Mock Respiratory Module 3

A 62-year-old man with a known history of metastatic breast cancer undergoes thoracic ultrasound for evaluation of a unilateral pleural effusion.

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

Echogenic swirling pattern

Correct Incorrect Correct answer

Presence of anechoic fluid without septations

Correct Incorrect Correct answer

Simple non-echogenic, clear fluid

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Thickened parietal pleura greater than 10 mm

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Floating echogenic particles within the effusion

Correct Incorrect Correct answer

A 45-year-old man 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 lived in New Zealand for the past 2 years. He denies recent antibiotic use or known contact with active tuberculosis.

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

A chest X-ray shows patchy consolidation with cavitation in the right upper lobe. Investigations show a CRP of 48 mg/L [<5] and a normocytic anaemia. Sputum is sent for acid-fast bacilli (AFB) smear, mycobacterial culture and GeneXpert MTB/RIF assay.

A junior registrar considers empirical azithromycin to cover atypical pneumonia while awaiting results.

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

Macrolides are ineffective against M. tuberculosis and may promote macrolide resistance in nontuberculous mycobacteria

Correct Incorrect Correct answer

Macrolide therapy invariably causes fatal hepatotoxicity when given before anti-tuberculosis treatment

Correct Incorrect Correct answer

Macrolides are absolutely contraindicated in all patients with cavitary lung lesions

Correct Incorrect Correct answer

Macrolides cause immune suppression that facilitates tuberculosis dissemination

Correct Incorrect Correct answer

Macrolides are rapidly bactericidal against M. tuberculosis and will mask the infection

Correct Incorrect Correct answer

A 45-year-old man presents with progressive dyspnoea and a non-productive cough over 6 months. His pulmonary function tests reveal a reduced diffusing capacity of the lung for carbon monoxide (DLCO).

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

DLCO measures the rate at which carbon monoxide crosses the alveolar–capillary membrane and binds haemoglobin

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

DLCO evaluates the maximum flow of air during forced expiration.

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Based on the pulmonary function test pattern shown (reduced vital capacity and total lung capacity with a preserved FEV1/FVC ratio, in keeping with a restrictive pattern), all of the following could account for this patient’s restrictive lung disease except:

Emphysema

Correct Incorrect Correct answer

Interstitial lung disease

Correct Incorrect Correct answer

Pleural effusions

Correct Incorrect Correct answer

Kyphoscoliosis

Correct Incorrect Correct answer

Neuromuscular weakness

Correct Incorrect Correct answer

Nintedanib is an intracellular tyrosine kinase inhibitor used in the treatment of idiopathic pulmonary fibrosis.

Which of the following correctly identifies its principal target receptors?

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

Correct Incorrect Correct answer

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 of the following paraneoplastic features is least commonly associated with squamous cell carcinoma of the lung?

Lambert-Eaton myasthenic syndrome

Correct Incorrect Correct answer

Hyperthyroidism

Correct Incorrect Correct answer

Hypertrophic pulmonary osteoarthropathy

Correct Incorrect Correct answer

Hypercalcaemia

Correct Incorrect Correct answer

Digital clubbing

Correct Incorrect Correct answer

A 45-year-old man with HIV, on antiretroviral therapy but with a recent decline in CD4 count to 180 cells/µL, presents with a 2-week history of progressive dyspnoea, non-productive cough and fever. Pneumocystis pneumonia is confirmed by a positive respiratory PCR for Pneumocystis jirovecii. Oral co-trimoxazole (trimethoprim-sulfamethoxazole) was commenced 5 days ago.

Despite therapy his respiratory status has deteriorated, with increased work of breathing and accessory muscle use. Arterial blood gas on room air reveals a PaO2 of 35 mmHg.

Which of the following is the most appropriate additional treatment to initiate?

Prednisone

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Intravenous pentamidine

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Clindamycin plus primaquine

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Atovaquone

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Caspofungin monotherapy

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A 40-year-old man with a 40 pack-year smoking history presents with increasing breathlessness and wheeze. Both the inspiratory and expiratory limbs of the flow-volume loop are flattened, so that the configuration approaches that of a rectangle.

