Full Question & Answer Text (for Search Engines)
Question 1:
A 60-year-old man presents with a history of cough and weight loss. He has smoked 40 cigarettes a day since he was 17 years old. He describes recent darkening of his skin and the chest X-ray reveals a mass (suspicious for lung cancer) at the left hilum. What is the most likely histology?
Options:
- Adenocarcinoma
- Large-cell carcinoma
- Mesothelioma
- Small-cell carcinoma
- Squamous-cell carcinoma
Correct Answer: Small-cell carcinoma
Explanation:
Correct Answer: D- Small-cell carcinoma Explanation Small-cell carcinoma Endocrine symptoms are seen in patients with lung cancer due to the syndrome of ectopic hormone secretion. Small-cell lung cancer and bronchial carcinoid tumours are both associated with ectopic adrenocorticotropic hormone (ACTH) secretion, which can cause increased skin pigmentation. In small-cell lung cancer, around 5% of cases are thought to manifest ectopic ACTH secretion. Adrenal metastatic spread should be excluded with appropriate imaging. Treatment of the clinical or biochemical abnormalities associated with endocrinopathies of non-endocrine origin is best directed at the primary disorder. In neoplastic disease, this might involve surgical excision, radiotherapy or chemotherapy. If the cancer cannot be targeted, symptomatic treatment should be given. Adenocarcinoma Adenocarcinoma is incorrect. Although adenocarcinoma could present as a hilar mass, it is not associated with ectopic ACTH production (that would explain the increased skin pigmentation). Large-cell carcinoma Large-cell carcinoma is incorrect. Although large-cell carcinoma could present as a hilar mass, it is not associated with ectopic ACTH production (that would explain the increased skin pigmentation). Mesothelioma Mesothelioma is incorrect. Mesiothelioma is a malignant pleural tumour that is related to asbestos exposure. It does not present as a hilar mass and is not associated with ectopic production of ACTH. Squamous-cell carcinoma Squamous-cell carcinoma is incorrect. Squamous-cell carcinomas are not associated with ectopic ACTH production; they are often associated with hypercalcaemia due to parathyroid hormone- related peptide secretion.
Question 2:
Which of the following is most likely to cause upper- lobe fibrosis on chest X-ray?
Options:
- Ankylosing spondylitis
- Idiopathic pulmonary fibrosis
- Rheumatoid arthritis
- Scleroderma
- Systemic lupus erythematosus
Correct Answer: Ankylosing spondylitis
Explanation:
Correct Answer: A- Ankylosing spondylitis Explanation Ankylosing spondylitis Causes of upper-lobe fibrosis on a chest X-ray are:
• Ankylosing spondylitis (affects the apices) • Tuberculosis • Sarcoidosis • Extrinsic allergic alveolitis • Silicosis • Allergic bronchopulmonary aspergillosis (ABPA) • Post-radiotherapy Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. Idiopathic pulmonary fibrosis is more likely to be associated with lower lobe fibrosis. Rheumatoid arthritis Rheumatoid arthritis is incorrect. Rheumatoid arthritis is more likely to be associated with lower lobe fibrosis. Scleroderma Scleroderma is incorrect. Scleroderma is more likely to be associated with lower lobe fibrosis. Systemic lupus erythematosus Systemic lupus erythematosus is incorrect. Systemic lupus erythematosus is more likely to be associated with lower lobe fibrosis.
Question 3:
Which cell type produces surfactant?
Options:
- Alveolar macrophage
- Endothelial cell
- Goblet cell
- Type I pneumocyte
- Type II pneumocyte
Correct Answer: Type II pneumocyte
Explanation:
Correct Answer: E- Type II pneumocyte Explanation Type II pneumocyte
Phospholipid molecules that reduce surface tension in the alveolar air–liquid interface are called surfactant. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls. Alveolar macrophage Alveolar macrophage is incorrect. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls. Endothelial cell Endothelial cell is incorrect. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls. Goblet cell Goblet cell is incorrect. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls. Type I pneumocyte Type I pneumocyte is incorrect. Surfactant is produced in conjunction with proteins from alveolar type II epithelial cells (type II pneumocytes) lying free in the alveolar spaces against alveolar walls.
Question 4:
A 26-year-old man presents with fever, headache and a moderately productive cough. The chest X- ray shows increased interstitial markings. Laboratory examinations show an elevated lactate dehydrogenase (LDH), anaemia and cold agglutinins. What is the most likely diagnosis?
