MULTIPLE CHOICE QUESTIONS
DR FAROOQ SATTAR DHEDHI
A 29-year-old woman is admitted to hospital with pleuritic chest pain and shortness
of breath. She has a past medical history of asthma which is usually well controlled.
She drinks 24 units of alcohol per week and smokes 15 cigarettes a day. Physical
examination demonstrates reduced breath sounds in the right hemithorax. A chest x
ray is performed and the film is shown below.
What is the most
appropriate treatment
strategy?
a) Aspiration
b) Discharge
c) High flow oxygen
d) Intercostal drain
insertion
e) Observation
usually well controlled.
She drinks 24 units of alcohol per week and smokes 15
cigarettes a day. Physical
examination is unremarkable. A chest x ray is performed and
the film is shown below.
What is the
underlying
diagnosis?
a) Acute
exacerbation of
asthma
b) Pleural effusion
c) Pneumonia
d) Pneumothorax
e) Pulmonary
embolus
airways disease.
On examination he is cachectic and clubbed; there are coarse
crackles in the right
upper zone. A chest x ray is performed and the image is shown
below.
What is the most
likely diagnosis?
a) Lung cancer
b) Pleural effusion
c) Pulmonary
haemorrhage
d) Right upper lobe
collapse
e) Right upper lobe
pneumonia
65-year-old man presents with chest pain, cough and shortness of breath.
He
has lost some weight recently. He has a past medical history of breast
cancer and chronic obstructive pulmonary disease. On examination he has
a temperature of 37.8℃, some coarse crepitations in the right
mid-zone and mild expiratory wheeze throughout both lungs. A CT of the
chest is performed and two of the sections are shown below.
What is the most
appropriate initial
treatment?
a) Co-amoxiclav
b) Non-steroidal anti-
inflammatory drugs
c) Radiotherapy
d) Treatment dose low
molecular weight
heparin
e) Ultrasound guided
drainage
Which of the following goes with
COPD?
A. Pre bronchodilator FVC <70%
B. Post bronchodilator FVC/FEV <70%
C. Pre bronchodilator FVC/FEV <70%
D. Post bronchodilator FEV/FVC <70%
A breathless patient undergoes pulmonary function testing.
The following results are obtained:
FEV1 74% predicted
FVC 68% predicted
TLC 77% predicted
TLCO 46% predicted
KCO 53% predicted
Which of the following is the most likely cause ?
a) Asthma
b) Chronic obstructive pulmonary disease
c) Cryptogenic fibrosing alveolitis
d) Kyphoscoliosis
e) Morbid obesity
A 63-year-old man is brought to hospital after being
found unconscious in his car. He is drowsy but rousable
and complains of a severe headache and
nausea.
On examination his temperature is 36.5°C but appears
flushed. Neck is supple and there is no palpable
lymphadenopathy. His BP is 110/65 mmHg. Heart
sounds normal with no murmurs or added sounds, and
his chest is clear to auscultation. The remainder of the
examination is unremarkable.
His son reported that his father, usually a skilled
model-maker, had appeared clumsy lately and had
been confused at times when talking on the telephone.
Haemoglobin 15.8 g/dL (13.0-18.0)
White cell count 10.1 ×109/L (4-11)
Platelets 401 ×109/L (150-400)
Serum sodium 140 mmol/L (137-144)
Serum potassium 4.4 mmol/L (3.5-4.9)
Serum urea 5.8 mmol/L (2.5-7.5)
Serum creatinine 110 μmol/L (60-110)
Serum glucose 4.5 mmol/L (3.0-6.0)
CSF opening pressure 150 mm H2O (50-180)
CSF cell count <3 mL-1 (≤5)
CSF protein 0.4 g/L (0.15-0.45)
CSF glucose 3.3 mmol/L (3.3-4.4)
Arterial blood gases breathing air:
PaO2 11.6 kPa (11.3-12.6)
PaCO2 4.3 kPa (4.7-6.0)
HCO3 20 mmol/L (20-28)
pH 7.33 (7.36-7.44)
Based on the information available to you,
which investigation would you like to do?
a) Carboxyhaemoglobin level
b) CT scan head
c) Estimation of carbon monoxide diffusion
factor (KCO)
d) Methaemoglobin level
e) Mini mental state examination
A 28-year-old man presented to hospital after becoming progressively more
breathless over the preceding day. He had developed a dry cough and reported
expectoration of bright red blood. He gave a history of malaise and low-grade fever
for five days. The rash (pictured) had appeared three days before presentation .
