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Iraqi Board Internal Medicine study materials
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Iraqi Board Internal Medicine practice questions

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Question 1Cardiology

A 58-year-old man presents with two hours of crushing central chest pain. Which electrocardiographic finding establishes the diagnosis of ST-elevation myocardial infarction?

  1. ST depression in a single lead
  2. T-wave inversion in lead III alone
  3. First-degree heart block
  4. ST elevation in two contiguous leads Correct answer.

Explanation

ST-elevation myocardial infarction is diagnosed when ST elevation meeting the amplitude criteria is present in two anatomically contiguous leads, reflecting transmural injury in a single coronary territory. ST depression and T-wave inversion indicate ischaemia without full-thickness injury, and conduction delay alone is non-specific.

Question 2Cardiology

Which oral agent has been shown to reduce mortality in patients with heart failure and a reduced ejection fraction?

  1. Furosemide
  2. Amlodipine
  3. Digoxin
  4. Bisoprolol Correct answer.

Explanation

Beta-blockers such as bisoprolol, carvedilol and metoprolol succinate reduce all-cause mortality in heart failure with reduced ejection fraction and are part of standard quadruple therapy. Loop diuretics relieve congestion but do not alter survival.

Question 3Cardiology

Using standard clinic blood pressure criteria, hypertension is diagnosed when the average reading is at least which value?

  1. 120/70 mmHg
  2. 160/100 mmHg
  3. 130/80 mmHg
  4. 140/90 mmHg Correct answer.

Explanation

Most international and regional guidelines, including those of the World Health Organization and the European Society of Cardiology, define hypertension as a clinic average of 140/90 mmHg or higher. A threshold of 130/80 mmHg is used by some bodies such as the American College of Cardiology, while 160/100 mmHg defines grade 2 hypertension rather than the diagnostic cut-off.

Question 4Cardiology

A haemodynamically stable patient with atrial fibrillation has a resting ventricular rate of 150 beats per minute and normal left ventricular function. Which drug is most appropriate for rate control?

  1. Atropine
  2. Metoprolol Correct answer.
  3. Adenosine
  4. Amiodarone bolus

Explanation

Intravenous beta-blockers such as metoprolol act on the atrioventricular node to slow ventricular rate and are first-line in stable patients without heart failure. Adenosine is used for narrow-complex tachycardias other than atrial fibrillation, and amiodarone is reserved for rhythm control or when rate control fails.

Question 5Cardiology

Which finding on a 12-lead electrocardiogram is most characteristic of hypocalcaemia?

  1. Prolonged QT interval Correct answer.
  2. Delta wave
  3. Peaked T waves
  4. Prominent U waves

Explanation

Hypocalcaemia prolongs the plateau phase of the action potential and therefore lengthens the QT interval, particularly the ST segment. Prominent U waves suggest hypokalaemia, a delta wave indicates an accessory pathway, and peaked T waves suggest hyperkalaemia.

Question 6Cardiology

Which of the following is a major Jones criterion for the diagnosis of acute rheumatic fever?

  1. Fever
  2. Arthralgia
  3. Carditis Correct answer.
  4. Elevated erythrocyte sedimentation rate

Explanation

The major Jones criteria are carditis, polyarthritis, chorea, erythema marginatum and subcutaneous nodules. Fever, arthralgia and raised acute-phase reactants are minor criteria that support the diagnosis only when evidence of preceding streptococcal infection is present.

Question 7Cardiology

A 30-year-old man has sharp central chest pain that is worse on inspiration and improves when he sits forward. What is the most likely diagnosis?

  1. Aortic dissection
  2. Pulmonary embolism
  3. Unstable angina
  4. Acute pericarditis Correct answer.

Explanation

Pleuritic chest pain that is relieved by leaning forward is the classic presentation of acute pericarditis, a diagnosis supported by a pericardial friction rub and diffuse ST elevation. Aortic dissection produces tearing pain radiating to the back, pulmonary embolism typically causes sudden dyspnoea, and ischaemic pain is exertional or pressure-like.