Options:
- Chlamydia pneumonia
- Extrinsic allergic alveolitis
- Mycoplasma pneumonia
- Non-Hodgkin lymphoma
- Pneumocystis jirovecii
Correct Answer: Mycoplasma pneumonia
Explanation:
Correct Answer: C- Mycoplasma pneumonia Explanation Mycoplasma pneumonia Acute, cold, autoimmune, haemolytic anaemia is commonly seen in adolescents and young adults following infection with Mycoplasma pneumoniae. Haemolysis occurs approximately 1–2 weeks following infection and is most commonly associated with a rise in polyclonal anti-I IgM antibodies with mycoplasma pneumonia. The typical patient is usually a young adult who experiences a respiratory tract infection accompanied by headache, myalgia, cough and fever, whose chest X-ray shows bronchopneumonia. The cough is often non- productive, but when sputum is obtained it is mucoid, shows predominantly mononuclear cells and shows no dominant organism. The diagnosis should be suspected in patients with a relatively mild form of pneumonia, particularly in previously healthy young adults. A characteristic feature is the relatively high frequency of extrapulmonary complications, including:
• Rash • Neurological syndromes (aseptic meningitis, encephalitis, neuropathies), • Myocarditis • Pericarditis • Haemolytic anaemia The pathogen lacks a cell wall and so is not susceptible to penicillin, cephalosporins or other antibiotics active against the bacterial cell wall. The therapeutic agents most commonly used are macrolides such as erythromycin, clarithromycin, azithromycin or doxycycline. Chlamydia pneumonia Chlamydia pneumonia is incorrect. Chlamydia pneumonia is a typical cause of pneumonia and, as such, many features in this case are compatible. However, cold agglutinins are associated with mycoplasmal pneumonia, not chlamydial pneumonia. Extrinsic allergic alveolitis Extrinsic allergic alveolitis is incorrect. The history of productive cough, fever and cold agglutinins make an infective cause of symptoms most likely – mycoplasmal pneumonia in particular. Non-Hodgkin lymphoma Non-Hodgkin lymphoma is incorrect. Fever, anaemia and elevated LDH levels may be features of non- Hodgkin lymphoma but the chest X-ray would be likely to show lymphadenopathy rather than increased interstitial markings and the productive cough makes mycoplasma pneumonia more likely. Pneumocystis jirovecii Pneumocystis jirovecii is incorrect. P. jirovecii pneumonia may present with increased interstitial infiltrates on a chest radiograph; however, the cough is often dry. Blood tests may show lymphopenia. Cold agglutinins are not associated with P. jirovecii pneumonia. The lack of history suggesting immunodeficiency makes P. jirovecii pneumonia unlikely.
Question 5:
A 61-year-old woman with nephrotic syndrome comes to the Respiratory Clinic with increased shortness of breath over the past 2 months. A large, left-sided pleural effusion was first diagnosed by her GP at the the time of onset of symptoms, and he prescribed an increased dose of diuretics. Despite increased furosemide and peripheral oedema having resolved, the effusion is unchanged on chest X- ray. Which of the following is the most appropriate next step?
Options:
- Blind pleural biopsy
- CT thorax
- Diagnostic pleural aspiration
- Increased furosemide
- Therapeutic drainage
Correct Answer: Diagnostic pleural aspiration
Explanation:
Correct Answer: C- Diagnostic pleural aspiration Explanation Diagnostic pleural aspiration In this situation, where peripheral oedema has resolved in response to increased diuretic therapy, although the effusion is unchanged, diagnostic pleural aspiration for cytology, protein, LDH, pH, gram stain, culture and sensitivity is most appropriate. Blind pleural biopsy Blind pleural biopsy is incorrect. Pleural biopsy could be considered, although this is usual post the aspiration results, and is undertaken under radiological guidance. CT thorax CT thorax is incorrect. A CT thorax may be appropriate here and should be considered particularly if diagnostic aspiration reveals the effusion is an exudate. Increased furosemide Increased furosemide is incorrect. Furosemide appears to have had no effect on the effusion thus far, despite resolving the peripheral oedema, so increasing the dose further without further investigation to establish the underlying aetiology of the effusion is inappropriate. Therapeutic drainage Therapeutic drainage is incorrect. Therapeutic drainage is not considered until the underlying diagnosis has been established.
Question 6:
A 72-year-old woman is admitted with sudden-onset, left-sided pleuritic chest pain with shortness of breath. She is being treated for asthma, which has been well controlled on a low dose of inhaled corticosteroids and long-acting ß-agonist. She underwent a left hemiarthroplasty 12 days ago and was discharged because she was doing well. Her chest is clear on auscultation. She is tachycardic (132 bpm) and an electrocardiogram shows sinus tachycardia. Her peak expiratory flow rate (PEFR) is 300 l/min (best 400 l/min). Arterial blood gases are as follows: pH 7.34, Pao2 7.6 kPa, Paco2 3.5 kPa. She is started on oxygen. A chest X-ray is normal. What would be the most appropriate immediate action you as the medical FY2 should take?
Options:
- Request a chest X-ray in expiration
- Request d-dimers urgently
- Start low-molecular-weight heparin, suspecting pulmonary embolus, and request a ventilation/perfusion (V/Q) scan
- Start low-molecular-weight heparin, suspecting pulmonary embolus, and request computed tomographic pulmonary angiography
- Start nebulised bronchodilators and monitor the PEFR
Correct Answer: Start low-molecular-weight heparin, suspecting pulmonary embolus, and request a ventilation/perfusion (V/Q) scan
Explanation:
Correct Answer: C- Start low-molecular-weight heparin, suspecting pulmonary embolus, and request computed tomographic pulmonary angiography Explanation Start low-molecular-weight heparin, suspecting pulmonary embolus, and request computed tomographic pulmonary angiography A CTPA would be the imaging investigation of choice in this case, after starting low-molecular- weight heparin Request a chest X-ray in expiration Request a chest X-ray in expiration is incorrect. A small pneumothorax, not apparent on the inspiratory chest X- ray, is unlikely because it would not cause marked hypoxia. Request d-dimers urgently Request d-dimers urgently is incorrect. The symptoms and findings point towards a pulmonary embolism, for which the clinical probability is high. Therefore, checking D-dimers is inappropriate as they should only be measured when the probability of a pulmonary embolus is low and further investigations would not be pursued. Start low-molecular-weight heparin, suspecting pulmonary embolus, and request a ventilation/perfusion (V/Q) scan Start low-molecular-weight heparin, suspecting pulmonary embolus, and request a ventilation/perfusion (V/Q) scan is incorrect. The diagnostic investigation of choice is computed tomographic pulmonary angiogram (CTPA), particularly in individuals with chronic lung disease. Start nebulised bronchodilators and monitor the PEFR Start nebulised bronchodilators and monitor the PEFR is incorrect. Her peak expiratory flow rate is only mildly reduced (75% of best). It is unlikely that this patient’s symptoms are due to an exacerbation of her asthma.
