Clinical SBAs
Clinical Respitory: (32 questions)

Questions

• 1
  A 19-year old woman with asthma does not have adequate symptom control. She is currently on salbutamol and low-dose beclometasone. According to the British Thoracic Society guidelines, what further treatment should be added next?
  Difficulty: Medium     Topic: Chronic asthma management
  a

  Montelukast

  b

  Ipratropium

  c

  Salmeterol

  d

  High dose inhaled beclometasone

  e

  Theophylline
  Explanation: Chronic management of adults (>17 years) with asthma should be conducted in accordance with British Thoracic Society guidelines and/or NICE guidelines.
  The BTS guidelines suggest: A short-acting beta-2-adrenoreceptor agonist (SABA) for relief use when required. Low-dose inhaled corticosteroid as maintenance is recommended for all patients. Next step initially involves trial of a long-acting beta-2-agonist (salmeterol). If this does not give improvement then it should be stopped and inhaled steroid dose should be increased. Next includes trialling montelukast (a leukotriene antagonist) and theophylline (a phosphodiesterase inhibitor). Ipratropium (a muscarinic antagonist) is used as a nebuliser in acute asthma and in chronic management of COPD.
  The NICE guidelines differ from the BTS guidelines in a couple of ways, the most contentious is the use of montelukast in adults as the initial add-on therapy. Further discussion of the differences can be found here: http://blogs.bmj.com/thorax/files/2017/12/BTS-SIGN-and-NICE-Asthma-guidelines.pdf
• 2
  A 23-year old woman with poorly controlled asthma is going to have a new medication started to control her respiratory disease and is told that it can cause severe side-effects in overdose. Which medication is she most likely to be starting?
  Difficulty: Hard     Topic: Asthma drugs side-effects
  a

  Oral salbutamol

  b

  Montelukast

  c

  Oral corticosteroids

  d

  Theophylline

  e

  Lithium citrate
  Explanation: Theophylline is a phosphodiesterase inhibitor and adenosine receptor antagonist that is part of step 4 in the BTS guidelines for treatment of asthma. In toxicity it can cause seizures and cardiac arrhythmias. In patients where toxicity is a concern then drug levels may be monitored. Oral salbutamol may be used for patients with persistently poor control on Step 4 in the BTS guidelines. Montelukast is a leukotriene antagonist that is used as part of add-on therapy for Step 3. Oral steroids are used in treatment of asthma exacerbations and long-term for Step 5 management of patients. After 3 months on oral steroids patients should be screened for osteoporosis, especially if they have other risk factors. Lithium is a mood stabiliser that requires monitoring, however it is not used to treat asthma.
• 3
  A 35-year old woman presents with breathlessness that “comes and goes”. She has a 10 year smoking pack history. Examination is unremarkable. She shows 20% improvement of PEFR with use of salbutamol. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Intermittent breathlessness
  a

  COPD

  b

  Pulmonary fibrosis

  c

  Cardiac failure

  d

  Bronchial carcinoma

  e

  Asthma
  Explanation: Intermittent shortness of breath with a normal examination suggests asthma. All of the others are likely to give symptoms that are similar every day and worsen with activity. 'A-D' are also more likely to give a history of progressive disease. Physical examination is usually normal in asthma when not during an attack whereas all of the other conditions listed are likely to demonstrate some physical signs. Asthma is exacerbated by smoking and a 10-pack year history is too short to give a patient COPD on its own e.g. without alpha-1-antitrypsin deficiency also present. Importantly, 20% improvement of peak expiratory flow rate with use of a beta-2-agonist shows significant reversibility, which would only occur with asthma. COPD may show some reversibility but less <15%.
• 4
  A 37 year old HIV+ man presents with a 1 month history of weight loss, fever and progressive shortness of breath with dry cough. He demonstrates marked desaturation on exercise. CXR shows diffuse bilateral infiltrates. What is the most likely causative organism?
  Difficulty: Medium     Topic: Immunocompromised pneumonia
  a

