Mock Respiratory Module 2

A 52-year-old woman with biopsy-proven sarcoidosis is found to have a corrected serum calcium of 2.85 mmol/L (2.10–2.60).

What is the primary mechanism by which hypercalcaemia develops in sarcoidosis?

Increased production of 1,25-dihydroxyvitamin D

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Impaired renal calcium excretion

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Enhanced osteoclastic bone resorption

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Elevated parathyroid hormone levels

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Granulomatous production of parathyroid hormone-related peptide

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A 65-year-old man with a 40 pack-year smoking history has a solid 12 mm lung nodule on CT. Serial imaging demonstrates a volume doubling time of 150 days.

Given this information, how should the nodule be characterised?

Suspicious for malignancy

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Definitively benign

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Requires immediate surgical resection without tissue diagnosis

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Likely due to an infectious process

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Highly unlikely to be malignant

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A 45-year-old man presents with a 2-month history of cough and transient pulmonary opacities on chest radiograph. Total serum IgE is 620 IU/mL (<100), Aspergillus fumigatus-specific IgE is 1.2 kU/L (<0.35), and A. fumigatus-specific IgG is elevated. He has no history of asthma or cystic fibrosis, and spirometry is normal. He was previously labelled as having allergic bronchopulmonary aspergillosis (ABPA).

What best explains why this diagnosis should be questioned?

The absence of a predisposing condition (asthma or cystic fibrosis) makes ABPA unlikely

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The A. fumigatus-specific IgG level is insufficient to support ABPA

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Normal spirometry definitively excludes ABPA

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The presentation is more consistent with COPD

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The laboratory tests are entirely non-specific

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Which type of interstitial lung disease is most likely to resolve with smoking cessation alone?

Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD)

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Acute interstitial pneumonia (AIP)

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Usual interstitial pneumonia (UIP)

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Lymphocytic interstitial pneumonia (LIP)

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Non-specific interstitial pneumonia (NSIP)

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A 40-year-old man has a parapneumonic effusion. All of the following are indications for prompt pleural space drainage EXCEPT:

Pleural fluid pH of 7.40

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Large, free-flowing effusion occupying more than half the hemithorax

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Positive pleural fluid culture

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Presence of pus on pleural fluid

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Positive pleural fluid Gram stain

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A 45-year-old woman admitted with right lower lobe pneumonia develops a right pleural effusion on day 6, with CRP 320 mg/L (<5). Diagnostic aspiration reveals pleural pH 7.10, and culture grows Streptococcus milleri (anginosus group). A chest drain is inserted; output is initially good but slows. Bedside ultrasound shows a large, multiloculated right effusion.

Which intervention is most likely to reduce the need for surgical drainage?

Intrapleural alteplase (tPA) and DNase (dornase alfa)

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Intrapleural streptokinase alone

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Intrapleural alteplase alone

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Intrapleural streptokinase and DNase

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Twice-daily saline flushes of the drain

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The RAPID score predicts outcome in pleural infection.

Which of the following is NOT a component of this scoring system?

Rise in serum creatinine

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Age

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Purulence of pleural fluid

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Serum albumin

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Source of infection (community versus hospital-acquired)

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Which of the following does NOT shift the oxyhaemoglobin dissociation curve to the left?

A decrease in pH (acidosis)

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A decrease in 2,3-diphosphoglycerate

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A decrease in arterial carbon dioxide tension

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A decrease in temperature

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The presence of carboxyhaemoglobin

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A 40-year-old woman presents with breathlessness and inspiratory stridor. The flow-volume loop demonstrates normal expiratory flow but a plateau of reduced flow during inspiration.

The most likely diagnosis is:

Unilateral vocal cord paralysis

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Fixed tracheal stenosis

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Large intrathoracic goitre causing tracheal compression

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Tracheomalacia

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Emphysema

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A 41-year-old man has the following lung function test results:

FEV1 1.40 L (30% predicted)
FVC 1.9 L (82% predicted)
FEV1/FVC (28% predicted)
TLC 124% predicted
RV 196% predicted
FRC 173%
DLCO 56% predicted
KCO 69% predicted 10% 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?