Question 8Cardiology

Which drug class is first-line for lowering low-density lipoprotein cholesterol in a patient with established coronary artery disease?

  1. Niacin
  2. Statins Correct answer.
  3. Bile acid sequestrants
  4. Fibrates

Explanation

Statins inhibit hydroxymethylglutaryl-coenzyme A reductase and produce the largest reduction in low-density lipoprotein cholesterol together with proven reductions in cardiovascular events in secondary prevention. Fibrates act mainly on triglycerides, and bile acid sequestrants and niacin are adjuncts with limited outcome evidence.

Question 9Cardiology

A patient with non-ST-elevation myocardial infarction has continuing chest pain and a GRACE score of 150. Which management strategy is most appropriate?

  1. Early invasive angiography Correct answer.
  2. Immediate fibrinolytic therapy
  3. Aspirin alone with early discharge
  4. Predischarge exercise stress testing

Explanation

A GRACE score above 140 with refractory symptoms places the patient in the high-risk group, for which an early invasive strategy with coronary angiography within 24 hours is recommended. Fibrinolysis has no role in non-ST-elevation acute coronary syndrome and may cause harm.

Question 10Cardiology

Which description best fits heart failure with preserved ejection fraction?

  1. Right heart failure due to pulmonary hypertension
  2. Diastolic dysfunction with a preserved ejection fraction Correct answer.
  3. A restrictive filling pattern caused by amyloidosis
  4. Systolic dysfunction with a dilated left ventricle

Explanation

Heart failure with preserved ejection fraction is defined by symptoms and signs of heart failure with an ejection fraction of 50 percent or more together with evidence of raised filling pressures and diastolic dysfunction. Dilated cardiomyopathy with systolic impairment defines heart failure with reduced ejection fraction.

Question 11Cardiology

Which finding on physical examination is most typical of severe aortic stenosis?

  1. Pansystolic murmur at the apex radiating to the axilla
  2. Slow-rising carotid pulse with an ejection systolic murmur Correct answer.
  3. Wide pulse pressure with a water-hammer pulse
  4. Early diastolic murmur at the left sternal edge

Explanation

Severe aortic stenosis obstructs left ventricular outflow, producing a low-volume, slowly rising carotid pulse (pulsus parvus et tardus) with a harsh ejection systolic murmur radiating to the carotids. The other signs describe mitral regurgitation, aortic regurgitation and aortic regurgitation respectively.

Question 12Cardiology

What is the most common cause of mitral stenosis worldwide?

  1. Infective endocarditis
  2. Left atrial myxoma
  3. Mitral annular calcification
  4. Rheumatic heart disease Correct answer.

Explanation

Rheumatic heart disease accounts for the great majority of mitral stenosis globally, producing leaflet thickening, commissural fusion and chordal shortening years after the initial streptococcal infection. Non-rheumatic causes such as annular calcification are far less common and usually occur in elderly patients.

Question 13Cardiology

A patient with a broad-complex tachycardia is hypotensive with a reduced level of consciousness. What is the most appropriate immediate treatment?

  1. Synchronised DC cardioversion Correct answer.
  2. Oral bisoprolol
  3. Intravenous adenosine
  4. Carotid sinus massage

Explanation

Any tachyarrhythmia producing haemodynamic compromise requires immediate synchronised direct-current cardioversion, which restores sinus rhythm and cardiac output. Drug therapy and vagal manoeuvres are reserved for stable patients.

Question 14Cardiology

In a patient with suspected infective endocarditis, which step is most important before antibiotics are started?

  1. Empirical gentamicin without cultures
  2. Serial erythrocyte sedimentation rate measurements
  3. Blood cultures from three separate sites Correct answer.
  4. A single transthoracic echocardiogram before any therapy

Explanation

At least three sets of blood cultures drawn from separate venepuncture sites before the first antibiotic dose are essential to identify the causative organism and guide targeted therapy. Starting antibiotics first can sterilise the cultures and leave the patient on unnecessary broad-spectrum treatment.

Question 15Cardiology

A 35-year-old patient with a mechanical mitral valve requires lifelong anticoagulation. Which agent is indicated?

