who examines her tells you she has crackles on her chest exam and orders a chest x-ray. The only thing it shows is peribronchial cuffing. A pulse oximeter confirms your worst fears. She has ventilation-perfusion inequality.
The whole clan is outside in waiting room. What can you tell them?
A. Grandma has pulmonary edema
B. Grandma has pneumonia
C. Grandma has asthma
D. Grandma has chronic bronchitis
Show answer
Correct Answer: A
FEEDBACK
A: Grandma has symptoms of cough and shortness of breath, coupled with dyspnea on exertion. She can't lay flat to sleep (orthopnea). Chest x-ray shows pulmonary edema (peribronchial cuffing) and nothing else. This is the cause of her ventilation-perfusion inequality.
14. A prominent businessman and big-time donor to University Hospital develops pulmonary edema after a myocardial infarction. He's recuperating nicely in the hospital's 4th Floor VIP suite, but he's still requiring supplemental oxygen. His wife, a former respiratory therapist, wants to know why and corners the hospital administrator for some answers. He promises to get some, and grabs the first white coat he can find to talk to her. Ever diligent, you stayed late on your off night to finish your notes and are the administrator's unfortunate victim. The hospital's financial future hangs in the balance. What's your answer?
A. The CO2 dissociation curve is commonly shifted to the right in pulmonary edema, causing hypoxemia.
B. CO2 retention commonly occurs in pulmonary edema, causing hypoxemia.
C. Distortion of the ventilation-perfusion relationship commonly occurs in pulmonary edema, causing hypoxemia.
D. Hyperventilation is commonly a feature of pulmonary edema, causing hypoxemia.
Show answer
Correct Answer: C
FEEDBACK
C: The CO2 dissociation curve has nothing to do with pulmonary edema and is not affected by it. Most patients with pulmonary edema breathe rapidly. CO2 retention is not common in pulmonary edema. Hyperventilation is not a cause of hypoxemia.
15. A New York stockbroker takes a nasty fall at Snowbird and ends up with a fractured femur. He receives a liter of IV fluid in the helicopter on the way to University Hospital and another one while waiting in the pre-op holding area. Since general anesthesia always drops the blood pressure, the anesthesiologist gives him yet another liter of fluid at a high infusion rate. He requires a lot of blood products during surgery. The next morning, he is short of breath and has a new cough. His pulse oximeter reads 78%. Can you explain the hypoxemia?
A. He has high altitude pulmonary edema from skiing at Snowbird.
B. He has neurogenic pulmonary edema from hitting his head in the fall.
C. He has drug induced pulmonary edema from general anesthesia.
D. He has volume overload pulmonary edema from intravenous fluids and blood.
Show answer
Correct Answer: D
FEEDBACK
D: We barely discussed high altitude pulmonary edema, which could have been a clue, but high altitude pulmonary edema is rare at Snowbird. There is nothing in the history about any head injury. General anesthesia is a vanishingly rare cause of inhalation injury or drug toxicity. The guy got a boatload of fluids and blood products. This is the best answer.
16. A 66 year old veteran seeks evaluation for breathing problems. He has a long smoking history, but doesn't cough much and rarely produces sputum. He is tall and skinny and admits to an unintentional weight loss of 10 pounds during the past year. His pulmonary function tests show a low FEV1/FVC. The chest x-ray shows flat diaphragms and evidence for hyperexpansion of the lungs. Which physical exam findings would be most consistent with this picture?
A. Normal breath sounds interspersed with wheezing.
B. Normal breath sounds interspersed with crackles.
C. Very quiet breath sounds interspersed with wheezing.
D. Very quiet breath sounds interspersed with crackles.
Show answer
Correct Answer: C
FEEDBACK
C: You needed to recognize this as an emphysema patient. These patients have very quiet breath sounds and do not have crackles.
