Full Question & Answer Text (for Search Engines)
Question 1:
Which one of the following statements about cystic fibrosis (CF) is true?
Options:
- Allergic bronchopulmonary aspergillosis is a recognised complication, occurring in 15% of adult CF patients
- Heterozygotes generally have clinically significant disease
- Neonatal screening for CF results in a better survival rate and reduced decline in lung function
- Reduced body mass index is an absolute contraindication for heart-lung transplantation
- The controlled intake of high-calorie food is the first line of management for patients with CF-related diabetes
Correct Answer: Allergic bronchopulmonary aspergillosis is a recognised complication, occurring in 15% of adult CF patients
Explanation:
Correct Answer: A- Allergic bronchopulmonary aspergillosis is a recognised complication, occurring in 15% of adult CF patients Explanation Allergic bronchopulmonary aspergillosis is a recognised complication, occurring in 15% of adult CF patients The increasing incidence of allergic bronchopulmonary aspergillosis (ABPA) is a recognised phenomenon. Allergic bronchopulmonary aspergillosis (ABPA) is encountered in 1 in 6 adult CF patients. Manifestations of ABPA include asthma symptoms, flitting opacities on the chest X-ray, increased eosinophil count, and hyper- reactivity to the skin prick test and increased specific plasma IgE. The main treatment is high-dose corticosteroids initially, with a smaller maintenance dose. The duration of treatment ranges from a few months to few years. Antifungal agents may be used to allow a reduction in corticosteroid dose. Heterozygotes generally have clinically significant disease Heterozygotes generally have clinically significant disease is incorrect. Different mutations responsible for cystic fibrosis across different racial subtypes are responsible for slightly differing patterns of disease, but drawing definitive correlations between genotype and disease severity is difficult. Neonatal screening for CF results in a better survival rate and reduced decline in lung function Neonatal screening for CF results in a better survival rate and reduced decline in lung function is incorrect. The most common mutation in patients with cystic fibrosis (CF) is the delta- F508 mutation. There is no correlation between genotype, the range of manifestations, the age of onset of symptoms and the survival rate in CF. However, neonatal screening allows the early implementation of prophylactic therapeutic measures. Prospective and retrospective studies have demonstrated that neonates detected by screening have a better nutritional status than those who were discovered by investigation of symptoms. The age of acquisition of Pseudomonas aeruginosa and the decline in lung function were found to be comparable in the two groups. Reduced body mass index is an absolute contraindication for heart-lung transplantation Reduced body mass index is an absolute contraindication for heart-lung transplantation is incorrect. Heart-lung transplantation is offered to patients who exhibit a rapid decline in lung function despite optimal treatment, and to patients with respiratory failure. Moderately reduced body mass index (BMI) is an indication for transplantation. A severe reduction in BMI is a relative contraindication to transplantation because it is associated with reduced survival but it is not an absolute contraindication. The controlled intake of high-calorie food is the first line of management for patients with CF-related diabetes The controlled intake of high-calorie food is the first line of management for patients with CF-related diabetes is incorrect. Diabetes is now seen in almost 10% of CF patients over the age of 20 years, the main manifestations being weight loss, repeated respiratory infections and decline in lung function. The treatment of choice is subcutaneous insulin therapy. Calorie intake should not be restricted in CF patients, who are prone to malnutrition due to their pancreatic insufficiency.
Question 2:
A 24-year-old HIV-positive man with a CD4 lymphocyte count of 150 cells/mm3 has been complaining of gradually worsening dyspnoea associated with a non- productive cough and fever for the last 2 weeks. A chest X-ray shows bilateral diffuse ground-glass opacities. What is the diagnosis?
Options:
- Infectious mononucleosis
- Legionellosis
- Pneumocystis jirovecii pneumonia
- Toxoplasmosis
- Tuberculosis
Correct Answer: Pneumocystis jirovecii pneumonia
Explanation:
Correct Answer: C- Pneumocystis jirovecii pneumonia Explanation Pneumocystis jirovecii pneumonia Pneumocystis jirovecii pneumonia (previously known as Pneumocystis carinii pneumonia (PCP)) typically presents with gradually increasing dyspnoea and cough over several weeks, but sometimes it presents as an acute illness with rapid deterioration over a few days. Cystic abnormalities and spontaneous pneumothoraces in patients with known or suspected HIV infection are usually caused by this pneumonia. In recognition of its genetic and functional distinctness, the organism that causes human PCP was renamed Pneumocystis jirovecii(Frenkel, 1999). Changing the organism’s name does not preclude the use of the acronym PCP. • Chest X-ray – usually shows diffuse ground-glass opacities, which strongly suggests the diagnosis. Sometimes, however, it shows nodular opacities or lobar consolidation, or can even be normal. • Lactate dehydrogenase – raised in approximately 90% of patients with Pneumocystis jirovecii pneumonia (but this can occur with other pulmonary diseases). • CD4 count – Pneumocystis jirovecii pneumonia is unlikely in a patient who has had a CD4 count above 200 cells/mm3 in the preceding 2 months in the absence of other HIV- associated symptoms. Infectious mononucleosis Infectious mononucleosis is incorrect. Infectious mononucleosis can mimic primary HIV infection with fever, sore throat and lymphadenopathy. However, it is not associated with pneumonia. Legionellosis Legionellosis is incorrect. The diagnosis of HIV coupled with low CD4 count should point the candidate towards an opportunistic infecting organism, and with the history of dry cough and diffuse ground-glass opacification, the description in this case is more fitting with P. jiroveciipneumonia than Legionella pneumonia. Toxoplasmosis Toxoplasmosis is incorrect. Toxoplasmosis is caused by infection with the toxoplasma parasite and is usually asymptomatic in healthy individuals. Individuals with HIV and a low CD4 count are at risk of symptomatic infection, which can be life threatening. It is classically associated with CNS infection in severe immunodeficiency with neurological symptoms dominating. Pulmonary involvement is not typical of toxoplasmosis. Tuberculosis Tuberculosis is incorrect. Tuberculosis is a reasonable differential here in an immunocompromised patient, but the radiograph appearances favour Pneumocystis jirovecii pneumonia.
