Respiratory

Question 1

You see a 68-year-old man in clinic, with a 40 (cigarette) pack year history, who
has been experiencing breathlessness on exertion and a productive cough of white
sputum over the last four months. You assess his spirometry results which reveal an
FEV1/FVC of 51 per cent with minimal reversibility after a 2-week trial of oral
steroids. Cardiological investigations are normal. Which of the following is the
most likely diagnosis?
A. Asthma
B. Chronic obstructive pulmonary disease (COPD)
C. Left ventricular failure
D. Chronic bronchitis
E. Lung fibrosis

Answer 1

B. Chronic obstructive pulmonary disease (COPD)

The ratio of FEV1/FVC indicates an obstructive pathology, a normal result would be 80%. This obstructive pathology excludes all the pathologies here except COPD (B) and Asthma (A). The lack of any reversability and the history here indicates COPD as the likely diagnosis.

If the FEV1/FVC ratio had been greater than 80% it would indicate a restrictive pathology such as fibrosis (E).

Chronic bronchitis (D) can
be defined as cough productive of sputum for three months of two successive
years which does not corroborate with the onset of symptoms. Left ventricular
failure (C) is obviously incorrect due to the fact that cardiological tests have
been mentioned as normal.

Question 2

A 67-year-old woman is admitted to accident and emergency with pyrexia (38.1°C)
and a cough productive of green sputum. The observations show a pulse rate of
101, BP 80/60 and respiratory rate of 32. She is alert and orientated in space and
time. Blood results reveal a WCC of 21, urea of 8.5 and chest x-ray shows a patch
of consolidation in the lower zone of the right lung. She is treated for severe
community-acquired pneumonia. Which of the following is the correct calculated
CURB-65 score?
A. 6
B. 8
C. 4
D. 0
E. 1

Answer 2

C. 4

The CURB-65 score is a prognostic tool approved by the british thoracic society, it consists of a score of 1 for each factor present of the following:

C – confusion, U – urea >7 mmol/L, R – respiratory rate
>30, B – blood pressure of less than 90 systolic or less than 60 diastolic
and 65 – age of 65 or above

A score between 0 and 1 indicates that the
patient may be treated as an outpatient. Patients with a score of 2 may be
considered for a short stay in hospital with outpatient follow up. Scores
between 3 and 5 indicate severe pneumonia and hospitalization with the
possibility of escalation to intensive care being required.

This patient has a score of 4, indicating severe pneumonia. From an ewxam techniqe perspective the question tells you that she is diagnosed as having severe pneumonia, so only a limited knowledge of the CURB-65 is needed to know the score must be 3,4, or 5. Only one of which is an option here.

Question 3

Which of the following organisms would typically be found in a patient with
atypical community-acquired pneumonia?
A. Staphylococcus aureus
B. Pseudomonas spp.
C. Streptococcus pneumonia
D. Legionella pneumophilia
E. Haemophilus influenza

Answer 3

D. Legionella pneumophilia

Community pneumonias: H. influenzae (E) and S. pneumoniae (C)

Hospital aquired pneumonias: S. aureus (A) and Pseudomonas spp. (B)

Atypical pneumonias: L. pneumophilia (D), Chlamydia spp. and Mycoplasma pneumoniae,

A urinary antigen test is routinely used for
the detection of Legionella spp. Serological tests can be used for the
detection of Mycoplasma and Chlamydia spp. and also Legionella spp.

Question 4

You are asked to interpret an arterial blood gas of a 76-year-old patient who was
admitted to accident and emergency with an acute onset of breathlessness and low
oxygen saturations. The test was taken on room air and read as follows: pH 7.37,
PO2 7.8, PCO2 4.1, HCO3 24, SO2 89 per cent. Choose the most likely clinical
interpretation from these arterial blood gas results:
A. Compensated respiratory acidosis
B. Type 1 respiratory failure
C. Compensated respiratory alkalosis
D. Type 2 respiratory failure
E. None of the above

Answer 4

B. Type 1 respiratory failure

Question 5

A 54-year-old woman is seen in clinic with a history of weight loss, loss of appetite
and shortnesss of breath. Her respiratory rate is 19 and oxygen saturations (on
room air) range between 93 and 95 per cent. On examination, there is reduced air
entry and dullness to percussion on the lower to midzones of the right lung. There
is also reduced chest expansion on the right. From the list below, select the most
likely diagnosis:
A. Right middle lobe pneumonia
B. Pulmonary embolism
C. Right-sided pleural effusion
D. Right-sided bronchial carcinoma
E. Right lower lobe pneumonia

Answer 5

C. Right-sided pleural effusion

The combination of reduced air entry, dullnes to percusson (lower and middle zones), and reduced expasion all point to a pleural effusion (C) as the most likely from this list. The classic descriptor for this dullness would be ‘stoney dullness’, but in reality this would be difficult to differentiate.

You wouldn’t expect any chest signs for a pulmonary embolus (B).

Pneumonia (A)(E) and a bronchial carcinoma (D) would initially present with bronchial breathing over the affected zone, although they can lead to an eventual plueral effussion.

Question 6

A 45-year-old woman with unexpected weight loss, loss of appetite and shortness
of breath presents to you in clinic. On examination, there is reduced air entry and
dullness to percussion in the right lung. A pleural tap is performed and the aspirate
samples sent for analysis. You are told that the results reveal a protein content of
>30 g/L. From the list below, select the most likely diagnosis:
A. Bronchogenic carcinoma
B. Congestive cardiac failure
C. Liver cirrhosis
D. Nephrotic syndrome
E. Meig’s syndrome

Answer 6

A. Bronchogenic carcinoma

A plural effussion with a greater than 30g/l protein is, by definition, an exudate. An effussion with a lower protein content than 30g/L is termed a transudate.

Transudates occur as a result of a process that draws water out of the circulation or pushes it out of the circulation. For example, an increased venous pressure will drive fluid into the tissues, and can be as a result of (cardiac failure (B), restrictive pericarditis, fluid overload. Hypoproteinaemia as seen in Cirrhosis (C), nephrotic syndrome (D), or malabsorption can cause fluid to move out of the serum.

