Case 1 - Respi

Question 1

Which of the following risk factors of chronic obstructive pulmonary disease (COPD) is modifiable but anatomically damaged for alleviation therapy of symptoms?

a. Tuberculosis
b. Asthma
c. Alpha 1-antitrypsin
d. Tobacco smoking

Answer 1

d. Tobacco smoking

Modifiable risk factors

• smoking or exposure to environmental tobacco smoke
• exposure to fumes and smoke from -carbon-based cooking and heating fuels, such as charcoal and gas
• occupational hazards (f example, exposure to pollutants and chemicals)
• poor nutrition
• pneumonia or childhood respiratory infection

Question 2

Which of the following ABG results indicates the need for intubation and mechanical ventilation in acute exacerbation of B. asthma?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

Answer 2

c. Respiratory acidosis

Initial blood gas results indicate respiratory alkalosis with hypoxemia. Developing respiratory acidosis or elevated PCO2 are indicators of status asthmaticus that indicate the need for ventilatory support.

Question 3

Which of the following environmental factors are common triggers of asthma symptoms associated with allergic sensitization, such as domestic pets?

a. Hygiene hypothesis
b. Dietary
c. Air pollution
d. Allergens

Answer 3

d. Allergens

(Allergens) House dust mite (HDM) allergens HDMs are ubiquitous pyroglyphidae that live in human dwellings. The mite’s gut contains potent digestive enzymes, notably proteases that persist in the feces, and these are thought to induce allergic sensitization and asthma

Question 4

In a patient with mild persistent asthma, which is the preferred treatment?

a. Low dose ICS
b. Low dose ICS + LABA
c. Medium dose ICS
d. Medium dose ICS + LABA

Answer 4

a. Low dose ICS

Question 5

Which one of the following increases the clearance of theophylline?

a. Childhood
b. Congestive Heart Failure
c. Liver disease
d. Pneumonia

Answer 5

a. Childhood

Increased clearance of theophylline are caused by the consumption of barbecued meats; youth (age 1-16 years); low-carbohydrate, high-protein diets; acidosis; and smoking cigarettes and marijuana. [1, 4, 5] Concomitant administration of phenytoin, phenobarbital, and rifampin can lead to increased clearance of and therefore low levels of theophylline Decreased theophylline clearance are caused by pneumonia; heart failure; infections; influenza vaccination; liver disease; chronic obstructive pulmonary disease (COPD); obesity; a high carbohydrate, low-protein diet; high levels of dietary methylxanthines (eg, caffeine); and the extremes of age.

Question 6

Patient AS has a cough and difficulty of breathing that wakes him up 2 days per week and requires use of Salbutamol MDI once daily to relieve his symptoms. What is the category of his bronchial asthma?

a. Intermittent
b. Mild persistent
c. Moderate persistent
d. Severe persistent

Answer 6

c. Moderate persistent

Question 7

Which of the following types of hypersensitive reactions does extrinsic asthma belong, according to Gell and Coomb classification?

a. Antibody mediated cytotoxic hypersensitivity
b. Cell mediated hypersensitivity
c. Immunoglobulin E mediated hypersensitivity
d. Immune complex mediated hypersensitivity

Answer 7

C. Immunoglobulin E mediated hypersensitivity

Type I immune reaction; immediate allergic reaction

Question 8

Jen is a known asthmatic. She experiences daytime symptoms of >2x per week with limitation in usual activities. This requires her to have >2x/week rescue treatment for symptom relief. Her asthma control status is said to be:

a. Controlled
b. Partly controlled
c. Uncontrolled
d. Severely controlled

Answer 8

B. Partly controlled
Controlled - No daytime symptoms, no limitations, no nocturnal symptoms, no need for rescue meds, normal lung function

Partly controlled - >2/week daytime symptoms, >2/week need for rescue med, with limitations in activity, and nocturnal symptoms.

Question 9

Which of the following statements about the use of Mepolizumab is/are correct?

a. It is an add on therapy for severe eosinophilic asthma
b. The treatment of other eosinophilic conditions as atopic dermatitis, eosinophilic esophagitis and nasal polyposis.
c. It is used as treatment of status asthmaticus in established allergic asthma phenotype.
d. Any of the options.

