Medicine Practical Examination Questions: Respiratory System

Complete Question Bank - Basics to Higher Level

GENERAL RESPIRATORY SYSTEM EXAMINATION QUESTIONS

Basic Level - Anatomy & Physical Exam

1. What are the boundaries of the lungs?
2. Name the lobes of the right and left lung.
3. What is the anatomical basis of tracheal deviation?
4. Where do you auscultate breath sounds for each lobe?
5. Demonstrate how to perform percussion of the chest. What are the different percussion notes?
6. What is the normal respiratory rate in an adult? In a child?
7. What is the difference between vesicular, bronchial, and bronchovesicular breath sounds? Where is each normally heard?
8. What is a friction rub? When do you hear it?
9. What is the difference between rhonchi and crackles (crepitations)? What conditions produce each?
10. What is tactile vocal fremitus? How do you elicit it and what does it mean?
11. What is vocal resonance? How is it different from tactile vocal fremitus?
12. What are the causes of decreased breath sounds?

Basic Level - Investigations

1. Name the components of a complete blood count relevant to respiratory disease.
2. What is sputum examination used for?
3. How is a chest X-ray read systematically?
4. What is the normal PaO2 on arterial blood gas?
5. What is the significance of an A-a gradient?
6. What is spirometry? What does it measure?
7. What is the difference between obstructive and restrictive lung disease on PFTs?
8. What is FEV1? What is FVC? What is FEV1/FVC ratio?

PNEUMONIA

Basic Level

1. Define pneumonia.
2. What is the most common causative organism of community-acquired pneumonia (CAP)?
3. What are the classic symptoms of pneumonia?
4. What signs do you expect on examination in a patient with consolidation (pneumonia)?
5. What are the classical chest X-ray findings in lobar pneumonia?
6. Differentiate lobar pneumonia from bronchopneumonia clinically and radiologically.
7. What is the difference between community-acquired, hospital-acquired, and ventilator-acquired pneumonia?
8. What are atypical pneumonias? Name three organisms.
9. What investigations do you do in a patient you suspect has pneumonia?
10. What is the first-line antibiotic for CAP in an outpatient?

Easy to Moderate Level

1. What is CURB-65? Expand it and explain each component.
2. A patient has CURB-65 score of 3 - what do you do?
3. What is the Pneumonia Severity Index (PSI)? How does it differ from CURB-65?
4. What is "walking pneumonia"? Which organism causes it?
5. What is the radiological appearance of atypical (Mycoplasma) pneumonia?
6. What is Legionnaire's disease? What organism? What is the route of transmission?
7. What is the role of blood cultures in pneumonia?
8. What is the significance of sputum Gram stain in pneumonia?
9. How does pneumonia cause hypoxemia? (Mechanism - V/Q mismatch, shunt)
10. In pneumonia, why does giving supplemental oxygen sometimes not fully correct hypoxemia?
11. What are the complications of pneumonia?
12. What is parapneumonic effusion? How do you differentiate it from empyema?
13. What is the role of urinary antigen testing in pneumonia?
14. What are the indications for ICU admission in pneumonia?

Moderate Level

1. A 65-year-old diabetic patient presents with productive cough, fever, and right-sided pleuritic chest pain for 3 days. Examination shows dullness, increased TVF, bronchial breathing, and aegophony over the right lower zone. Describe your management.
2. What is lung abscess? How does it differ from empyema? What organism is characteristically responsible?
3. What is Friedlander's pneumonia? Who gets it and what does the X-ray show?
4. What is the significance of "rusty sputum" in pneumonia?
5. Discuss the role of steroids in severe pneumonia.
6. What are the criteria for severe CAP (ATS/IDSA minor and major criteria)?
7. How do you distinguish bacterial from viral pneumonia?
8. What is ventilator-associated pneumonia (VAP)? What organisms cause it? How is it prevented?

Hard/Higher Level

1. Discuss the pathophysiology of hypoxemia in pneumonia. Why is V/Q mismatch the major mechanism in mild pneumonia while shunt dominates in severe pneumonia? (Refer to MIGET data - Murray & Nadel's: in mild pneumonia shunt averages 7.5% + low V/Q 4.2%; in severe pneumonia requiring mechanical ventilation, shunt rises to 21.9% and low V/Q to 10.9%)
2. What is immunocompromised pneumonia? What organisms are likely in an HIV patient with CD4 < 200?
3. Compare and contrast Pneumocystis jirovecii pneumonia (PCP) with bacterial CAP clinically, radiologically, and in terms of management.
4. Discuss antimicrobial de-escalation in hospital-acquired pneumonia.
5. What is the role of biomarkers (CRP, procalcitonin) in guiding antibiotic therapy in pneumonia?

