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Question 1
Incorrect
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A 54-year-old smoker comes to the clinic with complaints of chest pain and cough. He reports experiencing more difficulty breathing and a sharp pain in his third and fourth ribs. Upon examination, a chest x-ray reveals an enlargement on the right side of his hilum. What is the most probable diagnosis?
Your Answer: Lung collapse
Correct Answer: Bronchogenic carcinoma
Explanation:Diagnosis of Bronchogenic Carcinoma
The patient’s heavy smoking history, recent onset of cough, and bony pain strongly suggest bronchogenic carcinoma. The appearance of the chest X-ray further supports this diagnosis. While COPD can also cause cough and dyspnea, it is typically accompanied by audible wheezing and the presence of a hilar mass is inconsistent with this diagnosis. Neither tuberculosis nor lung collapse are indicated by the patient’s history or radiographic findings. Hyperparathyroidism is not a consideration unless hypercalcemia is present. Overall, the evidence points towards a diagnosis of bronchogenic carcinoma.
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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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A 40-year-old Afro-Caribbean man comes to the clinic complaining of fever, dry cough and joint pains. Upon examination, his chest is clear. He has several tender, warm, erythematous nodules on both shins. A chest X-ray reveals prominent hila bilaterally. What is the most probable diagnosis?
Your Answer: Sarcoidosis
Explanation:The patient is displaying symptoms that are typical of acute sarcoidosis, including erythema nodosum, bilateral hilar lymphadenopathy, and arthralgia. The patient’s ethnic background, being Afro-Caribbean, is also a factor as sarcoidosis is more prevalent in this population. It is important to take a thorough medical history as sarcoidosis can mimic other diseases. Mycoplasma pneumonia presents with flu-like symptoms followed by a dry cough and reticulonodular shadowing on chest X-ray. Pneumocystis jirovecii pneumonia causes breathlessness, fever, and perihilar shadowing on chest X-ray and is associated with severe immunodeficiency. Pulmonary TB causes cough, fever, weight loss, and erythema nodosum, with typical chest X-ray findings including apical shadowing or cavity, or multiple nodules. Pulmonary fibrosis presents with shortness of breath, a non-productive cough, and bilateral inspiratory crepitations on auscultation. However, the X-ray findings in this patient are not consistent with pulmonary fibrosis as reticulonodular shadowing would be expected.
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This question is part of the following fields:
- Respiratory
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Question 3
Incorrect
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A 68-year-old retired electrician presents with complaints of progressive dyspnea, unintentional weight loss, and two episodes of hemoptysis in the past week. He has a history of smoking 40 pack years. Upon examination, there is stony dullness at the right base with absent breath sounds and decreased vocal resonance.
Which of the following statements about mesothelioma is most accurate?Your Answer: It is caused by asbestos and smoking
Correct Answer: It may have a lag period of up to 45 years between exposure and diagnosis
Explanation:Understanding Mesothelioma: Causes, Diagnosis, and Prognosis
Mesothelioma is a type of cancer that affects the pleura, and while it can be caused by factors other than asbestos exposure, the majority of cases are linked to this cause. Asbestos was commonly used in various industries until the late 1970s/early 1980s, and the lag period between exposure and diagnosis can be up to 45 years. This means that the predicted peak of incidence of mesothelioma in the UK is around 2015-2020.
Contrary to popular belief, smoking does not cause mesothelioma. However, smoking and asbestos exposure can act as synergistic risk factors for bronchial carcinoma. Unfortunately, there is no known cure for mesothelioma, and the 5-year survival rate is less than 5%. Treatment is supportive and palliative, with an emphasis on managing symptoms and improving quality of life.
Diagnosis is usually made through CT imaging, with or without thoracoscopic-guided biopsy. Open lung biopsy is only considered if other biopsy methods are not feasible. Mesothelioma typically presents with a malignant pleural effusion, which can be difficult to distinguish from a pleural tumor on a plain chest X-ray. The effusion will be an exudate.
In conclusion, understanding the causes, diagnosis, and prognosis of mesothelioma is crucial for early detection and management of this devastating disease.
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This question is part of the following fields:
- Respiratory
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Question 4
Incorrect
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A 78-year-old man with known alcohol dependence presents to the Emergency Department with a few weeks of productive cough, weight loss, fever and haemoptysis. He is a heavy smoker, consuming 30 cigarettes per day. On a chest X-ray, multiple nodules 1-3 mm in size are visible throughout both lung fields. What is the best treatment option to effectively address the underlying cause of this man's symptoms?
Your Answer: Systemic chemotherapy
Correct Answer: Anti-tuberculous (TB) chemotherapy
Explanation:Choosing the Right Treatment: Evaluating Options for a Patient with Suspected TB
A patient presents with a subacute history of fever, productive cough, weight loss, and haemoptysis, along with a chest X-ray description compatible with miliary TB. Given the patient’s risk factors for TB, such as alcohol dependence and smoking, anti-TB chemotherapy is the most appropriate response, despite the possibility of lung cancer. IV antibiotics may be used until sputum staining and culture results are available, but systemic chemotherapy would likely lead to overwhelming infection and death. Tranexamic acid may be useful for significant haemoptysis, but it will not treat the underlying diagnosis. acyclovir is not indicated, as the patient does not have a history of rash, and a diagnosis of miliary TB is more likely than varicella pneumonia. Careful evaluation of the patient’s history and symptoms is crucial in choosing the right treatment.
