Pulmonology 🫁

Question 1

A 3 YO boy with barky cough, no inspiratory stridor, positive monophasic wheeze in auscultation, dx:

A. Beonchitis or bronchiolitis
B. Tracheomalacia
C. Laryngomalacia
D. Bronchial asthma

Answer 1

B. Tracheomalacia

Sx:
Upper airway- stridor &barking cough
Lower airway- monophasic wheeze

Question 2

A newborn/infant with stridor worse when supine improves when prone, what to do?

A. Start laser treatment
B. Tell mom it will resolve on its own by first birthday
C. Tell mom it will get worse
D. Do laryngioscope

Answer 2

B. Tell mom it will resolve on its own by first birthday

Stridor (positional) = laryngomalacia
Monophasic wheeze = Tracheomalacia

Question 3

1 month present with history of stridor that worsening in supine position.
Best diagnostic test:

A. Xray
B. CT
C. Laryngioscope
D. Barium

Answer 3

C. Laryngioscope

Laryngiomalacia
Resolve spontaneously within 12 mo age
Best Dx laryngoscope

Question 4

A child with history of croup and treated with steroid and epinephrine but not improved. Which is next?

A. Lateral neck Xray
B. CT scan
C. Visualized by laryngoscope
D. Chest Xray

Answer 4

A. Lateral neck Xray

Always rule out acute epiglottitis when patient with croup-like presentation
- stridor
- acute epiglottitis: look toxic, muffled voice, unable to speak or swallow

Question 5

A child known asthma and has frequent exacerbation after exercise. Which is best:

A. Avoid exercise
B. Short acting beta agonist
C. Long acting beta agonist
D. Inhaled steroid

Answer 5

B. Short acting beta agonist

Question 6

Child known asthmatic and not controlled on salbutamol inhaler and still has frequent day time symptoms 3 times per week
Best management:

A. Mast cell stabilizer
B. Leukotriene antagonist
C. Inhaled steroid
D. Oral steroid

Answer 6

C. Inhaled steroid

Step1: SABA
Step2: +Low dose ICS
Step3: +Double dose ICS
Step4: +Double dose ICS + LT modifier
Step5: +Oral CS

Question 7

7 YO known asthmatic and low dose ICS and still not controlled.
Which of the following best option:

A. Mast cell stabilizer
B. Oral steroid
C. LABA
D. Anti-IgE antibodies

Answer 7

C. LABA

Question 8

Child presented with asthma exacerbation. The patient did not respond to ß2 agonists. What is your next step?

A. Aminophyllin
B. Systemic steroid
C. Inhaled steroid
D. LABA

Answer 8

B. Systemic steroid
🗝️ exacerbation

Question 9

Patient present with severe asthma exacerbation on albuterol and long acting glucocorticoid. On exam: resp distress, diffuse expiratory wheeze. He received systemic steroid and ß2 agonist inhaler but no improvement. CXR: hyperinflation. Ph 7.3 .. Your plan:

A. Admission to ICU
B. Discharge and reassurance
C. Discharge and follow up next day
D. Start inhaled steroid

Answer 9

A. Admission to ICU

🚩 Low Ph is a sign of respiratory muscle fatigue & respiratory failure

🔹 Asthmatic patient has (resp alkalosis: hyperventilation and wash out CO2)

Question 10

A worried mother brings her baby to checkup and expresses concern of her child contracting TB from his grandfather. He had the BCG vaccine since birth.
What do you do?

A. Reassure, no need to do anything as baby already had the BCG vaccine
B. Do PPD test and request CXR
C. Start anti-TB Isoniazid and rifampin
D. Start all anti-TB meds

Answer 10

B. Do PPD test and request CXR

Best screening test for TB in children:
<2 yr: PPD & CXR
>2 yr: IGRA & CXR
Anti-TB high risk for resistance:
- Latent TB: (+PPD, -CXR) INH
- Active TB: (+PPD, +CXR) all 4

Question 11

2 YO child has PPD of 10 mm and is coming from Africa

A. Negative
B. Positive
C. This test not reliable anymore
D. Borderline

Answer 11

B. Positive

• childern <4 yr
• recent arrival from high prevalence countries (<5 yr)

Question 12

Best diagnostic test of asthma in children:
A. Methacholine challenge test
B. Spirometry
C. Blood gas
D. Chest XR

Answer 12

B. Spirometry

Reversible obstructive pattern after bronchodilator (FEV1/FVC <80%)

Question 13

Which of the following is the best to describe about asthma in children.

