1. RESPIRATORY
22. Which of the following, the arterial P O2 increase significantly when inspired P O2 is raised?
a. Idiopathic pulmonary fibrosis
b. Chronic obstructive pulmonary disease
c. Pneumonia
d. α1 -Antitrypsin deficiency 1
e. Osler-Rendu-Weber syndrome
23. The primary pathophysiologic problem in idiopathic pulmonary fibrosis is believed to be
a. microorganism-mediated activation of pulmonary neutrophils
b. immune complex– mediated activation of alveolarmacrophages
c. direct immune complex– mediated pulmonary interstitial damage
d. primary fibroblast proliferation
e. viral-mediated pulmonary epithelial damage
24. The important factor in the pathogenesis of asthma are
a. bronchial muscle contraction
b. mast cell and basophil degranulation
c. mucosal swelling
d. increased mucus production
e. destruction of the alveolar wall
25. A diagnosis of allergic bronchopulmonary aspergillosisin a person who has asthma and recurrent
pulmonary infiltrates would be supported by which of the following findings?
a. Delayed, tuberculin-type skin-test reaction to Aspergillus fumigatus
b. The presence of eosinophilia
c. Immediate skin test reaction to A. fumigatus
d. Positive aspergillus-specific IgE
e. The presence of alveolar neutrophilia on bronchoalveolar lavage (BAL)
26. Which of the following statements concerning obstructive sleep apnea syndrome is true?
a. Men and women are not equally affected.
b. Cor pulmonale and hypertension is resolve after obstruction is bypassed.
c. Sedatives are often useful in the improvement of quality of sleep.
d. Estrogens are frequently useful in improving respiratory drive.
e. Personality changes may be the presenting complaint.
27. Which of the following is associated with cystic fibrosis?
a. Portal hypertension
b. Systemic hypertension
c. Steatorrhea
d. Dextrocardia
e. Alveolar destruction
28. To decrease the likelihood of drug toxicity, the theophylline dose should be reduced in a patient with
asthma in which of the following circumstances?
a. Active tobacco user

2. b. Azithromycin use for Mycoplasma pneumonia
c. Augmented use for recurrent otitis media
d. Marijuana abuse
e. Phenobarbital use for a seizure disorder
29. Which of the following is a known consequence of asbestos exposure?
a. The same increased risk of mesothelioma as cigarette use
b. Pleural effusions, often initially benign
c. An increased incidence of both adenocarcinoma of the lung and small cell carcinoma of the lung
d. Pleural mesothelioma but not peritoneal mesothelioma
e. An restrictive pattern, typically revealed by pulmonary function testing
30. Regarding drugs treatment of brochial asthma
a. inhaled formoterol, a long-acting β2-agonist are not to be used to treat acute attacks
b. Oral candidiasis and dysphonia are the common side effect of prednisolone
c. Sodium cromoglycate has no side effect
d. Montelukast is a long-acting methylxanthines and could use as add-on therapy to inhaled
corticosteroid
e. Theophyline can cause seizures and arrhytmias
31. Assessment of acute asthma in adult
a. pulse rate <100/min, respiratory rate <25 breath/min,PEF between 50 to 75% predicted is mild
asthma attack
b. (B)SpO2 91-95%, talks in phrases, loud wheeze, are the feature of MODERATELY severe asthma
attack
c. pulse rate >120/min, talk in words, loud wheeze, are the feature of very severe astma attack
d. confusion, bradycardia or hypertension, silent chest are the feature of life-threatening asthma
attack
e. Normal or high PaCO2, high pH with severe hypoxaemia are the ABG markers of severe life-
threatening attack.
