A&P/EMBRYO
An investigator is studying the clearance of respiratory particles in healthy nonsmokers. An aerosol containing radio-labeled particles that are small enough to reach the alveoli is administered to the subjects via nonrebreather mask. A gamma scanner is then used to evaluate the rate of particle clearance from the lungs. The primary mechanism of particle clearance most likely involves which of the following cell types?
(a) Ciliated columnar cells
(b) Club cells
(c) Macrophages
(d) Type II pneumocytes
(C) Macrophages
A 54-year-old woman comes to the emergency department because of sharp chest pain and shortness of breath for 1 day. She has been coughing intermittently, which worsens the pain. She has osteoporosis, for which she takes raloxifene. Arterial blood gas analysis on room air shows:
pH 7.52; PCO 25 mmHg; PO2 65 mmHg; O2 saturation 92%
Physical examination is most likely to show which of the following findings?
(a) Unilateral swelling of the leg
(b) Pericardial friction rub
(c) Increased tactile fremitus
(d) Absent left radial pulse
(a) Unilateral swelling of the leg.
DVT --> PE.
A 54-year-old man comes to the physician because of excessive daytime sleepiness for 5 months. He wakes up frequently at night, and his wife says his snoring has become louder. He is 180 cm (5 ft 10 in) tall and weighs 104 kg (230 lb); his BMI is 33 kg/m2. His pulse is 80/min and his respiratory rate is 11/min. His jugular venous pressure is 7 cm H2O. He has 2+ pitting edema of the lower legs and ankles. Arterial blood gas analysis on room air shows a pH of 7.42 and a PCO2 of 41 mm Hg. An x-ray of the chest shows normal findings. Which of the following is the most likely underlying cause of this patient's condition?
(a) Increased responsiveness of the medulla
(b) Impaired myocardial relaxation
(c) Decreased hypocretin-1 levels
(d) Intermittent oropharyngeal collapse
(e) Daytime alveolar hypoventilation
(d) Intermittent oropharyngeal collapse
OSA.
A 53-year-old man comes to the physician because of a 1-day history of fever and chills, severe malaise, and cough with yellow-green sputum. He works as a commercial fisherman on Lake Superior. Current medications include metoprolol and warfarin. His temperature is 38.5°C (101.3°F), pulse is 96/min, respirations are 26/min, and blood pressure is 98/62 mm Hg. Examination shows increased fremitus and bronchial breath sounds over the right middle lung field. An x-ray of the chest shows consolidation of the right upper lobe. Which of the following is the most likely causal pathogen?
(a) Mycobacterium tuberculosis
(b) Pseudomonas aeruginosa
(c) Mycoplasma pneumoniae
(d) Staphylococcus aureus
(e) Haemophilus influenzae
(f) Streptococcus pneumoniae
(f) Streptococcus pneumoniae
A 29-year-old man comes to the physician for a follow-up examination. He has had numbness and tingling of his legs for the past 10 days. Three months ago, he was diagnosed with pulmonary tuberculosis and started on antituberculosis therapy. Examination shows dry scaly lips and cracks at the corner of the mouth. Sensation to pinprick and light touch is decreased over the lower extremities. His hemoglobin concentration is 10.4 g/dL and mean corpuscular volume is 76 μm3. Administration of which of the following is most likely to have prevented this patient's current symptoms?
(a) Iron
(b) Vitamin E
(c) Folic acid
(d) Vitamin B12
(e) Pyridoxine
(e) Pyridoxine (vitamin B6)
A 55-year-old man with recurrent pneumonia comes to the physician for a follow-up examination one week after hospitalization for pneumonia. He feels well but still has a productive cough. He has smoked 1 pack of cigarettes daily for 5 years. His temperature is 36.9°C (98.4°F) and respirations are 20/min. Cardiopulmonary examination shows coarse crackles at the right lung base. Microscopic examination of a biopsy specimen of the right lower lung parenchyma shows proliferation of clustered, cuboidal, foamy-appearing cells. These cells are responsible for which of the following functions?
