University of Balamand

Faculty of Medicine & Medical Sciences

In Association with St. George Hospital University Medical Center
Pulmonary Medicine: Structure and Function
Final On-Line Exam

1. All the following commonly occur on inhalation EXCEPT:

A. The diaphragm descends
B. The ribs are raised
C. The vertical dimension of the thoracic cavity increases
D. The abdominal muscles contract and push the abdominal viscera cranially
E. The external intercostal muscles contract

2. When passing a needle through the chest wall and into the pleural cavity in the
midaxillary line, the following structures will be pierced EXCEPT:
A. The skin
B. The external intercostal muscle
C. The parietal pleura
D. The internal intercostal muscle
E. The levator costarum

3. With a patient in the standing position, fluid in the left pleural cavity tends to gravitate
down to:
A. The oblique fissure
B. The costodiaphragmatic recess
C. The costomediastinal recess
D. The horizontal fissure
E. The cardiac notch
4. Which of the following statements concerning the lungs is INCORRECT:
A. Each lung is very elastic, and should the thoracic cavity be opened by a stab
wound, the lung shrinks to one-third or less in volume
B. The cardiac notch lies in the lower lobe of the left lung
C. The visceral pleura covering each lung lines the fissures that are situated between
the lobes
D. The apex of each lung extends up into the root of the neck and lies anterior to the
lower roots of the brachial plexus
E. The bronchi, connective tissue and visceral pleura of the lungs are supplied by the
bronchial arteries

5. Penetrating injuries of the lower thorax must be assumed to involve the abdominal cavity
until proven otherwise. The right dome of the diaphragm may arch as high as which
intercostal space?

A. Fourth
B. Fifth
C. Sixth
D. Seventh
E. Eighth

6. When the diaphragm descends in inspiration, which of the following is enlarged?

A. Esophageal hiatus
B. Aperture of the inferior vena cava
C. Aperture of the internal thoracic artery
D. Aortic hiatus
E. Medial lumbocostal arch

7. With respect to the pleural sacs, they:

A. Are normally in contact behind the xiphoid process
B. Normally communicate behind the lower manubrium
C. Extend two rib spaces below the lungs posteriorly during quiet breathing
D. Are in positive pressure which collapses the lung when the diaphragm is relaxed
E. Reach the upper border of the medial half of the clavicle at their highest points
8. The surgeon dissecting the root of the right lung may locate the bronchus by appreciating
that it:
A. Is the most anterior structure
B. Lies between the pulmonary veins and arteries
C. Is posterior to the pulmonary veins and arteries
D. Is the most inferior structure
E. Only Two Options are Right

9. The mediastinum is conventionally divided into four areas in anatomical and clinical
descriptions. Which of the following is CORRECT?

A. The phrenic nerve is found in the anterior mediastinum

B. The right recurrent laryngeal nerve appears in the superior mediastinum
C. A plane passing through the sternal angle and vertebral body T2 separates the
superior and inferior mediastina
D. The cupola of the pleura forms the upper limit of the superior mediastinum
E. The arch of aorta lies entirely within the superior mediastinum

10. The sternal angle is a surface landmark for all the following EXCEPT:

A. The origin of the main bronchi (carina)

B. Counting ribs---the second costosternal joint being of this site
C. The apex of the pericardial sac
D. The thoracic duct crossing from the right to the left side anterior to the
esophagus
E. The convergence of the pleural sacs

11. With respect to the trachea and bronchi:

A. The carina is at the level of the suprasternal notch

B. Inhaled safety pins are more apt to enter the right main bronchus
C. The trachea is prevented from collapse by a series of bony rings
D. The left bronchus is longer and branches outside the lung
E. There are more segmented bronchi in the left bronchi
12. An aneurysm (abnormal dilatation) of the aortic arch may affect the:
A. Right bronchus
B. Azygous vein
C. Left bronchus
D. Oblique sinus
E. Left ventricle

13. A barium swallow (contrast medium) shows the patient’s mid-esophagus to be

compressed by a structure anterior to it. This could be the:
A. Left ventricle
B. Right ventricle
C. Right bronchus
D. Left atrium
E. Thymus gland

14. During a pneumonectomy of the right lung, the esophagus is at risk when the surgeon
cuts the pulmonary ligament and retracts the lung. Which of the following structures
forms the pulmonary ligament?

