Pulmonary - Part 2

25 Questions | By Chachelly | Last updated: Nov 12, 2016 | Total Attempts: 325

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1.

A 55-year-old woman has had fever and dyspnea for a month along with a 2 kg weight loss. On physical examination her temperature is 37.7 C. A chest radiograph shows a reticulonodular pattern along with prominent hilar lymphadenopathy. A transbronchial lung biopsy is performed, and microscopic examination shows no viral inclusions, no fungi, no acid fast bacilli, and no atypical cells. Which of the following diseases is she most likely to have?
- A.
  
  Silicosis
- B.
  
  Sarcoidosis
- C.
  
  Asbestosis
- D.
  
  Tuberculosis
- E.
  
  Usual interstitial pneumonitis
2.

A 55-year-old man has been a cigarette smoker for the past 39 years. He has noted some blood-streaked sputum on coughing during the past week. He also has back pain. A chest radiograph shows a small 3 cm right hilar mass with several 1 to 2 cm peripheral lung nodules. A bone scan reveals multiple areas of increased uptake in the vertebrae, ribs, and pelvis. A sputum cytology reveals the presence of clusters of small cells having hyperchromatic nuclei and almost no cytoplasm. Which of the following laboratory test findings is he most likely to have as a consequence of his lung disease?
- A.
  
  Positive antinuclear antibody
- B.
  
  Platelet count of 55,000/microliter
- C.
  
  Plasma cortisol at 8 am of 5 microgm/dL
- D.
  
  Serum sodium of 113 mmol/L
- E.
  
  Hyperuricemia
3.

A 40-year-old woman has had a high fever for a week, accompanied by a cough productive of yellowish sputum. On physical examination her temperature is 38.2 C. There are diffuse rales in all lung fields. Her chest radiograph reveals patchy infiltrates in all lung fields, and there is a 4 cm rounded area of consolidation in the left upper lobe that has an air-fluid level. Examination of her sputum reveals numerous neutrophils. Which of the following infectious agents is most likely causing her pulmonary disease?
- A.
  
  Staphylococcus aureus
- B.
  
  Aspergillus niger
- C.
  
  Mycobacterium tuberculosis
- D.
  
  Mycoplasma pneumoniae
- E.
  
  Adenovirus
4.

At autopsy, a 60-year-old man is found to have a peripheral 7 cm area of golden-yellow consolidation on sectioning of the left lung. Microscopically, this area has alveoli filled with foamy macrophages. Which of the following conditions involving his lung is most likely to be responsible for this finding?
- A.
  
  Mycoplasma pneumoniae infection
- B.
  
  Cystic fibrosis
- C.
  
  Adenocarcinoma
- D.
  
  Silicosis
- E.
  
  Squamous cell carcinoma
- F.
  
  Malignant mesothelioma
- G.
  
  Thromboembolism
5.

A 12-year-old girl has the acute onset of dyspnea and wheezing. She coughs up a large, thick mucus plug. She has experienced similar previous episodes for the past 7 years, all of which lasted 1 to 6 hours. On physical examination her vital signs include T 37.1 C, P 109/minute, RR 27/minute, and BP 90/60 mm Hg. There are decreased breath sounds in all lung fields. A chest radiograph reveals hyperinflation but no infiltrates. Laboratory studies show WBC count of 8300/microliter with differential count of 60 segs, 3 bands, 16 lymphs, 10 monos, and 11 eosinophils. A sputum sample examined microscopically has increased numbers of eosinophils. Which of the following is the most likely diagnosis?
- A.
  
  Mycoplasma pneumonia infection
- B.
  
  Cystic fibrosis
- C.
  
  Hypersensitivity pneumonitis
- D.
  
  Bronchial asthma
- E.
  
  Aspiration of gastric contents
6.

A 40-year-old previously healthy woman, a non-smoker, has had episodes of fever, non-productive cough, and dyspnea over the past 3 months. Her symptoms disappeared after a month's vacation, but reappeared when she returned home to take care of her canaries. On physical examination there are no abnormal findings. A chest radiograph shows fine diffuse and nodular infiltrates in all lung fields. Her disease is most likely to be produced via which of the following mechanisms?
- A.
  
  Mast cell degranulation
- B.
  
  Progressive interstitial fibrosis
- C.
  
  Antigen-antibody complex formation
- D.
  
  Langerhans cell proliferation
- E.
  
  Infection with Mycobacterium kansasii
7.

