European Respiratory Society
Self-Assessment in Respiratory Medicine (out of print)

This book has been superseded by a newer edition.

Self-Assessment in Respiratory Medicine is an invaluable tool for any practitioner of adult respiratory medicine. The 111 multiple-choice questions cover the full breadth of the specialty, using clinical vignettes that test not only readers’ knowledge but their ability to apply it in daily practice. The questions have been compiled and tested by the ERS Adult HERMES Examination Committee specially for this book, making it the perfect revision aid for candidates for the European Diploma, as well as any specialists in respiratory medicine and other fields who wish to develop and improve their understanding.

  • European Respiratory Society
  1. Page iv
  2. Page vii
  3. Page 1
    1. Page 1

      A 33-yr-old female in the second trimester of pregnancy presents to the emergency room due to progressive dyspnoea for the past 48 h. She has a history of asthma. Her BMI is 40.5 kg·m−2, heart rate is 130 beats·min−1 and blood pressure is 110/75 mmHg. Breath sounds are diminished on both lung bases. The left calf is swollen. Her chest radiography is normal. Arterial blood gas analysis shows: PaO2 55 mmHg (7.315 kPa), PaCO2 30 mmHg (3.99 kPa) and pH 7.48 in room air.

      Which of the following is the next diagnostic procedure?

    2. Page 3

      Which of the following statements about the diagnosis of pleural mesothelioma is/are correct?

    3. Page 5

      Which one of the following statements concerning interventions aimed at promoting smoking cessation in patients with COPD is not correct?

    4. Page 7

      A 54-yr-old male is referred to you because of an unexpected finding on a chest CT performed after blunt chest trauma during a car accident. The lesion seen on the CT (below) extends about 1.5 cm above and 1.5 cm below the level shown in the figure. On consultation, the patient has no respiratory complaints but reports that he felt a little bit tired during the last month and had less energy. Walking was more difficult for him. His past medical history was uneventful. On physical examination no abnormalities were found. Haematology and chemistry including β-human chorionic gonadotropins (β-hCG), alpha fetoprotein and thyroid stimulating hormone (TSH) were normal.

      Which one of the following is the next most appropriate step?

    5. Page 9

      A 74-yr-old previously healthy male presents to the emergency department with new onset of dyspnoea on mild exertion and a 10-day history of right calf swelling. He has fainted twice this morning, his blood pressure is 85/55 mmHg; his heart rate is 130 beats/min and regular. Arterial blood gases reveal a PaO2 56 mmHg (7.448 kPa), PaCO2 of 28 mmHg (3.724 kPa) and pH of 7.47. Brain natriuretic polypeptide (BNP) and D-dimer are both elevated three-fold above the normal limit. A CT angiogram (angio-CT) confirms massive embolism of the common pulmonary artery reaching through the pulmonary valve.

      Which of the following is the appropriate initial therapy for this patient?

    6. Page 9

      A 25-yr-old female has suffered severe peripartum bleeding. She received 20 packed red blood cell transfusions and five fresh frozen plasma transfusions. After delivery, she had to be intubated and was placed on mechanical ventilation for respiratory failure. She is deeply sedated but occasionally triggers the ventilator. On the third day of mechanical ventilation, her arterial blood gas analysis shows a PaO2 50 mmHg (6.65) kPa, PaCO2 47 mmHg (6.251 kPa) and pH of 7.33. The ventilator settings are: inspiratory oxygen fraction (FIO2) 0.8; assist control with tidal volume (VT) 420 mL, frequency 18 breaths/min; inspiratory time (tI)/expiratory time (tE) 0.3; and peak end-expiratory pressure (PEEP) 10 cmH2O. Plateau pressure is 32 cmH2O. She weighs 60 kg. Chest radiography reveals bilateral diffuse pulmonary infiltrates.

      What would be the most appropriate change in the ventilator settings for this patient?

    7. Page 11

      A 58-yr-old male smoker with a smoking history of 50 pack-yrs presents to the emergency department after an episode of acute chest pain and shortness of breath. At admission he states that the pain has disappeared and he denies dyspnoea at rest. On physical examination, there is marked reduction of the breath sounds in the left hemithorax. The patient’s heart rate is 110 beats/min without any other abnormal clinical findings. His chest radiograph is shown below. Recent lung function tests had revealed an FVC of 70% predicted, an FEV1 of 45% pred and a TLCO of 65% pred.

      What is the most appropriate next step in the management of this patient?

    8. Page 13

      A 39-yr-old female presents with painful erythema nodosum. Her physical examination is unremarkable and her SpO2 on room air is 98%. Her chest radiograph shows bilateral hilar lymphadenopathy. Spirometry reveals an FEV1 of 79% predicted, an FVC of 89% predicted and an FEV1/FVC ratio of 77%, with a TLCO of 82% predicted.

      Which one of the following would be the most appropriate next step?

    9. Page 13

      Which of the following statements regarding manifestations and treatment of rheumatoid arthritis (RA) is/are correct?

    10. Page 15

      A 28-yr-old female complains of a 1-week history of severe hacking dry cough, slight dyspnoea and weakness. On examination, she is mildly unwell, but fully orientated and not cyanosed. However, she is pyrexial, pale and slightly jaundiced. The chest is clear on auscultation but the radiograph shows patchy, bilateral bronchopneumonic infiltrates. A full blood cell count shows normochromic anaemia with Hb of 9 g·dL−1 and neutrophil leukocytosis. Liver function tests show mild elevation of unconjugated bilirubin and raised lactate dehydrogenase (LDH). Blood urea and electrolytes are normal. There is no proteinuria.

      Which of the following investigations would be most likely to provide a diagnosis?

    11. Page 17

      Which of the following statements regarding treatment of sleep-related breathing disorders is correct?

    12. Page 19

      A 43-yr-old male complains of sudden bilateral chest pain, aggravated by inspiration and accompanied by malaise and slight fever. Physical examination shows some tenderness on both sides of the chest, but normal breath sounds. His chest radiograph appears normal, but ultrasound reveals small bilateral pleural effusions. The patient reports that, 1 week ago, one of his children was admitted to the hospital with acute meningitis.

      Which of the following is the most likely micro-organism causing his illness?

    13. Page 19

      A 35-yr-old English female with a 3-month history of lethargy and increasing dyspnoea went on holiday to Mallorca, Spain where she became unwell with nausea, vomiting, polyuria and confusion. A chest radiograph showed diffuse shadowing with bilateral hilar lymphadenopathy.

      Which one of the following investigations would be most useful in guiding her acute management?

    14. Page 21

      A 34-yr-old asthmatic female comes to the emergency room with progressive dyspnoea and non-productive cough over the past 3 days. Her best recorded peak expiratory flow is 60% and she has a SpO2 of 90%. She has stopped taking inhaled corticosteroids because she is 27 weeks pregnant and does not feel comfortable receiving medication while she is pregnant. She has been having mild symptoms for weeks. Now the symptoms have been getting worse and she has been waking at night for the past 10 days. She feels breathless and although she has used her relief inhaler every day in the past week and 3 times in the last hour, she does not feel better.

      Which one of the following is the most appropriate initial treatment for this patient?

    15. Page 23

      A 44-yr-old female smoking patient works in a pet shop. In her leisure time, she sculpts stones but despite suffering from cough and dyspnoea on exertion, she never wears a particulate filter. Her lung function currently shows a FEV1/inspiratory vital capacity (IVC) ratio of 68% and a TLC of 85% pred. TLCO is 65% predicted. Her allergy test is positive for dust mites, and for cat and horse epithelial allergens. Bronchoalveolar lavage (BAL) fluid contains 180×106 cells per μL, with 8% lymphocytes, 8% neutrophils and 84% macrophages. Transbronchial biopsy was not representative. Which one of the following interventions may have caused the clinical improvement and change in the radiograph?