Question 3:
A 38-year-old man with a history of asthma presents with weakness of his right hand and of plantar flexion of his left foot. His asthma is managed with a salmeterol– fluticasone combination inhaler. On examination, his blood pressure is 152/91 mmHg and he has polyphonic wheeze on auscultation of the chest. Investigations: Hb 13.2 g/dl WCC 8.2 x 109/l (raised eosinophils) PLT 180 x 109/l Sodium 139 mmol/l Potassium 4.3 mmol/l Creatinine 149 µmol/l Urine dipstick testing showed blood + and protein +. Which of the following is the most appropriate autoantibody to test for?
Options:
- Anti-double-stranded DNA (anti-dsDNA) antibodies
- Antinuclear antibody (ANA)
- Anti-smooth muscle antibody
- Cytoplasmic anti-neutrophil cytoplasmic antibody (cANCA)
- Perinuclear anti-neutrophil cytoplasmic antibody (pANCA)
Correct Answer: Perinuclear anti-neutrophil cytoplasmic antibody (pANCA)
Explanation:
Correct Answer: E- Perinuclear anti-neutrophil cytoplasmic antibody (pANCA) Explanation Perinuclear anti-neutrophil cytoplasmic antibody (pANCA) About 70% of patients with eosinophilic granulomatosis with polyangiitis have a positive pANCA (perinuclear anti-neutrophil cytoplasmic antibody) result. Eosinophilic granulomatosis with polyangiitis presents with symptoms of asthma, and more than 7/10 patients also have mononeuritis multiplex. Renal involvement leads to haematuria and proteinuria, hypertension and raised creatinine. The raised eosinophil count here is also typical of eosinophilic granulomatosis with polyangiitis. Treatment consists of corticosteroids, with or without additional therapy with cyclophosphamide. Without treatment, the 5-year survival rate for eosinophilic granulomatosis with polyangiitis is around 25%; with appropriate therapy this rises to over 60%. Anti-double-stranded DNA (anti-dsDNA) antibodies Anti-double-stranded DNA (anti-dsDNA) antibodies is incorrect. Anti-dsDNA antibodies are strongly associated with a diagnosis of systemic lupus erythematosus. Antinuclear antibody (ANA) Antinuclear antibody (ANA) is incorrect. Positive ANA antibodies are associated with systemic lupus erythematosus, Sjögren’s syndrome, scleroderma, and may also be found in Raynaud’s disease, polymyositis, juvenile chronic arthritis, or antiphospholipid antibody syndrome. Anti-smooth muscle antibody Anti-smooth muscle antibody is incorrect. Positive anti- smooth muscle antibodies are associated with autoimmune hepatobiliary disease. Cytoplasmic anti-neutrophil cytoplasmic antibody (cANCA) Cytoplasmic anti-neutrophil cytoplasmic antibody (cANCA) is incorrect. Positive cANCA antibodies are classically associated with granulomatosis with polyangiitis.
Question 4:
A 25-year-old patient with epilepsy aspirated gastric juice after a seizure (Mendelson syndrome). What is the most likely clinical symptom or sign?
Options:
- Bradypnoea
- Bronchospasm
- Laryngospasm
- Paradoxical breathing
- Tenderness to percussion
Correct Answer: Bronchospasm
Explanation:
Correct Answer: B- Bronchospasm Explanation Bronchospasm Mendelson syndrome is an acute pneumonia caused by regurgitation of stomach contents and aspiration of chemical material, usually gastric juices. It can cause severe bronchospasm. The pneumonia develops rapidly, and within hours the patient can become tachypnoeic, hypoxic and febrile. There is minimal sputum. The condition often follows anaesthesia, when the gag reflex is depressed. Bradypnoea Bradypnoea is incorrect. Bradypnoea would not be the most likely result of aspiration of gastric juice. Laryngospasm Laryngospasm is incorrect. Laryngospasm would not be the most likely result of aspiration of gastric juice. Paradoxical breathing Paradoxical breathing is incorrect. Paradoxical breathing would not be the most likely result of aspiration of gastric juice. Tenderness to percussion Tenderness to percussion is incorrect. Tenderness to percussion would not be the most likely result of aspiration of gastric juice.
Question 5:
Which one of the following conditions is most likely to be associated with obstructive spirometry and a normal Tlco (transfer factor for carbon monoxide)?
