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  • Question 1 - A 49-year-old Caucasian woman presents with a severe acute attack of bronchial asthma....

    Correct

    • A 49-year-old Caucasian woman presents with a severe acute attack of bronchial asthma. For 1 week, she has had fever, malaise, anorexia and weight loss. She has tingling and numbness in her feet and hands. On examination, palpable purpura is present and nodular lesions are present on the skin. Investigations revealed eosinophilia, elevated erythrocyte sedimentation rate (ESR), fibrinogen, and α-2-globulin, positive p-ANCA, and a chest X-ray reveals pulmonary infiltrates.
      Which one of the following is the most likely diagnosis?

      Your Answer: Allergic granulomatosis (Churg-Strauss syndrome)

      Explanation:

      Comparison of Vasculitis Conditions with Eosinophilia

      Eosinophilia is a common feature in several vasculitis conditions, but the clinical presentation and histopathologic features can help differentiate between them. Allergic granulomatosis, also known as Churg-Strauss syndrome, is characterized by asthma, peripheral and tissue eosinophilia, granuloma formation, and vasculitis of multiple organ systems. In contrast, granulomatosis with polyangiitis (GPA) involves the lungs and upper respiratory tract and is c-ANCA positive, but does not typically present with asthma-like symptoms or peripheral eosinophilia. Polyarteritis nodosa (PAN) can present with multisystem involvement, but does not typically have an asthma-like presentation or peripheral eosinophilia. Hypereosinophilic syndrome, also known as chronic eosinophilic leukemia, is characterized by persistent eosinophilia in blood and exclusion of other causes of reactive eosinophilia. Finally, microscopic polyangiitis is similar to GPA in many aspects, but does not involve granuloma formation and does not typically present with peripheral eosinophilia.

    • This question is part of the following fields:

      • Respiratory
      9.5
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  • Question 2 - A 65-year-old known alcoholic is brought by ambulance after being found unconscious on...

    Incorrect

    • A 65-year-old known alcoholic is brought by ambulance after being found unconscious on the road on a Sunday afternoon. He has a superficial laceration in the right frontal region. He is admitted for observation over the weekend. The admission chest X-ray is normal. Before discharge on Tuesday morning, he is noted to be febrile and dyspnoeic. Blood tests reveal a neutrophilia and elevated C-reactive protein (CRP). A chest X-ray demonstrates consolidation in the lower zone of the right lung.
      What is the most likely diagnosis?

      Your Answer: Hospital-acquired pneumonia (HAP)

      Correct Answer: Aspiration pneumonia

      Explanation:

      Aspiration pneumonia is a type of pneumonia that typically affects the lower lobes of the lungs, particularly the right middle or lower lobes or left lower lobe. It is often seen in individuals who have consumed alcohol and subsequently vomited, leading to the aspiration of the contents into the lower bronchi. If an alcoholic is found unconscious with a lower zone consolidation, aspiration pneumonia should be considered when prescribing antibiotics. Hospital-acquired pneumonia (HAP) is unlikely to occur within the first 48 hours of admission. Tuberculosis (TB) is a rare diagnosis in this case as it typically affects the upper lobes and the patient’s chest X-ray from two days earlier was normal. Staphylococcal pneumonia may be seen in alcoholics but is characterized by cavitating lesions and empyema. Pneumocystis jiroveci pneumonia is common in immunosuppressed individuals and presents with bilateral perihilar consolidations and possible lung cyst formation.

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      • Respiratory
      3.1
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  • Question 3 - An 80-year-old known alcoholic is brought by ambulance after being found unconscious on...

    Incorrect

    • An 80-year-old known alcoholic is brought by ambulance after being found unconscious on the road on a Sunday afternoon. He has a superficial laceration in the right frontal region. He is admitted for observation over the bank holiday weekend. Admission chest X-ray is normal. Before discharge on Tuesday morning, he is noted to be febrile and dyspnoeic. Blood tests reveal neutrophilia and elevated C-reactive protein (CRP) levels. A chest X-ray demonstrates consolidation in the right lower zone of the lung.
      What is the most likely diagnosis for this patient?

      Your Answer: Staphylococcal pneumonia

      Correct Answer: Aspiration pneumonia

      Explanation:

      Aspiration pneumonia is a type of pneumonia that typically affects the lower lobes of the lungs, particularly the right middle or lower lobes or left lower lobe. It occurs when someone inhales foreign material, such as vomit, into their lungs. If an alcoholic is found unconscious and has a consolidation in the lower zone of their lungs, it is highly likely that they have aspiration pneumonia. Antibiotics should be prescribed accordingly.

      Allergic bronchopulmonary aspergillosis is another condition that can cause breathlessness and consolidation on chest X-ray. However, it is unlikely to develop in a hospital setting and does not typically cause a fever. Treatment involves prednisolone and sometimes itraconazole.

      Tuberculosis (TB) is becoming more common in the UK and Europe, especially among immunosuppressed individuals like alcoholics. However, TB usually affects the upper lobes of the lungs, and the patient’s chest X-ray from two days prior makes it an unlikely diagnosis.

      Staphylococcal pneumonia can occur in alcoholics, but it is characterized by cavitating lesions and often accompanied by empyema.

      Pneumocystis jiroveci pneumonia is also common in immunosuppressed individuals and causes bilateral perihilar consolidations, sometimes with pneumatocele formation.

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      • Respiratory
      2.8
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  • Question 4 - A 38-year-old male presents with complaints of difficulty breathing. During the physical examination,...

    Incorrect

    • A 38-year-old male presents with complaints of difficulty breathing. During the physical examination, clubbing of the fingers is observed. What medical condition is commonly associated with clubbing?

