Respiratory Module 3

Which ultrasound finding is the strongest predictor of malignant pleural effusion?

Echogenic swirling

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Presence of pleural fluid with layered appearance

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Non-echogenic, clear fluid

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Thickened parietal pleura

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Floating echogenic particles in effusion

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A 45-year-old male presents with a 3-week history of productive cough, intermittent low-grade fever, night sweats, and unintentional weight loss of 5 kg. He is originally from the Philippines and has been living in New Zealand for the past 2 years. He denies any recent antibiotic use or known contacts with active tuberculosis.

On examination, he is afebrile with stable vital signs. Auscultation reveals bronchial breath sounds over the right upper lung zone.

A chest X-ray demonstrates patchy consolidation with cavitation in the right upper lobe.

Laboratory work-up shows a mildly elevated CRP of 48 mg/L and normocytic anaemia. Sputum samples are sent for AFB smear, culture, and GeneXpert MTB/RIF assay.

A junior registrar considers initiating empirical azithromycin therapy to cover atypical pneumonia pathogens while awaiting confirmatory tests.

What is the most appropriate reason to avoid empirical macrolide therapy in this patient?

Macrolides are ineffective against M. tuberculosis and may promote resistance in non-tuberculous mycobacteria

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Macrolide therapy can exacerbate liver dysfunction when given before anti-TB treatment is commenced.

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Macrolides are contraindicated in patients with cavitary lung lesions

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Macrolides may cause immune suppression that facilitates TB dissemination

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Macrolides are bactericidal against M. tuberculosis and may complicate the clinical picture

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A 45-year-old male presents with progressive dyspnea and a non-productive cough over the last six months. His pulmonary function tests (PFTs) reveal a reduced diffusing capacity of the lungs for carbon monoxide (DLCO).

Which of the following best explains the principle underlying the measurement of DLCO in PFTs?

DLCO measures the rate at which carbon monoxide crosses the alveolar-capillary membrane.

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DLCO assesses the volume of air expelled from the lungs after a maximal inhalation.

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DLCO evaluates the maximum flow of air during forced expiration.

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DLCO determines the total volume of air that the lungs can hold at maximal inhalation.

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DLCO quantifies the airway resistance from the trachea to the peripheral airways.

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Based on the pulmonary function test (PFT) pattern shown in the attached picture, all of the following conditions could be causes of this patient’s restrictive lung disease except:

Obesity

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Interstitial lung disease

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Pleural effusions

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Kyphoscoliosis

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Neuromuscular weakness

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Nintedanib is an intracellular tyrosine kinase inhibitor which has been recently shown to be useful in the treatment of idiopathic pulmonary fibrosis.

Which one is the correct target receptors for this drug?

fibroblast growth factor, platelet derived growth factor and vascular endothelial growth factor receptor.

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fibroblast growth factor receptor only

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fibroblast growth factor receptor and platelet derived growth factor

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fibroblast growth factor, platelet derived growth factor and epidermal growth factor receptor.

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Epidermal growth factor receptor and fibroblast growth factor receptor.

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Which one of the following paraneoplastic features is least commonly seen in patients with squamous cell lung cancer?

Lambert-Eaton syndrome

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Hyperthyroidism

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Hypertrophic pulmonary osteoarthropathy

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Hypercalcaemia

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Clubbing

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A 45-year-old patient with a history of HIV/AIDS, currently on antiretroviral therapy but with a recent decline in CD4 count to 180 cells/µL, presents to the emergency department with a 2-week history of progressive dyspnea, non-productive cough, and fever.

The patient was diagnosed with Pneumocystis pneumonia (PCP) based on clinical presentation and a positive sputum PCR for Pneumocystis jirovecii.

Treatment with oral co-trimoxazole was initiated 5 days ago. Despite initial therapy, the patient’s respiratory status has worsened, with increased work of breathing and use of accessory muscles. Arterial blood gas analysis reveals a pO2 of 35 mmHg, indicating significant hypoxia.

Given the patient’s deteriorating condition and hypoxia despite appropriate antimicrobial therapy for PCP, which of the following is the most appropriate treatment to initiate?

Prednisone

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IV pentamidine

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Clindamycin

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Atovaquone

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Trimetrexate

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A 40-year-old man with 40 pack year smoking history presents with increasing breathlessness and wheeze. Inspiratory and expiratory flowvolume curves are both “flattened” so that the configuration approaches that of a rectangle.

