Respiratory Medicine — MCQs

A 27-year-old woman with asthma attends for review. She was diagnosed with asthma 2 years ago and commenced on a low-dose ICS/LABA combination inhaler (budesonide/formoterol 200/6 micrograms, 2 puffs twice daily). She uses it regularly and reports good symptom control with minimal salbutamol use. She is planning to start trying for a baby and is concerned about her asthma medication during pregnancy. What is the most appropriate advice regarding her asthma treatment?

Q19

A 47-year-old man is admitted with a massive pulmonary embolism. CT pulmonary angiogram shows bilateral proximal pulmonary emboli with evidence of right ventricular strain. He is haemodynamically stable with blood pressure 110/70 mmHg, heart rate 105/min, and oxygen saturation 91% on 4L/min oxygen via nasal cannulae. Echocardiogram confirms right ventricular dilatation and dysfunction. He has no contraindications to thrombolysis. What is the most appropriate management?

Q20

A 58-year-old woman presents with a 3-month history of progressive breathlessness and dry cough. She has never smoked. Spirometry shows: FEV1 2.8L (92% predicted), FVC 3.1L (85% predicted), FEV1/FVC ratio 0.90. Chest radiograph shows bilateral interstitial shadowing. What pattern of lung disease do these spirometry results suggest?

Respiratory Medicine UK Medical PG Practice Questions and MCQs

Question 11: A 60-year-old man with COPD presents with increasing breathlessness, purulent sputum, and wheeze over 3 days. His usual medications are salbutamol and tiotropium inhalers. What is the most appropriate additional treatment?

A. Increase bronchodilator dose
B. Oral prednisolone
C. Antibiotics only
D. Oral prednisolone and antibiotics (Correct Answer)
E. IV aminophylline

Explanation: ***Oral prednisolone and antibiotics***- This patient presents with increased **dyspnea** and **purulent sputum**, which strongly suggests a moderate to severe **Acute Exacerbation of COPD (AECOPD)**, likely triggered by a bacterial infection (based on **Anthonisen criteria**).- Administration of **oral corticosteroids** (like prednisolone) is crucial for reducing airway inflammation, and **antibiotics** are required to eradicate the bacterial component indicated by the purulent sputum.*Increase bronchodilator dose*- While increasing bronchodilation (e.g., with nebulized short-acting agents) is a necessary step, it is insufficient alone to treat the serious underlying **inflammation** and **bacterial infection**.- This option neglects the critical role of systemic anti-inflammatory agents (**prednisolone**) and antimicrobial therapy in moderate-to-severe exacerbations.*Oral prednisolone*- **Systemic corticosteroids** are foundational for managing AECOPD by reducing airway inflammation and improving lung function.- However, the presence of **purulent sputum** strongly indicates a bacterial infection; therefore, **antibiotics** must be included alongside the prednisolone for adequate treatment response.*Antibiotics only*- Antibiotics are indicated due to the evidence of a bacterial trigger (purulent sputum), but they only address the infection, not the underlying severe inflammatory component of the exacerbation.- Optimal therapy for AECOPD involves the combined use of **antibiotics** and **systemic corticosteroids** to manage both infection and inflammation effectively.*IV aminophylline*- **IV aminophylline** (a methylxanthine) is a second or third-line agent due to its narrow therapeutic index, side effects, and limited evidence base for routine use in AECOPD.- It is generally reserved for patients with severe AECOPD who fail to improve rapidly despite optimal treatment with high-dose bronchodilators and **systemic corticosteroids**.

Question 12: A 35-year-old man presents with a 1-week history of productive cough with green sputum, fever, and left-sided chest pain. Chest X-ray shows left lower lobe consolidation. What is the most appropriate antibiotic treatment?

