MED1 Samplex Rationale 2 - Cough and Hemoptysis

MEDICINE I: COUGH AND HEMOPTYSIS
2017-2018 QUIZ SAMPLEX
Question Answer Rationale

1. What is the most common cause of hemoptysis B
worldwide?
A. Adenocarcinoma of the Lung
B. Mycobacterium tuberculosis
C. COPD
D. Acute Bronchitis
Page 5 in trans
2. Catamenial hemoptysis should be considered in which of B Catamenial hemoptysis
the following: ● Monthly hemoptysis with a woman’s menstrual cycle
A. 75 year old male smoker with cough for 5 years ● Results from pulmonary endometriosis
B. 55 year old female with monthly hemoptysis ● Rare manifestation of thoracic endometriosis, which commonly
C. 18 year old with prolonged bleeding parameters presents as pneumothorax. Hemothorax or lung masses can be
D. 45 year old female admitted due to chest trauma other initial presentations
○ Proliferation and shedding of an ectopic endometrium within
the bronchovascular bundle can lead to hemoptysis.
○ CT scan often shows cavities, nodules, bullous formations,
and ground glass opacities
○ Hormonal suppression of endometrium is usually considered
first, but video-assisted thoracoscopic or open surgery may be
needed if medical treatment fails
Page 5 in trans under Mechanical Etiology and Other causes
3. A patient coughed out 100 mL of blood. He consulted at B Mild Hemoptysis
the emergency room and was found to have BP 120/80 HR Specks of blood
80 RR 20. Which of the following best describes in Blood tinged sputum
hemoptysis? Often caused by infection
A. Minimal Hemoptysis Often managed as an outpatient
B. Moderate Hemoptysis
C. Massive Hemoptysis Moderate Hemoptysis
D. Minor Hemoptysis Specks of blood to around 200 mL in 24 hours
In between mild and massive
Non-life-threatening condition
Massive Hemoptysis
Large volume
Variable defined as >200-600 mL in 24 hours
Life threatening
Exsanguination from hemoptysis is rare
Drowning from aspirated blood is the usual cause of demise
Page 6 in trans
4. What causes the hemoptysis in Congestive Heart C Congestive Heart Failure
Failure? · Elevation of left atrial pressures causing rupture of small
A. Infection of airways alveolar capillaries
B. Dilatation of pulmonary artery · Results to pink, frothy sputum or blood-tinged secretions
C. Elevated left arterial pressures
D. Excessive diuretics Page 5 in trans under Vascular Etiology
5. Chest CT scan is used for hemoptysis for which A Chest CT scan
purpose? ● For most patients, next step in evaluation should be a standard
A. Guide arteriography or bronchoscopy to the regions of chest radiograph, if a source of bleeding is not found on plain
highest yield film, CT of the chest should be performed
B. Locate and stop the bleeding through embolization ● To localize the bleeding site and diagnose the cause of
C. Cauterization and laser therapy hemoptysis
D. Location the bleeding artery ● Bronchiectasis, lung abscess, and mass lesions (e.g. Cancer,
mycetomas and arteriovenous malformations)
● To guide arteriography or bronchoscopy to the regions of highest
field
● To assess for pulmonary embolism if history and PE suggest
venous thromboembolism
Page 6 in trans under Diagnostic tools
Lacson, S., Lao, E., Larga, R., Lesaca, A., Lim, J., Maclang, P., Mondez, R., Oabel, R., Padilla, K. 1 of 12
6. Accumulation of bradykinin and stimulation of C afferent C