  Pneumocystis jiroveci

  b

  Mycobacterium tuberculosis

  c

  Staphylococcus aureus

  d

  Streptococcus pneumoniae

  e

  Pseudomonas aeruginosa
  Explanation: P. jiroveci causes a bilateral pneumonia in immunosuppressed patients. It presents with fever, weight loss, dry cough and low SaO2 that is worse following exercise. TB is an important differential diagnosis but bilateral infiltrates is not a feature except in the presence of ARDS or miliary TB (which causes reticulo-nodular shadowing). S. aureus causes a bilateral cavitating pneumonia following influenza infection. S. pneumoniae is the most common cause of lobar pneumonia. P. aeruginosa is a cause of nosocomial pneumonia and in bronchiectasis.
• 5
  A 43-year old Afro-Caribbean woman presents with 3 months progressive shortness of breath. Chest X-ray shows bilateral hilar lymphadenopathy and bilateral reticular shadowing. Which of the following is least consistent with the diagnosis?
  Difficulty: Easy     Topic: 3-months progressive SOB
  a

  Erythema marginatum

  b

  Hypercalcaemia

  c

  Erythema nodosum

  d

  Raised serum ACE

  e

  Non-caseating granulomas
  Explanation: This woman has sarcoidosis, an idiopathic multi-system granulomatous disorder that is most common in Afro-Caribbean's. It affects the lungs in 90% of patients and the earliest sign is bilateral hilar lymphadenopathy, which may progress to interstitial fibrosis. Erythema nodosum, painful raised red areas over the shin, are associated with sarcoidosis. However erythema marginatum, red and white 'target' lesions, are associated with infection and hypersensitivity reactions but not sarcoid. Hypercalcaemia and raised serum angiotensin converting enzyme are found in sarcoidosis. On biopsy non-caseating granulomas are found in affected organs.
• 6
  A 43-year old man attends A&E 5 hours after he started a new job at an aviary. He is pyrexial, with myalgia, shortness of breath and a dry cough. This presentation is treated with oral prednisolone. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Pyrexia and breathlessness
  a

  Extrinsic allergic alveolitis (EAA)

  b

  Psittacosis

  c

  Pneumoconiosis

  d

  Avian influenza

  e

  Acute interstitial pneumonia (AIP)
  Explanation: Acute EAA occurs a few hours after exposure to the responsible antigen and this is a typical presentation. The patient may have several episodes associated with exposure before presenting. Prednisolone is the treatment, along with antigen avoidance. Psittacosis causes a bilateral pneumonia treated with tetracycline. Pneumoconiosis causes upper lobe fibrosis following organic material exposure. Avian influence and AIP both cause rapidly deteriorating function with infiltrates and ARDS requiring intubation.
• 7
  A 43-year old man presents with 1 day of pleuritic right sided chest pain, shortness of breath and fever. There are coarse crackles in the right lower zone and CXR shows blunting of the right costo-phrenic angle. Which finding is most likely to be present in the pleural fluid?
  Difficulty: Medium     Topic: Pleural fluid analysis
  a

  Blood-stained

  b

  <25g/L protein

  c

  Raised amylase

  d

  pH 7.4

  e

  LDH raised relative to serum
  Explanation: This man has a small parapneumonic effusion, which is most commonly an exudate (>35g/L protein). However it is unlikely that in practice that this man's effusion would be aspirated unless it was thought to be causing respiratory compromise or developed into an empyema. Raised LDH relative to serum is feature of exudates; as described by Light's criteria. Blood-stained fluid suggests malignancy or trauma. Raised amylase occurs in pancreatitis-related effusions. pH of <7.2 suggests an inflammatory (often infective or malignant) cause for the effusion. Therefore an effusion with normal pH is most likely to be a transudate, which is not a feature of parapneumonic effusions.
• 8
  A 45-year old male smoker presents with shortness of breath. His chest is hyperinflated, CT shows multiple bullae and biopsy demonstrates destruction of alveolar walls. He smoked for 5 years when he was a teenager. What investigation will confirm the diagnosis?
  Difficulty: Medium     Topic: Genetic lung disease
  a

