SCERespMedSampleQs.pdf

7/29/2019 SCERespMedSampleQs.pdf

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Updated Dec-11

Specialty Certificate in Respiratory Medicine

Sample Questions

Question 1

A 30-year-old man presented to the chest clinic with a chronic productive cough andincreasing breathlessness. He gave a history of recurrent chest infections sincechildhood. He and his partner had recently been referred for fertility treatment.

On examination, he had finger clubbing and scattered crackles throughout both lungfields.

What is the most likely diagnosis?

A bronchiectasisB cystic fibrosisC primary ciliary dyskinesiaD pulmonary fibrosisE pulmonary tuberculosis


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Question 2

A 60-year-old man, with type 2 diabetes mellitus, was admitted with a 4-day historyof cough, chest pain and loss of diabetic control.

Investigations showed a right-sided empyema.

What is the most likely infecting organism?

A Bacteroides sp.B EnterobacteriaceaeC Staphylococcus aureusD Streptococcus milleriE Streptococcus pneumoniae


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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 perhour.

Which management option is most likely to improve his sleep quality?

A continuous positive airway pressureB mandibular repositioning splintC non-invasive ventilationD uvuloplasty

E weight reduction advice


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Question 4

A 56-year-old man presented with shortness of breath.

Investigations:

actual SR*forced expired volume in 1 s (FEV1) (L) 0.96 2.9

forced vital capacity (FVC) (L) 2.24 0.6

residual volume (RV) (L) 3.52 +3.9

total lung capacity (TLC) (L) 5.89 +1.3

transfer factor for CO (TLCO) (mmol/min/kPa) 4.25 2.5

transfer coefficient (KCO) (mmol/min/kPa/L) 1.0 2.8

*SR is the standardised residual and represents the number of standard deviationsthe actual value is from the predicted value. The normal range for the SR of all lungfunction parameters is1.64 to +1.64.


A atrial septal defect with a left-to-right shuntB emphysemaC pulmonary haemorrhageD pulmonary vasculitisE usual interstitial pneumonitis


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Question 5

A 65-year-old smoker attended the outpatient clinic with a 2-week history ofpressure 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 atumour in the right upper lobe of the lung, and there was also evidence of a clotwithin the vessel. A bronchoscopy showed a tumour in the right upper lobe bronchusand biopsies confirmed that this was a small cell carcinoma of the bronchus.

What is the most appropriate management?

A anticoagulationB chemotherapy

C high-dose corticosteroidsD radiotherapy to the mediastinumE stenting of the superior vena cava


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Question 6

A 34-year-old man was admitted to hospital with a history of sudden onset of chestpain 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 nextmanagement step?

A chest tube insertionB high-flow oxygen

C non-invasive ventilationD simple aspirationE thoracic surgery


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Question 7

A 30-year-old man presented with erythema nodosum. Clinical examination of thechest was unremarkable.

Which feature on high-resolution CT scan would favour a diagnosis of sarcoidosis?

A centrilobular nodules along bronchovascular structures with an upper zonalpredominance

B diffuse ground-glass change with soft centrilobular nodules throughout lungC patchy ground-glass shadowing with no zonal predominanceD peripheral consolidation with an upper zonal predominanceE subpleural honeycombing with a lower zonal predominance


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Question 8

A 55-year-old woman with scleroderma presented with a 3-month history ofincreasing shortness of breath.

Which feature on high-resolution CT scan would favour a histological diagnosis ofnon-specific interstitial pneumonia?

A centrilobular nodules along bronchovascular structures with an upper zonalpredominance

B diffuse ground-glass change with soft centrilobular nodules throughout lungC patchy ground-glass shadowing with no zonal predominanceD peripheral consolidation with an upper zonal predominanceE subpleural honeycombing with a lower zonal predominance


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Question 9

A 66-year-old woman presented with a 4-week history of progressive breathlessnessand 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 signsof a right pleural effusion. Breast examination was normal.

A chest X-ray confirmed the presence of a large right pleural effusion. Aspirationyielded straw-coloured fluid, with a protein content of 45 g/L and cytology revealedsome atypical cells and lymphocytes.

What is the most likely cause of the effusion?

A adenocarcinoma of the lungB breast cancerC Meigs syndromeD mesotheliomaE recurrent lymphoma


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Question 10

A 26-year-old woman with stable Crohns disease was admitted with a 4-day historyof dyspnoea and haemoptysis. She required an FiO2 of 0.5 to maintain arterial

saturation at 93% (9498) with a normal PCO2.