COPD (Chronic Obstructive Pulmonary Disease)

Basic Level

1. Define COPD.
2. Define chronic bronchitis. (Clinical definition: productive cough for at least 3 consecutive months in at least 2 consecutive years)
3. Define emphysema.
4. What is the single most important risk factor for COPD?
5. What are the two classical phenotypes of COPD? Describe each. ("Blue bloater" vs "Pink puffer")
6. What symptoms does a COPD patient typically complain of?
7. What signs do you look for on examination in a COPD patient?
8. What is a barrel chest? Why does it occur in COPD?
9. What is pursed lip breathing? Why do COPD patients do this?
10. What is the use of accessory muscles of respiration? Name them.

Easy to Moderate Level

1. What spirometric finding is diagnostic of COPD? (Post-bronchodilator FEV1/FVC < 0.70)
2. Explain the GOLD classification/staging of COPD. What does each stage mean?
3. What is the difference between COPD and asthma on spirometry?
4. What is the mechanism of airflow obstruction in emphysema versus chronic bronchitis?
5. What is dynamic hyperinflation? How does it contribute to dyspnea in COPD?
6. What is cor pulmonale? How does COPD cause it?
7. What is the role of alpha-1 antitrypsin deficiency in COPD? What type of emphysema does it cause?
8. Differentiate centriacinar (centrilobular) from panacinar emphysema. Which is associated with smoking? Which with alpha-1 antitrypsin deficiency?
9. What are the indications for long-term oxygen therapy (LTOT) in COPD?
10. What is the Reid index? What is its significance?
11. What is hyperinflation on a chest X-ray? Name the radiological signs.
12. Name three bronchodilators used in COPD. What are their mechanisms of action?
13. What is the role of inhaled corticosteroids in COPD?

Moderate Level

1. A 60-year-old smoker presents with progressively worsening dyspnea, chronic cough with white sputum, and two hospitalizations last year for chest infections. Spirometry shows FEV1 = 45% predicted, FEV1/FVC = 0.58. How do you classify and manage this patient?
2. What is an acute exacerbation of COPD (AECOPD)? What are the common triggers?
3. How do you manage an acute exacerbation of COPD in the emergency department?
4. What is the risk of high-flow oxygen in COPD? What is the mechanism? (Hypercapnic drive, Haldane effect on CO2 carrying capacity, V/Q mismatch worsening)
5. What is the role of non-invasive ventilation (NIV/BiPAP) in COPD exacerbation?
6. Discuss the ABCD assessment tool in COPD.
7. What is the role of pulmonary rehabilitation in COPD?
8. What is the significance of the six-minute walk test in COPD?
9. How does COPD cause polycythemia?

Hard/Higher Level

1. Discuss in detail the pathophysiological mechanisms causing exercise limitation in COPD. Include concepts of dynamic hyperinflation, neuromechanical uncoupling, and ventilatory reserve. (Fishman's: erosion of VE/MVV toward or exceeding 100%; increased VD/VT; impaired inspiratory reserve volume)
2. What is the protease-antiprotease hypothesis in emphysema? Name the specific proteases and their sources.
3. Compare the hemodynamic effects of COPD on the right heart versus left heart.
4. What is the BODE index? What does it measure and predict?
5. Discuss the role of biologics and newer pharmacological agents in COPD management.
6. What are the surgical options for end-stage COPD? (Lung volume reduction surgery, bullectomy, lung transplant)
7. What is the relationship between small airway disease and COPD? What is the role of oscillometry?

TUBERCULOSIS (TB)

Basic Level

1. What organism causes TB? What type of organism is it?
2. What is the mode of transmission of TB?
3. What are the primary and post-primary (reactivation) forms of TB? How do they differ?
4. What are the classic symptoms of pulmonary TB?
5. What are the classical X-ray findings in post-primary pulmonary TB?
6. What is the Ghon focus? What is the Ghon complex?
7. What is a Ranke complex?
8. What is a Mantoux (tuberculin skin) test? How is it read?
9. What is the sputum examination for TB? How many samples are taken?
10. What is the BCG vaccine? What does it protect against?