A. Amoxicillin 500mg TDS for 5 days (Correct Answer)
B. Clarithromycin 500mg BD for 7 days
C. Doxycycline 100mg BD for 5 days
D. Co-amoxiclav 625mg TDS for 7 days
E. Ciprofloxacin 500mg BD for 7 days

Explanation: ***Amoxicillin 500mg TDS for 5 days***- This patient presents with **Community-Acquired Pneumonia (CAP)**, likely caused by **Streptococcus pneumoniae**, which is the most common bacterial cause in otherwise healthy adults.- **Amoxicillin** is the recommended **first-line oral antibiotic** for low-severity CAP in patients with no relevant comorbidities or penicillin allergy, with a typical course being 5-7 days.*Clarithromycin 500mg BD for 7 days*- **Clarithromycin** (a macrolide) is typically used when an **atypical pathogen** (e.g., *Mycoplasma pneumoniae*, *Chlamydia pneumoniae*) is suspected, or for patients with **penicillin allergy**.- The presence of **green sputum** suggests a typical bacterial pathogen like *S. pneumoniae*, making macrolide monotherapy less appropriate as first-line empiric treatment unless there's an allergy.*Doxycycline 100mg BD for 5 days*- **Doxycycline** is effective against both typical and atypical pathogens and is an alternative for CAP, particularly in cases of **penicillin allergy** or when atypical pneumonia is strongly considered.- While a viable option, it is generally considered a **second-line agent** or alternative to amoxicillin for uncomplicated CAP, with amoxicillin being preferred first-line in the absence of allergies.*Co-amoxiclav 625mg TDS for 7 days*- **Co-amoxiclav** (amoxicillin-clavulanate) provides broader coverage, including **beta-lactamase producing organisms** and *Haemophilus influenzae*, and is usually reserved for CAP in patients with **comorbidities** (e.g., COPD, bronchiectasis) or more severe disease.- For an otherwise healthy 35-year-old with low-severity CAP, the broader spectrum of Co-amoxiclav is **unnecessary** and may contribute to antibiotic resistance.*Ciprofloxacin 500mg BD for 7 days*- **Ciprofloxacin** (a fluoroquinolone) is a potent antibiotic generally reserved for **severe CAP requiring hospitalization**, patients with **significant comorbidities**, or when **drug-resistant pathogens** are suspected.- Its routine use for low-severity CAP in healthy individuals is **discouraged** due to potential side effects (e.g., C. difficile infection, QT prolongation) and the importance of **antibiotic stewardship**.

Question 13: A 52-year-old man presents with progressive dyspnea and dry cough over 12 months. He has clubbing and bilateral fine inspiratory crackles. HRCT shows honeycombing and traction bronchiectasis in lower lobes. What is the most likely diagnosis?

A. COPD
B. Asthma
C. Idiopathic pulmonary fibrosis (Correct Answer)
D. Sarcoidosis
E. Hypersensitivity pneumonitis

Explanation: ***Idiopathic pulmonary fibrosis*** - The constellation of progressive dyspnea and dry cough, physical exam findings of **clubbing** and **bilateral fine inspiratory crackles** (Velcro rales), coupled with a **UIP (usual interstitial pneumonia) pattern** on HRCT, is diagnostic of IPF. - The HRCT findings of **honeycombing** (cysts in a clustered, peripheral, subpleural distribution) and **traction bronchiectasis** that are lower lobe predominant confirm advanced fibrosis (UIP). *COPD* - COPD is an an **obstructive** lung disease characterized by airflow limitation, typically yielding abnormal PFTs indicating decreased FEV1/FVC ratio. - It is unlikely as the presentation lacks dominant wheezing or established risk factors like heavy smoking, and the HRCT findings are classic for a **restrictive fibrotic** process, not emphysema. *Asthma* - Asthma is a chronic inflammatory disorder of the airways leading to **reversible** episodes of wheezing, cough, and dyspnea, which typically respond to bronchodilators. - It does not cause progressive, irreversible lung parenchymal damage leading to **honeycombing** or **clubbing**. *Sarcoidosis* - Sarcoidosis is a multisystem granulomatous disease that typically presents with **bilateral hilar adenopathy** and often involves the upper and mid lung fields. - While it can cause fibrosis, the pattern on HRCT is usually characterized by nodularity, and the classic lower lobe-dominant **UIP pattern** is not typical. *Hypersensitivity pneumonitis* - HP (especially chronic fibrotic form) typically presents with lung damage localized to the **mid or upper lung zones**, often showing features like **centrilobular micronodules** or air trapping (mosaic attenuation). - It is less likely given the classic **lower lobe and subpleural** distribution of fibrosis and honeycombing characteristic of IPF/UIP.

