Specialty Certificate in Respiratory Medicine Sample Questions

Question 1 A 30-year-old man presented to the chest clinic with a chronic productive cough and increasing breathlessness. He gave a history of recurrent chest infections since childhood. He and his partner had recently been referred for fertility treatment. On examination, he had finger clubbing and scattered crackles throughout both lung fields. What is the most likely diagnosis? A B C D E bronchiectasis cystic fibrosis primary ciliary dyskinesia pulmonary fibrosis pulmonary tuberculosis

Updated Dec-11

Question 2 A 60-year-old man, with type 2 diabetes mellitus, was admitted with a 4-day history of cough, chest pain and loss of diabetic control. Investigations showed a right-sided empyema. What is the most likely infecting organism? A B C D E Bacteroides sp. Enterobacteriaceae Staphylococcus aureus Streptococcus milleri Streptococcus pneumoniae

Updated Dec-11

Question 3 A 45-year-old man presented with a 1-year history of snoring and unrefreshing sleep. There was a history of witnessed apnoeic episodes. His Epworth sleepiness score was 7/24. His body mass index was 29 kg/m2 (1825). His overnight sleep study demonstrated a 4% desaturation index of seven events per hour. Which management option is most likely to improve his sleep quality? A B C D E continuous positive airway pressure mandibular repositioning splint non-invasive ventilation uvuloplasty weight reduction advice

Updated Dec-11

Question 4 A 56-year-old man presented with shortness of breath. Investigations: actual 0.96 2.24 3.52 5.89 4.25 1.0 SR* 2.9 0.6 +3.9 +1.3 2.5 2.8

forced expired volume in 1 s (FEV1) (L) forced vital capacity (FVC) (L) residual volume (RV) (L) total lung capacity (TLC) (L) transfer factor for CO (TLCO) (mmol/min/kPa) transfer coefficient (KCO) (mmol/min/kPa/L)

*SR is the standardised residual and represents the number of standard deviations the actual value is from the predicted value. The normal range for the SR of all lung function parameters is 1.64 to +1.64. What is the most likely diagnosis? A B C D E atrial septal defect with a left-to-right shunt emphysema pulmonary haemorrhage pulmonary vasculitis usual interstitial pneumonitis

Updated Dec-11

Question 5 A 65-year-old smoker attended the outpatient clinic with a 2-week history of pressure in the head. On examination, he had clinical signs of superior vena caval obstruction. A CT scan of the chest showed that the superior vena cava was compressed by a tumour in the right upper lobe of the lung, and there was also evidence of a clot within the vessel. A bronchoscopy showed a tumour in the right upper lobe bronchus and biopsies confirmed that this was a small cell carcinoma of the bronchus. What is the most appropriate management? A B C D E anticoagulation chemotherapy high-dose corticosteroids radiotherapy to the mediastinum stenting of the superior vena cava

Updated Dec-11

Question 6 A 34-year-old man was admitted to hospital with a history of sudden onset of chest pain and severe breathlessness. He was a lifelong non-smoker. A chest X-ray was performed (see image).

According to British Thoracic Society guidelines, what is the most appropriate next management step? A B C D E chest tube insertion high-flow oxygen non-invasive ventilation simple aspiration thoracic surgery

Updated Dec-11

Question 7 A 30-year-old man presented with erythema nodosum. Clinical examination of the chest was unremarkable. Which feature on high-resolution CT scan would favour a diagnosis of sarcoidosis? A centrilobular nodules along bronchovascular structures with an upper zonal predominance B diffuse ground-glass change with soft centrilobular nodules throughout lung C patchy ground-glass shadowing with no zonal predominance D peripheral consolidation with an upper zonal predominance E subpleural honeycombing with a lower zonal predominance

Updated Dec-11

Question 8 A 55-year-old woman with scleroderma presented with a 3-month history of increasing shortness of breath. Which feature on high-resolution CT scan would favour a histological diagnosis of non-specific interstitial pneumonia? A centrilobular nodules along bronchovascular structures with an upper zonal predominance B diffuse ground-glass change with soft centrilobular nodules throughout lung C patchy ground-glass shadowing with no zonal predominance D peripheral consolidation with an upper zonal predominance E subpleural honeycombing with a lower zonal predominance