  1. Apixaban
  2. Warfarin Correct answer.
  3. Clopidogrel
  4. Rivaroxaban

Explanation

Vitamin K antagonists such as warfarin remain the only proven anticoagulants for mechanical heart valves, with the target international normalised ratio determined by valve type and position. Direct oral anticoagulants are contraindicated in mechanical valves because of excess thromboembolism and bleeding.

Question 16Cardiology

A patient presents with a blood pressure of 220/130 mmHg, chest pain and pulmonary oedema. What is the most appropriate initial management?

  1. Controlled intravenous BP reduction with monitoring Correct answer.
  2. Oral nifedipine to normalise blood pressure within one hour
  3. Rapid blood pressure normalisation within 30 minutes
  4. Sublingual captopril followed by discharge

Explanation

Hypertensive emergency with target-organ damage requires monitored intravenous therapy with a titratable agent and a controlled reduction in blood pressure, generally by no more than 20 to 25 percent in the first hour. Abrupt normalisation can precipitate cerebral, coronary or renal ischaemia.

Question 17Cardiology

Which set of findings is most characteristic of cardiac tamponade?

  1. Pulsus bisferiens and a wide pulse pressure
  2. Hypotension, raised JVP and soft heart sounds Correct answer.
  3. A pleuritic rub and a pericardial knock
  4. Hypertension, bradycardia and flushed skin

Explanation

Beck triad of hypotension, elevated jugular venous pressure and muffled heart sounds reflects the impaired diastolic filling caused by pericardial fluid under pressure. Pulsus paradoxus and echocardiographic right-sided chamber collapse support the diagnosis.

Question 18Cardiology

A young man with palpitations has a short PR interval and a delta wave on his ECG. Which drug is unsafe for rate control during pre-excited atrial fibrillation because it may accelerate conduction down the accessory pathway?

  1. Procainamide
  2. Lidocaine
  3. Verapamil Correct answer.
  4. Magnesium sulphate

Explanation

Atrioventricular nodal blocking drugs including verapamil, diltiazem, digoxin and adenosine are contraindicated in pre-excited atrial fibrillation because they slow nodal conduction while enhancing accessory pathway conduction, which can precipitate ventricular fibrillation. Procainamide, which slows the accessory pathway, is a safer choice.

Question 19Cardiology

Which echocardiographic feature is most characteristic of hypertrophic cardiomyopathy?

  1. Markedly reduced ejection fraction
  2. Left ventricular non-compaction
  3. Dilated left ventricle with thin walls
  4. Asymmetric septal hypertrophy Correct answer.

Explanation

Hypertrophic cardiomyopathy is defined by unexplained left ventricular hypertrophy, most often asymmetric with predominant septal involvement, and may cause dynamic outflow tract obstruction and diastolic dysfunction. Systolic function is typically preserved or hyperdynamic.

Question 20Cardiology

Which echocardiographic finding suggests acute right ventricular strain in a patient with pulmonary embolism?

  1. RV dilatation with septal flattening Correct answer.
  2. Severe concentric left ventricular hypertrophy
  3. Large pericardial effusion with tamponade
  4. Left ventricular ejection fraction of 25%

Explanation

Acute pressure overload of the right ventricle from pulmonary embolism causes right ventricular dilatation, hypokinesis of the free wall and flattening or bowing of the interventricular septum. These signs reflect raised pulmonary artery pressure and identify patients at higher risk of deterioration.

Question 21Cardiology

A patient with intermittent chest pain has a pain-free ECG showing deep, symmetrical T-wave inversion in leads V2 and V3 with no Q waves and minimal ST elevation. What does this pattern suggest?

  1. Acute pericarditis
  2. Critical proximal LAD stenosis Correct answer.
  3. Old inferior myocardial infarction
  4. Benign early repolarisation variant

Explanation

This is the Wellens pattern, which reflects a critically stenosed proximal left anterior descending artery after the pain has resolved and carries a high risk of extensive anterior infarction if untreated. Such patients require urgent angiography rather than stress testing.

Question 22Cardiology

Which finding best distinguishes constrictive pericarditis from restrictive cardiomyopathy?

