Respiratory system Questions

06 April 2020 11:09

Q1. A 32-year-old woman presents at 16 weeks of gestation with a dry cough that is worse at night
for the last 4 weeks. She wakes up coughing once per night on average. She also complains of
breathlessness and wheeze with exertion. She is known to have asthma and takes a salbutamol
inhaler. Recently she has been using the inhaler up to three times per day. Examination shows that
she is well at rest, and there is wheeze scattered throughout the chest. Peak flow is 65% of
predicted. What is the most appropriate first-line management?
A. Amoxicillin 500 mg three times daily for 7 days
B. Beclomethasone 200 microgram inhaler twice daily
C. Prednisolone 40 mg daily for 5 days
D. Salbutamol nebuliser 2.5 mg as required
E. Salmeterol inhaler 50 micrograms twice daily

Q2. A 23-year-old woman who is 11 weeks pregnant presents to her GP because her grandfather has
recently been diagnosed with pulmonary tuberculosis. He lives in Pakistan and she stayed with him
about a month ago. She has never been vaccinated against tuberculosis, and is concerned that she
may be at risk. She is fit and well with no past medical history. What is the most appropriate next
step in her management?
A. Chest X-ray
B. Early morning sputum sample for microscopy and culture
C. Interferon gamma release assay
D. Mantoux test
E. Vaccination with Bacillus Calmette-Guérin vaccine

Q3. A 30-year-old woman presents at 38 weeks of gestation with fever, myalgia, arthralgia, cough
and dyspnoea that began yesterday evening. She also has symptoms of vomiting. She was previously
fit and well. On examination she has a respiratory rate of 28, oxygen saturations of 90% on air, and
her pulse is 110. Blood pressure is 120/70 mmHg. Her chest has widespread wheeze and reduced air
entry. Chest X-ray shows patchy consolidation throughout both lungs. What is the most appropriate
initial treatment?
A. Co-amoxiclav 1.2 g three times daily and clarithromycin 500 mg twice daily intravenously
B. Oseltamivir 75 mg twice daily orally for 5 days
C. Oxygen 15 litres/minute via a non-rebreathe mask
D. Zanamivir 10 mg twice daily inhaler for 5 days
E. Zanamivir 600 mg twice daily intravenously for 5 days

Q4. A 23-year-old primigravida attends the emergency department at 34 weeks of gestation with
shortness of breath and wheeze. She has a history of asthma for which she takes salbutamol,
salmeterol and beclometasone inhalers.
She complains of symptoms of the common cold but has become increasingly breathless despite
increased used of her salbutamol inhalers.

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 increased used of her salbutamol inhalers.
The baby is moving well and the pregnancy has been uncomplicated. On examination, her pulse is
118 bpm, respiratory rate is 32, oxygen saturation is at 92% and she is unable to complete sentences
in one breath. Auscultation reveals widespread wheeze.
What is the most important initial treatment?
A. Intravenous magnesium sulphate
B. Nebulised ipratropium bromide
C. Nebulised salbutamol
D. Oral prednisolone
E. Supplemental oxygen

Q5. Sarah is a 38-year-old primigravida who works as a nursery nurse. She has no significant past
medical history. She smokes ten cigarettes per day. She presents at 32 weeks of gestation with fever,
cough and increasing breathlessness. On examination, her statistics are as follows:
• pulse = 95 bpm
• blood pressure = 105/68 mmHg
• temperature = 38.1°C
• saturations = 94% on air.
Auscultation shows reduced air entry and crackles in the left lower zone. Her X-ray shows
consolidation in the left lower lobe.
What is the most likely causative organism?
A. Haemophilus influenzae
B. Influenza A
C. Staphylococcus aureus
D. Streptococcus pneumoniae
E. Varicella zoster virus

