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  • Question 1 - A 56-year-old man has been diagnosed with small cell lung carcinoma. The tumor...

    Incorrect

    • A 56-year-old man has been diagnosed with small cell lung carcinoma. The tumor measures 4 centimeters in its largest dimension and is not invading any surrounding structures. However, there are metastases in the ipsilateral hilar lymph nodes, and no distant metastases have been found. What is the TNM score for this patient, considering the primary tumor (T), regional lymph nodes (N), and distant metastases (M)?

      Your Answer:

      Correct Answer: T2 N1 M0

      Explanation:

      It is crucial to have knowledge about the TNM system for staging lung cancer. The absence of distant metastases eliminates one of the options immediately (as M must be 0).

      The size and invasion of the tumor are significant factors:
      – T1 is less than 3 cm
      – T2 is between 3 cm and 7 cm
      – T3 is more than 7 cm and/or involves invasion of the chest wall, parietal pleura, diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium
      – T4 can be any size but involves invasion of other structures

      To differentiate between N1 and N2, remember that N1 involves ipsilateral hilar or peribronchial lymph nodes, while N2 involves ipsilateral mediastinal and/or subcarinal lymph nodes.

      Small Cell Lung Cancer: Characteristics and Management

      Small cell lung cancer is a type of lung cancer that usually develops in the central part of the lungs and arises from APUD cells. This type of cancer is often associated with the secretion of hormones such as ADH and ACTH, which can cause hyponatremia and Cushing’s syndrome, respectively. In addition, ACTH secretion can lead to bilateral adrenal hyperplasia and hypokalemic alkalosis due to high levels of cortisol. Patients with small cell lung cancer may also experience Lambert-Eaton syndrome, which is characterized by antibodies to voltage-gated calcium channels causing a myasthenic-like syndrome.

      Management of small cell lung cancer depends on the stage of the disease. Patients with very early stage disease may be considered for surgery, while those with limited disease typically receive a combination of chemotherapy and radiotherapy. Patients with more extensive disease are offered palliative chemotherapy. Unfortunately, most patients with small cell lung cancer are diagnosed with metastatic disease, making treatment more challenging.

      Overall, small cell lung cancer is a complex disease that requires careful management and monitoring. Early detection and treatment can improve outcomes, but more research is needed to better understand the underlying mechanisms of this type of cancer.

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  • Question 2 - A 42-year-old man from Turkey visits his doctor complaining of chronic breathlessness and...

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    • 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:

      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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  • Question 3 - What is the carrier rate of cystic fibrosis in the United Kingdom? ...

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    • 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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  • Question 4 - A 49-year-old man comes to the clinic with recent onset of asthma and...

    Incorrect

    • 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:

      Correct 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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  • Question 5 - A 65-year-old man presents with a persistent dry cough and unintentional weight loss...

    Incorrect

    • A 65-year-old man presents with a persistent dry cough and unintentional weight loss of 5kg over the past 3 months. He denies experiencing chest pain, dyspnoea, fever or haemoptysis. The patient has a history of smoking 10 cigarettes a day for the last 50 years and has been diagnosed with COPD. A nodule is detected on chest x-ray, and biopsy results indicate a tumour originating from the bronchial glands.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Adenocarcinoma of the lung

      Explanation:

      Adenocarcinoma has become the most prevalent form of lung cancer, originating from the bronchial glands as a type of non-small-cell lung cancer.

      While a bronchogenic cyst may cause chest pain and dysphagia, it is typically diagnosed during childhood and does not stem from the bronchial glands.

      Sarcoidosis may result in a persistent cough and weight loss, but it typically affects multiple systems and does not involve nodules originating from the bronchial glands.

      Small cell carcinoma of the lung is a significant consideration, but given the description of a tumor originating from the bronchial glands, adenocarcinoma is the more probable diagnosis.

      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.

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  • Question 6 - A 9-month-old girl is brought to the emergency department by her mother due...

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    • A 9-month-old girl is brought to the emergency department by her mother due to difficulty in breathing. The mother reports that her daughter has been restless, with a runny nose, feeling warm and a dry cough for the past 4 days. However, the mother is now quite worried because her daughter has not eaten since last night and her breathing seems to have worsened throughout the morning.

      During the examination, the infant has a respiratory rate of 70/min, heart rate of 155/min, oxygen saturation of 92% and a temperature of 37.9ºC. The infant shows signs of nasal flaring and subcostal recession while breathing. On auscultation, widespread wheezing is heard. The infant is admitted, treated with humidified oxygen via nasal cannula and discharged home after 2 days.

      What is the probable causative agent of this infant's illness?

      Your Answer:

      Correct Answer: Respiratory syncytial virus

      Explanation:

      Bronchiolitis typically presents with symptoms such as coryza and increased breathing effort, leading to feeding difficulties in children under one year of age. The majority of cases of bronchiolitis are caused by respiratory syncytial virus, while adenovirus is a less frequent culprit. On the other hand, croup is most commonly caused by parainfluenza virus.

