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Назва наукового напрямку (модуля): Семестр: 12 Pulmonology (Current practice in internal medicine) Опис: situational tasks Перелік питань: 1. A. * B. C. D. E. 2. A. * B. C. D. E. 3. A. * B. C. D. E. 4. A. * B. C. D. E. 5. A. * B. C. D. E. One worker in the surgical center is found to be culture-positive for streptococcal microorganisms in his nasal mucosa but has no symptoms of infection. What is this patient's status in the chain of infection? Reservoir Portal of entry Portal of exit Susceptible host Non of above 20-years-old man suffers from bronchial asthma, the attacks of dyspnea arise 3-4 times a day. Night attacks are present 2 times a week. FEV1 - 70 %, its variability during day is 30 %. What is your diagnosis? Moderate persistent BA Status asthmaticus Intermittent BA Severe persistent BA Mild persistent BA 47-year-old man is evaluated because of cough that has persisted for 6 months. He has no postnasal drip, wheeze, or heartburn. His physical examination, chest radiograph, and spirometry are normal. He receives no benefit from a 3-month trial of twice-daily proton-pump inhibitors, intranasal corticosteroids, and antihistamines. He has a family history of allergies. Which of the following would suggest the diagnosis of this patient? Methacholine challenge testing 24-hour esophageal pH monitoring CT scan of the sinuses Bronchoscopy CT scan of the chest 60-yr-old male non-smoker demonstrates such results of his pulmonary function tests: FEV1—1.4 l, FVC—3.5 l, FEV1/FVC—40%. After bronchodilator trial—FEV1/FVC—59%. After 2 weeks of prednisolone 30 mg daily FEV1/FVC = 72%. What is the diagnosis? Bronchial asthma COPD Emphysema Tracheal compression Pulmonary fibrosis A 10-yr-old boy presents with wheezing attacks and episodic shortness of breath. His PEFR is 400 l/min. What is the best method of treatment? ?2 agonist Erythromycin Plasmaphoresis Cyclophosphamide Co-trimoxazole 6. A. * B. C. D. E. 7. A. * B. C. D. E. 8. A. * B. C. D. E. 9. A. * B. C. D. 10. A. * B. C. D. E. A 17-year-old previously healthy man presents with a history of shortness of breath on exertion, particularly during basketball season, when he sometimes needs to sit down during practice to catch his breath. He does not notice any shortness of breath with routine activity. There is no family history of asthma. On physical examination, he is in no respiratory distress. His lungs are clear, with no wheezing during either tidal breathing or forced expiration. His heart is normal. Baseline spirometry is normal. What is the next diagnostic step? Exercise testing with postexercise spirometry Allergy testing Methacholine challenge testing Overnight oximetry Repeat lung volumes and diffusing capacity A 20-yr-old men presents with wheezing and shortness of breath. His PEFR is 400 l/min. Spirography: FEV1, FVC and Typhno index are low. What is the diagnosis? Asthma COPD Emphysema Pulmonary embolism Pneumonia A 20-yr-old woman is too breathless to speak. Her pulse is 120/min, respiratory rate is 30/min and PEFR is 100 l/min. Examination reveals a very quiet chest and CXR is normal. Choose the single most likely management: Nebulised salbutamol Pleural aspiration Heparin Intramuscular adrenaline Rapid infusion of saline A 25-year-old man is evaluated because of a 3-month history of episodic dyspnea at rest. The episodes occur approximately three times per week and are accompanied by cough. His symptoms awaken him at night approximately three times per month. He had asthma as a child, which resolved. His temperature is 36.5 C, pulse rate 85/min and regular, respiration rate 14/min, and blood pressure 125/75 mm Hg. The only abnormality noted on physical examination is bilateral wheezing without crackles. Chest radiograph is normal. Spirometry shows a forced expiratory volume in 1 sec (FEV1) 78% of predicted, and a forced vital capacity 93% of predicted. He has a 17% (430 ml) improvement in FEV1 after using bronchodilators. Which of the following is the most appropriate treatment Albuterol and a low-dose regimen for this patient? inhaled corticosteroid Albuterol Albuterol and a long-acting ?2-agonist A long-acting ?2-agonist A 28 years old patient, complaints on cough with small amount of colourless sputum, pain in the right half of thorax during breathing, shortness of breath, increase of temperature to 39 °С. Felt ill rapidly. Used aspirin. Objectively: herpes on lips. In lower lobe of right lung there is dull percussion sound, bronchial breathing. X-ray: there is homogeneous infiltration of right lower lobe. What is the most possible etiology of pneumonia? Pneumococcus Staphylococcus Mycoplasma Legionella Klebsiella 11. A. * B. C. D. E. 12. A. * B. C. D. E. 13. A. * B. C. D. E. 14. A. * B. C. D. A 34-year-old woman is evaluated because of a 1-year history of increased dyspnea on exertion. She has no symptoms at rest but has to stop about 15 minutes into her aerobics class because of dyspnea and occasional cough. She usually recovers fully in about an hour. One year ago she was able to do aerobics for 45 minutes without difficulty. Her vital signs are normal, and her physical examination is normal, including clear breath sounds. Baseline spirometry is also normal. Which of the following would be best next step in the management of this patient? Inhaled albuterol prior to exercise Oral leukotriene inhibitors Long-acting theophylline Inhaled ipratropium bromide prior to exercise Inhaled corticosteroids A 37-year-old man with asthma is evaluated because he continues to have frequent attacks and now feels his short-acting ?2-agonist is not providing relief. He states he is using his medications, including a long-acting ?2-agonist inhaler, inhaled high-dose corticosteroids, and a short-acting ?2-agonist inhaler as rescue medication. He has symptoms daily and nocturnal symptoms about twice per week. On physical examination, he is in mild respiratory distress. He is afebrile. Pulse rate is 90/min and regular, respiration rate is 18/min, and blood pressure is 140/85 mm Hg. He has bilateral wheezing. Spirometry shows a forced expiratory volume in 1 sec (FEV1) 65% of predicted; it improves with bronchodilators to 85% of predicted. He has no history of recent viral upper respiratory infections or rhinitis or symptoms of gastroesophageal reflux disease. Which of the following is the best next step in this patient’s management? Observe the patient using the metered-dose inhaler Add a leukotriene inhibitor Switch to an oral ?2-agonist and have the patient return for a pill count Initiate oral prednisone therapy and have the patient return for a pill count Have the patient return with a symptom and treatment log. A 38 years old patient, who drunk a lot of alcohol, has severe pneumonia. His condition got worse, the temperature of body rose to 39-40 °С, an unpleasant smell appeared from a mouth, increased amount of purulent sputum; increased ESR and amount of band leucocytes. On the X-ray - in the lower lobe of right lung there is massive infiltration with light area in a center. What complication is it necessary to suspect? Acute pulmonary abscess Bronchiectasis Infarction-pneumonia Gangrene of lungs Empyema of pleura A 40-year-old woman, a nurse, is evaluated because of worsening asthma symptoms. She has had mild, intermittent asthma since college, for which she has been using an albuterol inhaler as needed, usually less than once a month. During the past 3 months, she has experienced cough, tightness of the chest, and wheezing, which improve after the use of inhaled albuterol. She uses the inhaler twice a day on average and has awakened at least twice a week with nocturnal cough. She works three consecutive 12-hour day shifts, and the cough is regularly worse at the end of each shift. During her days off, she has fewer asthma symptoms and feels significantly better by the time she returns to work. She has a history of allergic rhinitis that has also recently become more symptomatic. Approximately 6 months ago, she acquired a kitten that sleeps in the bedroom. She has lived in her home for 6 years, and it is carpeted and has heavy draperies. Chest examination is notable for good air entry. There are scattered end-expiratory wheezes. In addition to treatment with inhaled corticosteroids, which of the following interventions is most likely to benefit this patient? Avoiding exposure to latex products Treatment with an oral antihistamine Getting rid of the kitten Removing the carpets and draperies from her home E. 15. A. * B. C. D. E. 16. A. * B. C. D. E. 17. A. * B. C. D. E. 18. A. * B. C. D. 19. A. B. * Treatment with a leukotriene-modifying drug A 46-year-old woman who works as a nurse is evaluated because of a 2-year history of episodic wheezing and a squeaky voice. This past spring, her symptoms worsened, requiring her to seek medical attention; she was placed on a short-acting ?2-agonist that did not provide much relief. She has no history of wheezing and says that these changes began after a severe influenza infection 3 years ago. Currently she feels well and has had no symptoms for several months; she is not taking any medications. Physical examination shows no abnormalities, and baseline spirometry is normal. What is the best test to evaluate this patient’s condition? Methacholine challenge testing Bronchoscopy to evaluate her trachea Exercise echocardiogram CT scan of the sinuses Non of above A 48 years old patient, complaints on weakness, dyspnea, pain in the left half of thorax, permanent cough with viscid sputum, in which particles of blood are sometimes determined. For the last 3 months lost 5 kg of body mass. On the X-ray of lungs there is total homogeneous shade determined from the left side. Organs of mediastinum are displaced to the left. What diagnosis is possible? Lung athelectasis Lung gangrene Total exudative pleurisy Pneumonia Empyema of pleura A 53-year-old woman with a history of mild persistent asthma is evaluated because of a recent increase in her symptoms, with dyspnea and cough occurring daily and a cough that awakens her once a week. She is currently using low-dose inhaled corticosteroids. She has no symptoms of rhinitis or gastroesophageal reflux. On physical examination, she has intermittent wheezing bilaterally. Which of the following is the most appropriate change in her therapy? Add a long-acting ?2-agonist Initiate azithromycin therapy Add a nebulized short-acting ?2-agonist Add inhaled ipratropium bromide Add a leukotriene inhibitor A 55-year-old man is evaluated in the emergency department because of an acute, severe asthma attack; he is hospitalized in the intensive care unit for aggressive medical therapy and monitoring. He is expectorating thick greenish sputum. His medical history includes hypertension, cholecystectomy and glaucoma. Chest radiograph reveals hyperinflation only. Medical therapy in the emergency department included repeated doses of aerosolized albuterol and ipratropium, as well as methylprednisolone, 125mg administered intravenously. Peak expiratory flow rate is unimproved at 80 l/min. Which of the following is the most appropriate next step in this patient’s management? Intravenous magnesium sulfate Nebulized ipratropium bromide administered by face mask Broad-spectrum antibiotics targeting community-acquired respiratory pathogens Inhaled corticosteroids A patient who is 2 days postoperative from a bowel resection tells her physician that she is having a hard time “catching her breath,” feels nauseated, and has chest pains when she inhales. The physician suspects that she is having a pulmonary embolism. What intervention should the physician perform before notifying the physician? Increase the IV flow rate Apply oxygen by mask or nasal cannula at 5 l/min C. D. E. 20. A. * B. C. D. E. 21. A. * B. C. D. E. 22. A. * B. C. D. E. 23. A. * B. C. D. E. 24. A. * B. C. D. E. Assess the chest and axillary area for the presence of petechiae Place the patient in shock position, with her head and neck flat and her legs elevated Non of above A young woman complains of wheeze, dyspnoea and cough. She cannot sleep at night because of a chronic cough. She and her mother love animals and together they have 14 cats. Her PEFR is normal but her CXR suggests hyperinflation. What is the previous diagnosis? Bronchial asthma Bronchogenic carcinoma Emphysema Respiratory failure Bronchitis After emotional exertion patient of 24 y.o. developed condition with dyspnea and prolonged expiration, distantional wheezes, frequent night symptoms. All that limited his physical activity. PEV and FEV1 < 60 %, daily variability -30 %. What diagnosis is possible? Severe persistent bronchial asthma Mild persistent bronchial asthma Persistent bronchial asthma of moderate severity Intermittent bronchial asthma Bronchospastic syndrome of allergic origin Drug abuser, a 41-yr-old man, presents with fever, cough and breathlessness. This was preceded by viral influenza. Chest radiograph shows multiple abscesses. What is the most possible etiology of disease? Staphylococcus aureus Cryptococcus Streptococcus pneumoniae Legionella pneumonia Mycobacterium avium Female B., 44 years old, complains on cough with mucous sputum, increase of temperature to 39 °С, weakness, dyspnea, sweating. Breathing rate - 26/min, skin is moist. Below left scapula there is shortening of percussion sound. Breathing during auscultation is weakened, moist rales. Blood test: L - 11х109/l, ESR - 29 mm/h. Your previous diagnosis? Left-side lower lobe pneumonia Gangrene of lungs Left-side exudative pleurisy Cancer of left side lower lobe Pulmonary abscess Female patient K., 46 years old, after decreasing of fever after flue noticed pain appeared in a thorax, cough with yellow-green sputum (amount-150 ml a day), sometimes with some blood. Objectively: breathing rate - 36/min. In lungs from the right side lower scapula there is dull sound during percussion, hard breathing, and moist rales. Blood test: L - 18,6х109/l, ESR -64 mm/h. Analysis of sputum: L -80-100 , Er - 40-50, elastic fibers, cocci. X-ray: lung roots are enlarged, from the right side lower lobe is heterogeneously infiltrated with two lighter areas. What is the most possible previous Right-sidediagnosis? pneumonia with abscesses Peripheral cancer Infiltrative tuberculosis in the phase of disintegration Exudative pleurisy Infarction-pneumonia 25. A. * B. C. D. E. 26. A. * B. C. D. E. 27. A. * B. C. D. E. 28. A. * B. C. D. E. 29. A. * B. C. D. Female, 34 years old, has an increase of body temperature to 38 °С, cough with purulent sputum, weakness, dyspnea, pain in a thorax during breathing. During percussion there is shortening of sound in the lower part of left lung, during auscultation – moist rales. What method of investigation is the decisive one to confirm diagnosis? X-ray examination Bacteriological analysis of sputum Spirometry Pneumotachometry Bronchography Girl, 18 y.o., pets seller, complaints mainly during working time on the attacks of dry cough, feeling of running nose. She often ills with viral respiratory infections. Her mother is ill with bronchial asthma. Objectively: breathing rate - 18/min. Heart rate - 80/min, BP - 110/70. In lungs vesicular breathing, dry wheezes are heard in distance. Tones of heart are weaker than normally. Test with berotec showed reversibility of bronchial obstruction. What tactic will be the best for the patient? To change job To use intal To use monteleucast To use berotec constantly To use antihystaminic preparations Girl, 23 y.o., for 2 years is ill with bronchial asthma. Recently attacks of dyspnea became more frequent and started to arise 4-5 times a week, night attacks - 2-3 times a month. She used salbutamol to remove the symptoms. Test with the antigen of home dust is positive. Objectively: condition is satisfactory. Breathing rate - 20/min. Heart rate - 76/min, BP -120/80. In lungs breathing is vesicular. Tones of heart are a little weak, rhythm is normal. What mechanism is desicive in development of bronchial obstruction in this case? Hyperreactivity of bronchi Тrachео-bronchial dyskinesia Violation of metabolism of arachidonic acid Adrenergic disorders Activity of the parasympathetic nervous system is increased Male patient F., 48 years old, during a week stayed at home with diagnosis of respiratory viral infection. Doctor noticed complaints on cough with small amount of mucus-purulent sputum, weakness. Objectively: condition is relatively satisfactory. T - 37,2 °С. Breathing rate - 18/min., pulse - 80/min., BP - 110/70. In lungs there is vesicular breathing, with a hard tint, single dry wheezes. Tones of heart are a little dull, rhythm is correct. What is the treatment tactic? To prescribe antibacterial therapy To stay at home