Respiratory

Question 1

Regarding lobar pneumonia, which of the following statements is correct?

A Rarely caused by streptococcus
B It is not usually associated with a productive cough
C A change from red to grey hepatisation occurs
D It is more common in the young and elderly

Answer 1

C

Explanation
Lobar pneumonia is more prevalent in the elderly and is associated with a productive cough. Streptococcus pneumoniae is the most common organism and there are 4 morphological phases starting with congestion, red hepatisation, grey hepatisation and resolution

Question 2

Regarding non-atopic (intrinsic) asthma, which of the following statements is correct?

A A positive family history is common
B Decreases vagal afferent responsiveness
C Is associated with atopy
D Is mainly triggered by viral respiratory illnesses rather than bacterial

Answer 2

D

Explanation
Non-atopic asthma is the second largest group of asthmas. It is also called non-reaginic. It is frequently caused by viral respiratory tract infections. A family history is uncommon. Serum IgE levels are normal and there are no other associated allergies. Skin tests are negative. It is thought that the virus induced inflammation of the respiratory mucosa lowers the threshold of the subepithelial vagal receptors to irritants

Question 3

Which of the following types of emphysema is most commonly associated with smoking and chronic bronchitis?

A Paraseptal
B Irregular
C Panacinar
D Centriacinar

Answer 3

D

Explanation
Centrilobular or centriacinar emphysema is associated with smoking and chronic bronchitis.

Panacinar or panlobular emphysema is associated with alpha 1 anti-trypsin deficiency.

Irregular emphysema or airspace enlargement is associated with fibrosis,

and paraseptal or ductal emphysema is associated with spontaneous pneumothorax

Question 4

Which of the following types of emphysema is most commonly associated pneumothorax in young patients?

A Paraseptal
B Irregular
C Panacinar
D Centiacinar

Answer 4

A

Explanation
Centrilobular or centriacinar emphysema is associated with smoking and chronic bronchitis.

Panacinar or panlobular emphysema is associated with alpha 1 antitrypsin deficiency.

Irregular emphysema or airspace enlargement is associated with fibrosis.

Paraseptal or ductal emphysema is associated with spontaneous pneumothorax

Paraseptal emphysema or distal acinar emphysema involves alveolar sacs and ducts around septa. The resulting bulla may lead to spontaneous pneumothorax

Question 5

All of the following cause compressive atelectasis, with the exception of?

A Pneumothorax
B Ascites
C Pleural effusion
D Asthma

Answer 5

D

Explanation
Compressive atelectasis results whenever the pleural cavity is partially or completely filled by fluid exudate, tumour, blood or air. It occurs commonly in patients in cardiac failure who develop pleural fluid, in patients who develop neoplastic effusion and in patients who have intra-abdominal pathology that results in an abnormal elevation of the diaphragm. Other types of atelectasis include resorption and contraction atelectasis.

Question 6

Which of the following is the most common form of emphysema in patients with alpha one antitrypsin deficiency?

A Paraseptal
B Irregular
C Panacinar
D Centriacinar

Answer 6

C

Explanation
Centrilobular or centriacinar emphysema is associated with smoking and chronic bronchitis. Panacinar or panlobular emphysema is associated with alpha 1 antitrypsin deficiency. Irregular emphysema or airspace enlargement is associated with fibrosis, and paraseptal or ductal emphysema is associated with spontaneous pneumothorax

Question 7

Which of the following is the most characteristic change occuring in chronic bronchitis?

A Columnar metaplasia of the bronchial epithelium
B Increase in smooth muscle thickness
C Decreased in goblet cell number
D Increase in size of the mucous glands

Answer 7

D

Explanation
In chronic bronchitis, although the number of the globet cells increases slightly, the major increase is in the size of the mucous glands. The bronchial epithelium may exhibit squamous metaplasia and dysplasia. The Reid index (ration of the thickness of the mucous gland layer to the thickness of the wall between the epithelium and the cartilage) is increased in chronic bronchitis (normal is 0.4)

Question 8

Which of the following statements is correct regarding squamous cell carcinoma of the lung?

A Is usually peripheral
B Is more common in females
C Is commonly associated with cigarette smoking
D Has a 5 year survival of 60%

Answer 8

C

Explanation
Squamous cell carcinoma has a 5 yr survival rate of around 40%. Men who smoke are at the highest risk. The site of the carcinoma commonly occurs around the hilum of the lung

Question 9

What happens to most particles 1-5 micrometers in diameter after they are breathed in?

A Exhaled away
B Lodged in trachea and bronchi
C Deposited in nose
D Phagocytosed by pulmonary alveolar macrophages

Answer 9

D

Explanation
Note: conflicting evidence relating to a polluted atmosphere. Explanation 1- comes from physiology sources, explanation 2 web sources and explanation 3 comes from pathological sources.

