Prometric Exam Questions for Pulmonology Specialists 2026: 20 MCQs with Answers on Asthma, COPD, Pneumonia, Tuberculosis, Pulmonary Embolism, Interstitial Lung Disease, Sleep Apnoea and Pleural Disease

The specialist pulmonary disease paper (PUL5081 at DHA, and the equivalents at SCFHS, QCHP, NHRA and the other authorities) is 100 to 150 single-best-answer questions in up to three hours with a pass mark of about 60%. The paper leans on the conditions that fill Gulf chest clinics: asthma and COPD in a dusty, hot climate, tuberculosis in a largely expatriate workforce, pulmonary embolism, interstitial lung disease and sleep apnoea in a population with high obesity rates. The licensing route is in the pulmonologist guide.

Airways disease

Question 1

A 30-year-old with asthma uses a salbutamol inhaler four times a week and wakes once a week with symptoms despite low-dose inhaled corticosteroid. The next step is:

1. Add a short-acting beta-agonist on a regular schedule
2. Check inhaler technique and adherence, then step up to low-dose inhaled corticosteroid plus formoterol as maintenance and reliever therapy (or add a long-acting beta-agonist), with trigger review
3. Start oral prednisolone long term
4. Add montelukast as monotherapy

Answer: B. Current GINA guidance no longer recommends salbutamol-only treatment at any step; poor technique and adherence explain most "uncontrolled" asthma.

Question 2

A patient with acute severe asthma has a peak flow of 40% predicted, respiratory rate 28, heart rate 115 and cannot complete sentences. After high-flow oxygen targeting saturations of 94 to 98%, the treatment includes:

1. Oral antibiotics and discharge
2. Nebulised salbutamol repeated or continuous, nebulised ipratropium, systemic corticosteroid within the first hour, and intravenous magnesium sulfate if there is a poor initial response, with early senior and ICU involvement if PaCO₂ is normal or rising
3. Intravenous aminophylline as first line
4. Sedation to reduce anxiety

Answer: B. A normal or rising carbon dioxide in a tiring asthmatic signals life-threatening asthma; sedation is contraindicated outside intubation.

Question 3

A 62-year-old smoker has an FEV₁/FVC of 0.62 post-bronchodilator and FEV₁ 55% predicted, two moderate exacerbations in the past year and a CAT score of 18. By GOLD 2024 grouping, the recommended initial inhaled therapy is:

1. A short-acting bronchodilator as needed only
2. Long-acting beta-agonist plus long-acting muscarinic antagonist (LABA/LAMA), adding inhaled corticosteroid if blood eosinophils are 300 cells/µL or more or exacerbations continue
3. Inhaled corticosteroid monotherapy
4. Oral theophylline

Answer: B. Group E (frequent exacerbators) start on dual bronchodilation; smoking cessation and vaccination remain the interventions that change mortality.

Question 4

Long-term oxygen therapy is indicated in stable COPD when:

1. Any patient reports breathlessness on stairs
2. Resting PaO₂ is 7.3 kPa (55 mmHg) or less on two occasions at least three weeks apart, or 7.3 to 8.0 kPa with pulmonary hypertension, polycythaemia or peripheral oedema, used for at least 15 hours a day in a non-smoker
3. Saturations fall to 92% on exertion
4. FEV₁ is below 50%

Answer: B. Survival benefit requires prolonged daily use; oxygen for exertional desaturation alone does not improve survival.

Infection

Question 5

A 70-year-old with community-acquired pneumonia has new confusion, urea 9 mmol/L, respiratory rate 32 and blood pressure 85/55 mmHg. The CURB-65 score and management are:

1. Score 1; oral amoxicillin at home
2. Score 4; admit, consider ICU, blood cultures, and intravenous beta-lactam plus macrolide (or a respiratory fluoroquinolone) covering typical and atypical organisms
3. Score 2; oral doxycycline at home
4. Score 0; no antibiotics needed

Answer: B. Confusion, urea above 7, respiratory rate 30 or more, and systolic BP below 90 each score one; age 65 or more adds the fifth point.

Question 6

A 35-year-old construction worker from South Asia has three weeks of cough, night sweats, weight loss and haemoptysis. Chest radiograph shows a right upper lobe cavity. The correct diagnostic approach is:

1. Empirical amoxicillin and review in two weeks
2. Respiratory isolation, at least two sputum samples for smear microscopy and culture plus a rapid molecular test (such as Xpert MTB/RIF) that also detects rifampicin resistance, HIV testing, and notification to public health
3. Tuberculin skin test alone
4. CT chest only

Answer: B. Molecular testing with resistance detection is standard; TB is notifiable and has residency implications in the Gulf, so documentation must be exact.

