Welcome to Chapter 4 Part 3 of our comprehensive Orthopedic Prometric Exam Simulator. This interactive test features 20 high-yield multiple-choice questions designed to help you prepare for the Saudi Prometric (SCFHS), DHA, HAAD, SLE, and OMSB orthopedic surgery exams.

Use the Study Mode to view detailed explanations instantly, or switch to Exam Mode to test your speed and accuracy under simulated testing conditions.

Prometric Exam Simulator

00:00

Start Quiz

Question 1

Which of the following is most likely to preclude curative lobectomy for lung carcinoma?

Explanation

Correct Answer: D- Malignant pleural effusions Explanation Malignant pleural effusions A malignant pleural effusion usually implies widely disseminated disease and any treatment is therefore often palliative. Forced expiratory volume in 1 s (FEV1) of 1.6 l Forced expiratory volume in 1 s (FEV1) of 1.6 l is incorrect. A forced expiratory volume in 1 s (FEV1) of over 1.5 l suggests that the patient has sufficient lung function to undergo an operation of this nature, but many of these patients will have considerable cardiorespiratory co-morbidity and a rigorous preoperative assessment is always required. Hypercalcaemia Hypercalcaemia is incorrect. Hypercalcaemia could be due to invasion of bone by the tumour, but this is not necessarily so; malignant cells in the lung tumour can produce humoral mediators which lead to an increase in the serum calcium level. Local invasion by primary tumour through the chest wall Local invasion by primary tumour through the chest wall is incorrect. Local invasion by the primary tumour through the chest wall is not in itself a reason why curative surgery should not be attempted, depending on the precise anatomy involved. Mediastinal lymph nodes enlarged on computed tomography (CT) Mediastinal lymph nodes enlarged on computed tomography is incorrect. The appearance of enlarged mediastinal lymph nodes on CT is suggestive of malignant spread but does not confirm it, thus this option is incorrect. A mediastinoscopy or biopsy guided by endobronchial ultrasound should be performed to confirm any enlarged nodes were malignant and if contralateral mediastinal nodes are confirmed malignant (ie N3 disease) then surgery would be contraindicated.

Question 2

A 32-year-old patient with asthma has been stable with inhaled salbutamol when required. Recently she has had to use her inhaler more frequently and also at night. What is the next step in her therapy?

Explanation

Correct Answer: E- Regular inhaled budesonide, inhaled salbutamol when required Explanation Regular inhaled budesonide, inhaled salbutamol when required This patient requires an escalation in her asthma management. At this stage with frequent use of salbutamol, a regular inhaled steroid for preventative therapy is required. With inhaled budesonide one appropriate option. Addition of oral corticosteroids Addition of oral corticosteroids is incorrect. Oral corticosteroids are reserved for step-5 managament of asthma that is not controlled with inhaled steroids, long- acting bronchodilators and additional oral therapies such as montelukast. Addition of oral leukotriene-receptor antagonist Addition of oral leukotriene-receptor antagonist is incorrect. Oral leukotriene-receptor antagonists are indicated as a trial after low dose inhaled corticosteroids. Addition of oral theophylline Addition of oral theophylline is incorrect. Oral theophylline is indicated after maximal inhaled corticosteroids and LABA if the asthma is still not controlled. Inhaled ß2-agonist at maximum dose Inhaled ß2-agonist at maximum dose is incorrect. The deterioration of symptoms on short-acting ß2- agonist monotherapy indicates inhaled steroids are required, ie step-2 asthma therapy.

Question 3

A 35-year-old woman presents with a 6-week history of malaise, with a dry cough, sweats and a stitch-like, right- sided chest pain. Apparently she had a heavy cold and cough at the beginning of the episode that improved initially. A past history of rheumatoid arthritis for which she takes weekly methotrexate is noted. On examination her BP is 125/80 mmHg, pulse is 75 bpm and regular. There are diminished breath sounds on the right-hand side of the chest and it is dull to percussion. There is no evidence of active synovitis. Investigations:

Hb 12.1 g/dl

WCC 11.2 × 109/l

PLT 303 × 109/l

ESR 72 mm/h

Na+ 137 mmol/l

K+ 4.3 mmol/l

Creatinine 110 μmol/l

CXR Right-sided pleural effusion Effusion pH 7.08 Effusion LDH 1556 U/l Effusion Glucose 2.0 mmol/l Effusion Protein 45 g/l Which of the following is the most likely diagnosis?

Explanation

Correct Answer: A- Empyema Explanation Empyema The pH, LDH and glucose all fit the criteria for diagnosis of empyema (rather than parapneumonic effusion) as defined in BTS guidelines. In all likelihood the empyema developed as a result of an acute pneumonia some 6 weeks earlier. Inflammatory pleural effusion Inflammatory pleural effusion is incorrect. The raised white count and ESR support the presence of continuing infection as no evidence is given of a flare of her rheumatoid. Mesothelioma Mesothelioma is incorrect. There is no history of asbestos exposure to support a diagnosis of mesothelioma. Parapneumonic effusion Parapneumonic effusion is incorrect. The pH, LDH and glucose all fit the criteria for diagnosis of empyema (raher than parapneumonic effusion) as defined in BTS guidelines. In all likelihood the empyema developed as a result of an acute pneumonia some 6 weeks earlier. Tuberculous effusion Tuberculous effusion is incorrect. With respect to tuberculosis we would expect a history of symptoms of greater than 6 weeks.

Question 4

A 71-year-old man who has a 40-pack-year smoking history presents to the GP with shortness of breath and bilateral ankle swelling. On examination he has a blood pressure of 145/90 mmHg, a plethoric face and bilateral coarse wheeze on auscultation of the chest. There is pitting oedema affecting both ankles. Which of the following has proved mortality benefit in this condition?

Explanation

Correct Answer: D- Long-term oxygen therapy Explanation Long-term oxygen therapy This patient has chronic obstructive pulmonary disease (COPD) with cor pulmonale, right ventricular failure. Both the National Heart Lung and Blood Institute (NHLB) and the Medical Research Council (MRC) trials showed a mortality benefit of long-term oxygen therapy (LTOT) in COPD. Although LTOT doubles the chances of survival, it must be used for over 15 h per day, but poor patient compliance often means this cannot be met. Bisoprolol Bisoprolol is incorrect. Bisoprolol offers benefit in left ventricular failure. Digoxin Digoxin is incorrect. Digoxin, although it offers relief of symptoms in severe heart failure, does not offer mortality benefit. Ipratropium Ipratropium is incorrect. Although useful for relief of COPD symptoms, ipratropium has no impact on survival. Ramipril Ramipril is incorrect. Ramipril offers benefit in left ventricular failure.

Question 5

A 60-year-old woman attends the clinic complaining of shortness of breath over the preceding 2 months. She has also had problems with nasal irritation, discharge and sinus pain. She is known to have asthma, which has recently been poorly controlled, despite inhaled steroids. Her full blood count has shown an eosinophilia of 13% and her chest X-ray shows peripheral pulmonary shadows. What is the most likely diagnosis?

