(B) CORRECT.

The chronic lung disease of cystic fibrosis often includes bronchiectasis, a disease
characterized by inflammation with obstruction and dilation and destruction of bronchi. This process is
diffuse throughout the lungs. The loss of pulmonary vascular bed with progressive bronchiectasis can
lead to pulmonary hypertension and cor pulmonale. The sweat chloride is a good screening test; genomic
testing is possible, but confounded by hundreds of CF mutations.
Question 1
An 8-year-old boy at birth appeared to be a normal term baby, but his neontal course was complicated by
the development of meconium ileus. His sweat chloride is found to be elevated. Throughout childhood he
has experienced multiple increasingly severe bouts of pneumonia with a productive cough, often with
Pseudomonas aeruginosa, and later Burkholderia cepacea, cultured from sputum. He is at greatest risk
for development of which of the following pulmonary abnormalities?
A Adenocarcinoma
B Bronchiectasis
C Lymphangiectasis
D Pleural fibrous plaques
E Pneumocystis jiroveci pneumonia
F Pneumothorax

(G) CORRECT. She has a lobar pneumonia, which is most often a community aquired pneumonia (the
nursing home counts as a community venue), following a debilitating course of Alzheimer disease. The
most common organism is Streptococcus pneumoniae (pneumococcus).
Question 2
A 70-year-old woman at an extended care facility for the past two years has increasing inability to perform
activities of daily living. She can no longer recognize family members. She is lethargic and spends most
of her days in a wheelchair or in bed. She develops an acute febrile illness and is noted to be coughing
up increasing quantities of yellowish sputum. Her temperature is 38C. A chest x-ray shows infiltrates
involving the left lower lobe. A sputum sample shows numerous neutrophils and gram-positive diplococci.
Which of the following infectious agents is most likely to cause her pulmonary disease?
A Pneumocystis jiroveci
B Listeria monocytogenes
C Cryptococcus neoformans
D Mycobacterium tuberculosis
E Legionella pneumophila
F Staphylococcus aureus
G Streptococcus pneumoniae
H Influenza A virus

(B) CORRECT. This is a description of the typical 'Ghon complex' of an initial, or primary, TB infection.
The peripheral granuloma does not produce symptoms, but the enlarged lymph nodes may impinge upon
airways. Most persons with a primary infection, however, are asymptomatic and the infection goes
unnoticed.
Question 3
An 11-year-old girl has experienced dyspnea for the past 2 weeks. Her temperature is 37.3C, pulse
85/minute, respiratory rate 30/minute, and blood pressure 110/60 mm Hg. On physical examination, her
lung fields are clear to auscultation. Her heart rate is regular and no murmurs or gallops are heard. A
chest radiograph shows prominent hilar lymphadenopathy along with a 1 cm peripheral right middle lobe
nodule. No infiltrates are present. A sputum gram stain shows normal flora and routine bacterial culture
reveals no pathogens. Which of the following conditions is she most likely to have?
A Hypersensitivity pneumonitis
B Mycobacterium tuberculosis infection
C Bronchial carcinoid tumor
D Infective endocarditis
E Goodpasture syndrome

(D) CORRECT. The activity of ambulation resulted in embolization of a thrombus that formed during his
period of immobilization in leg or pelvic veins. The thrombus became an embolus and traveled up the
vena cava, through the right heart, and to the pulmonary arterial tree of the lungs.
Question 4
On the 11th postoperative day following a radical prostatectomy for adenocarcinoma, a 70-year-old man
is recovering uneventfully. He then ambulates to the bathroom, but upon returning to his bed he suddenly
becomes extremely dyspneic and diaphoretic, with chest pain, palpitations, and a feeling of panic. Which
of the following post-operative pulmonary complications has he most likely developed?
A Pulmonary edema
B Pleural effusion
C Atelectasis
D Thromboembolus
E Diffuse alveolar damage

(C) CORRECT. Sarcoidosis is typified by non-caseating granulomas. However, culture of the tissue and a
careful search histologically should be made for organisms before beginning therapy with corticosteroids.
Extensive granulomatous disease can produce a restrictive pattern of pulmonary disease.
Question 5
A 50-year-old woman has lived in Oslo, Norway all her life and worked as a seamstress. She is a non-
smoker, but she has had increasing shortness of breath, fever, weight loss, and night sweats for the past
4 months. On physical examination her temperature is 37.6C. There are fine rales auscultated in all lung
fields. A chest radiograph reveals hilar lymphadenopathy and a reticulonodular pattern of small densities
in all lung fields. She demonstrates anergy by skin testing to mumps and Candida antigens. A
transbronchial biopsy is performed that microscopically shows numerous small pulmonary interstitial non-
caseating granulomas. Which of the following is the most likely diagnosis?
A Histoplasmosis
B Adenocarcinoma in situ
C Sarcoidosis
D Usual interstitial pneumonitis
E Berylliosis
F Tuberculosis
G Extrinsic allergic alveolitis