for some more days To go to work To send patient to pulmonologist To hospitalize patient to the pulmonological department Male patient G., 56 years old, complaints on permanent pain in a thorax which disturbs for last 2 months. Pain is not connected with breathing. There is also cough with particles of blood in sputum. Weakness, fatigue are present. On the chest X-ray in the lower lobe of right lung there is spherical shadow, size 4x6 cm, related to the lungs rhadicis. What is the most possible diagnosis? Perypheral lung cancer Tuberculoma Metastasis Pulmonary abscess E. 30. A. * B. C. D. E. 31. A. * B. C. D. E. 32. A. * B. C. D. E. 33. A. * B. C. D. E. 34. A. * B. C. D. E. Pneumonia Man, 32 y.o., complaints on attack of expiratory dyspnea, which lasts for 48 hours, cough with small amount of sputum. He is ill with bronchial asthma for 5 years, was treated with glucocorticosteroids, used inhalers. Objectively: condition is severe, patient sits. Diffuse cyanosis, pulse -110/min, BP 110/70. Tones of heart are weak, II tone is louder above the pulmonary artery. During percussion in lungs there is “bang-box” sound, large amount of dry wheezes. In blood there is eosinophylia - 18 %. What medicines are drugs of choice for this patient? Corticosteroids ?2-agonists Theophyllin Cholynolytics Antihystamines Man, 39 y.o., 8 last years is ill with bronchial asthma. Rapidly during physical work he felt worsening of breathing, cough, distance wheezes appeared and dyspnea began to increase. Medicine of what pharmacological group is it better to recommend for the patient to remove such attacks of dyspnea? of ?2-adrenoreceptors Agonists Metilxantines ?2-adrenoblockers Inhalated glucocorticoids Oral glucocorticoids Man, 46 y.o., suffers for the last 10 years from bronchial asthma. Rapidly during physical work he felt worsening of breathing, cough, distance wheezes appeared and dyspnea began to increase. Medicine of what pharmacological group is it better to recommend for the patient to remove such attacks of dyspnea? Agonists of ?2-adrenoreceptors Atropine Intal Epinephrine Monteleucast Man, 43 y.o., complaints on dyspnea during physical activity. Objectively: temperature 36,4 °С, breathing rate - 20/min, pulse - 78/min, BP-125/80. Emphysematous form of thorax. In lungs – weak vesicular breathing. What test should be passed by patient at home to decide question about efficiency of prescribed broncholytics? Peakflowmetry Spirography ECG-control of overload of right chambers of heart Bronchoscopy Analysis of sputum (amount and microscopy) Patient, 28 y.o., has running nose, attacks of dyspnea at night once a week. Felt ill after viral respiratory infection which was treated with acetilsalicylic acid. Eosynophylia was founded in blood and sputum. What disease may be suspected? Aspirin bronchial asthma Eosinophylic infiltrate of lungs Bronchial asthma of physical exertion Allergic rhinitis Bronchial asthma, exogenous form 35. A. * B. C. D. E. 36. A. * B. C. D. E. 37. A. * B. C. D. E. 38. A. * B. C. D. E. 39. A. * B. C. D. E. Patient, 30 y.o., after a viral infection has daily symptoms of dyspnea, which causes lowering of activity and bad sleep; night symptoms are more frequent then once a week. PEV and FEV1 - 60-80 %, day variability > 30 %. There is a necessity of daily usage of ?2-agonists of short action. What is the diagnosis? Persistent bronchial asthma of moderate severity Mild persistent bronchial asthma Intermittent bronchial asthma Severe persistent bronchial asthma Status asthmaticus Patient, 42 years old, complaints on attacks of dyspnea, every time uses 1-2 doses of salbutamol. These attacks are accompanied with cough and minimal amount of viscid glassy sputum. He is ill for 8 years. Objectively: temperature - 36,7 C; breathing rate – 21/min.; pulse-90/min.; BP - 130/80; FEV1 - 77 %. In lungs – solitary dry wheezes. Blood test: eosinophyles - 6 %. What medicines are “basic” in the treatment of this patient? Antiinflammatory Cholynolytics Mucolytics Antihystaminic ?2-agonists Patient, 44 y.o., complaints on attack of dyspnea, which arises suddenly at night. Connects this attack with overcooling. He is ill for more than 10 years. Thorax of emphysematous form. During percussion in lungs – “bang-box” sound. During auscultation there is plenty of dry wheezes. In blood: moderate leucocytosis, eosinophylia - 10 %. On the chest X-ray film – increased pneumatization of pulmonary tissue. What diagnosis is the most possible? Bronchial asthma, exacerbation phase Bronchiectasis, exacerbation phase COPD, exacerbation phase Chronic bronchitis Eosinophylic pulmonary vasculitis Patient J., 45 y.o., complaints on dyspnea during insignificant physical exertion, cough with minimal amount of “glass-like” sputum, attacks of dyspnea up to 3 times a day, more often at night, sweating. She is ill for more than 5 years. Has an allergy on dust, cockroaches. For treatment uses bekotid for near the year. Diagnosis? Bronchial asthma Eosinophylic pulmonary infiltrate COPD Bronchiectasis with bronchial spasm Pulmonary vasculitis (syndrome of Charg - Stross) Patient G., 47 y.o., with long history of bronchial asthma, has developed more frequent attacks of dyspnea. Inhalations of astmopent and berotec are not effective. From prescription of what medicine is it better to begin the intensive treatment? Glucocorticoids Oxygen therapy Bronchodylators Infusion therapy Heart glycosides 40. A. * B. C. D. E. 41. A. * B. C. D. E. 42. A. B. C. D. * E. 43. A. * B. C. D. E. 44. A. * B. C. D. E. 45. A. B. Patient Y.,49 y.o., complaints on dyspnea, cough. Sputum is absent. Used many puffs of salbutamol, intal, but without any efficacy. Objectively: sits, leaning on a table. Total cyanosis of the body. Peripheral edema is absent. Breathing is superficial, dyspnea, during auscultation breathing cannot be heard in some areas of lungs; wheezes are diffuse, expiration is considerably prolonged. Tones of heart are weak, tachycardia. Pulse - 112/min, BP - 110/70. Liver is near the edge of costal arch. What is the previous diagnosis? Status asthmaticus Bronchial asthma of moderate severity COPD Aspiration of foreign body Heart asthma Patient A., 35 y.o., noticed infrequent (rarer than 1 time a week) attacks of dyspnea, which are easily removed with inhalations of ?2-agonists of short action. During attack in lungs are heard dry wheezes, between attacks FEV1 is more than 80 % from normal. What is the diagnosis? Intermittent bronchial asthma Persistent bronchial asthma of moderate severity Mild persistent bronchial asthma Severe persistent bronchial asthma Given information is not enough for determination of severity of bronchial asthma Patient B., 25 years old engineer, appeared during a fire in the area of high concentration of CO (an industrial accident). In hospital delivered in the irresponsible state. What laboratory tests are the early criteria of estimation of severety of the state? Estimation of blood viscosity Anemia Leucocytosis Carboxihemoglobinemia Methemoglobinemia Patient complaints on attacks of dyspnea, which arise 1-2 times a week, night symptoms - 2 times a month and even more frequently. For a patient night sleep is violated as a result of attacks of dyspnea. FEV1 > 80 % from normal. What diagnosis would you suspect? Mild persistent BA Severe persistent BA Intermittent BA Moderate persistent BA Status asthmaticus Patient E., 43 years old, worker of coal mine, complaints on expiratory dyspnea, cough with dark sputum. On roentgenogram there are the linear-reticulated diffuse changes. Doctor thinks about anthracosis. Which characteristic is peculiar for the coal dust pneumoconiosis? Raised activity of phagocytosis Stimulation of carcinogenesis To cause the unspecific allergic reactions To cause the considerable mechanical irritation To form colloid precipitates Patient F., 46 years old, was hospitalized urgently with acute attack of dyspnea. Last 5 years he has been working on poultry farm. During examination bronchial asthma was diagnosed. What additional diagnostic methods are necessary to confirm the professional genesis of asthma? sanitary-hygienic characteristics of the work conditions echocardioscopy C. * D. E. 46. A. B. C. D. E. * 47. A. * B. C. D. E. 48. A. * B. C. D. E. 49. A. * B. C. D. allergic and immunological tests investigation of the function of external breath roentgenography of pulmonary system Patient G., 36 years old, works on a poultry factory. She was emergently hospitalized with acute attack of dyspnea. During observation bronchial asthma was diagnosed. What additional methods of research must be conducted above all things to confirm the professional genesis of bronchial asthma? roentgenologic research of breathing organs professional route of patient sanitary-hygienic characteristic of work conditions research of external breathing function allergic and immunological tests Patient H., a 52 years old man, is evaluated because of a 2-month history of nonproductive cough, myalgias, and low-grade fever. When his illness began, a chest radiograph showed bilateral alveolar infiltrates, and a presumptive diagnosis of community-acquired pneumonia was made. He was treated with oral azithromycin without effect, followed by a 10-day course of levofloxacin, also without effect. During the course of his illness he has lost 4.5 kg without significant anorexia. He is a lifetime nonsmoker and works as an office manager. He has no pets and no unusual hobbies. On physical examination, his vital signs are normal, except of respiration rate of 22/min. He is in mild respiratory distress on exertion. On examination of the chest, bilateral crackles are audible, without wheezing. Chest radiograph shows bilateral alveolar infiltrates, which are changed in location from those seen on his original radiographs. Pulmonary function tests show forced expiratory volume in 1 sec (FEV1) 75% of predicted, forced vital capacity (FVC) 72% of predicted, total lung capacity 80% of predicted, and diffusing lung capacity for carbon monoxide 65% of predicted. Arterial blood gas values, with the patient breathing room air, are PO2 62 mm Hg, PCO2 42 mm Hg, and pH 7.39.Which of the following is the most likely diagnosis? Cryptogenic organizing pneumonitis Hypersensitivity pneumonitis Resistant pneumococcal pneumonia Chlamydia pneumonia Bronchoalveolar cell carcinoma Patient has severe attack of bronchial asthma which lasts more than 1 hour. Usage of beta-agonists in inhalation, euphylline intravenously and cholynolytics was not effective. What medicines are necessary for emergency therapy? Glucocorticosteroids intravenously Beta-agonists intravenously Inhaled glucocorticosteroids Antihystaminic Nonsteroid anti-inflammatory medicines Patient I., a 50 years old man, is evaluated in the emergency department because of fever, nonproductive cough and 2-day history of myalgia and headache. He has also had nausea and diarrhea. He is a heavy smoker. On physical examination, he is slightly disoriented. Temperature is 38.9 C, pulse rate is 110/min, respiration rate is 32/min. Chest radiograph shows fluffy infiltrates to the right upper and lower lobes. Results of laboratory testing show serum sodium of 128 meq/L, blood urea nitrogen of 42 mg/dL, serum creatinine of 2.2 mg/dL, and serum creatine kinase of 250 U/L. Which one of the following is best next step in the management of this patient’s pneumonia? Initiate empiric antibiotic therapy for Legionella Order direct fluorescent antibody testing of the sputum for Legionella Order serologic testing for Legionella Send a urine specimen for measurement of Legionella antigen E. 50. A. * B. C. D. E. 51. A. B. * C. D. E. 52. A. B. C. * D. E. 53. A. B. C. D. E. * 54. A. * B. C. D. E. All of the above Patient J., 36 y.o., complains for fever (39 C), pain in the left part of the chest. Pleuropneumonia was diagnosed in the patient. What onset is typical for pleuropneumonia? Acute Latent Fulminant Gradual Non of the above Patient K., 27 y.o., complains for dry cough, hoarseness, general weakness, sweating, increase of body temperature up to 37,5 С. Data of physical examination: vocal fremitus is not changed, resonant pulmonary sound is heard above the lungs. Preliminary diagnosis? Acute purulent bronchitis Acute catarrhal bronchitis Pneumonia Pulmonary emphysema Pleural empyema Patient K., 37 years old, worker of the factory, during a fire appeared in the area of high concentration of CO. Into the clinic he was delivered without consciousness. In a blood test: Er - 4,5 x 1012/l, НЬ - 136 g/l, Le - 17,2 x 109/l, Eos - 0 %, band neutrophils - 5 %, segments - 65 %, lymphocytes - 22 %, monocytes - 3 %, ESR - 3 mm/h, carboxyhaemoglobin in blood - 52 %. What criterion is the most important for determination the severity degree of the patient’s state? Results of ECG and spirography Presence of violations of breathing Duration of unconsciousness Prevalence of trophic violations Development of vascular violations Patient M., 30 years old, during last 3 years works as a nurse in manipulations cabinet. Last year during the contact with penicilline she started tp complain on discomfort in throat, sneezing, attack of cough and dyspnea which disappear after inhalation of salbutamol. During last months attacks of dyspnea became more severe and occurred only at contact with penicilline. During the life she had not any diseases including allergic. She hadn’t received antibiotics. Can we consider the bronchial asthma is professional in this patient? no, we can’t yes, we can if we have conclusion about attacks of bronchial asthma yes, we can if we have conclusion about appearance of bronchial asthma attacks after contact with penicilline yes, we can yes, we can, if allergic and immunological tests are positive Patient M., 39 years old, complains on attacks of cough with yellow-brown sputum, pain in a right side, related to the deep breathing, sweating. He is ill for 6 days, after overcooling. Used aspirin. Objectively: T - 39,6 °С, breathing rate - 26/min, pulse - 110/min, BP -110/70. In lower part of right lung - moist loud rales. X-ray: in right lower lobe there is massive unhomogeneous infiltration with lighter areas, sinus is not changed. What complication of disease is the most possible? Abscesses Dry pleurisy Empyema of pleura Spontaneous pneumothorax Pulmonary athelectasis 55. A. B. C. D. * E. 56. A. * B. C. D. E. 57. A. * B. C. D. E. 58. A. * B. C. D. E. 59. A. * B. C. D. E. 60. A. * B. Patient N., 45 y.o., complains for fever (38 C), sweating, dry caugh and general weakness. Bronchopneumonia was diagnosed in the patient. What onset is typical for bronchopneumonia? Acute Latent Fulminant Gradual Non of the above Patient O., 29-yr-old male prostitute, has felt generally unwell for 2 months with some weight loss. Over the last 3 weeks he has noticed a dry cough with increasing breathlessness. Two courses of antibiotics from the GP have produced no improvement. The CXR shows bilateral interstitial infiltrates. What is the most possible etiology of disease? Pneumocystis carinii Streptococcus pneumoniae Mycoplasma pneumoniae Fungi Legionella pneumoniae Patient of 23, during viral respiratory infection used 1 gram of aspirin, after that he received an attack of severe dyspnea with prolonged expiration, prescription of euphylline was necessary. There were no allergic diseases in his history. He had two operations for the treatment of nasal poliposis. What is your diagnosis? Aspirin asthma Symptomatic bronchial spasm Intermittent bronchial asthma Persistent bronchial asthma Asthma of physical exertion Patient of 44, episodically in spring has dyspnea with worsening of expiration, wheezes in lungs. Brief daily symptoms are rarer than once a week, night symptomes occur less than 2 times a month. PEV and FEV1 - 80 %. Between exacerbations wheezes in lungs are absent. What is the possible diagnosis? bronchial asthma Intermittent Easy persistent bronchial asthma Middle persistent bronchial asthma Severe persistent bronchial asthma COPD Patient of 51, with 10-years history of bronchial asthma, develpos more frequent attacks of dyspnea and inhalations of astmopent and berotec are not effective. From prescription of what medicine is it better to begin intensive treatment? Glucocorticoids Oxygen therapy Bronchodylators Infusion therapy Heart glycosides Patient of 54, complaints on dyspnea during insignificant physical exertion, cough with minimal amount of sputum. Objectively: diffuse cyanosis. Thorax of emphysematous form. In lungs breathing is vesicular, weakened with prolonged expiration, dry wheezes are heard. BP -140/80. Pulse - 92/min, rhythmic. Spirography: FVC – 72 %, FEV1/FVC - 50 %. What is the type of respiratory failure in this patient? Obstructive Mixed type with