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  • Question 1 - A 70-year-old man is admitted to the respiratory ward with an exacerbation of...

    Incorrect

    • A 70-year-old man is admitted to the respiratory ward with an exacerbation of COPD. He has been experiencing increased breathlessness and a productive cough for the past week. He is currently on day three of his rescue medication regimen consisting of amoxicillin and prednisolone. According to his previous discharge summary, this patient has a history of carbon dioxide retention. He is currently receiving controlled oxygen therapy via a 28% venturi mask. What is the target oxygen saturation level for this patient?

      Your Answer: No target

      Correct Answer: 88%-92%

      Explanation:

      As a junior doctor, you will often encounter patients who retain carbon dioxide and depend on their hypoxic drive to breathe. When using Venturi masks to deliver controlled oxygen, it is important to set a target that balances the patient’s need for oxygen with their reliance on hypoxia to stimulate breathing. Answer 4 is the correct choice in this scenario. Providing too much oxygen, as in answers 2 and 3, can cause the patient to lose their hypoxic drive and become drowsy or confused. Answer 5 does not provide enough oxygen to properly perfuse the tissues. Failing to set a target for these patients is not good clinical practice.

      Guidelines for Oxygen Therapy in Emergency Situations

      In 2017, the British Thoracic Society updated its guidelines for emergency oxygen therapy. The guidelines state that in critically ill patients, such as those experiencing anaphylaxis or shock, oxygen should be administered through a reservoir mask at a rate of 15 liters per minute. However, certain conditions, such as stable myocardial infarction, are excluded from this recommendation.

      The guidelines also provide specific oxygen saturation targets for different patient populations. Acutely ill patients should have a saturation level between 94-98%, while patients at risk of hypercapnia, such as those with COPD, should have a saturation level between 88-92%. Oxygen levels should be reduced in stable patients with satisfactory oxygen saturation.

      For COPD patients, a 28% Venturi mask at 4 liters per minute should be used prior to the availability of blood gases. The target oxygen saturation level for these patients should be 88-92% if they have risk factors for hypercapnia but no prior history of respiratory acidosis. If the patient’s pCO2 is normal, the target range should be adjusted to 94-98%.

      The guidelines also state that oxygen therapy should not be used routinely in certain situations where there is no evidence of hypoxia, such as in cases of myocardial infarction, acute coronary syndromes, stroke, obstetric emergencies, and anxiety-related hyperventilation.

      Overall, these guidelines provide important recommendations for the appropriate use of oxygen therapy in emergency situations, taking into account the specific needs of different patient populations.

    • This question is part of the following fields:

      • Respiratory System
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  • Question 2 - A 10-year-old girl has been diagnosed with asthma. Her father asks you about...

    Incorrect

    • A 10-year-old girl has been diagnosed with asthma. Her father asks you about the cause of her symptoms. What is the best response?

      Inflammation of the lining of the bronchioles causes obstruction of the flow of air out from the lungs. This inflammation is reversible so symptoms of asthma may be intermittent. There may also be increased mucus production and bronchial muscle constriction.

      Your Answer: Infection of the airways causing them to become narrower

      Correct Answer: Reversible inflammation of the lining of the small airways causing them to become narrower

      Explanation:

      The bronchioles’ lining inflammation obstructs the outflow of air from the lungs, leading to asthma symptoms that may come and go. Additionally, there could be heightened mucus production and constriction of bronchial muscles.

      Asthma is a common respiratory disorder that affects both children and adults. It is characterized by chronic inflammation of the airways, resulting in reversible bronchospasm and airway obstruction. While asthma can develop at any age, it typically presents in childhood and may improve or resolve with age. However, it can also persist into adulthood and cause significant morbidity, with around 1,000 deaths per year in the UK.

      Several risk factors can increase the likelihood of developing asthma, including a personal or family history of atopy, antenatal factors such as maternal smoking or viral infections, low birth weight, not being breastfed, exposure to allergens and air pollution, and the hygiene hypothesis. Patients with asthma may also suffer from other atopic conditions such as eczema and hay fever, and some may be sensitive to aspirin. Occupational asthma is also a concern for those exposed to allergens in the workplace.

      Symptoms of asthma include coughing, dyspnea, wheezing, and chest tightness, with coughing often worse at night. Signs may include expiratory wheezing on auscultation and reduced peak expiratory flow rate. Diagnosis is typically made through spirometry, which measures the volume and speed of air during exhalation and inhalation.

      Management of asthma typically involves the use of inhalers to deliver drug therapy directly to the airways. Short-acting beta-agonists such as salbutamol are the first-line treatment for relieving symptoms, while inhaled corticosteroids like beclometasone dipropionate and fluticasone propionate are used for daily maintenance therapy. Long-acting beta-agonists like salmeterol and leukotriene receptor antagonists like montelukast may also be used in combination with other medications. Maintenance and reliever therapy (MART) is a newer approach that combines ICS and a fast-acting LABA in a single inhaler for both daily maintenance and symptom relief. Recent guidelines recommend offering a leukotriene receptor antagonist instead of a LABA for patients on SABA + ICS whose asthma is not well controlled, and considering MART for those with poorly controlled asthma.

    • This question is part of the following fields:

      • Respiratory System
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  • Question 3 - An 80-year-old woman visits her doctor complaining of a persistent cough. She has...

    Correct

    • An 80-year-old woman visits her doctor complaining of a persistent cough. She has been smoking 20 cigarettes a day for the past 30 years and is worried that this might be the reason for her symptom. The doctor diagnoses her with chronic obstructive pulmonary disease (COPD) which is likely caused by chronic bronchitis. Can you provide the definition of chronic bronchitis?

      Your Answer: Chronic productive cough for at least 3 months in at least 2 years

      Explanation:

      Chronic bronchitis is characterized by a persistent cough with sputum production for a minimum of 3 months in two consecutive years, after excluding other causes of chronic cough. Emphysema, on the other hand, is defined by the enlargement of air spaces beyond the terminal bronchioles. None of the remaining options are considered as definitions of COPD.

      COPD, or chronic obstructive pulmonary disease, can be caused by a variety of factors. The most common cause is smoking, which can lead to inflammation and damage in the lungs over time. Another potential cause is alpha-1 antitrypsin deficiency, a genetic condition that can result in lung damage. Additionally, exposure to certain substances such as cadmium (used in smelting), coal, cotton, cement, and grain can also contribute to the development of COPD. It is important to identify and address these underlying causes in order to effectively manage and treat COPD.

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      • Respiratory System
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  • Question 4 - A 59-year-old man comes to you with a dry cough that has been...

    Incorrect

    • A 59-year-old man comes to you with a dry cough that has been going on for three months and recent episodes of haemoptysis. He stopped smoking five years ago and has had two bouts of pneumonia in his left lower lobe in the last year. On examination, he is apyrexial and there are no notable findings.

