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PROBLEM BASED QUESTIONS (PBQs)

Diagnostic Clues:
 Decreased FEV1/FVC which improves significantly on bronchodilator
inhalation, (may/may not be associated with smoking )  Bronchial Asthma
 Decreased FEV1/FVC which does not improve significantly on  COPD (emphysema, chronic
bronchodilator inhalation (always associated with smoking) bronchitis).
 Preterm baby/ delivered by caesarean section of diabetic mother
who develops cyanosis soon after birth  Hyaline membrane disease
 Hypoxemia, polycythemia, hypercapnia  Chronic bronchitis
 Pink complexion, dyspnea, hyperventilation  Emphysema
 Consolidation of lung with cough, fever, ↑in WBC count,
(neutrophilia)  Pneumonia
 Red "Currant Jelly" sputum in alcoholic/diabetic  Klebsiella pneumonia
 Desquamated epithelium casts in sputum (curschmann spirals)  Bronchial asthma
 Worsening of breathlessness when exposed to cold, dust, pollen,
wheezing, prolonged expiration  Bronchial Asthma
 Barrel shaped chest, pulsed lip breathing, hyperinflation of lung,
Resonant on percussion  Emphysema
 Chronic cough, weight loss, fatigue, night sweats, fever, ↑ESR,
hilar lymphadenopathy, acid fast staining +ve  Tuberculosis IV
 Worsening of cough with change in character, with hemoptysis ,
dyspnea, weakness, weight loss in chronic smoker sputum
cytology revealed atypical cells  Lung cancer
 Acute onset of shortness of breathlessness at rest and pleuritic
chest pain with tachycardia, tachypnea with recent history of
surgery, long bone fracture or deep venous thrombosis, ↑D-
dimers  Pulmonary embolism.
 Chronic exercise intolerance with myalgia, fatigue, painful
cramps, myoglobinuria  McArdle’s disease.
 Acute onset of chest pain, dyspnea, trachea, shifted to other side,
Reduced cheat expansion, absent breath sound, tympanic note on
percussion  Pneumothorax
 Cough with foul smelling purulent sputum, changing in amount
with position and associated with clubbing, tramtrack
appearance in X-ray  Bronchiectasis
 Curschmann spirals and charcot-leyden crystals  Bronchial asthma
 Associated with bronchial obstruction, poor ciliary motility,
kartagner’s syndrome, cystic fibrosis  Bronchiectasis

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 Egg shell calcification or hilar lymph node, nodular lesions in

upper lobe in stone/ marble cutter and sand worker  Silicosis
 Macular lesion in upper lobe in a person with history of working
in coal mines  Anthracosis
 Bilateral symmetrical reticulonodular pattern-honey comb lung
associated with pleural thickening and plaques in a patient
working as plumber, shipbuilder  Asbestosis
 Rapidly worsening dyspnea, cyanosis crackels in chest, ↑in
pulmonary arterial wedge pressure, bilateral diffuse patchy
opacites in chest X-ray in a patient with a history of sepsis,
pneumonia, trauma, blood transfusion  ARDS
 Consolidation of lung at the apex with ptosis, enopthalmos,
meiosis and anhidrosis  Pancost tumor
 Man in the peripheral part of lung of nonsmoker female  Adenocarcinoma (causing
associated with clubbing Horner's syndrome)
 Hilar mass, associated with cavitation and hypercalcemia in
smoker and revealing keratin pearls and intercellular bridges in
histology  Squamous cell carcinoma.
 Hemorrhagic pleural effusions with pleural thickening associated
with asbestosis  Mesothelioma
 Iron containing nodules in alveolar sputum (ferruginous bodies)  Asbestosis

PAST QUESTIONS:
IV
PBQ 2013 KU
Problem–I
7. Mr. Krishna, a 50 years old man, diagnosed with emphysema five years back, and on regular
medications, recently developed with purulent sputum, increased shortness of breath and
fever. Routine blood test and pulmonary function test are ordered. He is admitted in hospital
and the medical team started six hourly salbutamol and Ipratropium bromide nebulisation and
intravenous antibiotics.
a. Describe the expected abnormalities of pulmonary function tests in this patient. [4]
b. What is the role of oxidant and antioxidant in emphysema in this case? [3]
c. What is the pharmacological basis of giving salbutamol and Ipratropium bromide nebulisation
in this patient? [3]
a. Ans:
Emphysema is an obstructive lung disease. So pulmonary function test resembles as that of
obstructive lung disease. These are as:
1. Forced vital capacity (FVC)→ decreased
2. FEV1( forced respiratory volume in 1 sec.) →decreased

