PULMONARY

Question 1
An 8-year-old boy at birth appeared to be a normal term baby, but his neontal course was
complicated by the development of meconium ileus. His sweat chloride is found to be elevated.
Throughout childhood he has experienced multiple increasingly severe bouts of pneumonia with a
productive cough, often with Pseudomonas aeruginosa, and laterBurkholderia cepacea, cultured
from sputum. He is at greatest risk for development of which of the following pulmonary
abnormalities?
A

Adenocarcinoma

Bronchiectasis

Lymphangiectasis

Pleural fibrous plaques

Pneumocystis jiroveci pneumonia

Pneumothorax

(B) CORRECT. The chronic lung disease of cystic fibrosis often includes bronchiectasis, a disease
characterized by inflammation with obstruction and dilation and destruction of bronchi. This
process is diffuse throughout the lungs. The loss of pulmonary vascular bed with progressive
bronchiectasis can lead to pulmonary hypertension and cor pulmonale. The sweat chloride is a
good screening test; genomic testing is possible, but confounded by hundreds of CF mutations.
Question 2
A 70-year-old woman at an extended care facility for the past two years has increasing inability to
perform activities of daily living. She can no longer recognize family members. She 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 38C. A chest x-ray
shows infiltrates involving the left lower lobe. A sputum sample shows numerous neutrophils and
gram-positive diplococci. Which of the following infectious agents is most likely to cause her
pulmonary disease?
A

Pneumocystis jiroveci

Listeria monocytogenes

Cryptococcus neoformans

Mycobacterium tuberculosis

Legionella pneumophila

Staphylococcus aureus

Streptococcus pneumoniae

Influenza A virus

(G) CORRECT. She has a lobar pneumonia, which is most often a community aquired pneumonia
(the nursing home counts as a community venue), following a debilitating course of Alzheimer
disease. The most common organism is Streptococcus pneumoniae (pneumococcus).
Question 3
An 11-year-old girl has experienced dyspnea for the past 2 weeks. Her temperature is 37.3C, pulse
85/minute, respiratory rate 30/minute, and blood pressure 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 middle lobe nodule. No infiltrates 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

Mycobacterium tuberculosis infection

Bronchial carcinoid tumor

Infective endocarditis

Goodpasture syndrome

(B) CORRECT. This is a description of the typical 'Ghon complex' of an initial, or primary, TB
infection. The peripheral granuloma does not produce symptoms, but the enlarged lymph nodes
may impinge upon airways. Most persons with a primary infection, however, are asymptomatic and
the infection goes unnoticed.


Question 4
On the 11th postoperative day following a radical prostatectomy for adenocarcinoma, 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 pulmonary complications has he most likely
developed?
A

Pulmonary edema

Pleural effusion

Atelectasis

Thromboembolus

Diffuse alveolar damage

(D) CORRECT. The activity of ambulation resulted in embolization of a thrombus that formed
during his period of immobilization in leg or pelvic veins. The thrombus became an embolus and
traveled up the vena cava, through the right heart, and to the pulmonary arterial tree of the lungs.
Question 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 37.6C. 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

Adenocarcinoma in situ

Sarcoidosis

Usual interstitial pneumonitis

Berylliosis

Tuberculosis

Extrinsic allergic alveolitis

(C) CORRECT. Sarcoidosis is typified by non-caseating granulomas. However, culture of the tissue
and a careful search histologically should be made for organisms before beginning therapy with
corticosteroids. Extensive granulomatous disease can produce a restrictive pattern of pulmonary
disease.
Question 6
A 43-year-old woman has had increasing dyspnea for 8 years. She has no cough or increased
sputum production. On physical examination there is bilateral hyperresonance to percussion in all
lung fields. A chest x-ray 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, particularly lower lobes. Which of the following laboratory findings is
she most likely to have?
A

