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  • Question 1 - A 47-year-old woman complains of dyspnoea, occasional fevers and mild weight loss which...

    Correct

    • A 47-year-old woman complains of dyspnoea, occasional fevers and mild weight loss which have all gotten worse over the past months. She does not complain of a cough but remembered that she had coughed once and produced a twig-shaped mucoid sputum mass. She has no haemoptysis. She has no past medical history and is on no medications.   Her chest X-ray reveals bilateral, perihilar, dense airspace shadowing. A HRCT of her thorax showed a ‘crazy paving’ pattern of extensive, dense, white infiltrates. Her spirometry was a restrictive pattern with reduced total lung capacity. She also had a bronchoscopy and lavage, which revealed periodic acid–Schiff (PAS)-positive proteinaceous fluid and elevated levels of surfactant proteins A and D.   What is the most likely diagnosis?

      Your Answer: Pulmonary alveolar proteinosis

      Explanation:

      Pulmonary alveolar proteinosis (PAP) is a lung condition that is caused by a build-up of proteins and other substances in the alveoli. The alveoli are the part of the lungs that contain air. PAP has the following symptoms:
      Shortness of breath, also called dyspnoea
      Chest pain or tightness
      Fever
      Weight loss
      Cough (sometimes, but not always)
      Low levels of oxygen in the blood
      Nail clubbing (abnormal growth of toenails or fingernails)

      Serologic studies are generally not useful for PAP. Flexible bronchoscopy with bronchoalveolar lavage (BAL) remains the criterion standard. Elevated levels of the proteins SP-A and SP-D in serum and BAL fluid may be useful. Elevated titer of neutralizing autoantibody against GM-CSF (immunoglobulin G [IgG] isotype) in serum and BAL fluid may be useful. Recent studies have proposed that deficiency of GM-CSF causes pulmonary alveolar proteinosis (PAP); all patients studied had the antibody to GM-CSF. Serum lactate dehydrogenase (LDH) level is usually elevated, but this finding is nonspecific.

      High-resolution computed tomography (HRCT) scan of the chest demonstrates areas of patchy ground-glass opacification with smooth interlobular septal thickening and intralobular interstitial thickening, which produces a polygonal pattern referred to as crazy paving.

      Light microscopy of the lung parenchymal tissue shows alveoli filled with a granular PAS base-reactive and diastase-resistant eosinophilic material.

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  • Question 2 - A female in her early 20's who has been diagnosed with asthma for...

    Incorrect

    • A female in her early 20's who has been diagnosed with asthma for the past four years visits the office for a review. She has been using Beclomethasone dipropionate inhaler 200mcg bd along with Salbutamol inhaler 100mcg prn and her asthma is still uncontrolled. Her chest examination is clear and she has good inhaler technique. What would be the most appropriate next step in the management of her asthma?

      Your Answer: Add salmeterol

      Correct Answer: Add a leukotriene receptor antagonist

      Explanation:

      The NICE 2017 guidelines state that in patients who are uncontrolled with a SABA (Salbutamol) and ICS (Inhaled corticosteroid e.g. Beclomethasone), a leukotriene receptor antagonist (LTRA) should be added.
      If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks.

      This recommendation is also stated in NICE 2019 guidelines.

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  • Question 3 - A 68 year old man is admitted with an infective exacerbation of chronic...

    Incorrect

    • A 68 year old man is admitted with an infective exacerbation of chronic obstructive pulmonary disease (COPD). Investigations: blood gas taken whilst breathing 28% oxygen on admission: pH 7.30 p(O2) 7.8 kPa p(CO2) 7.4 kPa Which condition best describes the blood gas picture?

      Your Answer: Partially compensated respiratory alkalosis

      Correct Answer: Decompensated type-2 respiratory failure

      Explanation:

      The normal partial pressure reference values are:
      – PaO2 more than 80 mmHg (11 kPa)
      – PaCO2 less than 45 mmHg (6.0 kPa).
      This patient has an elevated PaCO2 (7.4kPa)
      Hypoxemia (PaO2 <8kPa) with hypercapnia (PaCO2 >6.0kPa).
      The pH is also lower than 7.35 at 7.3

      Type 2 respiratory failure is caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected. Defined as the build-up of carbon dioxide levels (PaCO2) that has been generated by the body but cannot be eliminated. The underlying causes include:
      – Increased airways resistance (chronic obstructive pulmonary disease, asthma, suffocation)
      – Reduced breathing effort (drug effects, brain stem lesion, extreme obesity)
      – A decrease in the area of the lung available for gas exchange (such as in chronic bronchitis)
      – Neuromuscular problems (Guillain–Barré syndrome, motor neuron disease)
      – Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail chest.

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  • Question 4 - A 24 year old female, 28 weeks pregnant presents to the clinic complaining...

    Incorrect

    • A 24 year old female, 28 weeks pregnant presents to the clinic complaining of shortness of breath and right sided pleuritic chest pain. The doctor suspects pulmonary embolism. Which of the following statements is incorrect regarding the management of this case?