Question 7:
A 62-year-old patient has been admitted with a large, left-sided pneumothorax. He has a past history of chronic obstructive pulmonary disease (COPD), for which he has a home nebuliser and takes a high-dose Seretide inhaler. A chest drain was inserted some 60 h earlier, yet when you review it, the drain is still swinging and producing bubbles. Which of the following is the most appropriate next step?
Options:
- Cardiothoracic surgical review
- Change the drain for a larger bore one
- Remove the drain anyway
- Suction at -15 cm H20
- Suction at -25 cm H20
Correct Answer: Cardiothoracic surgical review
Explanation:
Correct Answer: A- Cardiothoracic surgical review Explanation Cardiothoracic surgical review In this situation suction may cause further damage, therefore surgical review is preferred with consideration for thoracoscopy and surgical pleurodesis. In patients who are unfit for surgery, either medical pleurodesis or a Heimlich valve could be considered. Suction is not routinely recommended and in this situation may cause further damage. When used in primary spontaneous pneumothorax (PSP) suction must be used with caution. Pressures should be in the range of -10–20 cm H20. Caution is advised in PSP because of the risk of pulmonary oedema developing, which appears to be a more common problem in younger patients and in those with larger PSPs. Change the drain for a larger bore one Change the drain for a larger bore one is incorrect. There is no evidence that a larger bore chest drain will cause a non-traumatic pneumothorax to resolve more quickly. There is, however, a higher risk of complications. Remove the drain anyway Remove the drain anyway is incorrect. This would be dangerous as the continued bubbling suggests an ongoing air leak. Suction at -15 cm H20 Suction at -15 cm H2O is incorrect. Suction is not routinely recommended and in this situation may cause further damage. Suction at -25 cm H20 Suction at -25 cm H2O is incorrect. Suction is not routinely recommended and in this situation may cause further damage.
Question 8:
A 60-year-old man presents to the clinic with a 6-month history of dyspnoea on exertion and a non- productive cough. On examination, there is clubbing and crepitations are heard at the lung bases. Lung function tests show a reduced vital capacity and an increased ratio of the forced expiratory volume in 1 second to the forced vital capacity (increased FEV1/FVC). What is the most likely diagnosis?
Options:
- Bronchiectasis
- Carcinoma of the lung
- Chronic obstructive pulmonary disease
- Idiopathic pulmonary fibrosis
- Tuberculosis
Correct Answer: Idiopathic pulmonary fibrosis
Explanation:
Correct Answer: D- Idiopathic pulmonary fibrosis Explanation Idiopathic pulmonary fibrosis This is a classical history of interstitial lung disease. Idiopathic pulmonary fibrosis (IPF), previously known as cryptogenic fibrosing alveolitis (CFA), is a progressive and usually fatal disease of unknown cause characterised by sequential acute lung injury with subsequent scarring and end-stage lung disease. It may occur in any decade of life but it is most commonly seen between the ages of 50 and 60 years; it is slightly more common in males. Clinical features:
• A history of progressive breathlessness on exertion in the absence of wheeze is typical • A dry cough might be present, but sputum production is unusual until the later stages of the disease • Constitutional symptoms such as weight loss and lethargy can occur • Haemoptysis is uncommon, but should suggest the development of lung malignancy – people with idiopathic pulmonary fibrosis have a seven- to 14-fold increased risk of developing lung cancer • Chest pain is uncommon • Lung function tests show a restrictive picture Recent reclassification of the group of idiopathic interstitial pneumonias has allowed characterisation of seven different histological patterns based on lung- biopsy analysis; the pattern in IPF is that of usual interstitial pneumonia (UIP). Bronchiectasis Bronchiectasis is incorrect. Bronchiectasis would be associated with a productive cough in most cases. Carcinoma of the lung Carcinoma of the lung is incorrect. The duration of symptoms is too long for a lung malignancy to be a likely cause of this man’s condition. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is incorrect. COPD would be associated with a decreased
FEV1/FVC ratio. Tuberculosis Tuberculosis is incorrect. The duration of symptoms along with lack of classical symptoms of tuberculosis such as fever, productive cough, night sweats and weight loss make this diagnosis unlikely.
Question 9:
A 28-year-old woman presents to the Emergency Department with an acute asthmatic attack. Which of the following lung function abnormalities is she likely to have?
