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 calcitoninc) type I pneumocytes secrete surfactantd) type II pneumocytes cover 25% of the alveolar surface in healthe) 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 cellsb) can be treated with inhaled nitric oxide, if care is taken to prevent nitric oxide-

induced systemic hypotensionc) is a diffuse disease equally affecting all areas of a patient’s lungsd) neutrophils have a key role in the pathogenesis of adult respiratory distress

syndrome, making it unlikely in neutropeniae) 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 carcinomasb) small cell tumours are unlikely to respond to chemotherapyc) the most common site of metastatic disease is the adrenalsd) bone is more frequently involved in metastatic disease than the livere) 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” lungb) alveolitisc) “ground glass” shadows on chest x-rayd) bronchospasme) PDGF and FGF release by alveolar macrophages

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

a) metastatic cerebral abscessb) kartagener’s syndromec) rubellad) necrotising ulceration of epithelium with areas of regeneratione) cystic fibrosis

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

a) emphysemab) amyloidosis c) chronic bronchitisd) bronchiectasise) cor pulmonale

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

a) collections of crystalloids made up of neutrophil membrane proteinb) whorls of shed epithelium within mucus plugsc) thickened basement membrane of bronchial epitheliumd) oedema and inflammatory infiltrate in bronchial wallse) 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 factorb) histaminasec) leukotriene C4d) arylsulphatase Be) major basic protein

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

a) bronchiolitis fibrosa obliteransb) squamous metaplasia and dysplasia of bronchial epitheliumc) mucus plugging of bronchiolesd) enlarged mucus-secreting glands of trachea and bronchie) inflammation and fibrosis of bronchioles

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

a) hypertrophy of submucosal glands in trachea and bronchib) marked increase in goblet cells in small airwaysc) hypersecretion of mucusd) reversible obstruction in bronchioles and small airwayse) secondary infection

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

a) peri-bronchiolar inflammatory cell infiltrateb) septal wall destruction in terminal bronchiolesc) fused alveoli forming large abnormal airspacesd) septal wall destruction in respiratory bronchiolese) 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 elastaseb) oxidants in cigarette smoke inhibit itc) it inhibits neutrophil-derived elastased) oxygen free radicals from neutrophils inhibit ite) 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 basesb) paraseptal (distal acinar) emphysema is associated with spontaneous

pneumothoracesc) centriacinar (centri-lobular) emphysema is more severe at lung apicesd) panacinar (pan-lobular) emphysema is associated with alpha-one antitrypsin

deficiencye) 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 failureb) nephrotic syndromec) pulmonary vein obstructiond) high altitudee) lymphatic obstruction

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

a) smoke inhalationb) aspiration of gastric contentsc) mitral stenosisd) fresh water drowninge) fat embolism

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

a) hyaline membrane diseaseb) chronic bronchitisc) adult respiratory distress syndromed) cardiac surgery using pump oxygenator during bypasse) long term 100% oxygen

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

a) congestive cardiac failureb) bronchial asthmac) bronchiectasisd) post operative statese) bronchogenic carcinoma

Section 1

Respiratory – Answers

1 E2 E3 C4 D5 C6 B7 A8 E9 D10 C11 B12 A13 E14 D15 C16 B17 A

Section 2

1) All of the following characterise familiar tumours except:

a) earlier age of onsetb) close relatives with same tumourc) multiple or bilateral tumoursd) specific marker phenotypese) increased relative risk in siblings

2) Malignant neoplasms:

a) are independent of hormonal influenceb) are always composed of homogenous cell linesc) arise from differentiated cells by a process of anaplasiad) display abnormal nuclei with pale nucleolie) typically grow more rapidly than benign

3) Regarding metastasis:

a) all carcinomas have the ability to metastasiseb) highly invasive carcinomas rarely metastasisec) carcinomas typically spread via lymphatics compared with haematogenous

spreadd) tumour cells develop increased cohesiveness of their cell surface in the formation

of cancer cell embolie) cells involved in lymphatic dissemination release degradative enzymes

4) Thrombus formation is inhibited by:

a) VWF – von Willebrand’s factorb) IL-1c) alpha 2-macroglobulin d) TNFe) endothelial cell injury

5) Most pulmonary emboli:

a) cause centrally located pulmonary haemorrhageb) cause pulmonary infarctionc) cause acute right heart failured) are clinically silente) lead to pulmonary hypertension

6) Adult respiratory distress syndrome:

a) is most frequently initiated by damage to type I alveolar cellsb) can be treated with inhaled nitric oxide, if care is taken to prevent nitric oxide

induced systemic hypotensionc) is a diffuse disease equally affecting all areas of a patient’s lungsd) neutrophils have a key role in the pathogenesis of adult respiratory distress

syndrome making it unlikely in neutropeniae) 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 personsb) causes a Ghon’s focus in the lungc) causes patchy atelectasisd) is a funguse) attaches selectively to type II alveolar cells

8) Cor Pulmonale may be caused by:

a) congenital heart diseaseb) mitral stenosisc) left ventricular failured) primary pulmonary hypertensione) aortic regurgitation

9) The features of bronchogenic carcinoma include:

a) the classification of ‘oat cell’ tumour within the large cell typeb) high initial response to chemotherapy for small cell typec) the strongest correlation with cigarette smoking in the adenocarcinoma typed) 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 haemorrhageb) cause pulmonary infarctionc) cause acute right heart failured) are clinically silente) lead to pulmonary hypertension

