IM Pulmonology

All PYQ before 2020 (4th + 6th year)

1) A 71-year old woman with chronic obstructive pulmonary disease is

admitted to the hospital with a 3-day history of cough and SOB, she
also reports sharp left sided chest pain with deep inspiration.
Examination reveals diminished breath sounds and dullness to
percussion on the affected zone. Chest radiograph shows a dense left
lower lobe infiltrate. Which of the following organisms is most likely
to be responsible for her pneumonia?
a) Bordetella pertussis
b) Streptococcus pneumonia
c) Mycoplasma pneumonia
d) Staphylococcus aureus
e) Klebsiella pneumonia

Answer: B
2) A 65-year old man presents with progressive shortness of breath.
Breath sounds are absent on the left side of the chest. Percussion of
the affected zone reveals dullness. Tactile vocal fremitus is
diminished on the left side. The trachea appears to be deviated
towards the left. Which of the following is the most likely cause?
a) Left main stem bronchial obstruction
b) Diffuse viral pneumonia
c) Left large pleural effusion
d) Left lower lobe bacterial pneumonia
e) Large right sided pneumothorax

Answer: A
3) A 58-year old male with COPD has frequent exacerbations during the
last year. He is also having worsening exertional dyspnea. Currently
he is on a combination of salmeterol and fluticasone inhaler. Which
of the following is the most appropriate next step in management?
a) Salbutamol nebulization
b) Salbutamol inhaler
 c) Long term oral steroids
d) Tiotropium
e) Theophylline

Answer: D (tiotropium is LAMA)

4) A 52-year old man comes to the physician with his wife because of a
1-year history of excessive daytime sleepiness. His wife is concerned
because he once fell asleep while driving at night and drove off the
road. His wife says that he has always snored loudly, and over the
past year, he has had episodes of choking or gasping for breath while
sleeping. His BMI is 33 kg/m2. His pulse is 76/min. his respiration are
14/min, and blood pressure is 150/90. Physical and neurological
examinations show no other abnormalities. Which of the following is
most likely to confirm his diagnosis?
a) An overnight sleep study
b) EEG
c) CT scan of the head
d) 24-hour ambulatory ECG monitoring
e) Laryngoscopy

Answer: A
5) Which of the following conditions is associated with the lowest
pleural effusion glucose level?
a) Heart failure
b) Simple para-pneumonis effusion
c) Liver cirrhopsis
d) Hypothyroidism
e) Rheumatoid arthritis

Answer: E
6) A 65-year old male with COPD presents with an acute exacerbation.
He is started on salbutamol and ipratropium nebulizers and given IV
steroid. However, blood gases on 28% of supplemental oxygen reveal
a PaO2 of 65 mmHg, a PaCO2 of 75 mmHg, and a Ph of 7.27. what is
the next appropriate step in management?
a) Intravenous aminophylline
 b) Magnesium sulphate infusion
c) Noninvasive ventilation
d) Reduce the percentage of supplemental oxygen
e) Intubation and mechanical ventilation

Answer: C
7) A 22-year old male with a seizure disorder has had increasing cough
and shortness of breath for 3 days and fever for one day. He has a
purulent sputum. He had a generalized tonic clonic seizure one week
ago. His temperature is 39.4 oC. crackles are heard upon auscultation.
The chest radiograph shows a right upper lobe infiltrate of the lung.
Which of the following is the most likely caused?
a) Pneumonia secondary to gram positive aerobes
b) Pneumonia secondary to anaerobes
c) Chemical pneumonitis
d) Pneumonia secondary to mycoplasma pneumoniae
e) Pneumonia secondary to gram negative aerobes

Answer: B
8) A 48-year old man who never smoked and works as a truck driver
presented to the clinic with decrease exercise tolerance and daytime
fatigue. His blood pressure is 145/90 mmHg, pulse rate 90 per
minute, and BMI 35 kg/m2. ABG showed PaCO2 = 55 mmHg, HCO3- =
33 mmol/L, and PaO2 = 80 mmHg on room air. Chest radiograph
showed normal heart size and clear lung fields. Which of the
following condition is the likely cause of his respiratory failure?
a) Obesity hypoventilation syndrome
b) Diaphragmatic eventration
c) Lung fibrosis
d) Chronic obstructive pulmonary disease (COPD)
e) Advanced dilated cardiomyopathy

Answer: A (OHS is 1- BMI>30 2- daytime hypercapnia 3- sleep

disordered breathing, we shoud ruling out other disorders that
may cause alveolar hypoventilation)
9) A patient has a right upper lobe mass on routine CXR which is
suspicious of lung cancer. What investigation should be performed
next?
a) Repeat CXR after 3 months
b) Bronchoscopy
c) Serum calcium and liver function test
d) Chest CT with intravenous contrast
e) Pulmonary function tests

Answer: D
10) A 67-year old male presents with a cough productive of green
sputum, associated with fever. On examination, heart rate 100/min,
BP 105/75 mmHg, temperature 39.2 oC, and respiratory rate 22/min.
chest exam reveals dullness at left lower base with crepitations.
Blood tests reveal a high BUN of 28 mmol/L (N 5-7.2), CRP of 7 (N <5)
and a creatinine of 110 mmol/L. A CXR reveals left lower lobe
consolidation. Which of the following in this case suggests a need for
ICU admission?
a) Consolidation on CXR
b) High CRP
c) Elevated blood urea nitrogen
d) Respiratory rate of 22
e) Systolic blood pressure of 105

Answer: C

11) Which of the following is the most worrying feature of a severe

asthma attack?
a) PaCO2 of 48 mmHg
b) Tachypnea, respiratory rate 28 per minute
c) Lobar consolidation on CXR
d) Previously required oral steroids
e) PaO2 65 mmHg

Answer: A(not sure)

12) A 20-year old man has had frequent upper respiratory infections
over the past 4 years. He has daily purulent sputum and has declining
exercise tolerance over the past 2 years. He and his wife has been
unable to conceive a child. Scattered expiratory wheezes and crackles
are heard over both lung fields. An x-ray of the chest shows
hyperinflation. Spirometry shows a decreased FEV1/FVC ratio. Which
of the following is most likely to confirm the diagnosis?
a) Arterial blood gas analysis
b) Sweat chloride test
c) Examination of sputum for eosinophils
d) Bronchoscopy
e) Sputum cytology

Answer: B (systic fibrosis)

13) A 32-year old male patient presents with a one week history of
malaise, fever, headache, and myalgia with a sore throat, dry cough,
and pleuritic chest pain. Physical examination reveals bilateral basal
crepitations and evidence of erythema nodosum. Blood test is
positive for cold agglutination. Given the most likely diagnosis, what
treatment should the patient receive?
a) Azithromycin
b) Ciprofloxacin
c) Co-amoxiclav
d) Co-trimoxazole
e) Cefuroxime

Answer: A mycoplasam pnemounia (erythema nodosum find in

sreptococus pnemonia and mycoplasam /cold agglutination test is
positive in mycoplasma pneumonia)

14) A 22-year female presents to ER with an exacerbation to her

asthma. She is wheezing with a respiratory rate of 26/min, a heart
rate of 90/min and oxygen saturation of 99%. Her peak flowmeter
rate (PEFR) is 220L/min (predicted 400 L/min). she is started on
salbutamol nebulizer and clinically improves with her wheezing
 sounding better. Her RR is 18, PERF 320, and Oxygen saturation is
100%. The next appropriate step of action is:
a) Discharge with 5-day course of prednisolone
b) Start ipratropium bromide nebulized
c) Admit for 4 hourly nebulizers and observation for 24 hours
d) Discharge with home nebulizer
e) Admit for intravenous hydrocortisone

Answer: A
15) A 20-year old man who has long standing bronchial asthma and
recurrent infiltrates presents to the clinic for evaluation. Which of the
following would support the diagnosis of allergic bronchopulmonary
aspergillosis?
a) Delayed tuberculin-type skin-test reaction to Aspergillus
fumigatus
b) Positive anti-nuclear antibody (ANA) serologic test
c) Immediate skin test reaction to Aspergillus fumigatus
d) The presence of peripheral eosinophilia
e) The presence of alveolar neutrophilia on bronchoalveolar lavage

Answer: C
16) A 22 year old female presents complaining of dyspnea. Her ABG
shows a PaO2 of 52 that becomes 54 on 40% of oxygen. Her PCO2 is
normal. What is the most likely cause of her condition?
a) ASD with Eisenmenger syndrome
b) COPD exacerbation
c) Idiopathic pulmonary fibrosis
d) Acute asthma exacerbation
Answer: ASD with Eisenmenger syndrome

17) 73. All of the following are possible causes of a thick walled
cavitatory lung infiltrates except
a) Squamous cell carcinoma
b) Lung abscess
c) Wegner’s granuloma
d) Pulmonary cyst
e) Mycetoma
 Answer: Pulmonary cyst

18) A 40 year old man presented with dyspnea for the duration of 1
month. His chest X-ray reveals a right sided pleural effusion. Analysis
of the pleural fluid shows a pleural fluid protein of 42 g/l and a serum
protein of 58 g/l. His pleural fluid glucose is 2.6 mmol/L. Which of the
following is the most likely cause of his effusion?
a) Pulmonary tuberculosis
b) Nephrotic syndrome
c) Protein losing enteropathy
d) Liver cirrhosis
e) Left ventricular failure
Answer: Pulmonary tuberculosis

19) A 30 year old man has a history of bilateral bronchiectasis and

recurrent pneumonias. He know presents to the clinics complaining
of cough and SOB and his sputum grows Pseudomonas Aeruginosa.
The best choice of antibiotics for this patient is
a) Amoxicillin/clavulinic acid
b) Piperacillin/tazobactam
c) Ceftriaxone
d) Cefotaxime
e) Vancomycin
Answer: Piperacillin/Tazobactam

20) A 52 year old male with a 50 pack year smoking history presented
to the physician complaining of hemoptysis. Physical examination is
not remarkable. His medical history is otherwise free. His basic labs
show: Sodium 123 mmol/L, chloride of 100 mmol/L and a potassium
level of 3.6 mmol/L. A chest X-ray shows a hilar mass. Bronchoscopic
examination shows extrinsic compression on the left bronchus with
brushings and bronchial washings were positive for malignancy.
Which of the following is the most likely pathological type of this
patient’s lung tumor
a) Small cell carcinoma
b) Squamous cell carcinoma
c) Large cell anaplastic carcinoma
d) Undifferentiated adenocarcinoma
 e) Bronchoalveolar carcinoma
Answer: Small cell carcinoma

21) A 65 year old woman presented with a 3 day history of

hemoptysis. She appears ill, pale and has bilateral red eyes, but there
were no other signs on physical examination. Her lab investigations
show:
Hemoglobin 89 g/L (115-165 g/L)
White cell count 13.6x109/L (4.0-11.0)
Eosinophil count 0.8x109/L (0.04-0.5)
Platelet count 389x109 (150-400)
Serum creatinine 4.4 mg/dl (0.6-1.2 mg/dl)
Serum CRP 293 mg/L
The patient’s urinalysis shows +2 protein and +2 blood. Chest xray
shows bilateral pulmonary infiltrates. Which of the following is the
most likely diagnosis?
a) Churg-strauss syndrome
b) Wegner’s granulomatosis
c) Anti-glomerular basement membrane antibody disease
d) Drug induced lupus
e) Tubulointerstitial nephritis with uveitis
Probable answer: Churg-strauss syndrome (not sure).

