Pulmonary - Part 1
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- 1.A 9-year-old boy was identified in childhood as having an elevated sweat chloride. Though he appeared to be a normal term baby, his neontal course was complicated by the development of meconium ileus. Throughout childhood he has experienced multiple increasingly severe bouts of pneumonia with a productive cough, often with Pseudomonas aeruginosa, and later Burkholderia cepacea, cultured from sputum. Based upon these findings, he is at greatest risk for development of which of the following pulmonary abnormalities?
- A.
Adenocarcinoma
- B.
Bronchiectasis
- C.
Lymphangiectasis
- D.
Pleural fibrous plaques
- E.
Pneumocystis carinii (jiroveci) pneumonia
- F.
Pneumothorax
- 2.A 70-year-old woman has been at an extended care facility for the past two years because of her increasing inability to attend to activities of daily living. She can no longer recognize family members. She has no movement disorder, but is lethargic and spends most of her days in a wheelchair or in bed. She develops an acute febrile illness and is noted to be coughing up increasing quantities of yellowish sputum. Her temperature is 38.2 C. A chest radiograph shows infiltrates that nearly fill the left lower lobe. Her family elects not to treat her acute illness, and she dies 4 days later. At autopsy, there is extensive consolidation of the left lower lobe, with numerous neutrophils within alveoli. Which of the following infectious agents is most likely to cause her pulmonary disease?
- A.
Pneumocystis carinii (jiroveci)
- B.
Listeria monocytogenes
- C.
Cryptococcus neoformans
- D.
Mycobacterium tuberculosis
- E.
Legionella pneumophila
- F.
Staphylococcus aureus
- G.
Streptococcus pneumoniae
- H.
Influenza A virus
- 3.A 9-year-old girl has complained of difficulty breathing for the past week. Her vital signs include T 37.9 C, P 80/minute, RR 25/minute, and BP 110/60 mm Hg. On physical examination, her lung fields are clear to auscultation. Her heart rate is regular and no murmurs or gallops are heard. A chest radiograph shows prominent hilar lymphadenopathy along with a 1 cm peripheral right lung nodule in the middle lobe. No infiltrates or masses are present. A sputum gram stain shows normal flora and routine bacterial culture reveals no pathogens. Which of the following conditions is she most likely to have?
- A.
Hypersensitivity pneumonitis
- B.
Mycobacterium tuberculosis infection
- C.
Bronchial carcinoid tumor
- D.
Infective endocarditis
- E.
Goodpasture syndrome
- 4.On the 11th postoperative day following a radical prostatectomy for adenocarcinoma of the prostate, a 70-year-old man is recovering uneventfully. He then ambulates to the bathroom, but upon returning to his bed he suddenly becomes extremely dyspneic and diaphoretic, with chest pain, palpitations, and a feeling of panic. Which of the following post-operative complications has he most likely developed?
- A.
Pulmonary edema
- B.
Pleural effusion
- C.
Atelectasis
- D.
Thromboembolus
- E.
Diffuse alveolar damage
- 5.A 50-year-old woman has lived in Oslo, Norway all her life and worked as a seamstress. She is a non-smoker, but she has had increasing shortness of breath, fever, weight loss, and night sweats for the past 4 months. On physical examination her temperature is 37.6 C. There are fine rales auscultated in all lung fields. A chest radiograph reveals hilar lymphadenopathy and a reticulonodular pattern of small densities in all lung fields. She demonstrates anergy by skin testing to mumps and Candida antigens. A transbronchial biopsy is performed that microscopically shows numerous small pulmonary interstitial non-caseating granulomas. Which of the following is the most likely diagnosis?
- A.
Histoplasmosis
- B.
Adenocarcinoma
- C.
Sarcoidosis
- D.
Usual interstitial pneumonitis
- E.
Berylliosis
- F.
Tuberculosis
- G.
Extrinsic allergic alveolitis
- 6.A 36-year-old woman has had increasing dyspnea for 8 years. She has no cough or increased sputum production. On physical examination there is hyperresonance to percussion. A chest radiograph reveals increased lung volumes with flattening of the diaphragmatic leaves bilaterally. The right heart border is prominent. A chest CT scan demonstrates decreased attenuation in all lung fields. Which of the following laboratory findings is she most likely to have?
- A.
Decreased serum ceruloplasmin
- B.
Increased sweat chloride
- C.
Elevated blood ethanol
- D.
Decreased serum alpha-1-antitrypsin
- E.
Positive urine opiates
- F.
