Chest Section (Revised KM 9/97)

The following are True/False questions:

1994, 1992
Regarding use of high kVp technique for CXR:
1. better bone detail
2. lower patient dose
3. better visualization of fatty structures such as the epicardial fat pad
4. greater latitude
5. lower contrast
*
High kVp CXR: poor on calcified objects and sacrifices bone detail, but good for
mediastinal detail. High kVp (80-120) and low kVp (60-80). High kVp diminishes patient dose -
fewer photons absorbed.
We use 75 kVp for spine and 125 kVp for CXR.
The lower the kVp, the more X-rays are attenuated in the patient. Also, at lower kVp
there are more interactions via the photoelectric effect (as opposed to higher Compton scattering
at higher kVp). Radiation of the highest energy possible (consistent with diagnostic quality)
should be used to minimize patient exposure.
Image contrast is reduced at higher kVp. Therefore, fat and water (soft tissue) are
difficult to differentiate and require lower kVp (as in mammography).
*
Answers: 1. False 2. True 3. False 4. True 5. True

1992
True statements regarding hypoplasia of the left pulmonary artery include all of the following
except:
6. it is associated with atresia of the left main bronchus
7. expiratory film is useful to differentiate from Swyer-James
8. the left lung is hyperlucent
9. associated with a right aortic arch
10. most cases are associated with tetralogy of Fallot
*
Pulmonary hypoplasia – completely formed but congenitally small bronchus with rudimentary
parenchyma, small vessels. R>L 3:1. RML (65%) > RUL (40%) > RLL (20%) > LUL (20%) > LLL
(15%).
Answer: 6. False 7. True 8. False As opposed to Swyer – James [increased lucency] 9.
False (unilateral pulmonary agenesis) 10. False (see 9.)
Dahnert 1996

1995
Regarding the PA radiograph of the chest:
11. Heart size is directly related to cardiac volume
12. Heart size increases in bradycardia
13. In a normal patient, the heart size changes no more than 10 mm between systole and
diastole
14. The heart size increases in direct proportion to the size of an ASD
15. The heart size is greater on lordotic examination

Answer: 11. False 12. True 13. True 14. False 15. True

1994
Which of the following are commonly seen with PCP in a patient with AIDS?
16. diffuse pulmonary opacities
17. multiple small nodules
18. multiple bilateral pulmonary cysts
19. hilar adenopathy
20. pleural effusion
20a. Normal chest radiograph
*
Pneumocystis - from Freundlich and Bragg p 494, and Dahnert
-most common pulmonary infection in AIDS
-patterns on CXR (listed from most to least common)
1. diffuse, fairly symmetric, fine to medium reticular opacification
2. fine to medium reticular pattern asymmetrically distributed
3. particular form of asymmetric involvement: upper lobe (in aerosolized
pentamidine users)
4. focal air space consolidation simulating pyogenic pneumonia
5. miliary disease simulating disseminated fungal or TB disease
6. pulmonary nodules with or without cavitation
7. spontaneous pneumothorax (not associated with other opportunistic infections
in AIDS)
8. pneumatoceles (seen in 10% of AIDS patients - resolve within 6 months)
9. lymphadenopathy and pleural effusion are very rare!
10. normal CXR in 10% - consider Ga-67 nuclear medicine scan or
bronchoscopy!
*
Answers: 16. True 17. True 18. True 19. False 20. False 20A. False (10%)

1995
Which of the following are encompassed by the pericardium:
21. aortic root
22. proximal right and left pulmonary arteries
23. the superior vena cava following the insertion of the azygous vein
24. the azygous vein just before it inserts into the superior vena cava
*
Ref: Netter atlas p. 200-201
Answer: 21. True 22. False 23. True 24. False

1994
Regarding Hodgkin Disease of the chest:
25. parenchymal disease can be seen in the absence of hilar adenopathy
26. hilar adenopathy can be seen in the absence of mediastinal adenopathy
27. pleural involvement is rare
28. posterior mediastinal adenopathy is common
*
Hodgkin Disease - Freundlich and Bragg p 352, and Dahnert
Parenchymal disease is "invariably" subsequent to hilar adenopathy, in fact, if a patient
with known Hodgkin has no mediastinal-hilar disease and a new pulmonary nodule appears, it
should be presumed to be unrelated and another source should be sought. Hilar adenopathy in
the absence of mediastinal adenopathy is rare. Pleural involvement is rare even in the presence
of a lymphomatous effusion. Most patients with pleural disease will have contiguous pulmonary
or chest wall disease. Lymphadenopathy is nearly always anterior, not posterior, particularly in
Hodgkin.
*
Answers: 25. False 26. False 27. True 28. False

1995
Regarding cystic fibrosis:
29. 1 out of every 20 (5%) of white adults is a heterozygote carrier
30. there are increased nucleic acids in bronchial secretions
31. diagnosis is made by increased sodium and chloride in the sweat
32. rectal involvement is a rare finding
33. infertility is more common in males
33a. . Focal biliary cirrhosis
33b. All sinuses are hypoplastic
*
Answer: 29. True 30. False 31. True 32. False (23% of untreated patients have rectal
prolapse between 6 months and 3 years) 33. True 33a. True (from inspissated bile – rare
clinically, up to 50% autopically). 33b. False (sinusitis with opacification of well developed
maxillary, ethmoid, and sphenoid sinuses. Frontal sinuses are hypoplastic).

1995, 1992
Regarding large conglomerate masses seen in silicosis:
34. they tend to be in the upper lobes
35. they retract toward the hila
36. they are premalignant
37. they are discoid in shape
38. they are secondary to tuberculous infection
*
The masses commonly develop in the midzone and periphery of the lung and migrate
toward the hilum leaving behind emphysematous tissue.
The masses are typically described as being “sausage” shaped, not discoid.
The large masses represent confluence of silicotic nodules which is sometimes
associated with superimposed TB. They predispose to TB, but even progressive massive
fibrosis doesn’t necessarily mean TB.
*
Answer: 34. True 35. True 36. False (but there is increased risk of lung carcinoma in
patients with PMF) 37. False 38. False

1995
Regarding Swyer-James syndrome:
39. the mediastinum deviates away from the affected lung on expiration
40. the affected side can be larger than the contralateral normal lung
41. is secondary to bronchiolitis obliterans
42. the segmental bronchi terminate abruptly (???)
43. pathologic specimens demonstrate anthacotic changes
43a. Most commonly related to childhood adenoviral infection
*
Ref: Dahnert 1996 p.388

Answer: 39. True (air trapping) 40. False 41. True 42. True (usually cutoff at 4th to 5th
generation – “pruned tree” bronchogram) 43. False 43a. True

1995
Which of the following may be signs of a small right pneumothorax on supine radiograph of the
chest:
44. a tongue-like contour of the cardiophrenic angle
45. elevation of the right hemidiaphragm
46. the hilum overlay sign
47. lucency at the lung base
48. rounded contour of the pericardial fat pad
*
Answer: 44. ??? 45. False 46. ??? (AK says false, Matt Glaser saw this as a true answer
on another set of questions) 47. True 48. True

