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Respiratory Quiz

6 th of June, 2014

25 y male presented with cough, chest pain and headache from last 4 days. He noticed rash over his extremities. On examination spo2 was 90% and he had bilateral wheeze on auscultation. Chest x-ray showed bilateral patchy infiltrates. Laboratory

parameters are shown below. What is most likely diagnosis

Hb 10gm/dl PLT 110

WBC 9.2,

Na 130,

K 4.6

Bil

3.

MCV 99

Crt 1.2

a) Chlamydia psittaci pneumonia b) Viral pneumonia(Influenza ) c) Mycoplasma pneumonia d) Legionella pneumonia
a)
Chlamydia psittaci pneumonia
b)
Viral pneumonia(Influenza )
c)
Mycoplasma pneumonia
d)
Legionella pneumonia
• 25 y male presented with cough, chest pain and headache from last 4 days. He

30 y female reports to your

clinic with shortness of breath on exertion. She denies cough or wheezing. She had history of road traffic accident 2 years earlier, required 8 weeks of

ICU care and mechanical

ventilation. Her flow volume

loop and spirometry results are shown.

FEV1 2.46 (67% pred)

FVC 4.06 (100%),

FEV1/FVC 53%

a) Chest wall deformity b) Pulmonary fibrosis c) Tracheal stenosis d) Tracheomalacia e) Vocal cord paralysis
a)
Chest wall deformity
b)
Pulmonary fibrosis
c)
Tracheal stenosis
d)
Tracheomalacia
e)
Vocal cord paralysis

Flow

• 30 y female reports to your clinic with shortness of breath on exertion. She denies

Volume

23 y male presents with sudden onset of chest pain and shortness of breath. He has no significant past history. RR = 34, sPO2= 93% on room air and pulse = 100 bpm. Chest radiograph was done(shown below). What is the diagnosis and next step in the

management.

a) Admit for high flow oxygen and repeat chest x-ray in the morning b) Discharge and
a)
Admit for high flow oxygen and repeat chest x-ray in the morning
b)
Discharge and follow chest x-ray in 5 days.
c)
Intra costal tube drainage
d)
Observation overnight
e)
Simple aspiration

60 year old male presents to respiratory clinic with day time somnolence, impaired concentration and morning headache. His BMI is 30 kg/m2 and EPSS 12. Full PSG demonstrates an AHI-2 and repetitive leg movements up to 5 sec in duration separated by 30 sec interval. What is the recommended treatment?

a) Recommend use of CPAP b) Modafinil c) Paroxetine d) Measures to reduce weight and reassess
a)
Recommend use of CPAP
b)
Modafinil
c)
Paroxetine
d)
Measures to reduce weight and reassess after 8 weeks
e)
None of the above

A

55

y

male

known to have

obstructive pulmonary disease, is

admitted

to

hospital

with

diagnosis of acute exacerbation

of COPD. After

1

hour

of

admission

on

standard

medical

treatment,

patients

vital

signs

and blood gases were.

GCS = 14/15

RR = 26 Pulse = 98

SBP = 110 SpO2 = 88% use of accessory muscles of respiration. pH= 7.26 pCO2 = 66.

a) Increase dose of bronchodilators b) Add antibiotics c) Increase Fractional oxygen concentration d) Use CPAP
a)
Increase dose of bronchodilators
b)
Add antibiotics
c)
Increase Fractional oxygen
concentration
d)
Use CPAP
e)
Use BPAP
f)
Patient is candidate for mechanical
ventilation
What is the next best step of management.
What
is
the
next
best step
of
management.