      Your Answer: D-dimer levels are of no use

      Correct Answer: Ventilation-perfusion scanning exposes the foetus to less radiation than computed tomographic pulmonary angiography

      Explanation:

      V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA – 1/280,000 versus less than 1/1,000,000 – but carries a lower risk of maternal breast cancer. The rest of the options are true.

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  • Question 5 - A 52 year old female, known case of rheumatoid arthritis presents to the...

    Correct

    • A 52 year old female, known case of rheumatoid arthritis presents to the clinic with dyspnoea, cough, and intermittent pleuritic chest pain. She was previously taking second line agents Salazopyrine and gold previously and has now started Methotrexate with folic acid replacement a few months back. Pulmonary function tests reveal restrictive lung pattern and CXR reveals pulmonary infiltrates. Which of the following treatments is most suitable in this case?

      Your Answer: Stop methotrexate

      Explanation:

      Methotrexate lung disease (pneumonitis and fibrosis) is the specific etiological type of drug-induced lung disease. It can occur due to the administration of methotrexate which is an antimetabolite, which is given as disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis. The typical clinical symptoms include progressive shortness of breath and cough, often associated with fever. Hypoxemia and tachypnoea are always present and crackles are frequently audible. Symptoms typically manifest within months of starting therapy. Methotrexate withdrawal is indicated in such cases.

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  • Question 6 - Which treatment of chronic obstructive pulmonary disease (COPD) increases the long-term prognosis in...

    Incorrect

    • Which treatment of chronic obstructive pulmonary disease (COPD) increases the long-term prognosis in patients?

      Your Answer: Inhaled β2-agonists

      Correct Answer: Long-term domiciliary oxygen therapy

      Explanation:

      COPD is commonly associated with progressive hypoxemia. Oxygen administration reduces mortality rates in patients with advanced COPD because of the favourable effects on pulmonary hemodynamics.

      Long-term oxygen therapy improves survival 2-fold or more in hypoxemic patients with COPD, according to 2 landmark trials, the British Medical Research Council (MRC) study and the US National Heart, Lung and Blood Institute’s Nocturnal Oxygen Therapy Trial (NOTT). Hypoxemia is defined as PaO2 (partial pressure of oxygen in arterial blood) of less than 55 mm Hg or oxygen saturation of less than 90%. Oxygen was used for 15-19 hours per day.

      Therefore, specialists recommend long-term oxygen therapy for patients with a PaO2 of less than 55 mm Hg, a PaO2 of less than 59 mm Hg with evidence of polycythaemia, or cor pulmonale. Patients should be evaluated after 1-3 months after initiating therapy, because some patients may not require long-term oxygen.

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  • Question 7 - A woman is being seen at the clinic. Her clinic notes are missing...

    Incorrect

    • A woman is being seen at the clinic. Her clinic notes are missing and the only results available are lung function tests. Her date of birth is also missing from the report.  FEV1 0.4 (1.2–2.9 predicted) Total lung capacity 7.3 (4.4–6.8 predicted) Corrected transfer factor 3.3 (4.2–8.8 predicted)   Which disease can be suspected From these results?

      Your Answer: Severe chronic obstructive pulmonary disease

      Correct Answer: Moderate COPD

      Explanation:

      The Stages of COPD:
      Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal.
      Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal.
      Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal.
      Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1.

      This patient has a FEV1 percent of 40 which falls within the stage 2 or moderate COP

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  • Question 8 - A 21 year-old male, who is a known alcoholic, presents with a fever,...

    Incorrect

    • A 21 year-old male, who is a known alcoholic, presents with a fever, haemoptysis, green sputum and an effusion clinically. There is concern that it may be an empyema.   Which test would be most useful to resolve the suspicion?

      Your Answer: Pleural fluid white cell count and differential

      Correct Answer: Pleural fluid pH

      Explanation:

      If a pleural effusion is present, a diagnostic thoracentesis may be performed and analysed for pH, lactate dehydrogenase, glucose levels, specific gravity, and cell count with differential. Pleural fluid may also be sent for Gram stain, culture, and sensitivity. Acid-fast bacillus testing may also be considered and the fluid may be sent for cytology if cancer is suspected.

      The following findings are suggestive of an empyema or parapneumonic effusion that will likely need a chest tube or pigtail catheter for complete resolution:
      -Grossly purulent pleural fluid
      -pH level less than 7.2
      -WBC count greater than 50,000 cells/µL (or polymorphonuclear leukocyte count of 1,000 IU/dL)
      -Glucose level less than 60 mg/dL
      -Lactate dehydrogenase level greater than 1,000 IU/mL
      -Positive pleural fluid culture

      The most often used golden criteria for empyema are pleural effusion with macroscopic presence of pus, a positive Gram stain or culture of pleural fluid, or a pleural fluid pH under 7.2 with normal peripheral blood ph.

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  • Question 9 - Which of the statements is most accurate regarding the lung? ...

    Incorrect

    • Which of the statements is most accurate regarding the lung?

