Archives: Medical Student Finals

MSFinals-5869

A 67-year-old man is three days post-elective low anterior resection for colorectal cancer. He is being managed in the High Dependency Unit. He has developed a cough productive of green phlegm, increased wheeze and breathlessness on minor exertion. He has a background history of smoking. He also suffers from stage 3 chronic obstructive pulmonary disease (COPD) and is a known carbon dioxide retainer. On examination, he is alert; his respiratory rate (RR) is 22 breaths/minute, blood pressure (BP) 126/78 mmHg, pulse 110 bpm, and oxygen saturations 87% on room air. He has mild wheeze and right basal crackles on chest auscultation.
Which of the following initial oxygen treatment routines is most appropriate for this patient?

MSFinals-5870

A middle-aged overweight woman visits the clinic accompanied by her husband. She expresses concern about feeling excessively tired during the day and experiencing frequent episodes of sleepiness.
Her husband reports that she snores heavily at night and sometimes stops breathing. Additionally, her work performance has been declining, and she is at risk of losing her job.
What is the most suitable initial step in managing this patient’s condition?

MSFinals-5871

A 25-year-old refuse collector arrives at the Emergency Department complaining of sudden breathlessness. He has no prior history of respiratory issues or trauma, but does admit to smoking around ten cigarettes a day since his early teenage years. Upon examination, the doctor suspects a potential spontaneous pneumothorax and proceeds to insert a chest drain for treatment. In terms of the intercostal spaces, which of the following statements is accurate?

MSFinals-5872

A 23-year-old man comes to the clinic complaining of sudden onset of difficulty breathing and sharp chest pain that worsens when he inhales. He has no significant medical history and is generally healthy and active. He admits to smoking and drinking occasionally. The patient is diagnosed with a pneumothorax caused by the spontaneous rupture of an apical bulla.
What is the most accurate description of the lung volume and chest wall position in this patient?

MSFinals-5873

A 68-year-old woman presents to the Emergency Department with a 48-hour history of shortness of breath and an increased volume and purulence of sputum. She has a background history of chronic obstructive pulmonary disease (COPD), hypertension and ischaemic heart disease. Her observations show: heart rate (HR) 116 bpm, blood pressure (BP) 124/68 mmHg, respiratory rate (RR) 18 breaths per minute and oxygen saturation (SaO2) 94% on 2l/min via nasal cannulae. She is commenced on treatment for an infective exacerbation of COPD with nebulised bronchodilators, intravenous antibiotics, oral steroids and controlled oxygen therapy with a Venturi mask. After an hour of therapy, the patient is reassessed. Her observations after an hour are: BP 128/74 mmHg, HR 124 bpm, RR 20 breaths per minute and SaO2 93% on 24% O2 via a Venturi mask. Arterial blood gas sampling is performed:
Investigation Result Normal value
pH 7.28 7.35–7.45
PO2 8.6 kPa 10.5–13.5 kPa
pCO2 8.4 kPa 4.6–6.0 kPa
cHCO3- (P)C 32 mmol/l 24–30 mmol/l
Lactate 1.4 mmol/l 0.5–2.2 mmol/l
Sodium (Na+) 134 mmol/l 135–145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
Chloride (Cl-) 116 mmol/l 98-106 mmol/l
Glucose 5.4 mmol/l 3.5–5.5 mmol/l
Following this review and the arterial blood gas results, what is the most appropriate next step in this patient’s management?

MSFinals-5874

A 62-year-old man presents to Accident and Emergency with complaints of chest pain and shortness of breath, which is predominantly worse on the right side. He has been experiencing these symptoms for about 24 hours, but they have worsened since he woke up this morning. The patient reports that the pain is worse on inspiration and that he has never experienced chest pain before. He is mostly bedridden due to obesity but has no history of respiratory issues. The patient is currently receiving treatment for newly diagnosed prostate cancer. There is a high suspicion that he may have a pulmonary embolus (PE). His vital signs are as follows:
Temperature 36.5 °C
Blood pressure 136/82 mmHg
Heart rate 124 bpm
Saturations 94% on room air
His 12-lead electrocardiogram (ECG) shows sinus tachycardia and nothing else.
What would be the most appropriate initial step in managing this case?

MSFinals-5875

A 28-year-old woman presents to the Emergency Department (ED) with sudden onset of shortness of breath and chest pain. She also reports haemoptysis. An ECG shows no signs of ischaemia. Her heart rate is 88 bpm and blood pressure is 130/85 mmHg. The patient flew from Dubai to the UK yesterday. She has type I diabetes mellitus which is well managed. She had a tonsillectomy two years ago and her brother has asthma. She has been taking the combined oral contraceptive pill for six months and uses insulin for her diabetes but takes no other medications.
What is the most significant risk factor for the likely diagnosis?

MSFinals-5876

A trauma call is initiated in the Emergency Department after a young cyclist is brought in following a road traffic collision. The cyclist was riding on a dual carriageway when a car collided with them side-on, causing them to land in the middle of the road with severe injuries, shortness of breath, and chest pain. A bystander called an ambulance which transported the young patient to the Emergency Department. The anaesthetist on the trauma team assesses the patient and diagnoses them with a tension pneumothorax. The anaesthetist then inserts a grey cannula into the patient’s second intercostal space in the mid-clavicular line. Within a few minutes, the patient expresses relief at being able to breathe more easily.

What signs would the anaesthetist have observed during the examination?

MSFinals-5877

A 68-year-old retired plumber presents with progressive shortness of breath, haemoptysis and weight loss. He has a smoking history of 25 pack years.
A focal mass is seen peripherally in the left lower lobe on chest X-ray (CXR).
Serum biochemistry reveals:
Sodium (Na+): 136 mmol/l (normal range: 135–145 mmol/l)
Potassium (K+): 3.8 mmol/l (normal range: 3.5–5.0 mmol/l)
Corrected Ca2+: 3.32 mmol/l (normal range: 2.20–2.60 mmol/l)
Urea: 6.8 mmol/l (normal range: 2.5–6.5 mmol/l)
Creatinine: 76 μmol/l (normal range: 50–120 µmol/l)
Albumin: 38 g/l (normal range: 35–55 g/l)
What is the most likely diagnosis?

MSFinals-5878

A 40-year-old Afro-Caribbean man comes to the clinic complaining of fever, dry cough and joint pains. Upon examination, his chest is clear. He has several tender, warm, erythematous nodules on both shins. A chest X-ray reveals prominent hila bilaterally. What is the most probable diagnosis?