Explanation

Correct Answer: C- Eosinophilic granulomatosis with polyangiitis Explanation Eosinophilic granulomatosis with polyangiitis Eosinophilicgranulomatosis with polyangiitis is an eosinophilic granulomatous inflammation of the respiratory tract with small- and medium-vessel necrotising vasculitis. It is diagnosed on finding four out of the following:

• Asthma • Blood eosinophilia > 10% • Vasculitic neuropathy • Pulmonary infiltrates • Sinus disease • Extravasculareosinophils on biopsy findings It is diagnosed clinically, although a biopsy should be sought for pathological confirmation. Allergic bronchopulmonaryaspergillosis Allergic bronchopulmonary aspergillosis (ABPA) is incorrect. ABPA is a condition in which people with asthma have a vigorous IgE response to Aspergillus, with associated eosinophilia, a positive skinprick test to Aspergillus and flitting consolidation on the chest X-ray. There is no associated sinus disease. Cryptogenic organising pneumonia Cryptogenic organising pneumonia (COP) is incorrect. COP is not typically associated with an eosinophilia. Granulomatosis with polyangiitis Granulomatosis with polyangiitis is incorrect. Granulomatosis with polyangiitis is not typically associated with an eosinophilia. Severe asthma Severe asthma is incorrect. This woman’s eosinophil count is high, higher than it would be with asthma alone, and the abnormal chest radiograph suggests an

alternative diagnosis. Causes of eosinophilia include:

• Allergic or hypersensitivity disease, including asthma with associated eczema • Allergic bronchopulmonary aspergillosis • Eosinophilic granulomatosis with polyangiitis • Loeffler syndrome • Tropical pulmonary eosinophilia • Chronic pulmonary eosinophilia • Hypereosinophilic syndrome • Acute eosinophilic pneumonia

Question 6

Which of the following investigations is most specific to allergic bronchopulmonary aspergillosis (ABPA)?

Explanation

Correct Answer: A- An early positive skinprick test for Aspergillus fumigatus Explanation An early positive skinprick test for Aspergillus fumigatus Positive skinprick tests reflect antigen-specific IgE. Computed tomographic (CT) evidence of proximal bronchiectasis Computed tomographic (CT) evidence of proximal bronchiectasis is incorrect. Proximal bronchiectasis is a feature of classical ABPA but it is not pathognomic and other causes of bronchiectasis should be considered. Positive history of exposure to Aspergillus Positive history of exposure to Aspergillus is incorrect. A specific exposure history is very difficult to elicit. Most people are exposed to small amounts of Aspergillus regularly and inhale spores in the air. However, only a minority become sensitised to Aspergillus and develop ABPA. Positive precipitins for Aspergillus Positive precipitins for Aspergillus is incorrect. Precipitins (IgG) are more usual with an aspergilloma, but may be positive in ABPA or in up to 10% of patients with asthma. Upper-zone fibrosis Upper-zone fibrosis is incorrect. Allergic bronchopulmonary aspergillosis is characterised by wheezy breathlessness, serum eosinophilia and pulmonary infiltrates on X-ray. Lobar collapse can also occur, due to mucus plugging. ABPA can cause apical fibrosis in its most severe form; however, there are many other causes of upper-lobe fibrosis, including tuberculosis, extrinsic allergic alveolitis, sarcoidosis and ankylosing spondylitis.

Question 7

A 58-year-old woman is admitted to the Emergency Department with suspected community- acquired pneumonia. She has a progressively worsening cough, productive of rusty sputum and shortness of breath over the past 3 days. She smokes five cigarettes per day, has hypertension treated with lisinopril, but no other significant past medical history. On examination her BP is 105/60 mmHg; pulse is 85/min and regular. There are signs of right lower lobe consolidation on auscultation. Respiratory rate is raised at 32, O2 sats on 40% O2 are 96%. Investigations:

Hb 13.1 g/dl

WCC 15.8 × 109/l

PLT 203 × 109/l CRP 230 mg/l

Na+ 138 mmol/l

K+ 4.5 mmol/l

Creatinine 122 μmol/l

Urea 6.9 mmol/l According to CURB-65 criteria, which of the following is a measure of increased severity?

Explanation

Correct Answer: C- Respiratory rate 32/min Explanation Respiratory rate 32/min CURB-65 criteria were drawn up to provide standardised assessment of the severity of pneumonia. They are listed below • confusion at onset (defined as an AMT of 8 or less) •

urea greater than 7 mmol/l (19 mg/dl) • respiratory rate of 30 breaths per minute or greater • blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less • age 65 or older. The number of criteria correlate well with mortality at 30 days:

• 0 – 0.7% • 1 – 3.2% • 2 – 13.0% • 3 – 17.0% • 4 – 41.5% • 5 – 57.0% Any score of 2 or greater usually requires hospitalisation. Age 58 Age 58 is incorrect. Age ≥ 65 is a measure of increased severity. CRP 230 mg/l CRP 230 mg/l is incorrect. CRP is not classed as a measure of increased severity. Urea 6.9 mmol/l

Urea 6.9 mmol/l is incorrect. Urea greater than 7 mmol/l is a measure of increased severity. WCC 15.8 × 109/l

WCC 15.8 × 109/l is incorrect. WCC is not part of the CURB-65 score, which is the severity scoring system used in the UK. The pneumonia severity index, used in the USA, does include WCC with a WCC < 4 × 109/l or > 20 × 109/l indicating increased severity of pneumonia.

Question 8

A 65-year-old man known to have chronic obstructive pulmonary disease presented with progressive respiratory failure. He was treated in the Intensive Care Unit with mechanical ventilation and he improved. After extubation he was transferred to the ward. On the 2nd day on the ward his temperature spiked and he developed a productive cough with a yellow-green sputum. Blood results showed leucocytosis. A chest X-ray revealed a right-sided middle- and lower-lobe pneumonia. What is the most probable cause of his pneumonia?

Explanation

Correct Answer: D- Pseudomonal pneumonia Explanation Pseudomonal pneumonia Pseudomonas is a common pathogen in patients with bronchiectasis and cystic fibrosis. It also causes hospital- acquired infections, particularly in intensive care units or after surgery. Nosocomial or hospital-acquired infections should be suspected in patients with an onset of symptoms at least 48 hours after admission to the hospital. The sputum colour also gives a clue to the most likely diagnosis. Treatment is with anti-pseudomonal penicillin, ceftazidime, meropenem or ciprofloxacin. Aspiration pneumonia Aspiration pneumonia is incorrect. There is no history given to suggest this gentleman has aspirated. Haemophilus pneumonia Haemophilus pneumonia is incorrect. Haemophilus pneumoniae is more typically seen as a cause of community acquired pneumonia. Pneumococcal pneumonia Pneumococcal pneumonia is incorrect. Pneumcoccal pneumonias are usually community acquired. This man has a nosocomial pneumonia and is likely associated with being invasively ventilated. Pseudomonas aeruginosa is a common cause of ventilator associated pneumonia. Staphylococcal pneumonia Staphylococcal pneumonia is incorrect. Staphylococcal pneumonias are typically seen in immunosuppressed patients and intravenous drug abusers or following a viral respiratory tract infection. Staphylococcus aureus can be a cause of nosocomial pneumonia but ventilator associated pneumonias occurring late into an admission are typically due to gram negative bacteria and therefore Pseudomonal pneumonia is more likely in this case.

Question 9

A 32-year-old nurse who has had a positive tuberculin skin test comes to you for advice. She had been in contact with a patient who had pulmonary tuberculosis some 6 days earlier, and has not received a BCG vaccination in the past. She is well and her chest X-ray is normal. She has started a course of isoniazid and rifampicin. Which of the following is the most appropriate occupational health advice?

