(92) A 24-year-old previously healthy woman goes to the emergency room because of the onset of severe respiratory distress with dyspnea and wheezing. She reports having taken aspirin for a headache 4 hours ago, but her headache is now gone. On physical examination she has a temperature of 36.9 C, pulse 88/minute, respiratory rate 26/minute, and blood pressure 110/70 mm Hg. There are expiratory wheezes on auscultation of the chest. Which of the following pulmonary abnormalities is she most likely to have?
(93) A 32-year-old woman received a left lung transplant 2 years ago for treatment of her cystic fibrosis. She has had no major episodes of rejection or infection. She now has increasing dyspnea and exercise intolerance for the past 5 months. On physical examination there are no abnormal findings. Which of the following pulmonary abnormalities is she most likely to have?
A Fibrous pleural plaques
B Pulmonary atherosclerosis
C Bronchoconstriction
D Interstitial pneumonitis
E Necrotizing vasculitis
F Bronchiectasis
G Thromboembolism
H Bronchiolitis obliterans
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(94) A 40-year-old man presents with increasing non-productive cough and dyspnea for the past 4 months. On physical examination there are some faint crackles auscultated over all lung fields. A chest radiograph shows multiple bilateral small <0.5 cm nodules. Laboratory studies show his serum creatinine is 4.4 mg/dL with urea nitrogen 40 mg/dL. A transbronchial biopsy is performed and on microscopic examination shows necrotizing granulomatous inflammation involving small peripheral arteries. Which of the following is the most likely diagnosis?
(95) A 55-year-old man has noted swelling of his feet for the past 3 months. He has no dyspnea or cough. On physical examination there is 2+ pitting edema to his knees. He is afebrile. A chest radiograph shows an enlarged right heart. A transthoracic needle lung biopsy is performed and on microscopic examination demonstrates peripheral pulmonary arteries with thickening and recanalization. Which of the following is the most likely diagnosis?
A Goodpasture syndrome
B Wegener granulomatosis
C Idiopathic pulmonary hemosiderosis
D Acute bacterial pneumonia
E Recurrent multiple pulmonary embolization
F Primary pulmonary hypertension
G Miliary tuberculosis
(96) A 40-year-old woman, a non-smoker, has had a worsening cough accompanied with left-sided chest pain for the past week, with several episodes of red-tinged sputum production. On physical examination she is afebrile. Breath sounds are decreased at the left lung base. A chest x-ray reveals a left lower lobe 4 to 5 cm area of consolidation. She is given antibiotic therapy but does not improve. Following a transbronchial biopsy, a left lower lobectomy is performed. She is doing well 10 years later. Which of the following neoplasms did she most likely have?
(97) A 32-year-old healthy man, a non-smoker, has a sudden episode of hemoptysis. On physical examination he is afebrile. There are decreased breath sounds over the left upper lung. A chest CT scan reveals an area of left upper lobe atelectasis. A bronchoscopy is performed, and there is a discrete reddish endobronchial mass seen within a segmental bronchus of the left upper lobe. A local resection is performed. He is doing well 10 years later. Which of the following neoplasms did she most likely have?
A Hamartoma
B Mesothelioma
C Carcinoid tumor
D Large cell anaplastic carcinoma
E Squamous cell carcinoma
F Small cell anaplastic carcinoma
G Metastatic adenocarcinoma
H Bronchioloalveolar carcinoma
(98) A 44-year-old man has smoked a pack of cigarettes a day for the past 25 years. He has had a chronic cough for at least 10 years. For the past 2 years the cough has become complicated by production of large quantities of sputum. A chest x-ray shows prominent pulmonary arteries and a prominent right heart border, with a slight increase in overall lung volume. A sputum cytology shows no atypical cells, only large amounts of mucus. Which of the following is the most likely diagnosis?
(99) A 22-year-old woman is employed by a stable at which horses are kept. She cleans out the straw and manure in the horse stalls, feeds hay to the horses, and grooms the horses, but does not ever get to ride the horses. Over the past few months she has had increasingly frequent episodes of fever, non-productive cough, and dyspnea. She does not have increased sputum production. On physical examination her temperature is 37.3 C. A chest radiograph shows a subtle pattern of reticulonodular infiltrates. Which of the following is the most likely diagnosis?