Investigations:

haemoglobin 88 g/L (115165)MCV 90 fL (8096)

white cell count 10.0 109/L (4.011.0)

platelet count 522 109/L (150400)erythrocyte sedimentation rate 102 mm/1st h (


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Question 11

A 42-year-old woman was referred with small-volume haemoptysis of less than ateaspoonful of blood-streaked sputum on three occasions. She had also coughed up

green sputum. Her weight was stable and exercise tolerance unlimited. She was nottaking any regular treatment. She had moved to the UK from Jamaica 23 yearspreviously. She denied exposure to tuberculosis. She had smoked approximately 15cigarettes per day for 30 years.

Clinical examination was unremarkable.

Investigations:

forced vital capacity 2.5 L (96% predicted)forced expiratory volume in 1 s 2.1 L (93% predicted)

peak expiratory flow rate 460 L/min (108% predicted)

chest X-ray hyperinflated lung fields

CT scan of thorax thin-walled cysts and smallnodules mostly in the upperlobes bilaterally

What is the most likely explanation of the CT findings?

A chronic obstructive pulmonary diseaseB hypersensitivity pneumonitisC lymphangioleiomyomatosisD Pneumocystis jirovecii pneumoniaE pulmonary Langerhans cell histiocytosis


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Question 12

A fit 63-year-old woman was found to have a right lower lobe bronchial carcinomathat was thought to be operable. She wanted to know what the surgical mortality wasfor a lobectomy.

What is the best estimate of 30-day mortality for lobectomy in England?

A


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Question 13

A 28-year-old man was referred to the chest clinic with intermittent breathlessnesson exertion. He was an ex-smoker, with a 5 pack-year history. He kept a budgerigar.

Investigations:

chest X-ray normal

ECG normal

actual % predicted standardisedresidual

forced expiratory volume in1 s (FEV1)

3.9 L 95 0.4

forced vital capacity 5.2 L 100 0.6

FEV1/FVC ratio 75 98 0.2

functional residual capacity 3.04 L 95 0.2

residual volume 1.6 L 98 0.1

total lung capacity 7.3 L 110 0.9

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

113 1

What is the most appropriate next investigation?

A avian precipitinsB bronchodilator challengeC echocardiographyD exercise testingE high-resolution CT scan of thorax


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Question 14

A 64-year-old man was admitted with fever and rigors. He had a dry cough with noexpectoration 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 cellcarcinoma of the bladder 3 months previously and was treated with a transurethralpartial resection of bladder followed by intravesicular BCG. He had also had anormal chest X-ray 1 year previously.

Investigations:

haemoglobin 136 g/L (130180)


neutrophil count 6.3 109/L (1.57.0)

platelet count 364 109/L (150400)

serum sodium 143 mmol/L (137144)serum potassium 4.4 mmol/L (3.54.9)serum creatinine 123 mol/L (60110)

interferon- release assay for tuberculosis non-reactive

bronchial washings no acid- and alcohol-fast bacilliseen; culture negative

CT scan of chest see image


A disseminated BCG infectionB histoplasmosisC metastatic transitional cell carcinomaD miliary tuberculosisE pulmonary sarcoidosis


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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-kgweight 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:



neutrophil count 4.3 109/L (1.57.0)


chest X-ray see image a

image a


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CT scan of chest see image b

image b

What is the most likely explanation for her CT scan appearances?

A aspergillosisB lung abscessC organising pneumoniaD sarcoidosisE tuberculosis


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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 wheezesthroughout 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 wasmuch less wheeze.

If the diameter of her bronchi increased by a factor of two after treatment, by whatfactor is the resistance of her airway most likely to decrease?

A 2

B 4C 8D 16E 32


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Question 17

A 49-year-old woman presented with a 4-week history of periodic retrosternaldiscomfort. She denied weight loss or any systemic symptoms.

Investigations:

CT scan of chest see image


A bronchogenic cystB lymphomaC seminomaD teratomaE thymoma


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Question 18

A 49-year-old woman presented with an 8-week history of increasing breathlessnessfollowing a flu-like illness. Her cough had now improved. She did not report anyweight 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 aspirationrevealed turbid-looking fluid. Following simple bench centrifugation, the pleural fluidremained turbid (a clear supernatant did not appear).

What is the most likely nature of the effusion?

