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Board-Style Question Bank

Board-Style Question Bank. Welcome to the APCCMPD board-style question bank brought to you by the University of Cincinnati! These questions have been brought to you and validated by the fellows and faculty of the University of Cincinnati Division of Pulmonary and Critical Care Medicine. 

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Board-Style Question Bank

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  1. Board-Style Question Bank Welcome to the APCCMPD board-style question bank brought to you by the University of Cincinnati! These questions have been brought to you and validated by the fellows and faculty of the University of Cincinnati Division of Pulmonary and Critical Care Medicine.  These questions can be used for educational purposes including incorporation into didactic lectures, board review conferences, or jeopardy-style learning games.  The questions are free to use without any charge and are intended for teaching purposes, not for use as medical advice.  I will be uploading questions to this website periodically.  Commentary on these questions is welcome and encouraged.  Users are also encouraged to submit their own questions for posting on this collaborative site.  Send emails to:  peter.lenz@uc.edu We look forward to your comments and collaboration.  With Gratitude, Peter H. Lenz, MDAssistant Professor & Associate Fellowship DirectorPulmonary & Critical Care MedicineUniversity of Cincinnati Disclaimer: The following slides and questions have been placed on the APCCMPD website for educational and teaching purposes.  They are not intended to provide assistance with patient care or to be used as medical advice or replace conversations or treatment from a physician. 

  2. According to a recent meta-analysis, what are the correct 6-month quit rates for smoking cessation respectively for:placebo, NRT monotherapy(patch or gum), buproprion, varenicline, and Dual NRT (patch + prn gum/lozenge)? • 2%, 6%, 8%, 18%, 12% • 6%, 8%, 9%, 20%, 22% • 10%, 15%,16%, 25%, 17% • 14%, 25%, 26%, 33%, 37% • 17%, 35%, 54%, 66%, 52% Author: Peter Lenz, MD

  3. According to a recent meta-analysis, what are the correct 6-month quit rates for smoking cessation respectively for:placebo, NRT monotherapy(patch or gum), buproprion, varenicline, and Dual NRT (patch + prn gum/lozenge)? • 2%, 6%, 8%, 18%, 12% • 6%, 8%, 9%, 20%, 22% • 10%, 15%,16%, 25%, 17% • 14%, 25%, 26%, 33%, 37% • 17%, 35%, 54%, 66%, 52% Author: Peter Lenz, MD

  4. Table from: Fiore et al: Treating Tobacco Use and Dependence: 2008. Update.  Clinical Practice Guideline.  Rockville, MD,  U.S. Department of Health and Human Services, Public Health Service,  2008 Author: Peter Lenz, MD

  5. Your non-oxygen dependent COPD patient is flying soon. You simulate 8,000 feet in the PFT Lab by having pt breathe 15% oxygen & discover that the PaO2 dropped to 56 mm Hg. Resting room air O2 sat=95%. What is the most appropriate next step? • In-flight oxygen not required for this patient • Write Rx for 2 LPM, have pt carry on to flight • Write Rx for 4 LPM, have pt carry on to flight • Contact airline and have them provide 2 LPM • Contact airline and have them provide 4 LPM Author: Peter Lenz, MD

  6. Your non-oxygen dependent COPD patient is flying soon. You simulate 8,000 feet in the PFT Lab by having pt breathe 15% oxygen & discover that the PaO2 dropped to 56 mm Hg. Resting room air O2 sat=95%. What is the most appropriate next step? • In-flight oxygen not required for this patient • Write Rx for 2 LPM, have pt carry on to flight • Write Rx for 4 LPM, have pt carry on to flight • Contact airline and have them provide 2 LPM • Contact airline and have them provide 4 LPM Author: Peter Lenz, MD

  7. BTS 2004 Guidelines PaO2 > 72 = 13% chance of significant hypoxemia “Significant Hypoxemia” is considered a PaO2 < 50 Breathing 15% FiO2 simulates PIO2 at 8,000 feet (cabin pressure) Table from: http://www.brit-thoracic.org.uk Author: Peter Lenz, MD