fibers is the mechanism of which cause of cough?
A. Upper airway cough syndrome
B. Asthma
C. ACE inhibitor cough
D. Acid reflux disease
7. The cough center is found in this region of brainstem: C
A. Nucleus tractus multipus
B. Tractus nucleus solitarium
C. Nucleus tractus solitarium
D. Tractus solitarium
8. Which of the following is TRUE regarding cough? C Cough is
A. It is a non-essential condition resulting from disease ● Essential protective function for airways and lungs
B. It is a disease in itself ● Clue to the presence of respiratory disease
C. Clue to the presence of respiratory disease ● Expected and accepted manifestation of disease
D. Uncommon and unexpected manifestation of disease Page 1 in trans
9. Capsaicin would initially stimulate which of the D Transient receptor potential cation channel subfamily V member 1
following? (TrpV1), also known as the capsaicin receptor and the vanilloid
A. Nucleus Tractus Solitarius receptor 1, is a cationic ion channel which are found in rapidly
B. Parasympathetic motor nerves adapting receptors and C fibers. TRPV1 expression is increased
C. Vagus nerves in patients with chronic cough.
D. Rapidly adapting receptors Page 1 in Trans
10. A 95 year old female was given codeine, which of the B Cough Suppressants
following is a side effect of narcotic cough suppressants? 1. Codeine/Hydrocodone
A. Osteoporosis ● Narcotic cough suppressant
B. Constipation ● Acts on cough center (nucleus tractus solitarius) in the brainstem
C. Insomnia ● Side effects: drowsiness and constipation
D. Anxiety ● May cause addictive dependence thus limiting their appeal for
long-term use
● Most potent
2. Dextromethorphan
● Over-the-counter (OTC)
● Centrally-acting cough suppressant
● Fewer side effects
● Less efficacious than narcotic cough suppressants
● Different site of action, thus, can be used in combination with
narcotic cough suppressants when necessary.
3. Benzonatate
● Inhibits neural activity of sensory nerves in the cough-reflex
pathway
● Generally free of side effects
● Its effectiveness in suppressing cough is variable and
unpredictable
Page 4 in trans
MATCHING TYPE Mechanism of Cough
1. Spontaneous cough starts with the stimulation of sensory nerve
COUGH endings thought to be rapidly adapting receptors and C fibers
Column A ○ Chemical stimuli – capsaicin
11. Chemical stimulation A ○ Mechanical stimuli – particulates in air pollution
12. Afferent impulses B ○ Rapidly adapting receptors and C fibers are found in afferent
13. Efferent impulses C nerve endings, which innervate the pharynx, larynx,
airways,terminal bronchioles, lung parenchyma, external
Column B auditory meatus, and esophagus.
A. rapidly adapting receptors and C fibers 2. Afferent impulse travels via the vagus and superior laryngeal
B. vagus and superior laryngeal nerves nerve and reach the cough center (found in the nucleus tractus
C. parasympathetic and motor nerves solitarius of the brainstem).
3. Efferent impulses coming from the cough centers travel to the
parasympathetic and motor nerves wherein the
diaphragm,intercostal muscles, and abdominal muscles are then
stimulated to contract and produce cough.
HEMOPTYSIS
Column A
14. Hemoptysis A
15. Epistaxis B
16. Hematemesis C
Column B
A. Expectoration of blood from the alveoli to the glottis
B. Bleeding from nasopharynx
C. Bleeding from the upper gastrointestinal tract
2017-2018 SHIFTING EXAM SAMPLEX

1. Which of the following is a common source of B Most common etiology of Hemoptysis: Infection of Medium -sized
hemoptysis? Airways
a. Trauma to the large airways
b. Infection of the medium airways
c. Inflammation of the small airways Page 5 in trans
d. Erosion of large blood vessels
2. Dilatation of a Pulmonary artery called Rasmussen’s B Rasmussen’s Aneurysm
aneurysm in a cavity formed by? ● Dilation of a pulmonary artery in a cavity formed by previous
a. Congenital malformations tuberculous infection
b. Previous tuberculous infection ● Common in developing countries where massive life-threatening
c. Pulmonary Hypertension hemoptysis occurs due to tuberculosis
d. Trauma to the chest o Infection causes inflammation
o Tissue necrosis causes cavitations
o Erosion into blood vessels causes bleeding
Infection → inflammation → tissue necrosis with cavitation of lung

