Asthma

Chapter 29 Asthma



Some wheeze, some don’t, but it’s still serious.




Clinical Case Problem 1: A 22-Year-Old Man with a Chronic Cough


A 22-year-old man presents to your office for assessment of a chronic cough. He has just moved to your city and will be attending the university there. He has moved into an apartment in the basement of a house.


As soon as he moved in, he began to notice a chronic, nonproductive cough associated with shortness of breath. He has never had these symptoms before, and he has no known allergies. When he leaves for school for the day, the symptoms disappear. The symptoms are definitely worse at night.


His landlady has three cats. He did not think he was allergic to cats, but now he thinks that might be the problem.


On examination, his respiratory rate is 16 breaths/minute and regular. He is in no distress at the present time. There are a few expiratory rhonchi heard in all lobes. His blood pressure is 120/70   mm Hg, and his pulse is 72 beats/minute and regular.



Select the best answer to the following questions




1. What is the most likely diagnosis in this patient?


a. paroxysmal nocturnal cough syndrome

b. hyporesponsive airways disease

c. cough variant asthma

d. allergic bronchitis

e. none of the above

2. In children, which of the following statements is (are) true?


a. it is sometimes difficult to differentiate asthma from bronchiolitis

b. some children with an episode of bronchiolitis do not develop asthma

c. the relationships among bronchiolitis, ongoing bronchial hyperactivity, and asthma are unclear, although many children with bronchiolitis develop asthma

d. a, b, and c

e. none of the above

3. Which of the following is (are) included in the working definition of asthma?


a. reversible airway obstruction

b. airway inflammation

c. bronchial airway hyperresponsiveness to a variety of stimuli

d. expiratory rhonchi

e. a, b, and c

f. all of the above

4. Which of the following statements regarding incidence and mortality of asthma is (are) false?


a. the mortality from asthma is increasing

b. the number of cases of asthma from various causes continues to increase

c. asthma mortality tends to be higher in inner cities in minorities

d. all of the above

e. none of the above

5. Asthma, from a pathophysiologic basis, is primarily


a. a bronchoconstricting process

b. an allergenic stimulus process

c. an inflammatory process

d. a bronchial hyperreactivity process

e. an immunoglobulin E–mediated antigen-antibody reaction

6. Following antigenic stimulation of the bronchial airway, which cell is most responsible for the beginning of the airway’s response?


a. the basophil

b. the mast cell

c. the eosinophil

d. the bronchial epithelial cell

e. the bronchial mucus-producing goblet cells

7. What substance(s) released by the cell is (are) most responsible for the beginning of the airway’s response?


a. histamine

b. proteolytic enzymes

c. heparin

d. chemotactic factors

e. all of the above

8. The parameter most useful in evaluating a patient with asthma is


a. peak flow

b. peak inspiratory flow rate

c. forced expiratory volume in 1 second (FEV1)

d. none of the above

e. all of the above

9. The main classification classes for asthma as provided by the Expert Panel Report 3 (2007) from the National Heart, Lung, and Blood Institute include


a. severe persistent

b. moderate persistent

c. mild persistent

d. intermittent

e. all of the above

10. The reversible airflow obstruction seen in asthma results from which of the following?


a. bronchoconstriction

b. mucous plug formation

c. edema

d. a and b

e. a, b, and c

11. Which of the following is (are) a clinical hallmark(s) of asthma?


a. cough

b. nocturnal dyspnea

c. wheezing

d. shortness of breath

e. a, c, and d

12. Which of the following is (are) associated with an increase in asthma incidence?


a. migration from a rural to an urban environment

b. migration from more developed countries to Indonesia, Greece, or India

c. migration from a Third World country to a westernized country

d. migration from temperate countries to more tropical countries

e. a and c


Clinical Case Problem 2: A 24-Year-Old Runner with Wheezing and Shortness of Breath


A 24-year-old otherwise healthy cross-country runner reports wheezing and shortness of breath only when she is exercising, especially in the cold air. These symptoms are getting worse.



13. Which of the following statements regarding exercise-induced bronchospasm (EIB) is false?


a. most patients with EIB already have clinically recognized asthma

b. EIB can occur in exercisers with no history or symptoms of asthma otherwise

c. during the past few decades, the prevalence of EIB has been increasing in elite athletes

