Pulmonary Practice Questions

Q: An investigator is studying early post-mortem changes in the lung. Autopsies are performed on patients who died following recent hospital admissions. Microscopic examination of the lungs at one of the autopsies shows numerous macrophages with brown intracytoplasmic inclusions. A Prussian blue stain causes these inclusions to turn blue. These findings are most consistent with a pathological process that would manifest with which of the following symptoms?

Shortness of breath that worsens when supine. ***Shortness of breath that worsens when supine*** - The presence of **hemosiderin-laden macrophages** (also known as **heart failure cells**) in the lung, indicated by brown intracytoplasmic inclusions staining positive with Prussian blue, signifies **pulmonary edema** due to chronic passive congestion. - This condition is typically caused by **left-sided heart failure**, which often manifests as **orthopnea** (shortness of breath worse when supine) and **paroxysmal nocturnal dyspnea**. *Purulent expectoration that worsens in the lateral recumbent position* - **Purulent expectoration**, particularly with positional worsening, is characteristic of a **lung abscess** or **bronchiectasis**, which are infectious conditions. - These conditions would feature neutrophils and necrotic debris, not hemosiderin-laden macrophages, as the primary microscopic finding. *Diaphoresis that worsens at night* - **Night sweats** and **diaphoresis** are classic symptoms of **tuberculosis** or certain malignancies like lymphoma. - These conditions are not typically associated with hemosiderin-laden macrophages as a primary pulmonary finding. *Lower extremity swelling that worsens on standing* - **Dependent edema** in the lower extremities that worsens with standing is a hallmark symptom of **right-sided heart failure** or **venous insufficiency**. - While related to heart failure, the pulmonary findings described (hemosiderin-laden macrophages) are more directly linked to chronic **left-sided heart failure** and pulmonary congestion. *Dry cough that worsens early in the morning* - A **dry cough** that is worse in the morning can be a symptom of **asthma**, **bronchitis**, or **GERD**. - These conditions do not typically present with hemosiderin-laden macrophages from chronic pulmonary congestion.

Q: A 65-year-old male presented to his primary care physician with exertional dyspnea. The patient had a 30-year history of smoking one pack of cigarettes per day. Physical examination reveals a barrel-chested appearance, and it is noted that the patient breathes through pursed lips. Spirometry shows decreased FEV1, FVC, and FEV1/FVC. This patient’s upper lobes are most likely to demonstrate which of the following?

Centriacinar emphysema. ***Centriacinar emphysema*** - This patient's history of **heavy smoking** and clinical presentation (dyspnea, barrel chest, pursed-lip breathing, abnormal spirometry) are highly suggestive of **COPD with emphysema**. - **Centriacinar emphysema** is the most common form of emphysema associated with **smoking** and predominantly affects the **upper lobes** of the lungs. *Panacinar emphysema* - This type of emphysema is typically associated with **alpha-1 antitrypsin deficiency** and affects the **lower lobes** of the lungs more uniformly. - While it also causes obstructive lung disease, it is not the primary form linked to smoking in the upper lobes. *Calcified nodule* - A **calcified nodule** in the lung usually represents a benign process, such as a healed **granuloma** from a fungal infection or tuberculosis. - It does not explain the widespread obstructive lung disease and changes seen in emphysema. *Hypersensitivity pneumonitis* - This is an **immunological reaction** to inhaled organic dusts or chemicals, leading to inflammation of the **alveoli and bronchioles**. - It typically causes a **restrictive or mixed pattern** on spirometry, not the **pure obstructive pattern** seen in this patient, and is not associated with smoking. *Uncalcified nodule* - An **uncalcified nodule** is a discrete lung lesion that could represent various pathologies, including **neoplasm** or **infection**. - This finding does not explain the diffuse obstructive lung disease, barrel chest, or pursed-lip breathing associated with emphysema.

Q: A 55-year-old woman comes to the physician with a 6-month history of cough and dyspnea. She has smoked 1 pack of cigarettes daily for the past 30 years. Analysis of the sputum sample from bronchoalveolar lavage shows abnormal amounts of an isoform of elastase that is normally inhibited by alpha-1 antitrypsin. The cell responsible for secreting this elastase is most likely also responsible for which of the following functions?

