Respiratory 2012 Mrcppass

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Respiratory

شكر خاص

رياض السيد رياضالدكتور شكر خاص ألخي وزميلي الفاضل

صاحب الفضل في ھذا الملف

أشرف شيخونكذلك البد أن أشكر أخي الفاضل وزميل العمل الدكتور

خالد يوسف الزھري

مصر –مستشفى سوھاج التعليمي

[email protected]

https://www.facebook.com/elzohryxp

May 2012

www.MRCPass.com Respiratory

Dr. Khalid Yusuf Elzohry ‐ Sohag Teaching Hospital ‐ 2012 2

Respiratory Q001 A man presents with symptoms suggestive of a pneumonia. The CXR confirms this.

Which of the following features suggests poor prognosis?

A. Respiratory rate of 20

B. Temperature 38°C

C. Age 60

D. Urea of 10

E. MTS score of 9 out of 10

Answer: d) urea of 10.

The CURB‐65 score for poor prognosis in pneumonia are :

* confusion (defined as an AMT of 8 or less)

* urea greater than 7 mmol/l

* respiratory rate of 30 breaths per minute or greater

* blood pressure less than 90 systolic or diastolic blood pressure 60 or less

* age 65 or older



Respiratory Q002

A 60 year old lady presents with shortness of breath. A chest X ray confirms that she has

a right sided pleural effusion. An Aspirate was taken and the sample was sent for several

tests.

Which one of the following is an indication for a chest drain?

A. High protein

B. Low glucose

C. Low LDH

D. PH <7.2

E. Blood stains

Answer: D) pH < 7.2

Although a high protein also points tow ards an exudates, a low pH is the best marker of

infection in an effusion requiring chest drain insertion.



Respiratory Q3

A 75 year old heavy smoker presents to the hospital with breathlessness, wheezing and

a cough with yellow sputum.

He has the following investigations: Hb 18 g/dl, WCC 12 x 10^9/l, ABGs show a pH of

7.38, pO2 of 8.5 kPa, pCO2 of 7 kPa.

What is the diagnosis?

A. Bronchiectasis

B. Chronic obstructive pulmonary disease

C. Mesothelioma

D. Tuberculosis

E. Cryptogenic fibrosing alveolitis

Answer: b) chronic obstructive pulmonary disease.

This patient has type II respiratory failure, without an acidosis, suggesting chronic CO2

retention. He also is a heavy smoker and has polycythaemia, making COPD most likely.

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Respiratory Q6

A 70 year old man with known chronic obstructive pulmonary disease (COPD) is

admitted with symptoms of worsening breathlessness and confusion. Following a dose

of 200mg iv hydrocortisone and two doses of salbutamol and atrovent nebulisers,

arterial blood gases were taken.

His arterial blood gases are as follows: pH 7.18, PO2 6.6 kPa , PCO2 12.0 kPa.

What should be done next?

A. Repeat dose of corticosteroids

B. Mechanical ventilation

C. 2 litres oxygen

D. Monteleukast

E. Magnesium infusion 2g

Answer: b) Mechanical ventilation.

This patient has type II respiratory failure with acidosis, and hence should be considered

for ventilation, either straight away or with a trial of NIPPV beforehand.



Respiratory Q7

A 40 year old woman has been breathless and is undergoing investigations for the

cause. She has a previous history of being a smoker and has a dry cough as well. Her

ABGs show a pO2 of 9 kPa and pCO2 of 5 kPa. Lung function tests show reduced vital

capacity, reduced TLCO but increased KCO.

What is the likely diagnosis?

A. COPD

B. Bronchial obstruction from a tumour

C. Kyphoscoliosis

D. Obstructive sleep apnoea

E. Fibrosing alveolitis

Answer: c) kyphoscoliosis.

In this scenario, the lung function indicates that the surface area for exchange are

inadequate (low TLCO) hence suggesting that lung expansion is reduced. How ever,

cardiac output is increased to compensate, and henced KCO is increased. Kyphoscoliosis

would restrict lung expansion, or a neuromuscular disorder (eg spina bifida) could cause

this.



Respiratory Q8

A 50 year old woman is admitted with infective exacerbation of asthma. She responds to

medical treatment but Aspergillus fumigatus is eventually cultured from her sputum.

Further investigations show serum total IgE level was elevated at 350 ng/ml (normal 40‐

180 ng/ml), RAST to Aspergillus fumigatus was class III, Aspergillus fumigatus precipitins

are negative.

What is the most appropriate management?

A. No change in medication

B. High dose oral corticosteroids

C. CT scan of the chest

D. Chest X ray

E. Itraconazole

Answer: a) No change in medication.

With negative Aspergillus fumigatus precipitins and serum total IgE less than 1000

ng/ml, this patient is unlikely to have Allergic Bronchopulmonary Aspergillosis (ABPA).

Features which are found commonly in asthmatics without ABPA include:

Positive immediate skin reactivity to Aspergillus fumigatus, which is present in 20‐30%

of asthmatics Positive serum precipitins to Aspergillus, which occur in 10% of asthmatics

without ABPA Recurrent mucoid impaction and atelectasis Peripheral blood eosinophilia

and elevation of serum total IgE.



Respiratory Q9

A 60 year old man presents with small amounts of haemoptysis and breathlessness. He

does not have pleuritic chest pains and has normal oxygen saturations.

In considering the potential diagnosis, haemoptysis can occur with which of the

following diagnosis?

A. Pulmonary fibrosis

B. Melanoma

C. Goitre

D. Thymoma

E. Aspergilloma

Answer: e) Aspergilloma.

Haemoptysis can be caused by pulmonary embolus, tuberculous infection, aspergilloma,

bronchial carcinoma, Goodpasture's syndrome and Wegener's granulomatosis.



Respiratory Q10

A 30 year old man gives a six‐month history of worsening breathlessness and coughs up

half a cupful of sputum daily. He was occasionally wheezy with viral illnesses as a young

child, works in a factory and has smoked 25 cigarettes per day for the last four years.

The most likely diagnosis is:

A. Lung carcinoma

B. Bronchiectasis

C. Asthma Asbestosis

D. Chronic obstructive pulmonary disease

E. Rheumatoid lung

Answer: b) Bronchiectasis.

Bronchiectasis is most likely due to the extensive amounts of sputum production. In a

young person, cystic fibrosis and hypogammaglobulinaemia should be considered.



Respiratory Q11

A 60 year old man has smoked for 10 years. He has a longstanding dry cough and

expiratory wheeze.

Examination reveals scattered rhonchi and reduced lung expansion.


A. Asthma

B. Lung carcinoma

C. Chronic bronchitis

D. Bronchiectasis

E. Extrinsic allergic alveolitis

Answer: c) chronic bronchitis.

The heavy smoking history and wheeze suggests chronic bronchitis.



Respiratory Q12

A 14 year old boy develops red eye and rhinitis frequently during the start of the

summer.

What is the likely triggering agent?

A. House dust mite

B. Grass pollen

C. Willow pollen

D. Isocyanates

E. Coal dust

Answer: B) grass pollen.

Grass pollen is released late May till August, and willow pollen is released from March

till June. As the allergic rhinitis is triggered during the start of summer, this is most likely

to be due to grass pollen.



Respiratory Q13

A 65 year old man presents with breathlessness that has got gradually worse over three

months. He has long‐standing atrial fibrillation, for which he takes warfarin and

amiodarone.

On examination his pulse is 100/min in AF, oxygen saturation was 90% on air. His JVP

was not raised and he has fine bibasal crackles. Arterial blood gas saturation showed

mild hypoxia and a pulmonary function test revealed a moderate restrictive picture.


A. Bronchiectasis

B. Pulmonary embolism

C. Pulmonary haemorrhage

D. Amiodarone induced interstitial lung disease

E. Congestive cardiac failure

Answer: d) amiodarone induced interstitial lung disease .

The case scenario would fit amiodarone induced interstitial lung disease or pulmonary

fibrosis. This may take several months or years to develop. Lung function tests may

show a restrictive picture with reduced transfer factor. A high resolution CT in this case

is likely to show diffuse "ground glass" opacities or interlobular septal thickening.



Respiratory Q14

A 65 year old man has been confirmed to have lung cancer.

Which form of cancer has the worst prognosis?

A. Small cell

B. Squamous cell

C. Adenocarcinoma

D. Large cell

E. Prostate metastasis

Answer: a) small cell.

Small cell lung cancer has the worst prognosis out of all lung cancers and is rarely

suitable for surgical resection. Even when diagnosed early the 2‐year survival is in the

order of 20‐25%. The main form of therapy is chemotherapy.

Small cell cancer is associated with syndrome of inappropriate antidiuretic hormone

(ADH) and squamous cell cancer is associated with paraneoplastic hypercalcaemia

through increased parathyroid‐related hormone. 75% of small cell cancers arise in the

proximal airways.



Respiratory Q15

A 22 year old female presents with a chest infection. She is unable to complete a

sentence and her peak flow rate was 40% of her normal level. She is treated with high

flow oxygen, nebulised bronchodilators and oral steroids but this is associated with little

change in her condition.

Which of the following treatments, given intravenously, would be the most appropriate

for this patient?

A. Aminophylline

B. Augmentin

C. Hydrocortisone

D. Magnesium

E. Salbutamol

Answer: D) Magnesium.

IV magnesium is recommended by the British Thoracic Society in severe exacerbation of

asthma. A dose of 2g (8 mmol) is given as a bolus iv dose in the acute presentation

period.