11) In bronchogenic carcinoma:

a) 30% of tumours are large cell carcinomasb) small cell tumours are unlikely to respond to chemotherapyc) the most common site of metastatic disease is the adrenalsd) bone is more frequently involved in metastatic disease than the livere) most tumours arise from medium-sized bronchi (4th to 9th order airways)

12) Concerning thrombo-embolism:

a) venous thrombi are characterised by lines of Zahnb) arterial thrombi are rarely occlusivec) thrombosis is more common with elevated protein C and Sd) the commonest site of mural arterial thrombus ffofnation is the femoral arterye) 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 D2 E3 E4 C5 D6 E7 D8 D9 B10 D11 C12 C13 B

Section 3

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

a) alveolar macrophages are derived from blood monocytesb) type I pneumocytes are involved in the repair of alveolar epitheliumc) type II pneumocytes produce surfactantd) there is a basement membrane separating the endothelial cells from the alveolar

lining epithelial cellse) the alveolar walls are perforated by pores of Kohn

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

a) high altitudeb) mitral stenosisc) shockd) lymphatic obstructione) LVF

3) The most common type of emphysema is:

a) centriacinarb) panacinarc) paraseptald) irregulare) none of the above

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

a) PiMMb) PiMZc) PiZZd) PiHZe) 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 reactionb) with antigen re-exposure there is cross-linking of IgG and the release of chemical

mediatorsc) sympathetic receptor stimulation provokes bronchoconstrictiond) the late-phase reaction starts one hour latere) 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 diseaseb) sarcoidosisc) idiopathic pulmonary fibrosisd) collagen vascular diseasese) ionising radiation

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

a) neutrophilsb) macrophagesc) mast cellsd) pancrease) bacteria

9) Adult respiratory distress syndrome:

a) improves with 100% of oxygenb) usually begins with damage to type I pneumocytesc) has hyaline membranes lining the alveolar walld) evenly effects all parts of the lungse) has a mortality rate of 90%

10) Which is not a morphological feature of asthma?

a) inflammatory infiltrate of bronchial wallsb) destruction of basement membrane of bronchial epitheliumc) hypertrophy of submucosal glandsd) hypertrophy of bronchial wall musclee) small areas of atelectasis

11) Regarding bronchogenic carcinoma:

a) adenocarcinoma has the strongest relationship to smokingb) non-small cell carcinomas respond best to chemotherapyc) the commonest site of metastasis is to the liverd) adenocarcinoma is the most common form of lung cancer in womene) SIADH predominantly occurs in squamous cell carcinoma

12) Regarding pulmonary tuberculosis:

a) primary infection usually occurs in the apicesb) secondary infection forms the Ghon complexc) reactivation rates are 30-40% of primary infectiond) bacilli prefer regions of low oxygen tensione) miliary tuberculosis occurs by lymphohaematogenous dissemination

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

a) bone marrowb) liverc) boweld) spleene) retina

Section 3

Answers

1 B2 C3 A4 C5 B6 E7 A8 A9 C10 B11 D12 E13 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 asthmaA 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 atelectasisb) CHF – compressive atelectasisc) ARDS – compressive atelectasisd) 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 sideb) compressive → shifts toward affected sidec) obstructive → towards affected sided) none are correct

3) Which is an example of haemodynamic pulmonary oedema?

a) high altitudeb) acute pancreatitisc) neurogenicd) lymphatic obstruction

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

a) longstanding CHFb) oedema due to microvascular injuryc) nephrotic syndromed) high altitude pulmonary oedema

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

a) at 7mmHgb) at 10mmHgc) at 28mmHgd) at 35mmHg

6) Which is not a mainly obstructive pulmonary disorder?

a) bronchiectasisb) ARDSc) chronic bronchitisd) asthma

7) Obstructive disease exhibits all but:

a) Poor lung elastic recoilb) ↓ FEV1

c) patchy involvement of V/Q mismatchd) a greatly reduced FVC

8) Which is most common?

a) paraseptal emphysemab) irregular emphysemac) acinar emphysemad) centriacinar emphysema

9) Which is associated with α1-antitryipsin deficiency?

a) paraseptal emphysemab) panacinar emphysemac) centriacinar emphysemad) irregular emphysema

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

a) atopic asthmab) aspirin-induced bronchospasmc) occupational asthmad) allergic broncho-pulmonary aspergillosis

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

a) cylindrical bronchiectasisb) mucus plugsc) Curschmann’s spiralsd) Charcot-Leyden crystals

12) Bronchial changes in asthma include all but:

a) smooth muscle hypertrophyb) thickened basement membranec) a significant increase in the number of submucosal glandsd) inflammatory eosinophilic infiltrate in bronchial wall

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

a) sarcoidosisb) collagen-vascular diseasec) idiopathic pulmonary fibrosisd) environmental disease

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

a) α1 –antitrypsin deficiencyb) widespread tuberculosisc) Goodpasturesd) amiodarone

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

a) eosinophilsb) lymphocytesc) macrophagesd) neutrophilse) variable

16) Regarding pneumoconiosis:

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

b) is usually caused by dusts measuring 10-20μmc) asbestosis is the most common occupational disease worldwided) is ????????more common in the general population

Section 4

Answers

1 C2 C3 D4 A5 C6 B7 D8 D9 B10 B11 A12 C13 D14 A15 E16 D