Respiratory

Question 1

1. Breathlessness
   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

Question 2

2. Assessment of pneumonia
   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

Question 3

3. Organisms in atypical pneumonia
   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

Question 4

4. Interpretation of arterial blood gases (1)
   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

Question 5

5. Shortness of breath (1)
   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

Question 6

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
   >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

Question 7

7. Diagnostics in respiratory medicine (2)
   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

Question 8

8. Management of asthma
   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

Question 9

9. Investigations
   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

Question 10

10. Interpretation of arterial blood gases (2)
    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

Question 11

11. Bronchiectasis
    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

Question 12

12. Finger clubbing
    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

Question 13

13. Lung tumours
    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

Question 14

14. Shortness of breath (2)
    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

Question 15

15. Investigating shortness of breath
    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

Question 16

16. Management of pulmonary emboli
    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

Question 17

17. Pancoast’s tumour
    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

Question 18

18. Cough
    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

Question 19

19. Cor pulmonale
    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 sclerosisE

Answer 19

E

Question 20

20. Chest x-ray interpretation
    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

Question 21

21. Asthma
    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

Question 22

22. Management of community-acquired pneumonia
    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

Question 23

23. Complications of pneumonia
    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
    24.

Answer 23

D

Question 24

24. Cystic fibrosis (1)
    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

Question 25

25. Cystic fibrosis (2)
    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

Question 26

26. Carcinogen exposure
    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

Question 27

27. Shortness of breath (3)
    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

Question 28

28. Hypersensitivity pneumonitis
    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

Question 29

29. Pyrexia
    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

Question 30

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

C

Question 31

31. Acute management of chronic obstructive pulmonary disease
    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

Question 32

32. Hyponatraemia
    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

Question 33

33. Severity of chronic obstructive pulmonary disease
    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

Question 34

34. Management of stable chronic obstructive pulmonary disease
    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

Question 35

35. Exacerbation of asthma
    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

Question 36

36. Haemoptysis
    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

Question 37

37. Management of respiratory disease
    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

Question 38

38. Side effects of tuberculosis treatment
    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

Question 39

39. Acute respiratory distress syndrome
    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

Question 40

40. Pyrexia and tachypnoea
    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