17. You are assigned to the Pulmonary team at University Hospital and your first patient is a 57 year old man who has dyspnea on exertion. He tells you that he is fine as long as he doesn't have to climb stairs or walk more than 100 feet. He is stocky in build and red faced. He has a very productive cough. He smokes two packs of cigarettes a day. On examination, you find that he has wheezes throughout his chest and his nail beds are blue. The chest x-ray shows a big cardiac silhouette. Pulmonary function tests show a low FEV1/FVC. His arterial blood gas on room air is as follows: PaO2 is 36, PaCO2 is 55, HCO3 is 26, pH 7.35. What is the most likely explanation for the blood gas findings?
A. There is ventilation-perfusion mismatching resulting in a high VA/Q ratio.
B. There is ventilation-perfusion mismatching resulting in a low VA/Q ratio.
C. There is ventilation-perfusion mismatching resulting in hypoventilation.
D. There is ventilation-perfusion mismatching resulting in diffusion limitation.
Show answer
Correct Answer: B
FEEDBACK
B: This is chronic bronchitis (productive cough, wheezing, dyspnea, smoking). The hallmark of these patients is ventilation-perfusion inequality. The airways are diseased, and the parenchyma is preserved, leading to the low VA/Q ratio.
18. A 65 year old woman is diagnosed with interstitial pulmonary fibrosis. She is mildly hypoxemic at rest, but becomes very hypoxemic while walking. What is the explanation for this?
A. Impaired diffusion with ventilation-perfusion inequality caused by fibrosis induced disrupted lung architecture.
B. Impaired diffusion with hypoventilation caused by fibrosis induced non-compliant lung parenchyma.
C. Impaired diffusion with shunt caused by fibrosis induced arteriovenous communications.
D. Impaired diffusion with low PAO2 caused by fibrosis induced tachypnea.
Show answer
Correct Answer: A
FEEDBACK
A: Non-compliant lung parenchyma leads to hyperventilation, not hypoventilation. Fibrosis destroys the capillary bed. It does not lead to the formation of any kind of vascular structure. Tachypnea leads to a high PAO2, not a low PAO2.
19. You are taking care of a critically ill woman who has developed severe respiratory complications following an emergency cesarean section. Her PaO2 is 40, PaCO2 is 32, pH is 7.46 and SaO2 is 75%. Her CBC is as follows: Hb 6, Hct 17.6, WBC 12.0, platelets 190,000. After receiving supplemental oxygen her PaO2 improves to 100 and her SaO2 to [snip]%. PaCO2 is 40 and pH is 7.40. What will her CaO2 be if she receives blood transfusion sufficient to raise her Hb to 12?
A. 17 mL/dL
B. 8 mL/dL
C. 12 mL/dL
D. 14 mL/dL
Show answer
Correct Answer: A
FEEDBACK
A: (1.39 x 12 x 0.[snip]) + (0.003 x 100) = 16.6 mL/dL
20. An Olympic speedskater has a blood gas drawn on room air shortly after he arrives in Salt Lake City. PaO2 is 70, PaCO2 is 40, pH is 7.41, HCO3 is 20 and SaO2 is 95%. What effect will using supplemental oxygen just prior to the competition have on his arterial oxygen content, CaO2?
A. As illustrated by the oxygen dissociation curve, increasing the PaO2 would add very little to his Hb saturation or arterial oxygen content.
B. As illustrated by the oxygen dissociation curve, increasing the PaO2 would add significantly to both his Hb saturation and arterial oxygen content.
C. As illustrated by the oxygen dissociation curve, increasing the PaO2 would add very little to his Hb saturation but would significantly increase arterial oxygen content.
D. As illustrated by the oxygen dissociation curve, increasing the PaO2 would significantly increase his Hb saturation but not his arterial oxygen content.