Note: Tubulointerstitial nephritis with uveitis is an attractive choice

but the lung involvement points more towards Churg-strauss
syndrome.
22) A 38 year old female is admitted to the hospital with a right lower
lobe pneumonia and in initiated on the appropriate antibiotics. Six
days later, the patient worsens clinically and develops a pleural
effusion. A diagnostic pleural tap is performed. Which of the
following pleural fluid results indicates the need for effusion drainage
a) Microscopy showing gram positive cocci
b) Pleural to serum lactate dehydrogenase level (LDH) ratio 0.6
c) Differential cell count demonstrating 0% neutrophils
d) Pleural to serum protein ratio 0.5
e) pH of 7.3
Answer: Microscopy showing gram positive cocci
23) A 55 year old male presents to the clinic with an 7 months history
of shortness of breath while walking uphill. His pulmonary function
test shows: FEV1: 53%, FVC: 93%, FEV1/FVC: 53, TLC: 110%, RV: 140%
and DLCO 51%. Which of the following is the most likely cause of his
breathlessness?
a) Bronchiolitis obilterans
b) Asthma
c) Emphysema
d) Heart failure
e) Sarcoidosis
Answer: Emphysema

24) An elderly patient who is a known case of COPD presents

complaining of increasing cough and shortness of breath. He has no
fever and has clear sputum. Which of the following will most likely
decrease the need for hospitalization?
a) Oral steroids
b) Inhaled corticosteroids
c) Bronchodilator
d) Antibiotics
e) Theophylline
Answer: A or B(not sure)
(the only information that I found is systemic steroids shorten
hospital stay and we use it only for patient who requiring
hospitalization)
(“Systemic steroids hasten resolution of symptoms and reduce
relapses and subsequent exacerbations for up to 6 months”
Harrison’s book)

25) All of the following are elements of the BODE index that indicate
an adverse outcome in a COPD patient except
a) Distance walked in the 6 minute walk test
b) Desaturation during the 6 minute walk test
c) BMI of <21
d) FEV1 of 35%
e) Modified medical research council (MMRC) dyspnea score of 4
Answer: B
26) All of the following are features of idiopathic pulmonary fibrosis
except:
a) Digital clubbing
b) Subpleural honeycombing on CT scan
c) Basilar crackles
d) Hilar adenopathy
Answer: Hilar adenopathy
27) A patient with intra-alveolar hemorrhage and hematuria, the least
likely cause would be:
a) +polyarteritisnodosa
b) HSP
c) Scleroderma
d) wegners granulomatosis

Note: PAN can affect nearly any site in the body EXCEPT the lung.

28) A case of uncontrolled asthma, on low dose ICS & probably short
acting beta agonist as needed (which she used frequently). Best
management would be:
a) +high dose ICS plus long acting beta agonist
b) change the steroid to leukotrine modifier
c) refer to IgE therapy
d) oral glucocorticosteroids

29) An elderly, smoker, diabetic, his ejection fraction is <25%,

diagnosed as having pneumonia. Chest x-ray showed a left-sided
pleural effusion. Thoracocentesis should be done because:
a) this is a transudative effusion
b) the patient is a smoker and he is having lung cancer
c) +this is a new finding with unknown etiology
d) all pleural effusions should be drained
Thoracocentesis => diagnostic evaluation for parapneumonic
effusions.

30) About PPD testing, one is true:

a) intradermal injection of live attenuated bacillus
b) +positive test indicates past exposure
c) negative test rules out TB
31) One of the following pleural effusion results is indicative of
empyema:
a) +gram stain showing gram positive cocci

Note: Empyema =>1-frank pus or organism demonstrate on gram

stain or culture 2-ph<7.2 ,glucose<40mg/dl, high WBC,pleural fluid
protein Serum protein>0.5 , pleural fluid LDH/ serum LDH>0.6

32) Pulmonary function test in bronchiectasis due to cystic fibrosis

would be:
a) ↓FEV1, ↓FVC, normal FEV1/FVC, ↓DLCO
b) +↓↓FEV1, ↓FVC, ↓FEV1/FVC, ↓DLCO
c) ↓↓FEV1, ↓FVC, ↓FEV1/FVC, normal DLCO
d) ↓FEV1, ↓FVC, normal FEV1/FVC, normal DLCO

Explanation: It is an obstructive lung disease (COPD, Asthma,

CF,Bronchiectasis). So, the ratio <70, DLCO also low.

33) Typical history of a female patient with active TB with mass on

chest x-ray. Which one of the following is true:
a) +PCR is a rapid and sensitive test
b) treat her with 4 drugs for 9 months
c) screen all contacts by chest x-ray
d) negative PPD rules out the diagnosis
e) sputum culture with negative AFB rules out the diagnosis

34) All can be caused by para-neoplastic syndrome of bronchogenic

carcinoma except:
a) hypertrophic pulmonary osteoarthropathy
b) hypercalcemia
c) +pericardial effusion
d) deep vein thrombosis
e) acanthosis nigricans

35) A case scenario suggestive of pulmonary embolism. The best

investigation to be done:
a) +CT angio
b) D dimer
c) Echocardiography
 Explanation: CT pulmonary angiography is the first-line diagnostic
test. It has the advantages of visualizing the distribution and extent of
the emboli, or highlighting an alternative diagnosis, such as
consolidation, pneumothorax or aortic dissection.

36) A known case of COPD, suddenly developed SOB and right sided
chest pain. On examination, percussion was tympanic on the right
side, trachea was deviated to the left side, and oxygen saturation was
low. First step in management would be:
a) +chest tube insertion

Explanation: This is a case of [Link] patients with

significant underlying chronic lung disease; however, secondary
pneumothorax may cause respiratory distress. In these patients, the
success rate of aspiration is much lower, and intercostal tube
drainage and inpatient observation are usually required, particularly
in those individuals over50 years old and those with respiratory
compromise.

37) PH 7.2, HCO3 16, CO2 45 .. What is the acid-base disorder:

a) +respiratory acidosis with metabolic acidosis
b) mixed respiratory alkalosis with metabolic acidosis

Explanation: few numbers that you have to remember:

[H+] = 40 nEq/L
pH = 7.40 (7.35-7.45)
PaCO2 = 40 mm Hg (35-45)
HCO3 = 24 mEq/L (22-26)g
pH=acidosis bcoz<7.4
respiratory acidosis bcoz CO2 > 40
metabolic acidosis bcoz HCO3 <24
Source: Lecture note acid base balance

38) A male patient presented with 10 Kg weight loss and constipation.

He is a smoker of 2 pack years. On examination, finger clubbing was
noted. Chest x-ray showed a cavitary lesion in the upper lobe. He was
previously healthy. What is the most likely diagnosis:
a) +lung cancer
b) lung abscess
c) sarcoidosis
39) A case of COPD exacerbation, you can give all of the following
except:
a) +oral theophylline
b) oral corticosteroid
c) inhaled fluticasone
d) inhaled salbutamol
e) inhaled ipratropium

40) Regarding post-primary tuberculosis, which of the following is

true?
a) The most common cause of resistance in Jordan is multi-drug
resistance
b) +First line treatment is: isoniazid, rifampicin, pyrazinamide,
ethambutol
c) Sputum remains infectious after 3 months of initiating therapy
d) Patient should be isolated for the whole treatment period
e) Treatment is at least for 12 months

Note: Chemotherapy regimens for TB are based on the principle of an

initial intensive phase (which rapidly reduces the bacterial
population), followed bya continuation phase to destroy any
remaining bacteria. • An initial 2 months therapy with four drugs
(isoniazid, rifampicin, pyrazinamide and ethambutol), followed by 4
moths of two drugs (isoniazid and rifampicin), has become standard
in the UK. Ethambutol may be omitted in non-cavitary smear
negative cases unless resistance is suspected. Streptomycin is rarely.

41) 12. Regarding chronic persistent asthma, which of the following is

false?
a) +NSAIDs are contraindicated in all patients
b) Eosinophilic inflammation of the bronchi is found
c) It’s a reversible obstruction
d) Inhaled steroids are the mainstay of treatment

Note: Approximately 10% to 20% of adults with asthma have

sensitivity to aspirin or a group of painkillers called non-steroidal anti-
inflammatory drugs -- or NSAIDS –such as ibuprofen (Motrin, Advil)
and naproxen (Aleve, Naprosyn). These drugs are frequently used to
 treat pain and reduce fevers.

42) A young female complaining of cough, shortness of breath almost

every day, with nocturnal symptoms 2-3 nights/week. FEV1 65%.
Which of the following is the best treatment?
a) Salbutamol as needed
b) Leukotriene modifier
c) Oral steroids
d) Low-dose inhaled corticosteroids with salbutamol as needed
e) +Medium-dose inhaled corticosteroids, long acting B2 agonist
and salbutamol as needed

43) A patient presented to the ER with acute-onset shortness of

breath. All of the following indicated a severe disease, EXCEPT:
a) Unilateral silent chest
b) A-a gradient of 30 mmHg
c) +Diffuse expiratory wheezes
d) Cyanosis
e) Anion gap of 25

Note: Wheezing during expiration alone is generally indicative of

milder obstruction than if present during both inspiration and
expiration, which suggests more severe airway narrowing.

44) All of the following are used in the management of acute

exacerbation of asthma, EXCEPT:
a) Inhaled corticosteroids
b) +Antibiotics
c) Salbutamol

45) (Short case). Which of the following is not a feature of COPD:

a) Increased residual volume
b) Increased TLC
c) Low FEV
d) Low FEV1
e) +Increased diffusion capacity (DLCO)

46) Regarding COPD, which of the following is true?

a) The most common cause is alpha-1-antitrypsin deficiency
b) Smoking causes panacinar emphysema
 c) C.+ Air pollution is known predisposing factor
d) Smoking cessation normalizes pulmonary function even in severe
cases

Note: Cigarette smoking is the most important risk factor.

Susceptibility to cigarette smoke varies but both the dose and
duration of smoking appear to be important. Other risk factors are
solid fuel fi res, air pollution, occupation (coal miners) and low socio-
economic class. Rarely, an inherited deficiency of α1 antitrypsin
predisposes to pre-mature emphysema.

47) Easy case, acute exacerbation of COPD, which of the following is

false?
a) +Corticosteroids are contraindicated if bacterial infection is
suspected
b) Oxygen therapy should be given to correct hypoxemia
c) Antibiotics are used

Note: Corticosteroids: Oral prednisolone (usually 30 mg for 5–10

days) reduces symptoms and improves lung function. Prophylaxis
against osteoporosis should be considered if frequent courses are
needed. Antibiotic therapy: Recommended for an increase in sputum
purulence, sputum volume or breathlessness. An aminopenicillin or a
macrolide should be used. Co-amoxiclav is only required in regions
where β-lactamase producing organisms are known to be common.

