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  • Question 1 - A 65-year-old male with a history of chronic obstructive pulmonary disease (COPD) has...

    Correct

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

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

      Your Answer: Smoking cessation

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory System
      21.1
      Seconds
  • Question 2 - A father brings his 5-year-old daughter to the GP with a 72-hour history...

    Incorrect

    • A father brings his 5-year-old daughter to the GP with a 72-hour history of left ear pain. She has had a cough with coryzal symptoms for the past four days. She has no past medical history, allergies or current medications, and she is up-to-date with her vaccinations. Her temperature is 38.5ºC. No abnormality is detected on examination of the oral cavity. Following otoscopy, what is the most likely causative pathogen for her diagnosis of otitis media?

      Your Answer: influenzae A

      Correct Answer: Streptococcus pneumoniae

      Explanation:

      Otitis media is primarily caused by bacteria, with viral URTIs often preceding the infection. The majority of cases are secondary to bacterial infections, with the most common culprit being…

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

    • This question is part of the following fields:

      • Respiratory System
      26
      Seconds
  • Question 3 - A man in his early fifties comes in with a painful rash caused...

    Incorrect

    • A man in his early fifties comes in with a painful rash caused by herpes on the external auditory meatus. He also has facial palsy on the same side, along with deafness, tinnitus, and vertigo. What is the probable diagnosis?

      Your Answer: Bell's palsy

      Correct Answer: Ramsay Hunt syndrome

      Explanation:

      Ramsay Hunt syndrome is characterized by a combination of Bell’s palsy facial paralysis, along with symptoms such as a herpetic rash, deafness, tinnitus, and vertigo. It is important to note that the rash may not always be visible, despite being present.

      While Bell’s palsy may present with facial paralysis, it does not typically involve the presence of herpetic rashes.

      Understanding Ramsay Hunt Syndrome

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

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

    • This question is part of the following fields:

      • Respiratory System
      7.9
      Seconds
  • Question 4 - A 75-year-old man presents with a 2-month history of progressive shortness of breath...

    Correct

    • A 75-year-old man presents with a 2-month history of progressive shortness of breath and a recent episode of coughing up blood in the morning. He has also experienced significant weight loss of over 12 lbs and loss of appetite. Upon physical examination, conjunctival pallor is noted. The patient has a 30 pack year history of smoking. A chest x-ray reveals a mediastinal mass and ipsilateral elevation of the right diaphragm. What structure is being compressed by the mediastinal mass to explain these findings?

      Your Answer: Phrenic nerve

      Explanation:

      Lung cancer can cause the hemidiaphragm on the same side to rise due to pressure on the phrenic nerve. Haemoptysis is a common symptom of lung cancer, along with significant weight loss and a history of smoking. A chest x-ray can confirm the presence of a mediastinal mass, which is likely to be lung cancer.

      A rapidly expanding lung mass can cause compression of surrounding structures, leading to complications. For example, an apical tumor can compress the brachial plexus, causing sensory symptoms in the arms or Erb’s or Klumpke’s palsies. Compression of the cervical sympathetic chain can cause Horner’s syndrome, which includes meiosis, anhidrosis, ptosis, and enophthalmos.

      A mediastinal mass can also compress the recurrent laryngeal nerve as it winds around the aortic arch, resulting in hoarseness of voice or aphonia. Superior vena caval syndrome is a medical emergency that can cause swelling of the face, neck, upper chest, and arms, as well as the development of collaterals on the chest wall. Malignancy is the most common cause, but non-malignant causes can include an aortic aneurysm, fibrosing mediastinitis, or iatrogenic factors.

      The Phrenic Nerve: Origin, Path, and Supplies

      The phrenic nerve is a crucial nerve that originates from the cervical spinal nerves C3, C4, and C5. It supplies the diaphragm and provides sensation to the central diaphragm and pericardium. The nerve passes with the internal jugular vein across scalenus anterior and deep to the prevertebral fascia of the deep cervical fascia.

      The right phrenic nerve runs anterior to the first part of the subclavian artery in the superior mediastinum and laterally to the superior vena cava. In the middle mediastinum, it is located to the right of the pericardium and passes over the right atrium to exit the diaphragm at T8. On the other hand, the left phrenic nerve passes lateral to the left subclavian artery, aortic arch, and left ventricle. It passes anterior to the root of the lung and pierces the diaphragm alone.

      Understanding the origin, path, and supplies of the phrenic nerve is essential in diagnosing and treating conditions that affect the diaphragm and pericardium.

    • This question is part of the following fields:

      • Respiratory System
      17.7
      Seconds
  • Question 5 - A 24-year-old man is admitted to the emergency department after a car accident....