Options:
- Increased airway conductance
- Increased forced expiratory ratio
- Increased forced vital capacity
- Increased gas transfer factor
- Increased residual volume
Correct Answer: Increased residual volume
Explanation:
Correct Answer: E- Increased residual volume Explanation Increased residual volume Because of gas trapping there is an increase in residual volume and an increase in total lung capacity, but the ratio of residual volume (RV) to total lung capacity (TLC) is increased (TLC = vital capacity (VC) + RV). Increased airway conductance Increased airway conductance is incorrect. Airway conductance (the reciprocal of airway resistance) is decreased in acute asthma. Increased forced expiratory ratio Increased forced expiratory ratio is incorrect. The classic abnormalities are reduced forced expiratory volume in 1 s (FEV1) and reduced forced vital capacity (FVC) with a decrease in FEV1/FVC. Increased forced vital capacity Increased forced vital capacity is incorrect. The classic abnormalities are reduced forced expiratory volume in 1 s (FEV1) and reduced forced vital capacity (FVC) with a decrease in FEV1/FVC. Increased gas transfer factor Increased gas transfer factor is incorrect. Gas transfer would be difficult to measure in acute asthma, but can be elevated in stable asthma, where there might be chronic hyperinflation giving rise to a greater surface area for blood/gas interfacing.
Question 10:
A 32-year-old chronic intravenous heroin abuser presents to the Emergency Department with increasing shortness of breath and general debility. He has been using heroin for the past 15 years and has had a number of hospital admissions for overdoses, skin infections and respiratory infections over the past few years. On examination: he is pyrexial (37.6 °C), blood pressure 115/72 mmHg, pulse 75 bpm. His right chest is dull to the mid-zone. Investigations show: Haemoglobin 10.5 g/dl White cell count 9.2 × 109/l Platelets 215 × 109/l Sodium 139 mmol/l Potassium 4.6 mmol/l Creatinine 135 µmol/l A postero-anterior chest X-ray shows a right-sided pleural effusion to the mid-zone. A pleural aspiration failed to produce a specimen. Which of the following is the most appropriate investigation with respect to the pleural effusion?
Options:
- Bronchoscopy
- Contrast-enhanced computed tomography of the chest
- Lateral chest X-ray
- Thoracoscopy
- Ultrasound scan of the chest and aspiration
Correct Answer: Ultrasound scan of the chest and aspiration
Explanation:
Correct Answer: E- Ultrasound scan of the chest and aspiration Explanation Ultrasound scan of the chest and aspiration Ultrasound is more sensitive in detecting effusions than chest radiographs and can be performed at the time of aspiration to improve the success rate and reduce risk of complications from aspiration. Bronchoscopy Bronchoscopy is incorrect. Bronchoscopy will not allow access or visualisation of the pleural space. Contrast-enhanced computed tomography of the chest Contrast-enhanced computed tomography of the chest is incorrect. CT chest is less sensitive for showing septations than ultrasound imaging. The failure to aspirate in this case may be because the diagnosis is empyema with multiple septations. Ultrasound-guided aspiration is recommended by the British Thoracic Society to improve the success rate of aspiration and reduce the risk of complications, eg pneumothorax. There are a number of possible causes of the effusion in this case, with infection and malignancy both possibilities. Given his long history of intravenous heroin abuse, HIV infection cannot be ruled out. Lateral chest X-ray Lateral chest X-ray is incorrect. Ultrasound is more sensitive in detecting effusions than chest radiographs and can be performed at the time of aspiration to improve the success rate and reduce risk of complications from aspiration. Thoracoscopy Thoracoscopy is incorrect. Thoracoscopy may be required in the investigation and management of pleural effusions, but is not a first-line investigation/procedure.
Question 11:
A 40-year-old man presents with a 2-month history of cough and breathlessness. He has also noticed haemoptysis, which he says has worsened gradually. On examination he has bilateral basal crepitations. His chest X-ray shows diffuse shadowing. He has moderate renal failure. He is previously well and holds down a job as a solicitor. Which investigation would be most useful in obtaining a diagnosis?
Options:
- Bronchoscopy
- Computed tomography (CT) of the thorax
- Renal biopsy
- Sputum sample
- Ventilation/perfusion scan
Correct Answer: Renal biopsy
Explanation:
Correct Answer: C- Renal biopsy Explanation Renal biopsy Goodpasture syndrome consists of diffuse pulmonary haemorrhage and glomerulonephritis with linear deposition of antibodies (90% of which are directed against the α3 chain of type IV collagen) along the glomerular basement membrane (GBM). Serological testing for anti-GBM antibodies and ANCA (anti-neutrophil cytoplasmic antibody) is crucial for confirming the diagnosis, and a renal biopsy is almost always warranted. Some healthy individuals exposed to inhaled oils, hydrocarbons or solvents can have borderline raised anti-GBM antibody levels. Anti-GBM antibodies have also been detected in HIV-negative patients with Pneumocystis pneumonia. Bronchoscopy Bronchoscopy is incorrect. Bronchosopy may show evidence of pulmonary haemorrhage in Goodpasture syndrome but is not definitively diagnostic. Computed tomography (CT) of the thorax Computed tomography (CT) of the thorax is incorrect. CT of the thorax would be likely to form part of the
investigation work-up of this gentleman and would show the degree of pulmonary haemorrhage and any lung parenchymal abnormality, but it would not be definitively diagnostic. Histology is required. Sputum sample Sputum sample is incorrect. Sputum sampling would help rule out infective cause of this man’s symptoms, but this is a history of Goodpasture syndrome and the sputum culture result would be expected to be normal. Ventilation/perfusion scan Ventilation/perfusion scan is incorrect. Ventilation/perfusion scans are an investigation for pulmonary embolism, which is not likely based on this history.