Q6. A 25-year-old nulliparous woman is referred to the obstetric medicine clinic at 14 weeks of
gestation with a history of asthma. She takes an inhaled corticosteroid twice daily (400 micrograms)
and reports using her short-acting beta-agonist inhaler twice a month. She has had no recent
hospital admissions due to exacerbations of her asthma, and has never been admitted to ICU.
She is extremely concerned regarding the maternal and fetal effects of her asthma and medication.
Which of the following is the most important advice regarding her ongoing management?
A. Add a long-acting beta-agonist (LABA) to her current medical management
B. Avoid oral steroid therapy due to the increased risk of congenital malformations
C. Continue with her current medical regimen and reassure that there are no adverse effects of
inhaled steroids or short-acting beta-agonists
D. Leukotriene inhibitors should be commenced as the next step in the event of a deterioration
in her asthma symptoms
E. Regular antenatal clinic review as she is at increased risk of fetal growth restriction and pre-
eclampsia

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 Q7. A 25-year-old nulliparous woman attends the labour ward at 32 weeks of gestation. She is a
known asthmatic and has recently had a 'chesty cough'. She has been non-compliant with her
inhalers (inhaled corticosteroids and long acting beta agonist) for fear of fetal side effects. She has a
widespread wheeze on auscultation of the lung fields.
Her vital signs are as follows:
• temperature = 36.9°C
• pulse = 110 bpm
• BP = 105/65 mmHG
• respiratory rate = 10/min
• SaO2 is 92% (on 5l O2).
The arterial blood gas (ABG) results are as follows:
• pH 7.32 (7.35–7.45)
• pO2 7.8 kPa (>10.6 kPa)
• pCO2 7.2 kPa (4.7–6.0 kPa)
• BE –4.2 (+/– 2).
What is the most appropriate next stage of her management?
A. Chest X-ray
B. Immediate review by medical emergency team/senior anaesthetist
C. Prescribe 20 mg prednisolone (once daily for 7 days) and oral co-amoxiclav 625 mg 8-hourly
D. Repeat ABG to monitor pH
E. Transfer to obstetric theatre for emergency caesarean section

Q8. A 28-year-old multiparous woman at 37 weeks of gestation attends her GP surgery with a rash
(developed 6 hours ago) and feeling unwell – her toddler was diagnosed with chickenpox 1 week
ago. She has no recollection of previous varicella infection and the booking bloods revealed varicella
IgG was negative.
Her past medical history includes moderate asthma, with an infective exacerbation treated with
steroids and oral antibiotics 4 weeks ago.
Which of the following is the most appropriate next step in her management?
A. Commence oral aciclovir 800 mg five-times a day for 5–7 days and organise antenatal clinic
follow up following completion of treatment
B. Induction of labour within 72 hours in a barrier nursed room
C. Refer to fetal medicine clinic for detailed ultrasound examination to exclude signs of fetal
varicella syndrome
D. Refer to hospital for assessment and commence oral aciclovir 800 mg five-times a day for
5–7 days
E. Varicella zoster immunoglobulin within the next 10 days

Q9. A 31-year-old woman at 38 weeks of gestation presents with purulent sputum, chest pain and
cough.
Her pulse is 110/min, respiratory rate is 24/min and temperature is 39°C.

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 Her pulse is 110/min, respiratory rate is 24/min and temperature is 39°C.
Her chest X-ray shows consolidation.
What is the most likely diagnosis?
A. Acute bacterial sinusitis
B. Allergic rhinitis
C. Asthma attack
D. Pneumonia
E. Pneumothorax

