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Question 1
Correct
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A 20 year old woman presents to the hospital with sharp, left-sided chest pain and shortness of breath.
On examination her pulse is 101 beats per minute and blood pressure is 124/61 mmHg. She is seen to be mildly breathless at rest but her oxygen saturation on air was 98%.
CXR reveals a left pneumothorax with a 4 cm rim of air visible.
Which management strategy is appropriate in this patient?Your Answer: Needle aspiration
Explanation:Pneumothorax is defined as air in the pleural space and may be classified as spontaneous, traumatic or iatrogenic. Primary spontaneous pneumothorax occurs in patients without clinically apparent lung disease.
Primary pneumothorax has an incidence of 18-28 per 100,000 per year for men and 1.2-6 per 100,000 per year for women. Most patients present with ipsilateral pleuritic chest pain and acute shortness of breath. Shortness of breath is largely dependent on the size of the pneumothorax and whether there is underlying chronic lung disease.Young patients may have chest pain only. Most episodes of pneumothorax occur at rest. Symptoms may resolve within 24 hours in patients with primary spontaneous pneumothorax. The diagnosis of a pneumothorax is confirmed by finding a visceral pleural line displaced from the chest wall, without distal lung markings, on a posterior-anterior chest radiograph.
Breathless patients should not be left without intervention regardless of the size of pneumothorax. If there is a rim of air >2cm on the chest X-ray, this should be aspirated.
Aspiration is successful in approximately 70 per cent of patients; the patient may be discharged subsequently. A further attempt at aspiration is recommended if the patient remains symptomatic and a volume of less than 2.5 litres has been aspirated on the first attempt.If unsuccessful, an intercostal drain is inserted. This may be removed after 24 hours after full re-expansion or cessation of air leak without clamping and discharge may be considered.
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This question is part of the following fields:
- Respiratory
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Question 2
Incorrect
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Which of the statements is most accurate regarding the lung?
Your Answer:
Correct Answer: The medial basal segment is absent in the left lower lobe
Explanation:The right and left lung anatomy are similar but asymmetrical. The right lung consists of three lobes: right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL). The left lung consists of two lobes: right upper lobe (RUL) and right lower lobe (RLL). The right lobe is divided by an oblique and horizontal fissure, where the horizontal fissure divides the upper and middle lobe, and the oblique fissure divides the middle and lower lobes. In the left lobe there is only an oblique fissure that separates the upper and lower lobe.
The lobes further divide into segments which are associated with specific segmental bronchi. Segmental bronchi are the third-order branches off the second-order branches (lobar bronchi) that come off the main bronchus.
The right lung consists of ten segments. There are three segments in the RUL (apical, anterior and posterior), two in the RML (medial and lateral), and five in the RLL (superior, medial, anterior, lateral, and posterior). The oblique fissure separates the RUL from the RML, and the horizontal fissure separates the RLL from the RML and RUL.
There are eight to nine segments on the left depending on the division of the lobe. In general, there are four segments in the left upper lobe (anterior, apicoposterior, inferior and superior lingula) and four or five in the left lower lobe (lateral, anteromedial, superior and posterior). The medium sized airways offer the maximum airway resistance, not smaller ones.
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This question is part of the following fields:
- Respiratory
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Question 3
Incorrect
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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:
Correct 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
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Question 4
Incorrect
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Which of the following parameters is increased as a result of asthma?
Your Answer:
Correct Answer: Residual volume
Explanation:In asthma, a reversible increase in residual volume (RV), functional residual capacity (FRC), and total lung capacity (TLC) may occur. There is a fall in FEV1, FVC and gas transfer.
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This question is part of the following fields:
- Respiratory
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Question 5
Incorrect
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A 14 year old girl with cystic fibrosis (CF) presents with abdominal pain.
