ࡱ>  rUbjbjΚΚ 8rM" " 4:~~~~~~~,V|++"&@"&"&"&~"&~"&"&*1vQ~[-yR~V0y҄"&҄Q~"&Q~++"&҄" :   Respiratory MCQs Di Flood RESPIRATORY SUSAN TUCKER 1.Which is the most common organism causing community acquired pneumonia? pneumococcus hemophilus influenzi viral gm negatives mycoplasma 2.which organism causing pneumonia has an increased association with COPD a) pneumococcus hemophilus influenzi viral gm negatives mycoplasma 3.Which organism causing pneumonia has an increased incidence in IV drug users and those post-influenza? a) pneumococcus staph aureus viral gm negatives mycoplasma 4.Which drug/s should be used in adult mild-mod. Community acquired pneumonia? amoxycillin doxycycline rulide any of the above as a single drug amoxycillin and rulide 5.Which drug regimen is suggested for severe community acquired pneumonia initially? benzyl penicillin and gentamicin and erythromycin benzyl penicillin and gentamicin ceftriaxone and gentamicin gentamicin and erythromycin flucloxacillin and gentamicin 6.Which bug makes up 50% of hospital acquired pneumonia? pneumococcus staph aureus gm ve bacilli legionella chlamydia psittici 7.What is the largest size spontaneous primary pneumothorax that can be managaed without aspiration or thoracostomy? 10% 15% 20% 30% 35% 8.In which sort of pneumoathorax is aspiration likely to be most successful? traumatic secondary primary iatrogenic equally effective in all of the above 9.What if the role of aspiration in traumatic pneumothoraces? there is no role first line management in small pneumathoraces only it should be tried in all pneumathoraces as long as there is no respiratory compromise it can be repeated twice before thoracostomy tube is considered none of the above 10.Whatis the recurrence rate of primary spontaneous pneumathoraces? 10% 20% 30% 40% 50% 11.Which is not a biochemical feature of transudative pleural effusions? protein<30g/l pleural protein:serum protein <0.5 pleural LDH : seurm LDH < 0.6 pleural glucose< serum glucose none of the above are biochemical features 12.Which of the list below is not the cause of an exudative pleural effusion? viral pneumonia pancreatitis TB Malignancy Nephrotic syndrome 13.Which of the list below is not a cause of a transudative pleural effusion? CCF PE SLE/RA Cirrhosis Nephritic syndrome 14.Which is not a possible cause of haemoptysis? PE Mitral stenosis Pneumonia Aortic stenosis Neoplasm 15.Which statement is false about haemoptysis? massive haemoptysis is greater than 600ml in 24 hours a CXR is normal in about 25 % of cases in any four cases, one is likely to be due to nonteuberculous infection, one due to neoplasia, one due to rarer causes and one idiopathic in massive hemoptysis the pt should be nursed bleeding lung up if possible a double lumen tube should be reserved for post brochoscopy as a rigid bronchoscope cannot be passed down it 16.Which drug/intervention is of no proven benefit in management of acute severe asthma in adults? steroids magnesium steroids CPAP Aminophylline 17.As a generalization, at what PEFR should someone be admitted? PEFR<25% pretreatment and <40% posttreatment PEFR<10% pretreatment and <20% posttreatment PEFR<40% pretreatment and <60% posttreatment PEFR<50% pretreatment and <70% posttreatment PEFR is of no value in this decision 18.Which statement is false? Ipratropium is of definite proven benefit in asthma when used with B agonists Ketamine is the intubation agent of choise but in ongoing therapy in acute asthma no benefit has yet been proven in the few studies done Oral steroids are as effective as parenteral steroids Aminophylline may have a role in acute treatment in children but not in adults No studies have been done to see whether adrenaine is better than parenteral salbutamol 19.Which is FALSE regarding CPAP in acute asthma? it decreases the work of breathing it causes bronchodilation and decreases airway resistance it improves gas exchange if used alone in severe asthma it may be an effective alternative to ETT when maximal pharmacotherapy is used it reduces the cardiovascular impact of changes in pressures caused by asthma 20.Which drug/intervention is rarely used acutely in the acute setting of exacerbation of COAD? salbutamol CPAP Aminophylline Steroids Ipratropium 21.Which statement is incorrect regarding the acute management of exacerbation of COAD? support for the widespread use of steroids is limited support for the use of salbutamol combined with ipratropium is limited B agonists are widely used assuming the possiblility of a small reversible component to the airflow obstruction Support for the widespread use of CPAP and BiPAP is minimal Theophylline is rarely used acutely 22.Regarding pulmonary emboli, which statement is correct? a normal Aa gradient excludes a PE a paO2>80 excludes a PE a normal CXR excludes a PE anticoagulation reduces mortality from PE from 30% to 10% all