      Your Answer: Aspergillosis

      Correct Answer: Pulmonary fibrosis

      Explanation:

      Respiratory and Other Causes of Clubbing of the Fingers

      Clubbing of the fingers is a condition where the tips of the fingers become enlarged and the nails curve around the fingertips. This condition is often associated with respiratory diseases such as carcinoma of the lung, bronchiectasis, mesothelioma, empyema, and pulmonary fibrosis. However, it is not typically associated with chronic obstructive airway disease (COAD). Other causes of clubbing of the fingers include cyanotic congenital heart disease, inflammatory bowel disease, and infective endocarditis.

      In summary, clubbing of the fingers is a physical manifestation of various underlying medical conditions. It is important to identify the underlying cause of clubbing of the fingers in order to provide appropriate treatment and management.

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      • Respiratory
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  • Question 5 - A 58-year-old Afro-Caribbean man presents to you with increasing difficulty in breathing and...

    Incorrect

    • A 58-year-old Afro-Caribbean man presents to you with increasing difficulty in breathing and shortness of breath. A chest examination reveals decreased expansion on the right side of the chest, along with decreased breath sounds and stony dullness to percussion. A chest X-ray reveals a pleural effusion which you proceed to tap for diagnostic serum biochemistry, cytology and culture. The cytology and culture results are still awaited, although the serum biochemistry returns back showing the following:
      Pleural fluid protein 55 g/dl
      Pleural fluid cholesterol 4.5 g/dl
      Pleural fluid lactate dehydrogenase (LDH) : serum ratio 0.7
      Which of the following might be considered as a diagnosis in this patient?

      Your Answer: Nephrotic syndrome

      Correct Answer: Sarcoidosis

      Explanation:

      Differentiating Causes of Pleural Effusion: Sarcoidosis, Myxoedema, Meigs Syndrome, Cardiac Failure, and Nephrotic Syndrome

      When analyzing a pleural effusion, the protein levels can help differentiate between potential causes. An exudate pleural effusion, with protein levels greater than 30 g/l, can be caused by inflammatory or malignant conditions such as sarcoidosis, tuberculosis, or carcinoma. However, if the protein level falls between 25 and 35 g/l, Light’s criteria should be applied to accurately differentiate. On the other hand, a transudate pleural effusion, with protein levels less than 30 g/l, can be caused by conditions such as myxoedema or cardiac failure. Meigs syndrome, a pleural effusion caused by a benign ovarian tumor, and nephrotic syndrome, which causes a transudate pleural effusion, can also be ruled out based on the biochemistry results. It is important to consider all potential causes and conduct further investigations to properly diagnose and manage the underlying condition.

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      • Respiratory
      2.4
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  • Question 6 - What condition is typically linked to obstructive sleep apnea? ...

    Correct

    • What condition is typically linked to obstructive sleep apnea?

      Your Answer: Hypersomnolence

      Explanation:

      Symptoms and Associations of Obstructive Sleep Apnoea

      Obstructive sleep apnoea is a condition characterized by hypersomnolence or excessive sleepiness. Other common symptoms include personality changes, witnessed apnoeas, and true nocturnal polyuria. Reduced libido is a less frequent symptom. The condition may be associated with acromegaly, myxoedema, obesity, and micrognathia/retrognathia. Sleep apnoea is a serious condition that can lead to complications such as hypertension, cardiovascular disease, and stroke.

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      • Respiratory
      2.9
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  • Question 7 - A 50-year-old man in the United Kingdom presents with fever and cough. He...

    Correct

    • A 50-year-old man in the United Kingdom presents with fever and cough. He smells strongly of alcohol and has no fixed abode. His heart rate was 123 bpm, blood pressure 93/75 mmHg, oxygen saturations 92% and respiratory rate 45 breaths per minute. Further history from him reveals no recent travel history and no contact with anyone with a history of foreign travel.
      Chest X-ray revealed consolidation of the right upper zone.
      Which of the following drugs is the most prudent choice in his treatment?

      Your Answer: Meropenem

      Explanation:

      Understanding Klebsiella Pneumoniae Infection and Treatment Options

      Klebsiella pneumoniae (KP) is a common organism implicated in various infections such as pneumonia, urinary tract infection, intra-abdominal abscesses, or bacteraemia. Patients with underlying conditions like alcoholism, diabetes, or chronic lung disease are at higher risk of contracting KP. The new hypervirulent strains with capsular serotypes K1 or K2 are increasingly being seen. In suspected cases of Klebsiella infection, treatment is best started with carbapenems. However, strains possessing carbapenemases are also being discovered, and Polymyxin B or E or tigecycline are now used as the last line of treatment. This article provides an overview of KP infection, radiological findings, and treatment options.

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      • Respiratory
      3.3
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  • Question 8 - The blood gases with pH 7.38, pO2 6.2 kPa, pCO2 9.2 kPa, and...

    Correct

    • The blood gases with pH 7.38, pO2 6.2 kPa, pCO2 9.2 kPa, and HCO3– 44 mmol/l are indicative of a respiratory condition. Which respiratory condition is most likely responsible for these blood gas values?

      Your Answer: Chronic obstructive pulmonary disease (COPD)

      Explanation:

      Respiratory Failure in Common Lung Conditions

      When analyzing blood gases, it is important to consider the type of respiratory failure present in order to determine the underlying cause. In cases of low oxygen and high carbon dioxide, known as type 2 respiratory failure, chronic obstructive pulmonary disease (COPD) is the most likely culprit. Asthma, on the other hand, typically causes type 1 respiratory failure, although severe cases may progress to type 2 as the patient tires. Pulmonary embolism and pneumonia are also more likely to cause type 1 respiratory failure, while pulmonary fibrosis is associated with this type of failure as well. Understanding the type of respiratory failure can aid in the diagnosis and management of these common lung conditions.

    • This question is part of the following fields:

      • Respiratory
      98.2
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  • Question 9 - A 14-year-old boy comes to your clinic complaining of wheezing for the past...