(D) CORRECT. AAT deficiency leads to lack of an anti-protease, which leads to development of
emphysema, typically a panlobular type affecting lower lobes more severely, and by the 5th decade.
Question 6
A 43-year-old woman has had increasing dyspnea for 8 years. She has no cough or increased sputum
production. On physical examination there is bilateral hyperresonance to percussion in all lung fields. A
chest x-ray reveals increased lung volumes with flattening of the diaphragmatic leaves bilaterally. The
right heart border is prominent. A chest CT scan demonstrates decreased attenuation in all lung fields,
particularly lower lobes. Which of the following laboratory findings is she most likely to have?
A Decreased serum ceruloplasmin
B Increased sweat chloride
C Positive urine nicotine
D Decreased serum alpha-1-antitrypsin
E Positive urine opiates
F Positive antinuclear antibody test

(A) CORRECT. Both squamous cell and small cell carcinomas, most common in smokers, tend to be
central in location. Squamous cell carcinomas of the lung are associated with hypercalcemia, though
overall the small cell carcinomas are best known for paraneoplastic syndromes.
Question 7
A 55-year-old man with a 50 pack year history of smoking cigarettes has recently experienced an episode
of hemoptysis along with his usual cough. On physical examination he has no abnormal findings. A
sputum for cytology on microscopic examination shows atypical cells with hyperchromatic nuclei and
orange-pink cytoplasm. Labortory studies show a serum calcium of 11.3 mg/dL, with phosphorus 2.1
mg/dL. Which of the following chest radiographic findings is this man most likely to have?
A Large hilar mass
B Pneumonia-like consolidation
C Peripheral nodule
D Carinal compression
E Left pleural thickening

(B) CORRECT. A Lung abscesses can result from aspiration of oropharyngeal or nasopharyageal
contents, where bacterial organisms as part of normal flora can be transported to the lungs. The
straighter bronchus to the right lung is more likely to conduct aspirated material. With septicemia, multiple
abscesses are more likely to be present. The infection is often polymicrobial and difficult to treat.
Question 8
During a cardiac arrest, a 58-year-old man, a non-smoker, receives cardiopulmonary resuscitative
measures and is brought to the hospital, where he is intubated. During the intubation procedure he
suffers aspiration of gastric contents. Over the next 10 days he develops a non-productive cough along
with a fever to 37.9C. A chest radiograph reveals a 4 cm diameter mass with an air-fluid level in the right
lung. A sputum gram stain reveals mixed flora. Which of the following conditions is he most likely to have?
A Squamous cell carcinoma
B Lung abscess
C Chronic bronchitis
D Bronchiectasis
E Bronchopulmonary sequestration

(C) CORRECT. The typical appearance of a viral lung infection is interstitial inflammation. The
inflammatory response is primarily T lymphocytes.
Question 9
A 66-year-old woman has had a worsening non-productive cough with malaise for the past week. Her
temperature increases to 37.4C. A chest radiograph reveals diffuse bilateral pulmonary interstitial
infiltrates in all lung fields. A sputum gram stain reveals normal flora and few neutrophils. She recovers
over the next two weeks without sequelae. Infection with which of the following organisms most likely
caused her illness?
A Mycobacterium tuberculosis
B Streptococcus pneumoniae
C Influenza A virus
D Cryptococcus neoformans
E Mycobacterium avium-complex

(C) CORRECT. Smoking remains the most frequent cause of lung cancer. Lung cancer does, however,
occur in nonsmokers. A small cell anaplastic carcinoma, as in this patient, is virtually always seen in
smokers. Small cell cancers arise in the central portion of the lung but are aggressive neoplasms that
spread quickly.
Question 10
A 58-year-old man has developed a non-productive cough worsening over the past 2 months. Last week
he noted the appearance of blood-streaked sputum. On physical examination there are some expiratory
wheezes auscultated over the left lung. A chest radiograph reveals a 5 cm mass near the left lung hilum.
A sputum cytology reveals the presence of small clusters of very hyperchromatic, pleomorphic cells with
scant cytoplasm. Which of the following is the most likely predisposing factor to development of his
pulmonary disease?
A Silicosis
B Radon gas exposure
C Smoking
D Asbestosis
E Chronic bronchitis

(C) CORRECT. He is most likely to have Pneumocystis jiroveci pneumonia in association with the
acquired immunodeficiency syndrome (AIDS). Note his lymphopenia from the very low CD4 count. PCP
infection produces an exudate composed of the Pneumocystis cysts and trophozoites with little
accompanying inflammation. The clinical findings in this case are typical as well.
Question 11
A 41-year-old man with a 6 kg weight loss over the past 3 months now has had worsening fever, non-
productive cough, and dyspnea for the past 3 days. His temperature is 38.2C and there are diffuse rales
in both lungs on auscultation. A chest radiograph shows patchy infiltrates in both lungs. Laboratory
studies show WBC count 3250/microliter with 81 segs, 3 bands, 5 lymphs, and 11 monos. His CD4
lymphocyte count is 79/microliter. Cryptosporidium parvum organisms are found in a stool specimen. A
bronchoalveolar lavage is performed, yielding fluid that microscopically demonstrates pink, foamy
exudate with little inflammation. Which of the following additional findings on microscopic examination is
he most likely to have in the BAL specimen?
A Acid fast bacilli
B Branching septate hyphae
C Multiple cysts with GMS stain
D Hemosiderin-laden macrophages
E Short gram positive rods

