Respiratory Medicine Pulmonology MCQs 2 | Medical Exam Questions

Respiratory Medicine Multiple Choice Questions 2 | Pulmonology 

CXR of a 66-year-old male shows unilateral hilar lymphadenopathy. What is the most likely etiology of unilateral hilar lymphadenopathy?

A. Sarcoidosis.

B. Tuberculosis.

C. Malignancy. ✅

D. Fungal infection.

E. Histiocytosis.

Question Explanation:

"Sarcoidosis is the number one cause of bilateral hilar adenopathy. Malignancy is the number one cause of unilateral hilar adenopathy. All of the causes can present either bilaterally or unilaterally.

A 24 year old medical student was found to have symmetrical bilateral hilar adenopathy on a routine chest X-ray. He was asymptomatic. On skin testing, he was found to be anergic. Chest CT revealed symmetrical non narcotizing hilar adenopathy. The treatment of choice in this patient would be

A. Isoniazid, rifampin, pyrazinamide

B. Steroids

C. Chemotherapy

D. Do nothing ✅

E. Amphotericin B

Question Explanation:

This patient has stage I sarcoid. He is not symptomatic and thus routine follow up is the only thing to do at this point. Anergy is common because of in decrease in circulating CD4 cells in the blood. Tuberculosis would most likely show up as asymmetrical adenopathy. The chest CT would showy necrotizing hilar adenopathy. This patient does not have tuberculosis, and thus isoniazid, rifampin, and PZA are not indicated. Steroids are indicated in symptomatic active pulmonary sarcoid as well as neurosarcoid and eye involvement. Chemotherapy would be the treatment of choice if this patient had lymphoma. Amphotericin B would be indicated if this patient had a fungal infection such as histoplasmosis or coccidioomycosis.

A 36 year old homeless IV drug abuser presents with weight loss, anorexia, cough, and night sweats. CXR shows bilateral upper lobe infiltrates. His sputum for acidfast bacilli cultures were positive for Mycobacteria tuberculosis. Which of the following is NOT recommended at this time?

A. Prophylaxis with isoniazid and vitamin B6.

B. Treatment with isoniazid, pyrazinamide, rifampin, and ethambutol.

C. Respiratory isolation.

D. Direct observed therapy upon discharge.

E. Check for sensitivities of the acid fast bacilli cultures.

Question Explanation:

This patient has active pulmonary tuberculosis and should be treated with a four drug regimen, not prophylaxis only If one is ppd positive, asymptomatic, and is younger than 35 years of age, then INH prophylaxis is recommended. Treatment with rifampin, isoniazid, pyrazinamide, and ethambutol is recommended for acute pulmonary tuberculosis for six to nine months. Respiratory isolation is recommended to prevent transmission of the tubercule bacilli via the respiratory tract. Direct observed therapy has been recommended by the Centers for Disease Control to ensure compliance in taking anti-tuberculosis medications and follow up in treatment. Sensitivities should be checked with cultures to make sure one is not dealing with multi drug resistant tuberculosis.

A patient is brought to the emergency room in acute pulmonary edema. The respiratory rate is 45/min and arterial blood gas reveals a 02 saturation of 69%. ECG is normal. What is the most appropriate management at this time?

A. Place the patient in a sitting position and start the patient on 100% 02. No drug therapy is usually needed.

B. Emergent dialysis.

C. Start 100% 02 and administer 10-20 mg furosemide and 2 mg morphine IV. ✅

D. Start 100% 02 and bolus patient with 2L of lactated ringers.

E. Start 100% 02 and load the patient with digitalis.

Question Explanation:

Initial therapy for acute pulmonary edema includes placing the patient in the sitting position to decrease venous return and the work of breathing. Oxygen is used to increase the arterial p02. Furosemide and morphine are the standard first line medications in the management of acute pulmonary edema. In this patient, with a rapid respiratory rate and low 02 saturation, these medications will be required to rapidly o decrease pulmonary congestion (furosemide) and decrease venous return (morphine). Dialysis is reserved for cases that fail initial pharmacologic intervention. A fluid bolus will exacerbate the pulmonary congestion. Digitalis is not acutely indicated in the absence of arrhythmia.