of the above are correct 23.With regards to PE which statement is CORRECT? embolectomy has a better outcome than thrombolysis in massive PE streptokinase is more effective with lower side effects than tPA in massive PE LMWH is probably as effective as unfractionated heparin TOE is sensitive for peripheral emboli Spiral CT angiography is better at detecting peripheral clots than central ANSWERS 1)A 2)B 3)B 4)D 5)A 6)C 7)C 8)C 9)A 10)E 11)D 12)E 13)C 14)D 15)D 16)E 17)A 18)A 19)C 20)C 21)D 22)D 23)C Which is true regarding community acquired pneumonia? Use of high dose penicillin in penicillin resistant Strep pneumoniae is rarely successful in treating the pneumonia. Mycoplasma pneumoniae is more commonly seen in elderly patients. Leigonella spp pneumonia is usually moderately severe and can cause pancreatitis, and myocarditis. H. influenzae is more commonly seen in young, otherwise well patients. Klebsiella pneumoniae is an aerobic gram positive bacillus. Which statement regarding pneumonia in INCORRECT? In patients with AIDS once the CD4 count reaches 800 they are at high risk of PCP. Mild PCP can be treated with oral cotrimoxazole for 21 days. Transplant patients are most at risk of opportunistic infections between days 30 and 120 post transplant. Gram ve organisms account for 50% of all hospital acquired pneumonias. Only 40% of patients who aspirate will develop pneumonia. Which is INCORRECT regarding lung abscess? 90% of patients will have evidence of periodontal disease or some predisposition to aspiration. Staph aureus is the most common cause. Sputum examination is often unhelpful in identifying the organism involved. Medical management with antibiotics for up to 2 months is the treatment of choice. Non infectious causes of lung abscess include rheumatoid nodules and pulmonary infarction. A patient with pneumonia develops a pleural effusion, which you aspirate. Which of the following is supportive of an empyema on examining the fluid? Pleural protein <30g/l Pleural glucose: plasma glucose > 1.0 Pleural LDH : serum LDH ratio < 0.6 pH 7.15 RBC > 100,000 mm3. 1=C 2=A 3=B 4=D Which of the following is incorrect regarding pneumothorax? 70% of patients with pneumothorax are smokers. Catamenial pneumothorax may occur probably secondary to endometrial metastases to lungs. Oxygen treatment will increase rate of pleural air resorption 4 times and should be given to all patients with pneumothorax. A patient with calculated average interpleural distance of 1cm can be managed conservatively. The recurrence rate of pneumothorax is approx 15% with half of those occurring in the first year. A 50 year old male presents with haemoptysis of approx 700 mls over 24 hours. Which is true regarding this man? The bleeding is most likely secondary to pulmonary vessels. The preferred position for this patient is with the affected lung up. Placement of an ETT will prevent possible contamination of the good lung with blood. Placement of a Robertshaw ETT will protect the good lung and allow passing of a fiberoptic bronchoscope. Bronchial artery embolization has an 80% chance of stopping the bleeding. Regarding treatment of asthma in adults which is the correct answer. Intravenous hydrocortisone will have faster onset of anti-inflammatory action than oral prednisolone. Nebulized ipatropium bromide in combination with salbutamol has been shown to have a better clinical outcome than salbutamol used alone. It has been shown that IV aminophylline use in severe asthmatics with optimal beta agonist and corticosteroid therapy will confer benefit. Magnesium has been shown in severe asthma to reduce admission rates and improve FEV1. Long acting beta agonist have been shown to be beneficial in acute exacerbations of asthma. Which is true of COAD? 100 % of patients with homozygous alpha-1 antitrypsin deficancy patients will exhibit evidence of emphysema eventually. pink puffers have predominantly chronic bronchitis. Use of longterm inhaled steroids has been shown to decrease morbidity. Use of CPAP in acute exacerbations will improve gas exchange. All of above are incorrect. 5=E 6=E 7=D 8=E Which is not true of lung transplant patients. Early rejection may present as cough, chest tightness and decline in FEV1 by greater than10%. Lung transplant patients do not require prophylaxis for endocarditis. Post transplant lymphoproliferative disease is usually fatal is occurring greater than one year post transplant. Obliterative bronchiolitis is the most common cause of death 2 years plus after transplant. CMV infection will usually cause neutropenia.. What is the overall probability of PE in a patient with a normal V:Q scan ? 