    16. Page 25

      A 45-yr-old male complains of dyspnoea on minimal exertion, orthopnoea and near fainting. In the past few years, the patient has reportedly suffered from several episodes of haematemesis and an oesophagogastroduodenoscopy had shown that this was due to oesophageal varices. On physical examination, he is pale, his blood pressure is 110/75 mmHg, heart rate is 74 beats/min and regular, and SpO2 in room air is 94%. There is a split second heart sound, pulmonary auscultation is normal, abdominal examination suggests ascites and he has bilateral lower limb oedema. Echocardiography reveals an estimated systolic pulmonary artery pressure of 45 mmHg and a left ventricular ejection fraction of 55%.

      Which of the following is the most likely diagnosis?

    17. Page 25

      A 53-yr-old male is diagnosed with small cell lung cancer (limited disease). His performance status is excellent (ECOG O) and he is offered treatment with a combination of cisplatin and etoposide for 4–6 cycles. He comes to you for a second opinion. Which of the following should you offer this patient?

    18. Page 27

      A 56-yr-old female suffers from obstructive apnoea/hypopnoea syndrome. On polysomnography, her AHI was 42 events·h−1 and her oxygen desaturation index (⩾4%) was 40 events·h−1. Due to discomfort with this treatment, she refused the proposed CPAP therapy, although a sleep study confirmed that her AHI was reduced to 5 events·h−1 by CPAP. Attempts to convince the patient to try nasal CPAP therapy again after adapting the mask and machine have been unsuccessful.

      Which one of the following alternative treatments is the most promising to relieve the symptoms in this patient?

    19. Page 29

      A 65-yr-old male is admitted to the hospital because of high fever and dyspnoea associated with purulent sputum. Physical examination reveals dullness on percussion on the right lower chest and rales on auscultation. Chest radiography shows a pneumonic infiltrate in the right upper lobe and a small pleural effusion. Thoracentesis is performed.

      Which of the following results of the pleural fluid analysis indicates the need for chest-tube drainage?

    20. Page 29

      A 60-yr-old homeless male is brought to the emergency department because of severe dyspnoea. The patient states that he can hardly walk anymore because of shortness of breath. This makes it difficult for him to purchase and carry his daily amount of two to three bottles of wine to his shelter. He occasionally smokes if he manages to get some cigarettes. Until he lost his home 10 yrs ago, he never smoked and only drank occasionally. His medical history is uneventful apart from tonsillectomy in childhood. During transfer from the ambulance stretcher to the hospital bed, he becomes cyanotic and more dyspnoeic as soon he is in upright position. The patient also has jaundice, digital clubbing and spider naevi. Physical examination shows some basilar wheeze. Cardiac auscultation is normal. The liver appears to be small; the spleen is of normal size and there are no signs of ascites or abdominal varices. Hepatojugular reflux is negative. Laboratory tests show moderately elevated liver enzymes (ALT 312 U·L−1) and normal CRP. Haemoglobin concentration is 10.1 g·dL−1 with a mean cellular volume of 107 fL. The leukocyte count is normal. PaO2 on room air in sitting position is 61 mmHg (8.113 kPa), PaCO2 is 32 mmHg (4.256 kPa) and pH is 7.42.

      What is the most likely diagnosis?

    21. Page 31

      A 45-yr-old female with a long history of mild asthma presents with cough, dyspnoea and fever of 18 days’ duration. On examination, her chest is clear but the chest radiograph shows bilateral peripheral infiltrates (below). Laboratory tests reveal an eosinophil count of 8,000 cells·mm−3, erythrocyte sedimentation rate of 65 mm in the first hour, mildly elevated total immunoglobulin E and weakly positive Aspergillus precipitins. The chest radiograph is shown below.

      Which one of the following is the most likely diagnosis?

    22. Page 33

      A 48-yr-old lorry driver suffers from excessive sleepiness and shortness of breath on minimal exertion. He has gained 35 kg in the last 10 yrs and now weighs 165 kg. The patient’s body mass index is 46 kg·m−2. His blood pressure is 135/90 mmHg and his pulse rate is 76 beats/min. He has bilateral leg oedema and neck vein distension. His second heart sound is accentuated. Lung auscultation is normal. An arterial blood gas analysis on room air reveals a PaO2 of 52 mmHg (6.9 kPa), PaCO2 of 65 mmHg (8.6 kPa), pH of 7.33, SpO2 of 87% and serum bicarbonate concentration of 33 mmol·L−1. A sleep study shows a mean nocturnal oxygen saturation of 83% and an AHI of 58 events·h−1, with predominantly obstructive apnoeas/hypopnoeas, some central apnoeas of up to 55 s in duration and several periods of rapid eye movement sleep-associated periods of hypoventilation with increases in PtcCO2. You decide to start the patient on nocturnal continuous positive airway pressure therapy via an oral–facial mask. After 4 weeks, the patient does not report a clear improvement in sleepiness. Therefore, you decide to change the mode of ventilation.

      Which one of the modes schematically depicted below is most appropriate?

    23. Page 35

      A 47-yr-old technician is evaluated for chronic cough and progressive dyspnoea on slight exertion. On pulmonary function testing, both FVC and FEV1 are 80% predicted, and diffusing capacity of the lung for carbon monoxide is 35% pred. Arterial blood gases show a pH of 7.45, PaO2 of 55 mmHg (7.315 kPa) and PaCO2 of 33 mmHg (4.389 kPa). The chest radiograph is remarkable for bilateral hilar enlargement and infiltrates of both lungs. Chest CT confirms bilateral hilar adenopathy and patchy lung infiltrates, predominantly of the upper lobes. A small pericardial effusion and small ascites around the liver are also noted. Bronchoscopy is performed. Bronchoalveolar lavage (BAL) reveals an elevated cell count of 760 cells·μL−1, with 6% neutrophils, 33% lymphocytes and 61% macrophages. Bacterial cultures of the BAL fluid remain sterile and no acid-fast bacilli are found. Mycobacterial cultures are pending. Transbronchial needle aspiration of the hilar lymph nodes demonstrates multiple noncaseating granulomas.

      What would be the most appropriate next diagnostic evaluation in this patient?

    24. Page 37

      In a 73-yr-old otherwise healthy heavy smoker with normal lung function, endobroncial biopsy of a tumour in the left lower lobe reveals nonsmall cell lung cancer. CT scans are shown below.

      Which one of the following is the most appropriate next action?

    25. Page 37

      A 38-yr-old black female is admitted to the hospital because of a 1-yr history of dyspnoea on exertion, mild fever and muscle fatigue. She has never smoked. On admission, her blood pressure is 115/70 mmHg, pulse rate is 125 beats/min and rhythmic, and respiratory rate is 26 beats/min. Erythema nodosum is detected on the extensor aspects of the lower legs. Auscultation reveals bilateral fine crepitation in the posterior chest middle fields. In a chest radiograph, unilateral hilar adenopathy and bilateral pulmonary infiltrates are detected. Hypercalcaemia and hypercalciuria are the only abnormal laboratory tests.

      Which of the following statements is most appropriate?

    26. Page 39

      A 46-yr-old male presents to your outpatient clinic. He suffers from increasing shortness of breath, increasing amounts of sputum and recurrent bronchopulmonary infections. He has infertility and had two operations for nasal polyposis and recurrent sinusitis. His lung function shows a combined obstructive–restrictive pattern. The CT scan of the thorax shows abnormalities in both lower lobes (below). Liver function tests and blood glucose concentration are within normal limits.

      Which one of the following is the most likely diagnosis in this patient?

    27. Page 41

      Which of the following statements about symptoms and signs of lung cancer is/are correct?

