Question Bank

A 48-year-old man comes to the office for an initial visit. He says that he feels well and has no medical problems. The patient has a 20-pack-year smoking history and does not use alcohol or illicit drugs. He is counseled on smoking cessation. To explain how smoking affects lung function, the patient is shown a graph of the expected change in forced expiratory volume in 1 second (FEV1) over time if he continues to smoke at the same rate (curve D in the image). Which of the following curves most likely demonstrates the expected FEV1 over time if this patient were to stop smoking now?

A 62-year-old man comes to the office for evaluation of progressive exertional dyspnea. His medical history is significant for pneumonia and hypertension. He has a 45-pack-year smoking history. On physical examination, breath sounds are decreased bilaterally and wheezes are heard. A CT scan of the chest is shown below. Which of the following cells are most responsible for the development of this patient's lung condition?

A 60-year-old woman is brought to the hospital due to progressive shortness of breath and cough for 2 weeks. The patient was diagnosed with right breast cancer and completed radiation therapy 6 weeks ago. Temperature is 37.3 C (99.1 F), blood pressure is 110/70 mm Hg, pulse is 90/min, and respirations are 22/min. Oxygen saturation is 93% on room air. Examination reveals inspiratory crackles over the right lung anteriorly; the lungs are otherwise clear to auscultation. Chest radiograph shows ground-glass opacities in the right lung where radiation was delivered. Laboratory studies reveal no significant changes. Acute radiation-induced lung injury is suspected. Histopathologic examination would most likely reveal formation of which of the following?

A 24-year-old man comes to the office due to paroxysmal episodes of breathlessness and wheezing for the past 6 months. He does not recognize any triggers for these episodes and reports they are not associated with exercise or stress. He has no history of recent illness. He had eczema as a child. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Lung examination shows good air movement and no wheezing. Sputum microscopy reveals many granule-containing cells and crystalloid masses. The sputum findings in this patient are a direct result of which of the following cytokines?

A 28-year-old previously healthy man comes to the urgent care clinic due to shortness of breath. He is on a ski vacation in Breckenridge, Colorado, situated at an altitude of 2926 m (9600 ft). On arrival 4 days ago, he experienced mild headache and nausea that resolved spontaneously, but since yesterday he has had worsening dyspnea and cough. He now feels short of breath even with minimal exertion. Temperature is 37.3 C (99.1 F), blood pressure is 134/82 mm Hg, pulse is 98/min, and respirations are 22/min. Oxygen saturation is 86% on ambient air, which rapidly improves to 95% with supplemental oxygen. Physical examination shows pink mucous membranes, flat neck veins, bilateral inspiratory crackles, and no heart murmurs or pedal edema. Chest x-ray reveals patchy alveolar infiltrates. Which of the following is the most likely cause of this patient's current condition?

A 65-year-old man comes to the office due to worsening exertional dyspnea over the past 3 months. This past year, he has had 4 respiratory infections that improved with medical therapy. He does not use alcohol or illicit drugs and has smoked 1 1/2 packs of cigarettes daily for 30 years. Temperature is 36.7 C (98.1 F), pulse is 76/min, and respirations are 18/min. On physical examination, breath sounds are diffusely decreased. Chest radiography reveals flattened hemidiaphragms, increased radiolucency of the lungs, and a long, narrow heart shadow. This patient's pulmonary function testing will most likely show which of the following patterns (total lung capacity; FEV1/FVC ratio; forced vital capacity; residual volume)?

A 45-year-old man comes to the emergency department due to severe dyspnea and chest discomfort that began earlier in the day. The dyspnea has been worsening throughout the day and is present at rest. He reports no inciting trauma. He has no other medical conditions and takes no medications. He has a 20-pack-year smoking history and does not use alcohol or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 110/60 mm Hg, and pulse is 96/min. Arterial blood gas on room air shows PaO2 of 54 mm Hg and PaCO2 of 26 mm Hg. Which of the following processes is most likely occurring in this patient?

A 57-year-old man is being evaluated for progressive shortness of breath. His respiratory flow-volume curve is shown in red (a leftward-shifted loop with increased total lung capacity and residual volume and a scooped-out expiratory limb, compared to normal). Which of the following pathologic findings is most likely to be present in this patient?

A 44-year-old man comes to the emergency department with a 3-day history of fever, chills, malaise, dyspnea, and a cough productive of "greenish" sputum. He has no prior medical problems and has never been hospitalized. He has a 25-pack-year smoking history and drinks 4-5 beers a week. His temperature is 39.4 C (103 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 20/min. On examination, dullness to percussion, crackles, and egophony are present at the right lung base. The remainder of the examination is normal. Chest x-ray shows a dense infiltrate occupying the entire right lower lobe. Which of the following most likely accounts for the color of this patient's sputum?

A 60-year-old woman comes to the emergency department due to shortness of breath and productive cough. She has a 30-pack-year smoking history. Oxygen saturation is 88% on room air. On physical examination, she appears uncomfortable and uses her accessory respiratory muscles to breathe. Expiratory wheezes are heard throughout the lungs. The patient is started on high-flow oxygen supplementation. Shortly afterward, she becomes increasingly lethargic and confused. This patient's clinical decline is most likely attributable to an increase in which of the following parameters?