Which of the following is the pain most likely linked to?Your Answer:
Correct Answer: Meconium ileus equivalent syndrome
Explanation:Meconium ileus equivalent (MIE) can be defined as a clinical manifestation in cystic fibrosis (CF) patients caused by acute intestinal obstruction by putty-like faecal material in the cecum or terminal ileum. A broader definition includes a more chronic condition in CF patients with abdominal pain and a coecal mass which may eventually pass spontaneously. The condition occurs only in CF patients with exocrine pancreatic insufficiency (EPI). It has not been seen in other CF patients nor in non-CF patients with EPI. The frequency of these symptoms has been reported as 2.4%-25%.
The treatment should primarily be non-operative. Specific treatment with N-acetylcysteine, administrated orally and/or as an enema is recommended. Enemas with the water soluble contrast medium, meglucamine diatrizoate (Gastrografin), provide an alternative form for treatment and can also serve diagnostic purposes. It is important that the physician is familiar with this disease entity and the appropriate treatment with the above mentioned drugs. Non-operative treatment is often effective, and dangerous complications following surgery can thus be avoided.
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This question is part of the following fields:
- Respiratory
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Question 6
Incorrect
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Which area in the body controls the hypoxic drive to breathe?
Your Answer:
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.
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This question is part of the following fields:
- Respiratory
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Question 7
Incorrect
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A 73 year old woman attends COPD clinic for review. Her blood gases were checked on her last visit two months back. The test was repeated again today.
The paO2 on both occasions was 6.8 kPa. There is no CO2 retention on 28% O2. She stopped smoking around 6 months ago and is maintained on combination inhaled steroids and long acting b2-agonist therapy.
What is the next best step in management?Your Answer:
Correct Answer: Suggest she uses an oxygen concentrator for at least 19 h per day
Explanation:Long-term oxygen therapy (LTOT) ≥ 15 h/day improves survival in hypoxemic chronic obstructive pulmonary disease (COPD). It significantly helps in reducing pulmonary hypertension associated with COPD and treating underlying pathology of future heart failure. There is little to no benefit of oxygen therapy for less than 15 hours.
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This question is part of the following fields:
- Respiratory
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Question 8
Incorrect
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How should DVT during pregnancy be managed?
Your Answer:
Correct Answer: Dalteparin
Explanation:Deep vein thrombosis (DVT) is a serious condition in which a blood clot forms in a deep vein, usually in the leg.
Subcutaneous low molecular weight heparin (LMWH) is the preferred treatment for most patients with acute DVT, including in pregnancy. A large meta-analyses comparing LMWH to unfractionated heparin (UFH) showed that LMWH decreased the risk of mortality, recurrent veno-thrombo embolism (VTE), and haemorrhage compared with heparin. Other advantages of LMWH may include more predictable therapeutic response, ease of administration and monitoring, and less heparin-induced thrombocytopenia. Disadvantages of LMWH include cost and longer half-life compared with heparin.
Warfarin, which is administered orally, is used if long-term anticoagulation is needed. The international normalized ratio (INR) is followed, with a target range of 2-3. Warfarin crosses the placenta and is teratogenic, causing a constellation of anomalies known as warfarin embryopathy, with greatest risk between the sixth and twelfth week of gestation.
Other options are not indicated for use. -
This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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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:
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.
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This question is part of the following fields:
- Respiratory
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Question 10
Incorrect
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A 54 year old male, with a smoking history of 15 pack years presents with worsening dyspnoea, fever and cough. He works at a foundry. Vitals are as follows:
Respiratory rate: 28/min
Heart rate: 80 bpm
Temp: 37.6C
Chest auscultation reveals bilateral crepitations throughout the lung fields.
Calcified hilar nodules are visible on the chest X-ray. Further evaluation shows an eggshell calcification on HRCT.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Silicosis
Explanation:Silicosis is a common occupational lung disease that is caused by the inhalation of crystalline silica dust. Silica is the most abundant mineral on earth. Workers that are involved for example in construction, mining, or glass production are among the individuals with the highest risk of developing the condition. Acute silicosis causes severe symptoms (e.g., exertional dyspnoea, cough with sputum) and has a very poor prognosis.