48) A patient with sarcoidosis and hypercalcemia, which of the

following is true?
a) Normal chest x-ray
b) Normal urine calcium excretion
c) Increased PTH
d) + Increased intestinal absorption of calcium
e) Hypogammaglobulinemia

49) Hypercalcemia normally suppresses the release of PTH and

therefore the production of calcitriol, but in sarcoidosis and other
granulomatous diseases, activated mononuclear cells (particularly
macrophages) in the lung and lymph nodes produce calcitriol from
calcidiol independent of PTH.
50) (Long case) A 16-year old male, known diabetic, presented with
abdominal pain and nausea, vomiting, rapid breathing. Lab results:
Na 130, K 6.3, Cl 95, HCO3 13, pH 7.21, Blood glucose 430 mg/dL.
Which of the following is not true?
a) He should be managed in the ICU
b) He should be started on insulin infusion
c) He has hyponatremia and hyperosmolarity
d) +The respiratory compensation is inappropriate
e) He has wide anion gap metabolic acidosis

51) Pseudomonas aeruginosa is likely associated with:

a) +Adult with cystic fibrosis
b) Meningitis in a diabetic
c) Following nail puncture

Note: Cystic fibrosis Clinical features:

The lungs are normal at birth, but bronchiectasis develops in
childhood. [Link] is the most common childhood organism;
Ps. Aeruginosa infection affects the majority of patients by
adolescence.

52) Regarding spontaneous pneumothorax, all of the following are

true EXCEPT:
a) Most commonly in ages 20-40 years
b) +If tension pneumothorax develops, the trachea will deviate to
the collapsed lung
c) Can occur during menstruation
d) Clinical features

53) Which of the following findings on thoracentesis is the most

helpful to diagnose empyema?
a) pH 7.1
b) Glucose 2.2 mmol/L
c) LDH 630
d) +Protein 55 g/dL
e) WBC 11,000 with 95% neutrophils

There is two correct answers A and D

Finding in empyema
Pleural fluid is pus
 Pleural fluid bacterial smears or culture are positive
Glucose<2.2 mmol/L or 60mg/dL
Ph<7.2
Protein is 3g/dl (30g/l.) or more
LDH>1000 IU/ml
Wbc>15000

54) (Long case) Patient presented with a picture of pneumonia, on

exam he didn’t have breath sounds despite use of accessory muscles.
pH 7.25, PaO2 60 mmHg, PaCO2 75 mmHg. The most likely cause of
hypoxemia is:
a) Pneumonia
b) Intrapulmonary shunt
c) Pulmonary embolism
d) +Hypoventilation
e) Pneumothorax

Note: The clinical manifestations of hypoventilation syndromes

usually are nonspecific, and in most cases, they are secondary to the
underlying clinical diagnosis. Manifestations vary depending on the
severity of hypoventilation, the rate of development of hypercapnia,
and the degree of compensation for respiratory acidosis that may be
present. As the hypoventilation continues to progress, more patients
develop increased hypercapnia and hypoxemia.

55) (Long useless case). pH 7.3, HCO3 12, PCO2 40, what is the acid-
base disorder?
a) Lactic acidosis
b) +Mixed metabolic acidosis and respiratory acidosis

56) Which of the following is an indication for placing an inferior vena

cava (IVC) filter?
a) +Active bleeding diathesis in a patient with history of DVT
b) Patient with right femur fracture
c) Patient with right heart thrombus
d) Recurrent PE on warfarin with INR of 1.5
e) Patient with upper limb DVT

Note: In a nutshell, Indications of IVC filter:

 Contraindication to anticoagulation in a patient that is in need
for anticoagulation
Recurrent PE despite adequate anticoagulation (INR= 2-3)

57) True about the guidelines in the treatment of pneumonia:

a) + Start empirical antibiotics in the ER

58) COPD best thing to do:

a) + Stop smoking

59) COPD in long term O2 therapy presented with acute SOB , all
could be acause except :
a) ACSpneumothorax
b) Pneumonia
c) +pulmonary TB

60) Most important in the management of hemoptysis:

a) +It depends on the rapidity of bleeding and cardiopulmonary
reserve

61) Case about ABG's of COPD pt ,ph = 7.15 , Pco2 = 45 , Hco3 = 17:
a) +Mixed metablic and respiratory acidosis

62) Not a complication of sleep apnea:

a) HTN
b) Sexual dysfunction
c) +Both are true

Note: complication of sleep apnea: daytime fatigue, HTN or heart

problems, type 2 diabetes, metabolic syndrome, liver problems,
complications with surgery, sleep deprived partner.

63) False about large pleural effusion:

a) +You can exclude TB with normal CXR

64) Why do we classify Pneumonia into CAP and HAP?

a) +To know the type of empirical antibiotics we should give

65) What is an indication for IVC (Inferior vena cava) or venous filter:
 a) +Inability to anticoagulate in a patient with upper extremity DVT
due to a vein catheterization
b) Recurrent PE in a patient already on Warfarin with INR 1.
c) Bleeding diathesis in a patient with femur fracture
d) A thrombus in the right ventricle

Note: Typically, IVC filters are used in patients with acute proximal
DVT and PE who have an absolute contraindication to anticoagulant
therapy (eg, recent surgery, hemorrhagic stroke, active bleeding).
Although not considered absolute indications, placement of an IVC
filter is also often considered as an adjunctive therapy in patients
with recurrent embolism despite adequate anticoagulation (INR= 2-
3), as well as in patients in whom an additional embolic event would
be poorly tolerated (eg, those with poor cardiopulmonary reserve
from massive PE or underlying cardiopulmonary disease,
hemodynamically unstable patients).

Absolute contraindication to IVC filter: thrombosis of IVC without PE,

complete thrombosis of access vessels. Although one of the relative
contraindications to IVC filter include an upper extremity DVT, a
Superior vena cava filter can be used.

The contraindications to IVC filter placement are absence of access,

IVC thrombosis, high bleeding risk , and septic emboli or positive
blood cultures.

66) An elderly male, alcoholic, poor oral hygiene, presented with

pulmonary infection, culture showed multiple organisms, the best
antibiotic for treatment:
a) +Clindamycin
b) Penicillin
c) 3rd generation cephalosporin with amikacin

Note: answer is A, but if there is other answer like Fluoroquinolones

+ clindamycin or beta-lactamase inhibitor, choose it. Because he is
alcoholic so most probably there is aspiration pneumonia.

For aspiration pneumonia, Infectious Diseases Society of

America (IDSA) guidelines recommend a beta-lactam/beta-
lactamase inhibitor, clindamycin, or a carbapenem.
67) Not used in the maintenance treatment of COPD:
a) +Oral steroids

68) An alcoholic patient comes with cough, chills, fever with putrid
smell of purulent sputum. Chest Xray was clear. What is your
diagnosis?
a) +Lung Abscess
b) Empyema

69) Case with recurrent sinusitis and cardiac sound was more clearly
heard on the right sided chest. What is your diagnosis?
a) +Kartegener Syndrome (immotile cilia syndrome with
dextrocardia)

70) A 66 years old male previously healthy came complaining of

scanty cough and pleuritic chest pain 5 days ago. It was associated
with fever 38.5 and watery diarrhea. He lived in apartment with
renovation. On physical exam, he appeared toxic looking and have
bilateral crepitations. CXR showed bilateral infiltrates. Labs showed
hyponatremia, hypophosphotemia, abnormal liver enzymes and low
platelets. What is your diagnosis?
a) Mycoplasma pneumonia
b) Psittacosis
c) +Legionella’s disease
d) Influenza disease
Note: Pulmonary sx + GI symptoms + Hyponatremia = Legionella

71) COPD O2 in room air 81%, with O2 increased ,not that much
exacerbation, no change in the sputum , wt can increase the survival?
a) +giving O2
 b) AB
c) rehabilatation,...
d) Acute exacerbations of COPD

Management:
Long-term supplemental oxygen therapy has been shown to reduce
symptoms and improve survival in COPD pts who are chronically
hypoxemic. Documentation of the need for O2 requires a
measurement of PaO2 or oxygen saturation (SaO2) after a period of
stability. Pts with a PaO2 ≤55 mmHg or SaO2 ≤88% should receive O2
to raise the SaO2 to ≥90%. O2 is also indicated for pts with PaO2 of
56–59 mmHg or SaO2 <90% if associated with signs and symptoms of
pulmonary hypertension or cor pulmonale. {Harrison}

72) 26yr female complaining of dyspnea o2 in room air 82 ,with 40%

O2 increased to 84 or 86 ur diagnosis:
a) ASD with Eissenmenger
b) exacer asthma (not sure)
c) ILD

73) one is wrong regarding allergic rhinitis:

a) can be treated by antihistamine and Na-cromoglycate.
b) can be seasonal or perennial.
c) the seasonal type can be helped by staying indoor.
d) +nasal congestion, greenish discharge, sneezing are common
presention.

74) 20 yr-old male, previously healthy, came with sudden chest pain
and SOB, on exam he has no shifted trachea, on the right side of his
chest: no air sounds and hyperresonance, your Dx is:
a) +spontaneous pneumothorax.
b) tensionpnuemothroax.

75) Case of SOB, Xray 1 cm mass in left side, high scan, what to do?
a) bronchoscope biopsy surgery
b) +invest for TB and other diagnosis ..(not sure)

76) One drug for pneumonia :

a) +Levofloxacin ..
77) Which of the following is true about
acute severe asthma :
a) +Pulse rate of 110
b) PaO2 is 65
c) PaCO2 is 44
d) O2 saturation is 90%
e) Wheezy chest
Answer: +Pulse rate of 110

78) What is wrong about life threatening asthma:

a) silent chest
b) Altered mental status
c) RR < 35
d) +PEF < 50% from predictable

79) What is wrong about asthma:

a) +Pollen and fungi known indoor allergens for asthma
b) Being exposed to active smoking in childhood increases the
chance of getting asthma
c) Asthma is more common in well-developed and industrial
countries
d) Dust mites r known indoor allergens for asthma
e) Isocyanate is a known occupational sensitizers

80) What is not TRUE to be done concerning the investigations of a

mass in that was found in the chest with Pleural effusion:
a) +Tumor markers
b) Bronchoscope
c) CT scan

81) A female patient 37 years old known to have DM came to the ER

complaining of acute progressive shortness of breath she had done
cesarean surgery (?) 10 days ago. Her pH = 7.46, O2= 52 , oxygen
saturation of 78%, HCO3= 24(?), glucose 15 mmol(?), what
investigation should be done next for the diagnosis?
a) +V / Q scan
b) Ketonemia and ketone bodies in urine

NOTE: Surgery in the last 3 months is a risk factor for Pulmonary

embolism, V/Q scan is used to know the ventilation perfusion ratio
which is INCREASED in PE because of the increase in dead space.
82) What is wrong:
a) +D-dimer +ve is diagnostic in PE

Note: D-dimer is of limited value, as it occurs in a number of

conditions including PE, myocardial infarction, pneumonia and sepsis.
However, low D-dimer levels (< 500 ng/mL measured by ELISA),
particularly where clinical risk is low, have a high negative predictive
value and further investigation is unnecessary.
The D-dimer result should be disregarded in high-risk patients, as
further investigation is mandatory even if it is normal.

83) What is wrong in sarcoidosis?

a) +Associated with hypocalcemia
b) Good prognosis
c) Sometimes not associated with lymphadenopathy

Note: it's associated with hypercalcemia which is explained by

the fact that granulomas produce active vit D.

