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50 Cards in this Set
- Front
- Back
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43 – obstructive lung disease
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Asthma:
-Asthma = Greek “to pant” -A type of ... lung disease -Chronic ... disorder of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and/or early morning -Symptoms are associated ... and airflow limitation that is at least partially ... -There is an increase in airway responsiveness (...) to certain stimuli |
obstructive
inflammatory bronchoconstriction reversible bronchospasm |
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*Extrinsic Asthma*
Acute Response -Starts within minutes and lasts about 6 hours after exposure to allergen -... --> mast cell release of mediators -Results in ... (have hard time breathing), ... (due to vascular permeability), increased mucus (causes coughing) Late phase Response -persist for 12+ hours & Mediators are mainly from ... (Neutrophils, Eosinophils and Basophils) |
IgE cross-linking
bronchospasm edema leukocytes |
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*Intrinsic Asthma*
Diverse non-immune mechanisms -... ingestion (MC) -Cold -Respiratory infections (mainly ...) -Stress -Exercise No family history |
Aspirin
viral |
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In asthmatics, there is an increased ... response
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eosinophil
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In COPD, there is an increased ... response and a decreased ... response
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neutrophil
macrophage |
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A normal Reid Index is less than .... Reid index = bc/ad
a-d is full thickness of ... to ... b-c is thickness of the .... If reid index is increasing, that means the ... is increasing. |
0.4
membrane to cartilage mucous gland mucous gland |
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... - Irreversible overinflation of air spaces distal to the terminal bronchioles, with destruction of their walls and without obvious fibrosis
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emphysema
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Emphysema: Multiple Types: according to distribution within the acinus
...: -Uniform involvement of the acinus -Associated with ... deficiency ...: -Enlargement of central parts of the acinus (respiratory bronchioles and alveolar duct) -Sparing of the peripheral alveoli (distal alveoli) -More common and more severe in ... segments of upper lobes -In heavy smokers and often associated with ... ...: -Enlargement of the distal parts of the acinus (subpleural), sparing the proximal parts ...: -No uniform acinar pattern (seen with scarring) |
Panacinar
α1-antitrypsin Centriacinar apical Chronic bronchitis Paraseptal Irregular |
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*Emphysema Etiology*
Protease- Antiprotease Hypothesis (imbalance between ... and ...) is most important Tobacco Smoking -recruits PMNs, macrophages & releases ... (including elastase, proteinase 3, cathepsin G) -inactivates ... (which has antielastase activity) Congenital ... deficiency |
proteases and protease-inhibitors
proteases alpha-1-antitrypsin alpha-1-antitrypsin |
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*Emphysema – Clinical*
-Age: ... to ... decades -Dyspnea with prolonged ... -Cough & expectoration (when associated bronchitis) -... shaped Chest (X-ray finding)- ↑AP diameter, flattened diaphragms -Pink puffers -Death is due to *Respiratory failure *CHF (Cor pulmonale) *Rupture of bullae --> ... |
fifth to eighth
expiration Barrel tension pneumothorax |
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44 – lung tumors
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*Lung Cancer*
About ...% of all smokers (former or current) eventually develop lung cancer Both the number of cigarettes smoked and number of years of smoking seem to correlate with the increased risk In people who quit smoking, the risk of developing lung cancer ..., but former smokers will still always have a ... risk of developing lung cancer than people who never smoked |
10
decreases higher |
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*Other Risk Factors*
... -Increased lung cancer rates among Hiroshima and Nagasaki atomic bomb survivors ... gas -Indoor air pollutant -Comes from natural decay of uranium -Seen in homes in areas with high amounts of radon in soil -... leading cause of lung cancer in America and claims about 20,000+ lives annually (EPA) |
Ionizing Radiation
Radon Second |
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Lung cancer:
... is #1 cause in the US ... is #2 cause in the US |
smoking
Radon |
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*Other Risk Factors*
Asbestos workers -... is most frequent malignancy in asbestos workers -If non-smoker: 5x increased risk of lung cancer -If smoker: 50-90x increased risk of lung cancer -Also have increased rates of ... and GI cancers |
Lung cancer
mesothelioma |
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If you have a pt w/ lung cancer and hypercalcemia, think about a ...
