European Respiratory Society
Self-Assessment in Respiratory Medicine

Self-Assessment in Respiratory Medicine is an invaluable tool for any practitioner wishing to test and improve their knowledge of adult respiratory medicine. The updated, second edition includes 261 multiple-choice questions covering the full breadth of the specialty, using clinical vignettes that test not only the readers' knowledge but their ability to apply that knowledge 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 who wish to exercise and improve their skills.

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

      A 36-year-old immunocompetent male patient was admitted to the hospital with prolonged recurrent fever, cough, anorexia and weight loss. Admission investigations revealed anaemia, while renal and liver function were within normal limits. A chest radiograph showed patchy infiltrates and cavitation in the right upper lobe. Microbiological and molecular tests in sputum were positive for Mycobacterium tuberculosis and treatment with isoniazid, rifampicin, ethambutol and pyrazinamide has been started. A few days later, the anti-tuberculosis drug susceptibility test shows isoniazid resistance.

      Which is the right treatment option for this patient?

    2. Page 3
      Abstract

      A 68-year-old man, who smoked for 20 years but stopped 15 years ago, experiences an acute myocardial infarction. Arterial blood gases 4 h after admission are PaO2 8.00 kPa (60 mmHg), PaCO2 4.40 kPa (33 mmHg) and pH 7.44. The chest radiograph is shown below.

      Now, 18 h later, the patient is much more dyspnoeic and is receiving nasal oxygen at a rate of 4 L ⋅ min−1. The neck veins have become more distended in the sitting position, the pulse rate is 128 beats per minute and regular, and a distinct summation gallop is noted at the sixth interspace in the anterior axillary line. Late inspiratory crackles are heard bilaterally halfway up the chest. The arterial blood gases are PaO2 6.4 kPa (48 mmHg), PaCO2 8.5 kPa (64 mmHg), and pH 7.24.

      Which is the most likely explanation for the hypercapnia?

    3. Page 5
      Abstract

      Which of the following statements about CPAP treatment in OSAS is/are true?

    4. Page 7
      Abstract

      A 22-year-old man is admitted to the emergency department after blunt chest trauma from the steering wheel in a motor vehicle accident. He is conscious and his vital signs are stable. There is no evidence of other injury. The chest radiograph shows a right pleural effusion occupying about half of the hemithorax. There are no obvious rib fractures and no pneumothorax.

    5. Page 9
      Abstract

      Regarding Pneumocystis jiroveci pneumonia in HIV-infected patients, which of the following statement(s) is/are correct?

    6. Page 11
      Abstract

      A 60-year-old female is referred for dyspnoea on exertion and chronic cough. Her dyspnoea and cough have worsened continuously during the past 12 months. Pulmonary function testing reveals an FVC of 72% predicted, FEV1 of 80% predicted and a TLCO of 38% predicted. A representative slice of the chest CT is shown below. Open-lung biopsy reveals randomly distributed foci of scarring with fibroblasts surrounded by normal lung parenchyma.

      What is the most appropriate therapy for this patient?

    7. Page 13
      Abstract

      A 32-year-old, HIV-positive man presents with dyspnoea, nonproductive cough and fever. Physical examination reveals a temperature of 39.4°C; the chest examination is normal. His medical records show that he was hospitalised to an AIDS ward 6 weeks ago during an unrecognised outbreak of drug-resistant tuberculosis.

      Which of the following tests would be helpful in the evaluation of this patient?

    8. Page 15
      Abstract

      Which of the following statements concerning the use of supplemental oxygen in patients with COPD is/are correct?

    9. Page 17
      Abstract

      During resting tidal breathing, mean inspiratory airflow is greater than mean expiratory airflow.

      Which one of the following explains this finding?

    10. Page 19
      Abstract

      In a study, pulse oximetry detected OSAS with a sensitivity of 70 % and a specificity of 96% compared with polysomnography. Male sex and older age are known risk factors for OSAS.

      Which of the following conclusion(s) can be drawn from this information?

    11. Page 21
      Abstract

      A 45-year-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 years and an episode of pneumothorax 6 months ago. On admission, her blood pressure is 130/80 mmHg, her heart rate is 100 beats per min and regular, and her respiratory rate is 32 breaths per 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?

    12. Page 23
      Abstract

      A 47-year-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 TLCO is 35% pred. Arterial blood gases show a pH of 7.45, PaO2 of 7.3 kPa (55 mmHg) and PaCO2 of 4.4 kPa (33 mmHg). 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 per μL, 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?

    13. Page 25
      Abstract

      A 75-year-old female is referred for dyspnoea on exertion and chronic cough that have worsened progressively over the past 12 months. Pulmonary function testing reveals an FVC of 72% predicted, FEV1 of 80% predicted and TLCO of 38% predicted. The chest radiograph shows bilateral patchy infiltrates, mostly at the lung bases. On HRCT, bilateral reticular opacities and clustered basal honeycombing are found. Open-lung biopsy reveals randomly distributed foci of usual interstitial pneumonia surrounded by normal lung parenchyma.

      What is the most appropriate therapy for this patient?

    14. Page 27
      Abstract

      A 46-year-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?

    15. Page 29
      Abstract

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

    16. Page 31
      Abstract

      Which of the following statements concerning exudative pleural effusions is/are true?

    17. Page 33
      Abstract

      A 54-year-old man with ischaemic cardiomyopathy undergoes coronary artery bypass surgery for severe proximal obstructive lesions. He is mechanically ventilated in pressure support mode overnight. The morning after surgery, he has several pulmonary artery wedge pressure readings of 18 mmHg but his chest radiography shows no evidence of congestive heart failure. He undergoes extubation and initially does well but 2 h later he experiences rapid onset of dyspnoea. His chest radiography now shows pulmonary oedema. An ECG shows sinus tachycardia but no evidence of myocardial ischaemia.

      Which of the following functional abnormalities related to discontinuation of mechanical ventilation is the most likely cause of the pulmonary oedema?

    18. Page 35
      Abstract

      Which of the following statements about cystic fibrosis is/are correct?

    19. Page 37
      Abstract

      Which of the following statements concerning the management of diffuse malignant mesothelioma of the pleura is/are true?

    20. Page 39
      Abstract

      Which of the following conditions will tend to increase the ventilation/perfusion ratio (i.e. increase West zone 1) and therefore the dead space ventilation in the top part of the lung?

    21. Page 41
      Abstract

      A 74-year-old never-smoking man, who is former government office worker, complains of a dry cough and progressive shortness of breath (New York Heart Association functional class III) for 6 months. He takes 20 mg enalapril daily for arterial hypertension. He has no other diseases. He has not kept animals, or been exposed to dust or fumes. Auscultation reveals Velcro rales over both lung bases. There is no clubbing. Pulmonary function tests cannot be performed because of impressive, possibly psychogenic, hyperventilation. While breathing room air, arterial blood gas analysis shows PaO2 9.64 kPa (72 mmHg), PaCO2 5.47 kPa (41 mmHg), pH 7.36, base excess –1.8 mmol⋅L−1 and SaO2 94%. His chest CT image is shown below.

      Which of the following is the most appropriate initial diagnostic procedure?

    22. Page 43
      Abstract

      A 24-year-old male student with cystic fibrosis presents to your office with a 4-week history of increasing dyspnoea and decreased exercise tolerance. His chronic cough productive of 90 mL greenish sputum per day has increased. He was hospitalised 2 years ago for a right pneumothorax. Current medications include pancreatic enzyme replacement, a multiple-vitamin supplement and bronchodilators as needed. He admits to some noncompliance with his daily chest physiotherapy regimen. The patient weighs 60 kg and is 170 cm tall. His pulse rate is 86 beats per min, blood pressure 106/78 mmHg, respiration rate 24 breaths per min, temperature 36.8˚C and SpO2 93%. Chest examination reveals diffuse, coarse crackles and expiratory rhonchi. His laboratory and spirometry results are as follows.

      Haematocrit % 41
      Leukocytes per μL 11 400
       Neutrophils % 78
       Lymphocytes % 16
       Eosinophils % 2
      6 months ago Current
      FVC % predicted 74 62
      FEV1 % predicted 48 40
      FEV1/FVC % 70 62

      His chest radiograph is shown below.

      Which of the following is the most efficacious management option?

    23. Page 45
      Abstract

      A 52-year-old woman known for poorly controlled asthma is referred to the emergency unit with acute dyspnoea. On her chest X-ray, multiple infiltrates are seen on both lungs, prominently on the lower parts. She also complains of weakness of her left arm and numbness of several fingertips on both hands. Her urine is microscopically positive for red blood cells. Purpura is seen on her right forearm and on her right ankle. Due to increasing dyspnoea despite bronchodilators, the patient is referred to the intensive care unit.

      Which of the following statements regarding the confirmation or rejection of the suspected diagnosis is most appropriate?

    24. Page 47
      Abstract

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

    25. Page 49
      Abstract

      A 25-year-old woman has had nearly continuous daytime sleepiness for 6 years. She either falls asleep or ‘blacks out’ involuntarily several times a day, especially in business meetings, and has to be awakened by colleagues. She has frequent nocturnal awakenings, sometimes associated with nightmares. She has been told that she snores, although she now lives alone. A review of her symptoms is remarkable for a several-year history of almost daily ‘collapsing’ spells, lasting 20–30 s, during which she feels her knees buckle, requiring her to sit for a few minutes. She is 152 cm tall, weighs 70 kg, has a neck circumference of 43 cm, a blood pressure of 100/72 mmHg and an otherwise normal physical examination.

      What is the most appropriate next step?

    26. Page 51
      Abstract

      A 64-year-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?

    27. Page 53
      Abstract

      A 38-year-old nonsmoking and otherwise healthy farmer complains of increasing cough and dyspnoea on exertion of almost 3 years’ 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?

    28. Page 55
      Abstract

      A 68-year-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 per min, breathing rate 32 breaths per min, and temperature 38.9 °C. Bronchial breath sounds are heard on auscultation of the right chest. Blood tests reveal a white blood cell count of 9000 × 109 per L with a left shift, haematocrit 46%, urea 22 mmol⋅L−1, creatinine 160 μmol⋅L−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?

    29. Page 57
      Abstract

      A patient on mechanical ventilation for acute respiratory distress syndrome develops a right-sided pneumothorax.

      Which of the following measures should be taken at this time?

    30. Page 59
      Abstract

      A 45-year-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. 5 years 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 7.6 kPa (57 mmHg), PaCO2 of 4.0 kPa (30 mmHg) 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?

    31. Page 61
      Abstract

      A 48-year-old female with a 25 pack-year 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 per 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?

    32. Page 63
      Abstract

      A 35-year-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 reticular opacities of the lung with bilateral hilar lymphadenopathy. Which one of the following investigations would be most useful in guiding her acute management?

    33. Page 65
      Abstract

      A 22-year-old patient with Duchenne muscular dystrophy is ventilated at home with a bilevel pressure-cycled ventilator. Following a lower airway infection, he experiences great difficulty in clearing bronchial secretions.

      Of the following treatments, which one is recommended in this case?

    34. Page 67
      Abstract

      Which of the following radiographic features is least likely to be found in Langerhans’ cell histiocytosis of the lung?

    35. Page 69
      Abstract

      A 46-year-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?