(C) CORRECT. Chronic bronchitis is defined clinically as persistent cough with sputum production for at
least 3 months in at least 2 consecutive years. Air pollution and smoking are key causes for chronic
bronchitis. The alteration of lung parenchyma predisposes to superimposed infection, typically with
bacterial organisms.
Question 12
A 64-year-old man has a 90 pack year history of smoking. For the past 5 years, he has had a cough
productive of copious amounts of mucoid sputum for over 3 months at a time. He has had episodes of
pneumonia with Streptococcus pneumoniae and Klebsiella pneumoniae cultured. His last episode of
pneumonia is complicated by septicemia and brain abscess and he dies. At autopsy, his bronchi
microscopically demonstrate mucus gland hypertrophy. Which of the following conditions is most likely to
explain his clinical course?
A Small cell carcinoma
B Congestive heart failure
C Chronic bronchitis
D Bronchial asthma
E Centrilobular emphysema
F Panlobular emphysema
G Bronchiectasis

(D) CORRECT. These findings are classic for exposure to asbestos. Pleural plaques are more frequent in
this condition than in other pneumonconioses, particularly with calcification. Asbestosis is a rare form of
pneumoconiosis that can lead to restrictive lung disease. The ferruginous bodies are asbestos fibers
encrusted with iron. Building materials from older houses may contain asbestos, which was used for
years because of its fire retardant properties.
Question 13
A 66-year-old man has had increasing dyspnea for the past year. He is retired from the construction
business. There are some rales auscultated in both lungs on physical examination. A chest radiograph
reveals bilateral diaphragmatic pleural plaques with focal calcification as well as diffuse interstitial lung
disease. A sputum cytology shows no atypical cells, only ferruginous bodies. Pulmonary function studies
reveal a low FVC and a normal FEV1/FVC ratio. These findings are most likely to suggest prior exposure
to which of the following environmental agents?
A Cotton fibers
B Silica dust
C Fumes with iron particles
D Asbestos crystals
E Beryllium
F Black mold spores

(D) CORRECT. He has multiple risk factors for ischemic heart disease leading to left heart failure and
pulmonary edema.
Question 14
A 58-year-old man has been a smoker for 40 years. He has worsening orthopnea over the past year. On
examination he has a body mass index of 35. He is afebrile. His blood pressure is 165/110 mm Hg.
Auscultation of his chest reveals rales in lower lung fields bilaterally. A chest x-ray shows bilateral lower
lobe infiltrates and a prominent left heart border. Laboratory studies show his Hgb A1C is 10%. Which of
the following pulmonary problems is he most likely to have?
A Pneumonia
B Fibrosis
C Atelectasis
D Edema
E Emphysema

(E) CORRECT. The hemoptysis suggests that the granulomas have eroded enough parenchyma and
involved a bronchus. A granulomatous reaction is typical for Mycobacterium tuberculosis infection.
Question 15
A 47-year-old man has lost 6 kg in 5 months. He has had a cough with hemoptysis along with pleuritic
chest pain for the past 2 weeks. On physical examination his temperature is 37.5C. A chest x-ray reveals
a bilateral and predominantly upper lobe reticulonodular pattern of infiltrates with cavitation. A sputum
sample is obtained and on light microscopic examination shows epithelioid cells with necrotic debris.
Laboratory studies show a WBC count of 5890/microliter with 78% granulocytes, 15% lymphocytes, and
7% monocytes. Which of the following additional histologic findings is most likely to be present in his
sputum?
A Branching, septated hyphae
B Pleomorphic cells with dark, angular nuclei
C Clusters of small RBC-sized cysts staining with GMS
D Large cells with intranuclear inclusions
E Acid fast bacilli

(B) CORRECT. Distal acinar (paraseptal) emphysema is not common, but does account for a significant
number of cases of spontaneous pneumothorax in young persons. It is not related to smoking. There are
subpleural bullae that can burst, even with minimal trauma. They may be multiple, accounting for
recurrent episodes. However, the total amount of lung involved is minimal, so pulmonary function tests
will be normal between episodes. He developed a tension pneumothorax in this case.
Question 16
A 20-year-old man falls to the ground while jogging. He suffers a minor abrasion to his left hand.
However, within minutes he becomes dyspneic with right-sided chest pain. Bystanders call an
ambulance. On arrival at the hospital, he has tachypnea and tachycardia. On physical examination breath
sounds are absent over the right lung fields. A chest radiograph shows that the mediastinum is shifted to
the left, and there are no fractures. A thoracentesis on the right yields a rush of air. Which of the following
conditions is he most likely to have?
A Bronchopleural fistula
B Distal acinar emphysema
C Foreign body aspiration
D Intrinsic asthma
E Pulmonary atherosclerosis

