Because Pathology Need Not Be the Root of All Suffering
The 205 questions about cardiovascular pathology, hematopathology, and lung pathology, which have been previously published on this blog and on www.pathologyreviewforStep1.com, have been combined into one book, randomized within those three headings, and published on Amazon.
The book costs $0.99, however, from 02/24/2020 to 02/28/2020, the book will be available for free download. The book can be found at the below link.
The general pathology questions (207 questions total) from this blog and www.pathologyreviewforStep1.com are available in Kindle format and can be downloaded from Amazon.
The book is priced at $ 0.99, but from 2/24 to 2/28, the book will be free to download.
Question 193
A 47-year-old male presents to an acute care clinic with complaints of a cough, fever, and difficulty breathing with exertion. He was diagnosed with asthma 4 years ago, frequently has episodes of allergic rhinitis, and underwent removal of nasal polyps surgically 1 year ago. A complete blood count reveals an elevated concentration of eosinophils (13%). Laboratory testing also reveals the presence of MPO-ANCA (p-ANCA). A chest x-ray reveals patchy infiltrates. Of the following, what would a biopsy of the lung most likely reveal?
A. Granulomatous inflammation and eosinophilic infiltrates of vessels
B. Neoplastic eosinophils
C. Nematode infestation
D. Foreign material, consistent with IV drug abuse
E. Small cell carcinoma
Answer: A (Granulomatous inflammation and eosinophilic infiltrates of vessels)
Explanation: The clinical presentation (male patient in their 40s with a history of asthma, allergic rhinitis, nasal polyps, eosinophilia and pulmonary infiltrates) is consistent with eosinophilic granulomatosis with polyangiitis (formerly known as Churg Strauss syndrome). Some of these patients (about 40%) will have MPO-ANCA (p-ANCA) directed against myeloperoxidase. A biopsy of the lung will reveal granulomatous inflammation and eosinophilic infiltrates of the vessels. Eosinophilic leukemia is very rare. While a nematode infestation could cause the eosinophilia, it would not be associated with the MPO-ANCA.
Question 194
A 61-year-old female presents to the emergency room with her husband. She reports that over the past two days she has had a severe headache and pain in her jaw on the left side, and now for the past 4 hours she has had double vision. Of the following, what is the most likely diagnosis?
A. Temporal arteritis
B. A non-ST elevation myocardial infarct with embolized mural thrombus
C. Aortic dissection with involvement of carotid artery
D. Polyarteritis nodosa
E. Late-onset systemic lupus erythematosus
Answer: A (Temporal arteritis)
Explanation: The clinical presentation (patient >55 years of age, presenting with headache, jaw pain, and visual changes) is consistent with temporal arteritis. Embolization of mural thrombus could cause a stroke; however, the jaw pain associated with an acute myocardial infarct would not likely occur in association with the embolized mural thrombus; instead, the jaw pain would occur at the time of the infarct, but the embolus would occur days or weeks later. There is no history of chest pain to support an aortic dissection and involvement of the common carotid artery (where extension would occur) would likely cause a stroke. While a headache can occur during a stroke, the patient has no focal neurologic change (e.g., weakness, sensation loss or both on one side of her body). Polyarteritis nodosa does not commonly involve the aorta and while SLE can cause vasculitis, the changes in the clinical scenario are most consistent with the distribution of involvement of temporal arteritis.
Question 195
A 60-year-old female presents to the emergency room. She reports that over the past four days she has had a headache, which worsened today, and is now associated with pain in her jaw on the left side. For the past 2 hours she has had blurry vision. Laboratory testing will reveal an increase in which of the following?
A. Troponin I
B. Alkaline phosphatase
C. ESR
D. D-dimer
E. TSH
Answer: C (ESR)
Explanation: The clinical presentation (patient >55 years of age, presenting with headache, jaw pain, and visual changes) is consistent with temporal arteritis. Patients with temporal arteritis will most often have an elevated ESR and elevated C-reactive protein. While a d-dimer can be elevated in patients with thrombosis, thrombosis is not necessarily a component of temporal arteritis, and thus would be less likely to be elevated.
Question 196
A 62-year-old male with systemic hypertension and a 35-pack-year smoking history presents to his primary care physician with complaints that over the past year he has had increasing shortness of breath when walking with his wife. While he used to be able to walk about a half of a mile, he can now only walk about 2 blocks before needing to stop. He also has shortness of breath at night and has started sleeping on two pillows and propped up in bed. Physical examination reveals an S3; however, there is no pitting edema of the lower extremities and his liver is not palpable. Of the following, which additional physical examination finding is most likely to be identified?
A. Elevated jugular venous distention
B. Massive splenomegaly
C. Crackles on auscultation of the chest
D. Bruit in the midportion of the right side of the back
E. Deviation of the tongue when extended
Answer: C (Crackles on auscultation of the chest)
Explanation: Chronic dyspnea, manifested as dyspnea on exertion and orthopnea (i.e., shortness of breath at night requiring pillows) associated with a history of risk factors for coronary artery atherosclerosis (the hypertension and smoking history) and the physical finding of an S3, is consistent with congestive heart failure. As there is no pitting edema of the lower extremities or hepatosplenomegaly, this individual has left-sided heart failure, and, of the choices, crackles on auscultation of the chest is the most likely additional finding and which would be caused by fluid in the lungs. Elevated jugular venous distention is consistent with right sided failure. While it could be possible for an individual to have right sided heart failure and an elevated jugular venous distention without pitting edema or hepatosplenomegaly, the better choice is still crackles, as individuals with right sided symptoms due to left sided failure should also have fluid in the lungs. Although right sided heart failure can lead to splenomegaly, it is not likely massive, and, as above, the absence of pitting edema and hepatosplenomegaly greatly decrease the chance that the right side of the heart is failing. A bruit in the right mid back could suggest renal artery stenosis, which could be present in an older male with risk factors for atherosclerosis, but does not have to be present. And, deviation of the tongue would indicate hypoglossal nerve injury, which is not related to the case presentation, unless there were a subtle stroke.