    Correct

    • A 24-year-old man is admitted to the emergency department after a car accident. During the initial evaluation, he complains of difficulty breathing. A portable chest X-ray shows a 3 cm gap between the right lung margin and the chest wall, indicating a significant traumatic pneumothorax. The medical team administers high-flow oxygen and performs a right-sided chest drain insertion to drain the pneumothorax.

      What is a potential negative outcome that could arise from the insertion of a chest drain?

      Your Answer: Winging of the scapula

      Explanation:

      Insertion of a chest drain poses a risk of damaging the long thoracic nerve, which runs from the neck to the serratus anterior muscle. This can result in weakness or paralysis of the muscle, causing a winged scapula that is noticeable along the medial border of the scapula. It is important to use aseptic technique during the procedure to prevent hospital-acquired pleural infection. Chylothorax, pneumothorax, and pyothorax are all conditions that may require chest drain insertion, but they are not known complications of the procedure. Therefore, these options are not applicable.

      Anatomy of Chest Drain Insertion

      Chest drain insertion is necessary for various medical conditions such as trauma, haemothorax, pneumothorax, and pleural effusion. The size of the chest drain used depends on the specific condition being treated. While ultrasound guidance is an option, the anatomical method is typically tested in exams.

      It is recommended that chest drains are placed in the safe triangle, which is located in the mid axillary line of the 5th intercostal space. This triangle is bordered by the anterior edge of the latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla. Another triangle, known as the triangle of auscultation, is situated behind the scapula and is bounded by the trapezius, latissimus dorsi, and vertebral border of the scapula. By folding the arms across the chest and bending forward, parts of the sixth and seventh ribs and the interspace between them become subcutaneous and available for auscultation.

      References:
      – Prof Harold Ellis. The applied anatomy of chest drains insertions. British Journal of hospital medicine 2007; (68): 44-45.
      – Laws D, Neville E, Duffy J. BTS guidelines for insertion of chest drains. Thorax, 2003; (58): 53-59.

    • This question is part of the following fields:

      • Respiratory System
      16.1
      Seconds
  • Question 6 - A 65-year-old patient presents at the lung cancer clinic for their initial assessment....

    Incorrect

    • A 65-year-old patient presents at the lung cancer clinic for their initial assessment. Their general practitioner referred them due to a persistent cough lasting 5 months and a weight loss of one stone in a month. The patient has quit smoking recently but used to smoke 20-30 cigarettes daily for 30 years. No asbestos exposure is reported.

      A circular lesion was detected in the right upper lobe during a recent chest x-ray. A subsequent computed tomography (CT) scan indicated that this lung lesion is indicative of a primary lesion.

      What is the most probable sub-type of lung cancer in this case?

      Your Answer: Bronchial adenoma

      Correct Answer: Adenocarcinoma

      Explanation:

      Adenocarcinoma has become the most prevalent form of lung cancer, as per the given scenario. This type of cancer accounts for approximately one-third of all cases and can occur in both smokers and non-smokers. Therefore, the most probable answer to the question is adenocarcinoma. Mesothelioma, on the other hand, is a rare and incurable cancer that is almost exclusively linked to asbestos exposure and affects the pleura. It would not present as an upper lobe mass, but rather as a loss of lung volume or pleural opacity. Alveolar cell carcinoma, which is less common than adenocarcinoma, would likely cause significant sputum production.

      Lung cancer can be classified into two main types: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). SCLC is less common, accounting for only 15% of cases, but has a worse prognosis. NSCLC, on the other hand, is more prevalent and can be further broken down into different subtypes. Adenocarcinoma is now the most common type of lung cancer, likely due to the increased use of low-tar cigarettes. It is often seen in non-smokers and accounts for 62% of cases in ‘never’ smokers. Squamous cell carcinoma is another subtype, and cavitating lesions are more common in this type of lung cancer. Large cell carcinoma, alveolar cell carcinoma, bronchial adenoma, and carcinoid are other subtypes of NSCLC. Differentiating between these subtypes is crucial as different drugs are available to treat each subtype.

    • This question is part of the following fields:

      • Respiratory System
      20
      Seconds
  • Question 7 - A 6-year-old girl is playing with some small ball bearings. Regrettably, she inhales...

    Incorrect

    • A 6-year-old girl is playing with some small ball bearings. Regrettably, she inhales one. In which of the following lung regions is the ball expected to settle?

      Your Answer: Right upper lobe

      Correct Answer: Right lower lobe

      Explanation:

      Due to the angle of the right main bronchus from the trachea, small objects are more likely to get stuck in the most dependent part of the right lung. This makes the right lung the preferred location for most objects to enter.

      Anatomy of the Lungs

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

    • This question is part of the following fields:

      • Respiratory System
      26.8
      Seconds
  • Question 8 - A senior woman with a history of chronic obstructive pulmonary disease (COPD) arrives...

