Mock Respiratory Module 4

A 55-year-old woman presents with a 2-year history of cough and dyspnoea. Imaging studies reveal a 3 cm mass in the right lung.

Fine-needle aspiration biopsy is performed, and the pathology report suggests a neuroendocrine tumour. Immunohistochemical staining is ordered to confirm the diagnosis.

Which of the following biomarkers is most specific for neuroendocrine tumours, including carcinoid tumours, and is likely to be positive in this patient’s tumour?

INSM1 (Insulinoma-associated protein 1)

Correct Incorrect Correct answer

Chromogranin A

Correct Incorrect Correct answer

Synaptophysin

Correct Incorrect Correct answer

TTF-1 (Thyroid transcription factor-1)

Correct Incorrect Correct answer

p40

Correct Incorrect Correct answer

A 65-year-old male presents to the emergency department with progressive breathlessness over the past two weeks. He has a history of chronic heart failure and type 2 diabetes mellitus.

On examination, he is tachypnoeic with a respiratory rate of 24 breaths per minute, oxygen saturation of 89% on room air, and decreased breath sounds with dullness to percussion at the right lung base.

A chest X-ray confirms a large right-sided pleural effusion.

Which of the following best explains the principal pathophysiological mechanism of breathlessness in this patient?

Decreased respiratory system compliance due to mechanical restriction and increased pleural pressure

Correct Incorrect Correct answer

Impaired gas exchange due to atelectasis and reduced perfusion in the compressed lung

Correct Incorrect Correct answer

Altered diaphragmatic movement leading to inefficient ventilation

Correct Incorrect Correct answer

Increased intrapleural pressure causing reduced venous return and decreased cardiac output

Correct Incorrect Correct answer

Compensatory hyperventilation to correct for hypoxemia leading to respiratory alkalosis

Correct Incorrect Correct answer

A 62-year-old male, an ex-heavy smoker with a 40 pack-year history, presents with worsening shortness of breath, chronic cough, and frequent exacerbations of COPD. His FEV1 is 18% of predicted, and his BODE index is 8. He has had two episodes of hypercapnic respiratory failure in the past year. Arterial blood gas analysis shows a PaCO2 of 53 mmHg and a PaO2 of 58 mmHg. He has recently been diagnosed with bowel cancer and is awaiting an oncology appointment.

Which of the following would exclude him from being considered for lung transplantation at this time?

Recent diagnosis of bowel cancer

Correct Incorrect Correct answer

FEV1 of 18% predicted

Correct Incorrect Correct answer

BODE index of 8

Correct Incorrect Correct answer

Chronic type 2 respiratory failure with PaCO2 >50 mmHg and/or PaO2 <60 mmHg

Correct Incorrect Correct answer

Recurrent exacerbations with hypercapnic respiratory failure

Correct Incorrect Correct answer

Which of the following is NOT a criterion for lung transplant referral/listing in interstitial lung disease (ILD)?

Decline in FVC of > 5% or decline in DLCO > 5% within the prior 6 months

Correct Incorrect Correct answer

Any form of pulmonary fibrosis with forced vital capacity (FVC) of <80% predicted or diffusing capacity of the lungs for carbon monoxide (DLCO) <40% predicted

Correct Incorrect Correct answer

Development of pulmonary hypertension demonstrated by ECHO or right-heart catheter

Correct Incorrect Correct answer

Desaturation to 50 m decline in 6-minute walk test distance in the past 6 months

Correct Incorrect Correct answer

Inflammatory ILD where there is progressive decline of pulmonary function with radiographic progression despite treatment

Correct Incorrect Correct answer

A 55-year-old male who underwent bilateral lung transplantation for idiopathic pulmonary fibrosis 18 months ago presents with progressive exertional dyspnoea and a persistent dry cough. He has been adherent to his immunosuppressive regimen.

Examination reveals bilaterally decreased breath sounds at the lung bases. Pulmonary function testing shows a significant decline in FEV1, now 65% of the stable post-transplant baseline established three months ago.