Question 197
A 48-year-old male presents to an acute care clinic complaining of worsening shortness of breath with exertion. He has not seen a physician in 20 years and considers himself healthy, eating a balanced diet and getting plenty of exercise. Physical examination reveals a harsh, late-peaking systolic murmur that is heard best at the 2nd right intercostal space and radiates to the carotid arteries. In addition, the point of maximal impulse is sustained and the second heart sound is difficult to hear. Of the following, what is the most likely diagnosis?
A. Aortic stenosis due to degenerative calcification of a bicuspid aortic valve
B. Aortic stenosis due to degenerative calcification of a tricuspid aortic valve
C. Aortic regurgitation
D. Mitral stenosis
E. Mitral regurgitation
Answer: A (Aortic stenosis due to degenerative calcification of a bicuspid aortic valve)
Explanation: The murmur is characteristic for aortic stenosis. The muffled 2nd heart sound is due to the fact that the valve is relatively immobile. Given the young age of the patient, the aortic stenosis is most likely due to a calcified bicuspid aortic valve, as aortic stenosis due to calcification of a tricuspid aortic valve normally occurs later in life.
Question 198
A 63-year-old female presents to her primary care physician. Yesterday she passed out while doing dishes, and for the past two weeks she has felt like her heart was beating irregularly and she sometimes she has shortness of breath while working in her vegetable garden. Her past medical history includes a laparoscopic cholecystectomy 25 years ago. Physical examination reveals an irregularly irregular pulse. Auscultation of her chest reveals no murmurs, gallops, or other abnormalities. If her disease process is not treated, of the following, which is she at greatest risk for?
A. Mitral stenosis
B. Atrial myxoma
C. Acute pericarditis
D. Local thrombosis of a coronary artery leading to acute myocardial infarct
E. Pulmonary hypertension
F. Acute cerebral infarct
Answer: F (Acute cerebral infarct)
Explanation: The physical examination reveals an irregularly irregular pulse, which is consistent with atrial fibrillation. Atrial fibrillation can cause syncope and palpitations, as the patient reports. Individuals with atrial fibrillation are at risk for forming mural thrombi in the left atrium. If these mural thrombi break loose and embolize, they can lead to a cerebral infarct (among other conditions). While embolism can lead to an acute myocardial infarct, atrial fibrillation would not predispose to the development of a thrombus within a coronary artery itself. If a thrombus forms locally, it is not an embolus. A thrombus can embolize; however, if this were the case, the thrombus would not have developed locally – it would have developed at a remote location and been carried by blood flow to the point where it caused symptoms. Atrial fibrillation can occur as a result of left atrial dilation and hypertrophy from mitral stenosis, but it is not a direct cause of mitral stenosis.
Question 189
A 25-year-old male graduate student is being seen by his family physician. Over the past two years, on several occasions during each year, he has developed several painful oral ulcers that resolved within about a week. Once during the last year, he developed a painful ulcer on his penis; however, he is not sexually active and did not seek treatment. Today, he presents with red lesions on his legs and he also reports a cluster of painful ulcers in his mouth. Of the following, in which country was he most likely born?
A. Turkey
B. Russia
C. Scotland
D. Brazil
E. Mexico
Answer: A (Turkey)
Explanation: In young males, the combination of oral ulcers, genital ulcers and skin lesions is consistent with Behcet syndrome. Skin lesions can include a variety of conditions, including erythema nodosum, which would produce the red lesions on the legs. The incidence of Behcet syndrome is highest from the eastern Mediterranean to China, which would include Turkey.
Question 190
A 26-year-old male is found unresponsive in his apartment after not reporting for work. An autopsy is performed, revealing a left hemothorax due to a ruptured thoracic aortic aneurysm. His past medical history includes recurrent oral ulcers, sometimes occurring in clusters, at least 5-6 times per year. The oral ulcers have been associated with occasional ulcers of the penis and several times, eye pain and redness. Of the following, which HLA type is associated with his disease process?
A. HLA B21
B. HLA B27
C. HLA B40
D. HLA B43
E. HLA B51
Answer: E (HLA B51)
Explanation: In a young male, recurrent episodes of apthous ulcers associated with penile ulcers and eye symptoms is consistent with Behcet syndrome. While not characteristic for the disease process, other organ systems can be involved, including the thoracic aorta in around 3-5% of patients. Behcet syndrome is associated with HLA B51.
Question 191
A 46-year-old male, who was diagnosed with asthma 4 years ago, and has had one outpatient surgery for nasal polyps, presents to an acute care clinic with complaints of a cough, fever and dyspnea with exertion. A complete blood count reveals an elevated concentration of eosinophils (14%). A chest x-ray reveals patchy infiltrates. Additional laboratory testing reveals MPO-ANCA. Of the following, what is the most likely diagnosis?
A. Granulomatosis with polyangiitis
B. Exacerbation of asthma
C. Illicit drug reaction
D. Polyarteritis nodosa
E. Eosinophilic granulomatosis with polyangiitis
Answer: E (Eosinophilic granulomatosis with polyangiitis)
Explanation: The clinical presentation (male patient in their 40s with a history of asthma, nasal polyps, eosinophilia and pulmonary infiltrates) is consistent with eosinophilic granulomatosis with polyangiitis (formerly known as Churg Strauss syndrome). Some of these patients (about 40%) will have MPO-ANCA (p-ANCA) directed against myeloperoxidase. Granulomatosis with polyangiitis is not associated with asthma or eosinophilia, and PR3-ANCA (c-ANCA) is most often present. Polyarteritis nodosa rarely involves the lungs, is not associated with eosinophilia, and is not routinely associated with ANCA. An exacerbation of asthma or illicit drug reaction would not explain the ANCA.
