PULMONOLOGY

katamin used in anas. in asthma

1. An asthmatic who needs daily short acting beta 2 inhalers, oralsteroids and daily
spirometry monitoring of PFTs. What is his asthma stage?
a.Mild intermittent
b.Mild persistent
c.Moderate
d.Severe
answer: D
Once the patient on oral steroid he/she classified as a severe asthma.
Reference: 1.http://www.med.umich.edu/1info/FHP/practiceguides/asthma/EPR-3_pock-
et_guide.pdf
2. Toronto note

2. Bilateral pneumonia treatment ??????? not sure

Answer :
Bilateral = macrolids ( eryhthromycin, azithromycin , niamycin , clarythromycine )
virus pneumonia or aspiration pneumonia
viral pneumonia : antiviral
aspiration pneumonia : clindamycin

3. most common cause of chronic cough in adult?

a GERD
b -postnasal drip
c asthma
answer : B
Reference: http://www.uptodate.com/contents/chronic-cough-in-adults-beyond-the-basics?
source=outline_link&view=text&anchor=H3#H3

4. What is the most specific investigation for TB ?

A. Sputum culture
B. PPD
Answer: A

5. Cancer of lung with high keratin ?

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Squamous cell carcinoma
Reference:1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155291/
2.http://misc.medscape.com/pi/iphone/medscapeapp/html/A279960-business.html#a3

6. Most common cause of obstructive sleep apnea ?

Obesity is the most commonly identified cause of obstructive sleep apnea. Patients present with
daytime somnolence and a history of loud snoring.
Other symptoms include:
Headache
Impairedmemoryandjudgement Depression
Hypertension
Erectiledysfunction
Bullneck
The most accurate test is polysomnography (sleep study) which shows multiple episodes of ap-
nea. Arrythmias and erythrocytosis are common.
Reference: master the board Page 164

7. Tb case, what is the next appropriate step to get a definitive dx?

A. Sputum smear under microscope
B. Sputum culture
Answer : B
The presence of acid-fast-bacilli (AFB) on a sputum smear or other specimen often indicates TB
disease. Acid-fast microscopy is easy and quick, but it does not confirm a diagnosis of TB be-
cause some acid-fast-bacilli are not M. tuberculosis. Therefore, a culture is done on all initial
samples to confirm the diagnosis. (However, a positive culture is not always necessary to begin
or continue treatment for TB.) A positive culture for M. tuberculosis confirms the diagnosis of TB
disease.
Reference: CDC

9. Pt have lesion in right upper lung look like calcium how to treated ?
Answer:
The first step in the evaluation of a pulmonary nodule is to look for a prior
x-ray. Finding the same pulmonary nodule on an x-ray done years ago
may save you from doing any further workup. If no prior x-ray is available,
then consider whether this patient is high or low risk for lung cancer.

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 In low-risk patients, <35 years of age and nonsmokers
with calcified nodules, you may follow
the patient with chest x-rays or chest CT every 3 months
for 2 years. Stop the follow-up if after
2 years there is no growth.

High-risk patients >50 years of age with a smoking his-

tory and a nodule are likely to have bron-
chogenic cancer. The best diagnostic procedure is open-
lung biopsy and removal of the nodule
at the same time.

Reference : 1.Kaplan Internal Medicine 2013

2.Master the board page156-157

10. Pt with barking cough and 38 temp which of the following symptoms is associated
with this disease ?
Answer:Croup usually begins with nonspecific respiratory symptoms (ie, rhinorrhea, sore throat,
cough). Fever is generally low grade (38-39C) but can exceed 40C. Within 1-2 days, the char-
acteristic signs of hoarseness, barking cough, and inspiratory stridor develop, often suddenly,
along with a variable degree of respiratory distress. Symptoms are perceived as worsening at
night, with most ED visits occurring between 10 pm and 4 am. Symptoms typically resolve within
3-7 days but can last as long as 2 weeks.
Spasmodic croup (recurrent croup) typically presents at night with the sudden onset of "croupy"
cough and stridor. The child may have had mild upper respiratory complaints prior to this, but
more often has behaved and appeared completely well prior to the onset of symptoms. Allergic
factors may cause recurrent croup due to respiratory epithelial changes from the viral infection.
Reference: http://emedicine.medscape.com/article/962972-clinical

