PULMONARY MEDICINE

QUIZ

ACKNOWLEDGEMENTS

• To the Pulmonary Medicine Department , Kottayam Medical college

• To My Quiz partner Sachin James

QUIZ MASTER’S ADVICE

6 ROUNDS …• Anatomy & Physiology ( 7 Qns )• Trivia ( 12 Qns )• Clinical Medicine & Investigations

( 15 Qns )• Respiratory Infections &

Neoplasms ( 18 Qns )• Respiratory Pharmacology ( 8 Qns )• Rapid Fire ( 30 Qns )

ARE U READY ?

ANATOMY & PHYSIOLOGY

Q1.

• The human respiratory tree may consist on an average of 23 generations (Weibel’s Lung Model)

• 1- 16 generations constitute the conducting zone ,while 17-23 constitute the transitional & respiratory zones.

• What is the 17th generation in the respiratory tree ?

ANSWER

• Respiratory Bronchiole

Q2.In the cross section of a bronchus, what is X ?

• X =

Thickness of the mucous gland layer / Thickness of the wall between epithelium & perichondrium

ANSWER

• X = Reid Index• Normal Reid Index – 0.4

Q3.Name these “named” connections .

• Pores of ‘X’ – Inter alveolar connections• Canals of ‘Y’ – connections between alveoli &

bronchioles• Channels of ‘Z’ – Interbronchiolar connections

ANSWER

• X – Kohn• Y – Lambert• Z – Martin

Q4.

• Surfactants are the molecules secreted mainly by Type 2 alveolar epithelial cells in the lungs .

• The surfactants lower surface tension – this in turn increase pulmonary compliance & prevent atelectasis at the end of expiration.

• The pulmonary surfactant mixture contains both Phospholipids & Proteins.

• Name the strongest & the chief phospholipid in the surfactant mixture.

ANSWER

• Dipalmitoyl phosphatidylcholine (DPPC)

Q5.

• Name the Neuroendocrine cells in the Lungs from which the Carcinoid tumour is thought to arise ?

ANSWER

• Kulchitsky cells

Q6.• The Club cells or Bronchiolar exocrine cells were known as X cells till

Dec 31st,2012.• They were named as X cells after an Austrian anatomist Y – Y was

an active member of Nazi Party & used to take tissues from executed victims for research.

• In May 2012,the editorial boards of most of the respiratory journals concluded that continued use of Y’s name would be equivalent to honouring him – so they brought about this name changing policy.

• The X cells (now Club cells) are found in the small airways , protect the bronchiolar epithelium & detoxifies the harmful substances inhaled into the lungs.

• Name X & Y.

ANSWER

• X - Clara cells • Y - Max Clara

Q7.

• What is the functional unit of lung as per High Resolution CT ( HRCT) Terminology ??

ANSWER

• Secondary Pulmonary Lobule• Each secondary pulmonary lobule is supplied

by a terminal bronchiole and a pulmonary artery branch. They are drained by pulmonary veins which form in at the periphery of the lobule and pass though the interlobular septa.

TRIVIA !!!!!

Q1.• X is a method of tapping on a surface to determine the

underlying structure & is used in clinical examination to assess the condition of the thorax or abdomen.

• X was first used to distinguish between empty & filled barrels of liquor & Y, an Austrian physician is said to be the first person who introduced this technique in modern medicine.

• But X was used by Z, a Persian polymath,as early as in 10th century CE.

• Z is widely known for his work, ”The Canon of Medicine ”, which was a standard medical textbook in many medival universities.

• Identify X,Y & Z

ANSWER

• X – Percussion• Y- Dr.Leopold Auenbrugger• Z - Avicenna

Q2.Identify this famous French Physician

credited with the invention of Stethoscope

ANSWER

Rene Laennac

Q3. Identify this German

physician who was a pioneer in microbiology.

He is known for his role in identifying the specific causative agents of tuberculosis, cholera, and anthrax and for giving experimental support for the concept of infectious disease .

He was awarded Nobel Prize for Medicine in 1905.

ANSWER

• Robert Koch

Q4.• In the late 1940s & 1950s, one common technique used by

the ……… industry to reassure a worried public was to incorporate images of physicians in their ads.

• The none-too-subtle message was that if the doctor, with all of his expertise, chose to use a particular brand, then it must be safe.