Finally Hypothyroidism and Meig’s syndrome (a right plural effussion with ovarian fibroma)(E) are two further causes of a transudate.

Exudates are sen as a result of infective/suprative (pneumonia, TB), inflammatory (Infarction, rheumatoid arthritis, SLE) or malignant (bronhogenic carcinoma, secondary metastases, lymphoma, mesothelioma, lymphangitis carcinomatosis) process.

We can see in this example that option (A) is the likely answer here.

Question 7

You are discussing a patient with your registrar who has become acutely short of
breath on the ward. After performing an arterial blood gas, you have high clinical
suspicion that the patient has a pulmonary embolism. Which of the following is the
investigation of choice for detecting pulmonary embolism?
A. Magnetic resonance imaging (MRI) of the chest
B. High-resolution CT chest (HRCT)
C. Chest x-ray
D. Ventilation/perfusion scan (V/Q scan)
E. CT pulmonary angiogram (CT-Pa)

Answer 7

E. CT pulmonary angiogram (CT-Pa)

CTPA (E) is regarded as the investigation of choice for detecting pulmonary embolus, it is readily available and is both sensitive and specific. It can detect an embolus down to the fifth order pulmonary arteries.

V/Q scan (D) is also sensitive and specific but is less readily available, due to the reporting of the V/Q scan a low probablity of PE V/Q would still need to be followed up with a CTPA. The only special case would be with pregnant patients where V/Q is preffered due to it’s lower radiation exposure.

Chest radiographs (C) are usually normal but can occasionally show decreased vascular markings, pulmonary infarction, a small effusion, or atelectasis.

A chest CT (B) will confirm atelectasis and pleaural effussion but will not show the pulmonary vasculature in enough detail.

MRI chest (A) is not used in PE diagnosis due to lengthy scan times and difficulty with out of hours scans. It is not the most accuurate method of imaging the vasculature.

Question 8

A 28-year-old man has been newly diagnosed with asthma. He has never been
admitted to hospital with an asthma exacerbation and experiences symptoms once
or twice a week. You discuss the treatment options with him. His peak expiratory
flow reading is currently 85 per cent of the normal predicted value expected for his
age and height. Which of the following is the most appropriate first step in
treatment?
A. Short-acting beta-2 agonist inhaler
B. Long-acting beta-2 agonist inhaler
C. Low-dose steroid inhaler
D. Leukotriene receptor antagonists
E. High-dose steroid inhaler

Answer 8

A. Short-acting beta-2 agonist inhaler

Current BTS guidelines advocate a stepwise approach to managing chronic asthma;

1- Short acting B2 agonist inhaler (A) such as salbutamol

2- add inhaled steroid 200-800 micrograms a day

3 - start long-acting B2 agonist, if limited response then also increase the steroid to 800 micrograms. If no responsce to the LABA then stop it and increase steroid to 800 micrograms.

4- increase steroid to up to 2000 micrograms a day and addition of a fourth drug eg leukotriene receptor antagonist, SR theophylline, β2 agonist tablet.

5- add daily steroid tablet, plus maximum dose inhaled steroid.

In this case the patient has mild asthma and is newly diagnosed, so a short acting B2 agonist is the best step.

Question 9

You see a 46-year-old man who has presented to accident and emergency with an
acute onset of shortness of breath. Your registrar has high clinical suspicion that
the patient is suffering from a pulmonary embolism and tells you that the patient’s
ECG has changes pointing to the suspected diagnosis. From the list below, which of
the following ECG changes are classically seen?
A. Inverted T-waves in lead I, tall/tented T-waves in lead III and flattened T waves in lead III
B. Deep S-wave in lead I, pathological Q-wave in lead III and inverted
T-waves in lead III
C. Flattened T-wave in lead I, inverted T-wave in lead III, and deep S-wave
in lead III
D. No changes in lead I, deep S-wave in lead III
E. Deep S-wave in lead I with no changes in lead III

Answer 9

B. Deep S-wave in lead I, pathological Q-wave in lead III and inverted
T-waves in lead III

Rarely in a pulmonary embolism there are ECG changes, these are charecteristically known as S1Q3T3 (B) which is a deep S wave in lead I, pathological Q wave in lead III and inverted T-wave in lead III.

The most common ECG finding in the case of a pulmonary embolism is of a sinus tachycardia. Other rarer signs can include; right axis deviation, RBBB, right ventricular strain (inverted T-waves in V1-V4), or atrial fibrilation.

Question 10

Which of the following arterial blood gas results, taken on room air, would you
expect to see in a 67-year-old patient who has been suffering with COPD for two
years and is not on home oxygen?
A. pH 7.35, PO2 11, PCO2 5.3, HCO3 24, SO2 98 per cent
B. pH 7.47, PO2 12, PCO2 5.1, HCO3 30, SO2 97 per cent
C. pH 7.44, PO2 8.3, PCO2 6.7, HCO3 28, SO2 93 per cent
D. pH 7.31, PO2 10.2, PCO2 6.8, HCO3 25, SO2 95 per cent
E. pH 7.30, PO2 11.5, PCO2 5.2, HCO3 18, SO2 96 per cent

Answer 10

C. pH 7.44, PO2 8.3, PCO2 6.7, HCO3 28, SO2 93 per cent

Patients with long term COPD require thier hypoxic drive to stimulate respiration, as the respiratory center is relatively insensitive to CO2. Typically COPD patients will have a type II respiratory failure picture, but the longstanding hypercapnia results in renal retention of bicarbonate and so compensates for the acidosis and normalises teh pH levels. We see this scenario in answer (C).

Question 11

You see a 46-year-old woman on your ward who has been diagnosed with
bronchiectasis following a three-month history of a mucopurulent cough. Which of
the following from the list below is not a cause of bronchiectasis?
A. Kartagener’s syndrome
B. Cystic fibrosis
C. Pneumonia
D. Left ventricular failure
E. Bronchogenic carcinoma

Answer 11

D. Left ventricular failure

Bronchiectasis is a chronic infection of the bronchi and bronchioles leading to permanent dilatation of the airways. it is mainly due to infection with H.influenzae, s.pneumoniae, s.aureus and p.aeruginosa.