32. Diagnosis of pulmonary tuberculosis
a. TB in patient with at least 1 initial direct smear positive with or without positive finding in chest
X-ray or culture
b. Culturing using radiometric methods is routinely done in Malaysia
c. Culture using egg-based media takes up within 2 weeks for final result
d. Chest X-ray revealed lesions at the upper lobe which are fibrosis and calcification, suggest active
disease
e. Positive Mantoux test indicates TB infection
33. The following are true regarding tuberculosis?
a. Pulmonary TB smear-negative, when at least 3 direct smear negative with radiographic
abnormalities only
b. Pulmonary TB smear-positive, when at least 2 direct smear positive
c. Person with DM and renal failure should be screen for active TB
d. Total diameter of cavitations, is more than 4 cm, is considered as moderately advance as in
Radiological classification

3. e. All suspected TB cases must be notified to the nearest District Health Office within 1 week of
admission
34. The following are true regarding management of TB?
a. All patients with pulmonary TB should repeat sputum smears after 2nd month, 4th month and 6th
month of the treatment
b. Treatment failure, relapse and chronic case are under Category II of treatment categories.
c. A patient who is not taking anti-TB treatment for 1 month or more considered as treatment
after interruption
d. Both of Rifampicin and Isoniazid reduced the metabolism of other drugs by act on the liver
enzyme
e. Streptomycin could not be taken with aminoglycoside, and amphotericin B, as it may potentiate
the neuromuscular blocking agents
35. The following are true regarding COAD?
a. Significant airway obstruction occurs only 10% to 15% of people who smoke.
b. The best tools in assessing severity of obstruction is FEV1/FVC compare to FEV1.
c. Chronic bronchitis is a clinical diagnosis defined as the presence of cough and sputum
production on most days for at least 3 consecutive months in a year.
d. RV may be 2 or 4 times higher than normal.
e. Probably the single most important intervention is to help patient quit smoking.
36. Which of the following disease does have an occupational exposure etiology?
a. Chronic bronchitis
b. Bronchiolitis obliterans
c. Bronchiectasis
d. Silo-filler’s disease
37. A 40 year old man with a BMI of 40 c/o excessive daytime sleepiness & headaches. The following
statements are true:
a. Inhaled steroids will improve his symptoms
b. Arterial O2 saturation will fall in cyclical manner
c. The diagnosis is confirmed if thee are more than 15 apnoeas or hypoapnoeas in 1 hour of sleep
d. Antibiotic will reduce rate of progression in mild cases
e. CPAP delivered at nite improves symptoms

4. ANSWER
Which of the following, the arterial P O2 increase significantly when inspired P O2 is raised?
a) Idiopathic pulmonary fibrosis
b) Chronic obstructive pulmonary disease
c) Pneumonia
d) α1 -Antitrypsin deficiency 1
e) Osler-Rendu-Weber syndrome
Oke, soklan ni i realy2 don’t know how to answer. But from what i understand is that for oxygen to
be effectively distributed to the systemic circulation depend on these 3 factors ; haemoglobin
concentration, cardiac output and oxygenation. Try bace artikel ni kinda interesting
(http://www.nda.ox.ac.uk/wfsa/html/u10/u1003_01.htm). So, if these 3 factors are impaired 
there will be impaired oxygen delivery (logic kn?). Berbalik kepade soklan, dye tny condition mane
bile inspired pO2 raised arterial pO2 pon raised and this relate to the 3 factors  condition which
lower the Hb concentration, lower cardiac output and impaired oxygenation(v/q mismatch, shunt,
slow diffusion)  lower pO2 artery despite increase pO2 alveoli.
a) F - Idiopathic pulmonary fibrosis (IPF) is an idiopathic interstitial pneumonia
(http://emedicine.medscape.com/article/301226-overview)  as the name suggest dye punye
pathophysiology same la mcm pneumonia cume yg ni da fibrosis. And in the artikel mention that
alveolar fibrosis cause slow diffusion which cause impaired oxygenation and impaired O2 circulation
in the systemic vessel.
b) F – Cause v/q mismatched because 1) The gradual destruction of alveolar septae (shown in the
image below) and of the pulmonary capillary bed in emphysema leads to a decreased ability to
oxygenate blood. The body compensates with lowered cardiac output and hyperventilation. This V/
Q mismatch results in relatively limited blood flow through a fairly well oxygenated lung with normal
blood gases and pressures in the lung. 2) Chronic bronchitis is associated with a relatively
undamaged pulmonary capillary bed. The body responds by decreasing ventilation and increasing
cardiac output. This V/Q mismatch results in rapid circulation in a poorly ventilated lung, leading to
hypoxemia and polycythemia (http://emedicine.medscape.com/article/297664-overview#a0104).