1-When an aerosol is inhaled, its fate depends on the size of particles. Large particles are removed by impaction in the nose and pharynx. This means that the particles are unable to turn the corners rapidly because of their inertia, and they are trapped on the wet mucosa. Medium size particles are deposited in small airways and elsewhere because of their weight. This is called sedimentation. The smallest particles (<0.1 micron in diameter) reach the alveoli, where some deposition occurs through the walls by diffusion. Many small particles are not deposited at all but are exhaled with the next breath. Once deposited in the alveoli, they are engulfed by macrophages that leave the area via the blood stream and the lymphatic system. If deposited on the bronchioles, they are swept up by the bronchiolar cilia and are either swallowed or expectorated.

2-size range and site of lodgement in pulmonary tree:

> 10 microns = upper airway. 5-10 microns = lower trachea or conducting airways. 0.5 - 5 microns = distal lung parenchyma (i.e. size of many bacteria)

One micron (or micrometer) is 0.001mm. A micrometer is one millionth of a meter, 1/1000000m

A nonometer is one billionth of a meter 1/1000000000.

3-The amount of dust retained in the lungs is determined by the dust concentration in ambient air, the duration of exposure, and the effectiveness of clearance mechanisms. Any influence, such as cigarette smoke, that affects the integrity of the mucocillary apparatus significantly predisposes to the collection of dust. The most dangerous particles range form 1-5micrometers in diameter because they reach the terminal small airways and air sacs and settle in the their linings. Under normal conditions there is a small pool of intra-alveolar macrophages that expands when the dust reaches the alveolar spaces. Protection is provided by phagocytosis. However this protection can be overwhelmed by a large dust burden by specific chemical interactions of the particles with cells

Finally: A useful way of rationalising these dimensions is that 1micron is approximately the diameter of a single coccus e.g. Streptococcus - the most common cause of typical pneumonia.

Question 10

The pathogenicity of Mycobacterium tuberculosis is caused by which of the following mechanisms?

A Is direct host cell killing by the bacillus
B Is due to caseous necrosis
C Is a hypersensitivity response to products of the tuberculosis bacteria
D Is impaired antibody response/cell mediated

Answer 10

C

Explanation
The development of cell mediated (type IV) hypersensitivity response explains the organism’s destructiveness in tissues and the emergence of resistance to the organisms. The T cells are responsible for killing the macrophages that have the bacilli. Lysis of macrophages results in the formation of caseating granulomas. Mycobacterium cannot grow in this acidic, extracellular environment which is lacking in oxygen, and so the infection is controlled.

Question 11

In obstructive (resorptive) atelectasis, which of the following statements is correct?

A Due to a partial obstruction of an airway
B It is caused by pleural fluid
C It involves the reabsorption of air
D The mediastinum moves away from the lesion

Answer 11

C

Explanation
Obstructive atelectasis is the consequence of complete obstruction of an airway which leads to resorption of the oxygen trapped in the dependant alveoli, without impairment of blood flow through the affected alveolar walls. Since lung volume is diminished, the mediastinum may shift towards the atelectic lung

Question 12

Which of the following statements is correct regarding the use of steroids in asthma?

A They are immediately effective
B They should be given nocte because of diurnal variation
C Cause bronchodilation
D They inhibit cytokines

Answer 12

D

Explanation
Steroids (in the nebulised form) are useful in the chronic management of asthma. Oral and IV doses, given in acute exacerbation, take a few hours to prevent the inflammatory response. They are given in the morning due to their diurnal variation. They have no effect on bronchodlitation

Question 13

Which of the following statements is true regarding lobar pneumonia?

A Is associated with immunosuppression
B Is not usually associated with a productive cough
C Involves morphological changes of red to grey hepatisation
D Is more common in the young than the elderly

Answer 13

C

Explanation
Lobar pneumonia is more prevalent in the elderly and is associated with a productive cough. Streptococcus pneumoniae is the most common organism and there are 4 morphological phases starting with congestion, red hepatisation, grey hepatisation and resolution

Question 14

Chronic bronchitis is characterised by which of the following?

A Goblet cell hypertrophy
B Mucus gland hypertrophy
C Chronic neutrophilic inflammation
D Smooth muscle hypertrophy

Answer 14

B

Explanation
In chronic bronchitis, although the number of the goblet cells increases slightly, the major increase is in the size of the mucous glands. The bronchial epithelium may exhibit squamous metaplasia and dysplasia. The Reid index (ratio of the thickness of the mucous gland layer to the thickness of the wall between the epithelium and the cartilage) is increased in chronic bronchitis (normal is 0.4). Grossly there is swelling, oedema and hyperaemia of the mucous membranes accompanied by mucopurulent secretions. Histologic features are chronic lymphocytic inflammation

Note: There is also bronchial smooth muscle hyperplasia.