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squamous cell carcinoma
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*Squamous Cell Carcinoma*
Strongly related to ... Arises from bronchial epithelium -Squamous metaplasia -> squamous dysplasia -> squamous carcinoma in situ -> invasive squamous cell carcinoma Males ... Females Usually ... located Gross: gray-white, firm bronchial mass |
smoking
> centrally |
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*Squamous Cell Carcinoma*
Micro: -Invasive nests of atypical squamous cells -... production (eosinophilic cytoplasm) -Intercellular bridges (...) Paraneoplastric syndrome -... *Due to parathyroid hormone related protein (PTHRP) |
Keratin
desmosomes Hypercalcemia |
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*Adenocarcinoma*
Less closely related to ... Proposed sequence -Atypical adenomatous hyperplasia -> Bronchioloalveolar carcinoma -> invasive adenocarcinoma Females ... Males Usually ... located Gross: peripheral gray-white mass with ... puckering Micro: -... formation -... production |
smoking
> peripherally pleural Gland Mucin |
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*Small Cell Carcinoma*
-Also known as ... carcinoma -Strongly associated with ... -No morphologically recognizable precursor lesion -Males ... Females -Usually ... located -Gross: Gray-white mass Micro: -Small round or polygonal cells -... cytoplasm -Nuclear molding -Granular (“...”) nuclear chromatin -Necrosis |
oat cell
smoking > centrally Scant (very little) salt and pepper |
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*Small Cell Carcinoma*
Paraneoplastric syndromes -Hyponatremia (increased water absorption leads to this) *... secretion -Cushing syndrome *... secretion |
ADH
ACTH |
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Small cell carcinomas are almost never cured ...
-they have a ... prognosis |
surgically
poor |
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In a smoker w/ a chronic cough, think ...
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cancer
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Symptoms for lung cancer in general:
Chronic ... Hemoptysis ... – nerve involvement Wheezing Shortness of breath ... – impaired clearance of mucous Non-specific symptoms -Loss of appetite -Weight loss -Fatigue -Weakness |
cough
Chest pain Pneumonia |
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*Bronchial Carcinoid Tumors*
-Younger age group (less than ... years old) -1-5% of all lung tumors -... grade malignant neoplasms -Precursor lesion: Diffuse idiopathic ... cell hyperplasia -Not associated with smoking -Males ... Females -Centrally or peripherally located -Gross: Spherical polypoid peribronchial mass with intact overlying mucosa that is usually 4 cm or less in size |
40
Low neuroendocrine = |
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*Bronchial Carcinoid Tumors*
Micro: -Groups of small round ... cells separated by fibrovascular stroma -... carcinoids (slower growing) have < 2 mitoses per 10 high power fields and no necrosis -... carcinoids (faster growing) have 2-10 mitoses per 10 high power fields and/or necrosis |
uniform
Typical Atypical |
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*Bronchial Carcinoid Tumors*
May be functional and produce vasoactive amines which cause ... syndrome (Attacks of diarrhea, flushing, cyanosis) Treatment is ... 5 yr survival -Typical carcinoids: 87% -Atypical carcinoids: 56% |
Carcinoid
surgical resection |
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45 – restrictive lung disease
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Sarcoidosis is most common in ...