c) F – Consolidation occur in pneumonia. Consolidation cause blood to shunt. Shunt occurs when
deoxygenated venous blood from the body passes unventilated alveoli to enter the pulmonary veins
and the systemic arterial system with an unchanged PO2 (40 mmHg)
(http://www.nda.ox.ac.uk/wfsa/html/u10/u1003_01.htm). This means increase in inspired pO2 x
increase arterial pO2 sbb gas exchange tade pon due to the fact dye pass the alveoli n teros masuk
systemic circulation.
d) F - Severe alpha 1 antitrypsin deficiency is a proven genetic risk factor for COPD (Harrison’s
Principle of Internal Medicine 16th Edition pg 1548)  v/q mismatched.
e) F – This is an autosomal dominant disorder typically identified by the triad of telangiectasia,
recurrent epistaxis, and a positive family history for the disorder
(http://emedicine.medscape.com/article/957067-overview). So, presentation of this disease is
hemorrhage. Hemorrhage=blood loss=low Hb. Despite the increase in inspired pO2 the arterial pO2
will not increase because the Hb concentration is lowered and as we all know Hb carries the O2 to
the whole body. Each gram of haemoglobin can carry 1.31 ml of oxygen when it is fully saturated
(http://www.nda.ox.ac.uk/wfsa/html/u10/u1003_01.htm)  maknenye di sini setiap Hb bule carry

5. byk tu je O2..klu Hb xckup so O2 yg tertinggal x dpt di uptake oleh Hb lens bb Hb len pond a cukup
kuota.
23. The primary pathophysiologic problem in idiopathic pulmonary fibrosis is believed to be
(A) microorganism-mediated activation of pulmonary neutrophils
(B) immune complex– mediated activation of alveolarmacrophages
(C) direct immune complex– mediated pulmonary interstitial damage
(D) primary fibroblast proliferation
(E) viral-mediated pulmonary epithelial damage
http://emedicine.medscape.com/article/301226-overview#a0104
Theory of pathophysiology of idiopathic pulmonary fibrosis include :
1. General inflammation lead to widespread parenchymal fibrosis. However, usage of anti
inflammatory and immune modulator shows minimal effectiveness. So teori ni da x pakai
skarang.
2. Currently is believed due to epithelial fibroblastic disease --- which unknown endogenous or
environmental stimuli disrupt the homeostasis of alveolar epithelial cells, resulting in diffuse
epithelial cell activation and aberrant epithelial cell repair.
a. Stimulus ( smoke, environmental pollutants, environmental dust, viral infections,
gastroesophageal reflux disease, chronic aspiration) --- alveolar epithelial damage ---
activation of alveolar epithelial cells --- migration, proliferation and activation of
mesenchymal cells with the formation of fibroblastic/myofibroblastic foci ---
accumulation of extracellular matrix + destruction of lung parenchyma.
b. Activated alveolar epithelium will secrete cytokines and growth factor --- this cytokine
and growth factor involve in migration and proliferation of fibroblast and conversion of
fibroblast to myofibroblast --- fibroblast and myofibroblast is responsible in fibrosis.
c. Growth factor also apoptosis of fibroblast ---so fibroblast bertambah banyak and fibrosis
pon bertambah byk.
3. Mutant telomerase --- shortening of telomerase can promote alveolar epithelial damage and
activate the epithelial repair --- fibrosis
4. Reduce caveolin-1 production --- caveolin-1 involve in regulation of extracellular matrix
secretion by growth factor and restore alveolar epithelial repair. Also level of cavelin-1 in patient
with idiopathic lung fibrosis is less than normal people
So answer :
A. False
B. False
C. True
D. True
E. True

6. 24. The important factor in the pathogenesis of asthma are
(A) bronchial muscle contraction
F – Cause its not complete. Wut happens is that there’s bronchospasm where there is contraction and
relaxation
(B) mast cell and basophil degranulation
F- once exposed to allergerns, T H2 cells induction cause release of interleukins IL-4 and IL-5 which leads
to synthesis of IgE which binds to mucosal mast cells and cause degranulatation
In late phase , mast cells also release additional cytokines which cause influx of other leukocytes namely
eosinophil. It plays a great deal of importance when it accumulate at the site of infection and cause
toxicity to airway epithelium and bronchocostrition. In other words, eosinophil amplify and sustain
inflammatory response
(C) mucosal swelling
T- cause its part of 5 inflammation features red, pain, edema, heat, loss of function
(D) increased mucus production
T-page 490 robbins upper right hand corner
(E) destruction of the alveolar wall
F- its a disease which focus on the bronchus. No effects wutsoever 2wards the alveolar
25. A diagnosis of allergic bronchopulmonary aspergillosis (ABPA) in a person who has asthma and
recurrent pulmonary infiltrates would be supported by which of the following findings
A: F – supportive criterion for diagnosis of ABPA is IMMEDIATE skin test reaction.