(a) Lecithin production
(b) Cytokine release
(c) Gas diffusion
(d) Mucus secretion
(a) Lecithin production
Type II pneumocytes.
Describe the A-a gradient of the following patients:
(i) Jason, winded as he has just reached the summit of Mt. Everest.
(ii) Malachi, who developed pancreatitis which led to acute hypoxemic respiratory failure requiring intubation. CXR demonstrates bilateral white-out.
(iii) Wanda, who overdosed on fentanyl.
(ii) Increased gradient; ARDS --> shunting and diffusion limitation.
(iii) Normal gradient; central hypoventilation.
WHO classifications of pulmonary hypertension:
1:
2:
3:
4:
5:
1: PAH.
2: LHF.
3: Pulmonary.
4: CTEPH.
5: Miscellaneous.
A 55-year-old woman comes to the physician because of fevers for 2 weeks. She works as a nurse and recently returned from a charity work trip to India, where she worked in a medically-underserved rural community. A tuberculin skin test 3 months ago prior to her trip showed an induration of 3 mm. Physical examination is unremarkable. An x-ray of the chest shows right-sided hilar lymphadenopathy. A sputum culture shows acid-fast bacilli. Which of the following immunologic processes most likely occurred first?
(a) Transportation of bacterial peptides to regional lymph nodes
(b) Formation of a nodular tubercle in the lung
(c) Replication of bacteria within alveolar macrophages
(d) Production of interferon-gamma by CD4+ T-cells
(c) Replication of bacteria within alveolar macrophages.
An 8-year-old girl is brought to the physician by her mother because of a 6-month history of episodic dry cough, shortness of breath, and chest tightness. She has seasonal allergic rhinitis. Physical examination shows high-pitched expiratory wheezes throughout both lung fields. Pulmonary function testing shows an FEV1 of 70% (N ≥ 80%). Which of the following drugs would be most effective at reducing bronchial inflammation in this patient?
(a) Salmeterol
(b) Theophylline
(c) Tiotropium
(d) Montelukast
(e) Budesonide
(e) Budesonide
A 12-year-old boy is brought to the emergency department because of acute left-sided chest pain and dyspnea following a motor vehicle accident. His pulse is 122/min and blood pressure is 85/45 mm Hg. Physical examination shows distended neck veins and tracheal displacement to the right side. The left chest is hyperresonant to percussion and there are decreased breath sounds. This patient would most benefit from needle insertion at which of the following anatomical sites?
(a) 2nd left intercostal space along the midclavicular line
(b) 5th left intercostal space along the midaxillary line
(d) Subxiphoid space in the left sternocostal margin
(a) 2nd left intercostal space along the midclavicular line
A 44-year-old man comes to the physician because of a 5-month history of persistent cough productive of thick, yellow sputum and worsening shortness of breath. One year ago, he had similar symptoms that lasted 4 months. He has smoked two packs of cigarettes daily for the past 20 years. Physical examination shows scattered expiratory wheezing and rhonchi throughout both lung fields. Microscopic examination of a lung biopsy specimen is most likely to show which of the following findings?
(a) Increase ciliated epithelial cells
(b) Decreased alveolar macrophages
(c) Increased club cells
(d) Increased goblet cells
(d) Increased goblet cells
A 63-year-old man is transferred from a rural hospital to a tertiary care hospital because of a 3-week history of fatigue and shortness of breath. Auscultation of the lungs shows diminished breath sounds at the right lung base. His serum total protein concentration is 6.2 g/dL. Bedside ultrasonography shows an anechoic collection in the lower margins of the right pleural cavity. Thoracentesis shows clear fluid with a protein concentration of 2.7 g/dL. Which of the following is the most likely underlying cause of this patient's pleural effusion?
(a) Pulmonary TB
(b) Pulmonary sarcoidosis
(c) Congestive heart failure
(d) Bacterial pneumonia
(c) Congestive heart failure.