Question 192
A 49-year-old male, who was diagnosed with asthma 3 years ago and frequently has episodes of allergic rhinitis, presents to an acute care clinic with complaints of a cough and fever. A complete blood count reveals an elevated concentration of eosinophils (15%). A chest x-ray reveals patchy infiltrates. Additional laboratory testing reveals MPO-ANCA. Of the following, which test or procedure would best confirm the diagnosis?
A. Lung biopsy
B. Pneumonectomy
C. Pulmonary function tests
D. MRI of the chest
E. Echocardiogram
Answer: A (Lung biopsy)
Explanation: The clinical presentation (male patient in their 40s with a history of asthma, allergic rhinitis, eosinophilia and pulmonary infiltrates) is consistent with eosinophilic granulomatosis with polyangiitis (formerly known as Churg Strauss syndrome). Some of these patients (about 40%) will have MPO-ANCA (p-ANCA) directed against myeloperoxidase. The best diagnostic procedure would be a lung biopsy to confirm the presence of the vasculitis. Removal of an entire lung is not necessary. While pulmonary function tests, MRI of the chest, and echocardiogram could be performed to help determine extent of the disease process, as eosinophilic granulomatosis with polyangiitis can involve the heart, none of these procedures would allow for a specific diagnosis such as a biopsy would.
Question 185
A 47-year-old female has a history of hypertension for many years that has been poorly controlled with medication. She is otherwise healthy and does not smoke. She decides to change physicians and her new physician conducts a thorough physical examination and identifies a bruit on the right side of the lower back. Of the following, which would best allow for definitive diagnosis of her underlying disease process?
A. Complete metabolic panel to include BUN and creatinine
B. Urine culture
C. Pelvic examination
D. Angiogram
E. CT scan of the abdomen
Answer: D (Angiogram)
Explanation: The clinical scenario is consistent with fibromuscular dysplasia of the renal artery, which would cause secondary hypertension that might be difficult to control with medication and would potentially have a bruit upon physical examination. The disease is most common among women 40-60 years of age. As fibromuscular dysplasia causes thickening of segments of the affected artery and can produce outpouchings, an angiogram of the vessel would be the definitive diagnostic procedure.
Question 186
A researcher is attempting to trigger intracerebral hemorrhage in laboratory rats to study the development of the condition. To facilitate this process, he is dosing the rats with various substances. A substance or combination of substances that does which of the following would have the best chance to produce an intracerebral hemorrhage?
Answer: E (Increase of all four–heart contractility, heart rate, peripheral resistance, and blood volume)
Explanation: One of the most common causes of intracerebral hemorrhage is hypertension. Blood pressure is cardiac output (which is determined by stroke volume and heart rate) x peripheral resistance. Heart contractility determines stroke volume and blood volume helps determine stroke volume. All other factors being equal, a substance or substances that increases heart contractility, heart rate, peripheral resistance and blood volume should cause the highest blood pressure, and should have the greatest chance to induce an intracerebral hemorrhage.
Question 187
A researcher wishes to study hypertension in vitro. Their lab has perfected a way to remove vascular tissue from rats and maintain their viability for several hours in which to conduct their experiments. To induce hypertension, the vessel is exposed to a mixture of four substances (prostacyclin, kinins, thromboxane and endothelin). Which combination of concentrations of substances below would be most effective in inducing hypertension?
Answer: C (Decreased prostacyclin and kinins, and increased thromboxane and endothelin)
Explanation: Both thromboxane and endothelin are vasoconstrictors, which would increase peripheral resistance and thus help induce hypertension in the vessel, whereas both prostacyclin and kinins are vasodilators, so a decreased concentration of these two substances would indirectly help induce hypertension (i.e., as there would be less opposition to the effects of the thromboxane and endothelin).
Question 188
A 23-year-old male presents to an acute care clinic complaining of pain in both his eyes and sensitivity to light that developed over night. He was no past medical history; however, he reports that he frequently develops ulcers in his mouth, about 5-6 times per year, which last for around 1 week, and four months ago he had a painful ulcer on his penis, which resolved over one week but he was afraid to report his symptoms. He has one sexual partner and they always use condoms for birth control. Of the following, what is the most likely diagnosis?
A. Herpes simplex infection
B. Syphilis
C. Cholesterol emboli
D. Drug reaction
E. Behcet disease
Answer: E (Behcet disease)
Explanation: Behcet disease occurs in younger adults, and characteristic features are recurrent oral apthous ulcers, ocular symptoms, and genital ulcers. Patients can also have musculoskeletal complaints, and GI or CNS involvement. While HSV can cause painful genital ulcers, the recurrent involvement of the mouth, eyes, and genitalia, in a patient with essentially no risk factor for a sexually transmitted disease would be more consistent with Behcet syndrome. Syphilis causes painless genital ulcers. While cholesterol emboli and a drug reaction could produce multi-system involvement, the history does not suggest either as a cause for the patient’s symptoms and past medical history.
Question 180
A 53-year-old male with a past medical history of hypertension for 15 years presents to the emergency room with complaints of a sharp tearing pain in his chest that radiates to his back. His admission blood pressure in the right arm is 171/100 mmHg and in the left arm is 137/80 mmHg. A chest x-ray reveals a widened mediastinum. Of the following, what is the most likely diagnosis?
A. Acute myocardial infarct with free wall rupture
B. Unstable angina
C. Hypertensive crisis
D. Aortic dissection
E. Pheochromocytoma
Answer: D (Aortic dissection)
Explanation: The clinical scenario is characteristic for an aortic dissection, which often occurs in older males and is associated with hypertension as the main underlying risk factor. The pain is often described as sharp or tearing and can radiate to the back. Depending upon the location of the dissection in the arch, the left subclavian artery and not the right subclavian artery can be involved, leading to asymmetric pulses. Because there is blood in the wall of the aorta, the mediastinum can be widened on chest x-ray.