Updated Dec-11

Question 9 A 66-year-old woman presented with a 4-week history of progressive breathlessness and discomfort over the right chest. Thirty years previously, she had undergone mantle radiotherapy for Hodgkins lymphoma. She had never smoked. Clinical examination showed evidence of radiotherapy change to the skin and signs of a right pleural effusion. Breast examination was normal. A chest X-ray confirmed the presence of a large right pleural effusion. Aspiration yielded straw-coloured fluid, with a protein content of 45 g/L and cytology revealed some atypical cells and lymphocytes. What is the most likely cause of the effusion? A B C D E adenocarcinoma of the lung breast cancer Meigs syndrome mesothelioma recurrent lymphoma

Updated Dec-11

Question 10 A 26-year-old woman with stable Crohns disease was admitted with a 4-day history of dyspnoea and haemoptysis. She required an FiO2 of 0.5 to maintain arterial saturation at 93% (9498) with a normal PCO2. Investigations: haemoglobin MCV white cell count platelet count erythrocyte sedimentation rate international normalised ratio serum creatinine serum albumin serum C-reactive protein CT scan of chest 88 g/L (115165) 90 fL (8096) 10.0 109/L (4.011.0) 522 109/L (150400) 102 mm/1st h (<20) 1.2 (<1.4) 67 mol/L (60110) 36 g/L (3749) 290 mg/L (<10) see image

What investigation is most likely to establish a diagnosis? A B C D E anti-glomerular basement membrane antibodies bronchoalveolar lavage echocardiography open lung biopsy transbronchial lung biopsy

Updated Dec-11

Question 11 A 42-year-old woman was referred with small-volume haemoptysis of less than a teaspoonful of blood-streaked sputum on three occasions. She had also coughed up green sputum. Her weight was stable and exercise tolerance unlimited. She was not taking any regular treatment. She had moved to the UK from Jamaica 23 years previously. She denied exposure to tuberculosis. She had smoked approximately 15 cigarettes per day for 30 years. Clinical examination was unremarkable. Investigations: forced vital capacity forced expiratory volume in 1 s peak expiratory flow rate chest X-ray CT scan of thorax 2.5 L (96% predicted) 2.1 L (93% predicted) 460 L/min (108% predicted) hyperinflated lung fields thin-walled cysts and small nodules mostly in the upper lobes bilaterally

What is the most likely explanation of the CT findings? A B C D E chronic obstructive pulmonary disease hypersensitivity pneumonitis lymphangioleiomyomatosis Pneumocystis jirovecii pneumonia pulmonary Langerhans cell histiocytosis

Updated Dec-11

Question 12 A fit 63-year-old woman was found to have a right lower lobe bronchial carcinoma that was thought to be operable. She wanted to know what the surgical mortality was for a lobectomy. What is the best estimate of 30-day mortality for lobectomy in England? A B C D E <2% 24% 56% 78% 910%

Updated Dec-11

Question 13

A 28-year-old man was referred to the chest clinic with intermittent breathlessness on exertion. He was an ex-smoker, with a 5 pack-year history. He kept a budgerigar. Investigations: chest X-ray ECG actual forced expiratory volume in 1 s (FEV1) forced vital capacity FEV1/FVC ratio functional residual capacity residual volume total lung capacity 3.9 L 5.2 L 75 3.04 L 1.6 L 7.3 L normal normal % predicted 95 100 98 95 98 110 113 standardised residual 0.4 0.6 0.2 0.2 0.1 0.9 1

transfer factor for CO (TLCO) 12.7 mmol/min/kPa

What is the most appropriate next investigation? A B C D E avian precipitins bronchodilator challenge echocardiography exercise testing high-resolution CT scan of thorax

Updated Dec-11

Question 14

A 64-year-old man was admitted with fever and rigors. He had a dry cough with no expectoration and reported no weight loss. He had no foreign travel apart from a holiday in the USA 1 year previously. He had been found to have transitional cell carcinoma of the bladder 3 months previously and was treated with a transurethral partial resection of bladder followed by intravesicular BCG. He had also had a normal chest X-ray 1 year previously. Investigations: haemoglobin white cell count neutrophil count platelet count serum sodium serum potassium serum creatinine interferon- release assay for tuberculosis bronchial washings 136 g/L (130180) 9.7 109/L (4.011.0) 6.3 109/L (1.57.0) 364 109/L (150400) 143 mmol/L (137144) 4.4 mmol/L (3.54.9) 123 mol/L (60110) non-reactive no acid- and alcohol-fast bacilli seen; culture negative see image