Chronic silicosis has a very variable prognosis and affected individuals may remain asymptomatic for several decades. However, radiographic signs are usually seen early on. Typical radiographic findings are calcifications of perihilar lymph nodes, diffuse ground glass opacities, large numbers of rounded, solitary nodules or bigger, confluent opacities. Avoiding further exposure to silica is crucial, especially since the only treatment available is symptomatic (e.g., bronchodilators). Silicosis is associated with an increased risk of tuberculosis and lung cancer. Berylliosis typically affects individuals who are exposed to aerospace industry. Histoplasmosis and tuberculosis do not form eggshell calcifications. -
This question is part of the following fields:
- Respiratory
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Question 11
Incorrect
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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:
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 unitRecent 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 aztreonamTherefore the appropriate treatment would be Cefotaxime and erythromycin.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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Briefly state the mechanism of action of salbutamol.
Your Answer:
Correct Answer: Beta2 receptor agonist which increases cAMP levels and leads to muscle relaxation and bronchodilation
Explanation:Salbutamol stimulates beta-2 adrenergic receptors, which are the predominant receptors in bronchial smooth muscle (beta-2 receptors are also present in the heart in a concentration between 10% and 50%).
Stimulation of beta-2 receptors leads to the activation of enzyme adenyl cyclase that forms cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This increase of cyclic AMP relaxes bronchial smooth muscle and decrease airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles.
Increased cyclic AMP concentrations also inhibits the release of bronchoconstrictor mediators such as histamine and leukotriene from the mast cells in the airway.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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An 80 year-old Zimbabwean woman with known rheumatoid arthritis was admitted to hospital with a four week history of weight loss, night sweats and cough. She was given a course of Amoxicillin for the past week but her condition deteriorated and she was referred to the hospital when she developed haemoptysis.
She was on maintenance prednisolone 10 mg once per day and four weeks earlier, she had received infliximab for a flare up of rheumatoid arthritis. She lived with her husband but had been admitted to hospital himself with influenza four days earlier. She was a lifelong non-smoker and worked most of her life as a missionary in Zimbabwe and South Africa.
On examination she looked cachexic and was pyrexial with a temperature of 38.5°C. Her blood pressure was 181/101 mmHg, pulse 121 beats per minute and oxygen saturations of 89% on room air. Her heart sounds were normal and there were no audible murmurs. Auscultation of her lung fields revealed bronchial breath sounds in the left upper zone. Examination of her abdomen was normal.
Mantoux test < 5mm (after 48 hours)
A chest radiograph revealed cavitating left upper lobe consolidation.
What is the most likely diagnosis?Your Answer:
Correct Answer: Post-primary tuberculosis
Explanation:Post-primary pulmonary tuberculosis is a chronic disease commonly caused by either endogenous reactivation of a latent infection or exogenous re-infection by Mycobacterium tuberculosis.
Post-primary pulmonary tuberculosis (also called reactivation tuberculosis) develops in 5%–20% of patients infected with M. tuberculosis.Found mainly in adults, this form of tuberculosis arises from the reactivation of bacilli that lay dormant within a fibrotic area of the lung. In adults, reinfection with a strain of mycobacterium that differs from that which caused the primary infection is also possible. Predisposing factors include immunosuppression, diabetes, malnutrition and alcoholism.
Infliximab is a monoclonal antibody against tumour necrosis factor α (TNF-α). It is FDA approved for many autoimmune conditions, including rheumatoid arthritis and Crohn’s disease. One of the many known side effects of infliximab therapy is reactivation of latent tuberculosis (TB). Because of the resemblances in clinical and radiological features, tubercular lesions in the lung may mimic malignancy. TB accounts for 27% of all infections initially presumed to be lung cancer on imaging studies.
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This question is part of the following fields:
- Respiratory
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Question 14
Incorrect
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Which of the following measurements is a poor prognostic factor in patients suffering from pneumonia?
Your Answer:
Correct Answer: Respiratory rate 35/min
Explanation:CURB Pneumonia Severity Score estimates the mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment.