      Your Answer: Physical signs placed anteriorly indicate disease in the lower lobes

      Correct Answer: The medial basal segment is absent in the left lower lobe

      Explanation:

      The right and left lung anatomy are similar but asymmetrical. The right lung consists of three lobes: right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL). The left lung consists of two lobes: right upper lobe (RUL) and right lower lobe (RLL). The right lobe is divided by an oblique and horizontal fissure, where the horizontal fissure divides the upper and middle lobe, and the oblique fissure divides the middle and lower lobes. In the left lobe there is only an oblique fissure that separates the upper and lower lobe.

      The lobes further divide into segments which are associated with specific segmental bronchi. Segmental bronchi are the third-order branches off the second-order branches (lobar bronchi) that come off the main bronchus.

      The right lung consists of ten segments. There are three segments in the RUL (apical, anterior and posterior), two in the RML (medial and lateral), and five in the RLL (superior, medial, anterior, lateral, and posterior). The oblique fissure separates the RUL from the RML, and the horizontal fissure separates the RLL from the RML and RUL.

      There are eight to nine segments on the left depending on the division of the lobe. In general, there are four segments in the left upper lobe (anterior, apicoposterior, inferior and superior lingula) and four or five in the left lower lobe (lateral, anteromedial, superior and posterior). The medium sized airways offer the maximum airway resistance, not smaller ones.

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  • Question 10 - An 80 year-old Zimbabwean woman with known rheumatoid arthritis was admitted to hospital...

    Correct

    • An 80 year-old Zimbabwean woman with known rheumatoid arthritis was admitted to hospital with a four week history of weight loss, night sweats and cough. She was given a course of Amoxicillin for the past week but her condition deteriorated and she was referred to the hospital when she developed haemoptysis.   She was on maintenance prednisolone 10 mg once per day and four weeks earlier, she had received infliximab for a flare up of rheumatoid arthritis. She lived with her husband but had been admitted to hospital himself with influenza four days earlier. She was a lifelong non-smoker and worked most of her life as a missionary in Zimbabwe and South Africa.   On examination she looked cachexic and was pyrexial with a temperature of 38.5°C. Her blood pressure was 181/101 mmHg, pulse 121 beats per minute and oxygen saturations of 89% on room air. Her heart sounds were normal and there were no audible murmurs. Auscultation of her lung fields revealed bronchial breath sounds in the left upper zone. Examination of her abdomen was normal.   Mantoux test < 5mm (after 48 hours) A chest radiograph revealed cavitating left upper lobe consolidation.   What is the most likely diagnosis?

      Your Answer: Post-primary tuberculosis

      Explanation:

      Post-primary pulmonary tuberculosis is a chronic disease commonly caused by either endogenous reactivation of a latent infection or exogenous re-infection by Mycobacterium tuberculosis.
      Post-primary pulmonary tuberculosis (also called reactivation tuberculosis) develops in 5%–20% of patients infected with M. tuberculosis.

      Found mainly in adults, this form of tuberculosis arises from the reactivation of bacilli that lay dormant within a fibrotic area of the lung. In adults, reinfection with a strain of mycobacterium that differs from that which caused the primary infection is also possible. Predisposing factors include immunosuppression, diabetes, malnutrition and alcoholism.

      Infliximab is a monoclonal antibody against tumour necrosis factor α (TNF-α). It is FDA approved for many autoimmune conditions, including rheumatoid arthritis and Crohn’s disease. One of the many known side effects of infliximab therapy is reactivation of latent tuberculosis (TB). Because of the resemblances in clinical and radiological features, tubercular lesions in the lung may mimic malignancy. TB accounts for 27% of all infections initially presumed to be lung cancer on imaging studies.

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  • Question 11 - A 14 year old girl with cystic fibrosis (CF) presents with abdominal pain....

    Incorrect

    • A 14 year old girl with cystic fibrosis (CF) presents with abdominal pain. Which of the following is the pain most likely linked to?

      Your Answer: Pyelonephritis

      Correct Answer: Meconium ileus equivalent syndrome

      Explanation:

      Meconium ileus equivalent (MIE) can be defined as a clinical manifestation in cystic fibrosis (CF) patients caused by acute intestinal obstruction by putty-like faecal material in the cecum or terminal ileum. A broader definition includes a more chronic condition in CF patients with abdominal pain and a coecal mass which may eventually pass spontaneously. The condition occurs only in CF patients with exocrine pancreatic insufficiency (EPI). It has not been seen in other CF patients nor in non-CF patients with EPI. The frequency of these symptoms has been reported as 2.4%-25%.

      The treatment should primarily be non-operative. Specific treatment with N-acetylcysteine, administrated orally and/or as an enema is recommended. Enemas with the water soluble contrast medium, meglucamine diatrizoate (Gastrografin), provide an alternative form for treatment and can also serve diagnostic purposes. It is important that the physician is familiar with this disease entity and the appropriate treatment with the above mentioned drugs. Non-operative treatment is often effective, and dangerous complications following surgery can thus be avoided.

