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
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%

Flow

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

What is the next best step of
management.
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

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

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

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)
What is the next step in management
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
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.

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 shunting
e) Carbon monoxide poisoning


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 ?
30 y female was labeled as bronchial asthma for her intermittent
shortness of breath and wheeze, 1 year earlier. She had received
ICS and LABA, with no relief of her symptoms.

HRCT chest was ordered to look for alternate etiology.
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 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.



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 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
0.21
pH 7.19
PaCO
2
65 mm Hg
%COHb 1.1%
PaO
2
45 mm Hg
SaO
2
90%
Hb 15.1 gm%
HCO
3
-
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 any specific treatment
c) Complete initial remission soon followed by relapse.
d) Diffuse reticulo-nodular changes in the lung and progressive shortness of
breath.

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 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) Multiple Gut loops

Which of the following is least likely to be associated
with smoking ?

a) Respiratory bronchiolitisassociated 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 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 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, 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 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.
30 y male presented with
hemoptysis. His various
laboratory parameters are give
below.

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
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 calcification
Lymphangioleiomyomatosis..all are true except

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 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.

Contraindications to surgery in non-small cell lung cancer
.all are true except
a) Esophageal invasion
b) FEV1 less than 1.8 L
c) malignant pleural effusion
d) severe ischemic heart disease
e) contralateral mediastinal lymph node involvement