21. Your alarm clock didn't go off and you missed those two hours of extra studying you were going to put in before the Pulmonary Organ System Final Exam. Still, you stayed awake through many of the lectures and read some of the syllabus. You hustled to get here just as the test papers were being handed out. You take your seat and look at the first problem. And then it hits you. You haven't got the foggiest idea of what the answer is. Your palms sweat, your chest feels tight and you begin to see stars before your eyes. Your room air blood gas at this point is something like this: PaO2 82 mm Hg, PaCO2 30 mm Hg, pH 7.48, HCO3 20 and SaO2 of [snip]%. Since this really isn't you, and you are currently in the process of totally killing this exam, interpret the blood gas report.
A. Respiratory alkalosis, normal A-a gradient
B. Metabolic alkalosis, normal A-a gradient
C. Respiratory alkalosis, widened A-a gradient
D. Metabolic acidosis, normal A-a gradient
Show answer
Correct Answer: A
FEEDBACK
A: pH 7.48, PaCO2 is 30, HCO3 is normal. A-a gradient is 6.
22. To celebrate their success in the Pulmonary Organ System, two dedicated medical students snowshoe into the Uintahs. They have a great time in their snow caves, and thanks to the Olympics, they can stay there for several days. Committed to the study of pulmonary Physiology
, they check their blood gases before they return. One specimen freezes in the portable blood gas analyzer they brought along, but the other is as follows: PaO2 40 mm Hg, PaCO2 30 mm Hg, pH 7.43, HCO3 18 and SaO2 of 81%. The barometer they bought at REI before they left tells them that the PB where they are is 450 mm Hg. How would you interpret this blood gas?
A. Normal A-a gradient, chronic respiratory alkalosis
B. Normal A-a gradient, metabolic alkalosis
C. Widened A-a gradient, respiratory alkalosis
D. Widened A-a gradient, metabolic acidosis
Show answer
Correct Answer: A
FEEDBACK
A: They are at altitude with a mildly elevated pH and a low PaCO2, consistent with chronic respiratory alkalosis. 0.21(450 -47) - 30/0.8 - 40 = 7.
23. A 23 year old insulin dependent diabetic woman "forgets" to take her insulin. She presents to the University Hospital Emergency Room with nausea, vomiting and is very thirsty. Her BMP (basal metabolic panel) is as follows: Na 133, K 5.5, Cl 96, CO2 13, BUN 18, creatinine 1.4 glucose 350. She also has the following blood gas: PaO2 70, PaCO2 22, pH 7.22, HCO3 15 and SaO2 of 94%. Interpret these data.
A. Non-anion gap metabolic acidosis, normal A-a gradient
B. Anion gap metabolic acidosis, widened A-a gradient
C. Non-anion gap respiratory acidosis, normal A-a gradient
D. Anion gap respiratory acidosis, widened A-a gradient
24. A 42 year old architect underwent arthroscopic surgery on his left knee at the University of Utah Hospital because of an injury suffered playing rec-league basketball. Three days later he develops sharp chest pain with inspiration, difficulty breathing and low grade fever. He returns to his orthopedic surgeon, who finds that aside from a pleural friction rub, his examination is normal. The chest x-ray is also normal. His blood gas is as follows: PaO2 55, PaCO2 40, pH 7.40, HCO3 22 and SaO2 of 89%. They don't discuss this sort of thing much during orthopedic surgery residencies, and this poor guy went to medical school at Harvard, where he didn't get the Pulmonary Organ System Course. What should the poor orthopedist do next?
A. Start empiric antibiotics for pneumonia with a pleural rub
B. Get a CT angiogram to look for pulmonary embolus with a pleural rub
C. Start bronchodilators for asthma with a pleural rub
D. Give diuretics for pulmonary edema with a pleural rub
Show answer
Correct Answer: B
FEEDBACK
B: Chest x-ray is normal, ruling out pneumonia. Asthma is an airway disease, does not cause pleural rubs (or I would have told you). There are no other signs of pulmonary edema (normal chest x-ray, no crackles), and no mention of anything that might have caused it. This is a very common scenario for pulmonary embolus.