Respiratory Q16

A 60 year man has been a smoker of 20 a day for 30 years. He has a cough and difficulty

in breathing for 3 days which has worsened and he presents to hospital. He has home

nebulisers but not home oxygen.

On examination, his oxygen saturations are 95%, blood pressure 110 / 60 mmHg and

respiratory rate 32. He has diffuse wheezes and is using his respiratory muscles. Arterial

blood gases done on 6 litres of oxygen show :

pH 7.25

P02 16 kPa

PCO2 8.2 kPa

What should be the next management step?

A. Non invasive ventilation

B. Intravenous antibiotics

C. Intubation and ventilation

D. Reduce inspired oxygen concentration

E. Increase oxygen concentration

Answer: d) reduce inspired oxygen concentration.

This man with Chronic Obstructive Pulmonary Disease (COPD) has blood gases showing

type II respiratory failure with acidosis. He has been placed on 6 litres of oxygen, which

is too much for a patient with severe COPD as the history of home nebuliser use

suggests.

His respiratory drive is suppressed by too much oxygen inspired, and hence reduction to

a lower concentration (e.g. 1 ‐ 2 litres) to maintain a pO2 above 8.5 kPa is

recommended.



Respiratory Q17

A 70 year woman has a history of dry cough for 2 months. She has lost 5 kg of weight

over the 2 months. Her chest X ray shows a left apical shadowing. Blood tests reveal a

raised white cell count of 16. She has not managed to cough up any sputum.

Which test should be performed?

A. CT scan of the chest

B. Serum ANCA

C. Ultrasound of the chest

D. Kveim test

E. Bronchoscopy

Answer: e) bronchoscopy.

This patient is likely to have TB due to the apical shadowing. In a patient who is unable

to expectorate sputum, bronchoscopy with lavage (send for AFB) should be performed

to confirm the diagnosis.



Respiratory Q18

A 65 year old man with emphysema presented with increasing dyspnoea and left‐sided

pleuritic chest pain. A chest radiograph reveals a left‐sided pneumothorax with a lung

edge measured 5 cm away from the chest wall.

The most appropriate management of his condition is:

A. Review with daily chest radiographs

B. Intercostal tube drainage

C. Refer to a respiratory outpatient clinic

D. CT chest

E. Simple aspiration

Answer: b) Intercostal tube drainage.

The lung edge measurement suggests a greater than 50% pneumothorax. A smaller

pneumothorax may be amenable to aspiration. In the context of chronic underlying

respiratory disease such as chronic obstructive pulmonary disorder and a large

pneumothorax, patients are best managed by pleural drainage.



Respiratory Q19

A 70 year old man attends the hospital with a history of proximal muscle weakness. He

also gives a history of cough of 12 weeks duration and complains of pain of the small

joints of the hands. He has small haemorrhages in the nail folds, but is not clubbed. On

examination of the chest he has bibasal crackles, and a chest radiograph reveals diffuse

reticular infiltrates. Lung function tests confirm a restrictive pattern.

What is the likely cause of his interstitial lung disease?

A. SLE

B. Dermatomyositis

C. Ankylosing spondylitis

D. Cryptogenic fibrosing alveolitis

E. Amiodarone induced fibrosis

Answer: b) Dermatomyositis.

In polymyositis and dermatomyositis patients often develop proximal muscle weakness

and of pain in the small joints of the fingers. They may have ragged cuticles and

haemorrhages at the finger nail folds. Interstitial lung disease can occur. Underlying

malignancy (lungs, ovaries, breasts and stomach) is present in 5% of cases.

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Respiratory Q21

A 40 year old man has a 3 month history of cough and dyspnoea. He smokes 20 a day.

There is no history of asbestos exposure.

His WBC count is 24 x 10^9/l with 70% neutrophils and 3.0 x 10^9/l (5%) eosinophils. IgE

level is elevated.

He has decreased breath sounds corresponding to parenchymal infiltrates on the CXR.

Which is the best test to confirm the diagnosis?

A. Sputum for Acid Fast Bacilli

B. HIV test

C. Autoimmune screen

D. Aspergillus RAST

E. Stool for ova, cysts, parasites

Answer: d) Aspergillus RAST.

The condition described is Allergic Broncho Pulmonary Aspergillosis, which is

commoner among asthmatics and cystic fibrosis patients. Eosinophilia and high IgE

levels are suggestive of this condition. RAST test for antibodies tow ards Aspergillus

confirms the diagnosis.



Respiratory Q22

A 45 yearold woman is admitted with a 2‐day history of fever, rigors and breathlessness.

She looks extremely unwell and is confused, cyanosed, has a respiratory rate of 24/min

and a systolic blood pressure of 85 mmHg.

There is bronchial breathing at her right base, where a chest radiograph reveals

consolidation.

Which would be the most appropriate antibiotic regimen?

A. Intravenous ceftazidime and intravenous gentamicin

B. Oral erythromycin

C. Intravenous cefotaxime and oral erythromycin

D. Intravenous amoxicillin and oral clarithromycin

E. Oral amoxicillin and oral clarithromycin

Answer: c) Intravenous cefotaxime and oral erythromycin.

Severe pneumonia as defined by the British Thoracic Society guidelines, is diagnosed

when there are two of the following features: confusion, urea >7mmol/l, respiratory

rate >30/min, and hypotension (SBP <90mmHg, DBP <60mmHg).

Appropriate treatment is with intravenous antimicrobials: cefuroxime 1.5g three times

daily or cefotaxime 1g three times daily daily PLUS erythromycin 500 mg four times daily

or clarithromycin 500mg twice daily.



Respiratory Q23

A 72 year old man presents with a history of worsening breathlessness and cough. His

arterial blood gases show the following recordings when taken at room air:

pH 7.25

pO2 6.4kPa

pCO2 8.9 kPa

Bicarbonate 31mmol/L

What is the most likely diagnosis?

A. Acute exacerbation of chronic obstructive pulmonary disease

B. Obstructive sleep apnoea

C. Pulmonary oedema

D. Pulmonary embolus

E. Pulmonary fibrosis

Answer: a) Acute exacerbation of chronic obstructive pulmonary disease.

The blood gas result would be most compatible with a patient with severe COPD and

chronic type 2 respiratory failure with an acute exacerbation (Hypoxia, respiratory

acidodis with raised CO2 and metabolic compensation).



Respiratory Q24

A 70 year old man presents with a chronic cough. He is a heavy smoker of over 40

cigarettes a day. CXR shows a peripheral right‐sided lesion. A biopsy which was taken

shows squamous cell carcinoma. No regional lymph nodes are involved. Lung function

tests show a FEV1 of less than 1.5 litres.

The recommended treatment is:

A. Chemotherapy

B. Radiotherapy

C. Lobectomy

D. Pneumectomy

E. Lung transplant

Answer: b) Radiotherapy.

Although surgical treatment is possible in non small cell lung carcinoma, a FEV1 of less

than 1.5 litres contraindicates surgery. Hence, radiotherapy is recommended.



Respiratory Q25

A 55 year old gentleman has pickw ickian syndrome. He has poor exercise tolerance of

50 yards and often feels lethargic at work.

Which of the following is the best investigation?

A. Echocardiography to assess cor pulmonale

B. CT scan of the chest

C. Blood gas

D. Sleep study

E. Exercise tolerance test

Answer: d) sleep study.

The diagnosis of obstructive sleep apnoea can be made with a sleep study

(polysomnography). In sleep apnoea, there is gross obesity and airways obstruction,

occasionally leading to type II respiratory failure. During the sleep study, > 10 episodes

of apneic episodes (pauses in breathing) satisfies the criteria for obstructive sleep

apnoea.



Respiratory Q26

A 60 year old man smoker of 35 pack years presents with a 6 month history of shortness

of breath. His past medical history includes diabetes and cervical spondylosis.

Spirometry shows FEV1 of 1 litre ‐ 65% predicted

FVC 1.03 litres ‐ 57% predicted

FEV1/FVC ratio of 95.

How would you interpret the spirometry results?

A. Normal

B. Mixed defect

C. Obstructive defect

D. Restrictive defect

E. Suggestive of haemorrhage

Answer: d) Restrictive defect.

Reduced FEV1 and FVC with normal FEV1 ratio is compatible with restrictive defect.

Causes of restrictive lung defect are :

‐ neurogenic or psychogenic causes

‐ abnormalities of the thoracic wall

‐ stiff parenchyma (pulmonary fibrosis)

‐ loss of lung tissue, e.g. pneumonectomy

‐ displacement



Respiratory Q27

A 65 year old man has worsening breathlessness. He has a past medical history of

arthritis and palpitations. On admission his oxygen saturations were 90% on air.

ABGs show pO2 9 kPa. pCO2 3.5 kPa, pH 7.36.

His chest X ray shows patchy shadowing in both lung peripheries.

Which one of the following drugs is likely to be responsible?

A. Codeine

B. Tramadol

C. Simvastatin

D. Amiodarone

E. Prednisolone

Answer: d) amiodarone.

The hypoxia and X ray changes suggest pulmonary fibrosis. Out of the list of

medications, amiodarone is the most likely candidate. A lung function test with transfer

factor and also high resolution CT will help to confirm the diagnosis of amiodarone

related pulmonary fibrosis.