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This question is part of the following fields:
- Respiratory
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Question 5
Correct
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A 60-year-old male smoker with severe rheumatoid arthritis comes to the clinic complaining of a dry cough and increasing difficulty in breathing over the past few months. During the examination, he appears to be mildly cyanosed and has end inspiratory crepitations. A chest x-ray reveals widespread reticulonodular changes. What is the most probable diagnosis?
Your Answer: Rheumatoid lung
Explanation:Diagnosis and Differential Diagnosis of Pulmonary Fibrosis
Pulmonary fibrosis is suspected in a patient with a history and examination features that suggest the condition. Rheumatoid lung is a common cause of pulmonary fibrosis, especially in severe rheumatoid disease and smokers. The reported changes on the chest X-ray are consistent with the diagnosis. However, to diagnose respiratory failure, a blood gas result is necessary.
On the other hand, bronchial asthma is characterized by reversible airways obstruction, which leads to fluctuation of symptoms and wheezing on auscultation. The history of the patient is not consistent with chronic obstructive pulmonary disease (COPD). Pneumonia, on the other hand, is suggested by infective symptoms, pyrexia, and consolidation on CXR.
In summary, the diagnosis of pulmonary fibrosis requires a thorough history and examination, as well as imaging studies. Differential diagnosis should include other conditions that present with similar symptoms and signs, such as bronchial asthma, COPD, and pneumonia.
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This question is part of the following fields:
- Respiratory
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Question 6
Correct
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A 24-year-old man, who is a known intravenous drug user, presented with progressive dyspnoea. On examination, his respiratory rate was 31 breaths per minute and his chest X-ray showed diffuse infiltrates in a bat-wing pattern. However, chest auscultation was normal. While staying in hospital, he developed sudden severe dyspnoea, and an emergency chest X-ray showed right-sided pneumothorax.
What is the underlying disease of this patient?Your Answer: Pneumocystis jirovecii infection
Explanation:Differential Diagnosis for a Young Injection Drug User with Dyspnea and Chest X-ray Findings
A young injection drug user presenting with gradually progressive dyspnea and a typical chest X-ray finding is likely to have Pneumocystis jirovecii infection, an opportunistic fungal infection that predominantly affects the lungs. This infection is often seen in individuals with underlying human immunodeficiency virus (HIV) infection-related immunosuppression. Other opportunistic infections should also be ruled out. Pneumocystis typically resides in the alveoli of the lungs, resulting in extensive exudation and formation of hyaline membrane. Lung biopsy shows foamy vacuolated exudates. Extrapulmonary sites involved include the thyroid, lymph nodes, liver, and bone marrow.
Other potential diagnoses, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, pneumoconiosis, and pulmonary histoplasmosis, are less likely. COPD and pneumoconiosis are typically seen in individuals with a history of smoking or occupational exposure to dust, respectively. Cystic fibrosis would present with a productive cough and possible hemoptysis, while pulmonary histoplasmosis is not commonly found in Europe.
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This question is part of the following fields:
- Respiratory
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Question 7
Incorrect
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A 36-year-old woman of African origin presented to the Emergency Department with sudden-onset dyspnoea. She was a known case of systemic lupus erythematosus (SLE), previously treated for nephropathy and presently on mycophenolate mofetil and hydroxychloroquine sulfate. She had no fever. On examination, her respiratory rate was 45 breaths per minute, with coarse crepitations in the right lung base. After admission, blood test results revealed:
Investigation Value Normal range
Haemoglobin 100g/l 115–155 g/l
Sodium (Na+) 136 mmol/l 135–145 mmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
PaO2on room air 85 mmHg 95–100 mmHg
C-reactive protein (CRP) 6.6mg/l 0-10 mg/l
C3 level 41 mg/dl 83–180 mg/dl
Which of the following is most likely to be found in this patient as the cause for her dyspnoea?Your Answer: High erythrocyte sedimentation rate (ESR)
Correct Answer: High diffusing capacity of the lungs for carbon monoxide (DLCO)
Explanation:This case discusses diffuse alveolar haemorrhage (DAH), a rare but serious complication of systemic lupus erythematosus (SLE). Symptoms include sudden-onset shortness of breath, decreased haematocrit levels, and possibly coughing up blood. A chest X-ray may show diffuse infiltrates and crepitations in the lungs. It is important to rule out infections before starting treatment with methylprednisolone or cyclophosphamide. A high DLCO, indicating increased diffusion capacity across the alveoli, may be present in DAH. A pulmonary function test may not be possible due to severe dyspnoea, so diagnosis is based on clinical presentation, imaging, and bronchoscopy. Lung biopsy may show pulmonary capillaritis with neutrophilic infiltration. A high ESR is non-specific and sputum for AFB is not relevant in this acute presentation. BAL fluid in DAH is progressively haemorrhagic, and lung scan with isotopes is not typical for this condition.