Options:
- Asthma
- Emphysema
- Interstitial lung disease
- Pulmonary hypertension
- Sarcoidosis
Correct Answer: Asthma
Explanation:
Correct Answer: A- Asthma Explanation Asthma Asthma is associated with airflow obstruction. Transfer factor is usually unaffected. The Tlco is sometimes increased in patients with bronchial asthma during an attack, but the cause of this change is not known. The other options are all incorrect. These conditions are all associated with a reduced transfer factor. The diffusion of carbon monoxide (CO) from the alveoli to the pulmonary blood is governed by the integrity of the alveolar membrane, the capillary blood volume, or both (the air–blood barrier). A reduction in the diffusion capacity of CO is encountered in conditions affecting the capillary bed size (eg pulmonary emboli, pulmonary vasculitis) or conditions that cause changes in the characteristics of the alveolar membrane, such as diseases in which some form of intra-alveolar filling process has occurred and the air–blood diffusion pathway is actually lengthened (eg pneumonia, pulmonary oedema, alveolar proteinosis). Similarly, the transfer factor for carbon monoxide (Tlco) is reduced in patients with infiltrative disorders of the lung that affect both the capillary bed size and the alveolar membrane integrity (eg sarcoidosis, interstitial lung diseases, collagen vascular diseases). Removal or destruction of lung tissue (eg post-surgery, emphysema) decreases both membrane and blood volume components and produces a low Tlco. An increase in Tlco results occasionally from an increase in capillary blood volume secondary to haemodynamic changes in the pulmonary circulation, an increase in pulmonary artrial or left atrial pressures (eg in congestive heart failure) or an increase in pulmonary blood flow (eg in artrial septal defect). Alveolar haemorrhage from any cause can result in a false increase of the Tlco despite the presence of an underlying diffusion defect. Emphysema Emphysema is incorrect. Emphysema is associated with a reduced transfer factor. Interstitial lung disease Interstitial lung disease is incorrect. Interstitial lung disease is associated with a reduced transfer factor. Pulmonary hypertension Pulmonary hypertension is incorrect. Pulmonary hypertension is associated with a reduced transfer factor. Sarcoidosis Sarcoidosis is incorrect. Sarcoidosis is associated with a reduced transfer factor.
Question 6:
What are the NICE indications for home oxygen?
Options:
- Cor pulmonale and low PO2
- Ischaemic heart disease
- Low forced expiratory volume in 1 s (FEV1)
- Low PCO2
- Low PO2 during exacerbations
Correct Answer: Cor pulmonale and low PO2
Explanation:
Correct Answer: A- Cor pulmonale and low PO2 Explanation Cor pulmonale and low PO2 The National Institute for Health and Care Excellence (NICE) states that the following are indications for considering long-term oxygen therapy (LTOT):
• Stable patients with a PaO2 of < 7.3 kPa when stable • Patients with a PaO2 of 7.3–8.0 kPa who are stable but who have an additional risk factor (e.g. secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema, pulmonary hypertension). Oxygen should be used for at least 15 h per day. Ischaemic heart disease Ischaemic heart disease is incorrect. Ischaemic heart disease is not an indication for home oxygen. Low forced expiratory volume in 1 s (FEV1) Low forced expiratory volume in 1 s (FEV1) is incorrect. A patient with a low FEV1 may also have significant chronic hypoxia and therefore would benefit from home oxygen therapy. However, a low FEV1 without significant chronic hypoxia is not an indication for home oxygen therapy. Low PCO2 Low PCO2 is incorrect. High PCO2 associated with chronic hypoxia may be an indication for home oxygen therapy if the patient meets the above thresholds. Low PO2 during exacerbations Low PO2 during exacerbations is incorrect. Chronic rather than acute significant hypoxia is an indication for home oxygen therapy.
Question 7:
A 77-year-old man is referred to the Respiratory Clinic with a cough, stridor and a hoarse voice. He is noted on X-ray to have a lung mass, and biopsy confirms squamous-cell carcinoma of the bronchus. On examination, his BP is 125/72 mmHg, pulse is 74/min, atrial fibrillation. There are coarse crackles and wheeze on auscultation of the chest. Investigations: Hb 12.6 g/dl WCC 10.0 × 109/l PLT 200 × 109/l Na+ 135 mmol/l K+ 4.2 mmol/l Creatinine 128 μmol/l Ca++ 2.88 mmol/l Laryngoscopy Left vocal cord palsy Which of the following is the greatest contra-indication to surgery?
Options:
- Atrial fibrillation
- Creatinine 128 μmol/l
- His age (77 years)
- Hypercalcaemia
- Vocal cord palsy
Correct Answer: Vocal cord palsy
Explanation:
Correct Answer: E- Vocal cord palsy Explanation Vocal cord palsy The vocal cord palsy implies recurrent laryngeal nerve injury, and the most likely explanation for this is invasion by the underlying bronchial carcinoma. As such the tumour is almost certainly not amenable to surgery. Atrial fibrillation Atrial fibrillation is incorrect. Although atrial fibrillation is associated with increased operative risk, it is subsidiary to the probable nerve injury due to tumour invasion.
Creatinine 128 μmol/l
Creatinine 128 μmol/l is incorrect. Although renal impairment is associated with increased operative risk, it is subsidiary to the probable nerve injury due to tumour invasion. His age (77 years) His age (77 years) is incorrect. Although his age is associated with increased operative risk, it is subsidiary to the probable nerve injury due to tumour invasion. Hypercalcaemia Hypercalcaemia is incorrect. Although hypercalcaemia is associated with increased operative risk, it is subsidiary to the probable nerve injury due to tumour invasion.
Question 8:
A 29-year-old woman noticed shortness of breath and dry cough while jogging last winter. Her GP trialed a salbutamol inhaler that she says gave her some relief, although she now wakes up twice a week at 0400 h with a troublesome cough despite using the inhaler a number of times per day. On examination there is scattered wheeze and her peak flow is 460 (530 predicted). What is the most appropriate therapy?