A 58-year-old woman comes to the office due to gradually worsening shortness of breath. She has a history of emphysema secondary to alpha-1 antitrypsin deficiency and uses inhaled bronchodilators and glucocorticoids. Lately she has been feeling short of breath even with minimal exertion. She has no other medical conditions and is a former smoker with a 5-pack-year history. Blood pressure is 130/80 mm Hg, pulse is 82/min, and respirations are 18/min. Physical examination shows increased anteroposterior chest diameter, prolonged expiratory phase, and decreased breath sounds bilaterally. The heart sounds are distant. Chest x-ray reveals hyperinflated lungs with no consolidation, pleural effusion, or pneumothorax. Which of the following sets of arterial blood gas findings on room air (pH; PaCO2 [mm Hg]; plasma HCO3 [mEq/L]; PaO2 [mm Hg]) is most likely to be seen in this patient?

A 54-year-old man comes to the emergency department due to fevers, shaking chills, and cough productive of copious sputum. He began having fever, cough, and sharp chest pains 10 days ago and was prescribed oral antibiotics by his primary care physician after a chest x-ray revealed a right lower lobe infiltrate. He has not been taking the medication as advised, and his symptoms have progressively worsened. Temperature is 39 C (102.2 F), blood pressure is 114/62 mm Hg, and pulse is 116/min. Physical examination reveals crackles in the right lower lung. Repeat chest x-ray reveals a round density with an air-fluid level in the lower lobe of the right lung. Which of the following is the most important contributor to the observed lung lesion in this patient?

A 54-year-old man comes to the office due to daytime sleepiness and lack of energy. The symptoms began 6 months ago and have progressively worsened so that he feels "completely drained" by the end of the day. His wife mentions that he snores loudly. His past medical history is unremarkable, although he has not seen a physician in over 10 years. He does not use tobacco or alcohol and works in the warehouse of an agricultural supply company. BMI is 34 kg/m2. Physical examination shows a narrow oropharynx and a large neck circumference. The patient is at increased risk of developing which of the following?

A 63-year-old man comes to the office due to 3 months of increasing cough with occasional hemoptysis, night sweats, and unintentional weight loss. He recently emigrated from South Africa, where he worked for many years in the gold mines. He has a history of silicosis diagnosed 10 years ago. Vital signs show a low-grade fever. Physical examination reveals diffuse, fine crackles with right upper lobe predominance. Chest x-ray shows diffuse, small nodules; hilar adenopathy with prominent calcifications; and a cavitary lung lesion in the right upper lobe. A sputum sample is sent for appropriate staining and culture. This patient's increased susceptibility to the current infection is best explained by which of the following factors?

A 68-year-old man comes to the emergency department due to cough, breathlessness, and chest pain. He has hypertension and type 2 diabetes mellitus and is a former smoker with a 20-pack-year history. Temperature is 38 C (100.4 F), blood pressure is 130/80 mm Hg, respirations are 22/min, and oxygen saturation is 95% on ambient air. The trachea is central. There is dullness to percussion over the lower right lung area compared to resonance on the left. Auscultation of the right lower lobe reveals breath sounds that are loud, hollow, and high-pitched. When the patient recites the word "ninety-nine" in a normal voice, the sound has higher clarity and intensity over the right base compared to other lung areas. Which of the following is the most likely cause of these findings?

A 37-year-old woman is evaluated for exertional shortness of breath. She has had progressive dyspnea for the last year and for the last 2 months has been unable to walk half a block without stopping to rest. She also describes lightheadedness during exertion. Medical history is insignificant, and vital signs are within normal limits. BMI is 23 kg/m2. Physical examination reveals a 2/6 holosystolic murmur at the lower sternal border that increases with inspiration. Further evaluation indicates no evidence of obstructive or interstitial lung disease or venous thromboembolism. Cardiac catheterization shows mean pulmonary artery pressure 43 mm Hg (normal: 8-20) and pulmonary capillary wedge pressure 9 mm Hg (normal: 6-12). Pharmacotherapy blocking the effects of which of the following substances is most likely to benefit this patient?

A 42-year-old man comes to his primary care physician due to daytime sleepiness. He often falls asleep during meetings and while watching television and has even fallen asleep while driving. He does not feel refreshed when waking and has occasional morning headaches. He has not had abnormal dreams or visual hallucinations when falling asleep or on waking. He has no significant past medical history and is a lifetime nonsmoker. He drinks 2 or 3 beers on Friday nights. Blood pressure is 148/100 mm Hg, pulse is 78/min and regular, and BMI is 32 kg/m2. Cardiopulmonary examination shows no abnormalities. Arterial blood gas analysis is normal. What is this patient's most likely diagnosis?