What is the most likely diagnosis?
a) Goodpasture's syndrome
b) Meningococcal septicaemia
c) Tuberculosis
d) Varicella pneumonia
e) Wegener's granulomatosis
progressively worsening dyspnoea on exertion. He also complained of a
nonproductive cough. Over the two days preceding admission the
patient had become breathless at rest and was started on oral co-
amoxiclav by his general practitioner. On examination he was febrile
38°C and looked unwell.Candida was noted on the tonsilar pillars. No
wheeze or crackles were heard in his chest.
is shown.
Which of the following
is most likely to assist in
making the diagnosis?
a) Blood pressure
measured in
inspiration and
expiration
b) Legionella urinary
antigen
c) Oxygen saturations
pre- and post-exercise
d) Peak expiratory flow
rate
A 25-year-old man presents with vague chest pain
and cough. His chest x ray, taken in the Emergency
department, is shown
What is the most
appropriate treatment
for this condition?
a) Amoxicillin/clavulanate
and clarithromycin
b) High-flow inspired
oxygen
c) Intercostal chest drain
insertion
d) Low molecular weight
heparin
e) Nebulised salbutamol
Which of the following is the most important in
establishing the cause of these lesions?
a) Anti-streptolysin O
titre
b) Chest x ray
c) Erythrocyte
sedimentation rate
d) Serum angiotensin
converting enzyme
(ACE)
e) Skin biopsy
A 27-year-old man was referred to hospital with fevers and haemoptysis.
Two weeks earlier he had presented to casualty following a grand mal
seizure. Pending the results of sputum cultures, what is the most
appropriate combination of antibiotics that should be used to treat this
patient initially?
a) Amoxicillin/clavulanate
+ clarithromycin
b) Azithromycin
c) Cefuroxime +
metronidazole
d) Flucloxacillin
e) Vancomycin +
ceftazidim
What organism has been cultured from a sputum sample
from a 15-year-old girl
with a chronic cough and diarrhoea?
a) Haemophilus
influenzae
b) Klebsiella
pneumoniae
c) Mycobacterium
tuberculosis
d) Pseudomonas
aeruginosa
e) Staphylococcus
aureus
A 62-year-old man attends the Emergency department because of
progressively worsening dyspnoea. He also gives a history of dry
cough and a lowgrade fever. He has a past history of hypertension, and
was hospitalised six months previously when he suffered an acute
inferior myocardial infarction that was complicated by left ventricular
failure and arrythmia. His chest x ray shows a diffuse interstitial
pneumonia.
Other investigations Which of the
are shown below. following agents is
most likely to have
ESR 110 mm/h caused these
findings?
FEV1 90% a) Amiodarone
b) Captopril
FVC 70% c) Procainamide
d) Propranolol
KCO 60% e) Verapamil
practitioner with a three month history of dry, nocturnal cough. He is
an ex-smoker having given up five years ago. He does not produce
any sputum, has not suffered with any haemoptysis and despite his
steady weight has an exercise tolerance similar to his work
colleagues. He denies any other symptoms of note. Examination
reveals he is 5' 10" (1.77m) tall and weighs 98kg (BMI = 31 kg/m2).
Chest is clear to auscultation
Results of spirometry What would be the
are shown below: most appropriate first
FEV1 3.0 L line investigation?
(Predicted 3.38 L)
FVC 4.4 L
a) 24 Hour
(Predicted 4.40 L) oesophageal pH and
FEV1/FVC 0.68 manometry
(Predicted 0.77 ) b) Bronchoscopy
c) Flexible
PEFR 540 L/min nasendoscopy
(Predicted 559 d) Peak flow chart
L/min)
e) Sleep studies
A 53-year-old engineer presents with increasing shortness of
breath on
exertion. Physical examination is normal apart from some
inspiratory crackles at both lung
bases. His chest x ray is shown.
What is the
diagnosis?
a) Asbestosis
b) Byssinosis
c) Siderosis
d) Silicosis
e) Talcosis
Disease Agent Effects
Aluminosis Alum, and al. oxide Fibrosis, bullae,
pneumothorax
Asbestosis Asbestos Pleural plaques, lung cancer
mesothelioma
Byssinosis Cotton, flax, hemp Airway obstruction, loss of
elasticity
Metal fume fever
Cadmium, cobalt, nickel,
zinc and others
Chemical pneumonitis Occupational asthma
Western Red Cedar and others Reversible airway obstruction
Siderosis Iron oxide Dust deposits
Silicosis Silica Dust deposits and fibrosis
Talcosis Talc, hydrated Mg. silicates Perivascular fibrosis
The structure shown below was identified on microscopy of a sputum sample
from a patient who presented with haemoptysis. He has an abnormal chest
radiograph.
