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 for Question 166
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 for Question 167
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 for Question 168
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 for Question 169
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 for Question 170
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.