Select Criteria:
Confusion (abbreviated Mental Test Score <=8) (1 point)
Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
Respiratory Rate > 30 per minute (1 point)
Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) The CURB-65 scores range from 0 to 5. Clinical management decisions can be made based on the score:
Score Risk Disposition
0 or 1 – 1.5% mortality – Outpatient care
2 – 9.2% mortality – Inpatient vs. observation admission
≥ 3 – 22% mortality – Inpatient admission with consideration for ICU admission with score of 4 or 5 -
This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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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 statement is incorrect regarding the management of this case?Your Answer:
Correct Answer:
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.
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This question is part of the following fields:
- Respiratory
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Question 16
Incorrect
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A 20 year old heroin addict is admitted following an overdose. She is drowsy and has a respiratory rate of 6 bpm. Which of the following arterial blood gas results (taken on room air) are most consistent with this?
Your Answer:
Correct Answer: pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa
Explanation:In mild-to-moderate heroin overdoses, arterial blood gas (ABG) analysis reveals respiratory acidosis. In more severe overdoses, tissue hypoxia is common, leading to mixed respiratory and metabolic acidosis.
The normal range for PaCO2 is 35-45 mmHg (4.67 to 5.99 kPa). Respiratory acidosis can be acute or chronic. In acute respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range (i.e., >45 mm Hg) with an accompanying academia (i.e., pH < 7.35). In chronic respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range, with a normal or near-normal pH secondary to renal compensation and an elevated serum bicarbonate levels (i.e., >30 mEq/L).
Arterial blood gases with pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa would indicate respiratory acidosis.
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This question is part of the following fields:
- Respiratory
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Question 17
Incorrect
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Which one of the following paraneoplastic features is less likely to be seen in patients with squamous cell lung cancer?
Your Answer:
Correct Answer: Lambert-Eaton syndrome
Explanation:Lambert-Eaton myasthenic syndrome (LEMS) is a rare presynaptic disorder of neuromuscular transmission in which release of acetylcholine (ACh) is impaired, causing a unique set of clinical characteristics, which include proximal muscle weakness, depressed tendon reflexes, post-tetanic potentiation, and autonomic changes.
In 40% of patients with LEMS, cancer is present when the weakness begins or is found later. This is usually a small cell lung cancer (SCLC). However, LEMS has also been associated with non-SCLC, lymphosarcoma, malignant thymoma, or carcinoma of the breast, stomach, colon, prostate, bladder, kidney, or gallbladder.
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This question is part of the following fields:
- Respiratory
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Question 18
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Respiratory
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Question 19
Incorrect
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Which virus is severe acute respiratory syndrome (SARS) caused by?
Your Answer:
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
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Question 20
Incorrect
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A 14 year old known asthmatic presents to the A&E department with difficulty breathing. She was seen by her regular doctor the day before with a sore throat which he diagnosed as tonsillitis and was prescribed oral Amoxicillin for 5 days.
Past medical history:
Ulcerative colitis diagnosed four years ago.
Current medications:
Inhaled salbutamol and beclomethasone
Mesalazine 400 mg TDS
She was observed to be alert and oriented but she had laboured breathing. Inspiratory wheeze was noted. She was pale, sweaty and cyanosed. Her temperature was 36.7ºC, pulse 121/minute and blood pressure 91/40 mmHg. The lungs were clear and the remainder of the examination was normal. She was given high-flow oxygen through a face mask but despite this her breathing became increasingly difficult.
What is the most likely causative agent?
Your Answer:
Correct Answer: Haemophilus influenzae
Explanation:Acute epiglottitis is a life-threatening disorder with serious implications to the anaesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. There is inflammatory oedema of the arytenoids, aryepiglottic folds and the epiglottis; therefore, supraglottitis may be used instead or preferred to the term acute epiglottitis.
Acute epiglottitis can occur at any age. The responsible organism used to be Hemophilus influenzae type B (Hib), but infection with group A b-haemolytic Streptococci has become more frequent after the widespread use of Hemophilus influenzae vaccination.
The typical presentation in epiglottitis includes acute occurrence of high fever, severe sore throat and difficulty in swallowing with the sitting up and leaning forward position in order to enhance airflow. There is usually drooling because of difficulty and pain on swallowing. Acute epiglottitis usually leads to generalized toxaemia. The most common differential diagnosis is croup and a foreign body in the airway. A late referral to an acute care setting with its serious consequences may result from difficulty in differentiation between acute epiglottitis and less urgent causes of a sore throat, shortness of breath and dysphagia.