Question 181
A 55-year-old male with a past medical history of poorly controlled hypertension for 10 years presents to the emergency room with complaints of a sharp tearing pain in his chest that radiates to his back. His admission blood pressure in the right arm is 165/98 mmHg and in the left arm is 134/81 mmHg. A chest x-ray reveals a widened mediastinum. Of the following, histologic examination of the aorta would most likely reveal?
A. Extensive neutrophilic infiltration
B. Extensive granulomatous infiltration
C. Marked hemosiderin deposition
D. Marked lipofuscin deposition
E. Cystic medial degeneration
Answer: E (Cystic medial degeneration)
Explanation: The clinical scenario is consistent with an aortic dissection, which is associated with hypertension as the main underlying risk factor. The pain is often described as sharp or tearing and can radiate to the back. Depending upon the location of the dissection in the arch, the left subclavian artery and not the right subclavian artery can be involved, leading to asymmetric pulses. Because there is blood in the wall of the aorta, the mediastinum can be widened on chest x-ray. Histologic examination of the aorta often reveals cystic medial degeneration. Neither marked hemosiderin deposition nor marked lipofuscin deposition normally occur in the aorta. While either Takayasu or giant cell arteritis can involve the aorta and would be associated with a granulomatous inflammation, neither is usually associated with a dissection, and both would be rare compared to an aortic dissection.
Question 182
A 63-year-old male with a known history of well-controlled hypertension that has been treated for 20 years dies in a motor vehicle accident after another driver runs a red light and strikes his vehicle. At the autopsy, which of the following pathologic findings is most likely to be identified by the pathologist?
A. Coarctation of the aorta
B. A nodule in the adrenal medulla
C. Retinal hemorrhages and papilledema
D. A pale eosinophilic acellular thickening of arterioles
E. A layered cellular proliferation of the wall of arterioles
Answer: D (A pale eosinophilic acellular thickening of arterioles)
Explanation: The histologic change most frequently associated with essential hypertension is hyaline arteriolosclerosis, which can be described as a pale eosinophilic acellular thickening of the arterioles, due to accumulation of plasma proteins within the wall. Retinal hemorrhage and papilledema, and a layered cellular proliferation of the wall of arterioles (i.e., hyperplastic arteriolosclerosis) are associated with malignant hypertension, which the clinical scenario does not fit, as malignant hypertension follows a rapid course, whereas a 20 year history is best consistent with essential hypertension. While coarctation of the aorta and a pheochromocytoma (i.e., the nodule in the adrenal medulla) cause hypertension, secondary hypertension is much less common than essential hypertension; also, conditions causing secondary hypertension are often diagnosed because the hypertension does not respond to medical treatment.
Question 183
A 52-year-old male presents to the emergency room with a history of chest pain that began 2 hours ago. The pain has been unrelenting, and is associated with shortness of breath and nausea. Laboratory testing reveals an elevated troponin I and EKG reveals ST elevation in leads V3-V6. The pathologic process that was the cause of his symptoms originated in which of the following types of blood vessels?
A. Elastic
B. Muscular
C. Small arteries
D. Arterioles
E. Capillaries
Answer: B (Muscular)
Explanation: The clinical scenario is consistent with an acute myocardial infarct. The most common cause of a myocardial infarct is atherosclerosis of the coronary arteries. The coronary arteries are a form of muscular artery.
Question 184
A 43-year-old male presents to the hospital with complaints of shortness of breath that has developed increasingly over the past year. Physical examination reveals bilateral crackles at the base of both lungs, but no murmurs or rubs. A chest x-ray reveals a bilateral pleural effusion at the lung bases. Laboratory testing reveals an elevated concentration of B-type natriuretic peptide. A CT scan of his trunk and head reveals a 3.5 cm mass at the left cerebral convexity. Surgical resection of the mass reveals it to be composed of an admixture of arteries and veins. Of the following, what was the mechanism for his presenting symptoms?
A. Cardiac metastases
B. Constrictive pericarditis
C. Focal bypass of capillaries
D. Childhood infection resulting in cardiac damage
E. Hypertensive due to increased intracranial pressure
Answer: C (Focal bypass of capillaries)
Explanation: The clinical scenario is consistent with congestive heart failure, with relatively slow onset of dyspnea, bilateral pleural effusions, and an elevated BNP. The mass in the head is an arteriovenous malformation. In an arteriovenous malformation, there is an abnormal connection between arteries and veins, bypassing the capillaries. Blood flowing through the mass therefore does not serve to oxygenate tissue. The heart is doing extra work to pump this un-used blood, and it is possible for heart failure to develop (i.e., high output cardiac failure). The mass is benign, and not even a neoplasm, and so cardiac metastases would not occur. As there is no murmur, chronic rheumatic valvulitis is not very likely. With increased intracranial pressure, there should likely be symptoms such as headache, nausea, vomiting, and as the mass is a congenital malformation, it would not (without hemorrhaging) elicit increased intracranial pressure as the body has had enough time to adapt to its presence.
Question 175
A 54-year-old male with a 5 year history of increasing shortness of breath presents to his family physician at his wife’s insistence for further testing. He has a 50 pack-year smoking history. Physical examination reveals a barrel chest, and auscultation of his chest reveals decreased breath sounds and occasional wheezes, but no crackles. A chest x-ray reveals a flattened diaphragm and increase lucency of the lung fields. Which of the following mechanisms played the greatest role in the primary development of his disease process?
A. Protease-anti-protease imbalance
B. Recurrent infections
C. Airway hypersensitivity to nicotine
D. Allergen enhancement of tissue fibrosis
E. Neoplastic infiltration of pulmonary parenchyma
Answer: A (Protease-anti-protease imbalance).