    28. Page 43

      A 24-yr-old medical student is consulting you before departing to Africa where he plans to climb Mt Kilimanjaro (5,895 m). Apart from seasonal allergic rhinitis, his medical history is unremarkable and he is physically very fit. He asks for your advice regarding prevention of altitude-related illness. You recommend a gradual ascent not exceeding 300–500 m every 24 h above 2,500 m, avoidance of physical overexertion and a low sleeping altitude if feasible. The student asks you to prescribe a drug for prevention of acute mountain sickness.

      Which one of the following is the most appropriate?

    29. Page 45

      A 55-yr-old secretary has been diagnosed with obstructive sleep apnoea syndrome based on excessive sleepiness (Epworth sleepiness score 14) with frequent episodes of dozing off at work, habitual snoring and an apnoea/hypopnoea index of 36 events·h−1 during polysomnography. Her BMI is 29.3 kg·m−2 and her blood pressure is 125/75 mmHg. Oral inspection reveals a Mallampati score of I with normal tonsillar size and normal teeth. There is a deviation of the nasal septum to the right and she seems to breathe predominantly through the left side of the nose. Treatment with nasal CPAP is explained and recommended to the patient. However, she declares that she would under no circumstances use any treatment that required wearing a mask.

      Which one of the following treatments is the most effective alternative treatment modality for this patient?

    30. Page 47

      A 73-yr-old retired insulating engineer presents with a 6-month history of increasing dyspnoea. He had worked with asbestos for 2 yrs, 35 yrs previously. He has seronegative rheumatoid arthritis, finger clubbing and basal crackles on chest examination. The CT scan is shown below.

      Which one of the following is the most likely diagnosis?

    31. Page 49

      A 74-yr-old female former smoker is referred to your office because of shortness of breath on moderate exertion. She has to stop after one flight of stairs because of dyspnoea but does not complain of chest pain. When asked, she also complains of frequent nocturnal awakenings and fatigue. She does not have fever, cough or sputum production. Her past medical history is remarkable for hypertension and a myocardial infarction 4 yrs ago. At that time, she had stopped smoking (after 45 pack-yrs exposure) and she has gained 8 kg of weight since. Her medication includes oral anticoagulation because of chronic atrial fibrillation, a diuretic, an angiotensin-converting enzyme (ACE) inhibitor and a tricyclic antidepressant. Her blood pressure is 125/75 mmHg, pulse rate is 65 beats/min and irregular, and lung auscultation is clear.

      Pulmonary function tests show mild restriction and diffusion impairment. Arterial blood gas analysis shows a PaO2 of 67 mmHg (8.9 kPa), PaCO2 of 27 mmHg (3.65 kPa), pH of 7.44, base excess of 4 mmol·L−1 and SpO2 of 94%.

      Chest radiography shows no pulmonary infiltrates or mass, but there is apical redistribution of perfusion and cardiomegaly. Recently, the doses of the ACE inhibitor and of the diuretic have been adjusted, but this did not significantly improve her condition.

      Which of the following evaluations will most likely contribute to improving her treatment?

    32. Page 51

      A 35-yr-old female presents to her family physician with unproductive cough and fever up to 37.8°C (axillary) during the past 48 h. On physical examination, she presents end-inspiratory crackles at the left lung base on auscultation, with no other abnormal findings. Chest radiography reveals a small consolidation in the left lower lung field. Her SpO2 was 97% on room air.

      Which of the following investigations is necessary for the management of this patient?

    33. Page 53

      A 69-yr-old male, with a history of smoking and asbestos exposure between the ages of 30 and 55yrs, complains of right-sided chest pain, breathlessness on exertion and cough. A chest radiograph shows a right pleural effusion associated with nodular pleural thickening. Thoracentesis shows a bloody coloured pleural effusion with a cytological suspicion of mesothelioma. Which of the following statements is/are true for this patient?

    34. Page 55

      A 45-yr-old female is admitted to the hospital because of severe dyspnoea and acute chest pain. Fever and cough are not present on admission. The patient reports mild dyspnoea on exertion for the past 2 yrs and an episode of pneumothorax 6 months ago. On admission, her blood pressure is 130/80 mmHg, her heart rate is 100 beats/min and regular, and her respiratory rate is 32 breaths/min. Chest radiography reveals small bilateral pneumothoraces. CT shows multiple round cysts involving the whole parenchyma; three micronodules, enlargement of axillary lymph nodes and a renal mass were also detected.

      Which of the following statements about this case is/are correct?

    35. Page 57

      You see an otherwise healthy 66-yr-old male with COPD complaining of shortness of breath after climbing two flights of stairs. He has no dyspnoea at rest. He expectorates greyish sputum, mainly in the morning. These symptoms have been present for the past 1–2 yrs. He has reduced smoking to only 5 cigarettes per day in recent years but has a smoking history of 30 pack-yrs. He is on no regular medication and has not been hospitalised in the past decade. Physical examination shows no abnormality. Post-bronchodilator spirometry shows an FEV1 of 72% predicted and a FEV1/ FVC ratio of 61%.

      Which of the following actions is/are appropriate?

    36. Page 59

      A 54-yr-old male smoker with a history of type II diabetes, hypothyroidism and obstructive sleep apnoea developed angina on exertion. A coronary angiogram showed that several cardiac vessels were critically occluded. Severe aortic stenosis was also diagnosed. Coronary artery bypass grafting and aortic valve replacement were performed. The patient had a good post-operative recovery and was assigned to cardiac rehabilitation and started on warfarin. Some weeks into the programme, he starts to complain of a cough, low-grade fever and worsening dyspnoea. A chest radiograph shows a moderate left-sided pleural effusion. A thoracentesis reveals the following: pH 7.35; glucose 3.5 mmol·L−1; lactate dehydrogenase (LDH) 590 U·L−1; and protein concentration 3.8 g·dL−1. Differential cell count revealed increased lymphocytes.

      Blood glucose is 5.6 mmol·L−1 and serum LDH is 410 U·L−1.

      Which one of the following is the most likely diagnosis?

    37. Page 61

      Which of the following statements about anti-tuberculosis (anti-TB) drugs is/are correct?

    38. Page 63

      A 57-yr-old male with a history of ischaemic heart disease, intermittent claudication, alveolar proteinosis and diabetes, with poor adherence to his medications, presents with a cough, wheeze and phlegm of several weeks’ duration. He has had low-grade fever and lost 4 kg in weight. Microscopic sputum examination reveals weakly acid fast-staining, filamentous branching organisms. A Ziehl–Neelsen stain of the patient’s sputum is shown below (reproduced from Sullivan et al. (2011), with permission from the publisher).

      Which one of the following is the most likely diagnosis?

    39. Page 65

      Which one of the following statements regarding post-operative outcome and prognosis in nonsmall cell lung cancer is incorrect?

    40. Page 67

      A 35-yr-old female is admitted to the emergency department with a history of repeated chest infections, diarrhoea, otitis media, pneumonia, lethargy and some weight loss. She has areas of vitiligo and a past history of haemolytic anaemia. Chest radiography shows bilateral mid-zone infiltrates. Pulmonary function tests show a mild restrictive ventilatory defect, with a reduced lung volume and diffusing capacity. A transbronchial lung biopsy shows a noncaseating granuloma.

      Which one of the following options is the most likely diagnosis?

    41. Page 69

      A 36-yr-old immunocompetent male is admitted to the hospital with symptoms of recurrent fever, cough, and anorexia and weight loss. Admission baseline investigations show normal renal and liver function tests. A chest radiograph shows patchy infiltrates and cavitations in the right and left upper lobe. Microbiological and molecular tests in sputum are positive for Mycobacterium tuberculosis. Initial molecular drug resistance testing of mutations associated with rifampicin and isoniazid resistance were negative.