84) The most common hospital acquired infection is:

a) Pneumonia
b) Influenza
c) +UTI

85) Not an indication for influenza vaccine:

a) Nursery resident
b) < 50 age
c) +Someone in contact with a TB patient
d) Someone with chronic lung disease

Note: Everyone 6 months of age and older should get an

influenza (flu) vaccine every season with rare exception
Vaccination to prevent flu is particularly important for people
who are at high risk of developing serious flu complications
86) What isn't a cause of hemoptysis?
a) A-V malformation
b) Bronchiectasis
c) Lung CA
d) +Lung fibrosis

87) Which of the following isn't a cause

of Exudative pleural effusion?
a) Acute pancreatitis
b) SLE
c) RA
d) +Nephrotic syndrome
e) Pulmonary infarction

88) What is wrong in a patient came

with bronchiectasis ?
a) Steroid may be used
b) Antibiotics must be used
c) +Increased CO diffusion

89) A patient has COPD, PFT

a) +FEV1/FVC= 65%, FEV1 =
50% > .

90) Signs of respiratory distress,

wrong answer:
a) Pursed lips
b) +Increased chest expansion
c) Use of accessory muscle
d) Intercostal recession

91) DLCO increase in:

a) Emphysema
b) Lung fibrosis
c) Sarcoidosis
d) +Pulmonary hemorrhage syndrome

Note: DLCO is decreased in: Lung fibrosis, emphysema, intrinsic

restrictive lung disease (e.g. IPF, sarcoidosis, collagen vascular
diseases, and amyloidosis), COPD, pulmonary embolism, pulmonary
hypertension, anemia. DLCO is increased in: Pulmonary hemorrhage,
 obesity, asthma, left-to-right shunt & polycythemia.

92) Tactile vocal fremitus (TVF) increase in:

a) +Consolidation
b) Emphysema
c) Collapse

Note: Tactile vocal fremitus is increased over areas of consolidation

and decreased or absent over areas of effusion or collapse.

93) All of TB treatment is matched with its S/E except:

a) +Ethambutol- hepatotoxicity.
b) Rifampicin – thrombocytopenia.
c) Isoniazid – peripheral neuropathy.
d) Streptomycin – deafness.
e) Pyrazinamide – gout.

94) All are risk factor for Tb except:

a) Young age group.
b) Long therapy of prednisolone.
c) HIV infection
d) +Something Else

95) Most common cause of community acquired pneumonia is:

a) +Strep. Pneumonia.
b) hemophilus influenza
c) Staph. Aureus.
d) klebsiella.

96) Man comes with SOB on examination there was dullness on right
side decrease tactile fremitus + shift of trachea to RT. What the most
 likely coz :
a) +Collapsed lung
b) Pneumonia
c) Consolidation from infection
Note: Tactile fremitus is decreased over areas of collapse, while
increased in pneumonia & over areas of consolidation.

97) 65 Years male presented with hemoptysis of few days + right

upper mass on chest x-ray + weight loss+ fatigue " apical lung tumor".
All can be true except:
a) +Horner's syndrome is unusual
b) Hoarseness is unexpected.
c) weakness and pain in right shoulder.

Note: Since it's on the right side, left recurrent laryngeal nerve is not
affected. Hoarseness is not expected.
Horner's is usual with Pancoast tumors! it causes distribution of the
sympathetic chain.

98) All are features of life threatening asthma except :

a) HR ‹ 50
b) RR › 25
c) PCO2 = 25
d) +inspiratory and expiratory wheeze

Note: should be silent chest.

Also RR>25 is indicated of acute sever
And pco2 isn’t from the criteria of life threatening
So I think this Q not written correctly

99) DLCO = 40 , FEV = 55% , FUC= 85% most likely is:

a) +Emphysema
b) Asthma
c) Sarcoidosis
d) lung fibrosis

Note:.55/.85=.64 obstructive (COPD or asthma)

DLCO = 40 Low (normal = 80 - 140) → emphysema
because in asthma it’ll increase.
DLCO decreased in:
alveolar wall & capillaries damage (emphysema)
alveolar-capillary membrane thickened (edema,
 consolidation or fibrosis).
Increased in: pulmonary hemorrhage, Obesity, asthma, left-to-right
shunt & polycythemia.

100) Doesn't cause clubbing:

a) Emphysema
b) idiopathic pulmonary fibrosis

101) About DVT is true :

a) Negative D-dimer test exclude the diagnosis.
b) Normal limb examination excludes the diagnosis.
c) Treatment for 9-12 months.
d) +Post thrombotic syndrome is known late complication.

Note: When individuals are at a high-probability of having DVT,

diagnostic imaging is preferred to a D-dimer test. For those with a
low or moderate probability of DVT, a D-dimer level might be
obtained, which excludes a diagnosis if results are normal.

102) 30 Years Jordanian male positive PPD, asymptomatic normal chest

x-ray, infectious TB, Latent :
a) TB-immune against
b) TB-childhood BCG
c) +latent infection

103) Cause of Bronchiectasis except:

a) young's syndrome
b) Kartagener's syndrome
c) cystic fibrosis
d) hypogammaglobulinemia
e) +Something else

104) 22 Years, 3 recurrent DVT, presents with PE:

a) protein C deficiency
b) protein S deficiency
c) +Factor V Leiden

105) most effective anti-inflammatory in bronchial asthma:

a) +Steroid
b) B2 agonist
c) Anti-IgE treatment
106) True about treatment of VTE except:
a) Targeted INR is 2-3
b) Thrombocytopenia is side effect of heparin use
c) + other

107) A middle aged male patient presented with cough and diffuse
wheezing, which of these goes with the diagnosis of asthma
rather than COPD:
a) +Rapid response to salbutamol
b) The patient had similar episode in last April
c) Chronic smoking

108) What's found in life threatening asthma:

a) +Confusion, Cyanosis (in other form)
b) HR > 125
c) PCO2 = 26
d) Tachypnea

109) Which one is true about asthma:

a) +Steroid is the most effective controller
b) FEV1/FVC is always < 70%

110) Obstructive sleep apnea is:

a) +Cessation of airflow through the nose & mouth despite
continuous respiratory effort.
b) Cessation of airflow through the nose & mouth with no
respiratory effort

111) All of these cause hemoptysis except:

a) TB
b) Acute tracheobronchitis
c) Bronchiectasis
d) Hemorrhagic telangiectasia
e) +Non-Hodgkin's lymphoma

112) A 16 years old female pt presented to ER complaining of SOB,

chills, fever, and pleuritic chest pain at the right side . on examination
we found absent breath sound, decrease TVF, and increase dullness
on right side , the trachea shift to the left, the most likely diagnosis:
a) +Right lobar pneumonia with large pleural effusion
b) Hodgkin lymphoma with atelectasis
 Note: pleural effusion will cause mass effect & tracheal shifting to the
opposite side.
113) Hospital acquired pneumonia:
a) +Develops 48 hrs after hospitalization
b) 14 days after hospitalization
c) 2 days before hospitalization

114) In inspection of respiratory system you will not concern on:

a) Symmetrical expansion
b) Respiratory rate
c) Respiratory depth
d) +Tracheal position
e) Change in anterior – posterior diameter
Note: Tracheal position is examined during palpation.

115) All of these may present with DLCO = 60% except:

a) Sarcoidosis
b) Interstitial pulmonary fibrosis
c) +Bronchial asthma
d) Anemia
e) Emphysema

Note: DLCO = 60 Low (normal = 80 - 140). DLCO is decreased in

lung fibrosis, sarcoidosis, emphysema & anemia, while increased
in asthma.

116) All about bronchial asthma are true except:

a) +Presence of nocturnal symptoms means uncontrolled asthma
b) Airway hyper-responsiveness
c) Airway inflammation is constant
Note: One night awakening /month consider controlled

117) Which of these is true about VTE:

a) positive D-dimer indicate DVT & PE
b) +S1QT3 are changes that found in ECG

118) Which one of these is true about ILD :

a) +Maximal vital capacity is decreased

119) A pt complaining of SOB on exam we found him to have 3 cm

 mass on the left side, decrease air entry, decrease TVF, and dullness
at the same side , what's wrong?
a) If he did bronchoscopy 1 Year ago, benign lesion will be found
b) Bone isotope scan

120) All of these are features of idiopathic pulmonary fibrosis except

a) Normal X-ray, Normal examination (In another form)
b) Honeycomb appearance on ct scan

Note: Chest X-ray for idiopathic pulmonary fibrosis usually shows

reticulonodular infiltration.

121) All of these are true about pt suspected to have thrombophilia

except:
a) 25 pt has DVT & his brother had PE 2 mon ago
b) +52 lady died from PE after travel from new york to Jordan
c) Young male with recurrent pulmonary embolism

Note: According to age, thrombophilia is suspected in the young.

122) All of these has bad prognosis in COPD except:

a) Corpulmonale
b) +Cessation of smoking

123) What is not related to smoking:

a) +sarcoidosis
b) Spontaneous pneumothorax
c) Emphysema
d) Chronic bronchitis
e) Laryngeal CA

Note: Smoking is protective against sarcoidosis.

124) Commonest cause of hemoptysis

a) +Infection
b) Bronchoscopy (iatrogenic)
c) Pulmonary edema
d) Bronchial CA
e) Bronchiectasis
 Note: The most common source of hemoptysis is airways disease.
And the most common of those is bronchitis (either acute or chronic).

125) What is wrong about interstitial lung disease:

a) +It is always associated with good prognosis
b) Dyspnea is a common symptom

126) Least common cause of community acquired pneumonia

a) Legionella
b) Mycoplasma
c) +Pseudomonas aurogenosa
d) Strep. Pneumonia

127) Most effective treatment of pseudomonas:

a) Cefazoline
b) Cefatoxime
c) Cefuroxime
d) +Ceftazidime

128) What goes against sarcoidosis:

a) Facial palsy
b) Lymphadenopathy
c) Spleenomegaly
d) Uveitis
e) +Clubbing

Note: Presentation of sarcoidosis: symptomatic:

Abnormal routine chest X-ray (30%) or abnormal liver function tests.
Respiratory and constitutional symptoms (20-30%)
Erythema nodosum and arthralgia (20-30%)
Ocular symptoms (5-10%)
Skin sarcoid (including lupus pernio) (5%)
Superficial lymphadenopathy (5%)
Other (1%), e.g. hypercalcaemia, diabetes insipidus, cranial nerve
palsies, cardiac arrhythmias, nephrocalcinosis .
129) Regarding respiratory system one is false:
a) +Tidal volume is 1.5 liter

Note: 500-600 ml

130) Regarding the anatomy of respiratory system one is true:

a) +The pleura is a negative pressure area

131) 58- The cause of pleural effusion with glucose level less than 40
mg/dl is:
a) +Empyema

Note: A low pleural glucose concentration (30-50 mg/dL) suggests

malignant effusion, tuberculous pleuritis, esophageal rupture, or
lupus pleuritis.
A very low pleural glucose concentration (ie, < 30 mg/dL) further
restricts diagnostic possibilities, to rheumatoid pleurisy or empyema.

132) SIADH in patient with lung cancer , the cause is:

a) +Small lung cell carcinoma

Note: SIADH and ACTH paraneoplastic syndromes are usually caused

by Small cell lung CA.

133) One is not of the paraneoplastic syndrome in lung CA

a) +Horner's syndrome

Note: Horner's syndrome (ipsilateral partial ptosis, enophthalmos,

miosis and hypohidrosis of the face) due to involvement of the
sympathetic chain at or above the stellate ganglion.
Pancoast's syndrome (pain in the shoulder and inner aspect of the
arm, sometimes with small muscle wasting in the hand) indicates
malignant destruction of the T1 and C8 roots in lower part of the
brachial plexus by an apical lung tumor.