(E) CORRECT. Diffuse alveolar damage (or ARDS as it is known clinically) is the final event following
severe lung injury from a variety of serious illnesses or accidents. In this case, it was probably initiated by
the hypotension ('shock lung') and potentiated by the 100% oxygen generating free radical damage.
Question 17
Following a vehicular accident with blood loss leading to prolonged, severe hypotension, a 30-year-old
man is intubated and placed on a mechanical ventilator. He has progressively decreasing oxygen
saturations despite increasing PEEP and FIO2 content of 100%. He remains afebrile. He dies 3 days
later. At autopsy, the distal lungs show pink hyaline membranes, thickened interstitium, and many
macrophages but few neutrophils. Which of the following pulmonary diseases most likely complicated his
course?
A Bronchopneumonia
B Chronic bronchitis
C Bronchiectasis
D Viral pneumonia
E Diffuse alveolar damage

(B) CORRECT. The differential diagnosis of a solitary peripheral coin lesion most often includes lung
cancer (adenocarcinoma most likely), granuloma, or hamartoma. Many people have had a remote,
subclinical tubercular or fungal infection leaving only a solitary granuloma. In this case the cough
suggests possible active infection, but it may just be an incidental, unrelated finding.
Question 18
A 51-year-old man complains of a slight cough he has had for a week. He is a non-smoker. On
auscultation of the chest his lung fields are clear. A chest radiograph shows a subpleural 'coin lesion' 2
cm in diameter in the right upper lobe. Which of the following is the most likely diagnosis for this lesion?
A Small cell carcinoma
B Granuloma
C Bronchiectasis
D Exogenous lipid pneumonia
E Silicosis

(B) CORRECT. Adenocarcinoma-in-situ can spread in a pneumonia-like pattern. The lack of a change
over time and the absence of a response to antibiotics should suggest an underlying non-infectious
process. Adenocarcinomas may occur in non-smokers.
Question 19
A 61-year-old man has had a cough without production of much sputum for the past week. On physical
examination he is afebrile. There are decreased breath sounds at the right lung base. A chest x-ray
reveals an area of consolidation in the right lower lobe. He is given antibiotic therapy, but a month later
the radiographic picture has not changed, and his cough continues. A bronchoalveolar lavage is
performed and yields atypical cells along with scattered alveolar macrophages. Which of the following is
the most likely diagnosis?
A Mycoplasma pneumonia
B Adenoccarcinoma-in-situ
C Sarcoidosis
D Pulmonary infarction
E Silica inhalation

(C) CORRECT. CMV produces a cytopathic effect with enlarged cells having prominent intranuclear
inclusions. CMV infection occurs most often with immune compromise, as in this case folowing
transplantation before engraftement.
Question 20
A 25-year-old man receives a hematopoietic stem cell transplant for treatment of acute myelogenous
leukemia. He develops increasing dyspnea 3 weeks later, along with fever and cough. On physical
examination his temperature is 37.8C. A chest radiograph shows irregular interstitial infiltrates. A
bronchoalveolar lavage is performed an on cytologic examination shows cells that are enlarged and have
prominent intranuclear inclusions. He is most likely to have an infection with which of the following
organisms?
A Toxoplasma gondii
B Candida albicans
C Cytomegalovirus
D Pneumocystis jiroveci
E Mycobacterium avium complex
F Influenza B virus
G Respiratory syncytial virus

(B) CORRECT. The symptoms and signs are classic for granulomatous disease. Sarcoidosis often
involves the hilar lymph nodes as well. No organisms can be found.
Question 21
A 54-year-old woman has had fever and dyspnea for a month along with a 2 kg weight loss. On physical
examination her temperature is 37.7C. A chest radiograph shows a reticulonodular pattern along with
prominent hilar lymphadenopathy. A transbronchial lung biopsy is performed, and microscopic
examination shows no viral inclusions, no fungi, no acid fast bacilli, and no atypical cells. Which of the
following diseases is she most likely to have?
A Silicosis
B Sarcoidosis
C Asbestosis
D Tuberculosis
E Usual interstitial pneumonitis

(D) CORRECT. He has a small cell anaplastic carcinoma with widespread metastases. The syndrome of
inappropriate ADH producing hyponatremia is one form of paraneoplastic syndrome seen with this
particular carcinoma.
Question 22
A 59-year-old man has been a cigarette smoker for the past 42 years. He has noted some blood-streaked
sputum on coughing during the past week. He also has back pain. A chest radiograph shows a small 3
cm right hilar mass with several 1 to 2 cm peripheral lung nodules. A bone scan reveals multiple areas of
increased uptake in the vertebrae, ribs, and pelvis. A sputum cytology reveals the presence of clusters of
small cells having hyperchromatic nuclei and almost no cytoplasm. Which of the following laboratory test
findings is he most likely to have as a consequence of his lung disease?
A Positive antinuclear antibody
B Platelet count of 55,000/microliter
C Plasma cortisol at 8 am of 5 microgm/dL
D Serum sodium of 113 mmol/L
E Serum uric acid of 14 mg/dL

(A) CORRECT. Pulmonary abscesses typically have an air-fluid level from liquefactive necrosis caused
by the collection of neutrophils. More virulent bacterial organisms such as Staphylococcus aureus are
likely to cause such a complication of a bronchopneumonia.
Question 23
A 40-year-old woman has had a high fever for a week, accompanied by a cough productive of yellowish
sputum. On physical examination her temperature is 38.2C. There are diffuse rales in all lung fields. Her
chest radiograph reveals patchy infiltrates in all lung fields, and there is a 4 cm rounded area of
consolidation in the left upper lobe that has an air-fluid level. Examination of her sputum reveals
numerous neutrophils. Which of the following infectious agents is most likely causing her pulmonary
disease?
A Staphylococcus aureus
B Aspergillus niger
C Mycobacterium tuberculosis
D Mycoplasma pneumoniae
E Adenovirus

