1. An 8-year-old female is admitted to the hospital for an exacerbation of asthma. She

has recently moved to this area and has not seen a primary care provider in more
than six months. She reports complaints of dyspnea, cough and wheeze
intermittently for the last four months. Initially the symptoms were only related to
exercise which forced her to stop playing actively with her friends. Now she has
symptoms almost daily and awakens several times each week with wheezing. She
lives in a non-smoking environment. She and her parents deny any known
environmental factors which contribute to her difficulty in breathing. Prior to the last
several months, she has had no respiratory problems.  Since admission, she has been
stabilized with frequent albuterol treatments and is feeling much better. She is alert
and conversive, able to speak and play without restriction when you see her in the
emergency room.Physical examination is significant for an only mildly elevated
respiratory rate and mild expiratory wheezing with no accessory muscle use/WOB at
this time. Spirometry done at this time reveals a reduced FEV1 and FEV1/FVC at 60%
of predicted for age. You consider asthma education needs for this patient and begin
thinking about appropriate medication regimens for her condition upon hospital
discharge. WHICH of the following is the MOST APPROPRIATE choice of
medication(s) to recommend to her and her parents for long-term maintenance
therapy of her condition?

A. Inhaled short-acting beta-2 agonist medication (albuterol), every 4-6 hours, as

symptoms warrant
B. Inhaled long-acting beta-2 agonist medication (salmeterol), twice daily
C. Inhaled corticosteroid twice daily, plus short-acting beta-2 agonist (albuterol)
treatment as needed
D. Oral prednisone tablets, twice daily
E. Montelukast (Singulair) tablets, once daily

2. A 10-month-old child is brought in for urgent evaluation by her worried parents. She
has been ill with low-grade fever, cough, and nasal congestion for several days. Last
night, her cough sounded "barky" like a seal and her parents are worried about her
ability to breathe. She seems to have more difficulty breathing when she becomes
upset. On examination, you note the child who is fussy but consolable. She appears
well hydrated and in no acute respiratory distress, although audible breath sounds
are noted when she begins to cry. You note her high-pitched barking cough. What
clinical finding would you expect to hear upon auscultation?

A. Decreased breath sounds over the right lung field

B. Prominent expiratory sounds caused by bronchospasm and inflammation of small
airways
C. Prominent inspiratory and expiratory sounds caused by mucous deposition in both
large and small airways
D. Prominent inspiratory sounds caused by re-expansion of collapsed of alveolar air
spaces
E. Prominent inspiratory sounds caused by subglottic airway narrowing
3. An 18-month-old girl is seen in the emergency department for sudden onset of
respiratory distress during a family picnic. She is afebrile and has otherwise been
well. Physical examination demonstrates unilateral wheezing in the right lung field.
What is the MOST LIKELY finding you will see on her chest x-ray?

A. A consolidation of the right lower lobe with mediastinal shift to the right
B. A foreign body in the right mainstem bronchus
C. A consolidation of the right lower lobe with no mediastinal shift
D. Hyperinflation of the right lung with mediastinal shift to the left
E. A normal chest X-ray

4. A 6-year old child presents to the emergency room with a four-day history of fever
and cough. He is otherwise healthy, although he did have a flu-like illness about 2
weeks ago. On further questioning, his mother tells you that he has been having a lot
of cough. She can t tell you if its productive or not, but the child says he thinks that
he swallows stuff after coughing. Physical examination is significant for temperature
of 39.3 C (102.7 F), and respiratory rate in the 40 s. Oxygen saturation is normal. On
exam, the patient is using accessory muscles of breathing. There are
decreased breath sounds over the right base, and dullness to percussion in the same
area. You obtain a PA and lateral CXR which reveals a lobar consolidation in the right
lower lobe. What is the MOST likely etiology of this patient s pulmonary process?

A. Mycoplasma pnemoniae
B. Streptococcus pneumoniae
C. Respiratory syncytial virus
D. Bordatella pertussis
E. Pseudomonas aeruginosa

5. A 3-week-old infant is brought to the emergency room by his parents. They report
that he seems to be breathing hard and had a couple of episodes where it looked like
he stopped breathing. They deny cyanosis or fever. When you ask his mother about
her pregnancy, she reports that it was uneventful. She had prenatal care. She had no
perinatal infections, and she was GBS negative. The patient was born at full term
via spontaneous vaginal delivery. His nursery course was uneventful and he went
home at approximately 36 hours of life. He established care with his pediatrician at 2
weeks of life, and his mother proudly reports that he had already surpassed his birth
weight. He received his first vaccination, and his mother reports that his
pediatrician said he was in excellent health. He is exclusively breast fed, and had
been eating well (approximately 15 minutes per breast every 1-2 hours) until today.
Of note, the patient s 4-year-old brother has a cold. Physical examination reveals the
following: Temperature: 37.7 C (100 F), respiratory rate 65, blood pressure 73/45,
heart rate 168, oxygen saturation is 90% on room air. The infant appears to be in
respiratory distress. There are deep subcostal retractions with inspiration. Exam of
the lungs reveals diffuse wheezing and poor air movement. Cardiovascular exam
reveals tachycardia, but no murmurs. Capillary refill is normal. After placing the
infant on supplemental oxygen, he appears much more comfortable and O2 sat
increases to 95%. You obtain a PA and lateral CXR which reveals hyperinflation and
 interstitial infiltrates. You obtain appropriate laboratory studies to hopefully identify
the organism causing this infant’s distress. Based upon the MOST LIKELY etiology for
this infant s respiratory difficulty, initial management should include WHICH of the
following measures:

