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Question 1
Incorrect
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A 54-year-old smoker comes to the clinic with complaints of chest pain and cough. He reports experiencing more difficulty breathing and a sharp pain in his third and fourth ribs. Upon examination, a chest x-ray reveals an enlargement on the right side of his hilum. What is the most probable diagnosis?
Your Answer: Chronic obstructive pulmonary disease (COPD)
Correct Answer: Bronchogenic carcinoma
Explanation:Diagnosis of Bronchogenic Carcinoma
The patient’s heavy smoking history, recent onset of cough, and bony pain strongly suggest bronchogenic carcinoma. The appearance of the chest X-ray further supports this diagnosis. While COPD can also cause cough and dyspnea, it is typically accompanied by audible wheezing and the presence of a hilar mass is inconsistent with this diagnosis. Neither tuberculosis nor lung collapse are indicated by the patient’s history or radiographic findings. Hyperparathyroidism is not a consideration unless hypercalcemia is present. Overall, the evidence points towards a diagnosis of bronchogenic carcinoma.
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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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A 30-year-old woman with asthma presented with rapidly developing asthma and wheezing. She was admitted, and during her treatment, she coughed out tubular gelatinous materials. A chest X-ray showed collapse of the lingular lobe.
What is this clinical spectrum better known as?Your Answer: Plastic bronchitis
Explanation:Respiratory Conditions: Plastic Bronchitis, Loeffler Syndrome, Lofgren Syndrome, Cardiac Asthma, and Croup
Plastic Bronchitis: Gelatinous or rigid casts form in the airways, leading to coughing. It is associated with asthma, bronchiectasis, cystic fibrosis, and respiratory infections. Treatment involves bronchial washing, sputum induction, and preventing infections. Bronchoscopy may be necessary for therapeutic removal of the casts.
Loeffler Syndrome: Accumulation of eosinophils in the lungs due to parasitic larvae passage. Charcot-Leyden crystals may be present in the sputum.
Lofgren Syndrome: Acute presentation of sarcoidosis with hilar lymphadenopathy and erythema nodosum. Usually self-resolving.
Cardiac Asthma: Old term for acute pulmonary edema, causing peribronchial fluid collection and wheezing. Pink frothy sputum is produced.
Croup: Acute pharyngeal infection in children aged 6 months to 3 years, presenting with stridor.
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This question is part of the following fields:
- Respiratory
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Question 3
Correct
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A 65-year-old man presents with haemoptysis over the last 2 days. He has had a productive cough for 7 years, which has gradually worsened. Over the last few winters, he has been particularly bad and required admission to hospital. Past medical history includes pulmonary tuberculosis (TB) at age 20. On examination, he is cyanotic and clubbed, and has florid crepitations in both lower zones.
What is the most likely diagnosis?Your Answer: Bronchiectasis
Explanation:Diagnosing Respiratory Conditions: Bronchiectasis vs. Asthma vs. Pulmonary Fibrosis vs. COPD vs. Lung Cancer
Bronchiectasis is the most probable diagnosis for a patient who presents with copious sputum production, recurrent chest infections, haemoptysis, clubbing, cyanosis, and florid crepitations at both bases that change with coughing. This condition is often exacerbated by a previous history of tuberculosis.
Asthma, on the other hand, is characterized by reversible obstruction of airways due to bronchial muscle contraction in response to various stimuli. The absence of wheezing, the patient’s age, and the presence of haemoptysis make asthma an unlikely diagnosis in this case.
Pulmonary fibrosis involves parenchymal fibrosis and interstitial remodelling, leading to shortness of breath and a non-productive cough. Patients with pulmonary fibrosis may develop clubbing, basal crepitations, and a dry cough, but the acute presentation and haemoptysis in this case would not be explained.
Chronic obstructive pulmonary disease (COPD) is a progressive disorder characterized by airway obstruction, chronic bronchitis, and emphysema. However, the absence of wheezing, smoking history, and acute new haemoptysis make COPD a less likely diagnosis.
Lung cancer is a possibility given the haemoptysis and clubbing, but the long history of productive cough, florid crepitations, and previous history of TB make bronchiectasis a more likely diagnosis. Overall, a thorough evaluation of symptoms and medical history is necessary to accurately diagnose respiratory conditions.