      Which one of the following is the recommended initial treatment for this patient?

    42. Page 71

      A 55-yr-old male consults you because of breathlessness, which has become gradually worse over a period of 1 yr. He also has a cough but does not produce phlegm. He is able to walk for 10 min (distance 400–500 m) after which he has to rest because of shortness of breath. He has no chest pain on exertion. His complaints have been present throughout the entire year but become worse in a humid environment and during the winter. He has no known allergies and no family history of lung disease. He is a current smoker with a history of 40 pack-yrs. His general practitioner prescribed salbutamol 400 μg as needed. The patient reports that this gives him a little more air. His medical history is otherwise uneventful. The physical examination is unremarkable. A laboratory work-up including haemoglobin, haematocrit and a differential white blood cell count, and chest radiography, were normal. Spirometry reveals the following results.

      Which of the following is the most likely diagnosis?

    43. Page 73

      A 56-yr-old missionary nun returns from Vietnam. She has been in the country for 6 months travelling among local communities. She has a cough, with some blood-streaked sputum, and she reports some breathlessness. She has no fever. Chest radiography shows a pleural effusion and cavitating lesions in the mid-zone on the same side as the pleural effusion. Thoracentesis shows an exudative pleural fluid and a low glucose concentration, and a differential cell count shows that the fluid contains >10% eosinophils.

      Which of the following is the most likely cause?

    44. Page 75

      Which of the following statements about lung cancer treatment is/are correct?

    45. Page 77

      One of the passengers on a flight from New York to Brussels was discovered to have multidrug-resistant (MDR) tuberculosis (TB) after she arrived in Brussels. Two weeks later you are consulted by one of the passengers who had been on the same flight and had been informed that she should seek medical advice. That passenger is otherwise healthy, and recent HIV and tuberculin tests were negative. Which one of the following management options would be most appropriate?

    46. Page 77

      A 53-yr-old obese male (BMI 30.1 kg·m−2) is diagnosed with obstructive sleep apnoea with an AHI of 45 events·h−1 and an oxygen desaturation index (ODI) of 40 events·h−1. He is given auto-adjusting nasal CPAP therapy with an allowed pressure range of 5–15 cmH2O. In the first night of adaptation, his AHI went down to 6 event·h−1 and his ODI was 4 events·h−1. Three days later, the patient reported that his sleepiness had already improved significantly. 1 month later, the patient returned to the sleep laboratory and complained of recurring daytime sleepiness. Ambulatory pulse oximetry showed an ODI of 34 events·h−1. Data downloaded from the CPAP machine suggested an adequate compliance by the patient as the machine was used 5.48 h per night on average. The applied pressures ranged from 5 to 13.5 cmH2O and the 90th pressure percentile was 12 cmH2O.

      Which one of the following steps is the least promising in this situation?

    47. Page 79

      A 42-yr-old male with COPD returning from a trip to Kenya 6 weeks ago has been diagnosed with smear-positive pulmonary tuberculosis (TB) after a 10-day hospitalisation for a respiratory tract infection. His 38-year-old wife is asymptomatic with normal chest radiography and has an unremarkable past medical history. Her tuberculin skin test (TST) is zero mm. Which of the following should be recommended to her?

    48. Page 79

      A 45-yr-old, HIV-positive male is admitted to the hospital because of fever and severe dyspnoea. Physical examination shows tachypnoea and tachycardia. Chest auscultation reveals bilateral fine crackles. Radiography shows extensive, bilateral, patchy lung infiltrates. Arterial blood gas analysis on room air reveals PaO2 45 mmHg (5.985 kPa), PaCO2 11 mmHg (1.463 kPa) and pH 7.56. Oxygen therapy (inspiratory oxygen fraction (FI,O2) 0.5) is promptly initiated. Arterial blood gas analysis after half an hour demonstrates PaO2 50 mmHg (6.65 kPa), PaCO2 15 mmHg (1.995 kPa) and pH 7.52. Brain natriuretic peptide concentration is normal.

      Which of the following statements regarding this patient is/are correct?

    49. Page 81

      Which of the following findings is/are consistent with acute pulmonary embolism occluding less than 50% of the pulmonary vasculature?

    50. Page 83

      Which of the following is/are true in pleural effusions?

    51. Page 85

      A 47-yr-old clothes salesman presents with dyspnoea on exertion that has developed over the past 6 months. He is a current smoker with a smoking history of 30 pack-yrs. He receives an angiotensin-converting enzyme (ACE) inhibitor for hypertension and occasionally takes ibuprofen for joint pains. He has no history of relevant exposure to environmental toxins or dust. His physical examination reveals bilateral, basal, fine, end-inspiratory crackles of Velcro type and clubbing of the fingers. His SpO2 on room air is 95%, but falls to 82% during a 6-min walk test. Spirometry shows a FEV1 of 74% predicted, a FVC of 68% predicted and an FEV1/FVC ratio of 88%. TLCO is 42% predicted. A recent high-resolution CT scan of the chest shows bilateral reticular opacities with honeycombing, predominantly in the periphery of the lung bases.

      Which one of the following is the most appropriate next step?

    52. Page 87

      A 68-yr-old male is admitted to the emergency room complaining about shortness of breath, fever, chills and cough with purulent sputum production for the last 2 days. He is a nonsmoker without any previous medical history. The patient looks tired but other than that he is in good condition without any confusion. Vital signs are blood pressure 105/70 mmHg, heart rate 110 beats/min, breathing rate 32 breaths/min, and temperature 38.9 oC. Bronchial breath sounds are heard on auscultation of the right chest. Blood tests reveal a white blood cell count of 9,000 cells per mm3 with a left shift, haematocrit 46%, Urea 22 mmol·L−1, creatinine 1.8 mg·dL−1, sodium 142 mmol·L−1 and oxygen saturation (room air) 92%. A chest radiograph demonstrates moderate cardiomegaly and a right lower lobe infiltrate with air bronchograms.

      Which one of the following is the appropriate management decision for this patient?

    53. Page 89

      A 48-yr-old female with a 25 pack-yr history of smoking presents with fever, cough and purulent sputum production and her chest radiograph shows consolidation of the right middle lobe. She has a history compatible with chronic bronchitis but normal spirometry and she had a bronchitis exacerbation 2 months ago for which she received treatment with moxifloxacin. Her blood pressure is 115/75 mmHg, her breathing rate is 18 breaths/min. She does not look severely ill but she is depressed and tired because she has spent long hours with her mother who was at a home for the elderly and died a week ago, 2 weeks after acquiring an influenza infection. The patient is anxious to get well soon and return to work because she has already taken a long time off.

      Which one of the following is the appropriate treatment for this patient?

    54. Page 89

      A 75-yr-old female is referred for dyspnoea on exertion and chronic cough. Dyspnoea and cough have worsened continuously during the past 12 months. Pulmonary function testing reveals a FVC of 72% predicted, FEV1 of 80% predicted and a TLCO of 38% predicted. The chest radiograph shows bilateral patchy infiltrates mostly at the lung bases. On high-resolution CT, bilateral reticular opacities and clustered basal honeycombing are found. Open lung biopsy reveals randomly distributed foci of usual interstitial pneumonia (UIP) surrounded by normal lung parenchyma.

      What is the most appropriate therapy for this patient?

    55. Page 91

      Which one of the following statements about lymphangioleiomyomatosis (LAM) is true?

    56. Page 93

      A 57-yr-old male with ischaemic heart disease is admitted with an episode of acute pulmonary oedema. Assessment shows a systolic blood pressure of 140 mmHg, SpO2 of 89%, PaO2 59 mmHG (7.847 kPa), PaCO2 26 mmHg (3.458 kPa) and pH of 7.34 in room air. After establishing initial therapy with nitrates, oxygen and loop diuretics, the emergency department team request your advice on the use of NIV or CPAP therapy.