Explanation: The history (54-year-old male with a >40 pack-year smoking history presenting with chronic dyspnea), physical examination (barrel chest, decreased breath sounds and wheezing), and x-ray (flattened diaphragm and increased lucency of the lung fields) are consistent with emphysema. Oxidative stress, inflammation, and an imbalance of proteases-anti-proteases are the three main mechanisms by which emphysema develops. Individuals with emphysema are at increased risk for pneumonia, and pneumonia contributes to exacerbations of the disease, but are not as important in the primary development of the disease process as is the protease-anti-protease imbalance. Airway hypersensitivity, important in asthma, is not important in the primary development of emphysema. Fibrosis is not a significant component of emphysema and neoplastic proliferation would more likely present as a restrictive lung disease, or, bronchiectasis, if there was airway obstruction, but is not the primary mechanism for the development of emphysema.
Question 176
A 35-year-old male with a 2 year history of increasing shortness of breath presents to his family physician for evaluation. He has a 15 pack-year smoking history. Auscultation of his chest reveals decreased breath sounds and occasional crackles. Pulmonary function testing reveals a decreased FEV1/FVC ratio. Of the following, which set of parameters best describes his disease process involvement of the lungs?
Answer: D (Panacinar and lower lobes)
Explanation: The clinical presentation (chronic dyspnea associated with decreased breath sounds and occasional crackles) combined with the PFTs (decreased FEV1/FVC ratio) is consistent with emphysema. Given his young age and mild smoking history, he most likely has α1-antitrypsin deficiency, which causes panacinar emphysema and affects more commonly the lower lobes, whereas emphysema due to smoking causes centriacinar emphysema and affects the upper lobes.
Question 177
A 32-year-old male with a 1 year history of increasing shortness of breath presents to his family physician for evaluation. He has a 10 pack-year smoking history. Auscultation of his chest reveals decreased breath sounds and occasional crackles. Pulmonary function testing reveals a decreased FEV1/FVC ratio. Of the following conditions, which is this patient at greatest risk for?
A. Early-onset degenerative aortic stenosis
B. Amyloidosis of the heart
C. Adenocarcinoma of the gallbladder
D. Hepatocellular carcinoma
E. Glioblastoma multiforme
Answer: D (Hepatocellular carcinoma)
Explanation: The clinical presentation (chronic dyspnea associated with decreased breath sounds and occasional crackles) combined with the PFTs (decreased FEV1/FVC ratio) is consistent with emphysema. Given his young age and mild smoking history, he most likely has α1-antitrypsin deficiency. Patients with α1-antitrypsin deficiency are at risk for emphysema and, often, cirrhosis of the liver. Individuals with cirrhosis of the liver are at risk for the development of hepatocellular carcinoma. α1-antitrypsin deficiency is not commonly associated with the other conditions listed.
Question 178
A 19-year-old female college student is being seen in the emergency room for an episode of severe dyspnea. In the last 5 years, she has had to go to the emergency room 4 times for a similar episode. Vital signs include blood pressure of 123/80 mmHg, heart rate of 112 bpm, and respiratory rate of 30 bpm. During inspiration, her systolic blood pressure decreases by 15 mmHg. Physical examination reveals her to be in acute distress. Auscultation of the chest reveals wheezes. The underlying mechanism of her disease process is which of the following?
A. Type I hypersensitivity reaction
B. Type II hypersensitivity reaction
C. Type III hypersensitivity reaction
D. Type IV hypersensitivity reaction
Answer: A (Type I hypersensitivity reaction)
Explanation: The clinical presentation (acute onset of severe dyspnea in a young adult, with history of previous such episodes in the past, and with wheezing, tachypnea, tachycardia, and pulsus paradoxus (the decrease in systolic blood pressure with inspiration) is consistent with asthma. The underlying mechanism of asthma is a type I hypersensitivity reaction.
Question 179
A 13-year-old female is brought to the emergency room by her parents as she has developed severe dyspnea, and they can see her using the muscles in her neck to help her breath. Her mother has a history of developing a rash after working outside on occasions. Her vital signs include blood pressure of 119/78 mmHg, heart rate of 115 bpm, and respiratory rate of 32 bpm. During inspiration, her systolic blood pressure decreases by 16 mmHg. Physical examination reveals her to be in acute distress. Auscultation of the chest reveals wheezes. Of the following, which histologic change is most likely present in the lungs?
A. Loss of pulmonary parenchyma
B. Numerous granulomas
C. Infiltrates of neutrophils
D. Infiltrates of plasma cells
E. Infiltrates of eosinophils
Answer: E (Infiltrates of eosinophils)
Explanation: The clinical presentation (acute onset of severe dyspnea in child, and with wheezing, tachypnea, tachycardia, and pulsus paradoxus) is consistent with asthma. Histologic changes in asthma include hypertrophy of the smooth muscle of the airways, sub-basement membrane fibrosis making the basement membrane appear thick, mucous gland hyperplasia, and infiltrates of eosinophils. Curschmann spirals (mucous casts of the airways with shed epithelium) and Charcot-Leyden crystals can also be identified. Given that this is her first presentation, the other histologic features of asthma would probably not be well-developed.
Question 171
A 31-year-old male is brought to the emergency room by friends because of his difficulty breathing. About 18 hours before his presentation to the emergency room, they reported he had been exposed to a benzene spill at his place of work. While he felt fine after the accident, his current symptoms have developed rapidly over the past 2 hours. Of the following, what is the most likely primary mechanism for his clinical presentation?