A. Broad spectrum antibiotic therapy to cover most likely organisms

B. Inhaled corticosteroid therapy along with antibiotics
C. Systemic corticosteroid therapy along with antibiotics
D. Supportive care, including oxygen, hydration and bulb syringe suction as needed
E. Ventilatory management as the infant is in significant respiratory distress

6. You see a 10-year-old boy in the emergency room with a 1 1/2 week history of
cough. He reports that his symptoms started with sore throat, headache, malaise,
and cough. He feels better overall, but his cough hasn t gone away. In addition, he
just started the little league season, and he notices that he gets really out of breath
when he s running the bases. On exam, the patient is afebrile, but his respiratory
rate is slightly increased. The patient appears comfortable at rest. Auscultation of
the lungs reveals diffuse rales. A PA and lateral CXR shows diffuse fine interstitial
infiltrates, and small bilateral pleural effusions. Heart size is normal. WHICH of the
following organisms is the MOST LIKELY cause of this patient s pulmonary process?

A. Mycoplasma pneumoniae
B. Streptococcus pneumoniae
C. Respiratory syncytial virus
D. Bordatella pertussis
E. Pseudomonas aeruginosa

7. A 16-month-old child is evaluated for respiratory distress in the middle of winter. His
anxious mother reports that he has had a few days of nasal congestion and drainage.
She also reports that the child has has felt warm to her, although she did not
measure his temperature. He started coughing earlier today and his mother reports
that the quality of his cough has recently changed, in that it is now becoming more
high-pitched and "barky" in nature. He has been otherwise healthy and has no
chronic illness. His mother thinks that his breathing has become much more labored
over the past several hours. Your examination reveals a child who appears to be in
mild respiratory distress with an elevated respiratory rate of 36. Other vital signs,
including oxygen saturation, are within normal parameters. There is no accessory
muscle use or work of breathing noted. The child is not posturing in an unusual
position and has a non-toxic appearance. You note that most of the child's work of
breathing appears to be upon inspiration. WHICH of the following findings are you
MOST likely to appreciate upon auscultation of this child's lung fields?

A. Expiratory wheezes
B. Fine crackles in bilateral lung fields
C. Inspiratory stridor
D. Rhonchi in bilateral lung fields
E. Whooping sound on inspiration
8. A 15-year-old girl with cystic fibrosis presents to the emergency room with fever and
worsening dyspnea. She has been admitted to the hospital several times this year
with pneumonia, and she just completed a course of antibiotics as an outpatient
about 2 weeks ago. She admits she may not have taken all the doses as prescribed.
In addition to bronchodilator therapy, she reports she had been on inhaled
tobramycin, but admits she hasn t taken it for awhile. She says she has been having
cough productive of yellowish-green sputum. Physical examination is notable for
vital signs as follows: temperature 38.5 C (101.3 F), respiratory rate 28, blood
pressure 105/67, heart rate 92, and oxygen saturation 92% on 2L via nasal cannula.
She is very thin and appears younger than her stated age. She is barrel-chested
(increased AP diameter of the thorax). There is diffuse wheezing on auscultation of
the lungs, and a markedly prolonged expiratory phase. A CXR shows marked
hyperinflation and lobar consolidation in the right middle lobe. WHICH of following
statements regarding cystic fibrosis is true?

A. Finding of bronchiectasis is inconsistent with a diagnosis of cystic fibrosis

B. Cystic fibrosis is an autosomal recessive condition inherited through gene
expression on chromosome number 5
C. Exacerbation of illness due to serious infection (as in the vignette above) is most
often caused by gram positive organisms
D. Maintenance therapy of cystic fibrosis includes bronchodilators, airway clearance
and DNAse
E. The underlying defect of cystic fibrosis is in sodium and potassium transport
channels in the lungs and other organs

9. A 5-year-old boy has had a low-grade fever, runny nose, non-productive cough, and
mild stridor for 2 days. He sounds like a seal when he coughs. He is non-toxic
appearing and has no increased work of breathing. What is the next step?