Question 14: A 56-year-old man presents with progressive dyspnea and chest tightness. Spirometry shows FEV1 1.2L (40% predicted), FEV1/FVC ratio 0.55. He has smoked 50 pack-years. What is the most appropriate initial treatment?

A. Salbutamol inhaler
B. Beclomethasone inhaler
C. Long-acting bronchodilator
D. Oral prednisolone
E. Smoking cessation (Correct Answer)

Explanation: ***Smoking cessation***- This is the **single most important initial intervention** and the cornerstone of managing **COPD**, as it is the only measure proven to slow the rate of **FEV1 decline** and improve long-term survival.- The patient’s severe obstructive lung disease (FEV1 40%) is assumed to be COPD due to his **heavy smoking history (50 pack-years)**, making addressing the cause the priority before initiating pharmacotherapy.*Salbutamol inhaler*- **Salbutamol**, a short-acting beta-agonist (**SABA**), is used as a **rescue medication** for immediate temporary relief of acute dyspnea but does not address the underlying disease progression.- It is not adequate as initial monotherapy for a patient with symptomatic, moderate-to-severe stable COPD.*Beclomethasone inhaler*- Inhaled corticosteroids (**ICS**) are generally added to long-acting bronchodilators only in patients with severe COPD and a history of clinically significant **annual exacerbations** or high **eosinophil counts**.- ICS monotherapy is discouraged in stable COPD due to potential side effects like pneumonia and lack of FEV1 benefit compared to bronchodilators.*Long-acting bronchodilator*- Long-acting bronchodilators (**LAMA or LABA**) are the current pharmaceutical standard of care for daily symptom management in stable COPD (GOLD group B and higher).- While essential for symptom control, **pharmacotherapy** must follow the primary advice of **smoking cessation**, which is necessary to halt disease progression.*Oral prednisolone*- **Oral steroids** are reserved for the treatment of **acute exacerbations of COPD (AECOPD)** when symptoms worsen acutely beyond baseline.- They are inappropriate for the long-term stable management of COPD due to significant systemic side effects.

Question 15: A 64-year-old man presents with progressive dyspnea and chest tightness. Chest X-ray shows bilateral lower lobe reticular shadowing. HRCT shows honeycombing and traction bronchiectasis. He has a history of working in shipbuilding. What is the most likely diagnosis?

A. Idiopathic pulmonary fibrosis
B. Asbestosis (Correct Answer)
C. Silicosis
D. Coal worker's pneumoconiosis
E. Hypersensitivity pneumonitis

Explanation: ***Asbestosis***- The history of working in **shipbuilding** strongly implicates exposure to **asbestos** fibers, which deposit primarily in the lower lobes.- HRCT findings of **honeycombing**, **traction bronchiectasis**, and subpleural basilar predominance indicate progressive pulmonary fibrosis, the hallmark of **asbestosis**.*Idiopathic pulmonary fibrosis*- IPF diagnosis is one of exclusion, requiring the absence of known causes of interstitial lung disease, such as the confirmed **asbestos exposure** present in this case.- Clinical and HRCT features like **honeycombing** and **traction bronchiectasis** (UIP pattern) overlap with asbestosis, but the presence of a clear occupational exposure rules out idiopathic etiology.*Silicosis*- Silicosis is typically seen in workers exposed to **silica dust** (e.g., mining, quarry work) and usually involves the **upper lung zones**.- Characteristic HRCT findings include small, well-defined **upper lobe nodules** and often **eggshell calcification** of hilar lymph nodes, findings inconsistent with the basilar reticular disease described.*Coal worker's pneumoconiosis*- CWP is caused by inhalation of **coal dust** and typically presents as small opacities in the **upper and middle lung zones**.- The exposure history (shipbuilding) and the basilar location of the reticular changes and honeycombing do not fit the typical pattern of **coal worker's pneumoconiosis (CWP)**.*Hypersensitivity pneumonitis*- This condition is caused by chronic inhalation of **organic antigens** (e.g., bird droppings, mold); the exposure linked to shipbuilding is **inorganic dust** (asbestos).- Chronic HP typically shows predominant features in the **middle and upper lobes**, such as **centrilobular nodules** or a **mosaic attenuation** pattern (air trapping), rather than basilar traction bronchiectasis and honeycombing.