25. A prominent senator from a tobacco producing state on the Atlantic coast (i.e. at sea level) develops angina and is felt to need coronary artery bypass grafting. No hypocrite, he has spent his life partaking of his state's most lucrative cash crop and as a result has developed significant obstructive lung disease. The anesthesiologist orders a room air blood gas as part of the preoperative evaluation. After he sees the results, he nervously tells the surgeon that surgery will be "an adventure". Here is the blood gas report: PaO2 30, PaCO2 60, pH 7.36, HCO3 33 and SaO2 of 76%. Why is the anesthesiologist so uptight?
A. The senator has a normal A-a gradient, and a metabolic acidosis
B. The senator has a widened A-a gradient and a compensated respiratory acidosis
C. The senator has a widened A-a gradient and a metabolic alkalosis
D. The senator has a normal A-a gradient and an acute respiratory acidosis
Show answer
Correct Answer: B
FEEDBACK
B: These are the same values as you had for the problem on compensated respiratory acidosis in small groups.
26. A 33 year old woman develops fever, chills, cough, shortness of breath and chest pain a few days after returning home from delivering her fourth child. A chest x-ray obtained by her primary care physician demonstrates a sizeable left lower lobe opacity, and she is admitted to your team for care. You are assigned to her.
Your history reveals that she has always been healthy and that the recent labor and delivery were uncomplicated. The baby is doing well. She has never smoked and does not work outside the home. Review of systems is unrevealing.
Physical exam demonstrates a drowsy and uncomfortable woman. Temperature is 103.1( F., respiratory rate is 32, blood pressure is 130/70, pulse is 110. She has percussion dullness over the left base posteriorly and crackles on auscultation of the same area. The rest of the exam is unremarkable.
Laboratory obtained by the primary care physician includes a CBC (WBC 17,000, Hgb 6.0, Hct 18, platelets 200,000), electrolytes (Na 135, K 3.7, Cl 105, HCO3 25) and coagulation studies (PT 14.2, APTT 36). A pulse oximeter reading on room air shows a hemoglobin saturation of 91%. Her hemoglobin saturation during her delivery was 97%.
Your team starts antibiotics for the pneumonia. Which one of the following should also be given to this patient?
A. Oxygen
B. Potassium
C. Blood
D. Cooling blanket
Show answer
Correct Answer: C
FEEDBACK
C: With a hemoglobin of 6.0, her CaO2 will be low, despite saturation of 91%
27. Interpret the following blood gas report: FiO2 0.21, Temp. [snip].7 F, PB 640 mmHg, PaO2 99, PaCO2 36, pH 7.45, HCO3 22, saturation 99%
A. Lab error
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Normal
Show answer
Correct Answer: A
FEEDBACK
A: The A-a gradient is a negative number, which indicates either that the patient was receiving supplemental oxygen (contrary to the report) or that there was some other foul-up. A negative A-a gradient is a physiologic impossibility
28. Interpret the following blood gas report: FiO2 0.21, Temp. 96.7 F, PB 760 mmHg, PaO2 99, PaCO2 36, pH 7.45, HCO3 22, saturation 99%
A. Lab error
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Normal blood gases
29. An 18 year old male is brought to the University of Utah Emergency Room after being found unconscious in his dorm room in a pool of his own vomit. He has a history of depression and recently expressed feelings of despondency to some of his friends. An empty pill bottle is found on the floor beside him. A blood gas obtained on room air at the start of his resuscitation is as follows: PaO2 44, PaCO2 60, pH 7.36, HCO3 24. Which one of the following diagnoses is most consistent with these values?
A. Aspiration of gastric contents from obvious vomiting
B. Pulmonary embolism from prolonged immobility
C. Hypoventilation from drug induced ventilatory suppression
D. Pneumonitis in response to drug overdose
Show answer
Correct Answer: C
FEEDBACK
C: A-a gradient is normal, ruling out the other choices.