Decreased serum ceruloplasmin

Increased sweat chloride

Positive urine nicotine

Decreased serum alpha-1-antitrypsin

Positive urine opiates

Positive antinuclear antibody test

(D) CORRECT. AAT deficiency leads to lack of an anti-protease, which leads to development of
emphysema, typically a panlobular type affecting lower lobes more severely, and by the 5th decade.
Question 7
A 55-year-old man with a 50 pack year history of smoking cigarettes has recently experienced an
episode of hemoptysis along with his usual cough. On physical examination he has no abnormal
findings. A sputum for cytology 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

Pneumonia-like consolidation

Peripheral nodule

Carinal compression

Left pleural thickening

(A) CORRECT. Both squamous cell and small cell carcinomas, most common in smokers, tend to be
central in location. Squamous cell carcinomas of the lung are associated with hypercalcemia, though
overall the small cell carcinomas are best known for paraneoplastic syndromes.

Question 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. Over the next 10 days he develops a non-productive cough
along with a fever to 37.9C. 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

Lung abscess

Chronic bronchitis

Bronchiectasis

Bronchopulmonary sequestration

(E) Incorrect. Sequestrations are masses of lung tissue without a normal connection to the airways.
They act as space occupying lesions and can cause obstruction. They are congenital anomalies.
Question 9
A 66-year-old woman has had a worsening non-productive cough with malaise for the past week.
Her temperature increases to 37.4C. 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 next two weeks without sequelae. Infection with which of the
following organisms most likely caused her illness?

Mycobacterium tuberculosis

Streptococcus pneumoniae

Influenza A virus

Cryptococcus neoformans

Mycobacterium avium-complex

(C) CORRECT. The typical appearance of a viral lung infection is interstitial inflammation. The
inflammatory response is primarily T lymphocytes.
Question 10
A 58-year-old man has developed a non-productive cough worsening over the past 2 months. Last
week he noted the appearance of blood-streaked sputum. On physical examination there are some
expiratory wheezes auscultated over the left lung. A chest radiograph reveals a 5 cm mass near the
left lung hilum. A sputum cytology reveals the presence of small clusters of very hyperchromatic,
pleomorphic cells with scant cytoplasm. Which of the following is the most likely predisposing
factor to development of his pulmonary disease?
A

Silicosis

Radon gas exposure

Smoking

Asbestosis

Chronic bronchitis

(C) CORRECT. Smoking remains the most frequent cause of lung cancer. Lung cancer does, however,
occur in nonsmokers. A small cell anaplastic carcinoma, as in this patient, is virtually always seen in
smokers. Small cell cancers arise in the central portion of the lung but are aggressive neoplasms
that spread quickly.
Question 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 38.2C and there are
diffuse rales in both lungs on auscultation. A chest radiograph shows patchy infiltrates in both
lungs. Laboratory studies show WBC count 3250/microliter with 81 segs, 3 bands, 5 lymphs, and 11

monos. 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

Branching septate hyphae

Multiple cysts with GMS stain

Hemosiderin-laden macrophages

Short gram positive rods

(C) CORRECT. He is most likely to have Pneumocystis jiroveci pneumonia in association with the
acquired immunodeficiency syndrome (AIDS). Note his lymphopenia from the very low CD4 count.
PCP infection produces an exudate composed of the Pneumocystis cysts and trophozoites with little
accompanying inflammation. The clinical findings in this case are typical as well.
Question 12
A 64-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 over 3 months at a time. He has had episodes
of pneumonia with Streptococcus pneumoniae and Klebsiella pneumoniae 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

Small cell carcinoma

Congestive heart failure

Chronic bronchitis

Bronchial asthma

Centrilobular emphysema

Panlobular emphysema

Bronchiectasis

(C) CORRECT. Chronic bronchitis is defined clinically as persistent cough with sputum production
for at least 3 months in at least 2 consecutive years. Air pollution and smoking are key causes for
chronic bronchitis. The alteration of lung parenchyma predisposes to superimposed infection,
typically with bacterial organisms.
Question 13
A 66-year-old man has had increasing dyspnea for the past year. 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, only ferruginous bodies.
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

