RACP Divisional Written Exam · FRACP

Pulmonology for the written exam

Everything Physify has for Pulmonology: short lessons written to Australian guidance, exam-style questions with a worked explanation for each, and Bedside, our AI tutor, under every one. Try a question below, no sign-up.

courses: 24courses
lessons: 175lessons
exam-style questions: 661exam-style questions
figures in the lessons: 33figures in the lessons

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Pulmonology

A 66 year old woman with influenza pneumonia is admitted to intensive care on high-flow nasal oxygen at 50 L/min and FiO2 0.6, with a PaO2 of 92 mmHg. The registrar wants to wean the FiO2 to a PaO2 target of 60 mmHg because a lower target reduces mortality. What is the most accurate response?

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What's covered

24 courses, each a set of lessons with a quiz after them. The bar shows how many questions each has. Open a course to see its lesson outline.

From the lessons

33 figures sit in the Pulmonology lessons: ECGs, diagrams, films and clinical images, each with what to look for. Here are 4. Tap one to enlarge it.

Six schematic flow-volume loops, each with expiratory flow above the line, inspiratory flow below, and volume running from TLC on the left to RV on the right, with the normal loop dashed for comparison. Normal: a rapid rise to peak expiratory flow, a near-linear fall to residual volume and a rounded inspiratory limb. Obstruction: a loop shifted to higher lung volumes with a low peak and a scooped, concave expiratory limb; FEV1/FVC below the LLN. Restriction: a narrow, tall loop shifted to lower volumes, small in volume with flows preserved for that volume; FEV1/FVC normal or high. Fixed upper airway obstruction: both limbs flattened into plateaus; FEF50/FIF50 about 1. Variable extrathoracic obstruction: inspiratory limb flattened, expiration normal; FEF50/FIF50 above 1. Variable intrathoracic obstruction: expiratory plateau with normal inspiration; FEF50/FIF50 well below 1. — Physify teaching diagram (schematic). Tap the image to zoom.

From the lesson “Lung Volumes, Diffusing Capacity and Flow-Volume Loops” in Pulmonary Diagnostics

Oxyhaemoglobin dissociation curve, saturation in per cent against PaO2 from 0 to 120 mmHg, computed with the Severinghaus equation at pH 7.40, PaCO2 40 mmHg and 37 degrees. The P50 is marked at about 27 mmHg. A PaO2 of 60 mmHg gives a saturation of about 90 per cent, marking the boundary between the steep part of the curve below it and the flat part above it. An illustrative right-shifted curve, drawn in long dashes and labelled on the curve (P50 up, easier unloading), is caused by raised hydrogen ion (acidosis), raised PCO2 (Bohr effect), fever, raised 2,3-BPG and HbS. An illustrative left-shifted curve, drawn dotted and labelled on the curve (P50 down, harder unloading), is caused by alkalosis, hypothermia, fetal haemoglobin (P50 about 19 mmHg), carboxyhaemoglobin, methaemoglobin and low 2,3-BPG in stored blood. — Physify teaching diagram. Tap the image to zoom.

From the lesson “Oxygen Carriage, the Dissociation Curve and Dyshaemoglobins” in Pulmonary Physiology

Flowchart for a pleural effusion. Tap with paired serum, measuring protein and LDH in both, plus pH, glucose, cells, Gram stain and culture, and cytology. Light's criteria make it an exudate if any one is met: 1, pleural to serum protein ratio above 0.5; 2, pleural to serum LDH ratio above 0.6; 3, pleural LDH above two-thirds of the upper limit of normal for serum LDH. None met: a transudate (heart failure, cirrhosis, nephrotic syndrome, hypoalbuminaemia, peritoneal dialysis); treat the cause. Any one met: an exudate; sensitivity is about 98 per cent, but about a quarter of transudates read as exudates, as diuresed heart failure concentrates protein and LDH. If heart failure is likely, check for a pseudo-exudate: any one of serum minus pleural albumin above 12 g/L (the best single test), serum minus pleural protein above 31 g/L (less specific), or pleural or serum NT-proBNP above 1,500 ng/L makes it a transudate from heart failure. If none, it is a true exudate, and the fluid is read in turn: pH below 7.2 in pleural infection means drain, with glucose below 3.3 mmol/L as the surrogate if pH is unavailable; neutrophils over 50 per cent suggest parapneumonic effusion, pulmonary embolism, pancreatitis or early tuberculosis, lymphocytes over 50 per cent malignancy, tuberculosis and others, and over 80 per cent tuberculosis, lymphoma or chylothorax, while a pleural haematocrit 50 per cent or more of the blood haematocrit is a haemothorax; ADA above 40 U/L in a lymphocytic exudate supports tuberculosis; the first cytology sample diagnoses about 60 per cent of malignant effusions, so stop after two; triglycerides above 1.24 mmol/L mean chylothorax. If still undiagnosed, in sequence: 1, contrast CT with the fluid still in situ; 2, a second cytology only if malignancy is suspected and CT shows no biopsy target, never a third; 3, tissue chosen by what CT shows: image-guided biopsy for thickening or a nodule with little fluid, local anaesthetic thoracoscopy for a large effusion with no target, VATS biopsy if thoracoscopy is unavailable or has failed, and closed Abrams biopsy only for suspected tuberculosis where it is common. — Physify teaching diagram. Tap the image to zoom.

From the lesson “Pleural Effusion: Imaging, Sampling and Transudate versus Exudate” in Pleural Diseases

Axial CT at the level of the heart: dozens of small, round, thin-walled air cysts spread evenly through both lungs, with normal lung between them. — Lymphangioleiomyomatosis in a woman with multiple renal angiomyolipomas: diffuse, uniform, round, thin-walled cysts with normal intervening lung. A renal angiomyolipoma with this CT is enough for the diagnosis without biopsy, and multiple angiomyolipomas raise the question of tuberous sclerosis. Image: Hellerhoff, CC BY-SA 3.0, via Wikimedia Commons; resized. Original. Tap the image to zoom.

From the lesson “Lymphangioleiomyomatosis” in Interstitial Lung Disease

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10 free Pulmonology questions

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Respiratory and Sleep Medicine high-yield summary

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Pulmonology in the clinical exam

14 interactive short cases and 5 long cases for the RACP Divisional Clinical Exam: you examine, present and are marked on the five RACP domains.

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Pulmonology on the blog

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