• RJ Reynold Company promoted the ads and their brand Camel was advertised as the most commonly used brand by doctors.

• The response of the organized medical community was to do nothing, because the ads showed doctors looking wise.

• RJ Reynolds Company is at present the second largest ………. company in the US.

• About which Industry am I talking about ?

ANSWER• Tobacco Industry

TOBACCO INDUSTRY

Q5.

Identify this German laryngologist who is regarded as the Founder of Bronchoscopy.

A part of the pharyngeal wall is named after him.

ANSWER

• Gustav Killian• Killian dehiscence• Killian forceps• Killian nasal speculum

Q6.

• X is Charles Dickens’ first novel.• There is a character by the name of Joe (The Fat

Boy Joe) who consumes large quantities of food & constantly falls asleep in any situation at any time of day.

• His sleep problem is the origin of the medical term Y which ultimately led to the description of Obesity Hypoventilation syndrome.

• Identify X & Y

ANSWER

• X – Pickwick Papers• Y – Pickwickian syndrome

Q7.

• This word means ,”out of place, unusual or extraordinary”.

• It was coined by Arthur F Coca & Robert A Cooke (both are American immunologists & allergy specialists) who in 1923 attempted to develop a classification for hypersensitiveness ,an abnormal level of sensitiveness for which the mechanism was not known.

• What is the word ?

ANSWER

• Atopy

Q8.• What is the active principle in the “Asthma

cigarettes” ,which were popular in Germany by this name in the mid 20th century ?

• These cigarettes consisted of powdered stramonium leaves & their inhalation brought about some relief from asthma.

• It caused dryness of mouth & mucous membranes and it was regarded as one of its major side effects.

• A later study proved that the active principle in this cigarette has got some beneficial effect on bronchial obstruction.

• ( Image follows )

ANSWER

• Atropine

Q9.• The image (next slide) is that of ……. , a British Respiratory

scientist, currently Professor of Thoracic Medicine at the National Heart & Lung Institute, Head of Respiratory Medicine at Imperial College and Honorary Consultant Physician at the Royal Brompton Hospital ,London.

• He is known for his groundbreaking research in the molecular mechanisms responsible for Asthma & COPD , which have helped formulate several novel treatment strategies (under clinical trial).

• Name him.

ANSWER

• Peter John Barnes

Q10.

• Who completed the first successful lung transplant and also the first successful double lung transplant in the world ?

ANSWER

• Joel D. Cooper

Q11.• The Mutter Museum is a medical museum located in Philadelphia

– it is a part of “The College of Physicians of Philadelphia” .• This museum is currently the only place where members of the

public can view slides of Einstein’s brain.• A notable attraction of this museum is “The Foreign Body

Collection of X”.• X is an American Laryngologist ,known as the “Father of

Endoscopy”.• His obituary referred to him as “one of the greatest ,if not the

greatest laryngologist of all time”.• Identify X.

ANSWER

• Chevaliar Jackson

Q12.Fill in the Blank.• John Hutchinson ,an English surgeon designed a device (which

was as tall as an adult patient) was essentially a calibrated bucket that was placed upside down in water.

• The volume of exhaled air from fully inflated lungs could accurately be measured by exhaling into a tube leading into the bucket.

• Dr. Hutchinson coined the term …………………….. when he realized that compromise of this crucial measurement was predictive for premature mortality.

• Because of the strong correlation between this measurement and mortality, Hutchinson argued that it should be utilized in actuarial predictions for life insurance policies.

• Neither the device nor its measurements were accepted by the insurance industry and the device was used primarily in a limited function to measure usable lung volumes in patients at tuberculosis sanitariums.

The device designed by John Hutchinson

ANSWER

• Vital Capacity • The device is Spirometer

CLINICAL MEDICINE & INVESTIGATIONS

Q1.What is the name of the the angle shown ?

ANSWER

• Lovibond Angle • Named after Dr.JL Lovibond ,a 20th century

English dermatologist

Q2.• This is a posture is adopted by

patients experiencing respiratory distress .

• It is thought that this position optimizes the mechanics of respiration by taking advantage of the accessory muscles of the neck and upper chest to get more air into the lungs.

• ( But a 2007 Indian study of COPD patients found no significant helpful effects for this posture )

• What is this posture known as ?