      Understanding Bronchiolitis

      Bronchiolitis is a condition that is characterized by inflammation of the bronchioles. It is a serious lower respiratory tract infection that is most common in children under the age of one year. The pathogen responsible for 75-80% of cases is respiratory syncytial virus (RSV), while other causes include mycoplasma and adenoviruses. Bronchiolitis is more serious in children with bronchopulmonary dysplasia, congenital heart disease, or cystic fibrosis.

      The symptoms of bronchiolitis include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Fine inspiratory crackles may also be present. Children with bronchiolitis may experience feeding difficulties associated with increasing dyspnoea, which is often the reason for hospital admission.

      Immediate referral to hospital is recommended if the child has apnoea, looks seriously unwell to a healthcare professional, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referring to hospital if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration.

      The investigation for bronchiolitis involves immunofluorescence of nasopharyngeal secretions, which may show RSV. Management of bronchiolitis is largely supportive, with humidified oxygen given via a head box if oxygen saturations are persistently < 92%. Nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth, and suction is sometimes used for excessive upper airway secretions.

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  • Question 7 - A 67-year-old man has been diagnosed with stage III lung cancer and is...

    Incorrect

    • A 67-year-old man has been diagnosed with stage III lung cancer and is concerned about potential complications. What are the risks he may face?

      Your Answer:

      Correct Answer: Pneumothorax

      Explanation:

      Pneumothorax is more likely to occur in individuals with lung cancer.

      Pneumothorax: Characteristics and Risk Factors

      Pneumothorax is a medical condition characterized by the presence of air in the pleural cavity, which is the space between the lungs and the chest wall. This condition can occur spontaneously or as a result of trauma or medical procedures. There are several risk factors associated with pneumothorax, including pre-existing lung diseases such as COPD, asthma, cystic fibrosis, lung cancer, and Pneumocystis pneumonia. Connective tissue diseases like Marfan’s syndrome and rheumatoid arthritis can also increase the risk of pneumothorax. Ventilation, including non-invasive ventilation, can also be a risk factor.

      Symptoms of pneumothorax tend to come on suddenly and can include dyspnoea, chest pain (often pleuritic), sweating, tachypnoea, and tachycardia. In some cases, catamenial pneumothorax can be the cause of spontaneous pneumothoraces occurring in menstruating women. This type of pneumothorax is thought to be caused by endometriosis within the thorax. Early diagnosis and treatment of pneumothorax are crucial to prevent complications and improve outcomes.

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  • Question 8 - A 10-year-old boy comes to your clinic with a complaint of ear pain...

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    • A 10-year-old boy comes to your clinic with a complaint of ear pain that started last night and kept him awake. He missed school today because of the pain and reports muffled sounds on the affected side. During otoscopy, you observe a bulging tympanic membrane with visible fluid behind it, indicating a middle ear infection. Can you identify which nerves pass through the middle ear?

      Your Answer:

      Correct Answer: Chorda tympani

      Explanation:

      The chorda tympani is the correct answer. It is a branch of the seventh cranial nerve, the facial nerve, and carries parasympathetic and taste fibers. It passes through the middle ear before exiting and joining with the lingual nerve to reach the tongue and salivary glands.

      The vestibulocochlear nerve is the eighth cranial nerve and carries balance and hearing information.

      The maxillary nerve is the second division of the fifth cranial nerve and carries sensation from the upper teeth, nasal cavity, and skin.

      The mandibular nerve is the third division of the fifth cranial nerve and carries sensation from the lower teeth, tongue, mandible, and skin. It also carries motor fibers to certain muscles.

      The glossopharyngeal nerve is the ninth cranial nerve and carries taste and sensation from the posterior one-third of the tongue, as well as sensation from various areas. It also carries motor and parasympathetic fibers.

      The patient in the question has ear pain, likely due to otitis media, as evidenced by a bulging tympanic membrane and fluid level on otoscopy.

      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 9 - 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:

      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 10 - A 65-year-old man is having a coronary artery bypass surgery. Which structure would...

    Incorrect

    • 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:

      Correct 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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  • Question 11 - What is the embryonic origin of the pulmonary artery? ...

    Incorrect

    • What is the embryonic origin of the pulmonary artery?

      Your Answer:

      Correct Answer: Sixth pharyngeal arch

      Explanation:

      The right pulmonary artery originates from the proximal portion of the sixth pharyngeal arch on the right side, while the distal portion of the same arch gives rise to the left pulmonary artery and the ductus arteriosus.

      The Development and Contributions of Pharyngeal Arches

      During the fourth week of embryonic growth, a series of mesodermal outpouchings develop from the pharynx, forming the pharyngeal arches. These arches fuse in the ventral midline, while pharyngeal pouches form on the endodermal side between the arches. There are six pharyngeal arches, with the fifth arch not contributing any useful structures and often fusing with the sixth arch.

