Section 1 - Improving care in ED



Section 1

Respiratory

1) In the lung:

a) the bronchioles differ from bronchi only in that they are of smaller diameter and lack cartilage in their walls

b) bronchial goblet cells secrete mucin, serotonin and calcitonin

c) type I pneumocytes secrete surfactant

d) type II pneumocytes cover 25% of the alveolar surface in health

e) type II pneumocytes are responsible for the regeneration of type I cells

2) Adult respiratory distress syndrome (ARDS):

a) is most frequently initiated by damage to type I alveolar cells

b) can be treated with inhaled nitric oxide, if care is taken to prevent nitric oxide-induced systemic hypotension

c) is a diffuse disease equally affecting all areas of a patient’s lungs

d) neutrophils have a key role in the pathogenesis of adult respiratory distress syndrome, making it unlikely in neutropenia

e) adult respiratory distress syndrome may be initiated as a result of blood contact with the membrane of a haemodialysis device

3) In bronchogenic carcinoma:

a) 30% of tumours are large cell carcinomas

b) small cell tumours are unlikely to respond to chemotherapy

c) the most common site of metastatic disease is the adrenals

d) bone is more frequently involved in metastatic disease than the liver

e) most tumours arise from medium-sized bronchi (4th-9th order airways)

4) Which of the following is NOT commonly associated with diffuse interstitial lung disease?

a) “honey-comb” lung

b) alveolitis

c) “ground glass” shadows on chest x-ray

d) bronchospasm

e) PDGF and FGF release by alveolar macrophages

5) Which of the following is NOT commonly associated with bronchiectasis?

a) metastatic cerebral abscess

b) kartagener’s syndrome

c) rubella

d) necrotising ulceration of epithelium with areas of regeneration

e) cystic fibrosis

6) Which of the following is NOT a complication associated with asthma?

a) emphysema

b) amyloidosis

c) chronic bronchitis

d) bronchiectasis

e) cor pulmonale

7) Which of the following is LEAST commonly seen in asthma?

a) collections of crystalloids made up of neutrophil membrane protein

b) whorls of shed epithelium within mucus plugs

c) thickened basement membrane of bronchial epithelium

d) oedema and inflammatory infiltrate in bronchial walls

e) hypertrophy of submucosal mucus glands and bronchial wall muscle

8) Which of the following substances released by eosinophils is directly TOXIC to respiratory epithelium?

a) platelet activating factor

b) histaminase

c) leukotriene C4

d) arylsulphatase B

e) major basic protein

9) What is the characteristic histologic feature of chronic bronchitis?

a) bronchiolitis fibrosa obliterans

b) squamous metaplasia and dysplasia of bronchial epithelium

c) mucus plugging of bronchioles

d) enlarged mucus-secreting glands of trachea and bronchi

e) inflammation and fibrosis of bronchioles

10) What is the hallmark and earliest feature of chronic bronchitis?

a) hypertrophy of submucosal glands in trachea and bronchi

b) marked increase in goblet cells in small airways

c) hypersecretion of mucus

d) reversible obstruction in bronchioles and small airways

e) secondary infection

11) Regarding the histological features of emphysema, which of the following is NOT usually seen?

a) peri-bronchiolar inflammatory cell infiltrate

b) septal wall destruction in terminal bronchioles

c) fused alveoli forming large abnormal airspaces

d) septal wall destruction in respiratory bronchioles

e) black pigment in walls of airways

12) Regarding the role of alpha-one antitrypsin in the pathogenesis of emphysema, which statement is INCORRECT?

a) it inhibits macrophage-derived elastase

b) oxidants in cigarette smoke inhibit it

c) it inhibits neutrophil-derived elastase

d) oxygen free radicals from neutrophils inhibit it

e) its absence allows elastic tissue destruction to go unchecked in the lung

13) Regarding the pathology of emphysema, which statement is INCORRECT?

a) panacinar (pan-lobular) emphysema is more severe at lung bases

b) paraseptal (distal acinar) emphysema is associated with spontaneous pneumothoraces

c) centriacinar (centri-lobular) emphysema is more severe at lung apices

d) panacinar (pan-lobular) emphysema is associated with alpha-one antitrypsin deficiency

e) paraseptal (distal acinar) emphysema is more severe at lung bases

14) Which of the following does NOT cause pulmonary oedema via purely haemodynamic mechanisms?