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3. Vital capacity → decreased

4. FEV1/FVC → decrease(<72%)
5. PEF 25-75( forced expiratory flow rate from 25% to 75% of VC) or average mid maximal
expiratory flow rate→ decreased
6. Peak expiratory flow rate (PEFR) →decreased
7. Residual volume (RV) → increased
8. Diffusion capacity → normal (it is decreased in other obstructive lung disease).
9. Total lung capacity(TLC)→ normal to increased
b. Ans:
- Emphysema is known to occur due to imbalance between protease antiprotease and oxidase
antioxidase system.
- Emphysema due to imbalance of oxidase antioxidase system is due to following reasons:
→ Normally, the lung contains a healthy complement of antioxidants (superoxide dismutase,
glutathione) that keeps oxidative damage to a minimum.
→ Tobacco smoke contains abundant reactive oxygen species (free radicals), which deplete
these antioxidant mechanisms, thereby inciting tissue damage.
→ Activated neutrophils also add to the pool of reactive oxygen species in the alveoli.
→ A secondary consequence of oxidative injury is inactivation of native antiprotease,
resulting in "functional" 1-antitrypsin deficiency even in patients without enzyme
deficiency. IV
c. Ans: Pharmacological basis of salbutamol and ipratropium bromide:
Disease:
- Emphysema is a chronic obstructive lung disease, so obstruction to the outflow of air causes
inflation of lung.
Drug:
Salbutamol:
- It is a short acting β 2 agonist which is used to abort the acute attack of asthma.
- It causes relaxation of smooth muscles in small sized airways by activating adenlyl cyclase
and increase intracellular cAMP.
Ipratropium bromide:
- It is anticholinergic drug which causes bronchodilation of mainly larger airways.
- It acts on the receptors like M1, M2, M3.
Basis:
- Thus both drug combination causes dilation of both small and large sized airways relieving
the symptoms.

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PBQ 2013 KU
Problem–II
8. A 40 years old lady developed upper respiratory infection followed by 390C temperature and
right sided pleuritic pain. On physical examination he had restricted chest movement on right
side with bronchial breath sounds. Chest X-ray showed large consolidation in right middle
lobe. Diagnosis of lobar pneumonia was made clinically and blood and sputum were sent to the
laboratory.
a. Describe the bronchial tree and bronchopulmonary segments with applied anatomy. [3]
b. Describe the laboratory diagnosis of respiratory pathogens in this case. [3]
c. Explain the gross and microscopic features of lung tissue from consolidated portion in this
case. [2 + 2 = 4]
a. Ans: Bronchial tree:
 Trachea divides into 2 principle bronchi at the level of low border of T4 Vertebra
 Thus parts of bronchial tree includes
1. Trachea
2. Two principal bronchi
3. Secondary lobar bronchi: for each lobe
- 3 on the right side
IV - 2 on the left side
4. Tertiary/ segmental bronchi
- For each bronchopulmonary segment
- 10 on each side(some book says 9 on left side)
- Further divides repeatedly to form:
5. Terminal bronchioles
6. Respiratory bronchioles
- Each part of lung aerated by respiratory bronchiole is known as pulmonary unit
7. Alveolar duct, atria, air saccules and pulmonary alveoli
Bronchopulmonary segments: described above
b. Ans: Laboratory diagnosis of Bacterial pneumonia:
1. Specimen collection:
- Sputum
- Blood
- Pleural fluid
- Transthoracic aspiration material

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2. Microscopy:
i. Gram staining: Adequate no. of pus cells and predominant organisms gives clue to the
probable pathogens.
a. Gram positive diplococci→ Streptococcus pneumonia
b. Gram negative short rod→ H. influenza
c. Gram positive cocci in chains→ S. aureus
ii. Ziehl-Neelsen staining:
 Presence of Acid fast bacilli→ M. tuberculosis
iii. Silver Methenamine stain:
 Useful for diagnosis of P. jiroveci
3. Cultural characteristics:
- Purulent sputum is best for culture.
- For viscid sputum, liquefying agent should be used to make it homogenous.
Culture media:
i. Blood agar:
 Incubated aerobically and anaerobically.
 -hemolysis and draghtman appearance→ S. pneumonia
ii. Chocolate agar:
 Selective for H. influenza
IV
 Colony morphology is smooth and gray on overnight incubation
iii. MacConkey agar:
 For lactose fermenter and non fermenter
iv. Anaerobic culture media:
 For anaerobic organism
v. Lowenstein –jensen
 For mycobacterial culture
 Non motile, non sporing, non capsulated
4. Biological test:
- Bile solubility
- Inulin fermentation test
- Optochin sensitivity test→ positive for S. pneumonia
- Capsular swelling test
5. Serology:
- Ag detection
- Ab detection