30. After a hard day of holding retractors on the Orthopedic Surgery service, you are called to admit an 80-year-old woman who fell out of bed at a local nursing home and broke her hip. She has a history of stroke and does not talk. Her nursing home chart reveals that she has a history of chronic congestive heart failure and borderline renal insufficiency. She has a productive cough.
Her physical examination is as follows:
Vitals: BP 80/50, Heart rate 120, respirations 32, temperature 94.5 F.
Head/neck: normal
Chest: bilateral crackles and percussion dullness at right base
Heart: S3 gallop present
Abdomen: soft, bowel sounds normal in character
Extremities: 2+ pitting edema bilaterally
Other data include:
BUN 40, Hgb 12.5, WBC 16,000, platelets 50,000
ABG: (room air) PaO2 50, PaCO2 32, pH 7.48, HCO3 24
CXR: "consolidation of the right middle and lower lobes, with some airspace disease in the left lower lobe as well."
Sputum and blood cultures - pending
The most important determinant of her prognosis is:
A. Her advanced age
B. The bacteria causing her pneumonia
C. Her comorbid illness(es)
D. The time interval between diagnosis and institution of antibiotic therapy
Show answer
Correct Answer: C
FEEDBACK
C: We discussed in class, small groups and in the syllabus that comorbid illness is a more important prognosticator than either the patient's age or the etiologic bacteria.
31. Your next door neighbor calls you over to look at his wife. She has had a productive cough for about three days, and is feeling poorly. She does not have a fever, but does complain of pleuritic chest pain. He is sure she has pneumonia. After some coaxing, you get your stethoscope and examine her. (Boy, is this embarrassing or what?) Her respiratory rate is 24, and her pulse is 100. Her chest is clear. What should you tell your neighbor at this point?
A. "I don't think she has pneumonia, but you should take her to the doctor for a CBC. That will tell us for sure."
B. "I don't think she has pneumonia, but you should take her to the doctor for a blood gas measurement. That will tell us for sure."
C. "I don't think she has pneumonia, but you should take her to the doctor for a chest x-ray. That will tell us for sure."
D. "I don't think she has pneumonia, but you should take her to the doctor for a sputum gram stain. That will tell us for sure."
Show answer
Correct Answer: C
FEEDBACK
C: Pneumonia is a diagnosis made by chest x-ray.
32. A middle-aged African-American male has advanced sarcoidosis. His PaO2 is 55 on room air. The FEV1/FVC ratio is higher than normal. The diffusion capacity (DLCO) is only 20% of that which is predicted for his age, height, weight and sex. Why is the diffusion capacity so low?
A. Enlarged lymph nodes from sarcoidosis compress the pulmonary arteries
B. Airway obstruction prevents normal distribution of inhaled gases
C. The pulmonary capillary bed is destroyed by the disease process
D. Sarcoid causes interstitial thickening
Show answer
Correct Answer: C
FEEDBACK
C: Remember that the DLCO measures how much carbon monoxide binds to pulmonary capillary blood, and that the thickened interstitium is not nearly the barrier to CO that it would be to oxygen. It is the loss of pulmonary capillary bed that lowers the DLCO. Lymph nodes and pulmonary artery compression is a bogus choice. The solubility of CO makes maldistribution of ventilation a non-issue.
33. You administer oxygen to an elderly woman with a PaO2 of 40, PaCO2 of 40, pH of 7.43 and HCO3 of 24. Repeat blood gas measurements after 30 minutes of therapy are as follows: PaO2 42, PaCO2 of 39, pH of 7.43 and HCO3 of 25. How do you explain these results?
A. Ventilation-perfusion inequality
B. Hypoventilation
C. Diffusion limitation
D. Shunt
Show answer
Correct Answer: D
FEEDBACK
D: PaO2 didn't change with administration of oxygen. This is the identifying feature of a shunt.