134) One of the following favors cryptogenic fibrosingalveolitis on

sarcoidosis:
 a) +Clubbing

Clubbing is associated with:

Lung disease: Lung cancer, mainly non-small-cell (54% of all cases),
not seen frequently in small-cell lung cancer (< 5% of cases)[7]
Interstitial lung disease most commonly fibrosing alveolitis
Complicated tuberculosis
Suppurative lung disease: lung abscess, empyema, bronchiectasis,
cystic fibrosis
Mesothelioma of the pleura
Arteriovenous fistula or malformation
Pseudo-clubbing may be seen in chronic renal failure
hyperparathyroidism, sarcoidosis, scleroderma, subungual hematoma
and chromosome deletion

135) All of the following are features of asthma except:

a) +Decreased DLCO

136) In operable bronchogenic carcinoma characterized by:

a) +Persistent hoarseness of voice

Note: Symptoms that suggest unresectable lesion:

- Weight loss > 10%
- Bone pain or other extrathoracic metastasis
- CNS symptoms (treated by radiation or chemotherapy)
- SVC syndrome
- Hoarsness
- Mediastinal adenopathy on the contralateral side
- Split-lung test tidal volume < 800 ml
- Tumor classification M1 within 3 months
- Tumor involving the trachea, esophagus, pericardium or chest wall

137) Regarding pneumonia, one is false:

a) +Mycoplasma pneumonia is a common cause of pleural effusion

Mycoplasma = atypical pneumonia = no sputum = cause 20%

pleuraleffusion
Complications that have been reported include:
 Severe pneumonia
Swelling of the brain (encephalitis)
Too few red blood cells, which means fewer cells to deliver oxygen
inthe body (hemolytic anemia)
Kidney problems (renal dysfunction)
Skin disorders (Stevens-Johnson syndrome, erythema multiforme,
toxic epidermal necrolysis)

138) Patient underwent knee joint arthroplasty , presented with

pleuritic chest pain, the investigation of choice is:
a) +V/Q scan
Note: CT is even better

139) 67- A case of Wegner's granulomatosis , the best management

initially:
a) +Combined cyclophosphamide and steroid

Note: WG = C-ANCA
The mainstay of treatment for Wegener’s granulomatosis (WG) is a
combination of corticosteroids and cytotoxic agents.
Medications used to treat GPA include high-dose cortisone
(prednisone) and the immunosuppressive drug cyclophosphamide
(Cytoxan). Recent reports also suggest that
trimethoprim/sulfamethoxazole (Bactrim) can also be helpful to
prevent relapse of disease activity in patients with GPA.

140) which of the followings doesn't cause pleuritic chest pain:

a) +Mesothelioma
b) Pleurisy

141) Note: Dyspnea and nonpleuritic chest wall pain are the most
common presenting symptoms of malignant mesothelioma.
(Approximately 60-90% of patients have symptoms of chest pain or
dyspnea.)

142) All indicate poor prognosis in pneumonia except :

a) +rectal temp 38.6 c
b) blood urea › 16 mmol
c) RR 36
 Note :CURB65
(1) Confusion.
(2) Urea > 7 mmol/L.
(3) RR > 30/min.
(4) BP (systolic <90 mmHg or diastolic <60 mmHg).
(5) Age > 65 years.

143) About asthma all are true, except:

144) +Antileukotriens are superior to steroids

Note: Antileukotriene treatment was associated with a 30%

increased risk of withdrawal because of poor asthma control. These
findings clearly indicatedthat LTRAs, although safe in patients with
mild-to-moderate asthma, are considerably less effective than low-
dose ICSs in preventing asthma exacerbations and maintaining
asthma control.

145) A case with symptoms suggestive of pulmonary embolism , one is

false :
a) +If D-dimer is +ve Dx is DVT.

Note: D-dimer not a diagnostic test but just a screening test. If the D-
Dimer is –ve, we can rule out DVT. Deep-vein thrombosis can be
ruled out in a patient who is judged clinically unlikely to have deep-
vein thrombosis and who has a negative D-dimer test. Ultrasound
testing can be safely omitted in such patients.

146) COPD patient , values of PaO2 ,PaCO2 , find A-a gradient .

a) (The law is PAO2= 150-(1.25*PaCO2) , A-a gradient = PAO2-PaO2)

147) One of the following is not a feature of influenza:

a) High fever
b) + productive cough
c) headache
d) pharyngitis

Common signs and symptoms of the flu include:

Fever over 100 F (38 C)
 Aching muscles, especially in your back, arms and legs
Chills and sweats
Headache
Dry, persistent cough
Fatigue and weakness
Nasal congestion
Sore throat

148) Which of the followings you don’t need to do to diagnose

pneumonia:
a) +blood culture

149) patient with left sided pleural effusion which is least helpful in
diagnosis TB :
a) +Zeil–Neelsen
b) Deaminase
c) γ interferon

Note: Patients with clinically suspected TB or other mycobacteriosis

were selected and were initially tested cytologically. In cases of
absent tumor cells, PCR for detection of Mtc DNA and Ziehl-Neelsen
stain (ZN) were performed.

150) 80- A case with CXR

showing hilar lymphadenopathy , bilateral infiltrates ofthe lung , FNA
findings releaved non-caseating granuloma (all suggestive
ofsarcoidosis ) the right treatment is :
a) +Prednisone
b) Abs for TB
c) Cyclophosphamide

Note: The pathology report showed chronic necrotizing granuloma.

The case was interpreted as lymph node sarcoidosis and treated with
corticosteroids (Prednisone).

151) One of the followings about the management of asthma in ER is

false:
a) +Antibiotics
b) O2
c) B-agonist (nebulizer)
 d) Nebulizer anticholinergic
e) IV steroid
Note: Antibiotics are not generally recommended for the treatment
of asthma exacerbations because viruses are a much more common
cause of exacerbations than bacteria. Thus antibiotics should be
reserved for relatively rare cases in which there is strong evidence of
a coexistent bacterial infection (e.g., pneumonia or sinusitis).

152) One of the followings regarding restrictive pulmonary disease

(Idiopathic pulmonary fibrosis) is false:
a) +Increased Diffuse capacity
b) Decreased TLC
c) Decreased residual volume
d) FEV / FVC > 80%

153) One of the followings regarding exudative pleural effusion is false:

a) Pleural / serum protein > 0.5
b) Pleural / serum LDH > 0.6
c) Protein > 30
d) LDH > 200
e) +Something else

Note: Lights criteria for exudative pleural effusion

LDH >2 third of serum LDH
LDH effusion/serum ratio <0.6
Protein effusion/serum ratio <0.5
If all true → transudative, 1 criterion not met → exudative

154) Female when she was pregnant, she had DVT, after 2 years she
developed bilateral redness scaly in her both legs:
a) +Stasis eczema

Note: venous eczema (varicose eczema) (gravitation eczema)

usually due to venous hypertension (Eg.. varicose DVT etc) in old
women, post-surgery after 2 years duration of venous hypertension
involving the lower limbs.

155) One of the followings is false about COPD:

a) +Always smoking is the cause
 b) Low body mass is poor prognosis
c) Associated with osteoporosis

156) One of the followings about management of COPD is false:

a) +Long term oral steroid
b) B-agonist
c) Ipratropium
d) Influenza vaccine yearly

Management of COPD:
(1) Ipratropium (mild)
(2) B2 Agonist (mild)
(3) Inhaled corticosteroids ( moderate )
(4) Home nebulizer (severe)
(5) Long term O2 Therapy ( PaO2<7.3k Pa / pulmonary
hypertention +corpulmonale / terminally ill patient )
(6) Diuretic ( edema )
(7) Other – i. stop smoking . ii. Exercise, iii. Diet, iv. Vaccination
( influenzaand pneumococcal ).

157) One of the followings is not used for testing of PE:

a) +Coagulation profile
b) V/Q mismatch
c) Spiral CT

158) One of the followings about pneumonia is false:

a) + Rare cause of death
b) Normal CXR exclude the dx
c) Treat initially empirically

159) One of the followings about TB is true:

a) + All cases need combination of drugs (at least 2)
b) Treatment at least 12 months
c) Isoniazide cross BBB
d) Resistance due to multiple drug resistance

160) Least to cause hemoptysis:

a) +Sarcoidosis
 b) Acute bronchitis
c) Bronchogenic CA
d) TB
e) PE

161) All these are controlled asthma except:

a) Resume drugs less than 2/week
b) +Nocturnal symptom once/month
c) Normal pulmonary function test

Note: I think all answers are correct because b consider controlled

asthma but some resources aren’t. So if other answers are correct
you should choose b.
("‫)وعلى ما بيقول المثل " إربط السؤال مطرح مابده صاحبه‬

162) 94- one of the followings does not cause pulmonary fibrosis:
a) +cystic fibrosis
b) amiodarone
c) RA
d) Scleroderma

Note: RA, SLE, Scleroderma, Dermatomyositis can cause ILF

drugs to cause ILF:
Amiodarone
Anakinra (IL-1 receptor antagonist)
Nitrofurantoin
Paraquat
Continuous oxygen
Cytotoxic agents (many, particularly busulfan, CCNU, bleomycin,
methotrexate).

163) What is inappropriate to be given in COPD emergency case

a) +High flow oxygen

Note: Acute exacerbations of chronic obstructive pulmonary disease

(COPD)are treated with controlled oxygen therapy (in hypoxemic
patients), inhaledbeta2 agonists, inhaled anticholinergics, antibiotics
and systemic corticosteroids.
164) What is the disease that presents especially as a restrictive lung
disease
a) +sarcoidosis
b) Esinophilic granuloma

165) All can cause decreased DLCO except

a) +Heart failure

166) All can be considered as controlled asthma except:

a) +Night symptoms )if more than 1/month)

Note: controlled asthma

(1) daytime< 2 times in 1 week
(2) none limitation of activity
(3) resume drug < 2/week
(4) normal pulmonary function test
(5) no case of exacerbation

167) Pleural effusion given LDH levels indicates (transudate pleural

effusion)all can cause this except:
a) +TB Exudate

168) Asymptomatic healthy patient on a pre-employment routine

medical checkup, found to have bilateral hilar lymphadenopathy on
chest x-ray, what is the best management
a) +Reassurance

Note: Sarcoidosis – 85% self-limiting. Treatment need when =

significant sign + inflammation changes

169) Which can be considered as a positive PPD test:

a) +A high risk person (history of close contact with a TB patient)
with morethan 10 mm reaction

Note: A tuberculin test conversion is defined as an increase of 10 mm

or more within a 2-year period, regardless of age.

5 mm or more is positive in:

- HIV-positive person
 - Recent contacts of TB case
- Persons with nodular or fibrotic changes on chest x-ray consistent
with old healed TB
- Patients with organ transplants and other
immunosuppressedpatients

10 mm or more is positive in:

- Recent arrivals (less than 5 years) from high-prevalencecountries
- Injection drug users
- Residents and employees of high-risk congregate settings
(e.g.,prisons, nursing homes, hospitals, homeless shelters, etc.)
- Mycobacteriology lab personnel
- Persons with clinical conditions that place them at high risk
(e.g.,diabetes, prolonged corticosteroid therapy, leukemia, end-
stagerenal disease, chronic malabsorption syndromes, low
bodyweight, etc.)
- Children less than 4 years of age, or children and
adolescentsexposed to adults in high-risk categories

15 mm or more is positive in:

- Persons with no known risk factors for TB

170) Case of cough , fever and bilateral basal infiltrates associated with
cold agglutinin :
a) +mycoplasma pneumonia.