Explanation

Correct Answer: A- Continue isoniazid and rifampicin for at least 3 months Explanation Continue isoniazid and rifampicin for at least 3 months The National Institute for Health and Care Excellence (NICE) Guideline 33 suggests that healthcare workers with a positive tuberculin test after exposure to tuberculosis (TB) should be treated with a combination of isoniazid and rifampicin for 3 months or isoniazid alone for a period of 6 months. The positive tuberculin test raises the possibility of latent TB infection in this healthcare worker, which can be associated with a not inconsiderable risk of infection for patients if there is later development of pulmonary TB. Continue isoniazid and rifampicin for 1 month then isoniazid for a further 2 months Continue isoniazid and rifampicin for 1 month then isoniazid for a further 2 months is incorrect. The National Institute for Health and Care Excellence (NICE) Guideline 33 suggests that healthcare workers with a positive tuberculin test after exposure to TB should be treated with a combination of isoniazid and rifampicin for 3 months or isoniazid alone for a period of 6 months. The positive tuberculin test raises the possibility of latent TB infection in this healthcare worker, which can be associated with a not inconsiderable risk of infection for patients if there is later development of pulmonary TB. Stay off work and have a repeat chest X-ray in 6 weeks Stay off work and have a repeat chest X-ray in 6 weeks is incorrect. There is no evidence this lady has active TB. She has latent TB, which is not infectious, and therefore she need not stay off work if she is well. Stay off work for 2 weeks while she is on the initial prophylactic isoniazid course Stay off work for 2 weeks while she is on the initial prophylactic isoniazid course is incorrect. There is no evidence this lady has active TB. She has latent TB, which is not infectious, and therefore she need not stay off work if she is well. Stay off work for 6 weeks Stay off work for 6 weeks is incorrect. There is no evidence this lady has active TB. She has latent TB, which is not infectious, and therefore she need not stay off work if she is well.

Question 10

A 30-year-old asthmatic patient has the following drug regimen: regular inhaled corticosteroids, regular inhaled long-acting•ß2-agonists (salmeterol), oral leukotriene- receptor antagonists and inhaled short-acting ß2-agonists when required. Although her compliance is good, her symptoms are still not satisfactorily controlled. What is the next step in her therapy?

Explanation

Correct Answer: D- Oral theophylline Explanation Oral theophylline Theophylline is indicated in the treatment of chronic asthma when symptoms are still not controlled despite inhaled corticosteroids, long-acting ß-agonists and leukotriene receptor antagonists. Theophylline improves lung function and symptoms, but side-effects occur more commonly. Antibiotics Antibiotics is incorrect. Antibiotics are only indicated if there is evidence of a (non-viral) infective exacerbation, which is not the case here. Oral cromoglicate Oral cromoglicate is incorrect. Inhaled, not oral, cromoglicate is used in the treatment of asthma. Oral steroids Oral steroids is incorrect. Oral steroids are appropriate in acute exacerbations of asthma. Their long- term use is reserved as ‘step 5’ treatment. This lady requires ‘step 4’ treatment. Switch to nebuliser Switch to nebuliser is incorrect. Salbutamol nebulisers are usually reserved for the management of acute asthma exacerbations. They are occasionally used at home by very severe asthmatics on otherwise maximal therapy.

Question 11

A 36-year-old lorry driver who smokes heavily has been complaining of a 2-day history of cough associated with fever. He also complains of right-sided chest pain on inspiration. On examination, he is slightly cyanosed, has a temperature of 38 °C, a respiratory rate of 38/min, a BP of 100/70 mm/Hg and a pulse rate of 130 bpm. He has basal crepitations and dullness to percussion at the right lung base. What is the most likely diagnosis?

Explanation

Correct Answer: B- Lobar pneumonia Explanation Lobar pneumonia The classic presentation of pneumonia is of a cough and fever with the variable presence of sputum production, dyspnoea and pleurisy. Most patients have constitutional symptoms such as malaise, fatigue and asthenia, and many also have gastrointestinal symptoms. Examination of the lung might reveal decreased vesicular breath sounds, localised foci of crepitations, dullness to percussion and sometimes bronchial wheeze. The chest X-ray is a pivotal test for the confirmation of pneumonia. Atelectasis due to carcinoma of the lung Atelectasis due to carcinoma of the lung is incorrect. The acute history associated with signs of infection and the relatively young age of this patient make a diagnosis of pneumonia more likely than lung cancer with atelectasis. Mesothelioma Mesothelioma is incorrect. There is no history suggestive of asbestos exposure here. The acute nature of this gentleman’s symptoms combined with evidence of infection make pneumonia a more likely diagnosis. Mesothelioma would typically have a more gradual onset of symptoms and present with progressive dyspnoea and/or chest pain. Pneumothorax Pneumothorax is incorrect. The history is compatible with infection and the signs are not compatible with pneumothorax. In pneumothorax clinical examination would reveal decreased air entry and hyper resonance to percussion. Tuberculosis Tuberculosis is incorrect. The history given is of respiratory infection, so tuberculosis is a possibility; however, nothing in the history suggests an increased risk of tuberculosis (eg previous TB, contact with patients known to have TB, immunosuppression, alcoholism). Therefore a bacterial pneumonia is more likely.

Question 12

Which lung disease is associated with the descriptions of ‘pink puffer’ and ‘blue bloater’?

Explanation

Correct Answer: A- Chronic obstructive pulmonary disease Explanation Chronic obstructive pulmonary disease Pink puffers have a good respiratory drive. Clinical features:

• Pursed-lip breathing with intense dyspnoea • Often thin and elderly • Sparce production of sputum • Oedema and overt heart failure (rare complications)

Investigations:

• Blood gases are near-normal until pre-terminally there is very severe airways obstruction • Total lung capacity increased • Reduction in transfer factor Blue bloaters have a poor respiratory drive. Clinical features:

• Quite mild dyspnoea • Often obese • Production of large volumes of sputum • Infective exacerbations • Often oedematous • Can develop cor pulmonale Investigations:

• Blood gases show hypercapnia, hypoxaemia, elevated plasma bicarbonate • Severe nocturnal hypoxaemia • Airways obstruction might only be moderate • Transfer factor approximately normal Cystic fibrosis Cystic fibrosis is incorrect. Cystic fibrosis is not associated with the descriptions in the question. Pulmonary fibrosis Pulmonary fibrosis is incorrect. Pulmonary fibrosis is not associated with the descriptions in the question. Small-cell lung cancer Small-cell lung cancer is incorrect. Small-cell lung cancer is not associated with the descriptions in the question. Tuberculosis Tuberculosis is incorrect. Tuberculosis is not associated with the descriptions in the question.

Question 13

A 30-year-old woman presents with shortness of breath. This began gradually, around 2 years ago, but now she is breathless on climbing a flight of stairs. There is no past history of note. On examination, the jugular venous pulse is raised, carotid pulse volume is reduced and there is evidence of right ventricular hypertrophy. There are right-sided murmurs on cardiac auscultation. Her chest X-ray shows pulmonary artery enlargement; the electrocardiogram shows right axis deviation and right ventricular hypertrophy. Arterial blood gases reveal hypoxia and hypercapnia; a lung perfusion scan is normal. Cardiac catheterisation reveals that right-sided pressures are markedly raised. Which diagnosis best fits with this clinical picture?

Explanation

Correct Answer: D- Primary pulmonary hypertension Explanation Primary pulmonary hypertension Primary pulmonary hypertension is characterised by the development of significantly raised pulmonary artery pressure with no apparent cause (normal VQ scan, no evidence of left heart failure). Plexogenic pulmonary arteriopathy is found in 30–60% of people with this condition and is characterised by medial hypertrophy and concentric laminar intimal fibrosis. The gene for primary pulmonary hypertension has now been mapped to chromosome 2, and mutations in the bone morphogenic protein receptor have been identified in some patients. Intravenous epoprostenol (prostacyclin) and oxygen therapy have been shown to improve quality of life in sufferers.

