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The chest x-ray film is most consistent with which of the following?
/ A. Emphysema
/ B. Interstitial disease
/ C. Lobar pneumonia
/ D. Lung cancer
/ E. PIeural effusion
Lung cancer (choice D), if large, would produce a mass lesion (often
involving a bronchus), or, if very small, might not be recognized on chest x-
ray.
Pleural effusion (choice E) would cause a whitened area due to fluid below
the lung
Question 2 of 4
The patient is sent for spirometry for further evaluation. FEV1 and FVC are both
shown to be about 60% of the expected values, and the ratio
of FEV1/FVC is 90%. These findings are most consistent with which of the
following?
/ A. Asthma
/ B. Bronchiectasis
/ C. Chronic bronchitis
/ D. Emphysema
/ E. Restrictive lung disease
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Explanation - Q: 1.2 Close
Asthma (choice A), bronchiectasis (choice B), chronic bronchitis (choice C),
and emphysema (choice D) all tend to produce obstructive patterns, with
FEV1 disproportionately decreased when compared to FVC.
Question 3 of 4
The correct answer is A. Working history often offers helpful clues about
possible toxic exposures that may have contributed to lung disease. Asbestos
was formerly a common constituent of insulating material in buildings
because of both its insulating properties and its fire-resistant properties.
People working on old buildings, particularly when removing the old
insulation, are consequently vulnerable to high exposures unless they take
care to minimize exposure with respirators. The risk to individuals living and
working in old buildings is usually markedly less, since the asbestos is
typically found behind walls. Individuals who work in asbestos mines
(principally in Canada, South Africa, and the former USSR) may also have
high exposures.
Beryllium (choice B) is used in the nuclear industry and in x-ray tubes, and
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was formerly used in ceramics, metallic alloys, and fluorescent lights.
Silica (choice E) is found in sand and glass, and significant exposures can be
seen in individuals working in environments where small particles of these
materials may become aerosolized.
Question 4 of 4
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A 70-year-old man is seen by his family practice physician during a routine office
visit. The man complains of not feeling well for the last three
months. Further questioning reveals that the patient has a chronic, unproductive
cough that he attributes to an old smoking history. Physical
examination is notable for a 15-pound weight loss since the last office visit three
months previously. A multinodular infiltrate is seen in the lung
field behind and above the right clavicle.
Question 1 of 5
The patient is injected intradermally with PPD. 3 days after the injection, there is
a 13-mm diameter area of induration at the injection site. This
reaction is an example of which of the following types of immune response?
/ A. Type l hypersensitivity
/ B. Type ll hypersensitivity, cytotoxic subtype
/ C. Type ll hypersensitivity, noncytotoxic subtype
/ D. Type lll hypersensitivity
/ E. Type IV hypersensitivity
The correct answer is E. This patient has a positive PPD test, as indicated
by an area of induration greater than or equal to 10 mm. PPD is a purified
protein derivative of tuberculin, so this finding indicates that the patient has
tuberculosis. The PPD reaction is an example of type IV hypersensitivity, also
known as delayed-type hypersensitivity.
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Explanation - Q: 2.2 Close
IgE, basophils, and mast cells (choice B) are involved in the production of
type I hypersensitivity.
Question 3 of 5
The strongest definitive identification of the pathogen responsible for this
patient's disease would be provided by a positive result on which of
the following biochemical tests?
/ A. Arylsulfatase
/ B. Heat-stable catalase
/ C. Niacin
/ D. Nitrate reductase
/ E. Urease
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*** More klepting in less time ***
Question 4 of 5
The mass lesion in the patient's lung is evaluated with fiberoptic bronchoscopy
with transbronchial biopsy. Sputum collected after the
procedure demonstrates acid-fast bacteria with a "beaded" appearance. Giant
cells found in the biopsy material would be likely to express
which of the following membrane markers?
/ A. CD4
/ B. CD8
/ C. CD14
/ D. CD16
/ E. CD19
CD4 (choice A) is a cell marker for helper T lymphocytes that would be found
in the halo of lymphocytes surrounding the Langerhans giant cells, but would
not be on the giant cells themselves.