      Each pharyngeal arch has its own set of muscular and skeletal contributions, as well as an associated endocrine gland, artery, and nerve. The first arch contributes muscles of mastication, the maxilla, Meckel’s cartilage, and the incus and malleus bones. The second arch contributes muscles of facial expression, the stapes bone, and the styloid process and hyoid bone. The third arch contributes the stylopharyngeus muscle, the greater horn and lower part of the hyoid bone, and the thymus gland. The fourth arch contributes the cricothyroid muscle, all intrinsic muscles of the soft palate, the thyroid and epiglottic cartilages, and the superior parathyroids. The sixth arch contributes all intrinsic muscles of the larynx (except the cricothyroid muscle), the cricoid, arytenoid, and corniculate cartilages, and is associated with the pulmonary artery and recurrent laryngeal nerve.

      Overall, the development and contributions of pharyngeal arches play a crucial role in the formation of various structures in the head and neck region.

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  • Question 12 - A 43-year-old woman comes to the respiratory clinic for an outpatient appointment. She...

    Incorrect

    • A 43-year-old woman comes to the respiratory clinic for an outpatient appointment. She has been experiencing increased breathlessness, particularly at night. Her medical history includes long-standing COPD, heart failure, and previous breast cancer that was treated with a mastectomy and radiotherapy. She used to smoke 20 cigarettes a day for 22 years but has since quit.

      During the examination, her respiratory rate is 23/min, oxygen saturation is 93%, blood pressure is 124/98mmHg, and temperature is 37.2ºC. A gas transfer test is performed, and her transfer factor is found to be low.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Pulmonary oedema

      Explanation:

      TLCO, also known as transfer factor, is a measurement of how quickly gas can move from a person’s lungs into their bloodstream. To test TLCO, a patient inhales a mixture of carbon monoxide and a tracer gas, holds their breath for 10 seconds, and then exhales forcefully. The exhaled gas is analyzed to determine how much tracer gas was absorbed during the 10-second period.

      A high TLCO value is associated with conditions such as asthma, pulmonary hemorrhage, left-to-right cardiac shunts, polycythemia, hyperkinetic states, male gender, and exercise. Conversely, most other conditions result in a low TLCO value, including pulmonary fibrosis, pneumonia, pulmonary emboli, pulmonary edema, emphysema, and anemia.

      Understanding Transfer Factor in Lung Function Testing

      The transfer factor is a measure of how quickly a gas diffuses from the alveoli into the bloodstream. This is typically tested using carbon monoxide, and the results can be given as either the total gas transfer (TLCO) or the transfer coefficient corrected for lung volume (KCO). A raised TLCO may be caused by conditions such as asthma, pulmonary haemorrhage, left-to-right cardiac shunts, polycythaemia, hyperkinetic states, male gender, or exercise. On the other hand, a lower TLCO may be indicative of pulmonary fibrosis, pneumonia, pulmonary emboli, pulmonary oedema, emphysema, anaemia, or low cardiac output.

      KCO tends to increase with age, and certain conditions may cause an increased KCO with a normal or reduced TLCO. These conditions include pneumonectomy/lobectomy, scoliosis/kyphosis, neuromuscular weakness, and ankylosis of costovertebral joints (such as in ankylosing spondylitis). Understanding transfer factor is important in lung function testing, as it can provide valuable information about a patient’s respiratory health and help guide treatment decisions.

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  • Question 13 - A 49-year-old man experiences blunt force trauma to the head and subsequently experiences...

    Incorrect

    • A 49-year-old man experiences blunt force trauma to the head and subsequently experiences respiratory distress, leading to hypercapnia. What is the most probable consequence of this condition?

      Your Answer:

      Correct Answer: Cerebral vasodilation

      Explanation:

      Cerebral vasodilation is a common result of hypercapnia, which can be problematic for patients with cranial trauma due to the potential increase in intracranial pressure.

      Understanding the Monro-Kelly Doctrine and Autoregulation in the CNS

      The Monro-Kelly doctrine governs the pressure within the cranium by considering the skull as a closed box. The loss of cerebrospinal fluid (CSF) can accommodate increases in mass until a critical point is reached, usually at 100-120ml of CSF lost. Beyond this point, intracranial pressure (ICP) rises sharply, and pressure will eventually equate with mean arterial pressure (MAP), leading to neuronal death and herniation.

      The central nervous system (CNS) has the ability to autoregulate its own blood supply through vasoconstriction and dilation of cerebral blood vessels. However, extreme blood pressure levels can exceed this capacity, increasing the risk of stroke. Additionally, metabolic factors such as hypercapnia can cause vasodilation, which is crucial in ventilating head-injured patients.