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This question is part of the following fields:
- Respiratory
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Question 8
Correct
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A 25-year-old man has suffered a left-sided pneumothorax. A chest drain has been inserted through the left fifth intercostal space at the mid-axillary line.
As well as the intercostal muscles, which other muscle is likely to have been pierced?Your Answer: Serratus anterior
Explanation:Muscles and Chest Drains: Understanding the Anatomy
The human body is a complex system of muscles, bones, and organs that work together to keep us alive and functioning. When it comes to chest drains, understanding the anatomy of the surrounding muscles is crucial for successful placement and management. Let’s take a closer look at some of the key muscles involved.
Serratus Anterior
The serratus anterior muscle is located on the lateral chest and plays a vital role in protracting the scapula and contributing to rotation. It is likely to be pierced with most chest drains due to its position, with its lower four segments attaching to the fifth to eighth ribs anterior to the mid-axillary line.Latissimus Dorsi
The latissimus dorsi muscle is a back muscle involved in adduction, medial rotation, and extension of the shoulder. It is not pierced by a chest drain.External Oblique
The external oblique muscle is located in the anterior abdomen and is not involved with a chest drain.Pectoralis Major
The pectoralis major muscle is situated in the anterior chest and is not affected by a chest drain, as it does not overlie the fifth intercostal space at the mid-axillary line. It flexes, extends, medially rotates, and adducts the shoulder.Pectoralis Minor
The pectoralis minor muscle lies inferior to the pectoralis major on the anterior chest. It is a small muscle and is not usually pierced with a chest drain, as it does not overlie the fifth intercostal space at the mid-clavicular line.In conclusion, understanding the anatomy of the muscles surrounding the chest is essential for successful chest drain placement and management. Knowing which muscles are likely to be pierced and which are not can help healthcare professionals provide the best possible care for their patients.
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This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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A 72-year-old woman is discovered outside in the early hours of the morning after falling to the ground. She is confused and uncertain of what happened and is admitted to the hospital. An abbreviated mental test (AMT) is conducted, and she scores 4/10. During the examination, crackles are heard at the base of her left lung.
Blood tests reveal:
Investigation Result Normal value
C-reactive protein (CRP) 89 mg/l < 10 mg/l
White cell count (WCC) 15 × 109/l 4–11 × 109/l
Neutrophils 11.4 × 109/l 5–7.58 × 109/l
The remainder of her blood tests, including full blood count (FBC), urea and electrolytes (U&Es), and liver function test (LFT), were normal.
Observations:
Investigation Result Normal value
Respiratory rate 32 breaths/min 12–18 breaths/min
Oxygen saturation 90% on air
Heart rate (HR) 88 beats/min 60–100 beats/min
Blood pressure (BP) 105/68 mmHg Hypertension: >120/80 mmHg*
Hypotension: <90/60 mmHg*
Temperature 39.1°C 1–37.2°C
*Normal ranges should be based on the individual's clinical picture. The values are provided as estimates.
Based on her CURB 65 score, what is the most appropriate management for this patient?Your Answer: Admit her to a general ward for treatment
Correct Answer: Admit the patient and consider ITU
Explanation:Understanding the CURB Score and Appropriate Patient Management
The CURB score is a tool used to assess the severity of community-acquired pneumonia and determine the appropriate level of care for the patient. A score of 0-1 indicates that the patient can be discharged home, a score of 2 suggests hospital treatment, and a score of 3 or more warrants consideration for intensive care unit (ITU) admission.
In the case of a patient with a CURB score of 3, such as a 68-year-old with a respiratory rate of >30 breaths/min and confusion (AMT score of 4), ITU admission should be considered. Admitting the patient to a general ward or discharging them home with advice to see their GP the following day would not be appropriate.
It is important for healthcare professionals to understand and utilize the CURB score to ensure appropriate management of patients with community-acquired pneumonia.
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This question is part of the following fields:
- Respiratory
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Question 10
Correct
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A 35-year-old woman with a history of asthma and eczema visits her General Practitioner and inquires about the reason for her continued wheezing hours after being exposed to pollen. She has a known allergy to tree pollen.
What is the most suitable explanation for this?Your Answer: Inflammation followed by mucosal oedema
Explanation:Understanding the Mechanisms of Allergic Asthma
Allergic asthma is a condition that is mediated by immunoglobulin E (IgE). When IgE binds to an antigen, it triggers mast cells to release histamine, leukotrienes, and prostaglandins, which cause bronchospasm and vasodilation. This leads to inflammation and edema of the mucosal lining of the airways, resulting in persistent symptoms or late symptoms after an acute asthma attack.
While exposure to another allergen could trigger an asthma attack, it is not the most appropriate answer if you are only aware of a known allergy to tree pollen. Smooth muscle hypertrophy may occur in the long-term, but the exact mechanism and functional effects of airway remodeling in asthma are not fully understood. Pollen stuck on Ciliary would act as a cough stimulant, clearing the pollen from the respiratory tract. Additionally, the Ciliary would clear the pollen up the respiratory tract as part of the mucociliary escalator.