CD16 (choice D) is a cell marker for NK cells, which would not be on the
giant cells in a TB granuloma.
CD19 (choice E) is a cell marker for B-lymphocytes, which are not likely to be
present in a TB granuloma, a reaction mediated exclusively by cell-mediated
immunity.
Question 5 of 5
The principal drug recommended for treatment of this patient's disease targets
which of the following molecules?
/ A. Arabinogalactan
/ B. Dihydrofolate reductase
/ C. Dihydropteroate synthetase
/ D. Mycolic acid
/ E. Peptidoglycan
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Explanation - Q: 2.5 Close
7
A 60-year-old man presents to the emergency department complaining of
shortness of breath, cough, and copious sputum production. He
states that he has been coughing for years, and has had increased sputum
production for several months each year. On examination, he is
obese, afebrile, cyanotic, and in acute distress. Coarse rales are auscultated
bilaterally at the lung bases. He smokes two packs of cigarettes
a day and has a seventy-five pack-year smoking history. A chest x-ray film
appears normaI, except for slightly enlarged lung fields.
Question 1 of 5
The correct answer is A. This patient has findings classic for the "blue bloater"
of chronic bronchitis. Patients with chronic bronchitis have excessive
tracheobronchial mucus production sufficient to cause cough with expectoration
for at least three months of the year for more than two consecutive years. "Blue
bloaters" are named for their obese body habitus, copious sputum production,
and cyanotic episodes. This condition may occur initially without airway
obstruction, but eventually, most patients progress to obstructive disease.
Patients with emphysema (choice B) represent another form of COPD. They are
known as "pink puffers" because they do not become cyanotic until they
decompensate. They display a thin body habitus and belabored breathing. This
patient is not consistent with the pink puffer of emphysema.
This patient does not have the classic findings for myocardial infarction (choice
C), which include: chest pressure or pain, shortness of breath, and/or pain that
radiates to the jaw or left arm.
It is unlikely that this patient has pneumonia (choice D). Patients with pneumonia
have cough with purulent sputum production, but they are usually febrile and
have chest x-ray opacities.
While the diagnosis of pulmonary embolus (choice E) is elusive due to its varied
presentations, it is unlikely that this patient has a pulmonary embolus. Findings
for PE include pleuritic chest pain, shortness of breath, hemoptysis, and a history
of calf pain indicative of deep vein thrombosis.
Question 2 of 5
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As this patient waits in the emergency department, his condition begins to
deteriorate. He turns increasingly blue and an arterial blood gas is
drawn. His PO2 is 45 mm Hg, which under normal conditions means that his
hemoglobin would be 75% saturated. Which of the following
mechanisms could cause a hemoglobin saturation of less than 75% at this pO2?
/ A. Decreased 2,3-DPG Ievels
/ B. Decreased hemoglobin
/ C. Decrease in body temperature
/ D. Decreased PCO2
/ E. Decreased serum pH
Choices A, C, and D increase the affinity of hemoglobin for O2, and thus
cause the Hb to retain the O2.
Choice B is a distracter.
Question 3 of 5
Why must care be exercised when administering O2 to this patient?
/ A. Administering O2 washes out alveolar CO2 and inhibits respiration
/ B. Chronic hypoxia alters the blood-brain barrier such that CO2 cannot diffuse
into the medullary apneustic center
/ C. Chronic hypoxia induces atrophy in the dorsal respiratory group in the
medulla
/ D. Increased PO2 worsens CO2 retention by decreasing respiratory drive
/ E. O2 is acutely toxic to the chronically hypoxic alveolar epithelium
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the PO2 rises, and the hypoxic stimulation disappears, and respiration can
become markedly depressed. The PCO2-dependent respiratory drive does
not revert immediately, and thus the patient hypoventilates and retains CO2,
which may precipitate coma, stupor, or death.
Administering O2 at high flow rates (choice A) may wash out alveolar CO2,
but this is not the mechanism for hypoventilation of the chronically hypoxic
patient.
Chronic hypoxia does not alter the diffusing capacity of the BBB (choice B).
Chronic hypoxia does not cause the respiratory center to atrophy (choice C).