Answer 9

A. It is an add-on therapy for severe eosinophilic asthma.

Question 10

The female and male ratio of the incidence of bronchial asthma in children is

a. 1:2
b. 1:1
c. 2:1
d. 3:1

Answer 10

A. 1:2 ????
Female-to-male ratio -> 1:2
Asthma predominantly occurs in boys in childhood, with a male-to-female ratio of 2:1 until puberty, when the male-to-female ratio becomes 1:1. Asthma prevalence is greater in females after puberty, and the majority of adult-onset cases diagnosed in persons older than 40 years occur in females. Boys are more likely than girls to experience a decrease in symptoms by late adolescence.

Question 11

Which of these clinical features of COPD is often the most concerning early symptoms due to persistence, progressiveness, and is usually worse with physical exertion?

a. Breathlessness
b. Chronic cough
c. Sputum
d. Wheeze

Answer 11

A. Breathlessness

Question 12

All the following are B2 agonist drugs available as metered dose inhalers EXCEPT

a. Albuterol
b. Terbutaline
c. Metaproterenol
d. None of the options

Answer 12

D. None of the options

Question 13

Which of the following is the median age of onset of bronchial asthma?

a. 2years old
b. 3years old
c. 5years old
d. 7years old

Answer 13

B. 3 years old

Question 14

Which of these relievers of B. asthma is the LEAST potent against bronchoconstriction due to reflex inhibition?

a. Albuterol
b. Formoterol
c. Ipratropium bromide
d. Theophylline

Answer 14

C. Ipratropium bromide

Muscarinic receptor antagonists, such as ipratropium bromide, prevent cholinergic nerve-induced bronchoconstriction and mucus secretion. They are less effective than β2-agonists in asthma therapy as they inhibit only the cholinergic reflex component of bronchoconstriction, whereas β2-agonists prevent all bronchoconstrictor mechanisms.

❌Theophylline - inhibit phosphodiesterase in airway
smooth muscle cells
❌Albuterol (Salbutamol) - short-acting B2-agonist
❌Formoterol - long-acting B2-agonist

Question 15

In the pathogenesis of extrinsic asthma, which of the following sequences allow eosinophils to release major basic protein and cationic protein to damage epithelial cells and produce airway constriction?

a. Hypersensitive reaction with exposure to extrinsic allergens.
b. Initial sensitization to an inhaled allergen.
c. Inhaled antigens cross-link antibodies on mast cells on mucosal surfaces.
d. Late phase reaction with recruitment of leukocytes

Answer 15

D Late phase reaction with recruitment of leukocytes.
Extrinsic = Allergic (?) Asthma
Allergen inhalation results in a marked increase in activated eosinophils in the airways at the time of the late reaction.

Question 16

Which of the following drugs produce modest improvements in expiratory flow rates and vital capacity and a slight improvement in arterial oxygen and carbon dioxide levels in patients with moderate to severe COPD?

a. Albuterol
b. Prednisone
c. Theophylline
d. Ipratropium bromide

Answer 16

Theophylline produces modest improvements in expiratory flow rates and vital capacity and a slight improvement in arterial oxygen and carbon dioxide levels in patients with moderate to severe COPD

Question 17

All of the following are risk factors for developing bronchial asthma EXCEPT.

a. Tobacco
b. Prematurity
c. URI
d. None of the options

Answer 17

d. None of the options

Question 18

Which of the following controllers of asthma inhibits mast cell and sensory nerve activation and effective in blocking trigger induced asthma?

a. Nedocromil sodium
b. Omalizumab
c. Cysteinyl leukotrienes
d. Budesonide

Answer 18

A. Nedocromil sodium

Omalizumab - Anti-IgE. It is a blocking antibody that neutralizes circulating IgE without binding to cell-bound IgE and, thus, inhibits IgE-mediated reactions.
Cysteinyl leukotrienes - these are potent bronchoconstrictors. They cause microvascular leakage and increase eosinophilic inflammation through activation of cys-LT1 receptors. (Antileukotrienes like montelukast and zafirlukast block cys-LT1 receptors)
Budesonide is a corticosteroid.