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  • Question 12 - A 51 year old obese female, with a history of smoking, presents to...

    Correct

    • A 51 year old obese female, with a history of smoking, presents to the clinic with worsening dyspnoea. She is currently on oestrogen therapy for menopausal symptoms. Clinical examination, ECG and radiological findings correspond to right sided heart failure. There are no signs of left ventricular dysfunction. Which of the following is the most likely cause of cor pulmonale?

      Your Answer: Recurrent small pulmonary embolisms

      Explanation:

      Postmenopausal oestrogen therapy and hormone therapy are associated with an increased risk of thromboembolism. The relative risk seems to be even greater if the treated population has pre-existing risk factors for thromboembolism, such as obesity, immobilization, and fracture. Cor pulmonale can occur secondary to small recurrent pulmonary embolisms. Pneumonias and bronchiectasis usually present with purulent sputum, and in case of carcinoma there may be other associated symptoms like weight loss, etc.

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  • Question 13 - A 63 year old man presents to the clinic complaining of a 6-month history...

    Incorrect

    • A 63 year old man presents to the clinic complaining of a 6-month history of shortness of breath on exertion and a non-productive cough.   On examination there is clubbing, and crepitations heard at the lung bases. Lung function tests show a reduced vital capacity and an increased FEV1/FVC ratio.   What is his diagnosis?

      Your Answer: COPD

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      Idiopathic pulmonary fibrosis (IPF) is a condition in which the lungs become scarred and breathing becomes increasingly difficult.
      The most common signs and symptoms of idiopathic pulmonary fibrosis are shortness of breath and a persistent dry, hacking cough. Many affected individuals also experience a loss of appetite and gradual weight loss.

      The clinical findings of IPF are bibasilar reticular abnormalities, ground glass opacities, or diffuse nodular lesions on high-resolution computed tomography and abnormal pulmonary function studies that include evidence of restriction (reduced VC with an increase in FEV1/FVC ratio) and/or impaired gas exchange (increased P(A-a)O2 with rest or exercise or decreased diffusion capacity of the lung for carbon monoxide [DLCO]).

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  • Question 14 - In which condition is the sniff test useful in diagnosis? ...

    Correct

    • In which condition is the sniff test useful in diagnosis?

      Your Answer: Phrenic nerve palsy

      Explanation:

      The phrenic nerve provides the primary motor supply to the diaphragm, the major respiratory muscle.
      Phrenic nerve paralysis is a rare cause of exertional dyspnoea that should be included in the differential diagnosis. Fluoroscopy is considered the most reliable way to document diaphragmatic paralysis. During fluoroscopy a patient is asked to sniff and there is a paradoxical rise of the paralysed hemidiaphragm. This is to confirm that the cause is due to paralysis rather than unilateral weakness.

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  • Question 15 - A 32 year old male with a history of smoking half a pack...

    Incorrect

    • A 32 year old male with a history of smoking half a pack of cigarettes per day complains of worsening breathlessness on exertion. He was working as a salesman until a few months ago. His father passed away due to severe respiratory disease at a relatively young age. Routine blood examination reveals mild jaundice with bilirubin level of 90 µmol/l. AST and ALT are also raised. Chest X-ray reveals basal emphysema. Which of the following explanation is most likely the cause of these symptoms?

      Your Answer: Gilbert's syndrome

      Correct Answer: α-1-Antitrypsin deficiency

      Explanation:

      Alpha-1 antitrypsin deficiency is an inherited disorder that may cause lung and liver disease. The signs and symptoms of the condition and the age at which they appear vary among individuals. This would be the most likely option as it is the only disease that can affect both liver and lung functions.
      People with alpha-1 antitrypsin deficiency usually develop the first signs and symptoms of lung disease between ages 20 and 50. The earliest symptoms are shortness of breath following mild activity, reduced ability to exercise, and wheezing. Other signs and symptoms can include unintentional weight loss, recurring respiratory infections, fatigue, and rapid heartbeat upon standing. Affected individuals often develop emphysema. Characteristic features of emphysema include difficulty breathing, a hacking cough, and a barrel-shaped chest. Smoking or exposure to tobacco smoke accelerates the appearance of emphysema symptoms and damage to the lungs.
      About 10 percent of infants with alpha-1 antitrypsin deficiency develop liver disease, which often causes yellowing of the skin and sclera (jaundice). Approximately 15 percent of adults with alpha-1 antitrypsin deficiency develop liver damage (cirrhosis) due to the formation of scar tissue in the liver. Signs of cirrhosis include a swollen abdomen, swollen feet or legs, and jaundice. Individuals with alpha-1 antitrypsin deficiency are also at risk of developing hepatocellular carcinoma.

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  • Question 16 - A young man presents to the clinic with recurrent episodes of breathlessness. Past...