Question 12:
A 26-year-old office secretary who smokes 10-15 cigarettes per day presented in the clinic after a couple of episodes of haemoptysis. She also said that she had felt tired recently and gave a history of treatment for a respiratory tract infection a couple of months ago. She said that she feels she never fully recovered from that infection and has been persistently coughing ever since. On examination, she looked pale, had minimal pedal oedema and diffuse crepitations on chest auscultation. Her urine was positive for protein and blood. A full blood count showed anaemia and the chest X-ray showed blotchy shadows over the lung fields. She is ANCA negative. What is your probable diagnosis?
Options:
- Bronchogenic carcinoma
- Goodpasture syndrome
- Granulomatosis with polyangiitis
- Pulmonary tuberculosis
- Sarcoidosis
Correct Answer: Goodpasture syndrome
Explanation:
Correct Answer: B- Goodpasture syndrome Explanation Goodpasture syndrome This is a case of Goodpasture syndrome, which usually occurs in people over the age of 16 years. It starts with an upper respiratory infection, followed by cough, intermittent haemoptysis and tiredness. Later on, anaemia develops and a massive episode of haemoptysis can occur. The typical chest X-ray picture is a manifestation of intrapulmonary haemorrhage. These features are followed, in weeks or months, by the development of glomerulonephritis. The basic cause of the disease is a type II cytotoxic reaction against the basement membrane of both the kidneys and lungs. Glomerulonephritis might present as asymptomatic proteinuria and/or microscopic haematuria. This is followed later on by the development of the acute nephritic syndrome, nephrotic syndrome and chronic renal failure. Bronchogenic carcinoma Bronchogenic carcinoma is incorrect. Despite her smoking history lung cancer would be very unlikely in a 26-year-old. The urinalysis findings, and chest radiograph appearances are not in keeping with bronchogenic carcinoma. Her total smoking exposure is also unlikely to be associated with the development of a bronchogenic carcinoma. Granulomatosis with polyangiitis Granulomatosis with polyangiitis is incorrect. Granulomatosis with polyangiitis may present with predominant respiratory symptoms, often with symptoms of granuloma formation, e.g. nosebleeds for a number of months before diagnosis. Alternatively patients may present with renal disease, those presenting with respiratory symptoms are said to have around an 80% chance of eventual renal dysfunction. Pulmonary tuberculosis Pulmonary tuberculosis is incorrect. This is a history of vasculitis. There is no history of fever or exposure to TB and the symptoms and test results are more in keeping with vasculitis. Sarcoidosis Sarcoidosis is incorrect. The symptoms are in keeping with vasculitis. Sarcoidosis would not be associated with positive urinalysis unless history was suggestive of renal calculi. ANCA would be negative in sarcoidosis and chet radiograph would most likely show bilateral hilar lymphadenopathy +/- pulmonary infiltrates.
Question 13:
A 29-year-old man is admitted feeling a little more tired than usual. He has no history of previous respiratory disease and works as a builder. On examination he is 184 cm in height, with a blood pressure of 142/80 mmHg, and his pulse is 80 bpm. His oxygen saturation is 95% on air. Breath sounds appear normal bilaterally on auscultation and his respiratory rate is 16/min. The chest X-ray shows a 1-cm rim of air on the right-hand side of the chest. Which of the following is the most appropriate management?
Options:
- Admit and observe
- Aspiration
- Discharge
- Large-size chest drain
- Small-size chest drain
Correct Answer: Discharge
Explanation:
Correct Answer: C- Discharge Explanation Discharge We are not given any indication that this man is in distress because his saturation is 95% and his respiratory rate is 16/min. With only a 1-cm rim of air, British Thoracic Society (BTS) guidelines therefore would suggest that he can be safely discharged, with instructions to return if he has significant pleuritic chest pain or feels more short of breath. Admit and observe Admit and observe is incorrect. We are not given any indication that this man is in distress because his saturation is 95% and his respiratory rate is 16/min. With only a 1-cm rim of air, British Thoracic Society (BTS) guidelines therefore would suggest that he can be safely discharged, with instructions to return if he has significant pleuritic chest pain or feels more short of breath. Aspiration Aspiration is incorrect. Significant shortness of breath or a rim of air of 2 cm or greater necessitates air aspiration as long as there is no history of previous chest pathology. Large-size chest drain Large-size chest drain is incorrect. Large-size chest drains are not recommended as first-line intervention in a atraumatic pneumothorax. Small-size chest drain Small-size chest drain is incorrect. If there is a history or evidence of previous chest disease, a small- bore chest drain is recommended if there is s ignificant shortness of breath or a rim of air of 2 cm or greater.
Question 14:
A 24-year-old medical student (height 165 cm, weight 78 kg) has been complaining of a few months’ history of shortness of breath on exertion and of coughing up blood once. She is a few days away from her final examinations and smokes 20 cigarettes per day. She takes no medication except for the oral contraceptive pill. Her only past medical history of note is a DVT after a long flight from Australia. What is the most likely diagnosis?
