UNIVERSITY OF THE PHILIPPINES MANILA

PHILIPPINE GENERAL HOSPITAL

DEPARTMENT OF MEDICINE

RESIDENTS EXAM
PULMONARY MEDICINE
March 29, 2007

MULTIPLE TRUE OR FALSE. There are 5 statements after each question. Determine whether
each statement is true or false. On the answer sheet, place an x in the box corresponding to
your answer.

1. TRUE of respiratory failure: (HPIM p. 1588)

a. can clinically manifest as hypoxemia with pO2 <80 mmHg at room air = o2 sat of less
than 90 despite an fio2 greater than 60
b. can clinically manifest as hypercarbia with pCO2 >45 mmHg arterial pco2 greater
than 50 and arterial ph less than 7.3
c. Respiratory failure is a common diagnosis in ICUs and the incidence is affected by the
number of co-morbid conditions -
d. There is an inverse relationship between the incidence of mortality from respiratory
failure and patients age -
e. The discovery of antibiotics has improved the prognosis for patients with respiratory
failure over the past several decades.

2. TRUE of the five separate components that may be affected in respiratory failure:
a. The nervous system is the control system and is composed of the dorsal and ventral
nuclei of the mesencephalic respiratory control group, and their associated afferent
and efferent neural pathways. (medullary)
b. The primary inspiratory muscle of breathing is the diaphragm which increases the
pressure in the pleural space during inspiration, establishing a pressure gradient
between the airway opening and the alveolar compartment.
c. Under normal conditions, the internal intercostals, suprasternal and
sternocleidomastoid muscles help the diaphragm during expiration. (inspiration)
d. The cartilaginous bronchi, respiratory bronchioles and alveoli provide surface area for
gas exchange. (for air conduction)
e. Failure of at least 2 of these 5 components leads to respiratory failure. (any)

3. TRUE of the clinical evaluation of patients with respiratory failure (HPIM p. 1589-90):
a. Oximetry provides a rapid way to determine blood O2 levels, and information regarding
alveolar ventilation and pCO2 levels. (does not provide ABG)
b. The emergent nature of respiratory failure requires that initial therapy be implemented
before the specific etiology is diagnosed and treated.
c. Abdominal paradoxus (diaphragmatic injuries) suggests controller dysfunction
which may be brought about by drugs that impair the respiratory drive. (finding awake
patient with significant hypercarbia/nypoxemia with no change of RR)
d. An awake, mildly sedated patient with either significant hypoxemia or hypercarbia who
demonstrates RR <12 breaths/min but who has(no) use of accessory muscles of
breathing is likely to have a defect in regulating respiratory drive.
e. The chest radiograph is a (not) useful tool for assessing the airway component. pe:
stridor, wheezing

4. Below are types of dysfunction that lead to respiratory failure paired with their supposed
associated features. Which are CORRECTLY PAIRED? (HPIM, p. 1589-90)
a. Controller dysfunction can be assessed by simply counting the respiratory rate
b. Pulmonary vascular dysfunction ECG may show LBBB or right heart strain - RBBB
c. Alveolar dysfunction physical examination findings like tubular breath sounds,
dullness on percussion and egophony
d. Pump dysfunction vital capacity <10 mL/kg, inspiratory force <-20 cmH20
e. Alveolar dysfunction presence of auto-PEEP (PE findings of consolidation, elevated
PaCO2, decreased PF ratio)
5. TRUE of the etiology and pathophysiology of ARDS: (HPIM, p. 1592)
a. The lung injury may be direct (indirect), as occurs in flail chest, or indirect (direct), as
may occur in near-drowning.
Direct: pneumonia, aspiration of gastric contents, pulmonary contusion, near drowning,
toxic inhalation injury
Indirect: sepsis, severe trauma, multiple bone fractures, flail chest, head trauma, burns,
multiple transfusions, drug overdose, pancreatitis, post cardiopulmonary bypass
b. Among patients with trauma, head trauma, near-drowning, toxic inhalations and burns
are the more common (rare) causes, while pulmonary contusion, multiple bone
fractures and flail chest are the rare (more common) causes.
Most common: trauma, pulmonary contusion, multiple bone fractures, chest wall trauma,
flail chest
Rare: head trauma, near drowning, txoci inhalation, burns
c. Injury to the pseudostratified ciliated columnar cells (alveolar cells) of the
tracheobronchial tree and type I pneumocytes leads to formation of edema fluid.
Exudative phase: alveolar capillary endothelial cells and type I pneumocytes (alreolar
epithelial cells) are ininjured leading to the loss of the normally tight alveolar barrier to fluid
and macromolecules
d. Unlike in heart failure, pulmonary edema that develops in ARDS affects all portions of
the lung and not only the dependent areas. (all areas ILD)
Predominantly involves the dependent portions of the lung leading to diminished aeration
and atelecdtasis
e. Microthrombi cause vascular obliteration and decreased pulmonary arterial blood flow
in ARDS.

6. TRUE statements regarding the clinical course of ARDS: (HPIM, p. 1592-3)

a. In addition to severe hypoxemia, respiratory alkalosis secondary to an increase in
pulmonary dead space is also seen in early ARDS. (respiratory acidosis)
b. The proliferative phase encompasses the first 7 days of the illness. (exudative)
Proliferative phase lasts from day 7-21
c. Differential diagnoses include diffuse pneumonia, alveolar hemorrhage, and
cardiogenic pulmonary edema. other differentials include acute interstitial lung
diseases, acute immunologic injury, hypersensitivity pneumonitis
d. The pulmonary infiltrate is initially made up of lymphocytes and later on replaced by
neutrophils as the disease progresses. (neutrophils) -
e. The presence of alveolar type III procollagen peptide is associated with a good (poor)
prognosis because of its indirect relationship to the formation of pulmonary fibrosis.

7. TRUE statements with regards to the management and treatment of patients with ARDS:
(HPIM, p. 1593-5)
a. Repeated alveolar overdistention and collapse are the two processes that may explain
why mechanical ventilation may cuase lung injury. Therefore, mechanical ventilation
can also aggravate lung injury.
b. Application of PEEP at 12 to 15 mmHg is the theoretical optimal PEEP for alveolar
recruitment.
c. There is a (no) mortality benefit with inverse ratio ventilation, that is lengthening the
inspiratory time so that it is longer than the expiratory time.
d. Extracorporeal membrane oxygenation (ECMO) has a clear survival benefit for
neonatal ARDS but not for adults.
e. Maintaining a normal or low left atrial filling pressure minimizes pulmonary edema and
prevents further decrease in arterial oxygenation and lung compliance.

