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  • Question 1 - In which condition is the sniff test useful in diagnosis? ...

    Correct

    • In which condition is the sniff test useful in diagnosis?

      Your Answer: Phrenic nerve palsy

      Explanation:

      The phrenic nerve provides the primary motor supply to the diaphragm, the major respiratory muscle.
      Phrenic nerve paralysis is a rare cause of exertional dyspnoea that should be included in the differential diagnosis. Fluoroscopy is considered the most reliable way to document diaphragmatic paralysis. During fluoroscopy a patient is asked to sniff and there is a paradoxical rise of the paralysed hemidiaphragm. This is to confirm that the cause is due to paralysis rather than unilateral weakness.

    • This question is part of the following fields:

      • Respiratory
      7.1
      Seconds
  • Question 2 - A 35 year old male who has smoked 20 cigarettes per day was...

    Incorrect

    • A 35 year old male who has smoked 20 cigarettes per day was referred to the National Chest Hospital because he has had a nine month history of shortness of breath which is getting worse. Tests revealed that he had moderate emphysema. His family history showed that his father died from COPD at the age of 52. Genetic testing found the PiSZ genotype following the diagnosis of alpha-1 antitrypsin (A1AT) deficiency. What levels of alpha-1 antitrypsin would be expected if they were to be measured?

      Your Answer: 60% of normal

      Correct Answer: 40% of normal

      Explanation:

      Alpha1-antitrypsin (AAT) deficiency, first described in 1963, is one of the most common inherited disorders amongst white Caucasians. Its primary manifestation is early-onset of pan acinar emphysema. In adults, alpha1-antitrypsin deficiency leads to chronic liver disease in the fifth decade. As a cause of emphysema, it is seen in non-smokers in the fifth decade of life and during the fourth decade of life in smokers.

      Symptoms of alpha1-antitrypsin (AAT) deficiency emphysema are limited to the respiratory system. Dyspnoea is the symptom that eventually dominates alpha1-antitrypsin deficiency. Similar to other forms of emphysema, the dyspnoea of alpha1-antitrypsin deficiency is initially evident only with strenuous exertion. Over several years, it eventually limits even mild activities.
      The serum levels of some of the common genotypes are:
      •PiMM: 100% (normal)
      •PiMS: 80% of normal serum level of A1AT
      •PiSS: 60% of normal serum level of A1AT
      •PiMZ: 60% of normal serum level of A1AT, mild deficiency
      •PiSZ: 40% of normal serum level of A1AT, moderate deficiency
      •PiZZ: 10–15% (severe alpha 1-antitrypsin deficiency)

    • This question is part of the following fields:

      • Respiratory
      45.9
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  • Question 3 - Which area in the body controls the hypoxic drive to breathe? ...

    Incorrect

    • Which area in the body controls the hypoxic drive to breathe?

      Your Answer: Hypothalamus

      Correct Answer: Carotid body

      Explanation:

      The carotid body consists of chemosensitive cells at the bifurcation of the common carotid artery that respond to changes in oxygen tension and, to a lesser extent, pH. In contrast to central chemoreceptors (which primarily respond to PaCO2) and the aortic bodies (which primarily have circulatory effects: bradycardia, hypertension, adrenal stimulation, and also bronchoconstriction), carotid bodies are most sensitive to PaO2. At a PaO2 of approximately 55-60 mmHg, they send their impulses via CN IX to the medulla, increasing ventilatory drive (increased respiratory rate, tidal volume, and minute ventilation). Thus, patients who rely on hypoxic respiratory drive will typically have a resting PaO2 around 60 mm Hg.

    • This question is part of the following fields:

      • Respiratory
      11.1
      Seconds
  • Question 4 - A 56 year old man who is a known alcoholic presents to the...

    Correct

    • A 56 year old man who is a known alcoholic presents to the clinic with a fever and cough. Past medical history states that he has a long history of smoking and is found to have a cavitating lesion on his chest x-ray.   Which organism is least likely to be the cause of his pneumonia?