Respiratory Q28

A 65 year old man has been diagnosed with chronic obstructive pulmonary disease

(COPD). Spirometry confirms severe COPD with a FEV1 of less than 25% predicted. In the

last year he has been admitted to hospital on 6 occasions with COPD exacerbation.

Which one of the following can help to reduce hospital admissions?

A. Tiotropium

B. Monteleukast

C. Oral theophyllines

D. Salmeterol

E. Hydrocortisone

Answer: a) Tiotropium.

Severe COPD is diagnosed if the FEV1 is less or equal to 30% predicted. Studies have

shown that patients treated with long acting anticholinergic (e.g. tiotropium) have few

er exacerbations per year.



Respiratory Q29

An 13 year old male has recent onset breathlessness. He has a history of wheezing

particularly during the summer when the pollen count is high.

Which of these tests would help to confirm the diagnosis?

A. Trial of inhaled corticosteroids

B. Trial of anticholinergics

C. Serial peak flow measurements

D. Lung function tests

E. Chest X ray

Answer: c) serial peak flow measurements.

The history of wheezing during pollen exposure suggests asthma. The best diagnostic

test for asthma would be demonstration of variable airways obstruction with serial peak

flow measurements. Asthmatic patients with exacerbation will demonstrate peak flows

lower than their predicted peak flow, and also a morning dip. There is also reversibility if

a bronchodilator (e.g. salbutamol) is administered.



Respiratory Q30

A 27 year old man presents with sudden onset left sided pleuritic chest pain and

breathlessness.

On examination he is distressed, tachypnoeic and has tracheal displacement to the right

together with a hyper‐resonant percussion note on the left side. There were no breath

sounds on the left. Chest x ray shows a < 2 cm left sided pneumothorax.

What is the best management procedure?

A. High dose oxygen

B. Intercostal drainage tube

C. Chemical pleurodesis

D. Aspiration of pneumothorax

E. Repeat chest x ray in 6 hours

Answer: d) aspiration of pneumothorax.

Treatment of a pneumothorax of < 2 cm margin would be initial aspiration.

This is less painful, leads to a shorter duration of admission, reduces the need for

pleurectomy.



Respiratory Q31

A 65 year year old lady presents with weight loss and haemoptysis and is admitted to

hospital. She has been a heavy smoker for 25 years. A Chest X ray shows a mass in the

right upper lobe.

Which is the best test to investigate at present?

A. Sputum cytology

B. CT scan of the lung

C. Transbronchial biopsy

D. Lymph node biopsy

E. Pleural biopsy

Answer: a) sputum cytology.

The mass seen on the CXR is likely to be a malignancy in view of the history of smoking,

haemoptysis and weight loss. The initial test should be sputum cytology, as the

diagnosis can be confirmed most easily. Staging CT scans can then be done to guide

further management after this.

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Respiratory Q33

A 20 year old male presents with breathlessness and wheezing.

Which of the following is most likely to suggest asthma?

A. Increased serum IgE

B. Wheezing induced by smoking

C. Obstructive picture in the lung function tests

D. Response to prednisolone

E. Diurnal PEFR variation > 20%

Answer: e) diurnal PEFR variation of >20%.

In asthma, diurnal PEFR variability is due to various degrees of bronchial hyperreactivity.

This is the best indicator of likely asthma. A raised IgE indicates atopy but is not

diagnostic of asthma.



Respiratory Q34

A 70 year old patient with COPD presents with cough and breathlessness which has

worsened over 2 months.

On admission, he has the following arterial blood gas results.

pH 7.32, pO2 7 kPa, pCO2 8 kPa, HCO3 34 mmol/l, Base Excess ‐1.

Which one of the following biochemical states fits best?

A. Chronic respiratory acidosis

B. Chronic respiratory alkalosis

C. Chronic metabolic acidosis

D. Chronic metabolic alkalosis

E. Acute metabolic acidosis

Answer: a) chronic respiratory acidosis.

There is a mild respiratory acidosis (pH < 3.5 and pCO2 > 6) and base excess is also not

elevated (in this case only ‐1). There is metabolic compensation, as indicated by a high

bicarbonate ( >30). The patient's history of COPD suggests that he has chronic hypoxia

and chronic CO2 retention, hence causing the picture of chronic respiratory acidosis.



Respiratory Q35

A breathless 35 year old woman has the following lung function tests:

FEV1 1.2 L (65%)

FVC 1.4 L (60%)

FEV1/FVC ratio = 82%predicted

TLC = 65% predicted

RV = 60% predicted

TLCO = 57% predicted

KCO = 105% predicted


A. COPD

B. Bronchiectasis

C. Cystic fibrosis

D. Scoliosis

E. Pneumonia

Answer: d) Scoliosis.

The lung function tests show a significant restrictive defect. Only kyphoscoliosis or a

pneumonitis may fit this picture but given the normal/high KCO (i.e. after correcting for

alveolar volumes), the most likely answer is kyphoscoliosis as the gas exchange after

correcting for the alveolar volume is high.



Respiratory Q36

A 70 year old man presented with shortness of breath. On examination, he had the signs

of a large right‐sided pleural effusion.

Investigations revealed: Pleural fluid analysis ‐ protein 65 g/L

What is the most likely cause?

A. Congestive cardiac failure

B. Nephrotic syndrome

C. Non specific pericarditis

D. Liver cirrhosis

E. Mesothelioma

Answer: e) Mesothelioma.

It is a case of exudative pleural effusion (protein >30 g/l). Mesothelioma is the most

likely cause in this case. Other causes are: malignancies, infection, autoimmune

conditions.



Respiratory Q37

A 75 year old man with COPD is on long‐term oxygen therapy (LTOT). He complains of

persistent leg swelling during a routine review .

His ABG on a supplemental oxygen flow rate of 2 l/min, shows:

pH of 7.35, pCO2 of 5.7kPa, pO2 of 7.8kPa and HCO3 of 28 mmHg

What should be done?

A. CXR

B. Overnight oxygen saturation monitoring

C. Echocardiogram

D. Repeat ABG on air

E. CT scan of the chest

Answer: b) Overnight oxygen saturation monitoring.

The presence of persistent oedema or secondary polycythaemia suggests that the

correction of overnight SaO2 may be inadequate. Nocturnal hypoxaemia may be evident

during an overnight SaO2 monitoring.

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Respiratory Q41

A 40 year old man is HIV positive. He presents with breathlessness to the hospital. Chest

XR shows bilateral interstitial lung markings. His oxygen levels desaturate upon

mobilising.

What should be commenced?

A. Amoxycillin

B. Amoxycillin and clarithromycin

C. Iv co‐trimoxazole

D. Doxycycline

E. Quadruple TB therapy

Answer: c) iv co‐trimoxazole.

The diagnosis is PCP. Silver staining rather than auramine should be done. Mortality is

10%. Iv co‐trimoxazole or pentamidine can be used. Desaturation is typical with exercise

in PCP. Other bacterial infections such as TB are more common among Africans.

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Respiratory Q43

A 16 year girl with know n cystic fibrosis presents with cough and fevers. Chest X ray

shows right lower zone consolidation.

What antibiotic should be commenced?

A. Amoxycillin

B. Metronidazole

C. Ceftazidime

D. Gentamicin

E. Piperacillin

Answer: C) Ceftazidime

Patients with cystic fibrosis often have pseudomonas as a pathogenic infection.

Ceftazidime and ciprofloxacin would cover the organism, and sometimes gentamicin or

meropenem may be required due to resistance.

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Respiratory Q45

A 70 year old man with chronic obstructive lung disease presents with a cough, fevers

and green sputum.

What is the antibiotic of choice?

A. Teichoplanin

B. Cefotaxime

C. Erythromycin

D. Amoxicillin

E. Ciprofloxacin

Answer: D) amoxicillin.

In COPD, the 3 bacterial species account for most isolates are : Haemophilus influenzae,

Streptococcus pneumoniae and Moraxella cattarhalis. First line treatment should be

with amoxicillin, but if the patient is allergic, a tetracycline should be used.

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Respiratory Q48

A 45 year man has a long history of productive cough. He had complained of frequent

chest infections.

Examination reveals bilateral inspiratory crackles in the bases of the lungs and clubbing

of the fingers.

Which of following treatments is likely to reduce the frequency of exacerbations?

A. Prophylactic antibiotics

B. Inhaled corticosteroids

C. Oral corticosteroids

D. Postural drainage

E. Lung transplant

Answer: D) postural drainage.

The patient has bronchiectasis, in which the common complication is difficulty

expectorating, postural drainage of secretions is helpful.



Respiratory Q49

A 60 year old man, ex‐smoker (20 pack‐years), was admitted to the hospital because of

a prolonged fever of up to 38.5°C over a period of 10 days, associated with a

progressively worsening shortness of breath, a nonproductive cough, weakness, and

fatigue.

The chest radiograph, showed consolidations at the base of both lungs, prominent

interstitial markings in the middle lung fields, and hazy infiltrates in the right upper lung

field.

A bronchoscopy was done and BAL fluid analysis showed alveolitis with macrophages of

65%, lymphocytes of 25%, and neutrophils of 10%.

Which drug is most likely to be responsible?

A. Sulphasalazine

B. Penicillamine

C. Gold

D. Methotrexate

E. Azathioprine

Answer: d) methotrexate.

The diagnosis is interstitial pneumonitis. Methotrexate is associated with interstitial

pneumonitis. This is rare but a serious complication. Diagnosis is based on the clinical

setting, clinical manifestations, radiographic abnormalities, bronchoalveolar lavage

(BAL), and lung histology.