8. TRUE statements regarding indications for the use of mechanical ventilation: (HPIM, p. 1595)
a. Mechanical ventilation should generally be instituted in acute hypercarbic respiratory
failure. to blow off carbon dioxide
b. If a patient is not in respiratory distress and is not mentally impaired by CO2
accumulation, it is not mandatory to initiate mechanical ventilation even if pCO2 is high.
c. Controlled hyperventilation is used to reduce cerebral blood flow in patients with
elevated intracranial pressure. -
d. Mechanical ventilation can reduce the work of breathing in patients with congestive
heart failure.
e. Ventilators are specially designed pumps that improve oxygenation by application of
high oxygen content and negative pressure. poaitive pressure
9. Mechanical ventilation is not without complications. Which of the following statements are
TRUE? (HPIM, p. 1599)
a. Barotrauma occurs when high pressures (>50 cmH2O) overdistend and disrupt lung
tissue. clinically manifest by interstitial emphysema, pneumomediastium,
subcutaneous emphysema or pneumothorax
b. Staphylococcus aureus is one of the common etiologies for nosocomial pneumonia
associated with mechanical ventilation.- VAP usually occurs in patients intubated for
greater than 72 hours. Most common are psydomonas, enteric gram negative rods
and staph
c. Administration of catecholamines (i.e. dopamine or norepinephrine) is the first line in
addressing hypotension resulting from elevated intrathoracic pressures. - fluids
d. Mild cholestasis is from the effects of increased intrathoracic pressure on the
intraluminal pressure of the intrahepatic ducts. portal vein pressure
e. Endotracheal intubation and mechanical ventilation have indirect effects on several
organ systems.
10. TRUE statements regarding weaning from mechanical ventilation: (HPIM, p. 1599)
a. Upper airway function must be intact for a patient to remain extubated but this is
difficult to assess in a patient who is intubated.
b. Although patients may not meet all the criteria for weaning, the likelihood that a patient
will tolerate extubation increases as more criteria are met.
c. SIMV and PSV (should be t piece and cpap weaning) are best tolerated by patients
who have undergone mechanical ventilation for brief periods. extended periods and
neuromuscular defects
d. In T-piece weaning, spontaneous breathing trials are initiated at 5 min/h followed by a
1-hour interval of rest, eventually increasing by 5-10 minute increments.
e. Gradual withdrawal of PSV (pressure support ventilation) continues until the level of
support is just adequate to overcome resistance of the chest wall (approx 15-20 cm
H2O). 5-10cmH2O

11. Which of the following conditions present as diffuse alveolar disease on chest radiography?
(HPIM, p. 1497) differentiate between alveolar and interstitial
a. infection (Pneumocystis, viral or bacterial pneumonia)
b. cardiogenic pulmonary edema
c. pulmonary infarction localized opacification. Others are pneumonia, neoplasm,
radiation pneumonitis, boop, bronchocentric granulomatosis
d. Metastatic neoplasm solitary circumscribed density or diffuse nodular disease
e. Idiopathic pulmonary fibrosis
Other diffuse alveolar disease: ARDS, diffuse alveolar hemorrhage, sarcoidosis
Interstitial: idiopathic pulmonary fibrosis, pulmo fibrosis with systemic rheumatic disease,
sarcoidosis, drug induced lung disease, pneumoconiosis, hypersensitivity pneumonitis,
infection (pneumocystis, viral pneumonia), langerhans cell histiocytosis

12. The two major patterns of abnormal ventilatory function are restrictive and obstructive
patterns. Which of the following is/are TRUE? (HPIM, p. 1500-1501)
a. The hallmark of the obstructive pattern is a decrease in expiratory flow rates.
b. With fully established obstructive disease, the ratio FEV1/FVC is decreased, FEF 25-
75
c. A low FEF 25%-75% (forced expiratoy flow between 25% and 75% of the vital
capacity) is a late finding in obstructive disease - early
d. In restrictive disease, residual volume is elevated as a result of airway closure during
expiration. - obstructive
e. The hallmark of restrictive disease is a decrease in lung volumes, primarily functional
residual capacity (FRC) and residual volume (RV) decrease in lung volumes
TLC, VC.

13. TRUE statements regarding normal physiology of and disturbances in gas exchange (HPIM, p.
1501-1502)
a. A normal individual at rest inspired 12-16 times/minute with each breath having a tidal
volume of 500 mL.
b. Seventy percent of the inspired volume remains on the conducting system (anatomic
dead space) while the remainder reaches the alveoli. 30%. The remaining 70%
reaches the alveolar zone, mixes rapidly with the gas already there and can participate
in gas exchange
c. In a patient with diffusion limitation across the alveoli, shortening of the transit time of
red cells in the alveolar capillaries is a compensatory response to prevent hypoxemia.
if erythrocyte transit time in the pulmonary circulation is shortened as occurs with
exercise, and diffusion is impaired, hypoxemia occurs.
d. Ventilation is highest in the apices and lowest in the bases of the lungs. The opposite
pattern is true for perfusion.
e. Hemoglobin is almost fully saturated (~90%) at pO2 of 80 mmHg,(should be 60mmHg)
and little additional O2 is carried by hemoglobin even with a substantial increase in
pO2 above this level.

14. TRUE of pulse oximetry which is a frequently used tool in measuring gas exchange: (HPIM p.
1503)
a. It provides intermittent rather than continuous data about a patients oxygenation. -
ABG
b. It is an alternative to measurement of pO2, with the latter (ABG) requiring arterial
puncture.
c. The signal from the oximeter may be unobtainable during states of decreased
peripheral perfusion.
d. When two wavelength of light are used, instead of only one, the pulse oximeter can
(cannot) distinguish between carboxyhemoglobin, methemoglobin and oxyhemoglobin.
e. An oxygen saturation of >90% is also an indirect measure of adequacy of CO2
elimination. not a measurement
15. Radiologic imaging tests are part of the diagnostic work up for patients with respiratory
disorders. Which of the following is/are TRUE? (HPIM p. 1505-6)
a. The use of cross sectional images in CT scan makes it possible to distinguish between
densities that would otherwise be superimposed on a plain radiograph.
b. The addition of contrast material in CT scans makes it possible to distinguish vascular
from nonvascular structures, such as lymph nodes and masses from blood vessels.
c. MRI provides a more detailed view of the pulmonary parenchyma with better spatial
resolution. Less well defined than a CT
d. Flowing blood does not produce a signal on MRI, so vessels appear as hollow tubular
structures.
e. Ultrasound is an effective tool in evaluating the pulmonary parenchyma as well as the
pleura. not a useful, helpful in the detection of pleural abnormalities, thoracentesis

16. TRUE statements regarding the etiology and prevalence of bronchial asthma: (HPIM p. 1508)
a. Asthma occurs in all age groups, but is more predominant in adulthood. affects 10-12
percent of adults and 15% of children
b. During childhood, the male:female ratio is 1:2 but the sex ratio reverses in adulthood.
in childhood, twice as many amles as females are asthmatic, but by adulthood, the sex
ration has equalized.
c. A patient with no family history of allergy, with negative skin tests, and with normal
serum levels of IgE does not have asthma. these patients, with non atopic or intrinsic
asthma, usually show later onset of disease (adult onset asthma) commonly have
concomitant nasal polyps, and may be aspirin sensitive, have more severe, persistent
asthma.
d. In general, asthma that has its onset during childhood has a strong allergic component
while that which develops later in life tends to be nonallergic or would have a mixed
etiology.
e. Male sex is the single largest risk factor for the development of asthma. - atopy