Question 7

Standard treatment for drug-susceptible pulmonary tuberculosis is:

1. Rifampicin and isoniazid for six weeks
2. Two months of rifampicin, isoniazid, pyrazinamide and ethambutol, then four months of rifampicin and isoniazid, with pyridoxine, baseline liver function and visual acuity checks and directly observed or supported treatment
3. Streptomycin monotherapy
4. Twelve months of isoniazid alone

Answer: B. Hepatotoxicity (rifampicin, isoniazid, pyrazinamide), optic neuritis (ethambutol) and peripheral neuropathy (isoniazid) are the monitored adverse effects; a four-month rifapentine-moxifloxacin regimen is an accepted alternative in selected patients.

Question 8

A ventilated ICU patient develops a new infiltrate, fever and purulent secretions on day 7. The most important principle in antibiotic selection is:

1. Use the same antibiotic as for community-acquired pneumonia
2. Cover hospital-acquired Gram-negative organisms including Pseudomonas and, where risk factors or local prevalence warrant, MRSA, guided by the unit's antibiogram, then de-escalate on culture results
3. Withhold antibiotics until cultures return
4. Give antifungals first

Answer: B. Multidrug-resistant Gram-negatives are a recognised problem in Gulf ICUs; stewardship and de-escalation are tested.

Vascular and interstitial disease

Question 9

A 45-year-old woman presents with sudden pleuritic chest pain and breathlessness ten days after a long flight. Heart rate 108, blood pressure 125/80, saturations 93%. Wells score is 4.5. The next step is:

1. D-dimer, and discharge if normal
2. CT pulmonary angiography directly (PE likely), with anticoagulation started while awaiting imaging if there is no contraindication
3. Chest radiograph only
4. Echocardiography and reassurance

Answer: B. D-dimer is used to rule out PE only when the pre-test probability is low or unlikely; a likely score goes straight to imaging.

Question 10

A patient with confirmed pulmonary embolism has a blood pressure of 80/50 mmHg not responding to fluids, and right ventricular dilatation on echocardiography. The treatment is:

1. Low-molecular-weight heparin only
2. Systemic thrombolysis (unless contraindicated), with catheter-directed or surgical embolectomy as alternatives, because this is high-risk (massive) PE
3. A direct oral anticoagulant
4. An inferior vena cava filter alone

Answer: B. Intermediate-risk PE with RV strain and raised troponin is anticoagulated and monitored, with rescue thrombolysis if deterioration occurs.

Question 11

A 68-year-old man has two years of progressive exertional breathlessness, dry cough, fine bibasal crackles and finger clubbing. High-resolution CT shows subpleural, basal-predominant honeycombing with traction bronchiectasis and no features suggesting an alternative. The diagnosis and treatment are:

1. Hypersensitivity pneumonitis; high-dose steroids
2. Idiopathic pulmonary fibrosis (usual interstitial pneumonia pattern); antifibrotic therapy with nintedanib or pirfenidone, oxygen as needed, pulmonary rehabilitation and transplant referral where appropriate
3. Sarcoidosis; methotrexate
4. Asbestosis; no treatment

Answer: B. Glucocorticoids and immunosuppression worsen outcomes in IPF; a multidisciplinary discussion confirms the diagnosis.

Question 12

A 32-year-old woman has bilateral hilar lymphadenopathy, erythema nodosum, ankle arthritis and fever. The most likely diagnosis and management are:

1. Lymphoma; chemotherapy
2. Löfgren syndrome (acute sarcoidosis); NSAIDs with expectant management, as spontaneous remission is the rule, and glucocorticoids reserved for organ-threatening disease
3. Tuberculosis; four-drug therapy
4. Pneumonia; antibiotics

Answer: B. Cardiac, neurological and ocular sarcoidosis, hypercalcaemia and progressive lung disease are indications for systemic treatment.

Sleep, pleura and cancer

Question 13

A 48-year-old man with a BMI of 38 reports loud snoring, witnessed apnoeas and daytime sleepiness while driving. Polysomnography shows an apnoea-hypopnoea index of 35 per hour. The first-line treatment is:

1. Weight loss advice alone
2. Continuous positive airway pressure, with weight management, alcohol and sedative avoidance, driving advice and assessment for hypertension and metabolic disease
3. A mandibular advancement device as first line for severe disease
4. Nocturnal oxygen

Answer: B. An AHI of 30 or more is severe; untreated sleep apnoea raises cardiovascular and road traffic risk, and licensing authorities expect driving advice to be documented.

Question 14

Pleural fluid analysis shows protein 45 g/L (serum 70), LDH 400 U/L (serum upper limit 250), pH 7.15, glucose 2.0 mmol/L and a purulent appearance. The appropriate management is:

1. Diuretics for a transudate
2. Prompt chest tube drainage plus intravenous antibiotics, because this is an empyema or complicated parapneumonic effusion; intrapleural tPA/DNase or surgery if drainage fails
3. Observation and repeat radiograph in a week
4. Therapeutic aspiration only

Answer: B. Light's criteria confirm an exudate; pH below 7.2 in an infected effusion mandates drainage.