A 26 year old HIV positive non-smoker person presents with massive hemoptysis, fever, and purulent sputum. CXR reveals a large right upper lobe cavitary lesion. The CT of the chest reveals a mass within the cavity. Bronchoscopy was performed and the culture grew branching hyphae. The most likely diagnosis is

A. Squamous cell carcinoma

B. Tuberculosis

C. Bronchiectasis

D. Aspergillus fumigatus ✅

E. Lung abscess

Question Explanation:

These "fungal balls" are found most often in patients with underlying lung disease and immunosuppression. Hemoptysis results from mechanical trauma resulting from the presence of the ball in the cavity. Squamous cell carcinoma of the lung is usually centrally located. This cancer is associated with smoking. Active tuberculosis pneumonitis can cause bronchiolar ulceration and necrosis of adjacent vessels and distant alveoli leading to hemoptysis. Bronchiectasis is usually caused by a mycobacterium, not a fungus; therefore, hyphae would not grow in cultured tissue sputum samples. However, patients with prolonged neutropenia or with bronchiectasis induced by toxic exposures are predisposed to infection with Aspergillus organisms. Samples taken from these patients would grow hyphae in culture. These patients would also exhibit hemoptysis. Chest X-ray findings are nonspecific; in many of these patients, they appear normal. The necrotizing effects of the primary infection on the lung parenchyma and vasculature can lead to hemoptysis. Predisposing factors for the development of lung abscesses include alcohol use, seizures, and poor oral hygiene.

A college student aged 20 years complains of a dry cough and fever for almost one week. She has had no recent exposure to sick roommates, pets, or any recent travel. CXR reveals a bilateral diffuse interstitial infiltrate. The most likely diagnosis is

A. Legionella pneumophila

B. Psittacosis

C. Klebsiella pneumonia

D. CMV pneumonitis

E. Mycoplasma pneumonia ✅

Question Explanation:

Mycoplasma pneumonia is more common in young people, and it is a community-acquired pneumonia. The chest X-ray infiltrate appears worse than findings on physical exam of the patient. A dry, hacking cough, fever, and myalgias are common. Bullous myringitis of the ears and positive serum for cold agglutinins are common. Legionella pneumophila is also a community-acquired pneumonia, but a productive cough is more common. Diagnosis usually depends on antibody titer in serum (rather than sputum) by indirect immunoflourescence assay. Psittacosis is associated with exposure to birds. This patient has no recent exposure to animals. Klebsiella pneumonia presents usually as a lobar pneumonia and is common in alcoholics. It is associated with a Gram-negative organism and the sputum is very productive. CMV pneumonia also presents as bilateral interstitial infiltrates, but patients are usually immunocompromised, which this patient is not.

An HIV positive male develops symptoms of pneumonia. His fingertips and lips are dusky blue and his blood oxygen saturation is 83%. The test that would be most helpful in confirming the most likely causative agent is

A. CD4 cell count

B. Direct fluorescent antibody test ✅

C. Enzyme-linked immunosorbent assay

D. Indirect fluorescent antibody tests

E. Western blot

Question Explanation:

The most common atypical pneumonia in AIDS is caused by the atypical fungus Pneumocystis jiroveci (formerly carinii). Patients with Pneurnocystis pneumonia have great difficulty producing sputum, so bronchial lavage or transmural biopsy is generally required. The sample is then submitted to the direct fluorescent antibody test or stained with Gomori's methenamine silver stain to visualize the organisms. The direct fluorescent antibody test is a technique to demonstrate the presence of antigen from a pathogen in a patient. Antigen detecting tests will remain useful throughout the life of an AIDS patient because they do not depend on detection of the patient's immune response to the pathogen (which maybe absent at the end of AIDS). When stained with methenamine silver, Pneumocystis cysts have a characteristic cup or boat shape; the trophozoites are difficult to demonstrate without electron microscopy. CD4 cell count determination is used to measure the progression of infection with the human immunodeficiency virus (HIV). Since the virus infects and destroys these cells, the number remaining in the circulation becomes a good predictor of the progression of disease.