A. Insufficient amount of surfactant
B. Necrosis of alveolar epithelial cells
C. Tumor embolism
D. Delayed allergic reaction to the chemical exposure
E. Rapid overgrowth of bacteria
Answer: B (Necrosis of alveolar epithelial cells)
Explanation: Given his rapid onset of shortness of breath within 1 day from a pulmonary chemical exposure, he most likely has acute respiratory distress syndrome (ARDS). Acute respiratory distress syndrome develops due to damage to the alveolar epithelial and/or endothelial cells, which result in leakage of protein-rich fluid into the alveolar airspaces and the resultant formation of hyaline membranes. While a loss of surfactant can occur during the process of ARDS it is not the primary mechanism for the clinical presentation. In hyaline membrane disease in premature infants, a deficiency of surfactant is the primary mechanism for the clinical presentation. While tumor embolism, a delayed allergic reaction to the chemical exposure, or a rapid overgrowth of bacteria could each have the potential for a rapid onset pulmonary-centered clinical process, each of these would be rare compared to the likelihood of ARDS in the above clinical scenario.
Question 172
A 25-year-old male has had a fever and cough productive of a thick yellow-green sputum for one week. He reports occasional sharp chest pain associated with the cough or breathing. Although he felt he had a cold that he could shake, he is now presenting to the emergency room, as over the past 2 hours, he has developed rapidly increasing shortness of breath. His vital signs are blood pressure of 142/83 mmHg, heart rate of 112 bpm, and respiratory rate of 30 bpm. Physical examination reveals no friction rub and the heart sounds do not sound distant. Of the following, which radiographic finding, if not already present, should develop shortly?
A. Bilateral opacities
B. A wedge-shaped opacity in the right lower lobe
C. A widened mediastinum
D. An enlarged cardiac silhouette
E. Diffuse consolidation of the entire lower lobe of the left lung
Answer: A (Bilateral opacities)
Explanation: The patient most likely had a bacterial pneumonia for one week, which could produce fever, a productive cough, and pleuritic chest pain. However, given his rapid change, resulting in progressive dyspnea, tachypnea and tachycardia, he has most likely developed acute respiratory distress syndrome (ARDS). One of the most common causes of ARDS is pneumonia. The characteristic x-ray finding would be bilateral opacities (due to filling of the alveolar airspaces with a mixture of inflammatory cells, and protein-rich edema fluid). ARDS is a diffuse disease process, and thus, the x-ray findings are typically bilateral. A wedged-shaped opacity in the right lower lobe could indicate an infarct due to a pulmonary thromboembolus, which can also present with acute respiratory insufficiency and patients can have a pleuritic chest pain, but he has no risk factors described for a pulmonary thromboembolus (e.g., immobility). A widened mediastinum is consistent with an aortic dissection, and the patient is not described to have hypertension, and the clinical presentation in the week prior is not characteristic for an aortic dissection. An enlarged cardiac silhouette would indicate cardiac hypertrophy or a tamponade. While acute pericarditis can occur in association with pneumonia and could present with increasing shortness of breath, the absence of friction rub and non-distant heart sounds do not support what would already be a relatively rare complication of pneumonia. A diffuse consolidation of the entire lobe of the left lung is consistent with a lobar pneumonia, which he most likely has; however, it would not fully explain the sudden change in clinical status.
Question 173
A 71-year-old male with a 10 year history of Alzheimer’s disease is identified by nursing home staff to have labored breathing. He is taken to the emergency room where a physical examination reveals a blood pressure of 138/81 mmHg, respiratory rate of 29 bpm, and heart rate of 109 bpm. He is admitted to the hospital. Over the next 6 hours, his condition worsens with increasing shortness of breath, and he develops bilateral rales. A chest x-ray reveals bilateral opacities in the pulmonary parenchyma throughout. He has no friction rub, and no S3 or S4 are heard on auscultation of the heart. Microscopic examination of this lungs would reveal which of the following?
A. Proteinaceous exudates layered on the alveolar septa
B. Extensive lymphatic tumor micro-emboli
C. Innumerable microscopic venous thrombi
D. Extensive eosinophilic infiltrates
E. Extensive plasma cell infiltrates
Answer: A (Proteinaceous exudates layered on the alveolar septa)
Explanation: Given the sudden change in his clinical status with rapidly increasing dyspnea associated with tachypnea and tachycardia, acute respiratory distress syndrome (ARDS) is a good possibility. Aspiration is a common cause of ARDS and can easily occur in a patient with long-standing Alzheimer disease. The bilateral opacities are also characteristic of ARDS, which would have been the cause of the rales. Congestive heart failure is in the differential diagnosis for ARDS, and with CHF patients would often have an S3. The characteristic histologic feature of ARDS is hyaline membranes, which are proteinaceous exudates layered on the alveolar septa. While all of the other choices could cause an acute respiratory decline, each would be rare compared to ARDS in the background of aspiration.
Question 174
A 59-year-old male with a 3 year history of increasing shortness of breath presents to his family physician for further testing. He has a 45 pack-year smoking history. The dyspnea is not accompanied by chest pain. He also reports that he frequently coughs up thick sputum, often for months at a time over the past three years. Auscultation of his chest reveals decreased breath sounds and occasional wheezes and crackles. Of the following, which set of parameters is most consistent with his disease process?
Answer: C (Increased TLC (total lung capacity), severely decreased FEV1 (forced expiratory volume), decreased FVC (forced vital capacity), and increased RV (residual volume)).
Explanation: In an older male with a >40 pack-year smoking history, who presents with chronic dyspnea associated with a chronic productive cough, and who has decreased breath sounds on physical examination and occasional wheezes and crackles, the most likely diagnosis is chronic obstructive pulmonary disease. In individuals with COPD, the FEV1 is severely decreased, and the residual volume is increased – the disease process is obstructive, so air cannot be exhaled, and air is trapped. The FVC is usually normal or decreased, and the total lung capacity can be increased, decreased or normal. Importantly, the FEV1/FVC ratio is decreased; in restrictive lung disease, the residual and TLC are decreased and the FEV1/FVC ratio is normal or increased.