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african-american females
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*Sarcoidosis - Clinical*
... (hard) granulomas can occur in any organ Pulmonary involvement is common -Bilateral hilar ... on chest X-ray May be asymptomatic May have cough, shortness of breath, skin lesions, fever, fatigue, muscle weakness, iritis, bone marrow involvement, spleen involvement (systemic) |
Non-caseating
lymphadenopathy |
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*Sarcoidosis - Clinical*
Most cases mild and self-limiting but course is unpredictable Elevated ... level Hyper... Treat with ... -~70% of patients recover with no or minimal sequelae |
angiotensin converting enzyme (ACE)
calcemia steroids |
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*Asbestos-Related Disease*
Occupational exposure to asbestos Linked to -Localized fibrous plaques or diffuse pleural fibrosis -Pleural effusions -Interstitial fibrosis (...) -... *Smoking and asbestos exposure results in a greater than 50X increase in risk of ... -... *Less common than lung carcinoma but greater than 1000X increased risk in asbestos workers |
asbestosis
Lung carcinoma lung cancer Mesothelioma |
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Review Questions
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A 63 year-old woman has had increasing dyspnea for 5 years. On physical examination her lungs are hyper-resonant without dullness. Tactile vocal fremitus is slightly decreased over all lung fields. Scattered expiratory wheezes and inspiratory rhonchi are present without basal crackles. She has a chest radiograph that reveals increased lung volumes and flattening of the diaphragmatic leaves. Which of the following inhaled substances, which increases the elaboration of neutrophil elastase, is most likely to cause her pulmonary disease?
1. Chlorine 2. Silica 3. Carbon dioxide 4. Cigarette smoke 5. Carbon |
4. Cigarette smoke
She has findings of emphysema, and smoking is the most likely underlying cause. The nicotine in the cigarette smoke is chemotactic for neutrophils, and cigarette smoke activates the alternative complement pathway, releasing more mediators for neutrophil recruitment. Neutrophil elastase can damage the lung parenchyma. |
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A 55-year-old man has been a cigarette smoker for the past 40 years. He has noted some blood-streaked sputum on coughing during the past week. He also has back pain. A chest radiograph shows a small 3 cm right hilar mass with several 1 to 2 cm peripheral lung nodules. A bone scan reveals multiple areas of increased uptake in the vertebrae, ribs, and pelvis. A sputum cytology reveals the presence of clusters of small cells having hyperchromatic nuclei and almost no cytoplasm. Which of the following laboratory test findings is he most likely to have as a consequence of his lung disease?
1. Positive antinuclear antibody 2. Markedly decreased platelet count 3. Very low serum morning cortisol 4. Decreased serum sodium 5. Hyperuricemia |
4. Decreased serum sodium
He has a small cell carcinoma with widespread metastases. The syndrome of inappropriate ADH producing hyponatremia is one form of paraneoplastic syndrome seen with this particular carcinoma. |
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A 44-year-old woman, a non-smoker, has had a fever and cough for the past 4 days. She does not have hemoptysis. She has not experienced weight loss, malaise, nausea, or vomiting. On physical examination her temperature is 37.7 C. There are decreased breath sounds over the right upper lung. A chest radiograph reveals a 6 cm area of infiltrates in the right upper lobe. She is given a course of antibiotic therapy, but her cough persists. A month later her chest x-ray now reveals a 3 cm peripheral mass in the right upper lobe. Which of the following neoplasms is most likely to be present in this woman?
1. Squamous cell carcinoma 2. Small cell carcinoma 3. Adenocarcinoma 4. Mesothelioma 5. Carcinoid tumor |
3. Adenocarcinoma
Adenocarcinomas are typically peripheral lung cancers and they show less of an association with smoking than central cancers (small cell and squamous cell carcinoma). |
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A 13-year-old girl experiences the sudden onset of wheezing with dyspnea. She had a similar episode a month ago. She is brought to the emergency room. On physical examination her breathing appears to have a prolonged expiratory phase with wheezing sounds. A chest radiograph appears normal with clear lung fields. Which of the following laboratory findings is she most likely to have?
1. Elevated sweat chloride 2. Numerous sputum eosinophils 3. Decreased CD4 lymphocyte count 4. Positive tuberculin skin test 5. Decreased alpha-1-antitrypsin |
2. Numerous sputum eosinophils
In children, exposure to an allergen is often the inciting event for extrinsic asthma. This form of obstructive lung disease is episodic and limited, so chronic lung changes are uncommon. |
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A 61-year-old man has had progressive dyspnea for the past 5 years. He does not have a significant cough. He is afebrile. A chest x-ray shows increased interstitial markings along with pleural thickening and calcified diaphragmatic pleural plaques. The right heart border is prominent and the pulmonary arteries appear prominent. A sputum gram stain shows normal flora and sputum cytology reveals no atypical cells. Which of the following environmental exposures is most likely to be associated with his findings?