On Life:
There are two great pleasures in gambling: that of winning and that of losing.
French Proverb.
1994
Which of the following are likely causes of pulmonary opacities in a patient will sickle cell
anemia?
49. focal pulmonary edema
50. pneumonia
51. subsegmental atelectasis
52. pulmonary infarct
*
An “acute chest syndrome” characterized by the abrupt onset of fever, chest pain, and
leukocytosis occurs in patients with homozygous sickle cell anemia and hemoglobin sickle cell
disease. It is very common and has been attributed to pneumonia, particularly when it affects
children. However, although there is little doubt that these patients are more susceptible to
pneumococcal, Haemophilus, and Mycoplasma pneumonia, most studies indicate that infection is
a relatively uncommon cause of the syndrome. Instead it is likely that most episodes result when
sickling leads to obstruction in the pulmonary vessels. Patients with sickle cell anemia also are
prone to the development of pneumococcal septicemia and pulmonary thrombosis and
thromboembolism.
Was this remembered wrong - should it be a “best answer” question? If so, the best answer
clearly is d.
Reference: baby Fraser and Pare 1994, p.826
*
Answer: 49. ??? 50. True 51. ??? 52. True

1993
All of the following animals are involved in the life cycle of hydatid disease (Echinococcus
granulosum):
53. pigs
54. horses
55. dogs
56. sheep
57. chicken
*
Dogs are the most important definitive hosts. The intermediate hosts are usually sheep.
Other animals which may be involved in the life cycle: camels, wolves, deer, coyotes, foxes.
*
Answer: 53. False 54. False 55. True 56. True 57. False

1993
The following disease can demonstrate bi-directional shunting:
58. L transposition
59. D transposition
60. Pulmonary atresia with intact ventricular septum
61. PDA
62.. TAPVR
*
L transposition has corrected circulation, therefore a shunt is not required. There are
discordant atria and ventricles such that the left atrium provides blood to the morphologic right
ventricle which then provides blood to the systemic circulation. Since the right ventricle is not
designed to do this, this is where the patient eventually has problems.
D transposition usually requires bi-directional shunting to maintain oxygenation
Pulmonary atresia with intact ventricular septum: RV ----> VSD ----> LV with pulmonary
blood flow by a systemic collateral.
Patent ductus arteriosus initially exhibits L-->R shunt but pulmonary hypertension may
reverse to R-->L.
In TAPVR the pulmonary venous return is to systemic veins (Type I) or directly back into
the right atrium or coronary sinus (Type II). The would result in a perpetual right-sided loop.
Therefore, there is an obligate ASD with blood flow from the right atrium to the left atrium and
then onto systemic arterial circulation. There is a “figure of 8” or “snowman” configuration on
chest X-ray. Blood flow is unidirectional.
Reference: Dahnert 1993, pp. 382-383
*
Answer: 58. False 59. True 60. False 61. True??? 62. False

1993
Causes of high output cardiac failure include:
63. thyrotoxicosis
64. sickle cell anemia
65. aortic insufficiency
66. aortocaval fistula
67. pulmonary AVM
67a. Paget disease of bone
*
Causes of high output cardiac failure include: hyperthyroidism, anemia, pregnancy, AVF,
beriberi, and Paget disease of bone(rare).
Reference: Cecil 1988, pp. 215-216
*
Answer: 63. True 64. True 65. False 66. True 67. True 67a. True

1994
Alveolar microlithiasis is associated with:
68. hypercalcemia
69. familial occurrence
69a. No uptake on bone scan
69b. Tends to involve the right > left lung
69c. Patients are typically much more symptomatic than chest radiograph suggests
69d. Male = female incidence
*
Reference: baby Fraser and Pare 1994, pp. 859-860; Dahnert 1996 p. 339
*
Answer: 68. False 69. True (50% - restricted to siblings) 69a. False (intense uptake) 69b.
False (diffuse involvement of both lungs) 69c. False (striking xray, mild clinical findings) 69d.
True (1:1)

1994
Which of the following are causes of pulmonary edema?
70. left atrial myxoma
71. mitral stenosis
72. mitral regurgitation
73. aortic stenosis
*
Answer: 70. True 71. True 72. True 73. False

1993
Which of the following is associated with an isolated right pleural effusion?
74. pancreatitis
75. injury to the lower thoracic duct
76. injury to the upper thoracic duct
77. Boerhaave syndrome
78. Ruptured aortic aneurysm
*
(also, CHF); Dahnert 1996 p. 534
*
Answer: 74. False (usually left) 75. True 76. False 77. False 78. False

1993
Regarding RDS
79. A normal chest X-ray at 6 hours excludes the diagnosis
80. peak lung abnormality/opacity around 6 or 7 days
81. intravenous surfactant is useful
82. associated with pleural effusion
83. is associated with hypoinflation in the early stage
*
79. is a direct quote from Kirks, p. 589.
In mild to moderate RDS the peak is at 3-5 days.
Aerosolized surfactant is used successfully.
Pure RDS is not associated with pleural effusions.
Hypoinflation is due to alveolar collapse.
The important pathologic characteristics of RDS are alveolar collapse and dilatation of
terminal airways rather than hyaline membranes. The terminal airways can rupture leading to
pneumothorax, pneumomediastinum, and pulmonary interstitial emphysema.
Incidence of RDS in baby <1000 g = 65%
1000 g = 50 % (27 weeks)
1500 g = 16% (31 weeks)
2000 g = 5 % (34 weeks)
2500 g = 1% (36 weeks)
Males are almost twice as likely to get RDS
CXR findings: reticulogranular infiltrates with generalized hypoventilation and air
bronchograms, pneumothorax, and pneumomediastinum. Pulmonary interstitial emphysema can
be superimposed. Clearing is from the periphery and upper to lower.
*
Answer: 79. True 80. False 81. False 82. False 83. True

1993
Regarding miliary tuberculosis:
84. patient can have a negative PPD
85. usually a pulmonary focus cannot be identified
86. these patients respond more rapidly than those with other types of tuberculosis
87. The radiographic changes take 6 weeks to develop
*
Quoting directly from baby Fraser and Pare 1994, pp. 324-325, “Miliary tuberculosis is
manifested by numerous, widely and uniformly distributed pinpoint opacities. The interval
between dissemination and the development of roentgenographically discernible disease is
probably 6 weeks or more, during which time the foci are too small to permit identification. When
first visible, the opacities measure little more than 1 mm in diameter; in the absence of adequate
therapy, they may reach 3-5 mm before the patient dies. By this time, they may have become
almost confluent, presenting a “snowstorm” appearance. With appropriate treatment,
roentgenographic clearing may be extremely rapid, usually faster than in nonhematogenous
pulmonary tuberculosis and without residua.”
“Three additional features are worth noting; (1) few patients die from miliary tuberculosis
without demonstrable abnormality on chest roentgenogram; (2) although the source of
dissemination of tubercle bacilli sometimes is apparent clinically or roentgenographically, at least
in adults, in many cases the primary focus is not obvious, even at necropsy; and (3) although not
widely recognized, the adult respiratory distress syndrome is clearly an occasional complication.”
*
Also Dahnert 1996 p. 393-395

Answer: 84. True 85. True 86. True 87. True

1991
Which of the following can give cystic changes in the lung apices?
88. histiocytosis X (EG)
89. lymphangioleiomatosis (LAM)
90. tuberous sclerosis (TS)
*
Histiocytosis X (eosinophilic granuloma) typically is bilateral in the upper lobes - it tends
to spare the costophrenic angles. There is a reticular pattern with cystic spaces. 15% can have
spontaneous pneumothorax. Adenopathy and effusion are extremely rare.
In lymphangioleiomyomatosis (LAM), there is normal or increased lung capacity. There
is diffuse proliferation of immature smooth muscle. There are multiple cysts of varying sizes in a
widespread distribution (including the apices). There are pleural effusions (unilateral or bilateral
chylous) in 60-70% and 40% develop pneumothorax. There is a reticular pattern. Adenopathy is
not uncommonly seen on CT. Tuberous sclerosis in the chest can have an identical appearance
to LAM.
*
Answers: 88. True 89. True 90. True