What is the most likely diagnosis?

Tracheal stenosis

Correct Incorrect Correct answer

Emphysema

Correct Incorrect Correct answer

Asthma

Correct Incorrect Correct answer

Kyphoscoliosis

Correct Incorrect Correct answer

Vocal cord paralysis

Correct Incorrect Correct answer

A 60-year-old man with a 30 pack-year smoking history presents with increasing breathlessness and wheeze. His flow-volume curve shows that all flow rates are diminished, with mean expiratory flow being lower than mean inspiratory flow and a scooped (concave) expiratory limb.

What is the most likely underlying cause?

Emphysema

Correct Incorrect Correct answer

Pulmonary fibrosis

Correct Incorrect Correct answer

Kyphoscoliosis

Correct Incorrect Correct answer

Tracheal stenosis

Correct Incorrect Correct answer

Unilateral vocal cord paralysis

Correct Incorrect Correct answer

A 43-year-old woman presents with increasing breathlessness and wheeze. Her flow-volume curves show normal inspiratory flow but flow limitation during expiration, producing an expiratory plateau.

This pattern is most likely caused by:

A variable intrathoracic obstruction

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A fixed extrathoracic obstruction

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A variable extrathoracic obstruction

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A fixed intrathoracic obstruction

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Widespread intrapulmonary (small airways) obstruction

Correct Incorrect Correct answer

A 55-year-old man has the following lung function 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 BMI is 42 kg/m² [18.5–24.9]

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

Diaphragmatic paralysis

Correct Incorrect Correct answer

Obesity

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Pulmonary fibrosis

Correct Incorrect Correct answer

Asthma

Correct Incorrect Correct answer

Pulmonary haemorrhage

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A 50-year-old man has the following results:

FEV1 2.0 L (61% predicted)
FVC 2.6 L (68% predicted)
FEV1/FVC 0.77 (80% predicted)
TLC 70% predicted
RV 75% predicted
His BMI is 40 kg/m² [18.5–24.9]
Arterial blood gas shows a normal pH with an elevated PaCO2 (>45 mmHg [35–45])

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

Obesity hypoventilation syndrome

Correct Incorrect Correct answer

Bilateral diaphragmatic paralysis

Correct Incorrect Correct answer

Diffuse alveolar haemorrhage

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Acute pulmonary embolism

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Asthma

Correct Incorrect Correct answer

A 55-year-old man has the following results:

FEV1 2.0 L (61% predicted)
FVC 2.6 L (68% predicted)
FEV1/FVC 0.77 (80% predicted)
TLC 70% predicted
RV 75% predicted
DLCO 48% predicted

His BMI is 31 kg/m² [18.5–24.9]. There is no bronchodilator response, and the chest X-ray is reported as normal.

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

Acute pulmonary embolism

Correct Incorrect Correct answer

Diaphragmatic paralysis

Correct Incorrect Correct answer

Obesity

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Asthma

Correct Incorrect Correct answer

Early interstitial lung disease (pulmonary fibrosis)

Correct Incorrect Correct answer

A 67-year-old man has the following results:

FEV1 1.40 L (56% predicted)
FVC 1.9 L (57% predicted)
FEV1/FVC reduced (50% predicted ratio value)
TLC 72% predicted
RV 75% predicted
DLCO 35% predicted
KCO 80% predicted, with a 4% improvement in FEV1 after bronchodilator.

His BMI is 31 kg/m² [18.5–24.9]

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

Idiopathic pulmonary fibrosis

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Previous lobectomy with coexisting emphysema

Correct Incorrect Correct answer

Obesity

Correct Incorrect Correct answer

Asthma

Correct Incorrect Correct answer

Acute pulmonary embolism

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

Acute asthma

Correct Incorrect Correct answer

Severe obesity

Correct Incorrect Correct answer

Left-to-right intracardiac shunt

Correct Incorrect Correct answer

Polycythaemia

Correct Incorrect Correct answer

Diffuse alveolar haemorrhage

Correct Incorrect Correct answer

You are asked by the Air New Zealand crew to advise on the aeromedical transfer of an unwell man with bronchopneumonia from Invercargill to Auckland.