1. Bird droppings 2. Asbestos 3. Tobacco smoke 4. Radon 5. Ragweed |
2. Asbestos
The pleural plaques are most typical for asbestos exposure |
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A 58-year-old man has developed a non-productive cough worsening over the past two months. Last week he noted the appearance of blood-streaked sputum. On physical examination there are some expiratory wheezes auscultated over the left lung. A chest radiograph reveals a 5 cm mass near the left lung hilum. A sputum cytology reveals the presence of small clusters of very hyperchromatic, pleomorphic cells with scant cytoplasm. Which of the following is the most likely predisposing factor to development of his pulmonary disease?
1. Silicosis 2. Radon gas exposure 3. Smoking 4. Asbestosis 5. Passive smoking |
3. Smoking
Smoking remains the most frequent cause of lung cancer. Lung cancer does, however, occur in nonsmokers. Small cell carcinoma, as in this patient, is typically seen in smokers |
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A 55-year-old man with a 55 pack year history of smoking cigarettes has recently experienced an episode of hemoptysis along with his usual cough. On physical examination there are no abnormal findings. He has a sputum cytology examination performed that demonstrates the presence of atypical cells with hyperchromatic nuclei and orange-pink cytoplasm. Laboratory studies show an elevated serum calcium of 11.3 mg/dL with normal total protein and albumin levels. Which of the following chest radiographic findings is this man most likely to have?
1. Large hilar mass 2. Pneumonia 3. Peripheral nodule 4. Left pleural thickening 5. Bilateral pleural effusions |
1. Large hilar mass
Both squamous cell and oat cell carcinomas tend to be central in location. Squamous cell carcinomas of the lung are associated with hypercalcemia, though overall the oat cell carcinomas are best known for paraneoplastic syndromes. |
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A 36-year-old woman has had increasing dyspnea for 8 years. She has no cough or increased sputum production. On physical examination there is hyperresonance to percussion. A chest radiograph reveals increased lung volumes with flattening of the diaphragmatic leaves bilaterally. The right heart border is more prominent than usual. A chest CT scan demonstrates emphysematous changes in all lung fields. Which of the following laboratory findings is she most likely to have?
1. Decreased serum ceruloplasmin 2. Increased sweat chloride 3. Elevated blood ethanol 4. Decreased serum alpha-1-antitrypsin 5. Positive urine opiates |
4. Decreased serum alpha-1-antitrypsin
AAT deficiency leads to lack of an anti-protease, which leads to development of panlobular emphysema. |
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A 55-year-old man has smoked 2 packs of cigarettes per day for 40 years. He has had a worsening cough for the past 5 months. In the past 2 weeks he has noted blood-tinged sputum. On physical examination no abnormal findings are noted. A chest x-ray shows a 6 cm right perihilar mass. Serum chemistries show an elevated calcium level of 12.6 mg/dL with normal total protein and albumin levels. Which of the following neoplasms is he most likely to have?
1. Squamous cell carcinoma 2. Carcinoid tumor 3. Adenocarcinoma 4. Small cell anaplastic carcinoma 5. Bronchioloalveolar carcinoma |
1. Squamous cell carcinoma
Of the primary lung tumors, squamous cell and small cell are most likely to be associated with smoking and most likely to be central in location. Hypercalcemia from elaboration of a parathormone-related peptide is more often a paraneoplastic effect of pulmonary squamous cell carcinoma than other cell types. |
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A 24-year-old previously healthy non-smoking woman goes to the emergency room because of the onset of severe respiratory distress with dyspnea and wheezing. She reports having taken aspirin for a headache 4 hours ago, but her headache is now gone. On physical examination she has a temperature of 36.9 C, pulse 88/minute, respiratory rate 26/minute, and blood pressure 110/70 mm Hg. There are expiratory wheezes on auscultation of the chest. Which of the following pulmonary abnormalities is she most likely to have?
