MRCP Part 1 Respiratory Medicine 1 — Questions and Answers
Question 1: A patient with COPD has an FEV1/FVC ratio of 0.6 and an FEV1 of 45% predicted. According to GOLD criteria, what severity is this?
- GOLD 1 (mild)
- GOLD 2 (moderate)
- GOLD 3 (severe) (Correct answer)
- GOLD 4 (very severe)
Correct answer: GOLD 3 (severe)
GOLD severity is based on FEV1 % predicted (post-bronchodilator): GOLD 1 ≥80%, GOLD 2 50–79%, GOLD 3 30–49%, GOLD 4 <30%. An FEV1 of 45% predicted places this patient in GOLD 3 (severe). The FEV1/FVC <0.7 confirms obstruction.
Question 2: Which organism is the most common causative pathogen in community-acquired pneumonia (CAP)?
- Klebsiella pneumoniae
- Legionella pneumophila
- Streptococcus pneumoniae (Correct answer)
- Staphylococcus aureus
Correct answer: Streptococcus pneumoniae
Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in the UK, accounting for approximately 30–40% of cases requiring hospitalisation. It typically causes a lobar pattern of consolidation.
Question 3: A patient with known asthma has a PEFR of 33% best and cannot complete sentences. What severity of asthma attack is this?
- Moderate acute asthma
- Severe acute asthma
- Life-threatening asthma (Correct answer)
- Near-fatal asthma
Correct answer: Life-threatening asthma
Life-threatening asthma is defined by any of: PEFR <33% best/predicted, SpO2 <92%, PaO2 <8 kPa, normal/high PaCO2 (>4.6 kPa), silent chest, poor respiratory effort, cyanosis, bradycardia, confusion, or exhaustion. PEFR 33% with inability to speak indicates life-threatening severity.
Question 4: A 25-year-old non-smoker presents with progressive dyspnoea and a CXR showing bilateral basal emphysematous changes. What rare condition should be considered?
- Sarcoidosis
- Alpha-1-antitrypsin deficiency (Correct answer)
- Lymphangioleiomyomatosis
- Hypersensitivity pneumonitis
Correct answer: Alpha-1-antitrypsin deficiency
Alpha-1-antitrypsin (AAT) deficiency should be suspected in young, non-smoking patients with premature emphysema, particularly with a basal distribution (unlike smoking-related emphysema which is upper lobe). Serum AAT levels and phenotyping confirm the diagnosis.
Question 5: Which of the following pleural fluid findings are most consistent with an exudate using Light's criteria?
- Pleural protein/serum protein ratio >0.5 (Correct answer)
- Pleural LDH < 2/3 upper limit of normal serum LDH
- Pleural LDH/serum LDH ratio <0.6
- Pleural protein <25 g/L
Correct answer: Pleural protein/serum protein ratio >0.5
Light's criteria classify an exudate if ANY of: (1) pleural protein/serum protein ratio >0.5, (2) pleural LDH/serum LDH ratio >0.6, or (3) pleural LDH > 2/3 upper limit of normal serum LDH are met. A pleural/serum protein ratio >0.5 alone classifies as an exudate.
Question 6: What is the most appropriate first-line treatment for a Wells score of 3 and a positive D-dimer in a patient with suspected PE?
- Commence therapeutic anticoagulation immediately
- Arrange V/Q scan first before treating
- Request CT pulmonary angiography and treat if confirmed (Correct answer)
- Arrange echocardiogram and treat only if right heart strain is seen
Correct answer: Request CT pulmonary angiography and treat if confirmed
A Wells score of 3 represents intermediate (moderate) probability for PE. CTPA is the investigation of choice. Anticoagulation may be started before imaging if there will be a significant delay (>1 hour) and there are no contraindications, but confirmation before committing to long-term therapy is preferred.
MRCP Part 1 Respiratory Medicine 1
A patient with COPD has an FEV1/FVC ratio of 0.6 and an FEV1 of 45% predicted.
According to GOLD criteria, what severity is this?