parenchyma → erosion of blood vessels → bleeding (hemoptysis)
Page 5 Trans
3. A 45 year old came from a trip in Southeast Asia and A Pulmonary Paragonimiasis
presented with cough, fever, and hemoptysis. He was noted ● Fluke infection transmitted by the consumption of raw or
to have ingested a delicacy with uncooked crabs. which of undercooked crab or crayfish
the following is most likely cause? ● caused by Paragonimus westermani
a. Paragonimus westermani ● Manifests with fever, cough and hemoptysis
b. Ascaris lumbricoides ● Must be considered in patients from endemic areas (Southeast
c. Echinococcus Asia and China) presenting with hemoptysis
d. Entamoeba histolytica ● Can mimic tuberculosis; should be considered as cause of
hemoptysis in recent immigrants from endemic areas
Page 5 Trans
4. A 75 year old smoker presenting with 3 months weight C Malignancy
loss was admitted due to hemoptysis. Which of the ● Hemoptysis a presenting symptom in only ~10% of patients
following would point to a metastatic disease as a cause of ● Cancers arising in the proximal airways are more likely to cause
hemoptysis? hemoptysis
a. Unintentional weight loss ○ Combination of multiple pulmonary nodules and hemoptysis
b. 120 pack year smoking history should raise suspicion of metastatic disease (e.g. melanoma,
c. Multiple pulmonary nodules sarcoma, adenocarcinoma)
d. Enlarged pulmonary arteries
Page 5 Trans
5. A 55 year old non smoker was admitted due to sudden A Congestive heart failure
onset of dyspnea and hemoptysis. Which of the following ● Elevation of left atrial pressures causing rupture of small alveolar
would point to congestive heart failure as a cause of capillaries
hemoptysis? ● Results to pink, frothy sputum or blood-tinged secretions
a. Pink, frothy sputum
b. Monthly recurrence Page 5 Trans
c. Non-productive cough
d. Weight loss
6. A 45 year old patient was admitted for fever and weight B Massive Hemoptysis
loss was noted to have massive hemoptysis. Which of the ● Large volume
following defines massive hemoptysis? ● Variable defined as >200-600 mL in 24 hours
a. 600 mL in 2 days BP 150/80 O2 sat 96% ● Life threatening
b. 500 mL in 24 hours O2 sat 85% ● Exsanguination from hemoptysis is rare
c. 50 mL in 24 hours O2 sat 84% ● Drowning from aspirated blood is the usual cause of demise
d. 1000 mL in 7 days
Mild Hemoptysis - Specks of blood; Often caused by infection
Moderate Hemoptysis - Specks of blood to around 200 mL in 24
hours; Non-life-threatening condition
Page 6 Trans
7. A 45 year old male went to the ER for fever and blood A Chest CT scan
streaked sputum. He was treated as a case of pneumonia ● For most patients, next step in evaluation should be a standard
due to X-ray findings and sputum tests. Which among the ff chest radiograph, if a source of bleeding is not found on plain
would warrant a chest CT scan? film, CT of the chest should be performed
a. Smoking history of 120 pack years ● To localize the bleeding site and diagnose the cause of
b. Positive sputum test for tuberculosis hemoptysis
c. Prolonged bleeding parameters ● Bronchiectasis, lung abscess, and mass lesions (e.g. Cancer,
d. Elevated Creatinine mycetomas and arteriovenous malformations)
● To guide arteriography or bronchoscopy to the regions of highest
field
● To assess for pulmonary embolism if history and PE suggest
venous thromboembolism
Mild hemoptysis
● If with risk factors like smoking and family history of cancer,
patient may require CT scan and/or bronchoscopy.
● If there are no risk factors, manage as an outpatient.
Page 6 Trans
8. Which of the following contains receptors that stimulate B Rapidly adapting receptors and C fibers are found in afferent nerve
cough? endings, which innervate the pharynx, larynx, airways, terminal
a. Pericardium bronchioles, lung parenchyma, external auditory meatus, and
b. Esophagus esophagus.
c. Mammary glands
d. Pectoralis muscle Page 1 Trans
9. A patient underwent tracheostomy which placed a C This is a sample exercise in the Learning Module
opening below the glottis. Which phase of cough would
most likely be ineffective? Note that Compressive Phase starts with the build-up of pressure
a. Inspiratory phase against a closed glottis. With tracheostomy, no build up of pressure
b. Expiratory phase would happen since there is an opening below the glottis.
c. Compressive phase
d. Irritation phase
10. Which phase of cough would have high flow rates? B EXPIRATORY PHASE
a. Inspiratory phase ● Sudden opening of the glottis
b. Expiratory phase produces a rapid rise in
c. Compressive phase expiratory flow
d. Irritation phase
Page 2 Trans
11. World health Organization (WHO) defines chronic cough B World Health Organization: Chronic Cough
in areas with high prevalence of TB by which duration? ● defines chronic cough in areas with high prevalence of TB as
a. 2 to 3 days cough of 2-3 weeks duration (rather than >8 weeks)
b. 2 to 3 weeks
c. 4 to 6 days ** Philippines is a country with high prevalence of TB; Patient’s
d. 1 to 2 weeks cough duration is 15 days which is more than 2 weeks **
12. In the Philippines, which of the following patients would B Page 3 Trans
be considered to have chronic cough?
a. A 75 year old smoker complaining of two days cough
b. A 25 year old medical student complaining of cough
for almost 15 days
c. A 63 year old technician with cough of less than 2
weeks
d. A 36 year old news with cough of 10 days and blood
streaked sputum
MATCHING TYPE A INSPIRATORY PHASE
COUGH C ● Subglottic Phase and Flow rate are both negative allowing air to
Column A B enter the thoracic cage.
13. Build up of intrathoracic pressure COMPRESSION PHASE
14. Glottic opening with blast of turbulent flow ● Once the glottis closes, there is no flow generated but there is a
15. Lengthening of expiratory muscles build-up in pressure.
EXPIRATORY PHASE
Column B ● Sudden opening of the glottis produces a rapid rise in expiratory
a. Inspiratory phase flow
b. Compressive phase
c. Expiratory phase Page 2 Trans
2016-2017 (2nd sem, 3rd shift, Quiz #1) SAMPLEX
1. Which of the following is/are true of cough variant D Page 3- 4 of trans

