1.

A 70 years old man with chronic obstructive lung disease requires 2L/min of nasal O2 to
treat his hypoxia, which is sometimes associated with angina. Now the patient has
developed pleuritic chest pain, fever and purulent sputum. While using oxygen at
increased flow rate of 5L/min, he becomes stuporous and develops respiratory acidosis
with CO2 retention and worsening hypoxia. What would be the next appropriate step in
the management of this patient:
A) Stop Oxygen
B) Begin medroxyprogesterone
C) Intubate and begin mechanical ventilation
D) Treat with antibiotics and observe in the general medicine ward for 24 hours
E) Begin sodium bicarbonate
2. A previously healthy 18 years old high school student suddenly develops left sided pleuritic
chest pain and dyspnoea while playing foot ball. In the emergency room examination reveals
B.P 110/60mmHg, pulse rate 110bpm, R.R 36/min and temp 98.6 °F. On chest auscultation
there was hyper-resonant percussion note and absent breath sounds over left chest
anteriorly. What is the most likely etiology of this patient’s condition:
A) Infection of the lung parenchyma
B) Malignant neoplasm of pleura
C) Rib fracture
D) Rupture of subpleural apical bleb
E) Anxiety
3. 40 years old alcoholic develops cough and fever. Sputum is fetid and examination shows
crackles over the right base. Chest x-ray shows consolidation in the right lower zone. Which
of the following is most likely etiologic agent:
A) Streptococcus pneumonie
B) Haemophilus influenza
C) Legionella pneumophilia
D) Anaerobes
E) Mycoplasma pneumonia
4. 65 years old man presents to the emergency department with worsening dyspnoea and
pleuritic chest pain. His medical history includes atrial fibrillation for which he is taking
warfarin. He reports consuming 24units of alcohol weekly and has a smoking history of 10
cigarettes daily for the past 10 years. On examination his respiratory rate is elevated at
24b/min. Chest x-ray reveals 1cm right sided pneumothorax alongside an old posterior 6th rib
fracture. What aspect of this patient’s history most strongly indicates the need for chest
drain insertion:
A) Old posterior 6th rib fracture
B) Over 55 years old and significant smoking history
C) Over 60 years old and significant alcohol history
D) Respiratory rate of 24b/min
E) Size of pneumothorax
5. A 35-year-old woman presents with a chronic history of a productive cough. On
examination, she has finger clubbing and late inspiratory crackles. She is suspected of
having bronchiectasis. Which gene is associated with bronchiectasis:
A) HLA DR1
B) HLA DR2
C) HLA DR3
 D) HLA B27
E) HLA DR 4
6. A 75-year-old woman presents to the emergency department with increasing
shortness of breath and right sided chest pain. On examination she has reduced
breathing sounds on the right side of her chest and it is dull to percuss. She takes
levothyroxine for Hashimoto's thyroiditis but otherwise has no past medical history.

A chest x-ray is performed, which shows a large right-sided pleural effusion, which is
aspirated and the sample sent for analysis:

PH: 7.3 protein: 39g/dl

Pleural LDH to serum LDH ratio: 0.8

Pleural protein to serum protein ratio: 0.7

What is the most likely cause of her pleural effusion?

A) Hypothyroidism
B) Lung cancer
C) Dressler syndrome
D) Meigs’ syndrome
E) Pulmonary tuberculosis
7. A 68-year-old male patient presents with a 6-month history of shortness of breath.
He mentions that it is worse on exertion and his exercise tolerance is reduced
compared to previously. He describes no associated wheeze, or haemoptysis but
does have a dry cough. He has a background of hypertension and takes amlodipine
5mg once a day. He has never smoked or worked with asbestos in the past.

On examination, he is comfortable at rest with oxygen saturations 95% on air. There

is no evidence of lymphadenopathy, clubbing or cyanosis. He has fine crackles at
both lung bases that do not alter on coughing.

You suspect the patient may have idiopathic pulmonary fibrosis and organise some
investigations.