Emphysema

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Previous lobectomy

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Obesity

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Pulmonary haemorrhage

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Asthma

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A 50-year-old man presents with exertional dyspnoea, two syncopal episodes, and a 2-week history of left calf pain. Blood pressure is 80/50 mmHg and heart rate 130 bpm. BNP and D-dimer are markedly elevated. Arterial blood gas shows pH 7.47, PaCO₂ 25 mmHg, PaO₂ 56 mmHg (respiratory alkalosis with hypoxaemia). CTPA reveals a large central pulmonary embolus.

Which parameter most strongly indicates the need for systemic thrombolysis?

Persistent hypotension

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Hypoxaemia on arterial blood gas

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Elevated serum BNP

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Elevated serum D-dimer

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Large central clot burden on CTPA

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Which investigation provides the highest diagnostic yield for pleural mesothelioma?

Pleural biopsy via medical thoracoscopy or VATS

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Serum mesothelin (SMRP)

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Serum fibulin-3

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High-resolution CT of the chest

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Pleural fluid cytology

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The LENT prognostic score is most applicable in which of the following conditions?

Malignant pleural effusion

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Community-acquired pneumonia

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Asthma

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Sarcoidosis

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Hospital-acquired pneumonia

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A 55-year-old current smoker with moderate COPD presents with acute dyspnoea and markedly reduced breath sounds on the left. Chest radiograph shows a large left pneumothorax measuring 6 cm between the lung margin and chest wall at the level of the hilum.

What is the most appropriate next step?

Insertion of a small-bore (≤14 Fr) chest drain

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Insertion of a large-bore (>20 Fr) chest drain

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Observation and high-flow oxygen alone

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Commence high-flow nasal oxygen only

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Simple needle aspiration

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Which factor has the greatest impact on prognosis in non-small cell lung cancer (NSCLC)?

Stage of cancer at presentation

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Presence of systemic symptoms

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Histological subtype

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Weight loss

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Performance status

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A 41-year-old fit man (BMI 31 kg/m²) has a right upper lobe adenocarcinoma, stage I on PET-CT.

His lung function test results:

FEV₁ 75% predicted.
FVC 82% predicted
FEV₁/FVC 0.6
DLCO 76% predicted.

What is the recommended treatment for his early-stage cancer?

Lobectomy followed by adjuvant chemotherapy

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Chemotherapy

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Stereotactic ablative body radiotherapy

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Anatomical surgical resection (lobectomy) alone

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Supportive care

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A 55-year-old man with resected stage II NSCLC is being considered for adjuvant therapy.

Which of the following is a recommended adjuvant chemotherapy regimen?

Cisplatin plus vinorelbine

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Cisplatin monotherapy

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Vinorelbine monotherapy

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Etoposide monotherapy

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Cytarabine (Ara-C)

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What is the treatment of choice for unresectable stage III NSCLC in a patient with good performance status?

Concurrent chemoradiotherapy followed by consolidation durvalumab

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Radiotherapy alone

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Chemotherapy alone

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Supportive care

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Erlotinib

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A 68-year-old woman with metastatic EGFR-mutant non-small cell lung cancer, commenced on erlotinib six weeks ago, presents with a two-week history of progressive dyspnoea and dry cough, acutely worsening over the past 48 hours.

She is hypoxaemic on room air (SpO₂ 88%). CT of the chest demonstrates new bilateral ground-glass opacities without a filling defect in the pulmonary arteries and no pleural effusion.

Considering her medication, which is the most probable drug-related diagnosis?

Erlotinib-induced interstitial lung disease (pneumonitis)

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Diffuse alveolar haemorrhage

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Lymphangitis carcinomatosis

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Pulmonary embolism

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Drug-induced (non-cardiogenic) pulmonary oedema

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Which of the following statements regarding nitric oxide (NO) in the airway is INCORRECT?

Fractional exhaled NO (FeNO) is decreased in poorly controlled eosinophilic asthma

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NO causes airway smooth muscle relaxation

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NO is derived largely from the airway epithelium

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NO is a product of L-arginine metabolism by nitric oxide synthase

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FeNO is useful for monitoring airway inflammation during treatment

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Which of the following factors confers a better response to erlotinib?