It is important to note that pollen inhaled into the respiratory system is not systemically absorbed. Instead, it binds to immune cells and exhibits immune effects through cytokines produced by Th1 and Th2 cells. Understanding the mechanisms of allergic asthma can help individuals manage their symptoms and prevent future attacks.
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This question is part of the following fields:
- Respiratory
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Question 11
Incorrect
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A 28-year-old man with cystic fibrosis (CF) arrives at the Emergency Department (ED) with haemoptysis. During his stay in the ED, he experiences another episode of frank haemoptysis, which measures 180 ml.
A prompt computed tomography (CT) aortogram is conducted, revealing dilated and tortuous bronchial arteries.
What action could potentially harm the management of this patient?Your Answer: Bronchial artery embolisation
Correct Answer: Non-invasive ventilation
Explanation:Treatment options for massive haemoptysis in cystic fibrosis patients
Massive haemoptysis in cystic fibrosis (CF) patients can be a life-threatening complication. Non-invasive ventilation is not recommended as it may increase the risk of aspiration of blood and disturb clot formation. IV antibiotics should be given to treat acute inflammation related to pulmonary infection. Tranexamic acid, an anti-fibrinolytic drug, can be given orally or intravenously up to four times per day until bleeding is controlled. CF patients have impaired absorption of fat-soluble vitamins, including vitamin K, which may lead to prolonged prothrombin time. In such cases, IV vitamin K should be given. Bronchial artery embolisation is often required to treat massive haemoptysis, particularly when larger hypertrophied bronchial arteries are seen on CT. This procedure is performed by an interventional vascular radiologist and may be done under sedation or general anaesthetic if the patient is in extremis.
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This question is part of the following fields:
- Respiratory
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Question 12
Correct
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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: 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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This question is part of the following fields:
- Respiratory
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Question 13
Correct
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A 29-year-old electrician was referred to the hospital by his general practitioner. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for the past three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. On the day of referral, he reported mild dyspnea, a global headache, myalgia, and arthralgia. During the examination, a maculopapular rash was observed on his upper body, and fine crackles were audible in the left mid-zone of his chest. Mild neck stiffness was also noted. His vital signs showed a fever of 39°C and a blood pressure of 120/70 mmHg.
The following investigations were conducted:
- Hb: 84 g/L (130-180)
- WBC: 8 ×109/L (4-11)
- Platelets: 210 ×109/L (150-400)
- Reticulocytes: 8% (0.5-2.4)
- Na: 137 mmol/L (137-144)
- K: 4.2 mmol/L (3.5-4.9)
- Urea: 5.0 mmol/L (2.5-7.5)
- Creatinine: 110 µmol/L (60-110)
- Bilirubin: 19 µmol/L (1-22)
- Alk phos: 130 U/L (45-105)
- AST: 54 U/L (1-31)
- GGT: 48 U/L (<50)
The chest x-ray revealed patchy consolidation in both mid-zones. What is the most appropriate course of treatment?Your Answer: Clarithromycin
Explanation:Mycoplasma Pneumonia: Symptoms, Complications, and Treatment
Mycoplasma pneumonia is a type of pneumonia that commonly affects individuals aged 15-30 years. It is characterized by systemic upset, dry cough, and fever, with myalgia and arthralgia being common symptoms. Unlike other types of pneumonia, the white blood cell count is often within the normal range. In some cases, Mycoplasma pneumonia can also cause extrapulmonary manifestations such as haemolytic anaemia, renal failure, hepatitis, myocarditis, meningism and meningitis, transverse myelitis, cerebellar ataxia, and erythema multiforme.
One of the most common complications of Mycoplasma pneumonia is haemolytic anaemia, which is associated with the presence of cold agglutinins found in up to 50% of cases. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies in paired sera. Treatment typically involves the use of macrolide antibiotics such as clarithromycin or erythromycin, with tetracycline or doxycycline being alternative options.
In summary, Mycoplasma pneumonia is a type of pneumonia that can cause a range of symptoms and complications, including haemolytic anaemia and extrapulmonary manifestations. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies, and treatment typically involves the use of macrolide antibiotics.
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This question is part of the following fields:
- Respiratory
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Question 14
Correct
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A 30-year-old woman comes to the General Practice Clinic complaining of feeling unwell for the past few days. She has been experiencing nasal discharge, sneezing, fatigue, and a cough. Her 3-year-old daughter recently recovered from very similar symptoms. During the examination, her pulse rate is 62 bpm, respiratory rate 18 breaths per minute, and temperature 37.2 °C. What is the probable causative organism for her symptoms?