What treatment should be started?
a) Intravenous
amoxicillin/clavulanic acid
+ clarithromycin
b) Intravenous amphotericin
B
c) Intravenous cefotaxime
d) Intravenous vancomycin
e) Isoniazid + rifampicin +
ethambutol +
pyrazinamide
What advice should be given to
prevent pneumonia after
abdominal surgery?
A Incentive spirometry
B Antibiotics
C Bronchodilators
D Oxygen inhalation
E Vaccination
A 21-year-old woman presented with a four week history of increasing
exertional dyspnoea and a dry cough. Her chest was clear to auscultation and
she was afebrile.
Her chest radiograph is shown below.
Investigations show:
Hb 13.2 g/dL (11.5-16.5)
WBC 3.9 ×109/L (4-11)
Neutrophils 2.5 ×109/L (1.5-7)
Lymphocytes 1.0 ×109/L (1.5-4)
Monocytes 0.4 ×109/L (0-0.8)
Platelets 390 ×109/L (150-400)
Sodium 141 mmol/L (137-144)
Potassium 4.7 mmol/L (3.5-4.9)
Urea 5.5 mmol/L (2.5-7.5)
Creatinine 102 μmol/L (60-110)
Calcium 2.6 mmol/L (2.2-2.6)
Bilirubin 8 μmol/L (1-22)
Alkaline phosphatase 110 U/L (45-105)
AST 22 U/L (1-31)
Total protein 55 g/L (61-76)
What is the most likely
diagnosis?
a) Chlamydia pneumoniae
pneumonia
b) Lymphoma
c) Pneumocystis carinii
pneumonia
d) Sarcoidosis
e) Wegener's
granulomatosis
This patient presented with a six month history of
increasing dyspnoea and
swollen legs
What is the
diagnosis?
a) Bacterial
endocarditis
b) Chronic renal
failure
c) Congestive
cardiac failure
d) Hypoalbuminaemi
An 82-year-old man presents with weight loss (5 kg) and a
hoarse voice of two
months duration.
His chest radiograph is shown below
What clinical signs are
likely to be found?
a) Dilated left pupil
b) Inability to blink left
eyelid
c) Inability to sweat on
the right upper body
d) Left eye ptosis
e) Right-sided
exophthalmos
A 55 year old male, smoker presented to ER
with shortness of breath. The respiratory
system examination revealed decreased chest
expension, barel shaped chest and wheezing
all over the chest. His ABGs revealed pH 7.21,
Pco2 90. what will be the next step in ER
a) CPAP
b) High flow oxygen
c) BIPAP
d) Iv steriods
e) Iv aminophylin
A 28-year-old plumber was referred to hospital by his general practitioner.
He had initially presented seven days previously, giving a three day history of
malaise, headache, and myalgia and subsequently developed a dry cough and
fever.
His GP had started a course of amoxicillin/clavulanic acid, but the symptoms
failed to
resolve. On the day of referral, the patient continued to complain of cough and
had
become mildly dyspnoic; he also complained of a global headache, myalgia and
arthralgia.
On examination, he appeared unwell and was febrile (39oC). A maculopapular
rash
was evident over his upper body. Heart sounds were normal; BP 120/70 mmHg.
On
auscultation of his chest, fine crackles were audible in the left mid-zone. Mild
neck
stiffness was noted.
Investigations revealed:
Hb 8.4 g/dL (13.0-18.0)
What is the most likely
WBC 8 ×109/L (4-11)
Platelets 210 ×109/L (150- cause of his abnormal
400) blood count?
Reticulocytes 8% (0.5-2.4)
Na 129 mmol/L (137-144)
K 4.2 mmol/L (3.5-4.9) a) Clavulanic acid toxicity
Urea 5.0 mmol/L (2.5-7.5) b) Glucose-6- phosphate
Creatinine 110 μmol/L (60- dehydrogenase
110)
Bilirubin 19 μmol/L (1-22)
deficiency
Alk phos 130 U/L (45-105) c) IgG antibodies (warm
AST 54 U/L (1-31) antibodies)
GGT 48 U/L (<50)
Chest x ray shows patchy
d) IgM cold agglutinin
consolidation in both mid- antibodies
zones
e) Sepsis syndrome
medical admissions unit
after developing sudden onset of right sided chest pain. For
the past 24 hours he has
felt unwell, with malaise, headache and myalgias. The GP's
letter states that the patient has become mildly confused over
the past three to four hours. On examination he is febrile
(39°C) and confused. Pulse 62 per minute, blood pressure
110/75 mmHg.