  ATP7B gene analysis

  b

  CFTR gene analysis

  c

  Alpha-1-antitrypsin levels

  d

  Alpha-feto-protein levels

  e

  ANCA levels
  Explanation: This man has emphysema due to AAT deficiency he is too young for smoking to be the cause and COPD is usually associated with a smoking history of over 20pack-years. AAT deficiency also causes cirrhosis but respiratory disease is the most common cause of death. 'A' is the test for Wilson's disease (copper accumulation) that does not affect the lungs. Wilson's can cause acute liver failure, haemolysis, acute renal failure and chronic damage to the basal ganglia. CFTR is the gene that is mutated in cystic fibrosis, which causes bronchiectasis. AFP is a tumour marker most associated with hepatocellular carcinoma and teratomas. ANCA is raised in several vasculitidies but they do not result in emphysema.
• 9
  A 46-year old lady presents with erythema nodosum and gross bilateral hilar lymphadenopathy. Bronchoscopic biopsy shows non-caseating granulomas. What is the most appropriate management?
  Difficulty: Hard     Topic: Granulomatous lung disease
  a

  Reassure and discharge

  b

  Paracetamol and follow-up CXR

  c

  Oral prednisolone

  d

  IV hydrocortisone

  e

  IV cyclophosphamide
  Explanation: This woman has sarcoidosis, which is an idiopathic multi-system granulomatous disease that most commonly affects the lung, liver and nervous system. This woman has Stage I pulmonary sarcoidosis (bilateral hilar lymphadenopathy only), which requires analgesia for and a follow-up CXR. Steroids are given for in sarcoidosis for: cardiac or neural involvement, hypercalcaemia, lung parenchymal involvement and uveitis. Usually oral prednisolone is given but in severe cases IV hydrocortisone and cyclophosphamide may be tried.
• 10
  A 46-year old male smoker attends the respiratory clinic. He is clubbed and has bilateral basal coarse inspiratory crackles. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Clubbing and coarse crackles
  a

  Bronchiectasis

  b

  Pneumoconiosis

  c

  COPD

  d

  Bronchial carcinoma

  e

  Pulmonary fibrosis
  Explanation: Bronchiectasis typically causes coarse crackles and can result in fingernail clubbing. Pneumoconioses are a group of interstitial lung disease that occur in response to industrial dusts. Their diagnosis requires a history of exposure to coal/silica/asbestos and usually affects the upper zones more than the lower zones. COPD does not cause clubbing. Bronchial carcinoma can cause a monophonic wheeze or lobar collapse, rarely crackles, and is unlikely to cause bilateral signs. Pulmonary fibrosis causes fine crackles, not coarse.
• 11
  A 46-year old smoker presents to his GP with cough that is worst at night. He feels short of breath when he plays 5-a-side. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Nocturnal cough
  a

  COPD

  b

  Pulmonary fibrosis

  c

  Cardiac failure

  d

  Bronchial carcinoma

  e

  Asthma
  Explanation: Asthma can begin in adulthood, known as 'intrinsic' asthma. Asthma is more common in children and the majority of these children will improve during adolescence. However it is possible for asthma to begin in adults and in these patients it is less often associated with specific triggers e.g. pollen. Nocturnal is a common symptom of asthma, as is exacerbation by exercise. COPD, pulmonary fibrosis and carcinoma don't typically show diurnal variation. Cardiac failure would cause breathlessness at night (orthopnoea or PND).
• 12
  A 51-year old woman presents with 9 months progressive shortness of breath. On examination he has bilaterally reduced expansion and breath sounds. There are bilateral fine end-inspiratory crackles and she is clubbed. Which of the following investigation findings is most likely to be present?
  Difficulty: Easy     Topic: Lung function tests
  a

  Markedly reduced FEV1:FVC

  b

  Increased total lung capacity

  c

  Increased gas transfer co-efficient

  d

  Reduced residual volume

  e

  Increased residual volume
  Explanation: This woman has interstitial lung disease, most likely idiopathic pulmonary fibrosis. A history of progressive breathlessness with fine crackles and clubbing makes IPF highly likely. It is a condition characterised by fibrosis that begins in the lung bases. It causes a restrictive defect with reduced breath sounds and expansion. On lung function tests this manifests as a reduced total lung capacity, functional vital capacity and residual volume. The forced expiratory volume in 1 second (FEV1) is likely to be reduced but in proportion to FVC therefore their ratio will remain the same, unlike in obstructive defects. Gas transfer co-efficient is reduced because fibrosis increases the diffusion barrier, which limits gaseous exchange.
• 13
  A 52-year old woman attends A&E with painless shortness of breath. She has colorectal cancer and depression. Respiratory rate 30/min, examination is otherwise normal. Which investigation is most likely to give the diagnosis?
  Difficulty: Medium     Topic: Painless shortness of breath
  a