asthma? A. cough-variant = cough is the only presenting symptom
A. cough is the only presenting symptom B. asthma is included in most common cause of cough
B. can cause chronic cough C. airway obstruction can be relieved by beta2 agonist and
C. treatment includes beta2 agonist and corticosteroids corticosteroids
D. all of the above
2. Which of the following has the highest yield for localizing C Page 6 of trans
the bleeding site during active bleeding?
A. chest x-ray Fiberoptic Bronchoscopy - to rule out endobronchial malignancy
B. chest CT scan and has the highest yield for localizing the bleeding site if
C. fiberoptic bronchoscopy performed during active bleeding
D. lung perfusion scan
3. A 23 year old non-smoker complains of weight loss, C Presumptive TB has any og the ff:
hemoptysis fever, and cough for more than 2 weeks. The ● Cough of at least 2 weeks duration
most likely cause of his hemoptysis is? ● unexplained cough of any duration in a close contact of a known
A. Streptococcus pneumoniae active TB case
B. Staphylococcus aureus ● chest xray findings suggestive of PTB with or without symptoms
C. Mycobacterium tuberculosis
D. Pseudomonas aeruginosa *The most common cause of hemoptysis worldwide is
Mycobacterium tuberculosis
#’s 4-7: A 75-year old male has been having cough for 3 Most common causes of cough:
months. The most likely cause/s of his cough is/are: ● Medications (ACE inhibitor induced)
4. bacterial pneumonia FALSE ● Nasopharyngeal drainage
5. upper airway cough syndrome TRUE ● GERD
6. gastrointestinal reflux disease TRUE ● Cough-variant asthma
7. tuberculosis TRUE ● Smoke inhalation/Smokers
● Post-nasal drip syndrome/Upper airway cough syndrome
● Chronic idiopathic cough/Cough hypersensitivity syndrome
● TB (in high prevalence areas)
#’s 8-10: The following examination should be done in a Not in the trans
patient with cough: 8. Earwax impaction or foreign body can stimulate the cough
8. Examination of the auditory canals and tympanic membrane TRUE reflex that can be oftenly be unrecognized
9. Examination of the nails TRUE 9. Check for clubbing of nails
10. Examination of the nasal passageways. TRUE 10. Examine for the presence of sputum production
2016-2017 (2nd Sem, 3rd Shifting Exam) SAMPLEX

1. Which of the following conditions will present with acute A Examples of Acute Cough:
cough? ● Respiratory tract infection
A. Respiratory Tract Infection ● Aspiration
B. Postviral tussive syndrome ● Inhalation of noxious chemicals
C. Pulmonary Tuberculosis ● Smoke
D. Gastroesophageal reflux disease B, C, D are examples of chronic cough (inflammatory, infectious,
neoplastic)
2. Which of the following conditions will unlikely present C Hemoptysis arise from the alveoli to the glottis
with hemoptysis?
A. Bronchiectasis Should be distinguished from other sources of bleeding, such as:
B. Pulmonary mass ● Epistaxis – bleeding from nasopharynx
C. Postnasal drip ● Hematemesis – bleeding from upper GIT
D. Pulmonary TB
Examples: Bronchiectasis, Pulmonary disease
3. A 55 year old hypertensive non-smoker consults for C Asthmatic bronchitis treatments are essentially the same as
nonproductive cough responsive to bronchodilators. Which those used to treat asthma and bronchitis, and may include:
of the following is the most possible cause? bronchodilators,
A. Calcium channel blocker use
B. esophageal cancer
C. bronchial asthma
D. foreign body
4-6. Match the description to the cough phase Inspiratory phase
Cough Phase ● Stimulated by irritation of receptors --> Build-up of volume

A. Inspiratory Phase ● The glottis opens upon reflex with inhalation of air.
B. Expiratory phase ● Lengthening of the expiratory muscles occurs with the
C. Compressive phase contraction of the diaphragm
● Air fills the thoracic cage, generating positive flows and
4. Phase wherein the expiratory muscles are lengthened 4. A pressures
while the glottis is open
Compressive phase
5. Phase wherein there is expiratory effort on a closed 5. C ● Starts with the build-up of pressure against a closed glottis
glottis ● Build-up of pressure is also due to adduction of the vocal cords
6. B that leads to a transient upper airway occlusion.
6. Phase wherein the glottis opens with generation of a ● This is then accompanied by contraction of the expiratory
brief blast of turbulent flow muscles, generating intrathoracic pressure as high as 300
mmHg.
Expiratory phase
● Starts with the sudden opening of the glottis and release of
laryngeal contraction, generating rapid expiratory flow
● Results to the generation of rapid flow
● The kinetic energy release is usually enough to dislodge mucous
and irritants from the insides of the airway walls.
7-14: TRUE or FALSE. Write A if TRUE and B if FALSE Massive Hemoptysis

● Large volume
7. Large-volume hemoptysis referred to as massive 7. A ● Variable defined as >200-600 mL in 24 hours
hemoptysis defined as hemoptysis of greater than 200 to ● Life threatening
600 mL in 24 hours ● Exsanguination from hemoptysis is rare
● Drowning from aspirated blood is the usual cause of demise
8. All patient should be asked about current and former 8. A
cigarette smoking In any patient with a history of cigarette smoking, airway inspection
should be part of the evaluation of new-onset hemoptysis as
9. The physical exam begins with an assessment of vital 9. B endobronchial lesions are not reliably visualized on CT
signs and oxygen saturation Assessment of vital signs and oxygen saturation - for evidence of
life threatening bleeding
10. Cough-variant asthma may present as cough in the 10. A
absence of wheezing, chest tightness and shortness of Top 4 most common causes of cough
breath ● Medications (ACE inhibitor-induced)
● Nasopharyngeal drainage
11. Any infection of the airways can result is hemoptysis 11. B ● Gastroesophageal reflux
● Cough-variant asthma
12. Chronic cough is defined as cough of >3 weeks duration 12. B
CHRONIC COUGH
13. Angiotensin receptor blockers commonly causes 13. B ● Duration: >8 weeks
chronic cough ● Examples:
○ Inflammatory
14. Other clues suggesting postnasal drainage cough are 14. A ○ Infectious
sneezing and throat clearing ○ Neoplastic
The most common causes of chronic cough are postnasal drip,

asthma, and acid reflux from the stomach. These three causes are
responsible for up to 90 percent of all cases of chronic cough.
Less common causes include infections, medications, and lung
diseases. especially cough-variant asthma, which causes a
cough as the main symptom

