LE 2 Respi (2024)

Question 1

The classic nodular granulomatous lesion in Primary Tuberculosis is:

A. Tubercle
B. Ghon complex
C. Langhans granuloma
D. Ghon lesion

Answer 1

A. Tubercle
Rationale: The document describes the classic nodular granulomatous lesion in primary tuberculosis as a tubercle, which is a small nodular lesion formed in the lungs during infection​

Question 2

True or False: Among the symptoms associated with PTB, hemoptysis with weight loss appears to consistently differentiate between PTB and non-TB respiratory disease.

A. True
B. Maybe
C. False

Answer 2

C. False
Rationale: The document specifies that only a chronic cough of more than two weeks consistently differentiates between PTB and non-TB respiratory diseases, not hemoptysis with weight loss

Question 3

A patient previously treated for TB, who has been declared cured or completed treatment and is now diagnosed with bacteriologically positive tuberculosis is:

A. Relapse
B. Treatment failure
C. New smear positive
D. Return after default

Answer 3

A. Relapse
Rationale: A relapse occurs when a patient who was previously treated and declared cured or completed treatment is again diagnosed with bacteriologically confirmed tuberculosis​

Question 4

Important determinants of TB transmission include:

A. The probability of contact with a person who has an infectious form of TB
B. The degree of infectiousness of the case
C. The intimacy, duration, and degree of infectiousness of the case
D. The shared environment in which the contact took place
E. All of the above

Answer 4

E. All of the above
Rationale: The document mentions all these factors as important determinants of TB transmission, including contact probability, degree of infectiousness, intimacy of contact, and shared environment​

Question 5

Characteristic of Secondary Tuberculosis:

A. Also called latent tuberculosis
B. All of the above
C. Results from reactivation of latent TB infection
D. Usually localized at the middle and lower lung zones

Answer 5

C. Results from reactivation of latent TB infection
Rationale: Secondary TB is caused by the reactivation of a latent TB infection and typically occurs in the upper lobes, not the middle and lower lung zones

Question 6

Which of the following statements is true regarding the diagnosis of PTB?

A. Disease activity can be diagnosed by upper lobe cavitary lesions on chest x-ray
B. All of the above
C. At present, the primary diagnostic test for diagnosing PTB is sputum Gene Xpert study
D. Emphasis to pursue bacteriologic confirmation vs. clinical diagnosis alone

Answer 6

C. At present, the primary diagnostic test for diagnosing PTB is sputum Gene Xpert study
Rationale: The document emphasizes that the Gene Xpert study is the current primary diagnostic test for PTB​

Question 7

The important clinical data to obtain regarding PTB includes:

A. History of TB exposure
B. History of BCG vaccination
C. Other medical conditions
D. All of the above

Answer 7

D. All of the above
Rationale: Important clinical data for diagnosing PTB includes a history of TB exposure, BCG vaccination, and other medical conditions that increase the risk of TB​

Question 8

The primary diagnostic test for PTB is:

A. Direct sputum smear microscopy
B. TB culture and sensitivity
C. Gene Xpert study
D. Chest x-ray

Answer 8

A. Direct sputum smear microscopy
Rationale: The primary diagnostic test for PTB mentioned in the document is Direct Sputum Smear Microscopy​

Question 9

The true statement regarding protective ventilatory strategy is:

A. Use the lowest possible fraction of inspired oxygen (FIO2) to keep the SaO2 at >90%
B. Use high levels of FIO2 to maintain SaO2 at >90%
C. Minimize the duration of oxygen therapy
D. Increase the respiratory rate to improve oxygenation

Answer 9

A. Use the lowest possible fraction of inspired oxygen (FIO2) to keep the SaO2 at >90%
Rationale: The document mentions that the protective ventilatory strategy is to use the lowest FIO2 necessary to maintain SaO2 above 90%

Question 10

Characteristics of a clinically diagnosed patient with PTB EXCEPT:
A. Radiographic abnormalities consistent with active PTB
B. Response to prior intake of empiric antibiotics
C. Two (2) negative sputum specimens for AFB smear or culture
D. Has been decided by a medical officer to have TB disease

Answer 10

A. Radiographic abnormalities consistent with active PTB

Question 11

A patient who has received one (1) month or more of anti-TB treatment in the past is called:
A. Retreatment
B. Treatment failure
C. Return after default
D. Relapse

Answer 11

A. Retreatment
Rationale: A patient who has received one month or more of anti-TB treatment in the past is considered a retreatment case​

Question 12

The following are true regarding the role of chest x-ray in PTB diagnosis:
A. Chest x-ray findings suggestive of PTB with or without symptoms are considered clinically diagnosed PTB
B. A single chest x-ray film cannot accurately confirm active PTB
C. Clinical correlation with or without bacteriologic confirmation is necessary
D. All of the above

Answer 12

B. A single chest x-ray film cannot accurately confirm active PTB

Question 13

Regarding pre-treatment screening for TB:
A. Provider-initiated counseling and screening for HIV for all patients
B. All of the above
C. Baseline ALT and creatinine are recommended for all cases
D. Serum uric acid and HbA1c are not routinely recommended

Answer 13

B. All of the above
Rationale: The document advises baseline ALT and creatinine testing, provider-initiated HIV screening, and notes that uric acid and HbA1c are not routinely recommended​

Question 14

The following statements are true regarding treatment for PTB:
A. Better compliance using directly observed treatment short (DOTS) course strategy must be implemented for better treatment outcomes
B. First-line drugs like INH and pyrazinamide are the most effective and necessary for the 6-month course treatment regimen
C. All of the above
D. A minimum of three (3) drugs for the intensive phase is recommended in areas where drug resistance is high

Answer 14

C. All of the above
Rationale: DOTS is crucial for better outcomes, first-line drugs are necessary, and three drugs are recommended for the intensive phase in areas with high resistance​