      Which of the following statements regarding treatment of this patient is/are true?

    57. Page 95

      An 83-yr-old male patient is referred to you because of a cough that started 6 months ago. He brings up some yellow phlegm and he recently noticed a little blood staining within his phlegm. Furthermore, he felt extremely tired. He had consulted his family physician who had prescribed antibiotics for 10 days which did not change the cough but the colour of the phlegm turned white. The chest radiograph revealed an enlarged right hilum.

      On further evaluation the patient complains about painful ankles and wrists, a diminished appetite and a weight loss of 5 kg in the last month. In the last month he lost a lot of energy, most of the day he is lying in his bed or sitting in a chair. He also needs some help with his personal hygiene. Further investigations revealed a squamous cell carcinoma of his right upper lobe and liver metastases.

      Which one of the following would be your most appropriate next therapeutic option?

    58. Page 97

      A 58-yr-old male hospitalised with a hip fracture for 1 week complains about shortness of breath, fever and cough with purulent sputum production for the past 2 days. He is a nonsmoker with a history of hypertension. The patient is in good clinical condition and in moderate respiratory distress. Vital signs are blood pressure 130/60 mmHg, heart rate 100 beats/min, breath rate 30 breaths/min and temperature 37.9 oC. Rales in the upright seated position and bronchial breath sounds are revealed on auscultation on the left chest posteriorly. A complete blood count shows a white blood cell count of 17,000 cells·mm−3 with 78% mature neutrophils, haematocrit 38%, blood urea nitrogen (BUN) 62 mg·dL−1, creatinine 1.0 mg·dL−1 and oxygen saturation on room air is 93%. A chest radiograph confirms left lower lobe pneumonia. The patient has not been on any antimicrobial therapy until now.

      Which one of the following is the appropriate empirical antibiotic therapy for this patient?

    59. Page 99

      During an influenza outbreak, a 35-yr-old obese female, who has a history of asthma, is admitted to hospital with worsening dyspnoea associated with a cough, wheeze and phlegm. The patient is treated for a virus-induced asthma exacerbation with intravenous corticosteroids and nebulised bronchodilators. She makes good progress over the next 48 h, but then becomes very distressed with rapid shallow breathing, cough and worsening arterial blood gases, and a dense bilateral consolidation. Bronchoalveolar lavage reveals lymphocytosis and high granulocyte count. Gram stain is negative. She is intubated, transferred to the intensive care unit and placed on broad-spectrum antibiotics. Despite assisted ventilation, she continues to deteriorate over the next few hours with severe hypoxaemia (PaO2 45 mmHg (5.985 kPa) on FiO2 1.0). Cardiac output needs to be supported with dobutamine in order to sustain a mean arterial blood pressure of 70 mmHg.

      Which one of the following is the next, most appropriate additional treatment?

    60. Page 101

      Which of the following radiological findings is characteristic of pulmonary Langerhans cell histiocytosis?

    61. Page 103

      A 45-yr-old female presents to you with increasing cough and fatigue for the past 4 months. She is a heavy smoker (40 cigarettes/day for 25 yrs), with a medical history of diabetes and hypertension. A chest radiograph shows a left upper lobe mass, para-aortic mediastinal lymphadenopathy and ipsilateral pleural effusion. These findings were confirmed on chest CT. Fibreoptic bronchoscopy with tumour biopsy confirmed the diagnosis of small cell lung cancer (SCLC). Pleural fluid cytological examination after thoracentesis was also positive for SCLC. Additional workup with upper abdomen and head CT were negative for metastasis. Her performance status on the ECOG scale was 0 (fully active, without restrictions).

      Which one of the following statements for this patient is false?

    62. Page 105

      A 35-yr-old female was admitted with acute dyspnoea, 12 months after the birth of her second child. During the past 6 months, she has suffered from mild dyspnoea (Medical Research Council grade 2) despite the fact that she has never smoked. Chest radiography revealed a unilateral pneumothorax, which was treated appropriately. The follow-up CT scan is shown below.

      Which one of the following is the most likely diagnosis?

    63. Page 107

      A 60-yr-old female is referred to you because of a subpleural noncalcified solitary nodule with sharp borders and a diameter of 7 mm in her right lower lobe. The nodule was detected on an abdominal CT performed to evaluate abdominal pain. Endoscopy revealed a duodenal ulcer as cause of the abdominal pain. The patient does not have any respiratory complaints. She stopped smoking 30 yrs ago after an exposure of approximately 15 cigarettes/day for 15 yrs.

      What is the most appropriate next step?

    64. Page 109

      Which of the following statements regarding the role of echocardiography and right heart catheterisation in the evaluation of pulmonary hypertension (PH) is/are correct?

    65. Page 111

      A 68-yr-old male with amyotrophic lateral sclerosis is consulting you in the presence of his wife and daughter. Four months ago, medical examinations performed to evaluate the cause of weakness in his arms led to the diagnosis. During the consultation, the patient and his family ask you to give them an honest estimate of how long he has to live. The patient is currently in fairly good condition, has a normal weight and is able to walk without dyspnoea, and he has no orthopnoea. Neurological examination confirms weakness of both arms, more on the left, and fasciculations of the tongue.

      Which one of the following examinations is least likely to give you information relevant for assessing the prognosis?

    66. Page 113

      A 64-yr-old male with stable COPD (FEV1 25% predicted) is offered a pulmonary rehabilitation (PR) course immediately after discharge from hospital following an acute exacerbation of COPD. His medical therapy has been optimised, but he is breathless on walking 200 m. The patient is sceptical about participating in the PR course.

      In explaining the potential benefits to the patient, which one of the statements below is evidence based?

    67. Page 115

      Which of the following statements concerning positional obstructive sleep apnoea (OSA) is false?

    68. Page 117

      A 46-yr-old female with a BMI of 26 kg·m−2 suffers from OSAS. The patient’s AHI in a recent sleep study was 34 events·h−1 with an average of 30 obstructive and four central events per hour. You explain the available treatment options to the patient in the presence of her husband. She is not enthusiastic about nasal CPAP but agrees to try it. After 3 weeks, she declares that CPAP was not acceptable for her, mainly for psychological reasons. She asks for another treatment modality. Which is the next appropriate examination that helps to decide on an alternative treatment?

    69. Page 119

      A 25-yr-old previously healthy female is referred to the emergency department of your hospital because of shortness of breath, fever and chills. She reports that she has had flu-like symptoms and fever of 39.9°C in the previous week. After 3 days, she felt better and the fever diminished. On the day of the current presentation she suddenly felt worse again, had high fever, chills, and shortness of breath. On physical examination she looks ill, but is well oriented. Respiratory rate was 32 breaths/min, heart rate 110 beats/min, blood pressure 100/55 mmHg. Auscultation reveals bronchial breath sounds and rales in the right hemithorax. Chest radiography reveals a lobar infiltrate in the left upper lobe. Laboratory results are as follows: erythrocyte sedimentation rate 135 mm·h−1, C-reactive protein 350 mg·L−1, leukocytes 19 cells·nL−1, urea 10.0 mmol·L−1, creatinine 110 mmol·L−1, sodium 135 mmol·L−1, potassium 4.0 mmol·L−1, haemoglobin 112 g·L−1. Liver function tests are normal. Arterial blood gas analysis on room air show the following: PaO2 51 mmHg (6.783 kPa), PaCO2 46 mmHg (6.118 kPa), pH 7.31, base excess −8.1 mmol·L−1.

      What is the most appropriate next action?