17. TRUE of the pathogenesis of asthma: (HPIM p. 1508)

a. Even in asymptomatic patients, the airways can be edematous and infiltrated with
eosinophils, neutrophils and lymphocytes.
b. Presence of airway edema, inflammatory cells, glandular hypertrophy and denudation
of the epithelium correlates with increased severity of asthma. ???
c. The inflammatory reaction is composed of bronchoconstriction, vascular congestion,
edema formation, increased mucus production and increased ciliary transport. ???
d. The airway epithelium can be destroyed and can be sloughed off into the lumen in the
form of Creola bodies.
e. Epithelial denudation exposes the sensory nerve endings, initiating neurogenic
inflammatory pathways.

18. TRUE of the pharmacologic stimuli that incite asthma: (HPIM p. 1509-10)
a. Allergic asthma is dependent on an IgG response controlled by T and B lymphocytes.
IgE
b. Most of the allergens that provoke asthma are associated with food rather than being
airborne. most common that causes exacerbation: viruses, there is little evidence that
allergic reactions to food lead to increasd asthma symptoms
c. The seasonal form of asthma results from allergy to feathers, animal dander, dust
mites and molds. perennial, seasonal would be due to pollen
d. the triad of perennial vasomotor rhinitis, nasal polyps and the development of asthma
is usually associated with beta adrenergic blockers. - aspirin
e. Chronic overexcitation of cysteinyl leukotrienes, which activate mast cells, is inhibited
by cromolyn sodium. leukotriene inhibitor, beta agonsists, best prevented by regular
inhaled glucocorticoids

19. TRUE of the stimuli that incite asthma: (HPIM, p. 1510-11)

a. Local use of beta-1 blockers in the eye for treatment of glaucoma is associated with
worsening asthma.
b. Air pollutants that can cause respiratory symptoms especially in asthmatics include
ozone, nitrogen oxide and sulfur dioxide.
c. High-molecular-weight compounds like wood and vegetable dusts release
bronchoconstrictor substances.
d. Low-molecular-weight compounds like metal salts and plastics cause symptoms via
immunologic mechanisms.
 e. Occupational factors are the most common of the stimuli that evoke asthma
exacerbations. respiratory tract infection

20. In asthma, the net result of contraction of smooth muscle, vascular congestion, edema of the
bronchial wall and presence of thick secretions is/are: (HPIM, p. 1511)
a. increase on airway resistance
b. decrease in expiratory volumes
c. increase in expiratory flow rates - decrease
d. hyperinflation
e. abnormal distribution of ventilation with normal perfusion of the lungs - inc

21. TRUE of the pathophysiology and clinical features of bronchial asthma: (HPIM. 1510-11)
a. Hypocarbia is a universal finding during acute exacerbations. - hypoxia
b. The finding of a low carbon dioxide tension is associated with quite severe levels of
obstruction. Due to inc ventilation
c. Cyanosis is a very late sign.
d. The sine qua non of asthma is dyspnea. - wheezing
e. Atelectasis may occur with formation of inspissated mucus.

22. TRUE of asthma and its differential diagnosis: (HPIM, p. 1511-12)

a. Dyspnea with wheezing upon awakening in the morning is an extremely common
feature such that its absence raises doubt about the diagnosis.- nocturnal
b. Upper airway obstruction by tumor or laryngeal edema typically manifests with stridor
and harsh respiratory sounds localized to the trachea.
c. Normal findings upon examination of the glottis when the patient is symptomatic
excludes the diagnosis of upper airway obstruction.
d. Endobronchial obstruction usually presents with persistent wheezing localized to one
area.
e. Recurrent pulmonary embolism and asthma can be easily differentiated by the
presence or absence of bronchospasm. recurrent bronchospasm

23. TRUE of the adrenergic stimulants used to treat asthma: (HPIM, p. 1512-1513)
a. The resorcinol and saligenin beta2 agonists are virtually devoid of significant cardiac
effects except at high doses.
b. The major side effect of beta2 agonists is palpitation. - tremor
c. In severe asthma, parenteral administration of beta2 agonists is more effective than the
inhaled route.
d. Salmeterol is not recommended for the treatment of acute episodes of asthma. -
formoterol
e. Adrenergic stimulants cause bronchodilation by activation of G proteins with resultant
formation of cAMP.

24. TRUE of the other medications used in the treatment of asthma: (HPIM p. 1512-13)
a. At high levels, methylxanthines can cause seizures and arrhythmias. common side
effects nausea, vomiting, headaches. Diuresis and palpitations may also occur
b. Anticholinergic agents are considered second line only to beta2 agonists because of
their significant side effects. they inhibit only the cholinergic reflex component of
bronchoconstriction, whereas b2 agonists prevent all bronchoconstrictor mechanisms
side effects are not usually a problem since there is no systemic absorption, the most
common side effect is dry mouth
c. Glucocorticoids, together with long acting beta2 agonists and mast cell stabilizing
agents (not included) are effective long-term bronchodilators.
d. Inhaled glucocorticoids are indicated in patients with persistent symptoms.
e. Inhaled steroids are safe and do not cause adrenal suppression even in high doses.
(can cause)

25. TRUE of hypersensitivity pneumonitis: (HPIM p. 1516-8)

a. Factors responsible for the expression of HP include both those related to the host and
the inciting agent.
b. The preferred treatment is avoidance of the causative agent.
c. Studies in humans and animal models suggest that immune complex hypersensitivity
is behind the pathogenesis of HP. cell mediated
d. Bronchoalveolar lavage consistently shows abundant eosinophils and mast cells
(lymphocyte).
e. A positive response to an inhaled antigen may include fever, chills, dyspnea, transient
airflow obstruction and peripheral and alveolar leukocytosis.
 26. TRUE of the laboratory findings in hypersensitivity pneumonitis: (HPIM p. 1518)
a. Peripheral eosinophilia is a consistent feature. Not neutrophilia and lymphophilia
b. The diagnosis is established by the presence of serum precipitins.- indicate sufficient
exposure to the causative agent for generation for immunologic response, but
diagnosis is not established solely by the presence of precipitins.
c. Chest x-ray shows no specific or distinctive changes.
d. Antinuclear antibodies are believed to have a pathogenic role.
e. Bronchiolitis can be seen in biopsy specimens, but vasculitis is not a feature of the
disorder.