Which of the following is most characteristic of chronic lung allograft dysfunction (CLAD) in this patient?

Persistent decline in FEV1 to ≤80% of baseline with an obstructive pattern (bronchiolitis obliterans syndrome phenotype)

Correct Incorrect Correct answer

Acute onset within the first month post-transplant

Correct Incorrect Correct answer

Improvement in pulmonary function tests over time

Correct Incorrect Correct answer

Complete reversibility with augmented immunosuppression

Correct Incorrect Correct answer

Rapid normalisation of spirometry after antibiotic therapy

Correct Incorrect Correct answer

A 55-year-old patient with end-stage kidney disease on peritoneal dialysis (PD) presents with recurrent shortness of breath.

Chest X-ray shows a large right-sided pleural effusion. There have been multiple previous episodes managed with thoracentesis.

Pleural fluid analysis reveals:

Glucose: 16.7 mmol/L (300 mg/dL) — markedly elevated (serum glucose normal 3.0–7.8 mmol/L)
Protein: 5 g/L (0.5 g/dL)
LDH: 50 U/L
pH: 7.45
Cell count: 100 cells/μL, predominantly mononuclear

Which of the following is the most likely cause of the recurrent pleural effusion?

Dialysate leakage from peritoneal dialysis

Correct Incorrect Correct answer

Heart failure

Correct Incorrect Correct answer

Malignancy

Correct Incorrect Correct answer

Pulmonary embolism

Correct Incorrect Correct answer

Tuberculosis

Correct Incorrect Correct answer

Treatment with an inhaled corticosteroid (ICS) should be considered in each of the following situations EXCEPT?

A stable COPD patient with no exacerbations in the last 12 months and a blood eosinophil count <100 cells/μL

Correct Incorrect Correct answer

An asthma exacerbation within the last two years

Correct Incorrect Correct answer

Asthma symptoms three or more times a week

Correct Incorrect Correct answer

Waking at least one night per week due to asthma symptoms

Correct Incorrect Correct answer

Asthma symptoms once a week

Correct Incorrect Correct answer

A 50-year-old male with a previous lung transplant develops a persistent cough and increasing shortness of breath over three days. Early inspiratory crackles are audible on auscultation. Pulmonary function testing demonstrates irreversible airflow obstruction with a reduced FEV1/FVC ratio and a low DLCO. His chest radiograph is normal; however, HRCT shows expiratory air trapping with a mosaic attenuation pattern, bronchiolectasis, and small airway wall thickening.

What is the most likely diagnosis?

Constrictive bronchiolitis (bronchiolitis obliterans)

Correct Incorrect Correct answer

Hypersensitivity pneumonitis

Correct Incorrect Correct answer

Sarcoidosis

Correct Incorrect Correct answer

Severe asthma

Correct Incorrect Correct answer

Chronic obstructive pulmonary disease

Correct Incorrect Correct answer

A 17-year-old male is referred with poorly controlled asthma. He has been taking inhaled budesonide 400 mcg one puff twice daily for the past five months but continues to have daily wheeze and cough, requiring frequent additional reliever use. His inhaler technique is satisfactory and all other treatable traits have been addressed.

His chest X-ray shows hyperinflation but is otherwise unremarkable. Spirometry shows a moderate obstructive pattern with a 15% (and 300 mL) increase in FEV1 after bronchodilator.

What is the most appropriate next step?

Combine his inhaled corticosteroid with formoterol as maintenance-and-reliever therapy (single-inhaler MART)

Correct Incorrect Correct answer

Add 10 mg prednisone on alternate days

Correct Incorrect Correct answer

Add oral montelukast

Correct Incorrect Correct answer

Increase budesonide to 800 mcg twice daily as monotherapy

Correct Incorrect Correct answer

Substitute a short-acting beta-agonist as his sole reliever

Correct Incorrect Correct answer

A 30-year-old female with a history of asthma and chronic rhinosinusitis develops worsening shortness of breath and wheezing after ingesting aspirin.