    70. Page 121

      A 65-yr-old male presents to you with increasing cough and breathlessness for the past 2 months, weight loss of 7 kg over the same period, two episodes of haemoptysis and increasing fatigue. He is a smoker of 20 cigarettes/day for 40 yrs. Chest radiography shows a left upper lobe mass with mediastinal widening. Diagnostic work-up shows adenocarcinoma stage IV with cN2 disease and adrenal metastasis. The diagnosis was based on cytology and epidermal growth factor receptor (EGFR)/anaplastic lymphoma kinase (ALK) status are negative. The patient’s status is good and no comorbidities are present. Which one of the following is the appropriate treatment strategy for this patient?

    71. Page 123

      A 49-yr-old secretary is referred for dyspnoea on exertion and a chronic cough. She has been extensively examined for a persistent fever, but no infectious cause could be identified. She also complains of painful swelling of her wrists and her ankles; her thighs and her upper arms ache when she exercises. Her fingers suddenly hurt and turn white when she plays the accordion. She also has markedly thickened skin over her knuckles. Pulmonary function testing reveals an FVC of 70% predicted and FEV1 of 75% pred; diffusing capacity of the lung for carbon monoxide is 45% pred. On HRCT, small pulmonary nodules and linear and ground-glass opacities of both lungs are found. Laboratory results are remarkable for elevated lactate dehydrogenase, creatine kinase and anti-Jo-1 antibody levels.

      What is the most likely diagnosis for this patient?

    72. Page 125

      In the National Emphysema Treatment Trial (NETT), cost-effectiveness of lung volume reduction surgery (LVRS) in patients with severe pulmonary emphysema was compared with medical treatment. The results revealed a cost-effectiveness ratio of LVRS of US$53,000 per qualityadjusted life yr (QALY) at 10 yrs of follow-up. These results suggest that:

    73. Page 127

      A 58-yr-old obese patient (BMI 39.6 kg·m−2) complains of new-onset of daytime fatigue and early morning headache. His wife reports that he snores heavily. The patient had an inferior wall myocardial infarction 2 yrs ago. His cardiologist reported normal systolic cardiac function but grade I diastolic dysfunction 1 month ago. The patient is a lifetime nonsmoker. His past medical history is unremarkable. A nocturnal pulse oximetry reveals an oxygen desaturation index (>3%) of 68 events·h−1. His daytime arterial blood gas analysis shows a PaO2 of 66 mmHg (8.8 kPa), a PaCO2 of 58.5 mmHg (7.8 kPa), an SpO2 of 93%, a pH of 7.38 and a bicarbonate level of 27 mmol·L−1.

      What is the most likely diagnosis?

    74. Page 129

      Which of the following diseases is/are associated with upper lobe fibrosis and loss of volume on chest radiography?

    75. Page 129

      A 46-yr-old female receives a platelet transfusion because of severe thrombocytopenia after adjuvant chemotherapy for breast cancer. 3 h later, she complains of an acute onset of shortness of breath. SpO2 is 76%, and arterial blood gas analysis reveals PaO2 of 45 mmHg (5.985 kPa), PaCO2 of 25 mmHg (3.325 kPa) and pH 7.50. Her blood pressure is 148/80 mmHg, heart rate is regular at 118 beats/min and temperature is 37.8°C. The patient is transferred to the intensive care unit and she is placed on NIV (spontaneous timed mode, inspiratory oxygen fraction 0.6, expiratory positive airway pressure (EPAP) 6 cmH2O, inspiratory positive airway pressure (IPAP) 14 cmH2O, frequency 15 breaths/min and inspiratory time 1.5 s). The chest radiograph shows bilateral pulmonary infiltrates. Arterial blood gases after 1 h on NIV are PaO2 62 mmHg (8.246 kPa), PaCO2 28 mmHg (3.72 kPa) and pH 7.48.

      What is the next appropriate step in the management of this patient?

    76. Page 131

      A 35-yr-old Caucasian male from South Africa, currently a resident of London, UK, presents to the emergency room with productive cough and low-grade fever of approximately 6 weeks’ duration. Six months ago, during a stay in South Africa, he had received treatment with isoniazid, rifampicin, pyrazinamide and ethambutol for smear-positive pulmonary tuberculosis (TB). The treatment had led to rapid clinical improvement and he therefore stopped it upon return to London, after a duration of 8 weeks.

      Clinical examination at admission reveals a BMI of 18 kg·m−2 and a temperature of 37.8°C but no other abnormal findings. Chest radiography shows bilateral upper lobe infiltrates with a cavitary lesion in the right upper lobe. The sputum contains acid-fast bacilli. A HIV test is negative. Results of rapid molecular-based drug susceptibility tests are pending.

      Which of the following should be recommended for this patient?

      H: isoniazid; R: rifampicin; Z: pyrazinamide; E: ethambutol; S: streptomycin. Numbers before the letters denote the duration of treatment in months.

    77. Page 133

      You see an otherwise healthy 52-yr-old female who has been treated by her general practitioner for 10 days with oral amoxicillin for fever up to 39°C and cough. 7 days after finishing the antibiotic therapy, she still feels weak. Her temperature is 37.2°C (oral). On examination, her respiratory rate is 20 breaths/min; there is dullness to percussion and breath sounds in the left base are absent. The chest radiograph is shown below.

      Which of the following statements is/are appropriate?

    78. Page 135

      Which of the following conditions warrants/warrant preventive therapy for patients known to have latent tuberculosis infection?

    79. Page 137

      The introduction of inhaled long-acting β-adrenergic agonists (LABAs) in asthma therapy may have adverse effects. In which of the following situations can the introduction of LABAs be expected to provide benefits that outweigh the potential harmful effects?

    80. Page 139

      A 75-yr-old female is admitted to the emergency department after a car accident. Besides complaining of lower back pain and some bruising of the chest, the patient seems well. She has been treated for rheumatoid arthritis for many years with methotrexate. Vital signs and physical examination do not reveal any abnormalities. The chest radiograph is normal except for spine osteophytic degeneration.

      Two days after being sent home with analgesic treatment, the patient returns to the emergency department. She now complains of dyspnoea. Physical examination reveals reduced breath sounds on the left lung base. The chest radiograph shows a moderate-sized left pleural effusion but no pulmonary infiltrates. Pleural fluid with a milky appearance is drained. Which of the following pleural fluid analyses confirms the suspected diagnosis?

    81. Page 139

      Which of the following statements concerning β-adrenergic blockers and inhaled β-adrenergic agonists is/are correct?

    82. Page 141

      Which of the following statements concerning the nocturnal recording shown below is correct?

    83. Page 143

      A 45-yr-old female is referred to you because she has recurrent episodes (3–6 times a yr) of bronchitis with fever for which she uses courses of antibiotics with good results. Between these episodes she coughs up phlegm in considerable amounts (during the day several spoons full). The colour of the phlegm varies from white to yellow; she has never seen blood in her phlegm. She smoked approximately 20 cigarettes/day from the age of 18 yrs until the age of 30 yrs. Since then she has stopped smoking. She has no complaints of shortness of breath, wheezing or tightness of the chest. Her family history is uneventful. Her flow–volume curve was normal. Her chest radiograph and CT are shown below.

      Which one of the following is the most appropriate next action?

    84. Page 145

      A 27-yr-old female in the 22nd week of pregnancy presents to her family physician because of recent onset of dyspnoea on moderate exertion and cough without sputum production causing frequent nocturnal awakening. She had been treated for bronchial asthma with inhaled corticosteroids and long-acting β-adrenergic agonists but stopped treatment at the beginning of the pregnancy because of fear of adverse effects on the fetus. On physical examination, she is in good general condition but lung auscultation reveals slight bilateral wheezing. Spirometry shows FVC of 90% predicted, FEV1 of 50% predicted and FEV1/FVC ratio of 55%. After inhalation of two puffs of salbutamol, FEV1 improved to 90% predicted while FVC remained 90% predicted.