11. Cancer of lung with high keratin ?

Answer: Non small cell cancer
Answer: Sq C C
According to the book it'sseq cell carcinoma:
https://books.google.co.uk/books?id=KZazAQAAQBAJ&pg=PA419&lpg=PA419&dq=Cancer+of
+lung+with+high
+keratin&source=bl&ots=7y0dnGMLzf&sig=grrvlAQfdvP3ch5lupGVw5OiLbY&hl=ar&sa=X&ved
=0ahUKEwi2sq6FhfHNAhWjLMAKHddZCEw4ChDoAQgrMAE#v=onepage&q=Cancer%20of
%20lung%20with%20high%20keratin&f=false

12. Calcified lesion in the upper lung?

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 A. Bronchoscope biopsy
B. Percutaneous biopsy
C. Thoracotomy
D. Follow up with serial x-ray
Answer: D
In asymptomatic pts with calcified nodule, we follow the pt with serial x ray for about 3months, if
it is not changed without Sx development, the calcification is mostly
benign.
The first step in the evaluation of a pulmonary nodule is to look for a prior x-ray. Finding the
same pulmonary nodule on an x-ray done years ago may save you from doing any further
workup. If no prior x-ray is available, then consider whether this patient is high or low risk for
lung cancer.
-In low-risk patients, <35 years of age and nonsmokers with calcified nodules, you may follow
the patient with chest x-rays or chest CT every 3 months for 2 years. Stop the follow-up if after 2
years there is no growth.
-High-risk patients >50 years of age with a smoking history and a nodule are likely to have
bronchogenic cancer. The best diagnostic procedure is open-lung biopsy and removal of the
nodule at the same time.(USMLE step 2CK)

13. Asthma on montelukast and Bronchodilator has dry cough every day came to ICU,
what to give for long term?
Answer: high-dose inhaled corticosteroid plus a leukotriene receptor antagonist plus an oral cor-
ticosteroid. Consider omalizumab for patients who have allergies.Medscape
Treatment Asthma is managed in a stepwise fashion of progressively adding more types of
treatment if there is no response.
Step 1. Always start the treatment of asthma with an inhaled short-acting beta agonist (SABA)
as needed. Examples of SABA are: Albuterol Pirbuterol Levalbuterol
Step 2. Add a long-term control agent to a SABA. Low-dose inhaled cortico- steroids (ICS) are
the best initial long-term control agent. Example of ICS are: Beclomethasone,budesonide,
unisolide, uticasone,mometasone, triamcinolone Alternate long-term control agents include:
Cromolynandnedocromiltoinhibitmastcellmediatorreleaseandeosin- ophil recruitment eo-
phylline Leukotrienemodiers:montelukast,zarleukast,orzileuton(bestwith atopic patients)
Step 3. Add a long-acting beta agonist (LABA) to a SABA and ICS, or increase the dose of the
ICS. LABA medications are salmeterol or formoterol.
Step 4. Increase the dose of the ICS to maximum in addition to the LABA and SABA.
Step 5. Omalizumabmay be added to the SABA, LABA, and ICS in those who have an in-
creased IgE level.
Step 6. Oral corticosteroids such as prednisone are added when all the other therapies are not-
sucient to control symptoms. Adverse Effects of Systemic Corticosteroids ey should be used as
a last resort because of very harsh adverse e ects such as: Osteoporosis Cataracts Adrena-
lsuppressionandfatredistribution Hyperlipidemia,hyperglycemia,acne,andhirsutism(particular-
lyin women) inningofskin,striae,andeasybruising (reference: master the board)

14. cystic fibrosis mode of inheritance?

Answer: autosomal recessive (AR)

15. A patient is coughing bloody frothy sputum. He has pulmonary edema, + hepatojugu-
lar reflux and lower limb edema. Capillary pressure is 3 times more than oncotic
pressure. What is the type of edema ?

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 A. Venous
B. Arterial
C. Interstitial
D. Capillary
Answer: C
Pulmonary edema in heart failure patient caused by increase of pulmonary venous pressure
lead to pulmonary venous distention and transudation of fluid. Also, lead to pulmonary capillar-
ies rupture.
Extra information:

Reference: Rapid Review Pathology, 4th edition

16. According to the new classification of lung cancer, which of the following is consid-
ered carcinoma in-situ?
A. Adenocarcinoma less than 2 cm.
B. Atypical hyperplasia
Answer: A :
Adenocarcinoma in situ (AIS) with no invasive features is a localized, small (3 cm) adenocarci-
noma with growth restricted to a non invasivelepidic pattern and an absence of papillary or mi-
cropapillary patterns or intraalveolar tumor cells. Reference: UpToDate.