Question 15

Which of the following is not a cause of compressive atelectasis?

A Pleural effusion
B Congestive cardiac failure (CCF)
C Asthma
D Pneumothorax

Answer 15

C

Explanation
Compressive atelectasis results whenever the pleural cavity is partially or completely filled by fluid exudate, tumour, blood or air. It occurs commonly in patients in cardiac failure who develop pleural fluid, in patients who develop neoplastic effusion and in patients who have intra-abdominal pathology that results in an abnormal elevation of the diaphragm. Other types of atelectasis include resorption and contraction atelectasis.

Question 16

Which of the following is not correct in relation to bronchogenic cysts?

A They may become dysplastic
B They occasionally cause pneumothorax
C They may contain mucus
D They are often connected to the tracheobronchial tree

Answer 16

D

Explanation
Bronchogenic cysts occur anywhere in the lungs as a single or, on occasion, multiple cystic spaces. They are usually found adjacent to bronchioles but are rarely in communication with the tracheobronchial tree. They are lined by bronchiolar-type epithelium and are usually filled with mucinous secretions. Complications include infection, rupture causing haemorrhage, pneumothorax or interstitial emphysema. There is a small risk of malignant deterioration

Question 17

The major morphological change in chronic bronchitis is which of the following?

A Increased mucosal gland depth (REID index)
B Smooth muscle hypertrophy
C Decreased goblet cell number
D Leukocyte infiltration

Answer 17

A

Explanation
In chronic bronchitis, although the number of the globet cells increases slightly, the major increase is in the size of the mucous glands. The bronchial epithelium may exhibit squamous metaplasia and dysplasia. The Reid index (ratio of the thickness of the mucous gland layer to the thickness of the wall between the epithelium and the cartilage) is increased in chronic bronchitis (normal is 0.4)

Question 18

Which of the following statements is true regarding lung carcinoma?

A Surgical resection is often effective for small cell carcinoma
B Small cell carcinoma is the most common type
C Distant spread occurs solely by lymphatic spread
D It most often arises around the hilum of the lung

Answer 18

D

Explanation
Lung cancer is currently the most frequently diagnosed major cancer in the world and is the most common cause of mortality. This is largely due to the carcinogenic effects of cigarette smoke

Lung cancer is a poor term as such tumours should be defined according to their cell lines. Lung cancers arise most often in and about the hilum of the lungs. About 3/4 of the lesions take their origin from bronchi. Only a small percentage of primary lung cancers arise in the peripheral lung substance. Adenocarcinoma is the most common lung cancer (37% of male and 47% of female lung cancers). It typically presents as a peripheral mass. However, these may also arise from the bronchi. Small cell and squamous cell carcinoma make up a smaller proportion of lung cancers each individually, but both present as central or hilar masses, and thus the majority of lung cancers arise around the hilum of the lung. Therefore, the majority of lung carcinomas are derived from the bronchi and are called bronchogenic cancers arising most often in and about the hilum of the lung. Distant spread occurs via the blood stream and lymphatic system.

Surgical resection is ineffective for small cell carcinoma

Extra:

In the latest textbook edition, in the morphology section of lung cancer, it does not say the sentence ‘Lung cancers arise most often in and about the hilum of the lungs. About 3/4 of the lesions take their origin from bronchi”. Rather it says: “lung Ca may arise in the peripheral of the lung (more often adenocarcinomas) or in the central/hilar region (more often squamous carcinoma), sometimes in association with recognizable precursor lesions. Also, the incidence of squamous carcinoma arising gin the periphery is increasing.

This may reflect a change in the answer. Given that adenocarcinoma is more common cancer (38%), lung cancer is more commonly found in the periphery.

Extra:

The question originally said: which is true regarding bronchogenic carcinoma.

Lung cancer or frequently if somewhat incorrectly known as bronchogenic carcinoma, is a broad term referring to the main histological subtypes of primary lung malignancies.

Source: radiopedia

Question 19

Which of the following statements is correct In regard to emphysema?

A Elastase activity is unaffected by oxygen free radicals
B The protease-antiprotease mechanism is the most plausible explanation for the disease
C Centriacinar destruction leads to obstructive overinflation
D A deficiency of alpha 1 antitrypsin is protective

Answer 19

B

Explanation
Emphysema is characterised by abnormal enlargement of the airspaces distal to the terminal bronchiole, accompanied by destruction of their walls, and without obvious fibrosis. In contrast, the enlargement of airspaces without destruction is termed overinflation. Alpha 1 antitrypsin is protective against elastases causing emphysema. Oxygen free radicals secreted by neutrophils inhibit alpha 1 antitrypsin and thus decrease the net antielastase activity in smokers

1) Centriacinar emphysema begins in the respiratory bronchioles and spreads peripherally. - It is associated with long-standing cigarette smoking and predominantly involves the upper half of the lungs. 2) Panacinar emphysema destroys the entire alveolus uniformly and is predominant in the lower half of the lungs. Panacinar emphysema generally is observed in patients with homozygous alpha1-antitrypsin (AAT) deficiency. 3) Paraseptal emphysema, also known as distal acinar emphysema, preferentially involves the distal airway structures, alveolar ducts, and alveolar sacs.