CT scan of chest

What is the most likely diagnosis? A B C D E disseminated BCG infection histoplasmosis metastatic transitional cell carcinoma miliary tuberculosis pulmonary sarcoidosis

Updated Dec-11

Question 15

A 25-year-old Caucasian woman was referred to the chest clinic with a productive cough. There was no history of fever or night sweats. She gave a history of 3-kg weight loss over the previous 6 months. She was a childminder and a non-smoker. She had been on one family holiday in the previous year to California. On examination, crackles were heard in both apices. No finger clubbing was noted. Investigations: haemoglobin white cell count neutrophil count platelet count chest X-ray 146 g/L (115165) 8.7 109/L (4.011.0) 4.3 109/L (1.57.0) 164 109/L (150400) see image a

image a

Updated Dec-11

CT scan of chest

see image b

image b

What is the most likely explanation for her CT scan appearances? A B C D E aspergillosis lung abscess organising pneumonia sarcoidosis tuberculosis

Updated Dec-11

Question 16

A 35-year-old woman was admitted with an acute asthmatic attack. On examination, she was using her accessory muscles and had polyphonic wheezes throughout her chest. She was treated with nebulised -adrenoceptor agonists and, within a few minutes, she said that her breathing felt much easier. On auscultation of her chest, there was much less wheeze. If the diameter of her bronchi increased by a factor of two after treatment, by what factor is the resistance of her airway most likely to decrease? A B C D E 2 4 8 16 32

Updated Dec-11

Question 17 A 49-year-old woman presented with a 4-week history of periodic retrosternal discomfort. She denied weight loss or any systemic symptoms. Investigations: CT scan of chest see image

What is the most likely diagnosis? A B C D E bronchogenic cyst lymphoma seminoma teratoma thymoma

Updated Dec-11

Question 18 A 49-year-old woman presented with an 8-week history of increasing breathlessness following a flu-like illness. Her cough had now improved. She did not report any weight loss. She had a history of moderately severe rheumatoid arthritis, for which she was taking methotrexate weekly. She had a 10 pack-year smoking history. On examination, a left-sided effusion was detected. Diagnostic pleural aspiration revealed turbid-looking fluid. Following simple bench centrifugation, the pleural fluid remained turbid (a clear supernatant did not appear). What is the most likely nature of the effusion? A B C D E chylothorax empyema malignant effusion pseudochylothorax rheumatoid effusion

Updated Dec-11

Question 19 A 75-year-old man was referred because of an abnormal chest X-ray. He had first presented 2 weeks previously to his general practitioner with a cough productive of yellow sputum. By the time of consultation, he had recovered completely and was feeling well. He reported no loss of appetite or weight. He had previously worked at a granite quarry. He had never smoked. On examination, there were no crackles or wheeze, and no finger clubbing. Investigations: chest X-ray small dense nodules bilaterally, mainly in the upper zones

What is the most likely diagnosis? A B C D E asbestosis kaolinosis progressive massive fibrosis silicosis stannosis

Updated Dec-11

Question 20 A 77-year-old man was referred because of progressive dyspnoea when walking uphill. He had a 2-month history of fatigue, anorexia and a 3-kg weight loss following a chest infection. He had a 25 pack-year smoking history. He was taking no respiratory medication. He had been treated for Parkinsons disease for 5 years. He was under review for prostatic outflow symptoms and had a mildly raised prostatespecific antigen. He had worked in the roofing industry from the age of 16 years. His mother had died from pulmonary tuberculosis when he was 6 years of age. On examination, he looked well, had no finger clubbing and was haemodynamically stable. There was decreased air entry on the left side of the chest and a dull percussion note. Investigations: chest X-ray see image

What is the most likely diagnosis to explain the chest X-ray findings? A B C D E adverse effects of anti-parkinsonian medication asbestos-related pleural disease chest trauma healed tuberculosis metastatic prostate cancer