Q10. A woman developed severe pre-eclampsia at 35 weeks of gestation and her labour was
induced. She needed an emergency caesarean section for suspected fetal compromise. She
developed sudden onset of breathlessness 6 hours post delivery. She has no history of chest pain,
palpitation or cough and no past history of chest or cardiac disease. She is on labetalol 200 mg TDS.
On examination she looks unwell; her heart rate is 100/min, BP is 130/80 mmHg, respiratory rate is
28/min, SpO2 is 94% on air and she is apyrexial. There are reduced breath sounds on chest
auscultation and normal heart sounds. There is poor urine output. There is no calf tenderness.
The results of the investigations are:
• haemoglobin = 95 gm/l
• platelet count = 110 x 109/l
• raised urea
• raised creatinine
• normal ALT
• low albumin
• CXR = bilateral infiltrates
• ABG on air = respiratory failure, PaO2 (kPa):FiO2= 24
• CTPA = no evidence of pulmonary embolism
• ECHO = pulmonary oedema with PCWP 15 mmHg; no evidence of cardiomyopathy.
She was reviewed by critical care team and a diagnosis of Acute Respiratory Distress Syndrome
(ARDS) was made.
Which of the following is not part of the diagnostic criteria for ARDS?
A. Acute onset of respiratory failure with risk factors
B. A pulmonary capillary wedge pressure <19 mmHg or no evidence of left atrial hypertension
C. Bilateral chest radiographic infiltrates
D. Impaired oxygenation manifested by a PaO2 (kPa)/FiO2 <27
E. Impaired oxygenation manifested by a PaO2 (kPa)/FiO2 <40

Q11. A 25-year-old lady presents to the GP 10 weeks into her first pregnancy. She has recently
arrived from Belarus. She complains of night sweats and a productive cough. She has lost 2kg since
the beginning of the pregnancy. What is the most appropriate investigation?
A. Chest X-ray
B. CT Chest

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 B. CT Chest
C. Early morning sputum sample for TB microscopy and culture
D. Mantoux test
E. Serum rapid diagnostic nucleic amplification test

Q12. An obese 38 year old primigravida undergoes an emergency caesarean section under general
anaesthetic for fetal bradycardia. Two days later she becomes acutely unwell with pyrexia,
tachycardia, tachypnoea and a productive cough. Chest X-ray shows left lower lobe consolidation.
What is the most likely causative organism?
A. Enterococcus
B. Haemophilus influenza
C. Pseudomonas aeruginosa
D. Staphylococcus aureus
E. Streptococcus pneumoniae
Q13. The following statements are true about pregnancy in women with chronic renal disease
except;
A. Successful obstetric outcome is rare when pre-pregnancy creatinine values exceed 125
micromol/l
B. Pre-existing hypertension is associated with a poor outcome, even with minimal renal
dysfunction
C. A decrement around 15-20% in renal function is to be anticipated near term
D. Termination of pregnancy should be considered for women with polyarteritis nodosa
E. The livebirth outcome for women on dialysis is approximately 70%

Q14. The following statements about pregnancy in women with renal allografts are true except;
A. The majority (more than 90%) of pregnancies in allograft recipients are successful
B. Pregnancy appears to have minimal impacts on the long-term graft prognosis
C. Women with allografts should be advised to wait about 4 years from transplantation before
attempting to become pregnant
D. Newer immunosuppressive treatments, such as cyclosporine, are potentially nephrotoxic
E. Vaginal delivery should be considered as the norm, with caesarean section reserved for
obstetric reasons

Q15. You are asked to review a 32-year-old woman in the antenatal clinic who is currently 13 weeks
into her fourth pregnancy. She had an uncomplicated vaginal delivery at term 7 years ago followed
by two first-trimester miscarriages. She was diagnosed with IgA nephropathy and needed a renal
transplant (allograft) 2 years ago. There is no other medical and no surgical history of note. She is
not a smoker. Currently, she is on prednisolone, azathioprine and tacrolimus. Her BMI is 26, her
blood pressure is 130/84 mmHg and she is not on any antihypertensive treatment. Her recent blood
test results are:
• haemoglobin = 10.2 g/dl
• serum albumin = 32 g/dl