A. Mediastinal parietal pleura

B. Central tendon of diaphragm
C. Endothoracic fascia
D. Costal parietal pleura
E. Visceral pleura

15. An incision for insertion of a chest tube has damaged a superficially located nerve over
the 5th or 6th intercostal space in the midaxillary line. Which of the following structures is
the most likely consequence of this injury?

A. Depressed shoulder
B. Diminished expiration
C. Weakened external rotation at shoulder
D. Weakened shoulder flexion
E. Winged scapula
16. Thoracic splanchnic nerves contain which of the following types of fibers?

A. Axons of neurons located in cervical sympathetic ganglia

B. Axons of neurons located in the intermedio-lateral cell column
C. Only general visceral efferet nerve fibers
D. Parasympathetic nerve fibers
E. Intercostal nerve fibers

17. When you place your stethoscope on a patient’s back, you are listening mainly to:
A. Upper lobe
B. Middle lobe
C. Lower lobe
D. Two Options are right

18. When you place your stethoscope on a patient’s anterior chest wall, you are listening
mainly to:

A. Upper lobe
B. Middle lobe
C. Lower lobe
D. Upper and middle lobes
E. Upper and lower lobes

19. You will listen to the middle lobe best by placing your stethoscope at the:

A. Sternum
B. Side and in axilla
C. Clavicle
D. Sternal angle
E. Xiphoid process
20. In the following chest PA (postero-anterior) and lateral, what is the location of the
pneumonia in this patient?

A. Right middle lobe

B. Left upper lobe
C. Right lower lobe
D. Left upper lobe
E. Right upper lobe

21. A 20 year-old male presents to the emergency department with sudden onset chest pain.
Chest PA and lateral radiographs are performed, revealing a subtle abnormality.
Additional chest radiograph in expiration is requested. Which of the following is the most
likely suspected abnormality?

A. Pleural effusion
B. Pneumothorax
C. Pneumonia
D. Lung mass
E. Mediastinal mass

22. Which of the following is NOT one of the recognized densities on a standard chest
radiograph?

A. Air
B. Bone
C. Soft tissue
D. Fluid
E. Fat
23. In the following chest PA, what is the most likely diagnosis of this patient?

A. Foreign body aspiration

B. Pneumonia
C. Pleural effusion
D. Pleural effusion
E. Normal CXR

24. A 50-year-old patient with inability to tolerate oral food intake, a feeding tube was
inserted, after which the following radiograph was performed. Where is the feeding tube
terminating?
A. Lower esophagus
B. Middle esophagus
C. Stomach
D. Left lower lobe bronchus
E. Left ventricle
25. A 40 year-old female presents with acute chest pain and dyspnea. What is the most likely
diagnosis in the following CT scan?

A. Thoracic aortic dissection

B. Thoracic aortic aneurysm, without rupture
C. Thoracic aortic aneurysm, ruptured
D. Mediastinal hemorrhage
E. Pulmonary embolism

26. Branches of the pulmonary arteries are basically divided into elastic arteries (proximal)
and muscular arteries (distal). The transformation of an elastic pulmonary artery into a
muscular artery occurs at:
A. The hilum of the Lung
B. The level where a primary (main) bronchus becomes a secondary (lobar) bronchus
C. The level where a secondary bronchus becomes a tertiary (segmental) bronchus
D. The level where a bronchus becomes a bronchiole
E. The level where a terminal bronchiole becomes a respiratory bronchiole