Question 20

Which of the following options is correct with regard to chronic bronchitis?

A Dysplasia of the epitheleum leads to emphysema
B Cigarette smoke stimulates alveolar leukocytes
C Infection is a primary cause
D The hallmark is hypersecretion of mucus in the large airways

Answer 20

D

Explanation
In chronic bronchitis, although the number of the globet cells increases slightly, the major increase is in the size of the mucous glands. The bronchial epithelium may exhibit squamous metaplasia and dysplasia. The Reid index (ratio of the thickness of the mucous gland layer to the thickness of the wall between the epithelium and the cartilage) is increased in chronic bronchitis (normal is 0.4). The role of infection is secondary. It is not important in initiating chronic bronchitis but it is important in maintaining it. Smoking affects the cilliary action of the respiratory mucosa and inhibits the ability of alveolar leukocytes to clear bacteria. Dysplasia leads to the possibility of developing respiratory cancer

Question 21

With regard to bronchial asthma, which of the following statements is correct?

A Primary mediators include eosinophilic and neutrophilic chemotactic factors
B Bronchial wall smooth muscle is atrophic
C IgG plays a role
D Sub-epitheleal vagal receptors in respiratory mucosa become desensitised to irritants

Answer 21

A

Explanation
Most asthma is associated with atopy, which represents an increased susceptibility to generate IgE in response to allergens. In addition, direct stimulation of subepithelial vagal receptors provokes bronchoconstriction through both central and peripheral reflexes, making them more sensitive. The bronchial smooth muscle becomes hypertrophic.

Question 22

Which of the following statements is correct regarding pulmonary tuberculosis?

A Langhans cells occur in coalescent granulomata
B Liquefactive necrosis precedes the formation of granulomata
C Bacilli establish themselves in sites of low oxygen tension
D The Ghon focus is a parenchymal peri-hilar lesion

Answer 22

A

Explanation
The Ghon focus is a parenchymal subpleural lesion found just above or below the interlobar fissure between the upper and lower lungs (distal airspaces of the lower part of the upper lobe or the upper part of the lower lobe). The bacilli thrive on oxygen. Granulomata form during the type IV cell mediated immune response. However, the bacilli may be toxic to the macrophages contributing to the caseous necrotic centre of a granuloma. Histologically, coalescent granulomata are composed of epitheliod cells surrounded by a zone of fibroblasts and lymphocytes that usually contain Langhans giant cells.

A gohn focus with nodal involvement is called a Gohn complex

Question 23

Which of the following options is correct in relation to bacterial pneumonias?

A The nasopharynx is inconsequential in defending the lung against infection
B Alveolar clearance of bacteria is achieved by lymphocytes
C Klebsiella pneumoniae is a common virulent agent
D Patchy consolidation of the lung is the dominant feature of a bronchopneumonia

Answer 23

D

Explanation
Klebsiella pneumoniae is a common pathogen but it occurs more commonly in the debilitated malnourished patient. Alveolar clearance is achieved mainly by macrophages. The nasopharynx is important in removing particles (droplets) containg the microorganisms by sneezing or blowing, and plays a vital role in defence against infection. Common agents include staphylococcus, streptococcus, pneumococcus, haemophilus, pseudomonas aeruginosa and coliform bacteria

Question 24

The most frequent site of a primary tuberculous lesion in lung is?

A Peripherally
B Lower zone of upper lobe
C Hilum
D Apex

Answer 24

B

Explanation
Primary tuberculosis (TB) implants in the lower part of the upper lobe or the upper part of the lower lobe. Secondary TB occurs near the apical pleura

Question 25

Drug induced asthma can occur following the ingestion of which of the following drugs?

A Pseudoephedrine
B Ibuprofen
C Oxycodone
D Paracetamol

Answer 25

B

Explanation
Aspirin and other NSAIDs trigger asthma in patients by inhibiting the cyclooxygenase pathway of the arachidonic acid metabolism, leading to a rapid decrease in prostaglandin E2. PGE2 normally inhibits the enzyme that generate proinflammatory mediators such as leukotrienes B4, C4,D4 and E4, which are believed to have central roles in aspirin induced asthma

Question 26

A patient presents to the ED. This is his 5th presentation since suffering from a bout of pneumonia 3yrs ago. His main clinical findings are cough, purulent sputa and fever. What is the most likely diagnosis?

