Pulmonology

Question 1

Mechanical factors are critically important in host defense in the pathophysiology of pneumonia. Which of the following is false regarding these host defense?

a. The hairs and turbinates of the nares capture larger inhaled particles before they reach the lower respiratory tract.
b. The branching architecture of the tra¬cheobronchial tree traps microbes on the airway lining, where mucociliary clearance and local antibacterial factors either clear or kill the potential pathogen.
c. The gag and cough reflexes offer no protection from aspiration
d. The normal flora adhering to mucosal cells of the oropharynx, whose components are remarkably constant, prevents patho¬genic bacteria from binding and thereby decreases the risk of pneumonia

Answer 1

c. The gag and cough reflexes offer no protection from aspiration

Question 2

The host inflammatory response, rather than proliferation of microorganisms, triggers the clinical syndrome of pneumonia. The release of inflammatory mediators, such as interleukin 1 and tumor necrosis factor, results in fever. *

a. Both statements are true
b. Both statement are false
c. 1st statement is true, 2nd statement is false
d. 1st statement is false, 2nd statement is false

Answer 2

a. Both statements are true

Question 3

Which of the following phase of pneumonia describes the red hepatization phase? *

a. With the presence of a proteinaceous exudate—and often of bacteria—in the alveoli
b. The presence of erythrocytes in the cellular intra-alveolar exudate gives this second stage its name, but neutrophil influx is more important with regard to host defense
c. The neutrophil is the predominant cell, fibrin deposition is abundant, and bacteria have disappeared.
d. None of the above

Answer 3

b. The presence of erythrocytes in the cellular intra-alveolar exudate gives this second stage its name, but neutrophil influx is more important with regard to host defense

Question 4

This phase corresponds with successful containment of the infection and improvement in gas exchange *

a. Edema
b. Red hepatization
c. Gray hepatization
d. Resolution

Answer 4

c. Gray hepatization

Question 5

Atypical organisms that can cause pneumonia includes except? *

a. Mycoplasma pneumoniae
b. Chlamydia pneumoniae
c. Influenza viruses
d. Klebsiella pneumoniae

Answer 5

d. Klebsiella pneumoniae

Question 6

A 45 year old male, smoker, with history of COPD is being managed as a case of community acquired pneumonia. Which of the following organisms suggest possible cause of the CAP of the patient? *

a. Chlamydia pneumoniae
b. Burkholderia cepacia
c. Hantavirus
d. Mycobacterium tuberculosis

Answer 6

a. Chlamydia pneumoniae

Question 7

7. Which of the following factor-pathogen pairing is false? *

a. Legionella- stay in hotel or on cruise ship in previous 2 weeks
b. H. capsulatum- exposure to bats or birds
c. Coxiella burnetii- exposure to cats or dogs
d. Francisella tularensis- exposure to rabbits

Answer 7

c. Coxiella burnetii- exposure to cats or dogs

Question 8

The main purpose of the sputum Gram’s stain is to ensure that a sample is suitable for culture. To be adequate for culture, a sputum sample must have >25 neutrophils and <10 squamous epithelial cells per low-power field. *

a. Both statements are true
b. Both statement are false
c. 1st statement is true, 2nd statement is false
d. 1st statement is false, 2nd statement is false

Answer 8

a. Both statements are true

Question 9

The following are risk factors for early deterioration on CAP, except? *

a. Multilobar infiltrates
b. Severe acidosis (pH <7.30)
c. Hyponatremia
d. Hyperglycemia

Answer 9

d. Hyperglycemia

Question 10

If CAP-MRSA is a consideration, which of the following will you start as a treatment? *

a. Add Linezolid + vancomycin + Clindamycin
b. Add Linezolid or vancomycin or Clindamycin
c. Add Linezolid or Vancomycin + Clindamycinc.
d. Add linezolid + Vancomycin or Clindamycin