  D-dimer

  b

  Ventilation-perfusion (V-Q) scan

  c

  12-lead ECG

  d

  Urine dipstick

  e

  Troponin T
  Explanation: This woman has had a pulmonary embolus. PE most commonly causes shortness of breath, pleuritic chest pain and a respiratory alkalosis. However if the infarction does not cause pleuritis then the PE may be painless. Malignancy, and especially adenocarcinoma, causes a hypercoaguable state and predispose to VTE. A V-Q scan is most likely to give the diagnosis. D-dimer is a non-specific test and may be raised due to CRC - it should not be done if suspicion of PE is high. Clinical suspicion of VTE can be calculated using scoring systems e.g. Wells score. 12-lead ECG and Troponin T are useful for diagnosing myocardial ischaemia and infarction however she has no risk factors for MI. Urine dipstick is unlikely to give useful information.
• 14
  A 55-year old man presents with a dry cough and shortness of breath preceded by a 5 day history of myalgia and fever. K+ 4.7mmol/L, Na+ 117mmol/L, urea 5.2mmol/L. CXR is normal. What is the most likely causative organism?
  Difficulty: Medium     Topic: Dry cough and 5-days SOB
  a

  Staphylococcus aureus

  b

  Legionella pneumophilia

  c

  Streptococcus pneumoniae

  d

  Moraxella catarrhalis

  e

  Haemophilus influenzae
  Explanation: Legionella pneumophilia causes dry cough and shortness of breath after a 'flu-like prodrome. It is associated with infected water therefore the history may reveal an occupation associated with water or recent travel. It also causes hyponatraemia and lymphopenia. There is a urinary antigen test that can be used for diagnosis. S. aureus causes a bilateral cavitating pneumonia following influenza infection. S. pneumoniae is the most common cause of lobar pneumonia. M. catarrhalis and H. influenzae are common causes of infective COPD exacerbations.
• 15
  A 56-year old man is admitted for his third pneumonia in 2 years. CXR show bilateral mid-zone tram-lines. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Tram-lines on CXR
  a

  COPD

  b

  Pneumoconiosis

  c

  Bronchiectasis

  d

  Bronchial carcinoma

  e

  Idiopathic pulmonary fibrosis (IPF)
  Explanation: All of these conditions can be associated with increased risk of infection. Tram-lines on CXR represent thickened, dilated bronchi that occur in bronchiectasis. Bronchiectasis is most often caused by severe childhood infection (measles, pertussis, pneumonia), cystic fibrosis or immunodeficiency. COPD shows signs of hyperinflation: increased antero-posterior diameter, barrel-shaped chest, >6 anterior ribs visible. Pneumoconioses cause upper lobe reticular shadowing. Carcinoma will show a mass or distal collapse. IPF causes basal reticular shadowing.
• 16
  A 67-year old man presents with 9 months of dry cough and progressive shortness of breath. He has bilateral fine inspiratory crackles and HRCT shows bilateral lower zone reticular fibrosis. What further investigation is needed to make the diagnosis?
  Difficulty: Medium     Topic: Dry cough and progressive SOB
  a

  None

  b

  Open lung biopsy

  c

  Transbronchial lung biopsy

  d

  Alpha-1-antitrypsin (AAT) measurement

  e

  Serum precipitins measurement
  Explanation: Idiopathic pulmonary fibrosis (IPF) is the most common form of idiopathic interstitial lung disease. The history, examination and HRCT findings are typical and in this situation biopsy is not needed for diagnosis. Atypical findings (e.g. ground-glass HRCT) would require a biopsy. Precipitins are raised in extrinsic allergic alveolitis, which usually affects the upper lobes and a history of allergen exposure. AAT deficiency results in emphysema, not fibrosis.
• 17
  A 67-year old man presents with a community acquired pneumonia. He is fully orientated, his respiratory rate is 32/min and blood pressure 118/76mmHg. Pulse oximetry gives an oxygen saturation of 92% on 15L/min oxygen. Chest X-ray shows a left lower zone consolidation. What is the next step in the management of his hypoxia?
  Difficulty: Easy     Topic: Community-acquired pneumonia treatment
  a