B: F – I’d say this one is false. The presence of eosinophilia (>500/mm3) is a minor criteria supportive of
ABPA. Pulmonary infiltrates too can cause eosinophilia. Hence for this case i.e. the patient has asthma
and recurrent pulmonary infiltrates, eosinophilia’s role in supporting the diagnosis of ABPA is considered
irrelevant.
C: T – it is a good test, but not specific to ABPA. It may be positive in 1-2% of general population and
14-38% of asthmatics without ABPA. And 10% of those with ABPA may have false negative. A positive
test should be confirmed by total serum IgE and aspergillus-specific IgE
D: T – not only aspergillus-specific IgE, but also IgG. These are helpful to confirm or exclude the diagnosis
of ABPA. It is present in almost all ABPA patient.
E: F – klu buat BAL for diagnosis of aspergillosis, have to use PCR and not look for alveolar
neutrophilia.but PCR is expensive and not included in the major and minor criteria for the diagnosis of
ABPA
Allergic Bronchopulmonary Aspergillosis (2008), Michael K. Cheezum, MD; Christopher J. Lettieri, MD,
Medscape Allergy & Immunology © 2008 Medscape http://www.medscape.com/viewarticle/571219
ADDITIONAL INFO for ABPA
Table 2. Diagnostic Criteria for Allergic Bronchopulmonary Aspergillosis
Major Criteria
• History of asthma (regardless of severity)

7. • Central (proximal) bronchiectasis on chest radiographs
• Immediate skin reactivity to Aspergillus
• Elevated total serum IgE (>1000 ng/mL)
• Elevated IgE or IgG to Aspergillus
Minor Criteria
• Serum eosinophilia (> 500/mm3)
• Precipitating antibodies to A fumigates
• Pulmonary opacities/infiltrates
• Mucous plugging
• Broncholiths
• Bronchial culture positive for Aspergillus
26. Which of the following statements concerning obstructive sleep apnea syndrome is true?
a) True. Sleep apnoea syndrome or obstructive sleep apnoea are not equally affected in males and
female. Based on the international study, http://emedicine.medscape.com/article/295807-
overview#a0156 , it shows that male have 2x or 3x higher prevalence of having sleep apnoea
syndrome. It is because, the obesity occurrence in men is central obesity where fat is deposited
at the trunk which includes the neck area.
b) False. Hypertension is resolved after the correction of sleep apnoea. However, cor pulmonale
also known as, right sided heart failure due to lung disease, wont resolve. The architecture and
structure of the heart of the right side already changed due to prolong pulmonary
vasoconstriction. Bahasa mudahnye, hanya nak mengelakkan jantung belah kanan jadi maken
parah. Sebab tu kite treat sleep apnoea. Bukan untuk menghilangkan cor pulmonale. Itu adalah
mustahil. From mechanism point of view, Michael G. Levitzky, Ph.D., Department of Physiology,
Louisiana State University Health Sciences Center. Hypoxic and hypercapnic condition lead to
pulmonary vasoconriction and pulmonary hypertension. It is also cause erythropoietin
production and cause polycytemia. Then increase haematocrit and blood viscosity. These lead to
increase right ventricular afterload and eventually lead to cor pulmonale.
c) False. Sedatives are not commonly used in improving the quality of sleep. This is because,
sedative may cause the muscles in the throat to relex more than usual and worsen the sleep
apnoea. It also may relex the respiratory muscles and reduce the effort of breathing and worsen
the sleep apnoea. It is used but under precaution . from
nsmc.partners.org/web/service/sleep_lab_sleep_apnea .
d) False. Based on a few literature that i have gone through, there were no single article saying
estrogens usage as one of the non surgical management. Therefore, it is not frequently used in
treating sleep apnoea syndrome.