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6. Blood count:
- Total and differential WBC count.
- Leucocytosis→ predominantly polymorphonuclear leucocytes(neutrophils)
7. Radioligic diagnosis
- Plain chest X-ray shows area of consolidation.
c. Ans:
Consolidation of lung occurs in stage of red hepatization and stage of grey hepatization .
Stage of Red hepatization(early consolidation of lung)
Gross:
- The lobe appears distinctly red, firm, and airless , with a liver- like consistency, hence the term
hepatization
Cut surface: dry, granular, airless, red
Microscopy:
- Fluid is replaced by fibrin
- Massive confluent exudation of neutrophils and Red cells.
- Bacteria phagocytosed by neutrophils
- Alveoler septa becomes less prominent

IV

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Stage of Gray hepatization (late consolidation)

Gross:
- A grayish brown, dry surface
Cut surface: dry, granular, grey.
Microscopy:
- Fibrin strands become more dense and numerous
- Cellular exudate is primarily composed of macrophage.
- Disintegration of red cells and neutrophils.
- Organisms are scanty.

IV

PBQs 2012 KU
Problem–I
A primi lady, known case of diabetes, presented to the hospital with labor pain on 32nd weeks
of gestation. The baby having 1.8 Kg was delivered by caesarean section (surgical procedure
to deliver the baby). The baby developed cyanosis soon after birth. On examination, there

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was increased respiratory and heart rate. He was kept on ventilator and admitted in neonatal
intensive care unit. Despite aggressive management including treatment by surfactant, the
baby died on 7th poush of delivery day. An autopsy was performed and showed solid liver like
lungs. [Hint: Hylanie membrane disease
a. Explain the pathogenesis of the disease of this baby. [3]
b. What is surfactant? Write down its synthesis. [1+2=3]
c. List the drugs which can be prescribed for this baby against respiratory pathogens. [4]
a. Ans: Pathogenesis of hyaline membrane disease
- Predisposed by
a. Immature lungs
b. Low gestational age
c. Deficiency in the pulmonary surfactant
d. Maternal diabetes and
e. Delivery by caesarean section

IV

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- Surfactant is produced by Type II alveolar cells after 35 weeks of gestation in the fetus.
- Before 35 weeks  deficiency of surfactantincrease in surface tension lung collapse with
each successive breath  progressive atelectasis and reduced lung compliance.
b. Ans:
- It is a complex mixture of several phospholipids, proteins and ions. It is surface active agent in
water, which means that it greatly reduces the surface tension of water and prevents
collapsing of alveoli.
- It is synthesized by Type II alveolar epithelial cells.
Components:
1. Dipalmitoylphosphatidyl choline (DPPC): 62%
2. Phosphatidyl glycerol: 5%
3. Other phospholipids: 10%
4. Neutral lipids: 13%
5. Proteins: 8%
6. Carbohydrate: 2%
Synthesis:
- Lamellar bodies (membrane bound organelles) in Type II alveolar epithelial
cells/pneumocytes are intracellular source of surfactant.
- Lamellar bodies contain surfactant phospholipids and surfactant proteins with are
synthesized in endoplasmic reticulum.
IV
- By exocytosis  lipid and protein are released into fluid lining alveoli phospholipid
arranged into a lattice (meshwork) structure called tubular myelin  Tubular myelin is
converted to surfactant in the form of film, that spreads over the entire surface of alveoli.
- The surfactant is again recycled by Type II pneumocytes/alveolar cells.
c. Ans:
- Prescribed drugs depend on the type of respiratory infections:
1. Antibiotics: for bacterial infections
i. Penicillin groups of drugs:
- Penicillin
- Amoxicillin
- Ampicillin
ii. Co-amoxiclav ( amoxicillin + clavulanic acid)
iii. Sulfonamide group of drugs:
- Cotrimoxazole (sulfamethoxazole + trimethoprin)
iv. Macrolides
- Azithromycin
- Clarithomycin