0% 4% 8% 10% none of the above. Which is incorrect regarding acute respiratory distress syndrome? Reduced compliance of lungs due to increased collagen and fibroblast activity is an early stage of ARDS. Severe hypoxaemia despite normal or low PaC02 occurs early. ARDS usually develops 12-72 hrs post triggering event. Mechanical ventilation can sometimes worsen oxygen delivary to tissues secondary to reduced cardiac output. Inhalational nitric oxide has been used in the treatment but is at present experimental due to unknown long term effects and clinical relevance of improvement. which is not a recognized sign on lateral neck xray of adult epiglottitis? Blunted swollen epiglottis Supraglottic haze Prevertebral swelling Swelling aryepiglottic folds All of the above. 9=B 10=B 11=A 12=E Respiratory MCQs Which of the following is most correct about respiratory infections in patients with HIV? CMV is a common cause of clinically significant disease CAP pneumonias are more common than PCP in patients with HIV PCP occurs when the CD4 count is between 800 and 1000 Mortality from bacterial pneumonia is higher in patients with HIV than in patients who are HIV-negative Pulmonary aspergillosis is not a life threatening illness. With regard to aspiration pneumonia, which of the following is incorrect? The right lower lobe is the commonest area for aspiration in the erect position pH less than 2.0 is associated with a higher mortality Many of the symptoms of aspiration are due to the bodys inflammatory response to the infectious or irritative material. Streptococcus species are the commonest infecting organism All patients who aspirate should be commenced on broad spectrum antibiotics. In patients with Tuberculosis, which of the following is incorrect? Aerosolised saliva and sputum are the commonest modes of transmission. Interferon 8 levels increase in patients who are responding to treatment. Pulmonary TB is an AIDS-defining illness. Extra-pulmonary manifestations are unlikely in HIV patients. Initial therapy is with isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months. In spontaneous pneumothorax, which is incorrect? 95% will have pleuritic chest pain on the side of the pneumothorax Only 5% with be tachypnoeic or tachycardic Spontaneous pneumothoraces of 35% deflation can be managed conservatively CT scan is the current gold standard for measuring deflation Spontaneous pneumothorax in HIV patients suggests PCP infection and carries a high mortality 1 B 2 E 3 D 4 C 23Which of the following is LEAST likely to cause upper lobe pulmonary fibrosis? Tuberculosis Asbestosis Sarcoidosis Silicosis Ankylosing Spondylitis 38A patient has known small cell bronchogenic carcinoma. He has no other medical history, and is on no medications. He presents with a serum Na of 126 (measured by ion sensitive electrode), and is clinically euvolaemic. Investigations will also reveal: Normal serum osmolarity Urine osmolarity less than plasma osmolarity Urinary Na less than 10mmol/L Low serum thyroxine None of the above 43An adult with severe asthma has been intubated. Mechanical ventilation should: Deliver high minute volumes Be set at a high inspiratory flow rate Be adjusted to maintain a normal PaCO2 Employ a high PEEP Have a short expiratory time (TE) Regarding COPD which is correct A >50% is caused by smoking B. 10% is caused by alpha-1- antitrypsin deficiency C. may be related to childhood respiratory illnesses 23. Massive haemoptysis is an occasional complication of aortic stenosis aortic incompetence mitral stenosis mitral incompetence right sided valve lesions c [rosen ch.78, tintin p379] from rupture of pulmonary bronchial venous connection 24. Clubbing is commonly associated with all but which of the following? bronchiectasis asbestosis COAD congenital heart dis idiopathic pulmonary fibrosis c [dunn p 803, T+OC p34] other common causes: IE, lung abscess, ca lung 25. Pleural exudates are characterised by a) protein > 50% serum b) LDH > 60% serum cholesterol > 30% serum pleural fluid cholesterol >1.5 mmol/L all of the above e [dunn p806] Lights criteria 26. Regarding lung volumes which is true Total Lung Capacity = Vital Capacity + Tidal Volume Inspiratory Reserve = TV + Residual Volume Tidal Volume = 1L in 70kg male Vital Capacity = 5L in 70 kg male none of the above d [dunn p769] 27. Common causes of lower lobe pulmonary fibrosis include bronchiectasis silicosis coalminers lung allergic alveolitis TB the rest are upper lobe + aspergillosis, sarcoid, ank spon 38. Which of the following indicates severe asthma? Pulsus paradoxus < 20 mmHg Pulsus paradoxus < 10 mmHg Pulsus paradoxus > 20 mmHg Pulsus paradoxus > 10 mmHg Pulsus paradoxus < 30 mmHg Pulsus paradoxus is an accentuation of the decrease in systolic blood pressure that normally occurs during inspiration. A drop in blood pressure of greater than 20 mm Hg (i.e., pulsus paradoxus > 20 mm Hg) indicates excessive negative intrathoracic pressure and correlates with severe asthma. In this situation, left ventricular after load and venous return to the right heart are increased, thereby causing a transient reduction in cardiac output and systolic blood pressure. 