34. A 19 year old man develops weakness in his legs a few days after recovering from a cold. This progresses daily and he soon has difficulty rising from a chair. He is almost completely paralyzed by the time his parents bring him to University of Utah Hospital where he is diagnosed with Guillain-Barre syndrome. A blood gas is obtained just as he is intubated:
PaO2 40, PaCO2 60, pH 7.24 and HCO3 28. A chest x-ray is normal. How do you explain the low PaO2?
A. Ventilation-perfusion inequality
B. Hypoventilation
C. Diffusion limitation
D. Shunt
Show answer
Correct Answer: B
FEEDBACK
B: Hopefully you identified an acute respiratory acidosis (low pH, high PaCO2, the cause of which is hypoventilation due to his muscle weakness.
35. Your Medicine team is on call at the VA Hospital and has just taken yet another admission. It's an elderly homeless man who was found seizing under an I-15 overpass. A chest x-ray obtained after the seizure is controlled shows a large right lower lobe opacity consistent with aspiration pneumonia. A blood gas on admission is as follows:
PaO2 40, PaCO2 32, pH 7.48, HCO3 28
Oxygen is administered for 30 minutes, after which another blood gas is obtained.
PaO2 60, PaCO2 40, pH 7.40, HCO3 26
What is the most likely explanation for his hypoxemia?
A. Ventilation-perfusion inequality
B. Hypoventilation
C. Diffusion limitation
D. Shunt
Show answer
Correct Answer: A
FEEDBACK
A: Hypoxemic, widened A-a gradient, responded to oxygen therapy. This rules out hypoventilation and shunt. Ventilation-perfusion mismatching is a feature of pneumonia. Diffusion limitation is unusual
36. A 55 year old woman falls victim to the "all you can eat for $2.49" offer at the local greasy spoon eatery and vomits all night. At 10:00 a.m. she presents for evaluation complaining of weakness and lightheadedness. Her violent emesis has been replaced by profound anorexia and she has some abdominal soreness. She has the following physical exam:
BP 105/70, Pulse 100, Resp 15, Temp [snip].7 F.
Head/neck: normal
Chest: clear
Heart: normal
Abdomen: soft, rare bowel sounds, sore to palpation
Extremities: no cyanosis or edema
CXR: clear
ABG on room air: PaO2 61 mm Hg, PaCO2 35 mm Hg, pH 7.52, HCO3 32 and SaO2 of 91%
Basic metabolic panel: Na 134, K 2.8, Cl 90, CO2 35, BUN 22, creatinine 1.2, glucose 105
How do you explain this picture?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis, compensated
D. Respiratory acidosis, compensated
Show answer
Correct Answer: A
FEEDBACK
A: pH is 7.52, so it is an alkalosis. PaCO2 is low-normal, and HCO3 is high.
37. A 33 year old HIV positive man undergoes bronchoscopy and bronchoalveolar lavage at the U. of U. because of new onset cough and dyspnea. Technical difficulties with the bronchoscope prolong the procedure unexpectedly. At its conclusion, the nurse notes that the patient is "barely responsive to painful stimuli" and turns off the sedative drip. A blood gas sent on room air is as follows: PaO2 45 mm Hg, PaCO2 60 mm Hg, pH 7.24, HCO3 20 and SaO2 of 81%. The blood gas can be explained by:
A. An acute change in ventilation
B. An acute change in perfusion
C. A chronic change in ventilation
D. A chronic change in perfusion
Show answer
Correct Answer: A
FEEDBACK
A: A-a gradient is normal, PaCO2 is high, pH is 0.16 lower than normal, consistent with an acute respiratory acidosis. This is caused by an acute change in ventilation resulting from oversedation at bronchoscopy.
38. At the annual family Christmas dinner, you notice that Grandma has a dry cough, and seems to be feeling ill. Your mother corners her and she admits that she gets short of breath with even mild exertion. She attributes this to the fact that she has not slept well recently. Every time she lays down she coughs and has to sit up to breathe. You're the family's doctor now, and everyone looks to you for an answer. She doesn't have a fever, but she is breathing about 28 times a minute.