27. Surfactant is produced by:

A. Goblet cells
B. Type I Pneumocytes
C. Type II Pneumocytes
D. Alveolar macrophages
E. Endothelial cells
28. Abundant, long and delicate microvilli on Electron Microscopy are characteristic of:
A. Goblet cells
B. Ciliated cells
C. Kulchitsky cells (Neuroendocrine cells)
D. Type I Pneumocytes
E. Mesothelial cells

29. Respiratory type mucosa is present in all of the following sites EXCEPT:
A. Nasal Cavity
B. Turbinates
C. Paranasal Maxillary Sinus
D. True Vocal Cords
E. Trachea

30. Lymphatic channels are present in all of the following locations EXCEPT:
A. Nasal mucosa
B. Mucosa of the airways
C. Fibrocollagenous septa separating the pulmonary lobules
D. Interalveolar septa
E. Pleura

31. In the trachea, the trachealis muscle is:

A. Anterior
B. Posterior
C. Circumferential
D. Lateral
E. Present only just below the larynx

32. Bronchial cartilage plates become discontinuous:

A. As bronchi enter the lung
B. In the segmental bronchi
C. In the respiratory bronchioles
D. In the immediate postcarinal bronchi (Main Bronchi)
E. None of the options is correct
 33. Alveolar macrophages:
A. Are part of the defensive mononuclear cell population of the lungs
B. Are motile cellular elements
C. Demonstrate phagocytosis of many particulates in the airways
D. May move directly from one alveolar space to another
E. All Options are correct

34. All of the following statements regarding bronchioles are correct EXCEPT:
A. They are present exclusively inside the lung
B. They are devoid of cartilage
C. They are devoid of smooth muscle
D. They are devoid of goblet cells
E. They are devoid of seromucous glands

35. Which of the following statements regarding Surfactant is correct?

A. It has an antimicrobial activity
B. It facilitates the phagocytosis of foreign material
C. It traps any foreign material or microorganisms and facilitates their elimination
D. It increases alveolar surface tension
E. It facilitates the expansion of the lungs during inspiration

36. Which of the following ventral body wall defects is least likely to be caused by failure of the
ventral body wall folds to close during embryological development?
A. Ectopia cordis
B. Omphalocele.
C. Gastroschisis.
D. Bladder extrophy.
E. Congenital diaphragmatic hernia.

37. An embryologist is studying the development of the phrenic nerve in human embryos. He
reads that these nerves course through tissues involved in body cavity partitioning. What
is this tissue?
A. Pleuropericardial fold.
B. Pleuroperitoneal membrane.
C. Septum transversum.
D. Dorsal mesentery.
E. Esophageal mesoderm.
38. A newborn baby with a severe congenital diaphragmatic hernia has large portion of his
abdominal viscera herniating into the thoracic cavity. The most common developmental
abnormality associated with this condition is:
A. Tracheoesophageal fistula.
B. Bronchopulmonary dysplasia.
C. Pulmonary hyperplasia.
D. Pulmonary hypoplasia.
E. Hyaline membrane disease.

39. A baby is born prematurely at around 22 weeks of gestation. The baby is found to be
suffering from severe respiratory distress. What stage of lung development would the lungs
have reached at the time of delivery?
A. Alveolar period.
B. Terminal sac period.
C. Pseudoglandular period.
D. Canalicular period.
E. Embryonic period.

40. What is the embryological source of the tracheal cartilages?

A. Endoderm.
B. Ectoderm.
C. Paraxial mesoderm.
D. Somatic lateral plate mesoderm.
E. Splanchnic lateral plate mesoderm.

41. Newborn preterm infants lacking adequate pulmonary surfactant production suffer
neonatal respiratory distress. Which of the following statements concerning pulmonary
surfactant is TRUE?
A. Production of surfactant increases during the last two weeks of gestation.
B. Pulmonary surfactant does not contain any proteins.
C. Pulmonary surfactant decreases the lung compliance.
D. Surfactant is produced by the alveolar macrophages.
E. Surfactant production begins in the “Alveolar period” of lung development.