prevalence of obstruction C. D. E. 61. A. * B. C. D. E. 62. A. * B. C. D. E. 63. A. B. C. D. E. * 64. A. * B. C. D. E. 65. A. * B. C. D. E. 66. A. * B. C. Restrictive Mixed type with prevalence of restriction Respiratory insufficiency is absent Patient P., a young male homosexual with Kaposi's sarcoma, complains of increasing breathlessness and a dry cough. He has a 3-day history of shivering, general malaise and productive cough. The X-ray shows right lower lobe consolidation. What is the most possible etiology of disease? Pneumocystis carinii Mycoplasma tuberculosis Haemophilus influenzae Chlamydia trachomatis Klebsiella pneumoniae Patient Q., 37 years old, was operated in the surgical department because of appendicitis. After 4 days appeared the recidive of chills, cough, dyspnea, fever 38,5 °С, returned leucocytosis with shift to the left in leucocyte formula. On X-ray there is infiltration of lower right lobe. What is the diagnosis? Nosocomial pneumonia Pulmonary abscess Infarction pneumonia Community-acquired pneumonia Tuberculosis Patient R., 48 y.o., complains for sharp pain in the right part of his chest at deep breathing and cough. Pain in the chest which relates to disease of respiratory system, is typical for Bronchiectatic disease Asthma Emphysema Exudative pleurisy Dry pleurisy Patient S., a 25-year-old male has just returned from holiday abroad, presents with flu-like illness, headaches, high fever. Prior to this, he had complained of abdominal pain, vomiting, diarrhea associated with blood per rectum. What is the most possible etiology of disease? Legionella pneumoniae Streptococcus pneumoniae Mycoplasma pneumoniae Pneumocystis carinii Fungi Patient V., a 24 years old barman, presents with a dry cough of sudden onset. He complains of a chest pain and rusty sputum. He also has a very high fever, rapid breathing, cyanosis and crepitations. Pneumonia was suspected. What is the most nesessary method of investigation? Chest X-ray Spirography Analysis of sputum General blood analysis General urine analysis Patient W., 62 y.o., suffers with morning cough with expectoration of large volume of greenish sputum. Sputum is better expelled in a certain position of patient’s body. Such kind of cough is typical for bronchiectatic disease asthma emphysema D. E. 67. A. * B. C. D. E. 68. A. * B. C. D. E. 69. A. * B. C. D. E. 70. A. * B. C. D. E. pneumonia pleurisy Patient W., 67 years old, during the epidemic of influenza after decreasing of fever noticed pain that appeared in a thorax, cough with yellow-green sputum (amount-100 ml a day), sometimes with some blood. Objectively: breathing rate - 36/min. In lungs from the right side lower scapula there is dull sound during percussion, hard breathing, and moist rales. Blood test: L - 18,6х109/l, ESR -64 mm/h. Analysis of sputum: L -80-100 , Er - 40-50, elastic fibres, cocci. X-ray: rhadicis are enlarged, from the right side lower lobe is heterogeneously infiltrated with two lighter areas. What is the most possible previous diagnosis? Right-side pneumonia with abscesses Peripheral cancer Infiltrative tuberculosis in the phase of disintegration Exudative pleurisy Infarction-pneumonia Patient X., 55 years old, was admitted to the hospital recently. He complaints on cough with very small amount of mucous-purulent sputum, significant weakness, increased temperature, which is accompanied with chill, dizziness. Objectively: t - 38°С. Breathing rate - 22/min. Heart rate - 90/min, BP - 110/70. From the right side below scapula the vocal fremitus is increased, percussion sound is shortened, vesicular breathing is weakened, small amount of moist rales. Tones of heart are dull, rhythm is correct, moderate tachycardia. Doctor suspected pneumonia. The presence of what syndrome let to suspect such diagnosis? Pulmonary tissue infiltration Intoxication Inflammation Bronchial obstruction Respiratory insufficiency Patient Z., a 33-yr-old car mechanic, is brought to casualty by his girlfriend. She describes a 2-day history of rigors, sweats and intermittent confusion. On examination he is agitated, sweaty and pyrexial with 38.6° C. He is hyperventilating and cyanosed despite receiving O2 by face mask. There is dullness to percussion and bronchial breathing at the left lung base. What method of investigation is necessary? Chest X-ray Spiral CT with contrast Arterial blood gases Blood count and film Urea and electrolytes of blood Previously healthy 28-year-old man is evaluated in the emergency department because of fever, productive cough, and shortness of breath. His temperature is 40 C, pulse is 120/min, respiration rate is 32/min, and blood pressure is 100/70 mm Hg. Measurement of arterial blood gases with the patient breathing room air shows PO2 of 55 mm Hg, PCO2 of 30 mm Hg, pH of 7.41. Chest radiograph reveals bilateral alveolar infiltrates with no effusions. Gram stain of the sputum reveals gram-positive diplococci. Which of the following is the most appropriate for this patient? Hospitalize him Treat him as an outpatient with oral therapy Treat him as an outpatient with intravenous therapy Hospitalize the patient in the intensive care unit All of the above 71. A. * B. C. D. E. 72. A. B. C. D. * E. 73. A. B. * C. D. E. 74. A. B. * C. D. E. 75. A. B. * C. D. E. 76. A. B. Previously healthy 32-yr-old woman presents with general malaise, severe cough and breathlessness, which has not improved with a 7 day-long course of Amoxycillin. There is nothing significant to find on examination. The X-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins. What is the most possible etiology of disease? pneumoniae Mycoplasma Legionella pneumonia Haemophilus influenzae Chlamydia trachomatis Klebsiella pneumoniae The 60-year-old patient tells you that she smoked three packs of cigarettes per day since she was 15 years old until she was 40, and then smoked two packs per day. How many pack-years should you record in the patient's history? 45 80 90 115 Non of above The 82-year-old patient has a pulmonary infection. Which action addresses the age-related change of increased vascular resistance to blood flow through pulmonary vasculature in this patient? Encouraging the patient to turn, cough, and deep breathe every hour Assessing the patient's level of consciousness Raising the head of the bed Humidifying the oxygen Non of above The patient has broken ribs that penetrated through the skin as a result of a motor vehicle crash 3 days ago. The patient now complains of increased pain, shortness of breath, and fever. Which assessment finding alerts the physician to the possibility of a pleural effusion and empyema? Wheezing on exhalation on the side with the broken ribs Absence of fremitus at and below the site of injury Crepitus of the skin around the site of injury Absence of gastric motility Non of above The patient has severe nasal congestion, headache, and sneezing but no rhinorrhea, watery eyes, sore throat, or fever. Which statement made by the patient alerts the physician to the possibility of rhinitis medicamentosa? “I have been taking two aspirins every 6 hours for this headache.” “My nose doesn't stay open even though I'm using nasal spray every hour.” “I have been taking a lot of vitamin C this year to keep from getting so many colds.” “The only way I can get to sleep with this nasal congestion is by taking an over-the-counter antihistamine at night.” Non of above The patient is 34 years old and has been diagnosed with COPD as a result of being homozygous for a mutation of the alpha1-antitrypsin (AAT) gene alleles. His wife has two normal AAT gene alleles. He is concerned that his two children may develop this problem. What is your best response? “Because neither of your parents have COPD and your wife does not have the abnormal gene alleles, your children will not be affected.” “Because your wife is not affected nor is or a carrier, your children will have normal levels of AAT and their risk is the same as for the general population.” C. D. * E. 77. A. B. C. D. * E. 78. A. * B. C. D. E. 79. A. * B. C. D. E. 80. A. * B. C. D. E. 81. A. * B. C. “Because you have the mutations and your wife does not, your son will be at an increased risk for developing COPD but your daughter will only be a carrier.” “Because both of your AAT gene alleles are mutated, your children will each have one abnormal gene and their risk for COPD is only increased if they smoke or are chronically exposed to other precipitating factors.” Non of above The patient is a 42-year-old man recently diagnosed with new-onset asthma. What specific patiental/demographic information should you obtain related to this diagnosis? Previous diagnosis of pneumonia or tuberculosis Known allergies and hypersensitivities Nutritional intake and diet history Occupation and hobbies Non of above The patient with hospital-acquired (nosocomial) pneumonia caused by a bacterial infection with a gram-negative microorganism is receiving treatment with intravenous amikacin (Amikin). In addition to frequent respiratory assessment, what other assessment should the physician routinely perform to identify a common complication of this medication? Monitor urine output every shift Perform neuro checks every 2 hours Examine the stool and vomitus for the presence of blood Monitor the complete white blood cell count and differential daily Non of above Woman 36 y.o., complaints on dry cough, dyspnea. Felt ill after viral respiratory infection 2 years ago. Objectively: breathing rate - 16/min, pulse -68/min, BP - 130/90. In lungs during percussion clear pulmonary sound. Auscultation – diffuse dry wheezes. To check reversibility of bronchial obstruction it is necessary to provide test with: Salbutamol Forced expiration Obzidan Physical exertion Oxygen Woman 45 y.o., is ill with bronchial asthma for 20 years. She came to pulmonologist to discuss plan of treatment in different cases. Now attacks arise 2-3 times a week, she uses intal, ventolin if necessary. What medicine would be useful in case of arising night attacks? Inhaled glucocorticosteroids To use intal To continue usual therapy To use prednisole To add atrovent to usual treatment Woman 58 y.o., is ill with bronchial asthma, entered the hospital with complaints on dyspnea and palpitation. Objectively: condition is severe, breathing is noisy with participation of additional breathing muscles, periodically cramps are present, diffuse cyanosis. In lungs – diffuse dry wheezes, breathing is weaker in the lower parts of lungs. Pulse - 100/min, liver is a little lower from the edge of costal arch, edema, 3 extrasystoles/min, BP - 140/100, РаO2 - 45, pH - 7,3. What syndrome is the most severe for this patient? Respiratory failure Blood hypertension Tachycardia D. E. 82. A. * B. C. D. E. 83. A. * B. C. D. E. 84. A. * B. C. D. E. 85. A. * B. C. D. E. Arrhythmia Heart failure Woman of 34, for 15 years is ill with bronchial asthma. Some time ago increased frequency of attacks of dyspnea, they arised 4-5 times a week, night attacks - 2-3 times a month. Used salbutamol to remove attacks. Objectively: condition is satisfactory. Breathing rate - 20/min. Heart rate - 76/min, BP - 120/80. In lungs there is vesicular breathing. Tones of heart are a little weak, rhythm is normal. What medicine must be used for the prophylaxis of attacks of bronchial asthma on the first stage? Corticosteroids in inhalations Corticosteroids in injections Regular usage of salbutamol Corticosteroids orally Cromoglicat sodium Woman of 62, is ill with bronchial asthma. Recently appeared pain behind the sternum, interruptions in work of heart. Objectively: t - 36,6 °С, pulse -78/min, extrasystoles are present, BP -160/95, breathing rate - 18/min. In lungs during auscultation - breathing with prolonged expiration, diffuse dry wheezes are present. What preparations are not indicated in this situation? ?-blockers Ca-channel blockers Nitrosorbid Sustak Anticoagulants Woman, 68 years old, with moderate emphysema is evaluated during a routine visit. She has chronic dyspnea on exertion but has no cough or sputum production. She uses supplemental oxygen, 2 l/min, when sleeping and on exertion. She currently uses albuterol and ipratropium four times per day, and salmeterol and theophylline twice per day. She is currently enrolled in a pulmonary rehabilitation program and is concerned about “catching a cold” from other people enrolled in the pulmonary rehabilitation program. What is the best advice for this patient? Practice good hand washing, attempt to avoid close prolonged contact with ill persons, and take pneumococcal and annual influenza vaccine Avoid any social functions where there will be large crowds Discontinue attendance at the pulmonary rehabilitation program Take a daily antibiotic (long-term suppressive antibiotic therapy) to prevent pneumonia All of the above Woman, a 76 years old resident of a nursing home, is evaluated in the emergency department because of decreasing mental status and hypothermia. She has a history of stroke and is currently taking only aspirin. She has been able to eat on her own and there have been no witnessed aspirations. She has not been treated recently with antibiotics. Her leukocyte count is 12,000/l, and her hemoglobin is 120 g/l. Serum electrolytes are within normal limits and she has mild chronic renal insufficiency. Chest radiograph shows a small interstitial infiltrate in the right lower lung field. She receives traditional empiric treatment for community-acquired pneumonia. Therapy for which of the following should also be considered? Enteric gram-negative organisms Pseudomonas aeruginosa Anaerobic bacteria Aspergillus fumigatus Mycobacterium tuberculosis 86. A. * B. C. D. E. 87. A. * B. C. D. E. 88. A. * B. C. D. E. 89. A. * B. C. D. E. 90. A. * B. C. D. 67-year-old man with chronic obstructive pulmonary disease is evaluated because of chronic dyspnea, minimally productive cough, and limited exercise tolerance. He thinks his dyspnea on exertion has worsened. He stopped smoking cigarettes 8 years ago and is currently using an ipratropium inhaler four times per day and salmeterol discus twice per day. His body mass index, which 6 months ago was 21, is now 19. On physical examination, he is afebrile, his pulse rate is 94/min and regular, and respiration rate is 20/min. His breathing is unlabored at rest. He has signs of chest hyperinflation and decreased breath sounds without wheezing. He has no peripheral edema. The remainder of his examination is normal; results of a fecal occult blood test are negative. Baseline spirometry is unchanged. Forced expiratory volume in 1 sec (FEV1) 35% of predicted Forced vital capacity (FVC) 85% of predicted FEV1/FVC ratio50% PO2 62 mm Hg PCO2 45 mm Hg pH 7.38 (with the patient breathing room air) Chest radiograph reveals only hyperinflation. What is the best Refer for pulmonary rehabilitation with exercise and nutritional counseling. way tohim manage this patient’s weight loss? Provide dietary instructions to increase his caloric intake. Treat him with anabolic steroids Prescribe oxygen supplementation to improve his oxygen consumption. Add inhaled corticosteroids to his medical regimen. 