Question 16: A 55-year-old man presents with progressive dyspnea and chest tightness. Spirometry shows FEV1 65% predicted, FEV1/FVC ratio 0.55. He has a 40 pack-year smoking history. What is the most likely diagnosis?

A. Asthma
B. COPD (Correct Answer)
C. Interstitial lung disease
D. Bronchiectasis
E. Lung cancer

Explanation: ***COPD***- The patient's **40 pack-year smoking history**, progressive dyspnea, and especially the spirometry showing a **fixed FEV1/FVC ratio of 0.55** (less than 0.70 or less than the lower limit of normal) are pathognomonic for **Chronic Obstructive Pulmonary Disease**.- COPD is characterized by persistent, irreversible, or poorly reversible **airflow limitation** caused by chronic inflammatory response to noxious particles or gases, most commonly cigarette smoke.*Asthma*- Asthma is primarily characterized by **reversible airflow obstruction**, meaning the FEV1/FVC ratio would significantly improve (typically >12% and 200 mL increase in FEV1) after bronchodilator administration.- While asthma causes dyspnea and chest tightness, its symptoms are often episodic and variable, demonstrating **airway hyperresponsiveness**, unlike the fixed, progressive obstruction seen in this patient.*Interstitial lung disease*- Interstitial lung diseases (ILDs) typically cause a **restrictive ventilatory defect**, where both FEV1 and FVC are reduced proportionally, leading to a **normal or increased FEV1/FVC ratio** (often >0.70).- This patient's FEV1/FVC ratio of 0.55 clearly indicates an **obstructive pattern**, making ILD an unlikely diagnosis based on spirometry alone.*Bronchiectasis*- While bronchiectasis can cause an obstructive pattern on spirometry, it is typically characterized by a **chronic productive cough** with mucopurulent sputum and characteristic **bronchial dilation** on high-resolution CT (HRCT) scans.- Given the significant smoking history and classic obstructive spirometry without mention of chronic purulent cough or HRCT findings, **COPD** is a more direct and common explanation for the findings.*Lung cancer*- Lung cancer is a concern in any heavy smoker with respiratory symptoms, but it typically presents with localized symptoms (e.g., hemoptysis, focal wheezing, weight loss) and often causes restrictive or normal spirometry, or localized obstruction if a large bronchus is involved.- The global, fixed **obstructive pattern** (FEV1/FVC 0.55) seen in this patient's spirometry is a hallmark of widespread **airway disease** like COPD, rather than a primary effect of a localized tumor.

Question 17: A 62-year-old woman with rheumatoid arthritis on methotrexate presents with progressive dyspnea and dry cough over 3 months. HRCT chest shows bilateral ground-glass opacities and honeycombing. What is the most likely cause?

A. Pneumocystis pneumonia
B. Rheumatoid lung disease
C. Methotrexate pneumonitis (Correct Answer)
D. Usual interstitial pneumonia
E. Hypersensitivity pneumonitis

Explanation: ***Methotrexate pneumonitis*** - This is a well-recognized idiosyncratic adverse effect of **methotrexate**, characterized by subacute onset of **dyspnea** and **dry cough** as seen in this patient. - HRCT findings of **ground-glass opacities** and **honeycombing** are consistent with interstitial lung disease, a common manifestation of methotrexate-induced lung injury.*Pneumocystis pneumonia* - While methotrexate is immunosuppressive, **Pneumocystis pneumonia (PCP)** typically has a more acute or subacute course, often with fever, and usually presents with ground-glass opacities without extensive honeycombing unless it's a very chronic, untreated case. - PCP is more common with higher levels of immunosuppression (e.g., HIV, high-dose steroids) than typically seen with methotrexate for RA, unless specific risk factors are present.*Rheumatoid lung disease* - Rheumatoid arthritis can cause various lung manifestations, including interstitial lung disease (ILD) with **ground-glass opacities** and **honeycombing**. - However, given the patient is on **methotrexate**, a drug highly associated with drug-induced pneumonitis with identical presentation, methotrexate pneumonitis is the *most likely* and *direct* cause to consider first.*Usual interstitial pneumonia* - **Usual interstitial pneumonia (UIP)** describes a specific histopathological and radiological pattern of interstitial lung disease, not a specific etiology. - While this patient's HRCT findings of **ground-glass opacities** and **honeycombing** could reflect a UIP pattern, the question asks for the *cause*, and methotrexate is a direct causal agent, making it a more specific answer than a descriptive pattern.*Hypersensitivity pneumonitis* - **Hypersensitivity pneumonitis** is an inflammatory lung disease caused by repeated exposure to inhaled antigens, leading to dyspnea and cough. - Although it can present with similar HRCT findings like ground-glass opacities, there is no history of specific **antigen exposure** provided in the case, making it less likely than drug-induced toxicity from methotrexate.