    36. Page 71
      Abstract

      A 55-year-old secretary has been diagnosed with OSAS based on excessive sleepiness (Epworth sleepiness score 14) with frequent episodes of dozing off at work, habitual snoring and an AHI of 36 events per h 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?

    37. Page 73
      Abstract

      A 66-year-old Dutch woman presents with 3 weeks of cough and sputum production, with haemoptysis and 2.3 kg weight loss in 1 month. She has a history of multiple episodes of childhood pneumonia. She does not smoke but says that she has had a chronic cough for 5 years, present throughout the day, with daily sputum production. Several times a year, she receives antibiotic therapy for purulent sputum. Her tuberculin skin test was positive 20 years ago. Chest radiography shows increased markings at the lung bases with ‘tramlines’ and dilated bronchial shadows. Furthermore, an infiltrate with a 1-cm thin-walled cavity in the right upper lobe is seen. A sputum smear for acid-fast bacilli is positive.

      Which of the following should be the next step in the management of this patient?

    38. Page 75
      Abstract

      A 60-year-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 years ago after an exposure of approximately 15 cigarettes per day for 15 years.

      What is the most appropriate next step?

    39. Page 77
      Abstract

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

    40. Page 79
      Abstract

      A 23-year-old, atopic laboratory technician experiences adult-onset asthma that she attributes to handling laboratory rats. She describes an almost immediate onset of asthma symptoms after entering the work place, with some resolution during the day, but subsequently, another asthmatic attack during the early evening after she returns home from work. Her peak expiratory flow data from a 5-week period of work followed by 3 weeks of holiday are shown below.

      Which of the following therapeutic approaches is most appropriate?

    41. Page 81
      Abstract

      A 65-year-old former smoker with COPD of Global Initiative for Chronic Obstructive Lung Disease grade 3, group D, is referred to the intensive care unit because of an acute exacerbation of his disease, presenting with increased dyspnoea and purulent sputum. Despite inhalation of salbutamol, intravenous antibiotics and corticosteroids, his condition worsens gradually over 30 min. He has not eaten or drunk for the last 5 h. On arterial blood gas analysis, pH is 7.25, PaO2 is 6.6 kPa (49.5 mmHg) and PaCO2 is 8.0 kPa (60 mmHg). He is agitated but cooperates with inhalation and opens his eyes on request. His respiratory rate is 26 breaths per min.

      Which therapeutic option is most appropriate in this situation?

    42. Page 83
      Abstract

      You see an otherwise healthy 66-year-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 years. He has reduced smoking to only five cigarettes per day in recent years but has a smoking history of 30 pack-years. 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?

    43. Page 85
      Abstract

      A 62-year-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 BMI 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% predicted with a normal flow–volume loop.

      Which of the following is/are correct?

    44. Page 87
      Abstract

      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 per h and the oxygen desaturation index is 30 events per h. Mean nocturnal oxygen saturation is 86% and the saturation never rises above 90% during the night. An arterial blood gas analysis reveals PaO2 7.05 kPa (53 mmHg), PaCO2 9.05 kPa (68 mmHg) and pH 7.42; bicarbonate is 34 mmol⋅L−1. Pulmonary function testing reveals a mild restrictive ventilatory disorder.

      Which of the following would be the appropriate initial therapy for this patient?

    45. Page 89
      Abstract

      A 65-year-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?

    46. Page 91
      Abstract

      A 69-year-old, lifelong heavy smoker is assessed for exertional dyspnoea. He has a past history of hypertension and 3 years ago, he had a cerebrovascular accident with good functional recovery.

      Spirometry shows FEV1 1.2 L, FVC 2.4 L, FEV1/FVC 50%, TLCO 50% predicted and oxygen saturation on room air 92%. After walking 310 m in 6 min, the patient is profoundly breathless, with Borg dyspnoea score 8 (out of 10) and oxygen saturation on room air 88%. 15 min after the exercise, repeat spirometry shows FEV1 1.0 L, FVC 2.0 L and FEV1/FVC 50%.

      What is the least likely cause of the breathlessness?

    47. Page 93
      Abstract

      A 49-year-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?

    48. Page 95
      Abstract

      A 50-year-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 diagnostic evaluation to perform next?

    49. Page 97
      Abstract

      A 49-year-old woman is referred for exercise testing to evaluate her dyspnoea. She stops the test because of dyspnoea at a maximal workload of 100 W (60% predicted) with a maximal oxygen uptake of 23 mL⋅kg−1⋅min−1 (58% predicted). Her heart rate reserve is 25 beats per min and her breathing reserve is 10%. Her inspiratory capacity before and at the end of the test is 1200 and 900 mL, respectively.

      What is the most likely cause of her dyspnoea?

    50. Page 99
      Abstract

      A 33-year-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 per min 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 7.315 kPa (55 mmHg), PaCO2 3.99 kPa (30 mmHg) and pH 7.48 in room air.

      Which of the following is the next diagnostic procedure?

    51. Page 101
      Abstract

      A 36-year-old woman develops a mild dry cough and shortness of breath during exercise. Pulmonary function testing shows FEV1 85% predicted, FVC 85% predicted, TLC 87% predicted and TLCO 65% predicted. A chest radiograph and two HRCT images of the lung are shown below.

      A bronchoalveolar lavage fluid cell count of 650 per μL was found, with 84% lymphocytes (CD4/CD8 ratio 0.1), 4% eosinophils and 2% basophils. Based on these findings, a differential diagnosis was made.

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

    52. Page 103
      Abstract

      A 35-year-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 8.65 kPa (65 mmHg), PaCO2 of 5.59 kPa (42 mmHg), 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?

    53. Page 105
      Abstract

      A 69-year-old man with severe COPD comes to your office and requests to be scheduled for lung volume reduction surgery. He has been hospitalised five times in the last year for acute COPD exacerbations. He is severely dyspnoeic when moving between rooms and is confined to his home. He reports increasing frustration with his declining quality of life. He has no other significant health problems. The patient’s current medical regimen includes ipratropium (four puffs, four times per day), salbutamol (two puffs, four times per day), sustained-release theophylline and nasal oxygen (3–4 L⋅min−1). Following a 2-week course of prednisone (40 mg daily), the patient did not improve symptomatically or spirometrically. Physical examination reveals pursed-lip breathing, a respiratory rate of 22 breaths per min, diffusely diminished breath sounds, end-expiratory wheezes and trace pedal oedema. A recent chest CT is shown below.

      The results of arterial blood gases studies on 3 L⋅min−1 nasal oxygen are shown below.

      PaO2 kPa (mmHg) 8.5 (64)
      PaCO2 kPa (mmHg) 5.6 (42)
      pH 7.37
      SaO2 % 89
      Carboxyhaemoglobin % 5.1

      The results of pulmonary function studies are shown below.

      FVC L (% predicted) 3.8 (81)
      FEV1 L (% predicted) 0.8 (24)
      Post-bronchodilators No improvement
      TLC % predicted 132
      Residual volume/TLC ratio 0.58
      TLCO % predicted 56

      Which of the following is most appropriate at this time?

    54. Page 107
      Abstract

      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 quality adjusted life year (QALY) at 10 years of follow-up.

    55. Page 109
      Abstract

      A 24-year-old nonsmoking woman was diagnosed with asthma 9 months ago, and has been on 500 μg beclomethasone and 9 μg formoterol, both twice daily, plus salbutamol as needed, since then. She has been asymptomatic for the past 3 months. Her FEV1 is 3.8 L (97% predicted).

      Which one of the following should you advise her to do?

    56. Page 111
      Abstract

      A 36-year-old woman presents to your office after coughing up 5–10 mL bright red blood the previous day. 3 days earlier she had noted the onset of a runny nose and frequent nonproductive cough. She denies experiencing fever, chest pain or dyspnoea. She has no previous history of haemoptysis but was hospitalised for pneumonia for 2 weeks at the age of 22 years. She has smoked half a pack of cigarettes per day for 16 years. She appears healthy except for a frequent nonproductive cough. The physical examination is normal, including vital signs, chest examination and cardiac examination. Laboratory studies show a haematocrit of 39%, leukocyte count of 8600 per µL and normal differential white blood cell count. Her platelet count is 17 5 000 per µL, blood urea nitrogen is 14 mg·dL−1 (0.78 mmol·L−1) and serum creatinine is 0.8 mg·dL−1 (0.04 mmol·L−1). Urinalysis shows no erythrocytes, 40–50 leukocytes per high-power field, few bacteria and no protein by dipstick. No casts are seen. Chest radiography is normal.

      Which of the following is the most appropriate diagnostic step to perform next?

    57. Page 113
      Abstract

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

    58. Page 115
      Abstract

      A 40-year-old, HIV-positive male consults his physician because of a 2-week history of right chest pain, night sweats and cough. His body temperature is 37.6 °C and vital signs are normal, and there is dullness on percussion, reduced lung sounds and some rales on the right lower chest. The chest radiograph is shown below.

      His C-reactive protein level is 119 mg⋅mL−1 (normal <5 mg⋅mL−1) and white blood cell count is 6570 cells per mm3. His CD4 cell count was 437 per µL 5 months ago.

      Which further examination should be recommended first?

    59. Page 117
      Abstract

      A 55-year-old male consults you because of breathlessness, which has become gradually worse over a period of 1 year. 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-years. 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.

      Predicted Measured pre-bronchodilator Measured post-bronchodilator Change
      FVC 3.75 L 2.34 L (62% pred) 2.75 L 0.41 L (+18%)
      FEV1 2.78 L 0.91 L (32% pred) 1.09 L 0.18 L (+20%)
      FEV1/FVC 73% 39% 40%

      Which of the following is the most likely diagnosis?

    60. Page 119
      Abstract

      A 73-year-old retired insulating engineer presents with a 6-month history of increasing dyspnoea. He worked with asbestos for 2 years, 35 years ago. 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?

    61. Page 121
      Abstract

      A 58-year-old taxi driver is referred for evaluation of excessive sleepiness. His wife reports that he is a heavy snorer, has frequent breathing pauses during sleep and appears to be increasingly depressed and without energy. Nocturnal pulse oximetry reveals repetitive oxygen desaturations (dip rate >4%, 34 events per h).

      Which of the following treatments is most likely to improve his symptoms?

    62. Page 123
      Abstract

      Regarding diffusing TLCO, which of the following statement(s) is/are correct?

    63. Page 125
      Abstract

      A 30-year-old nonsmoking female primary school teacher presents with new symptoms of nonproductive cough for 3 weeks. Once a week, she gives evening lessons in stone sculpting and is exposed to silica dust. She never wears a protective mask. She has no dyspnoea on exertion and is otherwise well. Pulmonary function shows a mild restrictive pattern with an FVC of 92% predicted. Her chest X-ray and chest CT scan are shown below.

      Which of the following statements is correct?

    64. Page 127
      Abstract

      A 37 year-old patient presents with adult-onset asthma. Due to increased production of brownish sputum production, and perihilar and upper lobe opacities on a conventional chest radiograph, a CT scan is performed showing central bilateral bronchiectasis and infiltrates. Bronchoscopy shows mucus plugs in the central airways.

      Which of the following statements concerning a suspected underlying disorder is correct?