    Incorrect

    • A 14-year-old boy comes to your clinic complaining of wheezing for the past week. His mother mentions that he had a similar issue a couple of years ago but hasn't had any problems since. He was treated with inhalers and recovered quickly at that time. The boy is an animal lover and has always had multiple pets, including dogs, cats, birds, and reptiles. He hasn't acquired any new pets in the last two months. Upon examination, there are no clinical findings. What would be the best next step to take?

      Your Answer:

      Correct Answer: Peak flow self-monitoring

      Explanation:

      Diagnosis of Wheezing in Children

      Wheezing is a common symptom in children, but it can have many causes. While asthma is a common cause of wheezing, it is important not to jump to conclusions and make a diagnosis based on conjecture alone. Instead, the next best course of action is to use a peak flow meter at home and follow up with lung function tests if necessary. It is also important to note that wheezing can sometimes be a symptom of cardiac failure, but this is not the case in the scenario presented.

      Removing pets from the home is not a necessary step at this point, as it may cause unnecessary stress for the child. Instead, if a particular pet is identified as the cause of the allergy, it can be removed at a later time. Skin patch tests for allergens are also not useful in this scenario, as they are only done in cases with high suspicion or when desensitization therapy is planned.

      In summary, a diagnosis of wheezing in children should not be made based on conjecture alone. Instead, it is important to use objective measures such as peak flow meters and lung function tests to determine the cause of the wheezing. Removing pets or conducting skin patch tests may not be necessary or useful at this point.

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      • Respiratory
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  • Question 10 - A 56-year-old woman presents to the Emergency Department with a 2-week history of...

    Incorrect

    • A 56-year-old woman presents to the Emergency Department with a 2-week history of productive cough with green sputum and a one day history of palpitations. She also had some rigors and fever. On examination:
      Result Normal
      Respiratory rate (RR) 26 breaths/min 12–18 breaths/min
      Sats 96% on air 94–98%
      Blood pressure (BP) 92/48 mmHg <120/80 mmHg
      Heart rate (HR) 130 bpm 60–100 beats/min
      Some bronchial breathing at left lung base, heart sounds normal however with an irregularly irregular pulse. electrocardiogram (ECG) showed fast atrial fibrillation (AF). She was previously fit and well.
      Which of the following is the most appropriate initial management?

      Your Answer:

      Correct Answer: Intravenous fluids

      Explanation:

      Treatment for AF in a Patient with Sepsis

      In a patient with sepsis secondary to pneumonia, the new onset of AF is likely due to the sepsis. Therefore, the priority is to urgently treat the sepsis with intravenous fluids and broad-spectrum antibiotics. If the AF persists after the sepsis is treated, other options for AF treatment can be considered. Bisoprolol and digoxin are not the first-line treatments for AF in this case. Oral antibiotics are not recommended for septic patients. Flecainide may be considered if the AF persists after the sepsis is treated.

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      • Respiratory
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  • Question 11 - A previously healthy 85-year-old woman is hospitalised and undergoes surgery to replace the...

    Incorrect

    • A previously healthy 85-year-old woman is hospitalised and undergoes surgery to replace the broken hip that she sustained as a result of falling down stairs. Upon discharge to a nursing home 10 days later, she is unable to ambulate fully and, about a month later, she dies suddenly.
      Which of the following is most likely to be the immediate cause of death found at post-mortem examination?

      Your Answer:

      Correct Answer: Pulmonary embolism

      Explanation:

      Likely Cause of Sudden Death in an Elderly Patient with Fracture

      Immobilisation after a fracture in elderly patients increases the risk of developing deep vein thrombosis (DVT), which can lead to pulmonary embolism. In the case of a sudden death, pulmonary embolism is the most likely cause. Pneumonia with pneumococcus is also a risk for elderly patients in hospital, but the absence of signs and symptoms of infection makes it less likely. Tuberculosis is also unlikely as there were no signs of an infectious disease. Congestive heart failure is a possibility in the elderly, but it is unlikely to cause sudden death in this scenario. While malignancy is a risk for older patients, immobilisation leading to pulmonary thromboembolism is the most likely cause of sudden death in this case.

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      • Respiratory
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  • Question 12 - A 28-year-old female patient presents to your clinic seeking help to quit smoking....

    Incorrect

    • A 28-year-old female patient presents to your clinic seeking help to quit smoking. Despite several attempts in the past, she has been unsuccessful. She has a medical history of bipolar disorder and well-managed epilepsy, for which she takes lamotrigine. She currently smokes 15 cigarettes per day and is especially interested in the health benefits of quitting smoking since she has recently found out that she is pregnant. As her physician, you decide to prescribe a suitable medication to assist her in her efforts. What would be the most appropriate treatment option?

      Your Answer:

      Correct Answer: Nicotine gum

      Explanation:

      Standard treatments for nicotine dependence do not include amitriptyline, fluoxetine, or gabapentin. Nicotine replacement therapy (NRT) can be helpful for motivated patients, but it is not a cure for addiction and may require multiple attempts. Bupropion and varenicline are other smoking cessation aids, but they have multiple side effects and may not be suitable for all patients. NICE guidelines recommend discussing the best method of smoking cessation with the patient, but NRT is considered safer in pregnancy.

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      • Respiratory
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  • Question 13 - A 32-year-old postal worker with asthma visits his GP for his annual asthma...

    Incorrect

    • A 32-year-old postal worker with asthma visits his GP for his annual asthma review. He reports experiencing breathlessness during his morning postal round for the past few months. Despite a normal examination, the GP advises him to conduct peak flow monitoring. The results show a best PEFR of 650 L/min and an average of 439 L/min, with a predicted PEFR of 660 L/min. What is the most likely interpretation of these PEFR results?

      Your Answer:

      Correct Answer: Suboptimal therapy

      Explanation:

      Differentiating Between Respiratory Conditions: A Guide

      When assessing a patient with respiratory symptoms, it is important to consider various conditions that may be causing their symptoms. One key factor to consider is the patient’s peak expiratory flow rate (PEFR), which should be above 80% of their best reading. If it falls below this level, it may indicate the need for therapy titration.