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This question is part of the following fields:
- Respiratory
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Question 4
Correct
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A 63-year-old man presents with complaints of dyspnoea, haemoptysis, and an unintentional 25 lb weight loss over the last 4 months. He reports a medical history significant for mild asthma controlled with an albuterol inhaler as needed. He takes no other medications and has no allergies. He has a 55 pack-year smoking history and has worked as a naval shipyard worker for 40 years. Examination reveals diffuse crackles in the posterior lung fields bilaterally and there is dullness to percussion one-third of the way up the right lung field. Ultrasound reveals free fluid in the pleural space.
Which one of the following set of test values is most consistent with this patient’s presentation?
(LDH: lactate dehydrogenase)
Option LDH plasma LDH pleural Protein plasma Protein pleural
A 180 100 7 3
B 270 150 8 3
C 180 150 7 4
D 270 110 8 3
E 180 100 7 2Your Answer: Option C
Explanation:Interpreting Light’s Criteria for Pleural Effusions
When evaluating a patient with a history of occupational exposure and respiratory symptoms, it is important to consider the possibility of pneumoconiosis, specifically asbestosis. Chronic exposure to asbestos can lead to primary bronchogenic carcinoma and mesothelioma. Chest radiography may reveal radio-opaque pleural and diaphragmatic plaques. In this case, the patient’s dyspnea, hemoptysis, and weight loss suggest primary lung cancer, with a likely malignant pleural effusion observed under ultrasound.
To confirm the exudative nature of the pleural effusion, Light’s criteria can be used. These criteria include a pleural:serum protein ratio >0.5, a pleural:serum LDH ratio >0.6, and pleural LDH more than two-thirds the upper limit of normal serum LDH. Meeting any one of these criteria indicates an exudative effusion.
Option C is the correct answer as it satisfies Light’s criteria for an exudative pleural effusion. Options A, B, D, and E do not meet the criteria. Understanding Light’s criteria can aid in the diagnosis and management of pleural effusions, particularly in cases where malignancy is suspected.
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This question is part of the following fields:
- Respiratory
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Question 5
Correct
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A 72-year-old woman is discovered outside in the early hours of the morning after falling to the ground. She is confused and uncertain of what happened and is admitted to the hospital. An abbreviated mental test (AMT) is conducted, and she scores 4/10. During the examination, crackles are heard at the base of her left lung.
Blood tests reveal:
Investigation Result Normal value
C-reactive protein (CRP) 89 mg/l < 10 mg/l
White cell count (WCC) 15 × 109/l 4–11 × 109/l
Neutrophils 11.4 × 109/l 5–7.58 × 109/l
The remainder of her blood tests, including full blood count (FBC), urea and electrolytes (U&Es), and liver function test (LFT), were normal.
Observations:
Investigation Result Normal value
Respiratory rate 32 breaths/min 12–18 breaths/min
Oxygen saturation 90% on air
Heart rate (HR) 88 beats/min 60–100 beats/min
Blood pressure (BP) 105/68 mmHg Hypertension: >120/80 mmHg*
Hypotension: <90/60 mmHg*
Temperature 39.1°C 1–37.2°C
*Normal ranges should be based on the individual's clinical picture. The values are provided as estimates.
Based on her CURB 65 score, what is the most appropriate management for this patient?Your Answer: Admit the patient and consider ITU
Explanation:Understanding the CURB Score and Appropriate Patient Management
The CURB score is a tool used to assess the severity of community-acquired pneumonia and determine the appropriate level of care for the patient. A score of 0-1 indicates that the patient can be discharged home, a score of 2 suggests hospital treatment, and a score of 3 or more warrants consideration for intensive care unit (ITU) admission.
In the case of a patient with a CURB score of 3, such as a 68-year-old with a respiratory rate of >30 breaths/min and confusion (AMT score of 4), ITU admission should be considered. Admitting the patient to a general ward or discharging them home with advice to see their GP the following day would not be appropriate.
It is important for healthcare professionals to understand and utilize the CURB score to ensure appropriate management of patients with community-acquired pneumonia.
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This question is part of the following fields:
- Respiratory
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Question 6
Correct
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A 67-year-old man comes to the Chest Clinic after being referred by his GP for a chronic cough. He complains of a dry cough that has been ongoing for 10 months and is accompanied by increasing shortness of breath. Despite multiple rounds of antibiotics, he has not experienced significant improvement. He has never smoked and denies any coughing up of blood. He used to work as a teacher and has not been exposed to any environmental dust or chemicals.