17. A male patient who is a smoker, developed symptoms. Ca: High. CXR showed solitary
nodule. What is the most likely diagnosis?
A. Squamous Cell Carcinoma SCC
B. Adenocarcinoma
Answer: A
High Ca > Paraneoplastic of SCC.
http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/calci-
um/high-calcium-in-people-with-cancer

18. Asymptomatic Patient. Chest X ray shows a unilateral calcified nodule on the upper
zone of his lung?
A. Adenoma
B. Granuloma
C. Hamartoma
D. SCC
Answer: B

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The most common cause of nodule calcification is granuloma formation, usually in the response
to healed infection.
Reference:http://radiopaedia.org/articles/calcified-pulmonary-nodules
Granuloma is account 25% and 15% of all benign causes, respectively. Active granulomatous
infections include tuberculosis, coccidioidomycosis, histoplasmosis, cryptococcus, and as-
pergillosis. Hamartomas comprise an additional 15% of benign lesions
Reference:http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematol-
ogy-oncology/pulmonary-nodules/
19. Patient with shoulder pain and pleurisy. Which part of the pleura causes radiation of
the pain to shoulder:
a. Visceral
b. Mediastinal
c. Costal
d. Anterior
Answer: B
Visceral pleura: insensitive to pain due to autonomic innervation.
Parietal pleura:
Costal and peripheral parts of diaphragmatic pleura are referred along intercostal nerves
to thoracic and abdominal wall.
Mediastinal and central diaphragmatic pleural pain referred to root of neck and over
shoulder (Dermatomes C3-C5). Reference: Lippincott's Concise Illustrated Anatomy:
Thorax, Abdomen & Pelvis.

20. Most common cause of excessive sleepiness in the daytime is?

A. Narcolepsy
B. Obstructive Sleep Apnea (OSA)
Answer: B
The most common causes of excessive daytime sleepiness are sleep deprivation,
obstructive sleep apnea, and sedating medications.
Reference: American Family
Physician Journals.

21. case of pneumonia, what ur finding on the auscultation?

A.dispred crackles
B.bronchial breath sound
C.absence of vesicular breath sound
Answer: B
(short textbook of medical diagnosis and management, INAM DANISH, page 344)
In lobar pneumonia: Bronchial breath sound+crackles
http://www.turner-white.com/pdf/hp_jan02_pulmonary.pdf

22. A patient with lung cancer. Lab results: low PTH and High Calcium. What is the rea-
son?
a. PTH related peptide for lung ca
Answer: A
Reference: kumar and clarks p:556

23. Patient with bronchiectasis. What else beside medical treatment can benefit this pa-
tient?
a. Chest physiotherapy , vaccination , corticosteroid
Answer: A
Reference: Toronto Notes

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24. Best drug to decrease bronchial secretion in COPD?
a. Ipratropium
Answer: A
Reference: Master the board.

25. A patient with chronic retrosternal pain, cough and metallic taste in mouth. What is
the most likely diagnosis?
a.GERD
Answer: A
heartburn (pyrosis) and acid regurgitation (together are 80% sensitive and specific for reflux)
sour regurgitation, water brash, sensation of a lump in the throat (bolus sensation) and frequent
belching. Usually a clinical diagnosis based on symptom history and relief following a trial of
pharmacotherapy (proton pump inhibitor (PPI): symptom relief 80% sensitive for reflux) . NB.
24-h pH monitoring is the most accurate test, but rarely required.
PPIs are the most effective therapy. Reference: Toronto Notes.

26. Definitive diagnosis of TB.

Answer : culture is done on all initial samples to confirm the diagnosis. (However, a positive
culture is not always necessary to begin or continue treatment for TB.) A positive culture for
M. tuberculosis confirms the diagnosis of TB disease.
http://www.cdc.gov/tb/publications/factsheets/testing/diagnosis.htm

27. Most common cause of acute bronchiolitis:

A. RSV
B. Adeno
C. Parainfluenza
Answer: A
Reference: http://emedicine.medscape.com/article/961963-overview

29. .A patient developed rhinorrhea and itching immediately after moving into new
apartment. There was Molds spores in the apartment
Answer: allergic Rhinitis

30. Rhinorrhea, cough and conjunctivitis etiology?

A- Rhinovirus
B- Adenovirus
Answer: B
The most common cause of rhinorrhea and sinusitis is Rhinovirus. But since there is also
conjunctivitis, then Adenovirus is more appropriate.
Reference: http://emedicine.medscape.com/article/302460-clinical
http://emedicine.medscape.com/article/211738-clinical