  1. Presence of ascites and peripheral oedema
  2. Respirophasic septal shift on echocardiography Correct answer.
  3. Chronic atrial fibrillation
  4. Markedly elevated BNP

Explanation

In constrictive pericarditis the rigid pericardium causes ventricular interdependence, so the interventricular septum shifts with respiration and tissue Doppler annular velocities remain preserved or even elevated. Restricted cardiomyopathy shows reduced annular velocities without respirophasic septal shift.

Question 23Cardiology

A 40-year-old man has had a syncopal episode. His ECG shows coved ST elevation with T-wave inversion in leads V1 and V2. Which condition is most likely?

  1. Brugada syndrome Correct answer.
  2. Left bundle branch block
  3. Acute anterior myocardial infarction
  4. Hyperkalaemia

Explanation

Coved ST elevation with T-wave inversion in the right precordial leads is the type 1 Brugada pattern, an inherited channelopathy that predisposes to polymorphic ventricular tachycardia and sudden death. Syncope in this context indicates a high risk of arrhythmic events.

Question 24Cardiology

A 45-year-old with resistant hypertension has unexplained hypokalaemia and a metabolic alkalosis. Which screening test is most appropriate?

  1. Plasma renin activity alone
  2. Plasma aldosterone-to-renin ratio Correct answer.
  3. Renal artery Doppler ultrasound
  4. 24-hour urinary metanephrines

Explanation

Resistant hypertension with hypokalaemia and metabolic alkalosis suggests primary hyperaldosteronism, for which an elevated aldosterone-to-renin ratio is the recommended screening test. Confirmation is then made with saline suppression or adrenal imaging.

Question 25Cardiology

A patient taking digoxin for heart failure presents with nausea, confusion and a heart rate of 40 per minute; the ECG shows bidirectional ventricular tachycardia. Which electrolyte abnormality most often precipitates this presentation?

  1. Hypercalcaemia
  2. Hypernatraemia
  3. Hypokalaemia Correct answer.
  4. Hyperkalaemia

Explanation

Hypokalaemia increases digoxin binding to the sodium-potassium ATPase and lowers the threshold for toxicity, so it is a common precipitant and should be corrected. Hyperkalaemia in this context is usually a marker of severe toxicity rather than its cause.

Question 26Cardiology

Which electrocardiographic pattern is most characteristic of atrial fibrillation?

  1. Progressive lengthening of the PR interval until a QRS complex is dropped
  2. Regular ventricular rhythm with sawtooth flutter waves at about 300 per minute
  3. Regular narrow-complex tachycardia at 150 per minute with P waves buried in the T wave
  4. Irregularly irregular ventricular rhythm with no discrete P waves Correct answer.

Explanation

Atrial fibrillation is defined by chaotic atrial activity with loss of coordinated atrial contraction, so no consistent P waves are seen and the ventricular response is irregularly irregular. The ventricular rate varies with atrioventricular nodal conduction and with any drugs or conduction disease present. The diagnosis is confirmed on a 12-lead ECG or rhythm strip rather than on clinical suspicion alone.

Question 27Cardiology

A 50-year-old male smoker describes episodes of chest tightness that waken him at night and settle within a few minutes. An ECG recorded during pain shows transient ST-segment elevation in the inferior leads that resolves with the pain, and coronary angiography shows no obstructive disease. Which agent is most appropriate for preventing further episodes?

  1. Atenolol, a beta-1 selective blocker
  2. Ramipril, an angiotensin-converting enzyme inhibitor
  3. Diltiazem, a calcium channel blocker Correct answer.
  4. Furosemide, a loop diuretic

Explanation

The nocturnal rest pain with transient, reversible ST elevation in the absence of obstructive coronary disease indicates coronary vasospasm, so the aim is to prevent spasm rather than to reduce myocardial oxygen demand. Calcium channel blockers are the first-line prophylactic therapy, with short-acting nitrates used to abort episodes, and smoking cessation is essential. Beta-blockers may worsen spasm through unopposed alpha-mediated constriction and are avoided where possible.