Answers (A)-(C) and (E) are all well known causes of brochiectasis. Causes can be divided into;

Congenital - CF, Young’s syndrome, primary cilliary dyskinesia, Kartagner’s syndrome

Aquired: Post-infection with measles, pertussis, bronchiolitis, pneumonia, TB and HIV. It can also be aquired due to bronchial obstruction seconday to tumours or foreign bodies, allergic brochopulmonary aspergillosis (ABPA), hypogammaglobulinaemia, rheumatoid arthritis, ulcerative colitis and idiopathic.

Question 12

A 30-year-old man presents to your clinic with a cough and finger clubbing. From
the list below, which of these answers is not a respiratory cause of finger clubbing?
A. Empyema
B. Mesothelioma
C. Bronchogenic carcinoma
D. Cystic fibrosis
E. COPD

Answer 12

E. COPD

Respiratory causes of clubbing include; bronchogenis carcinoma (C), empyema (A), mesothelioma (B), cystic fibrosis (D), lung abcess, fibrosing alveolitis and bronchiectasis.

COPD (E) is not a cause of clubbing, they may present with a CO2 retention flap, peripheral cyanocic, and tar staining on the fingertips.

Question 13

A 55-year-old woman, who has never smoked, presents to you on the ward with a
history of weight loss, decreased appetite and finger clubbing. You are told that her
chest x-ray revealed opacity in the hilar region of the right lung suggesting a
bronchogenic carcinoma. She is currently awaiting a CT-chest with bronchoscopy
to follow. From the list below, select the most likely diagnosis:
A. Squamous cell carcinoma of the lung
B. Adenocarcinoma of the lung
C. Small cell carcinoma of the lung
D. Large cell carcinoma of lung
E. Carcinoid tumour of the lung

Answer 13

B. Adenocarcinoma of the lung

Question 14

You see a 28-year-old man, with no past medical history, in accident and emergency
who developed an acute onset of pleuritic chest pain and shortness of breath while
playing football. On examination, oxygen saturations are 93 per cent on room air,
respiratory rate 20 and temperature is 37.1°C. There is decreased expansion of the
chest on the left side, hyper-resonant to percussion and reduced air entry on the
left. The most likely diagnosis is:
A. Left-sided pneumothorax
B. Left-sided pneumonia
C. Left-sided pleural effusion
D. Lung fibrosis
E. Traumatic chest injury

Answer 14

A. Left-sided pneumothorax

This patient has a classic pneumothorax (A), it is of sudden onset, leading to pleuritic pain, and with the examination findings of hyper resonance, decreased air entry and reduced saturations. Spontaneous pneumothoracies are usually seen in young, tall, thin men following sub-pleural bulla rupture.

Other causes of pneumothorax include; asthma,
COPD, TB, pneumonia, connective tissue disorders (e.g. Marfan’s syndrome,
Ehlers–Danlos syndrome), trauma, iatrogenic (e.g. pleural aspiration/
biopsy, percutaneous liver biopsy, etc.)

looking at the other options here;there is no suggestion of an infectious process here (B), an effusion would be dull to percussion (C), fibrosis (D) would have fine inspiratory crackles and wouldn’t occur suddenly during a game of football and there is no mention of any trauma (E)

Question 15

You are asked to request imaging for a patient with a suspected pneumothorax who
you have just examined in accident and emergency. Which of the following would
be the most appropriate first step imaging modality?
A. CT-chest
B. Ultrasound chest
C. Chest x-ray
D. V/Q scan
E. CT-PA

Answer 15

C. Chest x-ray

A chest x-ray (C) is the investigation of choice for a simple pneumothorax. A CT (A) would show a pneumothorax but is rather unecessary. V/Q (D) and CT PA (E) are for pulmonary embolism and US chest (B) would be used in effussions.

A pneumothorax that has a rim less than 2cm wide does not require treatment unless the patient is symptomatic or has underlying pathology. These patients should then have a repeat CXR to confirm the resoloution following the conservative approach. Larger pneumothoracies require the insertion of a chest drain.

Question 16

A 68-year-old woman has presented with acute onset shortness of breath 24 hours
after a long haul flight. Her blood results show a raised D-dimer level and the
arterial blood gas shows a PO2 of 8.3 kPa and PCO2 of 5.4 kPa. Your consultant
suspects a pulmonary embolism and the patient needs to be started on treatment
while a CT-PA is awaited. From the list below, please select the most appropriate
treatment regime.
A. Commence loading with warfarin and aim for an international
normalized ratio (INR) between 2 and 3
B. Thromboembolic deterrent stockings
C. Aspirin 75 mg daily
D. Prophylactic dose subcutaneous low molecular weight heparin
+ loading with warfarin and aim for INR between 2 and 3
E. Treatment dose subcutaneous low molecular weight heparin
+ loading with warfarin and aim for INR between 2 and 3

Answer 16

E. Treatment dose subcutaneous low molecular weight heparin
+ loading with warfarin and aim for INR between 2 and 3

With any presentation of a suspected pulmonary embolism treatment dose of sub-cutaneous LMW heparin and a loading dose of warfarin should be commenced (E). Once the INR has stabilised in the required range of 2-3 the LMW heparin can be stopped and the patient to continue on warfarin for a minimum of three months.

If this is the first presentation then 3-6 months is a usual treatment duration, but if this a reccurent PE then they may be on warfarin for life. If the PE is secondaryto malignancy then they will usually be on life-long LMW heparin as studies have shown improved anti-coagulation comnpared to warfarin.

Question 17

You see a 67-year-old man who has been referred to the chest clinic following a
three-month history of weight loss and signs which may suggest a Pancoast’s
tumour. Which of the following symptoms from the list below is not associated
with a Pancoast’s tumour?
A. Hoarse voice
B. Miosis
C. Anhydrosis
D. Exopthalmos
E. Ptosis

Answer 17

D. Exopthalmos

The classic triad of signs in Horner’s syndrome are; anhydrosis, miosis and ptosis. If the Horner’s is due to compression of the sympathetic chain due to a pancoast tumour thent he tumour may also affect the reccurrent laryngeal nerve, leading to a hoarse voice.