You persuade Grandma to go to the Emergency Room. The resident who examines her tells you she has crackles on her chest exam and orders a chest x-ray. The only thing it shows is peribronchial cuffing. A pulse oximeter confirms your worst fears. She has ventilation-perfusion inequality.
The whole clan is outside in waiting room. What can you tell them?
A. Grandma has pulmonary edema
B. Grandma has pneumonia
C. Grandma has asthma
D. Grandma has chronic bronchitis
Show answer
Correct Answer: A
FEEDBACK
A: Grandma has symptoms of cough and shortness of breath, coupled with dyspnea on exertion. She can't lay flat to sleep (orthopnea). Chest x-ray shows pulmonary edema (peribronchial cuffing) and nothing else. This is the cause of her ventilation-perfusion inequality.
39. A prominent businessman and big-time donor to University Hospital develops pulmonary edema after a myocardial infarction. He's recuperating nicely in the hospital's 4th Floor VIP suite, but he's still requiring supplemental oxygen. His wife, a former respiratory therapist, wants to know why and corners the hospital administrator for some answers. He promises to get some, and grabs the first white coat he can find to talk to her. Ever diligent, you stayed late on your off night to finish your notes and are the administrator's unfortunate victim. The hospital's financial future hangs in the balance. What's your answer?
A. The CO2 dissociation curve is commonly shifted to the right in pulmonary edema, causing hypoxemia.
B. CO2 retention commonly occurs in pulmonary edema, causing hypoxemia.
C. Distortion of the ventilation-perfusion relationship commonly occurs in pulmonary edema, causing hypoxemia.
D. Hyperventilation is commonly a feature of pulmonary edema, causing hypoxemia.
Show answer
Correct Answer: C
FEEDBACK
C: The CO2 dissociation curve has nothing to do with pulmonary edema and is not affected by it. Most patients with pulmonary edema breathe rapidly. CO2 retention is not common in pulmonary edema. Hyperventilation is not a cause of hypoxemia.
40. A New York stockbroker takes a nasty fall at Snowbird and ends up with a fractured femur. He receives a liter of IV fluid in the helicopter on the way to University Hospital and another one while waiting in the pre-op holding area. Since general anesthesia always drops the blood pressure, the anesthesiologist gives him yet another liter of fluid at a high infusion rate. He requires a lot of blood products during surgery. The next morning, he is short of breath and has a new cough. His pulse oximeter reads 78%. Can you explain the hypoxemia?
A. He has high altitude pulmonary edema from skiing at Snowbird.
B. He has neurogenic pulmonary edema from hitting his head in the fall.
C. He has drug induced pulmonary edema from general anesthesia.
D. He has volume overload pulmonary edema from intravenous fluids and blood.
Show answer
Correct Answer: D
FEEDBACK
D: We barely discussed high altitude pulmonary edema, which could have been a clue, but high altitude pulmonary edema is rare at Snowbird. There is nothing in the history about any head injury. General anesthesia is a vanishingly rare cause of inhalation injury or drug toxicity. The guy got a boatload of fluids and blood products. This is the best answer.
41. A 66 year old veteran seeks evaluation for breathing problems. He has a long smoking history, but doesn't cough much and rarely produces sputum. He is tall and skinny and admits to an unintentional weight loss of 10 pounds during the past year. His pulmonary function tests show a low FEV1/FVC. The chest x-ray shows flat diaphragms and evidence for hyperexpansion of the lungs. Which physical exam findings would be most consistent with this picture?
A. Normal breath sounds interspersed with wheezing.
B. Normal breath sounds interspersed with crackles.
C. Very quiet breath sounds interspersed with wheezing.
D. Very quiet breath sounds interspersed with crackles.
Show answer
Correct Answer: C
FEEDBACK
C: You needed to recognize this as an emphysema patient. These patients have very quiet breath sounds and do not have crackles.