A Bronchiectasis
B Extrinsic allergic alveolitis
C Bronchial asthma
D Bronchiolitis obliterans
E Chronic bronchitis
F Tuberculosis
G Wegener granulomatosis
(100) A 30-year-old man has had a non-productive cough with fever and dyspnea but no hemoptysis for the past 3 days. On physical examination his temperature is 37.6 C. A chest radiograph reveals bilateral perihilar infiltrates. Laboratory studies show his CD4 lymphocyte count is 133/microliter. Which of the following is the most likely diagnosis?
(101) A 45-year-old man has had a fever for 2 weeks. On physical examination his temperature is 37.8 C. Crackles are auscultated over upper lung fields. A chest radiograph shows upper lobe cavitary lesions and focal calcifications. Which of the following is the most likely diagnosis?
B Asbestosis
C Cor pulmonale
D Pneumocystis carinii (jirovecii) pneumonia
E Streptococcus pneumoniae pneumonia
F Sarcoidosis
G Secondary tuberculosis
H Influenza B infection
(102) A 30-year-old man has had a non-productive cough with fever for the past month. On physical examination his temperature is 37.5 C. A chest radiograph shows a peripheral 2 cm right lower lobe mass. A CT-guided needle biopsy is performed and microscopic examination shows spherules about 50 microns in size with thick capsules containing endospores staining positively with the Gomori methenamine silver stain. In which of the following geographic locations is he most likely to reside?
(103) A 40-year-old woman has had a fever with non-productive cough for the past 6 weeks. On physical examination her temperature is 37.7 C. A chest radiograph shows multiple nodules averaging 0.5 to 1 cm in all lung fields. A transbronchial biopsy is performed and microscopic examination shows small yeasts within macrophages that are 2 to 4 microns in size and stain positively with the Gomori methenamine silver stain.In which of the following geographic locations is she most likely to reside?
A Phoenix, Arizona
B Cheyenne, Wyoming
C Seattle, Washington
D Cape Town, South Africa
E Miami, Florida
E Natchez, Mississippi
E Matsumae-town, Hokkaido, Japan
E Kandy, Sri Lanka
(104) A 35-year-old man is involved in a motor vehicle accident and sustains injuries including blunt trauma to the chest and abdomen, right ischial fracture, right femoral fracture, and left tibial fracture. He is taken to surgery and the fractures are stabilized. Postoperatively he is doing well until two days after admission, when he suddenly develops severe dyspnea. Despite resuscitative measures, he dies. What special stain performed on a section of the lung at autopsy would most help to elucidate the probable cause for these findings?
(105) A 35-year-old woman has dyspnea worsening over the past two weeks. She is coughing up large amounts of sputum that resemble thick, gelatinous cream. She had a similar episode a year ago. A chest radiograph shows diffuse pulmonary opacification. A lung biopsy is performed, and microscopically every alveolus is filled with an acellular exudate. Lung lavage is performed and she recovers. Which of the following special stains performed on the biopsy will be most useful to demonstrate the nature of this exudate and the underlying disease?
A Acid fast stain
B Gomori methenamine silver (GMS) stain
C Periodic acid-Schiff (PAS) stain
D Oil red O stain
E Trichrome stain
F Congo red stain
G Calcofluor white stain
(106) A 21-year-old man has the sudden onset of hemoptysis. On physical examination he is afebrile. Rales are auscultated in both lungs. A chest radiograph shows scattered infiltrates in both lungs. A sputum gram stain and culture show normal flora. Sputum cytology shows numerous red blood cells, but no neutrophils and no atypical cells. He then develops hematuria 2 days later. Laboratory findings include serum urea nitrogen of 38 mg/dL with creatinine 4.5 mg/dL. A transbronchial lung biopsy is performed and shows extensive intra-alveolar hemorrhage. Through which of the following mechanisms is his disease most likely produced?
(107) Each Spring, a 15-year-old boy develops rhinorrhea with sneezing and stuffy nose. He also experiences episodes of wheezing and coughing during which he has difficulty breathing. During the most recent episode, physical examination reveals lungs clear to auscultation. He coughs up a large glob of mucus. Laboratory studies show a WBC count of 9150/microliter with differential of 66 segs, 4 bands, 15 lymphs, 7 monos, and 8 eosinophils, Hgb 14.4 g/dL, Hct 44.7%, MCV 90 fL, and platelet count 310,000/microliter. Through which of the following mechanisms is his disease most likely produced?