  8. Which of the following statements below best represents the effects of using a fixed ratio of 0.70 for diagnosing obstructive lung disease (OLD)? • The ATS says it is equivalent to using LLN • The ERS says it is equivalent to using LLN • Using a fixed ratio of 0.70 increases the risk of overdiagnosing OLD in young patients and underdiagnosing OLD in elderly patients • Using a fixed ratio of 0.70 increases the risk of underdiagnosing OLD in young patients and overdiagnosing OLD in elderly patients • Using a fixed ratio accounts for progressive age-related lung deterioration better than LLN. Author: Peter Lenz, MD

  9. Which of the following statements below best represents the effects of using a fixed ratio of 0.70 for diagnosing obstructive lung disease (OLD)? • The ATS says it is equivalent to using LLN • The ERS says it is equivalent to using LLN • Using a fixed ratio of 0.70 increases the risk of overdiagnosing OLD in young patients and underdiagnosing OLD in elderly patients • Using a fixed ratio of 0.70 increases the risk of underdiagnosing OLD in young patients and overdiagnosing OLD in elderly patients • Using a fixed ratio accounts for progressive age-related lung deterioration better than LLN. Author: Peter Lenz, MD

  10. An obstructive ventilatory defect is a disproportionate reduction in the maximal airflow from the lung in relation to the maximal volume (i.e., VC) that can be displaced from the lung. It implies airway narrowing during exhalation and is defined by a reduced FEV1/VC ratio below the 5th percentile of the predicted value. Pellegrino R, Viegi G, Brusasco V, Crapo RO, et al. Interpretative strategies for lung function tests. Eur Respir J 2005; 26:948-968. Author: Peter Lenz, MD

  11. What is the Aa gradient on Room Air at 8100 feet above sea level where Patm=525mm Hg, PH20=47 mm Hg and ABG = 7.5/24/67 ? 3 11 19 46 63 Not enough information Author: Peter Lenz, MD

  12. What is the Aa gradient on Room Air at 8100 feet above sea level where Patm=525mm Hg, PH20=47 mm Hg and ABG = 7.5/24/67 ? 3 11 19 46 63 Not enough information Author: Peter Lenz, MD

  13. For previous Question: PAO2 = 0.21(525 – 47) – 24/0.8 = 70 70 – PaO2 from ABG = 70-67 = 3 PAO2 = FiO2% x (Patm – PH2O) – pCO2/RQ Aa gradient = PAO2– PaO2 (from ABG) (Patm=525mm Hg, Room Air, PH20=47 mm Hg and ABG = 7.5/24/67) Author: Peter Lenz, MD

  14. What is the Aa gradient at 3600 feet above sea level where Patm=649mm Hg, PH20=47 mm Hg and ABG = 7.5/24/70 ? 1 14 26 51 63 Not enough information to compute Author: Peter Lenz, MD

  15. What is the Aa gradient at 3600 feet above sea level where Patm=649mm Hg, PH20=47 mm Hg and ABG = 7.5/24/70 ? 1 14 26 51 63 Not enough information to compute Author: Peter Lenz, MD

  16. What is the FiO2 in Denver at 5280 feet above sea level? • 14% • 17% • 19% • 21% • 25% Author: Peter Lenz, MD

  17. What is the FiO2 in Denver at 5280 feet above sea level? • 14% • 17% • 19% • 21% • 25% Author: Peter Lenz, MD

  18. FiO2 remains the same despite altitude, it is the Pb that changes TABLE V. Gas Pressures at Various Altitudes* *All pressures in mm Hg; Pike's Peak and Mt. Everest data from summits Graphic from: http://www.globalrph.com/martin_4_most2.htm Author: Peter Lenz, MD

  19. Which of the following is increased during pregnancy? • Respiratory rate • Expiratory reserve volume • Functional residual capacity • Tidal volume • Residual volume Author: Peter Lenz, MD

  20. Which of the following is increased during pregnancy? • Respiratory rate • Expiratory reserve volume • Functional residual capacity • Tidal volume • Residual volume Author: Peter Lenz, MD