Phagocytosis of foreign material. ***Phagocytosis of foreign material*** - The abnormal elastase described is **neutrophil elastase**, which is normally inhibited by **alpha-1 antitrypsin**. - **Neutrophils** are the primary cells responsible for secreting this elastase, and their main function is the **phagocytosis of foreign material** and pathogens. *Production of lactoferrin* - **Lactoferrin** is an iron-binding protein with antimicrobial properties, primarily produced by **neutrophils**, but it is not their defining or most unique function in the context of elastase secretion and lung pathology. - While neutrophils do produce lactoferrin, the question asks for a function that aligns with the described cellular pathology following elastase release. *Degradation of toxins* - While certain immune cells and organs (e.g., liver) are involved in **detoxification**, it is not a primary or most characteristic function of **neutrophils** in the lung. - Neutrophils are more focused on direct microbial killing and inflammation rather than broad toxin degradation. *Secretion of mucus* - **Mucus secretion** in the airways is primarily a function of **goblet cells** and submucosal glands, not neutrophils. - Excessive mucus secretion is a feature of chronic bronchitis, which can coexist with emphysema, but neutrophils themselves do not secrete mucus. *Diffusion of gases* - **Gas diffusion** is the primary function of **type I pneumocytes** in the alveolar sacs, which form the thin barrier between air and blood. - This function is entirely unrelated to the role of neutrophils or the secretion of elastase.

Q: A 15-year-old boy is brought to the emergency department with a 30 minute history of difficulty breathing. He was playing basketball in gym class when he suddenly felt pain in the right side of his chest that got worse when he tried to take a deep breath. Physical exam reveals a tall, thin boy taking rapid shallow breaths. There are decreased breath sounds in the right lung fields and the right chest is hyperresonant to percussion. Which of the following is true of the lesions that would most likely be seen in this patient's lungs?

Found near the pleura. ***Found near the pleura*** - This patient's symptoms (sudden chest pain, difficulty breathing, decreased breath sounds, hyperresonance) are classic for a **spontaneous pneumothorax**. - In primary spontaneous pneumothorax, the air leak typically results from the rupture of **subpleural blebs** or **bullae**, which are small air-filled sacs located just beneath the visceral pleura at the lung apices. - This is the key anatomic characteristic of the lesions responsible for this condition. *Found predominantly in the lower lobes* - Blebs causing primary spontaneous pneumothorax are typically found in the **apical (upper) regions** of the lung, not the lower lobes. - The apices experience greater mechanical stress during breathing, making blebs more likely to form and rupture there. - Lower lobe involvement is not characteristic of primary spontaneous pneumothorax in young, healthy individuals. *Related to liver failure* - **Liver failure** is not directly associated with the formation of subpleural blebs or bullae that cause spontaneous pneumothorax. - Liver failure can cause respiratory issues like **hepatopulmonary syndrome** or **ascites-related diaphragmatic splinting**, but not this specific type of lung lesion. *Related to smoking* - Smoking is a significant risk factor for **secondary spontaneous pneumothorax** by causing emphysema and damaging lung parenchyma, leading to bullae formation. - However, in a **15-year-old boy** with a primary spontaneous pneumothorax, the underlying blebs are often congenital or idiopathic, and smoking is less likely to be the direct cause. - The key feature is the **subpleural location** of these blebs, typically at the lung apices.

Q: A 56-year-old man comes to the physician for a follow-up examination one week after a chest x-ray showed a solitary pulmonary nodule. He has no history of major medical illness. He has smoked 1 pack of cigarettes daily for the past 30 years. Physical examination shows no abnormalities. A tuberculin skin test is negative. A CT scan of the chest shows a 2.1-cm well-circumscribed, calcified nodule in the periphery of the right lower lung field. A CT-guided biopsy of the lesion is performed. Histological examination of the biopsy specimen shows regions of disorganized hyaline cartilage interspersed with myxoid regions and clefts of ciliated epithelium. Which of the following is the most likely diagnosis?