A Emphysema
B Chronic bronchitis
C Bronchiectasis
D Asthma

Answer 26

C

Explanation
Bronchiectasis is a disorder in which there is destruction of smooth muscle and elastic tissue by chronic necrotizing infections leading to permanent dilation of bronchi and bronchioles.

It develops in association of a variety of conditions

Congenital or hereditary conditions (cystic fibrosis)

Infections (bacteria, viruses and fungi)

Bronchial obstruction (tumour, FB, mucus impaction)

Other (rheumatoid arthritis, SLE, lupus, COPD, post transplantation)

Idiopathic (1/4 to ½ of cases)

Obstruction and infection are the major conditions associated with bronchiectasis. It is likely that both are required for the development of fully fledged lesions.

Cor pulmonale, brain abscesses and amyloidosis are less common complications of bronchiectasis due to improved antibiotics and physiotherapy

Some have asked why the answer is not chronic bronchitis. I don’t disagree, my thought is that the stem specifically refers to a bout of pneumonia which has caused a patient to represent. Therefore, bronchiectasis may be more likely. Below are some extra sources

Extra: Source: Chest Journal.

Dlstinguishing bronchial deformity or dilatation occurs in bronchiectasis, as well as in acute and chronic bronchitis

Bronchiectasis consists of a permanent saccular or fusiform bronchial deformity following a previous pneumonia in the same area.

Acute bronchitis has a reversible cylindrical deformity of the dependent bronchi following an acute respiratory infection.

Chronic bronchitis has diffuse bronchographic features. Preliminary clinical studies suggest that these features may be due to elevated intrabronchial pressure produced by an obstructing mechanism during cough.

Extra: Source smartvest

Bronchiectasis is an irreversible, chronic condition where the airways in your lungs (bronchi) become damaged and abnormally widened from recurring inflammation or infection.

Common Signs and Symptoms of Bronchiectasis Include:

Chronic cough that produces mucus
Recurrent respiratory infections (e.g. tonsillitis, sinusitis, bronchitis, etc.)
Breathlessness and wheezing
General fatigue
COPD is similar to bronchiectasis in that it causes frequent pneumonias, inflammation, and permanent damage to your lungs. However, COPD is used as an umbrella term to describe other impaired breathing conditions, such as emphysema, chronic bronchitis, or asthma.

Question 27

Which of the folowing does is NOT an indication for a lung transplant

A Neoplastic terminal lung disease
B Idiopathic pulmonary fibrosis
C Idiopathic/familial pulmonary arterial hypertension
D End stage emphysema

Answer 27

A

Explanation
Indications for a lung transplant include almost all-non neoplastic terminal lung disease, provided the patient is able to take lifelong immunosuppressive medications.

The most common indications include:
- end stage emphysema
- idiopathic pulmonary fibrosis
- cystic fibrosis
- idiopathic/familial pulmonary arterial hypertension.

Often, only single lungs are transplanted as there is sufficient improvement in the patient from the one transplanted lung (and you can donate to two patients). Patients with chronic bilateral lung infections requiring transplant of both lungs in order to remove the reservoir of infection.

Question 28

Which of the following is true regarding malignant mesothelioma?

A The lifetime risk of developing mesothelioma in heavily exposed individuals is as high as 7-10%
B Sarcomatoid is the most common morphological type
C Mesothelioma arise in the thorax from the visceral pleura only
D There is an increased risk of mesothelioma in asbestos workers who smoke

Answer 28

A

Explanation
90% of reported mesotheliomas are asbestos related. The lifetime risk of developing mesothelioma in heavily exposed individuals is as high as 7-10%. There is a latent period of 25-45yrs for the development of asbestos related mesothelioma. Mesothelioma arise in the thorax from either the visceral or parietal pleura. There is no increased risk of mesothelioma in asbestos workers who smoke. However there is a markedly increased risk of asbestos related lung cancer in asbestos workers who smoke. Thus for asbestos workers (especially those that smoke), the risk of dying of lung cancer far exceeds that of developing mesothelioma. Morphology types: epitheliod (60%), sarcomatoid (20%) and mixed (20%). Asbestos bodies (and asbestos plaques) are found in increased umbers in the lungs of of patients with mesothelioma

Question 29

What type of genetic condition is cystic fibrosis?

A X-linked recessive
B X-linked dominant
C Autosomal recessive
D Autosomal dominant

Answer 29

C

Question 30

What are the typical pathological changes seen in bronchiectasis?

A Inflammation and necrosis
B Necrosis and infection
C Obstruction and infection
D Inflammation and obstruction

Answer 30

A

Explanation
Bronchiectasis is a disorder in which destruction of smooth muscle and elastic tissue by chronic necrotising infections leading to permanent dilatation of bronchi and bronchioles

Obstruction and infection are the major conditions associated with bronchiectasis , and it is likely that both are necessary for the development of full ledged lesion.