Question 19

Which of the following diagnostic findings is the best measure of bronchial asthma severity?

a. Arterial blood gas
b. Forced expiratory volume in 1 second
c. Forced vital capacity
d. Eosinophilia

Answer 19

B. FEV1 and C. FVC are both correct?????

Lung function, measured by spirometry: FEV1, FVC (or FEV6), FEV1/FVC (or FEV6 in adults). Spirometry is the preferred method for measuring lung function to classify severity

Question 20

Which of the following statements best describes a paradoxical pulse?

a. It is an increase in pulse wave amplitude during inspiration.
b. It is a decrease in pulse wave amplitude during expiration.
c. It is an increase in pulse wave amplitude during expiration.
d. It is a decrease in pulse wave amplitude during inspiration

Answer 20

D. It is a decrease in pulse wave amplitude during inspiration.

Question 21

Which of the following is the most common cause of bronchiolitis in <2 years old?

a. GBS
b. H. influenza
c. Adenovirus
d. Respiratory syncytial virus

Answer 21

D. Respiratory syncytial virus

Question 22

Which of the following statements regarding Methacholine Provocation Test for asthma is/are correct?

a. It is useful in diagnosing a patient whose main symptom is wheezing.
b. It is done for patient whose FEV1<1.5L.
c. It is usually done for research purpose.
d. Any of the options

Answer 22

A. It is useful in diagnosing a patient whose main symptom is wheezing.

Indications for testing include evaluating symptoms clinically suggestive of asthma and response to therapy. Contraindications of Methacoline Provocation test: FEV <1.5L (Therefore choice B is wrong).

Question 23

Which of the following lung volumes/capacities will increase in COPD during pulmonary function test?

a. Expiratory reserve volume (ERV) + residual volume (RV)
b. Inspiratory capacity (IC) + ERV
c. IC + RV
d. ERV + RV + IC

Answer 23

A. Expiratory reserve volume + residual volume

Question 24

All of the following are histological changes in bronchi with extrinsic asthma. Which one is the EXCEPTION?

a. Edema and a mixed inflammatory infiltrate
b. Hypertrophy of submucosal glands
c. Hypertrophy/hyperplasia of smooth muscle cells
d. Patchy loss of epithelial cells, goblet cell metaplasia

Answer 24

B. Hypertrophy of submucosal glands

• > Increased mucus secretion contributes to the viscid mucous plugs that occlude asthmatic airways, particularly in fatal asthma. There is hyperplasia of submucosal glands that are confined to large airways and of increased numbers of epithelial goblet cells. IL13 induces mucus hypersecretion in experimental models of asthma.
• > In asthmatic airways there is also a characteristic hypertrophy and hyperplasia of airway smooth muscle…
• > Airway epithelial shedding may be important in contributing to AHR (airway hyperresponsiveness)

Question 25

Which of the following timing of dyspnea is associated with B. asthma?

a. Acute episodes of nocturnal
dyspnea
b. Progressive dyspnea
c. Sudden onset of dyspnea
d. Slowly progressive dyspnea

Answer 25

A. Acute episodes of nocturnal dyspnea
Elimination:
A. Acute episodes of nocturnal dyspnea - ->Asthma. The characteristic symptoms of asthma are wheezing, dyspnea, and coughing, which are variable, both spontaneously and with therapy. Symptoms may be worse at night and patients typically awake in the early
morning hours. (Harrison’s. Ch 281. pg. 1963) -> Paroxysmal nocturnal dyspnea often attributed to CHF.
B. Progressive dyspnea - COPD (?)
C. Sudden onset - CVS condition, Asthma( typically follows a triggering event)
D. Slowly progressive dyspnea - COPD

Question 26

Which of the following drugs decreases the clearance of theophylline via enzyme inhibition?

a. Rifampicin
b. Phenobarbitone
c. Ethanol
d. Cimetidine

Answer 26

D. Cimetidine
❌Rifampicin - increase clearance
❌Phenobarbitone - increase clearance
❓Ethanol - ??
✔Cimetidine - decrease theophylline clearance by 30%

Question 27

A clenched fist held over the chest to describe ischemic chest pain is a sign known as

a. Murphy
b. Halstead
c. Cullen
d. Levine

Answer 27

D. Levine
✔Levine’s sign - clenched fist over chest indicating ischemic chest pain
❌Murphy’s sign - acute cholecystitis - examiner’s hand on middle inferior border of the liver. Positive if patient feels pain on mid-inspiration
❌Halstead test - to assess for thoracic outlet syndrome. Positive if there is decrease/absence of radial pulse.
❌Cullen - superficial edema and bruising around the umbilicus; indicates retroperitoneal / intra-abdominal hemorrhage / pancreatitis

Question 28

A FDA boxed warning issued on March 2020 about the use of montelukast is

a. Hepatoxicity
b. Kidney impairment with moderately elevated creatinine
c. Mental health side effects
d. Lactic acidosis

Answer 28

C. Mental health side effects

Because of the risk of mental health side effects, the benefits of montelukast may not outweigh the risks
in some patients, particularly when the symptoms of disease may be mild and adequately treated with other medicines.