Your Answer: Rhinovirus
Explanation:Identifying the Most Common Causative Organisms of the Common Cold
The common cold is a viral infection that affects millions of people worldwide. Among the different viruses that can cause the common cold, rhinoviruses are the most common, responsible for 30-50% of cases annually. influenzae viruses can also cause milder symptoms that overlap with those of the common cold, accounting for 5-15% of cases. Adenoviruses and enteroviruses are less common causes, accounting for less than 5% of cases each. Respiratory syncytial virus is also a rare cause of the common cold, accounting for only 5% of cases annually. When trying to identify the causative organism of a common cold, it is important to consider the patient’s symptoms, recent exposure to sick individuals, and prevalence of different viruses in the community.
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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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: Hepatic encephalopathy
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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This question is part of the following fields:
- Respiratory
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Question 16
Correct
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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: 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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This question is part of the following fields:
- Respiratory
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Question 17
Correct
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A 40-year-old patient visits his GP complaining of a dry cough that has persisted for 3 months. He has been smoking 20 cigarettes daily for the past 12 years and has no other medical history. Upon examination, no abnormalities are found, and his vital signs, including pulse rate, respiratory rate, blood pressure, temperature, and oxygen saturation, are all normal. Spirometry results reveal a forced expiratory volume in 1 second (FEV1) of 3.6 litres (predicted = 3.55 litres) and a forced vital capacity of 4.8 litres (predicted 4.72 litres). What is the most probable diagnosis?
Your Answer: Asthma
Explanation:Differential diagnosis of a dry cough in a young patient
A dry cough is a common symptom that can have various underlying causes. In a young patient with a ten-pack-year history of smoking and a 3-month duration of symptoms, several possibilities should be considered and ruled out based on clinical evaluation and diagnostic tests.
One possibility is asthma, especially if the cough is the main or only symptom. In this case, spirometry may be normal, but peak flow monitoring before and after inhaled steroid therapy can help confirm the diagnosis by showing an improvement in peak flow rate and/or a reduction in variability.
Chronic obstructive pulmonary disease (COPD) is less likely in a young patient, but spirometry can reveal obstructive patterns if present.
Community-acquired pneumonia is unlikely given the chronicity of symptoms and the absence of typical signs such as productive cough and inspiratory crackles.
Angina is an uncommon cause of a dry cough, and it usually presents with chest tightness on exertion rather than at night.
Bronchiectasis can cause a productive cough and crackles on auscultation, which are not present in this case.
Therefore, based on the available information, asthma seems to be the most likely diagnosis, but further evaluation may be needed to confirm it and exclude other possibilities.
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This question is part of the following fields:
- Respiratory
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Question 18
Correct
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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: 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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This question is part of the following fields:
- Respiratory
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Question 19
Incorrect
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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: Azithromycin
Correct 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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This question is part of the following fields:
- Respiratory
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Question 20
Correct
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A 67-year-old woman presents with right-sided pleural effusion. Thoracentesis is performed and the pleural fluid analysis reveals the following results:
Pleural fluid Pleural fluid analysis Serum Normal value
Protein 2.5 g/dl 7.3 g/dl 6-7.8 g/dl
Lactate dehydrogenase (LDH) 145 IU/l 350 IU/l 100-250 IU/l
What is the probable diagnosis for this patient?Your Answer: Heart failure
Explanation:Causes of Transudative and Exudative Pleural Effusions
Pleural effusion is the accumulation of fluid in the pleural space, which can be classified as transudative or exudative based on Light’s criteria. The most common cause of transudative pleural effusion is congestive heart failure, which can also cause bilateral or unilateral effusions. Other causes of transudative effusions include cirrhosis and nephrotic syndrome. Exudative pleural effusions are typically caused by pneumonia, malignancy, or pleural infections. Nephrotic syndrome can also cause transudative effusions, while breast cancer and viral pleuritis are associated with exudative effusions. Proper identification of the underlying cause is crucial for appropriate management of pleural effusions.
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This question is part of the following fields:
- Respiratory
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Question 21
Incorrect
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A 21-year-old man experiences sudden right-sided chest pain while exercising. The pain persists in the Emergency Department, but he is not short of breath. There is no past medical history of note. Observations are recorded:
temperature 36.6 °C
heart rate (HR) 90 bpm
blood pressure (BP) 115/80 mmHg
respiratory rate (RR) 18 breaths/minute
oxygen saturation (SaO2) 99%.
A chest X-ray reveals a 1.5 cm sliver of air in the pleural space of the right lung.
Which of the following is the most appropriate course of action?Your Answer: Insert a 16G cannula into the second intercostal space
Correct Answer: Consider prescribing analgesia and discharge home with information and advice
Explanation:Management Options for Primary Pneumothorax
Primary pneumothorax is a condition where air accumulates in the pleural space, causing the lung to collapse. The management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. Here are some management options for primary pneumothorax:
Prescribe analgesia and discharge home with information and advice: This option can be considered if the patient is not breathless and has only a small defect. The patient can be discharged with pain relief medication and given information and advice on how to manage the condition at home.
Admit for a trial of nebulised salbutamol and observation: This option is not indicated for a patient with primary pneumothorax, as a trial of salbutamol is not effective in treating this condition.
Aspirate the air with a needle and syringe: This option should only be attempted if the patient has a rim of air of >2 cm on the chest X-ray or is breathless. Aspiration can be attempted twice at a maximum, after which a chest drain should be inserted.