      Chronic obstructive pulmonary disease (COPD) is unlikely in a young patient without smoking history, and clinical examination is likely to be abnormal in this condition. On the other hand, variability in PEFR is a hallmark of asthma, and the reversibility of PEFR after administering a nebulized dose of salbutamol can help differentiate between asthma and COPD.

      Occupational asthma is often caused by exposure to irritants or allergens in the workplace. Monitoring PEFR for two weeks while working and two weeks away from work can help diagnose this condition.

      Interstitial lung disease may cause exertional breathlessness, but fine end inspiratory crackles and finger clubbing would be present on examination. Additionally, idiopathic pulmonary fibrosis typically presents after the age of 50, making it unlikely in a 36-year-old patient.

      Finally, an acute exacerbation of asthma would present with a shorter duration of symptoms and abnormal clinical examination findings. By considering these factors, healthcare providers can more accurately diagnose and treat respiratory conditions.

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      • Respiratory
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  • Question 14 - An 85-year-old man with chronic COPD presents for a review of his home...

    Incorrect

    • An 85-year-old man with chronic COPD presents for a review of his home oxygen therapy. The following results are from his arterial blood gas (ABG):
      pH 7.37 (normal range 7.35–7.45)
      pa(O2) 7.6 (normal range 10–14 kPa)
      pa(CO2) 8 (normal range 4.0–6.0 kPa)
      HCO3 37 (normal range 22–26 mmol)
      base excess +6 (normal range −2 to +2 mmol).
      Which of the following best describe this man’s blood gas result?

      Your Answer:

      Correct Answer: Compensation for respiratory acidosis secondary to chronic respiratory disease

      Explanation:

      Understanding ABGs: A Five-Step Approach and Mnemonic

      Arterial blood gas (ABG) analysis is a crucial tool in assessing a patient’s respiratory and metabolic status. The Resuscitation Council (UK) recommends a five-step approach to interpreting ABGs:

      1. Assess the patient.
      2. Assess their oxygenation (pa(O2) should be >10 kPa).
      3. Determine if the patient is acidotic (pH < 7.35) or alkalotic (pH > 7.45).
      4. Assess respiratory status by determining if their pa(CO2) is high or low.
      5. Assess metabolic status by determining if their bicarbonate (HCO3) is high or low.

      To aid in understanding ABGs, the mnemonic ROME can be used:

      – Respiratory = Opposite: A low pH and high pa(CO2) indicate respiratory acidosis, while a high pH and low pa(CO2) indicate respiratory alkalosis.
      – Metabolic = Equivalent: A high pH and high HCO3 indicate metabolic alkalosis, while a low pH and low HCO3 indicate metabolic acidosis.

      Compensation for respiratory acidosis secondary to chronic respiratory disease is characterized by a normal pH, high pa(CO2), and high HCO3, indicating renal compensation. In contrast, compensation for respiratory alkalosis secondary to chronic respiratory disease would show a low pa(CO2) and a high pH.

      Partial compensation for respiratory acidosis secondary to chronic respiratory disease is characterized by a high pa(CO2) and a high HCO3, with a normal pH indicating full compensation and a mildly altered pH indicating partial compensation. Compensation for metabolic acidosis secondary to chronic respiratory disease is not applicable, as this condition would present with low HCO3 levels.

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      • Respiratory
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  • Question 15 - A 25-year-old lady with a history of asthma is brought to the Emergency...

    Incorrect

    • A 25-year-old lady with a history of asthma is brought to the Emergency Department with an acute asthma attack. She has previously been admitted to the intensive therapy unit (ITU) with the same problem. Treatment is commenced with high-flow oxygen and regular nebulisers.
      Which of the following is a feature of life-threatening asthma?

      Your Answer:

      Correct Answer: Normal PaCO2

      Explanation:

      Assessment of Severity in Acute Asthma Attacks

      Acute asthma is a serious medical emergency that can lead to fatalities. To assess the severity of an asthma attack, several factors must be considered. Severe asthma is characterized by a peak flow of 33-50% of predicted or best, a respiratory rate of over 25 breaths per minute, a heart rate of over 110 beats per minute, and the inability to complete sentences. On the other hand, life-threatening asthma is indicated by a peak flow of less than 33% of predicted or best, a silent chest, cyanosis, and arterial blood gas showing high or normal PaCO2, which reflects reduced respiratory effort. Additionally, arterial blood gas showing hypoxia (PaO2 <8 kPa) or acidosis is also a sign of life-threatening asthma. Any life-threatening features require immediate critical care and senior medical review. A peak expiratory flow rate of less than 50% of predicted or best is a feature of an acute severe asthma attack. However, a pulse rate of 105 bpm is not a marker of severity in asthma due to its lack of specificity. Respiratory alkalosis, which is a condition characterized by low carbon dioxide levels, is actually a reassuring picture on the blood gas. In contrast, a normal carbon dioxide level would be a concern if the person is working that hard. Finally, the inability to complete full sentences is another feature of acute severe asthma.

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      • Respiratory
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  • Question 16 - A 63-year-old male smoker arrived in the Emergency Department by ambulance. He had...

    Incorrect

    • A 63-year-old male smoker arrived in the Emergency Department by ambulance. He had become increasingly breathless at home, and despite receiving high-flow oxygen in the ambulance he is no better. He has a flapping tremor of his hands, a bounding pulse and palmar erythema.
      What is the most likely cause of his symptoms?