    65. Page 129
      Abstract

      Which one of the following statements is correct regarding long-term use of inhaled corticosteroids in the treatment of moderate to severe COPD?

    66. Page 131
      Abstract

      A 63-year-old healthy woman, who has never smoked, has been visiting her family, including three grandchildren. The children have been suffering from a febrile illness, passing it between one another, and two of them have had severe earaches. After being at their home for 2 weeks, the patient experiences a nonproductive cough, fever and weakness. Her chest radiograph shows a right mid-lung infiltrate and a small pleural effusion. The white blood count of her pleural fluid is 560 cells per mm3. The cold agglutinin titre of her acute serum is 1:16. She responds to treatment with erythromycin.

      What could be done to confirm or rule out a diagnosis of Mycoplasma pneumonia?

    67. Page 133
      Abstract

      A 52-year-old patient with severe late-onset intrinsic asthma and a history of sinusitis stopped taking systemic corticosteroids 4 weeks ago. Now, he is suffering from fever, malaise and moderate weight loss. Due to severe chest pain that does not allow the patient to lie on his left side, he is referred to the intensive care unit. On auscultation, a pericardial friction rub is audible. On his skin, several new-onset haemorrhagic lesions are visible. His creatine kinase (CK) and CK-MB are elevated.

      Which laboratory test could best help to support the suspected diagnosis?

    68. Page 135
      Abstract

      Which of the following treatments has/have been shown to reduce mortality among selected patients with COPD in prospective randomised studies?

    69. Page 138
      Abstract

      A 72-year-old, previously healthy, nonsmoking woman suffers from progressive dyspnoea on exertion for several months. Treatment with a combined corticosteroid and long-acting β-adrenergic agonist inhaler for 3 months did not provide significant relief of symptoms. Clinical examination reveals a slight inspiratory and expiratory stridor but is otherwise normal. The spirometry results and flow–volume curve are shown in below.

      Parameter Predicted Measured % predicted
      FVCexL 2.90 2.63 91
      FEV1L 2.45 1.79 73
      FEV1/FVCex% 77 68 88
      PEF L⋅s−1 6.22 2.74 44
      MEF75%L⋅s−1 5.43 2.37 44
      MEF50%L⋅s−1 3.70 1.55 42
      MEF25%L⋅s−1 1.31 0.63 48
      MEF25–75%L⋅s−1 2.90 1.31 45

        FVCex: expiratory FVC; PEF: peak expiratory flow; MEFx%: maximum expiratory flow at x% of FVC.

      Bronchoscopic inspection of the trachea revealed the findings shown below.

      Laboratory tests, including C-reactive protein, and red and white blood cell counts, were within normal limits.

      Which one of the following is the most appropriate treatment?

    70. Page 141
      Abstract

      A 35-year-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. 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?

    71. Page 143
      Abstract

      A 33-year-old man presents with minor haemoptysis, fatigue, weight loss and recurrent nasal bleeding. The chest radiograph discloses multiple dense infiltrates, some with cavitation, and the serum cytoplasmic anti-neutrophil cytoplasmic antibody (cANCA) test is positive with elevated anti-proteinase 3 (PR3) IgG.

      Which of the following initial treatments is most appropriate for the suspected disease?

    72. Page 145
      Abstract

      A 28-year-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. 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. Blood urea and electrolytes are normal. There is no proteinuria. Results of blood cultures are pending. The chest radiograph is shown below.

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

    73. Page 147
      Abstract

      A 45-year-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 per 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?

    74. Page 149
      Abstract

      A 53-year-old obese male (BMI 30.1 kg⋅m−2) is diagnosed with OSA with an AHI of 45 events per h and an oxygen desaturation index of 40 events per h. He is given auto-adjusting nasal CPAP therapy with an allowed pressure range of 5–15 cmH2O. On the first night of adaptation, his AHI went down to 6 events per h and his ODI was 4 events per h. 3 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 oxygen desaturation index of 34 events per h. Data downloaded from the CPAP machine suggested an adequate compliance by the patient as the machine was used for 5.48 h per night on average. The applied pressure 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?

    75. Page 151
      Abstract

      A 65-year-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 per day for 40 years. 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?

    76. Page 153
      Abstract

      What is/are the characteristic(s) common to both nonasthmatic eosinophilic bronchitis and asthma?

    77. Page 155
      Abstract

      A 45-year-old female is referred to you by her general practitioner because she has recurrent episodes (three to six per year) of bronchitis with fever for which she uses courses of antibiotics with good results. Between these episodes, she coughs up phlegm in considerable amounts (several spoonfuls a day). The colour of the phlegm varies from white to yellow; she has never seen blood in her phlegm. She smoked approximately 20 cigarettes per day from the age of 18 years until the age of 30 years. 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?

    78. Page 157
      Abstract

      A 36-year-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 treatment for this patient?

    79. Page 159
      Abstract

      In a patient with left ventricular failure, of which of the following phenomena during sleep is a low waking PaCO2 (<4.7 kPa (<35 mmHg)) predictive?

    80. Page 161
      Abstract

      A 72-year-old patient with very severe COPD has been on long-term home oxygen therapy for 5 years. He suffers from recurrent exacerbations, which can usually be managed on an outpatient basis. Recently he was admitted to the hospital due to respiratory failure.

      Which of the following statements is false?

    81. Page 163
      Abstract

      A 24-year-old medical student is consulting you before departing to Africa where he plans to climb Mt Kilimanjaro (5895 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 2500 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?

    82. Page 165
      Abstract

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

    83. Page 167
      Abstract

      A 34-year-old man has pulmonary tuberculosis with the lung lesion confined to the left upper lobe, where there is a 3-cm cavity with extensive interstitial infiltration. He has had haematuria and pyuria for 4 weeks, and an intravenous pyelogram shows deformed collecting structures in the upper pole of the left kidney. Sputum and urine cultures are positive for Mycobacterium tuberculosis. A serum test for HIV infection is negative.

      Which one of the following is the treatment regimen of choice for this patient?

    84. Page 169
      Abstract

      A 24-year-old female is visiting your outpatient clinic for regular follow-up of her asthma. You have known this patient for 7 years 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 the age of 17 years, 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 200/6 µg twice a day to budesonide/formoterol 200/6 µg once in the morning. 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 only twice during the past 3 months because she felt so well.

      According to the Global Initiative for Asthma management strategy, what would be the most appropriate next action?

    85. Page 171
      Abstract

      A 26-year-old man with cystic fibrosis presents because of increasing dyspnoea and cough following recurrent episodes of chest infections. He has required frequent hospitalisation for intravenous antibiotics and vigorous chest physiotherapy. Previous sputum cultures revealed Pseudomonas aeruginosa sensitive to gentamicin, tobramycin and ciprofloxacin, but resistant to imipenem and other antibiotics. 2 months ago, his FVC was 1.6 L (45% predicted) and his FEV1 was 0.6 L (30% predicted). 4 months ago, he had a left-sided pneumothorax requiring chest tube insertion. During a routine follow-up visit 14 months ago, his FVC was 2.3 L (55% predicted) and FEV1 was 1.1 L (45% predicted). The patient is highly motivated and compliant with medications, twice-daily chest physiotherapy, and follow-up visits. He and his family members attribute his recent deterioration to depression because his girlfriend left him several months ago.

      At this time, for which of the following should the patient be referred?

    86. Page 173
      Abstract

      A 43-year-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 microorganism causing his illness?

    87. Page 175
      Abstract

      A 66-year-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 per min and his respiratory rate is 28 breaths per min. His temperature is normal and his SpO2 is 88% on room air, which improves to 95% on 2 L per min 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 7.28 kPa (56 mmHg), a PaCO2 of 3.99 kPa (30 mmHg), 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 per 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?

    88. Page 179
      Abstract

      Which of the following organisms is least likely to be part of the upper respiratory flora?

    89. Page 181
      Abstract

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

    90. Page 183
      Abstract

      A 71-year-old male is referred to you for evaluation of heavy snoring, daytime sleepiness, increasing shortness of breath, chronic cough and fatigue. His height is 184 cm, his weight is 106 kg and his oxygen saturation on room air at rest is 91%. His blood pressure is 160/90 mmHg, and heart rate is 96 beats per min and irregular. ECG shows atrial fibrillation. He regularly inhales ipratropium bromide for his COPD (Global Initiative for Chronic Obstructive Lung Disease grade 2). He smokes 20 cigarettes per day (total of 50 pack-years), drinks a bottle of wine every evening and takes 2.5 mg of temazepam before sleep because of frequent awakening with shortness of breath. The results of night-time pulse oximetry are shown in the below.

      Regarding the further management of this patient, which one of the following statements is wrong?

    91. Page 185
      Abstract

      To which of the following patients is the chest CT shown below most likely to belong?

    92. Page 187
      Abstract

      A 67-year-old man with a previous history of myocardial infarction has dyspnoea after climbing one set of stairs. He generally feels tired but does not fall asleep during the daytime (Epworth Sleepiness Scale score 8). His BMI is 25 kg⋅m−2. He is on a diuretic, a statin and aspirin but no other medication. His left ventricular ejection fraction was 34% 2 years ago when the patient was admitted with dyspnoea and pulmonary oedema. As his wife reports snoring, an ambulatory polygraphy is performed. The results are: AHI 26 events per h, central AHI 17 events per h, lowest SpO2 83%, SpO2 <90% for 5% of time in bed.

      What is the most appropriate next step?

    93. Page 189
      Abstract

      A 27-year-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?

    94. Page 191
      Abstract

      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?

    95. Page 193
      Abstract

      A 56-year-old female suffers from obstructive apnoea/hypopnoea syndrome. On polysomnography, her AHI was 42 events per h and her oxygen desaturation index (≥4%) was 40 events per h. 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 per h 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?

    96. Page 195
      Abstract

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

    97. Page 197
      Abstract

      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?

    98. Page 199
      Abstract

      A 35-year-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 of the following is the most likely diagnosis?

    99. Page 201
      Abstract

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

    100. Page 203
      Abstract

      A 74-year-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 per min and regular. Arterial blood gases reveal a PaO2 7.4 kPa (56 mmHg), PaCO2 of 3.7 kPa (28 mmHg) 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?

    101. Page 205
      Abstract

      Which of the following statements concerning initiation of β-blocker treatment in patients with advanced COPD (Global Initiative for Chronic Obstructive Pulmonary Disease grade 3 or 4) on inhalation therapy with a long-acting β-agonist and inhaled corticosteroids is/are correct?

    102. Page 207
      Abstract

      A 34-year-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% of her personal best 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?

    103. Page 209
      Abstract

      A 45-year-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 a PaO2 of 6.0 kPa (45 mmHg), PaCO2 of 1.5 kPa (11 mmHg) and pH of 7.56. He is intubated, and positive pressure ventilation is initiated with an inspiratory oxygen fraction (FIO2) of 0.5 and a positive end-expiratory pressure of 6 cmH2O. Arterial blood gas analysis after half an hour demonstrates a PaO2 of 6.7 kPa (50 mmHg), PaCO2 of 3.0 kPa (22 mmHg) and pH of 7.52. Brain natriuretic peptide concentration is normal, and echocardigraphy shows normal systolic and diastolic function as well as normal respiratory variation of the inferior vena cava size. Which of the following statements regarding this patient is/are correct?