42. The epithelial lining of the respiratory tract is derived from which of the following germ
layers?
A. Ectoderm.
B. Mesoderm.
C. Endoderm.
D. Neural crest cells.
E. Epiderm.
43. Which of the following does not contribute to the formation of the diaphragm?
A. The mesentery of the esophagus.
B. The pleuroperitoneal membranes.
C. The septum transversum.
D. The pleuropericardial membranes.
E. Muscular ingrowth from the thoracic body wall.

44. The body regulates skin blood flow during cold stress to minimize heat loss to the
environment. Which of the below statements concerning this regulation is correct?
A. The sympathetic adrenergic nerves to the sweat glands decrease sweating.
B. The sympathetic cholinergic nerves are activated.
C. The skin temperature is maintained near its value before cold exposure.
D. The chemical thermogenesis is a result of intense shivering.
E. Norepinephrine induces cutaneous vasoconstriction during the cold exposure.

45. Which of the following is occurring when a fever has "broken" and the core temperature is
falling back to normal?
A. Shivering.
B. Vasodilation.
C. Vasoconstriction.
D. Increase in thermogenesis.
E. Increase in the hypothalamic “set-point” for core body temperature.

46. Which of the following is the main mechanism for heat loss from the body of a nude person
at room temperature?
A. Radiation.
B. Conduction to air.
C. Conduction to solids.
D. Convection.
E. Evaporation.

47. A 28-year-old female immerses her hand in cold water (4° Celsius) for a one minute as a
dare with her friends. Which of the following represents one of the immediate
thermoregulatory responses that would be seen in this lady?
A. Her core body temperature will drop to the water’s temperature.
B. Her skin temperature will drop to the water’s temperature.
C. Local vasodilation will occur in an attempt to heat up the skin.
D. Local vasoconstriction will occur in an attempt to decrease heat loss.
E. Inhibition of chemical thermogenesis occurs.
48. On a hot and dry summer day, where the external temperature is near 40 degrees Celsius,
which of the following represents the primary mechanism for heat loss from the body of a
person walking outside?
A. Evaporation.
B. Conduction.
C. Convection.
D. Radiation.
E. Insensible losses from the lung.

49. A 35-year-old man travels for work from Lebanon to a country in Africa near the equator
where the weather is extremely hot. Which of the below processes will NOT happen in this
man during the first several weeks as a result of heat acclimatization?
A. Increase in the sweating rate in response to heat.
B. Increase in the production of aldosterone by the adrenal cortex.
C. Increase in the baseline plasma volume.
D. Decrease in the salt concentration in excreted sweat.
E. Increase in non-shivering thermogenesis.

50. The body regulates skin blood flow and sweating during heat stress to allow for heat
transfer to the environment. Which of the below statements concerning this regulation is
correct?
A. The sympathetic adrenergic nerves to the eccrine sweat glands increase sweating.
B. The sympathetic adrenergic nerves to the cutaneous vessels are inhibited during
heat stress.
C. The parasympathetic cholinergic nerves induce cutaneous vasodilation.
D. Acetylcholine is responsible for the majority of cutaneous vasodilation during heat
stress.
E. Atropine increases sweating from eccrine sweat glands.

51. Which of the following is NOT a function of the lungs?

A. Metabolism
B. Serves as a reservoir of blood for the left ventricle.
C. It is a filter to protect the systemic vasculature
D. Facilitates the exchange of O2 and CO2 between air and blood.
E. All Options are true.

52. Which of the following is the first branching of the bronchial tree that has gas exchanging
capabilities?

A. Terminal bronchioles
B. Respiratory bronchioles
C. Alveoli
D. Segmental bronchi
E. Alveolar ducts.
53. During inspiration, how does alveolar pressure compare to atmospheric pressure?

A. Alveolar pressure is greater than atmospheric.

B. Alveolar pressure is less than atmospheric.
C. Alveolar pressure is the same as atmospheric.
D. Alveolar pressure is one of the few pressures where the reference pressure is not
atmospheric

54. If a patient had a progressive lung disease that required an increasing pressure to fill the
same volume of lung, how would the lung's compliance be affected?