On the other hand, from the link below,as we all known, the prevalence of premenapausal
women having sleep apnoea is less than men. However, the risk is between men and women are
similar in post menopausal women. It is believed the hormones are the protective mechanism.
From the management point of view, HRT is frequently used in treating the sleep apnoea
syndrome. From European Respiratory Journal,
http://erj.ersjournals.com/content/22/1/161.full.pdf
e) True. Personality change may present as clinical features in sleep apnoea syndrome. It is
because, day time sleepiness will eventually affect the social life which then may cause lack of
socializing with people and depression.

8. From Harrison 17th edition chapter 259 sleep apnoea syndrome.
27. Which of the following is associated with cystic fibrosis?
(A) T - Thickened secretions also may cause liver problems. Bile secreted by the liver to aid in digestion
may block the bile ducts, leading to liver damage. Over time, this can lead to scarring and nodularity
(cirrhosis) , thus causing portal hypertension(http://www.medicinenet.com/cystic_fibrosis)
(B) T - http://www.mountnittany.org/wellness-library/healthsheets/documents?ID=5739
Pt who have pulmonary hpt may also have systemic hpt
(C) T - bcoz CF cause pancrease to secrete thicker and sticky mucus, thus blocking the tubes, or ducts, in
pancreas and prevents enzymes from reaching the intestines. One of the pancreatic enzymes is lipase.
without lipase, fat cannot be absorbed, then leads to steatorrhea
(http://www.medicinenet.com/cystic_fibrosis)
(D) F – no evidence
(E) F-it doesn’t cause alveolar destruction, but it cause fibrosis
(http://www.medicinenet.com/cystic_fibrosis)
28. To decrease the likelihood of drug toxicity, the theophylline dose should be reduced in a patient with
asthma in which of the following circumstances?
(A) Active tobacco user (F)
Smokers: Tobacco and marijuana smoking appears to increase the clearance of Theophylline by
induction of metabolic pathways.
(B) Azithromycin use for Mycoplasma pneumonia (F)
NO INTERACTION WITH THEO
(C) Augmented use for recurrent otitis media (yg ni x sure, sorry)
(D) Marijuana abuse (F)
(E) Phenobarbital use for a seizure disorder (F)
Phenobarbital increase clearance of theo. No need dose reduction.
Source:
http://www.drugs.com/pro/theophylline.html
29. Which of the following is a known consequence of asbestos exposure?
A) TRUE
B) FALSE
C) FALSE
D) TRUE
E) TRUE
(http://www.occup-med.com/)

9. Asbestos-Related Diseaseshttp://www.icdri.org/Medical/Mesothelioma_Consequences_exposure.htm
Asbestosis occurs when lung damage becomes so severe that non-functional scar tissue present in the
lungs prevents normal breathing. However, because lungs have a ‘reserve’ capacity, the disease is
already considerably advanced before an individual begins showing symptoms. Asbestosis is most
common in people who experience regular exposure to high concentrations of airborne asbestos fibers,
such as people who have worked in the manufacturing of asbestos products, particularly textiles. This
disease is only caused by exposure to asbestos. In America, four in every 10,000 people currently suffer
from asbestosis.
Lung Cancer is almost always fatal, regardless of the carcinogen involved. People who are exposed to
asbestos have an increased risk of developing lung cancer. The risk is compounded by smoking.
(bronchial carcinoma, adenocarcinoma)
Mesothelioma is a rare but invariably fatal form of cancer that most commonly develops in the lining of
the lungs, and occasionally develops in the lining of the abdominal cavity or heart. Mesothelioma
cancers are caused only by exposure to asbestos.
Pleural Abnormalities caused by exposure to asbestos include thickening, and plaques. Pleural
thickening occurs when asbestos-related scarring causes the walls of the lungs to thicken, and can cause
shortness of breath. Pleural plaques are dense bands of scar tissue that form in the lungs. People who
develop pleural plaques are believed to have an increased risk of developing lung cancer.
Other Cancers such as gastrointestinal cancer, colorectal cancer and cancers of the larynx, throat, and
kidneys may also have an increased risk of developing in people who are exposed to asbestos.