The only sign here not associated with a pancoast tumour is exopthalmos (D) which is seen in Grave’s disease. In a Horner’s syndrome there can be an Enopthalmos (sunken eye) due to loss of the angle of the eyelid (it’s more of an illusion).

Question 18

A 50-year-old Afro-Caribbean man, with no past medical history, presents with a
four-month history of dry cough and shortness of breath on exertion. The patient’s
GP referred him to the chest clinic after performing blood tests which revealed a
raised erythrocyte sedimentation rate (ESR) and serum angiotensin-converting
enzyme (ACE) level. You review the patient’s chest x-ray which reveals bilateral
hilar lyphadenopathy. From the list below, select the most likely diagnosis:
A. Rheumatoid arthritis
B. Systemic lupus erythematosus (SLE)
C. Sarcoidosis
D. Idiopathic pulmonary fibrosis
E. Bronchogenic carcinoma

Answer 18

C. Sarcoidosis

sarcoidosis (C) is a multisystemic granulomatous disorder of unknown aetiology which commonly affects adults, with a higher prevalance in afro-caribbean populations compared to caucasians. It is usually discovered as an incidental finding on a chest xray. 20-40% of sarcoid patients are asymptomatic, acute presentations include erythema nodusum, +/- polyarthralgia.

Ninety per cent of patients with pulmonary disease will have abnormal
chest x-rays with bilateral hilar lymphadenopathy. Other signs on chest
x-ray include pulmonary infiltrates or fibrosis. Patients may present with
dry cough, progressive dyspnoea, reduced exercise tolerance and chest
pain. In some patients with pulmonary sarcoidosis (10–20 per cent),
symptoms progress leading to a decline in lung function.
Some of the non-pulmonary manifestations of sarcoidosis include
lymphadenopathy, hepatomegaly, splenomegaly, uveitis, conjunctivitis,
lacrimal and parotid gland enlargement.
Blood tests may reveal a raised ESR, lymphopenia, deranged LFTs, elevated
serum ACE and raised immunoglobulins. Twenty-four hour urine
collections may reveal hypercalciuria.
Tissue biopsy (of lung, liver, lymph nodes, skin nodules or lacrimal glands)
is usually diagnostic, with histology revealing non-caseating granulomata.
Patients with bilateral hilar lymphadenopathy without systemic
manifestations do not require corticosteroid treatment. Acute presentations
usually require bed rest, NSAIDS and possibly corticosteroid therapy.
Corticosteroid treatment is usually indicated in patients with parenchymal
lung disease, uveitis, hypercalcaemia, neurological/cardiac involvement.
In severe disease, intravenous corticosteroid therapy or immune
suppressants may be required

Question 19

A 67-year-old man presents with dyspnoea and fatigue with signs of a raised
jugular venous pressure (JVP), hepatomegaly and peripheral oedema. The patient
has a longstanding history of COPD. You suspect cor pulmonale. Which of the
following is not a cause of cor pulmonale?
A. Pulmonary fibrosis
B. Primary pulmonary hypertension
C. Myasthenia gravis
D. COPD
E. Multiple sclerosis

Answer 19

E. Multiple sclerosis

cor pulmonale is right heart failure due to chronic pulmonary hypertension. Patients tend to present with dyspnoea, fatigue/syncope. Signs include cyanosis, tachycardia, raised JVP, right ventricular heav, loud P2 + pansystolic murmur, early diastolic murmur (Graham Steel), hepatomegaly and oedema.

Causes can be due to;

• Lung disease: severe/chronic asthma, COPD (D), bronchiectasis, pulmonary fibrosis (A), lung resection
• Pulmonaryvascular disease: PE, Pulmonary vasculitis, primary pulmonary hypertension (B), ARDS, Sickle cell disease, parasites
• Thoracic cage abnormalities: Kyphosis, scoliosis, thoracoplasty
• Neuromuscular: Myastenia gravis (C), poliomyelitism mnotor neurone disease
• Hypoventilation: Sleep apnoea, enlarged adenoids in children, cerebrovascular disease.

Multiple sclerosis (E) is not a cause of cor pulmonale.

Question 20

You are told by your registrar that a 69-year-old man has been admitted to the
chest ward with dyspnoea, cyanosis and finger clubbing. His chest x-ray shows
bilateral lower zone reticulo-nodular shadowing. From the list below, which is the
most likely diagnosis?
A. Bronchiectasis
B. Pulmonary fibrosis
C. Bronchogenic carcinoma
D. Bronchitis
E. COPD

Answer 20

B. Pulmonary fibrosis

neither COPD (E) or Bronchitis (D) lead to clubbing, and only pulmonary fibrosis (B) has chest xray changes classically described as reticulo-nodular shadowing.

Question 21

A 25-year-old woman is admitted to accident and emergency with a severe
exacerbation of asthma. On examination, her respiratory rate is 30, oxygen
saturations are 95 per cent on 15 L O2 and temperature is 37.2°C. As you feel the
peripheral pulse, the volume falls as the patient inspires. Which of the following
explains this clinical sign?
A. Increased left atrial filling pressures on inspiration
B. Decreased right ventricular filling pressures on inspiration
C. Peripheral vasodilation
D. Decreased right atrial filling pressures on inspiration
E. Decreased left atrial filling pressures on inspiration

Answer 21

E. Decreased left atrial filling pressures on inspiration

The decrease in intrathoracic pressure on inspiration causes dilatation of the pulmonary vasculature, leading to decreased venous return to the Left atrium (E). The upshot of this is a drop in BP with inspiration.

In addition, an increase in negative
intrathoracic pressure also causes increased venous return to the right
atrium which leads to expansion of the right side of the heart resulting in
compromised filling of the left side of the heart.