Neuroendocrine cells (choice C) are present in the respiratory tract. They are
the cell of origin for oat cell carcinomas, and the neuroendocrine capabilities
of these cells become evident with the paraneoplastic syndromes seen in this
high-grade carcinoma.
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They provide the majority of the surface area on which gas exchange occurs.
Question 5 of 5
Which of the following spirometry profiles would most likely be seen in this
patient?
/ A. Decreased TLC, decreased FEV1
/ B. Decreased TLC, decreased RV
/ C. Decreased TLC, increased FEV1
/ D. EIevated TLC, decreased FEV1
/ E. NormaI TLC, decreased FEV1
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her temperature at home was 103.4 F. In the emergency department, her
temperature is 39.9 C (103.8 F), blood pressure is 90/50 mm Hg,
pulse is 120/min, and respirations are 30/min. No breath sounds are heard over
her lower left lung field, but they can be heard at other sites.
Question 1 of 7
A chest x-ray film would be most likely to demonstrate which of the following:
/ A. A single roughly ovoid white area
/ B. Complete whitening over one lobe of her lungs
/ C. Marked dilation and elongation of bronchial spaces
/ D. Multiple small spotty areas of white found primarily near the bronchi
/ E. No obvious radiologic changes
The correct answer is B. This patient has lobar pneumonia, which is seen
radiologically as a complete whitening of one or more lobes of the lungs.
Question 2 of 7
Gram's stain of a smear from a sputum sample demonstrates gram-positive
lancet-shaped diplococci in short chains. Which of the following
would most likely be identified after culturing?
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The correct answer is E. Streptococcus pneumoniae is the most commonly
identified causative organism for bacterial pneumonia. Up to two-thirds of
bacteremic community-acquired pneumonias are due to this organism. 5-25%
of healthy individuals carry S. pneumoniae in their pharynx. The classic
description of S. pneumoniae on Gram's stain is that given in the question
stem. S. pneumoniae can be verified by the Quellung reaction, or
counterimmunoelectrophoresis to determine serotypes of isolated strains or
for case detection using sputum specimens (there are more than 80 distinct
serotypes based on studies of capsular antigens).
Question 3 of 7
Which of the following is thought to contribute to the ability of gram-positive
organisms to retain the Gram's stain during the decolorization
process?
/ A. Large periplasmic space
/ B. Presence of capsule
/ C. Presence of outer membrane
/ D. Presence of pili
/ E. Thick peptidoglycan layer
Explanation - Q: 4.3 Close
The correct answer is E. The peptidoglycan layer in the cell wall of gram-
positive organisms is much thicker than that in gram-negative organisms, and
is thought to contribute to the gram-positive staining reaction.
Pili (choice D) are small hair-like structures that are most often seen in gram-
negative organisms.
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Question 4 of 7
Which of the following is a characteristic feature on culture of this patient's
organism?
/ A. AIpha-hemolytic colonies inhibited by optochin on blood agar and lysed by
bile
/ B. Beta-hemolytic colonies that are bacitracin-resistant on blood agar
/ C. Beta-hemolytic colonies that are inhibited by bacitracin on blood agar
/ D. Catalase-negative organisms that hydrolyze esculin in 40% bile and 6.5%
NaCI
/ E. Catalase-positive, coagulase-positive organisms that cause beta-hemolytic,
yellow colonies on blood agar
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neutrophils, and fibrin develops, heralding the stage of red hepatization
(choice C; so-called because the lung resembles liver at this stage). During
the last half of the first week of illness, the red cells begin to break down, but
a fibrinous exudate remains in the alveoli; this is the stage of gray
hepatization. If death does not supervene, resolution (choice D) occurs in the
second week in untreated cases, with digestion of the exudate to leave
semifluid debris that are phagocytized, or coughed up. In some cases, the
exudate, rather than resolving in this manner, undergoes further organization
(choice A).
Question 6 of 7
The patient's infection is treated with parenteral penicillin, to which she promptly
responds. This drug acts by which of the following
mechanisms?