Silica dust

Fumes with iron particles

Asbestos crystals

Beryllium

Black mold spores

(D) CORRECT. These findings are classic for exposure to asbestos. Pleural plaques are more
frequent in this condition than in other pneumonconioses, particularly with calcification. Asbestosis
is a rare form of pneumoconiosis that can lead to restrictive lung disease. The ferruginous bodies
are asbestos fibers encrusted with iron. Building materials from older houses may contain asbestos,
which was used for years because of its fire retardant properties.
Question 14
A 58-year-old man has been a smoker for 40 years. He has worsening orthopnea over the past year.
On examination he has a body mass index of 35. He is afebrile. His blood pressure is 165/110 mm
Hg. Auscultation of his chest reveals rales in lower lung fields bilaterally. A chest x-ray shows
bilateral lower lobe infiltrates and a prominent left heart border. Laboratory studies show his Hgb
A1C is 10%. Which of the following pulmonary problems is he most likely to have?
A

Pneumonia

Fibrosis

Atelectasis

Edema

Emphysema

(D) CORRECT. He has multiple risk factors for ischemic heart disease leading to left heart failure
and pulmonary edema.
Question 15
A 47-year-old man has lost 6 kg in 5 months. He has had a cough with hemoptysis along with
pleuritic chest pain for the past 2 weeks. On physical examination his temperature is 37.5C. A chest
x-ray reveals a bilateral and predominantly upper lobe reticulonodular pattern of infiltrates with
cavitation. A sputum sample is obtained and on light 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 in his sputum?
A

Branching, septated hyphae

Pleomorphic cells with dark, angular nuclei

Clusters of small RBC-sized cysts staining with GMS

Large cells with intranuclear inclusions

Acid fast bacilli

(E) CORRECT. The hemoptysis suggests that the granulomas have eroded enough parenchyma and
involved a bronchus. A granulomatous reaction is typical for Mycobacterium tuberculosis infection.
Question 16
A 20-year-old man falls to the ground while jogging. He suffers a minor abrasion to his left hand.
However, within minutes he becomes dyspneic with right-sided chest pain. Bystanders call 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 he most likely to have?

Bronchopleural fistula

Distal acinar emphysema

Foreign body aspiration

Intrinsic asthma

Pulmonary atherosclerosis

(B) CORRECT. Distal acinar (paraseptal) emphysema is not common, but does account for a
significant number of cases of spontaneous pneumothorax in young persons. It is not related to
smoking. There are subpleural bullae that can burst, even with minimal trauma. They may be
multiple, accounting for recurrent episodes. However, the total amount of lung involved is minimal,
so pulmonary function tests will be normal between episodes. He developed a tension
pneumothorax in this case.
Question 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 FIO2 content 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

Chronic bronchitis

Bronchiectasis

Viral pneumonia

Diffuse alveolar damage

(E) CORRECT. Diffuse alveolar damage (or ARDS as it is known clinically) is the final event
following severe lung injury from a variety of serious illnesses or accidents. In this case, it was
probably initiated by the hypotension ('shock lung') and potentiated by the 100% oxygen
generating free radical damage.
Question 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
for this lesion?
A

Small cell carcinoma

Granuloma

Bronchiectasis

Exogenous lipid pneumonia

Silicosis

(B) CORRECT. The differential diagnosis of a solitary peripheral coin lesion most often includes
lung cancer (adenocarcinoma most likely), granuloma, or hamartoma. Many people have had a
remote, subclinical tubercular or fungal infection leaving only a solitary granuloma. In this case the
cough suggests possible active infection, but it may just be an incidental, unrelated finding.
Question 19
A 61-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

Adenoccarcinoma-in-situ

Sarcoidosis

Pulmonary infarction

Silica inhalation

(B) CORRECT. Adenocarcinoma-in-situ can spread in a pneumonia-like pattern. The lack of a change
over time and the absence of a response to antibiotics should suggest an underlying non-infectious
process. Adenocarcinomas may occur in non-smokers.