Pulmonary hamartoma. ***Pulmonary hamartoma*** - The histological description of **disorganized hyaline cartilage**, **myxoid regions**, and **ciliated epithelium** is pathognomonic for a pulmonary hamartoma, which is a benign tumor-like malformation. - The features of a **well-circumscribed** and **calcified nodule** on CT are also highly suggestive of a hamartoma. *Small cell lung carcinoma* - This is a **highly malignant neuroendocrine tumor** that typically presents as a centrally located mass, often with associated paraneoplastic syndromes. - Histologically, it would show small, dark, round to oval cells with scant cytoplasm, not mature cartilage or epithelium. *Bronchogenic cyst* - These are **congenital pulmonary anomalies** that are typically fluid-filled and lined by ciliated epithelium, but they do not contain cartilage or myxoid stromal elements. - They are usually cystic on imaging and rarely calcified in the described manner. *Eosinophilic granuloma* - This is a form of **Langerhans cell histiocytosis**, characterized by the proliferation of Langerhans cells and an inflammatory infiltrate rich in eosinophils. - It would present with **star-shaped nodules** or cysts on imaging and distinct histological features (birbeck granules, S100 positive Langerhans cells), very different from the described tissue. *Mature teratoma* - A mature teratoma contains **tissues derived from all three germ layers**, such as hair, teeth, bone, and various epithelial linings. - While it can contain cartilage and epithelium, the description of **disorganized hyaline cartilage interspersed with myxoid regions** in a lung nodule is most specific to a pulmonary hamartoma, not a widespread mixture of diverse mature tissues seen in a teratoma.

Q: A 72-year-old retired shipyard worker received a chest x-ray as part of a routine medical work-up. The radiologist reported incidental findings suggestive of an occupational lung disease. Which of the following descriptions is most consistent with this patient's film?

Fibrocalcific parietal pleural plaques on the diaphragm. ***Fibrocalcific parietal pleural plaques on the diaphragm*** - A retired **shipyard worker** has a high likelihood of **asbestos exposure**, which often leads to the development of **pleural plaques**, especially on the diaphragm and parietal pleura. - These plaques are **fibrocalcific** and are the most common radiographic manifestation of prior asbestos exposure, often found incidentally. *Hyperinflated lungs with a loss of lung markings* - This description is characteristic of **emphysema**, specifically the destruction of alveolar walls leading to air trapping and reduced vascular markings. - While smoking could be common among shipyard workers, this finding does not directly indicate an **occupational lung disease** specific to asbestos exposure. *Enlarged hilar lymph nodes* - **Enlarged hilar lymph nodes** are a prominent feature in conditions like **sarcoidosis**, tuberculosis, or certain lymphomas. - It is not a typical or specific finding for asbestos-related lung disease in the absence of other complications like malignancy. *Nodular calcium lesions in the apex of the lung* - **Nodular calcium lesions in the apex of the lung** are highly suggestive of **granulomatous disease**, most commonly **healed primary tuberculosis**. - This finding is not directly associated with asbestos exposure or other common occupational lung diseases. *No specific radiographic findings* - A **chest x-ray** is highly effective in detecting significant asbestos-related changes due to their characteristic appearance. - Given the patient's occupational history, the absence of specific findings would be less likely if there were any significant asbestos-related changes.

Q: A 66-year-old man presents with severe respiratory distress. He was diagnosed with pulmonary hypertension secondary to occupational pneumoconiosis. Biopsy findings of the lung showed ferruginous bodies. What is the most likely etiology?