(E) CORRECT. Most squamous cell carcinomas are located centrally and arise in bronchi, leading to
obstruction of a large airway that can cause a distal lipid pneumonia. In this case, the breakdown of lung
tissue distal to the mass yields an 'endogenous lipid pneumonia' with many macrophages. Some degree
of atelectasis may also be present from air resorbtion distal to the obstruction.
Question 24
At autopsy, a 60-year-old man is found to have a peripheral 7 cm area of golden-yellow consolidation on
sectioning of the left lung. Microscopically, this area has alveoli filled with foamy macrophages. Which of
the following conditions involving his lung is most likely to be responsible for this finding?
A Mycoplasma pneumoniae infection
B Cystic fibrosis
C Adenocarcinoma
D Silicosis
E Squamous cell carcinoma
F Malignant mesothelioma
G Thromboembolism

(D) CORRECT. In an acute asthmatic episode, there can be an outpouring of mucus which, along with
some dehydration, can lead to the formation of mucus plugs. These atopic asthmatic episodes in children
are usually initiated by a type I hypersensitivity reaction, typically with exposure to an allergen such as
pollen from goldenrod or other flowering plant. Up to 10% of children may be affected to some degree by
atopy.
Question 25
A 12-year-old girl has the acute onset of dyspnea and wheezing. She coughs up a large, thick mucus
plug. She has experienced similar previous episodes for the past 4 years, all of which lasted 1 to 4 hours.
On physical examination her vital signs include T 37.1C, P 109/minute, RR 40/minute, and BP 90/60 mm
Hg. There are decreased breath sounds in all lung fields. A chest radiograph reveals hyperinflation but no
infiltrates. Laboratory studies show WBC count of 8300/microliter with differential count of 60 segs, 3
bands, 16 lymphs, 10 monos, and 11 eosinophils. A sputum sample examined microscopically has
increased numbers of eosinophils. Which of the following is the most likely diagnosis?
A Mycoplasma pneumoniae infection
B Cystic fibrosis
C Hypersensitivity pneumonitis
D Bronchial asthma
E Aspiration of gastric contents

(C) CORRECT. Birds make a lot of organic dust from their feathers. The result upon inhalation of the bird
dust is an extrinsic allergic alveolitis. Getting away from the antigen (such as a vacation) will improve the
situation. This is a form of type 3 hypersensitivity. It may progress to involve type 4 hypersensitivity if
chronic.
Question 26
A 41-year-old previously healthy woman, a non-smoker, has had episodes of fever, non-productive
cough, and dyspnea over the past 3 months. Her symptoms disappeared after a month's vacation, but
reappeared when she returned home to take care of her canaries. On physical examination there are no
abnormal findings. A chest radiograph shows fine diffuse and nodular infiltrates in all lung fields. Her
disease is most likely to be produced via which of the following inflammatory mechanisms?
A Mast cell degranulation
B Progressive interstitial fibrosis
C Antigen-antibody complex formation
D Langerhans cell proliferation
E Infection with Mycobacterium kansasii

(D) CORRECT. She has findings of emphysema, and smoking is the most likely underlying cause. The
nicotine in the cigarette smoke is chemotactic for neutrophils, and cigarette smoke activates the
alternative complement pathway, releasing more mediators for neutrophil recruitment. Neutrophil elastase
can damage the lung parenchyma. Though neutrophils are not numerous in the lung with emphysema,
the cumulative effect of even small numbers of neutrophils over many years leads to the tissue damage.
Question 27
A 63-year-old woman has had increasing dyspnea for 5 years. On physical examination her lungs are
hyper-resonant without dullness. Tactile vocal fremitus is slightly decreased over all lung fields. Scattered
expiratory wheezes and inspiratory rhonchi are present without basal crackles. She has a chest
radiograph that reveals increased lung volumes and flattening of the diaphragmatic leaves. Spirometry
demonstrates an FEV1 that is decreased more than the FVC so that the FEV1/FVC ratio is less than 70%
of normal. Which of the following inhaled substances, which increases the elaboration of neutrophil
elastase, is most likely to cause her pulmonary disease?
A Chlorine
B Silica
C Carbon monoxide
D Nicotine
E Carbon
(D) CORRECT. Cor pulmonale is the result of pulmonary hypertension, which is the major cause for
pulmonary atherosclerosis. His emphysema has reduced the pulmonary vascular bed, promoting the
hypertension. Note that the forces driving systemic atherosclerosis are not operative on the pulmonary
arterial system.
Question 28
A 53-year-old man has had increasing dyspnea for the past 6 years, but no cough. On physical
examination there is increased jugular venous distension. He is afebrile. A chest radiograph shows
increased lucency in upper lung fields and increased lung volumes, with flattening of the diaphragmatic
leaves. There are no infiltrates. The pulmonary arteries are enlarged and prominent bilaterally, and his
right heart border is enlarged. Which of the following pathologic findings is most likely to be present in his
main pulmonary arteries?
A Granulomatous vasculitis
B Organizing thromboemboli
C Medial dissection
D Atherosclerosis
E Aneurysm formation