Respiratory Q50

A 40 year old woman has a history of cough with copious phlegm with intermittent

haemoptysis. She also gets recurrent chest infections and has a long history of joint

pains. She is on non‐steroidal anti‐inflammatory drugs.

Her chest radiograph shows linear radioluciences at both bases. A high‐resolution

computed tomography scan (HRCT) of the chest confirms bronchiectasis.

What is the likely cause?

A. Old tuberculosis

B. Hypogammaglobulinaemia

C. Rheumatoid arthritis

D. Cystic fibrosis

E. Kartagener's syndrome

Answer: c) Rheumatoid arthritis.

The case scenario suggests rheumatoid arthritis. 4 % of patients with rheumatoid

arthritis develop bronchiectasis. Other causes are chronic infection (TB, measles,

whooping cough etc), foreign body aspiration, hypogammaglobulinaemia, Kartagener's

syndrome, Young's syndrome, cystic fibrosis, allergic bronchopulmonary aspergillosis.



Respiratory Q51

A 35 year old lady has a headache, cough and myalgia.

On examination, she has a pyrexia and scattered crackles bilaterally on auscultation of

the chest. Rapid cold agglutinins was positive.


A. Tuberculosis

B. Staphylococcal pneumonia

C. Streptococcal pneumonia

D. Mycoplasma pneumonia

E. Legionella pneumonia

Answer: d) mycoplasma pneumonia.

Mycoplasma pneumonia is the commonest atypical pneumonia.

Approximately 15% of pneumonias in adults are due to Mycoplasma pneumoniae.

Transmission occurs from person to person by infected droplets. The incubation period

is 9‐21 days. The incidence is higher during the winter months. Fever, chills, cough and

headache are early symptoms. Dyspnoea, chest pain and haemoptysis are rare.

Small pleural effusions may occur but are rare. Cold agglutinins are usually present in a

titre greater than 1:32.



Respiratory Q52

A 32 year old man is admitted to hospital with a history of breathlessness of 4‐6 weeks

duration. He initially had flu‐like symptoms and was treated by his doctor with a 5‐day

course of amoxicillin. How ever, he then started coughing up blood, leading to urgent

referral.

On examination he was dyspnoeic at rest, with bilateral crackles on auscultation of the

lungs.

Investigation revealed anaemia and impaired renal function (creatinine 250 micromol/l).

Pulmonary function tests were normal apart from an abnormally high diffusion factor.

Urine dipstick testing showed the presence of red blood cells.


A. Goodpasture's syndrome

B. Farmer's lung

C. Invasive Aspergillosis

D. Extrinsic allergic alveolitis

E. Chronic eosinophilic pneumonia

Answer: a) Goodpasture's syndrome.

The clinical picture of pulmonary and renal involvement is typical of Goodpasture's

syndrome. The condition is due to the presence of circulating anti‐glomerular basement

membrane antibodies (anti‐GBM antibodies. Other causes of pulmonary haemorrhage

and renal failure include Wegener's granulomatosis, microscopic polyangiitis and

systemic lupus erythematous (SLE).

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Respiratory Q54

A 30 year old man with bronchial asthma was admitted to hospital for reassessment of

his recurring dry cough, chest tightness and wheezing.

Investigations show:

Neutrophils 6 (2‐7.5) x 10^9/l

Lymphocytes 3 (1.3‐3.5) x 10^9/l

Eosinophils 9 (0.04‐0.44) x 10^9/l

CXR shows reticulonodular shadowing

Investigations to look for causes of the eosinophilia (e.g., parasitosis, immunodeficiency

and malignant disease) included stool microscopy, tumour marker assays (for

carcinoembryonic antigen and cancer antigen (CA) 125, CA 19‐9, CA 15‐3 and CA 72‐4),

mammography, gastroduodenoscopy, bronchoscopy, abdominopelvic ultrasonography,

and vaginal and pelvic examination; all yielded normal findings.

Pulmonary function tests revealed a mild obstructive and moderate restrictive pattern

[FEV1] 46%,[FVC] 55%, ratio of FEV1 to FVC 72, peak expiratory flow 53%, [DLCO] 46%.


A. Tuberculosis

B. Loeffler's syndrome

C. Sarcoidosis

D. Pulmonary embolism

E. Wegener's granulomatosis

Answer: b) Loeffler's syndrome.

Hypereosinophilic syndrome is a rare condition where there is an idiopathic eosinophil

count of > 15 x 10^9/dl.

It is associated with Loeffler's syndrome which is a transient pulmonary reaction with

nodular or reticular shadowing (diffuse, fanshaped shadowing) on chest radiology and

eosinophilia.

Hypereosinophilic syndrome generally affects young men ages 20‐50. Thrombotic

tendency, neurological involvement (loss of intellect, depressed mood and poor

coordination) and restrictive cardiomyopathy occur. There is response to steroids.

The lung involvement results in nocturnal cough, productive sputum, wheezing and

dyspnea, which raises the

suspicion of bronchial hyperreactivity. Patients may be misdiagnosed as having asthma.

However, pulmonary function tests typically reveal no airflow limitation.

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Respiratory Q57

A 50 year old patient has become more breathless over several days. He was assessed

with a spectrum of tests. The chest X ray was normal. In the interpretation of his arterial

blood gases on air the following results were obtained:‐

pO2: 8.0 kPa

pCO2: 9.2 kPa

pH: 7.40

Base Excess +2

What disease is likely to have caused this?

A. Community acquired pneumonia

B. Bronchiectasis

C. Tuberculosis

D. Guillain barre syndrome

E. Small cell carcinoma

Answer: d) guillain barre syndrome.

The raised CO2 and hypoxia demonstrate type II respiratory failure. The causes of this

could be obstructive lung disease, neurogenic, or musculoskeletal (kyphoscoliosis).



Respiratory Q58

A 40 year lady presents with a 6 month history of intermittent haemoptysis. She

describes episodes of cutaneous flushing, which typically affects the head and neck. The

episodes are often associated with an unpleasant warm feeling, itching feeling. They last

for half an hour.

She is slightly breathless but has had no evidence of leg swelling or chest pain. She

smokes 10 cigarettes a day.

She has lost 3 kg of weight in the past two months and has been experiencing night

sweats. A Chest x ray shows sail sign in the left lower lobe, but no visible consolidation.

Which one of the following is the most likely diagnosis?

A. Wegener's granulomatosis

B. Goodpasture's syndrome

C. Carcinoid tumour

D. Sarcoidosis

E. Tuberculosis

Answer: c) carcinoid tumour.

A sail sign on the CXR indicates collapse of the left lower lobe. The likely diagnosis is a

carcinoid tumour, which is associated with smoking.

An early and frequent (94%) symptom of carcinoid tumors is cutaneous flushing, which

typically affects the head and neck. Episodes are often associated with an unpleasant

warm feeling, itching, palpitation, upper‐body erythema and edema, salivation,

diaphoresis, lacrimation, and diarrhea. Exercise, stress, or certain foods (eg, cheese)

may trigger an attack. Initial attacks are short, lasting only a few minutes. With time, the

duration increases to hours. Flushes are reported to be longest in association with

bronchial carcinoids.

Carcinoid tumours are neuroendocrine tumours arising from Kultchitzsky cells. They can

be central or peripheral, and are classified as typical or atypical depending on their

histology. They are slow growing tumours of lung with a peak incidence around age 40.

Bronchial obstruction is common. Diagnosis is by bronchoscopy and biopsy.

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Respiratory Q59

A 68 year old man with emphysema is referred to a chest clinic for consideration of

oxygen therapy. Despite maximal treatment with bronchodilators, his exercise tolerance

is reduced to about 25 yards.

Physical examination and pulmonary function test was consistent with emphysema.

There was no evidence of heart failure. ECG was normal. CXR showed hyperinflated lung

fields.

Oxygen saturation was 90%. ABG showed ph of 7.36, pCO2 of 3.7kPa, pO2 of 7.6 kPa.

What should be recommended?

A. Overnight SaO2 monitoring

B. Course of steroids

C. Walking test with a trial of oxygen

D. Repeated ABG in 6 weeks time

E. Long‐term oxygen therapy

Answer: c) Walking test with a trial of oxygen.

This patient does not meet the criteria for long term oxygen therapy, which is indicated

when the paO2 is persistently below 7.3 kPa on air. Clinical stability is defined as the

absence of exacerbation of chronic lung disease for the previous 5 weeks.

Patients without chronic hypoxaemia and not on LTOT, should be considered for

ambulatory oxygen therapy if they show evidence of exercise oxygen desaturation (a fall

of SaO2 of at least 4% below 90%), improvement in exercise capacity with ambulatory

oxygen therapy and motivation to use the ambulatory oxygen outside the house.

Assessment should be performed on both air and supplemental oxygen with the patient

blinded as to the content of the cylinder.



Respiratory Q60

A 50 year old woman presents with breathlessness that has been getting gradually

worse over a few weeks and she has difficulty mobilising. On physical examination she is

found to have a large left sided pleural effusion.

The presence of the effusion is confirmed by chest radiography.

The most appropriate initial investigation would be:

A. Diagnostic aspiration of pleural fluid

B. Sputum cytology

C. CT chest

D. Pleural biopsy

E. Mantoux test

Answer: a) Diagnostic aspiration of pleural fluid.