1-5. Match the clinical condition to the duration of cough. ACUTE COUGH
● Duration: <3 weeks
CONDITION ● Examples:
1. Viral upper respiratory cough ○ Respiratory tract infection
2. Bronchiectasis 1. A ○ Aspiration
3. Postnasal drip 2. C ○ Inhalation of noxious chemicals
4. Pneumonia 3. C ○ Smoke
5. Post infectious origin 4. A
5. C SUBACUTE COUGH
DURATION OF COUGH ● Duration: 3-8 weeks
A. Acute ● Examples:
B. Subacute ○ Tracheobronchitis
C. Chronic ○ Postviral tussive syndrome
CHRONIC COUGH
● Duration: >8 weeks
● Examples:
○ Inflammatory
○ Infectious
○ Neoplastic
Page 3 in trans
I. Uncommon Conditions Causing Chronic Cough

· Bronchitis
· Bronchiectasis
· Bronchogenic carcinoma
· Chronic bronchitis
· Bronchiolitis
· Pertussis
· Post infectious cough
· Interstitial lung disease
· Cystic fibrosis
· Psychogenic cough
· Habit cough
· Tic cough
Page 4 trans
6. Chronic cough by duration of symptom is defined as:
A. <3 weeks
B. 3-4 weeks
C. 5-6 weeks D
D. >8 weeks
7. A 29 year old male came in because of 2 month history of
cough with difficulty breathing, which is relieved by
nebulization.On physical exam of the chest she will present
with:
A. Asymmetrical chest expansion, increased tactile and vocal
fremitus, resonant on percussion, inspiratory wheezes C
B. Asymmetrical chest expansion, increased tactile and vocal
fremitus, dullness on percussion, expiratory wheezes
C. Symmetrical chest expansion, normal tactile and vocal
fremitus, resonant on percussion, expiratory wheezes
D. Symmetrical chest expansion, normal tactile and vocal
fremitus, dullness on percussion, inspiratory wheezes
8. A 55 year old male presents with chronic cough. To
investigate on the possibility of lung cancer, which history
finding should be asked?
A. accompanying dyspnea C
B. bilateral swelling
C. loosening of the clothes
D. presence of phlegm
9. In inflammation, cough center may be triggered with the Top 4 most common causes:
intake of ACE inhibitors via sensitization of: ● Medications (ACE inhibitor-induced)
A. A delta fibers via prostaglandin B ● Nasopharyngeal drainage
B. A delta and C fibers via bradykinin ● Gastroesophageal reflux
C. C fibers via cytokines ● Cough-variant asthma
D. Neurogenic inflammation via neurotrophins
Simplified Evaluation of Common Causes of Cough:
If the patient has cough of >3 weeks duration,
> Check if patient has ACE inhibitor treatment and STOP treatment
● Considered a class effect; not dose related
● Complication of treatment with ACEI is seen in 3-20% of patients
● Pathogenesis: Accumulation of bradykinin, causing stimulation of
C afferent fibers in the airways
● Diagnosis: Usually confirmed with resolution of the cough 1-4
weeks after discontinuation of offending agent
Page 3 trans
10. A 35-year old female presents with chronic cough. She “Postnasal drainage of any etiology can cause cough as a response
is a smoker and drinks alcoholic beverage. She has had to stimulation of sensory receptors of the cough-reflex pathway in
colds followed by frequent throat clearing for 4 weeks now. the hypopharynx or aspiration of draining secretions into the
She has post nasal drip. Which physical examination trachea. Clues suggesting this etiology include postnasal drip,
finding is expected? frequent throat clearing, and sneezing and rhinorrhea. On speculum
A. Cobblestone appearance of oropharynx A examination of the nose, excess mucoid or purulent secretions,
B. Putrid-smell of breath inflamed and edematous nasal mucosa, and/or polyps may be
C. Substernal tenderness seen; in addition, secretions or a cobblestoned appearance of the
D. Tenderness of sinuses mucosa along the posterior pharyngeal wall may be noted.”
Harrison’s 20th ed. (p. 231)