Phosphodiesterase-5 (PDE-5) inhibitors and endothelin receptor antagonists have also been shown to have some therapeutic effect. Unfortunately, several studies report a mean survival of only 2.5 years from diagnosis, with right ventricular failure and sudden death the main causes of death. Asthma Asthma is incorrect. This lady has evidence of significant right heart failure and her main respiratory symptom is dyspnoea rather than wheeze or cough. The symptoms and investigations described are not in keeping with a diagnosis of asthma. Chronic thromboembolic disease Chronic thromboembolic disease is incorrect. The perfusion scan is not suggestive of chronic thromboembolic disease, which makes primary pulmonary hypertension the most likely diagnosis. Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. Idiopathic pulmonary fibrosis (IPF) typically occurs in the sixth decade of life. If IPF is advanced enough to cause right ventricular hypertrophy (as is described in this case) then it is likely that the chest radiograph would show significantly abnormal lung fields with reticulonodular shadowing +/- honeycombing. Right ventricular failure Right ventricular failure is incorrect. This case does indeed describe right ventricular hypertrophy and failure, but given the dyspnoea and degree of hypoxia with a normal chest X-ray other than pulmonary artery hypertrophy and the patient’s age then primary pulmonary hypertension is the diagnosis that best fits the clinical picture in its entirety.

Question 14

You are called to see a 50-year-old woman who is having difficulty breathing after undergoing a laparoscopic cholecystectomy. She is making a lot of noisy inspiratory effort with stridor. You notice that she is on long-term warfarin for thromboembolic disease, salbutamol and inhaled steroids for asthma and penicillamine for severe rheumatoid arthritis. Which of the following tests would be the most helpful in diagnosing her current problem?

Explanation

Correct Answer: D- Spirometry with flow–volume loop Explanation Spirometry with flow–volume loop This woman has stridor due to cricoarytenoid arthritis. This is seen in studies in up to 75% of patients with rheumatoid arthritis. It can cause sore throat, hoarse voice and stridor, but is often asymptomatic. However, symptoms can rapidly worsen in the post-operative period. It is unrelated to any lung fibrosis. The flow– volume loop can be abnormal, as can direct laryngoscopy and high- resolution computed tomography of the larynx. Patients can need urgent tracheostomy and steroids, both orally and via joint injection. Chest X-ray Chest X-ray is incorrect. Chest X-ray may well be normal and therefore unhelpful here. Computed tomography scan of the chest Computed tomography (CT) scan of the chest is incorrect. CT chest would not show the cricoarytenoid arthritis. CT imaging of the larynx would be required. Peak flow Peak flow is incorrect. Peak flow measurement is useful in assessing the severity of an exacerbation of asthma.The presence of stridor makes an acute exacerbation of this lady’s asthma unlikely. Spirometry with transfer factor measurement Spirometry with transfer factor measurement is incorrect. This lady has stridor due to cricoarytenoid arthritis; this will not affect her transfer factor. The most appropriate and helpful combination of pulmonary function tests is spirometry with flow–volume loop.

Question 15

A 49-year-old woman has been admitted with haemoptysis and epistaxis. Her chest X-ray shows multiple rounded lesions with alveolar shadowing. Her serum is positive for cytoplasmic anti- neutrophil cytoplasmic antibody (c-ANCA). What is the most likely diagnosis?

Explanation

Correct Answer: C- Granulomatosis with polyangiitis Explanation Granulomatosis with polyangiitis Almost all patients will have evidence of granulomatous lung disease at presentation, which is often accompanied by alveolar capillaritis. The bronchi can also be affected and bronchial stenoses occur as late manifestations. Symptoms include:

• Cough • Dyspnoea • Haemoptysis • Chest pain (which can be pleuritic) Signs on chest examination depend on the nature of the pulmonary lesions and include:

• Fine crepitations • Bronchial breathing • Pleural rubs and signs of pleural effusion (less common) Radiology – pulmonary granulomas are usually diagnosed on the basis of chest X-ray and computed tomography, which show single or multiple rounded lesions, which can cavitate. Bronchoscopy – often reveals granulomatous inflammation and the diagnosis can sometimes be made from bronchial biopsies. Carcinoma of the lung Carcinoma of the lung is incorrect. The chest radiograph appearances, epistaxis and positive c-ANCA are far more in keeping with granulomatosis with polyangiitis than lung cancer. Echinococcosis Echinococcosis is incorrect. Echinococcosis is caused by a larval infection with initial infection occurring in the liver; it behaves like a slow-growing tumour and can spread to other organs like metastases. Presentation is typically with right upper quandrant pain and jaundice. Pulmonary disease can occur but is not classical and the

investigations described in this scenario are far more in keeping with vasculitis. Systemic lupus erythematosus Systemic lupus erythematosus (SLE) is incorrect. Pulmonary manifestations of SLE are variable and include pleurisy, pleural effusion, pneumonitis, pulmonary hypertension, interstitial lung disease and, rarely, diffuse alveolar haemorrhage. Cavitating lesions such as described in this case are not typical of SLE. Positive c-ANCA, as in this case, is associated with granulomatosis with angiitis. SLE is associated with positive antinuclear antibodies, double-stranded DNA antibodies and extractable nuclear antigens such as Sm, SSA, SSB and RNP antibodies. Tuberculosis Tuberculosis is incorrect. The chest radiograph appearances, epistaxis and positive c-ANCA are far more in keeping with granulomatosis with polyangiitis than tuberculosis.

Question 16

A 65-year-old patient with new-onset chronic obstructive pulmonary disease (COPD) asks you about his prognosis. Which of the following single tests is the most important predictor of survival in patients with COPD?

Explanation

Correct Answer: E- FEV1 (forced expiratory volume in 1 s) Explanation

FEV1 (forced expiratory volume in 1 s) The strongest predictors of survival in patients with COPD are:

• Age • Baseline FEV1 (forced expiratory volume in 1 s) Fewer than 50% of patients whose FEV1 has fallen to 30% of predicted are alive 5 years later. There is an even stronger relationship between survival and the post- bronchodilator FEV1, rather than the pre-bronchodilator

FEV1. Other unfavourable prognostic factors which become apparent in patients with severe disease include:

• Severe hypoxaemia • Raised pulmonary arterial pressure • Low carbon monoxide transfer Factors favouring improved survival are stopping smoking and a marked bronchodilator response. A reduced FEV1 is also an important additional risk factor for lung cancer, independent of age or cigarette smoking. Blood gases Blood gases is incorrect. Severe hypoxaemia or type 2 respiratory failure indicate an adverse prognosis in COPD, but are not as predictive as FEV1. Chest X-ray Chest X-ray is incorrect. A chest radiograph showing severe bullous emphysema suggests an adverse prognosis in COPD, but is not as predictive as FEV1. Electrocardiogram Electrocardiogram is incorrect. An electrocardiogram showing evidence of right ventricular hypertrophy and strain in COPD is suggestive of cor pulonale, which indicates an adverse prognosis in COPD, but this is not as predictive as FEV1. Exercise tolerance Exercise tolerance is incorrect. Poor exercise tolerance is an indicator of poorer prognosis in COPD, and exercise tolerance is taken into account when calculating the prognosis of an individual with COPD using the BODE index. The BODE index uses a patient with COPD’s

FEV1, 6 min walk distance, MRC breathlessness score and body mass index to calculate a score which can be used to predict long-term outcome. The higher an individual’s BODE index score, the poorer the prognosis. Thus exercise tolerance is a prognostic indicator; however, in isolation, it is not as predictive as FEV1.