d. EIB is found especially in those who engage in endurance sports

e. EIB is accurately diagnosed by the characteristic history

14. Which of the following is the agent of choice for the treatment of acute symptoms in these circumstances?


a. inhaled beta2 agonists

b. oral aminophylline

c. inhaled anticholinergics

d. inhaled sodium cromoglycate

e. oral corticosteroids

15. What is the mechanism of action of the agent of choice in question 14?


a. mast cell stabilizer

b. inhibitor of early-phase reaction

c. inhibitor of late-phase reaction

d. bronchodilator

e. none of the above

16. What is the pre-exercise preventive treatment of choice for EIB?


a. cromolyn or nedocromil inhaler

b. leukotriene modifiers

c. inhaled anticholinergic

d. inhaled steroid

e. inhaled beta2 agonist

17. Nonpharmacologic means of reducing EIB include all of the following except


a. a high-salt diet may decrease EIB by improving vascular volume

b. nose breathing

c. warming up for a 5-kilometer run by doing short sprints 20 minutes before

d. regular intake of higher levels of cold-water fish or fish oil may reduce EIB

e. a and c are both false

18. For a patient with EIB who has frequent symptoms despite nonpharmacologic treatment modalities and a beta2 agonist for acute symptoms, choose the list of long-term medications for better control in the correct order of efficacy (most effective to least effective).


a. salmeterol inhaled (Serevent)    >    inhaled corticosteroid    >    montelukast (Singulair)    >    theophylline

b. cromolyn inhaled (Intal)    >    montelukast (Singulair)    >    theophylline    >    salmeterol inhaled (Serevent)

c. tiotropium inhaled (Spiriva)    >    cromolyn inhaled (Intal)    >    montelukast (Singulair)    >    theophylline

d. inhaled corticosteroid    >    montelukast (Singulair)    >    salmeterol inhaled (Serevent)    >    theophylline

e. salmeterol inhaled (Serevent)    >    cromolyn inhaled (Intal)    >    montelukast (Singulair)    >    theophylline

19. Vocal cord dysfunction can masquerade as EIB or asthma. Characteristics of vocal cord dysfunction include all of the following except


a. hallmark symptoms include a sense of throat closing or choking with severe shortness of breath

b. it is found usually in highly competitive adolescent and young adult men

c. a bronchial provocation challenge test often needs to be done to exclude other entities such as EIB

d. directly witnessing an attack during exercise often is key in making a diagnosis

e. it usually occurs in 20- to 40-year-old women who often have a history of a psychological disorder

20. What is the chief characteristic of exercise-induced hyperventilation?


a. excess CO2 buildup during exercise leading to compensatory deep rapid breathing

b. loss of control of breathing, often during intense exercise, resulting in rapid shallow breaths

c. a method of banking oxygen just before intense exercise that may be mistaken for EIB

d. a recurrent syndrome triggered by even mild exercise in patients with panic disorder

e. none of the above


Clinical Case Problem 3: A 30-Year-Old New Patient with Chronic Asthma


Mr. Smith is a 30-year-old accountant who has noticed that his asthma, which he has had since he was a young child, has gotten worse. He has recently moved from a rural area to the urban area where you practice.



21. Which of the following stepped care classifications used to guide pharmacotherapy in asthma require(s) environmental control as the necessary first step for his treatment?


a. intermittent asthma

b. mild persistent asthma

c. moderate persistent asthma

d. severe persistent asthma

e. all of the above

22. All except which of the following are characteristics of mild persistent asthma?


a. symptoms occurring more than twice a week but less than once a day

b. exacerbations that affect activity

c. peak expiratory flow (PEF) greater than 80% of personal best

d. PEF variability of 20% to 30%

e. nocturnal symptoms two to three times per week

23. Which of the following most accurately describes the preferred pharmacologic treatment of moderate persistent asthma in adults?


a. inhaled sodium cromoglycate alone

b. inhaled beta2 agonists alone

c. inhaled corticosteroids alone

d. daily inhaled corticosteroids plus long-acting inhaled beta2 agonists, if needed

e. inhaled sodium cromoglycate continually plus intermittent inhaled beta2 agonists

24. All except which of the following are characteristics of severe persistent asthma?


a. continual symptoms

b. frequent exacerbations that may last days

c. infrequent nighttime symptoms

d. PEF rates less than 60% of personal best

e. PEF variability of more than 30%

25. Pharmacotherapy of severe persistent asthma includes


a. high-dose steroids by mask

b. long-acting bronchodilator

c. sustained-released theophylline

d. quick relief with an inhaled beta2 agonist as needed

e. all of the above

26. In a patient whose PEF rate is less than 50% of personal best, suggesting a severe exacerbation, the initial home treatment includes which of the following?


a. an inhaled short-acting beta2 agonist administered three times by metered-dosed inhaler or one time by nebulizer

b. inhaled cromolyn, three times by metered-dosed inhaler or one time by nebulizer

c. an inhaled corticosteroid, administered three times by metered-dosed inhaler or one time by nebulizer

d. subcutaneous self-administered epinephrine

e. none of the above

27. Which of the following pulmonary function tests is the most useful for diagnosis of asthma?


a. decreased forced vital capacity (FVC)

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Asthma

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