A 63-year-old woman has had increasing dyspnea for 5 years. On physical examination her lungs are hyper-resonant without dullness. Tactile vocal fremitus is slightly decreased over all lung fields. Scattered expiratory wheezes and inspiratory rhonchi are present without basal crackles. She has a chest radiograph that reveals increased lung volumes and flattening of the diaphragmatic leaves. Spirometry demonstrates an FEV1 that is decreased more than the FVC so that the FEV1/FVC ratio is less than 70% of normal. Which of the following inhaled substances, which increases the elaboration of neutrophil elastase, is most likely to cause her pulmonary disease?
- A.
  
  Chlorine
- B.
  
  Silica
- C.
  
  Carbon monoxide
- D.
  
  Nicotine
- E.
  
  Carbon
8.

A 54-year-old man has had increasing dyspnea for the past 6 years, but no cough. On physical examination there is increased jugular venous distension. He is afebrile. A chest radiograph shows increased lucency in upper lung fields and increased lung volumes, with flattening of the diaphragmatic leaves. There are no infiltrates. The pulmonary arteries are enlarged and prominent bilaterally, and his right heart border is enlarged. Which of the following pathologic findings is most likely to be present in his main pulmonary arteries?
- A.
  
  Granulomatous vasculitis
- B.
  
  Organizing thromboemboli
- C.
  
  Medial dissection
- D.
  
  Atherosclerosis
- E.
  
  Aneurysm formation
9.

A 44-y/o F, non-smoker, has had a fever and cough for the past 4 days. She does not have hemoptysis or weight loss, malaise, nausea, or vomiting. On physical examination her temperature is 37.6 C. There are decreased breath sounds over the right upper lung. A radiograph reveals a 6 cm area of infiltrates in the right upper lobe. She is given a course of antibiotic therapy, but her ough persists. A month later her chest x-ray now reveals a 3 cm peripheral mass in the right upper lobe. Which of the following neoplasms is most likely to be present in this woman?
- A.
  
  Squamous cell carcinoma
- B.
  
  Small cell anaplastic carcinoma
- C.
  
  Adenocarcinoma
- D.
  
  Mesothelioma
- E.
  
  Carcinoid tumor
10.

A 70-year-old woman has been bedridden for 5 weeks following a cerebrovascular accident (CVA). She has the sudden onset of dyspnea, but has no further symptoms until two days later when she experiences left sided pleuritic chest pain. A day later she suffers another CVA and dies. At autopsy, she is found to have a wedge-shaped area of hemorrhage based on the pleura of the left lower lobe. Which of the following pathologic findings in her pulmonary arterial branches is she most likely to have?
- A.
  
  Atherosclerosis
- B.
  
  Aspergillosis
- C.
  
  Fat embolism
- D.
  
  Vasculitis
- E.
  
  Thromboembolism
11.

A 38-year-old previously healthy woman has had a worsening non-productive cough for the past 4 days. On physical examination her temperature is 38.3 C. A chest radiograph shows patchy infiltrates and diffuse interstitial markings. Laboratory studies show a sputum gram stain with mixed flora. Her Hgb is 12.9 g/dL, platelet count 229,450/microliter, and WBC count 5815/microliter. Her cold agglutinin titer is elevated. Following a course of erythromycin therapy, she improves, with no complications. Which of the following infectious agents is most likely to cause the pulmonary disease seen in this woman?
- A.
  
  Nocardia asteroides
- B.
  
  Mycoplasma pneumoniae
- C.
  
  Mycobacterium kansasii
- D.
  
  Respiratory syncytial virus
- E.
  
  Chlamydia psittici
- F.
  
  Adenovirus
- G.
  
  Klebsiella pneumoniae
12.

A 23-year-old primigravida is found on prenatal testing to have an elevated hemoglobin A1C level. Her pregnancy is uncomplicated until the 29th week of gestation, when she has the onset of premature labor and delivers a male infant 24 hours later. The infant initially has Apgar scores of 4 and 6 at 1 and 5 minutes, but within an hour is in severe respiratory distress and requires intubation with mechanical ventilation. Which of the following pharmacologic therapies administered to the mother prior to birth could have helped to prevent this infant's neonatal respiratory distress?
- A.
  
  Hydrocortisone
- B.
  
  Nafcillin
- C.
  
  Ibuprofen
- D.
  
  Lecithin
- E.
  
  Vitamin A
- F.
  
  Surfactant
13.