A Mast cell degranulation
B Complement activation
C Antigen-antibody complex deposition
D CD4 lymphocyte infiltration
E Neutrophilic exudation
F NK cell mediated lysis
G Interferon gamma release from macrophages
H IgA release from plasma cells
(108) A productive cough with yellowish sputum production has been increasing for the past 3 days in a 40-year-old man, who has continued working 16 hours a day to produce a new television show. On physical examination he has a fever to 38.9 C. There is dullness to percussion at the right lung base. Gram stain of the sputum shows 4+ gram positive cocci in chains. Which of the following pulmonary pathologic abnormalities is he most likely to have?
(109) A 42-year-old man received an orthotopic cardiac transplant 2 months ago and has had mild acute cellular rejection treated with increasing immunosuppressive therapy. He has developed a non-productive cough with fever and headache over the past 2 weeks. On physical examination his temperature is 37.8 C. There are decreased breath sounds over his right lung. A chest radiograph reveals consolidation involving most of the right mid-lung. A bronchoalveolar lavage reveals long, filamentous, gram positive organisms to be present. Which of the following pulmonary pathologic abnormalities is he most likely to have?
A Acute abscessing bronchopneumonia
B Chronic abscessing pneumonia
C Interstitial pneumonitis
D Lobar pneumonia
E Miliary granulomata
F Necrotizing vasculitis
G Thromboemboli
(110) A 2-year-old child has had a runny nose and cough for the past 2 days and is febrile. The child suddenly develops a barking cough with hoarse cry. On physical examination his lung fields are clear on auscultation, but there is pronounced inspiratory stridor. Intubation is required to maintain the airway. He is most likely to have an infection with which of the following organisms?
(111) An 18-year-old marine in boot camp develops a sore throat over the past day. He has a mild fever, but no cough or respiratory difficulty. He then develops a headache with stiff neck within a few hours, followed by shock and appearance of a purpuric skin rash. He is most likely to have an infection with which of the following organisms?
A Group A beta-hemolytic streptococcus
B Corynebacterium diphtheriae
C Parainfluenza
D Bordatella pertussis
E Neisseria meningitidis
F Respiratory syncytial virus
G Streptococcus pyogenes
H Hemophilus influenzae
(112) A 35-year-old woman, a non-smoker, has had a chronic cough for over 15 years years, sometimes accompanied by fever and sputum production. On physical examination she has a temperature of 38 C. There are crackles auscultated over the left lung. A chest radiograph reveals consolidation of the left mid-lung field. A bronchogram demonstrates bronchial dilation and sacculation involving the first segmental bronchus and branches extending to the left lingular region. Which of the following mass lesions is she most likely to have?
(113) A healthy 44-year-old man, a non-smoker, goes to his physician for a routine check-up. On physical examination there are no abnormal findings. A chest radiograph reveals a 3 cm right upper lobe peripheral coin lesion. Which of the following mass lesions is he most likely to have?
A Pulmonary hamartoma
B Bronchial carcinoid
C Malignant mesothelioma
D Metastatic adenocarcinoma
E Large cell undifferentiated carcinoma
G Squamous cell carcinoma
H Intralobar sequestration
(114) A 50-year-old man has a chronic, non-productive cough along with dyspnea that has worsened over 3 months. He does not have hemoptysis. On physical examination he is afebrile. A chest radiograph reveals a diffuse reticulonodular pattern along with hilar adenopathy. A transbronchial lung biopsy is performed and on microscopic examination reveals non-caseating granulomata. Cultures and special stains for bacterial and mycobacterial organisms are negative. Which of the following diseases related to an environmental exposure is he most likely to have?
(115) A 65-year-old man has had progressive dyspnea for the past 15 years. He dies from pneumonia. At autopsy on gross examination his lungs have multiple 0.1 to 0.7 cm firm nodules scattered throughout all lobes, but more confluent in upper lobes. On microscopic examination these nodules show many polarizable needle-shaped crystals. Which of the following diseases related to an environmental exposure is he most likely to have?
A Silicosis
B Farmer's lung
C Berylliosis
D Anthracosis
E Byssinosis
F Silo-filler's disease
G Asbestosis
(116) A 49-year-old woman had an infiltrating ductal carcinoma of the left breast treated with mastectomy and chemotherapy 3 years ago. She has had a profound weight loss for 3 months and increasing dyspnea over the past month. On physical examination she is afebrile. There is dullness to percussion over all lung fields. Which of the following is most likely to be diagnosed with thoracentesis?
(117) A 44-year-old man has a history of rheumatic heart disease. He has had worsening dyspnea for the past year, along with pedal edema. An echocardiogram shows mitral, aortic, and tricuspid valve stenosis. Which of the following is most likely to be diagnosed with thoracentesis?
