Block 11 Pulmonary Path Dr Bellot Prt 1
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- 1.
After 20 years as a rock crusher, a 55‑year‑old man complains of shortness of breath, and you discover nodular lung shadows on chest x‑ray. Pleural biopsy reveals lesions with whorls of fibrous tissue containing birefringent particles. He has
- A.
Sarcoidosis
- B.
Silicosis
- C.
Asbestosis
- D.
Bagassosis
- E.
Tuberculosis
Correct Answer
B. SilicosisExplanation
The presence of nodular lung shadows on chest x-ray, along with the finding of lesions with whorls of fibrous tissue containing birefringent particles on pleural biopsy, suggests a diagnosis of silicosis. Silicosis is a lung disease caused by inhalation of crystalline silica dust, commonly seen in workers exposed to silica-containing materials such as rock dust. The fibrous tissue and birefringent particles seen in the biopsy are characteristic findings of silicosis. This condition can lead to shortness of breath and other respiratory symptoms.Rate this question:
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- 2.
A 68-year-old woman has solitary 2.0 cm peripheral (subpleural) right lung nodule discovered by x-ray during investigation of recent weight loss. She is a non-smoker. Biopsy confirms a malignant neoplasm. The tumor is LIKELY to be which of the following histologic types?
- A.
Undifferentiated small cell carcinoma
- B.
Squamous cell carcinoma
- C.
Mesothelioma – cancer of serous membrane; easily metasticized; you are done for
- D.
Adenocarcinoma
- E.
Carcinoid tumor
Correct Answer
D. AdenocarcinomaExplanation
Based on the information provided, the patient is a non-smoker and the lung nodule is found peripherally. Adenocarcinoma is the most common type of lung cancer in non-smokers and is often found in the outer regions of the lungs. Therefore, it is likely that the tumor in this case is an adenocarcinoma.Rate this question:
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- 3.
A 68-year-old man who smoked heavily for more than 40 years suddenly develops a tension pneumothorax. During emergency thorocotomy the lung was noted to show a blackish discoloration and several pleural bullous cyst-like projections, one of which had apparently ruptured. Regarding the underlying pathological process:
- A.
The history of heavy smoking is unrelated to the disease
- B.
It is more commonly seen in patients younger than 40 years of age- 1°pulmonary hypertension/corpulmonale
- C.
Fibrosis of the lung is the underlying pathological problem
- D.
Enzymatic destruction of lung tissue is likely
- E.
The lung disease is usually self-healing
Correct Answer
D. Enzymatic destruction of lung tissue is likelyExplanation
The answer "Enzymatic destruction of lung tissue is likely" is the correct explanation because the presence of a blackish discoloration and pleural bullous cyst-like projections suggests the possibility of enzymatic destruction of lung tissue. This can be seen in conditions such as necrotizing pneumonia or lung abscess, where enzymes released by bacteria or immune cells cause tissue damage. The history of heavy smoking may have contributed to the development of the underlying lung disease, but it is not directly related to the enzymatic destruction observed in this case. Fibrosis of the lung or self-healing of the disease are not supported by the given information.Rate this question:
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- 4.
A 70-year-old man is seen in the ER with severe dyspnea. X-ray demonstrates collapse of the right upper lobe of the lung. He has been a heavy smoker for more than 40 years and has COPD. Which is a LIKELY cause of his symptoms?
- A.
Thromboembolism
- B.
Pneumothorax
- C.
Hemothorax
- D.
Aspiration of vomitus
- E.
Massive pleural transudate
Correct Answer
B. PneumothoraxExplanation
The likely cause of the 70-year-old man's severe dyspnea and collapse of the right upper lobe of the lung is a pneumothorax. This is a condition where air accumulates in the pleural space, leading to lung collapse. Given the patient's history of heavy smoking and COPD, it is possible that the lung tissue may be weakened, making it more susceptible to the development of a pneumothorax. Thromboembolism, hemothorax, aspiration of vomitus, and massive pleural transudate are less likely causes in this scenario.Rate this question:
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- 5.