1994, 1992, 1989

Regarding the diaphragmatic crura:
91. right is thicker than the left
92. the thoracic duct runs posterior
93. the azygous vein runs posterior
94. diaphragmatic lymph nodes are ventral
95. the adrenal is anterior
*
Diaphragmatic crural relationships: from Lee and Sagel 1989, pp. 417-420, including Figures
5C and 35A, B, and C
The diaphragmatic crura, right and left, take origin from the anterolateral surface of the
upper lumbar vertebral bodies. They unite anteriorly to form the median arcuate ligament
surrounding the aorta immediately cephalic to the celiac trunk. The crura continue upward, the
right dividing to enclose the esophagus within the esophageal hiatus.
Adrenals are "outside" or not encompassed by the crura. They are definitely lateral to
the crura, but, depending on a patient’s body fat and other factors may be either anterior or
posterior to the crus. Anterior is probably a better answer, since they are not in the retrocrural
space.
Right crus is larger and originates lower than the left crus.
Diaphragmatic LN's are ventral to the crura, the retrocrural LN's are dorsal.
The two crura enclose a retrocrural space anterior to the upper lumbar vertebral bodies.
The major component of this space is the aorta, but the thoracic duct and azygous/hemiazygous
veins also lie within it. Therefore, the azygous vein and thoracic duct are posterior (dorsal) to the
crura.
Three openings in the diaphragm allow passage of major structures from the thorax to
the abdomen. The IVC passes through he most anterior aperture, at the level of the 8th thoracic
vertebra. The esophagus and the vagus nerve traverse the middle opening at the 10th level.
The most posterior opening allows passage of the aorta, azygous vein, hemiazygous vein, and
the thoracic duct at the T12 level.
*
Answers: 91. True 92. True 93. True 94. True 95. True

1993
Which of the following are associated with Churg-Strauss syndrome?
96. asthma
97. extravascular granuloma
98. hypereosinophilia
99. adenopathy
*
Churg-Strauss syndrome is also known as allergic granulomatosis. It was initially
described as:
1) asthma
2) fever
3) necrotizing vasculitis
4) extravascular granuloma
5) eosinophilia
Some think that Churg-Strauss is a variant of Wegener’s granulomatosis or
Polyarteritis nodosa (this is the so-called “overlap syndrome.”) Pathologically, it affects
small to medium arteries and veins with transmural infiltrates with a prominence of eosinophils.
The chest X-ray shows:
1) nonsegmental airspace disease which is peripherally located (similar to
eosinophilic pneumonia) and transitory, or
2) multinodular disease without cavitation, or
3) miliary disease with adenopathy
4) any of the above can be associated with pleural effusions
The disease usually responds to steroids or cyclophosphamide.
Reference: baby Fraser and Pare 1994, pp. 1952-1953
*
Answer: 96. True 97. True 98. True 99. True

1992
Which of the following are associated with transient opacities?
100. simple eosinophilic pneumonia (Loeffler’s)
101. chronic eosinophilic pneumonia
102. angiitis granuloma
*
Loeffler’s disease is classically associated with transitory and migratory peripheral
consolidations.
Chronic eosinophilic pneumonia has nonsegmental consolidation in the lung periphery
which is persistent for days or weeks (as opposed to Loeffler’s).
Angiitis granuloma includes Wegener’s granulomatosis, allergic granulomatosis, and
polyarteritis nodosa. It is characterized by transient pulmonary shadows.
*
Answer: 100. True 101. False 102. True

1993, 1991
Regarding asbestos-related pleural plaques:
103. they are commonly seen in the region of the costophrenic angle
104. they span less than 4 ribs
105. they arise on the visceral pleura
106. they spare the apices
107. all can be seen on CXR
108. most occur above the 4th rib
109. most occur below the 6th rib
*
Pleural plaques occur on the parietal pleura and are most commonly located (bilaterally)
between the 7th and 10th ribs in the posterolateral midportion of the chest wall. They are also
commonly seen on the aponeurotic portion of the diaphragm, the mediastinum, and following the
rib contours. They typically spare the visceral pleura, apices, and costophrenic angles
Reference: Dahnert 1993, p. 290
*
Answer: 103. False 104. True??? 105. False 106. True 107. False 108. False
109. True

1991
Regarding lung anatomy:
110. the right middle lobe bronchus is the narrowest
111. the apical posterior segment is on the right
112. the anteromedial segment is on the right
113. the lingula has superior and inferior divisions
*
Answer: 110. True 111. False 112. False 113. True

1994, 1991 (and multiple other years)

Which of the following findings are common in untreated lymphoma?
114. hilar lymph nodes without mediastinal lymph nodes
115. solitary mediastinal lymph nodes
116. paravertebral mass
117. calcified hilar lymph nodes
118. pulmonary infiltrates
*
Calcified lymph nodes are only present after radiation treatment (and chemotherapy?).
15-40% of patients with nodular sclerosing Hodgkin’s disease have pulmonary infiltrates,
but only with mediastinal disease; invariably subsequent to hilar adenopathy.

REVIEW OF LYMPHOMA
Hodgkin’s disease
- characterized by presence of Reed-Sternberg cells
- bimodal age distribution:
a. teenage children and young adults - good prognosis
b. patients >40 y/o - poorer prognosis
Non-Hodgkin’s lymphoma
- two broad categories (in kids)
a. lymphoblastic lymphoma
- generally tumors of thymocytes
- typically arise in the anterior mediastinum
- may produce dyspnea, wheezing, or stridor
- pleural effusions are common
b. nonlymphoblastic lymphoma
- express B-cell surface markers
- almost 80% are intraabdominal

Intrathoracic involvement by lymphoma occurs more commonly with Hodgkin disease

than it does with non-Hodgkin lymphoma. Despite many similarities, there are some
characteristic differences between the radiographic presentation of the two.
The most important distinction between the two diseases is their mode of spread.
Hodgkin disease spreads by extension to contiguous nodal chains, whereas non-Hodgkin
lymphoma often skips adjacent nodes. The tendency for contiguity may explain the
observation that in untreated patients with Hodgkin disease, parenchymal pulmonary
involvement nearly always occurs in the presence of mediastinal lymphadenopathy.
Isolated pulmonary involvement is considerably more frequent in patients with non-
Hodgkin lymphoma. Patients with Hodgkin lymphoma and treated nodal disease may
have a recurrence which is confined to the lung.
The most frequently involved nodal groups are in the anterior mediastinum and
paratracheal regions. Posterior mediastinal involvement is decidedly uncommon for either type
of lymphoma. When present it suggests the likelihood of retroperitoneal involvement.
CT may demonstrate low-density lymph nodes, which indicates cystic necrosis. Low-
density lymphadenopathy may occur in either form of lymphoma and may persist after successful
treatment.
Parenchymal involvement in lymphoma has a variable appearance. The patterns are
nonspecific, however, and include focal consolidation, ill-defined parenchymal nodules which may
cavitate, and widespread reticular-nodular opacities.
*
Answer: 114. False 115. True 116. False 117. False 118. False
1991
In a patient with AIDS and a unilateral hilar mass, which of the following are likely diagnostic
considerations?
119. lymphoma
120. AIDS-related complex
121. Mycobacterium tuberculosis (not MAI)
122. Kaposi’s sarcoma
*
Answer: 119. True 120. False 121. True 122. True