Options:
- Ampicillin
- Oral steroids
- Salbutamol inhaler
- Salbutamol inhaler and inhaled steroids
- Theophylline
Correct Answer: Salbutamol inhaler and inhaled steroids
Explanation:
Correct Answer: D- Salbutamol inhaler and inhaled steroids Explanation Salbutamol inhaler and inhaled steroids This patient needs to move to step 2 of the British Thoracic Society (BTS) guidelines for asthma therapy (regular preventer therapy). Inhaled steroids should be considered for patients who:
• Have had exacerbations of asthma in the last 2 years • Are using inhaled ß2-agonists three times a week or more • Are symptomatic three times a week or more, or waking one night a week. Ampicillin Ampicillin is incorrect. There is nothing to suggest an acute bacterial infection requiring antibiotic therapy. Oral steroids Oral steroids is incorrect. Oral steroids are used in acute exacerbations of asthma and in severe asthma as ‘step 5’ treatment. This woman does not have an acute exacerbation, she has poorly controlled chronic asthma and requires the addition of inhaled steroids (ie step 2 treatment). Salbutamol inhaler Salbutamol inhaler is incorrect. She already has a salbutamol inhaler and her symptoms are not controlled on this therapy alone. She requires additional medication. Theophylline Theophylline is incorrect. Theophylline can be given intravenously to treat acute exacerbations of asthma or orally as a long-term treatment as an add-on therapy forming part of ‘step 4’ treatment. This woman does not have an acute exacerbation, she has poorly controlled chronic asthma and requires the addition of inhaled steroids (ie step 2 treatment).
Question 9:
A 60-year-old hairdresser complains that, after an attack of flu last year, she has been more breathless than usual when taking her evening walk. She has also felt short of breath when climbing the stairs. She has become concerned that she has a cardiac problem. She has lost about 6.4 kg (14 lbs) in weight during the last year. She has smoked 20 cigarettes per day for 45 years but does not drink alcohol. Other than an occasional paracetamol for headache, she is on no regular medication. On examination she was apyrexic and had bilateral clubbing. No lymphadenopathy was seen. Her jugular venous pressure was not raised and heart sounds were normal. Bibasal inspiratory crepitations were audible. No pedal oedema was seen. Bilateral reticular shadowing, mostly on the bases, was seen on the chest X-ray. Routine bloods were normal, except for an ESR of 35 mm in the 1st hour. Her high-resolution computed tomography scan showed probable fibrosis, most marked in the basal region. Respiratory function tests showed a restrictive ventilatory defect. Bronchoalveolar lavage showed an increased number of cells – neutrophils and macrophages – but no malignant cells. An open-lung biopsy showed an exudate of intra-alveolar macrophages with patchy interstitial fibrosis. What is the likely diagnosis?
Options:
- Chronic left heart failure
- Extrinsic allergic alveolitis
- Idiopathic pulmonary fibrosis
- Lymphangitis carcinomatosis
- Sarcoidosis
Correct Answer: Idiopathic pulmonary fibrosis
Explanation:
Correct Answer: C- Idiopathic pulmonary fibrosis Explanation Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis (IPF), synonymous with 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 is most commonly seen between the ages of 50 and 60 years; it is slightly more frequent in males than females. A history of progressive breathlessness on exertion in the absence of wheeze is typical. A dry cough may be present, but sputum production is unusual until the later stages of the disease. Haemoptysis is uncommon, but should suggest the development of lung malignancy that occurs with a 7- to 14-fold relative risk in patients with idiopathic pulmonary fibrosis. Chest pain is uncommon. Constitutional symptoms such as weight loss and lethargy are recognised. Lung function tests show a restrictive picture. Recent re-classification of the group of idiopathic interstitial pneumonias have allowed characterisation of seven different histological patterns based on lung biopsy analysis; the pattern in IPF is that of usual interstitial pneumonia (UIP). All other causes should be excluded before diagnosing idiopathic pulmonary fibrosis. The median survival time is approximately 5 years. Chronic left heart failure Chronic left heart failure is incorrect. Cardiovascular examination was normal and CT findings were of insterstital lung disease. There is no indication that this lady has heart failure. Extrinsic allergic alveolitis Extrinsic allergic alveolitis is incorrect. Extrinsic allergic alveolitis usually causes upper lobe disease. There is no history given re potential allergen exposure. Histologyclasically shows a triad of diffuse interstitial chronic inflammation, poorly formed interstitial granulomas, and tiny foci of organizing pneumonia. Of these, the most striking and consistent finding is a cellular chronic interstitial pneumonia characterized by thickening of alveolar septa (interstitium) by an inflammatory infiltrate composed mainly of lymphocytes and scattered plasma cells, along with an occasional multinucleated giant cell and/or a few aggregates of histiocytes (granulomas). Lymphangitis carcinomatosis Lymphangitis carcinomatosis is incorrect. Lymphangitis carcinomatosis is a metastatic lung disease characterised by the diffuse infiltration and obstruction of the pulmonary parenchymal lymphatic system by tumour cells. Chest radiograph classically shows a reticular or reticulonodular pattern of infiltrates. CT scans showinterlobular septal thickening, fissural thickening and preservation of the normal parenchymal architecture at the level of the secondary pulmonary lobule. Hilar lymphadenopathy is present in 50% cases. Sarcoidosis Sarcoidosis is incorrect. Sarcoidosis would classically be associated with bilateral hilar lymphadenopathy on chest radiograph. CT would classically show lymphadenopathy, nodules particularly in a peri bronchovascular distribution and bilateral fibrotic changes predominatly in thr middle and upper lobes.