Question 22

A 55-year-old man, who has never smoked and with no past medical history, has
been diagnosed with right basal community-acquired pneumonia. There are
minimal changes on his chest x-ray and bloods reveal a neutrophil count of 8.2 and
a C-reactive protein (CRP) of 15. He has no drug allergies. Although he has a
productive cough of green sputum, his respiratory rate is 16, oxygen saturations
are 97 per cent on room air and his temperature is 37.4°C. You are asked to place
him on treatment. Which of the following treatment options would be appropriate
for this patient?
A. Oral amoxicillin
B. Oral erythromycin
C. Intravenous ertapenem
D. Intravenous ertapenem with a macrolide (e.g. clarithromycin)
E. Intravenous tazocin

Answer 22

A. Oral amoxicillin

This patient has a simple community aquired pneumonia, with a CURB-65 score of 0, indicating he can be treated with oral antibiotics in the community. The first line therapy for a suspected typical CAP is amoxicillin (A).

A macrolide, such as erythromycin (B), may be given if an atypical organism (mycoplasma or legionella for example) is suspected. This might be the case if the patient works with air conditioners, has just come back from holiday in an airconditioned room, and plumers for example.

Question 23

A 56-year-old woman who has recently been discharged from your ward, with oral
antibiotics for right basal community-acquired pneumonia, is re-admitted with
transient pyrexia and shortness of breath. She is found to have a right-sided pleural
effusion which is drained and some pleural aspirate sent for analysis. The results
reveal an empyema. Which of the following, from the pleural aspirate analysis,
would typically be found in a patient with an empyema?
A. pH >7.2, ↑ LDH, ↑ glucose
B. pH <7.2, ↑ LDH, ↑ glucose
C. pH >7.2, ↓ LDH, ↓ glucose
D. pH <7.2, ↑ LDH, ↓ glucose
E. pH <7.2, ↔ LDH, ↔ glucose

Answer 23

D. pH <7.2, ↑ LDH, ↓ glucose

Empyema can be defined as pus in the pleural space which can occur in
patients with resolving pneumonia. Associated symptoms include transient
fever, shortness of breath and pleural effusion on the side of the resolving
pneumonia. Management includes ultrasound-guided chest drain insertion
coupled with antibiotic therapy. The pleural aspirate obtained during the chest
drain insertion may appear turbid and (yellow) straw in colour. Empyema falls
into the category of exudates, hence protein content is >30 g/L.

In the case of an empyema the bacteria will be metabolising any sugars and will be producing acidic waste productes such as lactate. This means that (D) has to be the answer.

other causes of an acidic empyema (with normal blood pH) include: pleural infections, TB, malignancy, and oesophageal rupture.

Light’s criteria states that pleural fluid can be categorized as an exudate if one
or more of the following exist: (1) The pleural fluid protein divided by serum
protein >0.5; (2) Pleural fluid LDH divided by serum LDH >0.6 and (3) Pleural
fluid LDH is more than two-thirds the upper limits of normal serum LDH.
A low glucose level (<3.3 mmol/L) is usually seen in the following
conditions:
• empyema;
• rheumatoid arthritis;
• SLE;
• TB;
• malignancy;
• oesophageal rupture

Question 24

You are told that a patient in clinic has been diagnosed with cystic fibrosis using
the sodium chloride sweat test. Which of the following results from the latter test
would indicate a positive diagnosis of cystic fibrosis?
A. Sodium chloride <40 mmol/L
B. Sodium chloride >60 mmol/L
C. Sodium chloride >50 mmol/L
D. Sodium chloride <60 mmol/L
E. Sodium chloride <30 mmol/L

Answer 24

B. Sodium chloride >60 mmol/L

Mutations in the cystic fibrosis transmembrane conductase regulator (CTFR) gene on chromosome 7 tend to lead to increased chloride secretion and sodium absorption. This leads to thickend mucus secretions leading to accumulation and plugging. Primarly symptoms are of the respiratory and gastrointestinal systems.

Other features of the condition include; male infertility, osteoporosis, arthritis, vasculitis, hypertrophic pulmonary osteoarthropathy, nasal polyps and sinisitis.

Diagnosis is usually made by a sodium chloride sweat test, with a positive teast being greater than 60 mol/ (B). Genetic testing and faecal elastase may also be tested.

Management is based on the affected symptoms and can be listed as:
(1) Respiratory: postural drainage, bronchodilators, IV/PO antibiotics (for
infective exacerbations and prophylaxis); (2) Gastrointestinal: pancreatic
enzyme replacement, fat-soluble vitamin replacement therapy,
ursodeoxycholic acid treatment if impaired liver function exists. Gene
therapy, which entails transferring the CFTR gene to the lungs using
liposomes and adenovirus vectors. Although promising, gene therapy still
carries problems concerning efficiency and target delivery of the CFTR gene

Question 25

Which of the following organisms, responsible for causing chronic pneumonia, is
most commonly found in patients with longstanding cystic fibrosis?
A. L. pneumophilia
B. S. pneumonia
C. Burkholderia cepacia
D. Pseudomonas aeruginosa
E. H. influenza

Answer 25

D. Pseudomonas aeruginosa

Mucus build-up coupled with decreased mucociliary clearance results in
clogging of the airways and an inflammation-rich environment which
predisposes patients with cystic fibrosis to chronic lower respiratory tract
infections (LRTIs). The three most common organisms responsible for
causing LRTIs in cystic fibrosis are S. aureus, H. influenza and P. aeruginosa
(D). In the early stages of the condition, S. aureus and H. influenza colonize
and infect the lung parenchyma. With time and chronicity of disease,
P. aeruginosa and Burkholderia cepacia (C) predominate with 80 per cent of
patients harbouring the former and 3.5 per cent the latter, respectively.

Question 26

From, the list below, which of the following carcinomas of the lung is highly
associated with exposure to asbestos?
A. Adenocarcinoma
B. Small cell carcinoma
C. Squamous cell carcinoma
D. Malignant mesothelioma
E. Large cell carcinoma

Answer 26

D. Malignant mesothelioma

Asbestos exposure is a strong predisposing factor for the development of malignant mesothelioma (D). Around 90% of cases of malignant mesothelioma are linked to asbestos exposure. It is a rare cancer of the mesothelial cells of the pleura, and less commonly, of the pericardium or peritonium. It has a latent period of around 40-45 years from time of exposure and development of the condition.