Question 28Cardiology

A 68-year-old man with a long history of exertional breathlessness has a preserved left ventricular ejection fraction, concentric left ventricular wall thickening on echocardiography, and a low-voltage ECG. He also underwent bilateral carpal tunnel release in the past five years. Which diagnosis best explains this combination?

  1. Fabry disease
  2. Cardiac amyloidosis Correct answer.
  3. Hypertensive heart disease
  4. Hypertrophic cardiomyopathy

Explanation

The key rule is discordance between thick ventricular walls on imaging and low-voltage complexes on the ECG, which suggests infiltration rather than true myocyte hypertrophy, and bilateral carpal tunnel syndrome is a recognised early feature of transthyretin amyloidosis. Confirmation relies on serum free light chains with immunofixation to exclude AL amyloid, together with bone scintigraphy or tissue biopsy. Older men with heart failure and preserved ejection fraction should be screened for this treatable cause.

Question 29Respiratory Medicine

A 24-year-old non-smoker has episodic wheeze and nocturnal cough. Spirometry shows an FEV1 of 68% predicted, which rises by 15% and 250 mL after inhaled salbutamol. What is the most likely diagnosis?

  1. Asthma Correct answer.
  2. Idiopathic pulmonary fibrosis
  3. COPD
  4. Bronchiectasis

Explanation

The post-bronchodilator change exceeds both 12% and 200 mL, which defines significant reversibility and supports asthma in a young non-smoker. COPD usually occurs in older smokers and shows persistent airflow limitation that is not fully reversible.

Question 30Respiratory Medicine

Which post-bronchodilator spirometric finding establishes persistent airflow limitation in COPD?

  1. FEV1/FVC below 0.70 Correct answer.
  2. FEV1/FVC below 0.60
  3. FEV1/FVC below 0.80
  4. FEV1/FVC below 0.50

Explanation

GOLD defines COPD by a post-bronchodilator FEV1/FVC ratio below 0.70, confirming persistent airflow limitation. The FEV1 percentage predicted is then used to grade severity.

Question 31Respiratory Medicine

A patient develops sudden pleuritic chest pain and severe dyspnoea after a fall. There is tracheal deviation away from the affected side, absent breath sounds and hypotension. What is the immediate management?

  1. CT scanning first
  2. Chest radiography first
  3. Observation with oxygen
  4. Needle decompression Correct answer.

Explanation

Tension pneumothorax is a clinical diagnosis and treatment must not be delayed for imaging. Immediate needle decompression is followed by a definitive chest drain.

Question 32Respiratory Medicine

Which test is most appropriate to identify latent tuberculosis infection in a BCG-vaccinated household contact with a normal chest radiograph?

  1. Sputum AFB smear
  2. Chest radiograph
  3. Tuberculin skin test
  4. IGRA assay Correct answer.

Explanation

An interferon-gamma release assay is less affected by previous BCG vaccination than the tuberculin skin test. A positive result with no symptoms and a normal chest radiograph supports latent infection.

Question 33Respiratory Medicine

Which symptom combination most suggests obstructive sleep apnoea?

  1. Progressive exertional dyspnoea
  2. Productive cough and haemoptysis
  3. Recurrent pleural effusions
  4. Loud snoring and apnoeas Correct answer.

Explanation

Loud snoring, witnessed apnoeas and daytime somnolence are the classic symptoms of obstructive sleep apnoea. Diagnosis is confirmed by a sleep study showing an elevated apnoea-hypopnoea index.

Question 34Respiratory Medicine

Which finding during an acute asthma attack indicates a life-threatening episode?

  1. SpO2 of 94% on air
  2. A silent chest Correct answer.
  3. Mild end-expiratory wheeze
  4. Peak flow 60% predicted

Explanation

A silent chest means airflow is so reduced that wheeze is no longer audible, indicating impending respiratory failure. Other life-threatening features include cyanosis, exhaustion, bradycardia and a normal or rising PaCO2.

Question 35Respiratory Medicine

What is the most common bacterial cause of community-acquired pneumonia in adults?