A 29-year-old man complains of frequent chest infections and chronic productive cough since early childhood. He also suffers from chronic sinusitis He has been married for more than five years but has no children. His pulmonary disease is MOST LIKELY:
- A.
Bronchopneumonia
- B.
Bronchial asthma
- C.
Centriacinar emphysema
- D.
Bronchiectasis – kartagener syndrome
- E.
Tuberculosis
Correct Answer
D. Bronchiectasis – kartagener syndromeExplanation
The patient's history of frequent chest infections, chronic productive cough, chronic sinusitis, and infertility suggests Kartagener syndrome, which is a type of bronchiectasis. Kartagener syndrome is a genetic disorder characterized by the triad of bronchiectasis, chronic sinusitis, and situs inversus (organs in the mirror image position). This condition is caused by defects in the structure and function of cilia, leading to impaired mucociliary clearance and recurrent respiratory infections. Bronchiectasis is the most likely diagnosis in this patient based on the combination of symptoms and history.Rate this question:
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- 6.
Which of the following is LIKELY to occur following recurrent pulmonary thromboembolism?
- A.
Increased pulmonary vascular resistance
- B.
Red hepatization-The first stage of hepatization of lung tissue in pneumonia, in which the exudate is blood-stained
- C.
Gray hepatization- The second stage of hepatization of lung tissue in pneumonia, when the yellowish-gray exudate is beginning to degenerate before breaking down
- D.
Subpleural adenocarcinoma
- E.
Lung abscess
Correct Answer
A. Increased pulmonary vascular resistanceExplanation
Recurrent pulmonary thromboembolism refers to the repeated occurrence of blood clots in the pulmonary arteries. These clots can obstruct blood flow and cause damage to the lung tissue. Over time, this can lead to remodeling of the pulmonary vasculature, resulting in increased pulmonary vascular resistance. This increased resistance makes it harder for blood to flow through the lungs, leading to increased pressure in the pulmonary arteries. Therefore, it is likely that increased pulmonary vascular resistance would occur following recurrent pulmonary thromboembolism.Rate this question:
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- 7.
A mother brings her previously healthy three-year-old child to the clinic with a history of cough for one month and blood tinged sputum for one day. A chest x-ray reveals increased density of the right lower lobe, and slight shift of the mediastinum to the right. The MOST LIKELY diagnosis is:
- A.
Bronchial asthma
- B.
Hemorrhagic infarct of the lung
- C.
Primary pulmonary tuberculosis
- D.
Bronchopneumonia
- E.
Foreign body in the right lower lobe bronchus – obstructive/resorption atelectasis
Correct Answer
E. Foreign body in the right lower lobe bronchus – obstructive/resorption atelectasisExplanation
The most likely diagnosis in this case is a foreign body in the right lower lobe bronchus causing obstructive/resorption atelectasis. This is suggested by the history of cough and blood tinged sputum, as well as the findings on chest x-ray of increased density in the right lower lobe and slight shift of the mediastinum to the right. This indicates a possible blockage in the bronchus leading to collapse of the affected lung segment. Other options such as bronchial asthma, hemorrhagic infarct of the lung, primary pulmonary tuberculosis, and bronchopneumonia do not fit the clinical presentation and radiographic findings as well.Rate this question:
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- 8.
An asymptomatic 15-year-old child with a chest radiograph showing a small subpleural nodule in the middle lung zone and enlarged mediastinal lymph nodes MOST PROBABLY has:
- A.
Bronchopulmonary sequestration
- B.
Lobar pneumonia
- C.
Primary tuberculosis- combination of peripheral nodule and mediastinal lymph nodes is ghon complex
- D.
Primary atypical pneumonia
- E.