a) left ventricular failure

b) nephrotic syndrome

c) pulmonary vein obstruction

d) high altitude

e) lymphatic obstruction

15) Which of the following does NOT cause pulmonary oedema by inducing microvascular injury?

a) smoke inhalation

b) aspiration of gastric contents

c) mitral stenosis

d) fresh water drowning

e) fat embolism

16) Which of the following does NOT cause patchy atelectasis?

a) hyaline membrane disease

b) chronic bronchitis

c) adult respiratory distress syndrome

d) cardiac surgery using pump oxygenator during bypass

e) long term 100% oxygen

17) Which of the following does NOT cause obstructive (absorptive) atelectasis?

a) congestive cardiac failure

b) bronchial asthma

c) bronchiectasis

d) post operative states

e) bronchogenic carcinoma

Section 1

Respiratory – Answers

1. E

2. E

3. C

4. D

5. C

6. B

7. A

8. E

9. D

10. C

11. B

12. A

13. E

14. D

15. C

16. B

17. A

Section 2

1) All of the following characterise familiar tumours except:

a) earlier age of onset

b) close relatives with same tumour

c) multiple or bilateral tumours

d) specific marker phenotypes

e) increased relative risk in siblings

2) Malignant neoplasms:

a) are independent of hormonal influence

b) are always composed of homogenous cell lines

c) arise from differentiated cells by a process of anaplasia

d) display abnormal nuclei with pale nucleoli

e) typically grow more rapidly than benign

3) Regarding metastasis:

a) all carcinomas have the ability to metastasise

b) highly invasive carcinomas rarely metastasise

c) carcinomas typically spread via lymphatics compared with haematogenous spread

d) tumour cells develop increased cohesiveness of their cell surface in the formation of cancer cell emboli

e) cells involved in lymphatic dissemination release degradative enzymes

4) Thrombus formation is inhibited by:

a) VWF – von Willebrand’s factor

b) IL-1

c) alpha 2-macroglobulin

d) TNF

e) endothelial cell injury

5) Most pulmonary emboli:

a) cause centrally located pulmonary haemorrhage

b) cause pulmonary infarction

c) cause acute right heart failure

d) are clinically silent

e) lead to pulmonary hypertension

6) Adult respiratory distress syndrome:

a) is most frequently initiated by damage to type I alveolar cells

b) can be treated with inhaled nitric oxide, if care is taken to prevent nitric oxide induced systemic hypotension

c) is a diffuse disease equally affecting all areas of a patient’s lungs

d) neutrophils have a key role in the pathogenesis of adult respiratory distress syndrome making it unlikely in neutropenia

e) adult respiratory distress syndrome may be initiated as a result of blood contact with the membrane of a haemodialysis device

7) Pneumocystitis carinii:

a) produces pneumocystitis pneumonia in normal persons

b) causes a Ghon’s focus in the lung

c) causes patchy atelectasis

d) is a fungus

e) attaches selectively to type II alveolar cells

8) Cor Pulmonale may be caused by:

a) congenital heart disease

b) mitral stenosis

c) left ventricular failure

d) primary pulmonary hypertension

e) aortic regurgitation

9) The features of bronchogenic carcinoma include:

a) the classification of ‘oat cell’ tumour within the large cell type

b) high initial response to chemotherapy for small cell type

c) the strongest correlation with cigarette smoking in the adenocarcinoma type

d) that 50% of small cell type occur in non smokers

e) histological features identical in small cell carcinomas and squamous cell types

10) Most pulmonary emboli:

a) cause centrally located pulmonary haemorrhage

b) cause pulmonary infarction

c) cause acute right heart failure

d) are clinically silent

e) lead to pulmonary hypertension

11) In bronchogenic carcinoma:

a) 30% of tumours are large cell carcinomas

b) small cell tumours are unlikely to respond to chemotherapy

c) the most common site of metastatic disease is the adrenals

d) bone is more frequently involved in metastatic disease than the liver

e) most tumours arise from medium-sized bronchi (4th to 9th order airways)