A. Will persist to adulthood
B. 50% will resolve by adulthood
C. Will develop COPD
D. Will have growth failure

Answer 13

B. 50% will resolve by adulthood

Question 14

4 years of asthma and he is on inhaled steroid and inhaled beta agonist but still uncontrolled. Most likely reason:

A. Child abuse
B. Present of atopy
C. Failure of inhaler technique
D. Presence of dust

Answer 14

C. Failure of inhaler technique

Question 15

What type of respiratory failure usually develop in children with cerebral palsy?
A. Hypoxic
B. Hypercapnic
C. Hypocapnic
D. Alkalosis

Answer 15

B. Hypercapnic

🔸RF 1: Hypoxic , PO2 <60 , Oxygenate
- ILD, pneumonia, pulm edema, PE

🔸RF 2: Hypercapnic , PCO2 >50 , ventilate
- OLD, neurologic

Question 16

A child of mechanical ventilator
Blood gas: pH 7.3 , CO2 normal , O2 low
Most likely:

A. Type 1 RF (hypoxic)
B. Type 2 RF (hypercapnic)
C. Shock
D. Heart failure

Answer 16

A. Type 1 RF (hypoxic)

Question 17

A child has bilateral nasal polyps
Which if the following most helpful?

A. CT for nose
B. Xray
C. Sweat chloride test
D. Biopsy

Answer 17

C. Sweat chloride test

CF is most common cause for bilateral nasal polyps in children 👃🏻

Question 18

Baby diagnosed with CF his sweat chloride test +ve. He has normal brother.
To confirm diagnosis of CF:

A. CFTR gene in parent
B. CFTR gene in sibling
C. Chloride test for parent
D. Chloride test for sibling

Answer 18

B. CFTR gene in sibling

Diagnostic criteria of CF
———————————
One of:
Sweat chloride >60
2 CFTR mutation
NPD +ve
AND
One of:
Phenotypical finding of CF
Neonatal screen +ve
Family history +ve

Question 19

A child known case of CF had an uncle with same disease, his father and brother are normal.
What is the most appropriate next step?

A. Sweat chloride test for siblings
B. CXR for siblings
C. Sweat chloride test for father
D. Stool analysis

Answer 19

A. Sweat chloride test for siblings
CF is autosomal recessive

Question 20

Which of the following is the mist common initial presentation of CF in neonate?
A. Failure to thrive
B. Cough
C. Rectal prolapse
D. Meconium illeus

Answer 20

D. Meconium illeus

Question 21

13 months old girl present with fever 38, bilateral lung infiltrate, she looks mildly ill, what is the most likely organism?
A. Moraxella catarrhalis
B. Strep pneumonia
C. Hib influenza
D. Neisseria

Answer 21

B. Strep pneumonia

Question 22

3 YO child medically free, presented with fever and tachypnea RR:20, O2 sat 94%
You should:

A. Discharge on amoxicillin
B. Discharge on augmentin
C. Admit for IV ceftriaxone
D. Admit for IV fluid

Answer 22

A. Discharge on amoxicillin

▫️In-patient indications:
- RR >50 infant, >70 child 1 yr
- O2 sat <92%
- effusion or empyema
-toxic appearance

▫️Antibiotic choice:
🔹outpatient: Amoxicillin » 2°/3° gen cephalosporin » macrolide or clinda
🔹inpatient: Ceftriaxone + macrolide
🔹ICU: Ceftriaxone + macrolide + Vanco

Question 23

Child with cough, fatigue, low grade fever, 2 times bloody vomiting, Dullness to percussion. Dx:

A. Parapneumonic effusion
B. Pleural effusion
C. TB
D. Viral

Answer 23

A. Parapneumonic effusion

Question 24

5 months old came with respiratory distress, cough, sneezing, frothy sputum and cyanosis. On examination: diffuse wheezing and basal lung crepitation. CXR: bilateral infiltrates. Dx:

A. Bronchiolitis
B. Pulmonary edema
C. TB
D. Pneumonia

Answer 24

A. Bronchiolitis (RSV)
🗝️ age of 5 months, wheeze

Question 25

6 months with respiratory distress, low grade fever, diffuse wheezing.
Management:

A. Salbutamol
B. Hydration
C. Antibiotics
D. Steroid

Answer 25

B. Hydration

Bronchiolitis
Agent: -viral RSV-
Tx: O2, hydration, Ribavirin if immunocomp
🚫no role of: ABx, CS, hypertonic saline neub, ß-agonist neub