      What would be your first step in investigating this patient?

      Your Answer: CT chest

      Correct Answer: Chest x ray

      Explanation:

      Diagnosis of Bronchial Carcinoma

      The patient’s medical history indicates the possibility of bronchial carcinoma. The most appropriate initial investigation to confirm this diagnosis is a chest x-ray. Other tests such as blood cultures may not be useful for an apyrexial patient. However, additional investigations may be considered after the chest x-ray. It is important to prioritize the chest x-ray as the first line investigation to detect any abnormalities in the lungs. Proper diagnosis is crucial for timely treatment and management of bronchial carcinoma.

    • This question is part of the following fields:

      • Respiratory System
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  • Question 5 - A 70-year-old man presents with haemoptysis and undergoes a bronchoscopy. The carina is...

    Incorrect

    • A 70-year-old man presents with haemoptysis and undergoes a bronchoscopy. The carina is noted to be widened. Where does the trachea bifurcate?

      Your Answer: T7

      Correct Answer: T5

      Explanation:

      The trachea divides into two branches at the fifth thoracic vertebrae, or sometimes the sixth in individuals who are tall.

      Anatomy of the Trachea

      The trachea, also known as the windpipe, is a tube-like structure that extends from the C6 vertebrae to the upper border of the T5 vertebrae where it bifurcates into the left and right bronchi. It is supplied by the inferior thyroid arteries and the thyroid venous plexus, and innervated by branches of the vagus, sympathetic, and recurrent nerves.

      In the neck, the trachea is anterior to the isthmus of the thyroid gland, inferior thyroid veins, and anastomosing branches between the anterior jugular veins. It is also surrounded by the sternothyroid, sternohyoid, and cervical fascia. Posteriorly, it is related to the esophagus, while laterally, it is in close proximity to the common carotid arteries, right and left lobes of the thyroid gland, inferior thyroid arteries, and recurrent laryngeal nerves.

      In the thorax, the trachea is anterior to the manubrium, the remains of the thymus, the aortic arch, left common carotid arteries, and the deep cardiac plexus. Laterally, it is related to the pleura and right vagus on the right side, and the left recurrent nerve, aortic arch, and left common carotid and subclavian arteries on the left side.

      Overall, understanding the anatomy of the trachea is important for various medical procedures and interventions, such as intubation and tracheostomy.

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      • Respiratory System
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  • Question 6 - A 55-year-old woman comes to the clinic complaining of a persistent cough and...

    Incorrect

    • A 55-year-old woman comes to the clinic complaining of a persistent cough and increased production of sputum over the past year. She also reports feeling fatigued and experiencing shortness of breath. The patient mentions having had four chest infections in the last 12 months, all of which were treated with antibiotics. She has no medical or family history and has never smoked.

      The healthcare provider suspects that bronchiectasis may be the underlying cause of her symptoms and orders appropriate tests, including a sputum sample.

      What is the most likely organism to be identified?

      Your Answer: Respiratory syncytial virus

      Correct Answer:

      Explanation:

      Bronchiectasis patients may have various bacteria present in their respiratory system, with Haemophilus influenzae and Pseudomonas aeruginosa being the most common. Staphylococcus aureus has also been found but not as frequently. Respiratory syncytial virus has not been detected in acute exacerbations of bronchiectasis. It is crucial to identify the specific bacteria causing exacerbations as antibiotic sensitivity patterns differ, and sputum culture results can impact the effectiveness of treatment. These findings are outlined in the British Thoracic Society’s guideline for non-CF bronchiectasis and a study by Metaxas et al. on the role of atypical bacteria and respiratory syncytial virus in bronchiectasis exacerbations.

      Bronchiectasis is a condition where the airways become permanently dilated due to chronic inflammation or infection. Before treatment, it is important to identify any underlying causes that can be addressed, such as immune deficiencies. Management of bronchiectasis includes physical training, such as inspiratory muscle training, which has been shown to be effective for patients without cystic fibrosis. Postural drainage, antibiotics for exacerbations, and long-term rotating antibiotics for severe cases are also recommended. Bronchodilators may be used in selected cases, and immunizations are important to prevent infections. Surgery may be considered for localized disease. The most common organisms isolated from patients with bronchiectasis include Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella spp., and Streptococcus pneumoniae.

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      • Respiratory System
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  • Question 7 - A 65-year-old patient presents at the lung cancer clinic for their initial assessment....

    Incorrect

    • A 65-year-old patient presents at the lung cancer clinic for their initial assessment. Their general practitioner referred them due to a persistent cough lasting 5 months and a weight loss of one stone in a month. The patient has quit smoking recently but used to smoke 20-30 cigarettes daily for 30 years. No asbestos exposure is reported.

      A circular lesion was detected in the right upper lobe during a recent chest x-ray. A subsequent computed tomography (CT) scan indicated that this lung lesion is indicative of a primary lesion.

      What is the most probable sub-type of lung cancer in this case?

      Your Answer: Alveolar cell carcinoma

      Correct Answer: Adenocarcinoma

      Explanation:

      Adenocarcinoma has become the most prevalent form of lung cancer, as per the given scenario. This type of cancer accounts for approximately one-third of all cases and can occur in both smokers and non-smokers. Therefore, the most probable answer to the question is adenocarcinoma. Mesothelioma, on the other hand, is a rare and incurable cancer that is almost exclusively linked to asbestos exposure and affects the pleura. It would not present as an upper lobe mass, but rather as a loss of lung volume or pleural opacity. Alveolar cell carcinoma, which is less common than adenocarcinoma, would likely cause significant sputum production.

      Lung cancer can be classified into two main types: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). SCLC is less common, accounting for only 15% of cases, but has a worse prognosis. NSCLC, on the other hand, is more prevalent and can be further broken down into different subtypes. Adenocarcinoma is now the most common type of lung cancer, likely due to the increased use of low-tar cigarettes. It is often seen in non-smokers and accounts for 62% of cases in ‘never’ smokers. Squamous cell carcinoma is another subtype, and cavitating lesions are more common in this type of lung cancer. Large cell carcinoma, alveolar cell carcinoma, bronchial adenoma, and carcinoid are other subtypes of NSCLC. Differentiating between these subtypes is crucial as different drugs are available to treat each subtype.

    • This question is part of the following fields:

      • Respiratory System
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  • Question 8 - An 80-year-old woman presents to the emergency department with a 2-day history of...

    Incorrect

    • An 80-year-old woman presents to the emergency department with a 2-day history of severe abdominal pain, accompanied by nausea and vomiting. Upon examination, she has a distended abdomen that is tender to the touch, and bowel sounds are infrequent. Her medical history includes a hysterectomy and cholecystectomy. A CT scan is ordered, which reveals a bowel obstruction at the L1 level. What is the most likely affected area?