    104. Page 211
      Abstract

      A 74-year-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-years 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 per 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 8.9 kPa (67 mmHg), PaCO2 of 3.65 kPa (27 mmHg), 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?

    105. Page 213
      Abstract

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

    106. Page 215
      Abstract

      At which of the following points does the maximum flow–volume curve cross the volume axis?

    107. Page 217
      Abstract

      A 57-year-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?

    108. Page 219
      Abstract

      A 58-year-old Spanish male smoker with a history of COPD (post-bronchodilator FEV1 57% predicted) presents to the emergency department with a cough of more than 24 h duration accompanied by increased purulent sputum production. The patient has no history of lower respiratory tract infections and has received no antibiotics in the past 12 months. Physical examination: temperature 38.6°C, heart rate 112 beats per min, respiratory rate 34 breaths per min, and blood pressure 132/84 mmHg. Examination of the chest reveals crackles in the right lower lung field. The chest radiograph shows consolidation of the right lower lobe. Laboratory tests show a leukocyte count of 22 000 cells per μL with 90% neutrophils; sputum Gram stain shows mixed flora and many squamous epithelial cells. The patient is hospitalised.

      Which empiric antibiotic therapy should be started in this patient?

    109. Page 221
      Abstract

      A sales representative demonstrates a new peak expiratory flow (PEF) meter to you. In his documentation, you find a graph (below) that shows comparisons between PEF measurements in 61 patients by the new PEF meter and corresponding values measured by a Fleisch pneumotachograph, which is considered the reference gold standard.

      A table accompanying the graph says that the coefficient of correlation (r) among all 61 paired measurements is 0.96. For PEF values ≤500 L·min−1, the r=0.94, and for values >500 L·min−1, r=0.69:

      All data n=61 r=0.96 r2=0.92
      PEF >500 L·min−1 n=26 r=0.69 r2=0.48
      PEF ≤500 L·min−1 n=35 r=0.94 r2=0.89

      Which of the following statements is/are correct concerning this graph?

    110. Page 225
      Abstract

      An obese 60-year-old man complains of dyspnoea on exertion that has slowly progressed over the past year. He has no haemoptysis, chest pain, orthopnoea or paroxysmal nocturnal dyspnoea. Cardiovascular examination reveals a pulse rate of 102 beats per min, a blood pressure of 130/80 mmHg and distant heart sounds. The lungs are clear. Chest radiography shows borderline cardiomegaly with normal lung fields. Right-sided catheterisation of the heart shows a pulmonary capillary wedge pressure of 20 mmHg, and systolic, diastolic and mean pulmonary artery pressures of 45, 27 and 33 mmHg, respectively.

      Which is the most likely diagnosis?

    111. Page 229
      Abstract

      Which of the following options is of highest value for the diagnosis of hypersensitivity pneumonitis (extrinsic allergic alveolitis)?

    112. Page 231
      Abstract

      A 75-year-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?

    113. Page 233
      Abstract

      Which of the following statements about small cell carcinoma is true?

    114. Page 235
      Abstract

      A 63-year-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 100×106 cells per L, 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?

    115. Page 237
      Abstract

      A 55-year-old male nurse is seen in your office. He has had blood-streaked haemoptysis for 2 weeks following an upper respiratory infection and bronchitis. He has lost 5 kg in the past month and has continued to work full-time. He had smoked for 35 years, but quit 2 weeks ago. The physical examination reveals a mildly obese man in no distress. The lymph node examination reveals a firm 1.5-cm right supraclavicular lymph node. The rest of the physical examination (including a careful neurological examination) is normal. The relevant slices of the chest CT are shown below. The liver and adrenal glands are normal. Bronchoscopy is performed and biopsy of a polypoid mass in the right lower lobe reveals squamous cell lung cancer. A fine-needle aspiration of the right supraclavicular lymph node is positive for squamous cell carcinoma.

      What should be the treatment of this patient?

    116. Page 239
      Abstract

      A 75-year-old ex-smoker with COPD (Global Initiative for Chronic Obstructive Lung Disease grade 2) using long-acting bronchodilators has had shortness of breath, increased sputum expectoration and fever for 5 days. His heart rate is 115 beats per min, respiratory rate is 36 breaths per min, blood pressure is 100/65 mmHg and body temperature is 38.6°C, and he seems slightly confused. On lung auscultation, you hear crackles, mainly in the right lung, and diffuse wheezes.

      Which of the following is the best choice for the further management of this patient?

    117. Page 241
      Abstract

      A 16-year-old boy presents with his parents for evaluation of severe daytime somnolence. The patient had been healthy until the beginning of the school year, when he started to have increasing difficulty getting out of bed for school in the morning. He frequently misses the bus due to his tardiness, and after arriving at school he has difficulty staying focused on class work and sometimes dozes off. He has failed his examinations. His parents do not feel that he snores excessively and they have never witnessed apnoeas or unusual motor activity during his sleep. The patient typically goes to bed by 22:30–23:00 h but he often watches television in bed, sometimes to as late as 04:00 h. His parents have discouraged him from staying up so late but he notes that if he turns off the lights at 22:30 h, he is unable to sleep for several hours. On weekends, he often sleeps until 14:00–15:00 h. Sleep hygiene measures have not worked.

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

    118. Page 243
      Abstract

      A 38-year-old black female is admitted to the hospital because of a 1-year 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 per min and rhythmic, and respiratory rate is 26 beats per 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?

    119. Page 245
      Abstract

      In severe persistent allergic asthma, which of the following has therapy with the anti-IgE antibody omalizumab has been shown to do consistently?

    120. Page 247
      Abstract

      A 25-year-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 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 is otherwise normal. She has bilateral chronic leg ulcers.

      Which of the following is the likely diagnosis?

    121. Page 249
      Abstract

      You see an otherwise healthy 52-year-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 per 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?

    122. Page 251
      Abstract

      A 69-year-old teacher is consulting you as he has felt excessively sleepy during the day for several years. He reports almost having had an accident while driving on the motorway about 1 year ago due to lack of concentration. Recently, he hit a parked car because he had fallen asleep at the wheel. He complains of difficulty initiating night sleep and frequent awakenings, and he does not feel refreshed in the morning. His wife reports that he is a snorer and extremely restless during the night but she does not remember whether he has breathing pauses during the night. Another physician has performed nocturnal pulse oximetry, which showed 13 oxygen desaturations of >2% per h, 1% of the recording time with SpO2 <90% and an irregular pulse rate.

      Regarding the diagnosis, which of the following statements is most appropriate in this case?

    123. Page 253
      Abstract

      Which one of following measures is least predictive of the risk of death in COPD patients?

    124. Page 255
      Abstract

      A 35-year-old man is seen in the emergency department with a history of severe right-sided pleuritic pain of ∼1 h duration. He had two mild episodes of similar pain in the last 36 h and has been short of breath for ∼12 h. He sprained his ankle 8 h days previously. On physical examination, he is anxious, sweating and dyspnoeic. His temperature is 39°C, pulse rate is 110 beats per min, respiratory rate is 28 breaths per min and blood pressure is 150/105 mmHg. Lung and heart examinations are normal except for an S4. A chest radiograph shows plate-like atelectasis at the right base with slight elevation of the right hemidiaphragm. Arterial blood gases are PaO2 9.3 kPa (70 mmHg), PaCO2 4.2 kPa (32 mmHg) and pH 7.47.

      What should be done first?

    125. Page 259
      Abstract

      A 68-year-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 4), and uses daily tiotropium and albuterol as needed. His diabetes mellitus is well controlled with metformin. He has a confirmed allergy to amoxicillin. On physical examination, he is tachypnoeic (30 breaths per min) and tachycardic (110 beats per min), with a blood pressure of 130/90 mmHg. He is alert and fully oriented. On auscultation, he has bilateral wheezing and crepitation on the right lung base. His laboratory tests reveal white blood count 14 000 cells per μL, C-reactive protein 30 mg⋅L−1, blood urea concentration 10 mmol⋅L−1 and SpO2 82%, on inhaled oxygen fraction 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?

    126. Page 261
      Abstract

      Which of the following statements about hypersensitivity pneumonitis is not correct?

    127. Page 263
      Abstract

      A 58-year-old, female never-smoker presents with a mass on the left upper lobe with extensive mediastinal involvement. Bronchoscopy with biopsy reveals small cell lung cancer. Ipsilateral paratracheal and precarinal lymph nodes (N2) are cytologically positive but there are no distant metastases.

      Which of the following is best treatment?

    128. Page 265
      Abstract

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

    129. Page 267
      Abstract

      A 47-year-old woman comes to your office with 3 days of fever, shortness of breath and cough with mucoid sputum. On physical examination, she is alert but slightly confused; her temperature is 40°C, respiratory rate is 34 breaths per min and blood pressure is 110/50 mmHg. Examination of the chest shows bibasal crackles; the chest radiograph shows bilateral lower lobe infiltrates. Arterial blood gases with the patient breathing room air are PaO2 6.1 kPa (46 mmHg) and PaCO2 3.7 kPa (28 mmHg). She is admitted to the hospital, and therapy with ceftriaxone and clarithromycin is started. Legionella pneumonia is suspected.

      Which of the following is/are clinically useful tests for guiding the treatment of this patient?

    130. Page 269
      Abstract

      A 53-year-old male is diagnosed with small cell lung cancer (limited disease). His performance status is excellent (ECOG 0) 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?

    131. Page 271
      Abstract

      A 55-year-old chronic alcoholic man, who stopped drinking 2 weeks ago, complains of anorexia, bone pain, weakness, malaise and epigastric pain for 5 days. While antacids relieve the pain, the other symptoms persist. When the patient becomes confused, his family brings him to the emergency department. Physical examination reveals generalised muscle weakness and hyporeflexia. Because an arterial blood gas specimen shows values consistent with acute hypercapnic respiratory failure, the patient is intubated and mechanically ventilated.

      In addition to standard care, which of the following treatments is likely to be most beneficial in correcting his ventilatory failure?

    132. Page 273
      Abstract

      A 34-year-old woman has dyspnoea on minimal exertion and inspiratory/expiratory stridor. 3 years ago, she was hospitalised for severe pneumonia, and was tracheotomised and mechanically ventilated for 6 weeks. You perform spirometry to confirm your suspected diagnosis.

      Which of the following flow–volume curves is most likely to be recorded?

    133. Page 275
      Abstract

      A 65-year-old man was hospitalised for an exacerbation of newly diagnosed COPD. He was discharged 4 weeks ago and now presents to your office for a regular check up in late spring. You perform a spirometry test with the following results: FVC, 2.52 L (77% predicted); FEV1, 1.53 L (54% predicted); and FEV1/FVC, 61%. He has now recovered and feels well. He has never received any vaccinations since childhood.

      Which preventive approach against pneumonia is appropriate at this time?

    134. Page 277
      Abstract

      A 19-year-old female is referred to you for difficult-to-treat asthma. She has had a cough and breathlessness with noisy breathing for 1 year, and was diagnosed with asthma 8 months ago. Since then, she had been treated with salmeterol/fluticasone 50/500 μg twice daily and salbutamol as needed. Her chest radiograph is normal. Representative slices of her CT scan and her flow–volume curve are shown below.