Select the single best answer:

1995, 1992
1. All of the following are more prominent in the upper lobes than the lower lobes except:
a. adult onset cystic fibrosis
b. alpha-1-antitrypsin deficiency
c. centrilobular emphysema
d. Langerhan’s cell histiocytosis (eosinophilic granuloma)
e. silicosis
f. lymphangioleiomatosis
*
With alpha-1-antitrypsin deficiency there is severe panacinar emphysema with a basilar
predominance.
Centrilobular emphysema has tendency for upper lobes.
Histiocytosis X is usually bilaterally symmetric, more prominent in the upper lobes, and
spares the costophrenic angles.
*
Answer: b. alpha-1-antitrypsin deficiency (? F too)

1995
2. A 52 y/o male presents with fever and cough. He has patchy lung infiltrates and laboratory
tests are positive for anti-nuclear cytoplasmic antibodies (ANCA-1). Which of the following is the
most likely diagnosis?
a. Aspergillosis
b. Wegener’s granulomatosis
c. lymphangioleiomatosis
d. lymphomatoid granulomatosis
e. Goodpasture’s disease

Answer: b

1993
3. Exposure to silicic acid containing magnesium, iron, calcium, and sodium results in:
a. coal miner’s pneumoconiosis
b. asbestosis
c. silicosis
d. Kaolin lung (China clay lung/pneumoconiosis)
*
Exposure to large amounts of carbon-containing inorganic material gives coal miner’s
pneumoconiosis (CWP). The two major morphologic findings are the coal macule (1-5 mm
diameter and black) and progressive massive fibrosis (PMF) (10 mm diameter or greater).
Findings are scattered but tend to be more prominent in the upper lung zones. CXR reveals a
nodular pattern (1-5 mm) - the pattern is difficult to distinguish from silicosis. If PMF has not yet
developed, removal of patient from dust-laden environment usually stops the progression of the
disease.
Silicosis is due to exposure to silicon dioxide. Silica crystals are needle-shaped and
birefringent. Silicotic nodules range from 1-10 mm in diameter - larger nodules are felt to
represent progressive massive fibrosis (PMF). Nodules are usually more prominent in the upper
lobes and perihilar regions. Hilar lymph node prominence is common (egg-shell calcification can
be seen. It can been seen in other diseases (sarcoidosis) but is almost pathognomonic for
silicosis.) Caplan’s syndrome is the superimposition of necrobiotic rheumatoid nodules on a
silicotic background (more commonly seen in CWP). Silicosis predisposes to TB. The disease
often progresses to PMF even after removal from environment.
A less common pattern is silicoproteinosis which may look like pulmonary alveolar
proteinosis (usually in persons exposed to particularly high concentrations of silica).
Kaolin lung is due to exposure to kaolin, which is a fine white clay used in the
manufacture of porcelain = Al2Si2O5(OH)4. Although uncommon, when pathology is present is
resembles CWP.
Asbestos exposure is the generic term for exposure to any of the number of fibrous
silicates - serpentines (curved fibers - chrysolite*) and amphiboles (straight fibers - including
amosite*, arthophyllite, tremolite*, actinolite, and crocidolite*). (* = main ones responsible for
pleuropulmonary disease).
Plaques in asbestos-related pleural disease are on parietal pleura (usually overlying ribs
7 – 10 and on the domes of the diaphragm [look for calcification]). The visceral pleura may
contain areas of pleural fibrosis which may serve as a nidus for rounded atelectasis. Pleural
effusions are common and mesothelioma is a known complication of asbestos exposure.
Asbestosis can be defined as a pneumoconiosis characterized by more or less diffuse
parenchymal interstitial fibrosis secondary to the inhalation of asbestos fibers. Disease is first
noted as a fine reticular pattern at the bases. There is a known association with lung cancer,
especially in smokers (synergistic effect).
Talc may give a similar appearance to that caused by asbestos.
Reference: Freundlich pp. 289-303; Fraser and Pare pp. 707-729
*
Answer: b. asbestosis I think it is c. silicosis

1995
4. Which of the following cancers is least likely to metastasize to the chest?
a. osteosarcoma
b. renal cell carcinoma
c. prostate
d. melanoma
*
Answer: c

1992
5. Which one of the following is not typical of rheumatoid arthritis in the chest?
a. hilar adenopathy
b. pleural effusion
c. lower lobe interstitial disease
d. cavitary nodules
e. honeycombing
*
Pleural abnormality is the most common manifestation of RA in the thorax. The pleural
fluid is an exudate. In early stages one can see punctate or nodular interstitial lung disease. In
late stages there are medium to coarse reticular changes often more prominent at the bases.
The most advanced stage has honeycombing. Necrobiotic nodules, which are identical to the
subcutaneous rheumatoid nodules, often cavitate.
*
Answer: a. hilar adenopathy

1992
6. Unilateral left rib notching is seen in all of the following except:
a. right Blalock-Taussig shunt
b. coarctation with aberrant right subclavian
c. left forearm AVM
d. left brachial artery thrombosis
*
A Blalock-Taussig shunt is an end-to-side anastomosis of the subclavian artery to the
pulmonary artery, performed opposite to the side of the aortic arch. The object is to increase
pulmonary flow to treat causes of obstruction to pulmonary flow such as pulmonary artery atresia,
TOF, etc. Rib notching, if it occurs, should be on the same side as the shunt.
Chest wall and pulmonary AVMs can cause unilateral rib notching.
*
Answer: a. right Blalock-Taussig shunt

1993 c PreTest
7. Bulky mediastinal adenopathy is MOST characteristic of which one of the following subtypes of
lung cancer?
a. adenocarcinoma
b. squamous cell carcinoma
c. small-cell carcinoma
d. mucoepidermoid carcinoma
e. pulmonary blastoma
*
Bulky mediastinal adenopathy is common in sarcoidosis, lymphoma, granulomatous
disease, and intrathoracic or extrathoracic metastatic disease. In patients with lung cancer,
massive mediastinal nodal enlargement is characteristic of the small-cell subtype. Often, the
primary pulmonary lesion is so small that it is not visible, even by CT.
Staging of lung carcinoma:
T1 = mass less than 3 cm in diameter and not within 2 cm of carina
T2 = lesion that extends within 2 cm of the carina or a lesion with invasion limited to the
visceral pleura
T3 = invasion of nonvital structures such as pericardium, etc.
T4 = invasion a vital structures such as heart, aorta, trachea, and esophagus
(unresectable) “Malignant” pleural effusion, even if not associated with any other
findings which would suggest unresectable status, is unresectable.