30. Regarding drugs treatment of bronchial asthma
a) T – Long-acting inhaled agonist-salmeterol & formoterol (Should not be used for symptoms relief or
for exarcebation. Used with inhaled glucocorticoids). They provide sustained effects for 9 to 12 h.
They are particularly helpful for conditions such as nocturnal and exercice-induced asthma.
(Harrison’s Principle of Internal Medicine 16th Edition pg 1513). This medication is not to be used
for the quick relief of an acute asthma attack, nor is it a substitute for inhaled or oral corticosteroids
(e.g., beclomethasone, fluticasone, prednisone). In fact, it is generally used in combination with
another controller-type asthma medication (such as inhaled corticosteroids)
(http://www.medicinenet.com/formoterol_inhalation_powder-oral/article.htm). Do not initiate or
increase the dose during an exacerbation (http://www.mims.com/Malaysia/drug/info/formoterol/?
q=formoterol&type=brief&mtype=generic). Formoterol is used to prevent asthma attacks, and
should not be used for the relief of acute asthma symptoms
(http://www.mymedications.net/formoterol.php) – ini semua kerana mereka punye onset of action
is slow ~30minutes..sbb tu x gune mase acute attack..
b) T – The side effects increase in proportion to the dose-time product. In addition to thrush and
dysphonia, the increased systemic absorption that accompanies larger doses of inhaled steroids has
been reported to produce adrenal suppression, cataract formation, decreased growth in children,
interference with bone metabolism, and purpura (Harrison’s Principle of Internal Medicine 16th
Edition pg 1514). Other side effect of steroid use including candidiasis in (Oxford Handbook of
Clinical Medicine pg 371).
c) F – May precipitate asthma (Oxford Handbook of Clinical Medicine pg 174). Bronchospasm
http://www.mims.com/Malaysia/drug/info/sodium%20cromoglicate/sodium%20cromoglicate?
type=full&mtype=generic

10. d) F – Montelukast is a LEUKOTERINE RECEPTORS ANTAGONIST
(http://www.mims.com/Malaysia/drug/info/montelukast/montelukast?type=full&mtype=generic)
Theophylline = METHYLXANTHINE (Harrison’s Principle of Internal Medicine 16th Edition pg 1513) –
di sini terminology suda salah. However, both pon bule gune sebagai add on therapy to inhale
corticosteroid according to GINA guideline utk treatment step up.
e)T - Theophylline affects the cardiovascular (CV), central nervous (CN), gastrointestinal (GI), pulmonary,
musculoskeletal, and metabolic systems. Hypokalemia,
hyperglycemia,hypercalcemia, hypophosphatemia, and acidosis commonly occur after an acute
overdose (http://emedicine.medscape.com/article/818847-overview#a0104) – based on this, dye kaco
electrolytes kn, and as we all know electrolytes imbalance can cause mcm2 problem right including
arrhythmia which is caused by hypo/hyperkalemia and hypophostaemia (Oxford Handbook of Clinical
Medicine pg 688 + 693) and also seizure which can be caused by metabolic disturbance; hypoxia,
hypo/hyperNa, hypocalcemia, hypo/hyperglycemia,uremia (Oxford Handbook of Clinical Medicine pg
494). At plasma levels > 30 g/mL there is a risk of seizures and cardiac arrhythmias (Harrison’s Principle
of Internal Medicine 16th Edition pg 1513).
31. Assessment of acute asthma in adult
(A) pulse rate <100/min, respiratory rate <25 breath/min,PEF between 50 to 75% predicted is mild
asthma attack
(B)SpO2 91-95%, talks in phrases, loud wheeze, are the feature of MODERATELY severe asthma attack
(C) pulse rate >120/min, talk in words, loud wheeze, are the feature of very severe astma attack
(D) confusion, bradycardia or hypertension, silent chest are the feature of life-threatening asthma attack
(E) Normal or high PaCO2, high pH with severe hypoxaemia are the ABG markers of severe life-
threatening attack.