31. In which lobe does lobar pneumonia become ( m79ora)???

1. Right mid
2. Right upper
3. Right lower
4. Left upper
answer:Right lobe of lower lung
Ref https://books.google.com.sa/books?id=-CB3jViGHv0C&pg=PA32&dq=most+common+site
+in

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+pneumonia&hl=ar&sa=X&ved=0ahUKEwiWu_zn94DKAhXCvhQKHckOAccQ6AEILzAC#v=one
page&q=most%20common%20site%20in%20pneumonia&f=false

32. Which of the following medication decrease mucus production in a patient with em-
physema?
A. Cromolyn sodium
B. Steroids
answer : Anticholinergic agents will dilate bronchi and decrease secretions. They are very effec-
tive in COPD.
Cromolyn sodium (no benefit in COPD)
Ref : Master the board

33. Organism causing pneumonia after intubation in ICU ?

Answer:
-Pseudomonas,. S. aureus (from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056625/)
-Gram negative bacilli and S.aureusFrom Washington book

34. What of the following decrease the recurrence of asthma of the

following?
a. Salbutamol
b. Aminophylline
c. Ipratropium
d. Montelukast
Answer A ???
Medications upon discharge An asthmatic attack has not fully resolved even when symptoms
have abated. Residual airflow obstruction due to airway inflammation may last for several days.
Thus, in addition to short-acting beta agonists to be used as needed, the patient will need glu-
cocorticoids to treat the inflammation and prevent recurrent symptoms. Inhaled glucocorticoids
Treatment with regular inhaled glucocorticoids constitutes an important method to prevent
recurrent asthma attacks after discontinuation of oral glucocorticoids and to prevent the poten-
tial decline in lung function associated with any future severe asthma exacerbation
REF :http://www.uptodate.com/contents/treatment-of-acute-exacerbations-of-asthma-in-adults?
source=search_result&search=asthma&selectedTitle=3~150
Or LOW Dose cortisone
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2121160/

35. What of the following decrease the inflammation in asthma of the following? Lukiutrina
Answer: Rt answer is ICS

36. hemosiderin deposition in macrophage in lung in

a-CMV
b-Pneumocystisjiroveci
c-Chronic lung infection
Answer C: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2610638/

37. Pt had URTI ,2 weeks later developed orthopnea , severe pulmonary edema
-What is the dx .
A.Infective endocarditis
B.acute pericarditis
C.acute myocarditis
D.acute bronchitis

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 Answer C
Patients with myocarditis have a clinical history of acute decompensation of heart failure,
( e.g. tachycardia, gallop, mitral regurgitation, edema ).
In viral myocarditis, patients may present with a history of recent (within 1-2 wk) flu like syn-
drome of fevers, arthralgias, and malaise or pharyngitis, tonsillitis, or upper respiratory tract
infection.
http://emedicine.medscape.com/article/156330-clinical#b1

38. Pt healthy pt with no symptoms x ray is normal ,has negative hx of tuberculin test
now has positive test ..?
A. Reassure
B. give rifampicin and izo
C. give izo for 6 months
answer :C
The pt has latent TB ,so the treatment will be:
* 6 month or 9-month isoniazid daily,
* 3-month rifapentine plus isoniazid weekly,
* 3- or 4-month isoniazid plus rifampicin daily,
* 3 or 4-month rifampicin alone daily.
http://www.who.int/tb/challenges/ltbi/en/

39. patient have cough and sob x-Ray show consolidation in right upper lob what ttt?
Answer: Antituberculosisdrugs.TBmay be found in any part of the lung, but upper lobe involve-
ment is most common.
Reference: http://emedicine.medscape.com/article/230802-workup#c12

40. patient with asthma exacerbation ,Which drug will decrease the mucous secretion
more the bronchodilation :
A-oral steroids
B- ipratropium
C- leukotriene
Answer A
Corticosteroids reduce the mucus secretion by inhibiting the release of secretagogue from
macrophages.
Reference: http://www.ncbi.nlm.nih.gov/pubmed/3026210

41. A middle-aged man presents with a cough and fever lasting several weeks. Pos-
teroanterior chest radiograph shows a prominent paratracheal area on the right, lym-
phadenopathy, a cavitary opacity in the right upper lobe, and a focal consolidation in
the middle lung zone on the right.
CXR shown below. What is the dx?
A-COPD
B-BA
C-Pneumonia
D-TB