      It is important to note that the brain can only metabolize glucose, and a decrease in glucose levels can lead to impaired consciousness. Understanding the Monro-Kelly doctrine and autoregulation in the CNS is crucial in managing intracranial pressure and preventing neurological damage.

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  • Question 14 - A 29-year-old man visits his primary care physician with complaints of a malodorous...

    Incorrect

    • A 29-year-old man visits his primary care physician with complaints of a malodorous discharge from his right ear for the past 3 weeks. The patient also reports experiencing ear pain for the past 2 weeks and occasional mild dizziness. Upon examination, the skin around the ear and pinna appear normal, but the ear canal is filled with debris. After removing the debris, a small perforation and waxy debris are observed on the tympanic membrane.

      The Rinne test indicates that bone conduction is better than air conduction on the right, and the Weber test shows sound lateralization to the right. The patient has no significant medical history and has never presented with an ear problem before.

      What is the most likely condition based on this patient's clinical presentation?

      Your Answer:

      Correct Answer: Cholesteatoma

      Explanation:

      Cholesteatoma is a growth of non-cancerous squamous epithelium that can be observed as an ‘attic crust’ during otoscopy. This patient is displaying symptoms consistent with cholesteatoma, including ear discharge, earache, conductive hearing loss, and dizziness, which suggests that the inner ear has also been affected. It is important to distinguish cholesteatoma from otitis externa, as failure to diagnose cholesteatoma can lead to serious complications. Cholesteatoma can erode the ossicles bones, damage the inner ear and vestibulocochlear nerve, and even result in brain infections if it erodes through the skull bone.

      Otitis externa is an inflammation of the outer ear canal that causes ear pain, which worsens with movement of the outer ear. It is often caused by the use of earplugs or swimming in unclean water. Otitis media is an inflammation of the middle ear that can lead to fluid accumulation and perforation of the tympanic membrane. It is common in children and often follows a viral upper respiratory tract infection. Myringitis is a condition associated with otitis media that causes small vesicles or cysts to form on the surface of the eardrum, resulting in severe pain and hearing impairment. It is caused by viral or bacterial infections and is treated with pain relief and antibiotics.

      Understanding Cholesteatoma

      Cholesteatoma is a benign growth of squamous epithelium that can cause damage to the skull base. It is most commonly found in individuals between the ages of 10 and 20 years old. Those born with a cleft palate are at a higher risk of developing cholesteatoma, with a 100-fold increase in risk.

      The main symptoms of cholesteatoma include a persistent discharge with a foul odor and hearing loss. Other symptoms may occur depending on the extent of the growth, such as vertigo, facial nerve palsy, and cerebellopontine angle syndrome.

      During otoscopy, a characteristic attic crust may be seen in the uppermost part of the eardrum.

      Management of cholesteatoma involves referral to an ear, nose, and throat specialist for surgical removal. Early detection and treatment are important to prevent further damage to the skull base and surrounding structures.

      In summary, cholesteatoma is a non-cancerous growth that can cause significant damage if left untreated. It is important to be aware of the symptoms and seek medical attention promptly if they occur.

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  • Question 15 - A 26-year-old man has been referred to ENT by his doctor as he...

    Incorrect

    • A 26-year-old man has been referred to ENT by his doctor as he has swallowed a small chicken bone that feels stuck in his throat. During laryngoscopy, a chicken bone is observed lodged in the piriform recess. Which of the following nerves is most likely to be affected by the chicken bone?

      Your Answer:

      Correct Answer: Internal laryngeal nerve

      Explanation:

      When foreign objects get stuck in the piriform recess, particularly sharp items like bones from fish or chicken, they can harm the internal laryngeal nerve that lies beneath the mucous membrane in that area. Retrieving these objects also poses a risk of damaging the internal laryngeal nerve. However, the other nerves are not likely to be impacted.

      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 16 - A 48-year-old male presents for a preoperative evaluation for an inguinal hernia repair....

    Incorrect

    • A 48-year-old male presents for a preoperative evaluation for an inguinal hernia repair. During the assessment, you observe a loculated left pleural effusion on his chest x-ray. Upon further inquiry, the patient discloses that he worked as a builder three decades ago. What is the probable reason for the effusion?

      Your Answer:

      Correct Answer: Mesothelioma

      Explanation:

      Due to his profession as a builder, this individual is at risk of being exposed to asbestos. Given the 30-year latent period and the presence of a complex effusion, it is highly probable that the underlying cause is mesothelioma.

      Understanding Mesothelioma

      Mesothelioma is a type of cancer that affects the mesothelial layer of the pleural cavity, which is commonly linked to asbestos exposure. Although it is rare, other mesothelial layers in the abdomen may also be affected. Symptoms of mesothelioma include dyspnoea, weight loss, chest wall pain, and clubbing. In some cases, patients may present with painless pleural effusion. It is important to note that only 20% of patients have pre-existing asbestosis, but 85-90% have a history of asbestos exposure, with a latent period of 30-40 years.