11. Massive hemoptysis is defined as: a. Mild Hemoptysis
A. 50-99 mL/24hrs • Specks of blood
B. 100-199 mL/24 hrs C • Blood tinged sputum
C. 200-600 mL/24 hrs • Often caused by infection
D. 800-1000 mL/24 hrs • Often managed as an outpatient
b. Moderate Hemoptysis
• Specks of blood to around 200 mL in 24 hours
• In between mild and massive
• Non-life-threatening condition
c. Massive Hemoptysis
• Large volume
• Variable defined as >200-600 mL in 24 hours
• Life threatening
• Exsanguination from hemoptysis is rare
• Drowning from aspirated blood is the usual cause of demise
Page 6 trans
12. A 68 year old male came in because of hemoptysis
amounting to 50mL for the past 24 hrs. He was diagnosed
with prostate carcinoma and is undergoing treatment. He
has accompanying and difficulty of breathing. Which
finding would explain hemoptysis and difficulty of
breathing? D
A. clubbing
B. distended neck veins
C. systolic murmur at the apex
D. unilateral leg swelling
13. A 42 year old male has had bouts of massive
hemoptysis for the past 2 days. He has 10 pack year
smoking history and has family history for bronchogenic
carcinoma. Which physical examination finding is
important to determine need for advanced airway? D
A. cardiac rate
B. consciousness
C. presence of fever
D. rate of bleeding
page 6 (Diagnostic Evaluation) and page 7 trans

14. A 60-year old male consulted because of blood streaks Infections
and sputum production. Which is pertinent in history ● Most blood-tinged sputum and small-volume hemoptysis is due
taking? to viral bronchitis
A. accompanying orthopnea B ● Chronic bronchitis are at risk for superinfection with
B. previous pulmonary infections Streptococcus pneumoniae, Haemophilus influenzae, or
C. intake of antitussive medications Moraxella catarrhalis
D. previous abdominal surgery Page 5 trans
15. A 65 year old female presents with hemoptysis
amounting to 200 mL. She is a smoker and has
accompanying weight loss. Which physical examination
finding may be present?
A. crackles over both lung fields B
B. palpable supraclavicular mass
C. presence of blood from the nose
D. central cyanosis

1. A 55-year old female presents with hemoptysis amounting D Chest CT scan
to 200 mL. She consulted a tertiary hospital wherein chest CT ● To localize the bleeding site and diagnose the cause of
scan was requested. Localization of the bleeding site using hemoptysis
CT scan may be done in this condition to diagnose the cause ● Bronchiectasis, lung abscesses, and mass lesions (e.g. cancer,
of hemoptysis. mycetomas, and arteriovenous malformations)
A. Pulmonary embolism
B. Endocarditis
C. Chronic Bronchitis
D. Bronchiectasis Page 6 trans
2. . A 32-year-old male had 3 week history of hemoptysis B
described as blood-streaked sputum. He has had recurrent
bouts of hemoptysis for the past 5 months. There was,
likewise, history of cough, intermittent fever, weight loss and
malaise. Having in mind the most likely cause of hemoptysis
for this case, what additional information is important in the
patient’s history?
A. History of skin rash
B. Exposure to PTB
C. Associated edema
D. Recent travel history
3. A 49-year-old female came in because of hemoptysis B
amounting to 50 mL for the past 24 hours. She has had
intermittent difficult breathing and sudden swelling of the
right leg. What additional information is important in this
patient’s history?
A. History of PTB treatment
B. History of malignancy
C. History of HIV
D. Smoking history
4. Approach in patients with continuous hemoptysis and risk C Fiberoptic Bronchoscopy

factors for malignancy. ● In a patient with hemoptysis
A. 2D-echo ● with risk factors for malignancy
B. High resolution CT scan ● has highest yield for localizing the bleeding site if performed
C. Bronchoscopy during active bleeding
D. Pulmonary Angiography Page 6 of trans
5. Important information in the Past Medical History of B
patients with chief complaint of cough.
A. Diabetes mellitus
B. History of cancer
C. Diverticulosis
D. History of stroke
6. Pertinent finding in patients with chronic cough in our B
local setting.
A. Dyspnea
B. Fever
C. Chest pain
D. Insomnia
CASE for Questions 7-8:
CD, a 59-year-old female, came in due to hemoptysis amounting to a cumulative volume of 850cc/24 hrs. At the emergency room, BP was
110/60 mmHg, CR 86, regular, RR 19 breaths per minute, oxygen saturation of 93% in room air
7. What is the initial diagnostic evaluation in this case? B Chest CT scan
A. Chest CT scan with contrast studies ● To localize the bleeding site and diagnose the cause of
B. Chest radiograph hemoptysis
C. Fiber optic Bronchoscopy ● Bronchiectasis, lung abscesses, and mass lesions (e.g. cancer,
D. Pulmonary angiography mycetomas, and arteriovenous malformations)
Page 6 trans
8. Based on the presentation above, CD had an episode of? B (850cc = 850mL)
A. Catamenial hemoptysis Massive Hemoptysis
B. Massive hemoptysis ● variable defined as >200-600 mL in 24 hours
C. Diffuse alveolar hemorrhage
D. Bronchiectatic bleed Page 6 of trans
9. EF, a 48 year old male, nonsmoker, ha been complaining of C Upper airway cough syndrome
cough for more than 8 weeks. His chest radiograph was ● formerly known as Post-nasal drip syndrome
normal. He has no other comorbid conditions requiring ● can be caused by direct irritation or inflammation of the cough
maintenance medications. On examination, his posterior receptors in the upper airway
pharyngeal wall showed a cobblestone appearance of the ● no pathognomonic findings
mucosa. What condition does EF have? ● key diagnostic factors: post-nasal drip and cobblestone mucosa
A. Gastroesophageal reflux (https://bestpractice.bmj.com/topics/en-us/1209)
B. Drug-induced cough
C. Post-nasal drainage/drip
D. Vasculitis such as sarcoidosis
2012-2013 SHIFTING EXAM SAMPLEX