  21. Gas Exchange in Pregnancy • ↑ progesterone = increased central resp drive = ↑ Vt • So, pregnant patients hyperventilate with ↑Vt (Resp rate not ∆’d) • RV, FRC and ERV all DECREASED from uterus expansion Author: Peter Lenz, MD

  22. http://www.accessmedicine.ca Author: Peter Lenz, MD

  23. What is a normal ABG in a pregnant female in her third trimester? 7.33/48/90 7.36/44/106 7.39/41/93 7.43/31/100 7.51/26/85 Author: Peter Lenz, MD

  24. What is a normal ABG in a pregnant female in her third trimester? 7.33/48/90 7.36/44/106 7.39/41/93 7.43/31/100 7.51/26/85 Author: Peter Lenz, MD

  25. Gas Exchange in Pregnancy, Part 2 pCO2 > 42 is VERY WORRISOMEin a pregnant female pCO2 > 35 = possible fatiguing. pCO2 > 42 = acidosis bad for fetus Normal ABG in pregnancy: 7.44/30/100/23 on RA Range: 7.40-7.45/28-32/100-105/18-21 (HCO3 as compensation) OB Gyn literature supports goal paO2 in pregnancy is > 90 to prevent fetal hypoxemia goal PaCO2 of 30-32 Meschia G. Placental respiratory gas exchange and fetal oxygenation. Maternal-Fetal Medicine, Creasy RK, Resnik R (Eds), WB Saunders, Philadelphia 1999. Author: Peter Lenz, MD

  26. Which set of values is most consistent with BAL cell count values for healthy non-smoking adults? 90% Mø 7% Lymph 2% PMN 1% Eos 70% Mø 21% Lymph 9% PMN 1% Eos 70% Mø 16% Lymph 5% PMN 5% Eos 50% Mø 40% Lymph 5% PMN 5% Eos 50% Mø 33% Lymph 15% PMN 0% Eos Author: Peter Lenz, MD

  27. Which set of values is most consistent with BAL cell count values for healthy non-smoking adults? 90% Mø 7% Lymph 2% PMN 1% Eos 70% Mø 21% Lymph 9% PMN 1% Eos 70% Mø 16% Lymph 5% PMN 5% Eos 50% Mø 40% Lymph 5% PMN 5% Eos 50% Mø 33% Lymph 15% PMN 0% Eos Author: Peter Lenz, MD

  28. Author: Peter Lenz, MD

  29. What constitutes a normal BAL fluid CD4/CD8 lymphocyte ratio from a healthy non-smoking adult? • 0.5 • 1.0 • 1.3 • 1.6 • 2.2 • 3.3 Author: Peter Lenz, MD

  30. What constitutes a normal BAL fluid CD4/CD8 lymphocyte ratio from a healthy non-smoking adult? • 0.5 • 1.0 • 1.3 • 1.6 • 2.2 • 3.3 Author: Peter Lenz, MD

  31. What would you expect the BAL fluid CD4/CD8 lymphocyte ratio from a patient with pulmonary sarcoidosis to be? • 0.5 • 0.9 • 2.0 • 3.0 • 3.3 • 3.9 Author: Peter Lenz, MD

  32. What would you expect the BAL fluid CD4/CD8 lymphocyte ratio from a patient with pulmonary sarcoidosis to be? • 0.5 • 0.9 • 2.0 • 3.0 • 3.3 • 3.9 Author: Peter Lenz, MD

  33. BAL Tidbits Author: Peter Lenz, MD

  34. BAL Cell Counts Summary • CD4:CD8 1.5-2 = normal • CD4:CD8 >3.5 = suggestive of sarcoid • BAL eos>25% = eosinophilic lung disease • BAL PMN>50% = bacterial infection or ALI • Lymph’s>25%: suggests Granu.Lung Dz, HP, NSIP • Lymph’s> 50%: supportive HP, cell NSIP, Drug Author: Peter Lenz, MD

  35. The most common CFTR mutation seen in CF and its abnormality is best described as: • ∆F15: Arg-Arg to Arg-Gly mutation • DIOS: Alanine deletion • ∆F508: Phenylalanine addition • ∆F508: Phenylalanine deletion • ∆F508: Improper methylation Author: Peter Lenz, MD