A chylothoraxB empyemaC malignant effusion

D pseudochylothoraxE rheumatoid effusion


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Question 19

A 75-year-old man was referred because of an abnormal chest X-ray. He had firstpresented 2 weeks previously to his general practitioner with a cough productive ofyellow 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 agranite 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


A asbestosisB kaolinosisC progressive massive fibrosisD silicosisE stannosis


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Question 20

A 77-year-old man was referred because of progressive dyspnoea when walkinguphill. He had a 2-month history of fatigue, anorexia and a 3-kg weight loss followinga 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. Hewas under review for prostatic outflow symptoms and had a mildly raised prostate-specific antigen. He had worked in the roofing industry from the age of 16 years. Hismother had died from pulmonary tuberculosis when he was 6 years of age.

On examination, he looked well, had no finger clubbing and was haemodynamicallystable. There was decreased air entry on the left side of the chest and a dullpercussion note.

Investigations:

chest X-ray see image

What is the most likely diagnosis to explain the chest X-ray findings?

A adverse effects of anti-parkinsonian medicationB asbestos-related pleural diseaseC chest traumaD healed tuberculosisE metastatic prostate cancer


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Question 21

A 65-year-old man wished to travel to Europe on a 3-hour flight 4 weeks after anacute exacerbation of chronic obstructive pulmonary disease. His generalpractitioner referred him to the clinic for in-flight oxygen assessment.

Investigations:

oxygen saturation at rest breathing air 9394% (9498)

PO2 after hypoxic challenge testusing 15% FiO2 for 15 min: 7.8 kPa

forced expiratory volume in 1 s (FEV1) 43% of predicted

What is the most appropriate advice?

A he may fly with in-flight oxygen at a flow rate of 2 L/minB he may fly with in-flight oxygen at a flow rate of 4 L/minC he may fly without the need for in-flight oxygenD he should undergo a walk test as a prelude to flyingE reassess in 3 weeks


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Question 22

A 77-year-old man presented with haemoptysis and weight loss. He had been amoderate cigarette-smoker for most of his adult life.

Investigations:

CT scan 4-cm mass in left lower lobe; 2-cm station 7 lymph nodes

fibreoptic bronchoscopy squamous cell carcinoma in leftlower lobe

FDG-PET scan no pathological uptake outsidethe chest

What is the most appropriate next staging investigation of his lung cancer?

A endobronchial ultrasound (EBUS)-guided biopsyB explorative thoracotomyC left parasternal mediastinotomyD mediastinoscopyE percutaneous CT-guided biopsy


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Question 23

A 79-year-old man presented with weight loss and left-sided chest pains. He saidthat his symptoms had been present for at least 3 months. He had since stoppedsmoking.

On examination, he was comfortable at rest and appeared cachectic. His oxygensaturation was 94% (9498) breathing air.

Investigations:



serum total protein 60 g/L (6176)fasting plasma glucose 5.0 mmol/L (3.06.0)

CT scan of thorax left-sided pleural effusion

pleural pH 7.15pleural protein 46 g/dLpleural glucose 1.5 mmol/L (>2.2)

pleural cytology lymphocytes predominant; nomalignant cells

What is the most appropriate next step in his management?

A bronchoscopyB interferon- release assayC pleural biopsyD rheumatoid factorE tuberculin test


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Question 24

A 65-year-old man, weighing 75 kg, was admitted to the critical care unit afteremergency abdominal aortic aneurysm repair. There was no medical history of note.

What intervention is most likely to reduce his risk of acquiring ventilator-associatedpneumonia?

A early introduction of parenteral nutritionB introduction of sucralfate as stress ulcer prophylaxisC intubation of endotracheal tube using nasal routeD ventilation in prone positionE weekly replacement of ventilator tubing


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Question 25

A 39-year-old man gave a 3-month history of weight loss and feeling generallyunwell. He had X-linked agammaglobulinaemia and was being treated with regularintravenous infusions of immunoglobulin. He also had bronchiectasis and was taking

high-dose amoxicillin.

Investigations:

chest X-ray increased shadowingthroughout both lung fields

high-resolution CT scan of chest diffuse ground-glassshadowing throughout bothlungs with evidence of bilaterallower lobe bronchiectasis


A an exacerbation of his bronchiectasisB drug-induced pneumonitisC lymphocytic interstitial pneumoniaD lymphomaE Pneumocystis jirovecii pneumonia


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Question 26

A 47-year-old woman presented with a 1-year history of increasing wheeze andshortness of breath. She was a smoker (25 pack years) and had started working at alocal 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.


A atopic asthmaB chronic bronchitisC hypersensitivity pneumonitisD irritant-induced asthmaE occupational asthma


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Answers:

1. B

2. D

3. B

4. B

5. B

6. D

7. A

8. C

9. A

10. A11. 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

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