Respiratory Medicine Practice Questions

Q: A 78-year-old man with known COPD presents with increased breathlessness and purulent sputum for 3 days. He has had 4 exacerbations requiring hospital admission in the past year. Sputum culture from his previous admission 6 weeks ago grew Pseudomonas aeruginosa. Current observations: temperature 37.8°C, HR 98/min, BP 130/75 mmHg, RR 24/min, SpO2 88% on room air. He is started on controlled oxygen, nebulized bronchodilators, and oral prednisolone. Which antibiotic regimen is most appropriate?

IV ciprofloxacin or oral ciprofloxacin if appropriate. ***IV ciprofloxacin or oral ciprofloxacin if appropriate*** - This patient has significant risk factors for **Pseudomonas aeruginosa**, including a history of prior isolation and frequent exacerbations requiring hospital admission. - **Ciprofloxacin** is a fluoroquinolone with excellent activity against **Pseudomonas**, making it the most appropriate choice to target this pathogen. *Oral amoxicillin 500mg three times daily for 5 days* - **Amoxicillin** is a common first-line antibiotic for uncomplicated COPD exacerbations but does not cover **Pseudomonas aeruginosa**. - Given the patient's history of **Pseudomonas** isolation, using amoxicillin alone would likely lead to **treatment failure**. *Oral doxycycline 200mg loading dose then 100mg daily for 5 days* - **Doxycycline** is effective against common respiratory pathogens and some atypical bacteria, but it lacks activity against **Pseudomonas**. - It is generally reserved for patients with less severe exacerbations or those with **penicillin allergies**, neither of which negates the need for **Pseudomonas** coverage here. *Oral amoxicillin/clavulanate 625mg three times daily for 5 days* - **Amoxicillin/clavulanate (co-amoxiclav)** offers broader coverage than amoxicillin alone, including beta-lactamase producing bacteria, but still does not cover **Pseudomonas aeruginosa**. - The patient's specific history of **Pseudomonas** requires an antibiotic with proven **anti-pseudomonal** efficacy. *Oral clarithromycin 500mg twice daily for 5 days* - **Clarithromycin** is a macrolide, primarily used for atypical pathogens like Mycoplasma and Chlamydia, and some Gram-positive bacteria. - It has no significant activity against **Pseudomonas aeruginosa** and would be an ineffective choice in this clinical scenario.

Q: A 44-year-old man presents to the Emergency Department with sudden onset pleuritic chest pain and breathlessness 3 hours ago. He returned from Australia yesterday after a 24-hour flight. He has no other risk factors for venous thromboembolism. Observations: HR 95/min, BP 125/78 mmHg, RR 22/min, SpO2 94% on air. ECG shows sinus tachycardia. D-dimer is 580 ng/ml (normal <500). What is the most appropriate next step in management?

Calculate Wells score for PE and proceed according to the result. ***Calculate Wells score for PE and proceed according to the result***- The first step in evaluating a patient with suspected **pulmonary embolism (PE)** is to assess clinical probability using a validated score like the **Wells score**.- This risk stratification determines whether the patient requires an immediate **D-dimer** (if Wells score is low/intermediate) or immediate **CTPA** and interim anticoagulation (if Wells score is high). *Commence treatment dose low-molecular-weight heparin and arrange CTPA within 1 hour*- Empirical anticoagulation should generally only be started if the **clinical probability** is high and there will be a significant delay in obtaining definitive imaging.- It is premature to start treatment before completing the **Wells score** assessment to determine if PE is 'likely' or 'unlikely'. *Arrange chest X-ray and ventilation/perfusion (V/Q) scan*- While a **Chest X-ray** is useful to exclude other diagnoses, a **CTPA** is the first-line gold standard diagnostic test for most patients with suspected PE.- **V/Q scanning** is usually reserved for patients with **renal impairment**, contrast allergy, or in specific cases like pregnancy. *Repeat D-dimer in 24 hours*- A **D-dimer** level is already elevated (580 ng/ml); repeating it does not provide additional diagnostic value and delays necessary investigation.- Decisions must be made based on current clinical findings and the **Wells score** to ensure patient safety. *Discharge with safety-netting advice as Wells score is likely low*- The patient is currently symptomatic with **pleuritic chest pain**, **breathlessness**, and an **elevated D-dimer** after a significant risk factor (long flight).- Discharging the patient without completing the diagnostic pathway for PE would be unsafe given the clinical presentation and objective findings.