Davidson pg 676-677, Kumar n Clark
Assessment of acute asthma in adult include:
Ability to speak/ Pulse rate Respirator Blood Oxygen PEFR (% of
wheezing y rate pressure saturatio predicted
n normal/ best
value)
Mild Speak in Normal <25/min Normal >93% >60%
sentence/
wheezing
Moderate Speak in phrase / Normal 91-93% 50-60%
loud wheeze
Severe Unable to >110/min >25/min Normal <90% 30-50%
complete 1 ute
sentence in 1
breath / loud
wheeze
Life Silent Bradycard Hypotension <85% <30%
threatenin chest/confusion/ ia

11. g coma
Features suggesting of life threatening asthma include :
• a high PaCO2 >6 kPa
• severe hypoxaemia PaO2 < 8 kPa despite treatment with oxygen
• a low and falling arterial pH
Answer
1. True
2. True
3. True
4. True
5. True
32. Diagnosis of pulmonary tuberculosis?
(A) TB in patient with at least 1 initial direct smear positive with or without positive finding in chest X-ray
or culture
F- At least 3 sputum smear proves TB infection
(B) Culturing using radiometric methods is routinely done in Malaysia
I dunno. But i don’t think so. So maybe its false. It was stated in the CPG of this method but it doesn’t
mention whether its a routine IX
(C) Culture using egg-based media takes up within 2 weeks for final result
F- it takes 8 weeks
(D) Chest X-ray revealed lesions at the upper lobe which are fibrosis and calcification, suggest active
disease
F- lesions are often soft in active disease with little or no fibrosis and calcifiction
(E) Positive Mantoux test indicates TB infection
T- its in CPG TB 2002 page 11. But it doesn’t incidicate active disease
Source: CPG TB 2002
33. The following are true regarding tuberculosis
A: T – pulmonary TB smear negative:
- 3 direct smear negative with CXR abnormalities and decision to treat as TB
- Initial direct smear negative but culture positive.
http://www.scribd.com/doc/6946305/6/Radiological-classification
B: T – Pulmonary TB smear positive:
- Two sputum positive
- One sputum positive and CXR changes of TB
- One sputum positive with culture positive.
http://www.scribd.com/doc/6946305/6/Radiological-classification
C: T –Diabetes and renal failure are high risk group for TB infection. To get the long list of who should be
screened, visit: http://www.lakecountyil.gov/Health/resources/Documents/TBScreening.pdf(simpified
version) or
http://www.cdc.gov/mmwr/preview/mmwrhtml/00001642.htm(long version)
D: F – diameter of cavitation should not exceed 4cm to be radiologically classified as moderately
advanced. If exceed 4cm, it should be classified as far advanced.

12. http://www.scribd.com/doc/6946305/6/Radiological-classification
E: F – I couldn’t find the exact answer to this question. But based on my readings and findings, I’ll put it
as false. Because suspected TB case should do further investigations and diagnosis of TB is made as
stated in answer A and B. so, if not diagnosed, then no notification required.
34. The following are true regarding management of TB?
a) True. Sputum direct smear for acid fast bacilli should be done at 0 month (day of initiating
treatment), followed by 2 monthly, 4 monthly, 6 monthly.
In addition, chest xray also need to be performed together with sputum smear for every 2, 4, 6
months for the purpose of monitoring.
From CPG for the Control and Management of Tuberculosis 2002, ministry of health, academy of
medicine of Malaysia, page 16.
b) False. Category II of TB treatment include; treatment failure, relapse and treatment after
interruption. While chronic case is categorized under category III TB treatment.
The difference in category I,II,III are the regimens and management for each classes. for
category II and III, one of the management is to refer to chest physician while category I, we may
start with standard initiating regiment.
From CPG for the Control and Management of Tuberculosis 2002, ministry of health, academy of
medicine of Malaysia, page 12, treatment of anti tuberculosis.
c) False. Treatment after interruption is defined as patient yg x ambil ubat selame tempoh 2 bulan
ata lebih dan tatkala kembali kepada health care, sputum nya positive. Kekadang, ade yg
kembali dgn sputum smear negative, tp masih ade active TB by clinical and radiological
judgement. So, kalau sebulan x dikire treatment after interruption lagi.