Question 166
A 62-year-old male non-smoker has been referred to a pulmonologist by his primary care physician for recurring respiratory infections. Over the past two years he has gradually gotten more short of breath with activity, and has a chronic non-productive cough. He has lost about 5 lb. in that time, but reports no night sweats. Despite several antibiotic courses, he has never gotten better. Physical examination reveals clubbing of the fingers and bi-basilar crackles. X-ray reveals a reticular pattern at the bases, but no effusion. Pulmonary function testing reveals a FEV1/FVC ratio of 81% and a reduced total lung capacity. Of the following, what is the most likely diagnosis?
A. Idiopathic pulmonary fibrosis
B. Congestive heart failure due to untreated systemic hypertension
C. Mycobacterium tuberculosis
D. Small cell carcinoma of the lung
E. Recurrent Staphylococcus aureus pneumonia
Answer: A (Idiopathic pulmonary fibrosis)
Explanation: The slow onset of shortness of breath and the non-productive cough in an older individual is consistent with the clinical presentation of idiopathic pulmonary fibrosis, which can be misdiagnosed as infection or heart failure. Clubbing of the fingers and bi-basilar crackles are features of the disease process. The reticular pattern is consistent with the diagnosis, and the absence of effusions makes congestive heart failure unlikely. The pulmonary function tests are consistent with a restrictive lung disease, of which small cell carcinoma is not. While fibrosis associated with a mycobacterium tuberculosis infection or recurring Staphylococcus aureus pneumonia could possibly produce a restrictive lung disease, no other information supports either of these diagnoses (e.g., history of tuberculosis exposure, homelessness, etc.), or evidence of an infection (such as fever, productive cough, etc.).
Question 167
A 46-year-old male presents to his family physician indicating that over the past 2 years he has had increasing shortness of breath associated with a non-productive cough and 20 lb. weight loss. He has not traveled outside of his home state of Montana; however, his main hobby is using carrier pigeons to send messages. Physical examination reveals bilateral fine crackles and clubbing of the fingers. Of the following, what is the most likely diagnosis?
A. Acute hypersensitivity pneumonitis
B. Chronic hypersensitivity pneumonitis
C. Usual interstitial pneumonia
D. Congestive heart failure
E. Aortic stenosis due to calcified bicuspid aortic valve
Answer: B (Chronic hypersensitivity pneumonitis)
Explanation: The presenting (slow onset of dyspnea associated with a cough and weight loss) is consistent with a chronic disease and with interstitial lung disease. The physical examination, with bibasilar fine crackles and clubbing, is also consistent with interstitial lung disease. Given the history of using pigeons, chronic hypersensitivity pneumonitis is the best choice. Usual interstitial pneumonia occurs more commonly in older patients and is not associated with pigeons, and while congestive heart failure, or end stage of aortic stenosis with congestive heart failure, could have crackles and clubbing, nothing else in the question scenario supports these two diagnoses, such as a murmur heard on physical examination, or history of orthopnea or paroxysmal nocturnal dyspnea.
Question 168
A 49-year-old male with a history of chronic sinusitis that has been relatively refractory to medical treatment is brought to the emergency room by his wife because he has been coughing up a large amount of blood for the past two hours. In the week prior, he had developed cough, pain in his chest with breathing, and some shortness of breath. Assuming it was a bad cold, he wanted to wait it out, but the blood scared his wife. A chest x-ray reveals several areas of consolidation and a urinalysis reveals blood. Of the following, which is the most likely diagnosis?
A. Necrotic squamous cell carcinoma
B. Granulomatosis with polyangiitis
C. Disseminated Mycobacterium tuberculosis
D. Sudden onset congestive heart failure with massive hemoptysis
E. Pneumocystis jirovecki infection
Answer: B (Granulomatosis with polyangiitis)
Explanation: Involvement of the upper and lower respiratory tract (i.e., the chronic sinusitis and the consolidation of the lungs) and the kidney (the blood in the urine) are consistent with granulomatosis with polyangiitis, which occurs in individuals around this age. They can develop diffuse alveolar hemorrhage, which would explain the hemoptysis. Given his younger age and the lack of smoking history and the renal involvement, a necrotic squamous cell carcinoma is not likely. With no information to suggest immunosuppression, Pneumocystis is not likely. While tuberculosis can present with massive hemoptysis, he has no risk factors. Congestive heart failure is not commonly associated with massive hemoptysis and is normally a chronic process, and he has no history or other information to support this diagnosis.
Question 169
A 47-year-old male is brought to the emergency room by his wife because over the past two weeks he has had a bad cough, some shortness of breath, and pain with breathing. A chest x-ray was performed, revealing areas of consolidation and antibiotics were prescribed; however, he has not gotten better. He has no significant past medical history other than general malaise over the preceding year. Laboratory testing is performed including ANCA testing. MPO-ANCA is identified. A urinalysis reveals blood. Of the following, what is the most likely diagnosis?
A. Granulomatosis with polyangiitis
B. Polyarteritis nodosa
C. Microscopic polyangiitis
D. Kawasaki disease
E. Giant cell arteritis
Answer: C (Microscopic polyangiitis)
Explanation: Polyarteritis nodosa rarely involves the lungs and is not normally associated with ANCA positivity. Kawasaki disease primarily involves the heart, and is most commonly a disease of children. Giant cell arteritis most commonly involves the aorta and branches; so, none of these three diagnoses is a good choice. The presentation of granulomatosis with polyangiitis and microscopic polyangiitis can be very similar, and both can have MPO-ANCA; however, MPO-ANCA is most commonly associated with microscopic polyangiitis and not granulomatosis with polyangiitis.