68-year-old man with severe chronic obstructive pulmonary disease (forced expiratory volume in 1 sec 32% of predicted) is evaluated because of severe dyspnea and the inability to carry out his activities of daily living. He is on maximal bronchodilator and oxygen therapy. Which of the following might pulmonary rehabilitation improve? Exercise tolerance Forced expiratory volume in 1 sec Oxygenation Survival Non of above A 35-yr-old accountant presents with a chronic cough, dyspnea and wheezing. He produces copious sputum. His arterial carbon dioxide is low and his arterial oxygen is normal. Chest X-ray: high pneumatization of lungs. What is your diagnosis? Emphysema Bronchogenic carcinoma Pulmonary embolism Pneumonia Tuberculosis A 53-yr-old smoker with chronic cough and copious yellow sputum presents in a state of agitation. He is confused. His pulse is bounding. He has a terrible headache and you find papilloedema on fundoscopy. What is the cause? Emphysema Bronchogenic carcinoma Pneumonia Cardiac failure Bronchial asthma A 53-yr-old smoker with chronic cough and copious yellow sputum presents in a state of agitation. He is confused. His pulse is bounding. He has a terrible headache and you find papilloedema on fundoscopy. What may be found on chest X-ray? Signs of fibrosis and hyperpneumatization Infiltration Round shadow Round shadow with horizontal level of fluid E. 91. A. * B. C. D. E. 92. A. * B. C. D. E. 93. A. * B. C. D. E. 94. A. * B. C. D. E. Signs of fibrosis and local infiltration A 55-year-old man is evaluated in the emergency department because of a 5-day history of increased dyspnea and cough productive of yellow-green mucus. Nine months ago, he required prolonged mechanical ventilation for an exacerbation of chronic obstructive pulmonary disease. His medical history includes hypertension. On recent pulmonary function testing, the forced expiratory volume in 1 sec (FEV1) was 38% of predicted. His temperature is 38.1 C, pulse rate is 135/min and irregular, respiration rate is 25/min, and blood pressure is 90/65 mm Hg. He is mildly lethargic but arousable and oriented. He has a weak cough with pooling of secretions in the oral cavity and hypopharynx. Electrocardiogram demonstrates multifocal atrial tachycardia. Chest examination reveals accessory muscle use, coarse rhonchi, and decreased breath sounds at the right base. Leukocyte count is 1 7,000/?L. Chest radiograph shows right lower lobe consolidation. With the patient breathing 4 L oxygen, arterial blood gases show a PO2 of 50 mm Hg, a PCO2 of 65 mm Hg, and a pH of 7.25. Therapy with methylprednisolone sodium succinate, 125mg intravenously every 6 h, is initiated, along with nebulized albuterol and ipratropium bromide every 4 h, and azithromycin, 500 mg administered intravenously daily. Which of the following is the most appropriate additional Intubate and begin mechanical ventilation management? Initiate mucloytic therapy, chest physiotherapy, and oral-tracheal suctioning Administer a helium-oxygen mixture of 70%:30%, delivered by face mask Initiate bilevel noninvasive positive-pressure ventilation by face mask Administer 40% oxygen by Venturi mask A 55-year-old man is evaluated in the emergency department because of an acute, severe asthma attack; he is hospitalized in the intensive care unit for aggressive medical therapy and monitoring. He is expectorating thick greenish sputum. His medical history includes hypertension, cholecystectomy, and glaucoma. Chest radiograph reveals hyperinflation only. Medical therapy in the emergency department included repeated doses of aerosolized albuterol and ipratropium, as well as methylprednisolone, 125mg administered intravenously. Peak expiratory flow rate is unimproved at 80 L/min. Which of the following is the most appropriate next step in this patient’s management? Intravenous magnesium sulfate Nebulized ipratropium bromide administered by face mask Broad-spectrum antibiotics targeting community-acquired respiratory pathogens Inhaled corticosteroids Non of above A 56-yr-old man wheezes and coughs. He has tried to give up smoking, but he finds it very difficult. He is thin and healthy looking with a rounded chest. His breathing is noisy. His cough is unproductive. What method of investigation is not useful? Ultrasound examination Chest X-ray Spirography General blood analysis Sputum analysis A 56-yr-old man wheezes and coughs. He has tried to give up smoking, but he finds it very difficult. He is thin and healthy looking with a rounded chest. His breathing is noisy. His cough is unproductive. What treatment has to be prescribed? Salbutamol Amoxycillin Prednisolone ACC Bronchial lavage 95. A. * B. C. D. E. 96. A. * B. C. D. E. 97. A. * B. C. D. E. 98. A. * B. A 56-yr-old man wheezes and coughs. He has tried to give up smoking, but he finds it very difficult. He is thin and healthy looking with a rounded chest. His breathing is noisy. His cough is unproductive. What is the previous diagnosis? Emphysema Bronchogenic carcinoma Pneumonia Asthma Bronchitis A 57-year-old man with advanced chronic obstructive pulmonary disease (COPD) and systemic hypertension is evaluated because of a 6-day history of productive cough and shortness of breath. He uses inhaled albuterol and ipratropium bromide, a long-acting theophylline preparation, and lisinopril. He uses supplemental oxygen at night and during ambulation. Ciprofloxacin is prescribed for an exacerbation of COPD. Three days later, having had nausea for a day, the man is brought to the emergency department after he is found nearly unconscious. Arterial oxygen saturation is 89%, with the patient breathing room air. Electrocardiogram shows normal sinus rhythm with nonspecific ST-T changes in the lateral chest leads. Which of the following is likely to have interacted with ciprofloxacin and caused the symptoms that brought the man to the emergency department? Theophylline Albuterol Ipratropium bromide Lisinopril Oxygen A 59-year-old man with advanced chronic obstructive pulmonary disease is evaluated because of a daily cough productive of white or yellow sputum, dyspnea after climbing one flight of stairs, and a recent 4.5-kg weight loss with no associated change in appetite or food intake. The patient stopped smoking 4 years ago. On physical examination, he has diminished breath sounds throughout all lung fields. Arterial oxygen saturation measured by pulse oximetry with the patient at rest, breathing room air, is 87%. Chest radiograph suggests hyperinflation of the lungs but shows no pulmonary infiltrates or abnormalities of the cardiac silhouette. Pulmonary function studies show a forced expiratory volume in 1 sec 39% of predicted and forced vital capacity 78% of predicted. Which of the following may prolong life in this patient? Supplemental oxygen Albuterol Ipratropium bromide Theophylline Lisinopril A 60-year-old woman is hospitalized for an exacerbation of chronic obstructive pulmonary disease. She is treated with ipratropium bromide by nebulizer every 4 hours; intravenous azithromycin, 500 mg/d; methylprednisolone, 125 mg intravenously every 6 hours; and oxygen by nasal cannula. During the first 2 hospital days, her condition remains unchanged. On the 3rd hospital day, she develops increased dyspnea and a cough productive of sputum. On physical examination, she is awake and alert and in moderate respiratory distress. Her temperature is 36.7 C, pulse rate is 110/min, respiration rate is 20/min, and blood pressure is 150/90 mm Hg. Her lungs are hyperresonant to percussion, with accessory muscle use, poor air movement, mild wheezing, and no crackles. Chest radiograph demonstrates hyperinflation, with no other abnormalities. Leukocyte count is 16,000/L. Arterial blood gas measurements, with the patient breathing 1.5 L oxygen, show PO2 of 55 mm Hg, PaCO2 of 55 mm Hg, and pH of 7.32. She is transferred to the intensive care unit for close observation and possible assisted ventilation. Which of the following is most appropriate Add albuterol to ipratropium bromide by nebulizer every 4 hours additional management for this patient? Discontinue azithromycin and begin levofloxacin C. D. E. 99. A. * B. C. D. E. 100. A. * B. C. D. E. 101. A. * B. C. D. E. Begin intravenous aminophylline Increase methylprednisolone to 250 mg every 6 hours Increase oxygen by nasal cannula to 3 L/min A 66-year-old woman with chronic obstructive pulmonary disease is evaluated because of chronic cough and dyspnea. She currently uses a long-acting bronchodilator twice per day, an inhaled corticosteroid twice per day, ipratropium four times per day, and albuterol four to six times per day. She smokes 1 pack of cigarettes per day. On physical examination, her vitals signs are normal. Her oxygen saturation at rest and with exertion is 94%. She has diminished breath sounds, a prolonged expiratory-to-inspiratory phase, and no wheezes. Her heart rate and rhythm are regular, with physiologically split S2, and no murmurs or rubs. Chest radiograph reveals hyperinflation, increased retrosternal airspace, and flattened hemidiaphragms bilaterally. Which of the following should be initiated at this time to address this patient’s cough and dyspnea? Discuss techniques to help her to quit smoking Increase her use of the long-acting bronchodilator. Prescribe supplemental oxygen Provide emergency treatment for a tension pneumothorax Increase her dosage of inhaled corticosteroid. A 67-year-old man is evaluated because of a 3-week history of cough productive of blood-streaked sputum. A chest radiograph shows an infiltrate in the right upper lobe. He is treated with antibiotics for 2 weeks, but the blood-streaked sputum persists. A CT scan of the chest shows a mass obstructing the right upper lobe and evidence of postobstructive pneumonitis. Examination of the mediastinum shows enlarged lymph nodes in the right paratracheal space. A positron emission tomography (PET) scan shows uptake in the mass itself and in the lymph nodes in the right paratracheal space. Fiberoptic bronchoscopy is performed; an endobronchial lesion is identified and a sample is taken for biopsy. The biopsy shows squamous cell carcinoma. Which of the following is the best next step in this patients management? Perform immediate mediastinoscopy Refer him for radiation therapy Refer him for surgery Perform a repeat positron emission tomography scan Non of above A 70-year-old man is evaluated because of shortness of breath. He has noted progression of his symptoms, primarily with exertion over the past 6 months. He is unable to walk one flight of stairs or two blocks on level ground without becoming short of breath. He has no chest pain, paroxysmal nocturnal dyspnea, orthopnea, or lower extremity edema. He has a 40-pack-year history of cigarette smoking, but stopped smoking 10 years ago. He worked in a naval shipyard 50 years ago but has spent most of his working life as a schoolteacher. On physical examination, his respiration rate is 18/min but he does not appear short of breath. Examination of the chest shows an increased anterior-posterior diameter. On auscultation he has diffusely decreased breath sounds and a prolonged expiratory phase with no wheezing. He has no cyanosis or clubbing. Spirometry shows forced expiratory volume in 1 sec 55% of predicted and forced vital capacity 80% of predicted with a ratio of FEV1 to FVC 60%. Which of the following is the best test to evaluate this patients condition? Lung volumes and diffusing capacity Echocardiography Exercise spirometry Methacholine challenging testing Non of above 102. A. * B. C. D. E. 103. A. * B. C. D. E. 104. A. * B. C. D. E. 105. A. * B. C. D. E. 106. A. * B. C. D. A 71-year-old woman is evaluated because of progressive fatigue, weakness, and dyspnea on exertion. A former smoker, she has a history of advanced emphysema and is on continuous long-term oxygen therapy. She currently uses a long-acting bronchodilator twice per day, theophylline and an inhaled corticosteroid twice per day, ipratropium four times per day, and albuterol four to six times per day. Physical examination is normal. Heart and lung examinations are consistent with long-standing, advanced emphysema. Her laboratory and radiographic findings are unremarkable. Which of the following is the best next step in this patient’s management? Refer her to a multidisciplinary rehabilitation program Prescribe an antidepressant medication Prescribe an empiric course of “pulse dose” corticosteroids at 500 mg/d for 3 consecutive days Refer her for surgery Non of above A middle-aged smoker presents with chronic cough and phlegm. His sputum is tenacious but not yellow or blood stained. His chest is hyperinflated. His arterial carbon dioxide is high and is arterial oxygen is low. What is the previous diagnosis? Emphysema Bronchitis Bronchogenic carcinoma Pneumonia Respiratory failure For 8 years patient is disturbed with cough in the morning with little amount of sputum, shortness of breath. He is a smoker for more than 10 years. Objective examination: cyanosis, increased duration of expiration, dry wheezes. Possible diagnosis is: COPD Pneumonia Idiopathic alveolitis Bronchiectasis Bronchial asthma Man 39 y.o., driver, complaints on the shortness of breath during physical exertion, cough with the small amount of light sputum mostly in the morning. For a long time is ill with COPD. He is a smoker, uses alcohol episodically. Objectively: temperature - 36,5 °С, breathing rate - 24/min, pulse 90/min, BP - 120/ 80. During auscultation breathing is hard, moderate amount of dry wheezes. FEV1 - 68 % of normal index. What methods are necessary to prevent the disease? To stop smoking To change the job To avoid alcohol Sanation of chronic infection To change region of living Man 60 y.o., complains on expiration dyspnea which increases at the physical exertion, cough with small amount of mucus-purulent sputum mostly in the morning. He is ill with COPD. Objectively: temperature - 36,0 °С, breathing rate - 22/min, pulse - 84/min, BP - 110/70. Skin is moist, diffuse cyanosis. Auscultation: breathing is hard, diffuse dry and moist wheezes are present. FEV - 62 %; pharmacological test with atrovent showed 5 % increasing of this index. What mechanism of bronchial obstruction development is the most possible in this case? Diffuse sclerotic changes Hypercrynia Inflammatory edema Bronchial spasm E. 107. A. * B. C. D. E. 108. A. * B. C. D. E. 109. A. * B. C. D. E. 110. A. * B. C. D. E. 111. A. * B. C. D. E. 112. A. * Mucostasis Man of 43 complaints on dyspnea during physical activity. Objectively: temperature 36,4 °С, breathing rate - 20/min, pulse - 78/min, BP-125/80. Emphysematous form of thorax. In lungs – weak vesicular breathing. What research must be provided by patient at home to decide question about efficiency of prescribed broncholytics? Peakflowmetry Spirography ECG-control of overload of right departments of heart Bronchoscopy Analysis of sputum Patient 44 y.o., complaints on attack of dyspnea, which arises suddenly at night. Connects this attack with overcooling. He is ill for more than 10 years. Thorax of emphysematous form. During percussion in lungs – “box” sound. During auscultation there is plenty of dry wheezes. In blood: moderate leucocytosis, eosinophylia - 10 %. On the X-ray film – increased pneumatization of pulmonary tissue. What diagnosis is the most possible one? Bronchial asthma, exacerbation phase Bronchiectasis, exacerbation phase COPD, exacerbation phase Chronic bronchitis Eosinophylic pulmonary vasculitis Patient 47 y.o., complaints on cough, dyspnea during physical exertion, local pain in the heart region, general weakness. Suffers with COPD for 10 years. During auscultation of lungs were founded disseminated dry wheezes. Systolic blood pressure in the pulmonary artery is 50. It is the most important to prescribe for treatment: Euphyllin Bromhexin Caffeine Prednisone Atropin Patient complaints on attacks of dyspnea, which arises 1-2 times a week, night symptoms - 2 times a month and even more frequent. For a patient night sleep is broken as a result of attacks of dyspnea. FEV1 > 80 % from normal. What diagnosis would you suspect? Mild persistent BA Severe persistent BA Intermittent BA Moderate persistent BA Status asthmaticus A 14-yr-old student with cystic fibrosis rapidly deteriorated and developed acute respiratory failure while in hospital. Which infection is the most possible cause of deterioration of his state? Pseudomonas aeroginosa Pneumocystis carinii Chlamydia psittaci Ecoli Mycobacterium tuberculosis A 20-yr-old male IV drug abuser presents with breathlessness and cough. CXR reveals patchy areas of consolidation with abscess formation. Which infection is the most possible cause of his state? Staphylococcus aureus B. C. D. E. 113. A. * B. C. D. E. 114. A. * B. C. D. E. 115. A. * B. C. D. E. 116. A. * B. C. D. E. 117. A. * B. C. Chlamydia psittacci Coxiella burnetti Pneumocystis carinii Pseudomonas aeroginosa A 20-yr-old previously healthy woman presents with general malaise, severe cough and breathlessness, which has not improved with a 7 day course of Amoxycillin. There is nothing significant to find on examination. The X-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins. Which infection is the most possible cause of her state? Mycoplasma pneumoniae Legionella pneumonia Haemophilus influenzae Chlamydia trachomatis Klebsiella pneumoniae A 22-year-old previously healthy man is evaluated in the emergency department because of fever, productive cough, and shortness of breath. His temperature is 40 C, pulse is 120/min, respiration rate is 32/min, and blood pressure is 100/70 mm Hg. Measurement of arterial blood gases with the patient breathing room air shows PO2 of 55 mm Hg, PCO2 of 30 mm Hg, pH of 7.41. Chest radiograph reveals bilateral alveolar infiltrates with no effusions. Gram stain of the sputum reveals gram-positive diplococci. Which of the following is the most appropriate for this patient? Hospitalize him Treat him as an outpatient with oral therapy Treat him as an outpatient with intravenous therapy Hospitalize the patient in the intensive care unit All of the above A 22-yr-old barman presents with a dry cough of sudden onset. He complains of a chest pain and rusty sputum. He also has a very high fever, rapid breathing, cyanosis and crepitations. Pneumonia was suspected. What is the most