Q: A 29-year-old woman presents to her GP with a 3-month history of intermittent dry cough and wheeze, particularly at night and after exercise. She has no past medical history and takes no regular medications. Spirometry shows FEV1 2.8L (95% predicted), FVC 3.4L (98% predicted), FEV1/FVC ratio 0.82. What is the most appropriate next investigation to establish the diagnosis?

Fractional exhaled nitric oxide (FeNO) testing. ***Fractional exhaled nitric oxide (FeNO) testing*** - According to **NICE guidelines**, when an adult has symptoms suggestive of **asthma** but **normal spirometry** (FEV1/FVC > 0.7), the next objective test to perform is **FeNO**. - A FeNO level of **40 parts per billion (ppb)** or more is considered positive and supports the diagnosis by indicating **eosinophilic airway inflammation**. *Bronchial provocation testing with methacholine or histamine* - This test is typically reserved for cases where **spirometry** and **FeNO** results are inconclusive or discordant. - It assesses **airway hyper-responsiveness** but is more invasive and specialized than the initial FeNO measurement. *Peak flow variability monitoring for 2-4 weeks* - This is a possible diagnostic step, but per **NICE algorithm**, it is recommended if **FeNO** is between 25-39 ppb or if other objective tests are unavailable. - It requires high patient compliance to monitor **diurnal variation** over several weeks, making it less immediate than a FeNO test. *Trial of inhaled corticosteroid for 6 weeks* - A **therapeutic trial** is no longer recommended as the primary diagnostic tool in adults because it lacks **objective confirmation** of the disease. - Guidelines emphasize using **physiological tests** (like FeNO or bronchodilator reversibility) before starting long-term treatment. *Chest X-ray* - A **Chest X-ray** is useful for excluding alternative pathologies like **pneumonia** or **malignancy** but cannot confirm a diagnosis of asthma. - In a young patient with classic intermittent symptoms and normal spirometry, it is not the **diagnostic investigation of choice** for asthma.

Q: A 76-year-old woman is admitted with an infective exacerbation of COPD. She has type 2 respiratory failure on arterial blood gas with pH 7.32, PaCO2 7.8 kPa, PaO2 7.2 kPa, HCO3- 32 mmol/L on 28% venturi oxygen. She has been started on nebulized bronchodilators, IV antibiotics, and oral prednisolone. Despite optimal medical therapy, repeat ABG after 1 hour shows pH 7.28, PaCO2 8.4 kPa, PaO2 7.5 kPa, HCO3- 33 mmol/L. She is alert and cooperative. What is the most appropriate next step in her management?

Commence non-invasive ventilation (NIV). ***Commence non-invasive ventilation (NIV)***- The patient has **worsening acute hypercapnic respiratory failure** (pH dropping, PaCO2 rising) despite initial medical therapy, which is the primary indication for **NIV** in COPD exacerbations.- Since she is **alert and cooperative**, she is an ideal candidate for NIV, an evidence-based intervention that reduces mortality and the need for **invasive mechanical ventilation**.*Increase oxygen to 35% venturi mask*- Increasing oxygen in a patient with **COPD** and **Type 2 Respiratory Failure** can worsen **hypercapnia** by suppressing the **hypoxic drive** and increasing V/Q mismatch.- The primary issue is worsening **respiratory acidosis** (pH 7.28, rising PaCO2), which requires ventilatory support, not just increased oxygenation.*Commence intubation and mechanical ventilation*- **Invasive ventilation** is typically reserved for patients who fail NIV or have contraindications like **impaired consciousness**, severe hemodynamic instability, or inability to protect their airway.- As the patient is **alert and cooperative**, a trial of NIV is the appropriate first-line step to correct the worsening acidosis.*Give IV doxapram infusion*- **Doxapram** is a respiratory stimulant that is now **rarely used** and is considered inferior to **non-invasive ventilation** for managing acute hypercapnic failure in COPD.- It does not effectively address the underlying **work of breathing** or provide the direct ventilatory support offered by NIV.*Continue current management and repeat ABG in 2 hours*- The repeat ABG clearly indicates **clinical deterioration** (pH dropped, PaCO2 rose) despite initial optimal medical therapy.- Delaying escalation of care in the presence of worsening **acidosis** and hypercapnia significantly increases the risk of severe respiratory compromise.