Question 27

You see a 67-year-old man who has presented with a four-month history of
progressive shortness of breath, initially on exertion but now also at rest. Associated
symptoms include a dry cough. His past medical history includes atrial fibrillation,
hypertension and hypercholesterolaemia. On examination, oxygen saturations are
92 per cent on room air, respiratory rate is 19 and the patient is apyrexial. On
auscultation of the chest you hear bibasal fine inspiratory crackles. You review the
patient’s medication history. Which of the following drugs from the patient’s list is
most likely to cause the symptoms experienced by the patient?
A. Amlodipine
B. Aspirin
C. Amiodarone
D. Simvastatin
E. Alendronate

Answer 27

C. Amiodarone

Amiodorone (C) is one of several drugs associated with pulmonary fibrosis, other drugs include; bleomycin, bulsulfan, nitrofuratonin, methotrexate and sulfasalazine.

Question 28

You see a 70-year-old man diagnosed with hypersensitivity pneumonitis following
a four-month history of shortness of breath at rest and cyanosis. Which of the
following does not fall under the category of hypersensitivity pneumonitis?
A. Coal worker’s lung
B. Pigeon fancier’s lung
C. Mushroom picker’s lung
D. Farmer’s lung
E. Malt worker’s lung

Answer 28

A. Coal worker’s lung

hypersensitivity pneumonitis is also known as extrinsic allergic alveolitis (EAA) occurs as a result of inhalation of organic allergens.

Coal is not an organic compound, so (A) is not a form of EAA. It is a form of pneumoconiosis.

In the acute phase of the EAA hypersensitivity reaction, alveolar infiltration occurs with inflammatory cells (e.g. monocytes and macrophages/giant cells) giving rise to
poorly formed non-caseating interstitial granulomas. In the chronic phase,
well-formed granulomas and obliterative bronchiolitis may ensue. The chronic
inflammatory process causes alvelor destruction (honeycombing of the lung)
which is associated with fibrosis. The main causes include: farmer’s lung (D) –
from mouldy hay (Thermophilic actinomycetes, Aspergillus spp.,
Saccharopolyspora rectivirgula, Micropolyspora faeni); bird/pigeon fancier’s
lung (B) – feathers and bird droppings (avian proteins); mushroom picker’s lung
(C) – from mushroom compost (T. actinomycetes); malt worker’s lung (E) – from
mouldy barley (Aspergillus clavatus) and bagassosis – from mouldy bagasse
(T. actinomycetes). Four to six hours post allergen exposure, the patient may
experience fever, rigors, dry cough and dyspnoea. With disease progression,
increasing dyspnoea, weight loss, exertional dyspnoea, type-1 respiratory
failure and cor pulmonale may occur.

Question 29

A 44-year-old plumber has a 4-day history of fever and generalized myalgia. Two
days ago he developed a dry cough coupled with mild dyspnoea and has been
feeling very lethargic. On examination his temperature is 38.5°C, respiratory rate
20, oxygen saturations ranging between 93 and 96 per cent on room air and
auscultation of the chest reveals bibasal crackles. Bloods show a raised white cell
count of 18.2 and neutrophil count of 11.0, CRP of 90 and a raised ALT of 261 and
ALP 96. Chest x-ray reveals bibasal consolidation. The patient is treated with
antibiotics for bibasal pneumonia. From the list below, select the most likely
organism responsible for the pneumonia:
A. Pseudomonas spp.
B. S. pneumoniae
C. Mycoplasma pneumoniae
D. L. pneumophilia
E. S. aureus

Answer 29

D. L. pneumophilia

In EMQ-land any plumber with pneumonia needs to make you think of Legionella pneumonia. Legionella will produce a few days of myalgia, malaise and general flu-likesymptoms, and then the patient will develop a dry cough and sometimes dyspnoea.

anorexia, d&V, hepatitis, renal failure, confusion and coma may also occur. This patient has deranged LFTs.

Blood tests may also show lymphopenia and hyponatraemia. Urine
analysis may reveal microscopic haematuria and diagnosis is usually made
using legionella urinary antigen testing or serology.
Treatment comprises of high-dose macrolide therapy.

Question 30

Which of the drugs below would be the most appropriate to treat pulmonary
Aspergillus spp. infection?
A. Amoxicillin
B. Erythromycin
C. Amphotericin B
D. Flucloxacillin
E. Fluconazole

Answer 30

C. Amphotericin B

From the answers, amoxicillin (A), erythromycin (B) and flucloxacillin (D) are
all antibacterial agents and do not target fungal infections. Therefore the only
possible answers are C and E. Fluconzaole (E), although a widely used antifungal,
is not effective against Aspergillus spp. Amphotericin B, along with other
antifungals such as voriconazole, itraconazole and caspofungin, is effective intreating Aspergillus infections which can affect the lung in five ways:
(1) Type-1 hypersensitivity reaction causing atopic asthma through inhalation
of fungal spores; (2) Allergic bronchopulmonary aspergillosis (ABPA) which
results from a type-3 hypersensitivity reaction to A. fumigates; (3) Aspergilloma
(mycetoma) which is a fungus ball within a pre-existing cavity, often caused by
tuberculosis and sarcoidosis; (4) Invasive aspergillosis which occurs in
immunocompromised patients, SLE, burns and after broad-spectrum antibiotic
therapy; and (5) Hypersensitive pneumonitis (EAA)

Question 31

A 68-year-old woman is admitted to accident and emergency with shortness of
breath and cough. She has been a smoker for 25 years, smoking on average
20 cigarettes a day, and is a known COPD patient with home oxygen. The
observations read a pulse rate of 101, blood pressure of 100/60, respiratory
rate of 20, oxygen saturations of 88 per cent on air and temperature of 37.2°C.
On auscultation you hear bilateral expiratory wheeze. She is prescribed nebulizers
(salbutamol 5 mg + ipratropium 500 μg) with oxygen and chest x-ray requested.
Intravenous access has been established and bloods sent for analysis. From the list
below, select the most appropriate next step in this patient’s management plan.
A. Arterial blood gas sampling
B. Peak flow assessment
C. Urine dip ± microscopy and sensitivity
D. Start non-invasive ventilation (e.g. BIPAP)
E. Obtain sputum for microscopy, culture and sensitivity (MC&S)

Answer 31

A. Arterial blood gas sampling

This patient is having an exacerbation of COPD, an ABG in the first instance will give an indication of this patient’s acid base status, their CO2, and O2 levels. It will also allow the effects of any inital treatment to be monitored by serial ABG’s. This is particularly key when titrating CO2 retainers on to oxygen therapy.