Serum creatinine 99 μmol/L
Investigations show: (60-110)
Serum bilirubin 7 μmol/L (1-
Haemoglobin 16.5 g/dL (13.0- 22)
18.0) Serum aspartate
WBC 20.1 ×109/L (4-11) transaminase 63 U/L (1-31)
Neutrophils 18.5 ×109/L Serum alkaline phosphatase
(1.5-7) 100 U/L (45-105)
Lymphocytes 0.8 ×109/L (1.5- Serum albumin 39 g/L (37-49)
4) pH 7.42 (7.36-7.44)
Monocytes 0.8 ×109/L (0-0.8) pO2 9.9 kPa/75 mmHg (11.3-
Platelets 390 ×109/L (150-400) 12.6)
Serum sodium 121 mmol/L pCO2 3.9 kPa/29 mmHg (4.7-
(137-144) 6.0)
Serum potassium 4.3 mmol/L HCO3 22 mmol/L (20-28)
(3.5-4.9) Urinalysis: Protein (+)
Serum urea 6.2 mmol/L (2.5-
Which of the following
antibiotic regimes
would be most
effective in treating
this specific infection?
a) Amoxicillin
b) Doxycycline
c) Amoxicllin and
Erythromycin
d) Erythromycin and
rifampicin
e) Levofloxacin
• 62y old man comes to the ER c/o fever, cough & yellow green
Sputum for 2days. He start smoking at the age of 40ys. Following
which he developed a daily cough & whitish-yellow sputum. He
typically receives one or 2 course of AB per year. When his sputum
increases in volume & becomes darker. On exam temp 38.7 coarse
breath sounds are heard at the posterior base of the Rt lung.
Scattered wheezes & crackles are also auscultated. The WBC 13.5
12% bands 14% lymphocytes. CXR Rt lower lobe infiltrate. A chest
film obtained 2ys ago show Marking at the base of the Rt lung but
otherwise normal ,
In choosing an antimicrobial regimen for this pt u should cover
which of the following organism:
A- Mycobacterium TB
B- RSV
C- Nocardia brasilensis
D- Pseudomonas aeruginosa
E- Chlamydia
Young female K/c of asthma presented with
severe asthma exacerbation, SOB,
wheezing. Received Nebs and methyl
prednisone. Blood gas after 30 min. PH7.27
PCO2: High. Hypoxia and hypercabnia.
What to do next?
a. Non-invasive ventilation
b. Sodium bicarb
c. Salbutamol IV
d. Intubation
A 67y old man is evaluated for a SOB during exercise & an occasional
dry cough. He has a 2year Hx of seropositive RA. His Joint disease has
been well controlled since addition 3 months ago of MTX 12.5mg orally
once weekly, to his Prednisolone 5mg/d . he smokes two packs
Cigarettes per day. On physical exam he is afebrile. Joints deformity
Consistent with RA & rheumatoid nodules on the extensor surfaces of
his forearms. He has no Venous distention, or peripheral edema. on
Chest auscultation he has Inspiratory crackles.CXR showed bilateral
Basal infiltration. PFT showed. FEV 68% FVC 75% of predictor. FEV/FVC
86% TLC Is 70% of predicted. residual volume is 72% of predicted
DLco is 66% of predicted.
What is the next step in the management of this patient?
A-Cardiopulmonary exercise test
B-Begin a TNF antagonist
C- Initiate antibiotic therapy
D- Stop MTX therapy
E- Surgical lung biopsy
A 23-year-old woman is evaluated for management of
pulmonary arterial hypertension. She is minimally
symptomatic (New York Heart Association functional class I-
II). She was diagnosed with idiopathic pulmonary arterial
hypertension several months ago and is on no pulmonary
vasodilator therapy at this time. She inquires about
pregnancy.
Which of the following options regarding management
of pregnancy is most appropriate for this patient?
A- Addition of bosentan prior to proceeding with pregnancy
B admission toahigh-riskpregnancyunitat30 weeks
C- Cesarean delivery at 34 weeks
D- Recommend avoiding pregnancy
E- Treatment with low-molecular-weight heparin and aspirin
beginning at conception