      Diagnosis of mesothelioma is typically made through a chest x-ray, which may show pleural effusion or pleural thickening. A pleural CT is then performed to confirm the diagnosis. If a pleural effusion is present, fluid is sent for MC&S, biochemistry, and cytology. However, cytology is only helpful in 20-30% of cases. Local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield of around 95%. If an area of pleural nodularity is seen on CT, an image-guided pleural biopsy may be used.

      Management of mesothelioma is mainly symptomatic, with industrial compensation available for those who have been exposed to asbestos. Chemotherapy and surgery may be options for those who are operable. Unfortunately, the prognosis for mesothelioma is poor, with a median survival of only 12 months.

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  • Question 17 - A 65-year-old male with a history of chronic obstructive pulmonary disease (COPD) has...

    Incorrect

    • A 65-year-old male with a history of chronic obstructive pulmonary disease (COPD) has been admitted and treated for infective exacerbations of COPD three times in the past year. Despite his respiratory issues, he continues to smoke. He is currently receiving only short-acting beta2-agonist therapy. During his COPD patient review with the nurse practitioner at his local general practice, spirometry results reveal a drop in his FEV1 from 65% to 58%.

      What is the most effective approach to manage his condition and prevent further decline in his FEV1?

      Your Answer:

      Correct Answer: Smoking cessation

      Explanation:

      The most effective intervention to slow the decrease in FEV1 experienced by patients with COPD is to stop smoking. If the patient has no asthmatic/steroid-responsive features, the next step in management would be to add a long-acting beta2-agonist (LABA) and a long-acting muscarinic antagonist. If the patient has asthmatic/steroid-responsive features, the next step would be to add a LABA and an inhaled corticosteroid. Oral theophylline is only considered if inhaled therapy is not possible, and oral prednisolone is only used during acute infective exacerbations of COPD to help with inflammation and is not a long-term solution to slow the reduction of FEV1.

      The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenzae vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

      Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

      If the patient does not have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

      NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

      Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE does not recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

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  • Question 18 - A 14-year-old girl presents to her GP with complaints of earache and hearing...

    Incorrect

    • A 14-year-old girl presents to her GP with complaints of earache and hearing difficulty in her left ear. Upon examination, her GP observes a bulging tympanic membrane and diagnoses her with acute otitis media. The GP prescribes a course of oral antibiotics.

      However, after a few days, the girl's fever persists and her pain worsens, prompting her to visit the emergency department. Upon examination, the girl has a tender and erythematous retro-auricular swelling with a temperature of 38.9ºC. She has no ear discharge, and the rest of her examination is unremarkable.

      What complication has developed in this case?

      Your Answer:

      Correct Answer: Mastoiditis

      Explanation:

      Mastoiditis is a potential complication of acute otitis media, which can cause pain and swelling behind the ear over the mastoid bone. However, there is no evidence of tympanic membrane perforation, neurological symptoms or signs of meningitis or brain abscess, or facial nerve injury in this case.

      Acute otitis media is a common condition in young children, often caused by bacterial infections following viral upper respiratory tract infections. Symptoms include ear pain, fever, and hearing loss, and diagnosis is based on criteria such as the presence of a middle ear effusion and inflammation of the tympanic membrane. Antibiotics may be prescribed in certain cases, and complications can include perforation of the tympanic membrane, hearing loss, and more serious conditions such as meningitis and brain abscess.

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  • Question 19 - A patient in her 50s undergoes spirometry, during which she is instructed to...

    Incorrect

    • A patient in her 50s undergoes spirometry, during which she is instructed to perform a maximum forced exhalation following a maximum inhalation. The volume of exhaled air is measured. What is the term used to describe the difference between this volume and her total lung capacity?

      Your Answer:

      Correct Answer: Residual volume

      Explanation:

      The total lung capacity can be calculated by adding the vital capacity and residual volume. The expiratory reserve volume refers to the amount of air that can be exhaled after a normal breath compared to a maximal exhalation. The functional residual capacity is the amount of air remaining in the lungs after a normal exhalation. The inspiratory reserve volume is the difference between the amount of air in the lungs after a normal breath and a maximal inhalation. The residual volume is the amount of air left in the lungs after a maximal exhalation, which is the difference between the total lung capacity and vital capacity. The vital capacity is the maximum amount of air that can be inhaled and exhaled, measured by the volume of air exhaled after a maximal inhalation.

      Understanding Lung Volumes in Respiratory Physiology

      In respiratory physiology, lung volumes can be measured to determine the amount of air that moves in and out of the lungs during breathing. The diagram above shows the different lung volumes that can be measured.

      Tidal volume (TV) refers to the amount of air that is inspired or expired with each breath at rest. In males, the TV is 500ml while in females, it is 350ml.