  Continue 15L/min

  b

  Continuous positive airway pressure

  c

  Decide based on ABG measurement

  d

  Intubation and ventilation

  e

  Non-invasive ventilation
  Explanation: Community-acquired pneumonias are common and have a spectrum of severity. Arterial blood gases are indicated if a patient has saturations of 93% or less because it is difficult to infer PaO2. 93% is near the point of inflection on the oxygen-haemoglobin dissociation curve. For example, this patient may have 93% SaO2 but a PaO2 anywhere between 7-9kPa. Knowing his PaO2 is important to help guide oxygen therapy. It requires some form of oxygen therapy, in the absence of a history of COPD a high-flow facemask is appropriate. However until simple oxygen therapy has been trialled invasive ventilation is not indicated. If he is severely hypoxia on ABG, this in combination with clinical state will determine further management. The CURB65 (confusion with AMT ≤8, urea >7mmol/L, respiratory rate ≥30/min, systolic blood pressure <90mmHg and age ≥65yrs) score can be used to stratify risk. This man scores at least 2, for which admission is recommended. If a patient scores 3 or 4 when ITU admission should be considered.
• 18
  A 67-year old man presents with massive haemoptysis. He has a history of treated TB but is currently well. CXR shows an upper lobe cavity with a spherical opacity inside. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Massive haemoptysis
  a

  Tuberculosis

  b

  Bronchiectasis

  c

  Aspergillus

  d

  Vasculitis

  e

  Tumour
  Explanation: This patient as an Aspergilloma (or mycetoma), which is a localised Aspergillus infection that occurs in pre-existing cavities (from tuberculosis). Aspergillomas can be asymptomatic or cause chest pain, cough and massive haemoptysis. TB rarely causes massive haemoptysis. Bronchiectasis does cause haemoptysis but shows ring shadows and tram-lines on CXR. Vasculitidies can cause haemoptysis however would not have that X-ray appearance. Tumours cause masses on CXR but there are no other features in the history to suggest malignancy.
• 19
  A 6ft 21-year old man presents with the following arterial blood gases: PaO2 7.5kPa, PaCO2 7.9kPa, pH 7.25, BE +2. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Arterial blood gas interpretation
  a

  Pneumothorax

  b

  Salicylate overdose

  c

  Opioid overdose

  d

  COPD

  e

  Asthma
  Explanation: Blood gases show a type 2 respiratory failure. The base excess is normal, which suggests it is acute. This, and the patient's age, make COPD unlikely which would typically cause a chronic respiratory acidosis with raised base excess and normal anion gap. Salicylate OD causes a metabolic acidosis with respiratory alkalosis. Asthma and pneumothoraces most commonly cause a type 1 respiratory failure. Opioids suppress the response to a raised CO2, which results in hypoventilation and a type 2 respiratory failure but base excess is normal because the kidneys have not had time to re-absorb bicarbonate to compensate for the acidaemia.
• 20
  A 72-year old man is admitted with a severe infective exacerbation of long-standing COPD. On 24% oxygen: PaO2 6.2kPa, PaCO2 9.5kPa, pH 7.13, BE +6. Which of the following is least consistent with his condition?
  Difficulty: Easy     Topic: COPD exacerbation
  a

  Asterixis

  b

  Polycythaemia

  c

  Abbreviated mental test score of 10

  d

  Heart rate 136/min

  e

  Sternocleidomastoid hypertrophy
  Explanation: Infective exacerbations of COPD cause a rapid deterioration of symptoms and severe exacerbations have higher mortality. This man has a type 2 respiratory failure despite being on 24% oxygen. Confusion or agitation is an early sign in patients who are hypoxic or hypercapnic, compared with the other options it is least likely that this man would score 10/10 on the AMT. CO2 retention can cause a flapping tremor, also called asterixis, similar to that seen in hepatic encephalopathy. Polycythaemia is a complication of long-standing hypoxia which occurs in patients with COPD. It is likely that he will be significantly tachycardic due to his acidosis and respiratory failure. Sternocleidomastoid is one of the accessory muscles of respiration and in patients with severe COPD these muscles become hypertrophied as they are used to assist the work of breathing.
• 21
  A 72-year old woman is admitted with community-acquired pneumonia. Which of the following features is least likely to be present?
  Difficulty: Medium     Topic: Features associated with pneumonia
  a