(C) CORRECT. Peripheral lung cancers (adenocarcinoma and large cell carcinoma) show less of an
association with smoking than central lung cancers (small cell and squamous cell carcinoma). The focal
obstruction from the mass predisposed to infection.
Question 29
A 44-year-old woman, a non-smoker, has had a fever and cough for the past 4 days. She does not have
hemoptysis. She has not experienced weight loss, malaise, nausea, or vomiting. On physical examination
her temperature is 37.6C. There are decreased breath sounds over the right upper lung. A chest
radiograph reveals a 6 cm area of infiltrates in the right upper lobe. She is given a course of antibiotic
therapy, but her cough persists. A month later her chest x-ray now reveals a 3 cm peripheral mass in the
right upper lobe. Which of the following neoplasms is most likely to be present in this woman?
A Squamous cell carcinoma
B Small cell anaplastic carcinoma
C Adenocarcinoma
D Mesothelioma
E Carcinoid tumor

(E) CORRECT. An embolus to a medium-sized arterial branch may not be large enough to kill the patient,
but large enough to cause an infarction. Her bedridden state predisposes her to deep venous thrombosis
and thromboembolism--the CVAs are due to separate systemic arterial problems--or the systemic and
pulmonary embolization can be tied together by a hypercoagulable state, or more remotely by a
'paradoxical' embolus through a patent foramen ovale once the right sided-pressures increased following
the initial pulmonary thromboembolic event.
Question 30
A 70-year-old woman has been bedridden for 5 weeks following a cerebrovascular accident (CVA). She
has the sudden onset of dyspnea, but has no further symptoms until two days later when she experiences
left sided pleuritic chest pain. A radiologic imaging study show a wedge-shaped area consistent with
hemorrhage based on the pleura of the left lower lobe. Which of the following pathologic findings in her
pulmonary arterial branches is she most likely to have?
A Atherosclerosis
B Aspergillosis
C Metastatic carcinoma
D Vasculitis
E Thromboembolism

(B) CORRECT. Mycoplasma infection predominantly affects the interstitium, and is not a widespread
alveolar filling process. It is a cause for a 'primary atypical pneumonia' which is difficult to diagnose
because this organism is not cultured by routine methods for bacterial organisms. The cold agglutinin titer
is elevated in about half of cases and is a characteristic finding. Many cases respond to antibiotic therapy
with erythromycin.
Question 31
A 38-year-old previously healthy woman has had a worsening non-productive cough for the past 4 days.
On physical examination her temperature is 38.3C. A chest radiograph shows patchy infiltrates and
diffuse interstitial markings. Laboratory studies show a sputum gram stain with mixed flora. Her Hgb is
12.9 g/dL, platelet count 229,450/microliter, and WBC count 5815/microliter. Her cold agglutinin titer is
elevated. Following a course of erythromycin therapy, she improves, with no complications. Which of the
following infectious agents is the most likely cause for her pulmonary disease?
A Nocardia asteroides
B Mycoplasma pneumoniae
C Mycobacterium kansasii
D Respiratory syncytial virus
E Chlamydia psittici
F Adenovirus
G Klebsiella pneumonia

(A) CORRECT. She has diabetes, which inhibits fetal lung development. At 33 weeks, the baby's lungs
may not make sufficient surfactant, though type II pneumomonocytes are present and increasing in
number. Corticosteroids administered to the mother help to speed up type II pneumonocyte production of
surfactant in the baby. At birth, exogenous surfactant can be given to the neonate. In addition, diabetes
tends to impede fetal lung maturation.
Question 32
A 23-year-old primigravida is found on prenatal testing to have an elevated hemoglobin A1C level. Her
pregnancy is uncomplicated until the 33rd week of gestation, when she has the onset of premature labor
and delivers a male infant 24 hours later. The infant initially has Apgar scores of 4 and 6 at 1 and 5
minutes, but within an hour is in severe respiratory distress and requires intubation with mechanical
ventilation. Which of the following pharmacologic therapies administered to the mother prior to birth could
have helped to prevent this infant's neonatal respiratory distress?
A Hydrocortisone
B Nafcillin
C Ibuprofen
D Lecithin
E Vitamin A
F Surfactant

(B) CORRECT. Pulmonary hypertension and subsequent right heart failure can occur in the small number
of cases in which recurrent thromboembolism takes place. The right heart failure that occurs then leads to
hepatic passive congestion with centrilobular necrosis that is the cause for the increased transaminases
and LDH (but normal CK, since the heart is enlarged, but not ischemic).
Question 33
For the past 5 months, a 51-year-old woman has noted increased swelling of her lower legs as the day
progresses. She has no fever and no cough. On physical examination, she has pitting edema to the
knees. A chest radiograph reveals bilateral pleural effusions, and the right heart border is prominent.
Laboratory studies show a serum AST of 238 U/L, ALT 263 U/L, LDH 710 U/L, and CK 127 U/L. Which of
the following underlying diseases is most likely to cause these findings?
A Goodpasture syndrome
B Recurrent thromboembolism
C Renovascular hypertension
D Bronchial asthma
E Rheumatoid arthritis

