Respiratory Medicine MCQs 4 | Medical Exam Questions

Respiratory Medicine MCQs 4 | Medical Exam Questions

A 33-year-old male presents with low-grade fever. He has a poor excursion on the right side of the chest with decreased fremitus, flatness to percussion, and decreased breath sounds all on the right. The trachea deviates to the left. The most likely diagnosis is?

A. Pleural effusion ✅

B. Consolidated pneumonia

C. Atelectasis

D. Pneumothorax

Question Explanation:

The diagnosis in this patient is suggested by the physical exam findings. The findings of poor excursion, flatness of percussion, and decreased fremitus on the right side are all consistent with a right-sided pleural effusion. A large rightsided effusion may shift the trachea to the left. Histoplasmosis would be one possible cause of such an effusion. A pneumothorax should result in hyperresonance of the affected side. Atelectasis on the right side would shift the trachea to the right. A consolidated pneumonia would characteristically result in increased fremitus, flatness to percussion, and bronchial breath sounds, and would not cause tracheal deviation.

A 52-year-old male presented with acute respiratory failure during an episode of acute pancreatitis and was thought to have developed adult respiratory distress syndrome (ARDS). Which of the following would support a diagnosis of ARDS?

A. High pulmonary capillary wedge pressure

B. Hypercapnia

C. High protein pulmonary oedema ✅

D. Increased lung compliance

E. Egg shell calcification on X-Ray

Question Explanation:

ARDS is characterised by:

• hypoxemia

• reduced lung compliance

  pulmonary hypertension

• pulmonary infiltrates on the chest x-ray.

There is damage to the capillary and endothelial cell linings resulting in oedema and leakage of proteins and cells into the interstitial and alveolar spaces at normal pulmonary capillary hydrostatic pressures. Wedge pressure, unlike the high pressures seen with left ventricular failure (LVF) and pulmonary oedema, is often normal. Hypercapnia, often a late feature of ARDS, does not distinguish from any other cause of type 2 respiratory failure. Eggshell calcification on X-Ray is seen in Silicosis.

A girl aged 17 years with an acute exacerbation of asthma has a respiratory rate of 30 per minute, heart rate of 118 beats per minute and a peak expiratory flow rate (PEFR) of 30% of the predicted value. PaO2 is 9.01 kPa and PaCO2 is 3.49 kPa. After the administration of oxygen and steroids what is the appropriate next management step?

A. Intravenous aminophylline

B. Salbutamol via oxygen-driven nebuliser ✅

C. Intravenous salbutamol

D. Ipratropium bromide via oxygen-driven nebuliser

E. Salmeterol via breath-actuated inhaler

Question Explanation:

This patient has severe asthma as revealed by the low PEFR, low PO2 and signs. The next stage in the management is the administration of nebulised beta 2 agonists with supplementation of high flow oxygen (minimum of 61/minute). Beta 2 agonists can be administered in 15-30 minute intervals if required. Intravenous therapy with beta 2 agonists should only be used if inhaled therapies cannot be reliably administered.

Which of the following organisms that have been implicated in the pathogenesis of acute exacerbations of chronic bronchitis has exhibited resistance in vivo to amoxicillin?

A. Streptococcus pneumoniae ✅

B. Haemophilus influenzae

C. Moraxella catarrhalis

D. Chlamydia pneumoniae

E. Hemophilus parainfluenzae

A 70-year-old Male with a 2-year-old history of MI has dyspnoea. MI was complicated by ventricular arrhythmias. His oxygen saturations were 85% on air and a chest X-ray revealed bilateral patchy infiltration of both lung fields with a cardiothoracic ratio of 20/30 cm. Which of the following drugs is the culprit?

A. Amiodarone ✅

B. Sotalol

C. Aspirin

D. Procainamide

E. Lidocaine

Question Explanation:

This patient has desaturation with patchy infiltration on CXR suggesting a diagnosis of amiodarone-induced lung disease. Usually the presentation is insidious and the disorder associated with the cumulative dose. Treatment depends on withdrawing amiodarone and initiation of steroid therapy. Differential diagnosis is any lymphangitis/pneumontitis but high resolution CT can help by demonstration of radio-dense plaques etc.