58. What is the best position in which to place patient with massive haemoptysis? Affected side up Affected side down Trendelenburg Reverse Trendelenburg None of the above Tint chap 63 B 60. The following can cause a rise in peak inspiratory pressure (PIP) in a mechanically ventilated patient EXCEPT: insufficient muscle paralysis increased tidal volume bronchospasm pneumothorax increased I:E ratio E 9Severe Asthma is indicated by all of the following except Pt talking in words Silent chest PCO2 44mmHg PO2 89mmHg Pulsus paradoxus 47All of the following may have a role in the acute management of severe asthma EXCEPT magnesium salmeterol halothane helium ketamine. 50Symptoms heralding respiratory arrest during an asthma exacerbation include all of the following EXCEPT lethargy severe respiratory alkalosis and the use of accessory muscles of respiration a normal pCO2 on arterial blood gas a silent chest on auscultation agitation. 51Complications of Mycoplasma pneumonia infection include all of the following EXCEPT Guillain-Barr syndrome aseptic meningitis and encephalitis haemolytic anaemia pericarditis and myocarditis septic arthritis 52Which of the following is the BEST view to request when assessing for the presence of pneumothorax on chest x-ray? Supine anteroposterior Upright posteroanterior (PA) Inspiratory PA Lateral decubitus with the patient lying on the unaffected side Expiratory PA 10. Bronchiolitis CRX: hyperinflation Bronchodilators are controversial WBC usually normal Steroids contraindicated CXR: hyperinflation without infiltrates, peribronchial cuffing, atelectasis Steroids possible beneficial for mild to moderate, definitely not contra-indicated Adrenaline most effective therapy Bronchodilators may help, are controversial WCC doesnt help assessment A 43 year old man is receiving positive pressure ventilation on a respirator following a road traffic crash. His ABG shows a pH 7.54, PC02 28mmHg, P02 87mmHg, Bic 16 mmol/L. This blood gas shows: a) pure respiratory alkalosis b) respiratory alkalosis and hypoxaemia c) respiratory alkalosis and metabolic acidosis d) mixed respiratory and metabolic alkalosis e) metabolic alkalosis with partial respiratory compensation C 6. Uncuffed endotracheal tubes should be used for: a) tube sizes less than 6mm b) acute epiglottis c) blind nasotracheal intubation d) intubations with a Macintosh blade e) known fractured base of skull A 7. Cricoid pressure was first described by: a) Mendelson b) Danzi c) Sellick d)Tintinalli e)Meller C 9. All of the following drugs can be used in rapid sequence induction EXCEPT: a) atropine b) fentanyl c) isoflurane d) atracurium e) ketamine C 47. In asthma: a) the white blood cell count will often be elevated b) the ECG may show signs of acute left heart strain c) a CXR should be routine in all patients admitted d) blood gas results correlate well with pulmonary function testing e) theophylline dosing needs to be increased if erythromycin is given A 49. Regarding pleural effusion all of the following are true EXCEPT: a) can be tapped to make a diagnosis of pancreatitis b) can be detected radiographically when 10 ml of fluid is present c) is most commonly caused by congestive cardiac failure d) can result from rheumatoid arthritis e) will not produce mediastinal shift E 50. Sore throat is caused by all of the following a) neisseria gonorrheae b) mycoplasma pneumoniae c) bacteroides fragilis d) cytomegalovirus e) corynebacterium diptheriae C 51. Regarding empiric antibiotic therapy in pneumonia: a) cetazidime is used for atypical pneumonia b) clindamycin is used for aspiration pneumonia c) acyclovir is used for post influenza pneumonia d) erythromycin is used for PCP pneumonia e) amoxycillin alone is used for neonates with pneumonia 86. The patient with normal lungs and pulmonary gas exchange breathing 40% oxygen at sea level and breathing normally could be expected to achieve an arterial oxygen tension of about: 180 mm Hg 210 mm Hg 235 mm Hg 260 mm Hg 290 mm Hg 11) Regarding aspiration pneumonitis which is true a. Should be treated with high dose IV steroids b. Commonest organisms involved in community acquired are anaerobes and GNB c. d. e. a. Should be treated with high dose steroids. Cant find evidence for this b. *Commonest organisms are GNB and anaerobes. Staph aureus also common in mouth but more so in aspirated saliva than vomit 55) Which of the following is true of COPD a. Associated with decreased compliance b. Associated with low output cardiac failure c. Associated with reduced FVC but normal FEV1 d. e. 55) Which of the following is true of COPD a. Associated with decreased compliance false.increased compliance b. *Associated with low output CCF. 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