  An irregularly irregular pulse

  b

  Blunting of the costo-phrenic angle

  c

  Increased tactile vocal fremitus

  d

  A Gram-negative sputum culture

  e

  History of alcohol dependence
  Explanation: Community-acquired pneumonias are most commonly caused by Gram positive organisms (S. pneumoniae, M. catarrhalis) or viruses, unlike nosocomial pneumonia e.g. Pseudomonas. Pneumonia is associated with atrial fibrillation, indicated by an irregularly irregular pulse, especially in the elderly. Following treatment of the pneumonia the atrial fibrillation usually resolves however it may require rate-control in the meantime. A pleural effusion causes blunting of the costo-phrenic angle, which can be due to a parapneumonic effusion or empyema. A consolidation causes increased tactile vocal fremitus, which is assessed by feeling the transmission of voice through the chest wall. Patients with a history of alcohol dependence are more likely to develop pneumonia.
• 22
  A 78-year old presents with shortness of breath and pleuritic chest pain. Examination is normal. Medical history: hypertension, COPD and hypothyroidism. Which investigation is least useful?
  Difficulty: Medium     Topic: Pleuritic chest pain
  a

  Arterial blood gases

  b

  12-lead ECG

  c

  Chest X-ray

  d

  Ventilation-perfusion scan

  e

  CT pulmonary angiography
  Explanation: The main differential diagnoses in this patient are: pulmonary embolus, pneumothorax and MI with atypical pain. In a patient with pre-existing lung disease, interpretation of a V-Q scan can be very difficult therefore CTPA is more likely to demonstrate a PE. ABG will show the degree of respiratory impairment, most likely to be a type 1 respiratory failure. 12-lead ECG is important for any patient with chest pain to exclude MI; for this patient with a PE it is most likely to show sinus tachycardia. Acute deterioration in a patient with COPD could include pneumothorax (though unlikely with a normal exam) and CXR will help to exclude this diagnosis.
• 23
  A 78-year old woman with a history of hypercapnic respiratory failure presents with an atypical community acquired pneumonia. PaO2 7.9kPa. What is the most appropriate initial oxygen therapy?
  Difficulty: Hard     Topic: Hypercapnic pneumonia
  a

  4L/min via nasal speculums

  b

  24% oxygen with Venturi mask

  c

  35% oxygen with Venturi mask

  d

  60% oxygen with Venturi mask

  e

  15L/min via facemask with non-rebreather valve
  Explanation: For patients who have a history of type 2 respiratory failure (PaCO2 >6kPa with a PaO2 <8kPa) it appropriate to start on 24% oxygen. It is believed that a number of these patients rely on hypoxia to drive their respiratory rate. Normally humans sense CO2 levels to adjust their respiratory rate and depth, however patients with COPD can who are chronically hypercapnic lose this response. Initiating high-flow oxygen therapy reduces their hypoxia, therefore they lose their ventilation stimulus, which causes results in a rising PaCO2. After starting on 24% oxygen re-check ABG after 20minutes and if PaCO2 has not increased, then FiO2 can be increased until hypoxia is treated. Nasal specs are unlikely to give adequate oxygen if a patient is presenting acutely. Starting with higher FiO2 may reduce inspiratory drive so CO2 rises as ventilation falls.
• 24
  A previously well 33-year old woman presents with shortness of breath, right sided pleuritic chest pain, pyrexia and coarse crackles in the right chest. She is tachypnoeic, tachycardia and appears unwell. What is the most appropriate initial antibiotic therapy?
  Difficulty: Easy     Topic: First pneumonia treatment
  a