12) Concerning thrombo-embolism:

a) venous thrombi are characterised by lines of Zahn

b) arterial thrombi are rarely occlusive

c) thrombosis is more common with elevated protein C and S

d) the commonest site of mural arterial thrombus ffofnation is the femoral artery

e) the deep calf veins are the commonest site of DVT

13) Of all hospitalised deaths, what percentage are wholly or largely due to pulmonary embolus:

a) 5%

b) 10%

c) 20%

d) 50%

e) 75%

Section 2

Answers

1. D

2. E

3. E

4. C

5. D

6. E

7. D

8. D

9. B

10. D

11. C

12. C

13. B

Section 3

1) Regarding microscopic features of the alveolar wall, which is INCORRECT?

a) alveolar macrophages are derived from blood monocytes

b) type I pneumocytes are involved in the repair of alveolar epithelium

c) type II pneumocytes produce surfactant

d) there is a basement membrane separating the endothelial cells from the alveolar lining epithelial cells

e) the alveolar walls are perforated by pores of Kohn

2) Which cause of pulmonary oedema is due to microvascularity?

a) high altitude

b) mitral stenosis

c) shock

d) lymphatic obstruction

e) LVF

3) The most common type of emphysema is:

a) centriacinar

b) panacinar

c) paraseptal

d) irregular

e) none of the above

4) The most common phenotype associated with alpha1 AT deficiency is:

a) PiMM

b) PiMZ

c) PiZZ

d) PiHZ

e) PiHH

5) How much functioning pulmonary parenchyma is incapacitated before clinical manifestations of emphysema appear?

a) 25%

b) 331/3%

c) 40%

d) 50%

e) 65%

6) Regarding the pathogenesis of atopic asthma:

a) it is a type II hypersensitivity reaction

b) with antigen re-exposure there is cross-linking of IgG and the release of chemical mediators

c) sympathetic receptor stimulation provokes bronchoconstriction

d) the late-phase reaction starts one hour later

e) leukotrienes C4, D4, E4 and acetylcholine have a definitive role in bronchoconstriction

7) Which is the most common association with restrictive pulmonary disease?

a) environmental disease

b) sarcoidosis

c) idiopathic pulmonary fibrosis

d) collagen vascular diseases

e) ionising radiation

8) What is the main source of elastase in the lung?

a) neutrophils

b) macrophages

c) mast cells

d) pancreas

e) bacteria

9) Adult respiratory distress syndrome:

a) improves with 100% of oxygen

b) usually begins with damage to type I pneumocytes

c) has hyaline membranes lining the alveolar wall

d) evenly effects all parts of the lungs

e) has a mortality rate of 90%

10) Which is not a morphological feature of asthma?

a) inflammatory infiltrate of bronchial walls

b) destruction of basement membrane of bronchial epithelium

c) hypertrophy of submucosal glands

d) hypertrophy of bronchial wall muscle

e) small areas of atelectasis

11) Regarding bronchogenic carcinoma:

a) adenocarcinoma has the strongest relationship to smoking

b) non-small cell carcinomas respond best to chemotherapy

c) the commonest site of metastasis is to the liver

d) adenocarcinoma is the most common form of lung cancer in women

e) SIADH predominantly occurs in squamous cell carcinoma

12) Regarding pulmonary tuberculosis:

a) primary infection usually occurs in the apices

b) secondary infection forms the Ghon complex

c) reactivation rates are 30-40% of primary infection

d) bacilli prefer regions of low oxygen tension

e) miliary tuberculosis occurs by lymphohaematogenous dissemination

13) Which is not a favoured target for miliary seeding of tuberculosis?

a) bone marrow

b) liver

c) bowel

d) spleen

e) retina

Section 3

Answers

1. B

2. C

3. A

4. C

5. B

6. E

7. A

8. A

9. C

10. B

11. D

12. E

13. C

Respiratory Pathology Notes

Alveoli have interconnecting PORES OF KOHN permitting passage of bacteria and exudate between adjacent alveoli.

Incidence of pulmonary malignancy is rising in women and is the leading lethal visceral malignancy in both men and women, even surpassing breast cancer in women.

Lungs are secondarily involved in almost all terminal disease – eg atelectasis, pneumoniae etc.

