Clinical Colloquium

Question 1

Over the course of 3 days a previously well 40 yo man develops a fever, chills and rigors, shortness of breath and a cough productive of greeny-yellow sputum. On examination he is febrile and tachypnoeic and his right posterior chest is dull to percussion, with bronchial breath sounds and a pleural friction rub heard on auscultation.

What kind of pathology is this likely to be?

Answer 1

Lobar pneumonia – acute bacterial infection (fever, chills and rigors and productive sputum)
More pleura inflamed and failrly localized (friction rub)

Question 2

Over the course of 3 days a previously well 40 yo man develops a fever, chills and rigors, shortness of breath and a cough productive of greeny-yellow sputum. On examination he is febrile and tachypnoeic and his right posterior chest is dull to percussion, with bronchial breath sounds and a pleural friction rub heard on auscultation.

If examined under a microscope, the affected lung tissue ism ost likely to contain or demonstrate

Answer 2

ACUTE: An inflammatory infiltrate: Neutrophils

Likely to have Fibrin and Oedema

Question 3

Over the course of 3 days a previously well 40 yo man develops a fever, chills and rigors, shortness of breath and a cough productive of greeny-yellow sputum. On examination he is febrile and tachypnoeic and his right posterior chest is dull to percussion, with bronchial breath sounds and a pleural friction rub heard on auscultation.

Which of the following is most likely to be cultured from his sputum?

Answer 3

S.pneumoniae: the most common community acquired lobar pneumonia (and bronchopneumonia which has a lot of other causes).

Question 4

Over the course of 3 days a previously well 40 yo man develops a fever, chills and rigors, shortness of breath and a cough productive of greeny-yellow sputum. On examination he is febrile and tachypnoeic and his right posterior chest is dull to percussion, with bronchial breath sounds and a pleural friction rub heard on auscultation.

Which of the following is most likely to be cultured from his sputum?

Answer 4

S.pneumoniae: the most common community acquired lobar pneumonia (and bronchopneumonia which has a lot of other causes).

Question 5

A long-term cigarette smoker has a persistent cough with white sputum production for most months in the last 5 years.

What pathology is this person likely to have?

Answer 5

COPD – chronic bronchitis: productive cough for >3months for at least 2 consecutive years

Question 6

A long-term cigarette smoker has a persistent cough with white sputum production for most months in the last 5 years.

Which one of the following abnormalities in the bronchial walls represents the major change underlying these clinical features?

Answer 6

Key microscopic feature is enlargement of the submucosal seromucinous glands: increase in volume of the seromucinous glands

(Loss of cilia and Hyperplasia of goblet cells are minor components)

Question 7

A long-term cigarette smoker has a persistent cough with white sputum production for most months in the last 5 years.

Which one of the following abnormalities in the bronchial walls represents the major change underlying these clinical features?

Answer 7

Key microscopic feature is enlargement of the submucosal seromucinous glands: increase in volume of the seromucinous glands

(Loss of cilia and Hyperplasia of goblet cells are minor components)

Question 8

Pulmonary pathologies demonstrated by the arrows are likely to be..

Answer 8

• Image shows cavitations (TB, Lung abscess, broncho- and lobar pneumonia, infarction [which can cavitate because necrosis is the cause of cavitation])
• Areas of consolidation: can be due to TB, bronchopneumonia, metastatic tumours (look different)
• TB lesions are not abscess: pus is dead neutrophils while TB it is not pus

Question 9

Pulmonary pathologies demonstrated by the arrows are likely to have resulted from the effects of..

Answer 9

= Lysosomal enzymes caused by the inflammatory process

Question 10

The micrograph is from a healing myocardial infarction. The cell type arrowed response to a variety of polympeptides in this process that mediate their effects via which one of the following modes of signalling?

Answer 10

Fibroblasts in granulation tissue
- Paracrine
Macrophages are a key cell that release lots of growth factors for healing which give signals to fibroblasts

Question 11

The micrograph is from the lungs of a 68yo male patient who died following an episode of severe central chest pain where the pain radiated down his left arm with sever SOB associated with coughing pink frothy sputum. This result from

Answer 11

= Pulmonary oedema a transudate

= Increased hydrostatic pressure in the pulmonary capillaries and venules

Question 12

What are some things that can go wrong to cause papillary muscle rupture?