The first investigation should be diagnostic aspiration of pleural fluid.

Light’s criteria can be used to distinguish transudates from exudates: in exudates at

least one of the following three criteria are met:

pleural fluid protein concentration greater than 50% of that in plasma;

pleural fluid LDH greater than 60% of that in plasma;

pleural fluid LDH more that two thirds the upper limit of normal in plasma

In general, if the protein is < 30 g then it is considered to be a transudate, if > 30 g then

it is an exudate.

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Respiratory Q62

A 40 year old man has a 3 month history of cough, dyspnoea and sputum production. He

smokes 20 cigarettes a day and has a history of asthma. There is no history of asbestos

exposure.

His WBC count is 24 x 10^9/l with 70% neutrophils and 3.0 x 10^9/l (5%) eosinophils. IgE

level is elevated. He has decreased breath sounds corresponding to parenchymal

infiltrates on the CXR.

Which is the best test to confirm the diagnosis?

A. HIV test

B. Stool for ova,cysts,parasites

C. Autoimmune screen

D. Aspergillus precipitins

E. Sputum for Acid Fast Bacilli

Answer: d) Aspergillus precipitins.

The condition described is Allergic Broncho Pulmonary Aspergillosis, commoner among

asthmatics and cystic fibrosis patients. Wheeze, shortness of breath and productive

cough are symptoms.

Allergic bronchopulmonary aspergillosis results from an allergic reaction to Aspergillus

fumigatus which actually grow s in the walls of the bronchi.

Eosinophilia and high IgE levels are suggestive of the condition. Aspergillus precipitins

(lab test to detect antibodies) the diagnosis. The chest radiograph often shows evidence

of proximal bronchiectasis.



Respiratory Q63

A 55 year old woman is admitted with a history of syncopal episodes and

breathlessness. There is no prior history of recent travel.

On examination she looks distressed. Her pulse rate is 120 beats per minute, blood

pressure 85/60, JVP is elevated by 5 cm. Respiratory rate 26 per minute, there is a soft

systolic murmur at the left sternal edge. Breath sounds are clear.

Investigations show : HB 12.4 g/dL, Blood gases pH 7.42, Pa CO2 3.3 kPa, Pa O2 8.5 kPa.

She was put on high flow oxygen and given low molecular weight heparin.

The next step in management of this patient should be:

A. High dose aspirin

B. Coronary angiography

C. Urgent CTPA and consider thrombolysis

D. Intravenous unfractionated heparin

E. VQ scan

Answer: c) urgent CTPA and consider thrombolysis.

The diagnosis massive central pulmonary embolus as the patient is hypoxic and

hypotensive. The best management is to obtain an urgent CTPA and then thrombolyse if

there are no contraindications (e.g. high risk of bleeding).

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Respiratory Q65

A 60 year old lady has arthritic changes on her hand joints of ulnar deviation and

Butonniere's defomirty. She has chronic breathlessness.

Which of the following is a likely association?

A. Aspergillosis

B. Pulmonary fibrosis

C. Empyema

D. Lung carcinoma

E. Pulmonary emboli

Answer: b) pulmonary fibrosis.

The pulmonary complications of rheumatoid arthritis are :

pulmonary fibrosis (interstitial lung disease)

bronchiolitis obliterans with organizing pneumonia

bronchiectasis

interstitial pneumonitis secondary to drugs



Respiratory Q66

A 35 year old man has significant wheezing and breathlessness. Recordings of peak

flows shows diurnal variation. He was prescribed with salbutamol but continues to have

frequent wheezy episodes.

What is the next step in management?

A. Phosphodiesterase inhibitors

B. Leukotriene antagonists

C. Oral antibiotics

D. Inhaled corticosteroids

E. Oral steroids

Answer: d) inhaled corticosteroids.

Diurnal PEFR variation points tow ards a diagnosis of asthma. First line treatment are

short acting B agonists such as salbutamol and Patients who do not respond to B

agonists should be treated with inhaled corticosteroids (becotide or flixotide) which

help to reduce exacerbations in the long term.



Respiratory Q67

A 55 year old lady presents with worsening breathlessness. She has a history of

Raynaud’s phenomenon, heartburn and reflux.

On examination, the skin over her fingers is tight and shiny. She has multiple

telangiectasia over her face and nail‐fold capillary loops are seen. Her investigations

show she has Anticentromere antibodies.

What respiratory complication may occur?

A. Churg Strauss syndrome

B. Metastatic adenocarcinoma

C. Pulmonary hypertension

D. Allergic bronchopulmonary aspergillosis

E. Mesothelioma

Answer: c) pulmonary hypertension.

The patient has the clinical features of limited cutaneous scleroderma (LcSScformerly

CREST syndrome). Anticentromere antibodies occur in 70‐80% of these patients. A

significant respiratory complication is pulmonary hypertension. Treatment is with

prostaglandin analogues e.g. iloprost (intravenous infusions) or bosentan (oral).



Respiratory Q68

A 16 year old boy was brought to the A&E with wheeze and extensive rash whilst eating

at a Chinese takeaway.

On examination, he had extensive wheezes in his chest, stridor, as well as urticaria

covering his upper and lower limbs. His BP is 82/50 mmHg.


A. C1 Esterase Deficiency

B. Salmonella infection

C. Idiopathic urticaria

D. Asthma

E. Allergy

Answer: E) allergy

The scenario is consistent with a food allergy, e.g. nuts, leading to an anaphylactic

reaction. The patient should be treated with hydrocortisone (iv or im) as well as

chlorpheniramine.



Respiratory Q69

A 40 year old man with pneumonia is being examined.

Which one of the following positive auscultatory signs is diagnostic of bronchial

breathing?

A. Rhonchi

B. Increased vocal resonance

C. Aegophony

D. Whispering pectoriloquy

E. Fine inspiratory crepitations

Answer: d) Whispering pectoriloquy.

Whispering pectoriloquy is a diagnostic sign for bronchial breathing.



Respiratory Q70

A 16 year old boy with previous tuberculosis had a 7‐day history of progressive cough,

wheeze and tachypnoea, despite 4 days of intravenous flucloxacillin and cefotaxime

therapy.

Total serum IgE titre was 1600 IU (normal range, 0–180 IU) and the skin prick test was

positive for Aspergillus fumigatus.

What should he be treated with?

A. Praziquantel

B. Aciclovir

C. Itraconazole

D. Rifampicin

E. HAART

Answer: c) itraconazole.

Allergic bronchopulmonary aspergillosis (ABPA) is a diagnosis which can be confirmed by

significantly elevated serum IgE titre, positive skinprick tests for aspergillus, positive IgG

aspergillus precipitins.

Treatment is with antifungals. Steroids may be required in patients with respiratory

distress.

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Respiratory Q73

A 70 year retired sandblaster has worsening symptoms of cough, wheeze and

breathlessness. He has been keeping parrots for 15 years as a hobby.

Serum precipitins for M faeni are negative.

Chest X ray shows hyperinflated lungs.

His lung function tests show :

FEV1 1.8L (predicted 2.6)

FVC 3.0L (predicted 3.2)

FEV1/FVC 60%

Which of the following is the likely diagnosis?

A. Silicosis

B. Chronic obstructive airways disease

C. Farmer's lung

D. Allergic bronchopulmonary aspergillosis

E. Pigeon fancier's lung

Answer: b) chronic obstructive airways disease.

The lung function tests show an obstructive picture (reduced FEV1/FVC ratio).

Interestitial lung diseases are more likely to cause a restrictive picture on the lung

function test.



Respiratory Q74

A 60 year old asthmatic lady is admitted with sudden onset left sided pleuritic chest pain

accompanied by shortness of breath.

Arterial blood gases are as follow s: pH of 7.30, p02 of 7.5kPa, and pCO2 of 3.8 kPa.

Chest XR is normal. She is commenced on oxygen.

What is the most appropriate immediate action?

A. Request a chest XR in expiration

B. Request D‐dimer

C. Start low molecular weight heparin and request CT pulmonary angiography

D. Start low molecular weight heparin and request a V/Q scan

E. Broad spectrum antibiotics

Answer: c) Start low molecular weight heparin and request CT pulmonary angiography.

The symptoms and findings clearly point out tow ards pulmonary embolism (PE). As the

clinical probability of PE is high, measurement of D‐dimer should not be performed,

since the result would not alter the need for definitive investigation. Measurement of D‐

dimer should only be performed when the probability of PE is low , when a normal value

would be taken as reassuring and further investigation would not be pursued.

V/Q scan less likely to be unhelpful in view of her asthma; hence a CT pulmonary

angiogram would be the imaging procedure of choice.



Respiratory Q75

A 65 year old man has had 5 kg weight loss over 6 months. He is an ex smoker of 25

cigarettes a day for 40 years and used to work in a coal mine.

A Chest X ray shows a large right sided pleural effusion and several pleural plaques in

both lung peripheries.

Pleural aspiration reveals an exudate with 42 g of protein.

What investigation should be recommended?

A. Bronchoscopy

B. Lung function tests

C. Spiral CT of the chest

D. Thoracoscopy and biopsy

E. Sputum for AFB

Answer: d) thoracoscopy and biopsy.

This patient probably has a malignant effusion as demonstrated by the exudate from the

pleural effusion. As he is symptomatic, the best option would be to drain the fluid as

well as confirm a diagnosis simultaneously.