Positive antinuclear antibody test
- 7.A 55-year-old man with a 55 pack year history of smoking cigarettes has recently experienced an episode of hemoptysis along with his usual cough. On physical examination there are no abnormal findings. He has a sputum cytology examination performed that on microscopic examination shows atypical cells with hyperchromatic nuclei and orange-pink cytoplasm. Labortory studies show a serum calcium of 11.3 mg/dL, with phosphorus 2.1 mg/dL. Which of the following chest radiographic findings is this man most likely to have?
- A.
Large hilar mass
- B.
Pneumonia-like consolidation
- C.
Peripheral nodule
- D.
Carinal compression
- E.
Left pleural thickening
- 8.During a cardiac arrest, a 58-year-old man, a non-smoker, receives cardiopulmonary resuscitative measures and is brought to the hospital, where he is intubated. During the intubation procedure he suffers aspiration of gastric contents (pasta with mushrooms and peas). Over the next 10 days he develops a non-productive cough along with a fever to 37.9 C. A chest radiograph reveals a 4 cm diameter mass with an air-fluid level in the right lung. A sputum gram stain reveals mixed flora. Which of the following conditions is he most likely to have?
- A.
Squamous cell carcinoma
- B.
Lung abscess
- C.
Chronic bronchitis
- D.
Bronchiectasis
- E.
Bronchopulmonary sequestration
- 9.A 66-year-old woman has had a worsening non-productive cough with malaise for the past week. Her temperature increases to 37.4 C. A chest radiograph reveals diffuse bilateral pulmonary interstitial infiltrates in all lung fields. A sputum gram stain reveals normal flora and few neutrophils. She recovers over the course of the next two weeks without sequelae. Infection with which of the following organisms most likely caused her illness?
- A.
Mycobacterium tuberculosis
- B.
Streptococcus pneumoniae
- C.
Influenza A virus
- D.
Cryptococcus neoformans
- E.
Mycobacterium avium-complex
- 10.
- A.
Silicosis
- B.
Radon gas exposure
- C.
Smoking
- D.
Asbestosis
- E.
Passive smoking
- 11.A 41-year-old man with a 6 kg weight loss over the past 3 months now has had worsening fever, non-productive cough, and dyspnea for the past 3 days. His temperature is 38.2 C and there are diffuse rales in both lungs on auscultation. A chest radiograph shows patchy infiltrates in both lungs. Laboratory studies show a WBC count of 3250/microliter with differential of 78 segs, 3 bands, 5 lymphs, 11 monos, 2 eosinophils, and 1 basophil, Hgb 13.8 g/dL, Hct 41.4%, MCV 91 fL, and platelet count 317,000/microliter. His CD4 lymphocyte count is 79/microliter. Cryptosporidium parvum organisms are found in a stool specimen. A bronchoalveolar lavage is performed, yielding fluid that microscopically demonstrates pink, foamy exudate with little inflammation. Which of the following additional findings on microscopic examination is he most likely to have in the BAL specimen?
- A.
Acid fast bacilli
- B.
Branching septate hyphae
- C.
Multiple cysts with GMS stain
- D.
Hemosiderin-laden macrophages
- E.
Short gram positive rods
- 12.A 60-year-old man has a 90 pack year history of smoking. For the past 5 years, he has had a cough productive of copious amounts of mucoid sputum for months at a time. He has had episodes of pneumonia with Streptococcus pneumoniae and E. coli cultured. His last episode of pneumonia is complicated by septicemia and brain abscess and he dies. At autopsy, his bronchi microscopically demonstrate mucus gland hypertrophy. Which of the following conditions is most likely to explain his clinical course?
- A.
Squamous cell carcinoma
- B.
Congestive heart failure
- C.
Chronic bronchitis
- D.
Bronchial asthma
- E.
Centrilobular emphysema
- F.
Panlobular emphysema
- G.
Bronchiectasis
- 13.A 66-year-old man has had increasing dyspnea for the past year. He is a smoker. He is retired from the construction business. There are some rales auscultated in both lungs on physical examination. A chest radiograph reveals bilateral diaphragmatic pleural plaques with focal calcification as well as diffuse interstitial lung disease. A sputum cytology shows no atypical cells. Pulmonary function studies reveal a low FVC and a normal FEV1/FVC ratio. These findings are most likely to suggest prior exposure to which of the following environmental agents?
- A.
Cotton fibers
- B.
Silica dust
- C.
Fumes with iron particles
- D.
Asbestos crystals
- E.
Beryllium
- F.