42. You are assigned to the Pulmonary team at University Hospital and your first patient is a 57 year old man who has dyspnea on exertion. He tells you that he is fine as long as he doesn't have to climb stairs or walk more than 100 feet. He is stocky in build and red faced. He has a very productive cough. He smokes two packs of cigarettes a day. On examination, you find that he has wheezes throughout his chest and his nail beds are blue. The chest x-ray shows a big cardiac silhouette. Pulmonary function tests show a low FEV1/FVC. His arterial blood gas on room air is as follows: PaO2 is 36, PaCO2 is 55, HCO3 is 26, pH 7.35. What is the most likely explanation for the blood gas findings?
A. There is ventilation-perfusion mismatching resulting in a high VA/Q ratio.
B. There is ventilation-perfusion mismatching resulting in a low VA/Q ratio.
C. There is ventilation-perfusion mismatching resulting in hypoventilation.
D. There is ventilation-perfusion mismatching resulting in diffusion limitation.
Show answer
Correct Answer: B
FEEDBACK
B: This is chronic bronchitis (productive cough, wheezing, dyspnea, smoking). The hallmark of these patients is ventilation-perfusion inequality. The airways are diseased, and the parenchyma is preserved, leading to the low VA/Q ratio.
43. A 65 year old woman is diagnosed with interstitial pulmonary fibrosis. She is mildly hypoxemic at rest, but becomes very hypoxemic while walking. What is the explanation for this?
A. Impaired diffusion with ventilation-perfusion inequality caused by fibrosis induced disrupted lung architecture.
B. Impaired diffusion with hypoventilation caused by fibrosis induced non-compliant lung parenchyma.
C. Impaired diffusion with shunt caused by fibrosis induced arteriovenous communications.
D. Impaired diffusion with low PAO2 caused by fibrosis induced tachypnea.
Show answer
Correct Answer: A
FEEDBACK
A: Non-compliant lung parenchyma leads to hyperventilation, not hypoventilation. Fibrosis destroys the capillary bed. It does not lead to the formation of any kind of vascular structure. Tachypnea leads to a high PAO2, not a low PAO2.
44. You are taking care of a critically ill woman who has developed severe respiratory complications following an emergency cesarean section. Her PaO2 is 40, PaCO2 is 32, pH is 7.46 and SaO2 is 75%. Her CBC is as follows: Hb 6, Hct 17.6, WBC 12.0, platelets 190,000. After receiving supplemental oxygen her PaO2 improves to 100 and her SaO2 to [snip]%. PaCO2 is 40 and pH is 7.40. What will her CaO2 be if she receives blood transfusion sufficient to raise her Hb to 12?
A. 17 mL/dL
B. 8 mL/dL
C. 12 mL/dL
D. 14 mL/dL
Show answer
Correct Answer: A
FEEDBACK
A: (1.39 x 12 x 0.[snip]) + (0.003 x 100) = 16.6 mL/dL
45. An Olympic speedskater has a blood gas drawn on room air shortly after he arrives in Salt Lake City. PaO2 is 70, PaCO2 is 40, pH is 7.41, HCO3 is 20 and SaO2 is 95%. What effect will using supplemental oxygen just prior to the competition have on his arterial oxygen content, CaO2?
A. As illustrated by the oxygen dissociation curve, increasing the PaO2 would add very little to his Hb saturation or arterial oxygen content.
B. As illustrated by the oxygen dissociation curve, increasing the PaO2 would add significantly to both his Hb saturation and arterial oxygen content.
C. As illustrated by the oxygen dissociation curve, increasing the PaO2 would add very little to his Hb saturation but would significantly increase arterial oxygen content.
D. As illustrated by the oxygen dissociation curve, increasing the PaO2 would significantly increase his Hb saturation but not his arterial oxygen content.
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