Enzyme linked immunosorbent assay is used as the screening test to diagnose HIV infection. It is a serologic test (identifies antibodies against the virus) and once the patient progresses into full blown AIDS, antibody levels other than IgM will decline; so in general, serologic tests in late HIV infection tend to be less useful than tests that detect antigens from a pathogen. Indirect fluorescent antibody tests are techniques that identity antibody production in a patient. They are commonly used to identity autoimmune antibodies. Western blot is the confirmatory serologic test that is used in the diagnosis of HIV infection.

A 45 year old man presents for an employment physical examination. On examination the patient's nail beds are thickened, widened, and convex. He also finds tenderness over the distal ends of the radius, ulna, and fibula. The most appropriate diagnostic step at this time is

A. Chest radiography ✅

B. Endoscopy

C. MRI of the upper right quadrant

D. Penal sonography

E. Scrotal sonography

Question Explanation:

This patient has the finger clubbing and hypertrophic pulmonary osteoarthropathy that can be associated with bronchogenic carcinoma (other than squamous cell carcinoma benign mesothelioma, and diaphragmatic neurilemmoma. X-ray of the bones generally shows formation of new periosteal bone; arthritis may be present. The etiology of these changes remains a mystery. An alert; clinician may identify a cancer at an earlier, potentially curable stage by investigating a possible paraneoplastic syndrome.

A 55 year old woman with a long history of smoking presents with persistent nonproductive cough for the past 6 weeks. Examination shows obesity, rounded facies, and new onset hypertension. CXR demonstrates a 3 cm mass in the upper lobe of the right lung. A CT guided biopsy reveals sheets of undifferentiated cells with a high nuclear/cytoplasmic ratio and nuclear hyperchromasia. The most likely diagnosis is

A. Adenocarcinoma

B. Lymphoma

C. Metastatic adrenal tumor

D. Small cell carcinoma ✅

E. Squamous cell carcinoma →

Question Explanation:

This patient presents with Cushing syndrome and a pulmonary tumor. Approximately 10% of lung carcinomas manifest with paraneoplastic syndromes, of which Cushing syndrome is one of the most common. Small cell carcinomas which are of neuroendocrine origin, often retain the ability to secrete hormonal substances, for example ACTH. An additional clue to the correct choice is the H&E appearance of this tumor, which is composed of cells with hyperchromatic nuclei and scanty cytoplasm. Superficially, this malignancy may resemble a poorly differentiated lymphoma, but the history of paraneoplastic Cushing syndrome rules out this possibility. 

Adenocarcinoma is a malignant epithelial tumor characterized by glandular architecture and mucin secretion. Neoplastic cells tend to be larger than those of small cell carcinoma and to display conspicuous nucleoli. Metastatic adrenal tumor is a remote possibility, considering the rarity of this neoplasm. Furthermore, adrenal carcinomas are usually nonfunctioning. Squamous cell carcinoma is characterized by cells displaying squamous differentiation, i.e., abundant eosinophilic cytoplasm and extracellular or intracellular keratin formation. The most frequent paraneoplastic syndrome associated with squamous cell carcinoma is hypercalcemia.

A 42 year old Caucasian male presents with persistent cough and dyspnea. 4 months ago he remembers developing some red bumps on his legs and some joint swelling. His blood test is notable for elevated ACE levels. CXR shows bilateral hilar masses with lung parenchyma prominence. Biopsy of the masses shows noncaseating granulomas. Ziehl Neelsen and silver stains are negative. The most likely diagnosis is

A. Asbestosis

B. Beryllium exposure

C. Lymphoma

D. Primary tuberculosis

E. Sarcoidosis ✅

Question Explanation:

Sarcoidosis is a multisystem disease characterized by noncaseating granulomata in a variety of organs. The

disease may be symptomatic (respiratory and constitutional symptoms: erythema nodosum, uveitis, arthritis) or may be discovered incidentally when chest X-ray or autopsy reveals bilateral hilar adenopathy. Angiotensin converting enzyme (ACE) is elevated in 60% of sarcoidosis patients. Definitive diagnosis is based on biopsy, which reveals noncaseating granulomata that are negative for fungi or acid fast bacilli. Sarcoidosis is more common in individuals of African descent. 