For the past 5 months, a 51-year-old woman has noted increased swelling of her lower legs as the day progresses. She has no fever and no cough. On physical examination, she has pitting edema to the knees. A chest radiograph reveals bilateral pleural effusions, and the right heart border is prominent. Laboratory studies show a serum AST of 238 U/L, ALT 263 U/L, LDH 710 U/L, and CK 127 U/L. Which of the following underlying diseases is most likely to cause these findings?
- A.
  
  Goodpasture syndrome
- B.
  
  Recurrent thromboembolism
- C.
  
  Renovascular hypertension
- D.
  
  Bronchial asthma
- E.
  
  Rheumatoid arthritis
14.

A 51-year-old man received an orthotopic cardiac transplant a month ago. He has developed a fever with cough over the past 5 days. On physical examination his temperature is 37.5 C. A chest CT scan shows consolidation with abscess formation involving the left lower lobe. A sputum gram stain reveals normal upper respiratory tract flora. He does not respond to antibiotic therapy over the next 6 months. His mental status deteriorates and MR imaging of the brain shows multiple abscesses. He is most likely to have an infection with which of the following organisms?
- A.
  
  Mycoplasma pneumoniae
- B.
  
  Aspergillus fumigatus
- C.
  
  Mycobacterium avium-intracellulare
- D.
  
  Nocardia braziliensis
- E.
  
  Cytomegalovirus
- F.
  
  Pneumocystis carinii (jiroveci)
15.

Three weeks after visiting her grandmother dying from a respiratory tract infection, a healthy 5-year-old girl develops a fever along with wheezing. On physical examination her temperature is 37.9 C. Her lung fields are clear to auscultation but there are expiratory wheezes. A chest radiograph reveals a solitary 2 cm peripheral mid-lung nodule and marked hilar lymphadenopathy. Laboratory studies show Hgb 13.6 g/dL, platelet count 183,600/microliter, and WBC count 5480/microliter. These findings are most consistent with infection by which of the following organisms?
- A.
  
  Mycobacterium tuberculosis
- B.
  
  Candida albicans
- C.
  
  Coccidioides immitis
- D.
  
  Aspergillus flavus
- E.
  
  Bacteroides fragilis
- F.
  
  Streptococcus pneumoniae
- G.
  
  Respiratory syncytial virus
16.

A 44-year-old previously healthy man has the sudden onset of severe dyspnea. On physical examination he is afebrile. There are absent breath sounds over the right lung fields. A chest x-ray shows pulmonary atelectasis involving all of the right lung. Which of the following conditions is most likely to produce these findings?
- A.
  
  Aspiration of a foreign body
- B.
  
  Pulmonary embolism
- C.
  
  Squamous cell carcinoma
- D.
  
  Penetrating chest trauma
- E.
  
  Bronchiectasis
17.

A newborn male infant develops increasing respiratory distress within an hour following an uncomplicated vaginal delivery at 36 weeks gestation. A plain film radiograph reveals near opacification of both lungs. Despite intubation and positive pressure ventilation, the baby dies within two days. At autopsy, the infant's lungs demonstrate extensive pink hyaline membranes. Which of the following maternal conditions is most likely to increase the risk for this infant's respiratory distress?
- A.
  
  Gestational diabetes
- B.
  
  Hyperemesis gravidarum
- C.
  
  Iron deficiency
- D.
  
  Preeclampsia
- E.
  
  Systemic lupus erythematosus
18.

Following an acute pharyngitis lasting 4 days, a 10-year-old boy develops neck pain and marked halitosis. On physical examination is breath is very malodorous. A CT scan shows an abscess in the peritonsillar region. Laboratory studies include a culture of the abscess which grows anaerobic flora. Which of the following aerobic organisms is most likely to be cultured from his abscess?
- A.
  
  Staphylococcus aureus
- B.
  
  Hemophilus influenzae
- C.
  
  Corynebacterium diphtheriae
- D.
  
  Bordetella pertussis
- E.
  
  Group A Streptococcus
19.

A 65-year-old man has had no major medical problems prior to the past year, when he noted increasing malaise along with an 8 kg weight loss. He is a non-smoker. He currently does not have fever, cough, dyspnea, or any respiratory difficulties. On physical examination, he has non-tender supraclavicular lymphadenopathy. The lungs are clear to auscultation. A chest x-ray shows multiple solid nodules ranging from 1 to 3 cm scattered throughout all lung fields. No infiltrates or areas of consolidation are noted. Laboratory studies show Hgb 11.6 g/dL, Hct 34.7%, MCV 83 fL, and WBC count 6280/microliter. Which of the following pathologic processes in his lungs is most likely to account for these findings?
- A.
  