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• serum albumin = 32 g/dl
• serum creatinine level = 110 micromol/l
• eGFR = 53
• urine protein:creatinine ratio = 15
Her CMV titres were negative 4 months ago.
Which of the following statement is most appropriate in her case regarding pregnancy outcome and
management?
A. Prophylactic antibiotics are required to cover labour and any surgical procedure, including
episiotomy
B. Prophylactic anticoagulants should be started immediately
C. She will need serum azathioprine and tacrolimus levels every 2–4 weeks
D. The chance of graft rejection is 20%
E. The chance of successful obstetric outcome is 97%

Q16. You are asked to review 21-year-old woman in the maternity assessment unit who is currently
at 26 weeks of gestation. She had been feeling unwell for the last 24 hours and presented with fever
with rigor, right loin pain, urinary frequency and vomiting. There is no history of abdominal
tightenings or vaginal loss and she reports normal fetal movements.
On examination:
• pulse rate = 106 bpm
• blood pressure = 110/70 mmHg
• respiratory rate = 16 breaths per minute
• temperature = 38.2ºC
• moderate right renal angle tenderness
• well-grown baby with normal fetal heart rate on auscultation with hand-held Doppler.
Urinalysis reveals ++ proteinuria, ++ red cells, +++ leucocytes and nitrite positive.
You have made a diagnosis of pyelonephritis.
Which of the following statement is correct regarding pyelonephritis in pregnancy?
A. Complicates 5–10% of pregnancies
B. Management in pregnancy consists of hospital admission, with hydration and treatment
with broad-spectrum intravenous antibiotics
C. More common in pregnancy due to physiological dilation of the lower renal tract
D. Regular screening for asymptomatic bacteriuria should be offered to these women for the
remainder of their pregnancy because the recurrence rate of pyelonephritis is up to 40%
E. Women who do not respond to intravenous antibiotics within 24 hours should be offered
imaging of the urinary tract by ultrasound to exclude any abnormalities

Q17. You are asked to review the renal scan for Mrs Smith who is currently at 35 weeks of gestation
and has presented with right loin pain, which started 1 week ago. She is haemodynamically stable,
apyrexial with minimal right renal angle tenderness. Urinalysis is negative. Her renal function is
normal, with serum urea at 3.4 mmol/l and serum creatinine at 40 micromol/l. There is mild
hydronephrosis of right kidney, probably secondary to gravid uterus, but it is an otherwise normal-
looking kidney on renal scan.

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 looking kidney on renal scan.
Which of the following statement is correct regarding physiological renal adaptation to pregnancy?
A. Approximately 55% of pregnant women develop some oedema – especially towards term –
owing to physiological sodium and water retention
B. Creatinine clearance rises by approximately 10%
C. Creatinine values of 80 micromol/l or more during pregnancy suggest renal dysfunction and
should prompt further evaluation
D. Renal plasma flow increases up to 50% by the second trimester of pregnancy
E. The 'physiological hydronephrosis' of pregnancy can be dismissed as normal up to a
pelvicalceal diameter of approximately 3 cm

Q18. Mrs S is referred by her GP to the antenatal clinic for her booking visit as she had a caesarean
section in the past. She is otherwise fit and healthy with no significant past medical history. She is
currently 11 weeks pregnant by her dating scan. She reports no problems with her pregnancy so far.
You were looking through her booking bloods and MSU results done by her midwife 5 days ago. The
MSU showed growth of E. coli >105 colony forming units per millilitre. She denies any urinary
symptoms.
You have made a diagnosis of asymptomatic bacteriuria.
Which of the following statement is correct regarding asymptomatic bacteriuria in pregnancy?
A. All pregnant women should be offered screening for asymptomatic bacteriuria with urine
dipstick tests in early pregnancy as if untreated can lead to serious infection
B. Complicates 15–20% of pregnancies
C. Following successful treatment, 30% of women will have a relapse of bacteriuria
D. If untreated, 5% of women will develop acute pyelonephritis
E. There is no association with preterm rupture of membranes