    Incorrect

    • A young man presents to the clinic with recurrent episodes of breathlessness. Past medical history reveals recurrent episodes of colicky abdominal pain for the past three years. On examination, he has a productive cough with foul smelling sputum. Investigations show: Sputum culture with Heavy growth of Pseudomonas aeruginosa and Haemophilus influenzae. Chest x-ray: Tramline and ring shadows. What is his diagnosis?

      Your Answer: Chronic granulomatous disease

      Correct Answer: Cystic fibrosis

      Explanation:

      Cystic fibrosis (CF) is a multisystemic, autosomal recessive disorder that predominantly affects infants, children, and young adults. CF is the most common life-limiting genetic disorder in whites, with an incidence of 1 case per 3200-3300 new-borns in the United States.

      People with CF can have a variety of symptoms, including:
      Very salty-tasting skin
      Persistent coughing, at times with phlegm
      Frequent lung infections including pneumonia or bronchitis
      Wheezing or shortness of breath
      Poor growth or weight gain in spite of a good appetite
      Frequent greasy, bulky stools or difficulty with bowel movements
      Male infertility

      Signs of bronchiectasis include the tubular shadows; tram tracks, or horizontally oriented bronchi; and the signet-ring sign, which is a vertically oriented bronchus with a luminal airway diameter that is 1.5 times the diameter of the adjacent pulmonary arterial branch.

      Bronchiectasis is characterized by parallel, thick, line markings radiating from hila (line tracks) in cylindrical bronchiectasis. Ring shadows represent dilated thick-wall bronchi seen in longitudinal section or on-end or dilated bronchi in varicose bronchiectasis.

      Pseudomonas aeruginosa is the key bacterial agent of cystic fibrosis (CF) lung infections, and the most important pathogen in progressive and severe CF lung disease. This opportunistic pathogen can grow and proliferate in patients, and exposure can occur in hospitals and other healthcare settings.

      Haemophilus influenzae is regularly involved in chronic lung infections and acute exacerbations of CF patients

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  • Question 17 - A phrenic nerve palsy is caused by which of the following? ...

    Incorrect

    • A phrenic nerve palsy is caused by which of the following?

      Your Answer: Sarcoidosis

      Correct Answer: Aortic aneurysm

      Explanation:

      Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm.

      Thoracic aortic aneurysms are usually asymptomatic however chest pain is most commonly reported symptom. Left hemidiaphragm paralysis, because of left phrenic nerve palsy, is a very rare presentation of thoracic aortic aneurysm.
      Thoracic aortic aneurysm may present atypical symptoms such as dysphagia due to compression of the oesophagus; hoarseness due to vocal cord paralysis or compression of the recurrent laryngeal nerve; superior vena cava syndrome due to compression of the superior vena cava; cough, dyspnoea or both due to tracheal compression; haemoptysis due to rupture of the aneurysm into a bronchus; and shock due to rupture of the aneurysm.
      Common causes of phrenic nerve palsy include malignancy such as bronchogenic carcinoma, as well as mediastinal and neck tumours. Phrenic nerve palsy can also occur due to a penetrating injury or due to iatrogenic causes arising, for example, during cardiac surgery and central venous catheterization. Many cases or phrenic nerve palsy are idiopathic.

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  • Question 18 - A 75 year old man was admitted to the hospital with worsening dyspnoea....

    Correct

    • A 75 year old man was admitted to the hospital with worsening dyspnoea. He was given a five day course of Amoxicillin. On examination, his blood pressure was 89/59 mmHg with a respiratory rate of 35/min. A chest x-ray revealed left lower lobe consolidation. Past medical history: Type 2 diabetes mellitus Arterial blood gas on air: pH 7.34 pCO2 5.4 kPa pO2 9.0 kPa Which antibiotic therapy is the most suitable?

      Your Answer: Intravenous co-amoxiclav + clarithromycin

      Explanation:

      CURB Pneumonia Severity Score:
      – Confusion (abbreviated Mental Test Score <=8) (1 point)
      – Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
      – Respiratory Rate > 30 per minute (1 point)
      – Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) Based on the CURB Pneumonia Severity Score, the patient has severe pneumonia. According to the 2009 Centres for Medicare and Medicaid Services (CMS) and Joint Commission consensus guidelines, inpatient treatment of pneumonia should be given within four hours of hospital admission (or in the emergency department if this is where the patient initially presented) and should consist of the following antibiotic regimens, which are also in accordance with IDSA/ATS guidelines. For non-intensive care unit (ICU) patients:
      Beta-lactam (intravenous [IV] or intramuscular [IM] administration) plus macrolide (IV or oral [PO])
      Beta-lactam (IV or IM) plus doxycycline (IV or PO)
      Antipneumococcal quinolone monotherapy (IV or IM)

      If the patient is younger than 65 years with no risk factors for drug-resistant organisms, administer macrolide monotherapy (IV or PO)

      For ICU patients:
      IV beta-lactam plus IV macrolide
      IV beta-lactam plus IV antipneumococcal quinolone

      If the patient has a documented beta-lactam allergy, administer IV antipneumococcal quinolone plus IV aztreonam.