A. It would increase
B. It would stay the same.
C. It would decrease
D. These variables do not affect lung compliance

55. Which of the following is FALSE concerning respiratory distress syndrome in premature
infants?

A. Their ability to synthesize DPPC is limited.

B. Higher pressures are required to ventilate the lungs.
C. Lung compliance is low.
D. Positive pressure respirators are often used to assist them in breathing.
E. Alveoli tend to over expand and sometimes burst at the end of inspiration.

56. Which of the following is FALSE at FRC?

A. It is about 75% TLC.

B. The elastic recoil of the chest wall is outward.
C. The elastic recoil of the lung is inward.
D. The relaxation pressure of the lung and chest wall combined is at atmospheric
pressure.

57. Which of the following is FALSE concerning the airflow in the lungs?

A. During inspiration and expiration, the flow in the trachea and larger bronchi is
turbulent.
B. Towards the middle of the bronchial tree, the flow is turbulent at the branches and
laminar in between.
C. Near the end of the bronchial tree, the flow is laminar.
D. The acini have very small radii which significantly increases the total air flow
resistance of the bronchial tree
 58. To which of the following is alveolar PCO2 directly proportional?
A. Rate of CO2 production and alveolar ventilation.
B. Rate of CO2 production and rate of O2 consumption.
C. Alveolar ventilation and rate of O2 consumption.
D. Alveolar ventilation, rate of O2 consumption, and rate of CO2 production

59. If you blocked the blood supply to an alveolus, which of the following would NOT occur
as a result?
A. The ventilation perfusion ratio would be 0.
B. The PAO2 would be greater than normal.
C. The PACO2 would be 0.
D. All Options are true

60. Which of the following is FALSE concerning the relationships of the variables in
diffusion of O2 across a membrane?

A. Doubling the thickness of the membrane would cut the total flow of O2 in half.
B. Doubling the area of the membrane would double the total flow of O2 .
C. If you increased the alveolar concentration of O2, you would increase the total flow of
O2 across the alveolar membrane.
D. The lower the diffusion coefficient, the higher the total flow.
E. Increasing the arterial concentration of O2 would decrease the total flow of O2.

61. Which of the following will NOT increase the minute ventilation?

A. An increase in arterial pH.

B. An increase in arterial partial pressure of carbon dioxide.
C. Increase in alveolar pressure of carbon dioxide.
D. Exercise.
E. Hypoxia.

62. With regards to pulmonary gas exchange:

A. Transfer of nitrous oxide is perfusion limited

B. Transfer of oxygen is typically diffusion limited
C. At altitude the profound systemic hypoxemia favors oxygen diffusion
D. The diffusion rate for CO2 is double that of oxygen
E. Diffusion is inversely proportional to the partial pressure gradient

63. The hemoglobin oxygen dissociation curve moves up and to the left with :

A. Increased hydrogen ion concentration

B. Hypothermia
C. Increased 2,3 DPG
D. Hypercarbia
E. All Options are true
64. The Haldane effect refers to:

A. The increased capacity for deoxygenated blood to carry CO2

B. The dissociation constant for the bicarbonate buffer system
C. The chloride shift that occurs to maintain electrical neutrality
D. The carriage of dissolved CO2 according to Henry’s law
E. The shape of the CO2 dissociation curve

65. In control of ventilation, the medullary chemoreceptors respond to :

A. Oxygen tension
B. Hydrogen ion concentration
C. CO2 tension
D. H + concentration and CO2 tension
E. H + concentration and oxygen and CO2 tension

66. Compliance of the lung is reduced by all of the following EXCEPT:

A. Emphysema
B. Alveolar edema
C. Fibrosis
D. Consolidation
E. High expanding pressures

67. Lung compliance:

A. Is normally 100mL/cm water

B. Falls if the lung remains unventilated for long periods
C. Rises if the pulmonary venous pressure is increased
D. Falls as the lung ages
E. Is the area under the pressure volume curve