Answer 10

c. Add Linezolid or Vancomycin + Clindamycin

Question 11

Which among the following is a known major risk factor for asthma? *

a. Atopy
b. Environment
c. Diet
d. Infection

Answer 11

a. Atopy

Question 12

Due to extreme dyspnea, a 45-year-old woman was brought to our institution. Ate the Emergency Room, the patient’s vital signs are as follows: BP: 90/60, CR: 110 bpm, tachypneic at 40 breaths per minute, and SPO2 of 70% at room air. On physical examination, she was cyanotic and was stuporous. Diffuse crackles were heard on both lung fields during lung auscultation. ABGs done revealed the following: pH- 7.20, PCO2: 75, HCo3:16, PO2: 45. You then decided to intubate the patient.

In order to minimize ventilator- induced lung injury, you must

(A) Set VT to > 6 ml/ kg of predicted body weight

(B) To get rid of excess CO2, aim for a respiratory rate of more than 35 breaths per minute.

(C) Maintain a plateau pressure of < 30 cm H20

(D) None of the above

Answer 12

(C) Maintain a plateau pressure of < 30 cm H20

Question 13

Neuromuscular blockade for 48 hours on patients with severe ARDS increases survival and ventilator free days. Routine use of glucocorticoid is beneficial among patients managed as ARDS.

(A) Both statements are True
(B) Both statements are incorrect
(C) 1st statement is True. 2nd statement is False
(D) 1st statement is False. 2nd statement is True

Answer 13

(C) 1st statement is True. 2nd statement is False

Question 14

All are important aspects of ARDS management EXCEPT: *

(A) Fluid restriction and diuretic use to reduce atrial filling pressures

(B) Patients with severe ARDS are placed in a prone position.

(C) Surfactant replacement

(D) All of these play a role in the treatment of ARDS.

Answer 14

(C) Surfactant replacement

Question 15

The maximum lung function recovery time for patients who have survived ARDS is *

3 months
4 months
5 months
6 months

Answer 15

6 months

Question 16

To diagnose Obstructive Sleep Apnea/ Hypopnea Syndrome, the following conditions must be met EXCEPT. *

(A) snoring, snorting, gasping or breathing pauses during sleep

(B) Apnea- hypopnea index of > 10 episodes/hour in the absence of symptoms

(C) > 5 episodes of obstructive apnea and hypopnea per hour of sleep in symptomatic patients

(D) None of the above

Answer 16

(C) > 5 episodes of obstructive apnea and hypopnea per hour of sleep in symptomatic patients

Question 17

Central Sleep Apnea is an independent risk factor for developing what heart condition. *

A. Heart Failure
B. Atrial Fibrillation
C. Ischemic Heart Disease
D. A and B
E. B and C

Answer 17

D. A and B

Question 18

This is the gold standard treatment for OSAHS, with the highest level of efficacy. *

(A) BIPAP
(B) CPAP
(C) surgery- uvulopalatopharyngoplasty
(D) Upper airway neuro stimulation

Answer 18

(B) CPAP

Question 19

what is the second most common cause of your answer in number 12?

Left Ventricular Failure
Liver cirrhosis
Pneumonia
Malignancy

Answer 19

Malignancy

Question 20

Factors indicating the likely need for a procedure more invasive than a thoracentesis are the following. please arrange the following according to order of importance: most important to least important. *

Answer 20

1. Presence of gross pus in the pleural space
2. Positive gram stain or culture of the pleural fluid
3. Pleural fluid glucose <3.3 mmol/L (<60mg/dL)
4. Pleural fluid pH <7.2
5. Loculated pleural fluid

Question 21

Three malignancies which account for 75 percent of all malignant pleural effusions are the following EXCEPT: *

Lung cancer
Breast Cancer
Lymphoma
Colon Cancer

Answer 21

Colon Cancer

Question 22

All of the following is one of Light’s Criteria (for the diagnosis of pleural exudative effusions) EXCEPT: *