Prediction rule for clinical diagnosis of hp has been developed. Six significant predictors of hp
Exposure to a known antigen
Positive predictive antibodies to the antigen
Recurrent episodes of symptoms
Inspiratory crackles 4-8 hours after exposure
Weight loss
27. TRUE statements regarding environmental lung diseases: (HPIM p. 1521-22)
a. Removal of the patient from harmful exposure is often the only intervention that might
prevent further significant deterioration or lead to improvement in the patients
condition.
b. The pulmonary response to most injurious agents is specific for the causative agent.
c. Exposure to organic dusts capable of producing occupational asthma results in
pronounced obstructive patterns of pulmonary dysfunction.
d. For asbestosis, moderate to severe exposure has taken place for at least 10 years
before the disease manifests.
e. It is important to advise patients with a history of asbestos exposure to cease from
cigarette smoking because of the increased risk for mesotheliomas.mesotheliomas
though are not related to smoking, but lung cancers are. Both mesotheliomas and lung
cancer with increased risk.

28. TRUE of the occupational exposures which lead to pulmonary disease: (HPIM p. 1522-26)
a. Silicosis may be rapidly fatal despite the discontinuation of the exposure.
b. Patients with silicosis are at greater risk of acquiring tuberculosis.
c. Flax, hemp and jute produce a syndrome similar to byssinosis which is due to
exposure to moldy hay in cotton containing spores of thermophilic actinomycetes.
d. Firefighters and victims may also be exposed to large quantities of particulate smoke
which has more significant long-term effects than inhalation of the toxic fumes such as
cyanide or hydrochloric acid. carbon monoxide
e. Exposure to asbestos is not limited to persons who directly handle the material.

29. To the clinician, pneumonia is a constellation of symptoms and signs which include: (HPIM, p.
1528)
a. chills
b. sputum production
c. wheezes
d. egophony
e. bronchial breathing

30. TRUE of the host defenses that protect the lungs from being affected with pneumonia: (HPIM
p. 1528-9)
a. The sharp angular turn from the naso- and anterior oropharynx into the posterior
pharynx acts as baffles where inhaled particulate matter can impact.
b. Increased mucosal pH, presence of mucosal IgM (secretory IgA) and constant
desquamation of the epithelial cells prevents pathogens from attaching to the upper
respiratory tract.
c. Alveolar macrophages, present at a density of 1 per alveolus, play an important role in
both innate and acquired immunity.
d. Their ability to phagocytose multiple times is characteristic of their role in acquired
(innate) immunity.
e. Lymphocytes and mononuclear phagocytes are present in the lower respiratory tract,
but are not part of the immunologic defense in the upper respiratory tract where innate
immunity plays a major role.

31. TRUE regarding the factors in the pathogenesis of pneumonia: (HPIM p. 1529)
a. By far, the most common route for bacterial pneumonia is gross aspiration of
oropharyngeal secretions. - microaspirations
b. Hematogenous spread is the usual route for endemic fungi (Coccidiodes, Blastomyces,
Histoplasma) and Coxiella. - aerosolization
c. The pneumococcal capsule inhibits bacterial cell destruction by complement. -
phagocytosis
d. Hypogammaglobulinemia, lymphopenia (neutropenia), asplenia and reduction on NK
cell counts are host defense deficits that result in increased frequency and severity of
pneumonia.
e. Haemophilus influenzae is the most common pathogen in patients with functional or
anatomical asplenia. Strep pneumoniae

32. TRUE statements regarding the pathologic findings in pneumonia: (HPIM p. 1529-30)
a. Bronchopneumonia classically involves an entire lung homogeneously. - lobar
b. In the stage of red hepatization, many erythrocytes, neutrophils, desquamated
epithelial cells and fibrin are seen in the alveolar spaces.
 c. Fibrinous inflammation may extend across the pleural space, and may lead to pleural
adhesions.
d. In miliary pneumonia, the alveoli do not contain a significant exudate. interstitial
e. In interstitial pneumonia, there is inflammation of the alveolar walls and connective
tissue surrounding the bronchovascular tree.

33. Which of the following clues in the history and PE CORRECTLY correspond to the most likely
etiology of pneumonia? (HPIM p. 1531)
a. Health care worker Mycobacterium tuberculosis
b. Cooling tower maintenance worker Coxiella burnetti (legionella)
c. Sleeping in a rose garden Sporothrix schenckii
d. Structural lung disease Klebsiella pneumoniae (Pseudomonas)
e. Sickle cell disease Streptococcus pneumoniae

34. Definite (as opposed to probable and possible diagnosis of pneumonia is defined as:
(HPIM p.1531)
a. pathogen recovered from pleural fluid
b. isolation from a purulent sputum of Pseudomonas aeruginosa
c. Positive urinary antigen test for Legionella
d. Isolation of Mycobacterium tuberculosis from sputum
e. Fourfold or greater rise in titer of antibody between acute- and convalescent-phase
sera (probable)

35. TRUE of the clinical manifestations of pneumonia: (HPIM p. 1532-1533)

a. A diagnosis of pneumonia based on PE has a low sensitivity and specificity, thus this
should be confirmed by sputum examination. chest xray
b. All patients with T>38.5C and pleuritic chest pain should have a chest x-ray.
c. Fall and new-onset or worsening confusion may be important manifestations in the
elderly.
d. In general, for patients initially treated on an out-patient basis for pneumonia, those
admitted during the first week after the initial visit are admitted because of worsening of
comorbid illnesses (DM, CHF, asthma, IHD).
e. For hospitalized patients, clinical deterioration is uncommon once stability is attained.

36. The British Thoracic Society rule for definition of severe CAP include: (HPIM p. 1532)
a. creatinine > 2 mg/dL - confusion
b. urea >7 mmol/L
c. respiratory rate <10/min (>30)
d. bradycardia
e. arterial pH <7.35
BP <90/60
Age greater than 65 years old

37. TRUE of the diagnostic work up for pneumonia: (HPIM p. 1533)

a. If pneumonia is strongly suspected on clinical grounds and no opacity is seen on initial
chest x-ray, it is useful to repeat the radiograph after 24 to 48 hours or to have a chest
CT scan done.
b. The presence of pneumatocoele on chest x-ray suggests tuberculosis. staph
pneumonia
c. All patients who are admitted for CAP should have two sets of blood culture done, one
before initiation of antibiotic treatment and the other would be after the antibiotic
sensitivity studies have become available. because of the low yield and the lack of
significant impact on outcome, blood cultres are no longer considered de rigueur for all
hospitalized cap patients.
d. There is a great deal of interobserver variability in the interpretation of Gram-stained
sputum smears.
e. Urine antigen test for Legionella can detect all serogroups of L. pneumophilia but not
the other species of Legionella sp.