  Amoxicillin

  b

  Amoxicillin and erythromycin

  c

  Benzylpenicillin and gentamicin

  d

  Flucloxacillin

  e

  Ciprofloxacin
  Explanation: This woman has presented with a moderate-severe community acquired pneumonia. At this stage we do not know the organism's sensitivities and though it is most likely to be Streptococcus pneumoniae, antibiotics should be given to cover atypical infections, which includes amoxicillin with erythromycin. Most hospitals have their own local guidelines but a broad-spectrum penicillin plus macrolide is a most common combination. If the pneumonia were mild then treatment with amoxicillin alone would be appropriate. Benzylpenicillin and gentamicin is empirical therapy for suspected infective endocarditis. Flucloxacillin is 1st line treatment for cellulitis, which is most often caused by Staphylococcus aureus. Ciprofloxacin is a quinolone that can be used for treatment of Pseudomonas pneumonia, which most often occurs in immunocompromised patients or as a nosocomial infection.
• 25
  A previously well 42-year old man is on the acute medical unit being treated for a severe community-acquired pneumonia with IV co-amoxiclav and erythromycin. His is not improving and ABG now shows: PaO2 7.4kPa (FiO2 80%) and PaCO2 6.5kPa. After increasing his oxygen to 100%, what is the most appropriate next management?
  Difficulty: Hard     Topic: Resistant pneumonia management
  a

  High dose hydrocortisone

  b

  Add ciprofloxacin to cover atypicals

  c

  Add metronidazole to cover Gram negative bacteria

  d

  Transfer to respiratory ward for a trial of NIV

  e

  Transfer to ITU for a trial of NIV
  Explanation: This man is in type 2 respiratory failure despite 60% FiO2 and requires a trial of non-invasive ventilation. Many of these patients often need escalation to intubation and this cannot be provided on the respiratory ward therefore transfer to ITU for NIV is most appropriate. Pneumonia most commonly causes a type 1 respiratory failure therefore a raised PaCO2 demonstrates very severe infection. Steroids are part of the sepsis resuscitation bundle but are not the priority. Ciprofloxacin can be given if Pseudomonas is suspected and erythromycin is used to cover community-acquired atypicals. Metronidazole would be added if aspiration pneumonia were suspected.
• 26
  Which of the following is not a cause of pulmonary fibrosis?
  Difficulty: Medium     Topic: Pulmonary fibrosis
  a

  Rheumatoid arthritis

  b

  Nitrofurantoin

  c

  Aminophylline

  d

  Systemic sclerosis

  e

  Aspergillus
  Explanation: Aminophylline is a bronchodilator that is not associated with interstitial fibrosis. Rheumatoid arthritis can cause interstitial pneumonitis, which if untreated may progress to pulmonary fibrosis. Other pulmonary manifestations of rheumatoid arthritis are pleuritis, pleural effusions, pulmonary nodules and rarely Caplan's syndrome. Nitrofurantoin is a drug cause of pulmonary fibrosis, others include: amiodarone, bleomycin, sulfasalazine & busulfan. Systemic sclerosis is a connective tissue disease that results in wide-spread organ fibrosis, with respiratory failure from fibrosis being a common cause of death. Aspergillus can cause extrinsic allergic alveolitis, which results in interstitial fibrosis.
• 27
  Which of the following statements about breathing pattern is correct?
  Difficulty: Medium     Topic: Breathing patterns
  a

  Metabolic acidosis is associated with Cheyne-Stokes breathing

  b

  Kussmaul respiration can be precipitated by altitude

  c

  Pontine lesions are associated with hypoventilation

  d

  Hyperventilation can lead to muscle spasms

  e

  Anxiety is a rare cause of hyperventilation
  Explanation: Hyperventilation causes a respiratory alkalosis, which results in muscle spasms due to hypocalcaemia in response to the increased pH. Metabolic acidosis causes Kussmaul respiration, which is rapid, shallow breathing that acts to reduce PaCO2 that will bring blood pH back towards normal. Altitude (and raised ICP) causes Cheyne-Stokes breathing, which is alternating apnoea and hyperventilation. Pontine lesions cause hyperventilation as well as pin point pupils. Anxiety is a very common cause of hyperventilation, not rare, however more life-threatening diagnoses should be excluded first e.g. PE.
• 28
  Which of the following statements about lung cancer is not true?
  Difficulty: Medium     Topic: Lung cancer
  a