Pleural proteins/serum proteins greater than 0.5 ratio

m

LDH greater than 2/3 upper limit of normal for serum

Pleural LDH/serum LDH greater than 0.6 ratio

Answer 22

Total proteins greater than 2/3 upper limit of normal for serum

Question 23

A 63 year old female, diagnosed with uterine cancer came due to sudden onset difficulty of breathing. Patient has no cough, no fever and no chest pain. She had been bed-ridden for almost two months and with concomitant complaint of leg pain for 1 month. Pulmonary embolism is highly likely. What is your next step in the diagnostic algorithm? *

D-dimer
Chest CT scan
2DED
Peripheral venous ultrasound

Answer 23

Chest CT scan

Question 24

All of the following statements are true regarding D-dimer testing except *

(A) The d-dimer is less sensitive for DVT than for PE because the DVT thrombus size is smaller.

(B) Patients with a low-to-moderate likelihood of DVT or PE should undergo initial diagnostic evaluation with d-dimer testing alone without obligatory imaging tests.

(C) A normal d-dimer is a useful “rule out” test
(D) None of the above
(E) All of the above

Answer 24

(D) None of the above

Question 25

The best-known indirect sign of PE on transthoracic echocardiography is: hypokinesis of the RV free wall with normal or hyperkinetic motion of the RV apex. *

McConnell’s sign
Westermark’s sign
Palla’s sign
Hampton’s hump

Answer 25

McConnell’s sign

Question 26

These are factors/conditions which portend a high risk of an adverse clinical outcome despite anticoagulation, except *

Hemodynamic instability
RV dysfunction on echocardiography
RV enlargement on chest CT
Elevation of the D-dimer level

Answer 26

Elevation of the D-dimer level

Question 27

The most common cause of primary spontaneous pneumothorax *

COPD
Rupture of apical pleural blebs
Trauma
Unknown

Answer 27

Rupture of apical pleural blebs

Question 28

Risk factors of primary spontaneous pneumothorax includes the following, except *

Male sex
Uncontrolled asthma
Smoking
Family history 
Marfan Syndrome

Answer 28

Uncontrolled asthma

Question 29

65/ M with COPD is consulting for dyspnea. He is compliant to his inhaler therapy but reports that he needs to stop to rest when walking at his own pace on level ground. What is the grade of his dyspnea using the Modified Medical Research Council Dyspnea Scale?

a. Grade 2

b. Grade 1

c. Grade 3

d. Grade 4

Answer 29

mMRC—Modified Medical Research Council Dyspnea Scale.

0—only with strenuous activity
1—hurrying on level ground or walking up a slight hill
2— walk slower than peers or stop walking at their own pace
3—walking about 100 yards or after a few minutes on level ground
4—too breathless to leave the house or when dressing

Question 30

Which of the following is the procedure of choice to control massive hemoptysis?

a. Bronchial artery embolization

b. Surgical resection

c. Bronchoscopy with balloon catheter insertion

d. Rigid bronchoscopy with photocoagulation

Answer 30

a. Bronchial artery embolization

Question 31

Which of the following causes of hypoxia may be corrected by inspiring 100% O2 for several minutes?

a. Hypoventilation

b. Eisenmenger’s syndrome

c. Pulmonary atelectasis

d. Pulmonary AV malformation

Answer 31

a. Hypoventilation

Question 32

33/M post-stroke patient consulted for a 1-month history of on/off fever, productive cough with putrid smelling sputum and pleuritic chest pain. Chest X-ray showed a solitary thick-walled cavity measuring 5 cm with air-fluid level found at the middle posterior lobe of the right lung. Which of the following is the most appropriate empiric therapy?

a. Clindamycin

b. Ceftriaxone + Azithromycin

c. Metronidazole

d. Vancomycin

Answer 32

a. Clindamycin

Question 33

What disease condition is compatible with the flow-volume loop and pulmonary function test result shown below?
a. Acute asthma

b. Severe emphysema

c. Moderate obesity

d. Pulmonary fibrosis

Answer 33

Severe emphysema

Question 34

37/M consulted for shortness of breath, chest tightness and wheezing. He underwent spirometry with reduced FEV1 and reduced FEV1/FVC. He has been having troublesome daily symptoms and night-time awakening most days of the week. What initial treatment is recommended for the patient?