      MEFx%: predicted maximum expiratory flow at x% of FVC; PEF: predicted peak expiratory flow.

      Which of the following additional investigations is most appropriate?

    135. Page 281
      Abstract

      A 64-year-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 per min; heart rate is 112 beats per 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 per 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?

    136. Page 283
      Abstract

      An 83-year-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?

    137. Page 285
      Abstract

      A 54-year-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?

    138. Page 287
      Abstract

      A 56-year-old roofer undergoes a chest radiograph and, subsequently, a chest CT examination (below) because of persistent cough after a common cold. He is in good general health and physically fit.

      Which one of the following statements regarding the parenchymal lesion shown in the CT is most appropriate?

    139. Page 289
      Abstract

      A 59-year-old, overweight man suffers from newly diagnosed OSAS with daytime sleepiness.

      Based on randomised trials, which of the following benefits can treatment of his OSAS be expected to provide?

    140. Page 291
      Abstract

      Which lung cancer cell type is most commonly associated with paraneoplastic hypercalcaemia?

    141. Page 293
      Abstract

      A 52-year-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 years ago) with a 20 pack-year smoking history. Approximately 1 year 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?

    142. Page 297
      Abstract

      A 47-year-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-years. He receives an angiotensin-converting enzyme 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 HRCT 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?

    143. Page 299
      Abstract

      Which of the following statements about central sleep apnoea, Cheyne–Stokes respiration and periodic breathing is/are correct?

    144. Page 301
      Abstract

      A 45-year-old woman with a history of severe asthma and allergic rhinitis presents with a 2-week history of central chest pain aggravated by coughing, fever and haemoptysis. The chest radiograph is shown below. Her ECG fulfils criteria for low voltage. Her white blood cell count is 11 × 109 per L with 18% eosinophils.

      What is the most likely diagnosis?

    145. Page 303
      Abstract

      A 38-year-old nonsmoking woman had a left-sided pneumothorax that was successfully treated by drain insertion. Her chest radiograph and chest CT are shown below.

      Which one of the following is the most likely diagnosis?

    146. Page 305
      Abstract

      A 39-year-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?

    147. Page 307
      Abstract

      A 58-year-old male is referred for haemoptysis. His chest radiograph is shown below.

      His 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?

    148. Page 309
      Abstract

      A 40-year-old asthmatic woman has a follow-up visit to your office because of an acute exacerbation without obvious cause. She is compliant to her medication and her inhalation technique is correct. 2 weeks ago, she was prescribed prednisone tablets 40 mg per day for 5 days and her inhalation therapy was intensified by increasing the dose of budesonide/formoterol 200/6 ng from two to eight inhalations per day. Currently, she feels well. Her dyspnoea and cough have completely disappeared and she is not impaired in her usual daily activities as a nurse. Her current peak flow values are near her personal best of 420 L⋅min−1. Her FEV1 has increased from 48% predicted 2 weeks ago to 98% predicted now.

      What is the recommended next step?

    149. Page 311
      Abstract

      Which of the following statements concerning pleural effusion is/are true?

    150. Page 313
      Abstract

      A 45-year-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 8000 cells per mm3, erythrocyte sedimentation rate of 65 mm in the first hour, mildly elevated total IgE and weakly positive Aspergillus precipitins. The chest radiograph is shown below.

      Which one of the following is the most likely diagnosis?

    151. Page 315
      Abstract

      Which one of the following correctly defines oxygen delivery (DO2)?

    152. Page 317
      Abstract

      In a 73-year-old, otherwise healthy, heavy smoker with normal lung function, endobronchial biopsy of a tumour in the left lower lobe reveals non-small cell lung cancer. CT images are shown below.

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

    153. Page 319
      Abstract

      A 64-year-old alcoholic has jaundice and minimal ascites. He reports that he has smoked an average of one pack of cigarettes a day for 40 years. His total serum bilirubin is 240 mmol⋅L−1 (normal range 3–26 mmol⋅L−1). His arterial blood gas values are PaO2 4.9 kPa (37 mmHg), PaCO2 4.2 kPa (32 mmHg) and pH 7.45. He is given nasal oxygen at a flow rate of 4 L⋅min−1, and a repeat blood gas reveals PaO2 5.8 kPa (44 mmHg), PaCO2 4.6 kPa (35 mmHg) and pH 7.43. Spirometry and chest radiography are normal.

      To which one of the following is the hypoxaemia is most likely due?

    154. Page 321
      Abstract

      A 50-year-old stone-mason is referred for a mild chronic cough. He does not smoke and his medical history is unrevealing. His chest radiograph shows several small rounded opacities in both upper lung fields. Retrospectively, the same changes can be found on the chest radiograph taken by his family physician 2 years ago. A chest CT is performed (see figure). Pulmonary function testing reveals mild irreversible airway obstruction.

      Which measure should be taken to avoid progression of the patient’s lung disease?

    155. Page 323
      Abstract

      A 45-year-old man was discharged from the hospital 6 weeks ago after an asthma attack that had required intubation and mechanical ventilation. He is now in your office for a follow-up examination. He reports being free of symptoms and he is in good general condition. Pulmonary auscultation reveals bilateral wheezing. Spirometry shows an FEV1 of 75% predicted; on hospital discharge, his FEV1 was 96% predicted.

      You obtain additional information during the consultation.

      Which of the following suggest(s) that the patient is at risk of a fatal asthma attack?

    156. Page 325
      Abstract

      A 72-year-old male smoker with COPD was admitted to the hospital 2 days ago with a patchy right lower lobe pneumonia accompanied by fever, increased cough and dyspnoea. A sputum Gram stain showed Gram-positive cocci in pairs. He required oxygen (2 L⋅min−1) and was treated with intravenous ceftriaxone. Now, on the third day in the hospital, he is afebrile (for the past 24 h), has good oral intake, has no cough or sputum, and is not short of breath or tachypnoeic. His oxygen saturation on room air is 94%. A repeat chest radiograph shows a slight increase in the size of his right lower lobe infiltrate compared to his admission chest radiograph.

      What is the best clinical approach in the management of this patient?

    157. Page 327
      Abstract

      A 58-year-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 per min, breath rate 30 breaths per min and temperature 37.9 °C. 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 × 109 cells per L with 78% mature neutrophils, haematocrit 38%, creatinine 90 μmol⋅L−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?

    158. Page 329
      Abstract

      Which of the following statement(s) is/are true regarding pleural effusion?

    159. Page 331
      Abstract

      A 62-year-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 per min, blood pressure is 110/70 mmHg, respiratory rate is 24 breaths per 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?

    160. Page 333
      Abstract

      A 44-year-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. T LCO 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 L, 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?

    161. Page 335
      Abstract

      A 36-year-old woman presents with shaking chills, right back pain and dysuria. On physical examination, she has right costovertebral angle tenderness and appears flushed. Her heart rate is 115 beats per min and blood pressure is 80/35 mmHg. She is admitted to the intensive care unit for further treatment.

      Which of the following haemodynamic profiles is consistent with her condition?

    162. Page 337
      Abstract

      A 25-year-old, previously healthy woman 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. Today, she suddenly felt worse again, and had high fever, chills and shortness of breath. On physical examination she looks ill but is well oriented. Her respiratory rate is 32 breaths per min, heart rate 110 beats per min and 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. Her laboratory results are as follows: erythrocyte sedimentation rate 135 mm⋅h−1, C-reactive protein 350 mg⋅L−1, leukocytes 19 000 cells per μL, urea 10.0 mmol⋅L−1, creatinine 110 mmol⋅L−1, sodium 135 mmol⋅L−1, potassium 4.0 mmol⋅L−1 and Hb 112 g⋅L−1. Liver function tests are normal. Arterial blood gas analysis on room air shows the following: pH 7.31, PaCO2 6.1 kPa (46 mmHg), base excess −8.1 mmol⋅L−1 and PaO2 6.8 kPa (51 mmHg).

      What is the most appropriate next action?

    163. Page 339
      Abstract

      A 56-year-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?

    164. Page 341
      Abstract

      A 21-year-old man with Duchenne muscular dystrophy suffers from chronic alveolar hypoventilation. He is on 24-h NIV using a portable bilevel positive airway pressure ventilator operated in the spontaneous/timed mode. During a routine follow-up, you perform arterial blood gas analysis, which reveals an elevated PaCO2. Analysis of data stored in the ventilator memory shows that 90% of breaths are patient-triggered.

      Which of the following measures would be most likely to reduce hypercapnia?

    165. Page 343
      Abstract

      A 52-year-old woman complains of weight loss, asthenia and dyspnoea. Examination reveals symmetrical proximal weakness, elevated muscle enzymes in serum and muscle biopsy showing inflammation. Some relevant slices of the chest CT are shown below.

      Which of the following is a lung biopsy most likely to show?

    166. Page 345
      Abstract

      One of the passengers on a flight from New York to Brussels was discovered to have multidrug-resistant (MDR) tuberculosis after she arrived in Brussels. 2 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?

    167. Page 347
      Abstract

      A 32-year-old woman presents with a 1-week history of painful, tender lumps overlying the pretibial regions, low-grade fever and polyarthritis primarily involving her ankles. The chest radiograph is shown below.

      Bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsies are performed. The lavage fluid contains 30% lymphocytes; the remaining cells are mostly alveolar macrophages. Special stains for fungi and acid-fast bacilli are negative.

      Which one of the following statements about this disease is incorrect?

    168. Page 349
      Abstract

      A 67-year-old smoker with COPD suffers from an acute exacerbation with hypercapnic respiratory failure. There is no bed available in the intensive care unit. Therefore, you decide to treat the patient in the general ward. A nurse prepares a bilevel positive airway pressure home ventilator.

      Which of the tubes/masks shown below is most appropriate?

    169. Page 351
      Abstract

      Which one of the following statements about aspirin-exacerbated respiratory disease is correct?

    170. Page 353
      Abstract

      A 64-year-old woman undergoes diuretic therapy for severe congestive heart failure complicated by a right-sided pleural effusion. 3 weeks later, her symptoms are moderately improved and her weight has decreased by 4.5 kg, but the effusion persists. She denies have experienced fever, cough, chest pain or leg swelling. Physical examination shows an S3 and a grade 3/6 pansystolic murmur.

      Which is the most likely pleural fluid profile of this patient?

    171. Page 355
      Abstract

      A 50-year-old man is admitted for fever, mild haemoptysis and bilateral lung infiltrates. He is a smoker (100 pack-years), consumes alcohol daily (∼100 g⋅day−1) and was an employee at a gasoline station. His past medical history includes recurrent gout attacks and arterial hypertension. 2 weeks ago, he suffered from arthritis of his right knee, started to feel weak and experienced a marked loss of energy. 1 week ago, he began to cough up small amounts of blood-tinged sputum and was markedly short of breath with mild exertion. On admission, his temperature is 37.8°C, blood pressure is 190/90 mmHg and heart rate is 100 beats per min. He is dyspnoeic while speaking, his respiratory rate is 32 breaths per min and his oxygen saturation is 80% on room air. His chest radiograph and CT image are shown below.