  Parathyroid hormone related protein is made by adenocarcinoma

  b

  ADH is made by small cell carcinoma

  c

  Clubbing is not always present

  d

  It can cause an inflammatory arthritis

  e

  Neurological syndromes are associated with anti-Hu antibodies
  Explanation: Squamous cell carcinoma can cause hypercalcaemia from secretion of parathyroid hormone-related peptide. Adenocarcinoma is less frequently associated with paraneoplastic effects other than clubbing. Small cell carcinoma is the most common bronchial cancer to cause SIADH. Clubbing only occurs in 30% of patients. HPOA is a paraneoplastic inflammatory osteoarthritis associated with lung cancer. Cerebellar syndrome and limbic encephalitis are associated with anti-Hu antibodies.
• 29
  Which of the following statements is false?
  Difficulty: Medium     Topic: Respiratory examination 2
  a

  Paradoxical respiration can be caused by phrenic nerve lesions

  b

  Apical lung tumours can cause wasting of the lumbricals

  c

  Hypertrophic pulmonary osteoarthritis (HPOA) is associated with COPD

  d

  Hyperinflation causes reduced crico-sternal distance

  e

  Reduced pulse intensity on inspiration is associated with respiratory distress
  Explanation: HPOA causes clubbing and an inflammatory osteoarthritis most commonly in association with lung cancer, not COPD. Paradoxical respiration is when the abdomen moves out on inspiration and in on expiration to compensate for diaphragm paralysis. Apical lung tumours can invade the brachial plexus and cause T1 lesions, which innervate the lumbricals. The distance from cricoid cartilage to sternum reduces with hyperinflation. Pulsus paradoxus is a reduction in pulse intensity on inspiration, which occurs in cardiac tamponade and respiratory distress.
• 30
  Which of the following statements is true?
  Difficulty: Easy     Topic: Respiratory examination 1
  a

  Collapse causes tracheal deviation away from the pathology

  b

  Tactile vocal fremitus is more sensitive than vocal resonance

  c

  The hepatic dullness is preserved in hyperinflation

  d

  Slight tracheal deviation to the right is normal

  e

  The crackles heard in pulmonary fibrosis are typically at the beginning of inspiration
  Explanation: The trachea is normally midline or slightly to the right. Lobar collapse would normally draw the trachea towards the side of the pathology, whereas a pneumothorax may shift the trachea away from the affected side. Collapse and pneumothorax can oppose each other's action therefore not cause any tracheal shift, unless there is a tension pneumothorax where there will be gross tracheal shift away from the pneumothorax. Vocal resonance is a more sensitive test than tactile vocal fremitus. The liver normally dull but this can be lost in hyperinflation. Interstitial lung disease typically causes fine end-inspiratory crackles.
• 31
  Which of the following statements regarding eponymous conditions is incorrect?
  Difficulty: Easy     Topic: Eponymous syndromes
  a

  Churg-Strauss syndrome causes asthma

  b

  Caplan's syndrome is associated with rheumatoid arthritis

  c

  Guillain-Barré syndrome usually causes a type 1 respiratory failure

  d

  Goodpasture's syndrome causes pulmonary haemorrhage

  e

  Marfan's syndrome increases the risk of pneumothorax
  Explanation: Guillain-Barré syndrome causes severe weakness, which impairs ventilation therefore resulting in a type 2 respiratory failure. Churg-Strauss syndrome presents with asthma, eosinophilia and neuropathy. Caplan's syndrome is coal-miner's pneumoconiosis with pulmonary rheumatoid nodules. Goodpasture's causes acute renal failure and massive haemoptysis. Marfan's also causes aortic dissection and retinal detachment.
• 32
  Which of the not a cause of a hoarse voice?
  Difficulty: Medium     Topic: Hoarse voice differential
  a

  Hypothyroidism

  b

  Bronchial adenocarcinoma

  c

  Laryngeal carcinoma

  d

  Recurrent laryngeal nerve palsy

  e

  Laryngitis
  Explanation: Adenocarcinomas, unlike other forms of bronchial carcinoma, are usually peripheral therefore do not cause a change in voice. All the other options do cause a hoarse voice.