(D) CORRECT. Nocardia braziliensis infection can persist and lead to chronic abscesses. It can
complicate the course of immunocompromised patients. Though the lung is the portal of entry,
dissemination to brain is common.
Question 34
A 51-year-old man received an orthotopic cardiac transplant a month ago. He has developed a fever with
cough over the past 5 days. On physical examination his temperature is 37.5C. A chest CT scan shows
consolidation with abscess formation involving the left lower lobe. A sputum gram stain reveals normal
upper respiratory tract flora. He does not respond to antibiotic therapy over the next 6 months. His mental
status deteriorates and MR imaging of the brain shows multiple abscesses. He is most likely to have an
infection with which of the following organisms?
A Mycoplasma pneumoniae
B Aspergillus fumigatus
C Mycobacterium avium-complex
D Nocardia braziliensis
E Cytomegalovirus
F Pneumocystis jiroveci

(A) CORRECT. The pattern of lung involvement is the classical 'Ghon complex' of primary tuberculosis,
which is seen more commonly in children, though only about 5% of cases are symptomatic. The enlarged
hilar nodes can impinge upon central airways to produce obstruction.
Question 35
Three weeks after visiting her grandmother dying from a respiratory tract infection, a healthy 5-year-old
girl develops a fever along with dyspnea. On physical examination her temperature is 37.9C. Her lung
fields are clear to auscultation but there are expiratory wheezes. A chest x-ray reveals a solitary 2 cm
peripheral mid-lung nodule and marked hilar lymphadenopathy. Laboratory studies show Hgb 13.6 g/dL,
platelet count 183,600/microliter, and WBC count 5480/microliter. These findings are most consistent with
infection by which of the following organisms?
A Mycobacterium tuberculosis
B Candida albicans
C Coccidioides immitis
D Aspergillus flavus
E Bacteroides fragilis
F Streptococcus pneumoniae
G Respiratory syncytial virus

(D) CORRECT. Penetrating chest trauma would lead to pneumothorax with lung collapse (atelectasis).
Question 36
A study is performed reviewing medical records of adults presenting with sudden onset of severe
dyspnea. They were afebrile, with absent breath sounds over an entire lung, and chest x-ray showing
pulmonary atelectasis of an entire lung. Which of the following conditions is most likely to produce these
findings?
A Aspiration of a foreign body
B Pulmonary embolism
C Squamous cell carcinoma
D Penetrating chest trauma
E Bronchiectasis

(A) CORRECT. The hyperinsulinism in the baby as a result of the high maternal glucose impedes
development of the type II pneumonocytes. By 36 weeks there should normally be sufficient surfactant to
prevent hyaline membrane disease. Tests for fetal lung maturity include lamellar body count on amniotic
fluid, fluorescence polarization (fpol), phosphatidyl glycerol (PG), and L/S ratio.
Question 37
A newborn male infant develops increasing respiratory distress within an hour following an uncomplicated
vaginal delivery at 36 weeks gestation. A plain film radiograph reveals near opacification of both lungs.
Despite intubation and positive pressure ventilation, the baby dies within two days. At autopsy, the infant's
lungs demonstrate extensive pink hyaline membranes. Which of the following maternal conditions is most
likely to increase the risk for this infant's respiratory distress?
A Gestational diabetes
B Hyperemesis gravidarum
C Iron deficiency
D Preeclampsia
E Systemic lupus erythematosus

(E) CORRECT. A peritonsillar abscess is usually a complication of a 'strep' throat in a child.

Question 38
Following an acute pharyngitis lasting 4 days, a 10-year-old boy develops neck pain and marked halitosis.
On physical examination is breath is very malodorous. A CT scan shows an abscess in the peritonsillar
region. Laboratory studies include a culture of the abscess which grows anaerobic flora. Which of the
following aerobic organisms is most likely to be cultured from his abscess?
A Staphylococcus aureus
B Hemophilus influenzae
C Corynebacterium diphtheriae
D Bordetella pertussis
E Group A Streptococcus

(C) CORRECT. Multiple persistent masses should suggest metastases, rather than a primary lung tumor.
His lack of a cough or fever is against an infectious cause or aspiration.
Question 39
A 65-year-old man has had no major medical problems prior to the past year, when he noted increasing
malaise along with an 8 kg weight loss. He is a non-smoker. He currently does not have fever, cough,
dyspnea, or any respiratory difficulties. On physical examination, he has non-tender supraclavicular
lymphadenopathy. The lungs are clear to auscultation. A chest x-ray shows multiple solid nodules ranging
from 1 to 3 cm scattered throughout all lung fields. No infiltrates or areas of consolidation are noted.
Laboratory studies show Hgb 11.6 g/dL, Hct 34.7%, MCV 83 fL, and WBC count 6280/microliter. Which of
the following pathologic processes in his lungs is most likely to account for these findings?
A Pulmonary infarctions
B Recurrent aspiration
C Metastatic carcinoma
D Nocardia asteroides infection
E Silicosis