N0 = absence of lymph node involvement

N1 = metastases to the ipsilateral hilum
N2 = ipsilateral mediastinal and paratracheal nodal involvement
N3 = involvement of ipsilateral scalene or supraclavicular nodes, or contralateral nodal
disease (unresectable)

M0 = no metastases
M1 = metastases (unresectable)

Stages 0, I, II, and IIIA are resectable. Stage IIIB (T4, any N, M0 or any T, N3, M0) or stage IV
(any T, any N, M1) disease are usually unresectable.
*
Answer: c. small-cell carcinoma

1992
8. Which of the following metastases becomes a benign nodule after chemotherapy?
a. prostate
b. kidney
c. testes
d. breast
e. colon
*
Answer: c. testes
1992
9. Which of the following is the cell that regenerates following alveolar damage?
a. Type I pneumocyte
b. Type II pneumocyte
c. Type III pneumocyte
d. macrophage
*
Type I pneumocytes line most of the alveolar surface but appear to lack the capacity to
regenerate.
Type II pneumocytes, although they are only 8% of the cells, proliferate abundantly after
diffuse alveolar injury caused by oxygen or various fumes. They also manufacture, transport, and
secrete the surfactant; earliest production is 1t 18 weeks, and in amniotic fluid by 22 weeks.
*
Answer: b. Type II pneumocyte

1994, 1992
10. Which of the following causes an exudative pleural effusion?
a. neoplasm
b. cirrhosis
c. cardiogenic pulmonary edema
d. non-cardiogenic pulmonary edema
e. nephrotic syndrome/CRF
*
Transudates (protein 1.5-2.5 g/dl) = CHF, constrictive pericarditis, cirrhosis with ascites,
nephrotic syndrome, overhydration, glomerulonephritis, peritoneal dialysis, hypothyroidism,
chylous
Exudates (protein > 3 g/dl) = infection, cancer, PE, abdominal disease (pancreatitis,
Boerhaave syndrome, subphrenic abscess, abdominal tumor with ascites, Meig’s syndrome,
endometriosis, bile fistula, collagen vascular disease, trauma, Sarcoid, XRT, pneumonitis
*
Answer: a. neoplasm

1995, 1992
11. In a 34 y/o asymptomatic construction worker a routine CXR reveals unilateral pleural
effusion which resolves on its own in 6 weeks. Six months later the patient presents with a focal
upper lobe lung opacity. What is the most likely cause?
a. lung cancer
b. PE
c. TB
d. lymphoma
e. viral infection
f. asbestosis
*
The incidence of pulmonary tuberculosis has increased in recent years for two reasons:
AIDS and widespread urban decay with inadequate health care.
The primary infection may be acquired during childhood or as an adult. Radiographically,
the most common feature is hilar or mediastinal adenopathy. A focal pneumonitis, which does
not have a lobar predilection, may occur and is indistinguishable from typical bacterial
pneumonia. Pleural effusions are present in about 25% of cases.
In an immunocompetent host, reactivation tuberculosis results from endogenous disease
and commonly involves the posterior portions of the upper lobes and superior segments of the
lower lobes (anterior UL think Histo). Cavitation occurs frequently and is a strong indicator of
active disease.
Pleural effusion caused by tuberculosis may occur even in the absence of other
intrathoracic disease. Empyema necessitans is the term given to pleural tuberculosis which
extends into the subcutaneous tissue to form an abscess. A therapeutically resistant
bronchopulmonary fistula may result.
AIDS patients who develop pulmonary reactivation tuberculosis have radiographic
findings similar to primary tuberculosis, probably because of an impaired or absent
hypersensitivity reaction, and do not usually develop cavitary disease.
*
Answer: c. TB

1995
12. Which of the following is the most common radiographic presentation of bronchioloalveolar
carcinoma?
a. solitary pulmonary nodule
b. multiple pulmonary nodule
c. segmental consolidation
d. mediastinal lymphadenopathy
e. bilateral multifocal infiltrates
*
Answer: a. solitary pulmonary nodule

1995
13. A 60 y/o female presents with yellow finger nails and bilateral lower extremity lymphedema.
Which of the following would be the most likely finding on chest radiograph?
a. pleural effusion
b. multiple pulmonary nodules
c. bilateral hilar lymphadenopathy
d. cavitary mass
*
Answer: a. pleural effusion (probably chylous from lymphatic disease)

1995
14. MR is superior to CT for evaluation of which of the following?
a. non-small-cell carcinoma of the lung causing bronchial obstruction
b. bronchial carcinoid
c. small cell carcinoma of the lung
d. superior sulcus tumor
e. bronchioloalveolar cell carcinoma
*
Answer: d. superior sulcus tumor

1995
15. PCP is not usually seen until the CD4 count falls to what level?
a. 200 (units?)
b. 500
c. 1000
d. 2000
*
Answer: a Dahnert 1996 p. 337-338

1995
16. Where does the azygous vein insert?
a. on the anterior aspect of the SVC below the right mainstem bronchus
b. on the posterior aspect of the SVC below the right mainstem bronchus
c. on the posterior aspect of the SVC above the right mainstem bronchus
d. on the anterior aspect of the SVC above the right mainstem bronchus
*
Answer: c (Netter atlas plate 195)

1993
17. Which of the following lesions can result in peripheral oxygen desaturation?
a. pulmonary AVM
b. pulmonary varix
c. intralobar sequestration
d. Scimitar syndrome
*
Pulmonary AVM effectively bypasses the lung - the shunt is from the pulmonary artery to
a pulmonary vein (R-->L shunt). This will result in decreased oxygen saturation. Since there is
no increased flow the heart size will be normal. Cyanosis occurs in 25-50%.
Pulmonary varix is abnormal tortuosity and dilatation of a pulmonary vein (usually
central). There is no shunt involved so there is no cyanosis.
In intralobar sequestration, blood supply is via a systemic artery and drainage is via a
pulmonary vein, so this is a L--->L shunt and there is no cyanosis. Extralobar sequestration is
supplied and drained by systemic circulation so there is a L-->R shunt (aortic supply arises near
the diaphragm and runs in the inferior pulmonary ligament). Sequestrations are typically in the
lower left chest and have no normal connection with the bronchial tree or pulmonary arteries.
Congenital adenomatoid malformation is supplied by and drained by pulmonary
circulation; therefore it acts like a pulmonary AVM and gives cyanosis. The majority of patients
present in the neonatal period with increasing respiratory distress. It is space occupying, shifting
the mediastinum to the contralateral side.
Scimitar syndrome consists of hypoplasia of the right lung and right pulmonary artery.
The hypogenetic lung is supplied by systemic and pulmonary (???) arteries and drains via
anomalous pulmonary veins to the IVC. Therefore, this is also a L---->R shunt. It can be
associated with ASD, coarctation of the aorta, PDA, or tetralogy of Fallot, which-may give
cyanosis.
References: Dahnert 1993, p. 309, 320, 323; Fraser and Pare 1994, p. 258, 260, 277
*
Answer: a. pulmonary AVM

1994
18. Which of the following maneuvers best distends the azygous vein?
a. upright position with Valsalva maneuver
b. supine position with Valsalva maneuver
c. supine position with Mueller maneuver
d. upright position with Mueller maneuver
*
Azygous vein "maneuvers" - Felson p 237
- Valsalva maneuver: increase in the intrathoracic pressure and decrease in cardiac
output principally secondary to lowering venous return to the heart.
- Mueller maneuver: rapid forced inspiration with diminished intrathoracic pressure and
increased venous return.
The normal azygous vein arch silhouette always shrinks with upright positioning or
Valsalva-equivalent maneuvers.
*
Answer: c. supine position with Mueller maneuver

1994, 1993
19. Plasma oncotic pressure is:
a. 5 mm of Hg
b. 10 mm of Hg
c. 15 mm of Hg
d. 20 mm of Hg
e. 25 mm of Hg
*
Answer: e. 25 mm of Hg

1995
20. Which one of the following is false regarding pulmonary emboli?
a. rarely arise from the upper extremities
b. central emboli commonly result in pulmonary infarction
c. the clinical triad of chest pain, hemoptysis, and cough is present in a majority of patients with
angiographically proven emboli
d. ???
*
Answer: ???