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Answer: D

42. pt with lung nodule and high ca& parathyroid

hyperparathyroidism - lung ca
Answer:
PTH-RELATED PROTEIN : squamous cell carcinomas (lung)
Toronto Notes 2016 ,page 1275 ,Table 29. Paraneoplastic Syndromes
Kumar &ClarksEighthEdition,page 858

43. patient with pertussis best swap

A- Nasal swab
B- Nasopharyngeal
C- Tracheal
Answer B
The culture specimen should be obtained by using deep nasopharyngeal aspiration or by hold-
ing a flexible swab (Dacron or calcium alginate) in the patient posterior nasopharynx for 15-30
seconds or until a cough is produced.
http://emedicine.medscape.com/article/967268-workup#c9

44. lung found some material in the macrophage ( i can't remember biopsy of the material
)
a. (PCP ) pneumocystis cariniijinra
b. CMV
c. Bacterial
depend on the conten

45. pt present with sx of brochictasis what is the best advice?

A. stop smoking
Answer: A
http://emedicine.medscape.com/article/296961-treatment?src=refgatesrc1#d8

46. Smoker + hemoptysis what to do (not specified first or best)?

A.Chest x-ray

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 B.Chest CT
C.Ppd
D.Coagulation profile
Answer: A cause he is symptomati , we do x-ray for any PT with respiratory symptoms
Toronto notes

47. Pt with diarrhea and cxr showing bilateral infiltrates(pneumonia). Which organism re-
sponsible
A. Legionella
Answer:a
Kumar &ClarksEighthEdition ,page 837

48. 2 qs about croup

49. Q about. TB. Numbness

A. Pyridoxine
http://emedicine.medscape.com/article/124947-overview#a4

50. scenario about horner syndrome asking about the site of tumor :
Answer: Aon the lung apical .
Pancoast tumor (tumor in the apex of the lung, most commonly squamous cell carci-
noma)
http://emedicine.medscape.com/article/1220091-overview#a4

51. asthmatic pt on inhaled corticosteroids , asthma becomes more sever what should
you add :
A. LABA
Answer: A
The stepwise management of asthma(step 3 Inhaled corticosteroids and long-acting in-
haled 2 agonist) Kumar &ClarksEighth Edition,page830)

52. Patient with ventilator associated pneumonia. Culture showed lactose non-ferment-
ing, gram negative motile bacilli producing greenish colony and oxidase positive
what is the organism:
A. E. coli
B. Pseudomonas
C. Klebsiella
D. Proteus
Answer B
http://www.columbia.edu/itc/hs/medical/pathophys/id/2008/utiGNR.pdf

53. PPD was +ve , to prevent false +ve , what to do?!

A. Repeat it
B. Do X-ray
C. Do Mantoux test
Answer B
http://emedicine.medscape.com/article/1947912-overview#a6

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54. X-ray of the lung showed opacification with air fluid level? What is the moa of Abx?
Opacification with air level <<abscess
http://radiopaedia.org/articles/lung-abscess

55. Elderly, asthmatic, what is the best induction

A. Propofol
B. ketamine
Answer : B#
propofol is considered to be the agent of choice for induction of anesthesia in asthmatics.
http://www.ncbi.nlm.nih.gov/m/pubmed/11050961

56. long scenario about patient presented dry cough after being diagnosed with HTN
what is the cause:
A. furosemide
B. ACEI (they mentioned the drug name )
answer :B
The most common side effect is a mild dry cough due to their effect on bradykinin.(Cap-
topril, Enalapril, Lisinopril )Kumar &ClarksEighth Edition ,page 782

57.non small cell lung cancer has 4 risk factors which are stage of the disease , con-
dition of the patient and male sex
Answer:

57. In emphysema alpha one antitrypsin which part is affected:

A. Interstitial
B. Centroacinar
C. Peripheral
D. subseptal or something like this
Answer: Panacinar
http://emedicine.medscape.com/article/298283-overview#a4

59. pt develop cough during exercise :: which medication want to give her before exer-
cise .
Short-acting inhaled beta2-agonists (bronchodilators) stop symptoms

60. Old male with recurrent episodes of cough with sputum and hemoptysis:
A- bronchiectasis(my answer)
B- Tb)
Answer:A
Toronto Notes 2016 page1258

61. Old patient with small cell lung cancer treated by chemotherapy on
examination there is crepitation on the lung no LL swelling lab result showed
hyponatremia what is your advice ?(case of paraneoplastic syndrome (siadh ).
A- IV furosemide
B- Fluid restriction
C- Desmopressin
The answer is B