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v. Cephalosporin
- Cefixime
- Ceftriaxone
- Cefuroxime
v. Tetracycline group
- Tetracycline
- Doxycycline
2. Antifungl
i. Amphotericin B
ii. Ketoconazole
iii. Fluconazole
iv. Itraconazole
v. Nystatin
vi. Griseofulvin
3. Antiviral
- Generally no any medications are implicated, however, some drugs used are:
- Amantadine, Rimantadine, Oseltamivir (anti influenza)
PBQs 2012 KU
Problem –I
IV
A 50-year old chain smoker male presented to medical outpatient with history of cough and
hemoptysis for the last 6 months. On examination the physician found decreased chest
movement, dull on percussion and diminished breath sound on the right side of the chest.
Chest X-ray revealed consolidation in the upper lobe of right lung with destruction of second
and third ribs. Full blood count was within normal limits. AFB staining for tubercle bacilli and
mantoux test were negative. Sputum cytology revealed atypical cells having cytoplasmic
keratinization. [Hint: Bronchogenic carcinoma]
a. Describe the bronchopulmonary segments with clinical correlation of this case. [4]
b. Describe the lung function test. [3]
c. Write the interpretation of this microbiological investigation of this case. [3]
a. Ans: Bronchopulmonary segments:
- These are well defined anatomic, functional and surgical sectors of the lungs
- There are 10 segments on the right side and 10 on the left side
- Each one is aerated by a tertiary or segmental bronchus
- Each segment is pyramidal in shape with its apex directed towards the root of the lung.
- Each segment has a segmental bronchus, segmental artery autonomic nerves and lymph
vessels
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- The segmental vein lies in the connective tissue between adjacent bronchopulmonary
segments
- During segmental resection the surgeon works along the segmental veins to isolate a
particular segment
Bronchopulmonary Segments
Right lung Left lung
Lobes Segments Lobes Segments
A. Upper 1. Apical A. Upper
2. Posterior  Upper division 1. Apical
3. Anterior 2. Posterior
B. Middle 4. Lateral 3. Anterior
5. Medial  Lower division 4. Superior lingular
5. Inferior lingular
C. Lower 6. Superior
7. Anterior basal
8. Medial basal B. Lower 6. Superior
9. Lateral basal 7. Anterior basal
10. Posterior basal 8. Medial basal
9. Lateral basal
10. Posterior basal

- Chest X-ray revealed consolidation in upper lobe of right lung. So bronchopulmonary

segments involved in this case are:
i. Apical
IV
ii. Posterior
iii. Anterior
b. Ans: Pulmonary function test:
- Primary function of the lung is to maintain tension of O2 and CO2 of the arterial blood within
the normal range. The fundamental mechanisms involved in attaining this goal are
ventilation, diffusion and perfusion. Pulmonary function tests are based on the assessment of
these mechanisms.
Uses:
1. Diagnosis of respiratory dysfunctions.
2. Monitoring the progress of the disease.
3. Evaluating the efficacy of treatment.
4. Determining the efficacy of physical training.
5. Studying the prevalence of respiratory diseases in the community.
6. Assessing the respiratory fitness of the patients.
Pulmonary function tests:
1. Spirometry:
- Measurement of tidal volume, vital capacity, forced vital capacity.

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2. Measurement of functional residual capacity (FRC), dead space:

a. Measurement of FRC.
 By helium dilution technique.
 N2 washout technique.
b. Measurement of dead space
 Anatomical dead space is measured by rapid N2 meter.
 Physiologic dead space by Bohr's equation.
3. Measurement of airway resistance.
a. Measurement of timed vital capacity.
b. Peak expiratory flow rate.
 FEV1 estimation is the most diagnostic test.
 Maximum mid-expiratory flow rate (MMFR): Maximum flow rate achieved during
the middle third of the total expired volume.
 This is expressed as forced expiratory flow at 25% to 75% of the lung volume. It
indicates patency of small airways.
4. Diffusion capacity of lung: using CO (described earlier)
5. Closing volume for small airway diseases:
- The lung volume at which the airways at the base of the lungs close during expiration is
called closing capacity.
6. Analysis of blood and air.
- Concentration of O2 and CO2 in inspired and expired air.
IV - Arterial blood gas analysis.
- Mixed venous blood gas analysis.
c. Ans: Microbiological investigations done in the above cases are:
i. AFB staining:
Interpretations
If definite bacilli are seen, report as AFB positive. However, it is better to report the result
quantitatively as follows:
> 10 AFB/high power field +++
1-10 AFB/high power field ++
10-100 AFB/100 high power fields +
1-9 AFB/100 high power fields exact number
However if no AFB is seen, write the result as ‘no AFB seen’ and never write negative.
ii. Tuberculin test:
Interpretation of tuberculin reaction
1. 5-10mm – weak reaction
Positive:
 HIV-positive person
 Patients with organ transplants and other immuno suppressed patients