Procainamide causes increased arrhythmias, hypotension and lupus-like syndrome.

Lidocaine causes increased arrhythmias and CNS excitation and is either IV or IM so no long term use. Sotalol will cause dose-related torsade de pointes and cardiac depression.

The scenario is unlikely to pick Aspirin.

A 66-year-old man has community-acquired pneumonia. He has a history of a rash to penicillin. He has adverse prognostic features and a CURB score of 4. What would be an appropriate empirical antibiotic choice?

A. Augmentin and clarithromycin

B. Ampicillin and gentamycin

C. Cefuroxime and metronidazole

D. Cefuroxime and erythromycin ✅

E. Ciprofloxacin and clarithromycin

Question Explanation:

Community-acquired pneumonia is most commonly caused by Strep. Pneumoniae, hence the use of a beta- lactam antibiotic because of the increased incidence of atypical organisms such as mycoplasma. A macrolide such as erythromycin is also recommended. Augmentin is contraindicated as it is penicillin-based. Ciprofloxacin has poor cover against Strep. Pneumoniae and metronidazole is used for anaerobic infections. In this case a credible alternative for beta-lactam sensitivity is not mentioned and the best choice, because of clinical necessity since severe pneumonia can be fatal if treated with antibiotics that are not effective, is to go with the only cephalosporin and macrolide combination that is offered.

A 57-year-old has six months old deteriorating nonproductive cough and exertional dyspnea. She is cyanosed with finger clubbing and bilateral basal crackles. CXR shows bilateral basal shadowing and pulmonary investigations show:

PaO2 (on air)

8.5 kPa (11.5-12.5)

FEV1/FVC ratio

85%

Which of the following investigations is most likely to establish the diagnosis?

A. IgE Titers

B. Diffusion Capacity studies

C. Blood picture

D. Chest CT scan ✅

E. Serum ACE level

Question Explanation:

This patient has restrictive lung disease, most likely Cryptogenic fibrosing alveolitis, the cardinal features being breathlessness and cyanosis, clubbing occurs in two-thirds of cases. She is hypoxic on air, has a restrictive ventilatory defect, and a high resolution CT scan of the chest will show typical changes.

A 50 year old man complains of shortness of breath and cough for 6 months. Physical examination reveals clubbing with coarse crackles in both lung bases and enlarged lymph nodes are palpated. The most likely diagnosis is

A. Asthma

B. Reflux-induced cough

C. Chronic bronchitis

D. Sarcoidosis

E. Idiopathic pulmonary fibrosis ✅

Question Explanation:

Idiopathic pulmonary fibrosis (IPF), also known as cryptogenic fibrosing alveolitis, is a chronic, progressive interstitial lung disease with an unknown cause. It is one of the two classic interstitial lung diseases, the other being sarcoidosis. IPF is slightly more common in males and usually presents in patients greater than 50 years of age. Average survival from time of diagnosis varies between 2.5 and 3.5 years, depending on severity, although some patients live greater than 10 years. Symptoms are gradual in onset. The most common are dyspnea (difficulty breathing), but also include nonproductive cough, clubbing (a disfigurement of the fingers), and crackles (crackling sound in lungs during inhalation).

Sarcoidosis is an immune system disorder characterized by non-caseating granulomas (small inflammatory nodules). It most commonly arises in young adults. The cause of the disease is still unknown. Virtually any organ can be affected; however, granulomas most often appear in the lungs or the lymph nodes. Sarcoidosis is a systemic disease that can affect any organ. Common symptoms are vague, such as fatigue unchanged by sleep, lack of energy, weight loss, aches and pains, arthralgia, dry eyes, blurry vision, shortness of breath, a dry hacking cough or skin lesions such as erythema nodosum.