Volume time graph of a 56 y old male with 1 year history of exertional breathlessness and cough

a) Obstructive airway disease b) Restrictive airway disease FVC c) Mixed airway disease FEV1 d) Wrong
a)
Obstructive airway disease
b)
Restrictive airway disease
FVC
c)
Mixed airway disease
FEV1
d)
Wrong spirometry needs to repeat
e)
V
Type of defect cannot be made
from Volume time graph
O
L
FEV1/FVC = 78%
U
M
E
0
1s
2 s
time
4s
5s
6s

35 y female presented with fever, cough and chest pain. Chest x- ray showed right lower zone consolidation. CECT revealed multi loculated effusion. Pleural fluid analysis done showed

pH = 7 Total proteins = 4.5 mg/dl LDH = 1232 IU/L TLC 800 (80 N 20 L)

35 y female presented with fever, cough and chest pain. Chest x- ray showed right lower

What is the next step in management

a) Intracostal tube drainage b) Intrapleural streptokinase c) Broad spectrum Injectable antibiotics d) Surgical Decortication e)
a)
Intracostal tube drainage
b)
Intrapleural streptokinase
c)
Broad spectrum Injectable antibiotics
d)
Surgical Decortication
e)
Video assisted thorascopic surgery

35 y male presented with two month history of exertional dyspnea and dry cough. He was hypoxemic (spo2 86%) on room

air. His chest x ray showed bilateral alveolar and interstitial opacities and HRCT chest showed bilateral ground glass pattern with septal thickening. BAL fluid was positive for PAS stain

What is the most likely diagnosis

• 35 y male presented with two month history of exertional dyspnea and dry cough. He
• 35 y male presented with two month history of exertional dyspnea and dry cough. He

36 y male with a history of AIDS and pneumocystis infection presents to accident and emergency with severe respiratory distress. Ventilatory settings are

Rate =16 Tidal volume= 600ml

FiO2= 1.0

Arterial blood gas after 1 hour is

pO2= 350 mmHg pCO2= 36 pH = 7.32.

Alveolar oxygen tension is approximately equal to.
Alveolar oxygen tension is approximately equal to.
• 36 y male with a history of AIDS and pneumocystis infection presents to accident and
a) 105 b) 355 c) 576 d) 665 e) 712
a)
105
b)
355
c)
576
d)
665
e)
712

A 68 y women developed fever and shortness of breath. Her

examination revealed cyanosis and hypoxemia. She was given

100% of oxygen for 30 minutes and her blood gases were as follows.

pO2= 96

Pco2= 33

pH= 7.46 HCO3= 22mEq/l SaO2= 89%

The patient has which of the following

a) Alveolar hypoventilation b) Diffusion impairment c) V/Q inequality with V/Q units d) Right – left
a)
Alveolar hypoventilation
b)
Diffusion impairment
c)
V/Q inequality with V/Q units
d)
Right – left shunting
e)
Carbon monoxide poisoning
What is the diagnosis and further management ?
What is the diagnosis and further
management ?

65 y male, hypertensive with

ischemic stroke 4 years earlier,

with poor drug compliance. He was diagnosed as a case of carcinoma stomach 1 month

before. He presents with

shortness of breath. Examination revealed

Pulse = 112

SBP= 100 mmHg

spo2 = 85 % and RR= 37 /minute

What is the diagnosis and further management ? 65 y male, hypertensive with ischemic stroke 4

What is the diagnosis

What are the various modalities of treatment

What is the diagnosis What are the various modalities of treatment

25

y

male was

brought

to

AE

after

attempted

suicide with

narcotic over dose. He was obtunded with RR = 6 breaths /min

BP =80/60 Heart rate = 80/min SPO2 = 70% on room air.

Arterial blood gas showed pH = 7.09 paCO2 =80 paO2 = 42.

Which of the following is true regarding patients ABG?

a) Patient is hypoxemic due to hypoventilation with normal A-a gradient. b) Patient is hypoxemic due
a)
Patient is hypoxemic due to hypoventilation with normal A-a gradient.
b)
Patient is hypoxemic due to hypoventilation with increased A-a gradient.
c)
Patient is hypoxemic due to shunt with increased A-a gradient.
d)
Patient is hypoxemic due to mismatched V/Q with increased A-a gradient.
• 25 y male was brought to AE after attempted suicide with narcotic over dose. He

A 65 y male has been receiving mechanical ventilation for 10

days for community acquired pneumonia. Which of the

following factors indicate that patient is not likely to be

successfully extubated.

a) Alert mental status b) PEEP of 5 cm H2O c) pH > 7.35 d) Rapid
a)
Alert mental status
b)
PEEP of 5 cm H2O
c)
pH > 7.35
d)
Rapid shallow breathing index > 105 (RR/Tidal volume)
e)
SaO2 > 90% and FiO2
< 0.5

A

58-year-old

woman

is

being

evaluated

in

the

emergency department for acute dyspnea.