Easy to Moderate Level

1. What is primary TB? Where does it typically occur in the lung?
2. What is miliary TB? What is the X-ray appearance?
3. What is EPTB (extra-pulmonary TB)? Name five sites.
4. What is the standard first-line anti-TB regimen (DOTS)? Name the drugs and the duration.
5. What is HRZE stand for?
6. Explain the mechanism of action of each first-line anti-TB drug (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol).
7. What are the major side effects of each anti-TB drug?
8. What is directly observed therapy (DOTS)? Why is it important?
9. What is multi-drug resistant TB (MDR-TB)? Extensively drug-resistant TB (XDR-TB)?
10. What are the criteria for MDR-TB (resistant to isoniazid AND rifampicin)?
11. What is a positive Mantoux test in different groups? (≥5mm, ≥10mm, ≥15mm - know the cut-offs)
12. What is IGRA (Interferon Gamma Release Assay)? How is it different from Mantoux?
13. What is the Xpert MTB/RIF assay? What does it detect?
14. What is TB/HIV co-infection management?
15. When do you start ART in a TB/HIV co-infected patient?

Moderate Level

1. A 30-year-old patient presents with chronic cough for 3 months, evening fever, drenching night sweats, weight loss, and hemoptysis. Chest X-ray shows left upper lobe infiltrates with a cavity. Describe your approach.
2. What is the significance of cavitation in TB? What does it indicate pathologically?
3. What are the indications for prophylactic isoniazid (IPT - isoniazid preventive therapy)?
4. What is paradoxical worsening in TB treatment? What causes it?
5. What is an immune reconstitution inflammatory syndrome (IRIS) in TB?
6. How does TB cause pleural effusion? What are the characteristics of TB pleural fluid?
7. What is pericardial TB? How is it managed?
8. What is spinal TB (Pott's disease)? What is a psoas abscess?
9. Discuss the pathological spectrum from primary infection to latent TB to active disease.
10. What is the role of ADA (adenosine deaminase) in TB diagnosis?

Hard/Higher Level

1. Discuss endobronchial TB. What is the most common symptom? What does CT show? What are the complications? (Murray & Nadel's: tracheo-bronchial stenosis in up to 90%; intractable cough; circumferential tracheal thickening on CT)
2. What is the immunological basis of TB pathology? Discuss Th1 versus Th2 responses and the role of TNF-alpha.
3. What are the newer second-line drugs in MDR-TB? Discuss bedaquiline and delamanid.
4. Discuss the interaction of gut and lung microbiome in TB susceptibility. (Murray & Nadel's: high abundance of Prevotella associated with diminished protective cytokines IL-17 and IFN-gamma)
5. What is the pathophysiology of hemoptysis in TB? Name the Rasmussen aneurysm.
6. What is the role of surgery in TB? What are the indications?
7. Discuss the pharmacokinetics of rifampicin - why does it affect so many drugs?

PLEURAL EFFUSION

Basic Level

1. Define pleural effusion.
2. What are the two types of pleural effusion? How are they classified?
3. What are the symptoms of pleural effusion?
4. What are the physical signs of pleural effusion on examination? (Stony dull percussion, decreased/absent breath sounds, decreased TVF, tracheal deviation away in large effusion)
5. What is the minimum amount of fluid detectable on PA chest X-ray?
6. What is a costophrenic angle blunting? How much fluid is needed to blunt the CP angle?
7. What is a lateral decubitus X-ray used for in pleural effusion?
8. Name five causes of transudative pleural effusion.
9. Name five causes of exudative pleural effusion.

Easy to Moderate Level

1. What is Light's criteria? State all three criteria. (Fluid/serum protein >0.5; fluid/serum LDH >0.6; fluid LDH > 2/3 upper limit of normal serum LDH)
2. What is the sensitivity and specificity of Light's criteria?
3. What is the albumin gradient? When is it used? (Serum albumin - pleural fluid albumin; if >1.2 g/dL, it is a transudate even if misclassified by Light's)
4. Why do diuretics cause transudates to appear as exudates on Light's criteria?
5. What is the significance of pleural fluid glucose < 60 mg/dL?
6. What does a pleural fluid pH < 7.2 indicate?
7. What is pleural fluid ADA elevated in?
8. What is a chylothorax? What causes it? What does the fluid look like?
9. What is a hemothorax? What are the causes?
10. What is empyema? How is it managed?
11. What is the significance of pleural fluid cytology?
12. What is a therapeutic thoracentesis? What is the maximum volume that can be removed at one time?
13. What is re-expansion pulmonary edema?
14. What is the role of ultrasound in pleural effusion?