Question 10:
A 68-year-old man who has a long history of smoking presents to the Emergency Department with worsening shortness of breath. His general health has deteriorated over the past few months and recently he has been prescribed a salbutamol inhaler by his GP for cough and wheezing, particularly on exercise and at night. On examination he is lip pursing and has considerable wheeze on auscultation of the chest. He is pyrexial at 37.8 °C and has purulent sputum. He can only manage a peak flow of 150 l/min. Arterial blood gas sampling reveals a Pao2 of 7.2 kPa. He is allergic to penicillin. Which of the following would be the most appropriate choice for antibiotic therapy in this man?
Options:
- Ciprofloxacin 500 mg bd orally
- Clarithromycin 500 mg bd IV
- Co-amoxiclav 1.2 g tds intravenously
- Metronidazole 500 mg tds orally
- Penicillin V 500 mg qds orally
Correct Answer: Clarithromycin 500 mg bd IV
Explanation:
Correct Answer: B- Clarithromycin 500 mg bd IV Explanation Clarithromycin 500 mg bd IV This man has an exacerbation of chronic obstructive pulmonary disease (COPD). The most common causative pathogens are Haemophilus influenzae and Moraxella catarrhalis. The most appropriate antibiotic of the options listed would be a macrolide such as clarithromycin. It should be noted, however, that in patients taking theophyllines, concomitant use of macrolides can increase serum aminophylline levels. Other important acute treatments in this case would be repeated nebulisation with salbutamol and ipratropium 4- to 6-hourly, oxygen therapy and oral steroids. Non- invasive ventilation might be considered where the pH is 7.3 or less and the patient is not improving after 4 h of medical therapy. Ciprofloxacin 500 mg bd orally Ciprofloxacin 500 mg bd orally is incorrect. Ciprofloxacin will not adequately treat infection with Streptococcus pneumoniae, which is a common cause of respiratory infection in COPD. Co-amoxiclav 1.2 g tds intravenously Co-amoxiclav 1.2 g tds intravenously is incorrect. He is penicillin allergic, so this would not be an appropriate choice. Metronidazole 500 mg tds orally Metronidazole 500 mg tds orally is incorrect. Oral metronidazole is primarily used to treat Clostridium difficile infection. Absorption is poor in its oral form. Intravenous metronidazole is used to treat anaerobic infections, which are not a common cause of COPD exacerbations. Penicillin V 500 mg qds orally Penicillin V 500 mg qds orally is incorrect. He is penicillin allergic; this would not be an appropriate choice.
Question 11:
Which one of the following does not increase the risk of death in patients with severe pneumonia?
Options:
- Age 49 years
- Atrial fibrillation
- Diastolic blood pressure < 60 mmHg
- Urea > 7 mmol/l
- White blood cell count < 4 × 109/l
Correct Answer: Age 49 years
Explanation:
Correct Answer: A- Age 49 years Explanation Age 49 years An age of 49 would not be associated with an increased risk of mortality from pneumonia. The risk factors for increased mortality in severe pneumonia are:
• Age over 60 years • Tachypnoea (respiratory rate > 30/min) • Underlying disease • Confusion • Multilobular involvement • Serum albumin < 35 g/l • Hypoxia (Pao2 < 8 kPa) • Leucocytosis > 20 × 109/l • Bacteraemia Leukopaenia is also associated with a higher rate of mortality in pneumonia. The CURB-65 severity scores for community-acquired pneumonia are:
• Confusion • BUN > 19 mg/dl (7 mmol/l) • Respiratory rate ≥ 30 • Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg • Age ≥ 65 Atrial fibrillation Atrial fibrillation is incorrect. This is associated with increased risk of mortality. Diastolic blood pressure < 60 mmHg Diastolic BP < 60 mmHg is incorrect. This is associated with increased risk of mortality. Urea > 7 mmol/l
Urea > 7 mmol/l is incorrect. This is associated with increased risk of mortality. White blood cell count < 4— 109/l White blood cell count < 4 × 109/l is incorrect. This is associated with increased risk of mortality.
Question 12:
A 43-year-old patient with rheumatoid arthritis has been referred to you because of increasing shortness of breath and dry cough. Which medication is most likely to be responsible for her symptoms?
Options:
- Gold
- Ibuprofen
- Methotrexate
- Oral corticosteroids
- Sulfasalazine
Correct Answer: Methotrexate
Explanation:
Correct Answer: C- Methotrexate Explanation Methotrexate Methotrexate is an effective and moderately toxic disease-modifying anti-rheumatoid drug (DMARD). Pulmonary complications, in the form of pneumonitis (inflammation of the lung), are rare idiosyncratic reactions and are potentially lethal. The classical presentation is with rapid onset dyspnoea (shortness of breath), which may result in death after a few days. Therefore, patients should be advised to stop methotrexate if they experience dyspnoea or cough and to seek immediate medical attention. Gold Gold is incorrect. Gold has been superceded by newer and less toxic DMARDs. Side-effects from gold include dermatitis, stomatitis, haematuria, proteinuria including nephrotic syndrome and blood dyscrasias. Cases of pulmonary toxicity have been reported in the literature, but are relatively rare. Ibuprofen Ibuprofen is incorrect. Ibuprofen is not associated with pulmonary toxicity. Oral corticosteroids Oral corticosteroids is incorrect. Oral corticosteroids may increase risk of pulmonary infection but the description of respiratory symptoms in this case suggests a non- infective cause of pulmonary toxicity. Pulmonary toxicity due to a DMARD, in particular methotrexate is most likely. Sulfasalazine Sulfasalazine is incorrect. Sulfasalazine is associated with side-effects such as nausea and vomiting, rashes, arthralgia and hepatic dysfunction in up to 20% of patients. Sulphasalazine-induced pulmonary toxicity is rare.