1995
21. A 40 y/o female is scheduled for tricuspid (really!!)and pulmonic valve replacement. What is
the most likely diagnosis?
a. Pulmonary carcinoid
b. gastrointestinal carcinoid with metastases to the liver
c. rheumatic heart disease
d. ???
(IVDA was not a choice)
*
Answer: b. GI carcinoid with liver mets. She has right heart EFE secondary to carcinoid
syndrome. The left side is protected because the lung detoxifies the tumor products before they
see the left heart.

1993
22. Patients with severe autonomic dysreflexia may experience all the following except:
a. tachycardia
b. sweating
c. severe paroxysmal hypertension
d. anxiety
e. piloerection
*
Associations:
Loss of function: postural hypotension with faintness or syncope, anhydrosis,
hypothermia, bladder atony, obstipation, dry mouth, dry eyes, blurring of vision from lack of
pupillary and ciliary regulation, sexual impotence in males.
Hyperfunction: episodic hypertension, diarrhea, hyperhydrosis, and either tachycardia or
bradycardia
Severe paroxysmal hypertension may be due to pheochromocytoma.
Reference: Harrison’s p. 2105
*
Answer: d. anxiety

1993, 1988
23. The relationship between systemic and pulmonary vascular resistance is best characterized
by:
a. systemic greater than pulmonary by ratio 10 to 1
b. systemic greater than pulmonary by ratio of 100 to 1
c. pulmonary greater than systemic by ratio of 10 to 1
d. pulmonary greater than systemic by ratio of 100 to 1
e. equal values
*
Resistance = pressure/flow but pulmonary flow = systemic flow so:

Resistancesystemic/Resistancepulmonary = Pressuresystemic/Pressurepulmonary

= 100/10 = 10
(approximately - remember, use mean values for pressure)
*
Answer: a. systemic greater than pulmonary by ratio of 10 to 1

1994
24. A patient who has rheumatoid arthritis is also on penicillin. What is the most likely cause of
obstructive pattern on PFT's and hyperinflation of the lungs on CXR?
a. bronchocentric granulomatosis
b. bronchiolitis obliterans with organizing pneumonia
c. rheumatoid lung disease
d. usual interstitial pneumonia
*
Rheumatoid patient on penicillin develops hyperinflation on CXR and obstructive PFT's
- Bronchocentric granulomatosis: type I hypersensitivity reaction, obstructive pattern
secondary to small airway narrowing by bronchiole wall granulomas. This is one of the
members in the group “pulmonary angiitis with granulomatosis.”
- Rheumatoid lung and UIP both give restrictive pattern and diminished volumes.
*
Answer: a. bronchocentric granulomatosis

1994
25. What is the etiology of silo filler’s disease?
a. polymicrosporia
b. oxides of nitrogen
c. oxygen
d. thermoactinomyecitis
e. silicon dioxide
*
Silo-filler’s disease is caused by nitrogen dioxide fumes emitted from fresh silage.
Typically, there is a two-part reaction. The initial phase, which occurs soon after exposure, is
characterized by cough and dyspnea, often accompanied by pulmonary edema. After a recovery
period of two to three weeks, the symptoms recur and radiographs will often reveal a fine nodular
pattern corresponding to the development of bronchiolitis obliterans.
*
Answer: b. oxides of nitrogen (nitrogen dioxide)

1994
26. A young patient with recent history of IV drug abuse presents with thrombophlebitis, pleuritic
chest pain, high fever lasting for three weeks and multiple pulmonary infiltrates. What is the most
likely cause of this patient’s condition?
a. staphylococcal pneumonia
b. acute bacterial endocarditis
c. Pneumocystis
d. TB
*
Answer: b

1994
27. Regarding the combination of AIDS and TB, which one of the following is false?
a. may present with adenopathy alone
b. miliary pattern is common
c. resistant strains in institutionalized patients is common
d. there is a lack of inflammatory cells in pathologic specimens
e. patients respond to antituberculous medications with the same level of efficacy as
nonimmunocompromised patients
*
AIDS with TB, Freundlich and Bragg, p 495
MTB and MAC (avium complex) are commonest, but cheloni, gordoni, kansasi and
xenopi occur relatively commonly. Most AIDS TB is due to reactivation with heterogeneous
reticulonodular densities with or without cavitation in upper lobe apical and posterior segments
and superior segments of lower lobes. In later stages of HIV, disseminated TB occurs as diffuse,
symmetric coarse reticulonodular infiltrates. The pattern is only occasionally miliary and in this
stage rarely cavitary. Hilar and mediastinal adenopathy is seen in approximately 80% of AIDS
patients - unilateral or bilateral. Pleural fluid is seen in 10-20%. Responds well to
antituberculous medications, ??? if it responds to the same degree as non-immunocompromised
patients.
*
Answer: b. miliary pattern is common

1994
28. Pulmonary hypertension is seen with all of the following except:
a. Eisenmenger syndrome
b. Pulmonary AVM
c. Mitral valve stenosis
d. Hypoxia
*
Pulmonary hypertension is seen with Eisenmenger’s physiology, mitral valvular stenosis (venous
hypertension), and hypoxia.
However, Pulmonary AVM is a R to L shunt with no pulmonary hypertension. (can patient
have pulmonary hypertension secondary to hypoxia from shunt???)
*
Answer: b. Pulmonary AVM

1994
29. A patient with an ASD is most likely to have an enlarged:
a. left atrium
b. left ventricle
c. pulmonary artery
d. aorta
*
Answer: c. pulmonary artery. LA is small because blood shunted to right.

1994
30. The most common thing associated with an enlarged left atrium is:
a. right atrial myxoma
b. atrial fibrillation
c. atrial septal defect
d. primary pulmonary hypertension
e. aortic stenosis
*
Most common thing associated with enlarged left atrium is atrial fibrillation.
*
Answer: b. atrial fibrillation

1994
31. How much fluid is normally within the normal pleural space?
a. 0 ml
b. 5 ml
c. 10 ml
d. 15 ml
e. 20 ml
*
Amount of fluid in each pleural space: normally 1-5 cc, but normal may be as high as 15-
20cc. (from Mayo Clin Proc. 47: 493-506, 1972.)
*
Answer: b. 5 ml
1994, 1992
32. Rounded atelectasis is most commonly associated with a patient who has had recent:
a. pneumonia
b. pleural effusion
c. pulmonary embolism
d. pneumothorax
e. resolving subsegmental atelectasis
*
The pathogenesis is effusion, often secondary to asbestos exposure, giving compressive
atelectasis and parenchymal adherence to the parietal pleura. With fluid resolution, central lung
reexpands but peripheral lung remains atelectatic.
*
Answer: b. pleural effusion

Education:
I can prove at any time that my education tried to make another person out of me than the one I
became. It is for the harm, therefore, that my educators could have done me in accordance with
their intentions that I reproach them; I demand from their hands the person I now am, and since
they cannot give him to me, I make of my reproach and laughter a drumbeat sounding in the world
beyond.
Franz Kafka (1883-1924), German novelist, short-story writer. The Diaries of Franz Kafka 1910-
1923 (ed. by Max Brod, 1948), 1910 entry.
1993
33. A patient demonstrates hepatomegaly, lower extremity swelling, normal size heart on CXR
and a normal pericardium on MR. The LVEF is normal. The most likely diagnosis is:
a. constrictive pericarditis
b. amyloid heart disease
c. IHSS
d. Pompe’s disease
*
The case describes right-sided heart failure with normal LVEF (however, LV function may
be abnormal) and normal pericardium on MR. Therefore, amyloid is most likely.
Pompe’s disease is similar to endocardial fibroelastosis by imaging. It is a glycogen
storage disease which usually results in death in the first year of life secondary to conduction
abnormalities. There is massive cardiomegaly with CHF.
Reference: Dahnert 1993, p. 399
*
Answer: b. amyloid heart disease