Question 29

Which of the following is not a histopathologic finding in a small airway in fatal asthma?

a. the lumen in occluded with mucus plug
b. there is goblet cell metaplasia
c. there is an increase in basement membrane thickness and airway smooth muscle
d. there is vasoconstriction and increased numbers of blood vessels
e. the airway wall is thickened

Answer 29

D

Question 30

Number of breaths per minute in infants that are 0-6moths old

a. 30-60
b. 24-30
c. 20-30
d. 10-20

Answer 30

A.

healthy resting adult: 20
6-11y/o: 20
1-5y/o: 20-30
6-12months: 24-30
0-6months: 30-60

Question 31

Intermediate expiratory sound than is normally heard in the 1st and 2nd interspaces anteriorly between the scapulae wherein the inspiratory and expiratory sound are almost equal

a. vesicular
b. bronchovesicular
c. bronchial
d. tracheal

Answer 31

B
characteristics of breath sounds
vesicular: inspiratory > expiratory, soft, relatively low, over most of both lungs
bronchial: expiratory > inspiratory, loud, relatively high, over the manubrium
tracheal: inspiratory = expiratory, very loud, relatively high, over the trachea

Question 32

An imaginary line of the thoracic wall that indicates the intersection of the median place with the anterior thoracic wall

a. Anterior Median Line (AML)
b. Anterior Axillary Line (AAL)
c. Midclavicular Line (MCL)
d. Midaxillary Line (MAL)

Answer 32

A

Anterior Axillary Line (AAL) - runs vertically along the anterior axillary fold
Midclavicular Line (MCL) - passes through the midpoint of the clavicle, parallel to the AML
Midaxillary Line (MAL) - runs from the apex of the axillary fossa, parallel to the AAL
Posterior Axillary Line (PAL) - drawn vertically along the posterior axillary fold, spans from back to humerus
Posterior Median Line (PML) - vertical line along the tips of the spinous processes of the vertebrae
Scapular Lines (SLs) - parallel to the posterior median line and intersect the inferior angles of the scapula

Question 33

The muscles of inspiration that elevates the chest cage, include the following except:

a. External intercostals
b. Internal intercostals
c. Anterior serrati
d. Scaleni

Answer 33

B

Muscles of inspiration:
external intercostals - pull upper ribs forward wc elevates it causing inspiration
sternocleidomastoid muscles - lift the sternum
anterior serrati - lift many of the ribs
scaleni - lift first 2 ribs

Muscles of expiration: depress the chest cage
abdominal recti
internal intercostals

Question 34

It is the pressure of fluid between lung and chest wall pleura

a. recoil pressure
b. alveolar pressure
c. transpulmonary pressure
d. pleural pressure

Answer 34

D

a. recoil pressure - measure of elastic forces in the lungs that collapse the lung at each respiration
b. alveolar pressure - pressure inside the lung alveoli
c. transpulmonary pressure - difference between alveolar and pleural pressures

Question 35

Infection from which of the following is the most common trigger of asthma exacerbations?

a. Mycoplasma
b. Coronavirus
c. Rhinovirus
d. Respiratory syncytial virus

Answer 35

C

Question 36

Adventitious breath sound that is continuous, sinusoidal, musical, prolonged, relatively high-pitched with hissing or shrill quality.

a. crackles
b. rales
c. wheezes
d. rhonchi

Answer 36

C

crackles or rales: discontinuous, intermittent, nonmusical, and brief (fine: soft, high-pitched; coarse: louder, lower in pitch)
rhonchi: adventitious breath sound that is continuous, sinusoidal, musical, prolonged, relatively low-pitched with snoring quality