      The most suitable antibiotic therapy for this patient is therefore Intravenous co-amoxiclav + clarithromycin.

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  • Question 19 - A 57 year old homeless man presents with fever and a productive cough...

    Incorrect

    • A 57 year old homeless man presents with fever and a productive cough which has green sputum with streaks of blood. A chest x-ray reveals consolidation in the right upper lobe with evidence of cavitation. He is a known alcoholic. What is the most likely causative agent?

      Your Answer: Staphylococcus aureus

      Correct Answer: Klebsiella Pneumoniae

      Explanation:

      Infection with Klebsiella organisms occurs in the lungs, where they cause destructive changes. Necrosis, inflammation, and haemorrhage occur within lung tissue, sometimes producing a thick, bloody, mucoid sputum described as currant jelly sputum.
      The illness typically affects middle-aged and older men with debilitating diseases such as alcoholism, diabetes, or chronic bronchopulmonary disease. An increased tendency exists toward abscess formation, cavitation, empyema, and pleural adhesions.

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  • Question 20 - An elderly woman is referred with worsening chronic pulmonary disease (COPD). She smokes...

    Incorrect

    • An elderly woman is referred with worsening chronic pulmonary disease (COPD). She smokes seven cigarettes per day. Her exercise tolerance is only a few yards around the house now. Her FEV1 is 37% of predicted. What is the most appropriate intervention for this patient?

      Your Answer: Give bd inhaled beclomethasone

      Correct Answer: Give regular high-dose inhaled fluticasone and inhaled long-acting β-agonist

      Explanation:

      The Stages of COPD:
      Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal.
      Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal.
      Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal.
      Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1.

      This patient has a FEV1 percent of 37 which falls within the stage 3 or severe COPD.
      During stage 3 COPD, you will likely experience significant lung function impairment. Many patients will experience an increase in COPD flare-ups or exacerbations. For some people, the increase in flare-ups means they could need to be hospitalized at times as well.

      Inhaled corticosteroid (ICS) use in combination with long-acting β2-agonists (LABAs) was shown to provide improved reductions in exacerbations, lung function, and health status. ICS-LABA combination therapy is currently recommended for patients with a history of exacerbations despite treatment with long-acting bronchodilators alone. The presence of eosinophilic bronchial inflammation, detected by high blood eosinophil levels or a history of asthma or asthma–COPD overlap, may define a population of patients in whom ICSs may be of particular benefit.

      The Towards a Revolution in COPD Health (TORCH) trial was a pivotal, double-blind, placebo-controlled, randomized study comparing salmeterol plus fluticasone propionate (50 and 500 µg, respectively, taken twice daily) with each component alone and placebo over 3 years.26 Patients with COPD were enrolled if they had at least a 10-pack-year smoking history, FEV1 <60% predicted, and an FEV1:FVC ratio ≤0.70.26 Among 6,184 randomized patients, the risk of death was reduced by 17.5% with the ICS-LABA combination vs placebo (P=0.052). ICS-LABA significantly reduced the rate of exacerbations by 25% compared with placebo (P<0.001) and improved health status and FEV1 compared with either component alone or placebo.

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  • Question 21 - A 68 year old man who has chronic obstructive pulmonary disease (COPD) is...

    Correct

    • A 68 year old man who has chronic obstructive pulmonary disease (COPD) is reviewed. On examination, there is evidence of cor pulmonale with a significant degree of pedal oedema. His FEV1 is 44%. During a recent hospital stay his pO2 on room air was 7.4 kPa. Which one of the following interventions is most likely to increase survival in this patient?

      Your Answer: Long-term oxygen therapy

      Explanation:

      Assess the need for oxygen therapy in people with:
      – very severe airflow obstruction (FEV1 below 30% predicted)
      – cyanosis (blue tint to skin)
      – polycythaemia
      – peripheral oedema (swelling)
      – a raised jugular venous pressure
      – oxygen saturations of 92% or less breathing air.

      Also consider assessment for people with severe airflow obstruction (FEV1 30–49% predicted).

      Consider long-term oxygen therapy for people with COPD who do not smoke and who:
      have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable or have a PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following:
      – secondary polycythaemia
      – peripheral oedema
      – pulmonary hypertension.

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      • Respiratory
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  • Question 22 - A 32-year-old asthmatic woman presents with an acute attack. Her arterial blood gases...

    Correct

    • A 32-year-old asthmatic woman presents with an acute attack. Her arterial blood gases breathing air are as follows: pH 7.31 pO2 9.6 kPa pCO2 5.1 kPa What do these results signify?

      Your Answer: Her respiratory effort may be failing because she is getting tired

      Explanation:

      In any patient with asthma, a decreasing PaO2 and an increasing PaCO2, even into the normal range, indicates severe airway obstruction that is leading to respiratory muscle fatigue and patient exhaustion.