A Pneumothorax
B Hydrothorax
C Chylothorax
D Hemorrhagic effusion
E Empyema
A 55-year-old man has had worsening dyspnea for the past 5 years. On physical examination he is afebrile. There is hyperresonance over all lung fields. A chest CT scan shows diminished interstitial markings. His DLCO is diminished. Which of the following conditions is he most likely to have?
A Centrilobular emphysema
B Diffuse alveolar damage
C Sarcoidosis
D Bronchopulmonary dysplasia
E Diffuse scleroderma
A 23-year-old primigravida delivers a 3200 gm female infant at term following an unremarkable pregnancy. Ultrasound at 20 weeks had shown normal development for gestational age, with all major organs identified and normal in size and appearance. The amnionic fluid index was normal. Laboratory studies showed an alpha-fetoprotein 1.1 multiples of the mean (MoM). At birth, the baby has Apgar scores of 7 and 9 at 1 and 5 minutes. No external anomalies are noted. However, both the infant and placenta demonstrate a greenish staining. Which of the following conditions is most likely to explain respiratory distress that develops in this infant?
A Down syndrome
B Cytomegalovirus infection
C Cystic adenomatoid malformation
D Pulmonary sequestration
E Meconium aspiration
F Diaphragmatic hernia
A 33-year-old woman complains of a cough for 4 months, along with shortness of breath. On physical examination her temperature is 37.2 C. A chest radiograph demonstrates multiple small <1 cm nodules distributed throughout all lung fields, but more numerous in the upper lobes. A transbronchial biopsy is performed and on microscopic examination shows nodular aggregates of Langerhans cells with eosinophils, lymphocytes, plasma cells, and some fibroblasts with collagenization. Which of the following is the most likely diagnosis?
A Wegener granulomatosis
B Hypersensitivity pneumonitis
C Pulmonary eosinophilic granuloma
D Goodpasture syndrome
E Bronchial asthma
G Tuberculosis
A clinical study is conducted with subjects who are within 3 months of receiving an allogeneic bone marrow stem cell transplantation. The post-transplant pulmonary complications of these subjects are reviewed, along with diagnostic methods used. It is observed that one procedure to obtain material for pathologic diagnosis in these patients has a better yield than others, particularly when diffuse lower lobe infiltrates are seen with a chest radiograph. Which of the following procedures is most likely to have the highest diagnostic yield?
A Sputum cytology
B Bronchial washing
C Open lung biopsy
D Fine needle aspiration
E Bronchoalveolar lavage
An 18-month-old child is feeding poorly for 2 days, and then has rhinorrhea with low grade fever, cough, and wheezing with increasing difficulty breathing. Tachypnea develops and she is transported to the hospital where hypoxia is noted on admission. The occupancy rate at the hospital is very high because of many similar cases. The child had a normal birth weight at 40 weeks gestation and was sent home with mother from the hospital on the second day following birth. Which of the following infectious agents is most likely to cause her respiratory tract disease?
A Adenovirus
B Legionella pneumophila
C Mycoplasma pneumoniae
D Pneumocystis carinii (jirovecii)
E Streptococcus pneumoniae
F Cytomegalovirus
G Respiratory syncytial virus
A 54-year-old woman has had increasing dyspnea for the past 3 weeks. On physical examination she is afebrile. A chest radiograph reveals multiple 1 to 3 cm nodules in both lungs. A thoracentesis is performed. The pleural fluid obtained is serosanguinous. Cytologic examination of the fluid is most likely to demonstrate which of the following?
A Ferruginous bodies
B Cytomegalovirus
C Adenocarcinoma
D Lymphocytosis
E Polarizable crystals
A 48-year-old woman has worsening orthopnea for the past month. On physical examination she is afebrile. A bronchoalveolar lavage is performed and on cytologic examination there are numerous alveolar macrophages that are filled with hemosiderin. Which of the following is the most likely diagnosis?
A Aspiration pneumonia
B Mitral valve stenosis
C Blunt chest trauma
D Bronchiectasis
E Hepatic cirrhosis
After 25 days in hospital following a left cerebral infarction, a 67-year-old man with a history of congestive heart failure has a sudden episode of pleuritic chest pain on the left. He had shown steady improvement up to that point, remaining afebrile. Which of the following is the most likely diagnosis?
A Lobar pneumococcal pneumonia
B Pulmonary infarction
C Left upper lobe abscess
E Cytomegalovirus pneumonitis
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