Extra:

The histological findings vary with the activity and chronicity of the disease. In full blown disease-there is intense acute and chronic inflammatory exudation within the walls of the bronchi and bronchioles, associated with desquamation of the lining of the epithelium and extensive areas of ulceration. In some instances necrosis destroys the bronchial or bronchiolar walls and forms an abscess. Fibrosis develops in more chronic cases.

Note:

Not sure which answer is correct. the first statement is the first statement in the textbook- might be the most, correct? New thought: because it asks for the pathology of the infection, I have gone for inflammation and necrosis

Question 31

What is the mechanism of edema in pleural effusion secondary to pneumonia?

A Increased lymphatic flow
B Increased osmotic pressure
C Leukocyte mediated inflammation
D Increased venous pressure

Answer 31

C

Explanation
Pleural effusions are usually serous in nature due to transudates of lymphocyte-rich fluid. Decreased (obstructed) lymphatic flow may contribute.

Question 32

What is underlying pathological mechanism behind Acute Respiratory Distress Syndrome?

A Decreased osmotic pressure
B Protease-antiprotease imbalance
C Mucous gland hyperplasia
D Diffuse alveolar damage

Answer 32

D

Explanation
ARDS is a type of acute lung injury, whereby a disruption to the alveolar-capillary interface in the lung causes an acute neutrophilic inflammatory response and flooding of alveoli, with subsequent damage to type II pneumocytes and hyaline membrane formation. There is eventual organisation and fibrosis.

Question 33

Which of the following is a late change seen in an acute asthma attack?

A Epithelial cell damage
B Vasodilation
C Bronchoconstriction
D Mast cell degranulation

Answer 33

A

Explanation
The late inflammatory phase is characterized by persisting bronchospasm and edema, leukocyte infiltration, and eosinophil-mediated epithelial damage and loss.

Question 34

A 60-year-old man with a 30-pack-year history of smoking presents with cough, a constricted right pupil and ptosis. What nerve supply is likely affected in this lesion?

A CN V
B Thoracic sympathetic trunks
C CN III
D Cervical sympathetic trunks

Answer 34

D

Explanation
Horner’s syndrome is due to disruption of sympathetic activity. It is anatomically classified into three types, depending on where the pathology affects the sympathetic pathway – central, preganglionic, postganglionic. Preganglionic causes such as lung tumours, disrupt the cervical sympathetic trunks.

Decreased sweating is also a feature of Horner’s syndrome.

Extra: Horner syndrome is primarily an acquired condition secondary to systemic/local diseases or iatrogenic causes but maybe congenital and purely hereditary in some rare cases. Sympathetic fibers have an extensive course and can be interrupted during extracranial, intracranial, or intra-orbital traversal. The sympathetic fibers may be interrupted centrally, between the hypothalamus and the exit point of fibers from the spinal cord (C8 to T2), or the discontinuation could be peripheral, in the cervical sympathetic chain, at the level of superior cervical ganglion, or along the course of the carotid artery. Preganglionic Horner syndrome can be an ominous sign due to its association with pulmonary malignancies. Overall, the causes of Horner syndrome can be divided according to the anatomical location of disruption.

Source: National library of medicine: Horner syndrome

Question 35

What is the most common cause of pneumonia in an alcoholic?

A Mycoplasma pneumoniae
B E. coli
C S. aureus
D Klebsiella pneumoniae

Answer 35

D

Explanation
Klebsiella pneumoniae is the most common cause of gram-negative pneumonia. It afflicts debilitated individuals, especially chronic alcoholics.

Question 36

A 20-year-old man who had a splenectomy as a child presents with rusty coloured sputum and fever. What is the most likely causative organism?

A S. aureus
B E. Col
C Moraxella catarrhalis
D Streptococcus pneumococcus

Answer 36

D

Explanation
Patients with prior splenectomy are particularly susceptible to infections with encapsulated bacteria

Question 37

A 27-year-old female with a pulmonary embolus develops shock. What is the underlying mechanism?

A Increased osmotic pressure
B Increased vascular permeability
C Loss of plasma volume
D Impaired cardiac output

Answer 37

D

Explanation
This is likely due to acute RV failure.

Question 38

Lung abscesses are commonly associated with which pathogen?

A H Influenzae
B Mycoplasma pneumonia
C Staph Aureus
D Strep pneumococcus

Answer 38

D

Explanation
Although under any appropriate circumstances, any pathogen can produce an abscess, the commonly isolated organisms include aerobic and anaerobic streptococci, staph aureus and a host of gram-negative organisms.