      Your Answer:

      Correct Answer: Hypercapnia

      Explanation:

      Understanding Hypercapnia: A Possible Cause of Breathlessness and Flapping Tremor in COPD Patients

      Hypercapnia is a condition that can occur in patients with chronic obstructive pulmonary disease (COPD) and respiratory failure. It is caused by the retention of carbon dioxide (CO2) due to a relative loss of surface area for gas exchange within the lungs. This can lead to bronchospasm and inflammation, which can further exacerbate the problem. In some cases, patients with chronic hypoxia and hypercapnia may become dependent on hypoxia to drive respiration. If high concentrations of oxygen are given, this drive may be reduced or lost completely, leading to hypoventilation, reduced minute ventilation, accumulation of CO2, and subsequent respiratory acidosis (type 2 respiratory failure).

      External signs of hypercapnia include reduced Glasgow Coma Scale (GCS) score, flapping tremor (asterixis), palmar erythema, and bounding pulses (due to CO2-induced vasodilation). While other conditions such as hepatic encephalopathy, Parkinson’s disease, delirium tremens, and hyperthyroidism can also cause tremors and other symptoms, they do not typically cause breathlessness or the specific type of tremor seen in hypercapnia.

      It is important for healthcare professionals to recognize the signs and symptoms of hypercapnia in COPD patients, as prompt intervention can help prevent further complications and improve outcomes.

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  • Question 17 - A 68-year-old man with chronic obstructive pulmonary disease (COPD) visits his general practitioner...

    Incorrect

    • A 68-year-old man with chronic obstructive pulmonary disease (COPD) visits his general practitioner (GP) complaining of increased wheezing, breathlessness, and a dry cough. He is able to speak in complete sentences.
      During the examination, the following observations are made:
      Temperature 37.2 °C
      Respiratory rate 18 breaths per minute
      Blood pressure 130/70 mmHg
      Heart rate 90 bpm
      Oxygen saturations 96% on room air
      He has diffuse expiratory wheezing.
      What is the most appropriate course of action for this patient?

      Your Answer:

      Correct Answer: Prednisolone

      Explanation:

      Treatment Options for Acute Exacerbation of COPD

      When a patient presents with evidence of an acute non-infective exacerbation of COPD, treatment with oral corticosteroids is appropriate. Short-acting bronchodilators may also be necessary. If the patient’s observations are not grossly deranged, they can be managed in the community with instructions to seek further medical input if their symptoms worsen.

      Antibiotics are not indicated for non-infective exacerbations of COPD. However, if the patient has symptoms of an infective exacerbation, antibiotics may be prescribed based on the Anthonisen criteria.

      Referral to a hospital medical team for admission is not necessary unless the patient is haemodynamically unstable, hypoxic, or experiencing respiratory distress.

      A chest X-ray is not required unless there is suspicion of underlying pneumonia or pneumothorax. If the patient fails to respond to therapy or develops new symptoms, a chest X-ray may be considered at a later stage.

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  • Question 18 - A 32-year-old woman visits her General Practitioner seeking assistance to quit smoking. She...

    Incorrect

    • A 32-year-old woman visits her General Practitioner seeking assistance to quit smoking. She has been smoking ten cigarettes daily for the last 14 years and has no significant medical history. However, she is currently in her second trimester of pregnancy. What is the most suitable first-line smoking cessation option for this patient?

      Your Answer:

      Correct Answer: Behavioural therapy

      Explanation:

      Smoking Cessation Options for Pregnant Women: A Review of Medications and Therapies

      When it comes to quitting smoking during pregnancy or postpartum, behavioural therapy is the recommended first-line approach by the National Institute for Health and Care Excellence (NICE). Smoking cessation clinics can provide support for women who wish to quit smoking. Clonidine, a medication used for high blood pressure and drug withdrawal, has some effect on smoking cessation but is not licensed or recommended for this use by NICE. Bupropion, which reduces cravings and withdrawal effects, is contraindicated during pregnancy and breastfeeding. Nicotine replacement therapy can be used in pregnancy, but women should be informed of the risks and benefits and only used if behavioural support is ineffective. Varenicline, a medication that reduces cravings and the pleasurable effects of tobacco products, is contraindicated during pregnancy and breastfeeding due to its toxicity in studies. It is important for healthcare providers to discuss the available options with pregnant women and provide individualized recommendations for smoking cessation.

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  • Question 19 - You have a telephone consultation with a 28-year-old male who wants to start...

    Incorrect

    • You have a telephone consultation with a 28-year-old male who wants to start trying to conceive. He has a history of asthma and takes salbutamol 100mcg as needed.
      Which of the following would be most important to advise?

      Your Answer:

      Correct Answer: Take folic acid 5 mg once daily from before conception until 12 weeks of pregnancy

      Explanation:

      Women who are taking antiepileptic medication and are planning to conceive should be prescribed a daily dose of 5mg folic acid instead of the standard 400mcg. This high-dose folic acid should be taken from before conception until the 12th week of pregnancy to reduce the risk of neural tube defects. It is important to refer these women to specialist care, but they should continue to use effective contraception until they have had a full assessment. Despite the medication, it is still likely that they will have a normal pregnancy and healthy baby. If trying to conceive, women should start taking folic acid as soon as possible, rather than waiting for a positive pregnancy test.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

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  • Question 20 - A trauma call is initiated in the Emergency Department after a young cyclist...

    Incorrect

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

      What signs would the anaesthetist have observed during the examination?

      Your Answer:

      Correct Answer: Contralateral tracheal deviation, reduced chest expansion, increased resonance on percussion, absent breath sounds

      Explanation:

      Understanding Tension Pneumothorax: Symptoms and Treatment

      Tension pneumothorax is a medical emergency that occurs when air enters the pleural space but cannot exit, causing the pressure in the pleural space to increase and the lung to collapse. This condition can be diagnosed clinically by observing contralateral tracheal deviation, reduced chest expansion, increased resonance on percussion, and absent breath sounds. Treatment involves inserting a wide-bore cannula to release the trapped air. Delay in treatment can be fatal, so diagnosis should not be delayed by investigations such as chest X-rays. Other respiratory conditions may present with different symptoms, such as normal trachea, reduced chest expansion, reduced resonance on percussion, and normal vesicular breath sounds. Tracheal tug is a sign of severe respiratory distress in paediatrics, while ipsilateral tracheal deviation is not a symptom of tension pneumothorax. Understanding the symptoms of tension pneumothorax is crucial for prompt diagnosis and treatment.