Asbestosis exposure is characterized by calcified pleural plaques and preferential involvement of the lung bases. Although beryllium exposure may have similar findings, this patient has no apparent occupational risk of exposure. Lymphoma could lead to hilar adenopathy and lung parenchyma prominence. It would not be associated with granulomas. Primary tuberculosis, in an immunocompromised patient, may show noncaseating granulomas. The acid-fast stain, however, would be positive.

CXR of a 45 year old woman who presents with gradual onset of shortness of breath, chest pain, and fatigue shows bilateral hilar adenopathy and pulmonary, infiltrates. Biopsy of one of these lesions shows non-necrotizing granulomas. Stains for fungi and mycobacteria are negative and has no history of occupational exposure to airborne minerals or organic dusts. The most likely diagnosis is

A. Asbestosis

B. Berylliosis

C. Byssinosis

D. Sarcoidosis ✅

E. Tuberculosis

Question Explanation:

The diagnosis of sarcoidosis is usually made by exclusion. This disease is characterized by non-necrotizing granulomas developing most frequently in the lungs, lymph nodes, retina, heart, spleen, skin, and liver. Non- necrotizing granulomas may be seen in a number of other conditions, however, such as infections and certain forms of pneumoconiosis, which must be ruled out before making a diagnosis of sarcoidosis.

The etiopathogenesis of sarcoidosis is obscure. Cell mediated mechanisms are thought to be involved in an immune response to as yet unidentified antigens. About two-thirds of patients with sarcoidosis recover without residual functional deficits, 20% have permanent pulmonary or visual damage, and 1.0% die of pulmonary or cardiac involvement. Asbestosis, berylliosis, and byssinosis are all lung diseases caused by inhalation of airborne dusts. Asbestosis is due to chronic inhalation of asbestos fibers, which may affect workers involved in installation and removal of insulation.

Asbestosis leads to diffuse fibrosis of the lungs. In this case, granulomas are absent or scanty; the most characteristic sign of asbestos exposure is the asbestos body, which is an elongated; beaded rod composed of asbestos fibers coated by proteins. Chronic exposure to beryllium in mining and fabrication leads to berylliosis, a granulomatous condition of the lungs that is morphologically indistinguishable from sarcoidosis. Clinical history is therefore essential in excluding this condition. Byssinosis results from occupational exposure to cotton fibers. This condition belongs to a diversified category of diseases mediated by a hypersensitivity reaction against inhaled organic dusts. 

Farmer's lung, pigeon breeder's lung, air conditioner lung, and byssinosis are typical examples of these conditions, which lead to a granulomatous reaction that may progress to diffuse pulmonary fibrosis. Again, clinical history is crucial in the identification of this etiology. Tuberculosis is usually associated with necrotizing granulomas. This type of necrosis is also described as caseating because the necrotic material resembles cheese on gross examination. The absence of acid fast organisms in the biopsy material helps rule out this diagnosis.

A patient with long standing, progressive congestive heart failure develops worsening shortness of breath over 2 weeks period and dies in respiratory distress. At autopsy lungs are 3 times their normal weight. Histologically, the alveoli show a proteinaceous granular precipitate, engorged alveolar capillaries, and Hemosiderin laden macrophages. The following is the most likely diagnosis is

A. Candida pneumonia

B. Pneumococcal pneumonia

C. Pneumocystis pneumonia

D. Pulmonary edema ✅

E. Pulmonary infarction

Question Explanation:

These are the characteristic findings of pulmonary edema. The edema fluid is apparent as a proteinaceous granular precipitate after histologic processing of the tissue. Hemosiderin laden macrophages in the tissue, called "heart failure cells" are the end result of ingestion of red blood cells by alveolar macrophages. Pulmonary edema develops in her failure when the pulmonary venous pressure rises and the capacity for the tissue to reabsorb the fluid into the venous system is exceeded.

In Candida pneumonia fungal hyphae and spores would be described. In pneumocystis pneumonia gram positive cocci (Streptococcus pneumoniae) would be described. In Pneurnocystis pneumonia hat shaped, silver- stained cysts would be described. In pulmonary infarction, ischemic necrosis of alveoli would be described.

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