171) Do not add benefit to diagnose pneumonia is:

a) +Sputum culture

Note: Diagnostic tests for community-acquired pneumonia should

include a chest radiograph and complete blood count. The role of
routine sputum and blood cultures in this setting is controversial.

172) Not poor diagnostic factor in pneumonia:

a) +HR of 114

173) Not controlled asthma:

a) +2 nights per month or week ?

174) Case of suspected PE in postpartum woman to diagnose:

 a) +CT angio

175) Case of transudative pleural effusion:

a) first step of pleural effusion is to rule out heart failure

176) Diagnosis of TB:

a) +Closed lung biopsy ???

Note:Diagnosis of TB (Pulmonary):
Specimens required
Sputum* (induced with nebulised hypertonic saline if
notexpectorating)
• Bronchoscopy with washings or BAL
• Gastric washing* (mainly used for children)

Diagnostic tests
• Circumstantial (ESR, CRP, anemia etc.)
• Tuberculin skin test (low sensitivity/specificity)
• Stain
Ziehl–Neelsen
Auramine fluorescence
• Nucleic acid amplification
• Culture
• Response to empirical antituberculous drugs (usually seen after 5–
10 days)

177) Highly infectious TB:

a) +Cavitary TB

Note: usually TB involve lower lobe of the lungs

Cavitary TB involves the upper lobes of the lung. The bacteria cause
progressive lung destruction by forming cavities, or enlarged air
spaces. This type of TB occurs in reactivation disease. The upper lobes
of the lung are affected because they are highly oxygenated (an
environment in which M. tuberculosis thrives). Cavitary TB can,
rarely, occur soon after primary infection.

178) Congestive heart failure do not cause:

 a) +Decrease DLCO

Note: Chronic Heart failure will cause decrease in DLCO while left to
right intracardiac shunting may cause increase in DLCO. In congestive
heart failure DLCO increase.

179) What is not an indication of life threatening asthma :

a) +Respiratory alkalosis
b) Respiratory acidosis
c) Pulsus paradoxus
d) Exhaustion
Note: PCO2 normal or raised in life threatening asthma.

180) A young pt presented with cough, normal chest exam, complained

while ago from arthralgia & painful skin lesions on legs that has
resolved. CXR abnormal , PPD 3 mm , most likely cause :
a) +Sarcoidosis .
b) TB
c) Fibrosingalveolitis

181) A long time smoker presented with SOB , ECHO was done &
showeddilated RV , other findings were consistent with pulmonary
HTN ( abnormal ventricular motion, valvular dysfunction), most likely
diagnosis :
a) +Corpulmonale.

Note: Corpulmonale is heart disease secondary to lung disease.

182) Which one of the following is not at increased risk for TB:
a) +Flight attendants
b) Illicit drug users
c) Nursing home residents
d) Health care works

183) Who is at risk for pseudomonas chest infections :

a) +Pt with CF
 Note: P. aeruginosa is also a frequent cause of chronic respiratory
infection in patients with cystic fibrosis. As many as 80% of cystic
fibrosis patients may be colonized in the lung with P. aeruginosa and,
once established, it is very resistant to antibiotic treatment.

184) A known case of COPD presented to ER complaining of SOB &

Chest pain. On exam , absent breath sound on left lobe , tracheal
shift to the right ,Best management is :
a) +Chest tube

185) What goes more with COPD rather than asthma :

a) +Decrease DLCO
b) Decrease FEV/FVC
c) Increase RV
d) Increase TLC

Note: Emphysema lowers the DLCO, obstructive chronic bronchitis

does not affect the DLCO, and asthma frequently increases the DLCO.

186) An 80 years old female presented with fever , chest pain &
productive cough. CXR showed RT sided consolidation. Most common
etiology :
a) +Streptococcal pneumonia
b) Mycoplasma

187) What is the appropriate mono-therapy for pneumonia :

a) +Levofloxacin

188) A pt know to have common variable immunodeficiency “CVID”

presented with chest pain and productive cough , CXR showed cystic
lesions &dilated bronchi, what is the likely cause :
a) +Bronchiochiatasis

Note: Bronchiectasis findings on CXR are either Normal X-ray or

Dilated Bronchi and thickened bronchial walls, and possible fluid
filled cysts
189) A pt with long standing rhinorrhea, presented with cough. CXR
showed pulmonary nodules. The pt developed renal failure. Biopsy
was done and showed necrotizing granuloma , most likely diagnosis :
a) +Wegner granulomatosis
b) TB

190) A young male presented with finding consistent with DVT, similar
episode has occurred to his brother. The pt has normal O2 sat. he
denies any precipitating factors , what not to do for this pt :
a) +V/Q Scan.
b) Protein C / protein S.
c) Anti-phospholipid
d) Ant ithrombin II

191) A young female was diagnosed with pneumonia; CXR showed

effusion, pleural fluid was sampled. WBC 2000 , proteins > .5 of
serum with no growth on gram stain, most likely cause :
a) +Simple Para pneumonic effusion
b) Emphyema

Note: Pleural effusion hints

Empyema >> Observation (pus, putrid odor); culture
Malignancy >> Positive cytology
Tuberculous pleurisy >> Positive AFB stain, culture
Chylothorax>> Triglycerides (>110 mg/dL); lipoprotein
electrophoresis (chylomicrons)
Hemothorax>> Hematocrit (pleural fluid/blood >0.5)
Urinothorax>> Creatinine (pleural fluid/serum >1.0)

192) A pt presented to u complaining of nocturnal cough , no dyspnea

or other symptoms , the pt is on enalopril , chest examination
revealed scattered wheezes, least likely etiology:
a) +Idiopathic alveolitis
b) Enalopril
c) Nocturnal variant of asthma
d) GERD
e) Post nasal drip
193) Female 18 Years presented with hemoptysis 2x ,3days ago she
had right thigh swelling & erythema, you WILL DO ALL EXCEPT:
a) CT-PA
b) ABG
c) X-ray
d) +no anticoagulant
e) CBC

Note: Anticoagulation should be commenced immediately in patients

with a high or intermediate probability, but may be safely withheld in
patients with low clinical probability pending investigation.

194) COPD acute exacerbation what is wrong:

a) +non- invasive ventilation is contraindicated

195) Acute exacerbation of COPD, PH= 7.2, CO2=88,

HCO3=30,CL=100,Na=140, on ventilation 60% o2, what is TRUE:
a) +acute on top of chronic respiratory acidosis
b) decrease O2 supply

196) 134. Asthma symptoms 3x a day, 2 nights a week , you give:

a) +ICS + long acting B acting

197) ARDS one is wrong:

a) acute onset
b) bilateral infiltrate
c) no left atrium hypertension
d) PCWP less than 18
e) +Po2/Fio2 <300

Note: ARDS features are:

--Acute onset
--Bilateral infiltrates (radiographically similar to pulmonary edema)
--No evidence of elevated left atrial pressure (the pulmonary capillary
wedge pressure is ≤18 mmHg if measured)
--PaO2/FiO2 is ≤200 mmHg
 ARDS is often limited to patients requiring mechanical ventilation
where as milder form is called:Acute lung injury (ALI) is a milder form
which is different by PaO2/FiO2 is ≤300 mmHg

198) One isn't an indication of sever disease:

a) A-a gradient of 35 (normal 5-15)
b) +Expiratory Wheezes
c) Silent chest

199) least sensitive in TB dx :

a) +ZielNeelsen stain
b) closed Pleural bx
c) open pleural bx
d) interferon gamma
e) Adenosine of pleural fluid

200) Obstructive sleep apnea all EXCEPT :

a) ECG
b) EEG
c) respiratory muscle effort
d) +Evoked auditory potential

201) pleural effusion tap ,showed high LDH & high protein, All Except :
a) hemorrhagic disease
b) +Hepatic hydrothorax.

202) Pleural effusion one indicate empyema:

a) +Gram positive cocci stain
b) Low glucose
c) Low PH
Note: All answers are correct but culture is the most sensitive.

203) acute exacerbation of asthma , all can be given Except:

a) IV methylprednisolone
b) +Aminophylline

204) Case of high PCO2, low Po2 :

 a) +Severe asthma

205) All of these are found in obstructive sleep apnea , EXCEPT :

a) Impotence.
b) Morning headache.
c) +Increased sleep latency.
d) Poor job performance.
e) Intellectual deterioration.

206) A question about someone who had recurrent sinusitis, cough,

and his heart sounds weren't heard properly on the left side:
a) Kartegner's syndrome

Note: Primary ciliary dyskinesia (PCD), also immotile ciliary

syndrome or Kartagener syndrome, is an autosomal recessive genetic
disorder that causes defects in the action of cilia lining the respiratory
tract and fallopian tube, as well as in the flagella of sperm cells. The
main consequence of impaired ciliary function is reduced or
absent mucus clearance from the lungs, and susceptibility to chronic
recurrent respiratory infections,
including sinusitis, bronchitis, pneumonia, and otitis media.

207) Something about a very heavy smoker (40 pack years), progressive
SOB, FEV1/FVC=65, DLCO=40 (decreased cuznl=80-140)...?
a) COPD
b) Asthma
c) +emphysema

Note: COPD also correct but emphysema more specific

208) A case about a male who was stabbed, with tracheal deviation to
the opposite side, what will you find by physical examination :
a) +hyperresonance note of percussion

209) Latent TB is diagnosed by?

a) +positive mantoux test

Note: latent TB mean that person is healthy no symptoms only

positive test
210) Pulmonary emblism, the most sensitive ECG change:
a) +Sinus tachycardia ECG ( not S1Q3T3)

211) A 50 year old male schoolteacher presented complaining of

progressive dyspnea over the last year. He has no history of exposure
to chemotheurapeutic agents, or smoking. He has bilateral
inspiratory crackles on examination with decreased air entry
bilaterally. Which of the following is false about his disease?
a) +He has an obstructive pattern on spirometry
b) His disease is progressive

Note: mostly it is a restrictive lung disease as he is a school teacher.

212) Which of the following is correct about the management of COPD:

a) Administration of oxygen therapy when indicated improves the
condition but does not reduce mortality
b) +Inhaled corticosteroids reduce the frequency of exacerbations
c) Alpha 1 antitrypsin is the most common cause of emphysema
d) Smoking causes panacinar emphysema

Note: Oxygen therapy reduces the mortality rates, Alpha-1

antitrypsin is one of the causes, but the commonest cause for
emphysema is cigarette smoking, panacinar emphysema is usually
caused by alpha-1 antitrypsin.

213) About acute onset of shortness of breath, which of the following is

correct:
a) +Brain natriuretic peptide can be used to differentiate COPD
from pulmonary edema.

Note: Brain natriuretic peptide (BNP): is secreted by the ventricles of

the heart in response to excessive stretching of heart muscle cells, so
its increase in serum indicates a heart failure, so indicates a
pulmonary edema.