      Your Answer: Enterococcus faecalis

      Explanation:

      Cavitating pneumonia is a complication that can occur with a severe necrotizing pneumonia and in some publications it is used synonymously with the latter term. It is a rare complication in both children and adults. Albeit rare, cavitation is most commonly caused by Streptococcus pneumoniae, and less frequently Aspergillus spp., Legionella spp. and Staphylococcus aureus.

      In children, cavitation is associated with severe illness, although cases usually resolve without surgical intervention, and long-term follow-up radiography shows clear lungs without pulmonary sequelae
      Although the absolute cavitary rate may not be known, according to one series, necrotizing changes were seen in up to 6.6% of adults with pneumococcal pneumonia. Klebsiella pneumoniae is another organism that is known to cause cavitation.

      Causative agents:
      Mycobacterium tuberculosis
      Klebsiella pneumoniae
      Streptococcus pneumoniae
      Staphylococcus aureus

      Enterococcus faecalis was not found to be a causative agent.

    • This question is part of the following fields:

      • Respiratory
      33.9
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  • Question 5 - A 51 year old obese female, with a history of smoking, presents to...

    Incorrect

    • A 51 year old obese female, with a history of smoking, presents to the clinic with worsening dyspnoea. She is currently on oestrogen therapy for menopausal symptoms. Clinical examination, ECG and radiological findings correspond to right sided heart failure. There are no signs of left ventricular dysfunction. Which of the following is the most likely cause of cor pulmonale?

      Your Answer: Bronchiectasis

      Correct Answer: Recurrent small pulmonary embolisms

      Explanation:

      Postmenopausal oestrogen therapy and hormone therapy are associated with an increased risk of thromboembolism. The relative risk seems to be even greater if the treated population has pre-existing risk factors for thromboembolism, such as obesity, immobilization, and fracture. Cor pulmonale can occur secondary to small recurrent pulmonary embolisms. Pneumonias and bronchiectasis usually present with purulent sputum, and in case of carcinoma there may be other associated symptoms like weight loss, etc.

    • This question is part of the following fields:

      • Respiratory
      28
      Seconds
  • Question 6 - A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he...

    Incorrect

    • A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he has alpha-1 antitrypsin deficiency. What is the main role of alpha-1 antitrypsin in the body?

      Your Answer: Trypsin activator

      Correct Answer: Protease inhibitor

      Explanation:

      Alpha-1-antitrypsin (AAT) is a member of the serine proteinase inhibitor (serpin) family of proteins with a broad spectrum of biological functions including inhibition of proteases, immune modulatory functions, and the transport of hormones.

    • This question is part of the following fields:

      • Respiratory
      31.5
      Seconds
  • Question 7 - A 26 year old man with a history of 'brittle' asthma is admitted...

    Correct

    • A 26 year old man with a history of 'brittle' asthma is admitted with an asthma attack. High-flow oxygen and nebulised salbutamol have already been administered by the Paramedics. The patient is unable to complete sentences and he has a bilateral expiratory wheeze. He is also unable to perform a peak flow reading. His respiratory rate is 31/minute, sats 93% (on high-flow oxygen) and pulse 119/minute. Intravenous hydrocortisone is immediately administered and nebulised salbutamol given continuously. Intravenous magnesium sulphate is administered after six minutes of no improvement. These are the results from the blood gas sample that was taken after another six minutes: pH 7.32 pCO2 6.8 kPa pO2 8.9 kPa What is the most appropriate therapy in this patient?

      Your Answer: Intubation

      Explanation:

      The normal partial pressure reference values are: oxygen PaO2 more than 80 mmHg (11 kPa), and carbon dioxide PaCO2 lesser than 45 mmHg (6.0 kPa).
      This patient has an elevated PaCO2 of 6.8kPa which exceeds the normal value of less than 6.0kPa.
      The pH is also lower than 7.35 at 7.32

      In any patient with asthma, an increasing PaCO2 indicates severe airway obstruction that is leading to respiratory muscle fatigue and patient exhaustion.