Question 17

A 50-year-old woman is admitted with a dry cough, shortness of breath and a 2-week history of intermittent fevers. She had flu-like symptoms at the beginning of her illness. On examination she has right-sided crepitations and a chest X-ray shows patchy shadowing at her right lower lobe, with an air bronchogram. Her white cell count and C-reactive protein (CRP) are raised. She is started on antibiotics for community-acquired pneumonia, improves clinically and is discharged after 2 days. You see her in clinic 3 months later, when she tells you that she is no better. Her chest X-ray shows left upper-lobe consolidation. What is the most likely cause of this?

Explanation

Correct Answer: A- Cryptogenic organising pneumonia Explanation Cryptogenic organising pneumonia Cryptogenic organising pneumonia is a non-specific inflammatory pulmonary process, with buds of granulation tissue forming in the distal air spaces. Organising pneumonia can have a number of causes, including connective tissue disease, infection and drugs, but if there is no obvious cause it is called ‘cryptogenic’. It causes non-specific symptoms of fever, dry cough, malaise, anorexia and weight loss. Treatment is with steroids. Relapse is common, with further consolidation, and patients might need treatment with increased steroid doses. It is associated with raised a white cell count and C-reactive protein (CRP) levels. The chest X-ray can show consolidation, nodules or thickened septal lines. The consolidation typically occurs in different places at different times. Computed tomography (CT) findings are characteristic, with multiple patchy alveolar opacities, which often spontaneously migrate. The diagnosis might be made on the basis of CT alone, or on transbronchial or open lung biopsy. Eosinophilic pneumonia Eosinophilic pneumonia is incorrect. Acute eosinophilic pneumonia can present with cough, dyspnea, myalgia, fever and chest pain. Chest radiograph shows flitting peripheral infiltrates. Peripheral eosinophilia would likely be seen in acute eosinophilic pneumonia, which is not mentioned here. Lymphangioleiomyomatosis Lymphangioleiomyomatosis is incorrect. Lymphangioleiomyomatosis is a rare disease affecting women of childbearing age, who have abnormal proliferation of atypical smooth muscle cells throughout their lungs and airways – CT shows multiple small cysts. Cystic destruction of the lungs occurs and respiratory failure eventually develops. The condition is associated with the presence of abdominal tumours (eg angiomyolipomas and lymphangioleiomyomas). Pulmonary alveolar proteinosis Pulmonary alveolar proteinosis is incorrect. Pulmonary alveolar proteinosis is a rare defect in which the alveoli become filled with proteinaceous material that cannot be cleared. It usually presents between 30 and 50 years of age (unless congenital, which accounts for 10% of cases). Onset is often insidious, over several months to years. Patients typically present with a dry cough and breathlessness. Chest radiograh typically shows symmetrical perihilar and lower lobe consolidation. CT shows air-space shadowing, classically with a ‘crazy paving’ appearance due to interlobular septal thickening. Recurrent bacterial pneumonia Recurrent bacterial pneumonia is incorrect. Recurrent lobar bacterial infection is unusual in an immunocompetent adult.

Question 18

An anxious 22-year-old woman presented with mild shortness of breath on exertion that had come on gradually over several months. Her symptoms are intermittent, but worse in the evening, and her speech becomes slurred during the episodes. She has recently started treatment for anxiety. On examination, she looked depressed but there were no other positive clinical findings. Other than an ESR of 26 mm in the 1st hour, her routine blood results were normal. Chest X-ray, lung function tests and electrocardiography were all normal. What is the most likely diagnosis?

Explanation

Correct Answer: B- Myasthenia gravis Explanation Myasthenia gravis This young woman has myasthenia gravis, an autoimmune condition. Muscle weakness might not be apparent on a single examination, so the examination should be repeated – most affected are the ocular and shoulder-girdle muscles. Clinical features:

• Respiratory and proximal lower limb muscles can be involved early in the disease. • Breathlessness can develop early and cause sudden death. • Swallowing problems, slurred speech and difficulty in chewing can be caused by bulbar involvement. • Asymmetrical involvement of an external ocular muscle can mimic cranial nerve palsy but pupillary reflexes are normal. • Mild ptosis and weak facial muscles can make patients appear depressed. • Thymic enlargement is seen in only 15% of patients. Eaton–Lambert syndrome Eaton-Lambert syndrome is incorrect. Eaton–Lambert syndrome is often associated with malignancy, often small cell lung cancer and of note this patient is young and has a normal chest radiograph. Ocular muscles are usually less affected than is seen with myasthenia gravis. Respiratory muscles are not usually affected in Eaton–Lambert syndrome. Overall, myasthenia gravis is a more likely diagnosis here. Somatisation disorder Somatisation disorder is incorrect. Somatisation disorder is a diagnosis of exclusion. This lady has clear symptoms and signs compatible with myasthenia gravis therefore it is more likely she has a pathological underlying diagnosis. Transient ischaemic attack Transient ischaemic attack is incorrect. The symptoms have had a gradual onset over several months, there are no risk factors mentioned for cerebrovascular disease and her symptoms are bilateral. This is not a history of transient ischemic attacks. Unstable angina Unstable angina is incorrect. Angina is very unlikely in a 25-year-old. Regardless, the symptoms described are not in keeping with angina. They are in keeping with muscular weakness.

Question 19

A 38-year-old man presents to the GP complaining of shortness of breath. He has a history of smoking 10 cigarettes per day and is obese. Other history of note includes hypertension, for which he is treated with atenolol 50 mg daily. Pulmonary function shows:

• Peak expiratory flow rate (PEFR) 540 l/min (predicted is 600 l/min) • Ratio of the forced expiratory volume in 1 s to the forced vital capacity (FEV1/FVC) is 90% predicted • The FVC falls when measured supine versus standing up Which of the following is the most likely diagnosis?

Explanation

Correct Answer: E- Obesity-related changes in pulmonary function tests Explanation Obesity-related changes in pulmonary function tests This man has small reductions in the peak expiratory flow rate (PEFR) and in the ratio of forced expiratory volume in 1 s to the forced vital capacity (FEV1/FVC), and the FVC falls when measured in the supine position. The most likely explanation here is increased abdominal fat, leading to a functional reduction in FVC. Treatment of choice is aggressive weight reduction, and he should also be encouraged to stop smoking. Finally, atenolol might not be the most appropriate choice of antihypertensive treatment in a young man. If there is a suggestion of erectile dysfunction, a switch to an

alternative agent such as an angiotensin-converting enzyme (ACE) inhibitor should be considered. Asthma Asthma is incorrect. Asthma would be associated with an obstructive pattern of spirometry and PEFR would likely be lower. Atenolol-related obstructive lung picture Atenolol-related obstructive lung picture is incorrect. The spirometry pattern described here is restrictive not obstructive. Chronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease (COPD) is incorrect. COPD is associated with an obstructive pattern of spirometry and given this man’s age and likely less than 30-pack-year smoking history, COPD is unlikely. Early fibrotic lung disease Early fibrotic lung disease is incorrect. Fibrotic lung disease does cause a restrictive pattern on spirometry but the change in FVC on changing position coupled with the mention of his obesity makes obesity a more likely cause for his symptoms.

Question 20

A breathless 70-year-old smoker presents with the following lung function tests Forced expiratory volume in 1 second (FEV1) 1.5 l (60%) Forced vital capacity (FVC) 1.8 l (55%)

FEV1/FVC ratio 84% Total lung capacity (TLC) 66% predicted Residual volume (RV) 57% predicted Carbon monoxide transfer factor (Tlco) 55% predicted Transfer coefficient (Kco) 60% predicted What is the most likely diagnosis in this case?