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This question is part of the following fields:
- Respiratory
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Question 21
Incorrect
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A 28 year old female hiker begins complaining of headache and nausea after reaching a height of 5010 metres. Despite having the headache and feeling nauseous, she continues to hike but becomes progressively worse. She is seen staggering, complains of feeling dizzy and has an ataxic gait.
Which of the following is the appropriate treatment of this patient?Your Answer:
Correct Answer: Descent + dexamethasone
Explanation:High Altitude Cerebral Oedema (HACE) is a severe and potentially fatal manifestation of high altitude illness and is often characterized by ataxia, fatigue, and altered mental status. HACE is often thought of as an extreme form/end-stage of Acute Mountain Sickness (AMS). Although HACE represents the least common form of altitude illness, it may progress rapidly to coma and death as a result of brain herniation within 24 hours, if not promptly diagnosed and treated.
HACE generally occurs after 2 days above 4000m but can occur at lower elevations (2500m) and with faster onset. Some, but not all, individuals will suffer from symptoms of AMS such as headache, insomnia, anorexia, nausea prior to transitioning to HACE. Some may also have concomitant High Altitude Pulmonary Oedema (HAPE). HACE in isolation is rare, but the absence of concomitant HAPE or symptoms of AMS prior to deterioration does not rule-out the presence of HACE.
Most cases develop as a progression of AMS and will include a history of recent ascent to altitude and prior complaints/findings of AMS including a headache, fatigue, nausea, insomnia, and/or light-headedness. Some may also have signs/symptoms of HAPE. Transition to HACE is heralded by signs of encephalopathy including ataxia (usually the earliest clinical finding) and altered mentation which may range from mild to severe. Other symptoms may include a more severe headache, difficulty speaking, lassitude, a decline in the level of consciousness, and/or focal neurological deficits or seizures.
The mainstay of treatment is the immediate descent of at least 1000m or until symptoms improve. If descent is not an option, one may use a portable hyperbaric chamber and/or supplemental oxygen to temporize illness, but this should never replace or delay evaluation/descent when possible. If available, dexamethasone 8mg for one dose, followed by 4mg every 6 hours should be given to adults via PO, IM, or IV routes.
Acetazolamide has proven to be beneficial in only a single clinical study. The suggested dosing regimen for Acetazolamide is 250 mg PO, given twice daily. Though effective in alleviating or temporizing symptoms, none of the adjunct treatment modalities are definitive or a replacement for an immediate descent. -
This question is part of the following fields:
- Respiratory
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Question 22
Incorrect
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A patient with a history of asthma presents with worsening of her symptoms and dyspnoea. She recently started taking a new medicine and she feels it might have aggravated her symptoms.
Which of the following is likely responsible for her symptoms?Your Answer:
Correct Answer: Timolol eye drops
Explanation:β-blockers are the class of drug most often chosen to treat glaucoma, although other medical therapies are available. Systemic absorption of timolol eye drops can cause unsuspected respiratory impairment and exacerbation of asthma. Physicians should be alert to the possibility of respiratory side-effects of topical therapy with β-blockers. Leukotriene antagonists and salbutamol are used in asthma treatment. HRT and ferrous sulphate do not lead to the exacerbation of asthma.
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This question is part of the following fields:
- Respiratory
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Question 23
Incorrect
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A 40 year old farmer who is a non-smoker is experiencing increasing shortness of breath on exertion. He has been having chest tightness and a non-productive cough which becomes worse when he is at the dairy farm. He has no respiratory history of note. Extrinsic allergic alveolitis is the suspected diagnosis. Which factor would be responsible for this diagnosis?