      According to the British Thoracic Society guidelines:
      Indications for admission to intensive care or high-dependency units include
      patients requiring ventilatory support and those with acute severe or life-threatening asthma who are failing to respond to therapy, as evidenced by:
      • deteriorating PEF
      • persisting or worsening hypoxia
      • hypercapnia
      • arterial blood gas analysis showing fall in pH or rising hydrogen concentration
      • exhaustion, feeble respiration
      • drowsiness, confusion, altered conscious state
      • respiratory arrest

      Transfer to ICU accompanied by a doctor prepared to intubate if:
      • Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia
      • Exhaustion, altered consciousness
      • Poor respiratory effort or respiratory arrest

      A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.

      Consider giving a single dose of intravenous magnesium sulphate to
      patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy.
      Magnesium sulphate (1.2–2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

    • This question is part of the following fields:

      • Respiratory
      47.6
      Seconds
  • Question 8 - A 51 year old smoker was recently diagnosed with non small cell lung...

    Incorrect

    • A 51 year old smoker was recently diagnosed with non small cell lung carcinoma. Investigations show presence of a 3 x 3 x 2 cm tumour on the left side of the lower lung lobe. the mass has invaded the parietal pleura. Ipsilateral hilar node is also involved but there is no metastatic spread. What is the stage of this cancer?

      Your Answer: T3 N1 M0

      Correct Answer: T2 N1 M0

      Explanation:

      The tumour has only invaded the visceral pleura and measures 3cm in the greatest dimension. Hence it is designated at T2. Ipsilateral peribronchial and/or hilar lymph node involvement would make it N1. There is no distal metastasis so M would be 0.

    • This question is part of the following fields:

      • Respiratory
      34.1
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  • Question 9 - Which virus is severe acute respiratory syndrome (SARS) caused by? ...

    Incorrect

    • Which virus is severe acute respiratory syndrome (SARS) caused by?

      Your Answer: A rhinovirus

      Correct Answer: A coronavirus

      Explanation:

      Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by a coronavirus called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003.
      In general, SARS begins with a high fever (temperature greater than 38.0°C). Other symptoms may include headache, an overall feeling of discomfort, and body aches. Some people also have mild respiratory symptoms at the outset. About 10 to 20 percent of patients have diarrhoea. After 2 to 7 days, SARS patients may develop a dry cough. Most patients develop pneumonia. 

    • This question is part of the following fields:

      • Respiratory
      25.2
      Seconds
  • Question 10 - An elderly woman is admitted to the hospital with a community-acquired pneumonia (CAP)....

    Incorrect

    • An elderly woman is admitted to the hospital with a community-acquired pneumonia (CAP). Her medical notes state that she developed a skin rash after taking penicillin a few years ago. She has a CURB score of 4 and adverse prognostic features. Which of the following would be an appropriate empirical antibiotic choice?

      Your Answer: Ciprofloxacin and clarithromycin

      Correct Answer: Cefotaxime and erythromycin

      Explanation:

      Community-acquired pneumonia (CAP) is one of the most common infectious diseases and is an important cause of mortality and morbidity worldwide. Typical bacterial pathogens that cause CAP include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
      The CURB-65 is used as a means of deciding the action that is needed to be taken for that patient.
      Score 3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit

      Recent studies have suggested that the use of a beta-lactam alone may be noninferior to a beta-lactam/macrolide combination or fluoroquinolone therapy in hospitalized patients.

      Therapy in ICU patients includes the following:
      – Beta-lactam (ceftriaxone, cefotaxime, or ampicillin/sulbactam) plus either a macrolide or respiratory fluoroquinolone
      – For patients with penicillin allergy, a respiratory fluoroquinolone and aztreonam

      Therefore the appropriate treatment would be Cefotaxime and erythromycin.

    • This question is part of the following fields:

      • Respiratory
      35.9
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  • Question 11 - A 41 year old man who has had two episodes of pneumonia in...