(January 11, 2013)
1. Which of the following data is most important in the A
history taking of a patient presenting with cough?
A. Estimating the duration of cough

B. Description of character of cough
C. Determining the timing of the cough
D. Presence or absence of sputum production
2. A patient suspected of upper airway cough syndrome will D Upper Airway Cough Syndrome
have this associated history/physical exam findings: ● Formerly known as Post-nasal drip syndrome (PNDS)
● Can be caused by direct irritation or inflammation of the cough
A. Acute cough receptors in the upper airway
B. Reflux symptoms ● No pathognomonic findings
C. Wheezes
D. Post-nasal drip Trans (p. 3)
3. Which of the following symptoms/signs is associated with C

cough variant asthma?
A. Shortness of breath
B. Crackles
C. Cough
D. Irreversible airway obstruction
Trans (p. 3)
4. Which of the following data is important in the history B “Linking gastroesophageal reflux to chronic cough poses similar
taking of patients with cough due to gastroesophageal reflux challenges. It is thought that reflux of gastric contents into the
disease? lower esophagus may trigger cough via reflex pathways
initiated in the esophageal mucosa. Reflux to the level of the
A. Associated symptoms of hoarseness pharynx (laryngopharyngeal reflux), with consequent aspiration of
B. Heartburn especially on supine position gastric contents, causes a chemical bronchitis and possibly
C. Globus sensation pneumonitis that can elicit cough for days afterward, but it is a
D. Throat clearing rare finding among persons with chronic cough. Retrosternal
burning after meals or on recumbency, frequent eructation,
hoarseness, and throat pain may be indicative of
gastroesophageal reflux.”

5. Which of the following data is of utmost value in history A
taking of patients with cough?
A. Smoking history
B. Sputum color
C. Intake of beta blocker
D. Dysuria
6. A 25-year-old male presents with chronic cough. He has C “Postnasal drainage of any etiology can cause cough as a
has colds followed by frequent throat clearing for 4 weeks response to stimulation of sensory receptors of the cough-reflex
now. He reports trickling sensation over the throat. Which pathway in the hypopharynx or aspiration of draining secretions
physical examination finding is expected in this patient? into the trachea. Clues suggesting this etiology include postnasal
drip, frequent throat clearing, and sneezing and rhinorrhea. On
A. Fever speculum examination of the nose, excess mucoid or purulent
B. Curd-like discharge over the pharynx secretions, inflamed and edematous nasal mucosa, and/or polyps
C. Cobblestone appearance of the oropharynx may be seen; in addition, secretions or a cobblestoned
D. Stridor appearance of the mucosa along the posterior pharyngeal
wall may be noted.”

7. Which of the following is an important historical point in B “Careful history may point to the cause of hemoptysis. Fever,
patients with chief complaint of hemoptysis? chills, or antecedent cough may suggest infection. A history of
smoking or unintentional weight loss makes malignancy
A. Prior musculoskeletal or endocrine disease more likely. Patients should be asked about inhalational
B. Smoking history exposures. A thorough medical history with careful attention to
C. Sexual history chronic pulmonary disease should be obtained, and the clinician
D. Occupation should determine risk factors for malignancy and bronchiectatic
lung disease (e.g., cystic fibrosis, sarcoidosis).”