Question 15

Recommended treatment regimen for new cases of extrapulmonary TB of the joints:
A. 2HRZE/4HR
B. 2HRZES/1HRZE/9HRE
C. 2HRZE/10HR
D. 2HRZES/1HRZE/5HRE

Answer 15

C. 2HRZE/10HR
Rationale: The document recommends this treatment regimen for extrapulmonary TB involving the joints

Question 16

True or False: For management of retreatment cases for PTB, Xpert MTB/Rif for rifampicin susceptibility testing is required before initiating any treatment.
A. True
B. False

Answer 16

A. True
Rationale: Rifampicin susceptibility testing using Xpert MTB/Rif is required before initiating treatment in retreatment cases​

Question 17

The following statements are true for monitoring new cases for treatment response, EXCEPT:
A. For bacteriologically confirmed cases, get direct sputum smear microscopy (DSSM) at the end of the 2nd, 5th, and 6th months of treatment
B. Non-converters for category 1 should have DSSM repeated at the end of the 3rd month of treatment
C. Non-converters for category 1 should have a 1-month extended intensive phase
D. For clinically diagnosed cases, get DSSM at the end of the second month

Answer 17

C. Non-converters for category 1 should have a 1-month extended intensive phase
Rationale: The document states that an extended intensive phase is not recommended for non-converters in Category 1​

Question 18

True or False: Monitoring retreatment cases for treatment response should include DSSM at the end of the 2nd, 5th, and 8th months of treatment for both clinically and bacteriologically confirmed cases.
A. True
B. Maybe
C. False

Answer 18

A. True
Rationale: Monitoring retreatment cases includes DSSM at the end of the 2nd, 5th, and 8th months for both clinically and bacteriologically confirmed cases​

Question 19

For patients with elevated ALT of 3x the normal value but without signs and symptoms of drug-induced hepatotoxicity, anti-TB drugs should be discontinued.
A. False
B. True

Answer 19

A. False
Rationale: The document specifies that if ALT is elevated 3x the normal value without symptoms, treatment should continue with early monitoring​

Question 20

The following statements are true regarding atopy, EXCEPT:
A. It is the major risk for asthma
B. 80% develop allergic rhinitis
C. Genetically determined production of specific IgG antibody
D. Most common allergens include ragweed and pollens

Answer 20

C. Genetically determined production of specific IgG antibody
Rationale: Atopy involves the production of specific IgE antibodies, not IgG​

Question 21

Findings of asthma on spirometry:
A. Positive bronchoprovocation test (FEV1 <20% from baseline)
B. Positive airflow obstruction (FEV1 <80% predicted)
C. Positive reversible airflow obstruction (≥12% increase in FEV1)
D. All of the above

Answer 21

D. All of the above
Rationale: The document mentions positive bronchoprovocation, airflow obstruction, and reversible airflow obstruction as findings on spirometry in asthma

Question 22

The following are characteristics of Bronchial asthma:
A. Paroxysms of symptoms characterized by dyspnea, cough, and wheezing
B. Widespread narrowing of the airways relieved spontaneously or by medication
C. Chronic inflammatory disease of the airways, characterized by increased responsiveness to differential stimuli
D. All of the above

Answer 22

D. All of the above
Rationale: Bronchial asthma is characterized by paroxysms of symptoms like dyspnea, cough, and wheezing, widespread airway narrowing, and chronic airway inflammation​

Question 23

The single largest risk factor for the development of asthma is:
A. Air pollution
B. Atopy
C. Infections
D. Smoking

Answer 23

B. Atopy
Rationale: Atopy is noted as the single largest risk factor for developing asthma​

Question 24

The classic triad of asthma includes cough, dyspnea, and _____.
A. Hoarseness
B. Crackles
C. Stridor
D. Wheezing

Answer 24

D. Wheezing
Rationale: The classic triad of asthma includes cough, dyspnea, and wheezing​

Question 25

The most potent and effective medication for long-term control of asthma is: A. Systemic corticosteroids B. Antileukotrienes C. Inhaled corticosteroids D. Long-acting inhaled beta-2 agonists

Answer 25

C. Inhaled corticosteroids Rationale: Inhaled corticosteroids are described as the most potent and effective medication for long-term control of asthma​

Question 26

The most important medication in relieving asthma symptoms is: A. Methylxanthines B. Long-acting inhaled beta-2 agonists C. Short-acting inhaled beta-2 agonists D. Inhaled corticosteroids

Answer 26

C. Short-acting inhaled beta-2 agonists Rationale: Short-acting inhaled beta-2 agonists (SABAs) are the most important medication for relieving asthma symptoms​

Question 27

An asthmatic patient who has been maintained on high-dose inhaled corticosteroids + long-acting beta-2 agonist (ICS + LABA) is experiencing daytime symptoms 3 times a week with the use of his rescue medication up to 4 times a week. He claims that this has not affected his daily work, although he recently had one nocturnal attack in the past week. His predicted FEV1 is 80%. How would you assess the level of control of his asthma? A. Controlled B. Uncontrolled C. Partially controlled D. Cannot assess

Answer 27

C. Partially controlled Key Points: * Daytime symptoms: The patient experiences symptoms 3 times a week, which is more than the limit of 2 times per week for controlled asthma. * Rescue medication usage: The patient uses the rescue medication 4 times a week, exceeding the GINA guideline for controlled asthma, which is a maximum of 2 times per week. * Nocturnal symptoms: The patient has had one nocturnal attack in the past week, which indicates partial control since controlled asthma has no nocturnal symptoms. * FEV1: The patient's FEV1 is 80%, which falls within the acceptable range for both controlled and partially controlled asthma. Rationale: According to GINA guidelines, partially controlled asthma is defined by symptoms occurring more than twice a week, use of rescue medications more than twice a week, and the presence of any nocturnal symptoms. Since this patient meets these criteria, the asthma is assessed as partially controlled