A video assisted thoracoscopy would help to do this. In this procedure, an illuminated

tube is inserted through a small incision made betw een the ribs. It allows the operator

to visualize structures inside the chest and to perform simple procedures such as biopsy

and nodule excision.



Respiratory Q76

A 65 year old man with a smoking history of 50 a day for many years has been a chest

radiograph showing a lung mass. He is presently waiting a bronchoscopy.

Which one of the following supports a diagnosis of small cell lung cancer?

A. Disseminated intravascular coagulation

B. Hypertrophic pulmonary osteoarthropathy (HPOA)

C. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

D. Thrombocytosis

E. Hypercalcaemia

Answer: c) Syndrome of inappropriate antidiuretic hormone secretion (SIADH).

SIADH is most comonly seen with small cell carcinoma rather than non‐small cell

carcinoma. HPOA, hypercalcaemia without bone metastasis is more common in

squamous cell carcinoma. DIC and thrombocytosis are more common with

adenocarcinoma.



Respiratory Q77

A 60 year old woman presents with a 6‐month history of progressive shortness of

breath. Her past medical history is unremarkable apart from Raynaud’s syndrome for

which she takes a calcium channel blocker.

On examination she has telangiectasia.

Her chest radiograph shows clear lung fields, prominent pulmonary arteries and mildly

enlarged heart. Spirometry is normal, but gas transfer is reduced by 40% of predicted.


A. Cor pulmonale

B. Pulmonary arterial hypertension

C. Sarcoidosis

D. Pulmonary emboli

E. Pulmonary oedema

Answer: b) Pulmonary arterial hypertension.

The patient is likely to have scleroderma from the clinical history.

There is also associated pulmonary hypertension which such patients are at risk of.



Respiratory Q78

A 75 year old lady is admitted with an acute exacerbation of chronic obstructive

pulmonary disease (COPD). One hour after admission she remains distressed with a

respiratory rate of 35 per minute and is peripherally cyanosed. Repeated arterial blood

gases show a severe respiratory acidosis with a pH of <7.2.

Which of the following treatments is recommended?

A. Give intravenous infusion of aminophylline

B. Give intravenous hydrocortisone

C. Repeat bronchodilator therapy and arrange repeat arterial gases

D. Arrange for noninvasive positive pressure ventilation

E. High flow oxygen

Answer: d) Arrange for noninvasive positive pressure ventilation.

Non invasive positive pressure ventilation should be considered, especially in COPD

patients when there is a need for ventilatory assistance as indicated by worsening

dyspnoea, acute respiratory acidosis and worsening oxygenation. If this does not work

then intubation and ventilation may be necessary.

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Respiratory Q81

A 55 year old woman with rheumatoid arthritis is referred with a history of recurrent

chest infections, intermittent wheeze and production of half a teacupful of sputum

daily, on occasions with blood stained.


A. Pulmonary fibrosis

B. Bronchiectasis

C. Emphysema

D. Tuberculosis

E. Squamous lung carcinoma

Answer: b) Bronchiectasis.

Bronchiectasis is associated with rheumatoid arthritis, occurring in 3‐4% of patients with

this condition. As with all other causes of bronchiectasis, it presents with recurrent

chest infections and excessive sputum. Recurrent haemoptysis is a common feature.



Respiratory Q82

A 38 year old man with a history of depression is brought to the accident and

emergency department after being found unconscious in a garage. A friend said that he

complained of a headache, then had nausea and vomiting.

He then became unrousable.

Oxygen saturations are 95% on air and breath sounds are clear on auscultation.


A. Pulmonary eosinophilia

B. Pulmonary embolus

C. Adult respiratory distress syndrome

D. Pneumocystis pneumonia

E. Carbon monoxide poisoning

Answer: e) Carbon monoxide poisoning.

Carbon monoxide poisoning is produced by the incomplete combustion of carbon

containing fuels such as gas, coal, oil, wood and coke.

Headache is the most common symptom (90%) followed by nausea & vomiting, vertigo,

alteration in consciousness and weakness.

The cherry red skin colour occurs when COHb concentration exceeds 20% but it is rarely

seen in life. Pulse oximetry gives falsely high oxygen saturation sand it is not

recommended.



Respiratory Q83

A 45 year man has breathlessness and a dry cough. On examination, there are bilateral

basal crepitations in his lungs. Oxygen saturations are 95% on air. Circulating precipitins

towards Micropolyspora faeni are positive.


A. ABPA

B. Bagassosis

C. Farmer's lung

D. Bird fancier's lung

E. Cheese worker's lung

Answer: c) farmer's lung.

This is a form of hypersensitivity pneumonitis. Farmer's lung is caused by the

actinomycetes Micropolyspora faeni, and bagassosis is caused by Thermoactinomyces

sacchari.

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Respiratory Q85

A 70 year old man who has previously worked in the building trade presents with a

history of chest pain and dyspnoea. On examination he has evidence of a right‐sided

pleural effusion. Pleural aspiration is performed and a pleural biopsy taken. Histology

from the biopsy shows mesothelioma.


A. The diagnosis should be queried

B. Radiotherapy should be given to prevent seeding of tumour cells

C. Surgery

D. Chemotherapy should be given to prevent seeding of tumour

E. Curative radiotherapy should be given

Answer: b) Radiotherapy should be given to prevent seeding of tumour cells.

In mesothelioma no treatment has been shown to influence the universally fatal

outcome. After obtaining a positive biopsy, radiotherapy should be given in an attempt

to prevent seeding of tumour cells, around the area of the biopsy.

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Respiratory Q89

A 30 year old male patient presents with worsening rhinitis, cough and wheezing, which

has occurred for the past 2 years. On admission, his lung function tests show FEV1 of

55% predicted and FVC of 65% predicted and a chest X ray showed bilateral infiltrates.

He had an eosinophil count of 5 x 10^9/l (0.04‐0.4) and sputum eosinophilia of 80% was

also found. There was also elevated IGE levels of >1000 kU/L. Serum ANCA was positive

at a dilution of 1:1024.

A nasal biopsy showed chronic inflammation, with some areas suggestive of vasculitis,

and eosinophilic infiltration.

Which diagnosis is most likely?

A. COPD

B. Mesothelioma

C. Churg Strauss syndrome

D. Tuberculosis

E. Extrinsic allergic alveolitis

Answer: c) Churg Strauss syndrome.

There are many causes of pulmonary symptoms with eosinophilia including Loeffler's

syndrome, Churg Strauss syndrome, pulmonary eosinophilic syndrome and ABPA.

Extrinsic allergic alveolitis does not cause a wheeze and also does not cause

eosinophilia.

Churg‐Strauss syndrome is an uncommon condition characterised by asthma and blood

eosinophilia together with an eosinophilic vasculitis. The initial phase of the disorder is

one of asthma and allergic rhinitis, often followed by peripheral blood eosinophilia with

eosinophilic tissue disease. The vasculitic phase that follows is life‐threatening; how

ever, it can often be treated effectively with immunosuppression. It is associated with

granuloma formation and vasculitis affecting several organs e.g. skin, pericardium,

kidney and lung.

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Respiratory Q91

A 55 year lady has had a long history of productive cough and shortness of breath. She

often coughs up whitish sputum and is prone to chest infections. On examination her

temperature is 36° C, chest expansion is reduced and there are bilateral wet inspiratory

crackles.

Which one of the following treatments is most helpful?

A. Intravenous antibiotics

B. B agonist inhalers

C. Postural drainage

D. Morphine

E. Prednisolone

Answer: c) postural drainage.

This lady has bronchiectasis. There is no suggestion of a chest infection during this

episode of admission, hence postural drainage is the best treatment option.



Respiratory Q92

A 55 year old farmer has had progressive breathlessness over the past 2 years. He

presents with a severe episode of dyspnea and productive cough which occurred 6

hours after he started working. He mentions that these episodes are typical but today is

more severe. On admission, his O2 saturations are 94% on air.

CXR shows bilateral interstitial shadowing in upper zones.

Which of the following is the most useful test?

A. Precipitins to aspergillus

B. Sputum for AFB

C. Kveim test

D. Precipitins to Micropolyspora faeni

E. Bronchoscopy

Answer: d) precipitins to Micropolyspora faeni.

This patient is likely to have extrinsic allergic alveolitis. The classic presentation of

farmer's lung results from inhalational exposure to thermophilic Actinomyces species.

Patients with extrinsic allergic alveolitis may present acutely with a flulike illness with

cough. They can also present subacutely with recurrent pneumonia or chronically with

exertional dyspnea, productive cough, and weight loss.

The onset of symptoms after acute exposure is usually betw een 4 and 12 hours. Some

antigens provoke symptoms after repeated exposure; these include bioaerosols of

microbial or animal antigens and a few reactive chemicals.

Thermophilic actinomycetes species which can cause EAA include Saccharopolyspora

rectivirgula (formerly Micropolyspora faeni), Thermoactinomyces vulgaris,

Thermoactinomyces viridis, and Thermoactinomyces sacchari.



Respiratory Q93

A 60 year old woman had a CXR showing pulmonary fibrosis. Upon review , of her drug

history, which of the following drugs might she have been on in the past?

A. Clarithromycin

B. Amoxicillin

C. Busulphan

D. Omeprazole

E. Ciprofloxacin

Answer: C) busulphan.

Busulphan, bleomycin, amiodarone and nitrofurantoin are drugs which commonly cause

pulmonary fibrosis.