Question 20
A 25-year-old man receives a hematopoietic stem cell 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 37.8C. 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

Candida albicans

Cytomegalovirus

Pneumocystis jiroveci

Mycobacterium avium complex

Influenza B virus

Respiratory syncytial virus

(C) CORRECT. CMV produces a cytopathic effect with enlarged cells having prominent intranuclear
inclusions. CMV infection occurs most often with immune compromise, as in this case folowing
transplantation before engraftement.
Question 21
A 54-year-old woman has had fever and dyspnea for a month along with a 2 kg weight loss. On
physical examination her temperature is 37.7C. 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

Sarcoidosis

Asbestosis

Tuberculosis

Usual interstitial pneumonitis

(B) CORRECT. The symptoms and signs are classic for granulomatous disease. Sarcoidosis often
involves the hilar lymph nodes as well. No organisms can be found.
Question 22
A 59-year-old man has been a cigarette smoker for the past 42 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

Platelet count of 55,000/microliter

Plasma cortisol at 8 am of 5 microgm/dL

Serum sodium of 113 mmol/L

Serum uric acid of 14 mg/dL

(D) CORRECT. He has a small cell anaplastic carcinoma with widespread metastases. The syndrome
of inappropriate ADH producing hyponatremia is one form of paraneoplastic syndrome seen with
this particular carcinoma.
Question 23
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 38.2C. 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

Aspergillus niger

Mycobacterium tuberculosis

Mycoplasma pneumoniae

Adenovirus

(A) CORRECT. Pulmonary abscesses typically have an air-fluid level from liquefactive necrosis
caused by the collection of neutrophils. More virulent bacterial organisms such asStaphylococcus
aureus are likely to cause such a complication of a bronchopneumonia.
Question 24
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

Cystic fibrosis

Adenocarcinoma

Silicosis

Squamous cell carcinoma

Malignant mesothelioma

Thromboembolism

(E) CORRECT. Most squamous cell carcinomas are located centrally and arise in bronchi, leading to
obstruction of a large airway that can cause a distal lipid pneumonia. In this case, the breakdown of

lung tissue distal to the mass yields an 'endogenous lipid pneumonia' with many macrophages.
Some degree of atelectasis may also be present from air resorbtion distal to the obstruction.
Question 25
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 4 years, all of which lasted 1 to 4
hours. On physical examination her vital signs include T 37.1C, P 109/minute, RR 40/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 pneumoniae infection

Cystic fibrosis

Hypersensitivity pneumonitis

Bronchial asthma

Aspiration of gastric contents

(D) CORRECT. In an acute asthmatic episode, there can be an outpouring of mucus which, along
with some dehydration, can lead to the formation of mucus plugs. These atopic asthmatic episodes
in children are usually initiated by a type I hypersensitivity reaction, typically with exposure to an
allergen such as pollen from goldenrod or other flowering plant. Up to 10% of children may be
affected to some degree by atopy.
Question 26
A 41-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 inflammatory
mechanisms?
A

Mast cell degranulation

Progressive interstitial fibrosis

Antigen-antibody complex formation

Langerhans cell proliferation

Infection with Mycobacterium kansasii

(C) CORRECT. Birds make a lot of organic dust from their feathers. The result upon inhalation of the
bird dust is an extrinsic allergic alveolitis. Getting away from the antigen (such as a vacation) will
improve the situation. This is a form of type 3 hypersensitivity. It may progress to involve type 4
hypersensitivity if chronic.
Question 27
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

Silica

Carbon monoxide

Nicotine

Carbon

(D) CORRECT. She has findings of emphysema, and smoking is the most likely underlying cause. The
nicotine in the cigarette smoke is chemotactic for neutrophils, and cigarette smoke activates the
alternative complement pathway, releasing more mediators for neutrophil recruitment. Neutrophil
elastase can damage the lung parenchyma. Though neutrophils are not numerous in the lung with
emphysema, the cumulative effect of even small numbers of neutrophils over many years leads to
the tissue damage.
Question 28
A 53-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