Asbestos. ***Asbestos*** - The presence of **ferruginous bodies** on lung biopsy is highly characteristic of **asbestosis**, which is caused by occupational exposure to asbestos fibers. - Exposure to **asbestos** can lead to **pulmonary hypertension** due to the development of diffuse interstitial fibrosis and vascular remodeling. *Coal* - Exposure to **coal dust** causes **coal worker's pneumoconiosis** and can lead to progressive massive fibrosis but is not typically associated with ferruginous bodies as a defining marker. - While coal dust can cause pulmonary hypertension, the specific biopsy finding of ferruginous bodies points away from coal as the primary etiology. *Beryllium* - **Berylliosis** is a granulomatous disease that can cause interstitial lung disease, but its characteristic histological finding is **non-caseating granulomas**, not ferruginous bodies. - It is typically caused by exposure to beryllium, a light metal used in various industries. *Silica* - Exposure to **silica** causes **silicosis**, characterized by distinctive **fibrotic nodules** found predominantly in the upper lobes. - While silicosis can also lead to pulmonary hypertension, it does not typically present with ferruginous bodies on histology. *Iron* - Exposure to **iron dust** can cause **siderosis**, a benign pneumoconiosis where iron particles accumulate in the lungs, but it generally does not cause significant fibrosis or pulmonary hypertension. - Iron overload in the lung does not produce the characteristic ferruginous bodies observed in asbestos exposure.

Q: A 58-year-old man is brought to the emergency department after a witnessed tonic-clonic seizure. His wife says he has had a persistent dry cough for 6 months. During this time period, he has also had fatigue and a 4.5-kg (10-lb) weight loss. The patient has no history of serious illness and does not take any medications. He has smoked 1 pack of cigarettes daily for 35 years. He is confused and oriented only to person. Laboratory studies show a serum sodium concentration of 119 mEq/L and glucose concentration of 102 mg/dL. An x-ray of the chest shows an irregular, poorly demarcated density at the right hilum. Microscopic examination of this density is most likely to confirm which of the following diagnoses?

Small cell lung carcinoma. ***Small cell lung carcinoma*** - The patient's **hyponatremia** and **seizure** are indicative of **syndrome of inappropriate antidiuretic hormone (SIADH)**, a common paraneoplastic syndrome associated with **small cell lung carcinoma (SCLC)**. - The history of **heavy smoking**, **weight loss**, **fatigue**, **persistent cough**, and a **hilar mass** on chest X-ray are all classic presentations of SCLC. *Squamous cell lung carcinoma* - While strongly associated with smoking and often presenting as a hilar mass, it is more commonly linked to paraneoplastic syndromes like **hypercalcemia** due to PTHrP secretion, not SIADH. - Seizures in this context would likely be secondary to metastatic brain lesions rather than severe hyponatremia from SIADH directly. *Large cell lung carcinoma* - This type of lung cancer is often diagnosed by exclusion, when other more specific types cannot be identified. It can present with a variety of symptoms, but it is less consistently associated with **SIADH** than SCLC. - Tumors commonly grow rapidly and can present as large peripheral masses, though hilar involvement is also possible. *Bronchial carcinoid tumor* - These are typically **slow-growing neuroendocrine tumors** that are generally less aggressive than other lung cancers. - While they can cause paraneoplastic syndromes like **Cushing's syndrome** or **carcinoid syndrome**, SIADH is not a common association, and the patient's rapidly progressing symptoms and significant weight loss point away from this diagnosis. *Lung adenocarcinoma* - This is the most common type of lung cancer in **non-smokers**, although it can occur in smokers. It often presents as a **peripheral lung mass** and is less commonly associated with **hilar masses**. - While it can be associated with various paraneoplastic syndromes, **SIADH** is much less common compared to SCLC, and the clinical picture does not align as strongly.

Q: A 68-year-old man presents to the office with progressive shortness of breath and cough. A chest X-ray shows prominent hilar lymph nodes and scattered nodular infiltrates. Biopsy of the latter reveals noncaseating granulomas. This patient most likely has a history of exposure to which of the following?