Insert a chest drain: This option should be done if the second attempt of aspiration is unsuccessful. Once air has stopped leaking, the drain should be left in for a further 24 hours prior to removal and discharge.
Insert a 16G cannula into the second intercostal space: This option is used for tension pneumothoraces and is not indicated for primary pneumothorax.
In conclusion, the management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. It is important to choose the appropriate management option to ensure the best outcome for the patient.
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This question is part of the following fields:
- Respiratory
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Question 22
Correct
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You are on call in the Emergency Department when an ambulance brings in an elderly man who was found unconscious in his home, clutching an empty bottle of whiskey. On physical examination, he is febrile with a heart rate of 110 bpm, blood pressure of 100/70 mmHg and pulse oximetry of 89% on room air. You hear crackles in the right lower lung base and note dullness to percussion in those areas. His breath is intensely malodorous, and there appears to be dried vomit in his beard.
What is the most likely organism causing his pneumonia?Your Answer: Mixed anaerobes
Explanation:Types of Bacteria that Cause Pneumonia
Pneumonia is a serious respiratory infection that can be caused by various types of bacteria. One common cause is the ingestion of large quantities of alcohol, which can lead to vomiting and aspiration of gastric contents. This can result in pneumonia caused by Gram-negative anaerobes from the oral flora or gastric contents, which produce foul-smelling short-chain fatty acids.
Other types of bacteria that can cause pneumonia include Streptococcus pneumoniae, the most common cause of severe bacterial pneumonia requiring hospitalization. It is a Gram-positive, catalase-negative coccus. Staphylococcus aureus is a less common cause of pneumonia, often seen after influenzae infection. It is a Gram-positive, coagulase-positive coccus.
Legionella pneumophila causes Legionnaires’ disease, a severe pneumonia that typically affects older people and is contracted through contaminated air conditioning ducts or showers. The best stain for this organism is a silver stain. Chlamydia pneumoniae causes an ‘atypical’ pneumonia with bilateral diffuse infiltrates, and the chest radiograph often looks worse than is indicated by the patient’s presentation. C. pneumoniae is an obligate intracellular organism.
In summary, understanding the different types of bacteria that can cause pneumonia is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 23
Correct
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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: 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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This question is part of the following fields:
- Respiratory
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Question 24
Correct
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A 63-year-old man presents with complaints of dyspnoea, haemoptysis, and an unintentional 25 lb weight loss over the last 4 months. He reports a medical history significant for mild asthma controlled with an albuterol inhaler as needed. He takes no other medications and has no allergies. He has a 55 pack-year smoking history and has worked as a naval shipyard worker for 40 years. Examination reveals diffuse crackles in the posterior lung fields bilaterally and there is dullness to percussion one-third of the way up the right lung field. Ultrasound reveals free fluid in the pleural space.
Which one of the following set of test values is most consistent with this patient’s presentation?
(LDH: lactate dehydrogenase)
Option LDH plasma LDH pleural Protein plasma Protein pleural
A 180 100 7 3
B 270 150 8 3
C 180 150 7 4
D 270 110 8 3
E 180 100 7 2Your Answer: Option C
Explanation:Interpreting Light’s Criteria for Pleural Effusions
When evaluating a patient with a history of occupational exposure and respiratory symptoms, it is important to consider the possibility of pneumoconiosis, specifically asbestosis. Chronic exposure to asbestos can lead to primary bronchogenic carcinoma and mesothelioma. Chest radiography may reveal radio-opaque pleural and diaphragmatic plaques. In this case, the patient’s dyspnea, hemoptysis, and weight loss suggest primary lung cancer, with a likely malignant pleural effusion observed under ultrasound.
To confirm the exudative nature of the pleural effusion, Light’s criteria can be used. These criteria include a pleural:serum protein ratio >0.5, a pleural:serum LDH ratio >0.6, and pleural LDH more than two-thirds the upper limit of normal serum LDH. Meeting any one of these criteria indicates an exudative effusion.
Option C is the correct answer as it satisfies Light’s criteria for an exudative pleural effusion. Options A, B, D, and E do not meet the criteria. Understanding Light’s criteria can aid in the diagnosis and management of pleural effusions, particularly in cases where malignancy is suspected.
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This question is part of the following fields:
- Respiratory
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Question 25
Correct
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What is the most effective tool for assessing a patient who is suspected of having occupational asthma?
Your Answer: Serial measurements of ventilatory function performed before, during, and after work
Explanation:Occupational Asthma
Occupational asthma is a type of asthma that is caused by conditions and factors present in a particular work environment. It is characterized by variable airflow limitation and/or airway hyper-responsiveness. This type of asthma accounts for about 10% of adult asthma cases. To diagnose occupational asthma, several investigations are conducted, including serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. A consistent fall in peak flow values and increased intraday variability on working days, along with improvement on days away from work, confirms the diagnosis of occupational asthma. It is important to understand the causes and symptoms of occupational asthma to prevent and manage this condition effectively.