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62. Which one of these lung cancers is associated with anti epithelial cell receptor thera-
py ?
A- Adenocarcinoma
B- Squamous Cell Carcinoma
C- Small Cell Carcinoma
Answer: A
Kumar &ClarksEighth Edition,page861

63. 64.Old woman has HT its not controlled even with multi drugs .. She sleeps afternoon
alot and feels fatigue most of the time .. What is the cause of her resistance HT ?
a) Obstructive sleep apnea
Answer: A
Toronto Notes 2016page1045

64. Skin manifestation associated with cystic fibrosis:

A- seborrheic dermatitis
B- dermatitisherpetiformis
answer: B present with celiac disease, other two answers were irrelevant

65. embryonal alveolar from what?

A. saccule
I think the Q is not complete
Answer ; A
http://www.ncbi.nlm.nih.gov/m/pubmed/19175284/

66. Patient brought to ER comatosed with cherry red skin ?

A. co posing
answerA
http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?27/29/28112?source=re-
lated_link#H66

67. asthmatic controlled on albuterol PRN, now she got pregnant,

and she started to have daily symptoms & night ... ?
A. Inhaled steroid + LABA
I think the Q is not complete!!
Most likely answer A
The drugs that have been used for many years in asthma
therapy have now been shown to be safe and without teratogenic
potential. These drugs include SABA, ICS, and theophylline; there is
less safety information about newer classes of drugs such as LABA,
antileukotrienes, and anti-IgE. If an OCS is needed, it is better to use
prednisone rather than prednisolone because it cannot be converted to
the active prednisolone by the fetal liver, thus protecting the fetus from
systemic effects of the corticosteroid.

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68. patient presented to the ER with cough hemoptysis night sweats and malaise. what is
most appropriate initial step in the management?
A.isolation in negative pressure room
B.start anti TB
C.give OPD appointment after 2 weeks
Answer: B, TB case is usually confirmed by a positive culture for M. tuberculosis. However, in
some cases, patients are diagnosed with TB disease on the basis of their signs and symptoms,
even if their specimen does not contain M. tuberculosis CDC
Kaplan LNs internal medicine page201

69. COPD patient was on oral steroid and there was improvement 17%in breathing ,
which medication will u put him on :
A. theophylline
B. amitriptyline inhaler or oral
answer :
Prednisolone 30 mg daily should be given for 2 weeks, with measurements of lung function be-
fore and after the treatment period. If there is objective evidence of a substantial degree of im-
provement in airflow limitation (FEV1 increase >15%), prednisolone should be discontinued and
replaced by inhaled corticosteroids (beclometasone 40 g twice daily in the first instance, ad-
justed according to response).
Kumar &ClarksEighthEdition ,page 816

70. An Elderly pt presented to ER due to decreased level of consciousness lethargy

Pco2 20 mmhg
K2
Ph 7.2 I can't remember the rest of the labs and choices
What does she have?
A. high anion gap metabolic acidosis with primary respiratory alkalosis
answer:A
Toronto Notes 2016 ,page710,1252

71. pt with chest infx was treated with oral AB For 4 weeks later came complain from rt
lung effusion what dx?
a) Parapneumonic effusion empyema
b) TB
c) Lung ca
Answer:A
Kumar &ClarksEighthEdition ,page 837
Definition
pus in pleural space or an effusion with organisms seen on a Gram stain or culture (e.g. pleur-
al fluid is grossly purulent)
positive culture is not required for diagnosis
Etiology
contiguous spread from lung infection (most commonly anaerobes) or infection through chest
wall (e.g. trauma, surgery)

72. Old male with recurrent episodes of cough with sputum and hemoptysis
A. Bronchiectasis

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 B. Tb
Answer A
Bronchiectasis((chronic cough, purulent sputum (but 10-20% have dry cough), hemoptysis (can
be massive)) Toronto Notes 2016 ,page1258

73. what you'll seen on physical examination of pt with croup ??

