Internal-Medicine

Answers and Explanations
1. (C) Hypersensitivity pneumonitis is an inflammatory
disorder of the lungs involving alveolar
walls and terminal airways that is caused by
repeated exposure to organic agents. In this
example of “farmer’s lung,” the inhalation of
antigens present in moldy hay such as thermophilic
actinomyces or Aspergillus species are
the causative agents. When exposure to moldy
hay is stopped, symptoms and signs of
farmer’s lung all tend to abate and complete
recovery usually follows. In acute syndromes,
the presentation is 4–8 hours after exposure.
Symptoms include fever, chills, malaise, cough,
and dyspnea without wheezing. The rate of
disease depends on rainfall (which promotes
fungal growth) and agricultural practices
related to turning and stacking hay. In acute
and subacute presentations, removing exposure
to the antigen will result in complete
recovery. (Kasper, p. 1516)
2. (C) COPD is defined as a disease state that is
characterized by airflow limitation that is not
fully reversible. Emphysema and chronic bronchitis
are closely related, and the term COPD is
often used to encompass both. Chronic bronchitis
is a clinical syndrome defined as excessive
tracheobronchial mucous production
severe enough to cause productive cough for at
least 3 months of the year for at least two consecutive
years. Emphysema is defined as the
distention of air spaces distal to the terminale
bronchiole, with destruction of alveolar septa.
It is primarily a histologic diagnosis. Smoking
is the usual antecedent for COPD. (Kasper,
p. 1547)
3. (B) Tranquilizers and sedatives should be avoided
in prolonged asthma attacks. Bronchodilators,
fluids, aminophylline, and steroids may be
used. In acute situations, IV glucocorticoids are
frequently used. Results of therapy should be
monitored in an objective manner, with peak
expiratory flow rates or FEV1. In acute asthmatic
attacks, hypocarbia is usual on blood gas
analysis. Normal or elevated PaCO 2
is a bad
sign and requires intensive monitoring and
aggressive treatment. (Kasper, pp. 1570–1571)
4. (E) Allergic bronchopulmonary aspergillus
usually requires long-term treatment with glucocorticoids.
The major diagnostic criteria are
bronchial asthma, pulmonary infiltrates,
eosinophilia greater than 1000, immediate
wheal and flare response to Aspergillus fumigans,
serum precipitins to A. fumigans, elevated
serum IgE, and central bronchiectasis. (Kasper,
p. 1520)
5. (C) Relatively asymptomatic patients often
require no treatment. Steroids are used with
ocular (as in this case), CNS, or other serious
complications. Although 50% of patients are
left with permanent organ impairment, these
are usually not symptomatic or significant.
Only in 15–20% of cases does the disease
remain active or recur. Glucocorticoids are the
treatment of choice, but numerous other agents
have been used. (Kasper, p. 2023)
6. (D) The administration of oxygen may worsen
the syndrome of carbon dioxide narcosis
because the chief stimulus to ventilation is
often hypoxia, and when this is suddenly
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