FIO 2

pH

PaCO 2

%COHb

PaO 2

SaO

2

Hb

HCO 3

-

0.21

7.19

65 mm Hg

1.1%

45 mm Hg

90%

15.1 gm%

24 mEq/L

How would you characterize her state of oxygenation, ventilation, and acid-base balance

A 20 year old black nurse develops painful nodules on the skin of

both legs. She also has low grade fever and has lost 5 kgs in 2

months before presentation. Her chest X-ray showed bilateral

hilar lymphadenopathy. What is the most likely outcome of

patients illness?

a) Complete remission after a course of steroids and cytotoxic drugs. b) Complete remission with out
a)
Complete remission after a course of steroids and cytotoxic drugs.
b)
Complete remission with out any specific treatment
c)
Complete initial remission soon followed by relapse.
d)
Diffuse reticulo-nodular changes in the lung and progressive shortness of
breath.
• A 20 year old black nurse develops painful nodules on the skin of both legs.

65 year male known case of idiopathic pulmonary fibrosis on long term oxygen therapy and perfinedone. He presented with worsening of breathlessness, cough and fever. He was hypoxemic on room air with RR=26, Pulse =102. To made a diagnosis of acute exacerbation of IPF, which of the following is incorrect.

a) Previous or concurrent diagnosis of IPF b) Unexplained worsening or development of dyspnea within 30
a)
Previous or concurrent diagnosis of IPF
b)
Unexplained worsening or development of dyspnea within 30 days
c)
HRCT with new bilateral ground-glass abnormality and/or consolidation
on background of reticular or honeycomb pattern consistent with UIP
d)
Evidence of pulmonary infection by endotracheal aspirate or BAL
e)
Exclusion of alternative causes including: left heart failure, pulmonary
embolism, and identifiable cause of acute lung injury

What is the diagnosis?

a) Multiple lung abscess following aspiration pneu b) Multi locular Hydatid lung c) Cystic bronchiectasis d)
a)
Multiple lung abscess
following aspiration pneu
b)
Multi locular Hydatid lung
c)
Cystic bronchiectasis
d)
Multiple Gut loops

Which of the following is least likely to be associated

with smoking ?

a) Respiratory bronchiolitis–associated ILD b) Hypersensitivity pneumonitis c) Desquamative interstitial pneumonia d) Adult pulmonary Langerhans cell
a)
Respiratory bronchiolitis–associated ILD
b)
Hypersensitivity pneumonitis
c)
Desquamative interstitial pneumonia
d)
Adult pulmonary Langerhans cell histiocytosis
e)
Idiopathic pulmonary fibrosis

A 65 y old male known case of chronic obstructive lung disease. He

required emergency visit for his worsening of symptoms 4 times

last year. He reports breathlessness on routine daily activities. His

latest spirometry values are FEV1=36% of pred, FVC= 50% of

predicted. What is the severity of his COPD.

a) Group A b) Group B c) Group C d) Group D
a)
Group A
b)
Group B
c)
Group C
d)
Group D

A 45 y female with past medical history of poorly controlled asthma, HRCT

was suggestive of bronchiectasis and an area of consolidation. He had peripheral eosinophilia and had positive skin hypersensitivity test for aspergillus. He was started on treatment for aspergillosis. Which of the following tests is the most sensitive for monitoring treatment of ABPA?

a) Chest CT b) Total IgE level c) Pulmonary function testing d) Total peripheral blood eosinophil
a)
Chest CT
b)
Total IgE level
c)
Pulmonary function testing
d)
Total peripheral blood eosinophil count

30 y male had road traffic accident with fracture of his long bones ( lower limbs). He developed hypoxemia and obtundation 48 hours after admission to a multidisciplinary hospital. On examination he had GCS 12/15, Spo2 on room air 82%, petechial rash over axillae. He was febrile with tachycardia and tachypnea. NCCT head was normal, Chest radiograph revealed bilateral infiltrates. Diagnosis of fat embolism syndrome was made. Which of the following statement is true?