necessary method of investigation? Chest X-ray Spirography Analysis of sputum General blood analysis General urine analysis A 22-yr-old barman presents with a dry cough of sudden onset. He complains of a chest pain and rusty sputum. He also has a very high fever, rapid breathing, cyanosis and crepitations. What is your previous diagnosis? Pneumonia Asthma Lung abscess COPD Lung cancer A 24-yr-old car mechanic is brought to casualty by his girlfriend. She describes a 2-day history of rigors, sweats and intermittent confusion. On examination he is agitated, sweaty and pyrexial with 38.6° C. He is hyperventilating and cyanosed despite receiving O2 by face mask. There is dullness to percussion and bronchial breathing at the left lung basse. What method of investigation is nesessary? Chest X-ray Spiral CT with contrast Arterial blood gases D. E. 118. A. * B. C. D. E. 119. A. * B. C. D. E. 120. A. * B. C. D. E. 121. A. * B. C. D. E. 122. A. * B. C. D. E. 123. Blood count and film Urea and electrolytes A 24-yr-old man presents dry cough, skin manifestations and bone and muscle aches. His chest radiograph shows widespread patchy shadows. Blood tests show evidence of haemolysis. Which infection is the most possible cause of his state? Mycoplasma pneumoniae Pneumocystis carinii Chlamydia psittaci coli Pseudomonas aeroginosa A 27-yr-old male patient has just returned from holiday abroad presents with flu-like illness, headaches, high fever prior to this, he had complained of abdominal pain, vomiting, diarrhoea associated with blood per rectum. Which infection is the most possible cause of his state? Legionella pneumoniae Streptococcus pneumoniae Mycoplasma pneumoniae Pneumocystis carinii Fungi A 27-yr-old male prostitute has felt generally unwell for 2 months with some weight loss. Over the last 3 weeks he has noticed a dry cough with increasing breathlessness. Two courses of antibiotics from the GP have produced no improvement. The CXR shows bilateral interstitial infiltrates. Which infection is the most possible cause of his state? Pneumocystis carinii Streptococcus pneumoniae Mycoplasma pneumoniae Fungi Legionella pneumoniae A 28 years old patient, complaints on cough with small amount of colourless sputum, pain in the right half of thorax during breathing, shortness of breath, increase of temperature to 39 °С. Felt ill rapidly. Used aspirin. Objectively: herpes on lips. In lower lobe of right lung there is dull percussion sound, bronchial breathing. Chest X-ray: there is homogeneous infiltration of right lower lobe. What is the most possible etiology of pneumonia? Pneumococcus Staphylococcus Mycoplasma Legionella Klebsiella A 30-yr-old man with AIDS presents with fever, dry cough and dyspnoea. CXR shows diffuse bilateral alveolar and interstitial shadowing beginning in the perihilar regions and spreading outward. Which infection is the most possible cause of his state? Pneumocystis carinii Chlamydia psittacci Coxiella burnetti Staphylococcus aureus Pseudomonas aeroginosa A 35-yr-old previously healthy man returned from holiday five days ago. He smokes 10 cigarettes per day. He presents with mild confusion, a dry cough and mild pyrexia. His chest is normal. The X-ray shows widespread upper zone shadowing. Which infection is the most possible cause of his state? A. * B. C. D. E. 124. A. * B. C. D. E. 125. A. * B. C. D. E. 126. A. * B. C. D. E. 127. A. * B. C. D. E. 128. A. * B. C. D. Legionella pneumoniae Haemophilus influenzae Chlamydia trachomatis Pneumocystis carinii Klebsiella pneumoniae A 38 years old patient, who drunk a lot of alcohol, has severe pneumonia. His condition was worsened, the temperature of body rose to 39-40 °С, an unpleasant smell appeared from a mouth, increased amount of purulent sputum; increased ESR and amount of band leucocytes. On the X-ray in the lower lobe of right lung there is massive infiltration with bright area in a center. What complication is it necessary to suspect? Acute pulmonary abscess Bronchiectasis Infarction-pneumonia Gangrene of lungs Empyema of pleura A 40-yr-old man who works in an abattoir presents with sudden onset of fever, myalgia, headache, dry cough and chest pain. CXR shows patchy consolidation of the right lower lobe giving a ground glass appearance. Which infection is the most possible cause of his state? Coxiella burnetti Chlamydia psittacci Staphylococcus aureus Pneumocystis carinii Aspergillosis A 44-yr-old travelling insurance salesman presents with high fever myalgia abdominal pain and haemoptysis. CXR shows diffuse patchy lobar shadows. The cough progresses from a modest nonproductive cough to producing mucopurulent sputum. The fever persists for 2 weeks. Which infection is the most possible cause of his state? Legionella pneumophilia Mycoplasma pneumoniae Actinomycosis Tuberculosis Streptococcus pneumoniae A 48 years old patient, complaints on weakness, dyspnea, pain in the left half of thorax, permanent cough with viscid sputum, in which particles of blood are sometimes determined. For the last 3 months lost 5 kg of body mass. On the X-ray of lungs there is total homogeneous shade is determined from the left side. Organs of mediastinum are displaced to the left. What diagnosis is possible? Lung athelectasis Lungs gangrene Total exudative pleurisy Pneumonia Empyema of pleura A 48-yr-old man presents with fever, rigors, headache and diarrhea. He recently had been on a holiday abroad. CXR shows consolidation. Which infection is the most possible cause of his state? Legionella pneumoniae Staphylococcus aureus Crytococcus Streptococcus pneumoniae E. 129. A. * B. C. D. E. 130. A. * B. C. D. E. 131. A. * B. C. D. E. 132. A. * B. Mycobacterium avium A 50-year-old man is evaluated in the emergency department because of fever, a nonproductive cough, and a 2-day history of myalgia and headache. He has also had some nausea and diarrhea. He is a heavy smoker. On physical examination, he is slightly disoriented. Temperature is 38.9 0C, pulse rate is 110/min, respiration rate is 32/min. Chest radiograph shows fluffy infiltrates to the right upper and lower lobes. Results of laboratory testing show serum sodium of 128 meq/L, blood urea nitrogen of 42 mg/dL, serum creatinine of 2.2 mg/dL, and serum creatine kinase of 250 U/L. Which one of the following is best next step in the management of this patient’s pneumonia? Initiate empiric antibiotic therapy for Legionella Order direct fluorescent antibody testing of the sputum for Legionella Order serologic testing for Legionella Send a urine specimen for measurement of Legionella antigen All of the above A 50-yr-old man presents with shortness of breath and dry cough. CXR shows widespread pulmonary shadowing. He takes Azathioprine for resistant rheumatoid arthritis. Choose the most appropriate treatment. Co-trimoxazole Erythromycm Tetracycline Flucoxacillin Isoniazid A 52-year-old man is evaluated because of a 2-month history of nonproductive cough, myalgias, and low-grade fever. When his illness began, a chest radiograph showed bilateral alveolar infiltrates, and a presumptive diagnosis of community-acquired pneumonia was made. He was treated with oral azithromycin without effect, followed by a 10-day course of levofloxacin, also without effect. During the course of his illness he has lost 4.5 kg without significant anorexia. He is a lifetime nonsmoker and works as an office manager. He has no pets and no unusual hobbies. On physical examination, his vitals signs are normal, except for a respiration rate of 22/min. He is in mild respiratory distress on exertion. On examination of the chest, bilateral crackles are audible, without wheezing. Chest radiograph shows bilateral alveolar infiltrates, which are changed in location from those seen on his original radiographs. Pulmonary function tests show forced expiratory volume in 1 sec (FEV1) 75% of predicted, forced vital capacity (FVC) 72% of predicted, total lung capacity 80% of predicted, and diffusing lung capacity for carbon monoxide (DL CO) 65% of predicted. Arterial blood gas values, with the patient breathing room air, are PO2 62 mm Hg, PCO2 42 mm Hg, and pH 7.39. Which of the following is the most likely diagnosis? Cryptogenic organizing pneumonitis Hypersensitivity pneumonitis Resistant pneumococcal pneumonia Chlamydia pneumonia Bronchoalveolar cell carcinoma A 60-year-old man with chronic obstructive pulmonary disease is evaluated because of persistent cough and sputum production. He reports no fevers or weight loss. He has had increased sputum production over the past 6 to 9 months and moderately severe reduction in forced expiratory volume in 1 sec (FEV1 55% of predicted). His symptoms have been unresponsive to antibiotics. He has an 80-pack-year history of cigarette smoking. Chest radiograph reveals multiple small nodules in the left upper lung zone without infiltrate. Serologic testing for HIV is negative. Sputum cultures are negative for bacteria. A test for acid-fast bacillus is negative, but culture grows Mycobacterium avium-intracellulare with 1+ growth. Which of the following is the best next step in this patient’s Order a sputum culture for Mycobacterium avium-intracellulare management? Treat him for Mycobacterium avium-intracellulare without further testing C. A. * Perform bronchoscopy with bronchioalveolar lavage and transbronchial biopsy Order a HRCT scan of the chest All of the above A 62-year-old woman with moderate emphysema is evaluated during a routine visit. She has chronic dyspnea on exertion but has no cough or sputum production. She uses supplemental oxygen, 2 L/min, when sleeping and on exertion. She currently uses albuterol and ipratropium four times per day, and salmeterol and theophylline twice per day. She is currently enrolled in a pulmonary rehabilitation program and is concerned about “catching a cold” from other people enrolled in the pulmonary rehabilitation program. What is the best advice for this patient? Practice good hand washing, attempt to avoid close prolonged contact with ill persons, and take pneumococcal and annual influenza vaccine Avoid any social functions where there will be large crowds Discontinue attendance at the pulmonary rehabilitation program Take a daily antibiotic (long-term suppressive antibiotic therapy) to prevent pneumonia All of the above A 65-yr-old man currently undergoing chemotherapy of chronic leukaemia has felt unwell with fever and unproductive cough for 2 weeks despite treatment with broad-spectrum IV antibiotics. The CXR shows an enlarging right sided midzone consolidation. Which infection is the most possible cause of his state? Fungi Streptococcus pneumoniae Mycoplasma pneumoniae Pneumocystis carinii Legionella pneumoniae A 67-year-old woman is evaluated in the emergency department because of a 2-day history of fever and a cough productive of purulent sputum. She is intubated for hypoxic respiratory failure due to pneumonia and hospitalized in the intensive care unit. Her medical history is remarkable only for hypertension for which she takes a calcium channel blocker. She has never worked outside the home, has no pets, and has not traveled recently. Which of the following would be appropriate initial antibiotic therapy? A second-generation cephalosporin and macrolide A second-generation cephalosporin A third-generation cephalosporin, aminoglycoside, and macrolide An antipseudomonal ?-lactam/?-lactamase combination and fluoroquinolone All of the above A 70-year-old man is ready to be discharged in October from the hospital after treatment of an exacerbation of his chronic obstructive pulmonary disease. His only other medical problems include stable angina and hypertension. He has normal renal function and is well nourished. He quit smoking 2 years ago. He received pneumonia vaccine 2 years ago and influenza vaccine 1 year ago. Which of the following is true of his vaccination status? He should receive influenza vaccine B. C. D. E. He should receive pneumonia vaccine and influenza vaccine He should receive pneumonia vaccine He should receive neither pneumonia vaccine nor influenza vaccine Nothing of the above D. E. 133. A. * B. C. D. E. 134. A. * B. C. D. E. 135. A. * B. C. D. E. 136. 137. A. * B. C. D. E. 138. A. * B. C. D. E. 139. A. * B. C. D. E. 140. A. B. * C. D. E. 141. A. * B. C. A 70-year-old woman resident of a nursing home is evaluated in the emergency department because of decreasing mental status and hypothermia. She has a history of stroke and is currently taking only aspirin. She has been able to eat on her own and there have been no witnessed aspirations. She has not been treated recently with antibiotics. Her leukocyte count is 12,000/L, and her hemoglobin is 120 g/L. Serum electrolytes are within normal limits and she has mild chronic renal insufficiency. Chest radiograph shows a small interstitial infiltrate in the right lower lung field. She receives traditional empiric treatment for community-acquired pneumonia. Therapy for which of the following should also be considered? Enteric gram-negative organisms Pseudomonas aeruginosa Anaerobic bacteria Aspergillus fumigatus Mycobacterium tuberculosis A 72-year-old woman with a history of rheumatoid arthritis is evaluated because of persistent cough, purulent sputum production, and occasional scant hemoptysis. She reports no fever, but says she has difficulty gaining weight. She has never smoked cigarettes. She is hospitalized because of tachypnea and hypoxia. Spirometry shows moderately severe obstructive impairment. Chest radiograph shows tramlines without infiltrate. Gram stain of the sputum shows numerous leukocytes but no bacteria; culture results are pending. Previous IgE levels were normal. There is no eosinophilia. An immediate skin test for Aspergillus is negative. A tuberculin skin test performed last year was nonreactive. Which of the following is appropriate therapy for this patient? Intravenous fluoroquinolone and aminoglycoside A ?-lactam/?-lactamase combination Itraconazole A new-generation macrolide All of the above A businessman, had a rest during summer on Cyprus in 5-stars hotel. After 3 weeks of rest suddenly, without any cause, has got severe headache, pain in muscles, joints, dry cough, moderate dyspnea, pain in a thorax. X-ray: infiltration of lung tissue. In a blood test: absolute lymphopenia with moderate leucocytosis. Most possible etiological factor of pneumonia: Legionella Mycoplasma Pneumocysts Enteroviruses Pneumococcus A patient who is 2 days postoperative from a bowel resection tells her physician that she is having a hard time “catching her breath,” feels nauseated, and has chest pains when she inhales. The physician suspects that she is having a pulmonary embolism. What intervention should the physician perform before notifying the physician? Increase the IV flow rate Apply oxygen by mask or nasal cannula at 5 L/min Assess the chest and axillary area for the presence of petechiae Place the patient in shock position, with her head and neck flat and her legs elevated Non of above A pet shop owner presents with high swinging fever, cough and malaise. He has scanty rose spots over his abdomen. CXR reveals diffuse pneumonia. Which infection is the most possible cause of his state? Chlamydia psittacci Coxiella burnetti Staphylococcus aureus D. A. * Pneumocystis carinii Aspergillosis A previously healthy 18-yr-old girl has had influenza for the last 2 weeks. She is deteriorating and has a swinging fever. She is coughing up copious purulent sputum. CXR shows cavitating lesions. Which infection is the most possible cause of his state? Staphylococcus aureus Streptococcus pneumoniae Mycoplasma pneumoniae Pneumocystis carinii Legionella pneumoniae During the epidemic of influenza patient G., 59 y.o., after decreasing of fever noticed pain appeared in a thorax, cough with yellow-green sputum (amount-100 ml a day), sometimes with some blood. Objectively: breathing rate - 36/min. In lungs from the right side lower scapula there is dull sound during percussion, hard breathing, and moist rales. Blood test: L - 18,6х109/л, ESR -64 mm/h. Analysis of sputum: L -80-100 , Er - 40-50, elastic fibres, cocci. X-ray: rhadicis are enlarged, from the right side lower lobe is heterogeneously infiltrated with two lighter areas. What is the most possible previous diagnosis? Right-side pneumonia with abscesses Peripheral cancer Infiltrative tuberculosis in the phase of disintegration Exudative pleurisy Infarction-pneumonia Female B., 44 years old, complains on cough with mucous sputum, increase of temperature to 39 °С, weakness, dyspnea, sweating. Breathing rate - 26/min., skin is moist. Below left scapula there is shortening of percussion sound. Breathing during auscultation is weaker, moist rales. Blood test: L 11х109/l, ESR - 29 mm/h. Your