      Your Answer: Ileum

      Correct Answer: Duodenum

      Explanation:

      The 2nd segment of the duodenum is situated at the transpyloric plane, which corresponds to the level of L1 and is a significant anatomical reference point.

      The Transpyloric Plane and its Anatomical Landmarks

      The transpyloric plane is an imaginary horizontal line that passes through the body of the first lumbar vertebrae (L1) and the pylorus of the stomach. It is an important anatomical landmark used in clinical practice to locate various organs and structures in the abdomen.

      Some of the structures that lie on the transpyloric plane include the left and right kidney hilum (with the left one being at the same level as L1), the fundus of the gallbladder, the neck of the pancreas, the duodenojejunal flexure, the superior mesenteric artery, and the portal vein. The left and right colic flexure, the root of the transverse mesocolon, and the second part of the duodenum also lie on this plane.

      In addition, the upper part of the conus medullaris (the tapered end of the spinal cord) and the spleen are also located on the transpyloric plane. Knowing the location of these structures is important for various medical procedures, such as abdominal surgeries and diagnostic imaging.

      Overall, the transpyloric plane serves as a useful reference point for clinicians to locate important anatomical structures in the abdomen.

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      • Respiratory System
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  • Question 9 - A 49-year-old man comes to the clinic with recent onset of asthma and...

    Correct

    • A 49-year-old man comes to the clinic with recent onset of asthma and frequent nosebleeds. Laboratory results reveal elevated eosinophil counts and a positive pANCA test.

      What is the probable diagnosis?

      Your Answer: Eosinophilic granulomatosis with polyangiitis (EGPA)

      Explanation:

      The presence of adult-onset asthma, eosinophilia, and a positive pANCA test strongly suggests a diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA) in this patient.

      Although GPA can cause epistaxis, the absence of other characteristic symptoms such as saddle-shaped nose deformity, haemoptysis, renal failure, and positive cANCA make EGPA a more likely diagnosis.

      Polyarteritis Nodosa, Temporal Arteritis, and Toxic Epidermal Necrolysis have distinct clinical presentations that do not match the symptoms exhibited by this patient.

      Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome)

      Eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss syndrome, is a type of small-medium vessel vasculitis that is associated with ANCA. It is characterized by asthma, blood eosinophilia (more than 10%), paranasal sinusitis, mononeuritis multiplex, and pANCA positivity in 60% of cases.

      Compared to granulomatosis with polyangiitis, EGPA is more likely to have blood eosinophilia and asthma as prominent features. Additionally, leukotriene receptor antagonists may trigger the onset of the disease.

      Overall, EGPA is a rare but serious condition that requires prompt diagnosis and treatment to prevent complications.

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      • Respiratory System
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  • Question 10 - A 3-year-old male toddler of Asian descent is referred to a paediatrician by...

    Incorrect

    • A 3-year-old male toddler of Asian descent is referred to a paediatrician by his GP due to recurrent respiratory infections and failure to thrive. The doctor orders a sweat test, which comes back positive. What are the potential complications associated with the likely diagnosis?

      Your Answer: Pulmonary embolism

      Correct Answer: Steatorrhea

      Explanation:

      Cystic fibrosis can lead to steatorrhea, which is caused by the malabsorption of fat in the intestines. This is a common symptom of the disease and requires specialist management. While patients with CF may have a slightly increased risk of sensorineural hearing loss, this is mainly due to the side effects of certain drugs used to treat the disease. Melaena, which is the passage of dark faeces due to partially digested blood from the upper gastrointestinal system, is a rare symptom in patients with CF. There is no association between CF and intellectual disability. Although some studies suggest an increased incidence of pulmonary emboli in patients with CF, the associated risk is small and mainly due to the use of central venous catheters and liver dysfunction or vitamin K deficiency.

      Understanding Cystic Fibrosis: Symptoms and Other Features

      Cystic fibrosis is a genetic disorder that affects various organs in the body, particularly the lungs and digestive system. The symptoms of cystic fibrosis can vary from person to person, but some common presenting features include recurrent chest infections, malabsorption, and liver disease. In some cases, infants may experience meconium ileus or prolonged jaundice. It is important to note that while many patients are diagnosed during newborn screening or early childhood, some may not be diagnosed until adulthood.

      Aside from the presenting features, there are other symptoms and features associated with cystic fibrosis. These include short stature, diabetes mellitus, delayed puberty, rectal prolapse, nasal polyps, and infertility. It is important for individuals with cystic fibrosis to receive proper medical care and management to address these symptoms and improve their quality of life.

    • This question is part of the following fields:

      • Respiratory System
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  • Question 11 - A 65-year-old woman comes to the clinic complaining of fever and productive cough...

    Incorrect

    • A 65-year-old woman comes to the clinic complaining of fever and productive cough for the past two days. She spends most of her time at home watching TV and rarely goes outside. She has no recent travel history. The patient has a history of gastroesophageal reflux disease but has not been compliant with medication and follow-up appointments. Upon physical examination, crackles are heard on the left lower lobe, and her sputum is described as 'red-currant jelly.'

      What is the probable causative organism in this case?

      Your Answer: Pneumocystis jiroveci

      Correct Answer: Klebsiella pneumoniae

      Explanation:

      The patient’s history of severe gastro-oesophageal reflux disease (GORD) suggests that she may have aspiration pneumonia, particularly as she had not received appropriate treatment for it. Aspiration of gastric contents is likely to occur in the right lung due to the steep angle of the right bronchus. Klebsiella pneumoniae is a common cause of aspiration pneumonia and is known to produce ‘red-currant jelly’ sputum.

      Mycoplasma pneumoniae is a cause of atypical pneumonia, which typically presents with a non-productive cough and clear lung sounds on auscultation. It is more common in younger individuals.

      Burkholderia pseudomallei is the causative organism for melioidosis, a condition that is transmitted through exposure to contaminated water or soil, and is more commonly found in Southeast Asia. However, given the patient’s sedentary lifestyle and lack of travel history, it is unlikely to be the cause of her symptoms.

      Streptococcus pneumoniae is the most common cause of pneumonia, but it typically produces yellowish-green sputum rather than the red-currant jelly sputum seen in Klebsiella pneumoniae infections. It also presents with fever, productive cough, and crackles on auscultation.

      Understanding Klebsiella Pneumoniae

      Klebsiella pneumoniae is a type of bacteria that is commonly found in the gut flora of humans. However, it can also cause various infections such as pneumonia and urinary tract infections. It is more prevalent in individuals who have alcoholism or diabetes. Aspiration is a common cause of pneumonia caused by Klebsiella pneumoniae. One of the distinct features of this type of pneumonia is the production of red-currant jelly sputum. It usually affects the upper lobes of the lungs.