38. TRUE statements regarding the scoring systems or algorithms used to guide the decision
regarding the site of care (home vs. hospital) for patients with pneumonia: (HPIM p. 1534)
a. These systems are important diagnostic tools and do not take into account the
psychosocial reasons for admission.
b. Even if the scoring systems capture events at a single point in time, they are able to
predict a patients clinical course. not predictive
c. A physicians judgement should override any scoring system.
d. When a patient is sent home from the ER or clinic, it is advisable to follow up with a
telephone call within 48 hours.
e. Patients who are treated on an ambulatory basis must be given written information
about the warning signs of pneumonia exacerbation.
39. TRUE of the issues regarding antibiotic treatment of pneumonia: (HPIM p. 1534-55)
a. Since the etiology is frequently unknown, initial antibiotic therapy is often empirical.
b. Patients who received antibiotics within 8 hours after arrival in the emergency room
had a shorter hospital course and decreased number of complications but same
mortality rates than those who received the first dose >8 hours afterwards.
c. The increase in drug resistance has not been accompanied by clear evidence of drug
failure among patients with pneumococcal CAP.
d. Doxycycline is underused for the treatment of CAP in the ambulatory setting even if it is
active against penicillin-susceptible S. pneumoniae and the atypical pathogens.
e. Patients with pneumonia treated with a quinolone in the past 3 months should receive
treatment with another class of antibiotics.

40. Which of the following are the possibilities to consider when a patient with CAP fails to improve
despite treatment? (HPIM p. 1536)
a. There is another illness that presents like pneumonia.
b. The treatment regimen is targeting a wrong pathogen.
c. Presence of an anatomical defect in the lung.
d. Drug-associated fever
e. Treating the right pathogen with the wrong drug

41. TRUE of the pathologic findings in bronchiectasis: (HPIM p. 1541)

a. The components of the bronchial wall, including cartilage, muscle, and elastic tissue
are replaced by fibrosis.
b. Airways contain thick, purulent material.
c. Decreased vascularity of the bronchial wall as a result of inflammation as a result of
the inflammation, vascularity of the bronchial wall increases, with associated
enlargement of the bronchial arteries and anastomosis between the bronchial and
pulmonary arterial circulations.
d. Parenchyma supplied by the affected airways remains histologically normal.
abnormal, containing varying combinations of fibrosis, emphysema,
bronchopneumonia, and atelectasis
e. Bronchial and pulmonary arterial anastomoses

42. Generalized impairment of pulmonary defense mechanisms that may lead to bronchiectasis
include: (HPIM p. 1542)
a. endobronchial obstruction
b. immunoglobulin deficiency
c. cystic fibrosis
d. Kartageners syndrome
e. Foreign body aspiration

43. TRUE of the clinical findings and diagnosis of bronchiectasis: (HPIM p. 1542-43)
a. PE of the chest is variable; any combination of wheezing, crackles and rhonchi may be
heard
b. Bronchography is the current diagnostic test of choice. CT scan
c. Sputum examination shows predominance of macrophages, lymphocytes and
monocytes. neutrophils and colonization or infection with a variety of possible
organisms
d. Pulmonary function test may reveal a normal FEV1/FVC.
e. On radiography, the airway lumen may appear radiolucent rather than dense due to the
secretions. because the dilated airways may be filled with secretions, the lumen may
appear dense rather than radioluscent, producing an opaque tubular or branched
tubular structure

44. Clinical manifestations of cystic fibrosis include: (HPIM p. 1545)

a. meconium ileus
b. upper respiratory tract disease
c. dextrocardia
d. immotile spermatozoa
e. protein and fat malabsorption

45. TRUE of the risk factors associated with COPD: (HPIM p. 1547)
a. The dose-response relationship between cigarette smoking and reduced pulmonary
function accounts for the higher prevalence with increasing age.
b. The relationship of air pollution and chronic airflow obstruction remains unproven.
 c. Alpha1-antitrypsin deficiency is a proven genetic risk factor
d. Recurrent viral infections in childhood is associated with the development and
progression of COPD.
e. The magnitude of the effect of occupational dusts and fumes to the development of
COPD is more important than that of cigarette smoke, but is just less prevalent due to
the smaller number of people with these occupational exposures.

46. TRUE statements regarding the natural history and pathophysiology of COPD: (HPIM p. 1548-
49)
a. The rate of decline in respiratory function is not affected by changing environmental
exposures (i.e. quitting smoking)
b. In COPD, inspiratory flow rates may be well preserved even if FEV1 is markedly
reduced.
c. Airflow during forced exhalation is the result of the balance between lung compliance
and airway resistance.
d. Hyperinflation pushes the diaphragm into a flattened position, as demonstrated in a
chest radiograph, but this is of no physiologic significance.
e. Hypercarbia may not be seen during the early stages of COPD, and is not expected to
occur until FEV1 is <25%.

47. Cigarette smoking affects the large airways, small airways and alveoli in COPD. Which of the
following are TRUE? (HPIM p. 1549-50)
a. Changes in large airways are responsible for physiologic alterations while those in
small airways cause cough and sputum production.
b. Columnar metaplasia of the airways disrupts mucociliary clearance and predisposes to
carcinogenesis.
c. The major site of increased resistance in COPOD are the airways <2 centimeters in
diameter.
d. Panacinar emphysema, the type most commonly associated with cigarette smoking,
has a predilection for the lower lobes.
e. Small airway patency is maintained by the radial traction provided by the surrounding
lung parenchyma on the bronchioles at points of attachment to alveolar septa.

48. TRUE statements regarding the clinical presentation of patients with COPD: (HPIM p. 1551-
52)
a. Many patients date the onset of their illness to an acute exacerbation but careful
history reveals the presence of symptoms prior to the acute exacerbation.
b. The three most common symptoms are cough, sputum production and exertional
dyspnea.
c. Patients with predominant emphysema are referred to as blue bloaters, a reference to
fluid retention and more marked cyanosis.
d. Signs of overt heart failure, termed cor pulmonale, are relatively infrequent since the
advent of pneumococcal vaccines which have significantly reduced the number of
acute exacerbations.
e. Chest CT scan is currently the definitive test for establishing presence or absence of
emphysema.

49. TRUE statements regarding the treatment of COPD: (HPIM p. 1552-53)

a. All patients with COPD should be strongly urged to quit and educated about the
benefits of smoking.
b. Ipratropium bromide decreases the rate of decline of lung function and has also been
shown to improve symptoms.
c. Inhaled glucocorticoids have been shown to decrease the frequency of exacerbations.
d. Alpha1 antitrypsin augmentation is not recommended for severely alpha1-antitrypsin-
deficient persons while their pulmonary function test and chest CT scan are still normal.
e. COPD is the second most common indication for lung transplantation after resectable
lung caner.