Question 1

According to current BTS/SIGN guidelines, which of the following patients with asthma should be referred for specialist assessment?

Accepted Answer

A 40-year-old with unconfirmed diagnosis of asthma started on treatment in childhood without objective testing

Answer

A 25-year-old requiring SABA relief inhaler 4 times per week despite ICS 400 micrograms twice daily

Answer

A 55-year-old with good symptom control on ICS/LABA but had one exacerbation requiring oral steroids in the past year

Answer

A 35-year-old requesting step-down of treatment after 6 months of good control on low-dose ICS

Answer

A 50-year-old with well-controlled asthma requesting pneumococcal vaccination

Question 2

A 63-year-old woman is admitted with community-acquired pneumonia. She is treated with IV co-amoxiclav and clarithromycin. On day 3, she remains febrile at 38.5°C with persistent hypoxia requiring 4L oxygen. Repeat chest X-ray shows a right-sided pleural effusion. Diagnostic pleural aspiration yields 50ml of turbid fluid: pH 7.18, glucose 1.8 mmol/L, LDH 850 IU/L, protein 42 g/L. Gram stain shows Gram-positive cocci in chains. What is the most appropriate management?

Accepted Answer

Insert a chest drain and commence intrapleural fibrinolytic therapy

Answer

Continue current antibiotics and repeat chest X-ray in 48 hours

Answer

Change antibiotics to IV meropenem

Answer

Arrange video-assisted thoracoscopic surgery (VATS)

Answer

Arrange ultrasound-guided therapeutic aspiration of effusion

Question 3

A 33-year-old woman who is 32 weeks pregnant presents with sudden onset breathlessness and left-sided pleuritic chest pain. She has no past medical history. Observations: HR 105/min, BP 118/72 mmHg, RR 24/min, SpO2 96% on air. Two-level PE Wells score is 5.5 (PE likely). What is the most appropriate immediate management?

Accepted Answer

Commence treatment dose low-molecular-weight heparin immediately and arrange urgent CT pulmonary angiography

Answer

Perform D-dimer and proceed to imaging only if positive

Answer

Arrange V/Q scan as first-line imaging to minimize fetal radiation exposure

Answer

Commence unfractionated heparin infusion due to pregnancy

Answer

Arrange Doppler ultrasound of leg veins as first-line investigation

Question 4

A 78-year-old man with known COPD presents with increased breathlessness and purulent sputum for 3 days. He has had 4 exacerbations requiring hospital admission in the past year. Sputum culture from his previous admission 6 weeks ago grew Pseudomonas aeruginosa. Current observations: temperature 37.8°C, HR 98/min, BP 130/75 mmHg, RR 24/min, SpO2 88% on room air. He is started on controlled oxygen, nebulized bronchodilators, and oral prednisolone. Which antibiotic regimen is most appropriate?

Accepted Answer

IV ciprofloxacin or oral ciprofloxacin if appropriate

Answer

Oral amoxicillin 500mg three times daily for 5 days

Answer

Oral doxycycline 200mg loading dose then 100mg daily for 5 days

Answer

Oral amoxicillin/clavulanate 625mg three times daily for 5 days

Answer

Oral clarithromycin 500mg twice daily for 5 days

Question 5

A 41-year-old man with difficult-to-control asthma is reviewed in a specialist clinic. Despite maximum dose inhaled corticosteroids (fluticasone 2000 micrograms daily), LABA, and montelukast, he requires oral prednisolone courses monthly and uses salbutamol 8-10 times daily. Blood eosinophil count is 520 cells/microlitre, IgE is 420 IU/ml, and specific IgE to house dust mite and grass pollen are positive. FEV1 is 68% predicted. He has good inhaler technique and adherence. Which biologic therapy is most appropriate to consider first-line for this patient?