    Incorrect

    • A 41 year old man who has had two episodes of pneumonia in succession and an episode of haemoptysis is observed to have paroxysms of coughing and increasing wheezing. A single lesion which is well-defined is seen in the lower right lower lobe on a chest x-ray. There is no necrosis but biopsy shows numerous abnormal cells, occasional nuclear pleomorphism and absent mitoses. Which diagnosis fits the clinical presentation?

      Your Answer: Organised lung abscess

      Correct Answer: Bronchial carcinoid

      Explanation:

      Bronchial carcinoids are uncommon, slow growing, low-grade, malignant neoplasms, comprising 1-2% of all primary lung cancers.
      It is believed to be derived from surface of bronchial glandular epithelium. Mostly located centrally, they produce symptoms and signs of bronchial obstruction such as localized wheeze, non resolving recurrent pneumonitis, cough, chest pain, and fever. Haemoptysis is present in approximately 50% of the cases due to their central origin and hypervascularity.
      Central bronchial carcinoids are more common than the peripheral type and are seen as endobronchial nodules or hilar/perihilar mass closely related to the adjacent bronchus. Chest X-ray may not show the central lesion depending on how small it is.

    • This question is part of the following fields:

      • Respiratory
      48.3
      Seconds
  • Question 12 - A 23 year old female presents with a five month history of worsening...

    Incorrect

    • A 23 year old female presents with a five month history of worsening breathlessness and daily productive cough. As a young child, she had occasional wheezing with viral illnesses and she currently works in a ship yard and also smokes one pack of cigarettes daily for the past three years. Which of the following is the likely diagnosis?

      Your Answer: Asthma

      Correct Answer: Bronchiectasis

      Explanation:

      Bronchiectasis is a long-term condition where the airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection. The most common symptoms of bronchiectasis include:
      – a persistent productive cough
      – breathlessness.

      The 3 most common causes in the UK are:
      – a lung infection in the past, such as pneumonia or whooping cough, that damages the bronchi
      – underlying problems with the immune system (the body’s defence against infection) that make the bronchi more vulnerable to damage from an infection
      – allergic bronchopulmonary aspergillosis (ABPA) – an allergy to a certain type of fungi that can cause the bronchi to become inflamed if spores from the fungi are inhaled

    • This question is part of the following fields:

      • Respiratory
      38.3
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  • Question 13 - A 35-year-old woman is referred to the acute medical unit with a 5...

    Correct

    • A 35-year-old woman is referred to the acute medical unit with a 5 day history of polyarthritis and a low-grade fever. Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum. What is the most appropriate diagnosis?

      Your Answer: Lofgren's syndrome

      Explanation:

      Lofgren’s syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. Other symptoms include anterior uveitis, fever, ankle periarthritis, and pulmonary involvement.

      Löfgren syndrome is usually an acute disease with an excellent prognosis, typically resolving spontaneously from 6-8 weeks to up to 2 years after onset. Pulmonologists, ophthalmologists, and rheumatologists often define this syndrome differently, describing varying combinations of arthritis, arthralgia, uveitis, erythema nodosum, hilar adenopathy, and/or other clinical findings.

    • This question is part of the following fields:

      • Respiratory
      17.6
      Seconds
  • Question 14 - A 23 year old female is admitted with acute severe asthma. Treatment is...

    Correct

    • A 23 year old female is admitted with acute severe asthma. Treatment is initiated with 100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV hydrocortisone. There is no improvement despite initial treatment. What is the next step in management?

      Your Answer: IV magnesium sulphate

      Explanation:

      A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.

      Consider giving a single dose of intravenous magnesium sulphate to patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy. Magnesium sulphate (1.2–2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

    • This question is part of the following fields:

      • Respiratory
      10.7
      Seconds
  • Question 15 - A 24 year old female, 28 weeks pregnant presents to the clinic complaining...