A 66 year old man develops hemoptysis, weight loss and chest pain. His initial chest X-ray reveals a mass which is further confirmed by CT of the chest. Biopsy confirms malignancy. All of the following could be the cause of his lung cancer, except

A. Asbestos

B. Coal mining

C. Marijuana ✅

D. Nickel mining

E. Tobacco

Question Explanation:

Lung cancer is now the number one cause of cancer deaths in both men and women. Initial symptoms include hemoptysis, chest pain and weight loss. Imaging studies such as chest x-ray and chest CT are done. A bronchoscopy guided biopsy is needed to obtain a tissue sample which will be looked at by the pathologist to determine if the mass is malignant. Smoking causes 87% of all lung cancers. Other causes include exposure to the following: asbestos, radon, arsenic, chromium, coal dust, uranium, nickel, aromatic hydrocarbons and ethers. Marijuana, unlike tobacco and alcohol, does not appear to cause head, neck, or lung cancer.

A 44 year old man presents with sinusitis, fever, and malaise. Examination demonstrates rales at the right lung base and pallor. Serum creatinine level of 5.0 is present. CXR shows nodular cavities bilaterally. The most likely diagnosis is

A. Goodpasture's syndrome

B. Wegener's granulomatosis ✅

C. Sarcoidosis

D. Tuberculosis

E. Polyarteritis nodosa

Question Explanation:

Wegener's granulomatosis presents more commonly in men and almost always presents with an upper respiratory tract infection. Biopsy of the nodular lung tissue would reveal the necrotizing vasculitis. The ANCA test would be a good screening test, but the gold standard is biopsy. Renal failure with rapidly progressive glomerulonephritis is common. Goodpasture's syndrome is also more common in men. Both renal and pulmonary problems are also encountered, but it would be unusual to have an upper respiratory tract infection as well. Anti glomerular basement antibody would be a useful test. Sarcoidosis can present this way, but renal dysfunction is rare and the chest X-ray would usually reveal bilateral hilar adenopathy. Tuberculosis can also present this way, but renal dysfunction is rare, and the chest X-ray would more commonly have upper lobe infiltrates. Polyarteritis nodosa is a vasculitis which affects the medium to large arteries and commonly involves the kidneys. This disease would not initially involve the upper respiratory tract.

A 65-year-old man is currently recovering from an aortic valve replacement procedure. He gets a pulmonary embolus. He also has a history of hemorrhagic stroke earlier. What is the accurate management?

A. Caval filter ✅

B. Low molecular-weight heparin

C. Thrombolytic therapy

D. Unfractionated heparin

E. Unfractionated heparin and warfarin

Question Explanation:

This patient has two absolute contraindications to anticoagulation or thrombolytic therapy: recent surgery and a recent hemorrhagic stroke. He is in a difficult situation regarding his pulmonary embolus, as he is at high risk for a recurrent event. Usually, recurrent clots can kill a patient, so some form of prophylactic therapy is necessary. In patients with contraindications to anticoagulation, a vena caval filter (Greenfield filter) is appropriate. Recent surgery and hemorrhagic stroke are also a contraindication to thrombolytic therapy.

Low molecular-weight heparin, unfractionated heparin and unfractionated heparin and warfarin would all be reasonable treatments to start in a patient who had no contraindications to anticoagulation. Given the present patient's recent surgery, stroke, and septic emboli, however, anticoagulation is not appropriate.

A 61-year-old man has chronic cough for the past 3 years. He is smoking one pack per day for 20 years. He is febrile. There are diffuse wheezes and a prolonged expiratory phase. He has 1+ pitting edema, but no clubbing or cyanosis. Pulmonary function tests show an FEV1/FVC of 0.65. Arterial blood gas values are shown below.

pH:

7.34

Partial pressure of arterial oxygen:

70 mm Hg

Partial pressure of carbon oxygen:

50 mm Hg

Which of the following therapies will prolong this man's survival?