a) Fat embolism is only reported after multiple fractures of long bones b) Sickle cell disease,
a)
Fat embolism is only reported after multiple fractures of long bones
b)
Sickle cell disease, pancreatitis, total parenteral nutrition
can present with FES
c)
Schonfeld criteria is used to diagnose FES
d)
Steroids can be used to prevent development of FES
e)
Characteristic petechial rash is present in almost all
patients of FES

65 y male with one year history of dyspnea and non productive cough. On examination he had clubbing with chest auscultation revealing characteristic Velcro crepitation's. He desaturated with minimal exertion. Spirometry was s/o restrictive Ventilatory defect. HRCT chest showed features of UIP.

• Which of the following features favor HRCT diagnosis of UIP. a) Reticular abnormality b) Extensive
Which of the following features favor HRCT
diagnosis of UIP.
a)
Reticular abnormality
b)
Extensive ground glass abnormality
c)
Honey combing
d)
Traction bronchiectasis
e)
Diffuse bilateral nodules
f)
Upper or mid lung predominance

35 y male chronic smoker (10 packs/year), presented to

pulmonary clinic with multiple episodes of hemoptysis and left

sided chest pain. He had history of minor trauma chest two

years earlier. Evaluation for tuberculosis was inconclusive. CECT

was done (shown below). What is the most likely cause of his

hemoptysis.

• 35 y male chronic smoker (10 packs/year), presented to pulmonary clinic with multiple episodes of

What is the most possible etiology

Hb = 10.2 g/dl

 

TLC 5.4 (85/9)

PLT 123

Crt 2.2

Urine R/E

RBC ++

Albumin +

Sugar

nil

C-ANCA and p-ANCA +

CT chest and renal biopsy is shown

• What is the most possible etiology • Hb = 10.2 g/dl • TLC 5.4 (85/9)
• What is the most possible etiology • Hb = 10.2 g/dl • TLC 5.4 (85/9)

50 year male chronic smoker (45 packs/year). Under went

elective cholecystectomy. Perioperative chest x ray showed a

small approximately 1.5 cm nodular lesion, with no evidence of

effusion or consolidation. What are various parameters of

pulmonary nodule that increases the likely hood of malignancy

a) Age > 40 years b) Size more than 20 mm c) Smooth borders d) Eccentric
a)
Age > 40 years
b)
Size more than 20 mm
c)
Smooth borders
d)
Eccentric calcification

Lymphangioleiomyomatosis

..

all

are true except

a) Usualy seen in females during their child bearing age b) Chylous pleural effusions are common
a)
Usualy seen in females during their child bearing age
b)
Chylous pleural effusions are common
c)
Recurrent pneumothorces are seen
d)
Hormonal ablation and progestins are highly effective in the
treatment
e)
Hemoptysis is the most common presentation

You are considering oral omalizumab therapy for a patient

with severe

persistent

asthma

who

is

requiring

oral

prednisolone, in addition to inhaled steroids , LABAS and

montelukast. Which of the following is necessary prior to

initiating omalizumab?

1. Switch oral steroids to IV. 2. Demonstrate IgE levels >1000 IU/L. 3. Presence of sensitivity
1.
Switch oral steroids to IV.
2.
Demonstrate IgE levels >1000 IU/L.
3.
Presence of sensitivity to a perenial aeroallergen.
4.
Stop oral steriods.

Patients

with

chronic

hypoventilation

disorders

often

complain of a headache upon awakening. What is the cause of

this symptom?

1. Nocturnal micro aspiration and cough 2. Cerebral vasodilation. 3. Cerebral vasoconstriction 4. Polycythemia.
1.
Nocturnal micro aspiration and cough
2.
Cerebral vasodilation.
3.
Cerebral vasoconstriction
4.
Polycythemia.

Contraindications to surgery in non-small cell lung cancer …….all are true except

a) b) Esophageal invasion FEV1 less than 1.8 L c) d) malignant pleural effusion severe ischemic
a)
b)
Esophageal invasion
FEV1 less than 1.8 L
c)
d)
malignant pleural effusion
severe ischemic heart disease
e)
contralateral mediastinal lymph node involvement