    Correct

    • A 24 year old female, 28 weeks pregnant presents to the clinic complaining of shortness of breath and right sided pleuritic chest pain. The doctor suspects pulmonary embolism. Which of the following statements is incorrect regarding the management of this case?

      Your Answer: Ventilation-perfusion scanning exposes the foetus to less radiation than computed tomographic pulmonary angiography

      Explanation:

      V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA – 1/280,000 versus less than 1/1,000,000 – but carries a lower risk of maternal breast cancer. The rest of the options are true.

    • This question is part of the following fields:

      • Respiratory
      40.5
      Seconds
  • Question 16 - A 65 year old retired postman has been complaining of a two-month history...

    Correct

    • A 65 year old retired postman has been complaining of a two-month history of lethargy associated with dyspnoea. He has never smoked and takes no medication. The chest X-ray shows multiple round lesions increasing in size and numbers at the base. There is no hilar lymphadenopathy.   What condition does he most likely have?

      Your Answer: Pulmonary metastases

      Explanation:

      Pulmonary metastasis is seen in 20-54% of extrathoracic malignancies. The lungs are the second most frequent site of metastases from extrathoracic malignancies. Twenty percent of metastatic disease is isolated to the lungs. The development of pulmonary metastases in patients with known malignancies indicates disseminated disease and places the patient in stage IV in TNM (tumour, node, metastasis) staging systems.
      Chest radiography (CXR) is the initial imaging modality used in the detection of suspected pulmonary metastasis in patients with known malignancies. Chest CT scanning without contrast is more sensitive than CXR.
      Breast, colorectal, lung, kidney, head and neck, and uterus cancers are the most common primary tumours with lung metastasis at autopsy. Choriocarcinoma, osteosarcoma, testicular tumours, malignant melanoma, Ewing sarcoma, and thyroid cancer frequently metastasize to lung, but the frequency of these tumours is low.

    • This question is part of the following fields:

      • Respiratory
      19.1
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  • Question 17 - Which of the following regarding malignant mesothelioma is correct? ...

    Correct

    • Which of the following regarding malignant mesothelioma is correct?

      Your Answer: is treated with radiotherapy

      Explanation:

      Malignant mesothelioma is a type of cancer that occurs in the thin layer of tissue that covers the majority of the internal organs (mesothelium).
      Malignant Mesothelioma (MM) is a rare but rapidly fatal and aggressive tumour of the pleura and peritoneum. Aetiology of all forms of mesothelioma is strongly associated with industrial pollutants, of which asbestos is the principal carcinogen.

      Thoracoscopically guided biopsy should be performed if mesothelioma is suggested; the results are diagnostic in 98% of cases. No specific treatment has been found to be of benefit, except radiotherapy, which reduces seeding and invasion through percutaneous biopsy sites.

      Median survival for patients with malignant mesothelioma is 11 months. It is almost always fatal.

    • This question is part of the following fields:

      • Respiratory
      16.5
      Seconds
  • Question 18 - A 57 year old homeless man presents with fever and a productive cough...

    Correct

    • A 57 year old homeless man presents with fever and a productive cough which has green sputum with streaks of blood. A chest x-ray reveals consolidation in the right upper lobe with evidence of cavitation. He is a known alcoholic. What is the most likely causative agent?

      Your Answer: Klebsiella Pneumoniae

      Explanation:

      Infection with Klebsiella organisms occurs in the lungs, where they cause destructive changes. Necrosis, inflammation, and haemorrhage occur within lung tissue, sometimes producing a thick, bloody, mucoid sputum described as currant jelly sputum.
      The illness typically affects middle-aged and older men with debilitating diseases such as alcoholism, diabetes, or chronic bronchopulmonary disease. An increased tendency exists toward abscess formation, cavitation, empyema, and pleural adhesions.

    • This question is part of the following fields:

      • Respiratory
      11.9
      Seconds
  • Question 19 - A young man presents to the clinic with recurrent episodes of breathlessness. Past...