Question 170
A 23-year-old male is stabbed by another person in the chest. He is responsive when EMTs arrive, but is short of breath. His heart rate is 115 bpm. During the trip to the emergency room, his shortness of breath worsens; he develops hypotension; and he ultimately becomes unresponsive. Despite resuscitative efforts, he dies. An autopsy is performed. The right pleural cavity contains a measured 2 L of blood, which originated from an intercostal artery in the path of the stab wound. Microscopic examination of the right lung would reveal which of the following?
A. Extensive eosinophilic infiltrates
B. Patchy neutrophilic infiltrates
C. Collapse of alveoli
D. Numerous fat emboli
E. Foreign body embolus composed of the tip of the knife
Answer: C (Collapse of alveoli)
Explanation: The rapid accumulation of a large amount of fluid (i.e., blood) in the right pleural cavity would compress the lung, and not allow it to fill as normal with air (i.e., compression atelectasis). The time frame is too short for an acute pneumonia to be developing and extensive eosinophilic infiltrates would not be the normal response. Fat emboli occur as the result of bony trauma, usually of the long bones, and would not cause the blood to accumulate. Embolism of the knife tip would be exceptionally rare, and, since the artery was cut and not the vein, if the knife tip entered the blood supply, it would not be going to the heart.
Question 162
A 62-year-old male who has not seen a doctor in 20 years presents to a family physician at his wife’s insistence. Over the last 4 months he has had a chronic cough, occasional pain in his chest, and 20 lb. of weight loss. A chest x-ray reveals a mass in the upper lobe of the left lung. Biopsy reveals neoplastic squamous cells. Of the following, what was the most likely etiology of his neoplasm?
A. Cigarette smoke
B. Asbestos exposure
C. Radon exposure
D. Arsenic exposure
E. Past contact with radioactive substance
Answer: A (Cigarette smoke)
Explanation: All of the above exposures (i.e., cigarette smoke, asbestos, radon, arsenic, and radiation) are risk factors for lung carcinoma; however, the most common etiology of lung cancer is cigarette smoke.
Question 163
A 62-year-old male with a 45 pack year smoking history undergoes chest x-ray as a component of a pre-surgical evaluation for elective cholecystectomy. The x-ray reveals a mass in the lower lobe of the left lung. Laboratory testing reveals an ionized calcium concentration of 6.7 mg/dL (normal range: 4.56-5.40 mg/dL). A biopsy of the mass would most likely reveal which of the following?
A. Benign cartilage
B. Epithelial cells with intercellular bridges
C. Caseating granulomas
D. Mass of neutrophils admixed with bacterial cocci
E. Mass of abnormally connected arteries and veins
Answer: B (Epithelial cells with intercellular bridges)
Explanation: Given the history of smoking and the fact that lung cancer is often asymptomatic, the finding of an incidental mass on chest x-ray is concerning for a neoplasm. Squamous cell carcinoma produces PTH-related peptide, which can cause an elevated concentration of calcium. The features of squamous cell carcinoma include intercellular bridges and keratin pearls. A pulmonary hamartoma (benign cartilage) would not cause hypercalcemia. Although sarcoidosis can produce elevated concentrations of calcium and is often found in the lung, most sarcoidosis granulomas are non-caseating. Neither an abscess (i.e., a mass of neutrophils admixed with bacterial cocci) or an arteriovenous malformation (i.e., a mass of abnormally connected arteries and veins) are commonly associated with elevated concentrations of calcium, and he has no fever, or other symptoms indicative of an infection.
Question 164
A 65-year-old male with a history of hypertension, diabetes mellitus type II, and a 45 pack-year smoking history with chronic cough presents to an acute care clinic with complaints that he has gotten very sensitive to heat lately and cannot tolerate working outside in his garden for very long. Physical examination reveals drooping of his left upper eyelid and constriction of the left pupil compared to the right side. In addition, the left eye appears somewhat sunken in the orbit. Of the following, which procedure is most likely to identify the cause of his condition?
A. CT scan of the head
B. X-ray of the chest
C. Echocardiogram
D. Lumbar puncture
E. MRI of the pelvis
Answer: B (X-ray of the chest)
Explanation: The patient has features of Horner syndrome (enophthalmos – the sunken nature of the eye; ptosis – the drooping of the upper eyelid; miosis – constriction of the pupil; and the heat intolerance is a symptom of anhidrosis, which is lack of sweating). Given his age and smoking history, a lung neoplasm at the apex of the lung (i.e., a Pancoast tumor) would be a strong possible cause. Of the choices, an x-ray of the chest would be most likely to reveal the tumor.
Question 165
A 54-year-old male with a past medical history of hypertension and a 40 pack-year smoking history is undergoing a routine physical examination prior to a scheduled inguinal hernia repair. Physical examination reveals a small fixed palpable node above the left clavicle. A fine needle aspirate of this node reveals small cells with a high nuclear:cytoplasm ratio and high mitotic rate. No glandular formation or keratin production is evident. Molecular analysis of the cells would most likely reveal which of the following genetic abnormalities?
A. RB mutation
B. EGFR mutation
C. ALK rearrangement
D. p16/CDKN2A mutation
E. PTEN mutation
Answer: A (RB mutation)
Explanation: Given the age of the patient and smoking history, he is at risk for lung cancer. A palpable supraclavicular node (i.e., Virchow node) is characteristic for metastatic spread of a lung carcinoma. The cellular features are indicative of a small cell carcinoma, and the neoplasm has no features of either adenocarcinoma or squamous cell carcinoma. Over 90% of small cell carcinomas have a mutation of RB. EGFR mutations and ALK rearrangements are characteristic of adenocarcinomas, and p16/CDKN2A are very uncommonly found in small cell carcinoma and are more characteristic of non-small cell carcinoma. PTEN mutation is commonly associated with endometrial carcinoma and melanoma; however, it is uncommonly (6-9%) associated with lung carcinoma, and predominantly with squamous cell carcinoma.