His GP ordered a chest X-ray, which reveals reticular shadowing affecting both lung bases. Upon examination, he has clubbed fingers and fine-end inspiratory crackles. His heart sounds are normal, and he is saturating at 94% on room air with a regular heart rate of 80 bpm and regular respiratory rate of 20. There is no peripheral oedema.
What is the most probable diagnosis?Your Answer: Idiopathic pulmonary fibrosis
Explanation:Differential Diagnosis for Shortness of Breath and Clubbing: Idiopathic Pulmonary Fibrosis as the Likely Diagnosis
Shortness of breath and clubbing can be indicative of various respiratory and cardiac conditions. In this case, the most likely diagnosis is idiopathic pulmonary fibrosis, as evidenced by fine-end inspiratory crackles on examination, X-ray findings of bi-basal reticulonodular shadowing in a typical distribution, and the presence of clubbing. Bronchiectasis is another possible diagnosis, but the lack of purulent phlegm and coarse crackles, as well as chest X-ray findings inconsistent with dilated, thick-walled bronchi, make it less likely. Carcinoma of the lung is also a consideration, but the absence of a smoking history and chest X-ray findings make it less probable. Chronic obstructive pulmonary disease (COPD) is unlikely without a smoking history and the absence of wheeze on examination. Congestive cardiac failure (CCF) can cause shortness of breath, but clubbing is typically only present in cases of congenital heart disease with right to left shunts, which is not demonstrated in this case. Overall, idiopathic pulmonary fibrosis is the most likely diagnosis based on the clinical presentation and diagnostic findings.
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This question is part of the following fields:
- Respiratory
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Question 7
Correct
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A 68-year-old woman presents to the Emergency Department with a 48-hour history of shortness of breath and an increased volume and purulence of sputum. She has a background history of chronic obstructive pulmonary disease (COPD), hypertension and ischaemic heart disease. Her observations show: heart rate (HR) 116 bpm, blood pressure (BP) 124/68 mmHg, respiratory rate (RR) 18 breaths per minute and oxygen saturation (SaO2) 94% on 2l/min via nasal cannulae. She is commenced on treatment for an infective exacerbation of COPD with nebulised bronchodilators, intravenous antibiotics, oral steroids and controlled oxygen therapy with a Venturi mask. After an hour of therapy, the patient is reassessed. Her observations after an hour are: BP 128/74 mmHg, HR 124 bpm, RR 20 breaths per minute and SaO2 93% on 24% O2 via a Venturi mask. Arterial blood gas sampling is performed:
Investigation Result Normal value
pH 7.28 7.35–7.45
PO2 8.6 kPa 10.5–13.5 kPa
pCO2 8.4 kPa 4.6–6.0 kPa
cHCO3- (P)C 32 mmol/l 24–30 mmol/l
Lactate 1.4 mmol/l 0.5–2.2 mmol/l
Sodium (Na+) 134 mmol/l 135–145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
Chloride (Cl-) 116 mmol/l 98-106 mmol/l
Glucose 5.4 mmol/l 3.5–5.5 mmol/l
Following this review and the arterial blood gas results, what is the most appropriate next step in this patient’s management?Your Answer: The patient should be considered for non-invasive ventilation (NIV)
Explanation:Management of Respiratory Acidosis in COPD Patients
The management of respiratory acidosis in COPD patients requires careful consideration of the individual’s condition. In this scenario, the patient should be considered for non-invasive ventilation (NIV) as recommended by the British Thoracic Society. NIV is particularly indicated in patients with a pH of 7.25–7.35. Patients with a pH of <7.25 may benefit from NIV but have a higher risk for treatment failure and therefore should be considered for management in a high-dependency or intensive care setting. However, NIV is not indicated in patients with impaired consciousness, severe hypoxaemia or copious respiratory secretions. It is important to note that a ‘Do Not Resuscitate Order’ should not be automatically made for patients with COPD. Each decision regarding resuscitation should be made on an individual basis. Intubation and ventilation should not be the first line of treatment in this scenario. A trial of NIV would be the most appropriate next step, as it has been demonstrated to reduce the need for intensive care management in this group of patients. Increasing the patient’s oxygen may be appropriate in type 1 respiratory failure, but in this case, NIV is the recommended approach. Intravenous magnesium therapy is not routinely recommended in COPD and is only indicated in the context of acute asthma. In conclusion, the management of respiratory acidosis in COPD patients requires a tailored approach based on the individual’s condition. NIV should be considered as the first line of treatment in this scenario.