Q19. You are asked to review a 36-year-old woman in a joint obstetric–renal clinic who is currently
16 weeks pregnant into her second pregnancy. She had an uncomplicated caesarean section at term
for breech presentation 13 years ago.
She was diagnosed with reflux nephropathy and has been on haemodialysis for last 2 years. There is
no other medical and surgical history of note. She is not a smoker. Currently she is on calcium and
vitamin D supplements, erythropoietin injection and pregnancy vitamins.
Her BMI at her booking visit is 20. Her BP is 120/78 mm Hg and she is not on any antihypertensives.
A recent blood test showed:
• haemoglobin = 102 gm/l
• serum potassium level = 4.8 mmol/l
• serum creatinine level = 210 micromol/l
• serum urea level = 10 mmol/l
• eGFR = 10 ml/min/1.73m2
• normal bone profile
• normal plasma bicarbonate levels
• urine protein creatinine ratio: 95.

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 Which of the following statement is most appropriate in her case regarding pregnancy outcome and
management?
A. Chance of successful pregnancy outcome is 30% with both haemodialysis and CAPD
(continuous ambulatory peritoneal dialysis)
B. Dialysis is usually associated with oligohydramnios
C. Duration of haemodialysis must be increased to more than 20 hours/week for improved
outcome
D. Maintain serum urea at 25–30mmol/L
E. Pregnancy rate is approximately 1 in 400 women per year

Q20. You are asked to review a 28-year-old woman in the obstetric-renal clinic with chronic kidney
disease stage 3 secondary to reflux nephropathy and recurrent urinary tract infections (UTIs). She
has a BMI of 22, is a non-smoker and is planning her first pregnancy.
She has hypertension that is well controlled with ramipril. She takes nitrofurantoin 100 mg once
daily at night as antibiotic prophylaxis for her recurrent UTIs.
Her blood pressure is 135/85 mmHg and on urinalysis she has proteinuria 3+. Her most recent serum
creatinine is 150 and her eGFR is 38. Her most recent protein:creatinine ratio was 350 mg/mmol
creatinine.
What is the most appropriate medication addition or change at this stage in her prepregnancy
planning?
A. A 3-day treatment course of broad spectrum antibiotics should be prescribed for the
treatment of a symptomatic lower urinary tract infection (cystitis)
B. Antenatal thromboprophylaxis with low molecular weight heparin should be considered
from 28 weeks of gestation
C. Folic acid 5 mg once daily should be prescribed to reduce the risk of neural tube defects
D. Nitrofurantoin should be converted to an alternative antibiotic as it is associated with the
development of congenital abnormalities
E. Ramipril should be continued preconception and during the first trimester due to its
renoprotective effect

Q21. A 30-year-old woman is seen in the antenatal clinic. She is 24 weeks into her first pregnancy.
She has a history of recurrent urinary tract infections outside of pregnancy. Renal ultrasound and
baseline renal function tests were normal. She has been treated for three urinary tract infections in
pregnancy so far. She is allergic to nitrofurantoin. The most recent MSU result shows:
• white blood cells = 277/ul (0–40)
• red blood cells = 4/ul (0–44)
• epithelial cells = 17/ul (0–55)
Culture: >105 organisms/ml of Enterococcus species:
• co-amoxiclav = S
• cefalexin = R
• ciprofloxacillin = R
• pivmecillinam = R
• nitrofurantoin = S
• trimethoprim = S

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• trimethoprim = S
You decide that prophylactic antibiotics are indicated. What is the most appropriate antimicrobial
regimen to prescribe?
A. Cephalexin 125 mg nocte
B. Co-amoxiclav 375 mg nocte
C. Co-amoxiclav 375 mg twice daily
D. Trimethoprim 100 mg nocte
E. Trimethoprim 200 mg twice daily

Q22. For a woman with phenylketonuria , preconceptional target levels of Phe should be
A. 450-600
B. <600
C. 120-360
D. 400-500
E. 220-400