  1. M. pneumoniae
  2. Legionella spp.
  3. H. influenzae
  4. S. pneumoniae Correct answer.

Explanation

Streptococcus pneumoniae remains the most frequently identified bacterial pathogen in community-acquired pneumonia. Atypical organisms such as Mycoplasma and Legionella are less common overall.

Question 36Respiratory Medicine

Which set of variables is used in the CURB-65 score?

  1. Confusion, urea >7, RR ≥30, BP <90/60, age ≥65 Correct answer.
  2. Confusion, urea >10, RR ≥25, BP <100/70, age ≥60
  3. Confusion, urea >7, RR ≥20, BP <90/60, age ≥65
  4. Confusion, creatinine >150, RR ≥30, BP <90/60, age ≥65

Explanation

CURB-65 uses confusion, urea above 7 mmol/L, respiratory rate 30 or more, systolic BP below 90 or diastolic BP 60 or less, and age 65 or older. Each item scores one point and guides site of care.

Question 37Respiratory Medicine

A 35-year-old presents with pleuritic chest pain and tachycardia. The Wells score is low and there is no contraindication to anticoagulation. D-dimer is negative. What is the next step?

  1. No further imaging or anticoagulation
  2. Start therapeutic anticoagulation
  3. CT pulmonary angiography Correct answer.
  4. Ventilation-perfusion scan

Explanation

In low or intermediate pretest probability, a negative sensitive D-dimer excludes pulmonary embolism and imaging is unnecessary. High-probability patients proceed to CT pulmonary angiography regardless of the D-dimer.

Question 38Respiratory Medicine

Which triad is characteristic of Löfgren syndrome in sarcoidosis?

  1. Dyspnoea, basilar crackles, clubbing
  2. Fever, erythema nodosum, hilar nodes Correct answer.
  3. Cough, weight loss, upper-lobe cavitation
  4. Wheeze, eosinophilia, central bronchiectasis

Explanation

Löfgren syndrome consists of fever, erythema nodosum, bilateral hilar lymphadenopathy and often arthralgia. It usually carries a good prognosis and may resolve spontaneously.

Question 39Respiratory Medicine

Which investigation best confirms bronchiectasis in a patient with chronic cough and purulent sputum?

  1. HRCT scan Correct answer.
  2. Chest radiograph
  3. Fibreoptic bronchoscopy
  4. Spirometry

Explanation

High-resolution CT is the investigation of choice and shows dilated, thickened airways with a signet-ring appearance. Chest radiography is insensitive for mild or localised disease.

Question 40Respiratory Medicine

A 62-year-old smoker has a central lung mass, hyponatraemia with low serum osmolality and high urine sodium. Which histological type is most likely?

  1. Small cell carcinoma Correct answer.
  2. Adenocarcinoma
  3. Malignant mesothelioma
  4. Squamous cell carcinoma

Explanation

Small cell lung carcinoma commonly causes paraneoplastic syndromes, including ectopic ADH secretion leading to SIADH. It typically presents as a central mass in smokers.

Question 41Respiratory Medicine

In a COPD exacerbation with acute hypercapnic respiratory failure, which blood gas finding is the best indication to start non-invasive ventilation?

  1. pH 7.45 with PaCO2 45 mmHg
  2. pH 7.10 with PaCO2 95 mmHg
  3. pH 7.30 with PaCO2 70 mmHg Correct answer.
  4. pH 7.15 with PaCO2 85 mmHg

Explanation

Non-invasive ventilation is best indicated for acute hypercapnic respiratory failure with a pH between 7.25 and 7.35 despite optimal medical therapy. A pH of 7.30 with hypercapnia fits this window, whereas severe acidaemia often requires intubation.

Question 42Respiratory Medicine

A patient with systemic sclerosis develops pulmonary arterial hypertension. Which group of pulmonary hypertension does this belong to?

  1. Group 1 Correct answer.
  2. Group 4
  3. Group 3
  4. Group 2

Explanation

Pulmonary arterial hypertension associated with connective tissue disease is classified as group 1. Group 2 is due to left heart disease, group 3 to lung disease or hypoxia, and group 4 to chronic thromboembolic disease.