1993
34. Causes of Kerley’s “B” lines on CXR:
a. atrial myxoma
b. supradiaphragmatic TAPVR
c. aortic stenosis
d. scimitar syndrome
e. VSD
f. mitral valve prolapse
*
Causes of Kerley’s “B” lines include hydrostatic pulmonary edema, lymphangitic
carcinomatosis, and viral and Mycoplasma pneumonia.
Left atrial myxoma can cause obstruction to pulmonary venous return and therefore
hydrostatic pulmonary edema.
Supradiaphragmatic TAPVR does not have obstruction.
Scimitar acts like an AVF.
*
Answer: a. atrial myxoma

1994
35. Which of the following is the most common mediastinal mass in a child?
a. teratoma
b. neuroblastoma
c. ganglioneuroma
d. neuroma
e. bronchogenic cyst
*
Mediastinal masses in children: from Kirks p. 670.
Mediastinal mass frequency breaks down as follows: anterior (30%), middle (30%) and
posterior (40%). The most common mediastinal masses of childhood are of neural origin -
accounting for (95%) of the posterior mediastinal tumors. Neuroblastomas are much more
common than ganglioneuroblastoma or ganglioneuroma.
*
Answer: b. neuroblastoma

You can’t be a Real Country unless you have A BEER and an airline¾it helps if you have some
kind of a football team, or some nuclear weapons, but at the very least you need a BEER.
Frank Zappa (1940-93), U.S. rock musician. The Real Frank Zappa Book, Ch. 12 (1989; written
with Peter Occhiogrosso).

1993
36. In a one week old neonate with coarctation of the aorta, which of the following is least likely to
be true?
a. rib notching
b. inconspicuous ascending aorta
c. heart failure
*
Rib notching rarely occurs before the age of 7 y/o.
*
Answer: a. rib notching

1993
37. A middle-aged man suffers an acute MI and several days later develops a systolic murmur
and CHF. The most likely diagnosis is:
a. Flit’s (?) syndrome
b. cardiac rupture
c. papillary muscle rupture
d. occlusion of the coronary artery
e. rupture of the sinus of Valsalva
*
Papillary muscle rupture usually occurs about 3 days S/P MI and presents with a
holosystolic murmur of MR and CHF. Cardiac rupture occurs about seven days post MI and
presents with hypotension. (and a code!)
*
Answer: c. papillary muscle rupture

1994
38. Which term below best describes the terminal bronchial subunit?
a. acinus
b. primary lobule
c. secondary lobule
d. segment
e. alveolus
*
The acinus can be defined as that portion of the lung distal to a terminal bronchiole, comprising
the respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli.
Reference: baby Fraser and Pare 1994, p. 13
*
Answer: a. acinus

1993
39. The most common location for a thoracic chemodectoma (paraganglioma) is in:
a. thoracic inlet
b. posterior mediastinum
c. adjacent to the aortic arch
d. near the trachea
*
Answer: b. posterior mediastinum (WTM, Jr.)

1993
40. Lymphomatoid granulomatosis of the lung is also associated with involvement of which other
organ?
a. spleen
b. lymph nodes
c. bone marrow
d. CNS
*
Lymphomatoid granulomatosis is Type III of 5 types of pulmonary angiitis with
granulomatosis (see question 16 for more). It is an angiocentric and angiodestructive
lymphoreticular and granulomatous disease involving primarily the lungs. Lung nodules are the
most common finding - they are seen in 80% (20% cavitate). It may also involve the CNS, skin,
and kidney. Skin lesions are the most common extrapulmonary manifestation (40-50%) followed
by CNS involvement (20-30%). Overall, there is a 60% mortality with CNS and liver involvement
giving a grave prognosis. 10-20% develop lymphoma.
Reference: AFIP notes, Rosado-de-Christenson, pp. F-18 to F-20, July, 1994
*
Answer: d. CNS

1991
41. Which of the following is the most likely cause of a 47 y/o woman with new onset dyspnea?
a. ASD with Eisenmenger’s
b. mitral stenosis
c. Primary pulmonary arterial hypertension
*
Answers: b (classic question however is new onset of SOB in a pregnant women in her second
or third pregnancy – rheumatic heart disease).

1991
42. Diffuse infiltrates are NOT likely with?
a. MAI
b. Kaposi’s sarcoma
c. lymphoma
*
Answer: b. Kaposi’s sarcoma

1991
43. Radon is responsible for about what percentage of all lung cancers?
a. 1%
b. 5%
c. 10%
d. 20%
e. 33%
*
Answer: c. 10%

1995
44. Question on rounded pneumonia
organism that causes it - single best answer

Reference: Dahnert 1996 p. 379, 384

Answer: Best answer pneumococcus; others include other Strep., H. flu.

The following are matching questions:

1995
Matching regarding calcium in pulmonary nodules:
1. popcorn calcification
2. concentric lamilated calcification

a. Histoplasmoma
b. hamartoma
c. carcinoid
d. adenocarcinoma of the lung
*
Answer: 1. b 2. a

1995
Regarding staging of lung carcinoma:
3. A 2 cm mass in a lobar bronchus which causes lobar consolidation (no evidence of
adenopathy or distant metastases)
4. A mass within 2 cm of the mainstem bronchus with no evidence of lymph node or distant
metastases
5. A peripheral mass in the right lung with right hilar adenopathy and subcarinal adenopathy but
no evidence of distant metastases

a. Stage I
b. Stage II
c. Stage IIIa
d. Stage IIIb
e. Stage IV
*
Reference: Baby Fraser and Pare p. 476
*
Answer: 3. a 4. c 5. c

1993
6. Atrioventricular septum
7. Tricuspid valve
8. Parietal band

a. coronary sinus
b. moderator band
c. mitral valve
d. right coronary cusp of the aortic valve
e. crista supraventricularis
*
 In the right ventricle, the demarcation between posteroinferior inflow portion and
anterosuperior outflow portion is by prominent muscular bands forming an almost circular orifice:
1. parietal band
2. crista supraventricularis
3. septomarginal trabeculae (= septal band + moderator band)
Reference: Dahnert 1993, p. 373
*
Answers: 6. a 7. d??? 8. e

1993
9. Scimitar syndrome
10. tracheal bronchus
11. mesenchymal hamartoma of the lung
12. congenital lobar emphysema

a. Hyperinflation of the right lung

b. Hypoinflation of the right lung
c. Right upper lobe infiltrate
d. Right upper lobe hyperinflation
e. Right lower lobe hyperinflation
*
Scimitar syndrome is also known as the hypogenetic right lung syndrome. There is
hypoplasia of the right lung and right pulmonary artery with partial anomalous pulmonary venous
return to the systemic vasculature
Abnormal origin of the lobar bronchi, the commonest being tracheal origin of the RUL
bronchus, creates the so-called tracheal or pre-eparterial bronchus. Tracheal bronchus is usually
on the right and causes overinflation of the right upper lobe. Pig bronchus is a supernumerary
airway that usually arises from the inferior wall of the right main or intermediate bronchus (Ref:
Baby F&P p. 268)
Hamartoma of the lung may be endobronchial in 10% causing postobstructive
atelectasis.
Congenital lobar emphysema usually occurs in the LUL (42%), then RML (32%) and
finally the RUL (20%).
*
Answers: 9. b 10. d 11. c 12. d

1994
13. fibrosis in different stages of healing
14. uniform fibrosis

a. UIP
b. DIP
c. acute interstitial fibrosis (Hamman-Rich)
*
Pathology of DIP - UIP: Freundlich and Bragg p 445, and Dahnert
Usual Interstitial Pneumonia (IPF, Hamman-Rich): proteinaceous exudate into the
interstitium, hyaline membranes in the alveoli and necrosis of the alveolar lining. Inflammation
with fibrosis. Poor prognosis, death within 4-5 years.
Desquamative Interstitial Pneumonia: Inflammation without fibrosis. Alveoli lined with
cuboidal cells, accumulation of monos and nucs, preservation of lung architecture with minimal
fibrosis. Better prognosis.
Hamman-Rich: progressive form of UIP with death inside a year.
*
Answers: 13. ??? 14. ???