Explanation

Correct Answer: D- Interstitial lung disease Explanation Interstitial lung disease The lung function tests show a significant restrictive defect. Only interstitial lung disease or obesity can fit this picture. But given the decrease in Kco (ie after correcting for alveolar volumes), the most likely answer is interstitial lung disease. Anaemia Anaemia is incorrect. Anaemia can cause reduced transfer factor but would not cause/explain the other abnormaities seen on these pulmonary function tests. Asthma Asthma is incorrect. Asthma is associated with airflow obstruction, not restriction. Emphysema Emphysema is incorrect. Emphysema would be associated with airflow obstruction, not restriction (i.e normal FVC, and reduced FEV1/FVC ratio. TLC and RV would also be high, not low as is seen here. Obesity Obesity is incorrect. Obesity can cause a restrictive pattern of lung function but obesity alone would not affect the Kco. In the case of obesity, the gas exchange after correcting for the alveolar volume would in fact be high.

Full Question & Answer Text (for Search Engines)

Question 1:

Which of the following is most likely to preclude curative lobectomy for lung carcinoma?

Options:

Forced expiratory volume in 1 s (FEV1) of 1.6 l
Hypercalcaemia
Local invasion by primary tumour through the chest wall
Malignant pleural effusions
Mediastinal lymph nodes enlarged on computed tomography (CT)

Correct Answer: Malignant pleural effusions

Explanation:

Question 2:

Options:

Addition of oral corticosteroids
Addition of oral leukotriene-receptor antagonist
Addition of oral theophylline
Inhaled ß2-agonist at maximum dose
Regular inhaled budesonide, inhaled salbutamol when required

Correct Answer: Regular inhaled budesonide, inhaled salbutamol when required

Explanation:

Question 3:

A 35-year-old woman presents with a 6-week history of malaise, with a dry cough, sweats and a stitch-like, right- sided chest pain. Apparently she had a heavy cold and cough at the beginning of the episode that improved initially. A past history of rheumatoid arthritis for which she takes weekly methotrexate is noted. On examination her BP is 125/80 mmHg, pulse is 75 bpm and regular. There are diminished breath sounds on the right-hand side of the chest and it is dull to percussion. There is no evidence of active synovitis. Investigations: Hb 12.1 g/dl WCC 11.2 × 109/l PLT 303 × 109/l ESR 72 mm/h Na+ 137 mmol/l K+ 4.3 mmol/l Creatinine 110 μmol/l CXR Right-sided pleural effusion Effusion pH 7.08 Effusion LDH 1556 U/l Effusion Glucose 2.0 mmol/l Effusion Protein 45 g/l Which of the following is the most likely diagnosis?

Options:

Empyema
Inflammatory pleural effusion
Mesothelioma
Parapneumonic effusion
Tuberculous effusion

Correct Answer: Empyema

Explanation:

Question 4:

Options:

Bisoprolol
Digoxin
Ipratropium
Long-term oxygen therapy
Ramipril

Correct Answer: Long-term oxygen therapy

Explanation:

Question 5:

Options:

Allergic bronchopulmonaryaspergillosis
Cryptogenic organising pneumonia
Eosinophilic granulomatosis with polyangiitis
Granulomatosis with polyangiitis
Severe asthma

Correct Answer: Eosinophilic granulomatosis with polyangiitis

Explanation:

Correct Answer: C- Eosinophilic granulomatosis with polyangiitis Explanation Eosinophilic granulomatosis with polyangiitis Eosinophilicgranulomatosis with polyangiitis is an eosinophilic granulomatous inflammation of the respiratory tract with small- and medium-vessel necrotising vasculitis. It is diagnosed on finding four out of the following:
• Asthma • Blood eosinophilia > 10% • Vasculitic neuropathy • Pulmonary infiltrates • Sinus disease • Extravasculareosinophils on biopsy findings It is diagnosed clinically, although a biopsy should be sought for pathological confirmation. Allergic bronchopulmonaryaspergillosis Allergic bronchopulmonary aspergillosis (ABPA) is incorrect. ABPA is a condition in which people with asthma have a vigorous IgE response to Aspergillus, with associated eosinophilia, a positive skinprick test to Aspergillus and flitting consolidation on the chest X-ray. There is no associated sinus disease. Cryptogenic organising pneumonia Cryptogenic organising pneumonia (COP) is incorrect. COP is not typically associated with an eosinophilia. Granulomatosis with polyangiitis Granulomatosis with polyangiitis is incorrect. Granulomatosis with polyangiitis is not typically associated with an eosinophilia. Severe asthma Severe asthma is incorrect. This woman’s eosinophil count is high, higher than it would be with asthma alone, and the abnormal chest radiograph suggests an
alternative diagnosis. Causes of eosinophilia include:
• Allergic or hypersensitivity disease, including asthma with associated eczema • Allergic bronchopulmonary aspergillosis • Eosinophilic granulomatosis with polyangiitis • Loeffler syndrome • Tropical pulmonary eosinophilia • Chronic pulmonary eosinophilia • Hypereosinophilic syndrome • Acute eosinophilic pneumonia

Question 6:

Which of the following investigations is most specific to allergic bronchopulmonary aspergillosis (ABPA)?

Options:

An early positive skinprick test for Aspergillus fumigatus
Computed tomographic (CT) evidence of proximal bronchiectasis
Positive history of exposure to Aspergillus
Positive precipitins for Aspergillus
Upper-zone fibrosis

Correct Answer: An early positive skinprick test for Aspergillus fumigatus

Explanation:

Question 7:

A 58-year-old woman is admitted to the Emergency Department with suspected community- acquired pneumonia. She has a progressively worsening cough, productive of rusty sputum and shortness of breath over the past 3 days. She smokes five cigarettes per day, has hypertension treated with lisinopril, but no other significant past medical history. On examination her BP is 105/60 mmHg; pulse is 85/min and regular. There are signs of right lower lobe consolidation on auscultation. Respiratory rate is raised at 32, O2 sats on 40% O2 are 96%. Investigations: Hb 13.1 g/dl WCC 15.8 × 109/l PLT 203 × 109/l CRP 230 mg/l Na+ 138 mmol/l K+ 4.5 mmol/l Creatinine 122 μmol/l Urea 6.9 mmol/l According to CURB-65 criteria, which of the following is a measure of increased severity?

Options:

Age 58
CRP 230 mg/l
Respiratory rate 32/min
Urea 6.9 mmol/l
WCC 15.8 × 109/l

Correct Answer: Respiratory rate 32/min

Explanation:

Correct Answer: C- Respiratory rate 32/min Explanation Respiratory rate 32/min CURB-65 criteria were drawn up to provide standardised assessment of the severity of pneumonia. They are listed below • confusion at onset (defined as an AMT of 8 or less) •
urea greater than 7 mmol/l (19 mg/dl) • respiratory rate of 30 breaths per minute or greater • blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less • age 65 or older. The number of criteria correlate well with mortality at 30 days:
• 0 – 0.7% • 1 – 3.2% • 2 – 13.0% • 3 – 17.0% • 4 – 41.5% • 5 – 57.0% Any score of 2 or greater usually requires hospitalisation. Age 58 Age 58 is incorrect. Age ≥ 65 is a measure of increased severity. CRP 230 mg/l CRP 230 mg/l is incorrect. CRP is not classed as a measure of increased severity. Urea 6.9 mmol/l
Urea 6.9 mmol/l is incorrect. Urea greater than 7 mmol/l is a measure of increased severity. WCC 15.8 × 109/l
WCC 15.8 × 109/l is incorrect. WCC is not part of the CURB-65 score, which is the severity scoring system used in the UK. The pneumonia severity index, used in the USA, does include WCC with a WCC < 4 × 109/l or > 20 × 109/l indicating increased severity of pneumonia.