A- presence of inspiratory sounds
B- presence of expiratory wheeze
Answer: A but in severe both of them
The physical presentation of croup has wide variation. Most children have no more than a
"croupy" cough and hoarse cry. Some may have stridor only upon activity or agitation, whereas
others have audible stridor at rest and clinical evidence of respiratory distress. Paradoxically, a
severely affected child may have , stridor secondary to a greater degree of airway obstruction.
The child with croup typically does not appear toxic.
The child's symptoms can range from minimal inspiratory stridor to severe respiratory failure
secondary to airway obstruction.[14] In mild cases, respiratory sounds at rest are normal; how-
ever, mild expiratory wheezing may be heard. Children with more severe cases have inspiratory
and expiratory stridor at rest with visible supra sternal, intercostal, and subcostal retractions. Air
entry may be poor. Lethargy and agitation are due to marked respiratory difficulty and, hence,
hypoxia and increasing hypercarbia. Respiratory arrest may occur suddenly during an episode
of severe coughing.
http://emedicine.medscape.com/article/962972-clinical#b33

74. Case of asthma sever , cough every week , he took neublazer Steroid , wt next man-
agement ?
A. add long acting B agonist
B. ibrapritom
Answer: A
add long acting B agonist
The stepwise management of asthma(step 3 Inhaled corticosteroids and long-acting inhaled 2
agonist) Kumar &ClarksEighth Edition,page830)

75. Lung tumor with keratinization, what type of cells?

A. Epithelial
B. Squamous
Answer: B

76. 12yo bilateral lower lung infiltration ttt?

A. Ciprofloxacin
B. Azithromycin
C. penicillin
most likely B atypical pneumonia ttt by macrolides class if not available tetracycline
boy referral due to having recurrent chest infections & has brother die at 6yrs as same chest
infection sister normal all immunoglobulins low T Cell function good.

77. 61yo male patient with bilateral lung base infiltrate (x-ray chest)
cough ,diarrhea,Temp. 38.7c
Answer: any git symptoms with pneumonia symptoms >> Legionella pneumonia

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78. (long scenario ) ,what is the microorganism ?
A. legionella pneumonia
B. mycoplasma pneumonia
Answer: A

79. ptpreseneted with pneumonia symptoms for 2 weeks i think the gram stain negative :
A. mycoplasma pneumonia
Answer:

80. patient presented to the ER with cough hemoptysis night sweats and
malaise ?what is most appropriate initial step in the management
A.isolation in negative pressure room
B.start anti TB
C.give OPD appointment after 2 weeks
Answer: B TB case is usually confirmed by a positive culture for M. tuberculosis. However, in
some cases, patients are diagnosed with TB disease on the basis of their signs and symptoms,
even if their specimen does not contain M. tuberculosis CDC

81. typical history of pneumonia. x ray was done lower lobe consolidation was
found culture shows gram positive cocci arranged in clusters. catalase and
coagulase positive. what is the most appropriate AB for this infection?
A.oxacillin
B.penicillin G
C.amoxicillin
Answer: A

82. Status asthmaticus on drug inhibit cholinesterase what is the drug?

A. Ipratropium
Answer:

83. COPD developed , DM, developed Acute closure glaucoma; which

treatment.
Answer: (...systemic ophtha, local ..Acetazolamide )

84. asthmatic with 3/week of frequency on short acting and last sever attack was 3
months ago What the appropriate management ?
A. short
B. Long
C. ipratropium
D. Dexamethasone
This is the option not missing any info dexamethasone
RT answer ( add ICS) but b/c it is not from choices so we choose D

85. positive PPD skin test for adult man without any sign of TB infection what you will be
do ?
Answer: Chest X ray if negative INH for 9 m

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86. asthmatic controlled on albuterol PRN, now she got pregnant, and she started to have
daily symptoms & night ... ?
A. Inhaled steroid + LABA
Answer: A

87. boy referral due to having recurrent chest infections & has brother die at 6yrs as
same chest infection sister normal all immunoglobulins low T-cell function good..
A. X-LINKED agammaglobulinemia
Answer: A

88. 61yo male patient with bilateral lung base infiltrate (x-ray chest) cough,
diarrhea,Temp. 38.7c (long scenario ) ,what is the microorganism ?
A. legionella pneumonia
B. mycoplasma pneumonia
answer:A

89. patient with positive ppd , never was +ve before what is next step no x-ray findings?
A. isoniazid and rifampin 6 months
B. rifampin 3 months
Answer: isoniazid ..

90. if there is no iso then rifampin adult patient came to ER cant talk agonic what are you
going to do ?
A. look for object in his mouth
B. give him oxygen
answer:

91. After delivery shortness of breath at night. What findings in the x-Ray support diag-
nosis?
A) Increase in mediastinal width.
B) Increase shadowing
C) Cardiothoracic increase.
Answer: PE mostly she will have PE

92. Patient with hemoptysis, at first it was blood tinged then it appeared bright red blood
what should the next investigation be?
A) Chest x-ray
B) ppd
Answer: A

93. upper limb edema , intercostals vein engorgement , lesion in right lung ,
compression in which side :
A. Ant mediastinum
B. Post mediastinum
C. Rt hilum
D. Median mediastinum
. Answer : A??