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  • Question 21 - An 80-year-old man comes to the clinic complaining of increasing shortness of breath...

    Incorrect

    • An 80-year-old man comes to the clinic complaining of increasing shortness of breath and dry cough over the past three months. He gets breathless after walking a few hundred metres. He is a non-smoker and takes medication for type II diabetes mellitus. During examination, his pulse is 80/minute and regular, blood pressure (BP) 130/70 mmHg, bilateral clubbing of digits, oxygen saturation (SpO2) in room air is 90%. Auscultation reveals bilateral, fine, late inspiratory crackles, more marked in the mid-zones and at the lung bases. Chest X-ray reveals patchy shadowing at the lung bases. What is the definitive investigation to guide his management?

      Your Answer:

      Correct Answer: High-resolution computed tomography (HRCT) chest

      Explanation:

      High-resolution computed tomography (HRCT) chest is the most reliable test for diagnosing idiopathic pulmonary fibrosis (IPF). The radiological pattern seen in IPF is called usual interstitial pneumonia (UIP), which is characterized by honeycombing, reticular opacities, and lung architectural distortion. In advanced cases, there may be lobar volume loss, particularly in the lower lobes.

      Antinuclear antibody (ANA) and anti-cyclic citrullinated peptide (anti-CCP) tests are not useful for diagnosing IPF, as they are typically normal or only mildly elevated in this condition. These tests may be helpful in diagnosing interstitial lung disease associated with rheumatologic conditions, such as systemic lupus erythematosus or rheumatoid arthritis.

      Arterial blood gas (ABG) analysis can be performed in patients with IPF who are experiencing respiratory distress. This test typically shows type I respiratory failure with low oxygen levels and normal or decreased carbon dioxide levels. However, ABG analysis is not the definitive test for diagnosing IPF.

      Bronchoalveolar lavage may be considered if HRCT chest cannot detect the UIP pattern, but it is not typically necessary for diagnosing IPF.

      Pulmonary function tests (PFTs) can help differentiate between obstructive and restrictive lung diseases. In IPF, PFTs typically show a restrictive pattern, with decreased forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), and a normal or increased FEV1/FVC ratio. While PFTs are a useful initial test for evaluating lung function in patients with suspected IPF, they are not definitive for establishing a diagnosis.

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  • Question 22 - A 28-year-old woman presents to the Emergency Department (ED) with sudden onset of...

    Incorrect

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

      Your Answer:

      Correct Answer: Combined oral contraceptive pill

      Explanation:

      Assessing Risk Factors for Pulmonary Embolism in a Patient with Sudden Onset of Symptoms

      This patient presents with sudden onset of shortness of breath, chest pain, and haemoptysis, suggesting a pulmonary embolism. A history of long-haul flight and use of combined oral contraceptive pill further increase the risk for this condition. However, tonsillectomy two years ago is not a current risk factor. Type I diabetes mellitus and asthma are also not associated with pulmonary embolism. A family history of malignancy may increase the risk for developing a malignancy, which in turn increases the risk for pulmonary embolism. Overall, a thorough assessment of risk factors is crucial in identifying and managing pulmonary embolism in patients with acute symptoms.

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  • Question 23 - A 68-year-old man with known bronchial carcinoma presents to hospital with confusion. A...

    Incorrect

    • A 68-year-old man with known bronchial carcinoma presents to hospital with confusion. A computed tomography (CT) scan of the brain was reported as normal: no evidence of metastases. His serum electrolytes were as follows:
      Investigation Result Normal value
      Sodium (Na+) 114 mmol/l 135–145 mmol/l
      Potassium (K+) 3.9 mmol/l 3.5–5.0 mmol/l
      Urea 5.2 mmol/l 2.5–6.5 mmol/l
      Creatinine 82 μmol/l 50–120 µmol/l
      Urinary sodium 54 mmol/l
      Which of the subtype of bronchial carcinoma is he most likely to have been diagnosed with?

      Your Answer:

      Correct Answer: Small cell

      Explanation:

      Different Types of Lung Cancer and Their Association with Ectopic Hormones

      Lung cancer is a complex disease that can be divided into different types based on their clinical and biological characteristics. The two main categories are non-small cell lung cancers (NSCLCs) and small cell lung cancer (SCLC). SCLC is distinct from NSCLCs due to its origin from amine precursor uptake and decarboxylation (APUD) cells, which have an endocrine lineage. This can lead to the production of various peptide hormones, causing paraneoplastic syndromes such as the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and Cushing syndrome.

      Among NSCLCs, squamous cell carcinoma is commonly associated with ectopic parathyroid hormone, leading to hypercalcemia. Large cell carcinoma and bronchoalveolar cell carcinoma are NSCLCs that do not produce ectopic hormones. Adenocarcinoma, another type of NSCLC, also does not produce ectopic hormones.

      Understanding the different types of lung cancer and their association with ectopic hormones is crucial for proper management and treatment of the disease.

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  • Question 24 - A 67-year-old man comes to the Chest Clinic after being referred by his...

    Incorrect

    • A 67-year-old man comes to the Chest Clinic after being referred by his GP for a chronic cough. He complains of a dry cough that has been ongoing for 10 months and is accompanied by increasing shortness of breath. Despite multiple rounds of antibiotics, he has not experienced significant improvement. He has never smoked and denies any coughing up of blood. He used to work as a teacher and has not been exposed to any environmental dust or chemicals.

