This practice set contains high-yield board review questions covering key concepts in 1. General Principles & Basic Science. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 921
Topic: 1. General Principles & Basic Science
Which lung disease is associated with the descriptions of 'pink puffer' and 'blue bloater'?
Correct Answer & Explanation
. Chronic obstructive pulmonary disease
Explanation
Correct Answer: A- Chronic obstructive pulmonary disease. 'Pink puffers' (emphysema-predominant) have a good respiratory drive, pursed-lip breathing, and intense dyspnoea. 'Blue bloaters' (chronic bronchitis-predominant) have a poor respiratory drive, are often obese, produce large volumes of sputum, and may develop cor pulmonale. The other conditions listed are not associated with these specific clinical descriptions.
Question 922
Topic: 1. General Principles & Basic Science
A 30-year-old woman presents with shortness of breath. This began gradually, around 2 years ago, but now she is breathless on climbing a flight of stairs. There is no past history of note. On examination, the jugular venous pulse is raised, carotid pulse volume is reduced and there is evidence of right ventricular hypertrophy. There are right-sided murmurs on cardiac auscultation. Her chest X-ray shows pulmonary artery enlargement; the electrocardiogram shows right axis deviation and right ventricular hypertrophy. Arterial blood gases reveal hypoxia and hypercapnia; a lung perfusion scan is normal. Cardiac catheterisation reveals that right-sided pressures are markedly raised. Which diagnosis best fits with this clinical picture?
Correct Answer & Explanation
. Primary pulmonary hypertension
Explanation
Correct Answer: D- Primary pulmonary hypertension Explanation Primary pulmonary hypertension Primary pulmonary hypertension is characterised by the development of significantly raised pulmonary artery pressure with no apparent cause (normal VQ scan, no evidence of left heart failure). Plexogenic pulmonary arteriopathy is found in 30–60% of people with this condition and is characterised by medial hypertrophy and concentric laminar intimal fibrosis. The gene for primary pulmonary hypertension has now been mapped to chromosome 2, and mutations in the bone morphogenic protein receptor have been identified in some patients. Intravenous epoprostenol (prostacyclin) and oxygen therapy have been shown to improve quality of life in sufferers.Phosphodiesterase-5 (PDE-5) inhibitors and endothelin receptor antagonists have also been shown to have some therapeutic effect. Unfortunately, several studies report a mean survival of only 2.5 years from diagnosis, with right ventricular failure and sudden death the main causes of death. Asthma Asthma is incorrect. This lady has evidence of significant right heart failure and her main respiratory symptom is dyspnoea rather than wheeze or cough. The symptoms and investigations described are not in keeping with a diagnosis of asthma. Chronic thromboembolic disease Chronic thromboembolic disease is incorrect. The perfusion scan is not suggestive of chronic thromboembolic disease, which makes primary pulmonary hypertension the most likely diagnosis. Idiopathic pulmonary fibrosis Idiopathic pulmonary fibrosis is incorrect. Idiopathic pulmonary fibrosis (IPF) typically occurs in the sixth decade of life. If IPF is advanced enough to cause right ventricular hypertrophy (as is described in this case) then it is likely that the chest radiograph would show significantly abnormal lung fields with reticulonodular shadowing +/- honeycombing. Right ventricular failure Right ventricular failure is incorrect. This case does indeed describe right ventricular hypertrophy and failure, but given the dyspnoea and degree of hypoxia with a normal chest X-ray other than pulmonary artery hypertrophy and the patient’s age then primary pulmonary hypertension is the diagnosis that best fits the clinical picture in its entirety.
Question 923
Topic: Infection, Pharmacology & VTE
You are called to see a 50-year-old woman who is having difficulty breathing after undergoing a laparoscopic cholecystectomy. She is making a lot of noisy inspiratory effort with stridor. You notice that she is on long-term warfarin for thromboembolic disease, salbutamol and inhaled steroids for asthma and penicillamine for severe rheumatoid arthritis. Which of the following tests would be the most helpful in diagnosing her current problem?