Presence of an activating EGFR mutation

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Wild-type EGFR

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EGFR gene copy number (polysomy) <4 copies

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KRAS mutation

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VEGF mutation

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Which patient profile has the highest likelihood of harbouring an EGFR mutation and responding to erlotinib?

Asian, female, never-smoker, adenocarcinoma

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Caucasian, male, smoker, adenocarcinoma

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Asian, male, non-smoker, adenocarcinoma

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Caucasian, female, non-smoker, adenocarcinoma

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Asian, female, ex-smoker, adenocarcinoma

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Which of the following organisms is the LEAST likely cause of hospital-acquired pneumonia?

Candida albicans

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Escherichia coli

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Klebsiella pneumoniae

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Enterobacter species

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Acinetobacter baumannii

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What is the most common bacterial cause of community-acquired pneumonia?

Streptococcus pneumoniae

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Haemophilus influenzae

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Moraxella catarrhalis

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Staphylococcus aureus

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Legionella pneumophila

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A patient presents with a productive cough, fever, malaise, weight loss, and a cavitating lung lesion consistent with a lung abscess. What is the most appropriate initial management?

Intravenous amoxicillin-clavulanate

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Intravenous linezolid

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Intercostal catheter drainage

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Oral albendazole

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Intravenous gentamicin

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What is the most common cause of a lung abscess?

Anaerobic bacteria

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Klebsiella pneumoniae

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Nocardia species

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Staphylococcus aureus

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Streptococcus milleri (anginosus) group

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A 30-year-old New Zealand-born lifelong non-smoker with a 15-year history of chronic cough, treated as asthma with budesonide-formoterol, has a worsening cough despite inhaled therapy.

Bronchoalveolar lavage shows:

macrophages 19%
eosinophils 60%
neutrophils 4%,
lymphocytes 16%
no malignant cells
no acid-fast bacilli (TB culture pending).

Which treatment is most likely to be effective?

Her CXR is pictured below:

Oral prednisone (corticosteroid)

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Rifampicin, isoniazid, pyrazinamide and ethambutol

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A prolonged course of amoxicillin-clavulanate

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Oral azithromycin

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Penicillin

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A 41-year-old woman presents with a 3-day history of dry cough and dyspnoea preceded by flu-like symptoms.

Examination reveals a symmetrical erythematous rash with target lesions over the body.

What is the most likely causative organism?

Mycoplasma pneumoniae

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Pseudomonas aeruginosa

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Staphylococcus aureus

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Chlamydia pneumoniae

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Legionella pneumophila

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Which type of lung cancer is most commonly associated with cavitation?

Squamous cell carcinoma

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Carcinoid tumour

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Large cell carcinoma

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Small cell carcinoma

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Adenocarcinoma

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A 55-year-old man with COPD is admitted with right lower lobe pneumonia and a right pleural effusion. He is haemodynamically stable and improving on broad-spectrum antibiotics.

Diagnostic thoracentesis shows an exudate (by Light’s criteria) with pH 7.30, negative Gram stain, and no organisms.

What is the most appropriate next step?

Continue antibiotics and observe

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Insert an intercostal catheter

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Refer for surgery

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Add metronidazole

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Change to intravenous piperacillin-tazobactam

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Surgical lung biopsy has a role in the diagnosis of interstitial lung disease in all of the following scenarios EXCEPT:

Radiographic evidence of end-stage (honeycomb) fibrosis

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Pulmonary vascular disease of unclear origin requiring tissue confirmation

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Excluding a neoplastic process mimicking progressive ILD

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Unexplained hypoxaemia with a restrictive ventilatory defect and non-diagnostic imaging

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Suspected chronic hypersensitivity pneumonitis without a confident diagnosis

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Adaptive servo-ventilation (ASV) is likely to benefit all of the following patient groups EXCEPT:

Central sleep apnoea in a heart failure patient with a reduced left ventricular ejection fraction (≤45%)

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Complex (mixed) sleep apnoea syndrome

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Central sleep apnoea in a heart failure patient with preserved ejection fraction (HFpEF)

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Treatment-emergent central sleep apnoea

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Idiopathic central sleep apnoea with normal cardiac function

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Mock Respiratory Module 2

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