(B) CORRECT. Alpha-1-antitrypsin (AAT) deficiency leads to a panacinar form of emphysema which
involves the distal acinus beyond the respiratory bronchiole.
Question 40
A 43-year-old woman who does not smoke becomes increasingly dyspneic over 8 years' time. She does
not have a cough or increased sputum production. She is afebrile. On physical examination she has
decreased breath sounds with hyperresonance in all lung fields. A chest radiograph reveals increased
lucency of all lung fields. Laboratory studies show her serum alpha-1-antitrypsin level is 18 mg/dL. Which
of the following microscopic portions of the lung is most likely to be affected by her condition?
A Lymphatic channel
B Alveolar duct
C Bronchial artery
D Interstitium
E Terminal bronchiole

(C) CORRECT. The baby has been born prematurely, with incomplete lung development, and the lack of
sufficient alveolar development along with minimal pulmonary surfactant production leads to hyaline
membrane disease with respiratory distress in the newborn.
Question 41
A 30-year-old woman is in the 28th week of an uncomplicated pregnancy when she experiences the
sudden onset of severe abdominal pain, followed by vaginal bleeding, then the onset of labor. A girl infant
is delivered on the way to the hospital. On arrival within an hour, the baby is in respiratory distress and
requires intubation and mechanical ventilation. A day later, a chest radiograph shows opacification of both
lungs. The baby's respiratory status does not improve. Which of the following histopathologic findings is
most likely to be present in this baby's lungs?
A Neutrophilic exudates in the alveoli
B Irregular fibrosis with airspace dilation
C Minimal alveolar saccular development
D Diffuse alveolar hemorrhage
E Interstitial lymphocytic infiltrates

(A) CORRECT. She has an allergic bronchopulmonary aspergillosis. Her asthma is exacerbated by a type
I hypersensitivity reaction to the fungus in the bronchi.
Question 42
A 41-year-old woman has a 1 year history of episodic dyspnea. On physical examination there are
expiratory wheezes. Her chest radiograph shows a few small 0.5 cm perihilar nodules. Laboratory studies
show an elevated serum IgE along with peripheral blood eosinophilia. A sputum sample shows
eosinophils. Which of the following pathologic findings is most likely present in her bronchi?
A Non-invasive aspergillosis
B Blastomycosis
C Invasive candidiasis
D ANCA-associated vasculitis
E Cytomegalovirus

(E) CORRECT. The bronchopulmonary dysplasia (BPD) is a complication of the treatment for neonatal
respiratory distress. The positive pressure ventilation with the higher FIO2's, and the prolonged
intubation, all contribute. Generally, these are premature infants who had a respiratory complication
following birth, such as hyaline membrane disease.
Question 43
A male infant has initial Apgar scores of 5 and 6 at 1 and 5 minutes following birth by normal vaginal
delivery at 30 weeks gestation. However, increasing respiratory distress in the next hour requires
intubation and positive pressure ventilation. Two months later, the infant is finally taken off the ventilator,
but still does not oxygenate normally. Which of the following diseases has this infant most likely
developed?
A Diffuse alveolar damage
B Bronchial asthma
C Bronchiectasis
D Tracheo-esophageal fistula
E Bronchopulmonary dysplasia

(A) CORRECT. An inhaled object could obstruct a bronchus completely, with air resorbtion and collapse
of lung distal to the point of obstruction. This produces a shunt defect with a V/Q mismatch. Since there is
perfusion but no ventilation, even 100% oxygen will not make a difference. His hyperventilation has
acutely produced an uncompensated respiratory alkalosis.
Question 44
A 6-year-old child has the sudden onset of dyspnea with wheezing. On physical examination he is afebrile
but has absent breath sounds on the right. His temperature is 37C, pulse 82/minute, respiratory rate
32/minute, and blood pressure 100/60 mm Hg. An arterial blood gas measurement shows pO2 95 mm
Hg, pCO2 25 mm Hg, and pH 7.55. Following administration of 100% FiO2 by nasal canula, a repeat
measurement shows pO2 95 mm Hg, pCO2 25 mm Hg, and pH 7.55. Which of the following is the most
likely diagnosis?
A Foreign body aspiration
B Bronchial asthma
C Paraseptal emphysema
D Thromboembolism
E Carcinoid tumor

(B) CORRECT. Diffuse alveolar damage (DAD) is the pathologic term for adult respiratory distress
syndrome (ARDS) that is the final common pathway for many acute lung injuries. DAD produces
increasing interstitial thickening with mixed inflammation and features of an acute restrictive lung disease.
Question 45
A 60-year-old woman develops multiple organ failure 3 weeks following a pneumonia complicated by
septicemia. Antibiotic therapy has resulted in sputum and blood cultures that are now without growth of
organisms. Nevertheless, she requires intubation with mechanical ventilation, but it becomes
progressively more difficult to maintain her oxygen saturations. Ventilatory pressures must be increased.
A portable chest radiograph shows increasing opacification of all lung fields. Which of the following
pathologic processes is most likely now to be present in her lungs?
A Pulmonary arterial vasculitis
B Diffuse alveolar damage
C Extensive neutrophilic alveolar exudates
D Extensive intra-alveolar hemorrhage
E Widespread bronchiectasis