    Incorrect

    • A senior woman with a history of chronic obstructive pulmonary disease (COPD) arrives at the hospital complaining of worsening shortness of breath and a productive cough. As part of the initial evaluation, a chest X-ray is requested.

      What radiographic feature would you anticipate observing on her chest X-ray?

      Your Answer: Pleural effusion

      Correct Answer: Flattened diaphragm

      Explanation:

      The diaphragm of patients with COPD often appears flattened on a chest X-ray due to the chronic expiratory airflow obstruction causing dynamic hyperinflation of the lungs. Pleural effusions are commonly associated with infection, malignancy, or heart failure, while empyema is a result of pus accumulation in the pleural space caused by an infection.

      Understanding COPD: Symptoms and Diagnosis

      Chronic obstructive pulmonary disease (COPD) is a common medical condition that includes chronic bronchitis and emphysema. Smoking is the leading cause of COPD, and patients with mild disease may only need occasional use of a bronchodilator, while severe cases may result in frequent hospital admissions due to exacerbations. Symptoms of COPD include a productive cough, dyspnea, wheezing, and in severe cases, right-sided heart failure leading to peripheral edema.

      To diagnose COPD, doctors may recommend post-bronchodilator spirometry to demonstrate airflow obstruction, a chest x-ray to check for hyperinflation, bullae, and flat hemidiaphragm, and to exclude lung cancer. A full blood count may also be necessary to exclude secondary polycythemia, and body mass index (BMI) calculation is important. The severity of COPD is categorized using the FEV1, with a ratio of less than 70% indicating airflow obstruction. The grading system has changed following the 2010 NICE guidelines, with Stage 1 – mild now including patients with an FEV1 greater than 80% predicted but with a post-bronchodilator FEV1/FVC ratio of less than 0.7. Measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction.

      In summary, COPD is a common condition caused by smoking that can result in a range of symptoms and severity. Diagnosis involves various tests to check for airflow obstruction, exclude lung cancer, and determine the severity of the disease.

    • This question is part of the following fields:

      • Respiratory System
      11
      Seconds
  • Question 9 - A 29-year-old man visits his primary care physician with complaints of a malodorous...

    Incorrect

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

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

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

      Your Answer: Myringitis

      Correct Answer: Cholesteatoma

      Explanation:

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

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

      Understanding Cholesteatoma

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory System
      18.6
      Seconds
  • Question 10 - A 24-year-old male patient arrives at the Emergency Department complaining of abdominal pain,...

    Correct

    • A 24-year-old male patient arrives at the Emergency Department complaining of abdominal pain, nausea, vomiting, and a decreased level of consciousness. Upon examination, the patient exhibits Kussmaul respiration and an acetone-like breath odor.

      What type of metabolic disturbance is most consistent with the symptoms and presentation of this patient?

      Your Answer: Metabolic acidosis, oxygen dissociation curve shifts to the right

      Explanation:

      The correct answer is that metabolic acidosis shifts the oxygen dissociation curve to the right. This is seen in the condition described in the question, diabetic ketoacidosis, which is associated with metabolic acidosis. Acidosis causes more oxygen to be unloaded from haemoglobin, leading to a rightward shift in the curve. The other answer options are incorrect, as they either describe a different type of acidosis or an incorrect direction of the curve shift.

      Understanding the Oxygen Dissociation Curve

      The oxygen dissociation curve is a graphical representation of the relationship between the percentage of saturated haemoglobin and the partial pressure of oxygen in the blood. It is not influenced by the concentration of haemoglobin. The curve can shift to the left or right, indicating changes in oxygen delivery to tissues. When the curve shifts to the left, there is increased saturation of haemoglobin with oxygen, resulting in decreased oxygen delivery to tissues. Conversely, when the curve shifts to the right, there is reduced saturation of haemoglobin with oxygen, leading to enhanced oxygen delivery to tissues.

      The L rule is a helpful mnemonic to remember the factors that cause a shift to the left, resulting in lower oxygen delivery. These factors include low levels of hydrogen ions (alkali), low partial pressure of carbon dioxide, low levels of 2,3-diphosphoglycerate, and low temperature. On the other hand, the mnemonic ‘CADET, face Right!’ can be used to remember the factors that cause a shift to the right, leading to raised oxygen delivery. These factors include carbon dioxide, acid, 2,3-diphosphoglycerate, exercise, and temperature.

      Understanding the oxygen dissociation curve is crucial in assessing the oxygen-carrying capacity of the blood and the delivery of oxygen to tissues. By knowing the factors that can shift the curve to the left or right, healthcare professionals can make informed decisions in managing patients with respiratory and cardiovascular diseases.

    • This question is part of the following fields:

      • Respiratory System
      25.8
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory System (4/10) 40%
Passmed