Correct Answer & Explanation
. Spirometry with flow–volume loop
Explanation
Correct Answer: D- Spirometry with flow–volume loop Explanation Spirometry with flow–volume loop This woman has stridor due to cricoarytenoid arthritis. This is seen in studies in up to 75% of patients with rheumatoid arthritis. It can cause sore throat, hoarse voice and stridor, but is often asymptomatic. However, symptoms can rapidly worsen in the post-operative period. It is unrelated to any lung fibrosis. The flow– volume loop can be abnormal, as can direct laryngoscopy and high- resolution computed tomography of the larynx. Patients can need urgent tracheostomy and steroids, both orally and via joint injection. Chest X-ray Chest X-ray is incorrect. Chest X-ray may well be normal and therefore unhelpful here. Computed tomography scan of the chest Computed tomography (CT) scan of the chest is incorrect. CT chest would not show the cricoarytenoid arthritis. CT imaging of the larynx would be required. Peak flow Peak flow is incorrect. Peak flow measurement is useful in assessing the severity of an exacerbation of asthma.The presence of stridor makes an acute exacerbation of this lady’s asthma unlikely. Spirometry with transfer factor measurement Spirometry with transfer factor measurement is incorrect. This lady has stridor due to cricoarytenoid arthritis; this will not affect her transfer factor. The most appropriate and helpful combination of pulmonary function tests is spirometry with flow–volume loop.
Question 924
Topic: 1. General Principles & Basic Science
A 49-year-old woman has been admitted with haemoptysis and epistaxis. Her chest X-ray shows multiple rounded lesions with alveolar shadowing. Her serum is positive for cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA). What is the most likely diagnosis?
Correct Answer & Explanation
. Granulomatosis with polyangiitis
Explanation
Correct Answer: C- Granulomatosis with polyangiitis. Almost all patients have evidence of granulomatous lung disease at presentation, often accompanied by alveolar capillaritis. Radiology shows single or multiple rounded lesions, which can cavitate. The combination of haemoptysis, epistaxis, and positive c-ANCA is classic for granulomatosis with polyangiitis. Carcinoma of the lung, Echinococcosis, SLE, and Tuberculosis do not fit the clinical and serological profile as well as granulomatosis with polyangiitis.
Question 925
Topic: 1. General Principles & Basic Science
A 65-year-old patient with new-onset chronic obstructive pulmonary disease (COPD) asks you about his prognosis. Which of the following single tests is the most important predictor of survival in patients with COPD?
Correct Answer & Explanation
. FEV1 (forced expiratory volume in 1 s)
Explanation
Correct Answer: E- FEV1 (forced expiratory volume in 1 s). The strongest predictors of survival in patients with COPD are age and baseline FEV1. Fewer than 50% of patients whose FEV1 has fallen to 30% of predicted are alive 5 years later. While blood gases, ECG, and exercise tolerance provide prognostic information, they are not as predictive as FEV1.
Question 926
Topic: 1. General Principles & Basic Science
A 38-year-old man presents to the GP complaining of shortness of breath. He has a history of smoking 10 cigarettes per day and is obese. Other history of note includes hypertension, for which he is treated with atenolol 50 mg daily. Pulmonary function shows: Peak expiratory flow rate (PEFR) 540 l/min (predicted is 600 l/min), ratio of the forced expiratory volume in 1 s to the forced vital capacity (FEV1/FVC) is 90% predicted, and the FVC falls when measured supine versus standing up. Which of the following is the most likely diagnosis?
Correct Answer & Explanation
. Obesity-related changes in pulmonary function tests
Explanation
Correct Answer: E- Obesity-related changes in pulmonary function tests. The patient shows a restrictive pattern (reduced FVC, normal/high FEV1/FVC ratio) and a positional change in FVC, which is classic for obesity-related lung function changes due to increased abdominal fat. Asthma and COPD are associated with obstructive patterns. Fibrotic lung disease is less likely given the positional change and the clear association with obesity.
Question 927
Topic: 1. General Principles & Basic Science
A breathless 70-year-old smoker presents with the following lung function tests Forced expiratory volume in 1 second (FEV1) 1.5 l (60%) Forced vital capacity (FVC) 1.8 l (55%)
FEV1/FVC ratio 84% Total lung capacity (TLC) 66% predicted Residual volume (RV) 57% predicted Carbon monoxide transfer factor (Tlco) 55% predicted Transfer coefficient (Kco) 60% predicted What is the most likely diagnosis in this case?
Correct Answer & Explanation
. Interstitial lung disease
Explanation
Correct Answer: D- Interstitial lung disease Explanation Interstitial lung disease The lung function tests show a significant restrictive defect. Only interstitial lung disease or obesity can fit this picture. But given the decrease in Kco (ie after correcting for alveolar volumes), the most likely answer is interstitial lung disease. Anaemia Anaemia is incorrect. Anaemia can cause reduced transfer factor but would not cause/explain the other abnormaities seen on these pulmonary function tests. Asthma Asthma is incorrect. Asthma is associated with airflow obstruction, not restriction. Emphysema Emphysema is incorrect. Emphysema would be associated with airflow obstruction, not restriction (i.e normal FVC, and reduced FEV1/FVC ratio. TLC and RV would also be high, not low as is seen here. Obesity Obesity is incorrect. Obesity can cause a restrictive pattern of lung function but obesity alone would not affect the Kco. In the case of obesity, the gas exchange after correcting for the alveolar volume would in fact be high.