50. TRUE of the interstitial lung diseases: (HPIM p. 1554)

a. This is a homogenous group of disorders with similar clinical, roentgenographic,
physiologic and pathologic manifestations.
b. The two major histopathologic patterns are a granulomatous pattern, and a pattern in
which necrosis and atrophy predominate.
c. The development of interstitial fibrosis in some ILDs is often progressive and leads to
significant derangement of ventilatory function and gas exchange.
d. The radiographic finding of a bibasilar reticular pattern correlates with the pathologic
finding of small cystic spaces and progressive fibrosis, and portends a poor prognosis.
e. Most forms of ILD produce an obstructive defect on pulmonary function testing.
51. TRUE statements regarding the pathophysiology of pulmonary thromboembolism (PTE):
(HPIM p. 1561)
a. Venous thrombi may embolize to the systemic circulation via a patent foramen ovale or
atrial septal defect.
b. Upper extremity venous thrombosis is becoming more common due to the increased
use of central venous catheters, permanent pacemakers and internal cardiac
defibrillators, but these do not embolize and cause pulmonary embolism.
c. PTE can cause increased airway resistance due to constriction of airways distal to the
bronchi.
d. Increased right ventricular wall tension compresses the right coronary artery and may
precipitate myocardial ischemia and right ventricular infarction.
e. Progressive right heart failure is the usual cause of death from PTE.

52. TRUE regarding the clinical presentation of PTE: (HPIM p. 1561)

a. Patients with moderate to large pulmonary embolism have right ventricular hypokinesia
on echocardiography and systemic arterial hypotension.
b. Primary therapy with embolectomy or thrombolysis offers the greatest survival for
moderate to large pulmonary embolism.
c. Presence of a pulmonary infarction indicates a small pulmonary embolism.
d. A pulmonary embolus that lodges into the large pulmonary arteries causes exquisite
pain.
e. In older patients, because acute coronary ischemic syndromes are so common, one
may overlook the possibility of life-threatening pulmonary embolism.

53. TRUE of the diagnostic tests used for pulmonary embolism: (HPIM. 1562-63)
a. Nonimaging diagnostic modalities are generally less expensive but also less specific
than diagnostic modalities that employ imaging.
b. The D-dimer assay is not sensitive and therefore has no useful role among patients
who are already hospitalized.
c. Arterial blood gas is important in differentiating pulmonary embolism from other causes
of dyspnea.
d. Confirmed deep venous thrombosis via venous ultrasonography is usually an adequate
surrogate for pulmonary embolism.
e. Intravenous injection of small particulate aggregates of albumin labeled with a gamma-
emitting radionuclide would display the ventilation defects.

54. TRUE of the treatment modalities used for pulmonary embolism: (HPIM p. 1563-64)
a. Anticoagulation with heparin and warfarin constitutes primary therapy.
b. Placement of an inferior vena caval filter constitutes secondary prevention.
c. When right ventricular function remains normal in a hemodynamically stable patient, a
good clinical outcome is highly likely with anticoagulation alone.
d. For most patients, heparin and oral anticoagulation can be started together and
heparin discontinued on day 5 or 6 if the INR has been therapeutic for two consecutive
days.
e. When warfarin is initiated during an active prothrombotic state, the levels of protein C
and S decline, thus creating a paradoxical thrombogenic potential.

55. TRUE statements regarding the diagnostic approach for pleural effusion: (HPIM p. 1565-66)
a. Transudative effusions occur when local factors that influence the formation and
absorption of pleural fluid are altered.
b. The primary reason to make the differentiation between an exudate and a transudate is
that additional diagnostic procedures are indicated with transudative effusions.
c. If the serum-pleural fluid albumin gradient is >12 g/L, almost all such patients have a
transudative pleural effusion.
d. The leading causes of transudative pleural effusions in the US are left ventricular
failure, end stage renal disease and cirrhosis.
e. In a patient with heart failure, a diagnostic thoracentesis should be performed if the
effusions are not bilateral and comparable in size, if the patient is febrile, or if the
patient has pleuritic chest pain.
56. TRUE with regards to the various etiologies of pleural effusion: (HPIM p. 1566-67)
a. The predominant mechanism in hepatic hydrothorax is due to altered Starling forces
brought about by hypoalbuminemia.
b. Patients with anaerobic bacterial pneumonia and pleural effusion typically present with
a subacute illness with weight loss, a brisk leukocytosis, and mild anemia.
c. Malignant pleural effusions are the most common type of exudative effusions followed
by parapneumonic effusions.
d. The diagnosis most commonly overlooked in the differential diagnosis of a patient with
an undiagnosed pleural effusion is malignant mesothelioma.
e. Tuberculous effusions usually have high levels of adenosine deaminase (ADA), high
levels of tumor necrosis factor (TNF) alpha, or has a positive polymerase chain
reaction (PCR) for tuberculous DNA.

57. TRUE statements with regards to other causes of fluid in the pleural space (HPIM p. 1567-68)
a. In chylothorax, thoracentesis reveals a milky fluid and biochemical analysis reveals a
high level of triglycerides.
b. Treatment of choice for chylothorax is still tube thoracostomy.
c. When a diagnostic thoracentesis reveals a bloody fluid, a hemoglobin quantification
should be done on the pleural fluid to rule out hemothorax.
d. If the bleeding emanates from a laceration of the pleura, apposition of the pleural
surfaces is not likely to stop the bleeding and a chest tube still has to be inserted.
e. If the patient is febrile, has predominantly PMNs in the pleural fluid and has no
pulmonary parenchymal abnormalities, esophageal rupture or pancreatic disease
should be considered.

58. Pneumothorax is the presence of gas in the pleural space. Which of the following is TRUE?
(HPIM, p. 1568)
a. Primary spontaneous pneumothoraces occur almost exclusively in patients with alpha1
antitrypsin deficiency.
b. Pneumothorax in patients with lung disease is more life-threatening than it is in normal
individuals.
c. Traumatic pneumothoraces can result after penetrating and nonpenetrating chest
trauma.
d. Tension pneumothorax is life threatening because ventilation and cardiac output are
both compromised.
e. If a hemopneumothorax is present, at least two chest tubes must be inserted, one to
evacuate the air and the other to drain the blood.

59. TRUE statements regarding mediastinal masses: (HPIM, p. 1568)

a. The most common lesions in the middle mediastinum are thymomas, lymphomas and
teratomatous neoplasms.
b. Barium studies of the gastrointestinal tract are indicated in many patients with anterior
mediastinal lesions.
c. The first step in evaluating mediastinal masses is to look for signs and symptoms
which point to a malignancy.
d. CT scanning is the most valuable imaging technique for evaluating mediastinal
masses.
e. An Iodine-131 nuclear medicine scan can efficiently establish the diagnosis of
intrathoracic goiters.