A 33-year-old man with HIV comes to the physician because of a nonproductive cough and shortness of breath for 3 weeks. He feels tired after walking up a flight of stairs and after long conversations on the phone. He appears chronically ill. His temperature is 38.5°C (101.3°F), and pulse is 110/min. Pulse oximetry on room air shows an oxygen saturation of 95%. Upon walking, his oxygen saturation decreases to 85%. Cardiopulmonary examination is normal. Laboratory studies show a CD4+ T-lymphocyte count of 176/mm3. Results of urine Legionella antigen testing are negative. A CT scan of the chest shows diffuse, bilateral ground-glass opacities. Microscopic examination of fluid obtained from bronchoalveolar lavage will most likely show which of the following findings?
(a) Gram+, catalase+ cocci
(b) Silver-staining, disc-shaped cysts
(c) Intracellular, acid-fast bacteria
(d) Septate, acutely-branching hyphae
(b) Silver-staining, disc-shaped cysts
Pneumocystis jirovecii
A 65-year-old man with chronic obstructive pulmonary disease is admitted to the hospital for the treatment of worsening shortness of breath and productive cough. Three weeks later, he complains of weakness in the lower limbs. His muscle strength is 4/5 at both hips but normal elsewhere. The drug that is most likely responsible for this patient's muscle weakness inhibits which of the following?
(a) Adenosine receptor
(b) 5-lipoxygenase
(c) Nuclear factor Kappa-B (NFKB)
(d) Phospholipase C
(c) NFKB
Cushing (steroid toxicity)
SUBJECT:
Neonatal respiratory distress syndrome (NRDS)...
(i) Most common etiology
(ii) Underlying basis
(iii) Prophylactic
(iv) Therapy
(i) Prematurity--surfactant usually produced ~24 gestational weeks
(ii) Deficiency of fetal surfactant to keep alveoli patent
(iii) Maternal glucocorticoids promote endogenous surfactant production (not as necessary ~ 34 weeks gestation)
(iv) Exogenous surfactant, respiratory support
A 29-year-old African-American woman comes to the physician because of a 4-month history of fever, progressive shortness of breath, and a dry cough. During this time, she has also had a 5-kg (11-lb) weight loss. Two months ago, she was in Kenya for several weeks to visit her family. Physical examination shows fine crackles and wheezing over both lung fields. Her serum calcium concentration is 11.8 mg/dL. An x-ray of the chest shows reticular opacities in both lungs and bilateral hilar lymphadenopathy. Which of the following is the most likely underlying mechanism of this condition?
(a) Necrotizing inflammation
(b) Granulomatous inflammation
(c) Bronchial hyperresponsiveness
(d) Neoplastic transformation
(b) Granulomatous inflammation.
Sarcoidosis.
A previously healthy 21-year-old man is brought to the emergency department 4 hours after the sudden onset of shortness of breath and pleuritic chest pain. He has smoked 1 pack of cigarettes daily for the past 3 years. He is 188 cm (6.2 ft) tall and weighs 70 kg (154 lb); BMI is 19.8 kg/m2. Physical examination shows decreased tactile fremitus and diminished breath sounds over the left lung. Which of the following is the most likely cause of this patient's symptoms?
(a) Embolic occlusion of the pulmonary artery
(b) Rupture of a subpleural bleb
(c) Hyperresponsiveness of the bronchial system
(d) Inflammation of the costal cartilage
(e) Fibrosis of the pulmonary parenchyma
(b) Rupture of a subpleural bleb.
Primary spontaneous pneumothorax.
3 most common bacteria responsible for COPD exacerbations?
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
An 81-year-old man is brought to the emergency department by staff of an assisted living facility where he resides with fever and a cough that produces yellow-green sputum. His temperature is 39.1°C (102.3°F). Physical examination shows diffuse crackles over the right lung fields. An x-ray of the chest shows consolidation in the right lower lobe. Sputum cultures grow an organism that produces blue-green pigments and smells of sweet grapes. Treatment with piperacillin and a second agent is begun. Which of the following is the most likely mechanism of action of the second agent?