      The prognosis for Klebsiella pneumoniae infections is not good. It often leads to the formation of lung abscesses and empyema, which can be fatal. The mortality rate for this type of infection is between 30-50%.

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      • Respiratory System
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  • Question 12 - You are on call for the pediatric ward at night and are urgently...

    Correct

    • You are on call for the pediatric ward at night and are urgently called to a child who is choking on a piece of hot dog visible in their oropharynx. The child is in extremis with saturations of 87% and there is no effective cough.

      What is the most appropriate immediate management for this pediatric patient?

      Your Answer: Back blows

      Explanation:

      Resuscitation Council (UK) Recommendations for Choking Emergencies

      When faced with a choking emergency, the Resuscitation Council (UK) recommends a specific course of action. If the patient is able to cough effectively, encourage them to do so. If not, but they are conscious, try five back blows followed by five abdominal thrusts (Heimlich manoeuvre) and repeat if necessary. However, if the patient becomes unconscious, begin CPR immediately. It is important to note that a finger sweep is no longer recommended as it can push the obstruction further into the airway. Additionally, high flow oxygen is necessary for breathing, but nasopharyngeal airways will not help in this situation. Removal with forceps is also not recommended as it can be hazardous. If the Heimlich manoeuvre fails, a cricothyroidotomy should be considered. While this procedure is recommended in the US and UK, it is not encouraged in some countries like Australia due to the risk of internal injury from over-vigorous use.

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      • Respiratory System
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  • Question 13 - A 15-year-old boy presents to his GP with a painless swelling in his...

    Incorrect

    • A 15-year-old boy presents to his GP with a painless swelling in his neck. The mass is located centrally just below the hyoid bone and does not cause any difficulty in swallowing or breathing. Upon examination, the GP notes that the mass moves with protrusion of the tongue and with swallowing. The GP diagnoses the boy with a benign thyroglossal cyst, which is caused by a persistent thyroglossal duct, and advises surgical removal. Where is the thyroglossal duct attached to the tongue?

      Your Answer: Palatoglossal arch

      Correct Answer: Foramen cecum

      Explanation:

      The thyroglossal duct connects the thyroid gland to the tongue via the foramen caecum during embryonic development. The terminal sulcus, median sulcus, palatoglossal arch, and epiglottis are not connected to the thyroid gland.

      Understanding Thyroglossal Cysts

      Thyroglossal cysts are named after the thyroid and tongue, which are the two structures involved in their development. During embryology, the thyroid gland develops from the floor of the pharynx and descends into the neck, connected to the tongue by the thyroglossal duct. The foramen cecum is the point of attachment of the thyroglossal duct to the tongue. Normally, the thyroglossal duct atrophies, but in some people, it may persist and give rise to a thyroglossal duct cyst.

      Thyroglossal cysts are more common in patients under 20 years old and are usually midline, between the isthmus of the thyroid and the hyoid bone. They move upwards with protrusion of the tongue and may be painful if infected. Understanding the embryology and presentation of thyroglossal cysts is important for proper diagnosis and treatment.

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      • Respiratory System
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  • Question 14 - During a neck dissection, a nerve is observed to pass behind the medial...

    Incorrect

    • During a neck dissection, a nerve is observed to pass behind the medial aspect of the second rib. Which nerve from the list below is the most probable?

      Your Answer: Nerve to subclavius

      Correct Answer: Phrenic nerve

      Explanation:

      The crucial aspect to note is that the phrenic nerve travels behind the inner side of the first rib. Towards the top, it is situated on the exterior of scalenus anterior.

      The Phrenic Nerve: Origin, Path, and Supplies

      The phrenic nerve is a crucial nerve that originates from the cervical spinal nerves C3, C4, and C5. It supplies the diaphragm and provides sensation to the central diaphragm and pericardium. The nerve passes with the internal jugular vein across scalenus anterior and deep to the prevertebral fascia of the deep cervical fascia.

      The right phrenic nerve runs anterior to the first part of the subclavian artery in the superior mediastinum and laterally to the superior vena cava. In the middle mediastinum, it is located to the right of the pericardium and passes over the right atrium to exit the diaphragm at T8. On the other hand, the left phrenic nerve passes lateral to the left subclavian artery, aortic arch, and left ventricle. It passes anterior to the root of the lung and pierces the diaphragm alone.

      Understanding the origin, path, and supplies of the phrenic nerve is essential in diagnosing and treating conditions that affect the diaphragm and pericardium.

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  • Question 15 - A 35-year-old man comes to the clinic complaining of worsening retrosternal chest pain...

    Incorrect

    • A 35-year-old man comes to the clinic complaining of worsening retrosternal chest pain that radiates to the neck and shoulders and is pleuritic in nature. During examination, a pericardial friction rub is heard at the end of expiration. The diagnosis is pericarditis. What nerve supplies this area?

      Your Answer: Long thoracic nerve

      Correct Answer: Phrenic nerve

      Explanation:

      The correct answer is the phrenic nerve, which provides sensory innervation to the pericardium, the central part of the diaphragm, and the mediastinal part of the parietal pleura. It also supplies motor function to the diaphragm. The long thoracic nerve, medial pectoral nerve, thoracodorsal nerve, and vagus nerve are all incorrect answers.

      The Phrenic Nerve: Origin, Path, and Supplies

      The phrenic nerve is a crucial nerve that originates from the cervical spinal nerves C3, C4, and C5. It supplies the diaphragm and provides sensation to the central diaphragm and pericardium. The nerve passes with the internal jugular vein across scalenus anterior and deep to the prevertebral fascia of the deep cervical fascia.

      The right phrenic nerve runs anterior to the first part of the subclavian artery in the superior mediastinum and laterally to the superior vena cava. In the middle mediastinum, it is located to the right of the pericardium and passes over the right atrium to exit the diaphragm at T8. On the other hand, the left phrenic nerve passes lateral to the left subclavian artery, aortic arch, and left ventricle. It passes anterior to the root of the lung and pierces the diaphragm alone.

      Understanding the origin, path, and supplies of the phrenic nerve is essential in diagnosing and treating conditions that affect the diaphragm and pericardium.

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  • Question 16 - A 55-year-old man presents to his GP complaining of vertigo, describing a sensation...

    Incorrect

    • A 55-year-old man presents to his GP complaining of vertigo, describing a sensation of the room spinning around him. He reports that the symptoms are exacerbated when he rolls over in bed. The GP suspects that otoliths in the semicircular canals of the inner ear may be the cause. What diagnostic test could the GP perform to confirm this suspicion?

      Your Answer: Epley manoeuvre

      Correct Answer: Dix-Hallpike manoeuvre

      Explanation:

      Benign paroxysmal positional vertigo (BPPV) is suspected based on the patient’s history. To confirm the diagnosis, the Dix-Hallpike manoeuvre can be performed, which involves quickly moving the patient from a sitting to supine position and observing for nystagmus.