Question 8:

Options:

Aspiration pneumonia
Haemophilus pneumonia
Pneumococcal pneumonia
Pseudomonal pneumonia
Staphylococcal pneumonia

Correct Answer: Pseudomonal pneumonia

Explanation:

Question 9:

Options:

Continue isoniazid and rifampicin for at least 3 months
Continue isoniazid and rifampicin for 1 month then isoniazid for a further 2 months
Stay off work and have a repeat chest X-ray in 6 weeks
Stay off work for 2 weeks while she is on the initial prophylactic isoniazid course
Stay off work for 6 weeks

Correct Answer: Continue isoniazid and rifampicin for at least 3 months

Explanation:

Question 10:

Options:

Antibiotics
Oral cromoglicate
Oral steroids
Oral theophylline
Switch to nebuliser

Correct Answer: Oral theophylline

Explanation:

Question 11:

Options:

Atelectasis due to carcinoma of the lung
Lobar pneumonia
Mesothelioma
Pneumothorax
Tuberculosis

Correct Answer: Lobar pneumonia

Explanation:

Question 12:

Which lung disease is associated with the descriptions of ‘pink puffer’ and ‘blue bloater’?

Options:

Chronic obstructive pulmonary disease
Cystic fibrosis
Pulmonary fibrosis
Small-cell lung cancer
Tuberculosis

Correct Answer: Chronic obstructive pulmonary disease

Explanation:

Correct Answer: A- Chronic obstructive pulmonary disease Explanation Chronic obstructive pulmonary disease Pink puffers have a good respiratory drive. Clinical features:
• Pursed-lip breathing with intense dyspnoea • Often thin and elderly • Sparce production of sputum • Oedema and overt heart failure (rare complications)
Investigations:
• Blood gases are near-normal until pre-terminally there is very severe airways obstruction • Total lung capacity increased • Reduction in transfer factor Blue bloaters have a poor respiratory drive. Clinical features:
• Quite mild dyspnoea • Often obese • Production of large volumes of sputum • Infective exacerbations • Often oedematous • Can develop cor pulmonale Investigations:
• Blood gases show hypercapnia, hypoxaemia, elevated plasma bicarbonate • Severe nocturnal hypoxaemia • Airways obstruction might only be moderate • Transfer factor approximately normal Cystic fibrosis Cystic fibrosis is incorrect. Cystic fibrosis is not associated with the descriptions in the question. Pulmonary fibrosis Pulmonary fibrosis is incorrect. Pulmonary fibrosis is not associated with the descriptions in the question. Small-cell lung cancer Small-cell lung cancer is incorrect. Small-cell lung cancer is not associated with the descriptions in the question. Tuberculosis Tuberculosis is incorrect. Tuberculosis is not associated with the descriptions in the question.

Question 13:

Options:

Asthma
Chronic thromboembolic disease
Idiopathic pulmonary fibrosis
Primary pulmonary hypertension
Right ventricular failure

Correct Answer: Primary pulmonary hypertension

Explanation:

Correct Answer: D- Primary pulmonary hypertension Explanation Primary pulmonary hypertension Primary pulmonary hypertension is characterised by the development of significantly raised pulmonary artery pressure with no apparent cause (normal VQ scan, no evidence of left heart failure). Plexogenic pulmonary arteriopathy is found in 30–60% of people with this condition and is characterised by medial hypertrophy and concentric laminar intimal fibrosis. The gene for primary pulmonary hypertension has now been mapped to chromosome 2, and mutations in the bone morphogenic protein receptor have been identified in some patients. Intravenous epoprostenol (prostacyclin) and oxygen therapy have been shown to improve quality of life in sufferers.
Phosphodiesterase-5 (PDE-5) inhibitors and endothelin receptor antagonists have also been shown to have some therapeutic effect. Unfortunately, several studies report a mean survival of only 2.5 years from diagnosis, with right ventricular failure and sudden death the main causes of death. Asthma Asthma is incorrect. This lady has evidence of significant right heart failure and her main respiratory symptom is dyspnoea rather than wheeze or cough. The symptoms and investigations described are not in keeping with a diagnosis of asthma. Chronic thromboembolic disease Chronic thromboembolic disease is incorrect. The perfusion scan is not suggestive of chronic thromboembolic disease, which makes primary pulmonary hypertension the most likely diagnosis. Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. Idiopathic pulmonary fibrosis (IPF) typically occurs in the sixth decade of life. If IPF is advanced enough to cause right ventricular hypertrophy (as is described in this case) then it is likely that the chest radiograph would show significantly abnormal lung fields with reticulonodular shadowing +/- honeycombing. Right ventricular failure Right ventricular failure is incorrect. This case does indeed describe right ventricular hypertrophy and failure, but given the dyspnoea and degree of hypoxia with a normal chest X-ray other than pulmonary artery hypertrophy and the patient’s age then primary pulmonary hypertension is the diagnosis that best fits the clinical picture in its entirety.

Question 14:

Options:

Chest X-ray
Computed tomography scan of the chest
Peak flow
Spirometry with flow–volume loop
Spirometry with transfer factor measurement

Correct Answer: Spirometry with flow–volume loop

Explanation:

Question 15:

Options:

Carcinoma of the lung
Echinococcosis
Granulomatosis with polyangiitis
Systemic lupus erythematosus
Tuberculosis

Correct Answer: Granulomatosis with polyangiitis

Explanation:

Correct Answer: C- Granulomatosis with polyangiitis Explanation Granulomatosis with polyangiitis Almost all patients will have evidence of granulomatous lung disease at presentation, which is often accompanied by alveolar capillaritis. The bronchi can also be affected and bronchial stenoses occur as late manifestations. Symptoms include:
• Cough • Dyspnoea • Haemoptysis • Chest pain (which can be pleuritic) Signs on chest examination depend on the nature of the pulmonary lesions and include:
• Fine crepitations • Bronchial breathing • Pleural rubs and signs of pleural effusion (less common) Radiology – pulmonary granulomas are usually diagnosed on the basis of chest X-ray and computed tomography, which show single or multiple rounded lesions, which can cavitate. Bronchoscopy – often reveals granulomatous inflammation and the diagnosis can sometimes be made from bronchial biopsies. Carcinoma of the lung Carcinoma of the lung is incorrect. The chest radiograph appearances, epistaxis and positive c-ANCA are far more in keeping with granulomatosis with polyangiitis than lung cancer. Echinococcosis Echinococcosis is incorrect. Echinococcosis is caused by a larval infection with initial infection occurring in the liver; it behaves like a slow-growing tumour and can spread to other organs like metastases. Presentation is typically with right upper quandrant pain and jaundice. Pulmonary disease can occur but is not classical and the
investigations described in this scenario are far more in keeping with vasculitis. Systemic lupus erythematosus Systemic lupus erythematosus (SLE) is incorrect. Pulmonary manifestations of SLE are variable and include pleurisy, pleural effusion, pneumonitis, pulmonary hypertension, interstitial lung disease and, rarely, diffuse alveolar haemorrhage. Cavitating lesions such as described in this case are not typical of SLE. Positive c-ANCA, as in this case, is associated with granulomatosis with angiitis. SLE is associated with positive antinuclear antibodies, double-stranded DNA antibodies and extractable nuclear antigens such as Sm, SSA, SSB and RNP antibodies. Tuberculosis Tuberculosis is incorrect. The chest radiograph appearances, epistaxis and positive c-ANCA are far more in keeping with granulomatosis with polyangiitis than tuberculosis.