Organizing thromboemboli

Medial dissection

Atherosclerosis

Aneurysm formation

(D) CORRECT. Cor pulmonale is the result of pulmonary hypertension, which is the major cause for
pulmonary atherosclerosis. His emphysema has reduced the pulmonary vascular bed, promoting
the hypertension. Note that the forces driving systemic atherosclerosis are not operative on the
pulmonary arterial system.
Question 29
A 44-year-old woman, a non-smoker, has had a fever and cough for the past 4 days. She does not
have hemoptysis. She has not experienced weight loss, malaise, nausea, or vomiting. On physical
examination her temperature is 37.6C. There are decreased breath sounds over the right upper
lung. A chest radiograph reveals a 6 cm area of infiltrates in the right upper lobe. She is given a
course of antibiotic therapy, but her cough 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

Small cell anaplastic carcinoma

Adenocarcinoma

Mesothelioma

Carcinoid tumor

(C) CORRECT. Peripheral lung cancers (adenocarcinoma and large cell carcinoma) show less of an
association with smoking than central lung cancers (small cell and squamous cell carcinoma). The
focal obstruction from the mass predisposed to infection.
Question 30
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 radiologic imaging study show a wedge-shaped area
consistent with 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

Aspergillosis

Metastatic carcinoma

Vasculitis

Thromboembolism

(E) CORRECT. An embolus to a medium-sized arterial branch may not be large enough to kill the
patient, but large enough to cause an infarction. Her bedridden state predisposes her to deep
venous thrombosis and thromboembolism--the CVAs are due to separate systemic arterial
problems--or the systemic and pulmonary embolization can be tied together by a hypercoagulable
state, or more remotely by a 'paradoxical' embolus through a patent foramen ovale once the right
sided-pressures increased following the initial pulmonary thromboembolic event.
Question 31
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 38.3C. 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 the most likely
cause for her pulmonary disease?
A

Nocardia asteroides

Mycoplasma pneumoniae

Mycobacterium kansasii

Respiratory syncytial virus

Chlamydia psittici

Adenovirus

Klebsiella pneumoniae

(B) CORRECT. Mycoplasma infection predominantly affects the interstitium, and is not a widespread
alveolar filling process. It is a cause for a 'primary atypical pneumonia' which is difficult to diagnose
because this organism is not cultured by routine methods for bacterial organisms. The cold
agglutinin titer is elevated in about half of cases and is a characteristic finding. Many cases respond
to antibiotic therapy with erythromycin.
Question 32
A 23-year-old primigravida is found on prenatal testing to have an elevated hemoglobin A1C level.
Her pregnancy is uncomplicated until the 33rd 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

Nafcillin

Ibuprofen

Lecithin

Vitamin A

Surfactant

(A) CORRECT. She has diabetes, which inhibits fetal lung development. At 33 weeks, the baby's
lungs may not make sufficient surfactant, though type II pneumomonocytes are present and
increasing in number. Corticosteroids administered to the mother help to speed up type II

pneumonocyte production of surfactant in the baby. At birth, exogenous surfactant can be given to
the neonate. In addition, diabetes tends to impede fetal lung maturation.
Question 33
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

Recurrent thromboembolism

Renovascular hypertension

Bronchial asthma

Rheumatoid arthritis

(B) CORRECT. Pulmonary hypertension and subsequent right heart failure can occur in the small
number of cases in which recurrent thromboembolism takes place. The right heart failure that
occurs then leads to hepatic passive congestion with centrilobular necrosis that is the cause for the
increased transaminases and LDH (but normal CK, since the heart is enlarged, but not ischemic).
Question 34
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 37.5C. 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

Aspergillus fumigatus

Mycobacterium avium-complex

Nocardia braziliensis

Cytomegalovirus

Pneumocystis jiroveci

(D) CORRECT. Nocardia braziliensis infection can persist and lead to chronic abscesses. It can
complicate the course of immunocompromised patients. Though the lung is the portal of entry,
dissemination to brain is common.
Question 35
Three weeks after visiting her grandmother dying from a respiratory tract infection, a healthy 5-
year-old girl develops a fever along with dyspnea. On physical examination her temperature is
37.9C. Her lung fields are clear to auscultation but there are expiratory wheezes. A chest x-ray
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

Candida albicans

Coccidioides immitis

Aspergillus flavus

Bacteroides fragilis

Streptococcus pneumoniae

Respiratory syncytial virus

(A) CORRECT. The pattern of lung involvement is the classical 'Ghon complex' of primary
tuberculosis, which is seen more commonly in children, though only about 5% of cases are
symptomatic. The enlarged hilar nodes can impinge upon central airways to produce obstruction.
Question 36
A study is performed reviewing medical records of adults presenting with sudden onset of severe
dyspnea. They were afebrile, with absent breath sounds over an entire lung, and chest x-ray
showing pulmonary atelectasis of an entire lung. Which of the following conditions is most likely to
produce these findings?