      If BPPV is confirmed, the Epley manoeuvre can be used for treatment. This manoeuvre aims to dislodge otoliths by promoting fluid movement in the inner ear’s semicircular canals.

      Carpal tunnel syndrome can be diagnosed by a positive Tinel’s sign. This involves tapping the median nerve over the flexor retinaculum, causing paraesthesia in the median nerve’s distribution.

      The Trendelenburg test is used to assess venous valve competency in patients with varicose veins.

      Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.

      Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.

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      • Respiratory System
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  • Question 17 - Which one of the following is associated with increased lung compliance in elderly...

    Correct

    • Which one of the following is associated with increased lung compliance in elderly individuals?

      Your Answer: Emphysema

      Explanation:

      Understanding Lung Compliance in Respiratory Physiology

      Lung compliance refers to the extent of change in lung volume in response to a change in airway pressure. An increase in lung compliance can be caused by factors such as aging and emphysema, which is characterized by the loss of alveolar walls and associated elastic tissue. On the other hand, a decrease in lung compliance can be attributed to conditions such as pulmonary edema, pulmonary fibrosis, pneumonectomy, and kyphosis. These conditions can affect the elasticity of the lungs and make it more difficult for them to expand and contract properly. Understanding lung compliance is important in respiratory physiology as it can help diagnose and manage various respiratory conditions. Proper management of lung compliance can improve lung function and overall respiratory health.

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      • Respiratory System
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  • Question 18 - A 42-year-old man from Turkey visits his doctor complaining of chronic breathlessness and...

    Incorrect

    • A 42-year-old man from Turkey visits his doctor complaining of chronic breathlessness and a dry cough that has been worsening over the past 7 months. He has no significant medical history except for an allergy to penicillin. He is a non-smoker and does not consume alcohol. He works as a taxi driver and lives alone, but he is an avid collector of exotic pigeons and enjoys a cup of coffee every morning. The doctor suspects that his symptoms may be due to exposure to what causes pigeon fancier's lung?

      Your Answer: Mycobacterium avium

      Correct Answer: Avian proteins

      Explanation:

      Bird fanciers’ lung is caused by avian proteins found in bird droppings, which can lead to hypersensitivity pneumonitis. This is a type of pulmonary disorder that results from an inflammatory reaction to inhaling an allergen, which can be organic or inorganic particles such as animal or plant proteins, certain chemicals, or microbes. Similarly, other types of lung diseases such as tobacco worker’s lung, farmer’s lung, and hot tub lung are also caused by exposure to specific allergens in the environment.

      Extrinsic allergic alveolitis, also known as hypersensitivity pneumonitis, is a condition that occurs when the lungs are damaged due to hypersensitivity to inhaled organic particles. This damage is thought to be caused by immune-complex mediated tissue damage, although delayed hypersensitivity may also play a role. Examples of this condition include bird fanciers’ lung, farmers lung, malt workers’ lung, and mushroom workers’ lung. Symptoms can be acute or chronic and include dyspnoea, dry cough, fever, lethargy, and weight loss. Diagnosis is made through imaging, bronchoalveolar lavage, and serologic assays for specific IgG antibodies. Management involves avoiding the triggering factors and oral glucocorticoids.

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      • Respiratory System
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  • Question 19 - A 12-year-old girl is referred to a respiratory specialist due to persistent episodes...

    Incorrect

    • A 12-year-old girl is referred to a respiratory specialist due to persistent episodes of shortness of breath. She also suffers from severe hay fever and eczema. After undergoing a peak expiratory flow test, signs of outflow obstruction of her lungs are detected. The doctor prescribes beclomethasone and salbutamol for her and advises her mother to keep her away from dust, as asthma is often linked to hypersensitivity to dust. Which type of hypersensitivity is associated with asthma?

      Your Answer: Type 4 hypersensitivity

      Correct Answer: Type 1 hypersensitivity

      Explanation:

      Asthma is linked to type 1 hypersensitivity, which is caused by the binding of IgE to Mast cells, resulting in an inflammatory reaction. Other types of hypersensitivity include type 2, which involves the binding of IgG or IgM to cell surface antigens, type 3, which is immune complex-mediated, and type 4, which is T-cell mediated.

      Asthma is a common respiratory disorder that affects both children and adults. It is characterized by chronic inflammation of the airways, resulting in reversible bronchospasm and airway obstruction. While asthma can develop at any age, it typically presents in childhood and may improve or resolve with age. However, it can also persist into adulthood and cause significant morbidity, with around 1,000 deaths per year in the UK.

      Several risk factors can increase the likelihood of developing asthma, including a personal or family history of atopy, antenatal factors such as maternal smoking or viral infections, low birth weight, not being breastfed, exposure to allergens and air pollution, and the hygiene hypothesis. Patients with asthma may also suffer from other atopic conditions such as eczema and hay fever, and some may be sensitive to aspirin. Occupational asthma is also a concern for those exposed to allergens in the workplace.

      Symptoms of asthma include coughing, dyspnea, wheezing, and chest tightness, with coughing often worse at night. Signs may include expiratory wheezing on auscultation and reduced peak expiratory flow rate. Diagnosis is typically made through spirometry, which measures the volume and speed of air during exhalation and inhalation.

      Management of asthma typically involves the use of inhalers to deliver drug therapy directly to the airways. Short-acting beta-agonists such as salbutamol are the first-line treatment for relieving symptoms, while inhaled corticosteroids like beclometasone dipropionate and fluticasone propionate are used for daily maintenance therapy. Long-acting beta-agonists like salmeterol and leukotriene receptor antagonists like montelukast may also be used in combination with other medications. Maintenance and reliever therapy (MART) is a newer approach that combines ICS and a fast-acting LABA in a single inhaler for both daily maintenance and symptom relief. Recent guidelines recommend offering a leukotriene receptor antagonist instead of a LABA for patients on SABA + ICS whose asthma is not well controlled, and considering MART for those with poorly controlled asthma.

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      • Respiratory System
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  • Question 20 - A 65-year-old man is having a coronary artery bypass surgery. Which structure would...

    Correct

    • A 65-year-old man is having a coronary artery bypass surgery. Which structure would typically need to be divided during the median sternotomy procedure?

      Your Answer: Interclavicular ligament

      Explanation:

      During a median sternotomy, the interclavicular ligament is typically cut to allow access. However, it is important to avoid intentionally cutting the pleural reflections, as this can lead to the accumulation of fluid in the pleural cavity and require the insertion of a chest drain. The pectoralis major muscles may also be encountered, but if the incision is made in the midline, they should not need to be formally divided. It is crucial to be mindful of the proximity of the brachiocephalic vein and avoid injuring it, as this can result in significant bleeding.