Options:
- Goodpasture syndrome
- Hyperventilation syndrome due to stress
- Pulmonary embolism
- Sarcoidosis
- Tuberculosis
Correct Answer: Pulmonary embolism
Explanation:
Correct Answer: C- Pulmonary embolism Explanation Pulmonary embolism Acute pulmonary embolism can present in diverse ways:
• A syndrome of pleuritic pain or haemoptysis, in the absence of circulatory collapse, is the most frequent mode of presentation. This was the mode of presentation in 60% of patients recruited in a collaborative
investigation, the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). • A syndrome of dyspnoea in the absence of haemoptysis or pleuritic pain or circulatory collapse occurred in 25% in the PIOPED study. • Circulatory collapse (systolic blood pressure less than 80 mmHg or loss of consciousness) was an uncommon mode of presentation, occurring in only 15% in the PIOPED study. Obesity and a high oestrogen content in oral contraceptives have been linked to thromboembolic events. Most patients with pulmonary embolism were found to have smoked at one time or to be active smokers at the time of their pulmonary embolism. Goodpasture syndrome Goodpasture syndrome is incorrect. Goodpasture syndrome may present with pulmonary haemorrhage, and therefore haemoptysis, but the duration of symptoms is too long for this diagnosis to be likely. Hyperventilation syndrome due to stress Hyperventilation syndrome due to stress is incorrect. Haemoptysis is not a feature of hyperventilation and the other features described in this case point towards a more likely diagnosis of pulmonary embolism (obesity, previous DVT, contraceptive use and smoking). Sarcoidosis Sarcoidosis is incorrect. Haemoptysis is not a feature of sarcoidosis and the other features described in this case point towards a more likely diagnosis of pulmonary embolism (obesity, previous DVT, contraceptive use and smoking). Tuberculosis Tuberculosis is incorrect. There is no mention of fever, night sweats or weight loss. The history of obesity, previous DVT, haemoptysis and contraceptive use point towards pulmonary embolism.
Question 15:
A 59-year-old woman with severe rheumatoid arthritis presents to the Respiratory Clinic with worsening shortness of breath. She has had rheumatoid arthritis for 17 years and she is now managed with a methotrexate- based regime. Other medical history of note includes hypertension, for which she is treated with ramipril 10 mg daily. On examination, she has evidence of severe rheumatoid joint disease. Crackles are heard on auscultation of the chest. Investigation: Hb 11.0 g/dl WCC 4.8 x 109/l PLT 345 x 109/l Sodium 139 mmol/l Potassium 4.5 mmol/l Creatinine 140 µmol/l Chest X-ray shows patchy consolidation, small pulmonary nodules and small bilateral pleural effusions. Computed tomography (CT) of the thorax shows patchy ground-glass opacities (peribronchovascular region), bronchial wall thickening, areas of bronchial dilatation and centrilobular pulmonary nodules. Pulmonary function testing demonstrates a restrictive pattern, with reduced diffusion capacity for carbon monoxide (Dlco) with a fall in oxygenation on exercise. Which of the following is the most likely diagnosis?
Options:
- Bronchiectasis
- Chronic eosinophilic pneumonia
- Cryptogenic organising pneumonia
- Idiopathic pulmonary fibrosis
- Methotrexate-related pulmonary fibrosis
Correct Answer: Cryptogenic organising pneumonia
Explanation:
Correct Answer: C- Cryptogenic organising pneumonia Explanation Cryptogenic organising pneumonia Cryptogenic organising pneumonia (COP) occurs in patients with rheumatoid arthritis or other connective tissue disorders, and is associated with the typical radiographic and pulmonary function test picture seen here. Corticosteroids are the treatment of choice for COP, although relapse occurs on withdrawal of steroids in around 30% of cases. Bronchiectasis Bronchiectasis is incorrect. In bronchiectasis, chronic sputum production would be expected as a predominant symptom with a history of recurrent respiratory infections. Although bronchiectasis may not be visible on a chest radiograph it would almost certainly be noted on
CT scanning and pulmonary function tests would show an obstructive not restrictive pattern of spirometry.
Although bronchial dilatation has indeed been noted on this lady’s imaging, there is clearly more going on here to explain her symptoms. Chronic eosinophilic pneumonia Chronic eosinophilic pneumonia is incorrect. Chronic eosinophilic pneumonia is associated with an obstructive picture on pulmonary function testing. Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. Idiopathic pulmonary fibrosis is classically associated with a ‘usual interstitial pneumonia’ which can be detected on High- resolution computed tomography (HRCT) in approximately 80% of cases and classically affects the lung bases. Methotrexate-related pulmonary fibrosis Methotrexate-related pulmonary fibrosis is incorrect. Methotrexate-related pulmonary fibrosis is typically associated with ‘non-specific interstitial pneumonia’. CT features are variable and can include centrilobular nodules, reticulation and diffuse parenchymal opacification. However, the radiology findings in this case, particularly the peribronchial distribution that is mentioned, are more suggestive of bronchiolitis obliterans organising pneumonia (BOOP).
Question 16:
A 69-year-old former coal-miner is referred to you by the on-call team. There is a smoking history and he has been managed by his GP for chronic obstructive pulmonary disease (COPD). He has been admitted with dyspnoea that is now so bad that he is unable to manage at home and cannot walk from the chair to the bathroom. He has a cough that is productive of black sputum. Lung function tests show a mixed restrictive and obstructive picture. A chest X-ray shows marked changes with massive fibrotic masses, predominantly in the upper lobes. There are also changes consistent with lung destruction and emphysema. His rheumatoid factor is positive. Which diagnosis fits best with this clinical picture?