  36. The most common CFTR mutation seen in CF and its abnormality is best described as: • ∆F15: Arg-Arg to Arg-Gly mutation • DIOS: Alanine deletion • ∆F508: Phenylalanine addition • ∆F508: Phenylalanine deletion • ∆F508: Improper methylation Author: Peter Lenz, MD

  37. 12 16 18 19 22 23 You bronch’d a patient and wrote “all segmental airways inspected and no endobronchial lesions seen.” How many segments did you enter? Author: Peter Lenz, MD

  38. 12 16 18 19 22 23 You bronch’d a patient and wrote “all segmental airways inspected and no endobronchial lesions seen.” How many segments did you enter? Author: Peter Lenz, MD

  39. Fig. 2. The segmental bronchi. Each bronchopulmonary segment takes its name from the segmental bronchus supplying it. There are 10 segmental bronchi on the right and eight on the left. The left lung has two segments fewer than the right because the apical and posterior bronchi have a common stem and the medial basal bronchus is usually lacking. Thoracic Surgery ClinicsVolume 17, Issue 4, November 2007, Pages 571–585 Author: Peter Lenz, MD

  40. B A What structures are labeled as A & B respectively in this picture? 10R LN, Subclavian vein Innominate artery, Aorta Azygos vein, Aorta 4R LN, Brachiocephalic trunk SVC, Pulm Artery Author: Peter Lenz, MD

  41. B A What structures are labeled as A & B respectively in this picture? 10R LN, Subclavian vein Innominate artery, Aorta Azygos vein, Aorta 4R LN, Brachiocephalic trunk SVC, Pulm Artery Author: Peter Lenz, MD

  42. http://www.stanford.edu/dept/radiology/radiologysite/site93.htmlhttp://www.stanford.edu/dept/radiology/radiologysite/site93.html Author: Peter Lenz, MD

  43. Author: Peter Lenz, MD

  44. What is the incidence of anaphylaxis with omalizumab injection? • 0.01% • 0.1% • 1% • 10% • No reports of anaphylaxis with omalizumab Author: Peter Lenz, MD

  45. What is the incidence of anaphylaxis with omalizumab injection? • 0.01% • 0.1% • 1% • 10% • No reports of anaphylaxis with omalizumab Author: Peter Lenz, MD

  46. When does anaphylaxis occur with omalizumab injection? • Immediately • Within 1 hour post injection • Within 2 hours post injection • Within 24 hours post injection • After any injection Author: Peter Lenz, MD

  47. When does anaphylaxis occur with omalizumab injection? • Immediately • Within 1 hour post injection • Within 2 hours post injection • Within 24 hours post injection • After any injection Author: Peter Lenz, MD

  48. Anaphylaxis risk = 0.1% (premarketing trials) 0.2% (post-marketing reporting) -3/3507 (0.1%) pts in clinical trials got anaphylaxis -Anaphylaxis occurred after 1st dose as well as after any injection -Supply each candidate with epipen & instruct on use Corren J, Casale TB, Lanier B, et al. Safety and tolerability of omalizumab. ClinExp Allergy 2009; 39:788. Author: Peter Lenz, MD

  49. Administration of 1 liter of isotonic saline (containing 154 meq/L of sodium) in a 60 kg women with a serum sodium of 110 meq/L and an estimated TBW of 30 L (50 % of lean body weight) should raise the serum sodium by: 5.2 meq/L 3.3 meq/L 2.1 meq/L 1.4 meq/L 0.5 meq/L 0.2 meq/L Author: Peter Lenz, MD

  50. Administration of 1 liter of isotonic saline (containing 154 meq/L of sodium) in a 60 kg women with a serum sodium of 110 meq/L and an estimated TBW of 30 L (50 % of lean body weight) should raise the serum sodium by: 5.2 meq/L 3.3 meq/L 2.1 meq/L 1.4 meq/L 0.5 meq/L 0.2 meq/L Author: Peter Lenz, MD

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