A. Cessation of bets blockade

B. Home oxygen

C. Inhaled bronchodilators

D. Inhaled corticosteroids

E. Smoking cessation ✅

Question Explanation:

This patient has had a chronic productive cough for 3 consecutive months for 3 years. Further, chronic obstructive bronchitis has been confirmed with pulmonary function tests. Smoking is the most common etiology; in fact, 15% of smokers will develop some form of COPD. Cessation of smoking slows the progression of disease and improves survival. Home oxygen improves survival in patients with advanced disease, acute, exacerbations, or cor pulmonale. This patient is not yet at this stage. Indications for home oxygen therapy include:

• 02 saturation of 88%, or a Pa02 of 55 mm Hg

• Saturation 89% or PaO2 of 59 mm Hg if one of the following is present: edema indicating heart failure, P- pulmonale on ECG, hematocrit 56%.

Both cessation of beta blockade and inhaled bronchodilators improve symptoms and decrease the number of exacerbations; however, neither improves survival.

Inhaled corticosteroids are used in moderate COPD, where they have been shown to decrease the number of exacerbations and improve symptoms. However, there is no evidence that inhaled corticosteroids improve survival.

A 63 year old woman presents with stridor associated with a retrosternal goitre. The most appropriate investigation of her airways obstruction would be which one of the following?

A. FEV1/FVC ratio

B. Flow-volume loop ✅

C. Peak Expiratory Flow Rate

D. Spirometry

E. Transfer factor

Question Explanation:

The flow volume loop is the best method of for detecting an obstruction associated with a retrosternal mass.

A 66 year old male with hyperlucent lung fields develops extreme shortness of breath over a period of about 15 minutes. CXR shows shift of the mediastinum to the right, and the lung field on the left appears even more hyperlucent than before, with the exception of a white shadow near the heart border. The likely cause of his current problem is

A. Bronchogenic carcinoma

B. Pleural effusion

C. Pulmonary embolism

D. Rupture of an emphysematous bulla ✅

E. Tuberculosis

Question Explanation:

The patient's initially hyperlucent lung fields strongly suggest the presence of emphysema. The radiologic findings after the increase in shortness of breath are consistent with free air in the chest, which has collapsed the left lung and caused a shift in the location of the mediastinum. Such air might have been introduced by rupture of a bulla. Small pneumothoraces are usually well tolerated, but larger ones may require decompression (the needle from a syringe is sometimes used), or even surgical correction if bullae continue to leak air. Bronchogenic carcinoma would be expected to produce a mass lesion. Pleural effusion usually develops slowly and causes a whitening of lung fields when fluid is present. Pulmonary embolism can cause sudden shortness of breath but would not cause an increase in the lucency of the lung fields. Tuberculosis would be expected to produce a mass lesion in the lung.

A patient develops an acute febrile illness with shivers, nonproductive cough, and pleuritic chest pain. 5 days later he presents after abruptly having "coughed up" nearly a cup of blood stained sputum. Most likely to be seen on a CXR is

A. Blunting of diaphragmatic costal angles

B. A cavity with a fluid level ✅

C. Complete opacification of one lobe with no additional findings

D. Patchy consolidation centered on bronchi

E. Prominent bronchi that can be followed far out into the lung fields

Question Explanation:

This is a classic presentation of a pulmonary abscess. Chronic courses with less severe symptoms (with intermittent improvement following short courses of antibiotics) are also sometimes seen, particularly if the diagnosis was not suspected. A chest X-ray film typically shows pneumonic opacification in which a cavity, often with a fluid level, is visible. Pulmonic abscesses can be caused by anaerobes (most common, particularly if aspiration initiated the abscess), gram negative aerobic bacilli, and staphylococci. Therapy is based on the organisms isolated and should be continued for at least 4-6 weeks. In cases that fail to resolve, the possibility of coexisting carcinoma should be considered. Option A is the x-ray appearance of pleural effusion. Option C is the X-ray appearance of lobar pneumonia. Option D is the X-ray appearance of bronchopneumonia. Option E is the X-ray appearance of bronchiectasis.