Mold spores
- 14.A 58-year-old man has been a smoker for 40 years. He has had an 8 kg weight loss over the past 6 months accompanied by a chronic cough and malaise. He reports no fever, nausea, or vomiting. He had a recent episode of hemoptysis. A chest radiograph reveals a 5 cm diameter mass in the medial left upper lobe. Bronchoscopy reveals a mass lesion involving the left superior segmental bronchus. Which of the following cytologic findings is most likely to be present in this man?
- A.
Cysts staining with GMS in a bronchoalveolar lavage fluid
- B.
Pleural fluid with atypical mesothelial cells
- C.
Epthelioid cells with necrotic debris in a fine needle aspirate
- D.
Malignant appearing squamous cells in sputum
- E.
Intranuclear inclusions in large epithelial cells in bronchoalveolar lavage fluid
- 15.A 44-year-old man with a history of chronic alcohol abuse has lost 6 kg in the past five months. He has had a cough with hemoptysis along with pleuritic chest pain for the past 2 weeks. On physical examination his temperature is 37.5 C. A chest radiograph reveals a bilateral reticulonodular pattern of infiltrates. A transbronchial biopsy is performed and on microscopic examination shows epithelioid cells with necrotic debris. Laboratory studies show a WBC count of 5890/microliter with 78% granulocytes, 15% lymphocytes, and 7% monocytes. Which of the following additional histologic findings is most likely to be present on his biopsy?
- A.
Branching, septated hyphae
- B.
Pleomorphic cells with dark, angular nuclei
- C.
Clusters of small RBC-sized cysts staining with GMS
- D.
Small, rounded hyperchromatic cells with a high N/C ratio
- E.
Acid fast bacilli
- 16.A 20-year-old man falls to the ground while jogging along a city street early one morning. He suffers a minor abrasion to his left hand. However, within minutes he is very dyspneic and has right-sided chest pain. He walks into a nearby store, and the manager calls for an ambulance. On arrival at the hospital, he has tachypnea and tachycardia. On physical examination breath sounds are absent over the right lung fields. A chest radiograph shows that the mediastinum is shifted to the left, and there are no fractures. A thoracentesis on the right yields a rush of air. Which of the following conditions is most likely to have given rise to these events?
- A.
Bronchopleural fistula
- B.
Paraseptal emphysema
- C.
Foreign body aspiration
- D.
Intrinsic asthma
- E.
Pulmonary atherosclerosis
- 17.Following a vehicular accident with blood loss leading to prolonged, severe hypotension, a 30-year-old man is intubated and placed on a mechanical ventilator. He has progressively decreasing oxygen saturations despite increasing PEEP and FI02 of 100%. He remains afebrile. He dies 3 days later. At autopsy, the distal lungs show pink hyaline membranes, thickened interstitium, and many macrophages but few neutrophils. Which of the following pulmonary diseases most likely complicated his course?
- A.
Bronchopneumonia
- B.
Chronic bronchitis
- C.
Bronchiectasis
- D.
Viral pneumonia
- E.
Diffuse alveolar damage
- 18.A 51-year-old man complains of a slight cough he has had for a week. He is a non-smoker. On auscultation of the chest his lung fields are clear. A chest radiograph shows a subpleural "coin lesion" 2 cm in diameter in the right upper lobe. Which of the following is the most likely diagnosis?
- A.
Small cell anaplastic carcinoma
- B.
Granuloma
- C.
Bronchiectasis
- D.
Exogenous lipid pneumonia
- E.
Silicosis
- 19.A 60-year-old man has had a cough without production of much sputum for the past week. On physical examination he is afebrile. There are decreased breath sounds at the right lung base. A chest x-ray reveals an area of consolidation in the right lower lobe. He is given antibiotic therapy, but a month later the radiographic picture has not changed, and his cough continues. A bronchoalveolar lavage is performed and yields atypical cells along with scattered alveolar macrophages. Which of the following is the most likely diagnosis?
- A.
Mycoplasma pneumonia
- B.
Bronchioloalveolar carcinoma
- C.
Sarcoidosis
- D.
Pulmonary infarction
- E.
Silicosis
- 20.A 25-year-old man receives a bone marrow transplant for treatment of acute myelogenous leukemia. He develops increasing dyspnea 3 weeks later, along with fever and cough. On physical examination his temperature is 37.8 C. A chest radiograph shows irregular interstitial infiltrates. A bronchoalveolar lavage is performed an on cytologic examination shows cells that are enlarged and have prominent intranuclear inclusions. He is most likely to have an infection with which of the following organisms?
- A.
Toxoplasma gondii
- B.
Candida albicans
- C.
Cytomegalovirus
- D.
Pneumocystis carinii (jirovecii)
- E.
Mycobacterium tuberculosis
- F.
Influenza B virus
- G.
Respiratory syncytial virus
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