Staphylococcal pneumonia is associated with a high incidence of complications, such as lung abscess and empyema. Intravenous drug users are at high risk for development of staphylococcal pneumonia in association with endocarditis. It is also an important cause of hospital-acquired pneumonia.

extra: Anaerobic bacteria have been for decades the most dominant type of bacteria in lung abscess with Streptococcus spp (Streptococcus pneumonia serotype 3 i Streptococcus anginosus complex). Staphylococcus aureus is the most common isolated etiologic pathogen of lung abscess in children. (Brook I. Anaerobic pulmonary infections in children. Pediatr Emerg Care 2004;20:636-40.)

Extra:Anaerobes used to be the most common cause of community-acquired lung abscess, and Streptococcus species used to be the second most common cause. In recent years, this has been changing. Klebsiella pneumoniae is now an increasing cause of community- acquired lung abscess, but Streptococcus species continue to be major pathogens. (Lung abscess due to Streptococcus pneumoniae: a case series and brief review of the literature. Antonello Nicolini et al. Pneumonol Alergol Pol. 2014.)

This question has created some issues. Another bit of feedback. I am however going to leave the answer as is.

From up to date: “Most lung abscesses arise as a complication of aspiration. As such, they are typically polymicrobial and indolent in onset. Less commonly, lung abscesses complicate acute monomicrobial infections with pyogenic bacteria (eg, Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa” Answer may thus be staph aureus.

A user’s thoughts about this question as well

According to the TB that the questions are meant to be taken from; “Staphylococcal pneumonia is associated with a high incidence of complications, such as lung abscess and empyema.” And this is reinforced in Table: “Necrotizing Pneumonia and Lung Abscess Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pyogenes, and type 3 pneumococcus (uncommon)” Given that the state abscesses from Strep pneumococcus are “uncommon” then it would be hard to argue that this should be the right answer.

Question 39

Which type of lung cancer is most commonly associated with paraneoplastic syndromes?

A Small cell lung cancer
B Large cell lung cancer
C Metastases to the lung
D Adenocarcinoma

Answer 39

A

Explanation
Lung cancers, particularly small cell lung carcinomas, can cause paraneoplastic syndromes. Any histologic type of tumor may occasionally produce any one of the hormones, but tumors that produce ACTH and ADH are predominantly small cell carcinomas, whereas those that produce hypercalcemia are mostly squamous cell carcinomas.

Question 40

What is the most common bacterial trigger of COPD

A Klebsiella pneumonia
B Moraxella catarrhalis
C H. influenzae
D Streptococcus pneumoniae

Answer 40

C

Explanation
Streptococcus pneumoniae, or pneumococcus, is the most common cause of community-acquired acute pneumonia. H. influenzae is the most common bacterial cause of acute exacerbation of COPD. Moraxella catarrhalis is being increasingly recognized as a cause of bacterial pneumonia, especially in the elderly. It is the second most common bacterial cause of acute exacerbation of COPD.

Question 41

A young non-smoking woman presents with a 3 month history of cough with occasional blood-stained sputum. Her older brothers are married but without children. What is the most likely diagnosis?

A Cystic fibrosis
B Pulmonary TB
C Lung cancer
D Primary ciliary dyskinesia

Answer 41

D

Explanation
An odd question – but the significance of older brothers who are married but haven’t had children is presumably referring to an issue with sperm motility – because as we know there couldn’t be any further social/cultural issues that would be involved with deciding to not have children.

Current textbook: In primary ciliary dyskinesia (PCD), an autosomal recessive syndrome with a frequency of 1 in 15,000 to 40,000 births, ciliary dysfunction due to defects in ciliary motor proteins (e.g., mutations involving dynein) contributes to the retention of secretions and recurrent infections that in turn lead to bronchiectasis. The lack of ciliary activity interferes with bacterial clearance, predisposes the sinuses and bronchi to infection, and affects cell motility during embryogenesis, resulting in the situs inversus. Males with this condition tend to be infertile, as a result of sperm dysmotility.

Bronchiectasis causes severe, persistent cough; expectoration of foul smelling, sometimes bloody sputum; dyspnoea and orthopnoea in severe cases; and, on occasion, haemoptysis, which may be massive. Symptoms are often episodic and are precipitated by upper respiratory tract infections or the introduction of new pathogenic agents. Paroxysms of cough are particularly frequent when the patient rises in the morning, as the change in position causes collections of pus and secretions to drain into the bronchi.

Note:

Although cystic fibrosis (causing azoospermia and infertility) is more common. 1:2500 live births in the USA. The textbook specifically writes about PCD-Kartagener syndrome, males with this condition tend to be infertile, owing to the ineffective mobility of the sperm tail. The current textbook writes “rare autosomal recessive disorder that is frequently associated with bronchiectasis and infertility in males”

Given that the question specifically mentions brothers-married without children, PCD seems to be the right answer.

Question 42

Which statement is most correct?