Your Answer:
Correct Answer: Contaminated hay
Explanation:Extrinsic allergic alveolitis (EAA) refers to a group of lung diseases that can develop after exposure to certain substances. The name describes the origin and the nature of these diseases:
‘extrinsic’ – caused by something originating outside the body
‘allergic’ – an abnormally increased (hypersensitive) body reaction to a common substance
‘alveolitis’ – inflammation in the small air sacs of the lungs (alveoli)Symptoms can include: fever, cough, worsening breathlessness and weight loss. The diagnosis of the disease is based on a history of symptoms after exposure to the allergen and a range of clinical tests which usually includes: X-rays or CT scans, lung function and blood tests.
EAA is not a ‘new’ occupational respiratory disease and occupational causes include bacteria, fungi, animal proteins, plants and chemicals.
Examples of EAA include:
Farmer’s lung
This is probably the most common occupational form of EAA and is the outcome of an allergic response to a group of microbes, which form mould on vegetable matter in storage. During the handling of mouldy straw, hay or grain, particularly in a confined space such as a poorly ventilated building, inhalation of spores and other antigenic material is very likely.There also appears to be a clear relationship between water content of crops, heating (through mould production) and microbial growth, and this would apply to various crops and vegetable matter, with the spores produced likely to cause EAA.
Farmer’s lung can be prevented by drying crops adequately before storage and by ensuring good ventilation during storage. Respiratory protection should also be worn by farm workers when handling stored crops, particularly if they have been stored damp or are likely to be mouldy.
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This question is part of the following fields:
- Respiratory
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Question 24
Incorrect
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A 21 year old university student is taken to the A&E. She lives alone in a small apartment. She is normally fit and well but she has been complaining of difficulty concentrating in classes. She is a one pack per day smoker and she has no significant past medical history. She is also not on any medication.
She had a pulse of 123 beats per minute and her blood pressure was measured to be 182/101mmHg. She looked flushed. Chest x-ray was normal and her oxygen saturations were normal. She has typical features of carbon monoxide poisoning.
Initial investigations showed:
Haemoglobin 13.0 g/dL (11.5-16.5)
White cell count 10.3 x109/L (4-11 x109)
Platelets 281 x109/L (150-400 x109)
Serum sodium 133 mmol/L (137-144)
Serum potassium 3.7 mmol/L (3.5-4.9)
Serum urea 7.3 mmol/L (2.5-7.5)
Serum creatinine 83 μmol/L (60-110)
Drug screen Negative
Arterial blood gases on air:
pO2 7.9 kPa (11.3-12.6)
pCO2 4.7 kPa (4.7-6.0)
pH 7.43 (7.36-7.44)
Which test would confirm this diagnosis?Your Answer:
Correct Answer:
Explanation:Carbon monoxide (CO) is a colourless, odourless gas produced by incomplete combustion of carbonaceous material. Clinical presentation in patients with CO poisoning ranges from headache and dizziness to coma and death. Hyperbaric oxygen therapy can significantly reduce the morbidity of CO poisoning, but a portion of survivors still suffer significant long-term neurologic and affective sequelae.
Complaints:
Malaise, flulike symptoms, fatigue
Dyspnoea on exertion
Chest pain, palpitations
Lethargy
Confusion
Depression
Impulsiveness
Distractibility
Hallucination, confabulation
Agitation
Nausea, vomiting, diarrhoea
Abdominal pain
Headache, drowsiness
Dizziness, weakness, confusion
Visual disturbance, syncope, seizure
Faecal and urinary incontinence
Memory and gait disturbances
Bizarre neurologic symptoms, comaVital signs may include the following:
Tachycardia
Hypertension or hypotension
Hyperthermia
Marked tachypnoea (rare; severe intoxication often associated with mild or no tachypnoea)
Although so-called cherry-red skin has traditionally been considered a sign of CO poisoning, it is in fact rare.The clinical diagnosis of acute carbon monoxide (CO) poisoning should be confirmed by demonstrating an elevated level of carboxyhaemoglobin (HbCO). Either arterial or venous blood can be used for testing. Analysis of HbCO requires direct spectrophotometric measurement in specific blood gas analysers. Elevated CO levels of at least 3–4% in non-smokers and at least 10% in smokers are significant.
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This question is part of the following fields:
- Respiratory
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Question 25
Incorrect
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Which type of cell is responsible for the production of surfactant?