      Sternotomy Procedure

      A sternotomy is a surgical procedure that involves making an incision in the sternum to access the heart and great vessels. The most common type of sternotomy is a median sternotomy, which involves making a midline incision from the interclavicular fossa to the xiphoid process. The fat and subcutaneous tissues are then divided to the level of the sternum, and the periosteum may be gently mobilized off the midline. However, it is important to avoid vigorous periosteal stripping. A bone saw is used to divide the bone itself, and bleeding from the bony edges of the cut sternum is stopped using roller ball diathermy or bone wax.

      Posteriorly, the reflections of the parietal pleura should be identified and avoided, unless surgery to the lung is planned. The fibrous pericardium is then incised, and the heart is brought into view. It is important to avoid the left brachiocephalic vein, which is an important posterior relation at the superior aspect of the sternotomy incision. More inferiorly, the thymic remnants may be identified. At the inferior aspect of the incision, the abdominal cavity may be entered, although this is seldom troublesome.

      Overall, a sternotomy is a complex surgical procedure that requires careful attention to detail and a thorough understanding of the anatomy of the chest and heart. By following the proper techniques and precautions, surgeons can safely access the heart and great vessels to perform a variety of life-saving procedures.

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      • Respiratory System
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  • Question 21 - A 20-year-old man presents to the emergency department with diabetic ketoacidosis. After early...

    Incorrect

    • A 20-year-old man presents to the emergency department with diabetic ketoacidosis. After early treatment, an arterial blood gas is taken, which shows the following results.

      ABG result - temperature 35.0 ºC:

      pH 7.30 (7.35 - 7.45)
      PaCO2 3.5 kPa (4.7 - 6.0)
      PaO2 10 kPa (11 - 13)
      HCO3- 16 mEq/L (22 - 26)
      Na+ 138 mmol/L (135 - 145)
      K+ 3.3 mmol/L (3.5 - 5.0)

      What physiological change is occurring in this patient?

      Your Answer: Hypothermia is causing a decreased affinity of haemoglobin for oxygen

      Correct Answer: Metabolic acidosis is causing a decreased affinity of haemoglobin for oxygen

      Explanation:

      In acidosis, the oxyhaemoglobin dissociation curve shifts to the right, indicating a decrease in affinity of haemoglobin for oxygen. This is due to an increase in the number of [H+] ions, reflecting greater metabolic activity. Low [H+] levels cause a shift to the left. The low HCO3- in this patient can be explained by metabolic acidosis, but it does not cause a shift in the oxyhaemoglobin dissociation curve. Hypokalaemia may be a result of treatment for diabetic ketoacidosis, but it does not cause a shift in the oxygen dissociation curve. When temperature increases, the oxyhaemoglobin dissociation curve also shifts to the right, causing a decrease in haemoglobin affinity for oxygen. Hypothermia causes a shift to the left, indicating an increased affinity of haemoglobin for oxygen.

      Understanding the Oxygen Dissociation Curve

      The oxygen dissociation curve is a graphical representation of the relationship between the percentage of saturated haemoglobin and the partial pressure of oxygen in the blood. It is not influenced by the concentration of haemoglobin. The curve can shift to the left or right, indicating changes in oxygen delivery to tissues. When the curve shifts to the left, there is increased saturation of haemoglobin with oxygen, resulting in decreased oxygen delivery to tissues. Conversely, when the curve shifts to the right, there is reduced saturation of haemoglobin with oxygen, leading to enhanced oxygen delivery to tissues.

      The L rule is a helpful mnemonic to remember the factors that cause a shift to the left, resulting in lower oxygen delivery. These factors include low levels of hydrogen ions (alkali), low partial pressure of carbon dioxide, low levels of 2,3-diphosphoglycerate, and low temperature. On the other hand, the mnemonic ‘CADET, face Right!’ can be used to remember the factors that cause a shift to the right, leading to raised oxygen delivery. These factors include carbon dioxide, acid, 2,3-diphosphoglycerate, exercise, and temperature.

      Understanding the oxygen dissociation curve is crucial in assessing the oxygen-carrying capacity of the blood and the delivery of oxygen to tissues. By knowing the factors that can shift the curve to the left or right, healthcare professionals can make informed decisions in managing patients with respiratory and cardiovascular diseases.

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      • Respiratory System
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  • Question 22 - John, a 55-year-old man, arrives at the emergency department complaining of chest pain...

    Incorrect

    • John, a 55-year-old man, arrives at the emergency department complaining of chest pain that is relieved by leaning forward. He also mentions that the pain spreads to his left shoulder. The diagnosis is pericarditis.

      Which nerve is accountable for the referred pain in this case?

      Your Answer: Vagus nerve

      Correct Answer: Phrenic nerve

      Explanation:

      The phrenic nerve provides motor innervation to the diaphragm and sensory innervation to the pleura and pericardium. Pericarditis can cause referred pain to the shoulder due to the supraclavicular nerves originating at C3-4. It is important to note that there are no pericardial nerves. The spinal accessory nerve innervates the trapezius and sternocleidomastoid muscles, while the trochlear nerve supplies the superior oblique muscle. Although the vagus nerve has various functions, it does not supply the pericardium.

      The Phrenic Nerve: Origin, Path, and Supplies

      The phrenic nerve is a crucial nerve that originates from the cervical spinal nerves C3, C4, and C5. It supplies the diaphragm and provides sensation to the central diaphragm and pericardium. The nerve passes with the internal jugular vein across scalenus anterior and deep to the prevertebral fascia of the deep cervical fascia.

      The right phrenic nerve runs anterior to the first part of the subclavian artery in the superior mediastinum and laterally to the superior vena cava. In the middle mediastinum, it is located to the right of the pericardium and passes over the right atrium to exit the diaphragm at T8. On the other hand, the left phrenic nerve passes lateral to the left subclavian artery, aortic arch, and left ventricle. It passes anterior to the root of the lung and pierces the diaphragm alone.

      Understanding the origin, path, and supplies of the phrenic nerve is essential in diagnosing and treating conditions that affect the diaphragm and pericardium.

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      • Respiratory System
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  • Question 23 - Mrs. Johnson is an 82-year-old woman who visited her General practitioner complaining of...

    Incorrect

    • Mrs. Johnson is an 82-year-old woman who visited her General practitioner complaining of gradual worsening shortness of breath over the past two months. During the medical history, it was discovered that she has had Chronic Obstructive Pulmonary Disease (COPD) for 20 years.

      Upon examination, there are no breath sounds at both lung bases and a stony dull note to percussion over the same areas. Based on this clinical scenario, what is the probable cause of her recent exacerbation of shortness of breath?