(a) Impairs bacterial degradation of piperacillin
(b) Inhibits bacterial synthesis of folate (B9)
(c) Increases potency of piperacillin
(d) Inhibits bacterial ribosomal 50S subunit
(e) Inhibits DNA gyrase
(a) Impairs bacterial degradation of penicillin
Zosyn (piperacillin-tazobactam). Beta-lactamase inhibitor.
During a clinical study examining the diffusion of gas between the alveolar compartment and the pulmonary capillary blood, men between the ages of 20 and 50 years are evaluated while they hold a sitting position. After inhaling a water-soluble gas that rapidly combines with hemoglobin, the concentration of the gas in the participant's exhaled air is measured and the diffusion capacity is calculated. Assuming that the concentration of the inhaled gas remains the same, which of the following is most likely to increase the flow of the gas across the alveolar membrane?
(a) Entering cold chamber
(b) Deep exhalation
(c) Valsalva
(d) Treadmill exercise
(e) Treadmill exercise: Increased oxygen demand leads to increased alveolar recruitment, which increases alveolar surface area.
What other factors promote increased gas exchange? Can you think of how each of those factors can be impaired?
A 63-year-old woman is brought to the emergency department because of a 2-day history of severe epigastric pain and nausea. She has a 20-year history of alcohol use disorder. Nine hours after admission, she becomes increasingly dyspneic and tachypneic. Pulse oximetry on supplemental oxygen shows an oxygen saturation of 81%. Physical examination shows diffuse lung crackles, marked epigastric tenderness, and a periumbilical hematoma. Laboratory studies show normal brain natriuretic peptide. An x-ray of the chest shows bilateral opacities in the lower lung fields. Which of the following pathomechanisms best explains this patient's pulmonary findings?
(a) Alveolocapillary membrane leakage
(b) Intrapulmonary left-to-right shunt
(c) Embolic obstruction of pulmonary arteries
(d) Increased pulmonary capillary pressure
(a) Alveolocapillary membrane leakage.
ARDS.
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 one 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 mass at the right hilum. Microscopic examination of this mass is most likely to confirm which of the following diagnoses?
(a) Squamous cell lung carcinoma
(b) Small cell lung carcinoma
(c) Large cell lung carcinoma
(d) Bronchial carcinoid tumor
(e) Lung adenocarcinoma
(b) Small cell lung carcinoma
DAILY DOUBLE!!! Need to get all of it...
Characterize (a) breath sounds, (b) percussion, and (c) tracheal deviation (if appropriate) of the following clinical scenarios...
Pleural effusion, pneumothorax (tension), pneumonia.
(a) Effusion: decreased breath sounds, dull to percussion, no deviation.
(b) PTX: decreased BS, hyperresonant to percussion, contralateral deviation.
(c) PNA: bronchial breath sounds, dull to percussion, no deviation.
A 59-year-old man is brought to the emergency department one hour after developing shortness of breath and “squeezing” chest pain that began while he was mowing the lawn. He has asthma, hypertension, and erectile dysfunction. Current medications include salmeterol, amlodipine, lisinopril, and vardenafil. His pulse is 110/min and blood pressure is 122/70 mm Hg. Physical examination shows diaphoresis. An ECG shows sinus tachycardia. Sublingual nitroglycerin is administered. Five minutes later, his pulse is 137/min and his blood pressure is 78/40 mm Hg. Which of the following is the most likely mechanism of this patient's hypotension?
(a) Bradykinin accumulation
(b) Calcium channel antagonism
(c) Alpha1-receptor antagonism
(d) Cyclic GMP elevation
(e) Decreased NO production
(d) cGMP elevation
Concurrent use of PDE-5 inhibitors + nitrates leads to hypotension.
cGMP promotes smooth muscle relaxation (vasodilation) via increased NO production.