214) A 54 year old male with a strong history of smoking, presented

with a week’s duration of hemoptysis and shortness of breath. On
CXR a 5cm speculated border mass was located in the right upper
lobe of the lung. All of the following findings are possible except?
a) Hypercalcemia
 b) +Hypernatremia

Note: the case goes with lung CA, which is usually associated with
hyponatremia (paraneoplastic syndrome).

215) A 26 year old female presented with a fever, cough and shortness
of breath of several days duration. On examination, there is
decreased tactile vocal fremitus and dullness to percussion on the
right middle and lower lobes of her lungs. CXR revealed shifting of the
trachea to the left side. Which of the following is the most likely
diagnosis
a) +Right lower lobe pulmonary pneumonia with massive pleural
effusion
b) Left sided lung collapse
c) Right sided pneumothorax

216) Which of the following is a feature of life-threatening asthma:

a) Respiratory rate = 35
b) +Heart rate = 54
c) PEF= 40%
d) Severe diffuse wheezing

Note: life-threatening asthma is characterized by: PEF <33%, Silent

chest (no wheezes), bradycardia, hypotension, exhaustion, confusion
and agitation, hypercapnia, and coma. Also be careful! Life-
threatening asthma differs from acute severe asthma (status
asthmaticus) which is characterized by unable to complete a
sentence in one breath, RR> 25, Pulse> 110, and PEF< 50%.

217) Which of the following isn’t true about Legionnaire’s disease?

a) +It can be transmitted from human to human easily
b) It can present as a lobar pneumonia
c) Often detected using serological tests

Note: Legionnaires' disease is a form of atypical pneumonia caused

by Legionella bacteria. This bacterium is found naturally
in freshwater. It is usually spread by breathing in mist that contains
the bacteria. It can also occur when contaminated water is aspirated.
It typically does not spread directly between people. Usually it is
detected by urine serology.
218) A 34 year old female presented with skin lesions on her legs,
arthritis and fatigue. Her CXR revealed bilateral hilar adenopathy and
infiltrates through her lungs. Which of the following is least likely to
be true about her disease?
a) +PPD test is positive
b) An increase in angiotensin converting enzyme
c) Hypercalcemia
d) Diabetes insipidus

Note: usually it is not a TB case so PPD should be negative, and I think

the presentation goes with sarcoidosis.

219) 61. A patient presented with cough, night sweats and weight loss.
He is diagnosed as a case of pleural tuberculosis. Which of the
following is least helpful to confirm the diagnosis of tuberculosis in
this patient?
a) Pleural IFN-γ assay
b) +Skin PPD test
c) Closed pleural biopsy

Note: Maybe the biopsy or Interferon-γ is more sensitive for TB.

220) (Case) describing a patient with pulmonary tuberculosis. Which of

the following is the best suitable test to confirm the diagnosis of
tuberculosis in this patient?
a) +Acid fast stain of sputum and mycobacterial cultures

Note: other choices included a gram stain and bacterial culture which
was wrong.

221) 34-year old man diagnosed with pulmonary tuberculosis was

started on four first line drugs. Which of the following statements is
TRUE?
a) Sputum remain infectious for at least 3 months after initiation of
treatment
b) At least 12 months of treatment are required
c) +The outcome of daily anti-tuberculosis therapy is better than
that of 3 times weekly
d) He has to be isolated until he finishes anti-tuberculous drugs
 e) In Jordan the most common cause of treatment failure is multi-
drug resistant organisms

222) A 38-year-old premenopausal lady with a history of progressive

dyspnea. She is otherwise healthy. High resolution CT-chest shows
diffuse thin wall cystic lesions. She has recurrent episodes of bilateral
pneumothoraxes and one episode of right chylothorax. What is the
most likely diagnosis ?
a) +Lymphangioleiomyomatosis
b) Eosinophilic granuloma
c) Alveolar vasculitis
d) Idiopathic pulmonary fibrosis
e) Breast cancer

Note: Lymphangioleiomyomatosis (LAM) is a rare, progressive,

systemic disease that typically results in cystic lung destruction and
predominantly affects women, especially during child bearing
years. It occurs in more than 30% of women with tuberous sclerosis
complex (TSC-LAM), a heritable syndrome that is associated with
seizures, cognitive impairment and benign tumors in multiple tissues.
chylothorax with diffuse thin wall cystic lesions on HR-CT support the
Dx.

Eosinophilic granuloma(EG), also known as pulmonary histiocytosis X

(PHX) or
Pulmonary Langerhans cell histiocytosis X (PLCH), is an uncommon
interstitial lung disease that is epidemiologically related to tobacco
smoking. It chiefly affects young adults, primarily occurring in the
third or fourth decades of life
both of them have cystic lesion and may present as spontaneous PT
but EG rarely associate with plueral effusion and may present with
bone lesion “ribs”
HR-CT:Pathognomonic findings include nodules and cysts,
predominantly in the mid and upper lung zones, with sparing of the
costophrenic regions.

Alveolar vasculitis like goodpasture, Churg-Strauss Syndrome and

Microscopic Polyangiitispt usually coma with hemoptysis and
hameaturia
 Idiopathic pulmonary fibrosis progressibe SOB and dry cough .HR-CT
Demonstrates patchy, peripheral, subpleural, and bibasilar reticular
opacities

223) All of the following are recognized co-morbidities in patients with

chronic obstructive pulmonary disease EXCEPT:
a) +Thyroid cancer
b) Depression
c) Osteoporosis
d) Diabetes mellitus
e) Atrial fibrillation

224) One of the following statements is TRUE about COPD:

a) alpha one anti protease deficiency is responsible for the majority
of causessmoking
b) +all smokers has a degree of lung function treatment
proportional to amount of smoked cigarettes
c) airway inflammation is predominantly eosinophilic in
natureneutrophils, lymphocytes and macrophages
d) panacinar emphysema is typically seen in smokers centriacinar

Note: Alpha one anti protease deficiency is major cause for early
onset COPD

225) All of the following statements are true regarding jugular venous
pressure (JVP) EXCEPT:
a) JVP should be estimated in semi-sitting position (45 degree angle)
b) JVP rises with abdominal compression
c) External jugular vein is a reliable guide to right atrial pressure
d) +JVP is routinely measured from the level of right clavicle
 e) JVP is reduced with inspiration  will create a negative pressure
around the heart that sucks blood form the jugular vein toward
the heart so the pre. decrease

it’s easy Q “it’s measured from sternal angel”

226) A patient is presented with progressive shortness of breath and a

picture COPD, which element of the clinical picture would -if present-
support the diagnosis emphysema over asthma?
a) +pulmonary function show obstructive pattern with reduced
diffusion capacityemphysema affects the membrane where gas
exchange occurs but asthma doesn’t
b) presence of wheeze
c) age of patient is 25 years
d) female patient
e) complete resolution of symptoms with treatmentCOPD is
irreversible and asthma is reversible so with ttt the symptoms will
resolve.

227) All of the following are poor prognostic factors in chronic

obstructive pulmonary disease EXCEPT:
a) Body mass index of 25
b) Grade 4 dyspnea on the modified medical research council
dyspnea scale
c) +Presence of chronic type 2 respiratory failure
d) FEV1 30% of predicted
e) Six minute walking distance of 110 meters

Note: prognosis is calculated depending on BODE index

Or maybe the answer is A according to BODE index BMI>21 isn’t
indicate bad diagnosis.
228) Positive tuberculin skin test (17 mm induration) in an
asymptomatic 30-year old Jordanian person with normal chest X-ray
means that:
a) He has to be treated with four first line drugs for 6 months
b) He is at risk of developing active disease later in life
c) He is infectious to other people
d) +He was vaccinated
e) He has extrapulmonary tuberculosis

229) A 51-year-old marathon runner who regularly runs 8 miles a day

presents to your clinic with long history of progressive shortness of
breath when he runs for 3 miles that has been slowly getting worse
over the last 8 months despite increasing his training sessions. On
examination he has symmetry shallow breathing pattern with good
bilateral air entryand diffuse scattered bilateral inspiratory crackles.
He also has bilateral digital clubbing. All following statements
regarding this case are true EXCEPT:
a) Echocardiogram might show evidence of pulmonary hypertension
b) Disease is usually progressive
c) High resolution CT-chest might have characteristic distribution
d) +Spirometry usually shows severe obstructive defect
e) Bronchial lavage from bronchoscopy shows increase in neutrophils
countsee Q61\C
230) The most accurate determination of obstructive sleep apnea
severity is made by which of the following?
a) +Respiratory disturbance index (RDI)
b) Body mass index (BMI)
c) Periodic limb movement index (PLMI)
d) Neck circumference

Apnea–Hypopnea Index(AHI)
The AHI is calculated by dividing the number of apnea events by the
number of hours of sleep
Normal: 0-4 Mild sleep apnea: 5-14 Moderate sleep apnea:
15-29 Severe sleep apnea: 30 or more
RDI = (RERAs + Hypopneas + apneas) X 60 / TST (in minutes). That is,
RDI means the average number of episodes of apnea, hypopnea, and
respiratory event-related arousal per hour of sleep.[4] (TST is "total
sleep time".)
Note form Omar Sawas: The respiratory disturbance index (RDI) — or
respiratory distress Index — is a formula used in reporting
polysomnography (sleep study) findings. Like the apnea-hypopnea
index (AHI), it reports on respiratory events during sleep, but unlike
the AHI, it also includes respiratory-effort related arousals (RERAs)
the management:
231) The appropriate evidence-based strategy for treatment of
pneumonia with antibiotics is:
a) +Institute early antibiotic therapy empirically in the emergency
room
b) Give antibiotics only if pneumonia is severe enough to warrant
hospitalization
c) Give antibiotics only after the identification of specific
microorganism from the cultures obtained initially
d) Treat both hospital-acquired pneumonia and community-
acquired pneumonia initially with the same empirical antibiotics
until identification
e) Give antibiotics only when other comorbidities coexist

232) The most frequent indoor aeroallergen worldwide is:

a) Olive tree pollen antigen
b) Cockroach antigen
c) Pencillium fungal spore antigen
d) +House dust mite antigen
e) Cat antigen

233) A 30-year-old lady with chronic cough and shortness of breath,

palpitations and bilateral ankle joints pain associated with painful
tender skin nodular lesions on both lower extremities. She also has
fever and generalized weakness and fatigue. Chest X-ray showed
bilateral hilar lymphadenopathy. Lymph node biopsy confirms
presence of a non-ceseating granuloma. All of the following can be
associated with this disease EXCEPT:
a) +Hypocalcemia
b) Hoarseness of voice
c) Diabetes insipidus
d) Renal stones
e) Cardiomyopathy
Note: Sarcoidosis

234) A 25-year old patient is undergoing evaluation in the emergency

room for acute asthma exacerbation. Which of the following is a life
threatening feature?
a) Loud inspiratory and expiratory wheezes
b) Peak expiratory flow rate of 45% of predicted
c) Pulse rate of 134/min
 d) Respiratory rate of 33/min
e) +Confusion

235) During evaluation of severe hemoptysis which of the following

statements is true?
a) Death is usually due to hypovolemic shock from blood loss
b) Localizing the site of bleeding is not helpful in the management
c) +Urgent need for treatment is dictated by rapidity of bleeding
and respiratory function
d) An abnormality in CXR will reflect the exact site of bleeding
e) Amount of blood lost is usually accurately estimated by patients
or their families

Note: remember the most important thing in hemoptysis not the

volume of blood.