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2. 10–15 mm – moderate reaction

Positive:
 Residents and employees of high-risk congregate settings
 Prisons
 Nursing homes
 Hospitals
 Persons with clinical conditions that place them at high risk
 Diabetes
 Prolonged corticosteroid therapy
 Leukemia
3. 15 mm or more – strong reaction
Positive:
 Persons with no known risk factors for TB
False positive
 Previous administration of BCG vaccine
 Infection with nontuberculous mycobacteria
False negative
 Technical flaws
 Inadvertent subcutaneous injection IV
 Improper storage, insufficient dose
 Severe TB disease
 HIV (if CD4 count < 200 cells/ml)
 Diabetes

Probable Questions:
Problem–I
A 45 year old woman comes in OPD with high grade fever and cough since last 5 days. Chest
X-ray shows consolidation involving Rt. Lower lobe of lung. Blood report is as follows:
Hemoglobin: 13.5gm %, Platelets: 180,000/mm3
Total count: 15000/mm3, Differential count: N: 82%, L: 18%. [Hint: Pneumonia]
a. What is your diagnosis? [1]
b. Mention the stages of this condition. [2]
c. Describe the broncho-pulmonary segments of right lung. Which segment is most probably
involved in these cases? [3]
d. What are the possible pathogenic microorganisms found in lower respiratory tract? [4]
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Problem –II
A 10 year old male attended OPD with complaint of shortness of breath, wheezing and tight
feeling in the chest. He also had similar episodes of shortness of breath in the past when
exposed to pollens.
Blood report shows:
Hemoglobin: 14.5gm%, Platelets: 220,000/mm3
Total count: 11000/mm3. Differential count: N: 65%, E: 15%, L: 20%. [Hint: Bronchial asthma]
a. Discuss the pathogenesis of this disease in brief. [3]
b. Mention a drug that can be used in this case. Explain the rationale of using this drug. [4]
c. How restrictive and obstructive pulmonary diseases can be differentiated by using spirometry? [3]
Problem–III
A 23 years old woman presents with shortness of breath, tightness of chest and cough with
copious sputum since last one hour. On auscultation she had wheezes with prolonged
expiratory phase. She was orthopnoeic and had a respiratory rate of 32/minute. Physician
prescribed some medicine to relieve SOB? [Hint: Bronchial asthma]
a. What medication might have been prescribed? [3]
b. List major and minor respiratory muscles. [3]
c. Write the pathogenesis of asthma? [4]
IV Problem-IV
Krishna, 60 years old male from Bahunepati presented to the hospital complaints of
persistent cough with occasional production of blood streaked sputum. He did not give history
of fever. The patient also had three day morning sputum samples tested for AFB, which
turned out to be negative. Dr. Gurung sent the sputum of the patient to the laboratory for
the presence of atypical cells. Dr. Ramesh examined the sputum and found out that there was
presence of atypical cells. Dr. Gurung then decided to do bronchoscopy the next day for the
possible detection of neoplastic mass during bronchoscopy. Dr. Gurung saw that there was an
irregular mass partially obstructing right main bronchus. He took multiple biopsies from the
site and then sent for histopathology. Dr. Ramesh saw the slides of the biopsied specimen
and concluded that it was squamous cell carcinoma. Thereafter the patient was referred to
Bhaktapur cancer hospital for further management.
a. Describe how AFB staining is done and explain why is it used in case of suspected M.
tuberculosis infection? [4]
b. What must have been the histopathological picture of the biological specimen? Explain and
illustrate. [3]
c. Write short notes on bronchopulmonary segment. [3]