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94. 3 years old with a father known to have pulmonary TB his PPD 10mm what does he
have ?
. A. Strong +ve
C. Weak positive
D. Answer : A

95. Case of asthma sever , cough every week , he took neubelizer steroid , what next
management ?
A. Add long acting B agonist
B. Ipratropium
Answer : Add LABA
96. Pt with chronic interstitial lung disease in biopsy see small non necrotizing granul in
alveolar membrane Dx ?
A. TB
B. ARTHROSIS
C. Hypersensitivity pneumonitis
Answer : C

97. Obstructive sleep apnea . Most effective reatment ?

A. BMI less than 30
B. Cpap
Answer : B
Cpap shows to reduce CVS risk and CVS related deaths in Pt with OSA

98. Female came from 18 hours flight and she feel leg pain what you will take ?
A. Warfarrin
B. LMWH
C. unfractionated heparin and warafarin
answer : C , referance : uptodate

99. Prostate cancer pt with recurrent DVT , Best prophylaxis is ;

A. LMWH
B. Unfractionated heparin
C. LMWH short term therapy followed by warafarin
Answer : A

100.Pt with Small lung cancer and undergoing chemo , developed I dont remember
but lab value : low blood NA , and low urine osmolality , Tx ?
A. Desmopressen

Answer : the question is not cmplete so ;

If we said it,s SIADH , the answer will be fluid restriction

101.Female non smoker with nodule by ct found calcium and flat ;

A. Hamartoma
B. Mystheoma
C. No adeno
Answer : A

102.Smoker with hilar mass what suspect

A. Lymph node
B. Squamous cell Ca
C. Adenocarcinoma

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 Answer ; B

103.4 week black pt had mycoplasma pneumonia , what will be very high in LP ?
A. Protein
B. Wbc
C. Glucose

104. Low ph, bicarb , co2 ?

A. Compensated metabolic acidosis
Answer : non compensated

105. Broncial cancer mets to sympathetic plexus what the sign ?

A. Ptosis dilated pupil
Answer : is horners syndrome ptosis , anhidrosis . Miosis

Rheumatology
1. blue sclera + multiple fracture?
Answer: osteogenesis imperfecta
(This q should be in pedia section despite the answer is right )
Osteogenesis imperfecta (OI) is a genetic disorder characterized by bones that break easily, often from
little or no apparent cause.The majority of cases of OI (possibly 85-90 %) are caused by a dominant mu-
tation in a gene coding for type I collagen.
Type I
Most common and mildest type of OI.
Bones fracture easily. Most fractures occur before puberty.
Normal or near-normal stature.
Loose joints and muscle weakness.
Sclera (whites of the eyes) usually have a blue, purple, or gray tint.
Triangular face.
Tendency toward spinal curvature.
Bone deformity absent or minimal.
Brittle teeth possible.
Hearing loss possible, often beginning in early 20s or 30s.
Collagen structure is normal, but the amount is less than normal.
http://www.oif.org/site/PageServer?pagename=fastfacts
..
2. patient with symptoms of gout , which medication will help?
Answer: inhibit the xanthine oxidase (allopurinol)

The management in acute attack is NSAID if there is contraindication give colchicine, corticosteroid they
are a reasonable option when NSAIDs, COX-2 inhibitors, and colchicine are contraindicated. Avoid al-
lopurinol in acute cases
If chronic case give allopurinol to reduce uric acid level below 360 micromol/L (6 mg/dL) to prevent super-
saturation and crystal formation. Allopurinol is a purine analog; it is a structural isomer of hypoxan-

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 thine (a naturally occurring purine in the body) and is an inhibitor of the enzyme
xanthine oxi- dase.
https://en.wikipedia.org/wiki/Allopurinol
..
3. treatment of chronic pain?
Answer: Physiotherapy, NSAIDs, Acetaminophen, Antidepressants, Anticonvulsants, Muscle
relaxant and Opioids REFERENCE: https://www.asra.com/page/46/treatment-options-for-
chronic-pain
.
4. 60 year old female with distal phalangeal joint swelling and shoulder pain and
knee pain , x ray showed narrow joint space and osteophytes?
A. Rheumatoid arthritis
B. Osteoarthritis
Answer: B
REFERENCE: Toronto notes

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