Question 28

An asthmatic patient who has been maintained on high-dose inhaled corticosteroids + long-acting beta-2 agonist (ICS + LABA) is experiencing daytime symptoms 3 times a week with the use of his rescue medication up to 4 times a week. He claims that this has not affected his daily work, although he recently had one nocturnal attack in the past week. His predicted FEV1 is 80%. What would be the appropriate management for this case? A. Consider adding a leukotriene modifier B. Maintain on low-dose ICS + LABA C. Consider increasing the dose of his maintenance D. Consider adding oral corticosteroids

Answer 28

A. Consider adding a leukotriene modifier Key Points: * The patient is already on high-dose ICS + LABA, which is a strong regimen for asthma control. * The patient shows partial control, as evidenced by frequent use of rescue medication, daytime symptoms, and a nocturnal attack. This indicates the current regimen may not be sufficient. * FEV1 of 80% shows reasonably good lung function, suggesting that an immediate escalation to oral corticosteroids may not be necessary. Rationale: When asthma is partially controlled on a high-dose ICS + LABA regimen, the next step is to optimize control by adding a leukotriene modifier (such as montelukast or zafirlukast). This additional controller can target the inflammatory pathways involved in asthma that are not fully controlled by ICS and LABA alone. Increasing the dose of maintenance medications or adding oral corticosteroids is not recommended at this stage, as the patient does not exhibit uncontrolled asthma or severe exacerbations

Question 29

Characteristics of controlled asthma according to GINA 2000: A. Use of reliever up to 2 times a week B. Daytime symptoms 3 times a week C. None of the above D. Nocturnal symptoms once a week

Answer 29

A. Use of reliever up to 2 times a week Rationale: Controlled asthma according to GINA 2000 includes the use of relievers up to two times a week​

Question 30

The preferred reliever medication for asthma according to GINA 2000 is: A. ICS + Salmeterol B. Salbutamol C. ICS + Formoterol D. Salbutamol + Ipratropium

Answer 30

C. ICS + Formoterol Key Points: * GINA guidelines have evolved, and in more recent guidelines (since 2019), ICS + Formoterol is preferred as a reliever therapy due to its quick onset of action and its ability to provide both immediate relief (from Formoterol) and long-term anti-inflammatory effects (from the ICS). * Formoterol is a long-acting beta-2 agonist (LABA) that has a fast onset of action, unlike other LABAs like Salmeterol, making it suitable for use as a reliever. * Salbutamol (Albuterol) was historically the most widely used reliever (SABA), but newer guidelines emphasize the combination of ICS + Formoterol to address both symptoms and inflammation in asthma management. Rationale: GINA guidelines now prefer ICS + Formoterol as a reliever medication for better long-term control of asthma and to reduce reliance on short-acting beta-agonists (SABAs) like Salbutamol alone. This approach helps manage both immediate symptoms and underlying inflammation

Question 31

What factor is the most highly significant predictor of the rate of decline of FEV1 in COPD? A. Genetics B. Environment C. Smoking D. Age

Answer 31

C. Smoking Rationale: Smoking is the most significant predictor of the rate of decline of FEV1 in COPD, as it is the primary risk factor for the development and progression of COPD

Question 32

Characteristics of chronic obstructive pulmonary disease (COPD): A. Clinically defined condition with chronic cough and phlegm known as chronic bronchitis B. All of the above C. A disease state characterized by airflow limitation that is not fully reversible D. A slowly progressive disease with no symptom-free period

Answer 32

B. All of the above Rationale: COPD is defined by airflow limitation that is not fully reversible, includes chronic bronchitis, and is a progressive disease with no symptom-free period​

Question 33

Which is the correct sequence of pathogenetic events that lead to pulmonary emphysema? A. Chronic exposure to cigarette smoke, release of proteinases, inflammatory cell recruitment, ineffective repair of extracellular matrix B. Chronic exposure to cigarette smoke, inflammatory cell recruitment, release of proteinases, ineffective repair of extracellular matrix C. Chronic exposure to cigarette smoke, release of proteinases, ineffective repair of extracellular matrix, inflammatory cell recruitment D. Chronic exposure to cigarette smoke, ineffective repair of extracellular matrix, release of proteinases, inflammatory cell recruitment

Answer 33

B. Chronic exposure to cigarette smoke, inflammatory cell recruitment, release of proteinases, ineffective repair of extracellular matrix Rationale: The sequence involves chronic exposure leading to inflammatory cell recruitment, followed by the release of proteinases and the ineffective repair of the extracellular matrix, which leads to emphysema

Question 34

Characteristics of chronic bronchitis: A. Diffusing capacity is diminished B. Permanent destruction of alveolar septa C. Scanty mucoid secretions D. Cor pulmonale is common

Answer 34

D. Cor pulmonale is common Rationale: Cor pulmonale is commonly seen in chronic bronchitis due to long-term hypoxia and pulmonary hypertension. Other options describe features of emphysema, not chronic bronchitis​

Question 35

Characteristic of emphysema: A. Mild form of dyspnea B. Reid index is significantly increased C. Severely decreased elastic recoil D. Productive cough for 3 months over 2 consecutive years

Answer 35

C. Severely decreased elastic recoil Rationale: Emphysema is characterized by a severely decreased elastic recoil of the lungs, which leads to air trapping and hyperinflation​

Question 36

Pathologic type of emphysema which is commonly seen in patients who developed pneumothorax: A. Centriacinar emphysema B. Paraseptal emphysema C. Distal emphysema D. Panacinar emphysema

Answer 36

B. Paraseptal emphysema Rationale: Paraseptal emphysema is commonly associated with the development of spontaneous pneumothorax