Question 928
Topic: Biology, Genetics & Bone Healing
According to Perren's strain theory of fracture healing, what is the maximum tissue strain tolerated by lamellar bone formation?
Correct Answer & Explanation
. 2%
Explanation
Lamellar bone can only form in a low-strain environment of less than 2%. Cartilage tolerates up to 10% strain, while granulation tissue can tolerate up to 100% strain during secondary bone healing.
Question 929
Topic: Surgical Anatomy & Approaches
During an ilioinguinal approach to the acetabulum, brisk arterial bleeding is encountered near the posterior aspect of the superior pubic ramus. This vessel is most likely an anastomosis between which two arteries?
Correct Answer & Explanation
. Inferior epigastric and obturator
Explanation
The corona mortis is a vascular anastomosis between the external iliac system (inferior epigastric artery/vein) and the internal iliac system (obturator artery/vein). It is located on the posterior aspect of the superior pubic ramus.
Question 930
Topic: 1. General Principles & Basic Science
What is the primary biomechanical function of the proteoglycan aggrecan within the articular cartilage matrix?
Correct Answer & Explanation
. Attracting and binding water molecules
Explanation
Aggrecan is the predominant proteoglycan in articular cartilage. Its highly negatively charged glycosaminoglycan (GAG) side chains create an osmotic gradient that draws water into the matrix, providing compressive resistance.
Question 931
Topic: Biology, Genetics & Bone Healing
Which endogenous molecule functions by binding to RANKL (Receptor Activator of Nuclear Factor Kappa-B Ligand) to inhibit osteoclast differentiation and prevent excessive bone resorption?
Correct Answer & Explanation
. Osteoprotegerin (OPG)
Explanation
Osteoprotegerin (OPG) acts as a critical decoy receptor. By binding to RANKL, it prevents RANKL from interacting with its receptor (RANK) on osteoclast precursors, thereby halting osteoclastogenesis and reducing bone resorption.
Question 932
Topic: Surgical Anatomy & Approaches
A 35-year-old female sustains a closed midshaft humeral fracture and presents with a radial nerve palsy (wrist drop). The fracture is managed non-operatively in a functional brace. At 12 weeks, there is no clinical or EMG evidence of nerve recovery. What is the most appropriate next step in management?
Correct Answer & Explanation
. Surgical exploration of the radial nerve
Explanation
Failure of radial nerve recovery by 3 months (12 weeks) post-injury, confirmed by lack of clinical and EMG evidence of reinnervation, is an indication for surgical exploration of the nerve. Tendon transfers are typically reserved for permanent, unrecoverable injuries.
Question 933
Topic: Biology, Genetics & Bone Healing
Bone morphogenetic proteins (BMPs) are osteoinductive factors belonging to the TGF-beta superfamily. Which BMP is most heavily implicated in the standard FDA-approved formulation for open tibial shaft fractures (rhBMP-2)?
Correct Answer & Explanation
. BMP-2
Explanation
Recombinant human BMP-2 (rhBMP-2) is FDA-approved for use in acute, open tibial shaft fractures treated with an intramedullary nail. BMP-7 (OP-1) was previously approved for recalcitrant tibial nonunions under a humanitarian device exemption.
Question 934
Topic: Biomechanics & Biomaterials
Which of the following biomechanical terms best describes the progressive deformation of a viscoelastic material, such as articular cartilage, when subjected to a constant load over time?
Correct Answer & Explanation
. Creep
Explanation
Creep is defined as the time-dependent, progressive deformation of a material under a constant load. Stress relaxation is the decrease in stress over time when a material is held at a constant strain.
Question 935
Topic: Biology, Genetics & Bone Healing
A 68-year-old male presents with increasing leg bowing and deep bone pain. Radiographs reveal cortical thickening and coarsened trabeculae of the tibia. Serum alkaline phosphatase is markedly elevated, but calcium and phosphate are normal. Which medication is considered the first-line treatment for his symptomatic disease?