68. With regard to the neural control of respiration:

A. There are 3 neural mechanisms regulating respiration

B. The dorsal group of respiratory center has excitatory neurons
C. The ventral group of respiratory center is located in the pons
D. The main respiratory control center is located in the pons
E. Voluntary control system is located in the cerebral cortex
69. With respect to lung volumes:

A. FRC can be measured with a spirometer

B. The dilution measures the total volume of gas in the lung, including any trapped
behind closed airways
C. The volume of gas left in the lungs after a maximal expiration is the functional
residual volume
D. Vital capacity is the volume exhaled when a maximal inspiration is followed by a
maximal expiration
E. TLC is the volume of the lung available to partake in gas exchange

70. In regional ventilation and perfusion of the lung:

A. Upper regions of the lung ventilate better than the lower regions
B. When supine the apical and basal ventilation is equal
C. V/Q ratio increases down the lung
D. The highest alveolar pO2 is at the base of the lung
E. Two of the options are true

71. Which one of the following is activated in the lung?

A. Renin
B. Angiotensin
C. Kallikrein
D. Bradykinin
E. Prostaglandins

72. When CO2 diffuses into blood in systemic capillaries most of it:

A. Remains in solution as CO2

B. Converts to carb-amino compounds
C. Converts to bicarbonate ions in RBC
D. Combines with Hb directly
E. Combines with H2O in plasma to form carbonic acid

73. A man with normal lungs and arterial pCO2 of 40 mmHg takes an overdose of
barbiturates, which halves his ventilation but doesn’t change his CO2 production. What
does his arterial Pco2 rise to?

A. 50
B. 60
C. 70
D. 80
E. More data is needed to calculate the new Pco2
74. Regarding the lung:

A. There are about 500 million alveoli in the human lung

B. The terminal bronchioles are the smallest airways without alveoli
C. Anatomic dead space = 150 ml
D. Alveoli are about 0.3 mm in diameter
E. All options are true

75. This blood gas picture reveals which of the following? PH = 7.52, pCO2 = 20 mmHg,
pO2 = 120 mmHg, bicarb = 16 mmol/l

A. Metabolic alkalosis
B. Respiratory alkalosis with partial renal compensation
C. Metabolic acidosis
D. Respiratory acidosis
E. Mixed respiratory/metabolic alkalosis

76. Regarding oxygen transport:

A. The predominant way oxygen is transported in the blood is as dissolved oxygen

B. 1 gram of pure Hb can combine with 1.39 ml of oxygen
C. An anemic patient has a lowered arterial pO2 because the Hb is low
D. CO2 is 200 times more soluble than oxygen
E. Two of the options are true

77. In the lung, airway resistance:

A. Is mainly in small airways

B. Varies with change in lung volume
C. Increases by stimulation of adrenergic receptors
D. Can be measured by flow rate divided by pressure difference between mouth and
alveolus
E. Increases by breathing helium-oxygen mixture

78. Which of the following occur during inhalation?

A. Diaphragm contracts, pleural pressure increases, alveolar pressure decreases

B. Diaphragm relaxes, external intercostals contract, pleural pressure increases
C. Diaphragm relaxes, pleural pressure decreases, internal intercostals relax
D. External and internal intercostals contract, pleural and alveolar pressure increase
E. Diaphragm and external intercostals contract, pleural and alveolar pressures decrease
 79. What is the most common cause of impaired oxygenation?

A. Decreased diffusion capacity

B. Hypoventilation
C. V/Q mismatch
D. Shunting
E. Low FiO2

80. Regarding ventilation/perfusion differences in the lung:

A. In healthy individuals, anatomical dead space is less than physiologic dead space
B. The relative change in blood flow from apex to base is less than relative change in the
ventilation
C. Ventilation/perfusion differences are due to gravity
D. Ventilation/perfusion ratio is low at the base
E. All options are true