Question 37

True regarding pulmonary function tests for the diagnosis of COPD: A. No significant bronchodilator response means less than 20% increase in post-bronchodilator FEV1 B. A normal FEV1/FVC should need further assessment for COPD C. Spirometry is the only gold standard in the diagnosis D. A diminished inspiratory flow in the flow volume curve is characteristic E. All of the above

Answer 37

C. Spirometry is the only gold standard in the diagnosis Rationale: Spirometry is the gold standard for diagnosing COPD. A normal FEV1/FVC ratio excludes the diagnosis, and a significant bronchodilator response is typically seen in asthma, not COPD​

Question 38

A COPD patient with FEV1 of 35% predicted is classified according to GOLD guidelines 2019 as: A. GOLD 2 B. GOLD 3 C. GOLD 4 D. GOLD 1

Answer 38

B. GOLD 3 Rationale: According to the GOLD guidelines, an FEV1 of 30-50% predicted is classified as GOLD 3 (severe airflow limitation)​

Question 39

A COPD patient complaining of shortness of breath while walking uphill with a history of 1 admission due to severe exacerbation is classified according to GOLD guidelines as: A. Group C B. Group B C. Group A D. Group D

Answer 39

D. Group D Key Points: * Exacerbation history: The patient has had 1 hospitalization due to severe exacerbation, which places them in either Group C or D since both groups require ≥1 exacerbation leading to hospitalization. * Symptoms: The patient complains of shortness of breath while walking uphill, which suggests a more advanced symptom burden. According to the Modified Medical Research Council (mMRC) scale, this level of dyspnea corresponds to an mMRC ≥2, a criterion for Group D classification. Group C patients typically have lower symptom scores (mMRC 0-1, CAT < 10), so this symptom level aligns with Group D. Rationale: Given the history of hospitalization for exacerbation and the significant symptom burden (mMRC ≥2), this patient fits the criteria for Group D in the GOLD guidelines.

Question 40

Initial pharmacologic treatment for the above patient is: A. Inhaled corticosteroids (ICS) + LABA B. LAMA + long-acting beta agonist (LABA) C. Long-acting antimuscarinic agent (LAMA) D. Theophyllines

Answer 40

B. LAMA + long-acting beta agonist (LABA) Key Points: * Initial pharmacologic treatment for Group D: According to the GOLD guidelines, the recommended treatment for Group D includes a LAMA or LAMA + LABA combination to optimize symptom control and reduce exacerbation risk. * ICS + LABA may also be considered in patients with elevated eosinophil counts (≥300 cells/ uL), but the combination of LAMA + LABA is generally preferred as the initial treatment, especially when there is no clear indication of elevated eosinophils. Rationale: For Group D patients with high symptom burden and a history of severe exacerbation, LAMA + LABA provides enhanced bronchodilation and symptom control compared to a single bronchodilator

Question 41

A respiratory disease characterized by abnormal and permanent dilatation of the bronchi: A. Chronic bronchitis B. Bronchiectasis C. Cystic fibrosis D. Emphysema

Answer 41

B. Bronchiectasis Rationale: Bronchiectasis is characterized by abnormal and permanent dilatation of the bronchi, often due to chronic infection or inflammation​

Question 42

Atypical pneumonia is associated with the following organisms, EXCEPT: A. Respiratory syncytial viruses B. Moraxella catarrhalis C. Chlamydia pneumoniae D. Legionella pneumophila

Answer 42

B. Moraxella catarrhalis Rationale: Moraxella catarrhalis is typically associated with typical pneumonia, not atypical pneumonia, which is more commonly caused by organisms like Chlamydia pneumoniae and Legionella pneumophila

Question 43

Interstitial pneumonia is usually associated with: A. Tuberculosis B. Fungal infection C. Bacterial infection D. Viral infection

Answer 43

D. Viral infection Rationale: Interstitial pneumonia is commonly associated with viral infections, such as influenza or other respiratory viruses, rather than bacterial or fungal infections​

Question 44

The anti-pneumococcal and anti-Pseudomonal antibiotic/s include/s: A. Cefixime B. Piperacillin-tazobactam C. Ertapenem D. All of the above

Answer 44

B. Piperacillin-tazobactam Rationale: Piperacillin-tazobactam is active against both Pseudomonas aeruginosa and Streptococcus pneumoniae. Cefixime does not have activity against Pseudomonas, and Ertapenem does not cover Pseudomonas either​

Question 45

The following statements are true regarding microaspiration, EXCEPT: A. Gram (+) organisms are usually seen in hospitalized, debilitated patients B. More frequent in patients with impaired level of consciousness C. Anaerobic infection can be due to foreign body aspiration D. Usual pathogens are polymicrobial that colonize the oropharynx

Answer 45

A. Gram (+) organisms are usually seen in hospitalized, debilitated patients Rationale: Gram-negative organisms, not gram-positive organisms, are typically seen in hospitalized or debilitated patients who experience microaspiration. Anaerobic infections are frequently associated with aspiration, especially in patients with impaired consciousness​

Question 46

True or False: Most common mechanism of hepatic hydrothorax is due to increased production of pleural fluid caused by the decrease in oncotic pressure from hypoproteinemia found in cirrhosis. A. True B. False

Answer 46

B. False Rationale: The most common mechanism of hepatic hydrothorax is the passage of ascitic fluid into the pleural space through defects in the diaphragm, not from a decrease in oncotic pressure caused by hypoproteinemia​

Question 47

The following conditions indicate a more invasive procedure for parapneumonic pleural effusion, EXCEPT: A. pH of <7.20 B. PF glucose of >20 mg/dL C. Loculated pleural effusion D. Positive Gram stain

Answer 47

B. PF glucose of >20 mg/dL Rationale: A pleural fluid (PF) glucose level of <60 mg/dL (not >20 mg/dL) is an indicator of a more invasive procedure. The other factors, such as pH <7.20, loculated pleural effusion, and positive Gram stain, all suggest severe infection or complications, necessitating more invasive interventions like chest tube thoracostomy or thoracoscopy​