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Problem–V
A 60 years old woman visited OPD with complaint of fever with evening rise in temperature,
cough and blood in sputum since last 3 weeks. She also complaints of tiredness, of appetite
and weight loss. Blood and sputum was collected and sent to the laboratory for examination.
Sputum was positive for acid fast bacilli. [Hint: Tuberculosis]
a. Describe the complex seen in primary tuberculosis. [3]
b. Describe in brief the staining procedure and name the culture media used for the above
mentioned microorganism. [3]
c. Mention the chemotherapy used in this disease. [4]
Problem–VI
A 58 year old man was admitted with a history of shortness of breath that had progressively
worsened over the last five years. On examination his chest was barrel shaped, cyanosed and
had pursed lip breathing. His heart rate was 148 bpm, BP was 100/88mmHg. Respiratory rate
38/min. Spirometry showed decreased FEV1 and reduced vital capacity. ABG results showed.
H+=44nmol/l (Normal35-45nmol/l)
PCO2=9.3kpa (4.6-6dpa)
PO2=4.0kpa (10-13kpa)
HCO3=40 mmol/l (22-26mmol/l)
The patient was treated with salbutamol in combination with corticosteroids. [Hint: COPD]
a. Describe the pathogenesis of emphysema. [3]
IV
b. Write down the mechanism of action, adverse effects and contraindications of salbutamol? [3]
c. What is the physiological basis of tachypnea seen in this patient? What do a decrease FEV-1
and decreased vital capacity signify? [4]
a. Describe microanatomy of lung . [3]
b. How pCO2 is increased in this patient?? Describe its compensation by the body. [4]
c. Describe how salbutamol and corticosteroid help in this patient. [3]
Problem–VII
A 25 years old man presents with left sided pleurits chest pain and dyspnea of sudden onset,
soon after exercise. His medical history is completely unremarkable. He regularly engages in
sports, and smokes a couple of cigarettes everyday. He is confused with GCS score of 13/15.
Pulse is 104 bpm, regular, weak. JVP is elevated, trachea is deviated towards Right side.
Reduced chest expansion and absent breath sounds on left side. On CVS examination, apex
beat is not palpable. All other systems are normal. [Hint: Left sided pleural effusion]
a. What is your diagnosis? [1]
b. Describe about the pleural recesses and explain what happens to the pleural cavity.[3]
c. Explain with figure, how intrapleural & intrapulmonary pressure change during respiration. [3]
d. Explain the pathogenesis, how above condition develops. [3]

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Problem–VIII
Mr. Bidur Raut 64 years old male from jaljale, a known case of chronic obstructive pulmonary
disease was admitted to the hospital with fever, cough with purulent sputum and shortness of
breath for previous five days. He was diagnosed as a case of acute exacerbation of COPD
with oral antibiotics and prednisolone, Salbutamol-Ipratropium bromide nebulisation and
oxygen.
a. Describe the microscopic anatomy of lungs with figure.
b. Describe the pathophysiology of chronic bronchitis and emphysema.
c.. Explain how salbutamol-ipratropium bromide nebulisation helps in this patient and write
what you think about the rationale of giving oral prednisolone to this patient.
Problem–IX
A 20 years old male patient was presented to the OPD of MTH complaining of productive
cough, fever, fatigue, body aches, malaise and headache for 10 days. On history it was found
that he has got pigeons in his house. There are sparse rales over 1/3 of the right lung and no
pleural rubs . A sputum culture reveals fungus. [Hint: Cryptococcal pneumonia]
a. Describe the microanatomy of lung. [3]
b. Name fungal infections due to pigeon. List the name of different fungal infections in lung with
causative agents. [3]

IV c. List antifungal agents with their mechanism of action. [4]

Problem–X
A 60 year old anaemic man was transfused with unit of packed red cells. After half an hour
of the transfusion , he started to complain of breathlessness, fever and profuse sweating .
On examination , respiratory rate was 38 cycles/min , pulse rate was 100 bpm. Bilateral
reduced breath sounds with diffuse fine crackles was heard in all lung zones on auscultation.