Peak flow assessment
(B), urine analysis (C) and sputum analysis (E), although important tests,
do not need to be carried out initially. Non-invasive ventilation (D) would
be considered following full clinical assessment of the patient coupled
with his/her acid base status from the findings of the ABG

Question 32

During the consultant ward round, you see a 78-year-old woman who is being
investigated for hyponatraemia, weight loss and haemoptysis. A mass lesion was
detected on a CT-chest scan which has been biopsied and sent for histological
analysis. Your consultant has a high suspicion that the patient may have
bronchogenic carcinoma. From the list below, select the most likely type of
bronchogenic carcinoma that would explain the above patient’s symptoms:
A. Large cell carcinoma
B. Small cell carcinoma
C. Adenocarcinoma
D. Squamous cell carcinoma
E. Alveolar cell carcinoma

Answer 32

B. Small cell carcinoma

Small cell carcinomas (B) are thought to originate from the neuroendocrine
cells of the bronchus and express neuroendocrine markers which may lead
to ectopic hormone production (e.g. ADH and ACTH), resulting in the
paraneoplastic syndromes. The patient has a likely diagnosis of syndrome
of inappropriate ADH secretion (SIADH). This results in a dilutional
hyponatraemia. Twenty-four hour urine collection will reveal high urine
sodium concentration and high urine osmolality. Symptoms of weight loss
and haemoptysis can be seen in most types of bronchogenic carcinoma
but the presenting hyponatraemia makes small cell carcinoma (B) the most
appropriate answer here.

Question 33

The severity of COPD is assessed using post bronchodilator spirometery analysis.
From the list below, select the values that you would expect to see in a patient with
moderate COPD.
A. FEV1/FVC <0.7, FEV1 per cent predicted 30–49 per cent
B. FEV1/FVC <0.7, FEV1 per cent predicted ≥80 per cent
C. FEV1/FVC <0.7, FEV1 per cent predicted <30 per cent
D. FEV1/FVC <0.7, FEV1 per cent predicted 50–79 per cent
E. FEV1/FVC <0.7, FEV1 per cent predicted 60–70 per cent

Answer 33

D. FEV1/FVC <0.7, FEV1 per cent predicted 50–79 per cent

The values are obtained with post
bronchodilator spirometry and are as follow:
Mild COPD: FEV1/FVC <0.7, FEV1 % predicted ≥80 per cent (B)
Moderate COPD: FEV1/FVC <0.7, FEV1 % predicted 50–79 per cent (D)

Severe COPD: FEV1/FVC <0.7, FEV1 % predicted 30–49 per cent (A)
Very severe COPD: FEV1/FVC <0.7, FEV1 % predicted <30 per cent (C)
Very severe COPD can also be seen in patients with FEV1 % predicted <50
per cent with respiratory failure.

Question 34

A 58-year-old man with known COPD, diagnosed eight months ago, attends your
clinic with persistent shortness of breath despite stopping smoking and using his
salbutamol inhaler (given to him at the time of diagnosis), which he finds he is
using more frequently. You assess the patient’s lung function tests that have been
recorded just before he saw you in clinic on this occasion. His FEV1 = 65 per cent
of the predicted value. Oxygen saturations are 95 per cent on room air, respiratory
rate in 18, and his temperature is 37.1°C. From the list below, select the next most
appropriate step in this patient’s management.
A. 40 mg daily oral prednisolone for 5 days
B. Start long-term oxygen therapy
C. Start inhaled corticosteroid therapy
D. Add oral theophylline therapy
E. Add a long-acting β2 agonist inhaler

Answer 34

E. Add a long-acting β2 agonist inhaler

First stage in COPD management is a short acting beta2 agonist (SABA), such as salbutamol, or a short acting muscarinic antagonist (SAMA) such as ipatropium.

If the patient is not well controlled on one of these drugs then one of two pathways are available;

if FEV1>50% they can add a LABA (e.g salmeterol) to the SABA

or swap thier SAMA for a LAMA (eg tiotropium)

If FEV1 <50% they can add a combination LABA +corticosteroid inhaler, or the addittion of a LAMA to replace any SAMA.

If they still have problems then the remainin therapy is added (it’s a bit complex at this point).

In this case this patient is on a SABA with a good FEV1 so the next step would be to add a LABA or a LAMA. The closest answer then is (E)

Oxygen (i.e. long-term oxygen therapy) (B) therapy should be assessed in
patients who have any of the following:
• very severe airflow obstruction (e.g. FEV1 <30 per cent predicted);
• cyanosis;
• polycythaemia;
• peripheral odema;
• raised JVP;
• oxygen saturations less than or equal to 92 per cent on room air.

Question 35

A 58-year-old man is admitted with a mild exacerbation of asthma. He suffers with
hypertension which is controlled with medication. He was given 5 mg salbutamol
and 500 μg ipratropium nebulizers, on route to hospital, by paramedics and has
received ‘back to back’ salbutamol 5 mg nebulizers since admission to accident and
emergency. The patient was then sent to the acute medical unit where he was given
regular nebulizers along with his regular antihypertension medication. Before he
was discharged, his serum potassium reading was 2.9. Select, from the list below,
the drug which is most likely to have caused the hypokalaemia.
A. Ipratropium
B. Ramipril
C. Salbutamol
D. Amlodipine
E. Paracetamol

Answer 35

C. Salbutamol

Salbutamol (C) has a known side efect of driving potassium into the cells, and is acually sed for this effect in cases of hyperkalaemia.

Ramipril (B) can cause hyperkalaemia, none of th other drugs have any known effect on potassium levels.