Question 48

May develop in a young non-smoker individual with PTB: A. Traumatic pneumothorax B. Tension pneumothorax C. Primary spontaneous pneumothorax D. Secondary spontaneous pneumothorax

Answer 48

D. Secondary spontaneous pneumothorax** *Rationale:* A young non-smoker with PTB (pulmonary tuberculosis) may develop **secondary spontaneous pneumothorax**, which occurs in the presence of an underlying lung disease such as PTB

Question 49

Type of pneumothorax which is due to rupture of apical pleural blebs in patients with no underlying lung disease: A. Secondary spontaneous pneumothorax B. Primary spontaneous pneumothorax C. Tension pneumothorax D. Traumatic pneumothorax

Answer 49

B. Primary spontaneous pneumothorax** *Rationale:* **Primary spontaneous pneumothorax** is due to the rupture of apical pleural blebs in patients with no underlying lung disease

Question 50

Bronchogenic cysts are usually present as: A. Middle mediastinal tumor B. Posterior mediastinal tumor C. Anterior mediastinal tumor D. Inferior mediastinal tumor

Answer 50

A. Middle mediastinal tumor** *Rationale:* **Bronchogenic cysts** are usually present in the **middle mediastinum**

Question 51

Characteristic of acute mediastinitis: A. Most cases are due to chronic infection with tuberculosis or histoplasmosis B. May cause compressive symptoms in patients with fibrosing mediastinitis C. Develops granulomatous inflammation of the lymph nodes D. Presents with chest pain and dyspnea due to mediastinal infection

Answer 51

D. Presents with chest pain and dyspnea due to mediastinal infection** *Rationale:* **Acute mediastinitis** typically presents with chest pain and dyspnea due to infection of the mediastinum, often following esophageal rupture or post-surgical complications

Question 52

Recurrent laryngeal nerve palsy can be seen as a complication of this disorder: A. Acute mediastinitis B. Pneumothorax C. Chronic mediastinitis D. Pneumomediastinum

Answer 52

C. Chronic mediastinitis** *Rationale:* **Chronic mediastinitis**, particularly the fibrosing type, may compress structures such as the recurrent laryngeal nerve, leading to palsy

Question 53

True regarding unilateral diaphragmatic paralysis: A. Usual cause is nerve invasion from malignant tumor B. May lead to hypercapneic respiratory failure C. Causes severe morbidity in adults D. Treatment is by assisted ventilation

Answer 53

A. Usual cause is nerve invasion from malignant tumor** *Rationale:* **Unilateral diaphragmatic paralysis** is most commonly caused by nerve invasion from a malignant tumor, often seen in bronchogenic carcinoma

Question 54

High cervical trauma and myasthenia gravis can develop hypoventilation syndrome through this mechanism: A. Impairment of respiratory drive B. All of the above C. Defective respiratory neuromuscular system D. Impairment in the ventilatory apparatus

Answer 54

C. Defective respiratory neuromuscular system** *Rationale:* **High cervical trauma** and **myasthenia gravis** can cause hypoventilation syndrome through a defective respiratory neuromuscular system

Question 55

Hypoventilation due to impairment in the ventilatory apparatus will give this laboratory finding/s: A. Decrease in the maximal inspiratory and expiratory pressure (PI max and PE max) B. Normal lung volume and flow rates C. Decrease diaphragmatic pressure (EMGdi) on response to hypoxia D. Widened arterial-alveolar O2 concentration gradient (a-A PO2)

Answer 55

D. Widened arterial-alveolar O2 concentration gradient (a-A PO2) Rationale: Hypoventilation due to impairment in the ventilatory apparatus is characterized by an increase in the (A-a) PO₂ gradient, as indicated by abnormal ventilation, flow rates, and compliance. This reflects poor oxygenation due to issues with the ventilatory apparatus, leading to an increased gradient between arterial and alveolar oxygen levels. In contrast, the PImax and PEmax remain normal in this case, and the volume and flow rates are abnormal

Question 56

Type of respiratory failure, its pathophysiology, and/or associated clinical conditions: A. Type 3 respiratory failure, decrease in functional residual capacity B. Type 2 respiratory failure, alveolar flooding C. Type 4 respiratory failure, hyperperfusion of bronchial muscles secondary to shock D. Type 1 respiratory failure, alveolar hypoventilation

Answer 56

A. Type 3 respiratory failure, decrease in functional residual capacity** Type I: Acute Hypoxemic Respiratory Failure * Pathophysiology: Occurs with alveolar flooding and intrapulmonary shunt physiology, where blood passes through the pulmonary capillaries without being oxygenated due to conditions like pulmonary edema, pneumonia, or alveolar hemorrhage. Type II: Acute Hypercapnic Respiratory Failure * Pathophysiology: Caused by alveolar hypoventilation leading to an inability to eliminate CO₂, resulting in CO₂ retention/hypercarbia. Type III: Perioperative Respiratory Failure * Pathophysiology: Results from lung atelectasis, most commonly during the perioperative period, especially after general anesthesia. This decreases Functional Residual Capacity (FRC), causing collapse of dependent alveolar units. Type IV: Respiratory Failure Due to Shock * Pathophysiology: Results from hypoperfusion of respiratory muscles in patients experiencing shock. In this setting, a larger percentage of cardiac output is required to maintain respiratory function.