A. There are four major types of emphysema centriacinar, panacinar, distal acinar and diffuse
B. In centriacinar emphysema the proximal parts of the acini formed by the respiratory bronchioles are affected
C. Panacinar emphysema occurs more commonly in the upper zones of the lung
D. Distal acinar emphysema is most commonly associated with alpha-1 antitrypsin deficiency

Answer 42

B

A (incorrect) 4 types of emphysema - centriacinar, panacinar, distal acinar/ paraseptal, irregular
C (incorrect) lower lobes
D (incorrect) panacinar

Question 43

Which of the following is CORRECT regarding emphysema?

A. Panacinar emphysema accounts for more than 95% of clinical cases
B. α1-antitrypsin deficiency is associated with centriacinar emphysema
C. Unlike restrictive pulmonary disease, emphysema is not associated with small airway fibrosis
D. In smokers, the upper 2/3rd of the lungs are more severely affected

Answer 43

D

Question 44

Regarding chronic bronchitis, which is CORRECT?

A. Defined clinically as persistent cough with sputum production for at least 6months in at least 3 consecutive years without other identifiable cause
B. Earliest feature is mucous hypersecretion from goblet cells in small airways
C. Smoking leads to acquired CFTR (cystic fibrosis conductance regulator) dysfunction
D. Infection is important in initiating disease

Answer 44

B

Chronic bronchitis - productive cough for > 3months over 2 consecutive years without other causes found

Question 45

A characteristic histological finding in asthma is?

A. Thickening of the basement membrane of the bronchial epithelium
B. Inflammatory infiltrates in the bronchial walls with predominance of lymphocytes
C. An increased number of submucosal glands
D. Hyperplasia of the bronchial wall muscle

Answer 45

A

Question 46

Regarding asthma, which is CORRECT?

A. Atopic asthma is caused by a TH1 and Ig-E mediated reaction to environmental allergens
B. IL-4, IL-5 and IL-13 are important mediators
C. Inflammatory cells implicated in atopic asthma are macrophages, neutrophils and lymphocytes
D. Airway remodelling include sub-basement membrane fibrosis and decreased vascularity (increase sub-basement membrane and vascularity)

Answer 46

B

A (incorrect) TH2 , not TH1
C (incorrect) mast cells and eosinophils
D (incorrect) increased sub-basement membrane and vascularity

Question 47

Regarding CAP, select the most correct:

A. Streptococcus pneumonia is a part of the endogenous flora in 35% of adults.
B. Moraxella Catarrhalis is the most common cause of bacterial pneumonia in alcoholics
C. Haemophilus influenzae is a gram positive organism that is a major cause of life threatening acute lower respiratory tract infections in young children
D. Streptococcus pneumonia is the most common cause of community acquired acute pneumonia

Answer 47

D

A (incorrect) 20%
B (incorrect) Klebsiella
C (incorrect) gram -ve

Question 48

Regarding pulmonary infections, which is CORRECT?

A. Mycoplasma pneumoniae is the most common cause of CAP
B. Moraxella catarrhalis is the 2nd most common cause of COPD exacerbation, and a top 3 otitis media cause in children
C. Antigenic shift of influenza viruses, with mutations that alter viral H and M proteins, results in new strains and causes epidemics
D. Lobar pneumonia progress through 3 stages: red hepatization, grey hepatization, and resolution

Answer 48

B

A (incorrect) Step pneumoniae
B (correct) top 3 OM: M catarrhalis, H influenza, S pneumonia
C (incorrect) H&N protein
D (incorrect) 4 stages – congestion, red hepatization, grey hepatization, resolution

Question 49

Regarding PE, select the most correct:

A. 65% or thrombotic pulmonary embolisms arise from the lower limb
B. 40% of PE are small and produce no symptoms or signs
C. Most common cause of fat embolism is from rib fractures
D. 10% of PEs cause lung infarction

Answer 49

D

A (incorrect) 95%
B (incorrect) 60-80%
C (incorrect) DVT

Question 50

The most common haemodynamic mechanism of pulmonary oedema is that attributable to:

A. Increased hydrostatic pressure secondary to volume overload
B. Lymphatic obstruction
C. Increased hydrostatic pressure secondary to left-sided heart failure
D. Decreased oncotic pressure

Answer 50

C

Question 51

Atelectasis of the lung can be caused by all of the following except:

A. Acquired
B. Resorption
C. Compression
D. Constriction

Answer 51

D

Question 52

Which statement is most true?

A. In atelectasis caused by compression the mediastinum shifts toward the affected lung
B. Neonatal atelectasis a partially reversible disorder
C. Atelectasis caused by contraction cannot be reversed
D. Atelectasis is a reversible disorder

Answer 52

C

Question 53

Regarding primary lung cancer, select the most correct:

A. Adenocarcinoma is more common in males.
B. Small cell carcinomas have a strong relationship to cigarette smoking.
C. Squamous cell carcinoma is more common in females.
D. Large cell carcinomas are highly malignant.

Answer 53

B