ANSWER

• Tripod Posture

Q3.

• Which is the abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing ?

• The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.

ANSWER

Q4.FITB

• The inward movement of the lower rib cage during inspiration (instead of outward as is normal) implying a flat, but functioning, diaphragm, often associated with COPD is known as ………….

• COPD (more specifically emphysema) often lead to hyperinflation of the lungs due to air trapping. The resulting flattened diaphragm contracts inwards instead of downwards, thereby paradoxically pulling the inferior ribs inwards with its movement.

ANSWER

• Hoover’s sign• Named after Charles Franklin Hoover ,an

American Physician

Q5.

• The crackles heard in the Interstitial Fibrosis are referred to as

ANSWER

• Velcro like crackles ( they sound like a Velcro being ripped apart )

Q6.

• ………….. a crunching, rasping sound, synchronous with the heartbeat, heard over the precordium in spontaneous mediastinal emphysema produced by the heart beating against air-filled tissues.

• This sound is heard best over the left lateral position.

• It has been described as a series of precordial crackles that correlate with the heart beat and not the respirations.

ANSWER

• Hamman’s mediastinal crunch• Named after Dr.Louis Hamman

Q7.

• The auscultation of the sound “AH” instead of “EEE” when a patient phonates “EEE” is known as ?

ANSWER

• Aegophony • It is heard in Pneumonia

Q8.Name this criteria used to classify Pleural effusion as Exudative or

Transudative

ANSWER Light’s Criteria Named after

Richard W Light (He developed

this while working as an intern at John Hopkins Hospital)

Q9.

• The cytologic examination of Pleural Fluid revealed malignant cells.

• What is the principle behind this ?

ANSWER

• Exfoliative cytology

Q10.Identify this needle used for blind biopsy of the Pleura

Outer cannula(A) of the Needle with trocar point and cutting window, which can be closed with a turning action of the inner tube (B) inner stylet.

Complete Needle assembly with stylet needle. The needle is in the closed position

ANSWER

• Abram’s Pleural Biopsy Needle• Indications for pleural biopsy include the

following:Recurrent pleural effusion of unknown

etiologyPleural mass or thickening

Q12.

• The investigation of choice for the diagnosis of Pulmonary thromboembolism ?

ANSWER

• CT Pulmonary angiography• It may either confirm the suspected embolism

or highlight an alternative diagnosis.

Q13.

• Which is the molecular test that can detect TB bacilli from the Sputum sample by isolating genomic material from the sample by sonication,then amplifies it by PCR ,also identify all the clinically relevant rifampicin inducing mutations in the RNA polymerase beta(rpoB) gene in the bacilli ??

• The result is obtained within 2 hours !!!!

ANSWER

• Gene Xpert Study

Q14. The image shows the

histological finding in interstitial lung disease that is suggestive of significant occupational

Asbestos exposure. They are usually

identified following a parenchymal lung biopsy.

What are they known as ?

ANSWER

• Asbestos Body

Q15.Identify the cells (seen in chronic alveolar congestion)

ANSWER

• Heart Failure cells

RESPIRATORY INFECTIONS & NEOPLASMS

Q1.

• Name the long chain fatty acids found in the cell walls of the tuberculosis causing bacteria.

• These fatty acids lend the organism increased resistance to

chemical damage and dehydration, and prevent the effective activity of hydrophobic antibiotics.

allow the bacterium to grow readily inside macrophages, effectively hiding it from the host's immune system.

ANSWER

• Mycolic acids

Q2.

• Which organism is responsible for “Walking Pneumonia” ?

• It is so called because clinically patients do not feel very sick.

ANSWER

• Mycoplasma pneumoniae

Q3.

• Which is the most common lung malignancy in women & non smokers ?

ANSWER

• Adenocarcinomas

Q4.

• The most common causative agent responsible for Viral bronchiolitis in infants ?

ANSWER

• Respiratory Syncitial Virus (RSV)

Q5.

• Which organism is responsible for “Pseudohemoptysis” ?

ANSWER

• Serratia marcescens

Q6.

• Uveoparotid Fever (Heerdfordt’s syndrome) is a manifestation of ?

ANSWER

• Sarcoidosis

Q7.What is this known as ?

ANSWER

• Wallgren’s time table of tuberculosis • Named after Arvid wallgren

Q8.