Which of the following investigation findings would support a diagnosis of idiopathic

pulmonary fibrosis?
A) Reticular changes on CT imaging that is worse at the bases
B) Obstructive picture on spirometry
C) Extensive ground glass opacities on CT imaging
D) Increase transfer factor on spirometry
E) A lymphocytosis on broncheoalveolar lavage
8. A 65-year-old man presents to the emergency department with 3 days of shortness
of breath. He has a background of heart failure, asthma, and pulmonary fibrosis. On
examination, there is a non-blanching rash noted on his lower limbs. His observations
 are a heart rate of 101 bpm, blood pressure 102/66 mmHg, respiratory rate of 24
breaths/min, oxygen saturation of 92% on room air and temperature of 37.8ºC :
Transfer factor: raised
Chest x-ray : multifocal airspaces consolidation noted
What is the most likely diagnosis:
A) Asthma exacerbation
B) Exacerbation of pulmonary fibrosis
C) Pneumonia
D) Pulmonary haemorrhage
E) Pulmonary oedema
9. Which one of the following is the main criteria for determining whether a patient with
chronic obstructive pulmonary disease (COPD) should be offered long-term oxygen
therapy:
A) Two ABGs measurement with pO2< 6.3kPa
B) One ABGs measurement with pO2< 7.7kPa
C) One ABGs measurement with pO2< 8.3kPa
D) One ABGs measurement with pO2< 8.0kPa
E) Two ABGs measurement with pO2< 7.3kPa
10. A 71-year-old man is admitted with a four-hour history of acute shortness of breath
and pleuritic chest pain. He has a past medical history of chronic obstructive
pulmonary disease. A chest x-ray is performed on admission which shows the
following:
Chest x-ray: A 3cm pneumothorax in the right lung
The decision is made to insert a chest drain.

What are the correct landmarks for this procedure:

A) Anterior chest wall, 2nd intercostal space
B) Base of axilla, lateral pectoralis major, 2nd intercostal space, anterior latissimus dorsi
C) Base of axilla, midclavicular line, 2nd intercostal space, anterior latissimus dorsi
D) Base of axilla, lateral pectoralis major, 5th intercostal space, anterior latissimus dorsi
E) Base of axilla, midclavicular line, 5th intercostal space, anterior latissimus dorsi

11. Which one of the following markers is most useful for monitoring the progression of
patients with chronic obstructive pulmonary disease?
A) FEV1/FVC ratio
B) Lifestyle questionnaire
C) Oxygen saturations
D) FEV1
E) Number of exacerbations per year
12. The parents of a 3-year-old boy with cystic fibrosis ask for advice. They are
considering having more children. Neither of the parents have cystic fibrosis. What is
the chance that their next child will be a carrier of the cystic fibrosis gene?
A) 50%
B) 100%
 C) 1 in 25
D) 25%
E) 66.6%
13. A 57 year old man presents with gradually worsening dyspnoea on exertion for the
past 6 months. He has 40 pack year history of tobacco use. He has noted minimally
productive cough that worse in the morning for the past 2 years, otherwise he is
healthy without any co-morbids. On examination he is comfortable at rest with SpO2
93%. His neck veins are flat and his cardiac examination is normal. He has no basilar
crackles but breath sounds are distant bilaterally. Chest x-ray shows hyperexpansion
without cardiomegaly or pulmonary congestion. What is the most important next
step in staging patient’s illness:
A) Arterial blood gases
B) CT scan of chest
C) Exercise tolerance test with measurement of maximum oxygen consumption
D) Echocardiogram with estimation of RV pressure
E) Spirometry
14. A 30-year-old female with a past history of asthma presents to the Emergency
Department with pleuritic chest pain. Chest x-ray shows a right-sided pneumothorax
with a 1.5cm rim of air and no mediastinal shift. What is the most appropriate
management:
A) Admit for 48 hours observation
B) B. Intercostal drain insertion
C) C. Aspiration
D) D. Discharge
E) E. Immediate 14G cannula into 2nd intercostal space, midclavicular line
15. A 79-year-old man is admitted with a right lower lobe pneumonia. As well as showing
consolidation there also appears to be a moderate sized pleural effusion on the same
side. An ultrasound guided pleural fluid aspiration is performed. The appearance of
the fluid is clear and is sent off for culture. Whilst awaiting the culture results, which
one of the following is the most important factor when determining whether a chest
tube is placed:
A) Glucose of pleural fluid
B) LDH of the pleural fluid
C) pH of the pleural fluid
D) Potassium of the pleural fluid
E) Protein of the pleural fluid