Question 15

A tall, thin 22-year-old man has sudden pleuritic pain and breathlessness. Radiograph shows a 3 cm rim primary spontaneous pneumothorax. He is not breathless at rest. Appropriate first management is:

1. Immediate intercostal chest drain
2. Conservative management with observation or needle aspiration according to symptoms and current guidance, high-flow oxygen if admitted, smoking cessation advice and no flying until resolved and reviewed
3. Surgical pleurodesis at first presentation
4. Discharge with no follow-up

Answer: B. Modern guidance favours symptom-driven, less invasive management for primary spontaneous pneumothorax; tension pneumothorax, by contrast, needs immediate decompression.

Question 16

A 64-year-old smoker has a 2.5 cm peripheral right upper lobe nodule, no mediastinal nodes on PET-CT and no distant disease. Lung function is adequate. The recommended treatment for this clinical stage I non-small cell lung cancer is:

1. Palliative chemotherapy
2. Surgical resection (lobectomy with systematic nodal sampling), with stereotactic ablative radiotherapy if the patient is not fit for surgery, after tissue confirmation and multidisciplinary review
3. Radiotherapy to the whole chest
4. Observation with annual CT

Answer: B. Molecular testing (EGFR, ALK, ROS1, PD-L1) guides systemic therapy in advanced disease and increasingly in the adjuvant setting.

Physiology and procedures

Question 17

Spirometry shows FEV₁ 60% predicted, FVC 58% predicted and FEV₁/FVC 0.85, with reduced total lung capacity and a reduced transfer factor (DLCO). The pattern is:

1. Obstructive, suggesting asthma
2. Restrictive with reduced gas transfer, suggesting interstitial lung disease
3. Restrictive with normal gas transfer, suggesting chest wall or neuromuscular disease
4. Mixed

Answer: B. An extrapulmonary restriction (obesity, kyphoscoliosis, muscle weakness) preserves DLCO; parenchymal disease reduces it.

Question 18

Arterial blood gas on air: pH 7.30, PaCO₂ 8.5 kPa (64 mmHg), PaO₂ 7.0 kPa (53 mmHg), bicarbonate 34 mmol/L. This represents:

1. Acute type 1 respiratory failure
2. Acute-on-chronic type 2 (hypercapnic) respiratory failure with partial metabolic compensation, as seen in a COPD exacerbation; controlled oxygen targeting 88 to 92% and non-invasive ventilation if acidosis persists after initial treatment
3. Metabolic acidosis
4. Respiratory alkalosis

Answer: B. The raised bicarbonate shows chronic retention; uncontrolled high-flow oxygen worsens hypercapnia in these patients.

Question 19

Non-invasive ventilation is most clearly indicated in which patient?

1. A COPD exacerbation with pH 7.28 and PaCO₂ 9 kPa despite one hour of optimal medical therapy and controlled oxygen
2. A patient with a GCS of 6 and vomiting
3. Severe pneumonia with pH 7.42
4. An untreated pneumothorax

Answer: A. NIV reduces intubation and mortality in acidotic hypercapnic COPD exacerbations; reduced consciousness with inability to protect the airway, vomiting and undrained pneumothorax are contraindications.

Question 20

Before a bronchoscopy with transbronchial biopsy, the most important safety checks include:

1. Nothing beyond consent
2. Platelet count and coagulation, management of anticoagulants and antiplatelets per protocol, assessment of oxygen requirement and lung function, fasting, and availability of equipment for pneumothorax and bleeding
3. A dental check
4. An ECG only

Answer: B. Bleeding and pneumothorax are the major complications of transbronchial biopsy; endobronchial ultrasound has replaced mediastinoscopy for most nodal staging.

How to practise

• Know the scoring systems: CURB-65, Wells, PESI, GOLD groups, AHI thresholds, Light's criteria.
• Learn the drug safety: TB drug toxicity, steroid use in asthma versus IPF, oxygen targets in hypercapnia.
• Expect regional emphasis: TB screening and notification, dust-related asthma, obesity-related sleep apnoea, Gram-negative resistance.
• Practise under time in the Pulmonary Disease bank with the error-log method.

Related sets: internal medicine, emergency medicine and respiratory therapy. Intensive care candidates should also see the Critical Care Medicine bank.

Frequently asked questions

How many questions are in the Prometric pulmonology specialist exam?

Typically 100 to 150 single-best-answer MCQs in up to three hours, with a pass mark of about 60%, varying by authority.

Which pulmonology topics come up most?

Asthma and COPD management, pneumonia severity and antibiotics, tuberculosis, pulmonary embolism, interstitial lung disease, sleep apnoea and pleural disease.

Does the exam include blood gas and spirometry interpretation?

Yes. Expect several data-interpretation questions on gases, spirometry patterns and pleural fluid.

Which guidelines does the exam follow?

Current GINA, GOLD, ATS/ERS, BTS and ESC guidance; shared principles are tested rather than small differences.

Are these real exam questions?

No. They are original practice questions written to the published blueprint. Real exam content is confidential.