      Chest tightness and cough, which are the most common symptoms of asthma, are probably the result of inflammation, mucus plugs, oedema, or smooth muscle constriction in the small peripheral airways. Because major obstruction of the peripheral airways can occur without recognizable increases of airway resistance or FEV1, the physiologic alterations in acute exacerbations are generally subtle in the early stages. Poorly ventilated alveoli subtending obstructed bronchioles continue to be perfused, and as a consequence, the P(A-a)O2 increases and the PaO2 decreases. At this stage, ventilation is generally increased, with excessive elimination of carbon dioxide and respiratory alkalemia.

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      • Respiratory
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  • Question 23 - An elderly man presents with complaints of a chronic cough with haemoptysis and...

    Incorrect

    • An elderly man presents with complaints of a chronic cough with haemoptysis and night sweats on a few nights per week for the past four months. He is known to smoke 12 cigarettes per day and he had previously undergone treatment for Tuberculosis seven years ago. His blood pressure was found to be 143/96mmHg and he is mildly pyrexial 37.5°C. Evidence of consolidation affecting the right upper lobe was also found. Investigations;   Hb 11.9 g/dL, WCC 11.1 x109/L, PLT 190 x109/L, Na+ 138 mmol/L, K+ 4.8 mmol/L, Creatinine 105 μmol/L, CXR Right upper lobe cavitating lesion Aspergillus precipitins positive Which of the following is most likely the diagnosis?

      Your Answer: Reactivated tuberculosis

      Correct Answer: Aspergilloma

      Explanation:

      An aspergilloma is a fungus ball (mycetoma) that develops in a pre-existing cavity in the lung parenchyma. Underlying causes of the cavitary disease may include treated tuberculosis or other necrotizing infection, sarcoidosis, cystic fibrosis, and emphysematous bullae. The ball of fungus may move within the cavity but does not invade the cavity wall. Aspergilloma may manifest as an asymptomatic radiographic abnormality in a patient with pre-existing cavitary lung disease due to sarcoidosis, tuberculosis, or other necrotizing pulmonary processes. In patients with HIV disease, aspergilloma may occur in cystic areas resulting from prior Pneumocystis jiroveci pneumonia. Of patients with aspergilloma, 40-60% experience haemoptysis, which may be massive and life threatening. Less commonly, aspergilloma may cause cough and fever.

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  • Question 24 - Which of the following is not a known cause of occupational asthma? ...

    Incorrect

    • Which of the following is not a known cause of occupational asthma?

      Your Answer: Platinum salts

      Correct Answer: Cadmium

      Explanation:

      Occupational asthma (OA) could be divided into a nonimmunological, irritant-induced asthma and an immunological, allergy-induced asthma. In addition, allergy-induced asthma can be caused by two different groups of agents: high molecular weight proteins (>5,000 Da) or low molecular weight agents (<5,000 Da), generally chemicals like the isocyanates.
      Isocyanates are very reactive chemicals characterized by one or more isocyanate groups (–N=C=O). The main reactions of this chemical group are addition reactions with ethanol, resulting in urethanes, with amines (resulting in urea derivates) and with water. Here, the product is carbamic acid which is not stable and reacts further to amines, releasing free carbon dioxide.

      Diisocyanates and polyisocyanates are, together with the largely nontoxic polyol group, the basic building blocks of the polyurethane (PU) chemical industry, where they are used solely or in combination with solvents or additives in the production of adhesives, foams, elastomers, paintings, coatings and other materials.

      The complex salts of platinum are one of the most potent respiratory sensitising agents having caused occupational asthma in more than 50% of exposed workers. Substitution of ammonium hexachlor platinate with platinum tetra amine dichloride in the manufacture of catalyst has controlled the problem in the catalyst industry. Ammonium hexachlorplatinate exposure still occurs in the refining process.

      Rosin based solder flux fume is produced when soldering. This fume is a top cause of occupational asthma.

      Bakeries, flour mills and kitchens where flour dust and additives in the flour are a common cause of occupational asthma.

      Cadmium was not found to cause occupational asthma.

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  • Question 25 - Briefly state the mechanism of action of salbutamol. ...

    Incorrect

    • Briefly state the mechanism of action of salbutamol.

      Your Answer: Beta2 receptor agonist which increases cAMP levels and leads to muscle contraction and bronchoconstriction

      Correct Answer: Beta2 receptor agonist which increases cAMP levels and leads to muscle relaxation and bronchodilation

      Explanation:

      Salbutamol stimulates beta-2 adrenergic receptors, which are the predominant receptors in bronchial smooth muscle (beta-2 receptors are also present in the heart in a concentration between 10% and 50%).

      Stimulation of beta-2 receptors leads to the activation of enzyme adenyl cyclase that forms cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This increase of cyclic AMP relaxes bronchial smooth muscle and decrease airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles.

      Increased cyclic AMP concentrations also inhibits the release of bronchoconstrictor mediators such as histamine and leukotriene from the mast cells in the airway.

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      • Respiratory
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  • Question 26 - A 78 year old male presents to the emergency department with shortness of...