Beryllium. ***Beryllium*** - **Chronic beryllium disease** (CBD) is characterized by **noncaseating granulomas** in the lungs, similar to sarcoidosis, and is associated with occupational exposure to beryllium. - Exposure typically occurs in workers involved in aerospace, ceramics, and electronics manufacturing. *Asbestos* - Exposure to **asbestos** is primarily associated with **asbestosis**, which features diffuse interstitial fibrosis, and an increased risk of mesothelioma and lung cancer. - While it causes lung disease, it does not typically present with noncaseating granulomas as the primary pathological finding. *Silica* - **Silicosis** results from inhaling **crystalline silica** and is characterized by nodular opacities, often with “egg-shell” calcifications in hilar lymph nodes, and fibrotic nodules, but not noncaseating granulomas. - The granulomas in silicosis are typically fibrotic and hyalinized, lacking the noncaseating appearance. *Coal dust* - Inhalation of **coal dust** leads to **coal worker's pneumoconiosis** (CWP), which can range from simple CWP with small nodular opacities to progressive massive fibrosis (PMF). - The pathology involves **macrophage accumulation** laden with coal dust, leading to fibrosis, rather than forming noncaseating granulomas. *Organic dust* - Exposure to **organic dusts** (e.g., from molds, animal proteins, cotton) can lead to **hypersensitivity pneumonitis**, characterized by diffuse inflammation of the lung interstitium and airways. - While granulomas can sometimes be seen in hypersensitivity pneumonitis, they are often poorly formed and are not the defining feature of the occupational lung disease that aligns with the described clinical picture with prominent nodular infiltrates and noncaseating granulomas, which is more characteristic of beryllium.

Question 1

An investigator is studying early post-mortem changes in the lung. Autopsies are performed on patients who died following recent hospital admissions. Microscopic examination of the lungs at one of the autopsies shows numerous macrophages with brown intracytoplasmic inclusions. A Prussian blue stain causes these inclusions to turn blue. These findings are most consistent with a pathological process that would manifest with which of the following symptoms?

Accepted Answer

Shortness of breath that worsens when supine

Answer

Purulent expectoration that worsens in the lateral recumbent position

Answer

Diaphoresis that worsens at night

Answer

Lower extremity swelling that worsens on standing

Answer

Dry cough that worsens early in the morning

Question 2

A 65-year-old male presented to his primary care physician with exertional dyspnea. The patient had a 30-year history of smoking one pack of cigarettes per day. Physical examination reveals a barrel-chested appearance, and it is noted that the patient breathes through pursed lips. Spirometry shows decreased FEV1, FVC, and FEV1/FVC. This patient’s upper lobes are most likely to demonstrate which of the following?

Accepted Answer

Centriacinar emphysema

Answer

Panacinar emphysema

Answer

Calcified nodule

Answer

Hypersensitivity pneumonitis

Answer

Uncalcified nodule

Question 3

A 55-year-old woman comes to the physician with a 6-month history of cough and dyspnea. She has smoked 1 pack of cigarettes daily for the past 30 years. Analysis of the sputum sample from bronchoalveolar lavage shows abnormal amounts of an isoform of elastase that is normally inhibited by alpha-1 antitrypsin. The cell responsible for secreting this elastase is most likely also responsible for which of the following functions?

Accepted Answer

Phagocytosis of foreign material

Answer

Production of lactoferrin

Answer

Degradation of toxins

Answer

Secretion of mucus

Answer

Diffusion of gases

Question 4

A 13-year-old boy is brought to the emergency department with respiratory distress, fever, and a productive cough. Past medical history is significant for a history of recurrent bronchopneumonia since the age of 5, managed conservatively with antibiotics and mucolytic therapy. The patient's weight was normal at birth, but he suffered from a failure to thrive, although there was no neonatal history of chronic diarrhea or jaundice. His current vitals are a respiratory rate of 26/min, a pulse of 96/min, a temperature of 38.8℃ (101.8°F), a blood pressure of 90/60 mm Hg, and oxygen saturation of 88% on room air. On physical examination, there is coarse crepitus bilaterally and both expiratory and inspiratory wheezing is present. The chest radiograph shows evidence of diffuse emphysema. A sweat chloride test and nitroblue tetrazolium test are both within normal limits. A complete blood count is significant for the following:
WBC 26300/mm3
Neutrophils 62%
Lymphocytes 36%
Eosinophils 2%
Total bilirubin 0.8 mg/dL
Direct bilirubin 0.2 mg/dL
SGOT 100 U/L
SGPT 120 U/L
ALP 200 U/L
Results of serum protein electrophoresis are shown in the figure. Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Alpha-1 antitrypsin deficiency