Correct Answer & Explanation
. Intravenous zoledronic acid
Explanation
Intravenous nitrogen-containing bisphosphonates (like zoledronic acid) are the treatment of choice for symptomatic Paget's disease of bone due to their high efficacy and prolonged remission rates compared to older therapies.
Question 936
Topic: 1. General Principles & Basic Science
A 29-year-old intravenous heroin abuser is admitted to the Emergency Department with a severe cough, fever and rigors. He says that he has suffered progressively increasing shortness of breath on exertion over the past few days. On examination he has a pyrexia of 37.9 °C, his blood pressure is 122/75 mmHg and his body mass index (BMI) is 17 kg/m2. You hear mild crackles and wheeze on auscultation of his chest.
Investigation:
Hb 10.9 g/dl
WCC 6.1 x 109/l
PLT 245 x 109/l
Sodium 141 mmol/l
Potassium 4.0 mmol/l
Creatinine 90 µmol/l Lactate dehydrogenase (LDH) 420 U/l (normal range 70- 250 U/l) Oxygen saturations 92% on air, 89% after a walk test The chest X-ray shows diffuse bilateral infiltrates. Which of the following is the most likely diagnosis?
Correct Answer & Explanation
. Pneumocystis jirovecii pneumonia
Explanation
Correct Answer: C- Pneumocystis jirovecii pneumonia Explanation Pneumocystis jirovecii pneumonia The clinical picture seen here, with relatively little to find on auscultation, but with chest X-ray changes and desaturation on exercise, is very typical of Pneumocystis jirovecii infection. This can be diagnosed on the basis of a sputum sample, although bronchoalveolar lavage (BAL) might be required to obtain a suitable sample (the yield for BAL samples is over 90%). Co-trimoxazole or pentamidine are both effective treatments for the condition. Given the possible diagnosis, he should be screened for HIV. Endocarditis Endocarditis is incorrect. Intravenous drug users are at risk of right-sided endocarditis. However, the history given here is more in keeping with a primary respiratory infection. Klebsiella pneumoniae pneumonia Klebsiella pneumoniae pneumonia is incorrect. Intravenous drug users are at risk of Klebsiella and Staphylococcus aureus pneumonia. However, these typically cause a cavitating pneumonia and one would expect to find more on clinical examination given the degree of hypoxia. Staphylococcus aureus pneumonia Staphylococcus aureus pneumonia is incorrect. Intravenous drug users are at risk of Klebsiella and S. aureus pneumonia. However, these typically cause a cavitating pneumonia and one would expect to find more on clinical examination given the degree of hypoxia. Tuberculosis Tuberculosis is incorrect. Intravenous drug users are at risk of tuberculosis but the history would normally be longer than a few days, as is mentioned here. The relatively normal auscultation findings and desaturation on exercise are more in keeping with Pneumocystis pneumonia.
Question 937
Topic: 1. General Principles & Basic Science
Which one of the following statements about the peak expiratory flow rate (PEFR) is true?
Correct Answer & Explanation
. It is a parameter which relates to the degree of airway obstruction
Explanation
Correct Answer: B- It is a parameter which relates to the degree of airway obstruction Explanation It is a parameter which relates to the degree of airway obstruction The PEFR is a sensitive measurement of airway obstruction, although the maximal mid-expiratory flow rate is more changed in mild disease. A PEFR of less than 50% of normal is an indication for aminophylline therapy as the next step in patients with acute asthma A PEFR of less than 50% of normal is an indication for aminophylline therapy as the next step in patients with acute asthma is incorrect. Aminophylline is not routinely recommended for acute severe asthma. Intravenous magnesium may be considered in acute asthma with PEFR less than 50% of normal if there has been a failure to respond to nebulised bronchodilators. It is more related to age than to height It is more related to age than to height is incorrect. PEFR is more related to height than to age. It is not a sensitive parameter for assessing improvement in response to therapy in patients with acute bronchial asthma It is not a sensitive parameter for assessing improvement in response to therapy in patients with acute bronchial asthma is incorrect. The PEFR is a sensitive measurement of airway obstruction. It is usually effort- dependent, in people who have practised the test It is usually effort-dependent, even in people who have practised the test is incorrect. PEFR is effort- independent if the proper technique is used, which is more likely if the patient has practiced the test.
Question 938
Topic: 1. General Principles & Basic Science
A 50-year-old man who has a history of intravenous drug use is admitted with a productive cough, fevers and rigors. Examination and chest X-ray show a right-sided effusion and right lower-lobe consolidation. Pleural aspiration of the fluid shows it to be a clear and straw- coloured, with a protein level of 35 g/l and a pH of 7.12. It has been sent for culture, along with blood cultures. Which of the following would be the most appropriate course of management?