Bronchioloalveolar carcinoma
Correct Answer
C. Primary tuberculosis- combination of peripHeral nodule and mediastinal lympH nodes is ghon complexExplanation
The presence of a small subpleural nodule in the middle lung zone and enlarged mediastinal lymph nodes is most commonly seen in primary tuberculosis. This combination of findings is known as the ghon complex, which is a characteristic feature of primary tuberculosis infection. Other options such as bronchopulmonary sequestration, lobar pneumonia, primary atypical pneumonia, and bronchioloalveolar carcinoma do not typically present with this specific pattern of findings.Rate this question:
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- 9.
An 8-year-old child with a chronic productive cough is being investigated for cystic fibrosis and is discovered to have an elevated sweat chloride. This child is at great risk of developing:
- A.
Hypersensitivity pneumonitis
- B.
Bronchiectasis
- C.
Pleural mesothelioma
- D.
Bronchial asthma
- E.
Panacinar emphysema
Correct Answer
B. BronchiectasisExplanation
An elevated sweat chloride is a characteristic finding in cystic fibrosis, a genetic disorder that affects the function of the exocrine glands, including the sweat glands. Bronchiectasis is a common complication of cystic fibrosis, characterized by permanent dilation and damage to the bronchi. This occurs due to the buildup of thick mucus in the airways, leading to recurrent infections and inflammation. Therefore, the child with an elevated sweat chloride is at great risk of developing bronchiectasis.Rate this question:
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- 10.
On the 11th post-operative day, a patient walks to the bathroom, but upon returning to bed becomes extremely dyspneic and diaphoretic. His recovery to this point had been "uneventful". You strongly suspect which of the following?
- A.
Postoperative atelectasis
- B.
Adult respiratory distress syndrome (ARDS)
- C.
Pulmonary embolism
- D.
Massive pleural effusion
- E.
Nosocomial pneumonia
Correct Answer
C. Pulmonary embolismExplanation
The patient's sudden onset of dyspnea and diaphoresis after walking suggests a possible pulmonary embolism. Pulmonary embolism occurs when a blood clot travels to the lungs and blocks blood flow. This can cause symptoms such as shortness of breath, sweating, and chest pain. The fact that the patient's recovery had been uneventful up until this point further supports the suspicion of a pulmonary embolism, as it is a complication that can occur postoperatively.Rate this question:
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- 11.
A 50-year-old man died after being hospitalized for six days. At autopsy examination the lungs were found to be heavy, congested and stiff. Microscopic examination revealed thickening of the alveolar septa with interstitial edema, fibrin deposition and a mononuclear cell infiltration. Type-I pneumocytes were replaced partly by hyaline membrane and partly by proliferating type-II pneumocytes. The MOST LIKELY cause of these changes is:
- A.
Bronchopneumonia –acute inflammatory infiltrates extending from bronchioles to alveoli
- B.
Lobar pneumonia-intra alveolar exudates; congestion, red hepatization;gray hepatization; resolution; most often caused by strep pneu
- C.
Viral pneumonia/interstitial pneumonia
- D.
Bronchial asthma
- E.
Bronchiectasis
Correct Answer
C. Viral pneumonia/interstitial pneumoniaExplanation
The given answer of viral pneumonia/interstitial pneumonia is the most likely cause of the changes observed in the autopsy examination. The description of thickening of the alveolar septa with interstitial edema, fibrin deposition, and mononuclear cell infiltration is consistent with the characteristics of viral pneumonia or interstitial pneumonia. Additionally, the replacement of type-I pneumocytes by hyaline membrane and proliferating type-II pneumocytes is also indicative of viral pneumonia or interstitial pneumonia.Rate this question:
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- 12.
After 30 years working as a sandblaster, a 58-year-old man developed progressive dyspnea. X-ray revealed small nodules in bilateral upper lobes. It is LIKELY that he is developing:
- A.
Hypersensitivity pneumonitis- farmers lung
- B.
A restrictive lung disease –coal workers pneumocosis w/ massive pulmonary fibrosis; upper>lower
- C.
An obstructive lung disease
- D.
Tuberculosis
- E.