previous diagnosis? Left-side lower lobe pneumonia Gangrene of lungs Left-side exudative pleurisy Cancer of left side lower lobe Pulmonary abscess Female patient K., 46 years old, after decreasing of fever after flu noticed pain appeared in a thorax, cough with yellow-green sputum (amount-150 ml a day), sometimes with some blood. Objectively: breathing rate - 36/min. In lungs from the right side lower scapula there is dull sound during percussion, hard breathing, and moist rales. Blood test: L - 18,6х109/l, ESR -64 mm/h. Analysis of sputum: L -80-100 , Er - 40-50, elastic fibres, cocci. X-ray: rhadicis are enlarged, from the right side lower lobe is heterogeneously infiltrated with two lighter areas. What is the most possible previous diagnosis? pneumonia with abscesses Right-side Peripheral cancer Infiltrative tuberculosis in the phase of disintegration Exudative pleurisy Infarction-pneumonia Female, 34 years old, has an increase of body temperature to 38 °С, cough with purulent sputum, weakness, dyspnea, pain in a thorax during breathing. During percussion there is shortening of sound in the lower part of left lung, during auscultation – moist rales. What method of investigation is the decisive one to confirm diagnosis? Chest X-ray examination B. Bacteriological analysis of sputum E. 142. A. * B. C. D. E. 143. A. * B. C. D. E. 144. A. * B. C. D. E. 145. A. * B. C. D. E. 146. C. D. E. 147. A. * B. C. D. E. 148. A. * B. C. D. E. 149. A. * B. C. D. E. 150. A. * B. C. D. E. 151. A. * B. C. D. E. Spirometry Pneumotachometry Bronchography Male patient F., 48 years old, during a week was at home with diagnosis of respiratory viral infection. Doctor noticed complaints on cough with small amount of mucus-purulent sputum, weakness. Objectively: condition is relatively satisfactory. T - 37,2 °С. Breathing rate - 18/min, pulse - 80/min, BP - 110/70. In lungs there is vesicular breathing, with a hard tint, single dry wheezes. Tones of heart are a little dull, rhythm is correct. What is the treatment tactic? To prescribe antibacterial therapy To stay at home for some more days To go to work To send patient to pulmonologist To hospitalize patient to the pulmonological department Male patient G., 56 years old, complaints on permanent pain in a thorax which disturbs for last 2 months. Pain is not connected with breathing. There is also cough with particles of blood in sputum. Weakness, fatigue are present. On the X-ray of thorax in the lower lobe of right lung there is spherical shadow, size 4x6 cm, related to the lungs rhadicis. What is the most possible diagnosis? Perypheral lung cancer Tuberculoma Metastasis Pulmonary abscess Pneumonia Man 40 y.o., is ill with attacks of cough with yellow-brown sputum, pain in a right side, related to the deep breathing, sweating. He is ill for 6 days, after overcooling. Used aspirin. Objectively: T - 39,6 °С, breathing rate - 26/min, pulse - 110/min, BP -110/70. In lower part of right lung - moist loud rales. Chest X-ray: in right lower lobe there is massive unhomogeneous infiltration with lighter areas, sinus is not changed. What complication of disease is the most probable? Abscesses Dry pleurisy Empiema of pleura Spontaneous pneumothorax Pulmonary athelectasis On return to university, a 20-yr-old student presented with the onset of fever, malaise and a dry cough. The student health service gave him Amoxycilline. After a week he felt no better and his CXR showed patchy bilateral consolidation. Which infection is the most possible cause of his state? Mycoplasma pneumoniae Streptococcus pneumoniae Pneumocystis carinii Fungi Legionella pneumoniae Patient B., 26 years old, who used to drink alcohol, has right-side lower-lobe pneumonia. On the chest X-ray film there are infiltrative changes from the right side – in S 6 and S 10. He has no diseases of the respiratory tract before. From which medicine is it better to begin antibacterial therapy? Amoxyclav Biseptol Ofloxacin Tetracyclin Ceporin 152. A. * B. C. D. E. 153. A. * B. C. D. E. 154. A. * B. C. D. E. 155. A. * B. C. D. E. 156. A. B. C. D. E. * 157. A. * Patient K., 27 years old, has dry cough and pain, related to breathing, in the right half of thorax, fever - to 39,5 °С. In the right lung lower from scapula there is dullness during percussion, bronchial breathing. What is the most possible diagnosis for a patient? Right-side lower lobe pneumonia An abscess of lower lobe of right lung Bronchiectasis An athelectasis of lower lobe of right lung Exudative pleurisy Patient F., 38 years old, complaints on increase of temperature to 37,9 °С, cough with small amount of mucus-purulent sputum, pain in right part. He is ill for 5 days, after overcooling. Objectively: acrocyanosis. Pulse - 96/min. BP - 120/80. From the right side below scapula there is increased vocal fremitus, shortened percussion sound, moist rales. What is the most possible diagnosis? Community-acquired right side lobar pneumonia Right lung athelectasis Right-side exudative pleurisy Right lung athelectasis Infiltrative tuberculosis Patient of 53 y.o., complaints on cough with mucous sputum, increase of temperature to 39 °С, weakness, dyspnea, sweating. Breathing rate - 26/min, skin is moist. Below left scapula there is shortening of percussion sound. Breathing during auscultation is weaker, moist rales. Blood test: L 11х109/l, ESR - 29 mm/h. Your previous diagnosis? Left-side lower lobe pneumonia Gangrene of lungs Left-side exudative pleurisy Cancer of left side lower lobe Pulmonary abscess Patient of 56 years old, complaints on permanent pain in a thorax which disturbs for last 2 months. Pain is not connected with breathing. There is also cough with particles of blood in sputum. Weakness, fatigue are present. On the X-ray of thorax in the lower lobe of right lung there is spherical shadow, size 4x6 sm, related to the lungs rhadicis. What is the most possible diagnosis? Perypheral lung cancer Tuberculoma Metastasis Pulmonary abscess Pneumonia Patient G., 36 years, works on a poultry factory. Her emergency hospitalized with acute attack of dyspnoea. During observation was diagnosed bronchial asthma. What additional methods of research must be conducted above all things for confirmation of professional genesis of bronchial asthma? roentgenologic research of breathing organs professional route of patient sanitary-hygienic characteristic of work conditions research of function of the external breathing allergic and immunologic tests Patient G., 59 y.o., after decreasing of fever after flu noticed pain appeared in a thorax, cough with yellow-green sputum (amount-150 ml a day), sometimes with some blood. Objectively: breathing rate - 36/min. In lungs from the right side lower scapula there is dull sound during percussion, hard breathing, and moist rales. Blood test: L - 18,6х109/l, ESR -64 mm/h. Analysis of sputum: L -80-100 , Er - 40-50, elastic fibres, cocci. X-ray: rhadicis are enlarged, from the right side lower lobe is heterogeneously infiltrated with two lighter areas. What is the most possible previous diagnosis? Right-side pneumonia with abscesses B. C. D. E. 158. A. * B. C. D. E. 159. A. * B. C. D. E. 160. A. * B. C. D. E. 161. A. * B. C. D. E. 162. A. * Peripheral cancer Infiltrative tuberculosis in the phase of disintegration Exudative pleurisy Infarction-pneumonia Patient I., a 50 years old man is evaluated in the emergency department because of fever, a nonproductive cough, and a 2-day history of myalgia and headache. He has also had some nausea and diarrhea. He is a heavy smoker. On physical examination, he is slightly disoriented. Temperature is 38.9 C, pulse rate is 110/min, respiratory rate is 32/min. Chest radiograph shows fluffy infiltrates to the right upper and lower lobes. Results of laboratory testing show serum sodium of 128 meq/L, blood urea nitrogen of 42 mg/dL, serum creatinine of 2.2 mg/dL, and serum creatine kinase of 250 U/L. Which one of the following is best next step in the management of this patient’s pneumonia? Initiate empiric antibiotic therapy for Legionella Order direct fluorescent antibody testing of the sputum for Legionella Order serologic testing for Legionella Send a urine specimen for measurement of Legionella antigen All of the above Patient K. 38 y.o., who is in a hospital, after week noticed temperature increased to 39 0С, cough appeared with “ferruginous” sputum, pain in a thorax, related to the act of breathing, breathing rate is 26 per minute. On X-ray there is infiltration in the lower lobe of the left lung. What medicine is useful? Cephalosporin III generation Tetracyclin Penicillin Erythromycin Streptomycin Patient M., 39 years old, is ill with attacks of cough with yellow-brown sputum, pain in a right side, related to the deep breathing, sweating. He is ill for 6 days, after overcooling. Used aspirin. Objectively: T - 39,6 °С, breathing rate - 26/min., pulse - 110/min., BP -110/70. In lower part of right lung - moist loud rales. X-ray: in right lower lobe there is massive unhomogeneous infiltration with lighter areas, sinus is not changed. What complication of disease is the most possible? Abscesses Dry pleurisy Empiema of pleura Spontaneous pneumothorax Pulmonary athelectasis Patient N., 46 years old, was admitted into the surgical department and operated because of appendicitis. After 4 days appeared she developed chills, cough, dyspnea, fever 38,5 °С, leucocytosis with shift of leucocyte formula to the left. On chest X-ray there is infiltration of lower right lobe. What is the diagnosis? Nosocomial pneumonia Pulmonary abscess Infarction pneumonia Community-acquired pneumonia Tuberculosis Patient O., 29-yr-old male prostitute, has felt generally unwell for 2 months with some weight loss. Over the last 3 weeks he has noticed a dry cough with increasing breathlessness. Two courses of antibiotics from the GP have produced no improvement. The CXR shows bilateral interstitial infiltrates. What is the most possible etiology of disease? Pneumocystis carinii B. C. D. E. 163. A. * B. C. D. E. 164. A. * B. C. D. E. 165. A. * B. C. D. E. 166. A. * B. C. D. E. 167. A. * B. C. Streptococcus pneumoniae Mycoplasma pneumoniae Fungi Legionella pneumoniae Patient of 51 y.o., complaints on weakness, dyspnea, pain in the left half of thorax, permanent cough with viscid sputum, in which particles of blood are sometimes determined. For the last 3 months he lost 5 kg of body weight. On the X-ray of lungs there is total homogeneous shade is determined from the left side. Organs of mediastinum are displaced to the left. What diagnosis is possible? Lung athelectasis Lungs gangrene Total exudative pleurisy Pneumonia Empyema of pleura A 38 years old patient, who drunk a lot of alcohol, has severe pneumonia. His condition got worse, the temperature of body rose to 39-40 °С, an unpleasant smell appeared from a mouth, increased amount of purulent sputum; increased ESR and amount of band leucocytes. On the X-ray - in the lower lobe of right lung there is massive infiltration with light area in a center. What complication is it necessary to suspect? Acute pulmonary abscess Bronchiectasis Infarction-pneumonia Gangrene of lungs Empyema of pleura Patient of 43, complaints on cough with small amount of colourless sputum, pain in the right half of thorax during breathing, shortness of breath, increase of temperature to 39 °С. Felt ill rapidly. Used aspirin. Objectively: gerpes on lips. In lower lobe of right lung there is dull percussion sound, bronchial breathing. X-ray: there is homogeneous infiltration of right lower lobe. What is the most possible etiology of pneumonia? Pneumococcus Staphylococcus Mycoplasma Legionella Klebsiella Patient P., a young male homosexual with Kaposi's sarcoma, complains of increasing breathlessness and a dry cough. He has a 3-day history of shivering, general malaise and productive cough. The X-ray shows right lower lobe consolidation. What is the most possible etiology of disease? Pneumocystis carinii Mycoplasma tuberculosis Haemophilus influenzae Chlamydia trachomatis Klebsiella pneumoniae Patient Q., 37 years old, was admitted into the surgical department and operated because of appendicitis. After 4 days appeared she developed chills, cough, dyspnea, fever 38,5 °С, leucocytosis with shift of leucocyte formula to the left. On chest X-ray there is infiltration of lower right lobe. What is the diagnosis? Nosocomial pneumonia Pulmonary abscess Infarction pneumonia D. E. 168. A. * B. C. D. E. 169. A. * B. C. D. E. 170. A. * B. C. D. E. 171. A. * B. C. D. E. 172. A. * B. Community-acquired pneumonia Tuberculosis Patient S., a 25-year-old male has just returned from holiday abroad, presents with flu-like illness, headaches, high fever. Prior to this, he had complained of abdominal pain, vomiting, diarrhea associated with blood per rectum. What is the most possible etiology of disease? Legionella pneumoniae Streptococcus pneumoniae Mycoplasma pneumoniae Pneumocystis carinii Fungi Patient V., a 24 years old barman, presents with a dry cough of sudden onset. He complains of a chest pain and rusty sputum. He also has a very high fever, rapid breathing, cyanosis and crepitations. Pneumonia was suspected. What is the most nesessary method of investigation? Chest X-ray Spirography Analysis of sputum General blood analysis General urine analysis Patient W., 67 years old, during the epidemic of influenza after decreasing of fever noticed pain that appeared in a thorax, cough with yellow-green sputum (amount-100 ml a day), sometimes with some blood. Objectively: breathing rate - 36/min. In lungs from the right side lower scapula there is dull sound during percussion, hard breathing, and moist rales. Blood test: L - 18,6х109/l, ESR -64 mm/h. Analysis of sputum: L -80-100 , Er - 40-50, elastic fibres, cocci. X-ray: rhadicis are enlarged, from the right side lower lobe is heterogeneously infiltrated with two lighter areas. What is the most possible previous diagnosis? Right-side pneumonia with abscesses Peripheral cancer Infiltrative tuberculosis in the phase of disintegration Exudative pleurisy Infarction-pneumonia Patient X., 55 years old, was admitted to the hospital recently. He complaints on cough with very small amount of mucous-purulent sputum, significant weakness, increased temperature, which is accompanied with chill, dizziness. Objectively: t - 38°С. Breathing rate - 22/min. Heart rate - 90/min, BP - 110/70. From the right side below scapula the vocal fremitus is increased, percussion sound is shortened, vesicular breathing is weakened, small amount of moist rales. Tones of heart are dull, rhythm is correct, moderate tachycardia. Doctor suspected pneumonia. The presence of what syndrome let to suspect such diagnosis? Pulmonary tissue infiltration Intoxication Inflammation Bronchial obstruction Respiratory insufficiency Patient Z., a 33-yr-old car mechanic is brought to casualty by his girlfriend. She describes a 2-day history of rigors, sweats and intermittent confusion. On examination he is agitated, sweaty and pyrexial with 38.6° C. He is hyperventilating and cyanosed despite receiving O2 by face mask. There is dullness to percussion and bronchial breathing at the left lung base. What method of investigation is necessary? Chest X-ray Spiral CT with contrast C. D. E. 173. A. * B. C. D. E. 174. A. * B. C. D. E. 175. A. * B. C. D. E. 176. A. * B. C. D. E. 177. A. B. C. D. * Arterial blood gases Blood count and film Urea and electrolytes Previously healthy 28-year-old man is evaluated in the emergency department because of fever, productive cough, and shortness of breath. His temperature is 40 C, pulse is 120/min, respiration rate is 32/min, and blood pressure is 100/70 mm Hg. Measurement of arterial blood gases with the patient breathing room air shows PO2 of 55 mm Hg, PCO2 of 30 mm Hg, pH of 7.41. Chest radiograph reveals bilateral alveolar infiltrates with no effusions. Gram stain of the sputum reveals gram-positive diplococci. Which of the following is the most appropriate for this patient? Hospitalize him Treat him as an outpatient with oral therapy Treat him as an outpatient with intravenous therapy Hospitalize the patient in the intensive care unit All of the above Previously healthy 32-yr-old woman presents with general malaise, severe cough and breathlessness, which has not improved with a 7 day-long course of Amoxycillin. There is nothing significant to find on examination. The X-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins. What is the most possible etiology of disease? pneumoniae Mycoplasma Legionella pneumonia Haemophilus influenzae Chlamydia trachomatis Klebsiella pneumoniae Female, 34 years old, has an increase of body temperature to 38 °С, cough with purulent sputum, weakness, dyspnea, pain in a thorax during breathing. During percussion there is shortening of sound in the lower part of left lung, during auscultation – moist rales. What method of investigation is the decisive one to confirm diagnosis? X-ray examination Bacteriological analysis of sputum Spirometry Pneumotachometry Bronchography Female B., 44 years old, complains on cough with mucous sputum, increase of temperature to 39 °С, weakness, dyspnea, sweating. Breathing rate - 26/min, skin is moist. Below left scapula there is shortening of percussion sound. Breathing during auscultation is weakened, moist rales. Blood test: L - 11х109/l, ESR - 29 mm/h. Your previous diagnosis? Left-side lower lobe pneumonia Gangrene of lungs Left-side exudative pleurisy Cancer of left side lower lobe Pulmonary abscess The 60-year-old patient tells you that she smoked three packs of cigarettes per day since she was 15 years old, until she was 40, and then smoked two packs per day. How many pack-years should you record in the patient's history? 