236) A 72-year-old man with long standing chronic obstructive

pulmonary disease comes to the clinic with shortness of breath and
ankle swelling. He has a raised JVP and bilateral lower limb pitting
edema consistent with right heart failure. His BP is 152/89 mmHg.
Which of the following will have most benefits effect on his
prognosis?
a) Bisoprolol
b) Furosemide
 c) +Salmeterol/fluticasone inhalers
d) Homo oxygen
e) Ramipril

237) A 29-year old female with long standing history of asthma

presents with cough and wheeze most of the days, with frequent
nocturnal awakening FEV1 is 64% of predicted. Which of the
following is the best treatment to control her asthma ?
a) Inhaled salmeterol twice daily
b) +Regular inhaled corticosteroid and long beta-2 agonist
c) Regular low dose oral prednisolone
d) Inhaled salbutamol every 4-6 hours
e) Regular leukotrine modifier and inhaled salbutamol as needed
238) Which of the following is NOT part of management in pulmonary
edema?
a) IV nitroglycerin
b) IV morphine
c) O2
d) IV furosemide
e) +IV digoxin

239) Treatment of latent TB?

a) +9month isoniazid
b) 9 month rifampicin
Note: In latent TB There are several treatment regimens currently
in use: isoniazid for 9 months is the gold standard (93% effective).
Wiki

240) Drugs in TB what is wrong?

a) Pyrazinamide cause gout
b) Ethambutol optic neuritis
c) +Isoniazid cause peripheral neuropathy in young more than
elderly

Note: in the general population and around 6.5% in the elderly.

241) Which is not a complication of Obstructive sleep apnea:

a) adult Attention deficit hyperactivity.

242) >12% in asthma :

a) Fev1
b) Peek flow

243) Isn’t bad prognostic in COPD:

244) +Bmi>25

245) Best in COPD (case) to prolong survival: -

a) O2
b) +stop smoking
Note: if no smoking cessation choice, O2 therapy is the next best.
246) A 52-year-old male with a 50 pack year smoking history presented
to the physician complaining of hemoptysis. Physical examination is
not remarkable. His medical history is otherwise free. His basic labs
show: Sodium 123 mmol/L, chloride of 100 mmol/L and a potassium
level of 3.6 mmol/L. A chest X-ray shows a hilar mass. Bronchoscopic
examination shows extrinsic compression on the left bronchus with
brushings and bronchial washings were positive for malignancy.
Which of the following is the most likely pathological type of this
patient’s lung tumor:
a) +Small cell Aplastic carcinoma
b) Squamous cell carcinoma
c) Large cell anaplastic carcinoma
d) Undifferentiated adenocarcinoma
e) Bronchoalveolar carcinoma

247) All of the following are used to evaluate severity of an asthma

exacerbation except:
a) +Lower limb edema
b) Peak expiratory flow
c) Heart rate
d) Ability to complete sentences
e) Use of accessory muscles

248) A 51-year old man with a 4-month history of upper respiratory

tract congestion, bloody rhinorrhea, and elevated serum creatinine
when investigated for hemoptysis. His ESR is 100 and C-ANCA is
positive. A CT scan of the chest shows bilateral pulmonary nodules. A
thoracoscopicbronchoalveolar lavage shows necrotizing
granulomatous inflammation with multinucleated giant cells. Which
of the following is the most likely diagnosis?
a) Churg-Strauss syndrome
b) +Wegner’s granulomatosis
c) Mycobacterium tuberculosis infection
d) Rheumatoid lung
e) Mixed connective tissue disease

249) Which one of the following is correct about Reversible asthma:

a) +An increase in FEV1 by at least 12% after giving the medication
 b) B- An increase in FEV1 by at least 15% after giving the medication

250) Which one of the following will indicate life survival in a patient
with COPD :
a) +FEV1
b) B-FVC
c) C-Chest X ray
d) D-ECG
e) E-Echocardiogram

251) A patient present with night snoring , decrease consciousness, and

day time somnolence.. this is most likely with :
a) +Hypoglycemia
b) Stroke
c) Insulin hypersensitivity

252) Which one of the following TB is most likely to present with gram
positive sputum and acid fast stain:
a) +PrimaryTB
b) Miliary TB
c) Latent TB

253) Which one of the following is incorrect about sarcoidosis:

a) +Bilateral pleural effusion is common
b) Lupus pernio
c) Mediastinal lymphadenopathy

254) Which one of the following will indicate chest surgery :

a) Low LDH
b) High protein
c) High glucose
d) +Sero-sangouneous fluid
e) PH<7.2

255) Which one of the following findings of asthma is correct:

a) +Low FEV1, Low FVC, Low FEV1/FVC, High DLCo
256) Which one of the following is wrong about PE:
a) Negative D-Dimmer will make the diagnosis unlikely
b) CT angio is the preferable diagnostic test
c) +S1Q3T3 is the most common finding in ECG
Note: The most common finding in ECG is sinus tachycardia.

257) Which one of the following is not a contraindication of excision of

lung tumor :
a) +Paraneoplastic syndrome
b) Paralysis of recurrent laryngeal nerve
c) Paralysis of phrenic nerve
d) Bone pain

258) A patient with intra-alveolar hemorrhage and hematuria, the least

likely cause would be:
a) +Polyarteritis nodosa
b) HSP
c) scleroderma
d) wegners granulomatosis

259) Most common risk factor of TB worldwide?

a) HIV
b) DM
c) +Poverty
d) Use of immunosuppressant
e) chronic renal disease

Note: Low socioeconomic status & poverty the most common &
important risk factor worldwide.

260) Latent TB?

a) +Interferon gamma -cavitation in CXR -infects others –coughing

261) Life threatening asthma?

a) paCo2 45
b) PEF less than 35%
c) +PaO2 55 ++
d) can’t lie flat
 e) use of accessory muscles

262) Something that is in favor for exudative Pleural effusion:

a) Pleural protein to serum ratio 0.6
b) +Pleural LDH to serum ratio 0.6

263) Case of kartagener’s syndrome (recurrent infections and absent

left sided heart sounds?
a) Immotile cilia disease

264) A 3 cm lung tumor with effusion which one is false?

a) CT guided biopsy
b) +Bronchoscopy**
c) surgery is not indicated if the malignancy is diffused
d) a case of IIA non-smallcell CA
e) 1 year ago x ray was normal

Note: Non-small cell tumors (non-squamous) are associated with

pleural effusion and they are usually at the periphery. Peripheral
tumors are diagnosed by CT-guided biopsy, while central tumors
bronchoscopy is the preferred method of tissue biopsy.

265) What is correct about the treatment of COPD :

a) Noninvasive ventilation, oral cotricosteroid -long term oxygen
therapy, Bronchodilator, LABA.

Note: I think there is some info missing or misplaced in this

question!!!

266) Spirometry results showed obstructive pattern with 11%

improvement to bronchodilator:
a) +COPD
b) Bronchial Asthma

267) Female known case of asthma, presented with asthma

exacerbation 2nd time, with history of renal impairment,
Erythematous rash, which is correct cc?
a) Normal cbc this condition is related to ANCA gene mutation
b) Coronery artery disease
 c) Churg strauss syndrome
Answer: A or missing option.
Note: Churg-Strauss syndrome doesn’t affect kidneys and there is
neuropathy.

268) Pt complaining of fever, arthralgia and vomiting ‫وكمان كالم كثير‬cast

and HTN:
a) It can resolve spontaneously
Note: w

269) Type 1 respiratory failure:

a) +Normal PCO2 low PO2

270) Not a risk factor for Obstructive Sleep Apnea:

a) +Sleep deprivation
b) Diuretic
c) CNS medication
d) Obesity

271) All are risk factors for COPD except:

a) Obesity
b) Low socio-economic status
c) Smoking
d) +Alcohol

272) Which is not a restrictive pattern?

a) +Cystic fibrosis
b) Interstitial pneumonitis
c) Morbid obesity
d) Pneumonectomy

273) Tracheal deviation :

a) +Pneumonia with effusion

274) Case: pt with lung cancer in chest x Ray , best next step:
a) CT with IV contrast
b) Bronchoscopy
275) Doesn't go with Empyema :
a) Fev1/Fvc =85%
b) Tlco=160
c) DLco=50

Note: I think there is something wrong with Q and As. And if he

means emphysema the answer will be A.

276) A 62-year old woman with lung cancer comes to the emergency
department because of fever for 2 days. Ten days ago, she received a
chemotherapy dose of paclitaxel and carboplatin. She feels tired but
has not had nausea or vomiting. Her temperature is 39.5 oC, BP
100/70 mmHg, pulse 115/min. the lungs are clear to auscultation.
Her hematocrit is 32%, absolute neutrophilic count is 300/mm 3, and
platelet count is 80.000/mm3. Which of the following is the most
appropriate next step in treatment?
a) Additional chemotherapy
b) Intravenous corticosteroid therapy
c) +Intravenous antibiotic therapy
d) Transfusion of 6 units of platelets
e) Assurance as it is self-limiting.

277) The most serious side effect of the chemotherapeutic group of

anthracyclines is:
a) Cardiomyopathies
b) Thrombocytopenia
c) Lung Fibrosis
d) Hemorrhagic Cystitis

278) Pt with PE and no risk factors for how long u treat with
anticoagulant?
a) 6 months
b) +3-4 months
c) 12 months
279) Female pt with a lot of symptoms (fatigue, cough, rash on legs) +
bilateral lymphadenopathy on chest x ray, what is the diagnosis?
a) Sarcoidosis
b) TB
Note: some ppl said they answer it as TB because both come with
bilateral hilar LAP and with EN, so I guess u need to focus on this
question maybe some information’s missed.

280) Which of the following is an example of Type 2 respiratory failure:

a) bronchial asthma
b) +kyphoscoliosis
c) pneumonia
d) Pulmonary embolism

281) PFT with obstructive pattern (low ratio) with no improvement

with salbutamol and dec. DLCO, which of the following is the most
likely diagnosis?
a) Asthma
b) COPD
282) Pt with long hx of fatigue, SOB and cough, PFT as follow: Fev1/fvc
: 84, Fev1 : 74, Fvc : 62
a) +Interstitial pulmonary fibrosis
b) COPD

283) Most common cause of infection in ICU patients?

a) mycoplasma
b) +Acinetobacter baumanii

Note: Acinetobacter baumannii is a typically short, almost round, rod-

shaped (coccobacillus) Gram-negative bacterium. It can be an
opportunistic pathogen in humans, affecting people with
compromised immune systems, and is becoming increasingly
important as a nosocomial infection.

284) Female pt was in a flight for 10 hours, presented with S&S of PE, +
d dimer, best next step?
a) VQ scan
b) pulmonary angiography
c) +Start anticoagulation
Note: highly suspected PE  start anticoagulation
285) Pt with Pleural effusion was found to be exudative, what is the
cause?
a) heart failure
b) nephrotic
c) +TB

286) Pt with liver cirrhosis, was found to have right sided pleural
effusion, analysis of it showed it is transudate , all of the following are
correct except:
a) +inappropriate treatment of pneumonia
b) pleural/ serum protein <0.5
c) pleural/serum LDH<0.6
d) this is a result from his liver cirrhosis

287) Eosinophilic granuloma do not give bronchiectasis:

Done by: Tawfiq Aldabaa