Q23. A 28 yr old woman is 18 weeks pregnant and is a known to hav ephenylketonuria, all are
included in her management plan except;
A. They should undergo dried blood spot Phe level testing three times per week,
B. Tyr is required in supplementary form after 28 weeks of gestation.
C. The risk of congenital heart defects is quoted at 7–10%
D. Neonates born to mothers with PKU should be offered PKU screening on day 5, as per the
routine national screening programme.
E. Common clinical manifestations of PKU are IUGR, microcephaly, congenital heart disease and
facial dysmorphism,

Options
Q24-26
A. Chlamydia pnumonie
B. H influenza
C. Psudomonas auruginosa
D. Staph aureus
E. Streptococcus pneumoni
F. Influenza virus
G. Klebsiella pneumoni
For each case select most probable causative organism
Q24. A 27-year-old woman presents at 24 weeks of gestation with cough, shortness of breath,
wheeze, anorexia and weight loss. She is known to have cystic fibrosis but there is no other
significant history. Examination shows widespread wheeze and crackles. A chest X-ray shows a
ground glass appearance, more so in the upper lobes
Q25. A 27-year-old smoker presents at 24 weeks of gestation with fever, shortness of breath and a
cough productive of green sputum. She denies any chest pain, has no history of respiratory disease
and has no significant travel history. Examination shows reduced air entry and coarse crackles at
the left base. A chest X-ray shows left lower lobe collapse/consolidation

Q26. A 27-year-old smoker presents at 24 weeks of gestation with fever, shortness of breath,
cough, vomiting and watery diarrhoea. She feels generally unwell with arthralgia and myalgia. She

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cough, vomiting and watery diarrhoea. She feels generally unwell with arthralgia and myalgia. She
has no significant past medical history and no travel history. Examination shows widespread
wheeze with reduced air entry at both bases. A chest X-ray shows poorly-defined patchy areas of
consolidation throughout both lung fields
Options
Q27-32

A. Infective endocarditis
B. Atypical pneumonia
C. Amniotic fluid embolism
D. Anemia
E. Asthama
F. Bacterial pneumonia
G. Viral pneumonia
H. Mitral stenosis
I. Peripartum Cardiomyopathy
J. Tuberculosis

Q27. A 16-year-old presents at 32 weeks of gestation with shortness of breath, haemoptysis and
night sweats. She moved to the UK from Afghanistan 1 year ago. The symptoms have been present
for 1 month and her GP has tried two different courses of antibiotics. The chest X-ray shows a
normal-sized heart.
Q28. A 39-year-old primigravida is induced at 41 weeks for reduced fetal movements. Following
prostaglandin administration, she develops uterine hyperstimulation. The cardiotocogram
becomes pathological and an emergency caesarean section is performed. During recovery, she
complains of breathlessness and is noted to be tachycardiac, hypotensive and cyanotic. Blood
tests show disseminated intravascular coagulation and a chest X-ray shows bilateral ground glass
appearance.
Q29. A 25-year-old with HIV presents with cough, fever, breathlessness and a generalised vesicular
rash which began 2 days ago. She is 14 weeks pregnant. On auscultation, there are a few scattered
crackles. Chest X-ray shows multiple ill-defined small nodules throughout the lungs.
Q30. A 38-year-old obese para 4 is admitted at 37 weeks of gestation with increasing
breathlessness, palpitations and a dry cough. She complains of orthopnoea. On admission her
pulse is 105 with blood pressure 148/96 mmHg. ECG shows sinus tachycardia with non-specific ST-
segment changes.
Q31. A 23-year-old woman who is known to be infected with HIV attends with productive cough,
fever and dyspnea. On examination she is unwell with signs of shock. There are crackles heard
over the left lower lobe and there is a dull percussion note. Blood cultures show Gram-positive
cocci.
Q32. A 36-year-old primigravida presents at 25 weeks of gestation with fever, productive cough
and breathlessness. She has recently been on holiday to Spain. A chest X-ray shows consolidation
in the right lower lobe. Sputum is sent for Gram stain and culture but is negative.

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