Options:
- Asthma
- Category 1 pneumoconiosis
- Chronic obstructive pulmonary disease
- Progressive massive fibrosis
- Tuberculosis
Correct Answer: Progressive massive fibrosis
Explanation:
Correct Answer: D- Progressive massive fibrosis Explanation Progressive massive fibrosis Progressive massive fibrosis (PMF) is associated with fibrotic masses in the apices, sometimes up to 10 cm in diameter. There are also emphysematous changes. There is a mixed obstructive and restrictive lung defect with reduced transfer factor. Rheumatoid factor and antinuclear antibody are often positive. There is usually a history of dust inhalation (eg coal dust), and PMF can progress rapidly, even in the absence of further dust exposure, leading to respiratory failure and eventually death. Category 2 pneumoconiosis progresses to PMF in around 7% of cases. The rate of progression of category 3 pneumoconiosis is much higher, at around 30%. The 0–3 classification is defined by the International Labour Organisation and reflects an increasing density of small opacities on the chest radiograph. Asthma Asthma is incorrect. The majority of this history is not in keeping with asthma, eg black sputum, no mention of wheeze, mixed spirometry pattern (airflow restriction is not in keeping with asthma), fibrotic masses, lung destruction and emphysema on chest X-ray (in pure asthma the chest X-ray will be normal or show hyperinflation). Category 1 pneumoconiosis Category 1 pneumoconiosis is incorrect. Category 1 pneumoconiosis is the least severe form of pneumoconiosis and chest radiograph will show just a few opacities and normal lung markings will be clearly visible. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease is incorrect. Given this man’s smoking history and presence of emphysema on his chest X-ray it is reasonable to believe he has a degree of COPD. However, the Question: asks which option best fits the clinical picture and, given the additional features mentioned re his chest X-ray findings, black sputum, positive rheumatoid factor and his occupational history, then progressive massive fibrosis is the correct option. Tuberculosis Tuberculosis (TB) is incorrect. A previous history of pulmonary TB is a risk factor for the development of PMF in individuals with silicosis, but this scenario is not suggestive of active pulmonary TB. There is no history of weight loss, fevers, night sweats or purulent sputum. The chest radiograph does not show lymphadenopathy or consolidation.
Question 17:
A 29-year-old breathless Afro-Caribbean woman is referred by the ophthalmologists with anterior uveitis and a suspected diagnosis of sarcoidosis. Which of the following clinical features is most strongly associated with sarcoidosis?
Options:
- A slowly worsening picture of breathlessness with no periods of improvement
- Bronchoalveolar lavage shows an eosinophilia
- Decreased gas-transfer factor (DLCO) with decreased gas-transfer coefficient (KCO)
- Obstructive defect on spirometry
- Positive Mantoux test
Correct Answer: Decreased gas-transfer factor (DLCO) with decreased gas-transfer coefficient (KCO)
Explanation:
Correct Answer: C- Decreased gas-transfer factor (DLCO) with decreased gas-transfer coefficient (KCO) Explanation Decreased gas-transfer factor (DLCO) with decreased gas-transfer coefficient (KCO) Decreased gas transfer factor (DLCO) accompanied by elevated gas transfer coefficient (KCO) is characteristic of extrathoracic restriction and not of intrapulmonary restriction – both are usually decreased in intrapulmonary sarcoidosis. A slowly worsening picture of breathlessness with no periods of improvement A slowly worsening picture of breathlessness with no periods of improvement is incorrect. Spontaneous remission of respiratory symptoms is not uncommon and might allow a ‘wait and see’ policy to be adopted at the outset before embarking on immunosuppressive therapy. Bronchoalveolar lavage shows an eosinophilia Bronchoalveolar lavage shows an eosinophilia is incorrect. Bronchoalveolar lavage typically shows a lymphocytosis. Obstructive defect on spirometry Obstructive defect on spirometry is incorrect. Spirometry usually shows a restrictive defect. Positive Mantoux test Positive Mantoux test is incorrect. Mantoux or Heaf testing is usually negative and reflects cutaneous anergy.
Question 18:
A 17-year-old girl has chronic cough and recurrent respiratory infections over the past 2–3 years. Which one of the following pieces of clinical information in her history would point most strongly to the development of bronchiectasis?
Options:
- History of eczema
- History of wheeze
- Pale stools and low weight
- Pepperpot calcification on chest X-ray
- Previous whooping cough in early childhood
Correct Answer: Previous whooping cough in early childhood
Explanation:
Correct Answer: E- Previous whooping cough in early childhood Explanation Previous whooping cough in early childhood A history of previous whooping cough is a well-known risk factor for bronchiectasis. History of eczema History of eczema is incorrect. Eczema is not associated with bronchiectasis. History of wheeze History of wheeze is incorrect. Wheeze often occurs in bronchiectasis, but asthma would be the most likely diagnosis in an adolescent complaining of wheeze. Pale stools and low weight Pale stools and low weight is incorrect. Pale stools and low weight suggests cystic fibrosis. Pepperpot calcification on chest X-ray Pepperpot calcification on chest X-ray is incorrect. Pepperpot calcification on a chest X-ray suggests previous varicella infection, which rarely gives rise to further symptoms.