A. Chest x-ray to evaluate for the steeple sign

B. Discharge with close follow-up if symptoms worsen
C. Nebulized epinephrine
D. Laryngoscopy
E. Parenteral steroids

10. A 15-month-old-girl presents to the outpatient clinic on a winter afternoon with

fever, shortness of breath, and wheezing. If a chest x-ray revealed hyperinflated
lungs with peribronchial cuffing without consolidation, what would be the likely
diagnosis?

A. Epiglottitis
B. Croup
C. Chlamydia pneumonia
D. Viral pneumonia
E. Pneumococcus
11. You are offering advice to a new mother as she and her newborn are about to be
discharged home after an uneventful delivery. The mother asks about sudden infant
death syndrome (SIDS) and wants to learn more. What is an appropriate response?
A. Pacifiers should be avoided
B. Prone sleeping is a preventative strategy
C. The underlying cause is determined by autopsy
D. Bilateral retina hemorrhages are pathognomonic
E. There is a higher risk in infants of women who smoke

12. A 14-year-old-boy has persistent rhinorrhea, itchy eyes and nose, and post-nasal
drip. He has no pets, does not smoke, and uses an allergen-free pillowcase. What is
the first-line pharmacologic treatment?
A. Continue conservatice management
B. Prescribe oral antihistamine
C. Prescribe intranasal corticosteroid
D. Prescribe intramuscular epinephrine
E. Prescribe inhaled steroids

13. A 12-year-old girl is diagnosed with asthma. She has nighttime symptoms twice
aweek and daily daytime symptoms. Which of the following should NOT be part of
her long-term treatment?
A. Inhaled steroids
B. Leukotriene-receptor antagonist
C. Short-acting beta agonist
D. Oral prednisone
E. Long-acting beta agonist

14. A 9-year-old child presents to you in GP with his mother, complaining of nocturnal
cough and poor exercise tolerance during PE at school. He has a known diagnosis of
asthma, for which he is prescribed salbutamol and an inhaled corticosteroid. What
would be your first step in subsequent management of the patient?
A. Refer to respiratory pediatrician
B. Increase dose of inhaled corticosteroid
C. Add regular oral steroids
D. Check compliance and inhaler technique
E. Add LABA

15. A 2-year-old child presents to you with stridor at rest, hoarse voice, barking cough
and generally poor air entry. You prescribe a single dose of oral dexamethasone.
What other treatment may you want to administer?
A. Humidified air inhalation
B. Nebulised adrenaline
C. IV antibiotics
D. Nebulised salbutamol
E. Inotropic agents
16. You are looking after a 10 month-old child with bronchiolitis. He was born at term
and has no other diagnosed medical conditions. What should your management be?
A. Bronchodilators
B. IV antibiotics
C. Steroids
D. Enteral fluids & oxygen to maintain SpO2 > 92%
E. Palivizumab

17. You review a child with asthma in the respiratory clinic. Which of these is not a
feature of good symptom control in asthma?
A. No sleep disturbance
B. <2/week daytime symptoms
C. No exacerbations
D. Using salbutamol ~2/day
E. No limitation on daily activities

18. A 5-year-old boy develops pertussis. He has a history of frequent fainting attacks 2
years ago; the diagnosis of long QT syndrome has been established since then. He
lives with her mother in a single house. Of the following, the MOST appropriate
antimicrobial regimen is
A. Azithromycin for the child only
B. Azithromycin for the child and mother
C. Trimethoprim-sulphamethaxazole (TMP-SMX) for the child and azithromycin for
the mother
D. Azithromycin for the child and clarithromycin for the mother
E. TMP-SMX for the child and mother

19. A 4-year-old boy has recent exposure with his grandfather who has active
tuberculosis disease. His TST is negative. Of the following, your NEXT step in the
management is to
A. Start isoniazid (INH) for 10 weeks than repeat the TST
B. Start INH for 9 months
C. Observe for early development of tuberculosis infection
D. Repeat TST after 2 weeks
E. Start rifampin for 6 months

20. A school-aged boy developed non-productive cough; he has a preceding headache,

malaise, fever, and sore throat few days before. Examination is not significant.
Chest radiograph shows bronchopneumonic changes in the right lower lobe. Of the
following, the MOST likely causative pathogen is
A. Staphylococcus aureus
B. Streptococcus pneumoniae
C. Mycoplasma pneumoniae
D. Parainfluenza virus
E. Respiratory syncytial virus
21. A 2-year-old boy has rhinorrhea, mild cough, and low-grade fever for 2 days, after
that he develops barking cough, hoarseness, and inspiratory stridor; crying greatly
aggravates his symptoms and the child prefers to sit up in bed. Respiratory rate was
34 breath/min, heart rate 110 beat/min, and oxygen saturation 95%. Of the
following, the MOST likely diagnosis is
A. laryngotracheobronchitis
B. acute epiglottitis
C. acute infectious laryngitis
D. spasmodic croup
E. bacterial tracheitis