Accepted Answer

Omalizumab (anti-IgE monoclonal antibody)

Answer

Mepolizumab (anti-IL-5 monoclonal antibody)

Answer

Benralizumab (anti-IL-5 receptor monoclonal antibody)

Answer

Dupilumab (anti-IL-4 receptor alpha monoclonal antibody)

Answer

Continue optimizing conventional therapy before considering biologics

Question 6

A 55-year-old woman is admitted with community-acquired pneumonia. Initial assessment shows: temperature 38.9°C, BP 108/65 mmHg, HR 110/min, RR 28/min, SpO2 91% on room air, confusion (AMT 7/10). Blood results show urea 8.2 mmol/L. Chest X-ray confirms right lower lobe consolidation. What is her CURB-65 score and the recommended management setting?

Accepted Answer

CURB-65 score 4; consider ITU admission as high severity pneumonia

Answer

CURB-65 score 2; consider hospital-supervised treatment or home treatment depending on clinical judgment

Answer

CURB-65 score 3; admit to hospital as moderate to high severity pneumonia

Answer

CURB-65 score 3; consider ITU admission as high severity pneumonia

Answer

CURB-65 score 2; manage as outpatient with oral antibiotics

Question 7

A 44-year-old man presents to the Emergency Department with sudden onset pleuritic chest pain and breathlessness 3 hours ago. He returned from Australia yesterday after a 24-hour flight. He has no other risk factors for venous thromboembolism. Observations: HR 95/min, BP 125/78 mmHg, RR 22/min, SpO2 94% on air. ECG shows sinus tachycardia. D-dimer is 580 ng/ml (normal <500). What is the most appropriate next step in management?

Accepted Answer

Calculate Wells score for PE and proceed according to the result

Answer

Commence treatment dose low-molecular-weight heparin and arrange CTPA within 1 hour

Answer

Arrange chest X-ray and ventilation/perfusion (V/Q) scan

Answer

Repeat D-dimer in 24 hours

Answer

Discharge with safety-netting advice as Wells score is likely low

Question 8

A 69-year-old man with severe COPD (FEV1 35% predicted) on home oxygen therapy (15 hours daily) is reviewed in clinic. Despite triple inhaler therapy (LABA/LAMA/ICS), he remains breathless on minimal exertion (MRC grade 4) and has had 3 hospital admissions for exacerbations in the past 12 months. His oxygen saturations are 89% on room air. He is an ex-smoker (quit 2 years ago, 50 pack-year history). BMI is 32 kg/m². What additional intervention is most likely to improve his survival?

Accepted Answer

Adding prophylactic azithromycin 250mg three times weekly

Answer

Referring for pulmonary rehabilitation

Answer

Starting long-term oral corticosteroids

Answer

Referring for lung volume reduction surgery

Answer

Adding oral theophylline

Question 9

A 29-year-old woman presents to her GP with a 3-month history of intermittent dry cough and wheeze, particularly at night and after exercise. She has no past medical history and takes no regular medications. Spirometry shows FEV1 2.8L (95% predicted), FVC 3.4L (98% predicted), FEV1/FVC ratio 0.82. What is the most appropriate next investigation to establish the diagnosis?

Accepted Answer

Fractional exhaled nitric oxide (FeNO) testing

Answer

Bronchial provocation testing with methacholine or histamine

Answer

Peak flow variability monitoring for 2-4 weeks

Answer

Trial of inhaled corticosteroid for 6 weeks

Answer

Chest X-ray

Question 10

A 76-year-old woman is admitted with an infective exacerbation of COPD. She has type 2 respiratory failure on arterial blood gas with pH 7.32, PaCO2 7.8 kPa, PaO2 7.2 kPa, HCO3- 32 mmol/L on 28% venturi oxygen. She has been started on nebulized bronchodilators, IV antibiotics, and oral prednisolone. Despite optimal medical therapy, repeat ABG after 1 hour shows pH 7.28, PaCO2 8.4 kPa, PaO2 7.5 kPa, HCO3- 33 mmol/L. She is alert and cooperative. What is the most appropriate next step in her management?

Accepted Answer

Commence non-invasive ventilation (NIV)

Answer

Increase oxygen to 35% venturi mask

Answer

Commence intubation and mechanical ventilation

Answer

Give IV doxapram infusion

Answer

Continue current management and repeat ABG in 2 hours

Respiratory Medicine — MCQs

Respiratory Medicine — MCQs

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