What would be the most likely diagnosis to explain this result?

Tracheal stenosis

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Emphysema

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Asthma

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Kyphoscoliosis

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Vocal cord paralysis

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A 60-year-old man with 30 pack year smoking history presents with increasing breathlessness and wheeze. A flow volume curve shows that all the flow rates are diminished with mean expiratory flow being less than the mean inspiratory flow rate.

What could be the underlying cause to explain this finding?

emphysema

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pulmonary fibrosis

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kyphoscoliosis

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tracheal stenosis

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vocal cord paralysis

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A 43-year-old woman presents with increasing breathlessness and wheeze. Inspiratory and expiratory flow-volume curves show normal inspiration but flow limitation during expiration producing an “expiratory plateau”.

The flow-volume curves are most likely to be caused by:

a variable intra-thoracic obstruction

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a fixed extra-thoracic obstruction

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a variable extra-thoracic obstruction

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a fixed intra-thoracic obstruction

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widespread intra-pulmonary obstruction

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A 55-year-old man has the following lung function test results:

FEV1 2.0 L (61% predicted)
FVC 2.6 L (68% predicted)
FEV1/FVC 0.77
TLC 72% predicted
RV 75% predicted
DLCO 64% predicted
KCO 110% predicted
His body mass index (BMI) is 42 kg/m2 [18-25].

Which of the following is the best explanation for these results?

Diaphragmatic paralysis

Correct Incorrect Correct answer

Obesity

Correct Incorrect Correct answer

Pulmonary fibrosis

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Asthma

Correct Incorrect Correct answer

Pulmonary haemorrhage

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A 50-year-old man has the following lung function test results:

FEV1 2.0 L (61% predicted)
FVC 2.6 L (68% predicted)
FEV1/FVC 77% (80% predicted)
TLC 70% predicted
RV 75% predicted
His body mass index (BMI) is 40 kg/m2 [18-25].

ABG shows normal pH with elevated CO2.

Which of the following is the best explanation for these results?

Obesity hypoventilation syndrome

Correct Incorrect Correct answer

Diaphragmatic paralysis

Correct Incorrect Correct answer

Pulmonary haemorrhage

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Pulmonary embolism

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Asthma

Correct Incorrect Correct answer

A 55-year-old man has the following lung function test results:

FEV1 2.0 L (61% predicted)
FVC 2.6 L (68% predicted)
FEV1/FVC 77% (80% predicted)
TLC 70% predicted
RV 75% predicted
DLCO 48% predicted

His body mass index (BMI) is 31 kg/m2 [18-25]. No bronchodilator response. Normal CXR.

Which of the following is the best explanation for these results?

Pulmonary embolism

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Diaphragmatic paralysis

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Obesity

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Asthma

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Pulmonary fibrosis

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A 55-year-old man has the following lung function test results:

FEV1 1.40 L (56% predicted)
FVC 1.9 L (57% predicted)
FEV1/FVC (50% predicted)
TLC 70% predicted
RV 75% predicted
DLCO 35% predicted
KCO 80% predicted
4% improvement in FEV1 after bronchodilator

His body mass index (BMI) is 31 kg/m2 [18-25].

Which of the following is the best explanation for these results?

Pulmonary fibrosis

Correct Incorrect Correct answer

Previous lobectomy

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Obesity

Correct Incorrect Correct answer

Asthma.

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Pulmonary embolism

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Which of the following condition is not typically associated with increased DLCO?

Pulmonary embolism

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Severe obesity

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Asthma

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Polycythaemia

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Pulmonary hemorrhage

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You are asked to consult on the aerial transfer of a sick man with bronchopneumonia. By what amount will you expect the alveolar oxygen to drop when the plane is pressurised at an altitude of 5000 feet?
(The atmospheric pressure at 5000 feet is 647 mmHg. The carbon dioxide level is 45 mmHg, the respiratory quotient is 0.8 and the water vapour pressure is 47 mmHg. These values remain constant. The flight will begin at sea level where the atmospheric pressure is 760 mmHg.)

21-25mmHg

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5-10mmHg

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11-15mHg

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16-20mmHg

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26-30mmHg

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Hypoventilation is the main mechanism for hypoxemia in the following conditions except?