Question 16:

Options:

Blood gases
Chest X-ray
Electrocardiogram
Exercise tolerance
FEV1 (forced expiratory volume in 1 s)

Correct Answer: FEV1 (forced expiratory volume in 1 s)

Explanation:

Correct Answer: E- FEV1 (forced expiratory volume in 1 s) Explanation
FEV1 (forced expiratory volume in 1 s) The strongest predictors of survival in patients with COPD are:
• Age • Baseline FEV1 (forced expiratory volume in 1 s) Fewer than 50% of patients whose FEV1 has fallen to 30% of predicted are alive 5 years later. There is an even stronger relationship between survival and the post- bronchodilator FEV1, rather than the pre-bronchodilator
FEV1. Other unfavourable prognostic factors which become apparent in patients with severe disease include:
• Severe hypoxaemia • Raised pulmonary arterial pressure • Low carbon monoxide transfer Factors favouring improved survival are stopping smoking and a marked bronchodilator response. A reduced FEV1 is also an important additional risk factor for lung cancer, independent of age or cigarette smoking. Blood gases Blood gases is incorrect. Severe hypoxaemia or type 2 respiratory failure indicate an adverse prognosis in COPD, but are not as predictive as FEV1. Chest X-ray Chest X-ray is incorrect. A chest radiograph showing severe bullous emphysema suggests an adverse prognosis in COPD, but is not as predictive as FEV1. Electrocardiogram Electrocardiogram is incorrect. An electrocardiogram showing evidence of right ventricular hypertrophy and strain in COPD is suggestive of cor pulonale, which indicates an adverse prognosis in COPD, but this is not as predictive as FEV1. Exercise tolerance Exercise tolerance is incorrect. Poor exercise tolerance is an indicator of poorer prognosis in COPD, and exercise tolerance is taken into account when calculating the prognosis of an individual with COPD using the BODE index. The BODE index uses a patient with COPD’s
FEV1, 6 min walk distance, MRC breathlessness score and body mass index to calculate a score which can be used to predict long-term outcome. The higher an individual’s BODE index score, the poorer the prognosis. Thus exercise tolerance is a prognostic indicator; however, in isolation, it is not as predictive as FEV1.

Question 17:

Options:

Cryptogenic organising pneumonia
Eosinophilic pneumonia
Lymphangioleiomyomatosis
Pulmonary alveolar proteinosis
Recurrent bacterial pneumonia

Correct Answer: Cryptogenic organising pneumonia

Explanation:

Question 18:

Options:

Eaton–Lambert syndrome
Myasthenia gravis
Somatisation disorder
Transient ischaemic attack
Unstable angina

Correct Answer: Myasthenia gravis

Explanation:

Correct Answer: B- Myasthenia gravis Explanation Myasthenia gravis This young woman has myasthenia gravis, an autoimmune condition. Muscle weakness might not be apparent on a single examination, so the examination should be repeated – most affected are the ocular and shoulder-girdle muscles. Clinical features:
• Respiratory and proximal lower limb muscles can be involved early in the disease. • Breathlessness can develop early and cause sudden death. • Swallowing problems, slurred speech and difficulty in chewing can be caused by bulbar involvement. • Asymmetrical involvement of an external ocular muscle can mimic cranial nerve palsy but pupillary reflexes are normal. • Mild ptosis and weak facial muscles can make patients appear depressed. • Thymic enlargement is seen in only 15% of patients. Eaton–Lambert syndrome Eaton-Lambert syndrome is incorrect. Eaton–Lambert syndrome is often associated with malignancy, often small cell lung cancer and of note this patient is young and has a normal chest radiograph. Ocular muscles are usually less affected than is seen with myasthenia gravis. Respiratory muscles are not usually affected in Eaton–Lambert syndrome. Overall, myasthenia gravis is a more likely diagnosis here. Somatisation disorder Somatisation disorder is incorrect. Somatisation disorder is a diagnosis of exclusion. This lady has clear symptoms and signs compatible with myasthenia gravis therefore it is more likely she has a pathological underlying diagnosis. Transient ischaemic attack Transient ischaemic attack is incorrect. The symptoms have had a gradual onset over several months, there are no risk factors mentioned for cerebrovascular disease and her symptoms are bilateral. This is not a history of transient ischemic attacks. Unstable angina Unstable angina is incorrect. Angina is very unlikely in a 25-year-old. Regardless, the symptoms described are not in keeping with angina. They are in keeping with muscular weakness.

Question 19:

A 38-year-old man presents to the GP complaining of shortness of breath. He has a history of smoking 10 cigarettes per day and is obese. Other history of note includes hypertension, for which he is treated with atenolol 50 mg daily. Pulmonary function shows: • Peak expiratory flow rate (PEFR) 540 l/min (predicted is 600 l/min) • Ratio of the forced expiratory volume in 1 s to the forced vital capacity (FEV1/FVC) is 90% predicted • The FVC falls when measured supine versus standing up Which of the following is the most likely diagnosis?

Options:

Asthma
Atenolol-related obstructive lung picture
Chronic obstructive pulmonary disease (COPD)
Early fibrotic lung disease
Obesity-related changes in pulmonary function tests

Correct Answer: Obesity-related changes in pulmonary function tests

Explanation:

Correct Answer: E- Obesity-related changes in pulmonary function tests Explanation Obesity-related changes in pulmonary function tests This man has small reductions in the peak expiratory flow rate (PEFR) and in the ratio of forced expiratory volume in 1 s to the forced vital capacity (FEV1/FVC), and the FVC falls when measured in the supine position. The most likely explanation here is increased abdominal fat, leading to a functional reduction in FVC. Treatment of choice is aggressive weight reduction, and he should also be encouraged to stop smoking. Finally, atenolol might not be the most appropriate choice of antihypertensive treatment in a young man. If there is a suggestion of erectile dysfunction, a switch to an
alternative agent such as an angiotensin-converting enzyme (ACE) inhibitor should be considered. Asthma Asthma is incorrect. Asthma would be associated with an obstructive pattern of spirometry and PEFR would likely be lower. Atenolol-related obstructive lung picture Atenolol-related obstructive lung picture is incorrect. The spirometry pattern described here is restrictive not obstructive. Chronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease (COPD) is incorrect. COPD is associated with an obstructive pattern of spirometry and given this man’s age and likely less than 30-pack-year smoking history, COPD is unlikely. Early fibrotic lung disease Early fibrotic lung disease is incorrect. Fibrotic lung disease does cause a restrictive pattern on spirometry but the change in FVC on changing position coupled with the mention of his obesity makes obesity a more likely cause for his symptoms.

Question 20:

A breathless 70-year-old smoker presents with the following lung function tests Forced expiratory volume in 1 second (FEV1) 1.5 l (60%) Forced vital capacity (FVC) 1.8 l (55%) FEV1/FVC ratio 84% Total lung capacity (TLC) 66% predicted Residual volume (RV) 57% predicted Carbon monoxide transfer factor (Tlco) 55% predicted Transfer coefficient (Kco) 60% predicted What is the most likely diagnosis in this case?

Options:

Anaemia
Asthma
Emphysema
Interstitial lung disease
Obesity

Correct Answer: Interstitial lung disease

Orthopedic Prometric MCQs - Chapter 4 Part 1

Orthopedic Prometric MCQs - Chapter 4 Part 3

You Might Also Like

Orthopedic Prometric MCQs - Chapter 4 Part 10

Orthopedic Prometric MCQs - Chapter 4 Part 9

Chapter Index