45 80 90 115 E. 178. A. B. * C. D. E. 179. A. B. * C. D. E. 180. A. B. * C. D. E. 181. A. B. * C. D. E. 182. A. B. C. D. * E. Non of above The 82-year-old patient has a pulmonary infection. Which action addresses the age-related change of increased vascular resistance to blood flow through pulmonary vasculature in this patient? Encouraging the patient to turn, cough, and deep breathe every hour Assessing the patient's level of consciousness Raising the head of the bed Humidifying the oxygen Non of above The patient diagnosed with moderate stage COPD says there is no sense in stopping smoking now because the damage is done. Which response is the best rationale for encouraging this patient to stop smoking? “The damage will be reversed.” “The COPD will progress more slowly.” “Your risk for asthma development, which would further reduce your lung function, will be decreased.” “You will be less likely to lose excessive amounts of weight and will have a more normal appearance.” Non of above The patient has broken ribs that penetrated through the skin as a result of a motor vehicle crash 3 days ago. The patient now complains of increased pain, shortness of breath, and fever. Which assessment finding alerts the physician to the possibility of a pleural effusion and empyema? Wheezing on exhalation on the side with the broken ribs Absence of fremitus at and below the site of injury Crepitus of the skin around the site of injury Absence of gastric motility Non of above The patient has severe nasal congestion, headache, and sneezing but no rhinorrhea, watery eyes, sore throat, or fever. Which statement made by the patient alerts the physician to the possibility of rhinitis medicamentosa? “I have been taking two aspirins every 6 hours for this headache.” “My nose doesn't stay open even though I'm using nasal spray every hour.” “I have been taking a lot of vitamin C this year to keep from getting so many colds.” “The only way I can get to sleep with this nasal congestion is by taking an over-the-counter antihistamine at night.” Non of above The patient is 34 years old and has been diagnosed with COPD as a result of being homozygous for a mutation of the alpha1-antitrypsin (AAT) gene alleles. His wife has two normal AAT gene alleles. He is concerned that his two children may develop this problem. What is your best response? “Because neither of your parents have COPD and your wife does not have the abnormal gene alleles, your children will not be affected.” “Because your wife is not affected nor is or a carrier, your children will have normal levels of AAT and their risk is the same as for the general population.” “Because you have the mutations and your wife does not, your son will be at an increased risk for developing COPD but your daughter will only be a carrier.” “Because both of your AAT gene alleles are mutated, your children will each have one abnormal gene and their risk for COPD is only increased if they smoke or are chronically exposed to other precipitating factors.” Non of above 183. A. * B. C. D. E. 184. A. * B. C. D. E. 185. A. * B. C. D. E. 186. A. * B. C. D. E. 187. The patient with hospital-acquired (nosocomial) pneumonia caused by a bacterial infection with a gram-negative microorganism is receiving treatment with intravenous amikacin (Amikin). In addition to frequent respiratory assessment, what other assessment should the physician routinely perform to identify a common complication of this medication? Monitor urine output every shift Perform neuro checks every 2 hours Examine the stool and vomitus for the presence of blood Monitor the complete white blood cell count and differential daily Non of above A 35-year-old man is evaluated because of a 2-week history of low-grade fevers, fatigue, cough, pleuritic chest pain, and increasing dyspnea on exertion. He is a construction worker and is having difficulty performing his usual tasks. He has a 10-pack-year history of cigarette smoking. On physical examination, he has right chest pain but no respiratory distress at rest. Temperature is 38.2 C, pulse rate is 112/min and regular, and respiration rate is 20/min. There is evidence of a right pleural effusion and no other abnormalities. Peripheral blood leukocyte count is 9,000/L, with 80% neutrophils and 15% lymphocytes. Liver function test results are normal. Chest radiograph shows a moderate right pleural effusion with minimal contralateral shift and no parenchymal infiltrates. Thoracentesis yields minimally turbid yellow fluid with results as follows: Pleural fluid nucleated cell count 3000/L with 5% neutrophils, 85% lymphocytes, and 1% macrophages Pleural fluid total protein 5.2 g/dL Pleural fluid serum lactate dehydrogenase 230 U/L Pleural fluid glucose 80 mg/dL Pleural fluid pH 7.36 Pleural fluid Gram and acid-fast bacilli stains are negative. Tuberculin skin test is negative. Cytologic evaluation for malignant cells is negative. What is the most likely diagnosis? Tubercular pleurisy Lung cancer Parapneumonic effusion Pulmonary embolism Benign asbestos pleural effusion A 37-yr-old man who has had recurrent chest infections since a serious bout of influenza 3-yr ago presents with chronic productive cough. His sputum is tenacious and blood stained. On auscultation you find crackling. What treatment is necessary? Postural drainage Surgical excision Prednisolone Ipratropium Pleurectomy A 38 years old patient, who drunk a lot of alcohol, has severe pneumonia. His condition was worsened, the temperature of body rose to 39-40 °С, an unpleasant smell appeared from a mouth, increased amount of purulent sputum; increased ESR and amount of band leucocytes. On the X-ray in the lower lobe of right lung there is massive infiltration with light area in a center. What complication is it necessary to suspect? Acute pulmonary abscess Bronchiectasis Infarction-pneumonia Gangrene of lungs Empyema of pleura A 48 years old patient, complaints on weakness, dyspnea, pain in the left half of thorax, permanent cough with viscid sputum, in which particles of blood are sometimes determined. For the last 3 months he lost 5 kg of body mass. On the X-ray of lungs there is total homogeneous shade determined from the left side. Organs of mediastinum are displaced to the left. What diagnosis is possible? A. * B. C. D. E. 188. A. * B. C. D. E. 189. A. * B. C. D. E. Lung athelectasis Lung gangrene Total exudative pleurisy Pneumonia Empyema of pleura A 56-year-old construction worker, a heavy smoker, sustains severe trauma to his left chest. Chest pain is severe for several minutes but subsides over the next hour. Because the chest pain does not resolve completely, he is evaluated in the emergency department 2 hours later, where results of a chest radiograph and complete blood count with differential are normal. The next day, he leaves on a week-long vacation to South America. During that time, he has intermittent chest discomfort and gradually increasing dyspnea with exertion. Upon returning home, he sees his physician because of dyspnea. Chest radiograph shows a large left-sided pleural effusion with minimal contralateral shift. At thoracentesis, 500 cc of brownish-colored fluid is removed and analyzed with the following results. Pleural fluid nucleated cell count 4000/mL with 10% neutrophils, 30% lymphocytes, 15% macrophages, and 45% eosinophils Pleural fluid hematocrit 10% Pleural fluid total protein 4 g/dL Pleural fluid serum lactate dehydrogenase 200 UIL Pleural fluid glucose 80 mg/dL Pleural fluid pH 7.35 Cytology test results are negative. Pain medication is prescribed for the patient. When he returns 14 days later, complete blood count shows a leukocyte count of 9000/?L with 20% eosinophils and chest radiograph shows that the pleural effusion has decreased substantially. Which of the following Post-traumatic hemothorax is the most likely diagnosis? Benign asbestos pleural effusion Paragonimiasis Lung cancer Pulmonary infarction A 60-year-old man is evaluated because of a 6-week history of progressive dyspnea on exertion, fatigue, a decrease in appetite, and a weight loss of 1.8 kg. He has a 30-pack-year history of cigarette smoking and drinks two or three cocktails every evening. He has no gastrointestinal complaints and no history of a febrile illness. On physical examination, he is afebrile with normal vital signs. The only abnormalities noted on chest examination are findings compatible with a right pleural effusion. Chest radiograph confirms a pleural effusion occupying 40% of the right hemithorax without evidence of loculation. There are no obvious parenchymal lesions and no mediastinal adenopathy. Results of pleural fluid analysis are as follows. Pleural fluid nucleated cell count 2800/?L with 10% neutrophils, 50% lymphocytes, 30% macrophages, and 10% mesothelial cells Pleural fluid total protein 3.8 g/dL (pleural fluid/serum ratio 0.60) Pleural fluid serum lactate dehydrogenase 210 U/L (ratio of pleural fluid to upper limits of normal serum lactate dehydrogenase 0.72) Pleural fluid amylase 30 mg/dL (pleural fluid/serum ratio 0.5) Pleural fluid glucose 50 mg/dL Pleural fluid pH 7.26 Which of the following is the most likely diagnosis? Malignant effusion Complicated parapneumonic effusion Esophageal rupture Rheumatoid pleurisy Acute pancreatitis 190. A. * B. C. D. E. 191. A. * B. C. D. E. 192. A. * B. C. D. E. 193. A. * B. C. D. E. A 60-year-old man with a history of alcohol abuse is evaluated because of the insidious onset of dyspnea over the course of 6 weeks. He has no cough, chest or abdominal pain, or hemoptysis. He smoked 1.5 packs of cigarettes per day for 25 years and stopped smoking 4 years ago. He has a moderate-sized right pleural effusion. Chest radiograph shows the effusion with minimal contralateral mediastinal shift and is otherwise normal. Pleural fluid analysis shows clear yellow fluid with 500 nucleated cells/L, 10% neutrophils, 25% lymphocytes, 60% macrophages, and 5% mesothelial cells. Pleural fluid values are as follows: Total protein 1.1 g/dL Serum lactate dehydrogenase 4l U/L Serum amylase 20 U/L Glucose 100 mg/dL pH 7.45 Ratio of pleural fluid to serum (PF/S) total protein 0.2 Ratio of pleural fluid to serum lactate dehydrogenase (upper limits of normal) 0.35 Other laboratory results show a serum albumin of 2.4 g/dL, an INR of 1 .5, and a normal urinalysis. Electrocardiogram is normal. Which of the following is the most likely diagnosis? Hepatic hydrothorax Congestive heart failure Chronic pancreatitis Lung cancer Nephrotic syndrome A 72-year-old woman is evaluated because of morning headaches and swelling in the lower extremities that worsens as the day progresses. She is able to sleep supine, using one pillow at night, and notices shortness of breath walking distances greater than 20 feet. On physical examination, significant findings include diminished breath sounds, distant heart sounds, with pulmonic valve component equal in intensity to aortic valve component, and paradoxical splitting of the S2. Laboratory finding include a Pa O2of 59mm Hg, Pa CO2 of 44 mm Hg, and pH of 7.41. Electrocardiogram shows right ventricular hypertrophy with cor pulmonale and right axis deviation. Which of the following is the best rationale for long-term oxygen therapy for this patient? Evidence of cor pulmonale and a PaO2 between 55 and 60 mm Hg The PaO2 is less than or equal to 65 mm Hg Her morning headaches Dyspnea All of the above A man of 38 years old felt ill 2 weeks ago with cough, weakness, increased temperature up to 38,0 °С. His condition suddenly got worse after 7 days of the disease, when chills and sweating appeared, and evening temperature increased up to 39,0 °С. 2 days prior to hospitalization the patient after cough expectorated a large amount of stinky bloody sputum; after this he felt better. Objectively: pulse - 80/min, brteathing rate - 20/min, t - 37,6 °С. What changes are possible on the chest X-ray? Presence of cavity with horizontal level of fluid Displacement of mediastinum to the side of homogeneous shade The homogeneous rounded shade is in the pulmonary tissue Shade in a lower lobe with diagonal upper border Darkening of lung lobe A student complaints on cough with production of mucus-purulent sputum, sometimes with particles of blood, t - 37,6 °С, weakness, sweating. Since childhood he was often ill with cold, for last several years there were exacerbations of COPD twice. Doctor suspected bronchiectatic disease in this patient. What method of investigation may confirm this diagnosis? Bronchography Anamnesis morbi Physical examination of lungs Scintigraphy of lungs Tomography of lungs 194. A. * B. C. D. E. 195. A. * B. C. D. E. 196. A. * B. C. D. E. 197. A. * B. C. D. E. 198. A. * B. C. D. Female patient K., 46 years old, after decreasing of fever after flue noticed pain appeared in a thorax, cough with yellow-green sputum (amount-150 ml a day), sometimes with some blood. Objectively: breathing rate - 36/min. In lungs from the right side lower scapula there is dull sound during percussion, hard breathing, and moist rales. Blood test: L - 18,6х109/l, ESR -64 mm/h. Analysis of sputum: L -80-100 , Er - 40-50, elastic fibers, cocci. X-ray: lung roots are enlarged, from the right side lower lobe is heterogeneously infiltrated with two lighter areas. What is the most possible previous diagnosis? Right-side pneumonia with abscesses Peripheral cancer Infiltrative tuberculosis in the phase of disintegration Exudative pleurisy Infarction-pneumonia Female, 34 years old, has an increase of body temperature up to 38 °С, cough with purulent sputum, weakness, dyspnea, pain in a thorax during breathing. During percussion there is shortening of sound in the lower part of left lung, during auscultation – moist rales. What method of investigation is the decisive one to confirm diagnosis? X-ray examination Bacteriological analysis of sputum Spirometry Pneumotachometry Bronchography Male patient G., 56 years old, complaints on permanent pain in a thorax which disturbs for the last 2 months. Pain is not connected with breathing. There is also moist cough with particles of blood in sputum. Weakness, fatigue are present. On the chest X-ray in the lower lobe of right lung there is spherical shadow, with size of 4x6 cm, related to the lung’s rhadicis. What is the most possible diagnosis? Perypheral lung cancer Tuberculoma Metastasis Pulmonary abscess Pneumonia Man of 26 years old after measles (in childhood) constantly suffers from cough with production of mucus-purulent sputum up to 200 ml, mainly in the morning. There is periodical increase of temperature up to 38 °С. At auscultation - dry, and in lower parts - moist rales. On chest X-ray - there is “web-like” deformation of pulmonary picture. Your diagnosis? Bronchiectasis COPD Bronchial asthma Tuberculosis Pneumosclerosis Man of 26 years old, complaints on prickly pain during breathing, cough, dyspnea. Objectively: t 37,5 °С, breathing rate - 19/min, heart rate and pulse - 92/min; BP - 120/80. Breathing is vesicular. From the left side in lateral and lower regions of thorax in the phase of inspiration and expiration there is sound which increases during pressure with stethoscope and it is preserved after cough. EKG - without pathological changes. Your diagnosis? Acute pleurisy Spontaneous pneumothorax Intercostal neuralgia Subcutaneous emphysema E. 199. A. * B. C. D. E. 200. A. * B. C. D. E. 201. A. * B. C. D. E. 202. A. * B. C. D. E. 203. A. * B. C. D. Dry pericarditis Man of 50 y.o. complaints on dyspnea, cough, pain in the left part of thorax, increasing of temperature up to 37,5 °С. He felt ill three weeks ago. He smokes for 30 years. Objectively: low feeding, cyanosis of lips, emphysematous thorax, on the left side – from the 6th rib and below a dull sound is present. Breathing is