      Your Answer: Infective exacerbation of COPD

      Correct Answer: Pleural transudate effusion secondary to cor pulmonale

      Explanation:

      The most likely cause of a pleural transudate is heart failure. This is due to the congestion of blood into the systemic venous circulation, which can result from long-standing COPD and increase in pulmonary vascular resistance leading to right-sided heart failure or cor pulmonale. Other options such as infective exacerbation of COPD or pulmonary edema secondary to heart failure are less likely to explain the clinical signs. Pleural exudate effusion secondary to cor pulmonale is also not the most appropriate answer as it would cause a transudate pleural effusion, not an exudate.

      Understanding the Causes and Features of Pleural Effusion

      Pleural effusion is a medical condition characterized by the accumulation of fluid in the pleural space, which is the area between the lungs and the chest wall. The causes of pleural effusion can be classified into two types: transudate and exudate. Transudate is characterized by a protein concentration of less than 30g/L and is commonly caused by heart failure, hypoalbuminemia, liver disease, and other conditions. On the other hand, exudate is characterized by a protein concentration of more than 30g/L and is commonly caused by infections, pneumonia, tuberculosis, and other conditions.

      The symptoms of pleural effusion may include dyspnea, non-productive cough, and chest pain. Upon examination, patients may exhibit dullness to percussion, reduced breath sounds, and reduced chest expansion. It is important to identify the underlying cause of pleural effusion to determine the appropriate treatment plan. Early diagnosis and treatment can help prevent complications and improve the patient’s overall health.

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      • Respiratory System
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  • Question 24 - A 26-year-old woman comes to your clinic complaining of feeling dizzy for the...

    Incorrect

    • A 26-year-old woman comes to your clinic complaining of feeling dizzy for the past two days. She describes a sensation of the room spinning and has been experiencing nausea. The dizziness is relieved when she lies down and has no apparent triggers. She denies any hearing loss or aural fullness and is otherwise healthy. Upon examination, she has no fever and otoscopy reveals no abnormalities. You suspect she may have viral labyrinthitis and prescribe prochlorperazine to alleviate her vertigo symptoms. What class of antiemetic does prochlorperazine belong to?

      Your Answer: Antimuscarinic

      Correct Answer: Dopamine receptor antagonist

      Explanation:

      Prochlorperazine belongs to a class of drugs known as dopamine receptor antagonists, which work by inhibiting stimulation of the chemoreceptor trigger zone (CTZ) through D2 receptors. Other drugs in this class include domperidone, metoclopramide, and olanzapine.

      Antihistamine antiemetics, such as cyclizine and promethazine, are H1 histamine receptor antagonists.

      5-HT3 receptor antagonists, such as ondansetron and granisetron, are effective both centrally and peripherally. They work by blocking serotonin receptors in the central nervous system and gastrointestinal tract.

      Antimuscarinic antiemetics are anticholinergic drugs, with hyoscine (scopolamine) being a common example.

      Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.

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      • Respiratory System
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  • Question 25 - A 29-year-old man visits his GP with a complaint of a persistent cough....

    Incorrect

    • A 29-year-old man visits his GP with a complaint of a persistent cough. He reports coughing up large amounts of yellow sputum and occasionally blood on a daily basis for the past few years. Lately, he has noticed that his clothes seem loose on him and he frequently feels fatigued.

      What is the most probable underlying condition responsible for this patient's symptoms?

      Your Answer: Extrinsic allergic alveolitis

      Correct Answer: Kartagener's syndrome

      Explanation:

      Kartagener’s syndrome is a condition that can lead to bronchiectasis due to a defect in the cilia, which impairs the lungs’ ability to clear mucus. Bronchiectasis is diagnosed when a person produces large amounts of sputum daily, experiences haemoptysis, and loses weight. While other conditions may cause tiredness, weight loss, or haemoptysis, they are not typically associated with bronchiectasis.

      Understanding Kartagener’s Syndrome

      Kartagener’s syndrome, also known as primary ciliary dyskinesia, is a rare genetic disorder that was first described in 1933. It is often associated with dextrocardia, which can be detected through quiet heart sounds and small volume complexes in lateral leads during examinations. The pathogenesis of Kartagener’s syndrome is caused by a dynein arm defect, which results in immotile cilia.

      The features of Kartagener’s syndrome include dextrocardia or complete situs inversus, bronchiectasis, recurrent sinusitis, and subfertility. The latter is due to diminished sperm motility and defective ciliary action in the fallopian tubes. It is important to note that Kartagener’s syndrome is a rare disorder, and diagnosis can be challenging. However, early detection and management can help improve the quality of life for those affected by this condition.

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      • Respiratory System
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  • Question 26 - What is the carrier rate of cystic fibrosis in the United Kingdom? ...

    Incorrect

    • What is the carrier rate of cystic fibrosis in the United Kingdom?

      Your Answer:

      Correct Answer: 1 in 25

      Explanation:

      Understanding Cystic Fibrosis

      Cystic fibrosis is a genetic disorder that causes thickened secretions in the lungs and pancreas. It is an autosomal recessive condition that occurs due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which regulates a chloride channel. In the UK, 80% of CF cases are caused by delta F508 on chromosome 7, and the carrier rate is approximately 1 in 25.

      CF patients are at risk of colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia (previously known as Pseudomonas cepacia), and Aspergillus. These organisms can cause infections and exacerbate symptoms in CF patients. It is important for healthcare providers to monitor and manage these infections to prevent further complications.

      Overall, understanding cystic fibrosis and its associated risks can help healthcare providers provide better care for patients with this condition.

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      • Respiratory System
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  • Question 27 - A 5-year-old boy comes to the clinic with his mother, complaining of ear...

    Incorrect

    • A 5-year-old boy comes to the clinic with his mother, complaining of ear pain that started last night. He has been unable to sleep due to the pain and has not been eating well. His mother reports that he seems different than his usual self. The affected side has muffled sounds, and he has a fever. Otoscopy reveals a bulging tympanic membrane with visible fluid-level. What is the structure that connects the middle ear to the nasopharynx?

      Your Answer:

      Correct Answer: Eustachian tube

      Explanation:

      The pharyngotympanic tube, also known as the Eustachian tube, is responsible for connecting the middle ear and the nasopharynx, allowing for pressure equalization in the middle ear. It opens on the anterior wall of the middle ear and extends anteriorly, medially, and inferiorly to open into the nasopharynx. The palatovaginal canal connects the pterygopalatine fossa with the nasopharynx, while the pterygoid canal runs from the anterior boundary of the foramen lacerum to the pterygopalatine fossa. The semicircular canals are responsible for sensing balance, while the greater palatine canal transmits the greater and lesser palatine nerves, as well as the descending palatine artery and vein. In the case of ear pain, otitis media is a likely cause, which can be confirmed through otoscopy. The pharyngotympanic tube is particularly important in otitis media as it is the only outlet for pus or fluid in the middle ear, provided the tympanic membrane is intact.