      His GP ordered a chest X-ray, which reveals reticular shadowing affecting both lung bases. Upon examination, he has clubbed fingers and fine-end inspiratory crackles. His heart sounds are normal, and he is saturating at 94% on room air with a regular heart rate of 80 bpm and regular respiratory rate of 20. There is no peripheral oedema.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      Differential Diagnosis for Shortness of Breath and Clubbing: Idiopathic Pulmonary Fibrosis as the Likely Diagnosis

      Shortness of breath and clubbing can be indicative of various respiratory and cardiac conditions. In this case, the most likely diagnosis is idiopathic pulmonary fibrosis, as evidenced by fine-end inspiratory crackles on examination, X-ray findings of bi-basal reticulonodular shadowing in a typical distribution, and the presence of clubbing. Bronchiectasis is another possible diagnosis, but the lack of purulent phlegm and coarse crackles, as well as chest X-ray findings inconsistent with dilated, thick-walled bronchi, make it less likely. Carcinoma of the lung is also a consideration, but the absence of a smoking history and chest X-ray findings make it less probable. Chronic obstructive pulmonary disease (COPD) is unlikely without a smoking history and the absence of wheeze on examination. Congestive cardiac failure (CCF) can cause shortness of breath, but clubbing is typically only present in cases of congenital heart disease with right to left shunts, which is not demonstrated in this case. Overall, idiopathic pulmonary fibrosis is the most likely diagnosis based on the clinical presentation and diagnostic findings.

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  • Question 25 - A 5-year-old girl comes to her general practice clinic with her mother. She...

    Incorrect

    • A 5-year-old girl comes to her general practice clinic with her mother. She has been experiencing nasal congestion, sneezing, and a sore throat for the past few days. During the examination, her pulse rate is 80 bpm, respiratory rate is 20 breaths per minute, and temperature is 36.9 °C. She has no significant medical history. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Common cold

      Explanation:

      Possible Diagnosis for a Young Girl with Respiratory Symptoms

      A young girl is experiencing respiratory symptoms, including sore throat, sneezing, and nasal congestion. Here are some possible diagnoses to consider:

      1. Common cold: This is a common viral infection that can cause mild fever, especially in children.

      2. Hay fever: This is an allergic reaction to specific allergens, such as pollen, that can cause similar symptoms to the common cold, but with a chronic and fluctuating course.

      3. Infectious mononucleosis: This is a viral infection that can cause fatigue, fever, laryngitis, and a rash, but is less likely in this case.

      4. influenzae: This is a seasonal viral infection that can cause more severe symptoms, such as high fever, headache, and muscle aches.

      5. Meningitis: This is a serious bacterial infection that can cause non-specific respiratory symptoms, but also tachycardia, hypotension, high fever, photophobia, neck stiffness, and petechial rash, which are not mentioned here.

      Possible Diagnoses for a Young Girl with Respiratory Symptoms

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  • Question 26 - After reviewing a patient with chronic obstructive pulmonary disease (COPD) in clinic, the...

    Incorrect

    • After reviewing a patient with chronic obstructive pulmonary disease (COPD) in clinic, the respiratory consultant discusses the anatomy of the lungs with a group of undergraduate students.
      With regard to the lungs, which one of the following statements is accurate?

      Your Answer:

      Correct Answer: The lungs receive a dual blood supply

      Explanation:

      Facts about the Anatomy of the Lungs

      The lungs are a vital organ responsible for respiration. Here are some important facts about their anatomy:

      – The lungs receive a dual blood supply from the pulmonary artery and the bronchial arteries. A pulmonary embolus may only result in infarction when the circulation is already inadequate.
      – The left lung has two lobes, while the right lung has three. The horizontal fissure is present only in the right lung.
      – Each lung has ten bronchopulmonary segments, which can be selectively removed surgically if diseased.
      – The right bronchus is shorter, wider, and more vertical than the left bronchus, making it more likely for foreign bodies to enter it. Aspiration pneumonia and abscess formation are common in the apical segment of the right lower lobe.

      Important Facts about the Anatomy of the Lungs

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  • Question 27 - A 65-year-old man snores at night and his wife reports it is so...

    Incorrect

    • A 65-year-old man snores at night and his wife reports it is so loud that he often wakes her up. She notes that her husband sometimes appears to not take a breath for a long time and then gasps for air before continuing to snore. He suffers from daytime headaches and sleepiness. He has a body mass index (BMI) of 40 kg/m2.
      What would the most likely arterial blood gas result be if it was measured in this patient?

      Your Answer:

      Correct Answer: Compensated respiratory acidosis

      Explanation:

      Understanding Compensated and Uncompensated Acid-Base Disorders

      Acid-base disorders are a group of conditions that affect the pH balance of the body. Compensation is the body’s natural response to maintain a normal pH level. Here are some examples of compensated and uncompensated acid-base disorders:

      Compensated respiratory acidosis occurs in patients with obstructive sleep apnea. The kidney compensates for the chronic respiratory acidosis by increasing bicarbonate production, which buffers the increase in acid caused by carbon dioxide.

      Compensated respiratory alkalosis is seen in high-altitude areas. The kidney compensates by reducing the rate of bicarbonate reabsorption and increasing reabsorption of H+.

      Compensated metabolic acidosis occurs in patients with diabetic ketoacidosis. The body compensates by hyperventilating to release carbon dioxide and reduce the acid burden. The kidney also compensates by increasing bicarbonate production and sequestering acid into proteins.

      Uncompensated respiratory acidosis occurs in patients with Guillain–Barré syndrome, an obstructed airway, or respiratory depression from opiate toxicity. There is an abrupt failure in ventilation, leading to an acute respiratory acidosis.

      Uncompensated metabolic acidosis occurs in patients with lactic acidosis or diabetic ketoacidosis. The body cannot produce enough bicarbonate to buffer the added acid, leading to an acute metabolic acidosis.