Answer 12

A complication of Myocardial Infarction (1-14days post MI)
Infective endocarditis (acute necrosis)

Question 13

What are some things that can go wrong to cause acute mitral incompetence (and to left heart failure)?

Answer 13

Papillary muscle rupture - a complication of Myocardial Infarction (1-14days post MI)
Infective endocarditis (acute necrosis)

Question 14

The micrograph is from a healing myocardial infarction. The cell type arrowed response to a variety of polypeptides in this process that mediate their effects via which one of the following modes of signalling?

Answer 14

Fibroblasts in granulation tissue
- Paracrine
Macrophages are a key cell that release lots of growth factors for healing which give signals to fibroblasts

Question 15

What are some things that can go wrong to cause acute mitral incompetence (and to left heart failure)?

Answer 15

Papillary muscle rupture - a complication of Myocardial Infarction (1-14days post MI)
Infective endocarditis (acute necrosis)

Question 16

The pathological process demonstrated is most likely a result in …

Answer 16

Interstitial pulmonary fibrosis

Causes Honeycomb lung - a restrictive lung disease

Question 17

What is a key difference between emphysema and honeycomb (restrictive) lung disease?

Answer 17

There is no fibrosis or thickening of alveolar walls with emphysema (or chronic bronchitis)

Question 18

The pathological process demonstrated is most likely to result in:

a. bronchial obstruction
b. pulmonary hypertension
c. a pulmonary abscess
d. impaired elastic recoil

Answer 18

Pulmonary arterial hypertension (which can go to cor pulmonale)

Obliteration of the arteries leaning to hypertension

Question 19

The pathological process demonstrated is most likely to result in:

a. bronchial obstruction
b. pulmonary hypertension
c. a pulmonary abscess
d. impaired elastic recoil

Answer 19

Pulmonary arterial hypertension (which can go to cor pulmonale)

Obliteration of the arteries leaning to hypertension

Question 20

A 73yo man with a history of MI 5 years previously and angina but no other CV problems, has been experiencing SOB on exertion and swelling of his ankles been getting progressively worse over last few weeks. No chest pain. BP130/85 and pulse 75 and regular. Apex beat displaced laterally, heart sounds dual no murmur and inspiratory crepitations and lung bases bilaterally. Only medication he is on long acting nitrate for his angina. Whist shopping one day he complains of sudden onset severe chest pain but collapses and dies within minutes

a. Recent MI
b. LV dilatation
c. aortic stenosis
d. LV wall thickening
e. RV dilation

Answer 20

LV Dilation

Ischaemic myocytes = electrically unstable: don’t need an infarct just need acutely ischaemic tissue. Ischamiea = 20-30 minutes and then the necrosis occurs. Leads to abnormal circuits that leads to ventricular fibrillation.
Scar tissue can predispose to VF
Myocarditis can lead to VF
Dilatation is a predisposing factor to VF: LV is of higher mass in hypertrophy: eccentric hypertrophy. They need more blood and they don’t get the blood and leads to ischameia. More common to dilation (eccentric hypertrophy). Evidence because displaced apex beat and angina.

Could have also had a PE but because it is likely cardiac due to previous Hx and no suggestion of risk factors for DVT.

Question 21

A middle aged man collapses. He is with his wife who said he is active and had not been unwell recently. He has no signifacne past medical Hx. He is now lying on the floor, is unresponsive and his pulse and breathing are absent despite clear airways. Resucessatation was attempted and he was taken to the nearest hospital by ambulance but declared deat 30 minutes later. What is the cause?

a. Focal pallor of the myocardium in keeping with recent infarction
b. Thrombosed atherscloeritc coronary artery
c. Massive pulmonary embolism
d. Haemopericardium

Answer 21

No evidence of myocardial infarct (small chance of silent infarction)
Thrombosed atherosclerotic coronary artery is most common = sudden cardiac death
More likely because he is a man and middle aged.

Question 22

The photograph of a valve in the heart: The LV of this patient is likely to

a. Appear normal
b. Be dilated
c. Have thickened wall

Answer 22

Mitral valve (fossa ovalis and two cusps)
Thickening of the valve = calcified – chronic rheumatic valve disease
Mitral stenosis = appear normal

Question 23

What does mitral valve prolapse look like? (myxomatous valve)

Answer 23

Chordae normal

Valve cusps dilated and higher up