Your Answer:
Correct Answer: Type II pneumocyte
Explanation:Type I pneumocyte: The cell responsible for the gas (oxygen and carbon dioxide) exchange that takes place in the alveoli. It is a very thin cell stretched over a very large area. This type of cell is susceptible to a large number of toxic insults and cannot replicate itself.
Type II pneumocyte: The cell responsible for the production and secretion of surfactant (the molecule that reduces the surface tension of pulmonary fluids and contributes to the elastic properties of the lungs). The type 2 pneumocyte is a smaller cell that can replicate in the alveoli and will replicate to replace damaged type 1 pneumocytes. Alveolar macrophages are the primary phagocytes of the innate immune system, clearing the air spaces of infectious, toxic, or allergic particles that have evaded the mechanical defences of the respiratory tract, such as the nasal passages, the glottis, and the mucociliary transport system. The main role of goblet cells is to secrete mucus in order to protect the mucous membranes where they are found. Goblet cells accomplish this by secreting mucins, large glycoproteins formed mostly by carbohydrates. -
This question is part of the following fields:
- Respiratory
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Question 26
Incorrect
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A 52 year old female, known case of rheumatoid arthritis presents to the clinic with dyspnoea, cough, and intermittent pleuritic chest pain. She was previously taking second line agents Salazopyrine and gold previously and has now started Methotrexate with folic acid replacement a few months back. Pulmonary function tests reveal restrictive lung pattern and CXR reveals pulmonary infiltrates.
Which of the following treatments is most suitable in this case?Your Answer:
Correct Answer: Stop methotrexate
Explanation:Methotrexate lung disease (pneumonitis and fibrosis) is the specific etiological type of drug-induced lung disease. It can occur due to the administration of methotrexate which is an antimetabolite, which is given as disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxemia and tachypnoea are always present and crackles are frequently audible. Symptoms typically manifest within months of starting therapy. Methotrexate withdrawal is indicated in such cases.
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This question is part of the following fields:
- Respiratory
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Question 27
Incorrect
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A 32 year old male with a history of smoking half a pack of cigarettes per day complains of worsening breathlessness on exertion. He was working as a salesman until a few months ago. His father passed away due to severe respiratory disease at a relatively young age. Routine blood examination reveals mild jaundice with bilirubin level of 90 µmol/l. AST and ALT are also raised. Chest X-ray reveals basal emphysema. Which of the following explanation is most likely the cause of these symptoms?
Your Answer:
Correct Answer: α-1-Antitrypsin deficiency
Explanation:Alpha-1 antitrypsin deficiency is an inherited disorder that may cause lung and liver disease. The signs and symptoms of the condition and the age at which they appear vary among individuals. This would be the most likely option as it is the only disease that can affect both liver and lung functions.
People with alpha-1 antitrypsin deficiency usually develop the first signs and symptoms of lung disease between ages 20 and 50. The earliest symptoms are shortness of breath following mild activity, reduced ability to exercise, and wheezing. Other signs and symptoms can include unintentional weight loss, recurring respiratory infections, fatigue, and rapid heartbeat upon standing. Affected individuals often develop emphysema. Characteristic features of emphysema include difficulty breathing, a hacking cough, and a barrel-shaped chest. Smoking or exposure to tobacco smoke accelerates the appearance of emphysema symptoms and damage to the lungs.
About 10 percent of infants with alpha-1 antitrypsin deficiency develop liver disease, which often causes yellowing of the skin and sclera (jaundice). Approximately 15 percent of adults with alpha-1 antitrypsin deficiency develop liver damage (cirrhosis) due to the formation of scar tissue in the liver. Signs of cirrhosis include a swollen abdomen, swollen feet or legs, and jaundice. Individuals with alpha-1 antitrypsin deficiency are also at risk of developing hepatocellular carcinoma. -
This question is part of the following fields:
- Respiratory
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Question 28
Incorrect
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A 75 year old man was admitted to the hospital with worsening dyspnoea. He was given a five day course of Amoxicillin.
On examination, his blood pressure was 89/59 mmHg with a respiratory rate of 35/min. A chest x-ray revealed left lower lobe consolidation.