• Which is the most commonly involved organ in metastasis from a pulmonary malignancy?

ANSWER

• Adrenal Glands

Q9.

• Name the pathogen well known to cause pneumonia in immunocompromised individuals .

• The risk of infection with this pathogen increases when CD4+ T cell levels are less than 200 cells/μL.

ANSWER

• Pneumocystis jiroveci

Q10.

• Which is the parasitic infestation that is associated with raised Pulmonary arterial pressure ?

ANSWER

• Schistosomiasis

Q11.

• What is the reactive arthritis occurring in patients with active tuberculosis known as ??

ANSWER

• Poncet’s arthritis• The occurrence of polyarthritis in patients with active

tuberculosis was first reported by Antonin Poncet in 1897 .

• In contrast to the usual tuberculous arthritis which is monoarticular, infectious and destructive, tuberculous rheumatism (Poncet’s disease) is a non-destructive parainfective polyarthritis occurring in patients with active tuberculosis, which resolves completely on anti-tuberculosis therapy

Q12.

• What is the new name of “Bronchioloalveolar carcinoma” ?

ANSWER

• Adenocarcinoma in situ (AIS)

Q13.

• What is the paraneoplastic syndrome caused by Parathyroid hormone like peptide,a peptide secreted by tumour cells ?

ANSWER

• Hypercalcemia

Q14.

• “Swimming Pool granuloma” is caused by

ANSWER

• Mycobacterium marinum

Q15.

• A patient with small cell lung cancer developed muscle weakness .

• The patient was investigated & antibodies against presynaptic voltage-gated calcium channels in the neuromuscular junction was detected.

• What is the condition known as ?

ANSWER

• Lambert Eaton Syndrome

Q16.

• Endemic hemoptysis is seen in ?

ANSWER

• Paragonimas westermani infestation

Q17.

• The image is the X Ray of Wrist & Forearm of a patient with Bronchogenic Carcinoma.

• The patient had Clubbing of fingers & pain in the forearm.

• The X Ray Finding is ?

ANSWER

• Hypertrophic Pulmonary Osteoarthropathy

Q18.

• This is a characteristic histological finding in a patient with squamous cell carcinoma of lungs.

• What is this known as ?

ANSWER

• Keratin Pearls

RESPIRATORY PHARMACOLOGY

Q1.

• Which is the monoclonal antibody targeted against IgE used for treating moderate to severe allergic asthma & chronic spontaneous urticaria ?

ANSWER

• Omalizumab

Q2.

• Which is the ultra long acting beta agonist approved for use in COPD patients ?

• It is delivered as an aerosol formulation through a dry powder inhaler .

ANSWER

• Indacaterol

Q3.

• Name the antitubercular drug approved by Food & Drug Administration in 2012 – specifically approved to treat MDR TB ?

• It is in fact the first drug to be approved for Anti tubercular therapy in 40 years !!!

ANSWER

• Bedaquiline

Q4.

• Name the Phospho diesterase 4 (PDE 4) inhibitor that is used as an orally administered drug for the treatment of inflammatory conditions of the lungs such as chronic obstructive pulmonary disease (COPD) ?

ANSWER

• Roflumilast

Q5.

• Which is the first line antitubercular drug that is active in the acidic environment also ??

ANSWER

• Pyrazinamide (Z)• Pyrazinamide diffuses into M. tuberculosis, where

the enzyme pyrazinamidase converts pyrazinamide to the active form pyrazinoic acid. Under acidic conditions, the pyrazinoic acid that slowly leaks out converts to the protonated conjugate acid, which is thought to diffuse easily back into the bacilli and accumulate. The net effect is that more pyrazinoic acid accumulates inside the bacillus at acid pH than at neutral pH.

Q6.

• This drug is used as a mucolytic agent - it reduces mucus viscosity by splitting disulfide bonds linking proteins present in the mucus (mucoproteins).

• It is also used for the treatment of Paracetamol overdose,as a nephroprotective agent,in hemorrhagic cystitis ,to prevent the progression of Interstitial lung disease and in some psychiatric disorders.

• Which drug ?

ANSWER

• Acetyl Cysteine

Q7.

• This drug is a leukotriene receptor antagonist (LTRA) used for the maintenance treatment of asthma and to relieve symptoms of seasonal allergies .