Correct Answer & Explanation
. Start intravenous benzylpenicillin and oral clarithromycin and insert a chest drain into the effusion
Explanation
Correct Answer: A- Start intravenous benzylpenicillin and oral clarithromycin and insert a chest drain into the effusion Explanation Start intravenous benzylpenicillin and oral clarithromycin and insert a chest drain into the effusion This man has pneumonia and an empyema. He has an exudative acidic effusion, with a pH of below 7.2. This therefore needs drainage as well as antibiotic treatment, with intravenous benzylpenicillin and clarithromycin being reasonable choices. Start intravenous cefuroxime and oral metronidazole and arrange a medical thoracoscopy Start intravenous cefuroxime and oral metronidazole and arrange a medical thoracoscopy is incorrect. Medical thoracoscopy is not indicated in this setting. The first-line management of empyema is intravenous antibiotics and chest drain insertion. Start intravenous cefuroxime and oral metronidazole and reassess the size of the effusion in 3 days Start intravenous cefuroxime and oral metronidazole and reassess the size of the effusion in 3 days is incorrect. If the effusion was parapneumonic and not an empyema (iepH > 7.2 and culture- negative), treatment with antibiotics and reassessment of the effusion would be a reasonable course of management. However, if the patient’s fever, white cell count or inflammatory markers fail to settle, this course should be employed together with repeated aspiration to ensure empyema has not subsequently developed. Start oral amoxicillin and oral metronidazole and refer to the thoracic surgeons for debridement Start oral amoxicillin and oral metronidazole and refer to the thoracic surgeons for debridement is incorrect. Empyemas which fail to resolve with medical management alone might indicate the need for surgical intervention with debridement. Surgical management is not a first-line treatment, nor are oral antibiotics (intravenous antibiotics are required). Start oral amoxicillin and oral metronidazole and repeat a pleural tap the next day Start oral amoxicillin and oral metronidazole and repeat a pleural tap the next day is incorrect. Empyema would be inadequately treated by oral antibiotics and repeat pleural tap the following day would be highly unlikely to add any valuable clinical information to guide management.
Question 939
Topic: 1. General Principles & Basic Science
A 45-year-old woman visits the surgery with her 15-year-old son, who has recently been diagnosed with asthma. She has researched the pathology of asthma and has a number of questions about potential causative factors. Which of the following responses best describes the pathology of asthma?
Correct Answer & Explanation
. Asthma occurs due to a combination of airway hyper-responsiveness, airflow limitation and airway inflammation
Explanation
Asthma occurs due to a combination of airway hyper-responsiveness, airflow limitation and airway inflammation. This is a 'know it or you don't' question. In many Western countries the prevalence of asthma is increasing, particularly during the second decade of life, where it can affect up to 10–15% of the population. The pathogenesis can be described as having three components: Asthma is characterized by airflow limitation that is usually reversible spontaneously or with treatment, although later on in the disease there may be an irreversible component to airflow limitation. There is also airway hyper-responsiveness to a wide range of external stimuli. A predominantly eosinophilic pattern of inflammation occurs, with associated plasma exudates, edema, mucus-plug formation, bronchial smooth muscle hypertrophy and long-term epithelial damage.
Question 940
Topic: Infection, Pharmacology & VTE
A 48-year-old woman is admitted with a 2-day history of fever with rigors and breathlessness. On examination, she looks extremely unwell and is confused and cyanosed. She has a respiratory rate of 36/min and a systolic blood pressure of 86 mmHg. There is dullness on percussion and bronchial breathing at her right base. The chest X-ray reveals consolidation. Which of the following would be the most appropriate antibiotic regimen to use?
Correct Answer & Explanation
. Intravenous co-amoxiclav and intravenous clarithromycin
Explanation
This woman has severe pneumonia as defined by the British Thoracic Society (BTS) guidelines, which requires the presence of any two of the following features: Confusion, Urea > 7 mmol/l, Respiratory rate > 30/min, Hypotension (systolic BP < 90 mmHg, diastolic BP < 60 mmHg). Appropriate treatment (as recommended by BTS) is with intravenous antimicrobials: Co-amoxiclav 1.2 g three times daily or cefuroxime 1.5 g three times daily or cefotaxime 1 g three times daily or ceftriaxone 2 g once daily together with: Erythromycin 500 mg four times daily or clarithromycin 500 mg twice daily.
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