Question 18: A 27-year-old woman with asthma attends for review. She was diagnosed with asthma 2 years ago and commenced on a low-dose ICS/LABA combination inhaler (budesonide/formoterol 200/6 micrograms, 2 puffs twice daily). She uses it regularly and reports good symptom control with minimal salbutamol use. She is planning to start trying for a baby and is concerned about her asthma medication during pregnancy. What is the most appropriate advice regarding her asthma treatment?

A. Stop the ICS/LABA combination and use salbutamol only during pregnancy
B. Continue the ICS/LABA combination as the benefits of good asthma control outweigh any risks (Correct Answer)
C. Switch to oral prednisolone throughout pregnancy as it is safer than inhaled therapy
D. Reduce the ICS dose by half during pregnancy to minimise fetal exposure
E. Stop the LABA component and use ICS alone during pregnancy

Explanation: ***Continue the ICS/LABA combination as the benefits of good asthma control outweigh any risks***- Maintaining **good asthma control** is critical during pregnancy because poorly controlled asthma increases the risk of **fetal hypoxia**, **pre-eclampsia**, and **low birth weight**.- Most asthma medications, including **budesonide** and **formoterol**, have a strong safety profile and are recommended to be continued if they are effective for the patient.*Stop the ICS/LABA combination and use salbutamol only during pregnancy*- Stopping maintenance therapy leads to a high risk of **acute exacerbations**, which are far more dangerous to the fetus than the medication.- **SABA monotherapy** is insufficient for patients who previously required combination therapy to maintain control.*Switch to oral prednisolone throughout pregnancy as it is safer than inhaled therapy*- **Inhaled therapy** is preferred as it delivers medication directly to the airways with minimal **systemic absorption** compared to oral steroids.- Long-term **oral prednisolone** is associated with higher risks of **gestational diabetes** and maternal hypertension.*Reduce the ICS dose by half during pregnancy to minimise fetal exposure*- Reducing the dose in a well-controlled patient increases the risk of the asthma becoming **uncontrolled** during a period where stability is vital.- Guidelines suggest maintaining the **minimum effective dose** that was achieved prior to pregnancy rather than making arbitrary reductions.*Stop the LABA component and use ICS alone during pregnancy*- Removing the **LABA** in a patient previously requiring combination therapy can lead to a loss of symptom control.- Current clinical guidelines state that **LABAs** are not known to be harmful to the fetus and should be continued if needed for asthma stability.

Question 19: A 47-year-old man is admitted with a massive pulmonary embolism. CT pulmonary angiogram shows bilateral proximal pulmonary emboli with evidence of right ventricular strain. He is haemodynamically stable with blood pressure 110/70 mmHg, heart rate 105/min, and oxygen saturation 91% on 4L/min oxygen via nasal cannulae. Echocardiogram confirms right ventricular dilatation and dysfunction. He has no contraindications to thrombolysis. What is the most appropriate management?