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Respiratory Q95

A 22 year old woman has asthma for which she is using her salbutamol inhaler two or

three times a day.

What should be the next step in her management if she worsens?

A. Advise her to use the salbutamol inhaler regularly three times a day

B. Add regular inhaled steroid, e.g. beclometasone 100 microg twice daily

C. Add regular salmeterol twice daily

D. Add regular inhaled steroid, e.g. beclometasone 1000 microg twice daily

E. Add regular inhaled steroid, e.g. beclometasone 1000 microg twice daily, plus regular

long‐acting inhaled beta agonist

Answer: b) Add regular inhaled steroid, e.g. beclometasone 100 microg twice daily.

The British Thoracic Society Asthma guidelines are as follows:

Step 1: PRN use of inhaled short‐acting beta agonists

Step 2: regular inhaled steroids

Step 3: high‐dose inhaled steroids, or low ‐dose inhaled steroids plus long‐acting beta

agonist

Step 4: high‐dose inhaled steroid and regular bronchodilators (sustained release

theophylline, inhaled ipatropium, oral long‐acting beta agonist, high‐dose

inhaled bronchodilators, cromoglycate / nedocromil) Step 5: addition of regular

steroid tablets



Respiratory Q96

A 60 year old woman with know n COPD is referred with a 4‐month history of morning

headaches. She describes a dull headache which is generalised, worst upon waking up.

She has home nebuliser (salbutamol and atrovent) but is not on home oxygen.

A routine arterial blood gas on admission showed a pH of 7.34 pCO2 of 6.2 kPa, pO2 of

8.8 kPa and HCO3 30 mmHg.


A. Long‐term oxygen therapy

B. Ambulatory oxygen therapy

C. CT chest

D. Overnight SaO2 and CO2 monitoring

E. Repeat ABG

Answer: d) Overnight SaO2 and CO2 monitoring.

Morning headaches are often ascribed to patients with nocturnal hypoxia or early

morning hypercapnia. They are often associated with sleep apnea or a chronic

respiratory disease such as COPD.

The admission blood gases show mild hypoxia, and hypercapnia. There is respiratory

acidosis with metabolic compensation. It suggests that there is a high likelihood of

chronic hypoxia.

If oxygen monitoring confirmed nocturnal hypoxia (defined as O2 sats of < 90% for

more than 30% of sleep time), she may require nocturnal oxygen supplementation.



Respiratory Q97

A couple attend the GP surgery with their 2 year old daughter. She has a history of

repeated chest infections, failure to thrive, and steatorrhoea (fatty stools). They also

have an 8 year old child who is fit and well.


A. Pulmonary Eosinophilia

B. Asthma

C. Cystic fibrosis

D. Congenital Tuberculosis

E. Bochdalek Hernia

Answer: c) Cystic fibrosis.

The gene defect in cystic fibrosis is in a mutation on chromosome 7. The inheritance is

autosomal recessive so the other child without symptoms has not inherited two CF

genes. Pulmonary disease develops over a few months after birth. Common infective

organisms are pneumoccocus, Haemophilus influenzae and Pseudomonas aeruginosa.



Respiratory Q98

A 45 year old man complains of wheeziness which is worse. He has a history of asthma.

His current medication consists of a low dose of inhaled corticosteroids and inhaled

short‐acting beta 2 agonist taken three to four times a day.

What should be done next?

A. Add oral steroids

B. Add an inhaled long‐acting beta 2 agonist

C. Add a long‐acting anticholinergic

D. Add a short acting anticholinergic

E. Add a leucotriene receptor antagonist

Answer: b) Add an inhaled long‐acting beta 2 agonist.

According to the British Thoracic Society guidelines the next step would be to add an

inhaled long‐acting beta 2 agonist (LABA) and then assess the situation. If there is a

good response to LABA, this medication should be continued. If there is benefit from

LABA but control is still inadequate, LABA should be continued, and the inhaled

corticosteroids should be increased to a high dose.



Respiratory Q99

A 65 year old heavy smoker is admitted with a history of increasing breathlessness. This

has been precipitated by the development of a cough with yellow purulent sputum.

The organisms that are likely to cause infective exacerbations of COPD are:

A. Streptococcus pneumoniae, Legionella pneumophilia, Mycoplasma pneumoniae

B. Streptococcus pneumoniae, Klebsiella pneumoniae, E coli

C. Streptococcus pneumoniae, Haemophilus influenzae, Moxarella catarrhalis

D. Streptococcus pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus

E. Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophilia

Answer: c) Streptococcus pneumoniae, Haemophilus influenzae, Moxarella catarrhalis.

In infective exacerbations of COPD, Streptococcus pneumoniae and Haemophilus

influenzae, as well as Moraxella are the commonest organisms.



Respiratory Q100

A 65 year old man has longstanding breathlessness on exertion. He has been smoking 20

cigarettes a day over a period of 30 years.

On examination, the patient is breathless with use of accessory muscles and resting

activation of the abdominal muscles. The chest is barrel shaped.

With regards to this case, which one of the following is know n to be a predictor of

mortality?

A. Spirometry

B. Fibrotic changes

C. Body Mass Index

D. Arterial blood gases

E. How many cigarettes were smoked

Answer: c) Body Mass Index.

A low body mass index is a known predictor of mortality in patients with chronic

obstructive pulmonary disease.



Respiratory Q101

A 40 year man presents with shortness of breath. On admission he is unw ell and has a

respiratory rate of 32 breaths per minute. His chest is wheezy on auscultation.

Arterial blood gases show :

pO2 9.5 kPa, pCO2 3.5 kPa, pH 7.48, HCO3 25, BE +2.

What is the likely clinical scenario?

A. Lactic acidosis secondary to metformin

B. Anxiety disorder

C. Asthma attack

D. Chronic bronchitis

E. Pneumothorax

Answer: c) asthma attack.

The patient has a respiratory alkalosis (pH > 7.45) which is acute since the bicarbonate

levels are normal (22‐28). There is hypoxia and the patient is hyperventilating in

response and blowing off CO2.

This would be consistent with an asthma attack.

In an anxiety attack, hypoxia would not be present.



Respiratory Q102

A 30 year old man is admitted with a history of haemoptysis, cough and dyspnoea. He

has been previously fit and has smoked 25 cigarettes a day for the last 10 years. A chest

XR shows diffuse alveolar infiltrates. He has a microcytic, hypochromic anaemia, urine

dipstick confirms haematuria and proteinuria. His lung function tests shows a normal

spirometry and a TLCO of 125% predicted.


A. Pulmonary emboli

B. Chest trauma

C. Goodpasture's syndrome

D. Pulmonary tuberculosis

E. Pneumonia

Answer: c) Goodpasture's syndrome.

Goodpasture's syndrome is characterised by diffuse alveolar haemorrhage and

glomerulitis. Men are commonly affected with most cases occurring betw een the ages

of 20‐30 years. It is more likely to occur in smokers. The anti glomerular basement

antibody (Anti‐GBM) is present in up to 90% of the patients. Renal histology usually

shows a focal segmental necrotizing glomerulitis with crescent formation. The TLCO is

increased during active bleeding and can be used to monitor disease activity. An

increase above 30% of baseline is suggestive of an intra‐alveolar bleed.



Respiratory Q103

A 60 year old man presents with sever breathlessness following an upper respiratory

tract infection.

Which of the following would support a diagnosis of acute respiratory distress syndrome

(ARDS)?

A. High protein content of pulmonary oedema fluid

B. Normal chest Xray

C. High pulmonary capillary wedge pressure

D. Increased lung compliance

E. High CO2 levels

Answer: a) High protein content of pulmonary oedema fluid.

Acute respiratory distress syndrome is characterised by hypoxaemia, reduced lung

compliance, pulmonary hypertension and pulmonary infiltrates on chest X ray. There is

damage to the capillary endothelial cell linings resulting in oedema leakage of proteins

cells into interstitial alveolar spaces.

A high pulmonary capillary wedge pressure suggests heart failure. High CO2 reflect type

II respiratory failure and are non specific.



Respiratory Q104

A 60 year old man had a transbronchial biopsy confirming squamous cell carcinoma of

the lung.

Which of the following is a contraindication tow ards surgical resection?

A. Hypercalcaemia

B. Superior vena caval obstruction

C. Previous radiotherapy

D. Metastasis to local lymph nodes

E. Pleural effusion

Answer: b) superior vena caval obstruction.

Extensive nodal spread, distal metastases, stage IIIB or more, and superior vena caval

obstruction are contraindications tow ards surgery for lung cancer.



Respiratory Q105

In which of the following have randomised controlled trials shown that long‐term oxygen

therapy (LTOT) reduces mortality?

A. Asthma

B. Chronic obstructive lung disease

C. Cryptogenic fibrosing alveolitis

D. Cystic fibrosis

E. Pulmonary sarcoidosis

Answer: B) Chronic obstructive lung disease.

There is evidence for a small reduction in mortality in patients with COPD and resting

hypoxia. Although indications for LTOT are largely based on mortality data, some studies

have also suggested improvements in other outcome measures, including depression,

cognitive function, quality of life, exercise capability, and frequency of hospitalisation.

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Respiratory Q107

A 35 year old man has symptoms of wheezing and has been diagnosed as having late

onset asthma. How ever, his GP measured routine blood tests and found that he had a

creatinine of 250 umol/l.

What antibody is likely to be helpful in confirming the diagnosis?