      Inspiratory reserve volume (IRV) is the maximum volume of air that can be inspired at the end of a normal tidal inspiration. The inspiratory capacity is the sum of TV and IRV. On the other hand, expiratory reserve volume (ERV) is the maximum volume of air that can be expired at the end of a normal tidal expiration.

      Residual volume (RV) is the volume of air that remains in the lungs after maximal expiration. It increases with age and can be calculated by subtracting ERV from FRC. Speaking of FRC, it is the volume in the lungs at the end-expiratory position and is equal to the sum of ERV and RV.

      Vital capacity (VC) is the maximum volume of air that can be expired after a maximal inspiration. It decreases with age and can be calculated by adding inspiratory capacity and ERV. Lastly, total lung capacity (TLC) is the sum of vital capacity and residual volume.

      Physiological dead space (VD) is calculated by multiplying tidal volume by the difference between arterial carbon dioxide pressure (PaCO2) and end-tidal carbon dioxide pressure (PeCO2) and then dividing the result by PaCO2.

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  • Question 20 - A 63-year-old man arrives at the ER with a recent onset of left-sided...

    Incorrect

    • A 63-year-old man arrives at the ER with a recent onset of left-sided facial paralysis. He reports experiencing a painful rash around his ear on the affected side for the past five days. Your suspicion is Ramsay Hunt syndrome. What virus is responsible for this condition?

      Your Answer:

      Correct Answer: Varicella zoster virus

      Explanation:

      The geniculate ganglion of the facial nerve (CN VII) reactivates the varicella-zoster virus, causing Ramsay Hunt syndrome.

      Infectious mononucleosis (glandular fever) is primarily linked to the Epstein-Barr virus.

      Viral warts are commonly caused by human papillomavirus (HPV), with certain types being associated with gynaecological malignancy. Vaccines are now available to protect against the carcinogenic strains of HPV.

      Oral or genital herpes infections are caused by the herpes simplex virus.

      Understanding Ramsay Hunt Syndrome

      Ramsay Hunt syndrome, also known as herpes zoster oticus, is a condition that occurs when the varicella zoster virus reactivates in the geniculate ganglion of the seventh cranial nerve. The first symptom of this syndrome is often auricular pain, followed by facial nerve palsy and a vesicular rash around the ear. Other symptoms may include vertigo and tinnitus.

      To manage Ramsay Hunt syndrome, doctors typically prescribe oral acyclovir and corticosteroids. These medications can help reduce the severity of symptoms and prevent complications.

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  • Question 21 - 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 22 - An 80-year-old man with metastatic lung cancer arrives at the acute medical unit...

    Incorrect

    • An 80-year-old man with metastatic lung cancer arrives at the acute medical unit with sudden shortness of breath. A chest x-ray shows a malignant pleural effusion encasing the right lung. The medical registrar intends to perform a pleural tap to drain the effusion and send a sample to the lab. The registrar takes into account the effusion's position around the lung. What is the minimum level of the effusion in the mid-axillary line?

      Your Answer:

      Correct Answer: 10th rib

      Explanation:

      The parietal pleura can be found at the 10th rib in the mid-axillary line, while the visceral pleura is closely attached to the lung tissue and can be considered as one. The location of the parietal pleura is more inferior than that of the visceral pleura, with the former being at the 8th rib in the midclavicular line and the 10th rib in the midaxillary line. The location of the parietal pleura in the scapular line is not specified.

      Anatomy of the Lungs

      The lungs are a pair of organs located in the chest cavity that play a vital role in respiration. The right lung is composed of three lobes, while the left lung has two lobes. The apex of both lungs is approximately 4 cm superior to the sternocostal joint of the first rib. The base of the lungs is in contact with the diaphragm, while the costal surface corresponds to the cavity of the chest. The mediastinal surface contacts the mediastinal pleura and has the cardiac impression. The hilum is a triangular depression above and behind the concavity, where the structures that form the root of the lung enter and leave the viscus. The right main bronchus is shorter, wider, and more vertical than the left main bronchus. The inferior borders of both lungs are at the 6th rib in the mid clavicular line, 8th rib in the mid axillary line, and 10th rib posteriorly. The pleura runs two ribs lower than the corresponding lung level. The bronchopulmonary segments of the lungs are divided into ten segments, each with a specific function.

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  • Question 23 - Which of the following nerve roots provide nerve fibers to the ansa cervicalis?...

    Incorrect

    • Which of the following nerve roots provide nerve fibers to the ansa cervicalis?