      Laboratory results show a serum C-reactive protein concentration of 320 mg⋅L−1, Hb 102 g⋅L−1, creatinine 145 mmol⋅L−1 and normal liver enzymes. Urine analysis reveals large amounts of deformed erythrocytes. Anti-glomerular basement membrane antibodies are moderately elevated (twice the normal value). Bronchoscopy confirms diffuse alveolar haemorrhage with no infection.

      What is the most appropriate management of this case?

    172. Page 357
      Abstract

      A 35-year-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 IgE 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?

    173. Page 359
      Abstract

      A 52-year-old man, who is a teacher and a nonsmoker, complains of a dry cough that he has had for the past 8 months. Within the past 3 months, he has felt some shortness of breath. He has been previously healthy and does not take any medication. Detailed history does not suggest any occupational or environmental risk factors. Fine crackles (velcro) can be heard over both lung. There is no clubbing. CT of the lung shows an extensive, bilateral ground-glass pattern together with reticular opacities, especially in the periphery. There is no honeycombing or lymphadenopathy.

      Which of the following is the most likely diagnosis?

    174. Page 361
      Abstract

      A 62-year-old woman with COPD is admitted to the hospital because of fever, fatigue and severe dyspnoea. Her nutritional status is normal but she is cyanotic and breathing at 35 breaths per min. The clinical examination and the chest radiograph disclose a consolidation of the left lower lobe. Because respiratory acidosis is worsening, she is admitted to the intensive care unit and intubated. She is treated with an intravenous antibiotic, prednisone (50 mg per day) and inhaled bronchodilators. The lung consolidation slowly resolves after 14 days but several attempts to resume spontaneous breathing fail because of tachypnoea, unbearable dyspnoea and elevation of PaCO2.

      At this point, which is the most appropriate test to identify the cause of weaning failure?

    175. Page 363
      Abstract

      Regarding determination of lung volumes, which of the following statements is/are correct?

    176. Page 365
      Abstract

      Which of the following statements is/are correct concerning asbestos-related malignancies?

    177. Page 367
      Abstract

      During an influenza outbreak, a 35-year-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 6.0 kPa (45 mmHg) 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?

    178. Page 369
      Abstract

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

    179. Page 371
      Abstract

      A 47-year-old restaurant owner with a 50 pack-year history of cigarette smoking presents with a productive cough with blood-streaked sputum. The physical examination is normal. The patient has an unremarkable past medical history and is taking no medications. Laboratory studies reveal a haemoglobin of 120 g⋅L−1 and haematocrit of 37%. Serum sodium is 124 mmol⋅L−1, potassium is 4.2 mmol⋅L−1, chloride is 97 mmol⋅L−1 and bicarbonate is 24 mmol⋅L−1. Kidney and liver function tests are normal. The chest radiograph is shown in the figure. Bronchoscopy reveals a partially occluded right mainstem bronchus 3 cm below the main carina by an extrinsically compressing mass appearing to erode through the medial wall of the right mainstem bronchus. Brush cytology specimens are positive for tumour cells.

      Which of the following is the most likely lung carcinoma causing this clinical presentation?

    180. Page 373
      Abstract

      A 50-year-old female nonsmoker presents to the emergency unit with severe cough and nonpurulent sputum production for 6 weeks, becoming worse in the last 3 days. She has no fever but has lost 4 kg body weight. On bronchoscopy, adenocarcinoma positive for the marker thyroid transcription factor-1 was diagnosed in transbronchial biopsies of the left lower lobe and a right-sided paratracheal fine-needle aspiration of a lymph node.

      Which of the following tests has the highest probability of being positive and may alter treatment?

    181. Page 375
      Abstract

      A 45-year-old smoker is admitted to hospital after a motorcycle accident. He is otherwise in good health and his previous history is unremarkable. A thoracoabdominal CT is performed that shows an absence of traumatic lesions but discloses a 4-mm nodule in the left upper lobe, defined as a solid noncalcified opacity. There is no previous radiological examination available.

      What is the most appropriate management strategy?

    182. Page 377
      Abstract

      Which of the following statements concerning occupational sensitivity to latex is/are true?

    183. Page 379
      Abstract

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

    184. Page 381
      Abstract

      A 53-year-old insulation worker with probable former asbestos exposure presents to the emergency department with new-onset dyspnoea. Chest ultrasound reveals a right-sided pleural effusion.

      Which of the following finding(s) on a CT image would further support previous exposure to asbestos?

    185. Page 383
      Abstract

      A 48-year-old lorry driver suffers from excessive sleepiness and shortness of breath on minimal exertion. He has gained 35 kg in the last 10 years and now weighs 165 kg. The patient’s BMI is 46 kg⋅m−2. His blood pressure is 135/90 mmHg and his pulse rate is 76 beats per 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 6.9 kPa (52 mmHg), PaCO2 of 8.6 kPa (65 mmHg), 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 per h, 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?

    186. Page 385
      Abstract

      A 27-year-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?

    187. Page 387
      Abstract

      A patient with very severe COPD has an FVC of 2.7 L (60% of predicted), FEV1 of 0.8 L (25% of predicted) and FEV1/FVC of 30%.

      In which of the following is a therapeutic exercise programme likely to result?

    188. Page 389
      Abstract

      A 48-year-old man has had a recent onset of numbness and paraesthesia of his feet. He has an 8-year history of intermittent wheezing and shortness of breath. Physical examination reveals mild expiratory wheezes, a skin rash consisting of small purpuric lesions over the lower extremities, and loss of sharp/blunt distinction over the lower extremities. His chest radiograph shows mild hyperinflation but is otherwise normal. His white blood cell count is 14 000 per μL with 7% neutrophils, 20% eosinophils and 10% lymphocytes. His erythrocyte sedimentation rate is 70 mm⋅h−1. His serum antinuclear antibody titre is 1:40 with a speckled pattern. Biopsy of a skin lesion shows necrotising granulomatous lesions with a dense infiltrate of eosinophils and a capillaritis.

      Which of the following is the most likely diagnosis?

    189. Page 391
      Abstract

      Which one of the following statements about lymphangioleiomyomatosis is true?

    190. Page 393
      Abstract

      A 57-year-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?

    191. Page 395
      Abstract

      A 29-year-old smoker is referred because of recurrent pneumonia of the right lower lobe over the last 3 years. Each time, he promptly responds to antibiotic therapy. Between pneumonic episodes, the patient is well. His chest radiographs are shown below.

      Which is the most likely diagnosis?

    192. Page 397
      Abstract

      A 57-year-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 7.8 kPa (59 mmHg), PaCO2 3.5 kPa (26 mmHg) 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?

    193. Page 399
      Abstract

      Which of the following statements concerning cryptogenic organising pneumonia is correct?

    194. Page 401
      Abstract

      An obese (BMI 32.5 kg⋅m−2), diabetic man with arterial hypertension is diagnosed with OSA (AHI 45 events per h). In addition to weight loss, you recommend CPAP treatment.

      What is an evidence-based benefit of your recommendation?

    195. Page 403
      Abstract

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

    196. Page 405
      Abstract

      A 46-year-old female never-smoker, domestic cleaner, with a BMI of 32.5 kg⋅m−2, is evaluated in an asthma clinic. She is receiving treatment from her family doctor, with salmeterol/fluticasone 50/500 twice daily and montelukast 10 mg once daily for the past 6 months. She has been taking salbutamol several times daily and has been waking up 1–2 times every night for the past 2 weeks.

      Which of the following comorbidities is not related to poor control of her asthma?

    197. Page 409
      Abstract

      Which of the following statement(s) concerning non-cystic fibrosis bronchiectasis in adults is/are true?

    198. Page 411
      Abstract

      A 55-year-old man presents to the hospital with community-acquired pneumonia.

      Which of the following is not a risk factor for an increased chance of death from this pneumonia?

    199. Page 413
      Abstract

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

    200. Page 415
      Abstract

      For diagnosis of hypersensitivity pneumonitis, which of the following statements is true?

    201. Page 417
      Abstract

      A 56-year-old man is referred to you 6 days after surgery because of shortness of breath. He had a coronary artery bypass graft using the internal mammary artery. Extubation was routinely accomplished the day after surgery. Chest tubes were removed and the patient began to ambulate on the third post-operative day. At that time, he noticed shortness of breath with a gradual in onset that not associated with chest pain, sweating or tachypnoea. On physical examination, the patient is not cyanotic. He has a respiratory rate of 28 shallow breaths per min. Breath sounds are heard bilaterally but there is dullness at the left base, both anteriorly and posteriorly. The recent sternotomy wound appears not to be infected and no flail chest is present. The chest radiograph of the patient is shown below.

      Bedside spirometry reveals a decrease in FVC of 50% from the pre-operative value. Arterial blood tests show a PaO2 of 10.6 kPa (80 mmHg), and normal PaCO2 and pH.

      Which of the following tests is most likely to prove the cause of the shortness of breath?

    202. Page 419
      Abstract

      A 45-year-old woman presents to the office with a 3-week history of mild shortness of breath. She does not drink or smoke. She had generally been in good health until she began losing weight 2 months ago. Her family history is unremarkable. She is afebrile, and her chest examination reveals dullness and decreased breath sounds at the left base. Her abdomen is not tender and has normal bowel sounds. The results of laboratory studies and her chest radiograph are shown below.

      Peripheral blood Thoracocentesis
      Haematocrit % 37 Cells per μL 980
      Leukocytes per μL 8700 Lymphocytes % 70
       Neutrophils % 67 Neutrophils % 20
       Lymphocytes % 20 Mesothelial cells % 1
       Monocytes % 10 Protein g⋅L−1 4.3
       Eosinophils % 3 Lactate dehydrogenase U⋅L−1 300
      Serum protein g⋅L−1 6.2 Glucose mmol⋅L−1 3.4
      Serum lactate dehydrogenase U⋅L−1 210 Pleural fluid pH 7.37
      Serum glucose mmol⋅L−1 3.9 Cytology No malignant cells

      Which of the following is the most likely explanation for the effusion?

    203. Page 421
      Abstract

      A 58-year-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 years 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 per h. His daytime arterial blood gas analysis shows a PaO2 of 8.8 kPa (66 mmHg), a PaCO2 of 7.8 kPa (58.5 mmHg), an SpO2 of 93%, a pH of 7.38 and a bicarbonate level of 27 mmol⋅L−1.

      What is the most likely diagnosis?

    204. Page 423
      Abstract

      Which of the following statements about oxygen saturation measured by pulse oximetry is/are correct?

    205. Page 425
      Abstract

      A 35-year-old builder presents with a 10-year history of progressively worsening daytime sleepiness and disruptive snoring. He now falls asleep several times a day whenever he is inactive, such as while watching television, and even during work breaks and whilst waiting for lunch to be served in a restaurant. He is concerned about losing his job. He is a lifetime nonsmoker. He jogs 2–3 km daily without difficulty. His past history and a review of his symptoms are otherwise unremarkable. He is 180 cm tall, weighs 91 kg and has a neck circumference of 47.5 cm. Physical examination is otherwise normal. Polysomnography reveals 62 obstructive apnoeas/hypopnoeas per hour (AHI 62 events per h), mostly associated with oxygen desaturations to 70–79%; sometimes, his SpO2 is <70%. His waking oxygen saturation is 94%. You recommend CPAP therapy for this patient but he is not convinced.