• The drug was developed by MERCK,an American pharmaceutical company & the first part of the name of the drug is named after a Canadian city (the second largest Canadian city) where the drug was developed.

• The drug is ?

ANSWER

• Monteleukast • ‘Mont’ from Montreal

Q8.

• Name the Epidermal Growth Factor Receptor inhibitor (EGFR) inhibitor approved by FDA on July 2015 as a first line treatment for Non small cell carcinomas.

ANSWER

• Geftinib

RAPID FIRE

• Q1.Which is the hereditary condition predisposing to emphysema ?

• Alpha 1 Antitrypsin deficiency

• Q2.What are the components of Samter’s triad ?• Asthma,Aspirin Intolerance & Nasal Polyposis

• Q3.What is the immediate management in Tension Pneumothorax ?

• Needle Thoracostomy

• Q4.The gene responsible for Cystic Fibrosis is located on ?

• Chromosome 7• Q5.Bronchial Thermoplasty is a treatment

modality (approved by FDA in 2010) for ?• Bronchial asthma• Q6.The drug of choice for Pneumocystis jiroveci

pneumonia is ?• Cotrimoxazole

• Q7.What is the investigation of choice for diagnosing Obstructive Sleep Apnoea ?

• Polysomnography• Q8.Prone Position Ventilation is

recommended for ?• Acute Respiratory Distress Syndrome (ARDS)• Q9.CURB -65 is a scoring system for ?• Community acquired Pneumonia (CAP)

• Q10.What is the most common cause for SVC obstruction in young adults ?

• Lymphoma• Q12.Which is the occupational lung disease that

mimics sarcoidosis clinically,radiologically & histopathologically ?

• Beryllosis• Q13.Where is the National Institute for Research

for tuberculosis located ?• Chennai

• Q14.What is the pattern of inheritance of Cystic Fibrosis ?

• Autosomal Recessive• Q15.Bronchiectasis , Sinusitis & Situs Inversus –this

triadis found in?• Kartagener’s Syndrome• Q16.Which is the first anti tubercular drug to be

discovered ?• Streptomycin

• Q17.Expand GOLD.• Global Initative for Obstructive Lung Disease

• Q18.Expand LVRS• Lung Voulme Reduction Surgery

• Q19.Expand VATS• Video assisted Thoracoscopy

• Q19.The only pharmacologic therapy that have demonstrated uniequivocally to decrease mortality rates in patients with COPD.

• Supplemental Oxygen therapy /Long Term Oxygen Therapy (LTOT)

• Q21.The most common cause of Chylothorax • Trauma (Surgical)

• Q22.The triad of Ovarian fibroma,Pleural effusion & ascites is called

• Meig’s Syndrome• Q23.Name the biochemical agent used in Positron

emission tomography (PET) .• 18 - Fluoro deoxy Glucose • Q24.Which obstructive lung disease is considered

as a systemic disease ?• Chronic Obstructive Pulmonary Disease (COPD)

• Q23.List the 4 common indications for Lung transplantation.• COPD, Idiopathic Pulmonary Fibrosis, Cystic fibrosis, Alpha 1

antitrypsin deficiency emphysema & Idiopathic Pulmonary Arterial Hypertension

• Q24.List any 3 therapeutic indications for bronchoscopy.• Foreign Body removal, Control of Hemoptysis, Dilatation of

airways partailly or completely occluded by tumours (LASER Therapy, Cryotherapy, Argon plasma coagulation, Electrocautery, Balloon Bronchoplasty & Dilation ,Stent placement)

• Q25.List any 2 conditions where epitheloid granulomas are seen.

• Tuberculosis,Sarcoidosis• Q26. List any 3 drugs that can be given for

cessation of smoking.• Bupropion,Cytisine,Varnecillin• Q27.List 3 Non Small cell carcinomas• Large cell carcinoma, Squamous cell carcinoma &

Adenocarcinoma

• Q28.Which respiratory disease was previously called as “Consumption” because of the severe wasting that occurred in patients ?

• Tuberculosis • Q29.Which group of Antihypertensives worsen Asthma ?• Nonselective Beta Blockers• Q30.Which group of antihypertensives is known to

produce Dry Cough ?• ACE -inhibitors

HOPE YOU ALL ENJOYED IT !!