Updated Dec-11

Question 21 A 65-year-old man wished to travel to Europe on a 3-hour flight 4 weeks after an acute exacerbation of chronic obstructive pulmonary disease. His general practitioner referred him to the clinic for in-flight oxygen assessment. Investigations: oxygen saturation at rest breathing air PO2 after hypoxic challenge test using 15% FiO2 for 15 min: forced expiratory volume in 1 s (FEV1) What is the most appropriate advice? A B C D E he may fly with in-flight oxygen at a flow rate of 2 L/min he may fly with in-flight oxygen at a flow rate of 4 L/min he may fly without the need for in-flight oxygen he should undergo a walk test as a prelude to flying reassess in 3 weeks 9394% (9498)

7.8 kPa 43% of predicted

Updated Dec-11

Question 22 A 77-year-old man presented with haemoptysis and weight loss. He had been a moderate cigarette-smoker for most of his adult life. Investigations: CT scan 4-cm mass in left lower lobe; 2cm station 7 lymph nodes squamous cell carcinoma in left lower lobe no pathological uptake outside the chest

fibreoptic bronchoscopy

FDG-PET scan

What is the most appropriate next staging investigation of his lung cancer? A B C D E endobronchial ultrasound (EBUS)-guided biopsy explorative thoracotomy left parasternal mediastinotomy mediastinoscopy percutaneous CT-guided biopsy

Updated Dec-11

Question 23 A 79-year-old man presented with weight loss and left-sided chest pains. He said that his symptoms had been present for at least 3 months. He had since stopped smoking. On examination, he was comfortable at rest and appeared cachectic. His oxygen saturation was 94% (9498) breathing air. Investigations: haemoglobin platelet count serum total protein fasting plasma glucose CT scan of thorax pleural pH pleural protein pleural glucose pleural cytology 105 g/L (130180) 480 109/L (150400) 60 g/L (6176) 5.0 mmol/L (3.06.0) left-sided pleural effusion 7.15 46 g/dL 1.5 mmol/L (>2.2) lymphocytes predominant; no malignant cells

What is the most appropriate next step in his management? A B C D E bronchoscopy interferon- release assay pleural biopsy rheumatoid factor tuberculin test

Updated Dec-11

Question 24 A 65-year-old man, weighing 75 kg, was admitted to the critical care unit after emergency abdominal aortic aneurysm repair. There was no medical history of note. What intervention is most likely to reduce his risk of acquiring ventilator-associated pneumonia? A B C D E early introduction of parenteral nutrition introduction of sucralfate as stress ulcer prophylaxis intubation of endotracheal tube using nasal route ventilation in prone position weekly replacement of ventilator tubing

Updated Dec-11

Question 25 A 39-year-old man gave a 3-month history of weight loss and feeling generally unwell. He had X-linked agammaglobulinaemia and was being treated with regular intravenous infusions of immunoglobulin. He also had bronchiectasis and was taking high-dose amoxicillin. Investigations: chest X-ray increased shadowing throughout both lung fields diffuse ground-glass shadowing throughout both lungs with evidence of bilateral lower lobe bronchiectasis

high-resolution CT scan of chest

What is the most likely diagnosis? A B C D E an exacerbation of his bronchiectasis drug-induced pneumonitis lymphocytic interstitial pneumonia lymphoma Pneumocystis jirovecii pneumonia

Updated Dec-11

Question 26 A 47-year-old woman presented with a 1-year history of increasing wheeze and shortness of breath. She was a smoker (25 pack years) and had started working at a local bakery as a cleaner 2 years previously. Her wheeze had improved on holiday and was better on her days off. On examination, she had nasal congestion and marked expiratory wheeze. What is the most likely diagnosis? A B C D E atopic asthma chronic bronchitis hypersensitivity pneumonitis irritant-induced asthma occupational asthma

Updated Dec-11

Answers: 1. B 2. D 3. B 4. B 5. B 6. D 7. A 8. C 9. A 10. A 11. E 12. B 13. D 14. A 15. E 16. D 17. E 18. D 19. D 20. B 21. C 22. A 23. C 24. B 25. C 26. E

Updated Dec-11