[Hint: Transfusion related acute lung injury]

a. What is your diagnosis. [1]
b. Describe structure of alveocapillary membranes. What are the factors affecting diffusion of
gases? [3]
c. Describe the pathogenesis of above disease. [3]
d. How will you manage the patient? [3]
Problem–XI
A 35 year old women from syanjha presents with fever and productive foul smelling cough of
yellowish , viscid sputum changing with position for one week . She gives similar episodes
dating from childhood. She is dyspneic with respiratory rate of 30 cycles/min. Clubbing is

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noted in all fingers. On respiratory system examination, bilateral crackles and wheezing is
noted. X-ray shows dilated bronchi with tramtrack appearance. [Hint: Bronchiectasis]
a. What is your diagnosis? [1]
b. Describe bronchial tree. [3]
c. Explain pathogenesis of bronchiectasis. [3]
d. How do you manage her? List the name of antibiotics which can be prescribed. [3]
Other possible questions:
a. Describe microanatomy of lung, bronchilar tree.
b. Etiology of bronchiectasis
c. Describe infertility in relation to this case.
Problem–XII
A 28 years old man presents with severe dyspnea and wheezing for 1 day. He was diagnosed
with mild persistent bronchial asthma in childhood, and is currently on a salbutamol inhaler.
He also experienced a mild productive cough, rhinorrhoea and sore throat during the
preceding weeks. He doesnot smoke. On general examination, he looked dyspneic and cannot
complete a sentence in one breath. Respiratory rate is 30 breaths/min, SaO2: 92%, pulse: 120
bpm. Diffuse inspiratory and expiratory phase.
a. What is your diagnosis? What is the impact of sympathetic and parasympathetic stimulation
in this patient? [3] IV
b. Describe the pathogenesis or the disease. [3]
c. List the drugs used to treat it. How does salbutamol help in this patient? [4]
Problem–XIII
A 42 years old man present with exertional dyspnea for 10 years, which rapidly progressed over
last 7 months to the point that it is now present even at rest. He also experienced non productive
cough and generalized weakness. On detailed history, it was found that he worked as a stone
cutter for 10 years until 7 years ago. His full blood count is normal, but the ESR is 45mm/hr.
Upper zone or chest/lung shows reduced expansion, dullness on percussion and bronchial
breathing. On chest X-ray bilateral nodular masses and mottled opacities was noted, especially in
the upper lobes. Lung function shows both restrictive and obstructive pattern.
[Hint: Silicosis]
a. What is your diagnosis? [1]
b. Describe bronchopulmonary segments in relation to this patient. [3]
c. What are the difference in lung function test between restrictive and obstructive disease? [3]
d. Write about morphological changes in this disease. [3]

FAST TRACK BASIC SCIENCE MBBS -1209-

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Problem–XIV
A 50 years old man presents with low grade fever, non productive cough and dyspnea for 2
weeks, which rapidly, worsened over the last 2 days. He also felt unwell and experienced
anorexia and weight loss over the preceding 3 months. He had engaged in unprotective sexual
inter course with commercial sex workers over the years-most recently last month. Chest X-
rays shows diffuse interstitial infiltrates. On general examination, he looks cachectic,
dyspneic with oral candidiasis. Respiratory rate was 30 cycles/min. Few fine crackles was
heard in both the lung fields.
Total WBC count = 4250/mm3 (4,000-11,000)
Neutrophil–70%
Lymphocytes-25%
Microscopy revealed:
Gram stain: Negative
ZN stain : Negative
Giemsa stain: Multiple thick walled cysts and pleomorphic trophozoites with reddish nuclei
and bluish cytoplasm.
Methenamine silver stain: Walls of the cysts are stained.
[Hint: P. Jiroveci pneumonia in AIDS]
IV
a. What is your diagnosis? Explain the change in arterial blood gas analysis with reference to this
patient. [4]
[Hint: Hyperventilation   CO2 washout  Alkalosis  Compensation]
b. Double the diffusion of gasses in the alveoli. [3]
c. Interpret microscopical finding. Write other laboratory findings in this case. [3]
Problem–XV
A 85 years old man present with progressive dyspnea, fatigue and anorexia for three months.
He also experienced pain in the lower right side of his chest during this time. He was
shipyard worker for 30 years. On general examination, he looks chronically ill and cachectic.
On respiratory examination, diminished chest movement on right side, reduced breath sound
and dull percussion note was noted. X-ray shows moderate pleural effusion on right side.
Pleural fluid was mixed with blood and was +ve for malignant cells. There was associated
pleural thickening. [Hint: Mesothelioma]
a. Describe the layers of pleura and pleural recesses. [3]
b. Write short note of pneumoconiosis. [4]
c. Describe the mechanism of development of dyspnea & fatigue with reference to this patient.[3]

-1210- FAST TRACK BASIC SCIENCE MBBS