      Which one of the following recommendations is most appropriate for this patient?

    85. Page 145

      A 35-yr-old male is admitted to hospital because of acute onset of fever (38°C), dry cough, severe dyspnoea and mental confusion. Arterial blood pressure is 140/80 mmHg, heart rate is regular at 120 beats/min and respiratory rate is 36 breaths/min. Arterial blood gas analysis reveals a PaO2 of 65 mmHg (8.645 kPa), PaCO2 of 42 mmHg (5.586 kPa), bicarbonate concentration of 24.2 mmol·L−1 and a pH of 7.42. Chest radiography and CT show diffuse, bilateral pulmonary infiltrates. Bronchoalveolar lavage reveals 920×109 cells·L−1 with 35% eosinophils, 8% neutrophils and 57% macrophages. A broad search for parasitic infestation is negative.

      Which of the following statements about this case is correct?

    86. Page 147

      A 27-yr-old, previously healthy female presents with acute onset of dyspnoea and coughing spells with blood-tinged sputum. Chest radiography shows extensive bilateral opacities. The patient is hypoxic on room air (SpO2 84%). Sequential bronchoalveolar lavage reveals progressively bloodier fluid return. You decide to look for an autoimmune disease.

      Which one of the following anti-body panels is least likely to confirm the diagnosis?

    87. Page 147

      Which of the following statements is/are correct regarding multidrug-resistant tuberculosis?

    88. Page 149

      A 57-yr-old male previously diagnosed with non-Hodgkin’s lymphoma (NHL) presents with a cough and dyspnoea for 1 week. He has a history of night sweats. Examination shows a right-sided pleural effusion. A thoracentesis of the effusion reveals a milky fluid.

      Which one of the following statements concerning the pleural fluid is most likely to be true?

    89. Page 149

      Adjuvant or neoadjuvant chemotherapy for operable nonsmall cell lung cancer has been shown to be beneficial in which of the following conditions? (T: Tumour; N: node; M: metastasis.)

    90. Page 151

      A 45-yr-old banker complains of dyspnoea when he climbs the stairs to his office on the third floor. When he reaches the second floor, his chest feels tight and several times he has almost fainted so that he had to sit down until he recovered. Five yrs ago, he fractured his right ankle at a golf tournament. The fracture was complicated by a deep vein thrombosis of the right leg with concomitant pulmonary embolism. On lung function testing, lung volumes are normal and TLCO is 35% predicted. SpO2 on room air is 86%, and arterial blood gas analysis reveals a PaO2 of 57 mmHg (7.581 kPa), PaCO2 of 30 mmHg (3.99 kPa) and pH of 7.47. Echocardiography shows a normally functioning left ventricle; the right ventricle is dilated and the systolic pulmonary pressure is estimated to be 50 mmHg.

      Which of the following is the next appropriate step in the management of this patient?

    91. Page 153

      A 46-yr-old nonsmoking patient suffers from recurrent purulent bronchitis. He complains of increased sputum production but is otherwise well. A CT scan shows bilateral, mainly lower lobe tubular bronchiectasis.

      Which of the following investigation(s) is/are important for treatment decisions?

    92. Page 155

      Which of the following statements concerning initiation of β-blocker treatment in patients with advanced COPD (GOLD grade III or IV) on inhalation therapy with a long-acting β-agonist and inhaled corticosteroids is/are correct?

    93. Page 155

      A morbidly obese lorry driver (BMI 47 kg·m−2) is referred to the sleep laboratory because of excessive daytime sleepiness. The sleep study reveals an AHI of 36 events·h−1 and the oxygen desaturation index is 30 events·h−1. Mean nocturnal oxygen saturation is 86% and the saturation never rises above 90% during the night. An arterial blood gas analysis reveals PaO2 53 mmHg (7.049 kPa), PaCO2 of 68 mmHg (9.044 kPa), and a pH of 7.42; bicarbonate is 34 mmol·L−1. Pulmonary function testing reveals a mild restrictive ventilatory disorder.

      Which would be the appropriate initial therapy for this patient?

    94. Page 157

      A 45-yr-old HIV-positive male (CD4 cells 250 cells per μL), is referred to you because of a tuberculin skin test with 7-mm induration. He has no specific complaints, has not had contact with tuberculosis patients in the past, and has not had a Bacille Calmette-Guérin (BCG) vaccination. Chest radiography is normal.

      Which one of the following is the most appropriate next step?

    95. Page 157

      A 58-yr-old male is referred for haemoptysis. Chest radiography reveals bilateral patchy infiltrates. The patient is hypoxaemic: SpO2 is 87%. Urine analysis reveals microscopic haematuria; 60% of the erythrocytes are of glomerular origin. Creatinine clearance is 27 mL·min−1. Perinuclear anti-neutrophil cytoplasmic antibody (myeloperoxidase) titre is elevated in the serum.

      What is the first choice treatment for this patient?

    96. Page 159

      A 38-yr-old nonsmoking and otherwise healthy farmer complains of increasing cough and dyspnoea on exertion of almost 3 yrs’ duration. Due to acute clinical worsening with dyspnoea even at rest and hypoxaemia (SpO2 of 88% on room air), the patient was admitted to the emergency department. There were no clinical and laboratory signs of infection. Pulmonary function testing was not feasible. A chest radiograph and CT were obtained. A bronchoscopy with a bronchoalveolar lavage was performed. It revealed a predominance of lymphocytes and only occasional eosinophils and macrophages. Open-lung biopsy findings are shown.

      Which one of the following is the most likely diagnosis?

    97. Page 161

      A 65-yr-old male complains about increasing dyspnoea on exertion. The patient had worked as an insulator for many years. Ten yrs previously, he suffered from a myocardial infarction. Percussion reveals dullness of the right lower chest, auscultation reveals diminished breath sounds over the area of dullness. Chest radiography and ultrasound show a medium-sized pleural effusion. Mediastinoscopy revealed several infiltrated lymph nodes. Medical thoracoscopy demonstrates a diffuse malignant mesothelioma on both pleural layers with infiltration of the pericardium. Immune histology reveals a biphasic cell type. Which one of the following is the best treatment option?

    98. Page 163

      Which of the following statements concerning the nocturnal recording below is false?

    99. Page 165

      A 68-yr-old male presents to his primary care physician with cough, sputum production and fever up to 39.5°C in the past 48 h. He has COPD (Global Initiative for Chronic Obstructive Lung Disease grade IV) and uses daily tiotropium and albuterol as needed. His diabetes mellitus is well controlled on metformine. He has a confirmed allergy to amoxicillin. On physical examination he is tachypnoeic (30 breaths/min) and tachycardic (110 beats/min), with a blood pressure of 130/90 mmHg. He is alert and fully oriented. On auscultation, he presents bilateral wheezing and crepitation on the right lung base. His laboratory tests reveal: white blood count 14,000 cells·mL−1, C-reactive protein (CRP) 30 mg·L−1, blood urea concentration 10 mmol·L−1, SpO2 82%, inhaled oxygen fraction (FIO2 0.21). Chest radiography shows consolidation in the right upper and lower lung fields. Which of the following is the most appropriate antibiotic regimen for this patient?

    100. Page 167

      A 24-yr-old female is visiting your outpatient clinic for regular follow-up of her asthma. You have known this patient for 7 yrs because she has allergic asthma (allergies to house dust mites, grass and tree pollen). During the pollen season, she has only minor complaints of intermittent allergic rhinitis, for which she uses an antihistamine as needed. At age 17 yrs, she was admitted to the hospital because of a severe asthma attack. Since then, she has been followed up regularly. Her last check-up was 3 months ago. She was stable at that time. Therefore you reduced her medication from budesonide/formoterol/(100/6 μg) twice a day to budesonide 100 μg twice a day and terbutaline 500 μg as needed. Since then she has remained completely asymptomatic both in the daytime and at night. She plays tennis twice a week without any problems. She has used her terbutaline twice during the past 3 months. She admits she has used the budesonide only once a day for the past 2 months because she felt so well.