a. As needed low dose inhaled corticosteroid (ICS)-formoterol

b. As needed short-acting β2-agonist

c. Low dose maintenance ICS-formoterol

d. Medium dose maintenance ICS-formoterol

Answer 34

d. Medium dose maintenance ICS-formoterol

Question 35

Which of the following pathologic types of emphysema is associated with cigarette smoking?

a. Centrilobular

b. Panlobular

c. Paraseptal

d. Panseptal

Answer 35

Centrilobular

Centrilobular Emphysema
~ associated with cigarette smoking
~ upper lobe and superior segment of lower lobe

Panlobular Emphysema
~ Associated with alpha 1 antitrypsisn deficiency
~ evenly distributed across acinar units

Paraseptal Emphysema
~ pleural margins with relative sparing of the lung core or central regions

Question 36

65/M consulted for persistent dyspnea. He presents with a 5-year history of cough and chronic sputum production. He was previously diagnosed with COPD but was non-compliant to his inhaler therapy. Currently, he complains of breathlessness when walking briskly on level ground or at his own pace. He also has a history of one hospital admission six months prior due to exacerbation. What is his COPD Group Severity Classification?

a. A

b. B

c. C

d. D

Answer 36

C

Question 37

Which of the following interstitial lung diseases (ILD) is strongly associated with smoking?

a. Respiratory bronchiolitis-associated ILD

b. Idiopathic pulmonary fibrosis (IPF)

c. Nonspecific interstitial pneumonitis (NSIP)

d. Sarcoidosis

Answer 37

Respiratory bronchiolitis-associated ILD

Question 38

Which of the following interstitial lung diseases presents with non-caseating granulomas on histopathology?

a. TB-associated ILD

b. Systemic sclerosis-associated ILD

c. Sarcoidosis

d. Acute interstitial pneumonia

Answer 38

c. Sarcoidosis

Question 39

Which of the following is the most common cancer associated with asbestos exposure?

a. Mesothelioma

b. Lung cancer

c. Breast cancer

d. Lymphoma

Answer 39

b. Lung cancer

Question 40

Which of the following laboratory parameters can differentiate an effusion from malignancy versus heart failure?

a. Lactate dehydrogenase

b. Glucose

c. Differential count

d. pH

Answer 40

a. Lactate dehydrogenase

Question 41

45/F with breast cancer was admitted for fever, dyspnea and weight loss. She immediately underwent thoracentesis for left-sided pleural effusion. Further work-up revealed loculated pleural effusion, gross pus in the pleural space, pleural fluid glucose 40 mg/dL and presence of gram-negative organism on Gram stain. Which of the following patient factors most importantly indicates a need for a more invasive procedure than a thoracentesis?

a. Loculated pleural effusion

b.Gross pus in the pleural space

c. Pleural fluid glucose 40 mg/dL

d. Gram-negative organism on Gram stain

Answer 41

a. Loculated pleural effusion

Question 42

Which of the following compartments of the mediastinum is commonly affected by masses of vascular origin?

a. Anterior

b. Middle

c. Posterior

d. Lateral

Answer 42

b. Middle

Question 43

50/M was brought to the ER due to dyspnea and was found to have massive pleural effusion. Thoracentesis showed milky fluid which was found to have triglyceride 150 mg/dL. What is the treatment of choice for his condition?

a. Insertion of a chest tube and administration of octreotide

b. Ligation of the thoracic duct

c. Percutaneous transabdominal thoracic duct blockage

d. Prolonged thoracostomy with chest tube drainage

Answer 43

a. Insertion of a chest tube and administration of octreotide

Initial Management
¤ CTT plus ocreotide
• Not for very prolonged period of time because this will lead to malnutrition and immunologic incompetence