      Your Answer:

      Correct Answer: C1, C2 and C3

      Explanation:

      The ansa cervicalis muscles can be remembered using the acronym GHost THought SOmeone Stupid Shot Irene. These muscles include the GenioHyoid, ThyroidHyoid, Superior Omohyoid, SternoThyroid, SternoHyoid, and Inferior Omohyoid. The ansa cervicalis is made up of a superior and inferior root, which originate from C1, C2, and C3. The superior root begins where the nerve crosses the internal carotid artery and descends in the anterior triangle of the neck. The inferior root joins the superior root in the mid neck region and can pass either superficially or deep to the internal jugular vein.

      The ansa cervicalis is a nerve that provides innervation to the sternohyoid, sternothyroid, and omohyoid muscles. It is composed of two roots: the superior root, which branches off from C1 and is located anterolateral to the carotid sheath, and the inferior root, which is derived from the C2 and C3 roots and passes posterolateral to the internal jugular vein. The inferior root enters the inferior aspect of the strap muscles, which are located in the neck, and should be divided in their upper half when exposing a large goitre. The ansa cervicalis is situated in front of the carotid sheath and is an important nerve for the proper functioning of the neck muscles.

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  • Question 24 - A 44-year-old heavy smoker presents with a productive cough and progressively worsening shortness...

    Incorrect

    • A 44-year-old heavy smoker presents with a productive cough and progressively worsening shortness of breath on exertion. The patient's spirometry results are forwarded to you in clinic for review.

      Tidal volume (TV) = 400 mL.
      Vital capacity (VC) = 3,300 mL.
      Inspiratory capacity (IC) = 2,600 mL.
      FEV1/FVC = 60%

      Body plethysmography is undertaken, demonstrating a residual volume (RV) of 1,200 mL.

      What is this patient's total lung capacity (TLC)?

      Your Answer:

      Correct Answer: 4,500 mL

      Explanation:

      To calculate the total lung capacity, one can add the vital capacity and residual volume. For example, if the vital capacity is 3300 mL and the residual volume is 1200 mL, the total lung capacity would be 4500 mL. It is important to note that tidal volume, inspiratory capacity, and the FEV1/FVC ratio are other measurements related to lung function. Residual volume refers to the amount of air left in the lungs after a maximal exhalation, while total lung capacity refers to the volume of air in the lungs after a maximal inhalation.

      Understanding Lung Volumes in Respiratory Physiology

      In respiratory physiology, lung volumes can be measured to determine the amount of air that moves in and out of the lungs during breathing. The diagram above shows the different lung volumes that can be measured.

      Tidal volume (TV) refers to the amount of air that is inspired or expired with each breath at rest. In males, the TV is 500ml while in females, it is 350ml.

      Inspiratory reserve volume (IRV) is the maximum volume of air that can be inspired at the end of a normal tidal inspiration. The inspiratory capacity is the sum of TV and IRV. On the other hand, expiratory reserve volume (ERV) is the maximum volume of air that can be expired at the end of a normal tidal expiration.

      Residual volume (RV) is the volume of air that remains in the lungs after maximal expiration. It increases with age and can be calculated by subtracting ERV from FRC. Speaking of FRC, it is the volume in the lungs at the end-expiratory position and is equal to the sum of ERV and RV.

      Vital capacity (VC) is the maximum volume of air that can be expired after a maximal inspiration. It decreases with age and can be calculated by adding inspiratory capacity and ERV. Lastly, total lung capacity (TLC) is the sum of vital capacity and residual volume.

      Physiological dead space (VD) is calculated by multiplying tidal volume by the difference between arterial carbon dioxide pressure (PaCO2) and end-tidal carbon dioxide pressure (PeCO2) and then dividing the result by PaCO2.

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  • Question 25 - A 68-year-old man arrives at the Emergency Department complaining of sharp and stabbing...

    Incorrect

    • A 68-year-old man arrives at the Emergency Department complaining of sharp and stabbing central chest pain that radiates to his back, neck, and left shoulder. He reports feeling feverish and states that sitting forward relieves the pain while lying down worsens it. The patient also mentions a recent hospitalization for a heart attack three weeks ago. During auscultation at the left sternal border, a scratchy sound is heard while the patient leans forward and holds his breath. His ECG shows widespread ST-segment saddle elevation and PR-segment depression. Can you identify the nerve responsible for his shoulder pain?

      Your Answer:

      Correct Answer: Phrenic nerve

      Explanation:

      The referred pain to the shoulder in this case is likely caused by Dressler’s syndrome, a type of pericarditis that occurs after a heart attack. The scratchy sound heard during auscultation is a pericardial friction rub, which is a common characteristic of pericarditis. The phrenic nerve, which supplies the pericardium, travels from the neck down through the thoracic cavity and can cause referred pain to the shoulder in cases of pericarditis.

      The axillary nerve is responsible for innervating the teres minor and deltoid muscles, and dysfunction of this nerve can result in loss of sensation or movement in the shoulder area.

      While the accessory nerve does innervate muscles in the neck that attach to the shoulder, it has a purely motor function and is not responsible for sensory input. Additionally, the referred pain in this case is not typical of musculoskeletal pain, but rather a result of pericarditis.