Question 19:
A 30-year-old man from Russia is seen in the Emergency Department. He was diagnosed with pulmonary tuberculosis (TB) 4 months ago in Russia and is taking rifampicin and isoniazid. He comes because of a productive cough, fevers, weight loss and malaise. What would you like to do next?
Options:
- Admit him to hospital, send a sputum sample and add the current WHO recommendations for multidrug- resistant tuberculosis (MDRTB)
- Admit him to hospital, send a sputum sample and start him on amoxicillin
- Admit him to hospital, send a sputum sample and start him on amoxicillin and pyrazinamide
- Admit him to hospital, send a sputum sample and start him on pyrazinamide
- Send a sputum sample and arrange to see him in outpatients
Correct Answer: Admit him to hospital, send a sputum sample and add the current WHO recommendations for multidrug- resistant tuberculosis (MDRTB)
Explanation:
Correct Answer: A- Admit him to hospital, send a sputum sample and add the current WHO recommendations for multidrug-resistant tuberculosis (MDRTB) Explanation Admit him to hospital, send a sputum sample and add the current WHO recommendations for multidrug-resistant tuberculosis (MDRTB) The concern with this man is one of MDRTB. He is failing on his current regime and has clinical features of active TB. Management should involve sending sputum for culture and polymerase chain reaction (PCR) testing before starting further treatment. If he has confirmed MDRTB, ensure he is on five or more drugs to which the organism is likely to be susceptible. Risk factors for MDRTB • Poor compliance (the most common reason) • Previous anti-TB treatment • HIV infection • Contact with drug-resistant TB Admit him to hospital, send a sputum sample and start him on amoxicillin Admit him to hospital, send a sputum sample and start him on amoxicillin is incorrect. Although this man could have a superimposed simple bacterial infection, this should not deter you from investigating and treating him for TB, as most of the antibiotics used for TB will cover the usual bacterial chest pathogens. Admit him to hospital, send a sputum sample and start him on amoxicillin and pyrazinamide Admit him to hospital, send a sputum sample and start him on amoxicillin and pyrazinamide is incorrect. Amoxicillin will not treat tuberculosis, therefore this plan would only involve the addition of one anti-tuberculous agent, is incorrect management and could induce further antibiotic resistance and limit treatment options further. Admit him to hospital, send a sputum sample and start him on pyrazinamide Admit him to hospital, send a sputum sample and start him on pyrazinamide is incorrect. A single drug should never be added to a failing TB regime. Add two or three, ideally drugs to which the organism is known to be sensitive and which the patient has not taken previously. Send a sputum sample and arrange to see him in outpatients Send a sputum sample and arrange to see him in outpatients is incorrect. This gentleman has possible MDRTB and therefore needs urgent admission and isolation while he is further investigated and treated.
Question 20:
A 44-year-old woman presents with peripheral calcinosis, sclerodactyly and oesophageal reflux. On further questioning it transpires that she has also had worsening shortness of breath over the past few months and Raynaud’s phenomenon when she goes out on a cold day or puts her hands into cold water. On examination, her blood pressure is 155/91 mmHg and her pulse is 92 bpm and regular. She has multiple telangiectasia, and sclerodactyly with peripheral calcinosis. Auscultation of the chest reveals scattered crackles. Investigations show: haemoglobin 12.9 g/dl, white cell count 8.2 × 109/l, platelets 203 × 109/l, sodium 138 mmol/l, potassium 4.4 mmol/l, creatinine 134 µmol/l. Which of the following is the most likely pulmonary manifestation of this disorder?
Options:
- Bronchiectasis
- Irreversible obstructive lung defect
- Non-specific interstitial pneumonia
- Pulmonary haemorrhage
- Reversible obstructive lung defect
Correct Answer: Non-specific interstitial pneumonia
Explanation:
Correct Answer: C- Non-specific interstitial pneumonia Explanation Non-specific interstitial pneumonia The diagnosis here is non-specific interstitial pneumonia (NSIP). Scleroderma, the obvious underlying condition here, is associated with generalised interstitial lung disease. Case series and multiple lung biopsy reviews suggest that NSIP is the most usual pattern of fibrotic lung disease seen in scleroderma. Treatment: Cyclophosphamide and mycophenolate mofetil might have an effect on progression of fibrotic lung disease, and the usual range of agents such as PDE- 5 inhibitors and endothelin-receptor antagonists can be used in the treatment of pulmonary hypertension. Bronchiectasis Bronchiectasis is incorrect. Bronchiectasis is not classically associated with scleroderma; however, case series have been described. The most likely pulmonary manifestations that occur in scleroderma are pulmonary hypertension and NSIP. Irreversible obstructive lung defect Irreversible obstructive lung defect is incorrect. The diagnosis here is NSIP, which would be associated with a restrictive pattern on spirometry. Pulmonary haemorrhage Pulmonary haemorrhage is incorrect. Pulmonary haemorrhage can occur in scleroderma but is relatively rare. The findings described in this case are more in keeping with NSIP. Reversible obstructive lung defect Reversible obstructive lung defect is incorrect. The diagnosis here is non-specific interstitial pneumonia, which would be associated with a restrictive pattern on spirometry.