60. TRUE statements regarding disorders affecting the diaphragm: (HPIM p. 1569)
a. Most patients with severe diaphragmatic weakness present with hypoxemic respiratory
failure, frequently complicated by atelectasis, pneumonia and cor pulmonale.
b. The treatment of choice for diaphragmatic weakness is assisted ventilation.
c. Bilateral paralysis is more common than unilateral diaphragmatic paralysis.
d. In unilateral diaphragmatic paralysis, confirmation is achieved with the sniff test.
e. Most common cause of phrenic nerve invasion is from a malignancy, usually a
lymphoma.
61. TRUE of the physiologic changes in hypoventilation disorders: (HPIM p. 1570)
a. Regardless of cause, the hallmark of all alveolar hypoventilation syndromes is an
increase in alveolar pCO2.
b. The resulting respiratory acidosis leads to a compensatory increase in plasma
bicarbonate and chloride concentrations.
c. The disturbances in arterial blood gases are generally less pronounced in sleep
because of the decreased requirement to eliminate carbon dioxide.
d. Hypercapnia results in pulmonary vasodilatation and cerebral vasoconstriction.
e. Motor neuron disease is an example of hypoventilation syndrome from impaired
respiratory drive.

62. TRUE statements regarding sleep apnea: (HPIM p. 1573-74)

a. Sleep apneas not only cause excessive daytime sleepiness but also have important
cardiovascular consequences.
b. In central sleep apnea, the neural drive to respiratory muscles is transiently abolished.
c. The definitive event in obstructive sleep apnea (OSA) is occlusion of the upper airway
usually at the level of the nasopharynx.
d. The immediate factor leading to the collapse of the upper airway is the generation of a
positive pressure during inspiration that exceeds the ability of the airway dilator and
abductor muscles to maintain airway stability.
e. Sleep plays a permissive role by reducing the activity of the muscles and their
protective reflex response.

63. TRUE statements regarding the clinical features of OSA: (HPIM p. 1573-74)
a. Snoring per se in the absence of OSA is not definitely associated with long-term health
risks.
b. The most common manifestations are cognitive and behavioral disturbances that are
thought to arise from fragmentation of sleep.
c. In patients with OSA, systemic blood pressure falls during sleep at the termination of
each obstructive event as a result of parasympathetic nervous activation.
d. Drivers with OSA experience more vehicular accidents compared with other drivers as
a result of excessive daytime sleepiness.
e. The key diagnostic findings are episodes of airflow cessation at the nose and mouth
with evidence of decreased respiratory effort.

64. TRUE statements regarding Type III (perioperative) and Type IV respiratory failure: (HPIM p.
1584)
a. Type III occurs as a result of impaired ability to cough out secretions due to general
anesthesia.
b. In Type III respiratory failure, after general anesthesia, decreases in functional residual
capacity lead to collapse of dependent lung units.
c. Upright positioning and aggressive control of incisional / abdominal pain are useful
interventions for perioperative respiratory failure.
d. Type IV respiratory failure results from alveolar flooding with subsequent
intrapulmonary shunt physiology.
e. In Type IV, mechanical ventilation can allow redistribution of cardiac output from the
respiratory muscles and back to vital organs.

65. In pulmonary edema, mechanical ventilation with positive end-expiratory pressure (PEEP) can
have multiple beneficial effects which include: (HPIM p. 1616)
a. decreased preload
b. decreased afterload
c. redistribution of lung water from intraalveolar to the extraalveolar space
d. increase in lung volume
e. avoidance of atelectasis
 66. TRUE of the treatment regimens used for pulmonary edema: (HPIM p. 1616-17)
a. The loop diuretics furosemide, bumetanide and torsemide are effective, but not in the
presence of hypoalbuminemia, hyponatremia or hypochloremia.
b. Furosemide is also a venodilator that reduces preload rapidly.
c. To reduce afterload, patients without hypotension should be maintained in the sitting
position with the legs dangling along the side of the bed.
d. Intraaortic balloon pump (IABP) may help to relieve cardiogenic pulmonary edema in
severe mitral stenosis or ventricular septal rupture.
e. Diuretics and preload reduction are also the mainstays in the treatment of reexpansion
pulmonary edema that develops after removal of air or fluid that has been in the pleural
space for some time.

67. Which of the following are CORRECT statements with regards to mechanical ventilation?
(HPIM p. 1596-97)
a. The trigger is what the ventilator senses to initiate an assisted breath.
b. Cycle refers to the factors which determine the end of expiration and signal the start of
the next respiratory cycle.
c. In synchronized intermittent mandatory ventilation (SIMV), every breath delivered
consists of the operator-specified tidal volume.
d. Assist control mode ventilation (ACMV) is the preferred mode for patients with
documented barotrauma and for postoperative thoracic surgical patients.
e. Pressure-control ventilation (PCV) allows patients with intact respiratory drive to
exercise inspiratory muscles between assisted breaths.

68. The factors that indicate the likely need for a procedure more invasive than a thoracentesis
include: (HPIM p. 1566)
a. loculated pleural fluid
b. pleural fluid pH >7.40
c. pleural fluid adenosine deaminase > 45 IU/L
d. presence of gross pus in pleural space
e. pleural fluid glucose <60 mg/dL

69. Hyperresonance, decreased fremitus, decreased breath sounds and decreased voice
transmission are seen in: (HPIM p. 1496)
a. consolidation or atelectasis with blocked airway
b. asthma
c. emphysema
d. pneumothorax
e. interstitial lung disease

70. TRUE statements regarding the clinical presentation of patients with disease of the respiratory
system: 9HPIM p. 1495)
a. Cough per se is not useful for the differential diagnosis of respiratory disease.
b. Hemoptysis can originate from disease of the airways, the lung parenchyma or the
vasculature.
c. Pleuritic chest pain usually originates from the involvement of the visceral pleura.
d. Pneumonia and Aspergillosis are examples of generalized parenchymal diseases that
cause hemoptysis.
e. Consolidation with a patent airway is resonant on percussion while that with a blocked
airway is dull on percussion.

MULTIPLE CHOICE: Choose the BEST answer.

1. Least common primary cause of respiratory failure: (HPIM, p. 1589)

a. controller dysfunction
b. pump dysfunction
c. airway dysfunction
d. alveolar compartment dysfunction
e. pulmonary vascular dysfunction
2. The rapid shallow breathing index is an integrative index of respiratory performance that
predicts success of liberation from mechanical ventilation. It is equivalent to:
a. (respiratory rate) x (vital capacity)
b. (minute ventilation) / (respiratory rate)
c. (respiratory rate) / (tidal volume)
d. (tidal volume) x (respiratory rate)
e. (tidal volume) / (respiratory rate)

3. Feature of the proliferative phase of ARDS (HPIM, p. 1592-3)

a. leukocytes traffick into the interstitium and alveoli
b. proliferation of Type II pneumocytes
c. acinar architecture shows emphysema-like changes
d. significant concentrations of cytokines like IL-1, IL-8, and TNF alpha are present in the
lung
e. Condensed plasma proteins aggregate with cellular debris to form hyaline membrane
whorls.

4. Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) can be differentiated
by: (HPIM, p. 1592)
a. chest x-ray
b. signs and symptoms
c. ABG
d. Etiology
e. Pulmonary capillary wedge pressure

5. Low tidal volume ventilation is the only recommendation with Level A evidence for ARDS.
What is the only recommendation with Level B evidence, meaning it is recommended therapy
based on supportive but limited clinical data? (HPIM, p. 1594)
a. High-PEEP
b. Prone position
c. Minimize left atrial filling pressures
d. Glucocorticoids
e. Inhaled nitric oxide

6. Which of the following is valuable in predicting mortality in ARDS? (HPIM, p. 1595)

a. level of PEEP used in mechanical ventilation
b. respiratory compliance
c. extent of alveolar infiltrates by chest x-ray
d. all of the above
e. none of the above

7. Which is the most clinically important complication of mechanical ventilation brought about by
barotrauma? (HPIM, p. 1599)
a. subcutaneous emphysema
b. pneumothorax
c. pneumomediastinum
d. interstitial emphysema
e. subglottic stenosis

8. The sounds created when there is free liquid in the airway lumen are called: (HPIM, p. 1496)
a. rales
b. rhonchi
c. fremiti
d. egophony

9. Which of the following chest radiographic patterns and their causes is INCORRECTLY paired?
(HPIM, p. 1497)
a. solitary circumscribed density : bacterial abscess
b. diffuse alveolar disease : acute respiratory distress syndrome
c. localized opacification (infiltrate) : cardiogenic pulmonary edema
d. diffuse nodular disease : eosinophilic granuloma
10. Consolidation or atelectasis with blocked airway has the following PE findings: (HPIM, p. 1496)
a. dull on percussion, increased fremiti, bronchial breath sounds
b. dull on percussion, decreased fremiti, decreased breath sounds
c. resonant on percussion, normal fremiti, vesicular breath sounds
d. hyperresonant on percussion, increased fremiti, decreased breath sounds
11. Which of the following lung volumes or capacities is NOT measured by having the patient
breath into and out of a spirometer? (HPIM, p. 1499)
a. tidal volume
b. expiratory reserve volume
c. vital capacity
d. functional residual capacity

12. A cause of parenchymal restrictive lung disease (HPIM, p. 1500)

a. cystic fibrosis
b. Myasthenia gravis
c. Sarcoidosis
d. Ankylosing spondylitis

13. Current diagnostic test of choice for bronchiectasis: (HPIM, p. 1542)

a. bronchography
b. spirometry
c. computed tomography
d. ventilation scan
e. chest radiography

14. Asthma, if due to an adverse reaction to aspirin, can be inhibited by: (HPIM, p., 1510)
a. Aminophylline
b. Zileuton
c. Cromolyn
d. Fluticasone
e. Salmeterol

15. The major side effect of beta agonists is: (HPIM, p. 1512)
a. palpitations
b. tremors
c. elevated BP
d. oral thrush
e. hypokalemia

16. Which of the following can be mixed with oxygen for patients with severe airway obstruction as
it reduces airway resistance and improves the effect of aerosolized bronchodilators? (HPIM, p.
1515)
a. xenon
b. helium
c. argon
d. nitrogen
e. carbon dioxide

17. Most common route for bacterial pneumonia is: (HPIM, p. 1529)
a. hematogenous
b. microaspiration
c. contiguous spread
d. aerosolization
e. macroaspiration

18. Which is NOT an idiopathic type of pulmonary infiltrates with eosinophilia?

a. Loefflers syndrome
b. Allergic granulomatosis of Churg and Strauss
c. Eosinophilia-myalgia syndrome
d. Hypereosinophilic syndrome
19. The single most useful clinical sign of the severity of pneumonia in a person without underlying
lung disease is (HPIM p. 1532):
a. Cyanosis
b. Pulsus paradoxus
c. Respiratory rate
d. Use of accessory muscles
e. Urine output

20. Pneumonia-related deaths are much more likely to occur during the ____ week of
hospitalization: (HPIM p. 1533)
a. first
b. second
c. third
d. fourth

21. Bronchiectasis associated with allergic bronchopulmonary aspergillosis (ABPA) is usually:

(HPIM p. 1542)
a. varicose
b. cylindrical
c. proximal
d. nodular

22. Aerosolized recombinant DNase, which decreased viscosity of sputum by degrading DNA
released from inflammatory cells, has been shown to improve pulmonary function of
bronchiectasis from what cause? (HPIM p. 1543)
a. allergic bronchopulmonary aspergillosis
b. cystic fibrosis
c. Mycobacterium avium complex
d. Influenza virus
e. Hypogammaglobulinemia

23. The only therapy demonstrated to decrease mortality in COPD is: (HPIM p. 1552)
a. smoking cessation
b. supplemental oxygen
c. nicotine patch
d. genetic engineering
e. theophylline

24. The antidote for life-threatening hemorrhage due to heparin is: (HPIM p. 1564)
a. argatroban
b. hirudin
c. protamine sulfate
d. vitamin K
e. neutral protamine Hagedorn

25. Which of the following is TRUE regarding the use of warfarin for pulmonary embolism?: (HPIM
p. 1564)
a. Patients who have received prolonged courses of antibiotics should receive smaller
initial doses.
b. Warfarin-induced skin necrosis is associated with a low initial dose of warfarin.
c. Heparin should be avoided during pregnancy because of possible embryopathy, and
warfarin is a suitable alternative.
d. A malnourished patient should receive larger doses of warfarin initially because of
hypoalbuminemia.
e. Warfarin prevents gamma-hydroxylation activation of coagulation factors II, VII, IX and
X.

26. The most common cause of pleural effusion in AIDS patients is: (HPIM p. 1567)
a. Bacterial infection
b. tuberculosis
c. Kaposis sarcoma
d. Primary effusion lymphoma
e. Pneumocystis carinii
 27. An eosinophilic pleural fluid is associated with: (HPIM, p. 1567-68)
a. Meigs syndrome
b. Coronary artery bypass graft
c. Drugs
d. Radiotherapy
e. Yellow nail syndrome

28. Which of the following mechanisms is CORRECTLY paired to the specific disorder causing
chronic hypoventilation? (HPIM p. 1570)
a. impaired respiratory drive obesity hypoventilation
b. defective respiratory neuromuscular system COPD
c. impaired venilatory apparatus ankylosing spondylitis
d. impaired respiratory drive involving brainstem respiratory neurons metabolic alkalosis

29. Treatment of choice for obstructive sleep apnea: (HPIM p. 1575)

a. avoidance of alcohol
b. continuous positive airway pressure
c. uvulopalatopharyngoplasty
d. cessation of smoking
e. protriptyline

30. It is often difficult to distinguish cardiogenic from noncardiogenic causes of pulmonary edema.
Which biochemical marker, if increased supports heart failure as the cause of acute dyspnea
with pulmonary edema? (HPIM p. 1616)
a. vasopressin
b. brain natriuretic peptide
c. nesiritide
d. aldosterone
e. renin

BONUS: Among your batchmates, whom do you most admire professionally, and why? (Write your
answer in the answer sheet).