Question 57

A 30-year-old male non-smoker was brought to the ER due to severe difficulty in breathing. Past medical history showed he underwent an appendectomy six months ago. He is an office worker, a known asthmatic with poor compliance to his medications. Vital signs: BP - 100/60, CR - 120, RR - 40. PE showed absent breath sounds. Patient was eventually intubated after no adequate response to initial management. What is the most probable type of respiratory failure in this case? A. Type 3 respiratory failure B. Type 4 respiratory failure C. Type 1 respiratory failure D. Type 2 respiratory failure

Answer 57

D. Type 2 respiratory failure Rationale: This patient's history of asthma with poor compliance and presentation of severe difficulty breathing, absent breath sounds, and subsequent need for intubation suggests Type 2 respiratory failure. Type 2 respiratory failure, or hypercapnic respiratory failure, is often caused by conditions that result in alveolar hypoventilation, such as asthma. The inability to effectively ventilate leads to CO₂ retention, which is common in obstructive lung diseases like asthma

Question 58

Typical Arterial Blood Gas (ABG) result in a patient with Hypoxemic Respiratory Failure: A. pH – 7.05; pCO2 – 35; HCO3 – 10; pO2 – 80; O2 saturation – 96% B. pH – 7.25; pCO2 – 30; HCO3 – 15; pO2 – 70; O2 saturation – 93% C. pH – 7.15; pCO2 – 59; HCO3 – 25; pO2 – 65; O2 saturation – 92% D. pH – 7.35; pCO2 – 45; HCO3 – 25; pO2 – 55; O2 saturation – 89%

Answer 58

D. pH – 7.35; pCO2 – 45; HCO3 – 25; pO2 – 55; O2 saturation – 89%** *Rationale:* Hypoxemic respiratory failure typically presents with low pO2 and normal or slightly elevated pCO2【65†source】.

Question 59

Condition where non-invasive positive pressure ventilation is highly effective: A. 60-year-old female with 2 weeks history of dyspnea, fever, and cough with copious respiratory secretions B. 50-year-old male with dyspnea on exertion, a smoker on LAMA inhaler but with poor compliance C. 65-year-old female with chest pain and dyspnea, (+) uncontrolled hypertension and diabetes D. 25-year-old male drug addict with decreased sensorium and cyanosis

Answer 59

B. 50-year-old male with dyspnea on exertion, a smoker on LAMA inhaler but with poor compliance** *Rationale:* Non-invasive positive pressure ventilation (NIPPV) is highly effective in patients with COPD exacerbations, especially when they have poor compliance with medications【65†source】.

Question 60

One may start weaning from mechanical ventilation with the following condition: A. GCS - 5 B. 60-year-old male with High Risk CAP given the first dose of Piperacillin-Tazobactam 4.5 grams IV, ANST (-) C. BP – 100/60 on Norepinephrine drip D. PEEP – 5, FIO2 – 40%

Answer 60

D. PEEP – 5, FIO2 – 40%** *Rationale:* The patient is ready for weaning with a PEEP of 5 and FIO2 at 40%, both within acceptable ranges for starting the weaning process

Question 61

Alveolar flooding as a cause of acute hypoxemic respiratory failure may be secondary to: A. Immediate status post-abdominal surgery B. Asthma in acute exacerbation C. Consolidation on chest imaging D. Pulmonary metastasis

Answer 61

C. Consolidation on chest imaging** *Rationale:* Alveolar flooding leading to hypoxemic respiratory failure can be secondary to consolidation, often seen in pneumonia

Question 62

A 55-year-old hypertensive and diabetic male (height – 5’5”; weight 136 lbs) was admitted to the ICU due to a vehicular accident with a PWI of multiple fractures, marginal pneumothorax of the left lung, and cerebral contusion. VS: BP – 90/60; CR – 130; RR – 36. Patient was intubated upon transfer from the ER with initial MV settings of: FIO2 – 100%, Vt – 500 ml, mode - A/C. ABG was done after 1 hour: pH – 7.46. pCO2 – 33, HCO3 – 21, pO2 – 60. What is the most probable diagnosis? A. Severe head trauma secondary to VA B. Cardiogenic pulmonary edema C. Mild pulmonary contusion D. Acute respiratory distress syndrome

Answer 62

D. Acute respiratory distress syndrome** *Rationale:* The patient’s presentation with trauma, high respiratory rate, hypoxemia despite mechanical ventilation, and multiple fractures suggests ARDS

Question 63

Same patient was referred to both IDS (started Piperacillin-Tazobactam and Levofloxacin) and pulmonologist after 48 hours due to an increase in thick yellowish secretions per ET, repeat CXR showed new infiltrates on both lung fields, and repeat ABG results showed: pH – 7.35, pCO2 – 46, HCO3 – 19, pO2 – 75 with FIO2 at 70%. How will you now manage the MV of this patient? A. Add PEEP at 10 cm H2O and increase FIO2 to 100% B. Decrease Vt to 350 ml and add PEEP at 5 cm H2O C. Maintain Vt and add PEEP at 25 cm H2O D. Shift mode to SIMV and start progressive weaning

Answer 63

A. Add PEEP at 10 cm H2O and increase FIO2 to 100%** *Rationale:* In patients with worsening respiratory status and new infiltrates, increasing PEEP and FIO2 can improve oxygenation and alveolar recruitment

Question 64

True statement regarding protective ventilatory strategy: A. Adjust the PEEP to maintain bronchial airway patency while preventing overdistention and closure/reopening B. Use the lowest possible fraction of inspired oxygen (FIO2) to keep the SaO2 at ≥90% C. Normalization of pH through elimination of CO2 is desirable, thus permissive hypercapnia is avoided D. Set a target tidal volume close to 6 mL/kg of actual body weight

Answer 64

B. Use the lowest possible fraction of inspired oxygen (FIO2) to keep the SaO2 at ≥90%** *Rationale:* The protective ventilatory strategy aims to minimize oxygen toxicity by using the lowest possible FIO2 to maintain adequate oxygen saturation

Question 65

At the end of a Spontaneous Breathing Trial (SBT), the patient may be extubated if: A. Systolic blood pressure <90 mmHg + f/Vt of >105 B. O2 saturation <90% + f/Vt of <105 C. Heart rate decreased from 100 to 70 per minute + f/Vt of >105 D. Respiratory rate <35/minute in 6 minutes + f/Vt of <105