Definitive Management
¤ Percutaneous transabdominal thoracic duct blockage
¤ Ligation of the Thoracic duct

Question 44

what level of apnea-hypopnea index can you make a diagnosis of obstructive sleep apnea/hypopnea syndrome in the absence of symptoms?

a. Apnea-hypopnea index > 20 episodes/hour

b. Apnea-hypopnea index > 15 episodes/hour

c. Apnea-hypopnea index > 10 episodes/hour

d. Apnea-hypopnea index > 5 episodes/hour

Answer 44

Apnea-hypopnea index > 15 episodes/hour

Question 45

Which of the following interventions must be done in a 26/M obese patient on CPAP and complaining of aerophagia?

a. Administer antacids

b. Change mask interface

c. Provide bilevel positive airway pressure

d. Provide heated humidification

Answer 45

ANTACIDS

Aerophagia is the medical term forexcessive and repetitive air swallowing. We all ingest some air when we talk, eat, or laugh. People with aerophagia gulp so much air, it produces uncomfortable gastrointestinal symptoms. These symptoms include abdominal distension, bloating, belching, and flatulence. Hence, giving antacids may relieve his symptoms

Question 46

A 28/M with COVID-19 was sent to the ER for a 1-week history of progressive dyspnea and febrile episodes. At the ER, he was intubated for respiratory distress and was immediately admitted at the ICU. Chest radiograph showed bilateral opacities and normal-sized heart. Post intubation ABG showed pH 7.3, HCO3 9, pCO2 25, PaO2 200 at FiO2 100%. What is the ARDS severity?

a. Moderate

b. Mild

c Severe

d. Critical

Answer 46

Moderate

Question 47

45/F with preexisting barotrauma was intubated for respiratory distress. Which of the following is the preferred mode of ventilation for this patient?

a. Pressure-control ventilation

b. Inverse-ratio ventilation

c. Intermittent mandatory ventilation

d. Airway pressure release ventilation (APVR)

Answer 47

a. Pressure-control ventilation

Question 48

45/M with critical COVID -19 was hooked to high-flow nasal cannula (40 LPM, FiO2 90%) at the ER. After two hours, findings showed RR 30, O2 saturation was 90% at FiO2 90%, with the rest of the vital signs stable. What is the Rox Index?

a. 3.3

b. 0.33

c. 0.37

d. 3.7

Answer 48

a. 3.3

Question 49

Which of the following criteria may aid in distinguishing transudative from exudative effusion outside of the Light’s criteria?

a. Pleural fluid protein/serum protein >0.5

b. Pleural fluid LDH/serum LDH >0.6

c. Pleural fluid LDH more than two-thirds the normal upper limit for serum

d. Gradient between serum and pleural fluid protein levels >31 g/L

Answer 49

d. Gradient between serum and pleural fluid protein levels >31 g/L

Question 50

Which of the following is not a component in the calculation of the sepsis-related organ failure assessment (SOFA) score?

a. PaO2/FiO2

b. WBC count

c. Bilirubin count

d. Urine output

Answer 50

b. WBC count

Question 51

Which of the following laboratory tests may be performed to measure eosinophilic airway inflammation and may be used as a test of compliance with therapy?

a. Exhaled NO

b. Radioallergosorbent test

c. Metacholine challenge test

d. Measurement of PEF twice daily

Answer 51

a. Exhaled NO

Question 52

Which of the following ABG pictures is consistent with impending respiratory failure from severe acute asthma?

a. pH 7.4; pCo2 40; PaO2 80; HCO3 35
b. pH 7.2; pCo2 24; PaO2 88; HCO3 7
c. pH 7.5; pCo2 18; PaO2 100; HCO3 27
d. pH 7.3; pCo2 20; PaO2 80; HCO3 14

Answer 52

a. pH 7.4; pCo2 40; PaO2 80; HCO3 35

ABG of asthma may show normal or increasing PCO2 in impending respiratory failure