A. Commence therapeutic dose DOAC and monitor closely
B. Commence therapeutic dose unfractionated heparin infusion (Correct Answer)
C. Administer systemic thrombolysis with alteplase
D. Arrange urgent surgical embolectomy
E. Arrange catheter-directed thrombolysis

Explanation: ***Commence therapeutic dose unfractionated heparin infusion***- This patient has an **intermediate-high risk pulmonary embolism (PE)**, defined by right ventricular (RV) strain on CT/Echocardiogram but maintaining **haemodynamic stability**.- **Unfractionated heparin (UFH)** is preferred in high-risk scenarios because of its **short half-life** and rapid reversibility should the patient deteriorate and require invasive intervention or thrombolysis.*Commence therapeutic dose DOAC and monitor closely*- While **Direct Oral Anticoagulants (DOACs)** are standard for low-risk PE, they are generally avoided in the acute phase of **submassive PE** where haemodynamic collapse is a risk.- DOACs lack the **immediate reversibility** and titration flexibility provided by a heparin infusion in a monitored hospital setting.*Administer systemic thrombolysis with alteplase*- **Systemic thrombolysis** is specifically reserved for **high-risk (massive) PE**, characterized by **haemodynamic instability** (systolic BP <90 mmHg or obstructive shock).- In stable patients with RV dysfunction, the risk of **major hemorrhage** (including intracranial bleed) usually outweighs the benefit of rapid clot lysis.*Arrange urgent surgical embolectomy*- **Surgical embolectomy** is an invasive procedure indicated primarily when systemic thrombolysis is **contraindicated** or has failed in a clinically unstable patient.- It is not first-line therapy for a haemodynamically stable patient with **preserved blood pressure**.*Arrange catheter-directed thrombolysis*- **Catheter-directed thrombolysis** is an emerging therapy for intermediate-high risk PE but remains a second-line option dependent on local expertise.- Standard practice mandates starting **parenteral anticoagulation** first; specialized interventional techniques are considered only if clinical deterioration occurs despite medical therapy.

Question 20: A 58-year-old woman presents with a 3-month history of progressive breathlessness and dry cough. She has never smoked. Spirometry shows: FEV1 2.8L (92% predicted), FVC 3.1L (85% predicted), FEV1/FVC ratio 0.90. Chest radiograph shows bilateral interstitial shadowing. What pattern of lung disease do these spirometry results suggest?

A. Obstructive lung disease
B. Restrictive lung disease (Correct Answer)
C. Mixed obstructive and restrictive disease
D. Normal lung function
E. Small airways disease

Explanation: ***Restrictive lung disease***- The **FEV1/FVC ratio is 0.90 (90%)**, which is normal or elevated, indicating no airflow obstruction. Restrictive lung diseases are characterized by reduced lung volumes, but the FEV1/FVC ratio often remains preserved or high.- The clinical picture of **progressive breathlessness**, **dry cough**, and **bilateral interstitial shadowing** on chest radiograph are classic features of interstitial lung diseases, which cause a restrictive pattern.*Obstructive lung disease*- This pattern is characterized by a **decreased FEV1/FVC ratio** (typically below 0.70 or 70%) due to increased airway resistance during expiration. The patient's ratio of 0.90 clearly rules out an obstructive pattern.- Diseases like **COPD** and **asthma** fall into this category, often presenting with a history of smoking (not present here) or hyperreactivity.*Mixed obstructive and restrictive disease*- A mixed pattern would demonstrate both a **reduced FEV1/FVC ratio (obstruction)** and **reduced lung volumes (restriction)**, such as a significantly reduced FVC. This patient's FEV1/FVC ratio is elevated, ruling out a significant obstructive component.- Such patterns are typically seen in patients with co-existing conditions, which is not supported by the spirometry or clinical findings here.*Normal lung function*- While FEV1 (92%) and FVC (85%) are within or near the normal predicted range, the **elevated FEV1/FVC ratio** combined with the patient's **progressive symptoms** and **bilateral interstitial shadowing** on X-ray clearly indicate underlying lung pathology.- A patient with significant symptoms and radiographic findings cannot be classified as having normal lung function despite relatively preserved volumes.*Small airways disease*- Primarily affects the **smaller bronchioles**, leading to subtle airflow limitation that may manifest as a reduced **FEF 25-75%** (mid-expiratory flow rates) or a normal FEV1/FVC ratio initially.- This condition does not typically cause the prominent **bilateral interstitial shadowing** seen on chest radiograph, which points toward parenchymal involvement.

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Acute severe asthma

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Asthma diagnosis and long-term management

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COPD diagnosis and exacerbations

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Community-acquired pneumonia

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Pulmonary embolism

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