By approximately how much would you expect the alveolar oxygen tension (PAO2) to fall when the aircraft cabin is pressurised to an equivalent altitude of 5000 feet?

Use the following assumptions in your calculation:

Cabin atmospheric pressure at 5000 feet is 647 mmHg
Assume PaCO2 is 45 mmHg [35–45]
The respiratory quotient is 0.8
Water vapour pressure is 47 mmHg
FiO2 remains 0.21
The flight departs from sea level with an atmospheric pressure of 760 mmHg

21–25 mmHg

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5–10 mmHg

Correct Incorrect Correct answer

11–15 mmHg

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26–30 mmHg

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16–20 mmHg

Correct Incorrect Correct answer

Hypoventilation is the principal mechanism of hypoxaemia in all of the following conditions except:

Lobar atelectasis

Correct Incorrect Correct answer

Obesity hypoventilation syndrome

Correct Incorrect Correct answer

Guillain-Barré syndrome with respiratory muscle involvement

Correct Incorrect Correct answer

Kyphoscoliosis

Correct Incorrect Correct answer

Opioid overdose

Correct Incorrect Correct answer

The alveolar–arterial oxygen gradient (A–aO2) varies with age.

Which of the following is considered the principal physiological mechanism accounting for the normal (small) A–aO2 gradient in healthy individuals?

Ventilation–perfusion (V/Q) mismatch

Correct Incorrect Correct answer

Variation in the distribution of ventilation

Correct Incorrect Correct answer

Variation in diffusion of oxygen

Correct Incorrect Correct answer

Anatomical right-to-left shunt

Correct Incorrect Correct answer

Variation in the distribution of pulmonary blood flow

Correct Incorrect Correct answer

The hypoxaemia of interstitial lung disease is mainly due to:

Diffusion limitation plus V/Q mismatch

Correct Incorrect Correct answer

Alveolar hypoventilation

Correct Incorrect Correct answer

Right-to-left shunt

Correct Incorrect Correct answer

V/Q mismatch alone

Correct Incorrect Correct answer

Diffusion limitation alone

Correct Incorrect Correct answer

The following arterial oxygen tensions are recorded in a patient breathing room air and then 100% oxygen:

PaO2 50 mmHg on room air
PaO2 63 mmHg on 100% oxygen

What is the best explanation for these results?

Right-to-left (intracardiac or intrapulmonary) shunt

Correct Incorrect Correct answer

Interstitial pulmonary fibrosis

Correct Incorrect Correct answer

Chronic obstructive pulmonary disease

Correct Incorrect Correct answer

Pulmonary embolism

Correct Incorrect Correct answer

Methaemoglobinaemia

Correct Incorrect Correct answer

All of the following conditions are associated with obstructive sleep apnoea except:

Hyperthyroidism

Correct Incorrect Correct answer

Obesity

Correct Incorrect Correct answer

Hypothyroidism

Correct Incorrect Correct answer

Acromegaly

Correct Incorrect Correct answer

Cor pulmonale

Correct Incorrect Correct answer

A 43-year-old man is referred for investigation of snoring and witnessed apnoeas. A diagnostic polysomnogram confirms obstructive sleep apnoea. Nasal continuous positive airway pressure (CPAP) is recommended.

Which of the following is the primary reason this patient would benefit from CPAP for his OSA?

Excessive daytime sleepiness

Correct Incorrect Correct answer

Presence of cardiovascular comorbidity

Correct Incorrect Correct answer

Arousal index greater than 15 per hour on the sleep study

Correct Incorrect Correct answer

Hypertension

Correct Incorrect Correct answer

Impaired cognitive function

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A 43-year-old man weighing 100 kg presents with a 5-year history of excessive daytime sleepiness and a recent motor vehicle accident attributed to falling asleep at the wheel. Polysomnography confirms moderate-to-severe obstructive sleep apnoea.