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This question is part of the following fields:
- Respiratory
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Question 26
Correct
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Emily is a 6-year-old overweight girl brought in by concerned parents who are worried about her loud snoring and frequent interruptions in breathing which have been getting progressively worse. Her parents have been receiving complaints from the school teachers about her disruptive and inattentive behaviour in class. On examination, Emily has a short, thick neck and mildly enlarged tonsils but no other abnormalities.
What is the next best step in management?Your Answer: Order an overnight polysomnographic study
Explanation:Childhood Obstructive Sleep Apnoea: Diagnosis and Treatment Options
Childhood obstructive sleep apnoea (OSA) is a pathological condition that requires prompt diagnosis and treatment. A polysomnographic study should be performed before booking for an operation, as adenotonsillectomy is the treatment of choice for childhood OSA.
The clinical presentation of childhood OSA is non-specific but typically includes symptoms such as mouth breathing, abnormal breathing during sleep, poor sleep with frequent awakening or restlessness, nocturnal enuresis, nightmares, difficulty awakening, excessive daytime sleepiness or hyperactivity, and behavioural problems. However, parents should be reassured that snoring loudly is very normal in children his age and that his behaviour pattern will improve as he matures.
Before any intervention is undertaken, the patient should be first worked up for OSA with a polysomnographic study. While dental splints may have a small role to play in OSA, they are not the ideal treatment option. Intranasal budesonide is an option for mild to moderate OSA, but it is only a temporising measure and not a proven effective long-term treatment.
In conclusion, childhood OSA requires prompt diagnosis and treatment. Adenotonsillectomy is the treatment of choice, but a polysomnographic study should be performed before any intervention is undertaken. Parents should be reassured that snoring loudly is normal in children his age, and other treatment options such as dental splints and intranasal budesonide should be considered only after a thorough evaluation.
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This question is part of the following fields:
- Respiratory
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Question 27
Incorrect
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A 35-year-old call centre operator with a 6-year history of sarcoidosis presents with worsening shortness of breath during his visit to Respiratory Outpatients. This is his fifth episode of this nature since his diagnosis. In the past, he has responded well to tapered doses of oral steroids. What initial test would be most useful in evaluating his current pulmonary condition before prescribing steroids?
Your Answer: High-resolution computed tomography (HRCT) of the chest
Correct Answer: Pulmonary function tests with transfer factor
Explanation:Pulmonary Function Tests with Transfer Factor in Sarcoidosis: An Overview
Sarcoidosis is a complex inflammatory disease that can affect multiple organs, with respiratory manifestations being the most common. Pulmonary function tests with transfer factor are a useful tool in assessing the severity of sarcoidosis and monitoring response to treatment. The underlying pathological process in sarcoidosis is interstitial fibrosis, leading to a restrictive pattern on pulmonary function tests with reduced transfer factor. While steroids are often effective in treating sarcoidosis, monitoring transfer factor levels can help detect exacerbations and assess response to treatment. Other diagnostic tests, such as arterial blood gas, chest X-ray, serum ACE levels, and HRCT of the chest, may also be useful in certain situations but are not always necessary as an initial test. Overall, pulmonary function tests with transfer factor play a crucial role in the management of sarcoidosis.
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This question is part of the following fields:
- Respiratory
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Question 28
Correct
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A 65-year-old man presents to the Emergency Department with sudden breathlessness and haemoptysis. He had just returned from a trip to Thailand and had been complaining of pain in his left leg. His oxygen saturation is 88% on room air, blood pressure is 95/70 mmHg, and heart rate is 120 bpm. He has a history of hypertension managed with lifestyle measures only and used to work as a construction worker. While receiving initial management, the patient suddenly becomes unresponsive, stops breathing, and has no pulse. Despite prolonged resuscitation efforts, the patient is declared dead after 40 minutes. Which vessel is most likely to be affected, leading to this patient's death?
Your Answer: Pulmonary artery
Explanation:Differentiating Thrombosis in Varicose Veins: Symptoms and Diagnosis
Pulmonary artery thrombosis is a serious condition that can cause sudden-onset breathlessness, haemoptysis, pleuritic chest pain, and cough. It is usually caused by a deep vein thrombosis that travels to the pulmonary artery. Computed tomography pulmonary angiogram (CTPA) is the preferred imaging modality for diagnosis.
Pulmonary vein thrombosis is a rare condition that is typically associated with lobectomy, metastatic carcinoma, coagulopathies, and lung transplantation. Patients usually present with gradual onset dyspnoea, lethargy, and peripheral oedema.
Azygos vein thrombosis is a rare occurrence that is usually associated with azygos vein aneurysms and hepatobiliary pathologies. It is rarely fatal.
Brachiocephalic vein thrombosis is usually accompanied by arm swelling, pain, and limitation of movement. It is less likely to progress to a pulmonary embolus than lower limb deep vein thrombosis.
Coronary artery thrombus resulting in myocardial infarction (MI) is characterised by cardiac chest pain, hypotension, and sweating. Haemoptysis is not a feature of MI. Electrocardiographic changes and serum troponin and cardiac enzyme levels are typically seen in MI, but not in pulmonary embolism.