absent between scapulas from the left side. X-ray: intensive homogeneous darkening from the left side, shade of heart is shifted to the right. Your diagnosis? Exudative pleurisy Athelectasis of lungs Infiltrative tuberculosis Dry pleurisy Pneumonia Man of 56 years old, alcoholic, felt ill suddenly: temperature increased to 40 °С, weakness, cough appeared with production of dark sputum. Objectively: condition is severe. T - 39,5 °С. Breathing rate - 30/min. Heart rate is 100/min., BP - 110/70. In lungs from the right side there are moist rales. Tones of heart are dull, rhythm is correct, tachycardia. On the chest X-ray film of lungs there is infiltration of right upper lobe. What complication is the most possible? Pulmonary abscess Endocarditis Bronchiectasis Pericarditis Pulmonary bleeding Man of 54 y.o., complaints on pain in a thorax, dyspnea, cough with bloody sputum. In anamnesis: long history of cough with purulent sputum up to 200 ml per day, mostly in the morning, periodically increasing of temperature up to 37,8 °С, sweating, chills. He smokes since 14. Objectively: low weight, skin with grey tint, edema of face, fingers has shape of "drumsticks", in lungs - pulmonary and bang-box sound, in some parts dull sound, dry and moist rales. In blood: leucocytosis, moderately increased ESR. What is the most possible cause of pulmonary bleeding in this case? Bronchiectasis Tuberculosis Chronic bronchitis Pulmonary abscess Pulmonary cancer On the X-ray of 46 y.o. patient, which complaints on increase of temperature and cough with sputum, in the 10th segment of left lung was founded ring-shape shade with a diameter 8 cm with thick walls and horizontal level. Other pulmonary parts - without changes. Diagnosis? Pulmonary abscess Bronchiectasis Tubercular cavern Tuberculoma Gangrene of lungs Patient N., 35 y.o., complaints on cough with large amount of purulent sputum in the morning, sometimes with particles of blood, general weakness, loss of weight. The general condition is satisfactory, thorax of emphysematous form, breathing rate - 18/min. During auscultation there is rough breathing, diffuse dry rales. What instrumental method of investigation is the decisive one for diagnosis? Bronchography Chest X-ray Bronchoscopy with biopsy Spirometry E. 204. A. * B. C. D. E. 205. A. * B. C. D. E. 206. A. * B. C. D. E. 207. A. * B. C. D. E. 208. A. * B. C. Scintigraphy Patient of 19 years old, complaints on increase of temperature up to 39 °С at evenings, severe cough, production of large amount of sputum with an unpleasant smell. He is ill for several years, the last exacerbation is related to overcooling. During comparative percussion of lungs – in right lower parts pulmonary sound is dull, during auscultation – moist rales. What disease is the most possible? Bronchiectasis COPD Abscess of lungs Gangrene of lungs Community-acquired pneumonia Patient of 20 years old complaints on increase of temperature up to 37,5 °С, dyspnea, cough with purulent sputum, sometimes with particles of blood. Objectively: fingers has shape of "drumsticks". During auscultation breathing is hard, dry and moist wheezes are present. On X-ray – pulmonary fibrosis. What is the diagnosis? Bronchiectasis Bronchial asthma COPD Abscess of lungs Canceromatosis of lungs Patient of 25 years old complaints on pain in the left part of thorax, absence of appetite, severe sweating; after 7-days of permanent fever during an attack of cough he produced 150 ml of yellow sputum. Objectively: temperature - 38,7 C; breathing rate – 22/min; pulse-96/min; BP 110/70. Chest X-ray: from the left side there is shade of round form with clear borders, with light areas in a center. What auscultative sign will confirm the diagnosis of this patient? Amphoryc breathing Crepitation Moist rales Bronchial breathing Dry rales Patient of 28 years old, complaints on severe prickly pain in the left part of thorax, connected with breathing, dry cough, subfebrile temperature. He is ill for 3 days, after overcooling. Objectively: position is on the right side, left part of thorax falls behind during breathing, there is clear pulmonary sound at percussion, vesicular breathing is decreased from the left side, in the phase of inspiration and expiration there is sound which increases during pressure with stethoscope and it doesn’t disappear saved after cough. On chest X-ray pulmonary fields are without changes, left sinus is opened incompletely. The most possible diagnosis: Dry pleurisy Pneumonia Acute bronchitis Spontaneous pneumothorax COPD Patient of 50 years old after overcooling developed a fever up to 40 °С, dyspnea and pain in the right part of thorax are present. Approximately 100 ml of purulent sputum with bloody particles and unpleasant smell was producted. On chest X-ray in the right lung there is unhomogeneous massive infiltration with two bright areas. Mycobacteria tuberculosis and atypical cells in sputum were not founded. Diagnosis? Acute abscess of lungs Gangrene of lungs Infiltrative tuberculosis with destruction D. E. 209. A. * B. C. D. E. 210. A. * B. C. D. E. 211. A. * B. C. D. E. 212. A. * B. C. D. E. 213. A. * B. C. Tumor of lungs with destruction Empyema of pleura Patient of 50 years old, entered hospital on the 9th day of disease with complaints on increase of temperature up to 38,5 °С, acute weakness, pain in the area of right scapula during breathing, dry cough. Objectively: Breathing rate -28/min. Pulse - 100/min, signs of intoxication. Under the area of right scapula there is dull percussion sound, bronchial breathing, single moist rales and crepitation. Three days later there was an attack of cough with production of 200 ml of purulent sputum, after that temperature of body decreased. On the chest X-ray film under the corner of scapula an infiltration of lungs of round shape with horizontal level of fluid was found. Diagnosis? Acute pulmonary abscess Pulmonary cyst Cancer of lungs with destruction Bronchiectasis Empyema of pleura Patient came to doctor with exacerbation of COPD. During examination were founded signs of respiratory insufficiency of II degree. What symptom is the main clinical sign of respiratory insufficiency of the II degree? Presence of dyspnea during usual physical exertion Worsening of external breathing functions Presence of arterial hypoxemia as cyanosis Hypertrophy of muscles of neck and abdominal press Perypheral oedema Patient complaints on severe cough with production of 600 ml a day purulent sputum of chocolate color with a putrid smell. Felt ill suddenly, temperature - 39 °С. On the chest X-ray film there is an area of darkening with cavities in a center, with unclear contours and with the level of fluid. What disease may be suspected? Pulmonary gangrene Tubercular cavern Pulmonary abscess Bronchiectasis Cancer of lungs with destruction Patient has fever, temperature - 39 °С, there is cough with production of sputum with unpleasant smell and particles of blood. During auscultation of lungs in right lower lobe there is amphoric breathing, moist rales. On the chest X-ray film: in the right lower lobe there is a cavity 4 cm in diameter, with the level of fluid. What is the possible diagnosis? Pulmonary abscess Gangrene of lungs Infiltrative tuberculosis Cancer of lungs Pneumonia Patient M., 39 years old, is ill with attacks of cough with yellow-brown sputum, pain in a right side, related to the deep breathing, sweating. He is ill for 6 days, after overcooling. Used aspirin. Objectively: T - 39,6 °С, breathing rate - 26/min., pulse - 110/min., BP -110/70. In lower part of right lung - moist loud rales. X-ray: in right lower lobe there is massive unhomogeneous infiltration with lighter areas, sinus is not changed. What complication of disease is the most possible? Abscesses Dry pleurisy Empyema of pleura D. E. 214. A. * B. C. D. E. 215. A. * B. C. D. E. 216. A. * B. C. D. E. 217. A. * B. C. D. E. 218. A. * Spontaneous pneumothorax Pulmonary athelectasis Patient N., 31 y.o., complaints on cough with production of mucus-purulent sputum with an unpleasant smell by “full mouth”, subfebrile temperature, dyspnea, loss of body mass. He is ill since childhood. Objectively: skin is pale, fingers are changed as "drumsticks", nails - "sentinel glass", percussion sound is mosaical, breathing is hard, places of moist rales in the places of dull percussion sound. Your diagnosis: Bronchiectasis Viral pneumonia COPD in the phase of exacerbation Abscess of lungs Hypoplasia of lungs Patient of 54 years old, complaints on shortness of breath during mild physical exertion, cough with some amount of sputum. Objectively: diffuse cyanosis. Thorax of emphysematous form. In lungs there is a bit weakened vesicular breathing with prolonged expiration, dry wheezes. BP -140/80. Pulse - 92/min, rhythmical. Spyrometry: FVC – 36 %, FEV1 – 49 %, FEV1/FVC - 50 %. What is the type of respiratory insufficiency in this patient? Mixed Restrictive Obstructive Respiratory insufficiency is not present It is impossible to make conclusion Patient of 32 y.o. complaints on dyspnea, pain in the right side of thorax during breathing, cough with ferruginous sputum, fever with chills, weakness. Objectively: breathing rate - 24/min, vocal fremitus is increased in the back-lower region of the right part of thorax, during percussion sound is dull, at auscultation – crepitation is heard. After 5 days of treatment dyspnea increased, vocal fremitus became weaker, and it is almost impossible to hear vesicular breathing. What complication developed in this patient? Exudative pleurisy Athelectasis Carnification of lungs Abscesses Pneumothorax Patient of 32 y.o., who drunk a lot of alcohol, has severe pneumonia. His condition was worsened, the temperature of body rose to 39-40 °С, an unpleasant smell appeared from a mouth, increased amount of purulent sputum; increased ESR and amount of band leucocytes. On the X-ray - in the lower lobe of right lung there is massive infiltration with bright area in a center. What complication is it necessary to suspect? Acute pulmonary abscess Bronchiectasis Infarction-pneumonia Gangrene of lungs Empyema of pleura Patient of 51 y.o. complaints on severe dyspnea, pain in the left part of thorax. Objectively: breathing rate - 30/min, heart rate - 108/min. Above the left part of thorax vocal fremitus is significantly decreased, during percussion sound is dull, at auscultation – weak vesicular breathing. On chest X-ray - homogeneous shade up to the level of the 2nd rib with diagonal upper border, organs of mediastinum are displaced to the right. Method of choice in the treatment of this patient is: Pleural punction B. C. D. E. 219. A. * B. C. D. E. 220. A. * B. C. D. E. 221. A. * B. C. D. E. 222. A. * B. C. D. E. 223. Intravenous usage of large doses of glucocorticosteroids Emergent bronchoscopy Inhalation of b2-agonists of short action Intravenous antibiotics Patient of 52 y.o. came to the doctor with complaints on temperature 38,6 С, weakness, sweating, cough with production of purulent sputum (up to 100 ml a day) with an unpleasant smell, pain in the right part of thorax during breathing. On the chest X-ray it was found “ring-like” shade with the level of fluid. When abscess may be called “chronic”? In case of absence of healing signs after a monthly treatment In case of presence of complications In the case of development of chronic bronchitis In the case of development of diffuse pneumosclerosis In the case of development of pulmonary insufficiency Patient V. complaints on dyspnea at rest, fever, sweating, pain in a thorax. During examination the right part of thorax is slowed down in the act of breathing, percussion - dull sound, auscultation absence of respiratory sounds. On the X-ray: homogeneous darkening of 2/3 of right lung. The most informative diagnostic method in this case: Pleural punction Pneumotachometry Bronchography Bronchoscopy Spyrometry Student of 17 years old, in childhood was often ill with respiratory diseases. In a period between respiratory viral diseases, cough was present with the production of sputum. Once noticed particles of blood in sputum. In lungs, especially from the right side, there are different moist rales. Sputum is mucous-purulent, up to 50 ml per day. On the chest X-ray film – fibrosis and “web” picture mostly in the right lower lobe. What is the most possible diagnosis? Bronchiectasis Chronic pulmonary disease Chronic bronchitis Metapneumonic pneumosclerosis Metatubercular pneumosclerosis Patient of 36 years old, complaints on dyspnea, feeling of pressure in the right half of thorax, increasing of temperature up to 38,7 °С, cough with production of small amount of mucus-purulent sputum. He is ill for a week, after overcooling. Objectively: light acrocyanosis of lips, pulse is rhythmic, 90/min, BP - 140/85. The right half of thorax is slowed down in the act of breathing. Percussion – from the right side below corner of scapula there is dull sound. In this region breathing sounds are not heard. What is the most possible diagnosis? Right side exudative pleurisy Bronchiectasis Right side lower lobe pneumonia Right side pulmonary athelectasis Right side abscess of lungs Patient of 68 years old, complaints on dry cough, elevation of temperature up to 37,5 °С, pain in a thorax during breathing. 5 days ago he had trauma of thorax. Objectively: pallor, lag of right half of thorax during breathing. Auscultation – weakened breathing and sound of friction of pleura in right lower region. In blood: leucocytosis, increased ESR. X-ray - pulmonary fields are not changed. Your clinical diagnosis? A. * B. C. D. E. 224. A. * B. C. D. E. 225. A. * B. C. D. E. 226. A. * B. C. D. E. 227. A. B. C. * D. E. 228. A. * B. Dry pleurisy Pneumonia Exudative pleurisy Thraumatic pneumothorax Cancer of lungs Patient D., 47 years old, came to the doctor with complaints on fever up to 39 °С, sweating, dry cough, dyspnea, pain in the right part of thorax during deep breathing and cough. Felt ill suddenly six days ago. Objectively: condition is severe, skin is pale, breathing rate - 28/min, breathing sounds are not heard in the lower lobe of right lung, during percussion there is dull sound, during auscultation breathing is significantly weakened. Your previous diagnosis: Right-side exudative pleurisy Pneumonia Acute bronchitis Thromboembolia of pulmonary artery Right-side hydrothorax Patient L., 26 years old, with left-side lower-lobe pneumonia during cough feels acute pain in the left part of thorax. Objectively: diffuse cyanosis, dilation of the left half of thorax, at percussion tympanitis, auscultation - absence of respiratory sounds above the left part of thorax. Displacement of right border of heart to the medioclavicular line. What method of investigation will be the most informative in this case: Chest X-ray Bronchoscopy Bronchography Pneumotachymetry Spyrometry Student of 22, felt ill suddenly. He has fever up to 39 °С, cough, pain under the right scapula during inspiration and cough. In 3 days the dyspnea increased, respiratory rate is up to 32/min. Below the corner of right scapula there is dull percussion sound, vocal fremitus is decreased, breathing sounds are not auscultated. The most effective method of treatment is: Pleural punction Prescribing of furosemid Bed regimen Prescribing of cephalosporin Physiotherapy The patient who has experienced blunt trauma to the chest is at risk for developing a hemothorax. Which would the physician expect to find in a patient with a hemothorax? Hemoptysis Paradoxical chest movements Percussion dullness on affected side Hypertympanic sound on affected side Non of above Woman of 55 years old, complaints on dull pain in the right half of thorax, unproductive cough, dyspnea. In anamnesis – rheumatic fever. During examination of lungs from the right side from the third rib and below there is dull sound at percussion, breathing in this area is significantly weakened. On the chest X-ray: homogeneous darkening with diagonal upper border from the 3rd rib and below. Analysis of received exudate: Rivalt test - positive, microscopy revealed lymphocytes. Previous diagnosis? serous pleurisy Exudative Right-side hydrothorax C. D. E. 229. A. * B. C. D. E. Empyema of pleura Chylothorax Mezotelioma of pleura Woman of 58 years old, entered the hospital with complaints on dyspnea and palpitation. Objectively: condition is severe, nervous, breathing is noisy with participation of additional breathing muscles, periodical cramps, diffuse cyanosys. In lungs – diffuse dry rales, in lower parts of lungs breathing is significantly weaker. Pulse - 100/min, oedema, 3 extrasystoles/min, BP - 140/100, Ра O2 - 45, pH - 7,3. What is the main syndrome in this case? Respiratory insufficiency Blood hypertension Tachycardia Arrhythmia Heart failure