Atelectasis

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Obesity hypoventilation syndrome

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Guillain barre syndrome with respitory muscle involvement

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Kyphoscoliosis

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Opiate overdose

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The alveolar-arterial gradient for oxygen tension in arterial blood (PAaO2) may vary with age.

Which one of the following is considered to be the main physiological mechanism for a normal PA-aO2?

Ventilation/perfusion (V/Q) mismatch.

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Variation in distribution of ventilation.

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Variation in diffusion for oxygen

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Right to left shunt.

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Variation in distribution of pulmonary blood flow.

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The mechanism of hypoxemia in interstitial lung disease is mainly due to?

Diffusion limitation + V/Q mismatch

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Hypoventilation

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Right to left shunt

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Purely by V/Q mismatch

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Purely by diffusion limitation

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The PaO2 are shown below for an individual breathing room air and then 100% oxygen: PaO2 (mmHg) 50.0 (breathing air) PaO2 (mmHg) 63.0 (on 100% oxygen)

What would be the best explanation for the above results?

Intracardiac shunt

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interstitial pulmonary fibrosis

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chronic obstructive pulmonary disease

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pulmonary embolism

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methaemoglobinaemia

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The following medications causes reduce REM sleep except?

Bupropion

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Venlafaxine

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Citalopram

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Moclobemide

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Amitriptylline

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The following conditions are associated with obstructive sleep apnea except?

Hyperthyroidism

Correct Incorrect Correct answer

Obesity

Correct Incorrect Correct answer

Marfan's syndrome

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Acromegaly

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Cor Pulmonale

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A 43-year-old man is referred for investigation of snoring and witnessed apnoeas. A diagnostic sleep study confirms the diagnosis of obstructive sleep apnea. Therapy with nasal continuous positive airway pressure (CPAP) is recommended.

Which of the following would be the reason why this person would use CPAP for his OSA?

Daytime sleepiness

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Presence of cardiovascular comorbidity

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Arousal index of >15/hour on the sleep study

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Hypertension

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Cognitive function

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A 43-year-old male, weighing 100 kg, presents with a 5-year history of excessive daytime sleepiness. He reports a recent motor vehicle accident attributed to falling asleep at the wheel. Subsequent evaluation, including a sleep study, confirms a diagnosis of obstructive sleep apnea (OSA).

What is the most appropriate next step in management?

Trial of CPAP

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Advise on weight loss

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upper airway surgery

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Mandibular enhancement splint

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Daytime stimulant treatment with methylphenidate.

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Following a polysomnographic evaluation in a patient with a history of left ventricular failure, episodes of decreased oxygen saturation were observed without accompanying respiratory efforts.

What is the most likely explanation for these findings?

Central sleep apnea

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Obstructive sleep apnea

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Narcolepsy

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Upper airway resistance syndrome

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Obesity hypoventilation syndrome

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A patient reports experiencing significant discomfort in the legs, primarily at night, described as an irresistible urge to move them.

During a polysomnographic study, frequent, uniform limb movements were recorded, each lasting between 0.5 and 5 seconds, with an amplitude exceeding 25% of toe dorsiflexion measured during calibration.

Laboratory investigations, including a full blood count (FBC) and electrolytes (U&Es), are within normal ranges, yet ferritin levels are found to be low.

What is the most appropriate management approach for this patient?

Oral iron therapy.

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Levodopa

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Ropinirole

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Pramipexole

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Cabergoline

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A patient presents with excessive daytime sleepiness, cataplexy, sleep paralysis and hypnogogic hallucination.

What is the diagnosis?

Narcolepsy

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Obstructive sleep apnea

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Central sleep apnea

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Periodic leg movement

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Epilepsy

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Which of the following medication is least useful in Narcolepsy?

Prazosin

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Dexamphetamine

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Methylphenidate

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Caffeine

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Anti-depressants

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Which of the following mechanisms is primarily involved in the development of hypertension in patients with obstructive sleep apnea (OSA)?

Intermittent hypoxia leading to increased sympathetic nervous system activity and systemic inflammation

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Decreased sympathetic nervous system activity during sleep apnea episodes leading to reduced blood pressure

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Increased insulin sensitivity and improved glucose metabolism during sleep apnea episodes

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Enhanced parasympathetic nervous system activity during sleep apnea episodes, leading to bradycardia and hypotension

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Increased secretion of antidiuretic hormone (ADH) during wakefulness, leading to diuresis and reduced blood pressure

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A 50-year-old male smoker presents to your clinic complaining of a persistent cough and unexplained weight loss over the past two months.On examination, you note a palpable lymph node in the left supraclavicular fossa.