Aspiration of a foreign body

Pulmonary embolism

Squamous cell carcinoma

Penetrating chest trauma

Bronchiectasis

(D) CORRECT. Penetrating chest trauma would lead to pneumothorax with lung collapse
(atelectasis).
Question 37
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

Hyperemesis gravidarum

Iron deficiency

Preeclampsia

Systemic lupus erythematosus

(A) CORRECT. The hyperinsulinism in the baby as a result of the high maternal glucose impedes
development of the type II pneumonocytes. By 36 weeks there should normally be sufficient
surfactant to prevent hyaline membrane disease. Tests for fetal lung maturity include lamellar body
count on amniotic fluid, fluorescence polarization (fpol), phosphatidyl glycerol (PG), and L/S ratio.
Question 38
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

Hemophilus influenzae

Corynebacterium diphtheriae

Bordetella pertussis

Group A Streptococcus

(E) CORRECT. A peritonsillar abscess is usually a complication of a 'strep' throat in a child.

Question 39
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

Recurrent aspiration

Metastatic carcinoma

Nocardia asteroides infection

Silicosis

(C) CORRECT. Multiple persistent masses should suggest metastases, rather than a primary lung
tumor. His lack of a cough or fever is against an infectious cause or aspiration.
Question 40

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

Alveolar duct

Bronchial artery

Interstitium

Terminal bronchiole

(B) CORRECT. Alpha-1-antitrypsin (AAT) deficiency leads to a panacinar form of emphysema which
involves the distal acinus beyond the respiratory bronchiole.
Question 41
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

Irregular fibrosis with airspace dilation

Minimal alveolar saccular development

Diffuse alveolar hemorrhage

Interstitial lymphocytic infiltrates

(C) CORRECT. The baby has been born prematurely, with incomplete lung development, and the
lack of sufficient alveolar development along with minimal pulmonary surfactant production leads
to hyaline membrane disease with respiratory distress in the newborn.
Question 42
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

Blastomycosis

Invasive candidiasis

ANCA-associated vasculitis

Cytomegalovirus

(A) CORRECT. She has an allergic bronchopulmonary aspergillosis. Her asthma is exacerbated by a
type I hypersensitivity reaction to the fungus in the bronchi.
Question 43
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

Bronchial asthma

Bronchiectasis

Tracheo-esophageal fistula

Bronchopulmonary dysplasia

(E) CORRECT. The bronchopulmonary dysplasia (BPD) is a complication of the treatment for
neonatal respiratory distress. The positive pressure ventilation with the higher FIO2's, and the
prolonged intubation, all contribute. Generally, these are premature infants who had a respiratory
complication following birth, such as hyaline membrane disease.
Question 44
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 37C, pulse 82/minute,
respiratory rate 32/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

Bronchial asthma

Paraseptal emphysema

Thromboembolism

Carcinoid tumor

(A) CORRECT. An inhaled object could obstruct a bronchus completely, with air resorbtion and
collapse of lung distal to the point of obstruction. This produces a shunt defect with a V/Q
mismatch. Since there is perfusion but no ventilation, even 100% oxygen will not make a difference.
His hyperventilation has acutely produced an uncompensated respiratory alkalosis.
Question 45
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

Diffuse alveolar damage

Extensive neutrophilic alveolar exudates

Extensive intra-alveolar hemorrhage

Widespread bronchiectasis

(B) CORRECT. Diffuse alveolar damage (DAD) is the pathologic term for adult respiratory distress
syndrome (ARDS) that is the final common pathway for many acute lung injuries. DAD produces
increasing interstitial thickening with mixed inflammation and features of an acute restrictive lung
disease.