      According to the GINA guidelines, what would be the most appropriate next action?

    101. Page 169

      A 50-yr-old female with an unremarkable previous medical history reports progressive dyspnoea. The chest CT is shown below.

      Which one of the following is the most appropriate next diagnostic evaluation?

    102. Page 171

      A 66-yr-old male with a history of hypertension is hospitalised for colon cancer surgery. He undergoes a successful subtotal colectomy and ileocolic anastomosis, without any signs of complication. His immediate post-operative state is good, but on post-operative day 4 he develops sudden-onset shortness of breath and also has two episodes of haemoptysis. His blood pressure is 130/70 mmHg; his pulse is regular, with a rate of 110 beats/min and his respiratory rate is 28 breaths/min. His temperature is normal and his SpO2 is 88% on room air, which improves to 95% on 2 L·min−1 of oxygen via nasal cannula. He has mildly decreased breath sounds at his left lung base and a normal S1 and S2 without murmurs or gallops. His abdomen is soft and non-tender with normal bowel sounds. The patient does not have any oedema or tenderness in the lower extremities.

      The laboratory analyses, including a complete blood cell count and basic metabolic panel, are normal. Arterial blood gas analysis on room air demonstrates a PaO2 of 56 mmHg (7.28 kPa), a PaCO2 of 30 mmHg (3.99 kPa), and a pH of 7.48, with an SpO2 of 90%. Chest radiography reveals left basilar segmental atelectasis. The ECG shows tachycardia of 116 beats/min and a right bundle branch block, which is a new finding for this patient.

      Which of the following is the next diagnostic test in order to confirm your diagnosis in this patient?

    103. Page 175

      A 63-yr-old male is admitted to hospital because of dyspnoea, without fever. The patient reports mild dyspnoea on exertion during the last year. He is short of breath in the mornings, specifically when getting out of bed. Physical examination reveals the use of respiratory accessory muscles; breath sounds are slightly decreased and no jugular venous distension is present. On the abdomen, there are occasional spider naevi, and hepatomegaly and ascites are noted. Oxygen saturation is 86% in the sitting position and increases to 91% with the patient lying down. Laboratory blood tests, including white blood cell count, D-dimer, brain natriuretic protein, troponin and myoglobin, and ECG, are normal. Chest radiography shows cardiomegaly with bilateral pleural effusions. Ultrasound-guided paracentesis is performed and 1 L fluid is removed. Fluid examination reveals a polymorphonuclear cell count of 100×109 cells·L−1, a protein concentration of 3.9 g·dL−1, and no organisms on Gram stain and culture.

      Which of the following is the most likely diagnosis?

    104. Page 177

      A 62-yr-old male complains of shortness of breath on mild exertion, such as climbing one flight of stairs. He has no chest pain. The referring general practitioner reports that the patient has a long history of arterial hypertension and a previous myocardial infarction with subsequent heart failure. Accordingly, the patient is on a β-blocker, an angiotensin-converting enzyme inhibitor and a diuretic. The last echocardiogram showed a left ventricular ejection fraction of 35%. The Epworth sleepiness scale reveals a score of 11. His wife reports that he is snoring irregularly with intermittent pauses. The patient has a body mass index of 34 kg·m−2, no signs of oedema and the lungs are clear. Spirometry reveals a vital capacity of 92% predicted and FEV1 of 94% pred with a normal flow–volume loop.

      Which of the following is/are correct?

    105. Page 179

      A 35-yr-old female patient, suffering from asthma since childhood, receives budesonide/formoterol (200/6 μg) combination treatment (two inhalations twice daily), and montelukast once daily. The patient has no nocturnal symptoms, nor does she report any limitation of activities. However, she uses salbutamol for relief three times weekly, her FEV1 is 70% predicted and she has received three courses of oral steroids in the past year. Her immunoglobulin (Ig) E levels have been 150–250 kU·L−1 over the course of the past 3 months.

      Which one of the following statements is correct regarding her management?

    106. Page 181

      A 62-yr-old male presents to the emergency department with acute shortness of breath and chest pressure. He was discharged from the hospital 5 days ago after a haemorrhagic stroke. His past medical history includes hypertension, obesity and obstructive sleep apnoea. On physical examination, the patient’s heart rate is 98 beats/min, blood pressure is 110/70 mmHg, respiratory rate is 24 breaths/min and SpO2 is 86% on room air. Laboratory analyses, including a complete blood cell count, basic metabolic panel, cardiac enzymes and coagulation studies are normal. An ECG shows sinus tachycardia with an incomplete right bundle branch block and nonspecific T-wave abnormalities. Echocardiography reveals an estimated pulmonary artery pressure of 60 mmHg, tricuspid regurgitation and right atrial and ventricular enlargement. A diagnosis of pulmonary embolism (PE) is made, based on CT pulmonary angiogram of the chest, which reveals multiple thrombi extending into the lobar and segmental branches of the right pulmonary artery. In addition the CT scan reveals thrombi in the pelvic veins.

      Which of the following is the best management option for this patient?

    107. Page 183

      A 52-yr-old female with a medical history of hypertension and hypercholesterolemia presents with progressive shortness of breath. She is an ex-smoker (she quit smoking 15 yrs ago) with a 20 pack-yr smoking history. Approximately 1 yr ago she began to notice shortness of breath on exertion.

      She was initially seen by her family doctor and prescribed bronchodilators, with no clear improvement. When her symptoms got worse, with fatigue and dizziness in addition to shortness of breath during usual everyday activities such as shopping or climbing stairs, she was referred to a cardiologist for further evaluation.

      A transthoracic echocardiogram was performed with the following findings: estimated pulmonary artery systolic pressure of 70 mmHg, right ventricular dilatation with hypokinesis. Normal left ventricular size and function, with an ejection fraction of 55%.

      Which of the following examinations should be included in the further diagnostic evaluation of this patient?

    108. Page 187

      Large randomised controlled trials in patients with mild­to­moderate COPD have shown unambiguously that inhaled bronchodilators improve which of the following?

    109. Page 189

      A 25-yr-old African female presents to the emergency department. She has reportedly just completed a short-distance flight from Paris to London. She complains that she is short of breath and has a cough and pain when taking deep breaths. She was in a good state of health until 1 week prior to her trip, when she developed a cold. On examination, she has pale conjunctivae. The chest examination shows a pleural rub but otherwise is normal. She has bilateral chronic leg ulcers.

      Which of the following is the likely diagnosis?

    110. Page 193

      A 64-yr-old female presents to the emergency department complaining of sudden onset of dyspnoea with pleuritic chest pain in her left hemithorax for the past 3 h. The patient underwent coronary artery bypass graft surgery 9 months ago and has been in a stable condition ever since. Her treatment includes a β-blocker, an angiotensin-converting enzyme inhibitor, furosemide and low-dose aspirin. On examination she is dyspnoeic with a respiratory rate of 18 breaths/min; heart rate is 112 beats/min. Auscultation reveals decreased breath sounds at the base of the left lung. Her ankles are symmetrically swollen and non-tender. SpO2 on room air is 88%. The ECG reveals a sinus tachycardia of 104 beats/min but no other abnormal findings. Chest radiography confirms a small pleural effusion on the left side.

      Which of the following options is the most appropriate next step in the management of this patient?

    111. Page 195

      Which of the following statements concerning non-cystic fibrosis bronchiectasis in adults is/are true?

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