16. A30 years old female seen in the clinic presented with nonspecific symptoms fatigue
Weight loss myalgia and joint pain over the past 03 months. She also recently
develop shortness of breath and cough as well as purplish nodular skin lesion on her
anterior lower limb. Serum ACE level raised and chest X-ray shows bilateral hilar
lymphadenopathy and pulmonary infiltrates. What prognostic statement is this with
patient condition:
A) Most patient only get better but only with treatment
B) Most patient get better even without treatment
C) Only minority of patient get better even with treatment
D) Only minority of patient get better without treatment
E) there is no treatment that improves progression

17. A 50 year old male patient with long standing chronic obstructive pulmonary disease
presents with insidious onset of aching in the distal extremities particularly wrists
bilaterally. He reports 10-lb weight loss. The skin over wrists is warm and
erythematous and there is bilateral clubbing. Plain film of the forearm reveals
bilateral periosteal thickening but no joint abnormality. Which of the following is
most appropriate next step in management of this patient:
A) Start Vancomycin
B) Aspirate both wrists
C) Obtain chest x-ray
D) Begin methotrexate therapy
E) Obtain erythrocyte sedimentation rate
18. A 63 year old man who has been previously healthy is admitted to hospital with a
2day history of cough, fever and right sided pleuritic chest pain. Chest x-ray shows
consolidation of right lower lobe and free flowing right sided pleural effusion.
Thoracentesis is performed and pleural fluid has the following characteristics:

Cell count: 1110/mm3

Glucose : 75mg/dl ( serum glucose: 85mg/dl )

Protein : 4.0mg/dl ( serum protein 7.0mg/dl )

LDH : 400U/L ( serum LDH 200U/L )

pH of fluid : 7.35

What is the pathogenesis of the pleural effusion:

A) Increase in hydrostatic pressure

B) Decrease in oncotic pressure
C) Increase permeability of visceral pleural membrane
D) Bacterial infection of pleural space
E) Haemorrhage into pleural space
19. An obese 50 year old woman presents with insomnia, daytime sleepiness and fatigue.
During sleep study she had recurrent episodes of arterial desaturation about 30
events per hour with evidence of obstructive apnoea. Which of the following is the
treatment of choice for this patient:
A) Nasal continuous positive airway pressure
B) Uvulopalatopharngeoplasty
C) Hypocaloric diet
D) Tracheostomy
 E) Oxygen via nasal cannula
20. A 35 year old woman complain of slowly progressive dyspnoea. Her history is
otherwise negative and there is no cough, sputum production, pleuritic chest pain or
thrombophlebitis. She has taken appetite suppressants at different times. On
examination there is jugular venous distention , a palpable right ventricular lift and
loud P2 heart sound. Chest x-ray shows clear lung fields and oxygen saturation of
94% on room air. ECG shows right axis deviation. A perfusion lung scan is normal with
no segmental deficits. Which of the following is most likely diagnosis:
A) Pulmonary arterial hypertension
B) Recurrent pulmonary emboli
C) Right to left cardiac shunt
D) Interstitial lung disease
E) Left ventricular diastolic dysfunction
21. Which one of the following would shift the oxygen dissociation curve to the left:
A) Acidosis
B) Carboxyhemoglobin
C) Raised pCO2
D) Pyrexia
E) Raise 2,3 DPG Level
22. Which one of the following is least associated with Kartagener's syndrome:
A) Male subfertility
B) Recurrent sinusitis
C) Dextrocardia
D) Malabsorption
E) Bronchiectasis
23. A 41-year-old man presents to his doctor with a persistent cough. This has been
present for the past six months and for the past two weeks he has been coughing up
blood on a daily basis. He also feels more short-of-breath when exerting himself than
normal. He is a non-smoker and has no past medical history of note. On examination
he is noted to have reduced air entry in the right upper zone. A chest x-ray shows a
right upper lobe collapse and a subsequent bronchoscopy demonstrates a cherry-red
lesion in the right superior lobar bronchus. What is the most likely diagnosis?
A) Small cell lung carcinoma
B) Large cell lung carcinoma.
C) Lung carcinoid
D) Broncheoalveolar carcinoma
E) Bronchial adenocarcinoma
24. A 35-year-old female with sarcoidosis is started on a course of prednisolone. Which
one of the following is a suitable indication for commencing steroid therapy in such
patients?
A) Bilateral hilar lymphadenopathy
B) Arthralgia
C) Hypercalcemia
D) Erythema nodosum
 E) Serum ACE>120u/L
25. Asthma is:
A) Chronic reversible
B) Acute reversible
C) Chronic irreversible
D) Acute irreversible
E) NOT

ALL THE BEST