      If he decides against CPAP, which of the following is the most important risk that you should explain to him?

    206. Page 427
      Abstract

      Which of the following factors does not influence TLCO measured by the single-breath method?

    207. Page 429
      Abstract

      A 45-year-old man is admitted to the hospital due to recurrent haematemesis and syncopal episodes. He has a history of gastric and duodenal ulcers but no other serious diseases. Gastroscopy reveals a gastric ulcer with no active bleeding. Lab results show severe anaemia with a Hb concentration of 44 g⋅L−1. Coagulation tests are normal. He receives 9 units packed red blood cells and 6 units fresh frozen plasma. The total amount of fluid replaced is 6.3 L in 9 h. During transfusion of the last two units of packed red blood cells, the patient becomes severely dyspnoeic, febrile (39°C) and hypoxaemic (oxygen saturation on 4 L oxygen by nasal cannula 88%). An echocardiogram shows normal left ventricular function but the pulmonary arterial pressure is elevated (systolic transtricuspid pressure gradient 50 mmHg), and the right atrium and ventricle are dilated. A CT angiogram of the chest rules out pulmonary emboli but reveals diffuse infiltrates (see below).

      What is most likely the cause of this disease?

    208. Page 433
      Abstract

      A 28-year-old, schizophrenic, unemployed man is referred to you for evaluation of an abnormal chest radiograph and CT. The patient has a 3-month history of chest pain and nonproductive cough with 4 kg weight loss. The chest radiograph shows an anterior mediastinal mass. This mass is confirmed by chest CT showing probable involvement of the anterior chest wall. CT of the chest and abdomen is otherwise unremarkable. The physical examination is normal. The patient refuses any invasive procedures.

      Which noninvasive test might be of value in confirming a diagnosis?

    209. Page 435
      Abstract

      A 69-year-old male, with a history of smoking and asbestos exposure between the ages of 30 and 55 years, 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?

    210. Page 437
      Abstract

      Which of the following test results will most reliably differentiate between asthma and emphysema?

    211. Page 439
      Abstract

      A 25-year-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 of 6.7 kPa (50 mmHg), PaCO2 of 6.3 kPa (47 mmHg) and pH of 7.33. The ventilator settings are: inspiratory oxygen fraction (FIO2) 0.8; assist control with tidal volume 420 mL and frequency 18 breaths per min; inspiratory time (tI)/expiratory time (tE) ratio 1/3; and positive 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?

    212. Page 441
      Abstract

      An otherwise healthy 32-year-old woman, who is an employee in a nursing home, is given a tuberculin skin test (TST). Her reaction is a 2-mm induration. 2 weeks later, on repeat testing, her reaction is 4 mm. 14 months later, a person in the home is diagnosed as having pulmonary tuberculosis. The TST of the still asymptomatic employee is repeated and shows 22 mm induration at 48 h; an interferon-γ release assay is positive. Posteroanterior and lateral chest radiographs show no abnormalities.

      What should be recommended?

    213. Page 445
      Abstract

      A 46-year-old, nonsmoking female patient with no previous disease history is admitted to your ward with a 2-week history of persistent cough and haemoptysis, and progressive exercise dyspnoea. She reports no fever or upper respiratory symptoms. Physical examination shows normal vital signs with a SpO2 of 92% in ambient air and scattered bilateral crackles on lung auscultation. The chest radiograph reveals patchy bilateral alveolar consolidation confirmed by CT. Lung function tests show a mild restrictive pattern with a TLCO of 110% predicted. Laboratory investigation shows mild anaemia (Hb 10.5 g⋅dL−1), a normal white blood cell count and differential cell count, haematuria, and proteinuria. Bronchoalveolar lavage confirms alveolar haemorrhage.

      Which of the following diagnoses would a positive myeloperoxidase anti-neutrophil cytoplasmic antibody test favour?

    214. Page 447
      Abstract

      A 75-year-old male complains about increasing dyspnoea on exertion. The patient worked with building insulation for many years. 10 years ago, he suffered 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, and this is confirmed by a CT scan, which also shows enlarged mediastinal lymph nodes. Medical thoracoscopy demonstrates a diffuse malignant mesothelioma on both pleural layers with infiltration of the pericardium. An endobronchial ultrasound-guided lymph node biopsy revealed bilateral infiltrated lymph nodes. Immune histology reveals a biphasic cell type.

      Which one of the following is the best treatment option?

    215. Page 449
      Abstract

      α1-antitrypsin (α1-AT) deficiency (PiZZ) is detected in a 65-year-old nonsmoker with mild COPD (FEV1 82% predicted).

      When counselling the patient, which of the following is/are correct?

    216. Page 451
      Abstract

      A 24-year-old woman in her 24th week of pregnancy is seen in the emergency department complaining of sudden onset of shortness of breath, nonproductive cough and sharp pain over the left lower chest. On examination, there are crackles at the base of the left lung. Her left calf is tender and slightly warm. Her arterial blood gas results are PaO2 10.8 kPa (81 mmHg), PaCO2 4.5 kPa (34 mmHg) and pH 7.44. D-dimers are positive.

      What is the first test you should ask for in this patient?

    217. Page 453
      Abstract

      Which of the following statements concerning positional OSA is false?

    218. Page 455
      Abstract

      A 35-year-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 TLCO. A transbronchial lung biopsy shows a noncaseating granuloma.

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

    219. Page 457
      Abstract

      A 45-year-old female presents to you with increasing cough and fatigue for the past 4 months. She is a heavy smoker (40 cigarettes per day for 25 years), 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?

    220. Page 459
      Abstract

      Which of the following is associated with moderately severe thoracic scoliosis (Cobb angle 60–90°)?

    221. Page 461
      Abstract

      A 32-year-old man, known to be HIV-positive for 4 years, is referred to you for evaluation of pulmonary complaints and possible sputum induction. Approximately 2 years ago, the patient developed a chronic, productive cough that has persisted. The sputum colour varies, ranging from white to yellow and green. Several courses of antibiotic therapy have cleared the sputum colour to white each time, but sputum purulence recurs. He has had intermittent fever but does not have night sweats. He is dyspnoeic only on extreme exertion. He has not received anti-HIV medication or trimethoprim and sulfamethoxazole. He does not smoke cigarettes. He smoked marijuana in the past but quit 7 months ago. Physical examination reveals a thin, tired-looking man. The remainder of the physical examination is normal. A chest radiograph shows increased markings, primarily in the lung bases, but is unchanged compared with 3, 6 and 9 months ago. The CD4 count is 253 cells per mm3, and serum lactate dehydrogenase is 120 U⋅L−1. Arterial blood gases while breathing ambient air are PaO2 88 mmHg (11.7 kPa), PaCO2 36 mmHg (4.8 kPa) and pH 7.44.

      What should be recommended?

    222. Page 463
      Abstract

      A 75-year-old man with COPD has been treated with low-dose oral corticosteroids. He has had multiple acute exacerbations, which were treated with amoxicillin; the most recent one was 3 weeks ago. He now presents with pleuritic chest pain of acute onset, cough with purulent sputum, fever up to 38.5 °C and right lower lobe consolidation on chest radiography. A sputum sample shows sheets of neutrophils with intra- and extracellular Gram-positive diplococci. The patient is admitted to the hospital.

      Which of the following is the best initial empiric therapy for this patient?

    223. Page 465
      Abstract

      A 46-year-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 per h 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?

    224. Page 467
      Abstract

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

    225. Page 469
      Abstract

      Which of the following conditions is not included in the tetrad of symptoms usually associated with narcolepsy?

    226. Page 471
      Abstract

      An 18-year-old woman has had a cough and progressive dyspnoea for the past 3 years. The cough is nonproductive and is usually associated with exercise. She has had episodes of bronchitis with purulent thick sputum lasting ∼1 week, which were treated with antibiotics. Over the past year, she has experienced chronic fatigue, decreased exercise tolerance and increasingly frequent episodes of bronchitis. She has had a 3-week trial of oral corticosteroids, with little change in her symptoms. She is a nonsmoker. Her 20-year-old brother has asthma. The patient appears to be well nourished. Her blood pressure is 120/75 mmHg, pulse rate is 80 beats per min and regular, and respiratory rate is 18 breaths per min. A chest examination and radiograph are normal. Arterial blood gases on room air show a PaO2 of 8.0 kPa (60 mmHg), PaCO2 of 4.4 kPa (33 mmHg) and pH of 7.45. Pulmonary function tests show an FVC of 2.92 L (90% predicted), FEV1 of 2.0 L (75% predicted) and FEV1/FVC of 68%. FEV1 increases by 10% following inhalation of albuterol. Sputum culture reveals Staphylococcus aureus.

      Which test is most likely to lead you to the correct diagnosis?

    227. Page 473
      Abstract

      A 35-year-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?

    228. Page 475
      Abstract

      A 40-year-old, male nonsmoker who is wheezing and has a persistent cough accompanied by episodic dyspnoea is referred to your office for spirometric evaluation.

      Which of the following flow–volume curves is most likely to be recorded?

    229. Page 477
      Abstract

      A 68-year-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?

    230. Page 479
      Abstract

      A 42-year-old male never-smoker complains about dyspnoea occurring after physical exercise. He was a professional water polo player for two decades. His BMI is 35 kg⋅m−2. He is non-atopic, has cardiomegaly and a pulse rate of 58 beats per min. His baseline lung function is normal (FEV1 3.8 L, 105% predicted). 15 min after a standard maximal exercise protocol his FEV1 is 2.9 L and his pulse rate is 68 beats per min.

    231. Page 481
      Abstract

      A 21-year-old female is referred to your clinic for further evaluation of her asthma. She describes typical symptoms of asthma including night-time cough and wheeze, as well as shortness of breath in the daytime that limits her ability to play sport. She has been prescribed an inhaled corticosteroid but she does not wish to take this medication because she has heard that steroids are dangerous. In particular, she states that she read about a person that developed ‘a brain fungal infection when they used steroids’.

      Which approach is best used to enhance her adherence to therapy?

    232. Page 483
      Abstract

      A 42-year-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 0 mm.

      Which of the following should be recommended to her?

    233. Page 485
      Abstract

      An 18-year-old competitive swimmer is referred to your clinic for evaluation. She is very keen to obtain a certificate for competition that confirms that she has asthma. She reports that she regularly uses short- and long-acting β-agonists as well as an inhaled corticosteroid for her asthma.

      Physical examination reveals no wheezing. Further testing shows an exhaled nitric oxide fraction (FeNO) of 3 ppb and serum IgE concentration of 3 kU⋅L−1, and a full blood count shows an eosinophil count of >1.5 × 105 per L. A bronchial provocation test with methacholine demonstrates a provocative concentration causing a 10% fall in FEV1 of 16 mg⋅mL−1. Peak flow recorded by the patient over a month shows normal diurnal variation (9%) and the patient has normal spirometry.

      Which of the test results makes asthma unlikely in this case?