Question 13:
A patient who has had wheezy breathlessness for many years and who has previously been shown to have pulmonary infiltrates on chest X-ray and blood eosinophilia undergoes a high-resolution computed tomographic scan. This shows proximal bronchiectasis. Which of the following tests would be most useful in establishing the cause of her bronchiectasis?
Options:
- Aspergillus skin-prick test
- Bronchoscopy and bronchoalveolar lavage
- Histamine challenge test
- Measurement of total IgE
- Serum anti-neutrophil cytoplasmic antibody (ANCA)
Correct Answer: Aspergillus skin-prick test
Explanation:
Correct Answer: A- Aspergillus skin-prick test Explanation Aspergillus skin-prick test Allergic bronchopulmonary aspergillosis is characterised by:
• Asthmatic symptoms • Peripheral blood eosinophilia • Positive skin tests or circulating precipitins to Aspergillus fumigatus • Abnormal chest X-ray • Raised total IgE A proportion of patients develop proximal bronchiectasis as a consequence of mucus plugging. Treatment during acute episodes is usually with oral corticosteroids. Of the options listed, aspergillus skin-prick test is the most specific investigation for allergic bronchopulmonary aspergillosis. Bronchoscopy and bronchoalveolar lavage Bronchoscopy and bronchoalveolar lavage is incorrect. Bronchoscopy and bronchoalveolar lavage are not diagnostic in allergic bronchopulmonary aspergillosis. Diagnosis is made on clinical, serological and radiological criteria. Histamine challenge test Histamine challenge test is incorrect. Histamine challenge test is a test used in the diagnosis of asthma and is partuclarly helpful in cough variant asthma. Measurement of total IgE Measurement of total IgE is incorrect. Total IgE is a helpful test in establishing the diagnosis of allergic bronchopulmonary aspergillosis, but in isolation is not specific enough to establish the diagnosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) Serum anti-neutrophil cytoplasmic antibody (ANCA) is incorrect. ANCA testing is used to confirm a diagnosis of vasculitis.
Question 14:
An obese 40-year-old woman with a history of asthma presents with progressive breathlessness. On examination she has a raised jugular venous pressure, ankle oedema, right parasternal heave and a murmur consistent with tricuspid regurgitation. Chest auscultation is clear. You understand from her husband that she has had progressively worsening symptoms over the past year. He has noticed that she has had particular problems with snoring and stopping breathing at night since he met her. Arterial blood gas results show: pH 7.39, Po2 7.3 kPa (normal range 11.3–12.6 kPa), Pco2 4.9 kPa (4.7–6.0 kPa). What is the most likely diagnosis?
Options:
- Atrial septal defect
- Chronic asthma
- Primary pulmonary hypertension
- Pulmonary fibrosis
- Secondary pulmonary hypertension
Correct Answer: Secondary pulmonary hypertension
Explanation:
Correct Answer: E- Secondary pulmonary hypertension Explanation Secondary pulmonary hypertension The history of snoring is suggestive of sleep apnoea. Sleep apnoea is known to result in chronic nocturnal hypoxia, which in turn leads to pulmonary artery vasoconstriction. Eventually cor pulmonale develops, which is seen here.Treatment for this woman is likely to involve aggressive attempts to lose weight and nocturnal ventilatory support, probably using continuous positive airway pressure (CPAP) ventilation. Atrial septal defect Atrial septal defect is incorrect. Atrial septal defects can cause pulmonary hypertension, but patients would usually have a younger age at presentation. On auscultation split 1st and particularly 2nd heart sounds are often heard and an ejection systolic murmur is heard when moderate to large left to right shunts develop. Chronic asthma Chronic asthma is incorrect. There is nothing convincing in the history to suggest this lady has severe chronic asthma causing her cor pulmonale. The history is indicating a diagnosis of obstructive sleep apnoea and this is the most likely cause of her pulmonary hypertension. Primary pulmonary hypertension Primary pulmonary hypertension is incorrect. There is a clear aetiology for this lady’s pulmonary hypertension, i.e. she has secondary pulmonary hypertension. Pulmonary fibrosis Pulmonary fibrosis is incorrect. There is no occupational or drug exposure or comorbid connective tissue disease mentioned to suggest this patient is at risk of pulmonary fibrosis. There is no mention of clubbing or basal crackles that may suggest idiopathic pulmonary fibrosis. The history given is suggestive of secondary pulmonary hypertension as a consequence of untreated obstructive sleep apnoea.
Question 15:
A 72-year-old woman is admitted with an infective exacerbation of chronic obstructive pulmonary disease. On admission, her blood gases taken while breathing 28% oxygen are: pH 7.31, Pao2 7.9 kPa, Paco2 7.5 kPa. Which of the following best describes the blood gas picture?