      Injuries involving the long thoracic nerve often result in winging of the scapula and are commonly caused by axillary surgery.

      Although the vagus nerve does supply parasympathetic innervation to the heart, it is not responsible for the referred pain in this case, as the pericardium is innervated by the phrenic nerve.

      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 26 - A 65-year-old man is having a left pneumonectomy for bronchogenic carcinoma. When the...

    Incorrect

    • A 65-year-old man is having a left pneumonectomy for bronchogenic carcinoma. When the surgeons reach the root of the lung, which structure will be situated furthest back in the anatomical plane?

      Your Answer:

      Correct Answer: Vagus nerve

      Explanation:

      At the lung root, the phrenic nerve is situated in the most anterior position while the vagus nerve is located at the posterior end.

      Anatomy of the Lungs

      The lungs are a pair of organs located in the chest cavity that play a vital role in respiration. The right lung is composed of three lobes, while the left lung has two lobes. The apex of both lungs is approximately 4 cm superior to the sternocostal joint of the first rib. The base of the lungs is in contact with the diaphragm, while the costal surface corresponds to the cavity of the chest. The mediastinal surface contacts the mediastinal pleura and has the cardiac impression. The hilum is a triangular depression above and behind the concavity, where the structures that form the root of the lung enter and leave the viscus. The right main bronchus is shorter, wider, and more vertical than the left main bronchus. The inferior borders of both lungs are at the 6th rib in the mid clavicular line, 8th rib in the mid axillary line, and 10th rib posteriorly. The pleura runs two ribs lower than the corresponding lung level. The bronchopulmonary segments of the lungs are divided into ten segments, each with a specific function.

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  • Question 27 - As the pregnancy progresses, at what stage does the foetus typically begin producing...

    Incorrect

    • As the pregnancy progresses, at what stage does the foetus typically begin producing surfactant?

      A mother has been informed that she will have to deliver her baby prematurely due to complications in the pregnancy. To decrease the chances of neonatal distress syndrome, doctors have administered steroids to stimulate surfactant production in the foetus. They clarify that the foetus is already generating its own surfactant, and these steroids will enhance the process.

      Your Answer:

      Correct Answer: Week 22

      Explanation:

      Lung development in humans begins at week 4 with the formation of the respiratory diverticulum. By week 10, the lungs start to grow as tertiary bronchial buds form. Terminal bronchioles begin to form around week 18. The saccular stage of lung development, which marks the earliest viability for a human fetus, occurs at around 22-24 weeks when type 2 alveolar cells start producing surfactant. By week 30, the primary alveoli form as the mesenchyme surrounding the lungs becomes highly vascular.

      The Importance of Pulmonary Surfactant in Breathing

      Pulmonary surfactant is a substance composed of phospholipids, carbohydrates, and proteins that is released by type 2 pneumocytes. Its main component, dipalmitoyl phosphatidylcholine (DPPC), plays a crucial role in reducing alveolar surface tension. This substance is first detectable around 28 weeks and increases in concentration as the alveoli decrease in size. This helps prevent the alveoli from collapsing and reduces the muscular force needed to expand the lungs, ultimately decreasing the work of breathing. Additionally, pulmonary surfactant lowers the elastic recoil at low lung volumes, preventing the alveoli from collapsing at the end of each expiration. Overall, pulmonary surfactant is essential in maintaining proper lung function and preventing respiratory distress.

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  • Question 28 - 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:

      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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  • Question 29 - A 70-year-old man visits his primary care physician with complaints of hearing difficulties....

    Incorrect

    • A 70-year-old man visits his primary care physician with complaints of hearing difficulties. He states that he has been increasingly struggling to hear his wife's conversations for the past six months. He is concerned that this problem will worsen and eventually lead to complete hearing loss, making it difficult for him to communicate with his children over the phone. His wife is also distressed by the situation, as he frequently asks her to turn up the volume on the television. The man has no history of exposure to loud noises and has well-controlled hypertension. He is a retired police officer and currently resides with his wife. What is the primary pathology underlying this man's most likely diagnosis?

      Your Answer:

      Correct Answer: Degeneration of the cells at the cochlear base

      Explanation:

      The patient has a gradual-onset hearing loss, which is most likely due to presbycusis, an aging-related sensorineural hearing loss. This condition has multiple causes, including environmental factors like noise pollution and biological factors like genetics and oxidative stress. Damage to the organ of Corti stereocilia from exposure to sudden loud noises can also cause hearing loss, which is typically sudden and associated with a history of exposure to loud noises. Other conditions that can cause hearing loss include cholesteatoma, which is due to the accumulation of keratin debris in the middle ear, and otosclerosis, which is characterized by the overgrowth of bone in the middle ear.

      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 30 - 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:

      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.

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