      Understanding these different types of acid-base disorders and their compensatory mechanisms is crucial in diagnosing and treating patients with these conditions.

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  • Question 28 - A 68-year-old woman with a long history of rheumatoid arthritis presents to her...

    Incorrect

    • A 68-year-old woman with a long history of rheumatoid arthritis presents to her general practitioner complaining of a chronic cough, weight loss and haemoptysis. She smokes ten cigarettes a day. You understand that she has begun anti-tumour necrosis factor (TNF) antibody treatment around 9 months earlier. On examination, her rheumatoid appears quiescent at present.
      Investigations:
      Investigation Result Normal value
      Chest X-ray Calcified hilar lymph nodes,
      possible left upper lobe fibrosis
      Haemoglobin 109 g/l 115–155 g/l
      White cell count (WCC) 11.1 × 109/l 4–11 × 109/l
      Platelets 295 × 109/l 150–400 × 109/l
      Erythrocyte sedimentation rate (ESR) 61 mm/h 0–10mm in the 1st hour
      C-reactive protein (CRP) 55 mg/l 0–10 mg/l
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Creatinine 100 μmol/l 50–120 µmol/l
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer:

      Correct Answer: Active pulmonary tuberculosis

      Explanation:

      Differential diagnosis of calcified lymph nodes and upper lobe fibrosis in a patient with rheumatoid arthritis

      A patient with rheumatoid arthritis presents with calcified lymph nodes and upper lobe fibrosis on a chest X-ray. Several possible causes need to be considered, including active pulmonary tuberculosis, lymphoma, rheumatoid lung disease, bronchial carcinoma, and invasive aspergillosis. While anti-TNF antibody medication for rheumatoid arthritis may increase the risk of tuberculosis and aspergillosis, it is important to rule out other potential etiologies based on clinical examination, imaging studies, and laboratory tests. The presence of soft, fluffy, and ill-defined lesions on chest X-ray may suggest active tuberculosis, while the absence of upper lobe fibrosis may argue against lymphoma or radiotherapy-induced fibrosis. Pulmonary nodules and lung fibrosis at the lung bases are more typical of rheumatoid lung disease, but calcified nodes with upper lobe fibrosis are unusual. Bronchial carcinoma may be a concern given the patient’s age and smoking history, but typically lymph nodes are not calcified. Invasive aspergillosis is more likely in immunosuppressed patients and can be detected by a CT scan and a serum galactomannan test. A comprehensive differential diagnosis can guide further evaluation and management of this complex case.

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  • Question 29 - A 70-year old man is being evaluated by the respiratory team for progressive...

    Incorrect

    • A 70-year old man is being evaluated by the respiratory team for progressive cough and shortness of breath over the last 10 months. He has no history of smoking and is typically healthy. The only notable change in his lifestyle is that he recently started breeding pigeons after retiring. Upon examination, the patient is diagnosed with interstitial pneumonia.
      What is the most frequently linked organism with interstitial pneumonia?

      Your Answer:

      Correct Answer: Mycoplasma

      Explanation:

      Types of Bacterial Pneumonia and Their Patterns in the Lung

      Bacterial pneumonia can be caused by various organisms, each with their own unique patterns in the lung. Mycoplasma, viruses like RSV and CMV, and fungal infections like histoplasmosis typically cause interstitial patterns in the lung. Haemophilus influenzae, Staphylococcus, Pneumococcus, Escherichia coli, and Klebsiella all typically have the same alveolar pattern, with Klebsiella often causing an aggressive, necrotizing lobar pneumonia. Streptococcus pneumoniae is the most common cause of typical bacterial pneumonia, while Staphylococcus aureus pneumonia is typically of the alveolar type and seen in intravenous drug users or patients with underlying debilitating conditions. Mycoplasma pneumonia may also have extra-pulmonary manifestations. These conditions are sometimes referred to as atypical pneumonia.

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  • Question 30 - A 58-year-old man presents to the Emergency Department with increasing shortness of breath...

    Incorrect

    • A 58-year-old man presents to the Emergency Department with increasing shortness of breath and cough for the last two days. The patient reports feeling fevers and chills and although he has a chronic cough, this has now become productive of yellow sputum over the last 36 hours. He denies chest pain. His past medical history is significant for chronic obstructive pulmonary disease (COPD) for which he has been prescribed various inhalers that he is not compliant with. He currently smokes 15 cigarettes per day and does not drink alcohol.
      His observations and blood tests results are shown below:
      Investigation Result Normal value
      Temperature 36.9 °C
      Blood pressure 143/64 mmHg
      Heart rate 77 beats per minute
      Respiratory rate 32 breaths per minute
      Sp(O2) 90% (room air)
      White cell count 14.9 × 109/l 4–11 × 109/l
      C-reactive protein 83 mg/l 0–10 mg/l
      Urea 5.5 mmol/l 2.5–6.5 mmol/l
      Physical examination reveals widespread wheeze throughout his lungs without other added sounds. There is no dullness or hyperresonance on percussion of the chest. His trachea is central.
      Which of the following is the most appropriate next investigation?

      Your Answer:

      Correct Answer: Chest plain film

      Explanation:

      The patient is experiencing shortness of breath, cough with sputum production, and widespread wheeze, along with elevated inflammatory markers. This suggests an infective exacerbation of COPD or community-acquired pneumonia. A chest X-ray should be ordered urgently to determine the cause and prescribe appropriate antibiotics. Treatment for COPD exacerbation includes oxygen therapy, nebulizers, oral steroids, and antibiotics. Blood cultures are not necessary at this stage unless the patient has fevers. A CTPA is not needed as the patient’s symptoms are not consistent with PE. Pulmonary function tests are not necessary in acute management. Sputum culture may be necessary if the patient’s CURB-65 score is ≥3 or if the score is 2 and antibiotics have not been given yet. The patient’s CURB-65 score is 1.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (8/8) 100%
Passmed