Answer 65

D. Respiratory rate <35/minute in 6 minutes + f/Vt of <105** *Rationale:* A respiratory rate of <35 and an f/Vt (rapid shallow breathing index) of <105 are indicators that a patient may be ready for extubation after a successful spontaneous breathing trial

Question 66

A patient has moderate ARDS with the following clinical picture (you need to compute for the P/F ratio): A. FIO2 of 100%; pO2 of 110; acute onset; CXR with infiltrates in 1 of 4 quadrants; PCWP of 16 mmHg B. FIO2 of 100%; pO2 of 110; subacute onset; CXR with infiltrates in 2 of 4 quadrants; PCWP of 16 mmHg C. FIO2 of 100%; pO2 of 90; acute onset; CXR with infiltrates in 2 of 4 quadrants; PCWP of 16 mmHg D. FIO2 of 100%; pO2 of 110; acute onset; CXR with infiltrates in 2 of 4 quadrants; PCWP of 16 mmHg

Answer 66

A. FIO₂ of 100%; pO₂ of 110; acute onset; CXR with infiltrates in 1 of 4 quadrants; PCWP of 16 mmHg. P/F ratio = 110 / 1.0 = 110 This falls within the moderate ARDS range.

Question 67

Risk factor associated with poor outcome among patients with ARDS secondary to COVID-19: A. Past medical history of allergic rhinitis B. Serum creatinine of 2.5 mg/dl from 1.2 mg/dl baseline C. Lymphocytes on CBC at 40% D. 35-year-old male

Answer 67

B. Serum creatinine of 2.5 mg/dl from 1.2 mg/dl baseline Rationale: Acute kidney injury (AKI) with elevated serum creatinine is a known risk factor for poor outcomes in ARDS, especially in COVID-19 patients. Renal dysfunction often complicates the clinical course of ARDS.

Question 68

A 50-year-old male was brought by his wife to your clinic because of alarmingly long pauses of absent breathing while sleeping, without dyspnea nor chest pain. He is a known hypertensive for 3 years and maintained on Amlodipine 10 mg OD and Losartan 100 mg OD. On consult, BP is 160/90 mmHg and computed BMI is 35. How will you manage this patient? A. Ask for an ECG B. Request for a polysomnogram C. Schedule for an upper airway endoscopy D. Perform spirometry

Answer 68

B. Request for a polysomnogram Rationale: The patient's symptoms, along with a BMI of 35 (obesity), suggest obstructive sleep apnea (OSA). A polysomnogram (sleep study) is the diagnostic test of choice for confirming OSA​

Question 69

Unlikely cause of mortality in a patient with Obstructive Sleep Apnea: A. Cerebrovascular disease B. Diabetes mellitus C. Hepatic dysfunction D. Road accidents

Answer 69

B. Diabetes mellitus Rationale: Diabetes mellitus is associated with complications of OSA but is not a direct cause of mortality. In contrast, cerebrovascular disease, hepatic dysfunction, and road accidents are common causes of mortality in OSA patients([MED2] LE2.03 Sleep Apn…).

Question 70

Definition of Obstructive Sleep Apnea: A. 5 apneic events per hour in an elderly male B. 5 hypopneic events per hour in a 45-year-old female C. Daytime sleepiness with an obvious cause in a 23-year-old male call center agent D. 5-9 second breathing pauses numbering about 10 per hour in an 11-year-old boy

Answer 70

A. 5 apneic events per hour in an elderly male Rationale: OSA is defined by at least 5 obstructed breathing events (apnea or hypopnea) per hour of sleep, with clinical symptoms like excessive daytime sleepiness([MED2] LE2.03 Sleep Apn…).

Question 71

Identify the patient with the most number of risk factors for Obstructive Sleep Apnea: A. 38-year-old female smoker with hypothyroidism B. 50-year-old female non-smoker with a short mandible C. 70-year-old male non-smoker with a BMI of 30 D. 45-year-old male smoker with a BMI of 28

Answer 71

C. 70-year-old male non-smoker with a BMI of 30 Rationale: Advanced age and a higher BMI are significant risk factors for OSA. The 70-year-old male with a BMI of 30 has the most risk factors compared to the other options([MED2] LE2.03 Sleep Apn…).

Question 72

Questions about OSA or features of a patient with possible OSA that should be noted in a routine health maintenance evaluation: A. Past medical history of a reduced TMJ dislocation B. Nighttime sleepiness in a call center agent working in an 11 PM – 7 AM shift C. BP of 140/90 on first consult and 120/80 during the second consult D. BMI of 29

Answer 72

D. BMI of 29 Rationale: Obesity (BMI ≥ 30) is a significant risk factor for OSA. A BMI close to 30, such as 29, would suggest a higher likelihood of OSA in a routine health evaluation([MED2] LE2.03 Sleep Apn…).

Question 73

Incidence of COVID-19 seems to be lower in this condition compared to the general population: A. Central sleep apnea B. Obstructive sleep apnea C. Pulmonary hypertension D. Cystic fibrosis

Answer 73

D. Cystic fibrosis Rationale: The incidence of COVID-19 appears to be lower in patients with cystic fibrosis compared to the general population, likely due to stringent infection control measures in this population([MED2] LE2.03 Sleep Apn…) .