Moderate Level

1. A patient with known heart failure has bilateral pleural effusions. What type are they? How do you confirm? What is the management?
2. A patient presents with a unilateral right-sided pleural effusion with fever and pleuritic chest pain. Pleural fluid shows pH 7.15, glucose 40 mg/dL, LDH 900 IU/L, protein 4.5 g/dL. How do you classify and manage?
3. What is hepatic hydrothorax? What is the mechanism? (Murray & Nadel's: small diaphragmatic defects allowing ascitic fluid into pleural space; 85% right-sided; may occur without visible ascites)
4. How is hepatic hydrothorax managed? (Salt restriction, diuretics; TIPS for refractory cases; VATS pleurodesis; indwelling pleural catheter as bridge to transplant)
5. What is the LIGHT criteria modification used in heart failure patients on diuretics?
6. What are the causes of a lymphocyte-predominant exudate?
7. What is the significance of eosinophils in pleural fluid?
8. Discuss the management of malignant pleural effusion. What is pleurodesis?
9. What is an indwelling pleural catheter (IPC)? What are its indications?
10. What cells are predominantly seen in pleural fluid in TB versus malignancy versus parapneumonic effusion?
11. What is the role of VATS in undiagnosed exudative pleural effusion?

Hard/Higher Level

1. Discuss the hemodynamic effects of large pleural effusion on cardiac function, particularly right ventricular filling. (Murray & Nadel's: large right-sided effusions can cause hemodynamic compromise via echocardiographic evidence of RV filling impairment)
2. Discuss the gas exchange abnormalities in pleural effusion. Why does thoracentesis inconsistently improve PaO2? (Murray & Nadel's: shunt averages 6.9% in effusion; 30 minutes after 700 mL removal, arterial PO2 and shunt do not change significantly; low V/Q regions may actually increase)
3. What is the mechanism of hypoxemia in pleural effusion versus pneumonia versus COPD? Compare and contrast.
4. Discuss the evaluation and management of chylothorax following cardiac surgery or thoracic malignancy.
5. What is Yellow Nail Syndrome? What are the three components?
6. Compare closed needle biopsy (Abrams needle) versus VATS versus medical thoracoscopy for undiagnosed exudative effusion. What is the diagnostic yield?

CROSS-CUTTING / INTEGRATION QUESTIONS (Higher Level)

1. A patient has a pleural effusion. How does the effusion fluid analysis help you distinguish between TB pleurisy, malignant effusion, and parapneumonic effusion?
2. Compare the chest X-ray appearances of pneumonia, TB (upper lobe cavity), COPD (hyperinflation), and pleural effusion.
3. How does COPD predispose to pneumonia and TB?
4. Discuss the concept of V/Q mismatch versus shunt versus diffusion limitation as mechanisms of hypoxemia. Which predominates in each of the four diseases?
5. A patient on TB treatment develops worsening symptoms. What differential diagnosis do you consider? (IRIS, MDR-TB, drug side effect, second disease)
6. Discuss the management of a patient with COPD admitted with acute exacerbation who is found to have a parapneumonic effusion.
7. Compare the PFT pattern in: (a) Pneumonia (b) COPD (c) Pleural effusion (d) TB with fibrosis
8. What are the indications for mechanical ventilation in respiratory failure from each of these four diseases?
9. How do you monitor treatment response in each disease? What investigations do you repeat and when?
10. A 50-year-old male smoker presents with weight loss, hemoptysis, and a right upper lobe mass. How do you differentiate between TB reactivation and lung cancer?

EXAMINATION TECHNIQUE / OSCE-TYPE QUESTIONS

1. Demonstrate how you would perform a complete respiratory system examination.
2. How do you elicit and interpret the following signs:
   • Tracheal deviation
   • Chest expansion asymmetry
   • Tactile vocal fremitus
   • Aegophony / whispering pectoriloquy
   • Stoney dull vs. dull percussion
3. How do you present a chest X-ray to the examiner?
4. How do you perform and interpret spirometry?
5. How do you perform a thoracentesis? What are the complications?
6. Demonstrate reading an ABG report. Classify a given ABG.

KEY NUMBERS TO REMEMBER FOR PRACTICALS