She responds to salbutamol, oral corticosteroids, and inhaled corticosteroid therapy.

Which additional clinical feature would you expect in this patient?

Nasal polyps

Correct Incorrect Correct answer

Aortic regurgitation

Correct Incorrect Correct answer

Palmar erythema

Correct Incorrect Correct answer

Subcutaneous nodules

Correct Incorrect Correct answer

Finger clubbing

Correct Incorrect Correct answer

A patient is on long-term inhaled corticosteroid therapy for asthma.

Which local complication is most likely to occur?

Dysphonia (hoarse voice)

Correct Incorrect Correct answer

Oral candidiasis

Correct Incorrect Correct answer

Posterior subcapsular cataract

Correct Incorrect Correct answer

Skin thinning

Correct Incorrect Correct answer

Osteoporosis

Correct Incorrect Correct answer

Which of the following is the recommended empirical antibiotic regimen for a patient with low-severity community-acquired pneumonia managed in the community?

Amoxicillin plus doxycycline

Correct Incorrect Correct answer

Benzylpenicillin alone

Correct Incorrect Correct answer

Amoxicillin plus gentamicin

Correct Incorrect Correct answer

Ciprofloxacin

Correct Incorrect Correct answer

Vancomycin

Correct Incorrect Correct answer

What is the most common fungal infection in solid organ transplant recipients overall?

Candida species

Correct Incorrect Correct answer

Aspergillus species

Correct Incorrect Correct answer

Mucorales (zygomycetes)

Correct Incorrect Correct answer

Scedosporium species

Correct Incorrect Correct answer

Cryptococcus species

Correct Incorrect Correct answer

In immunosuppressed patients, the galactomannan assay is most useful in the diagnosis of which infection?

Invasive aspergillosis

Correct Incorrect Correct answer

Staphylococcus aureus bacteraemia

Correct Incorrect Correct answer

Gram-negative bacteraemia

Correct Incorrect Correct answer

Candida albicans infection

Correct Incorrect Correct answer

Meningococcal sepsis

Correct Incorrect Correct answer

What is the most commonly isolated bacterium in acute exacerbations of COPD?

Haemophilus influenzae

Correct Incorrect Correct answer

Pseudomonas aeruginosa

Correct Incorrect Correct answer

Streptococcus pneumoniae

Correct Incorrect Correct answer

Moraxella catarrhalis

Correct Incorrect Correct answer

Klebsiella pneumoniae

Correct Incorrect Correct answer

In a 65-year-old male with COPD, which of the following carries the greatest risk of death over the next 12 months?

Hospitalisation for an acute exacerbation of COPD

Correct Incorrect Correct answer

FEV1 of 60% predicted

Correct Incorrect Correct answer

BMI of <20kg/m2.

Correct Incorrect Correct answer

PaO2 of 58mmHg

Correct Incorrect Correct answer

PaCO2 of 47mmHg

Correct Incorrect Correct answer

The BODE index predicts mortality risk in patients with COPD.

Which of the following is NOT a component of the BODE index?

Age

Correct Incorrect Correct answer

FEV1(% of predicted)

Correct Incorrect Correct answer

Six-minute walk distance

Correct Incorrect Correct answer

Dyspnoea (mMRC) scale

Correct Incorrect Correct answer

Body mass index

Correct Incorrect Correct answer

In patients with COPD, which of the following interventions has the greatest impact on mortality?

Smoking cessation

Correct Incorrect Correct answer

Short-acting beta-agonist

Correct Incorrect Correct answer

Influenza vaccination

Correct Incorrect Correct answer

Long-acting beta-agonist

Correct Incorrect Correct answer

Pulmonary rehabilitation

Correct Incorrect Correct answer

An 80-year-old male with advanced COPD presents with a six-month history of progressive breathlessness, orthopnoea, and paroxysmal nocturnal dyspnoea. He is hypoxaemic at rest with a resting SpO2 of 86%. There is globally reduced air entry with fine bibasal inspiratory crackles. His JVP is elevated. He has ascites and pitting oedema to the knees.