Past medical history: Type 2 diabetes mellitus
Arterial blood gas on air:
pH 7.34
pCO2 5.4 kPa
pO2 9.0 kPa
Which antibiotic therapy is the most suitable?Your Answer:
Correct Answer: Intravenous co-amoxiclav + clarithromycin
Explanation:CURB Pneumonia Severity Score:
– Confusion (abbreviated Mental Test Score <=8) (1 point)
– Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
– Respiratory Rate > 30 per minute (1 point)
– Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) Based on the CURB Pneumonia Severity Score, the patient has severe pneumonia. According to the 2009 Centres for Medicare and Medicaid Services (CMS) and Joint Commission consensus guidelines, inpatient treatment of pneumonia should be given within four hours of hospital admission (or in the emergency department if this is where the patient initially presented) and should consist of the following antibiotic regimens, which are also in accordance with IDSA/ATS guidelines. For non-intensive care unit (ICU) patients:
Beta-lactam (intravenous [IV] or intramuscular [IM] administration) plus macrolide (IV or oral [PO])
Beta-lactam (IV or IM) plus doxycycline (IV or PO)
Antipneumococcal quinolone monotherapy (IV or IM)If the patient is younger than 65 years with no risk factors for drug-resistant organisms, administer macrolide monotherapy (IV or PO)
For ICU patients:
IV beta-lactam plus IV macrolide
IV beta-lactam plus IV antipneumococcal quinoloneIf the patient has a documented beta-lactam allergy, administer IV antipneumococcal quinolone plus IV aztreonam.
The most suitable antibiotic therapy for this patient is therefore Intravenous co-amoxiclav + clarithromycin.
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This question is part of the following fields:
- Respiratory
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Question 29
Incorrect
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A 26 year old male from Eastern Europe has been experiencing night sweats, fevers, and decreased weight for several months. He also has a chronic cough which at times consists of blood. He is reviewed at the clinic and a calcified lesion was detected in his right lung with enlarged calcified right hilar lymph nodes. His leukocytes are just below normal range and there is a normochromic normocytic anaemia. Acid-fast bacilli (AFB) are found in one out of five sputum samples. Sputum is sent for extended culture.
Which diagnosis fits best with his signs and symptoms?Your Answer:
Correct Answer: Active pulmonary tuberculosis
Explanation:Classic clinical features associated with active pulmonary TB are as follows (elderly individuals with TB may not display typical signs and symptoms):
– Cough
– Weight loss/anorexia
– Fever
– Night sweats
– Haemoptysis
– Chest pain (can also result from tuberculous acute pericarditis)
– FatigueTest:
Acid-fast bacilli (AFB) smear and culture – Using sputum obtained from the patient.
AFB stain is quick but requires a very high organism load for positivity, as well as the expertise to read the stained sample. This test is more useful in patients with pulmonary disease.
Obtain a chest radiograph to evaluate for possible associated pulmonary findings. If chest radiography findings suggest TB and a sputum smear is positive for AFB, initiate treatment for TB. -
This question is part of the following fields:
- Respiratory
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Question 30
Incorrect
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A 66-year-old man with newly-diagnosed small cell carcinoma discusses his further treatment options with the team of doctors.
Which statement is incorrect about small cell carcinoma?Your Answer:
Correct Answer: Patients with small cell lung cancer always benefit from surgery
Explanation:Small cell lung cancer (SCLC) is characterized by rapid growth and early dissemination. Prompt initiation of treatment is important.
Patients with clinical stage Ia (T1N0) after standard staging evaluation may be considered for surgical resection, but combined treatment with chemotherapy and radiation therapy is the standard of care. Radiation therapy is often added at the second cycle of chemotherapy.
Historically, patients undergoing surgery for small cell lung cancer (SCLC) had a dismal prognosis. However, more recent data suggest that patients with true stage I SCLC may benefit from surgical resection.
Common sites of hematogenous metastases include the brain, bones, liver, adrenal glands, and bone marrow. The symptoms depend upon the site of spread.
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This question is part of the following fields:
- Respiratory
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