1991 (actually T/F question)

Regarding thymoma:
15. red cell aplasia
16. hypogammaglobulinemia
17. Eaton-Lambert
18. carcinoid
*
Thymoma is an epithelial neoplasm of the thymus. It is the most common primary thymic
tumor and the most common primary tumor of the anterior superior mediastinum. It has slow
growth and usually benign behavior. Don’t use the terms “benign” or “malignant” with
thymoma - use “encapsulated” or “invasive.” 40% have cysts macroscopically and almost
100% microscopically. 30% have focal necrosis and hemorrhage. Calcification appears in
approximately 10%.
The following are parathymic syndromes/associations:
1. myasthenia gravis - 20% of patients with myasthenia gravis have thymoma;
40% of patients with thymoma have myasthenia gravis
2. pure red cell aplasia - rare condition, but 50% have thymoma
3. hypogammaglobulinemia
4. collagen vascular disease

Eaton-Lambert is a paraneoplastic syndrome associated with small cell cancer of the

lung
*
Answers: 15. True 16. True 17. False 18. False

1993
19. Chronic eosinophilic pneumonia
20. Loeffler’s syndrome
21. Tropical eosinophilia
23. Polyarteritis nodosa

a. transient migratory infiltrate

b. peripheral infiltrates
c. miliary nodules
*
The above entities can be grouped together as eosinophilic lung disease. Eosinophilic
lung disease is the prototype for conditions which predominately affect the peripheral lung zones.
It may be idiopathic (e.g., chronic eosinophilic pneumonia) or may be associated with drugs,
parasitic infection, or hypersensitivity. It may also result from a vasculitic condition, such as the
Churg-Strauss syndrome (allergic granulomatosis), which consists of the triad of asthma,
eosinophilia, and a systemic vasculitis. (Amiodarone, an antiarrhythmic medication with
substantial pulmonary toxicity, also causes peripheral lung opacities in the absence of blood or
tissue eosinophilia, for reasons which are not understood.) Fraser and Pare cover this on pages
1251-1298. They can be divided into three categories:

Idiopathic
- transient, benign = Loeffler’s
- prolonged, slightly more aggressive = chronic eosinophilic pneumonia
- prolonged, aggressive = hypereosinophilic syndrome
Eosinophilic Lung
- Drug = nitrofurantoin, PCN, etc.
- Specific Etiology
- Parasite induced = tropical eosinophilia
- Fungus = ABPA
Eosinophilic lung associated with connective tissue disease or vasculitis:
- RA
- Wegener’s (Types I (classic) and II (limited) of 5 Types of Pulmonary Angiitis
with Granulomatosis - Type III = lymphomatoid granulomatosis, Type IV =
necrotizing granulomatosis, Type V = bronchocentric granulomatosis)
 - Churg-Strauss
- PAN
- Sarcoid

All of the above can have identical CXR. However:

Loeffler’s is the most benign of the conditions, it is transitory in nature, and the abnormal
CXR often resolves within 2 weeks. Single or multifocal homogenous areas of consolidation are
seen in a peripheral, nonsegmental location parallel to the chest wall (“fleeting infiltrates”). It is
not associated with cavitation, adenopathy, pleural effusions, or cardiomegaly.
Chronic eosinophilic pneumonia has predilection for females and has a more protracted
course. Unusual association with therapeutic desensitization is seen. The airspace fill with
inflammatory cells containing lots of eosinophils. Diagnosis can be made with BAL. The CXR
findings can be identical to Loeffler’s disease but tend to persist for weeks. Patients are given
steroids.
Tropical eosinophilia is due to infection with filariasis (Wuchereria bancrofti). Patients
present with asthma. Although the CXR can look like Loeffler’s it can also have a miliary
pattern with adenopathy, splenomegaly, chronic cough, and nighttime asthma. This is
called Weingarten’s syndrome.
Polyarteritis nodosum is due to vasculitis involving the small to medium muscular arteries
of multiple organs. The most common CXR findings are cardiomegaly, CHF, pericardial or
pleural effusions - all as a consequence of renal involvement. Fraser and Pare states that
the most characteristic CXR finding is patchy consolidation of nonsegmental distribution
identical to Loeffler’s. Angiograms demonstrating multiple aneurysms of arteries is diagnostic.
*
Answers: 19. b 20. a 21. c 22. a

1993
23. cystic fibrosis
24. Pulmonary gangrene

a. Proteus and E. coli

b. Strep. pneumoniae and Klebsiella
c. Staph. aureus and Pseudomonas aeruginosa
d. mycobacterium tuberculosis and Hazori
*
With cystic fibrosis, there is recurrent focal pneumonitis.
*
Answer: 23. c 24. b

The physician can bury his mistakes, but the architect can only advise his clients to plant vines.
Frank Lloyd Wright (1869-1959), U.S. architect. New York Times Magazine (4 Oct. 1953).

1992
25. solitary cavitary mass
26. multiple small nodules
27. central bronchiectasis

a. aspergillus fumigatus
b. histoplasmosis
c. nocardia
d. Cryptococcus
*
Aspergillus fumigatus has central bronchiectasis as its sine qua non. There is
irreversible dilatation of the inner 2/3 of the bronchial tree. High resolution CT is the method of
choice for detection.
Persons who have been heavily exposed to histoplasmosis get acute diffuse nodular
disease with fairly discrete nodules throughout the lungs.
Nocardia is most often seen as airspace pneumonia and frequently has cavitation.
Cryptococcus is most commonly a fairly well-circumscribed mass 2-10 cm in diameter.
Widely disseminated disease can give miliary pattern or multiple diffuse ill-defined shadows.
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Answer: 25. d 26. b 27. a

1994, 1992
28. tidal volume
29. FRC
30. vital capacity

a. volume between normal inspiration and expiration

b. volume between normal expiration and full expiration
c. volume between full inspiration and normal inspiration
d. volume between full inspiration and full expiration
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normal inspiration --> expiration = tidal volume
normal expiration --> full expiration = expiratory reserve volume
normal inspiration --> full inspiration = inspiratory reserve volume
full inspiration --> full expiration = vital capacity
normal expiration --> full inspiration = inspiratory capacity

Residual volume, functional residual capacity(RV + ERV), and total lung capacity cannot
be directly measured but can be easily calculated through a variety of methods.
Reference: baby Fraser and Pare 1994, p. 154
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Answer: 28. a 29. none of the above 30. d