Arterial blood gas shows a PaO2 of 56 mmHg with a normal PaCO2 and normal pH. Chest X-ray shows hyperinflated lung fields with interstitial oedema.

What is the best intervention to improve his long-term survival?

Long-term oxygen therapy for at least 15 hours per day

Correct Incorrect Correct answer

A frusemide infusion

Correct Incorrect Correct answer

Periodic paracentesis for ascites

Correct Incorrect Correct answer

Short-burst (as-needed) oxygen therapy

Correct Incorrect Correct answer

Triple inhaler therapy

Correct Incorrect Correct answer

Calculate the A-a gradient of this patient based on the following ABG:

Ph 7.49
pCO2 48 mmHg
PO2 54 mmHg
HCO3 33 mmHg

(Assume the atmospheric pressure at sea level is 760 mmHg., the respiratory quotient is 0.8 and the water vapour pressure is 47 mmHg.Fi02 is 0.21.)

36mmHg

Correct Incorrect Correct answer

25mmHg

Correct Incorrect Correct answer

30mmHg

Correct Incorrect Correct answer

40mmHg

Correct Incorrect Correct answer

45mmHg

Correct Incorrect Correct answer

Which of the following is a contraindication to curative surgical resection in lung cancer?

Vocal cord paralysis due to recurrent laryngeal nerve involvement

Correct Incorrect Correct answer

Haemoptysis

Correct Incorrect Correct answer

FEV1 of 1.9 L

Correct Incorrect Correct answer

Squamous cell histology

Correct Incorrect Correct answer

Corrected calcium of 2.84 mmol/L (reference 2.10–2.60 mmol/L)

Correct Incorrect Correct answer

Which of the following features is NOT consistent with a diagnosis of non-asthmatic eosinophilic bronchitis?

The condition is not corticosteroid-responsive

Correct Incorrect Correct answer

Presence of >3% eosinophils in induced sputum

Correct Incorrect Correct answer

Absence of airway hyperresponsiveness

Correct Incorrect Correct answer

A recognised cause of chronic cough

Correct Incorrect Correct answer

Atopy occurring at a similar frequency to the general population

Correct Incorrect Correct answer

The use of tiotropium in COPD improves all of the following EXCEPT?

The long-term rate of decline in lung function

Correct Incorrect Correct answer

Frequency of exacerbations

Correct Incorrect Correct answer

FEV1

Correct Incorrect Correct answer

Symptom scores

Correct Incorrect Correct answer

Quality of life

Correct Incorrect Correct answer

Which of the following monoclonal antibodies is indicated in the treatment of allergic asthma in young adults?

Omalizumab

Correct Incorrect Correct answer

Natalizumab

Correct Incorrect Correct answer

Infliximab

Correct Incorrect Correct answer

Interferon alfa

Correct Incorrect Correct answer

Tocilizumab

Correct Incorrect Correct answer

Which of the following is NOT an indication for bronchoscopy in patients with bronchiectasis?

Routine bronchoscopic sampling of the lower respiratory tract in stable disease

Correct Incorrect Correct answer

To exclude proximal airway obstruction in localised disease

Correct Incorrect Correct answer

HRCT suggesting non-tuberculous mycobacterial infection with negative sputum cultures

Correct Incorrect Correct answer

Failure to respond to appropriate treatment

Correct Incorrect Correct answer

Localised bronchiectasis confined to a single lobe in a child

Correct Incorrect Correct answer

Which type of lung cancer is most strongly associated with smoking?

Small cell lung carcinoma

Correct Incorrect Correct answer

Adenocarcinoma

Correct Incorrect Correct answer

Large cell carcinoma

Correct Incorrect Correct answer

Carcinoid tumour

Correct Incorrect Correct answer

Squamous cell carcinoma

Correct Incorrect Correct answer

A 50-year-old smoker is found to have an asymptomatic solitary pulmonary nodule on CT.