  Pulmonary infarctions
- B.
  
  Foreign body aspiration
- C.
  
  Metastatic carcinoma
- D.
  
  Nocardia asteroides infection
- E.
  
  Silicosis
20.

A 43-year-old woman who does not smoke becomes increasingly dyspneic over 8 years' time. She does not have a cough or increased sputum production. She is afebrile. On physical examination she has decreased breath sounds with hyperresonance in all lung fields. A chest radiograph reveals increased lucency of all lung fields. Laboratory studies show her serum alpha-1-antitrypsin level is 18 mg/dL. Which of the following microscopic portions of the lung is most likely to be affected by her condition?
- A.
  
  Lymphatic channel
- B.
  
  Alveolar duct
- C.
  
  Bronchial artery
- D.
  
  Interstitium
- E.
  
  Terminal bronchiole
21.

A 30-year-old woman is in the 28th week of an uncomplicated pregnancy when she experiences the sudden onset of severe abdominal pain, followed by vaginal bleeding, then the onset of labor. A girl infant is delivered on the way to the hospital. On arrival within an hour, the baby is in respiratory distress and requires intubation and mechanical ventilation. A day later, a chest radiograph shows opacification of both lungs. The baby's respiratory status does not improve. Which of the following histopathologic findings is most likely to be present in this baby's lungs?
- A.
  
  Neutrophilic exudates in the alveoli
- B.
  
  Irregular fibrosis with airspace dilation
- C.
  
  Decreased lamellar bodies in type II pneumocytes
- D.
  
  Diffuse alveolar hemorrhage
- E.
  
  Interstitial lymphocytic infiltrates
22.

A 41-year-old woman has a 1 year history of episodic dyspnea. On physical examination there are expiratory wheezes. Her chest radiograph shows a few small 0.5 cm perihilar nodules. Laboratory studies show an elevated serum IgE along with peripheral blood eosinophilia. A sputum sample shows eosinophils. Which of the following pathologic findings is most likely present in her bronchi?
- A.
  
  Non-invasive aspergillosis
- B.
  
  Blastomycosis
- C.
  
  Invasive candidiasis
- D.
  
  Wegener granulomatosis
- E.
  
  Cytomegalovirus
23.

A male infant has initial Apgar scores of 5 and 6 at 1 and 5 minutes following birth by normal vaginal delivery at 30 weeks gestation. However, increasing respiratory distress in the next hour requires intubation and positive pressure ventilation. Two months later, the infant is finally taken off the ventilator, but still does not oxygenate normally. Which of the following diseases has this infant most likely developed?
- A.
  
  Diffuse alveolar damage
- B.
  
  Bronchial asthma
- C.
  
  Bronchiectasis
- D.
  
  Tracheo-esophageal fistula
- E.
  
  Bronchopulmonary dysplasia
24.

A 6-year-old child has the sudden onset of dyspnea with wheezing. On physical examination he is afebrile but has absent breath sounds on the right. His temperature is 37 C, pulse 82/minute, respiratory rate 28/minute, and blood pressure 100/60 mm Hg. An arterial blood gas measurement shows pO2 95 mm Hg, pCO2 25 mm Hg, and pH 7.55. Following administration of 100% FiO2 by nasal canula, a repeat measurement shows pO2 95 mm Hg, pCO2 25 mm Hg, and pH 7.55. Which of the following is the most likely diagnosis?
- A.
  
  Foreign body aspiration
- B.
  
  Bronchial asthma
- C.
  
  Paraseptal emphysema
- D.
  
  Thromboembolism
- E.
  
  Carcinoid tumor
25.

A 60-year-old woman develops multiple organ failure 3 weeks following a pneumonia complicated by septicemia. Antibiotic therapy has resulted in sputum and blood cultures that are now without growth of organisms. Nevertheless, she requires intubation with mechanical ventilation, but it becomes progressively more difficult to maintain her oxygen saturations. Ventilatory pressures must be increased. A portable chest radiograph shows increasing opacification of all lung fields. Which of the following pathologic processes is most likely now to be present in her lungs?
- A.
  
  Pulmonary arterial vasculitis
- B.
  
  Diffuse alveolar damage
- C.
  
  Extensive neutrophilic alveolar exudates
- D.
  
  Extensive intra-alveolar hemorrhage
- E.
  
  Widespread bronchiectasis