Question 37

Major antigen-presenting cells in bronchial asthma that take up allergens and process them into peptides, and migrate to local lymph nodes

a. Langerhan cells
b. B cells
c. dendritic cells
d. macrophages

Answer 37

C

Question 38

These are the major target cells for inhaled corticosteroids.

a. airway smooth muscles
b. fibroblasts
c. dendritic cells
d. epithelial cells

Answer 38

D

Question 39

T lymphocytes play an important role in coordinating the inflammatory response in asthma through the following, except:

a. recruitment and survival of eosinophils
b. release of cytokines
c. promote TH2 differentiation
d. maintenance of mast cell population in the airways

Answer 39

c. promote TH2 differentiation - role of immature dendritic cells

Question 40

The following are TH2 cytokines that mediate allergic inflammation, except:

a. IL-4
b. IL-5
c. IL-9
d. IL-12
e. none of the options
f. two of the options

Answer 40

D should be IL-13

anti-inflammatory: IL-10 and IL-12

Question 41

The following are effects of inflammation to airway epithelium which causes epithelial damage and may contribute to AHR by:

a. loss of its barrier function to allow penetration of allergens
b. loss of relaxant factor
c. exposure of sensory nerves
d. loss of enzymes that degrade certain peptide inflammatory mediators like bradykinin
e. two of the options
f. all of the options

Answer 41

F

Question 42

The following are characteristics of structural changes in airway remodeling, except:

a. increased airway smooth muscle
b. fibrosis
c. angiogenesis
d. mucus atrophy

Answer 42

D

Question 43

Limitation of airflow that is due to bronchoconstriction results in:

a. reduction in FEV1, FEV1/FVC ratio and increase in PEF and airway resistance
b. reduction in FEV1/FVC ratio and increase in FEV1, PEF and airway resistance
c. reduction in FEV1, FEV1/FVC ratio, PEF and increase in airway resistance
d. reduction in airway resistance, FEV1, FEV1/FVC ratio, and increase in PEF

Answer 43

C

Question 44

The following statements are true of Airway Hyperresponsiveness, except:

a. It is a characteristic physiologic abnormality of asthma
b. It describes the excessive bronchodilator response to multiple triggers
c. An increase in AHR is linked to the frequency of asthma symptoms
d. The multiple asthma triggers when inhaled have no effect on normal airways

Answer 44

B

Question 45

Patient CL, 25, with a history of childhood asthma consulted your clinic because he experiences breathlessness while at rest and prefers sitting and is also agitated. During PE, HR is at 115bpm, SaO2 95%, and a loud wheeze is heard throughout exhalation. He is classified to be in:

a. Mild Asthma attack
b. Moderate Asthma attack
c. Severe Asthma attack
d. Respiratory Arrest

Answer 45

B

Question 46

It is a noninvasive test to measure eosinophilic airway inflammation.

a. fractional exhaled nitric oxide (FENO)
b. arterial blood gas
c. skin tests
d. allergen challenge

Answer 46

A

arterial blood gas - test that measures the pH and levels of oxygen and carbon dioxide in the blood from an artery
skin tests - skin prick tests for common inhalant allergens
allergen challenge

Question 47

It is the first line of treatment for asthma

a. long-acting inhaled beta-agonists
b. long-acting inhaled anticholinergics
c. short-acting inhaled beta-agonists
d. inhaled corticosteroid therapy

Answer 47

D

Question 48

Short-acting B2 agonist that acts on b2 adrenergic receptors to relax the bronchial smooth muscle with adverse effects of tremors and nervousness

a. salmeterol
b. albuterol
c. arformoterol
d. levalbuterol

Answer 48

B

Question 49

Lowers free plasma IgE to undetectable levels → significantly reduces the magnitude of both early and late bronchospastic response to antigen challenge. Adverse effect: anaphylaxis

a. Omalizumab
b. Mepolizumab
c. Reslizumab
d. Dupilumab

Answer 49

A

Question 50

It is all that is required for patients with mild, intermittent asthma.

a. long-acting inhaled beta-agonists
b. long-acting inhaled anticholinergics
c. short-acting inhaled beta-agonists
d. inhaled corticosteroid therapy

Answer 50

C

Question 51

The following are factors that affect the decrease in clearance of theophylline, except:

a. liver disease
b. high carbohydrate diet
c. barbecued meat
d. pneumonia
e. vaccination

Answer 51

C