Question 36

A 56-year-old man attends your clinic with a three-month history of a productive
cough with blood-tinged sputum, following his return from India. Associated
symptoms include lethargy, night sweats and decreased appetite. He is normally fit
and healthy with no past medical history. On examination, the patient’s chest has
good air entry bilaterally with no added sounds and his temperature is 37.3°C.
A sputum sample sent from the patient’s GP reveals a growth of acid fast bacilli.
From the list below, which is the most likely diagnosis?
A. Pulmonary embolism
B. Tuberculosis
C. Bronchitis
D. Pneumonia
E. Bronchogenic carcinoma

Answer 36

B. Tuberculosis

all of the answers here can lead to heamoptosis, however, the description of acid fast bacilli screams mycobacteria, which in this case is tuberculosis (B).

Question 37

Your clinic patient has been diagnosed with pulmonary tuberculosis (TB) following
a three-month history of haemoptysis and fever. The patient is due to start on
treatment and you are asked by your registrar which of the following regimes is the
most suitable. The patient has no known drug allergies and, in addition, liver
function tests and urea and electrolytes results are all within normal ranges. From
the list below, which of the following answers is the most appropriate and
recommended treatment regimen for this patient?
A. Three months of isoniazid, rifampicin, ethambutol and pyrazinamide,
followed by three months of isoniazid and rifamipicin
B. Four months of isoniazid and rifampicin, followed by two months of
isoniazid, rifampicin, ethambutol and pyrazinamide
C. Six months of isoniazid, rifampicin, ethambutol and pyrazinamide
D. Six months of isoniazid and rifampicin
E. Two months of isoniazid, rifampicin, ethambutol and pyrazinamide,
followed by four months of isoniazid and rifampicin

Answer 37

E. Two months of isoniazid, rifampicin, ethambutol and pyrazinamide,
followed by four months of isoniazid and rifampicin

NICE guidelines for fully drug susceptable TB are for two months 4 drug therapy ‘RIPE’, and then four months of Isoniazid and Rifampicin. The only special case is if there is CNS involvement.

Second-line drugs (e.g. amikacin, capreomycin, cycloserine, azithromycin,
clarithromycin, moxifloxain and levofloxacin) are used in special
situations such as bacterial resistance and drug intolerance.

Question 38

A 45-year-old man with diabetes, diagnosed with pulmonary TB who started
treatment two months ago, presents to you with a week’s history of pins and
needles in his hands and feet with associated numbness. He tells you that his
symptoms started since he stopped taking the vitamins given to him at the start of
his TB treatment. From the list below, which of the following drugs is responsible
for the symptoms described by the patient?
A. Pyrazinamide
B. Rifampicin
C. Ethambutol
D. Isoniazid
E. None of the above

Answer 38

D. Isoniazid

This patient is suffering from peripheral neuropathy secondary to isoniazid
(D) administration. Isoniazid is associated with depletion of vitamin B6
(pyridoxine) and therefore results in peripheral neuropathy. Other side
effects include rash, deranged liver function (, CNS effects
and sideroblastic anaemia.

pyrazinamide (A) can cause arthralgia, hepatoxicity, gastrointestinal
disturbances, rash, pruritus and sideroblastic anaemia.

Side effects of rifampicin (B) include hepatoxicity, fever, gastrointestinal disturbances, rash and can also cause the urine and tears to become an orange–red colour which is considered a benign side effect.

The side effects associated with ethambutol (C) include optic
neuritis, red–green colour blindness, peripheral neuropathy and vertical
nystagmus. Although ethambutol could also be a possible answer here, the clue given in the question points to the patient having stopped taking his vitamins
which are usually given in conjunction with isoniazid treatment.

Question 39

A 37-year-old woman is admitted to accident and emergency with severe facial
burns. Despite prompt management, she develops acute respiratory distress
syndrome (ARDS). Which of the following is not associated with the diagnostic
criteria for ARDS?
A. Bilateral infiltrates on chest x-ray
B. Acute onset
C. Pulmonary capillary wedge pressure >19
D. Refractory hypoxaemia (PaO2:FiO2 <200)
E. Lack of clinical congestive heart failure

Answer 39

C. Pulmonary capillary wedge pressure >19

Causes can be divided into: (1) Pulmonary (e.g. pneumonia, gastric
aspiration, inhalation of smoke/soot, trauma, contusions and vasculitis);
and (2) extrapulmonary (e.g. septic/haemorrhagic shock, multiple transfusions, DIC and pancreatitis).

Clinical features include cyanosis, tachypnoea, tachycardia, peripheral
vasodilation and bilateral fine inspiratory crackles.

A diagnosis of ARDS is made if all four of the following criteria exist:
1 acute onset (B);
2 bilateral infiltrates present n chest X-ray (A);

3 pulmonary capillary wedge pressure of <19 mmHg or lack of clinical
congestive heart failure (E);
4 refractory hypoxaemia with PaO2:FiO2 <200 (D) for ARDS.

A total intrathoracic compliance of <30 mL/cm H2O may also exist.
Management is ITU based and involves supportive therapy and treating
the underlying cause.

Question 40

You see a 76-year-old woman in accident and emergency who has been admitted
with a 1-day history of shortness of breath and pyrexia (38.4°C). The patient’s past
medical history includes hypertension, stroke and insulin-dependent diabetes. She
has no known drug allergies. The nursing staff report that the patient vomited after
her lunchtime meal yesterday. On examination the patient’s respiratory rate is 26,
oxygen saturations 93 per cent on room air. On auscultation of the chest, you hear
right basal crackles. You suspect that this patient is suffering from aspiration
pneumonia. From the list below, which is the most appropriate antibiotic regimen
for this patient?
A. Intravenous cefuroxime and metronidazole
B. Oral amoxillicin and metronidazole
C. Intravenous clarithromycin
D. Intravenous cefuroxime
E. Oral co-amoxiclav

Answer 40

A. Intravenous cefuroxime and metronidazole

It is very important to consider the use of a broad spectrum antibiotic
coupled with another agent that will cover for anaerobic bacteria from the
oral flora and gastric contents (e.g. Bacteroides spp., Prevotella spp.,
Fusobacterium spp., etc.). In addition, this patient is systemically unwell
and the use of intravenous antibiotics would be more appropriate in the
initial stages of treatment.

So the best choice from the above list would be (A) for it’s broad cover and IV administration.