A. Antinuclear antibody

B. Anti phospholipids antibody

C. Anti Ro antibody

D. Anti nuclear cytoplasmic antibody

E. Anti gliadin antibody

Answer: D) anti nuclear cytoplasmic antibody.

The clinical diagnosis is likely to be an ANCA positive small vessel vasculitis such as

polyarteritis nodosa, as there is pulmonary and renal involvement. Churg Strauss

syndrome should also be considered (only a small proportion of patients with Churg

Strauss have a positive ANCA)



Respiratory Q108

A 60 year old man has a long history of smoking and COPD. His resting PO2 is 7.2 kPa

and his continues to be breathless despite being on home nebulisers. He is assessed for

long term oxygen therapy (LTOT).

When is LTOT indicated?

A. PO2 <7.2 kPa

B. PO2 <7.8 kPa

C. PO2 <8 kPa

D. PO2 <8.5 kPa

E. PO2 <9 kPa

Answer: a) pO2 <7.2 kPa.

When there is polycythaemia or pulmonary hypertension, Long Term Oxygen Therapy is

indicated when pO2 < 8kPa. In uncomplicated COPD, it is indicated when pO2 < 7.2kPa



Respiratory Q109

A 60 year old woman with asthma presents with a history of acute breathlessness and

pleuritic chest pain. Her arterial blood gases show the following readings:

pH 7.35, pO2 6.8 kPa, pCO2 4 kPa, bicarbonate 25 mmol/L

Which test is most specific to acute pulmonary embolism?

A. MRI of the chest

B. CT pulmonary angiogram

C. Chest x‐ray

D. D‐Dimers

E. V/Q scan

Answer: b) CT pulmonary angiogram.

Most of the tests are helpful but a CT pulmonary angiogram remains the gold standard

diagnostic test for pulmonary embolism.



Respiratory Q110

A 35 year old man presents with swelling of his lips and around the throat following

consumption of prawns. His

investigations show :

serum IgE 150 kU/L (0‐120)

C3 level is 77 mg/dL (65‐190)

C4 level is 45 mg/dL (15‐50)

Which of the following diagnosis is likely?

A. C1 esterase inhibitor deficiency

B. Allergic reaction

C. Systemic mastocytosis

D. Moon face

E. Cellulitis

Answer: b) allergic reaction.

Mildly elevated IgE concentration suggests an allergic reaction to praw ns. In

angioneurotic oedema due to C1 esterase inhibitor deficiency, a low C4 with normal C3

level is seen (C2 is also low but not commonly measured).



Respiratory Q111

A 40 year old man has with a 2 year history of increasing shortness of breath. This is

worse with exertion e.g. climbing the stairs at home and is even slightly so at rest. He is

a non‐smoker.

On examination, his pulse is 95 beats/min and his blood pressure is 140/95 mmHg. He

has finger clubbing and a crackling noise at the end of inspiration over the bases of the

lungs. There was no ankle oedema Lung function tests show :

FVC 2.5 l (predicted 3.2 )

FEV1 2.1 l (predicted 2.4)

FEV1 % 76% (predicted 75%)

Diffusing Capacity: Gas Transfer Factor for carbon monoxide: DLCO 17

ml/min/mmHg (predicted) 25

Which one of the following diagnosis is likely?

A. Aspergilloma

B. Guillain‐Barre syndrome

C. Cryptogenic fibrosing alveolitis

D. Asthma

E. Congestive cardiac failure

Answer: c) cryptogenic fibrosing alveolitis.

A reduced FVC, with normal FEV1, FEV1% and PEF usually indicates restriction of lung

volume . KCO (transfer factor) is also reduced in fibrotic lung disease, as in this case. The

additional findings of inspirational crackles and clubbing suggests the diagnosis of

cryptogenic fibrosing alveolitis.



Respiratory Q112

A 60 year old man has severe COPD requiring home nebulisers and home oxygen. He is

admitted with an infective exacerbation.

Which of the following results would be expected on the arterial blood gases?

A. PH 7.25 paCO2 7 paO2 7.5 HCO3 30

B. PH 7.10 paCO2 7 paO2 4 HCO3 24

C. PH 7.30 paCO2 4 paO2 8.5 HCO3 30

D. PH 7.40 paCO2 4 paO2 4 HCO3 22

E. PH 7.45 paCO2 3 paO2 12 HCO3 24

Answer: a) pH 7.25 paCO2 7 paO2 7.5 HCO3 30.

A long standing COPD patient would be expected to have a high bicarbonate. However

this patient is unwell with type II respiratory failure (high CO2) and hence has

uncompensated respiratory acidosis.

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Respiratory Q114

A 34‐year‐old woman presented with a dry cough, thorax constriction, and generalised

weakness. During the preceding 5 months, she had experienced these dry cough

episodes tw ice a week. A lung function test showed a restriction of the vital capacity

(71% of the adjusted reference value), and the diffusion capacity was also reduced (66

to 68%).

Bronchoalveolar lavage specimens were obtained, the lymphocytes were increased up

to 41% (norm, <10%), and neutrophils were increased up to 6% (norm, <2%) with a

normal total cell count.


A. Asthma

B. Pulmonary embolus

C. Tuberculosis

D. Extrinsic allergic alveolitis

E. Alpha 1 antitrypsin deficiency

Answer: d) extrinsic allergic alveolitis.

Extrinsic Allergic Alveolitis is a type III or type IV response. There is no eosinophilia. IgG

and lymphocytes are involved in immune response. Antigens of micropolyspora faeni

and thermoactinomyces are 0.5‐5 microns . These antigens which may be detected as

serum precipitins.

The acute form takes about 6 hours for sensitisation to the inhaled antigen. The chronic

form may take weeks.



Respiratory Q115

A 65 year old patient with COPD is on maximal treatment.

Which one of the following is likely to prevent further disease progression?

A. Steroids

B. Beta agonist inhalers

C. Stopping smoking

D. Tiotropium

E. Home oxygen

Answer: C) stopping smoking.

In COPD, discontinuation of smoking is the only features which has been shown to

reduce disease progression.



Respiratory Q116

A 60 year old male smoker has emphysema.

His lung function tests show :

FEV1 is 0.5 (20% predicted)

FVC is 2.2 (61% predicted)

FEV1:FVC ratio of 26%

His arterial blood gases show a PO2 of 7.5 and 7.2 on two separate occasions. He is

mildly breathless at rest, but severely breathless on exertion.

What is the best measure of his respiratory function?

A. TLCO

B. FEV1

C. FVC

D. KCO

E. TLC

Answer: b) FEV1.

The breathlessness worsens considerably without much change in oxygen tension,

suggesting that the cause of his dyspnoea is hyperinflation of his chest which worsens

on exertion.

Severity of emphysema is defined by the British Thoracic Society (BTS) in relation to

FEV1, not FEV1:FVC ratio. Mild is 60‐80% predicted; moderate 40‐60% and severe <40%.



Respiratory Q117

A 40 year old lady was admitted to hospital with fevers and cough productive of

sputum.

Chest X‐ray shows diffuse patchy consolidation around the left lung. She has had a flu

like illnes 4 weeks ago, and has a past medical history of asthma. She also smokes 10

cigarettes a day.

Which organism is likely to be responsible?

A. Mycoplasma

B. Pseudomonas

C. Klebsiella

D. Staphylococcus

E. Tuberculosis

Answer: d) staphylococcus.

Following a viral infection, patients are predisposed to staphylococcal infection. The

chest XR changes suggest staphlococcus rather than streptococcus (which would cause

lobar consolidation).

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Respiratory Q119

A 40 year old woman presents with breathlessness, cough and fever. On examination,

she has basal crackles in the lung fields. Circulating precipitans to Micropolyspora faeni

are positive.

Which of the following is the most likely diagnosis?

A. Pigeon fanciers' lung

B. Allergic Bronchopulmonary Aspergillosis

C. Farmers' lung

D. PCP infection

E. Pulmonary fibrosis

Answer: c) Farmers' lung.

Farmer's lung is the most common type of hypersensitivity pneumonitis.

Hypersensitivity pneumonitis, also known as extrinsic allergic alveolitis, is associated

with intense or repeated exposure to inhaled biologic dusts. The classic presentation of

farmer's lung results from inhalational exposure to thermophilic Actinomyces species

and occasionally from exposure to various Aspergillus species.

Acute farmer's lung develops after large exposure to moldy hay or contaminated

compost. Symptoms often spontaneously resolve within 12 hours to days if antigen

exposure is eliminated or avoided. It manifests as new onset of fever, chills,

nonproductive cough, chest tightness, dyspnea, headache, and malaise.



Respiratory Q120

A 50 year old meat factory worker has been unw ell with fever, cough, sweats and

lethargy. On examination, he had a purpuric rash and hepatosplenomegaly.


A. Pulmonary embolism

B. Respiratory syncytial viral pneumonia

C. Streptococcal pneumonia

D. Q fever pneumonia

E. Aspergilloma

Answer: d) Q fever pneumonia.

Q fever is due to Coxiella burnetii and is acquired via animal contact. It can occur in

outbreaks in farming communities and in abbatoirs. Treatment is with prolonged

courses of tetracyclines. Rarely infection can be persistent leading to chronic symptoms

including fatigue, malaise and sweats. Hepatitis, hepatosplenomegaly, maculopapular

rash and endocarditis are associated.

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Respiratory 2012 Mrcppass