A 33-year-old woman comes to the office due to worsening exertional dyspnea. She previously jogged frequently but now becomes short of breath while walking her dog in the park. She has no other significant medical history and takes no medications. She smokes a pack of cigarettes daily and does not use alcohol or illicit drugs. Blood pressure is 124/76 mm Hg, pulse is 78/min, and respirations are 20/min. BMI is 27 kg/m2. Cardiac examination is unremarkable. Laboratory studies reveal markedly decreased serum alpha-1 antitrypsin levels. Which of the following pulmonary function test patterns (total lung capacity; FEV1/FVC ratio; diffusing capacity for carbon monoxide [DLCO]) is most likely to be present in this patient?

A nonsmoking patient presents with dyspnea, cough, and weight loss and has pleural thickening on imaging. Gross pathology of the lungs (shown) demonstrates encasement of the lungs in a rind-like, calcified mass. Which of the following is the most likely diagnosis?

A 56-year-old man comes to the office due to worsening cough for the past several months. He initially had a morning cough productive of minimal sputum, but now the cough occurs throughout the day with large amounts of yellowish sputum. The patient also has breathlessness on moderate exertion. He has had 3 hospitalizations over the past year for respiratory infections. The patient has smoked a pack of cigarettes daily for the past 30 years and has failed multiple attempts to quit. Oxygen saturation is 90% at rest and decreases to 84% with moderate exertion. Which of the following additional findings is most likely to be seen in this patient?

A 76-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is found to have a laceration of the spleen and is taken for emergent laparotomy. During surgery, the patient goes into cardiac arrest and dies, despite aggressive resuscitation efforts. Autopsy examination is performed and shows areas of thickening inside the chest wall as shown below. Lung examination shows fibrosis of the lower lobes. Pathologic examination of these fibrotic areas is most likely to reveal which of the following findings?

An 18-year-old man is evaluated for recurrent episodes of shortness of breath, wheezing, runny nose, and watery eyes. The patient reports that his symptoms have recently worsened since he started training outdoors for an upcoming marathon. He does not use tobacco, alcohol, or illicit drugs. Skin testing is performed to determine symptom triggers. A pricking device is used to apply allergen extract underneath the skin. After 15 minutes, the patient develops raised, erythematous plaques with surrounding erythema at the application site. Which of the following mediators is the first to be released during the pathogenesis of this patient's skin findings?

A 6-year-old Caucasian boy is brought to the office by his mother due to recurrent episodes of sinusitis. He also has a chronic cough that never seems to go away. The mother says that his previous pediatrician performed a "sweat test" to help determine the cause of his frequent infections, but results were normal. DNA testing was inconclusive. Despite these results, the new physician suspects that the patient has an inherited disorder and orders nasal transepithelial potential difference measurements. In this test, an isotonic solution of sodium chloride is applied to the nasal mucosal surface, and the electrical potential overlying the mucosa is compared with that of the interstitial fluid. The results show a transepithelial potential difference that is more negative than normal. This patient's nasal mucosa is most likely to demonstrate which of the following physiologic changes?

A research study is conducted to evaluate the effects of various serum proteins in health and disease states. Healthy volunteers and patients with various medical conditions are recruited. In an experiment, purified insoluble elastin is exposed to stimulated neutrophils, which results in the degradation of the elastin molecules into smaller peptides. This process can be inhibited by adding serum from healthy volunteers but not from a specific patient population. Which of the following is the strongest recommendation for patients in this specific population?

A 63-year-old man comes to the emergency department due to a 1-week history of progressively worsening shortness of breath and cough. The shortness of breath is exacerbated when the patient lies flat in bed; he has to prop himself up with 3 pillows to sleep well at night. He was treated for a myocardial infarction 2 weeks ago and had 2 stents placed in the left anterior descending artery. The patient's other medical conditions include long-standing hypertension and type 2 diabetes mellitus. Blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 22/min. Pulse oximetry is 89% on room air. Physical examination reveals bilateral crackles at the lung bases and an S3. Which of the following is most likely present in this patient?

[Stem text was not captured in the OCR; the following is a faithful paraphrase reconstructed from the explanation.] A patient with recent extended travel (prolonged immobilization) presents with acute-onset dyspnea and tachypnea, a normal lung examination, and sinus tachycardia on ECG. Pulmonary embolism is suspected. Because CT angiography requires intravenous contrast that must be avoided in this patient (chronic kidney disease, risk of contrast-induced nephropathy), a ventilation/perfusion (V/Q) scan is performed. Which of the following V/Q scan patterns is the most definitive diagnostic finding for pulmonary embolism?

A 34-year-old man comes to the office due to shortness of breath. He reports an episodic cough and chest tightness for the past 4 months. The patient was recently on a 2-week vacation in Arizona and reports that he had no symptoms during the trip but that they restarted when he returned home. He has no prior medical conditions and takes no medications. The patient smoked marijuana in his early 20s for several years but does not use tobacco or alcohol. He started working at a chemical manufacturing factory 7 months ago and has had no sick contacts. Temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 76/min, and respirations are 18/min. On physical examination, expiration is mildly prolonged and there are scattered wheezes. Office spirometry shows an FEV1/FVC of 82%, and chest radiography reveals no abnormalities. Which of the following features is most likely involved in the pathogenesis of this patient's condition?

A 48-year-old homeless man is brought to the emergency department after being found unresponsive on the sidewalk.