Options:
- Compensated type I respiratory failure
- Compensated type II respiratory failure
- Decompensated type I respiratory failure
- Decompensated type II respiratory failure
- Partially compensated respiratory alkalosis
Correct Answer: Decompensated type II respiratory failure
Explanation:
Correct Answer: D- Decompensated type II respiratory failure Explanation Decompensated type II respiratory failure The patient’s blood gases show that she is hypoxic on oxygen – the Paco2 is elevated (Paco2> 6 kPa) and the
pH is low. These confirm a respiratory acidosis. There is hypoxia combined with CO2 retention. The blood gas picture is therefore one of decompensated type II respiratory failure. The prognosis is poor unless treated appropriately. The treatment in this case should be non- invasive positive-pressure ventilation (NIPPV). Data from good-quality randomised controlled trials indicate that NIPPV should be recommended as the first-line intervention, coupled with standard medical care, in all suitable patients with respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease. A trial of NIPPV should be considered early in the course of respiratory failure, before severe acidosis develops, as a means of avoiding endotracheal intubation and reducing treatment failure and mortality. Compensated type I respiratory failure Compensated type I respiratory failure is incorrect. The terms compensated/decompensated in respiratory failure refer to compensation for hypercapnoea. There is nothing to compensate for in type 1 respiratory failure ie the CO2 is low or normal so these options do not make sense. Regardless the gases show type II respiratory failure (low
pO2 and raised pCO2). Compensated type II respiratory failure Compensated type II respiratory failure is incorrect. The
pH would be normal in compensated type II respiratory failure (i.e. pH 7.35-7.45). Decompensated type I respiratory failure Decompensated type I respiratory failure is incorrect. The terms compensated/decompensated in respiratory failure refer to compensation for hypercapnoea. There is nothing to compensate for in type 1 respiratory failure ie the CO2 is low or normal so these options do not make sense. Regardless the gases show type II respiratory failure (low pO2 and raised pCO2). Partially compensated respiratory alkalosis Partially compensated respiratory alkalosis is incorrect. The pH is acidotic. Respiratory alkalosis would be represented by a high pH (>7.45) and a low pCO2 (<4kPa)
Question 16:
A 50-year-old woman presents to the respiratory clinic with symptoms of increasing shortness of breath and a chronic cough. She was originally diagnosed by her GP as having asthma, but has had no significant response to a salbutamol inhaler. There has been slow weight loss over the past 6 months and problems with night sweats. On examination her BP is 155/72 mmHg, pulse is 70/min and regular. There are scattered crackles on auscultation of the chest. There is erythema nodosum and erythematous plaques resembling psoriasis. Investigations: Hb 12.2 g/dl WCC 10.9 x 109/l PLT 192 x 109/l ESR 62 mm/1st hour Na+ 138 mmol/l K+ 4.3 mmol/l Creatinine 120 μmol/l CXR Bilateral hilar lymphadenopathy You suspect sarcoid. Which of the following is the best way to confirm the diagnosis?
Options:
- Bronchoalveolar lavage
- CT thorax
- Kveim test
- Serum ACE
- Skin biopsy
Correct Answer: Skin biopsy
Explanation:
Correct Answer: E- Skin biopsy Explanation Skin biopsy Skin biopsy of one of the plaques is potentially very useful, and is likely to confirm the presence of non- caseating granulomas. An alternative diagnostic route could be via endobronchial and transbronchial biopsies. Bronchoalveolar lavage Bronchoalveolar lavage is incorrect. Bronchoalveolar lavage may show increased lymphocytes in the fluid in keeping with sarcoidosis, but this is non-specific. CT thorax CT thorax is incorrect. Although CT thorax is likely to confirm the presence of interstitial lung disease in a pattern suggestive of sarcoidosis, it is not definitive in establishing the diagnosis. Kveim test Kveim test is incorrect. Kveim testing is now obsolete because of the risk of transmission of new variant CJD and the time taken to obtain a result. Serum ACE Serum ACE is incorrect. Serum ACE is only raised in 60% of patients with sarcoidosis and is not specific for the condition.
Question 17:
A 61-year-old man with a 40 pack-year smoking history presents with chronic cough, haemoptysis and weight loss. Unfortunately his chest X-ray reveals a large mass at the left hilum, suggestive of a bronchial carcinoma. A raised calcium is noted on routine blood work-up. What type of carcinoma would best fit this clinical picture?
Options:
- Adenocarcinoma of the bronchus
- Bronchoalveolar-cell carcinoma
- Large-cell bronchial carcinoma
- Small-cell bronchial carcinoma
- Squamous-cell carcinoma of the bronchus
Correct Answer: Squamous-cell carcinoma of the bronchus
Explanation:
Correct Answer: E- Squamous-cell carcinoma of the bronchus Explanation Squamous-cell carcinoma of the bronchus Squamous-cell and small-cell bronchial carcinomas tend to occupy a central location. Squamous-cell carcinomas are more frequently associated with hypercalcaemia, so this is the correct answer in this case. In terms of frequency:
• 30% each are adenocarcinomas and squamous-cell carcinomas • 20% are small-cell carcinomas • 15–20% are large-cell carcinomas • 5% are bronchoalveolar-cell carcinomas. Adenocarcinoma of the bronchus Adenocarcinoma of the bronchus is incorrect. Lung cancers of this cell type tend to occur more frequently in the periphery of the lung. Bronchoalveolar-cell carcinoma Bronchoalveolar-cell carcinoma is incorrect. Bronchoalveolar-cell carcinoma has no correlation with cigarette smoking, making one of the other cell types more likely. Large-cell bronchial carcinoma Large-cell bronchial carcinoma is incorrect. Lung cancers of this cell type tend to occur more frequently in the periphery of the lung. Small-cell bronchial carcinoma Small-cell bronchial carcinoma is incorrect. As described, the hypercalcaemia makes squamous-cell carcinoma more likely.