Which of the following features is the strongest predictor of malignancy?

Irregular, spiculated margins

Correct Incorrect Correct answer

Size less than 4 mm

Correct Incorrect Correct answer

Doubling time greater than 500 days

Correct Incorrect Correct answer

Diffuse or central "popcorn" calcification

Correct Incorrect Correct answer

A smooth, discrete border

Correct Incorrect Correct answer

Vital capacity is the sum of:

Tidal volume, inspiratory reserve volume and expiratory reserve volume

Correct Incorrect Correct answer

Tidal volume and expiratory reserve volume

Correct Incorrect Correct answer

Tidal volume and inspiratory reserve volume

Correct Incorrect Correct answer

Tidal Volume and residual volume

Correct Incorrect Correct answer

Inspiratory reserve volume and expiratory reserve volume

Correct Incorrect Correct answer

Which of the following is NOT, in itself, a diagnostic criterion for cystic fibrosis in an individual?

Elevated sweat chloride on two separate occasions

Correct Incorrect Correct answer

A positive newborn screening test

Correct Incorrect Correct answer

Having a sibling with cystic fibrosis

Correct Incorrect Correct answer

A genotype with two CF-causing CFTR mutations

Correct Incorrect Correct answer

Demonstrated abnormalities of ion transport across nasal or airway epithelium

Correct Incorrect Correct answer

A recent randomised controlled trial demonstrated the efficacy of the CFTR modulator combination elexacaftor–tezacaftor–ivacaftor.

Which group of CF patients is most likely to benefit from this combination therapy?

Patients with at least one F508del mutation

Correct Incorrect Correct answer

Patients homozygous for the R117H missense mutation

Correct Incorrect Correct answer

Patients homozygous for the W1282X nonsense mutation

Correct Incorrect Correct answer

Patients homozygous for the R553X nonsense mutation

Correct Incorrect Correct answer

Which of the following is the greatest risk factor for developing lung cancer?

Cigarette smoking

Correct Incorrect Correct answer

Therapeutic thoracic radiation

Correct Incorrect Correct answer

Asbestos exposure

Correct Incorrect Correct answer

Occupational heavy-metal exposure

Correct Incorrect Correct answer

Residential radon exposure

Correct Incorrect Correct answer

Which is now the most common histological type of lung cancer, particularly among females?

Adenocarcinoma

Correct Incorrect Correct answer

Large cell carcinoma

Correct Incorrect Correct answer

Squamous cell carcinoma

Correct Incorrect Correct answer

Small cell carcinoma

Correct Incorrect Correct answer

Bronchoalveolar carcinoma

Correct Incorrect Correct answer

A 60-year-old ex-smoker (10 pack-year history) is referred for further management of COPD with worsening dyspnoea over six months despite maximal medical therapy and completion of pulmonary rehabilitation.

Lung function shows: FEV1 1.8 L (82% predicted); FVC 2.74 L (96% predicted); FEV1/FVC 0.66; TLC >110% predicted; RV >250% predicted; DLCO 50% predicted.

Which of the following factors would make her a LESS favourable candidate for bullectomy?

HRCT demonstrating homogeneous, diffuse emphysema without a single dominant bulla

Correct Incorrect Correct answer

TLC >100% and RV >200% predicted

Correct Incorrect Correct answer

Being an ex-smoker

Correct Incorrect Correct answer

Age 60 years

Correct Incorrect Correct answer

Progressive dyspnoea despite maximal inhaler therapy

Correct Incorrect Correct answer

Mock Respiratory Module 4

Quiz Summary

Information

Results

Results

Categories

1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

7. Question

8. Question

9. Question

10. Question

11. Question

12. Question

13. Question

14. Question

15. Question

16. Question

17. Question

18. Question

19. Question

20. Question

21. Question

22. Question

23. Question

24. Question

25. Question

26. Question

27. Question

28. Question

29. Question

30. Question

31. Question

32. Question

33. Question