      Anatomy of the Ear

      The ear is divided into three distinct regions: the external ear, middle ear, and internal ear. The external ear consists of the auricle and external auditory meatus, which are innervated by the greater auricular nerve and auriculotemporal branch of the trigeminal nerve. The middle ear is the space between the tympanic membrane and cochlea, and is connected to the nasopharynx by the eustachian tube. The tympanic membrane is composed of three layers and is approximately 1 cm in diameter. The middle ear is innervated by the glossopharyngeal nerve. The ossicles, consisting of the malleus, incus, and stapes, transmit sound vibrations from the tympanic membrane to the inner ear. The internal ear contains the cochlea, which houses the organ of corti, the sense organ of hearing. The vestibule accommodates the utricule and saccule, which contain endolymph and are surrounded by perilymph. The semicircular canals, which share a common opening into the vestibule, lie at various angles to the petrous temporal bone.

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  • Question 28 - A 44-year-old woman is scheduled for a thyroidectomy due to symptomatic tracheal compression....

    Incorrect

    • A 44-year-old woman is scheduled for a thyroidectomy due to symptomatic tracheal compression. She has a history of hyperthyroidism that was controlled with carbimazole. However, she was deemed a suitable candidate for thyroidectomy after presenting to the emergency department with dyspnoea and stridor.

      As a surgical resident assisting the ENT surgeon, you need to ligate the superior thyroid artery before removing the thyroid glands to prevent excessive bleeding. However, the superior laryngeal artery, a branch of the superior thyroid artery, is closely related to a structure that, if injured, can lead to loss of sensation in the laryngeal mucosa.

      What is the correct identification of this structure?

      Your Answer:

      Correct Answer: Internal laryngeal nerve

      Explanation:

      The internal laryngeal nerve and the superior laryngeal artery are closely associated with each other. The superior laryngeal artery travels alongside the internal laryngeal branch of the superior laryngeal nerve, beneath the thyrohyoid muscle. It originates from the superior thyroid artery near its separation from the external carotid artery.

      If the internal laryngeal nerve is damaged, it can result in a loss of sensation to the laryngeal mucosa. The nerve is situated beneath the mucous membrane of the piriform recess, making it vulnerable to injury from sharp objects like fish and chicken bones that may become stuck in the recess.

      Anatomy of the Larynx

      The larynx is located in the front of the neck, between the third and sixth cervical vertebrae. It is made up of several cartilaginous segments, including the paired arytenoid, corniculate, and cuneiform cartilages, as well as the single thyroid, cricoid, and epiglottic cartilages. The cricoid cartilage forms a complete ring. The laryngeal cavity extends from the laryngeal inlet to the inferior border of the cricoid cartilage and is divided into three parts: the laryngeal vestibule, the laryngeal ventricle, and the infraglottic cavity.

      The vocal folds, also known as the true vocal cords, control sound production. They consist of the vocal ligament and the vocalis muscle, which is the most medial part of the thyroarytenoid muscle. The glottis is composed of the vocal folds, processes, and rima glottidis, which is the narrowest potential site within the larynx.

      The larynx is also home to several muscles, including the posterior cricoarytenoid, lateral cricoarytenoid, thyroarytenoid, transverse and oblique arytenoids, vocalis, and cricothyroid muscles. These muscles are responsible for various actions, such as abducting or adducting the vocal folds and relaxing or tensing the vocal ligament.

      The larynx receives its arterial supply from the laryngeal arteries, which are branches of the superior and inferior thyroid arteries. Venous drainage is via the superior and inferior laryngeal veins. Lymphatic drainage varies depending on the location within the larynx, with the vocal cords having no lymphatic drainage and the supraglottic and subglottic parts draining into different lymph nodes.

      Overall, understanding the anatomy of the larynx is important for proper diagnosis and treatment of various conditions affecting this structure.

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  • Question 29 - Which one of the following statements relating to the root of the spine...

    Incorrect

    • Which one of the following statements relating to the root of the spine is false?

      Your Answer:

      Correct Answer: The subclavian artery arches over the first rib anterior to scalenus anterior

      Explanation:

      The suprapleural membrane, also known as Sibson’s fascia, is located above the pleural cavity. The scalenus anterior muscle is positioned in front of the subclavian vein, while the subclavian artery is situated behind it.

      Thoracic Outlet: Where the Subclavian Artery and Vein and Brachial Plexus Exit the Thorax

      The thoracic outlet is the area where the subclavian artery and vein and the brachial plexus exit the thorax and enter the arm. This passage occurs over the first rib and under the clavicle. The subclavian vein is the most anterior structure and is located immediately in front of scalenus anterior and its attachment to the first rib. Scalenus anterior has two parts, and the subclavian artery leaves the thorax by passing over the first rib and between these two portions of the muscle. At the level of the first rib, the lower cervical nerve roots combine to form the three trunks of the brachial plexus. The lowest trunk is formed by the union of C8 and T1, and this trunk lies directly posterior to the artery and is in contact with the superior surface of the first rib.

      Thoracic outlet obstruction can cause neurovascular compromise.

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  • Question 30 - An 80-year-old man is brought to the emergency department in respiratory arrest. According...

    Incorrect

    • An 80-year-old man is brought to the emergency department in respiratory arrest. According to his partner, he has a history of congestive heart failure and has recently been battling an infection. After being placed on mechanical ventilation, you observe that the patient has decreased lung compliance.

      What could be the cause of this observation?

      Your Answer:

      Correct Answer: Pulmonary oedema

      Explanation:

      Reduced lung compliance is a common consequence of pulmonary edema, which occurs when fluid accumulates in the alveoli and exerts mechanical stress on the air-filled alveoli. This can happen in patients with acute decompensation of congestive cardiac failure, often triggered by an infection. On the other hand, emphysema can increase compliance due to long-term damage that reduces the elastic recoil of the lungs. Additionally, lung surfactant produced by type II pneumocytes can increase lung compliance. Finally, aging can also lead to increased compliance as the loss of lung connective tissue can reduce elastic recoil.

      Understanding Lung Compliance in Respiratory Physiology

      Lung compliance refers to the extent of change in lung volume in response to a change in airway pressure. An increase in lung compliance can be caused by factors such as aging and emphysema, which is characterized by the loss of alveolar walls and associated elastic tissue. On the other hand, a decrease in lung compliance can be attributed to conditions such as pulmonary edema, pulmonary fibrosis, pneumonectomy, and kyphosis. These conditions can affect the elasticity of the lungs and make it more difficult for them to expand and contract properly. Understanding lung compliance is important in respiratory physiology as it can help diagnose and manage various respiratory conditions. Proper management of lung compliance can improve lung function and overall respiratory health.

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Respiratory System (16/25) 64%
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