Internal-Medicine

Answers: 15–35 255
26. (C) The increased vascular permeability is the
hallmark of the disease. Diagnostic criteria
include acute onset, PaO 2
/FiO 2
= 200 mm Hg
(regardless of positive end-expiratory pressure
[PEEP] level), bilateral infiltrate on frontal CXR,
and pulmonary artery occlusion pressure =
18 mm Hg (or if not measured, no evidence of
left atrial hypertension). (Kasper, p. 1592)
27. (B) Allergic bronchopulmonary aspergillosis
(in asthmatics), parasitic reactions, and drugs
are known causes of pulmonary eosinophilia.
Idiopathic causes include Löeffler’s syndrome
(benign, acute eosinophilic pneumonia), chronic
eosinophilic pneumonia, hypereosinophilic
syndrome, and Churg-Strauss allergic granulomatosis.
(Kasper, p. 1520)
28. (E) There is no diagnostic blood test, but twothirds
of patients with sarcoidosis will have an
elevated level of ACE. Also there is an elevated
ESR, hyperglobulinemia, and occasionally
hypercalcemia, which are all nonspecific findings.
A false-positive rheumatoid factor (RF)
and antinuclear antibodies (ANA) antibodies
can also be seen. The gallium scan is positive in
patients with sarcoidosis. (Kasper, p. 2022)
29. (B) Yearly influenza vaccination is indicated
for patients with COPD. Evidence for pneumococcal
vaccination is not definitive but some
advocate giving it as well. There is no role for
vaccination with H. influenzae B or meningococcus
in patients with COPD. Dietary support
to prevent malnutrition and improve muscle
strength can be helpful. Exercise programs
seem to provide subjective improvement as
well. Obviously, stopping smoking is crucial.
(Kasper, p. 1552)
30. (C) Acute mediastinitis is a rare complication of
upper endoscopy. It can also result from
trauma to the trachea or esophagus, or dissection
of the retroperitoneum. Clinical presentation
may include substernal chest pain,
subcutaneous emphysema, and Hamman’s
signs, a crunching or clicking noise synchronous
with the heartbeat. (Kasper, p. 1568)
31. (C) Hemoptysis suggests infection in a patient
with advanced lung disease. Pancreatic
exocrine function is poor. Nasal polyps are
common, but not rectal polyps. About 7% of
cases of cystic fibrosis are diagnosed after age 18.
Because of improved therapy, cystic fibrosis is
no longer just a pediatric disease. Median survival
is now 32 years for men and 29 years for
women. (Kasper, p. 1543)
32. (B) Hypoxemia while receiving 100% oxygen
indicates right-to-left shunt. Shunts permit circulation
of blood that never passes through the
ventilated lung. Shunting can occur within the
lung (atelectasis, vascular abnormalities) or
outside the lung (congenital cardiac malformations).
The hypoxemia of ventilation-perfusion
mismatch is more easily correctable by 100%
oxygen. (Kasper, pp. 1503–1504)
33. (C) Bony deformities of the chest can lead to
respiratory failure with raised PCO 2
, as well as
recurrent pulmonary infection. Most patients
develop a restrictive lung disease pattern
with decreased compliance, reduced TLC and
VC. In addition, because of the reduced compliance,
the resting position of the lung
changes such that FRC is reduced. Finally, the
net effect is an increase in the work of breathing.
The pattern on pulmonary function testing
is usually that of a restrictive pattern.
(Kasper, p. 1569)
34. (A) The VC is reduced in emphysema, but the
FEV1 is grossly reduced because of high
airway resistance. In predominant emphysema,
diffusing capacity is more profoundly
decreased than in predominant bronchitis.
(Kasper, p. 1549)
35. (E) All forms of asbestos fiber have been associated
with lung disease. Restrictive, not
obstructive, disease is characteristic. Lung
cancer, either squamous cell or adenocarcinoma,
is the most common malignancy and
the risk is greatly increased by smoking. Benign
pleural effusions can occur in both symptomatic
and asymptomatic individuals. Reports