Viral pneumonia
Correct Answer
B. A restrictive lung disease –coal workers pneumocosis w/ massive pulmonary fibrosis; upper>lowerExplanation
The correct answer is a restrictive lung disease - coal workers pneumoconiosis with massive pulmonary fibrosis; upper>lower. This is likely because the man has been working as a sandblaster for 30 years, which exposes him to silica dust. Silica dust inhalation is a known cause of coal workers pneumoconiosis, which is a restrictive lung disease characterized by the formation of nodules and fibrosis in the lungs. The fact that the nodules are located in the bilateral upper lobes further supports this diagnosis.Rate this question:
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- 13.
A 28-year-old Black woman is discovered to have bilateral hilar adenopathy and gives a history of fever, chest pain and weight loss. Prominant in your diagnostic considerations is:
- A.
Squamous cell carcinoma
- B.
Asbestosis
- C.
Silicosis
- D.
Sarcoidosis
- E.
Undifferentiated small cell carcinoma
Correct Answer
D. SarcoidosisExplanation
The correct answer is sarcoidosis. Sarcoidosis is a systemic granulomatous disease that can affect multiple organs, including the lungs. It commonly presents with bilateral hilar adenopathy, fever, chest pain, and weight loss. Squamous cell carcinoma and undifferentiated small cell carcinoma are types of lung cancer, which may present with similar symptoms but are less likely in this case. Asbestosis and silicosis are occupational lung diseases caused by exposure to asbestos and silica dust, respectively, and typically present with respiratory symptoms rather than systemic symptoms.Rate this question:
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- 14.
Pulmonary abscesses are particularly prone to develop in the right lung, rather than the left, when they follow:
- A.
Chest trauma
- B.
Pneumonia
- C.
Pulmonary embolism
- D.
Cancer of the lung
- E.
Aspiration of foreign material – prone to deposition in R lung
Correct Answer
E. Aspiration of foreign material – prone to deposition in R lungExplanation
When foreign material is aspirated into the lungs, it tends to preferentially settle in the right lung rather than the left. This is because the right main bronchus is wider, shorter, and more vertical compared to the left main bronchus. As a result, foreign material is more likely to enter and become lodged in the right lung. This can lead to the development of pulmonary abscesses in the right lung rather than the left.Rate this question:
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- 15.
Your patient has been complaining of night fevers and loss of weight. He is a non‑smoker. Radiological studies show cavitary disease at the apex of the right lung. You strongly suspect
- A.
Pneumococcal pneumonia
- B.
Hypersensitivity pneumonia
- C.
Secondary tuberculosis
- D.
Pancoast tumor
- E.
Sarcoidosis
Correct Answer
C. Secondary tuberculosisExplanation
The patient's symptoms of night fevers and weight loss, along with the radiological findings of cavitary disease at the apex of the right lung, strongly suggest secondary tuberculosis. Secondary tuberculosis occurs when a previously latent tuberculosis infection reactivates in the body, leading to the development of active disease. The cavitary lesions seen on radiological studies are a characteristic feature of tuberculosis. Additionally, the patient's non-smoking status and absence of other specific risk factors for alternative diagnoses make secondary tuberculosis the most likely explanation for the symptoms.Rate this question:
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- 16.
A predominantly interstitial reaction in the lung is MOST LIKELY associated with
- A.
Asbestosis
- B.
Bronchopneumonia-brocilo
- C.
Lobar pneumonia-inta alveolar
- D.
Fungal infection
- E.
Viral infection
Correct Answer
E. Viral infectionExplanation
A predominantly interstitial reaction in the lung is most likely associated with viral infection. Viral infections can cause inflammation and damage to the interstitial tissue in the lungs, leading to interstitial lung disease. This type of reaction is characterized by thickening and scarring of the interstitium, which is the tissue that surrounds and supports the air sacs in the lungs. Other conditions listed, such as asbestosis, bronchopneumonia, lobar pneumonia, and fungal infection, may also cause lung damage but are less commonly associated with interstitial reactions.Rate this question:
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- 17.
Which statement concerning asbestos is correct?
- A.
There is a time lag of 20 40 years between exposure and evidence of neoplasm
- B.
