NMS Q&A Family Medicine

Pneumonia and Bronchitides 836. The answer is C. Restrictive lung disease. The reducedFVC, the amount one can exhale in one breath after fullinspiration, defines restrictive lung disease. FEV 1 is theproportion of the FVC (as a percentage) that can beexhaled in 1 second and can be normal in restrictive lungdisease. FEV 1 /FVC is normal if 95% of the predicted ratiois achieved (i.e., 75% of the FVC exhaled within 1 second).Poor effort is not a likely explanation in this case, as thepatient has a history of athleticism and determination.The chronicity rules out pneumonia. Both acute asthmaand COPD manifest prolonged FEV 1 on spirometry, notreduced FVC. Mesothelioma occurs virtually solely inpeople who have worked around and have inhaled dustfrom asbestos. Pulmonary fibrosis has several causes,among which is respiratory bronchiolitis-associated interstitiallung disease. It occurs in this age group in heavysmokers. It remits in 20% of cases and may respond toglucocorticoids. The median life expectancy with thediagnosis is more than 10 years. Smoking cessation is necessary.The other major cause is idiopathic pulmonaryfibrosis, a disease that comes on in a person’s late 50s, hasno known treatment, and whose prognosis is approximately3 years after diagnosis.7. The answer is B. The reduced FEV 1 and FEV 1 /FVCratio are indicative of COPD. Actually, the spirometryfindings are also compatible with acute asthma, as bothconditions are characterized by reduced capacity to exhaleair. The clinical information given in the vignette rulesagainst asthma in the chronicity, the absence of wheezing,and the pursed lips during expiration, a nearly pathognomonicfinding for COPD. (Although advanced and criticallysevere asthma may not exhibit wheezing, thatcombination occurs in association with far advanced andacute illness compared with the case presented.)8. The answer is D. Eosinophilic bronchitis, though not arare disease in pulmonary clinics, is uncommon in primarycare practice. PND, asthma, and GERD, the “pathogenictriad of chronic cough,” account for a significantmajority of chronic cough in nonsmoking, immunocompetentcases. There may be two causes in 18% to 62% ofcases. Chronic cough is defined as persistent for morethan 8 weeks. Bronchiectasis is a strong fourth cause. Insmokers, of course, chronic bronchitis and COPD cometo the fore. Angiotensin-converting enzyme inhibitorscause cough in 5% to 20% of cases. PND appears to havean atopic basis and may respond to an H1 antihistamine.PND may be associated with sinusitis; sinus x-rays may benegative in some 20% to 40% of cases. It should be appreciatedthat asthma may manifest cough without wheezingin up to 57% of cases. A methacholine challenge test isrecommended in possible asthma cases as being virtually100% sensitive so that a negative test effectively rules outasthma. Although a 24-hour esophageal pH monitor isthe gold standard for diagnosis of GERD, empiric treatmentwith H pump blocking agents such as omeprazoleis a more practical approach. Chest x-ray is abnormal in87% of cases of bronchiectasis, although a computedtomography scan of the chest is superior.9. The answer is E, asthma. Intermittent breathlessnessand the existence of triggering factors, allergic rhinitis,and a prolonged expiratory phase describe asthma. Unlikewith COPD, the prolonged expiratory phase is caused by adynamic spasm of the bronchiolar musculature and isreversible by medication.10. The answer is D, being a smoker and having a barrelchest and prolonged expiratory phase. COPD is evidencedby these findings and is statistically likely, given the historyof smoking. Both asthma and COPD exhibit a prolongedexpiratory phase of respiration. However, thatabnormality in COPD is virtually fixed while in asthma itoccurs in bouts.11. The answer is C, congestive heart failure. In this situation(history of hypertension, coronary artery disease,diabetes; orthopnea, paroxysmal nocturnal dyspnea; andpedal edema, jugular venous distention), CHF is a statisticallikelihood; however, the cause of dyspnea is not diagnosedby the symptomatology given.12. The answer is B, hyperventilation syndrome. For historyof generalized anxiety, panic disorder, and sighingbreathing, the cause is anxiety disorder, hyperventilation.The attendant respiratory alkalosis aggravates the symptomsof anxiety. However, care must be taken not toassume that all anxious hyperventilation is functional, aspulmonary embolus and acute CHF certainly can be associatedwith apprehension and anxiety.13. The answer is A, GERD. For postprandial dyspnea,the cause is gastroesophageal reflux, aspiration, or foodallergy. Always there would be an accompanying cough.14. The answer is A. Penicillin remains the drug of choicein this typical community-acquired case in a previouslyhealthy person with lobar pneumonia. The etiologic agentmaybe assumed to be caused by S . pneumoniae . Becauseof the acuteness of the case, this patient will need to behospitalized for a day or two but should respond dramatically.Trimethoprim/sulfamethoxazole (Bactrim, Septra),although theoretically effective against the gram-positiveside of the spectrum, is bacteriostatic, not bacteriocidal. Ifthe patient is allergic to penicillin, then most clinicianswould employ a macrolide antibiotic, such as clarithromycin.In the acutely ill patient who is to be in treatmentfor acute pneumonitis, tetracycline is not powerfulenough for this clinical situation. However, of subacuteprogression of a lower respiratory infection, where mycoplasmamay be considered, both the tetracyclines and the