22. A 3-year-old healthy child suddenly develops a sore throat and fever. Within a
matter of hours, the patient appears toxic, swallowing is difficult with drooling, and
labored breathing. The neck is hyperextended and the child assumes the tripod
position. Of the following, the MOST likely diagnosis is
A. laryngotracheobronchitis
B. acute epiglottitis
C. acute infectious laryngitis
D. spasmodic croup
E. bacterial tracheitis

23. A 9-year old girl with asthma is brought to the office for the first time. On average,
she uses her albuterol inhaler three times per week, but for the past 10 days, she
has been wheezing both day and night and is using the inhaler three to four times
per day. On examination, you note diffuse wheezing and moderate subcostal
retractions. Which of the following is the next step in management?
A. Order a chest radiograph to assess for pneumonia
B. Refer the child to an allergist for allergen immunotherapy
C. Start an oral leukotriene modifier
D. Start a low-dose inhaled corticosteroid
E. Start a short course of systemic corticosteroids

24. A 6-week-old female infant presents with increased work of breathing and a
staccato-type cough for 3 days. On physical examination you note a temperature of
37.1C, a respiratory rate for 60 breaths/minute, and bilateral conjunctival
erythema. The lungs are clear except for mild wheezing at the bilateral lung bases.
Which of the following is correct regarding her likely diagnosis?
A. Pneumonia is unlikely given the absence of fever, and therefore a noninfectious
cause of the patient’s symptoms should be sought.
B. Infection was transmitted by a maternal genital infection.
C. Blood culture will be positive in 50% of cases.
D. Corticosteroids are indicated and will improve the patient’s clinical course.
E. Inhaled mucolytics should be considered.

25. A 3-year-old boy presents with acute onset of fever (temperature up to 39.7 C),
diminished appetite, and drooling. He has been previously well, and inspection of
his immunization records reveals that all are up-to-date for his age. On
 examination, you note that he appears very ill and prefers to sit leaning forward on
his hands with his neck hyperextended. His voice is muffled. Which of the following
is correct regarding his likely diagnosis?
A. This patient likely has bacterial tracheitis and should be started on
antistaphylococcal antibiotics.
B. Racemic epinephrine should be administerd immediately.
C. Anesthesiology and otolaryngology should be consulted to visualize his airway
and intubate him in a controlled environment (eg. Operating room).
D. An anterior-posterior radiograph of the neck will show a ‘steeple sign’.
E. The throat should be examined with a tongue depressor to rule out a
retropharyngeal abscess.

26. A previously healthy 13-year-old boy presents with a 2-week history of

nonproductive cough and low-grade fever. On examination, you note a normal
respiratory rate and no evidence of respiratory distress but are surprised to hear
inspiratory rales at the bilateral lung bases. Which of the following is the most likely
cause of pneumonia in this adolescent?
A. Pneumocystis jiroveci
B. Staphylococcus aureus
C. Group B streptococcus
D. Bordetella pertussis
E. Mycoplasma pneumoniae

27. A 5-month old female infant in a day care facility develops a low-grade fever
(temperature up to 38.2 C), rhinorrhea, and cough. A few days later, she is
brought to the emergency department with tachypnea, chest retractions, diffuse
expiratory wheezing, and fine inspiratory crackles bilaterally. Which of the
following is correct regarding her likely diagnosis?
A. Chest radiography will demonstrate decreased lung volumes with bilateral lobar
consolidation.
B. Chlamydia trachomatis should be considered as a possible etiologic agent.
C. Supportive care is the most important management.
D. Intravenous antibiotics should be started.
E. Bronchoscopy is indicated.

28. A 2-year old toddler presents with a 3-day history of increasing inspiratory stridor,
cough, and increased work of breathing. On examination, you confirm the
inspiratory stridor and also note intercostal retractions and tachypnea with a
respiratory rate of 44 breaths/minute. Which of the following is correct regarding
the cause and management of the probable diagnosis?
A. Parainfluenza virus is the most likely cause.
B. Foreign body aspiration is unlikely because of the absence of a history of
choking.
C. Corticosteroid therapy is contraindicated.
D. A ‘thumbprint sign’ will be found on a lateral radiograph of the neck.
E. Antibiotics against Staphylococcus aureus are indicated.
 29. A 5-year-old boy is on ATT treatment (H/R/Z/E) for tuberculous cervical
lymphadenitis. After 2 weeks of starting the treatment, he develops nausea and
vomiting. SGPT (ALT) was found to be twice the normal range and total bilirubin of
2.5 mg/dl. Choose the most appropriate action.
A. Stop R & H
B. Stop H, R, and Z
C. Stop all 4 drugs
D. Stop R
E. Continue treatment with close monitoring

30.

Lancar Bahasa inggris