Question 18:
An 18-year-old man presents with a gradual onset of pallor, weakness, lethargy, dry cough and occasional haemoptysis. There are no extrapulmonary features. His chest X-ray shows diffuse pulmonary infiltrates. Lung biopsy shows no vasculitic changes and no evidence of immunoglobulin or complement deposition. His gas transfer factor (Tlco) is found to be elevated. Renal function is normal. What is the most likely diagnosis?
Options:
- Behets disease
- Goodpasture syndrome
- Granulomatosis with polyangiitis
- Idiopathic pulmonary haemosiderosis
- Systemic lupus erythematosus
Correct Answer: Idiopathic pulmonary haemosiderosis
Explanation:
Correct Answer: D- Idiopathic pulmonary haemosiderosis Explanation Idiopathic pulmonary haemosiderosis Idiopathic pulmonary haemosiderosis tends to occur in younger people and is characterised by pallor, weakness, lethargy, dry cough and occasional haemoptysis. There are no abnormal immunological features. Gas transfer is elevated as blood is already in the alveolar space. Behçet’s disease Behçet’s disease is incorrect. We are given no history of orogenital ulceration, which counts against a diagnosis of Behçet’s. Goodpasture syndrome Goodpasture syndrome is incorrect. There are no extrapulmonary features. There are no abnormal immunological features, which differentiates it from Goodpasture syndrome (where antibodies to basement membrane of lung and kidneys are seen). Granulomatosis with polyangiitis Granulomatosis with polyangiitis is incorrect. There are no signs of sinusitis or renal disease, making granulomatosis with polyangiitis less likely. Systemic lupus erythematosus Systemic lupus erythematosus (SLE) is incorrect. SLE is unlikely given the lack of extrapulmonary features.
Question 19:
A 62-year-old smoker with a 2-day history of cough and fever is admitted with a diagnosis of left- sided pneumonia and left-sided pleural effusion up to the 6th intercostal space. Pleural fluid is aspirated and sent for tests. Which one of the following is an indication for inserting a chest drain?
Options:
- Bloodstained pleural fluid
- Pleural fluid glucose > 2 mmol/l
- Pleural fluid lactate dehydrogenase > 200 IU/l
- Pleural fluid pH < 7.2
- Serous pleural fluid
Correct Answer: Pleural fluid pH < 7.2
Explanation:
Correct Answer: D- Pleural fluid pH < 7.2 Explanation Pleural fluid pH < 7.2 Pleural effusions should be drained:
• When the fluid is infected • When the pH is < 7.2 • When a Gram stain shows the presence of organisms • When the fluid is frankly purulent • When clinical improvement is slow despite antibiotic therapy Bloodstained pleural fluid Bloodstained pleural fluid is incorrect. This is not an indication for insertion of a chest drain. Pleural fluid glucose > 2 mmol/l Pleural fluid glucose > 2 mmol/l is incorrect. This is not an indication for insertion of a chest drain. Pleural fluid lactate dehydrogenase > 200 IU/l Pleural fluid lactate dehydrogenase > 200 IU/l is incorrect. This is not an indication for insertion of a chest drain. Serous pleural fluid Serous pleural fluid is incorrect. This is not an indication for insertion of a chest drain.
Question 20:
A 47-year-old woman presents with a chronic cough, weight loss and haemoptysis. She is a lifelong non- smoker and has previously been completely well, on no regular medication. On examination she looks thin and her body mass index (BMI) is 20 kg/m2. Her blood pressure is 132/70 mmHg and her pulse is 80 bpm and regular. General respiratory and abdominal examination is unremarkable. Investigation: Hb 12.4 g/dl WCC 7.8 x 109/l PLT 211 x 109/l Sodium 139 mmol/l Potassium 4.4 mmol/l Creatinine 110 µmol/l Albumin 31 g/l (normal range 37-49 g/l) Alanine aminotransferase (ALT) 231 U/l (5-35 U/l) A chest X-ray shows a right upper-lobe tumour with hilar extension. Bronchoscopy was performed but no biopsies were obtained (washings negative so far). Which of the following is the most likely diagnosis?
Options:
- Adenocarcinoma
- Bronchial carcinoid
- Large-cell carcinoma
- Small-cell carcinoma
- Squamous-cell carcinoma
Correct Answer: Adenocarcinoma
Explanation:
Correct Answer: A- Adenocarcinoma Explanation Adenocarcinoma The peripheral nature of this tumour and the fact that the patient is a lifelong non-smoker make adenocarcinoma the most likely diagnosis. Because the primary tumour is peripheral it is quite possible that an initial bronchoscopy might be negative. It would be worth repeating the bronchoscopy in this case, although thoracoscopy or computed tomography-guided biopsy are other methods that could be used to obtain tumour material. Given the hilar lymphadenopathy, it is unlikely that this patient will be a candidate for surgery Bronchial carcinoid Bronchial carcinoid is incorrect. The weight loss is suggestive of an underlying malignancy. There are no symptoms to suggest metastatic carcinoid, therefore adenocarcinoma is more likely. Large-cell carcinoma Large-cell carcinoma is incorrect. Large-cell carcinoma is typically peripherally located, as in this case, but one would expect a history of smoking. Small-cell carcinoma Small-cell carcinoma is incorrect. A history of smoking would be expected in small-cell carcinoma. Squamous-cell carcinoma Squamous-cell carcinoma is incorrect. A history of smoking would be expected in squamous-cell carcinoma.
