Respiratory medicine

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

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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

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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

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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

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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

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Question 6

Diagnostics in respiratory medicine (1) 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 >30g/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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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 8.3kPa and PCO2 of 5.4kPa. 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 75mg 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

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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

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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

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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

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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

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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 15L 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

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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

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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

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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 <40mmol/L B. Sodium chloride >60mmol/L C. Sodium chloride >50mmol/L D. Sodium chloride <60mmol/L E. Sodium chloride <30mmol/L

Answer 24

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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

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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

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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

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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

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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

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Question 30

Treatment of aspergillosis 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

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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 5mg + ipratropium 500μg) 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

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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

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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

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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. 40mg 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

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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 5mg salbutamol and 500μg ipratropium nebulizers, on route to hospital, by paramedics and has received ‘back to back’ salbutamol 5mg 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

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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

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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

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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

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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

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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

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