Free UKMLA respiratory questions with explanations

B. Silent chest on auscultation

Asthma severity is classified by a discrete set of life-threatening features: silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness, hypotension, arrhythmia, SpO2 below 92% and PEF below 33% of predicted. A silent chest reflects airflow so reduced that no audible wheeze is generated and is the classic auscultatory marker that an acute severe attack has crossed into life-threatening territory.

D. A lenticular collection forming an obtuse angle with the chest wall

An empyema lies in the pleural space, so it is lenticular, meets the chest wall at an obtuse angle, compresses and displaces the adjacent lung and shows the split-pleura sign of separated, enhancing visceral and parietal pleura. A lung abscess is a parenchymal cavity, so it is round with a thick irregular wall, makes an acute angle with the chest wall and destroys rather than displaces the surrounding lung. Air-fluid levels can occur in both, so they do not discriminate. The distinction matters because an empyema needs a chest drain and an abscess does not.

C. Suspected cancer pathway referral for lung cancer

Anyone aged 40 and over with unexplained haemoptysis is referred using a suspected cancer pathway referral for lung cancer. The urgent direct access chest X-ray in 1.1.2 applies to a different group, those aged 40 and over with two or more of cough, fatigue, shortness of breath, chest pain, weight loss or appetite loss, or one or more in an ever-smoker. Haemoptysis is not on that list, and a normal chest X-ray does not exclude lung cancer.

E. Discharge with outpatient respiratory follow-up

After successful needle aspiration of a pneumothorax with confirmed radiographic re-expansion and a clinically stable, asymptomatic patient, the appropriate management is discharge with outpatient respiratory follow-up. Written safety-net advice, smoking cessation counselling, avoidance of air travel until cleared at review after radiographic resolution, and permanent avoidance of scuba diving unless a definitive surgical procedure has been performed should be provided.

D. Occupational asthma

Work-related wheeze and cough that improve on holidays and recur on return to work, together with a peak flow diary showing lower readings on working days, is strongly suggestive of occupational asthma, though work-exacerbated pre-existing asthma produces the same pattern and specific IgE or challenge testing is needed to confirm sensitisation. Flour dust is a well-recognised high-molecular-weight sensitiser in bakers (baker's asthma), and serial peak flow monitoring across work and rest periods is the key investigation.

D. Biologic therapy with anti-IL-5 agent

Severe eosinophilic asthma refractory to maximal inhaled and oral maintenance therapy with blood eosinophils ≥300 cells/microlitre and frequent exacerbations meets the NICE criteria for the anti-IL-5 biologics mepolizumab and benralizumab (reslizumab needs 400 cells/microlitre or more with 3 or more exacerbations), which reduce exacerbations and oral steroid burden. This patient's elevated eosinophils at 450 cells/microlitre and poor control despite high-dose ICS/LABA, LTRA and maintenance prednisolone make an anti-IL-5 agent the appropriate next step.

A. Alpha-1 antitrypsin deficiency

Alpha-1 antitrypsin deficiency is the likely diagnosis given early-onset basal panacinar emphysema in a non-smoker combined with deranged transaminases, reflecting both pulmonary (unopposed neutrophil elastase activity) and hepatic (misfolded protein accumulation in hepatocytes) manifestations. Serum alpha-1 antitrypsin level should be tested in any patient developing COPD under 45, in non-smokers, or with a family history.

E. Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome (LEMS) is a paraneoplastic disorder most commonly associated with small cell lung cancer, caused by autoantibodies against presynaptic voltage-gated calcium channels, which impairs acetylcholine release at the neuromuscular junction. The classic triad of proximal muscle weakness that improves with repeated activity (post-tetanic potentiation), hyporeflexia with reflex return after sustained contraction, and autonomic features makes the diagnosis in a smoker with a central lung mass.

C. Exercise-induced bronchoconstriction

Transient bronchospasm triggered by airway cooling and drying during vigorous exercise produces classic exercise-induced bronchoconstriction, particularly in atopic young people with airway hyperresponsiveness. An inhaled bronchodilator 10-15 minutes pre-exercise (a SABA, or ICS-formoterol in those already on AIR or MART) prevents symptoms; in a person with established asthma, exercise-induced symptoms usually indicate inadequate control and ICS-containing therapy should be reviewed first.

C. Streptococcus pneumoniae

Streptococcus pneumoniae is the most common cause of post-influenza secondary bacterial pneumonia, classically producing a biphasic illness with rusty sputum and lobar consolidation; influenza damages respiratory epithelium and impairs mucociliary clearance, allowing pneumococcal superinfection. Empirical cover should include S. pneumoniae and S. aureus when bacterial superinfection complicates influenza; co-amoxiclav (given with clarithromycin as first-line for high-severity community-acquired pneumonia) covers both.