    Correct

    • A young man presents to the clinic with recurrent episodes of breathlessness. Past medical history reveals recurrent episodes of colicky abdominal pain for the past three years. On examination, he has a productive cough with foul smelling sputum. Investigations show: Sputum culture with Heavy growth of Pseudomonas aeruginosa and Haemophilus influenzae. Chest x-ray: Tramline and ring shadows. What is his diagnosis?

      Your Answer: Cystic fibrosis

      Explanation:

      Cystic fibrosis (CF) is a multisystemic, autosomal recessive disorder that predominantly affects infants, children, and young adults. CF is the most common life-limiting genetic disorder in whites, with an incidence of 1 case per 3200-3300 new-borns in the United States.

      People with CF can have a variety of symptoms, including:
      Very salty-tasting skin
      Persistent coughing, at times with phlegm
      Frequent lung infections including pneumonia or bronchitis
      Wheezing or shortness of breath
      Poor growth or weight gain in spite of a good appetite
      Frequent greasy, bulky stools or difficulty with bowel movements
      Male infertility

      Signs of bronchiectasis include the tubular shadows; tram tracks, or horizontally oriented bronchi; and the signet-ring sign, which is a vertically oriented bronchus with a luminal airway diameter that is 1.5 times the diameter of the adjacent pulmonary arterial branch.

      Bronchiectasis is characterized by parallel, thick, line markings radiating from hila (line tracks) in cylindrical bronchiectasis. Ring shadows represent dilated thick-wall bronchi seen in longitudinal section or on-end or dilated bronchi in varicose bronchiectasis.

      Pseudomonas aeruginosa is the key bacterial agent of cystic fibrosis (CF) lung infections, and the most important pathogen in progressive and severe CF lung disease. This opportunistic pathogen can grow and proliferate in patients, and exposure can occur in hospitals and other healthcare settings.

      Haemophilus influenzae is regularly involved in chronic lung infections and acute exacerbations of CF patients

    • This question is part of the following fields:

      • Respiratory
      55
      Seconds
  • Question 20 - A 40 year old truck operator who smokes one and a half packs...

    Correct

    • A 40 year old truck operator who smokes one and a half packs of cigarette per day complains of a cough and fever for the last three days. He also has right-sided chest pain when he inhales. On examination he is slightly cyanosed, has a temperature of 38.1°C, a respiratory rate of 39/min, a BP of 104/71 mm/Hg and a pulse rate of 132/min. He has basal crepitations and dullness to percussion at the right lung base. What could be a probable diagnosis?

      Your Answer: Bronchopneumonia

      Explanation:

      Bronchopneumonia presents as a patchy consolidation involving one or more lobes, usually the dependent lung zones, a pattern attributable to aspiration of oropharyngeal contents.

      Symptoms of bronchopneumonia may be like other types of pneumonia. This condition often begins with flu-like symptoms that can become more severe over a few days. The symptoms include:
      – fever
      – a cough that brings up mucus
      – shortness of breath
      – chest pain
      – rapid breathing
      – sweating
      – chills
      – headaches
      – muscle aches
      – pleurisy, or chest pain that results from inflammation due to excessive coughing
      – fatigue
      – confusion or delirium, especially in older people

      There are several factors that can increase your risk of developing bronchopneumonia. These include:
      – Age: People who are 65 years of age or older, and children who are 2 years or younger, have a higher risk for developing bronchopneumonia and complications from the condition.
      – Environmental: People who work in, or often visit, hospital or nursing home facilities have a higher risk for developing bronchopneumonia.
      – Lifestyle: Smoking, poor nutrition, and a history of heavy alcohol use can increase your risk for bronchopneumonia.
      – Medical conditions: Having certain medical conditions can increase your risk for developing this type of pneumonia. These include: chronic lung disease, such as asthma or chronic obstructive pulmonary disease (COPD), HIV/AIDS, having a weakened immune system due to chemotherapy or the use of immunosuppressive drugs.

    • This question is part of the following fields:

      • Respiratory
      37.5
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (11/20) 55%
Passmed