1. Fibrous pleural plaques 2. Pulmonary atherosclerosis 3. Bronchoconstriction 4. Lobar pneumonia 5. Small cell carcinoma |
3. Bronchoconstriction
Aspirin sensitivity is a cause for asthma with bronchospasm. |
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A 32-year-old healthy man, a non-smoker, has a sudden episode of hemoptysis. On physical examination he is afebrile. There are decreased breath sounds over the left upper lung. A chest CT scan reveals an area of left upper lobe atelectasis. A bronchoscopy is performed, and there is a discrete reddish endobronchial mass seen within a segmental bronchus of the left upper lobe. A local resection is performed. He is doing well 10 years later. Which of the following neoplasms did he most likely have?
1. Mesothelioma 2. Squamous cell carcinoma 3. Carcinoid tumor 4. Small cell carcinoma 5. Large cell carcinoma |
3. Carcinoid tumor
Carcinoid tumors are typically small and benign, but they tend to arise in bronchi and can produce obstruction and bleeding. |
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A 60-year-old woman has been a cigarette smoker since the age of 18, averaging a pack a day of unfiltered cigarettes. She works as a dispatcher for a trucking company. She has had a chronic cough for 15 years, but she has had several episodes of hemoptysis in the past two weeks. On physical examination there are no abnormal findings. A chest radiograph shows an ill-defined left hilar mass. A transbronchial lung biopsy is performed and microscopic examination shows clusters of small, hyperchromatic cells with scant cytoplasm. Which of the following laboratory test findings is most likely to be present in this woman?
1. Hyperuricemia 2. Hyperbilirubinemia 3. Hypercalcemia 4. Hyponatremia 5. Polycythemia |
4. Hyponatremia
Small cell carcinomas can elaborate an ADH-like substance |
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Each spring, a 15-year-old boy develops rhinorrhea with sneezing and stuffy nose. He also experiences episodes of wheezing and coughing during which he has difficulty breathing. He coughs up large globs of mucus. Through which of the following mechanisms is his disease most likely produced?
1. IgE cross-linking 2. Complement activation 3. CD4 lymphocyte infiltration 4. NK cell mediated lysis 5. IgA release from plasma cells |
1. IgE cross-linking
Bronchial asthma is an allergic response. Sensitization to an antigen leads to fixation of IgE on mast cells, and when the allergen is again encountered, the mast cells degranulate, releasing vasoactive substances to produce a localized form of type I hypersensitivity reaction |
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A 49 year-old man has smoked 2 packs of cigarettes per day since age 16 and has worked in an asbestos mine for 30 years. He has no family history of cancer. He is at highest risk for the development of which of the following?
1. Lung carcinoma 2. Mesothelioma 3. Pancreatic carcinoma 4. Colon carcinoma 5. Sarcoidosis |
1. Lung carcinoma
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A 26 year-old woman presents with a 3 month history of persistent cough, dyspnea with exertion, and eye irritation. She has a history of a kidney stone which passed 6 months ago. She is afebrile. A chest X-ray shows bilateral hilar adenopathy and parenchymal infiltrates. Which of the following serum laboratory findings are most likely for this patient?
1. Elevated ACE level, decreased calcium 2. Elevated ACE level, increased calcium 3. Decreased ACE level, increased calcium 4. Decreased ACE level, decreased calcium |
2. Elevated ACE level, increased calcium
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A 45 year-old man was born and raised in Cumberland Gap, TN. He is a non-smoker and presents to his doctor with hemoptysis. He is eventually diagnosed with squamous cell carcinoma. Environmental testing at his residence reveals the presence of a gas, which has been shown to be a risk factor for developing lung cancer, at a concentration of 6 pCi/L . This gas is
1. Uranium 2. Radium 3. Radon 4. Carbon dioxide 5. Ether |
3. Radon
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