/ A. Inhibits bacterial protein synthesis
/ B. Inhibits growth of cell walls
/ C. Interferes with bacteriaI DNA synthesis
/ D. Interferes with folate metabolism
/ E. Punches holes in cell membranes
Explanation - Q: 4.6 Close
The correct answer is B. The penicillins and cephalosporins both inhibit cell
wall synthesis. Penicillin G is the preferred antibiotic for sensitive strains; 25%
of strains are resistant and can be treated with cephalosporins, erythromycin,
and clindamycin. Pneumococcal pneumonia can be prevented in a number of
cases; the pneumococcal vaccine contains 23 specific polysaccharide
antigens found in 85-90% of the serious pneumococcal infections.
Agents that disrupt cell membranes (choice E) include azole and polyene
antifungal agents.
Question 7 of 7
A few minutes after the patient receives the antibiotic therapy, she develops an
adverse reaction characterized by an itchy skin eruption and
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acute respiratory distress. This reaction is most likely attributable to which of the
following mechanisms?
/ A. Antibody-mediated cellular dysfunction
/ B. Complement-dependent reaction
/ C. Delayed-type hypersensitivity
/ D. IgE-mediated mast cell degranulation
/ E. Immune-complex deposition
The correct answer is D. This patient has had an acute allergic reaction to
the antibiotic, which can be further classified as an immediate hypersensitivity
reaction. These reactions are mediated in a way similar to hay fever, with
preformed IgE binding to the antibiotic antigen, and then the antigen-antibody
complex triggering degranulation of mast cells with release of histamine and
other active substances. These substances then cause both the itchiness of
the skin and the bronchospasm that caused the respiratory distress.
A 14-year-old girl receives a bone marrow transplant as part of her treatment for
acute lymphoblastic lymphoma. During the period of profound
immunosuppression before the marrow engrafts, she develops nonproductive
cough, fever, mild hemoptysis, and pleuritic chest pain. A plain
chest x-ray film shows a pleuraI-based wedge-shaped lesion with focal
cavitation. Open chest lung biopsy reveals necrosis and hemorrhage.
Septate fungal forms with dichotomous 45-degree branching are seen in the
necrotic areas and involving the walls of several blood vessels.
When the fungus is cultured, it is found to be a monomorphic fungus.
Question 1 of 6
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Explanation - Q: 5.1 Close
The correct answer is A. The fungi that cause "deep infections" in humans
are subdivided into the dimorphic forms (which, depending upon temperature,
can be either yeast forms or hyphal forms) and the monomorphic forms
(which grow in the same general form at different temperatures). Of the fungi
listed, only Aspergillus is monomorphic. Aspergillus is a common saprophytic
mold found on decaying material in the environment throughout the world. It
can cause human diseases, including allergic bronchopulmonary aspergillosis
(which is essentially an allergic reaction to inhaled Aspergillus conidia or
spores), fungus ball (in which the Aspergillus grows without invading in a
preexisting cavitary lesion of the lung), invasive aspergillosis (including
pneumonia, meningitis, and other systemic infections), and cellulitis. Invasive
aspergillosis is most often seen in severely immunocompromised patients
with severe neutropenia, notably including those with a history of
transplantation, chronic granulomatous disease, and leukemia. This patient's
presentation is typical for invasive pulmonary aspergillosis. The other fungi
listed (choices B, C, D, and E) are all dimorphic.
Characteristics to look for with Candida include both pseudohyphae and true
hyphae (choice A), budding yeasts (choice B), and occasionally germ tubes
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(choice C, better seen with some culture methods).
Question 3 of 6
Question 4 of 6
Which of the following is the most appropriate pharmacotherapy for this patient?
/ A. Amphotericin B
/ B. CIotrimazole
/ C. FIuconazole
/ D. FIucytosine
/ E. Griseofulvin
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infections.
Question 5 of 6
Which of the following best describes the mechanism of action of the most
appropriate medication for this patient's disease?
/ A. Forms pores in fungal membranes
/ B. Inhibits the demethylation of lanosterol
/ C. Inhibits squalene epoxidase
/ D. Inhibits thymidylate synthase
/ E. Interferes with the synthesis of ergosterol
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Question 6 of 6
Toxicity to which of the following organs is most likely to limit the administration
of the most appropriate medication for this patient's disease?
/ A. Brain
/ B. Heart
/ C. Kidney
/ D. Liver
/ E. Lung
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