In summary, the symptoms and diagnosis of thrombosis vary depending on the affected vein. It is important to consider the patient’s medical history and perform appropriate imaging and laboratory tests for accurate diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 29
Incorrect
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A 61-year-old man presents to the Respiratory Clinic with a history of two episodes of right-sided bronchial pneumonia in the past 2 months, which have not completely resolved. He has been a heavy smoker, consuming 30 cigarettes per day since he was 16 years old. On examination, he has signs consistent with COPD and right-sided consolidation on respiratory examination. His BMI is 18. Further investigations reveal a right hilar mass measuring 4 x 2 cm in size on chest X-ray, along with abnormal laboratory values including low haemoglobin, elevated WCC, and corrected calcium levels. What is the most likely diagnosis?
Your Answer: Adenocarcinoma of the bronchus
Correct Answer: Squamous cell carcinoma of the bronchus
Explanation:Types of Bronchial Carcinomas
Bronchial carcinomas are a type of lung cancer that originates in the bronchial tubes. There are several types of bronchial carcinomas, each with their own characteristics and treatment options.
Squamous cell carcinoma of the bronchus is the most common type of bronchial carcinoma, accounting for 42% of cases. It typically occurs in the central part of the lung and is strongly associated with smoking. Patients with squamous cell carcinoma may also present with hypercalcemia.
Bronchial carcinoids are rare and slow-growing tumors that arise from the bronchial mucosa. They are typically benign but can become malignant in some cases.
Large cell bronchial carcinoma is a heterogeneous group of tumors that lack the organized features of other lung cancers. They tend to grow quickly and are often found in the periphery of the lung.
Small cell bronchial carcinoma is a highly aggressive type of lung cancer that grows rapidly and spreads early. It is strongly associated with smoking and is often found in the central part of the lung.
Adenocarcinoma of the bronchus is the least associated with smoking and typically presents with lesions in the lung peripheries rather than near the bronchus.
In summary, the type of bronchial carcinoma a patient has can vary greatly and can impact treatment options and prognosis. It is important for healthcare providers to accurately diagnose and classify the type of bronchial carcinoma to provide the best possible care for their patients.
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This question is part of the following fields:
- Respiratory
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Question 30
Correct
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A 38-year-old woman presents to the Emergency department with a two-week history of palpitations and breathlessness. She has a past medical history of diabetes mellitus, which is well controlled on metformin 850 mg bd, and longstanding hypertension for which she has been on therapy for several years. Her current medications include captopril 50 mg bd, furosemide 40 mg od, and nifedipine 20 mg bd. She recently consulted her GP with symptoms of breathlessness, and he increased the dose of furosemide to 80 mg od.
On examination, the patient is overweight and appears distressed. She is afebrile, with a pulse of 120, regular, and a blood pressure of 145/95 mmHg. Heart sounds 1 and 2 are normal without added sounds or murmurs. Respiratory rate is 28/minute, and the chest is clear to auscultation. The rest of the examination is normal.
Investigations:
- Hb: 134 g/L (normal range: 115-165)
- WBC: 8.9 ×109/L (normal range: 4-11)
- Platelets: 199 ×109/L (normal range: 150-400)
- Sodium: 139 mmol/L (normal range: 137-144)
- Potassium: 4.4 mmol/L (normal range: 3.5-4.9)
- Urea: 5.8 mmol/L (normal range: 2.5-7.5)
- Creatinine: 110 µmol/L (normal range: 60-110)
- Glucose: 5.9 mmol/L (normal range: 3.0-6.0)
- Arterial blood gases on air:
- pH: 7.6 (normal range: 7.36-7.44)
- O2 saturation: 99%
- PaO2: 112 mmHg/15 kPa (normal range: 75-100)
- PaCO2: 13.7 mmHg/1.8 kPa (normal range: 35-45)
- Standard bicarbonate: 20 mmol/L (normal range: 20-28)
- Base excess: -7.0 mmol/L (normal range: ±2)
What is the appropriate treatment for this patient?Your Answer: Calming reassurance
Explanation:Managing Respiratory Alkalosis in Patients with Panic Attacks
Patients experiencing hyperventilation may develop respiratory alkalosis, which can be managed by creating a calming atmosphere and providing reassurance. However, the traditional method of breathing into a paper bag is no longer recommended. Instead, healthcare providers should focus on stabilizing the patient’s breathing and addressing any underlying anxiety or panic.
It’s important to note that panic attacks can cause deranged ABG results, including respiratory alkalosis. Therefore, healthcare providers should be aware of this potential complication and take appropriate measures to manage the patient’s symptoms. While paper bag rebreathing may be effective in some cases, it should be administered with caution, especially in patients with respiratory or cardiac pathology.
In summary, managing respiratory alkalosis in patients with panic attacks requires a holistic approach that addresses both the physical and emotional aspects of the condition. By creating a calming environment and providing reassurance, healthcare providers can help stabilize the patient’s breathing and prevent further complications.
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This question is part of the following fields:
- Respiratory
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