All asbestos fibers are equally toxic- serpentine and amphimobile(worse one)
- C.
The biological effect of exposure is determined entirely by the weight of the fiber
- D.
All "ferruginous" bodies represent asbestos fibers
- E.
Patients need both tobacco exposure and asbestos exposure to develop mesothelioma
Correct Answer
A. There is a time lag of 20 40 years between exposure and evidence of neoplasmExplanation
The correct answer states that there is a time lag of 20-40 years between exposure to asbestos and evidence of neoplasm. This means that it takes several decades for the harmful effects of asbestos exposure to manifest as neoplasms (abnormal growth of cells) in the body. This time lag is important to consider when assessing the health risks associated with asbestos exposure and monitoring individuals who have been exposed to asbestos.Rate this question:
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- 18.
Of the following lung tumors which is MOST LIKELY to be associated with hypercalcemia?
- A.
Large cell undifferentiated carcinoma
- B.
Adenocarcinoma
- C.
Bronchioloalveolar carcinoma
- D.
Squamous cell carcinoma
- E.
Mesothelioma
Correct Answer
D. Squamous cell carcinomaExplanation
Squamous cell carcinoma is the most likely lung tumor to be associated with hypercalcemia. Squamous cell carcinomas are known to produce parathyroid hormone-related protein (PTHrP), which can lead to increased calcium levels in the blood. PTHrP acts similar to parathyroid hormone and stimulates the release of calcium from bones, resulting in hypercalcemia. This association is not commonly seen with other types of lung tumors such as large cell undifferentiated carcinoma, adenocarcinoma, bronchioloalveolar carcinoma, or mesothelioma.Rate this question:
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- 19.
A 64-year-old African American woman presents with complaints of shortness of breath and dry cough. These symptoms, per the patient's statement, had an insidious onset and have been present for the past few weeks. Her physical examination is unremarkable. Her pulse, BP and temperature are as follows: 80/min, 130/90 mm Hg and 98.9°F. The patient's lab results and lung biopsy are as follows The next step in the patient's management entails:
- A.
Nothing, the disease has a self-limited course and will regress spontaneously
- B.
Performing acid-fast and silver stains on the biopsy
- C.
Treat the patient with antifungal drugs
- D.
Treat the patient with anti-tuberculous drugs
- E.
Treat the patient with steroids and immunosuppressive drugs
Correct Answer
B. Performing acid-fast and silver stains on the biopsyExplanation
The candidate in this case presents with respiratory symptoms. The clinician requested a chest X-ray to evaluate the patient's lung and mediastinum. The plain X-ray showed the presence of a midline hilar that obviously abuts the bronchi, therefore explaining the irritating dry cough. As for any mass lesion, a biopsy was done. The histologic section shown in the image shows hilar lymph node tissue with multiple granulomas composed of epithelioid histiocytes with occasional giant cells. The increased serum calcium is frequently encountered in granulomatous disease predominantly sarcoidosis.
The next step in the patient's management should entail evaluating the biopsy for mycobacteria and fungi. These organisms are also associated with granulonnatous disease in the lymph nodes and can present with the same symptoms such as the current patient. The acid-fast stain is performed on tissue sections to detect Mycobacterium tuberculosis, which is the etiologic agent of tuberculosis. The silver stain such as Gomori's methenannine silver is frequently used in the lab to detect fungal organisms in tissue sections.
The rationale behind performing these stains on the tissue sections is to rule out the possibility of an infectious granulomatous disease before treating with steroids, which is the therapy of choice in sarcaidosis. However steroids are contraindicated in infectious granulomatous diseases since it mil make the organisms flourish by suppressing the host's immune system. Once the etiology of the granulonnatous disease is unveiled, the treatment with the respective therapeutic regimen can be initiated but not before that. Although some cases of sarcoidosis regress spontaneously, once the disease becomes symptomatic it should be treated. In addition, there are no criteria to aid in identifying the cases that will regress spontaneously versus those that will progress.Rate this question:
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