Atelectasis = collapse, forming relatively airless parenchyma, reducing oxygenation and predisposing to infection

➢ Obstruction (resorption) atelectasis in asthma, bronchitis, bronchiectasis and post operative

➢ Compression atelect by pleural fluid on air, eg in cardiac failure, pneumoth??? and malignancy. Mediastinum shifts away, as opposed to obstructive resorptive, where it shifts to

➢ Contraction atelect from fibrosis, which may not be reversible, where others are

ARDS: Caused by diffuse alveolar capillary damage → hypoxaemia refractory to oxygen therapy. Usually severe pulmonary oedema is present (non cardiogenic). Caused by viral infection, oxygen toxicity, inhaled toxins, aspiration of gastric contents, septic shock, pancreatitis, other shock, hypersensitivity to organic solvents, often combination of shock, oxygen therapy and sepsis → 60% mortality

Bronchial asthma

A C R I D H E R B

Asthma is a chronic relapsing inflammatory ‘disorder’, with hyper-reactive airways, leading to episodic reversible bronchoconstriction

Section 4

1) Which is the incorrect pairing?

a) asthma – obstructive atelectasis

b) CHF – compressive atelectasis

c) ARDS – compressive atelectasis

d) bronchiectasis – obstructive atelectasis

2) Atelectatic processes can move the mediastinum from centre, which is correct?

a) patchy atelectasis can shift it away from the affected side

b) compressive → shifts toward affected side

c) obstructive → towards affected side

d) none are correct

3) Which is an example of haemodynamic pulmonary oedema?

a) high altitude

b) acute pancreatitis

c) neurogenic

d) lymphatic obstruction

4) Haemosideran-laden macrophages found in the alveoli are most consistent with:

a) longstanding CHF

b) oedema due to microvascular injury

c) nephrotic syndrome

d) high altitude pulmonary oedema

5) Pulmonary oedema from hydrostatic increase in pulmonary capillary pressure will start to occur:

a) at 7mmHg

b) at 10mmHg

c) at 28mmHg

d) at 35mmHg

6) Which is not a mainly obstructive pulmonary disorder?

a) bronchiectasis

b) ARDS

c) chronic bronchitis

d) asthma

7) Obstructive disease exhibits all but:

a) Poor lung elastic recoil

b) ↓ FEV1

c) patchy involvement of V/Q mismatch

d) a greatly reduced FVC

8) Which is most common?

a) paraseptal emphysema

b) irregular emphysema

c) acinar emphysema

d) centriacinar emphysema

9) Which is associated with α1-antitryipsin deficiency?

a) paraseptal emphysema

b) panacinar emphysema

c) centriacinar emphysema

d) irregular emphysema

10) Which is not type I hypersensitivity immune reaction based?

a) atopic asthma

b) aspirin-induced bronchospasm

c) occupational asthma

d) allergic broncho-pulmonary aspergillosis

11) The pathological changes include all of the following EXCEPT:

a) cylindrical bronchiectasis

b) mucus plugs

c) Curschmann’s spirals

d) Charcot-Leyden crystals

12) Bronchial changes in asthma include all but:

a) smooth muscle hypertrophy

b) thickened basement membrane

c) a significant increase in the number of submucosal glands

d) inflammatory eosinophilic infiltrate in bronchial wall

13) Which is the most common association with restrictive pulmonary disease?

a) sarcoidosis

b) collagen-vascular disease

c) idiopathic pulmonary fibrosis

d) environmental disease

14) Which is not a cause of restrictive lung disease?

a) α1 –antitrypsin deficiency

b) widespread tuberculosis

c) Goodpastures

d) amiodarone

15) In the initial alveolitis of restrictive disease, which is the most common inflammatory cell?

a) eosinophils

b) lymphocytes

c) macrophages

d) neutrophils

e) variable

16) Regarding pneumoconiosis:

a) simple and complicated coal workers pneumoconiosis causes severe impairment of pulmonary function

b) is usually caused by dusts measuring 10-20μm

c) asbestosis is the most common occupational disease worldwide

d) is ????????more common in the general population

Section 4

Answers

1. C

2. C

3. D

4. A

5. C

6. B

7. D

8. D

9. B

10. B

11. A

12. C

13. D

14. A

15. E

16. D

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