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This question is part of the following fields:
- Respiratory
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Question 8
Incorrect
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A 62-year-old female patient complains of breathlessness and weight loss over the past three months. She is a smoker who consumes 10 cigarettes per day. During the examination, you observe clubbing of the fingers and a few crackles in the chest. What is the probable diagnosis?
Your Answer: Emphysema
Correct Answer: Pulmonary fibrosis
Explanation:Respiratory Causes of Clubbing
Clubbing is a condition where the fingertips and nails become enlarged and rounded. It is often associated with respiratory and cardiovascular diseases. One of the respiratory causes of clubbing is pulmonary fibrosis, which is characterized by weight loss and breathlessness. Other respiratory causes include bronchiectasis, empyema, bronchial carcinoma, and mesothelioma. These conditions can also lead to weight loss and breathlessness, making it important to seek medical attention if these symptoms are present. On the other hand, cardiovascular causes of clubbing include cyanotic congenital heart disease and infective endocarditis. It is important to identify the underlying cause of clubbing in order to provide appropriate treatment and management.
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This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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A 50-year-old lady with known chronic obstructive pulmonary disease (COPD) is admitted to the Respiratory Ward with shortness of breath, cough and wheeze. On examination, she appears unwell and short of breath, and there is an audible wheeze. Her respiratory rate is 30 breaths per minute, pulse rate 92 bpm and oxygen saturations 90% on room air. She reports that she is able to leave the house but that she has to stop for breath after walking approximately 100 m. What grade on the MODIFIED MRC dyspnoea scale would this patient be recorded as having?
Your Answer: 2
Correct Answer: 3
Explanation:Managing COPD: Non-Pharmacological, Pharmacological, and Surgical Approaches
Chronic obstructive pulmonary disease (COPD) is a progressive condition that affects the airways and is often caused by smoking. Symptoms include coughing, wheezing, and shortness of breath. While there is no cure for COPD, there are various management strategies that can help improve symptoms and quality of life.
Non-pharmacological approaches include quitting smoking, losing weight if necessary, and participating in physiotherapy and pulmonary rehabilitation to improve lung function and exercise capacity. Pharmacological treatment includes the use of bronchodilators and inhaled corticosteroids, as well as oral prednisolone and antibiotics during exacerbations. Diuretics may also be necessary for patients with cor pulmonale and edema. Long-term oxygen therapy can help manage persistent hypoxia.
Surgical options for COPD include heart and lung transplantation. The modified MRC dyspnoea scale can be used to assess the degree of breathlessness and guide treatment decisions. The BODE index, which includes the mMRC dyspnoea scale, is a composite marker of disease severity that takes into account the systemic nature of COPD.
Overall, managing COPD requires a comprehensive approach that addresses both the physical and systemic aspects of the disease. With proper management, patients can improve their symptoms and quality of life.
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This question is part of the following fields:
- Respiratory
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Question 10
Correct
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A 62-year-old man who is a smoker presents with gradual-onset shortness of breath, over the last month. Chest radiograph shows a right pleural effusion.
What would be the most appropriate next investigation?Your Answer: Pleural aspirate
Explanation:Investigations for Pleural Effusion: Choosing the Right Test
When a patient presents with dyspnoea and a suspected pleural effusion, choosing the right investigation is crucial for accurate diagnosis and management. Here are some of the most appropriate investigations for different types of pleural effusions:
1. Pleural aspirate: This is the most appropriate next investigation to measure the protein content and determine whether the fluid is an exudate or a transudate.
2. Computerised tomography (CT) of the chest: An exudative effusion would prompt investigation with CT of the chest or thoracoscopy to look for conditions such as malignancy or tuberculosis (TB).
3. Bronchoscopy: Bronchoscopy would be appropriate if there was need to obtain a biopsy for a suspected tumour, but so far no lesion has been identified.
4. Echocardiogram: A transudative effusion would prompt investigations such as an echocardiogram to look for heart failure, or liver imaging to look for cirrhosis.
5. Spirometry: Spirometry would have been useful if chronic obstructive pulmonary disease (COPD) was suspected, but at this stage the pleural effusion is likely the cause of dyspnoea and should be investigated.
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This question is part of the following fields:
- Respiratory
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