Question 43Respiratory Medicine

What happens to the diffusing capacity for carbon monoxide (DLCO) in emphysema?

  1. Mildly raised
  2. Raised
  3. Reduced Correct answer.
  4. Normal

Explanation

Emphysema destroys alveolar walls and the pulmonary capillary bed, reducing the surface area available for gas exchange. DLCO is therefore reduced and helps distinguish emphysema from asthma, in which it is usually normal or raised.

Question 44Respiratory Medicine

A bird fancier develops fever, cough and breathlessness after antigen exposure, and HRCT shows centrilobular nodules. What is the most important initial management?

  1. Oral corticosteroids
  2. Antigen avoidance Correct answer.
  3. Antifibrotic therapy
  4. Broad-spectrum antibiotics

Explanation

Hypersensitivity pneumonitis is driven by exposure to an inhaled antigen, so identifying and avoiding the antigen is the cornerstone of management. Corticosteroids may be used for severe or persistent disease but do not replace exposure control.

Question 45Respiratory Medicine

What is the standard regimen for newly diagnosed drug-sensitive pulmonary tuberculosis in an adult?

  1. 9 months of HR
  2. 2 months HRZS then 4 months HR
  3. 2 months HRZE then 4 months HR Correct answer.
  4. 6 months of HRZE

Explanation

Drug-sensitive pulmonary tuberculosis is treated with a two-month intensive phase of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by a four-month continuation phase of isoniazid and rifampicin. This gives a total of six months.

Question 46Respiratory Medicine

In a symptomatic adult, which apnoea-hypopnoea index (AHI) on sleep study is diagnostic of obstructive sleep apnoea?

  1. ≥10
  2. ≥30
  3. ≥5 Correct answer.
  4. ≥1

Explanation

Obstructive sleep apnoea is diagnosed when the AHI is 5 or more with compatible symptoms, or 15 or more even without symptoms. An AHI of 30 or more indicates severe disease rather than the diagnostic threshold.

Question 47Respiratory Medicine

Which finding in pleural fluid meets Light's criteria for an exudate?

  1. Pleural LDH 100 U/L
  2. Pleural protein 20 g/L
  3. Pleural/serum LDH 0.7 Correct answer.
  4. Pleural/serum protein 0.4

Explanation

Light's criteria classify fluid as exudative if any one of the following is present: pleural/serum protein ratio above 0.5, pleural/serum LDH ratio above 0.6, or pleural LDH above two-thirds the upper limit of normal for serum. A pleural/serum LDH ratio of 0.7 therefore meets the criteria.

Question 48Respiratory Medicine

A 40-year-old non-smoker has basilar-predominant emphysema and deranged liver enzymes. Which test is most appropriate?

  1. Antinuclear antibody titre
  2. Serum alpha-1 antitrypsin level Correct answer.
  3. Sweat chloride test
  4. Serum angiotensin-converting enzyme

Explanation

Alpha-1 antitrypsin deficiency causes panacinar, lower-lobe-predominant emphysema and can also cause liver disease. Serum alpha-1 antitrypsin level is the initial test, followed by phenotyping if it is low.

Question 49Respiratory Medicine

Which radiological feature is most typical of allergic bronchopulmonary aspergillosis?

  1. Peripheral bronchiectasis
  2. Central bronchiectasis Correct answer.
  3. Lung cavitation
  4. Pleural effusion

Explanation

Allergic bronchopulmonary aspergillosis causes mucus plugging of the central airways, leading to central bronchiectasis. It occurs in patients with asthma or cystic fibrosis and is associated with eosinophilia and a raised IgE.

Question 50Respiratory Medicine

Which thoracic malignancy is most strongly associated with asbestos exposure?

  1. Typical carcinoid tumour
  2. Squamous cell carcinoma
  3. Malignant mesothelioma Correct answer.
  4. Small cell carcinoma

Explanation

Asbestos exposure is strongly linked to malignant mesothelioma, which arises from the pleura and often presents with pleural thickening or effusion. Asbestos also increases the risk of lung cancer, but the association is strongest for mesothelioma.