    234. Page 487
      Abstract

      A 58-year-old, never-smoking woman is referred to you because of progressive dyspnoea. This patient grew up in a rural area. She is now divorced and has lived alone in a new, four-room flat for 4 years. She works part-time as a house cleaner in a home for children. For 1 h a week, she works in the laundry room, where she sometimes notices humid walls. The chest radiograph is normal. Pulmonary function testing reveals an FEV1 of 1.45 L (77% of predicted), an FVC of 1.66 L (74% of predicted) and a TLCO of 2.3 mmol⋅min−1⋅kPa−1 (34% of predicted). A pulmonary thromboembolism has been excluded by a negative D-Dimer test. The patient’s family doctor advises her to stop working for 4 weeks. Dyspnoea and pulmonary function thereafter are unchanged. Further diagnostic work-up reveals a cell count in the bronchoalveolar lavage (BAL) fluid of 653 per μL (60% lymphocytes, 5% neutrophils, 3% mast cells and 32% macrophages). Serum precipitins to common antigens are negative.

      In this situation, which of the following statements is correct?

    235. Page 489
      Abstract

      A 58-year-old woman is referred to you. She has dyspnoea on minimal exertion, stopped smoking 5 years ago, and is on regular treatment with bronchodilators and inhaled corticosteroids. Pulmonary function tests show FEV1 0.41 L (18% predicted), FVC 0.82 L (30% predicted), FEV1/FVC 51%, TLC 8.12 L (170% predicted) and residual volume 6.49 L (359% predicted). Her TLCO is 15% of predicted. On exercise testing, her peak oxygen consumption is 21% predicted. Chest CT shows diffuse emphysema. Over the last 16 months, her clinical condition has remained stable but pulmonary function has slightly declined.

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

    236. Page 491
      Abstract

      Your laboratory technician calls you one morning because she has difficulties calibrating the flow meter of the body plethysmograph. You verify appropriate function of the 3-L calibration syringe. Then, you check the recorded calibration procedure, which is displayed on the computer screen:

      What is the most appropriate conclusion?

    237. Page 493
      Abstract

      A 68-year-old man is treated with nocturnal CPAP at 8 mbar because of a central sleep apnoea syndrome due to his congestive heart failure. His medical history is remarkable for aortocoronary bypass surgery 2 years ago, after his second myocardial infarction. His left ventricular ejection fraction is 30%. He is treated with diuretics, angiotensin-converting enzyme inhibitors, spironolactone and β-blockers. His ECG reveals sinus rhythm and the R-wave is lacking in the anterior leads. He has problems wearing the CPAP mask every night and he asks about the benefit of CPAP treatment.

      Which of the following benefits is scientifically established?

    238. Page 495
      Abstract

      Which of the following statements concerning the management of spontaneous pneumothorax is/are true?

    239. Page 497
      Abstract

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

    240. Page 499
      Abstract

      Which of the following statements concerning malignant mesothelioma of the pleura is true?

    241. Page 501
      Abstract

      A 75-year-old woman with severe COPD is admitted to the hospital with hypercapnic respiratory failure. She has been taking long-term corticosteroids and, during exacerbations, receives 40 mg prednisolone per day. On day 7 of mechanical ventilation, the patient is febrile with a temperature to 39°C and has purulent sputum. Her leukocyte count is 18 000 cells per μL. A chest radiograph shows new bilateral lower-lobe patchy infiltration. She is treated with amikacin and imipenem. 3 days later, she has a reduction in her fever and her sputum becomes slightly less purulent, but her infiltrates persist and she remains mechanically ventilated. A sputum culture obtained before starting therapy shows Escherichia coli that is sensitive to both medications she is receiving. No other organisms are found on the sputum culture. Which of the following is the most appropriate decision in the management of this patient’s therapy at this time?

    242. Page 503
      Abstract

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

    243. Page 505
      Abstract

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

    244. Page 507
      Abstract

      A 46-year-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 5.99 kPa (45 mmHg), PaCO2 of 3.33 kPa (25 mmHg) and pH 7.50. Her blood pressure is 148/80 mmHg, heart rate is regular at 118 beats per 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 per min and inspiratory time 1.5 s). The chest radiograph shows bilateral pulmonary infiltrates. Arterial blood gases after 1 h on NIV are PaO2 8.25 kPa (62 mmHg), PaCO2 3.72 kPa (28 mmHg) and pH 7.48.

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

    245. Page 509
      Abstract

      A 42-year-old woman who abuses intravenous drugs has a cough, blood-streaked sputum and a temperature of 38.8°C. She has lost 13 kg over the past 3 months. Chest radiography shows a right upper lobe infiltrate with cavitation. Three sputum smears are positive for acid-fast bacilli and culture results are pending. Gram staining of her sputum shows numerous leukocytes and scant Gram-positive cocci in clusters. The tuberculin skin test shows 0 mm induration at 48 h. The CD4+ T-cell count is 4.9 × 108 per L. Her serum is positive for antibodies to HIV.

      The most likely diagnosis is pulmonary infection due to which one of the following?

    246. Page 511
      Abstract

      By which one of the following is pulmonary emphysema most reliably diagnosed?

    247. Page 513
      Abstract

      A 55-year-old healthy, non-smoking, HIV-negative native European woman with no known exposure to persons with tuberculosis has a tuberculin skin test as part of a routine check-up examination. Induration of 18 mm is noted. Her chest radiograph is normal.

      What is the appropriate medication regimen for this person?

    248. Page 515
      Abstract

      Individuals with which of the following α1-antitrypsin phenotypes are at highest risk of developing emphysema?

    249. Page 517
      Abstract

      Which statement concerning malignant mesothelioma is correct?

    250. Page 519
      Abstract

      A 37-year-old woman received antibiotic therapy for pneumonia of the right lower lobe 10 weeks ago. Her fever resolved but moderate cough and dyspnoea persisted, and 4 weeks ago, she was treated for otitis media. Now, she is admitted to the hospital due to increasing fatigue, fever and arthralgias. Blood tests reveal a C-reactive protein of 66 mg⋅dL−1 (normal <10 mg⋅dL−1), Hb 87 g⋅L−1 (normal 12.5–15.5 g⋅L−1), leukocyte count 1.33 × 1010 cells per L (normal 4.0–11.0 × 109 cells per L) and thrombocyte count of 8.0 × 1014 per L (normal <4.0 × 1014 per L). A CT image is shown below. Bronchoscopy showed stenosis in the middle lobe bronchus (also shown below, arrow). Bronchoalveolar lavage revealed 27% neutrophils without growth of any microorganisms.

      What has to be done next to support the suspected diagnosis?

    251. Page 521
      Abstract

      A 69-year-old man with COPD (FEV1 25% predicted) is admitted to the hospital with a 5-day history of progressive dyspnoea that has made it nearly impossible for him to eat, sleep or walk across the room. He is on long-term oxygen treatment at 2 L⋅min−1. 2 months ago, his arterial blood gases on 2 L⋅min−1 oxygen were PaO2 8.6 kPa (65 mmHg), PaCO2 7.4 kPa (56 mmHg) and pH 7.38.

      On admission, he has increased cough newly productive of yellow sputum. His sputum volume has decreased from 10–15 mL per day to 5–10 mL per day. His medications include inhaled ipratropium and salbutamol. On physical examination, the patient’s pulse rate is 110 beats per min, respiration rate is 36 breaths per min and blood pressure is 146/76 mmHg. He is cachectic, sitting and leaning forward in obvious respiratory distress with pursed-lip breathing. A chest examination reveals palpable contractions of the sternocleidomastoid muscles and diffusely diminished breath sounds with pan-expiratory wheezing. The physical examination is otherwise unremarkable. Arterial blood gases on 2 L⋅min−1 nasal oxygen show a PaO2 of 6.0 kPa (45 mmHg), PaCO2 of 8.8 kPa (66 mmHg) and pH of 7.31.

      Which of the following therapies is not likely to benefit this patient?

    252. Page 523
      Abstract

      A 45-year-old HIV-positive male (CD4 cells 2.50 × 108 per L), 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?

    253. Page 525
      Abstract

      A 41-year-old woman receiving high-dose inhaled corticosteroids is referred with a diagnosis of ‘refractory asthma’. In the preceding 6 months, she has been treated in the emergency room for abrupt, acute, short-lived episodes of apparent life-threatening asthma attacks. She has never smoked. Her asthma symptoms began after the death of her brother. While discussing her brother’s death, she becomes agitated and suddenly develops an acute attack. Her blood pressure is 140/70 mmHg, pulse rate is 88 beats per min and respiratory rate is 16 breaths per min. On auscultation, wheezes are noted over the anterior portions of her chest. Her arterial blood gases are PaO2 9.8 kPa (74 mmHg), PaCO2 4.8 kPa (36 mmHg) and pH 7.42.

      Which of the following is most likely to provide a correct diagnosis in this patient?

    254. Page 527
      Abstract

      Which of the following factor(s) would increase the risk for malignancy of a solitary pulmonary nodule?

    255. Page 529
      Abstract

      A 58-year-old male smoker with a smoking history of 50 pack-years 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 per 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% predicted and a TLCO of 65% predicted.

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

    256. Page 531
      Abstract

      Which of the following statements about OSAS is false?

    257. Page 533
      Abstract

      Which of the following statements is/are correct regarding exercise physiology and ventilation?

    258. Page 535
      Abstract

      A 72-year-old man presents because of extreme exertional dyspnoea and fatigue that have progressed over the last 3 years. COPD was diagnosed 3 years ago and oxygen (1 L⋅min−1) was prescribed for arterial hypoxaemia (PaO2 7.0 kPa (52 mmHg)). He smoked two packs of cigarettes daily for 20 years but had stopped 30 years ago. On physical examination, he appears ill. His neck veins are distended to the angle of the mandible while sitting up. Cardiac examination reveals a grade 3/6 pansystolic murmur along the left sternal border. Peripheral oedema is also present. The results of pulmonary function and arterial blood gas studies are shown below.

      FVC L (% predicted) 4.2 (98)
      FEV1L (% predicted) 3.6 (87)
      PaO2kPa (mmHg) 7.4 (56)
      PaCO2kPa (mmHg) 4.2 (32)
      pH 7.41

      Chest radiography shows large pulmonary arteries but no other abnormalities. ECG shows Q-waves in II, III and aVF. Echocardiography shows enlargement of the right atrium and right ventricle as well as severe pulmonary hypertension with an estimated systolic pulmonary artery pressure of 78 mmHg. There is no evidence of mitral stenosis or an atrial septal defect. The left ventricle appears normal. Which of the following is the most appropriate next step?

    259. Page 537
      Abstract

      A 61-year-old woman who has severe COPD seeks advice about taking an international flight. Spirometry yields the following values: FVC 2.8 L (78% predicted); FEV1 0.7 L (29% predicted); arterial blood gases breathing air at sea level are PaO2 6.50 kPa (49 mmHg), SaO2 85%, PaCO2 6.10 kPa (46 mmHg), and pH 7.38. These values are very similar to those of 6 and 12 months ago.

    260. Page 541
      Abstract

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

      Vertical lines represent 30-s intervals. NP: nasal pressure swings; THO: rib cage excursions; ABD: abdominal excursions.

    261. Page 543
      Abstract

      A 60-year-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 years 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 (alanine transaminase 312 U ⋅ L−1) and normal C-reactive protein. Hb 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 8.1 kPa (61 mmHg), PaCO2 is 4.3 kPa (32 mmHg) and pH is 7.42.

      What is the most likely diagnosis?