What is the most appropriate next step in management?

Trial of CPAP

Correct Incorrect Correct answer

Advise weight loss alone

Correct Incorrect Correct answer

Upper airway surgery

Correct Incorrect Correct answer

Mandibular advancement splint

Correct Incorrect Correct answer

Daytime stimulant therapy with methylphenidate

Correct Incorrect Correct answer

Following polysomnography in a patient with a history of left ventricular systolic dysfunction, episodes of oxygen desaturation are observed without accompanying respiratory effort.

What is the most likely explanation?

Central sleep apnoea

Correct Incorrect Correct answer

Obstructive sleep apnoea

Correct Incorrect Correct answer

Narcolepsy

Correct Incorrect Correct answer

Upper airway resistance syndrome

Correct Incorrect Correct answer

Obesity hypoventilation syndrome

Correct Incorrect Correct answer

A patient reports significant discomfort in the legs, chiefly at night, described as an irresistible urge to move them that is relieved by movement. Polysomnography records frequent, stereotyped limb movements each lasting 0.5–5 seconds with an amplitude exceeding 25% of toe dorsiflexion recorded at calibration. Full blood count and electrolytes are normal, but serum ferritin is low.

What is the most appropriate initial management?

Oral iron therapy

Correct Incorrect Correct answer

Levodopa

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Ropinirole

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Pramipexole

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Cabergoline

Correct Incorrect Correct answer

A patient presents with excessive daytime sleepiness, cataplexy, sleep paralysis and hypnagogic hallucinations.

What is the diagnosis?

Narcolepsy (type 1)

Correct Incorrect Correct answer

Obstructive sleep apnoea

Correct Incorrect Correct answer

Central sleep apnoea

Correct Incorrect Correct answer

Periodic limb movement disorder

Correct Incorrect Correct answer

Epilepsy

Correct Incorrect Correct answer

Which of the following medications is least useful in the management of narcolepsy?

Benztropine

Correct Incorrect Correct answer

Dexamfetamine

Correct Incorrect Correct answer

Methylphenidate

Correct Incorrect Correct answer

Modafinil

Correct Incorrect Correct answer

Antidepressant (SSRI/SNRI)

Correct Incorrect Correct answer

Which of the following mechanisms is primarily involved in the development of hypertension in patients with obstructive sleep apnoea?

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

Increased insulin sensitivity and improved glucose metabolism during sleep apnea episodes

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

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

Correct Incorrect Correct answer

A 50-year-old man with a significant smoking history presents with a 6-month history of persistent cough and weight loss. He describes progressive proximal weakness of the arms and legs, difficulty rising from a chair and climbing stairs, an unsteady gait, and a dry mouth.

On examination there is bilateral ptosis, proximal limb weakness without wasting, and absent deep tendon reflexes; muscle strength and reflexes improve transiently with repeated or sustained effort. The neurologist suspects a paraneoplastic syndrome.

What is the most likely underlying malignancy?

Small cell lung cancer

Correct Incorrect Correct answer

Squamous cell lung cancer

Correct Incorrect Correct answer

Testicular cancer

Correct Incorrect Correct answer

Ovarian cancer

Correct Incorrect Correct answer

Colorectal cancer

Correct Incorrect Correct answer

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

Urinary desmosines

Correct Incorrect Correct answer

Serum Krebs von den Lungen-6

Correct Incorrect Correct answer

Serum surfactant protein-D

Correct Incorrect Correct answer

Serum latent transforming growth factor-beta binding protein 4 (LTBP-4)

Correct Incorrect Correct answer

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

Lung transplantation

Correct Incorrect Correct answer

Glucocorticoids

Correct Incorrect Correct answer

Cyclophosphamide

Correct Incorrect Correct answer

Pirfenidone

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Nintedanib

Correct Incorrect Correct answer

Mock Respiratory Module 3

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