From CPG for the Control and Management of Tuberculosis 2002, ministry of health, academy of
medicine of Malaysia, page 10, diagnosis of tuberculosis.
d) False. Isoniazid side effect is true, reduce the metabolism of other drugs such as anti
epileptic;phenytoin, by acting on the liver enzyme. While, rifampicin didn’t have the same side
effect. It induce liver enzyme,therefore reduce other drug concentration in plasma such as; OCP,
oral hypoglycaemic agents, henytoin, corticosteroid, anticoagulants,cyclosporine, phenytoin,
cimetidine, theophyline, digitalis glycosides.
e) True. Drug interaction such as aminoglycosides, amphotericin B, cephalosporin, ethacrynic acid,
cyclosporine, cisplatin, frusemide, vancomycin may cause or potentiate (menguatkan) effect of
neuromascular blocking agent yg diberikan ketika anaesthesia
35. The following are true regarding COAD?
(A) T - Perhaps 10 to 20 percent of heavy smokers will become COPD sufferers, which suggests there
may be a sensitivity factor that renders some individuals more susceptible.
(http://webcache.googleusercontent.com)

13. (B) F-assessment of COPD severity is based on FEV1 value-CPG, management of COPD, 2nd edition, page
12
(C) F - Chronic bronchitis is a clinical diagnosis defined as the presence of cough and sputum production
on most days for at least 3 consecutive months in 2 successive years- http://www.medterms.com
(D) T – RV(residual volume) is the amount of air that remains in the lungs when measuring vital capacity
after a maximal exhalation. In persons with COAD, RV is usually increased dramatically from normal
because air is trapped in the damaged lung and cannot be exhaled normally.
(E) T-because smoking is one of the major risk factor for COPD
36. Which of the following disease does have an occupational exposure etiology?
A. Chronic bronchitis (F) kumar n clarks page 878
Kl acute ,yes
B. Bronchiolitis obliterans (T)
http://en.wikipedia.org/wiki/Bronchiolitis_obliterans. There are many industrial inhalants that
are known to cause various types of bronchiolitis, including bronchiolitis obliterans
C. Bronchiectasis (F) - Bronchiectasis has both congenital and acquired causes, with the latter
more frequent.
D. Silo-filler’s disease (T) www.righthealth.com/Wellness
Bronchiectasis has both congenital and acquired causes, with the latter more frequent.
37. A 40 year old man with a BMI of 40 c/o excessive daytime sleepiness & headaches. The following
statements are true:
This patient is having obstructive sleep apnea due to obesity.
A) FALSE
No drugs are used to treat OSA. General measures includes weight loss, avoidance of alcohol
for 4-6 hours prior to bedtime, and sleeping on one’s side rather than on the stomach or back,
are elements of conservative nonsurgical treatment. People with mild apnea have a wider
variety of options, while people with moderate-to-severe apnea should be treated with nasal
continuous positive airway pressure (CPAP).
(Sources from www.emedicine.com)
B) FALSE
An underlying mechanism for how clusters of apneas occur and the rate of oxygen desaturation has
been recently studied. It predicted increased desaturation rates solely based on the size of
oxygen reuptake.This occurs when mixed-venous blood with depleted oxygen saturation arrives
at the lung in time with the apnea phase.The rapid change in oxygen desaturation occurred after
the second apnea in a series of 10 produced; apneas that followed the second apnea did not
have accelerated changes when compared with the second apnea. Isolated apneas did not show
rapid changes in oxygen saturation.
(Sources from www.emedicine.com)
C) FALSE
Overnight studies of breathing, oxygenation and sleep quality are diagnostic but the level of
complexity of investigations will vary depending on the probability of diagnosis, differential
diagnosis and resources. The current threshold for diagnosing the sleep apnoea/hypopnoea
syndrome is 15 apnoeas/hypopnoeas per hour of sleep, where an apnoea is a 10-second or

14. longer breathing pause and a hypopnoea a 10-second or longer 50% reduction in breathing.
(Davidson page 667)
D) FALSE
No drugs used in treating OSA.(Sources from www.emedicine.com)
E) TRUE
Most of the patients need to use continuous positive airway pressure (CPAP) delivered by a
nasal mask every night at home. CPAP keeps the throat open by keeping the upper airway
pressure above atmospheric. The pressure for CPAP is set in the laboratory to the lowest that
will prevent apnoeas, hypopnoeas and awakenings. CPAP results in improvements in
symptoms, daytime performance, quality of life and survival.
(Davidson page 667)