A chest X-ray (CXR) reveals a “white out” appearance of the left lung, prompting further investigation with a bronchoscopy.

The bronchoscopy results indicate the presence of an undifferentiated carcinoma. Additionally, laboratory tests show elevated levels of serum neuron-specific enolase (NSE).

What is the most likely diagnosis?

Small cell lung cancer

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Squamous cell lung cancer

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Large cell lung carcinoma

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Bronchoalveolar cell cancer

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Undifferentiated adenocarcinoma

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In the management of non-small cell lung cancer, what is the optimal treatment for someone with resectable Stage II disease?

Neoadjuvant chemotherapy + Durvalumab pre-surgery followed by adjuvant Durvalumab post-surgery.

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Surgical resection without neoadjuvant chemotherapy

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Neoadjuvant chemotherapy followed by surgery.

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Neoadjuvant chemotherapy + Durvalumab pre-surgery followed by adjuvant chemotherapy + Durvalumab post-surgery

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Neoadjuvant Durvalumab pre-surgery followed by adjuvant Durvalumab post-surgery

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A 50-year-old male with a significant smoking history presents with a 6-month history of persistent cough and weight loss. More recently, he has experienced progressive weakness in both arms and legs, difficulty with balance and an unsteady gait, and challenges in arising from a seated position and climbing stairs. He also reports symptoms of dry mouth.

Upon physical examination, you observe bilateral ptosis with no significant findings in other cranial nerves. Notably, there is an exaggerated elevation of the eyelids following sustained upward gaze. The patient demonstrates proximal limb weakness, yet without evident muscle wasting, and deep tendon reflexes are absent. Interestingly, muscle strength appears to improve with repeated activity.

Given the neurological findings and the patient’s smoking history, the consulting neurologist raises a suspicion of a paraneoplastic syndrome, likely associated with an underlying malignancy.

What is the most likely underlying malignancy?

Small cell lung cancer

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Squamous cell lung cancer

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Testicular cancer

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Ovarian cancer

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Bowel cancer

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A 32-year-old fit and active male, who is a non-smoker, presents to his general practitioner with a persistent cough and mild dyspnea on exertion. A chest X-ray followed by a CT scan reveals a 3 cm solitary pulmonary nodule in the left upper lobe with no evidence of mediastinal lymph node involvement or distant metastases on PET CT. Biopsy confirms small cell lung cancer (SCLC).

Considering his excellent performance status and limited stage disease, which of the following is the most appropriate initial treatment option?

Surgery followed by adjuvant chemotherapy if no nodal disease is found on histology.

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Surgery followed by adjuvant chemo-radiotherapy regardless of nodal disease on histology.

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Platinum-based chemotherapy combined with thoracic radiotherapy

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Surgical resection only

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Surgery followed by adjuvant chemo-radiotherapy if no nodal disease is found on histology.

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Which biomarker has been proposed as a noninvasive diagnostic tool for idiopathic pleuroparenchymal fibroelastosis (PPFE)?

Urinary desmosines

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Serum Krebs von den Lungen-6

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Serum surfactant protein-D

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Serum latent transforming growth factor-beta binding protein 4

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Which of the following intervention may potentially have a role in idiopathic pleuroparenchymal fibroelastosis (PPFE)?

Lung transplant

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Glucocorticoid

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Cyclophosphamide

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Pirfenidone

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Nintedanib

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A 65-year-old with man with a past medical history of hepatocellular carcinoma was started on nivolumab last month and had underwent 2 cycles. He now presents with worsening shortness of breath and is found to be hypoxic with a resting oxygen saturation of 80 percent on arrival to the emergency department.

His HRCT chest shows diffuse ground glass opacities (GGO’s) and infectious workup including blood cultures, sputum cultures and pneumonia workup were all found to be unremarkable.

The following interventions would all be appropriate except?

Cease Nivolumab and only restart once the patient has fully recovered.

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Discontinue Nivolumab permanently.

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Proceed to bronchoscopy with bronchoalveolar lavage.

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Cover with empiric antibiotics

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Commence IV methylprednisone

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Average score
Your score

Respiratory Module 3

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