Question 74

Demographic predominance of cystic fibrosis: A. Whites < Asians B. Asians > African-Americans C. African-Americans > Whites D. Asians < African-Americans

Answer 74

D. Asians < African-Americans Rationale: Cystic fibrosis is most common among Whites (~1 in 3,300 live births), and it is much less frequent in African Americans (~1 in 15,000) and Asians (~1 in 33,000). This makes option D the correct answer, indicating that Asians have a lower incidence of cystic fibrosis than African-Americans

Question 75

Represent the cardinal diagnostic tests for cystic fibrosis: A. Markedly high sweat electrolyte measurement and clinical symptoms B. Newborn screening (positive) and CFTR mutation analysis C. CFTR mutation analysis and markedly high sweat electrolyte measurement D. Clinical symptoms and (+) newborn screening

Answer 75

C. CFTR mutation analysis and markedly high sweat electrolyte measurement Rationale: The cardinal diagnostic tests for cystic fibrosis include CFTR mutation analysis and sweat chloride testing, which typically shows markedly elevated sweat electrolyte levels .

Question 76

Standardization of clinical intervention has led to remarkable benefits among patients with Cystic Fibrosis. This initiative has improved which endpoint: A. Weight gain B. Reduction in transitional dyspnea index C. Improvement in blood gases D. Fewer coughing episodes

Answer 76

A. Weight gain** **Rationale:** Standardization of clinical intervention in cystic fibrosis has improved **nutritional status**, including weight gain, as part of overall patient management. Improving nutrition is a key focus in the treatment of cystic fibrosis

Question 77

Respiratory sequelae of cystic fibrosis that require hospitalization: A. Pneumothorax B. Pleural effusion C. Any severity of respiratory exacerbation D. Hematochezia

Answer 77

A. Pneumothorax** **Rationale:** Respiratory sequelae of cystic fibrosis that require hospitalization include **pneumothorax**, a potentially life-threatening complication. Other choices, like pleural effusion and hematochezia, are not as commonly associated with cystic fibrosis exacerbations requiring hospitalization

Question 78

Granulomatous interstitial lung disease with a known cause is exemplified by: A. Lymphangioleiomyomatosis B. Hypersensitivity pneumonitis C. Sarcoidosis D. Asbestosis

Answer 78

B. Hypersensitivity pneumonitis** **Rationale:** **Hypersensitivity pneumonitis** is a type of granulomatous interstitial lung disease with a known cause, often due to inhaled organic antigens. Other options like sarcoidosis and asbestosis may also involve granulomatous inflammation, but hypersensitivity pneumonitis has a well-established environmental trigger

Question 79

Chest x-ray and interstitial lung disease: A. Honeycombing correlates with pathologic findings of small cystic spaces and progressive fibrosis and portends a poor prognosis B. In a large number of cases, chest x-ray is specific, thus pointing to a specific diagnosis C. Correlates poorly with the clinical or histopathologic stage of the disease D. May be first suspected on the basis of an abnormal film most commonly revealing a bibasilar nodular pattern

Answer 79

A. Honeycombing correlates with pathologic findings of small cystic spaces and progressive fibrosis and portends a poor prognosis** **Rationale:** **Honeycombing** on a chest x-ray or CT is a classic sign of **advanced fibrosis** in interstitial lung disease and is associated with a poor prognosis. It corresponds to small cystic spaces in the lungs and indicates irreversible damage

Question 80

Definite risk for inducing idiopathic pulmonary arterial hypertension: A. Dasatinib B. Amphetamines C. Cocaine D. Dexfenfluramine

Answer 80

D. Dexfenfluramine Rationale: According to the table, dexfenfluramine is listed under drugs with a definite risk of inducing idiopathic pulmonary arterial hypertension (IPAH). Other drugs such as dasatinib and amphetamines are classified as "likely" to induce pulmonary arterial hypertension, while cocaine is classified as "possible." Therefore, dexfenfluramine is the correct answer

Question 81

Confirmatory test in the diagnosis of pulmonary hypertension: A. pro-BNP B. 2-D echocardiogram C. Cardiopulmonary exercise testing D. Right heart catheterization

Answer 81

D. Right heart catheterization Rationale: Right heart catheterization is considered the gold standard for diagnosing pulmonary hypertension (PH). It measures the mean pulmonary artery pressure (mPAP), pulmonary capillary wedge pressure (PCWP), and pulmonary vascular resistance (PVR), which are critical in confirming the diagnosis and determining whether the PH is precapillary or postcapillary. Other tests, like the 2-D echocardiogram, are useful for screening and estimating pressures, but right heart catheterization is necessary for definitive diagnosis

Question 82

30. Most common pathophysiologic finding in COPD: - A. Reduced expiratory flow rate - B. Increased lung compliance - C. Decreased inspiratory flow rate - D. Reduced pulmonary capillary blood volume

Answer 82

A. Reduced expiratory flow rate Rationale: The hallmark of COPD is airflow limitation, particularly during expiration, due to airway obstruction and loss of elastic recoil. This results in a reduced expiratory flow rate, which is commonly observed in spirometry tests. Increased lung compliance can occur due to the loss of elastic recoil, but the reduced expiratory flow rate is more characteristic of COPD

Question 83

31. Typical history found in COPD: - A. Cigarette smoking - B. Occupational exposure to dust or chemicals - C. History of recurrent respiratory infections in childhood - D. All of the above

Answer 83

D. All of the above Rationale: The most common risk factor for COPD is cigarette smoking, but occupational exposure to dust and chemicals and a history of recurrent respiratory infections in childhood can also contribute to the development of COPD. These are well-recognized contributors to the disease

Question 84

32. Airflow limitation and hyperinflation in COPD are due to: - A. Loss of elastic recoil of the lung - B. Increased airway resistance - C. Reduced lung compliance - D. Decreased respiratory muscle strength

Answer 84

A. Loss of elastic recoil of the lung Rationale: In COPD, the destruction of alveolar structures leads to a loss of elastic recoil, which contributes to airflow limitation and lung hyperinflation. This loss of recoil means that the lungs cannot efficiently expel air, leading to trapped air and hyperinflation. Increased airway resistance also contributes but is secondary to the structural changes that occur with loss of recoil