Answer

Wilson’s disease

Answer

Kartagener syndrome

Answer

Cystic fibrosis

Answer

Chronic granulomatous disease

Question 5

A 15-year-old boy is brought to the emergency department with a 30 minute history of difficulty breathing. He was playing basketball in gym class when he suddenly felt pain in the right side of his chest that got worse when he tried to take a deep breath. Physical exam reveals a tall, thin boy taking rapid shallow breaths. There are decreased breath sounds in the right lung fields and the right chest is hyperresonant to percussion. Which of the following is true of the lesions that would most likely be seen in this patient's lungs?

Accepted Answer

Found near the pleura

Answer

Found in the lower lobes

Answer

Related to liver failure

Answer

Found predominantly in the lower lobes

Answer

Related to smoking

Question 6

A 56-year-old man comes to the physician for a follow-up examination one week after a chest x-ray showed a solitary pulmonary nodule. He has no history of major medical illness. He has smoked 1 pack of cigarettes daily for the past 30 years. Physical examination shows no abnormalities. A tuberculin skin test is negative. A CT scan of the chest shows a 2.1-cm well-circumscribed, calcified nodule in the periphery of the right lower lung field. A CT-guided biopsy of the lesion is performed. Histological examination of the biopsy specimen shows regions of disorganized hyaline cartilage interspersed with myxoid regions and clefts of ciliated epithelium. Which of the following is the most likely diagnosis?

Accepted Answer

Pulmonary hamartoma

Answer

Small cell lung carcinoma

Answer

Bronchogenic cyst

Answer

Eosinophilic granuloma

Answer

Mature teratoma

Question 7

A 72-year-old retired shipyard worker received a chest x-ray as part of a routine medical work-up. The radiologist reported incidental findings suggestive of an occupational lung disease. Which of the following descriptions is most consistent with this patient's film?

Accepted Answer

Fibrocalcific parietal pleural plaques on the diaphragm

Answer

Hyperinflated lungs with a loss of lung markings

Answer

Enlarged hilar lymph nodes

Answer

Nodular calcium lesions in the apex of the lung

Answer

No specific radiographic findings

Question 8

A 66-year-old man presents with severe respiratory distress. He was diagnosed with pulmonary hypertension secondary to occupational pneumoconiosis. Biopsy findings of the lung showed ferruginous bodies. What is the most likely etiology?

Accepted Answer

Asbestos

Answer

Coal

Answer

Beryllium

Answer

Silica

Answer

Iron

Question 9

A 58-year-old man is brought to the emergency department after a witnessed tonic-clonic seizure. His wife says he has had a persistent dry cough for 6 months. During this time period, he has also had fatigue and a 4.5-kg (10-lb) weight loss. The patient has no history of serious illness and does not take any medications. He has smoked 1 pack of cigarettes daily for 35 years. He is confused and oriented only to person. Laboratory studies show a serum sodium concentration of 119 mEq/L and glucose concentration of 102 mg/dL. An x-ray of the chest shows an irregular, poorly demarcated density at the right hilum. Microscopic examination of this density is most likely to confirm which of the following diagnoses?

Accepted Answer

Small cell lung carcinoma

Answer

Squamous cell lung carcinoma

Answer

Large cell lung carcinoma

Answer

Bronchial carcinoid tumor

Answer

Lung adenocarcinoma

Question 10

A 68-year-old man presents to the office with progressive shortness of breath and cough. A chest X-ray shows prominent hilar lymph nodes and scattered nodular infiltrates. Biopsy of the latter reveals noncaseating granulomas. This patient most likely has a history of exposure to which of the following?

Accepted Answer

Beryllium

Answer

Asbestos

Answer

Silica

Answer

Coal dust

Answer

Organic dust

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Pulmonary — MCQs

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