8. A 20-year-old female consulted because of blood streaking B
and purulent sputum. Which of the following is pertinent in
the history taking of this patient?
A. Thyroid enlargement
B. Associated with acute cough
C. Patient is most likely taking aspirin
D. Paroxysmal Nocturnal Dyspnea
9. A 65-year-old male current smoker presents with D “In contrast, patients with risk factors for malignancy (i.e., age >40
hemoptysis and cough of 2 months duration. There is or a smoking history)...”
associated weight loss and anorexia. Which of the following “A history of smoking or unintentional weight loss makes
is/are pertinent in the history and is/are suggestive of lung malignancy more likely.”
cancer?
Harrison’s 20th ed. (p. 233-234)
A. Age of >40 years old
B. Smoking history
C. Constitutional symptoms such as weight loss and
anorexia
D. All of the above
10. A 45-year-old female presents with hemoptysis D Chest CT scan
amounting to 200 mL. She consulted a tertiary hospital ● To localize the bleeding site and diagnose the cause of
wherein chest CT scan was requested. Which of the hemoptysis
following condition warrants localization of the bleeding site ● Bronchiectasis, lung abscesses, and mass lesions (e.g. cancer,
using CT scan to diagnose the cause of the hemoptysis? mycetomas, and arteriovenous malformations)
A. Pulmonary embolism
B. Endocarditis
C. Chronic bronchitis
D. Bronchiectasis Page 6 trans
11. A 30-year-old male had 3-week history of hemoptysis B ● Fever is usually low grade at onset but becomes marked with
described as blood-streaked sputum. He has had recurrent progression of disease. It is classically diurnal, with an afebrile
bouts of hemoptysis for the past 5 months. There was period early in the morning and a gradually rising temperature
likewise history of cough, intermittent fever, weight loss and throughout the day, reaching a peak in the late afternoon or
malaise. Having in mind the most like cause of hemoptysis evening. Fever subsides during sleep, but night sweats may
for this case, what additional information is important is this occur. Fever and night sweats are more common among
patient’s history? patients with advanced pulmonary TB
● Cough may be absent or mild initially and may be non-
A. History of skin rash productive or productive of only scant sputum. Initially, it may
B. Exposure to TB be present only in the morning, when accumulated secretions
C. Associated edema during sleep are expectorated. As the disease progresses,
D. History if NSAID use cough becomes more continuous throughout the day and
productive of yellow or yellow-green and occasionally blood-
streaked sputum, which is rarely foul smelling. Symptomatic
individuals are more likely to have smear-positive sputum.
Frank hemoptysis, due to caseous sloughing or
endobronchial erosion, typically occurs later in the disease and
is rarely massive. Nocturnal coughing is associated with
advanced disease, often with cavitation.
● Dyspnea can occur in the setting of extensive parenchymal
involvement, pleural effusions, or a pneumothorax. Pleuritic
chest pain is not common but, when present, signifies
inflammation abutting or invading the pleura, with or without an
effusion. Rarely, this can progress to frank empyema.
● Anorexia, wasting (consumption), and malaise are common
features of advanced disease and may be the only presenting
features in some patients.
UpToDate
12. A 55-year-old female came in the emergency room C
because of 1-week history of hemoptysis described as
coughing out 2-3 spoonful of fresh blood, 4-5 times per day.
She has had repeated episodes of hemoptysis of the same
character in the past, for the last 5 years. She volunteers
repeated hospitalization for pneumonia when she was
younger. Having in mind the most likely cause of hemoptysis
for this case, which physical examination finding is expected
to be present in this patient?
A. Alar flaring
B. Bradypnea
C. Crackles on both lung fields
D. Fixed splitting of 2nd heart sound
For questions 13-14: A 19-year-old female came in because of hemoptysis amounting to 50 mL for the past 24 hours. She has had
intermittent difficulty breathing and sudden swelling of the right leg.
13. Having in mind the most likely cause of hemoptysis for B A possible side-effect of taking OCP is hypercoagulability.
this case, what additional information is important in this Formation of blood clots (DVT) increases risk of embolism which
patient’s history? may travel to the lungs and lodge in major blood vessels.
Manifestations of which include: pain in the chest, shortness of
A. History of PTB treatment breath, or coughing up blood.
B. History of oral contraceptive use
C. History of HIV http://depts.washington.edu/hhpccweb/health-resource/birth-
D. Smoking history control-pills-combined-oral-contraceptives-2/
https://www.ncbi.nlm.nih.gov/pubmed/2960241
14. Which of the following physical examination findings is D
expected to present in this patient?
A. telengiectasia
B. clubbing
C. holosystolic murmur
D. unilateral leg swelling

MED1 Samplex Rationale 2 - Cough and Hemoptysis

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MEDICINE I: COUGH AND HEMOPTYSIS

2017-2018 QUIZ SAMPLEX

Question Answer Rationale

6. Accumulation of bradykinin and stimulation of C afferent C

C. Bleeding from the upper gastrointestinal tract

2017-2018 SHIFTING EXAM SAMPLEX

Question Answer Rationale

Infection → inflammation → tissue necrosis with cavitation of lung

2016-2017 (2nd sem, 3rd shift, Quiz #1) SAMPLEX

Question Answer Rationale

1. Which of the following is/are true of cough variant D Page 3- 4 of trans

2016-2017 (2nd Sem, 3rd Shifting Exam) SAMPLEX

Question Answer Rationale

Cough Phase ● Stimulated by irritation of receptors --> Build-up of volume

7-14: TRUE or FALSE. Write A if TRUE and B if FALSE Massive Hemoptysis

The most common causes of chronic cough are postnasal drip,

2015-2016 (2nd Sem, 3rd Shifting Exam) SAMPLEX

I. Uncommon Conditions Causing Chronic Cough

Harrison’s 20th ed. (p. 231)

page 6 (Diagnostic Evaluation) and page 7 trans

2014-2015 (2nd Sem, 3rd Shifting Exam) SAMPLEX

Question Answer Rationale

4. Approach in patients with continuous hemoptysis and risk C Fiberoptic Bronchoscopy

2012-2013 SHIFTING EXAM SAMPLEX

A. Estimating the duration of cough

3. Which of the following symptoms/signs is associated with C

Harrison’s 20th ed. (p. 231)

Harrison’s 20th ed. (p. 231)

Harrison’s 20th ed. (p. 233)

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