    Incorrect

    • A 78 year old male presents to the emergency department with shortness of breath that has developed gradually over the last 4 days. His symptoms include fever and cough productive of greenish sputum. Past history is notable for COPD for which he was once admitted to the ICU, 2 years back. He now takes nebulizers (ipratropium bromide) at home. The patient previously suffered from myocardial infarction 7 years ago. He also has Diabetes Mellitus type II controlled by lifestyle modification. On examination, the following vitals are obtained. BP : 159/92 mmHg Pulse: 91/min (regular) Temp: Febrile On auscultation, there are scattered ronchi bilaterally and right sided basal crackles. Cardiovascular and abdominal examinations are unremarkable. Lab findings are given below: pH 7.31 pa(O2) 7.6 kPa pa(CO2) 6.3 kPa Bicarbonate 30 mmol/L, Sodium 136 mmol/L, Potassium 3.7 mmol/L, Urea 7.0 mmol/L, Creatinine 111 μmol/L, Haemoglobin 11.3 g/dL, Platelets 233 x 109 /l Mean cell volume (MCV) 83 fl White blood cells (WBC) 15.2 x 109 /l. CXR shows an opacity obscuring the right heart border. Which of the following interventions should be started immediately while managing this patient?

      Your Answer: High flows oxygen (15 l)

      Correct Answer: Salbutamol and ipratropium bromide nebulisers

      Explanation:

      Acute exacerbations of chronic obstructive pulmonary disease (COPD) are immediately treated with inhaled beta2 agonists and inhaled anticholinergics, followed by antibiotics (if indicated) and systemic corticosteroids. Methylxanthine therapy may be considered in patients who do not respond to other bronchodilators.
      High flow oxygen would worsen his symptoms. Usually titrated oxygen (88 to 92 %) is given in such patients to avoid the risk of hyperoxic hypercarbia in which increasing oxygen saturation in a chronic carbon dioxide retainer can inadvertently lead to respiratory acidosis and death.

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  • Question 27 - Which of the following measurements is a poor prognostic factor in patients suffering...

    Incorrect

    • Which of the following measurements is a poor prognostic factor in patients suffering from pneumonia?

      Your Answer: Temperature 39°C

      Correct Answer: Respiratory rate 35/min

      Explanation:

      CURB Pneumonia Severity Score estimates the mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment.
      Select Criteria:
      Confusion (abbreviated Mental Test Score <=8) (1 point)
      Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
      Respiratory Rate > 30 per minute (1 point)
      Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) The CURB-65 scores range from 0 to 5. Clinical management decisions can be made based on the score:
      Score Risk Disposition
      0 or 1 – 1.5% mortality – Outpatient care
      2 – 9.2% mortality – Inpatient vs. observation admission
      ≥ 3 – 22% mortality – Inpatient admission with consideration for ICU admission with score of 4 or 5

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  • Question 28 - A 20 year old heroin addict is admitted following an overdose. She is...

    Incorrect

    • A 20 year old heroin addict is admitted following an overdose. She is drowsy and has a respiratory rate of 6 bpm. Which of the following arterial blood gas results (taken on room air) are most consistent with this?

      Your Answer: pH = 7.55; pCO2 = 3.4 kPa; pO2 = 14.3 kPa

      Correct Answer: pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa

      Explanation:

      In mild-to-moderate heroin overdoses, arterial blood gas (ABG) analysis reveals respiratory acidosis. In more severe overdoses, tissue hypoxia is common, leading to mixed respiratory and metabolic acidosis.

      The normal range for PaCO2 is 35-45 mmHg (4.67 to 5.99 kPa). Respiratory acidosis can be acute or chronic. In acute respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range (i.e., >45 mm Hg) with an accompanying academia (i.e., pH < 7.35). In chronic respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range, with a normal or near-normal pH secondary to renal compensation and an elevated serum bicarbonate levels (i.e., >30 mEq/L).

      Arterial blood gases with pH = 7.31; pCO2 = 7.4 kPa; pO2 = 8.1 kPa would indicate respiratory acidosis.

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  • Question 29 - A 50 year old retired coal miner with simple silicosis presented with shortness...

    Correct

    • A 50 year old retired coal miner with simple silicosis presented with shortness of breath. He had been short of breath for 3 months. Around 3 months ago he began keeping turtle doves as pets. On auscultation he had basal crepitations and chest x-ray showed fine nodular shadowing in the apices.   What is the most likely diagnosis?

      Your Answer: Extrinsic allergic alveolitis

      Explanation:

      Extrinsic allergic alveolitis (EAA) refers to a group of lung diseases that can develop after exposure to certain substances. The name describes the origin and the nature of these diseases:

      ‘extrinsic’ – caused by something originating outside the body
      ‘allergic’ – an abnormally increased (hypersensitive) body reaction to a common substance
      ‘alveolitis’ – inflammation in the small air sacs of the lungs (alveoli)

      Symptoms can include: fever, cough, worsening breathlessness and weight loss. The diagnosis of the disease is based on a history of symptoms after exposure to the allergen and a range of clinical tests which usually includes: X-rays or CT scans, lung function and blood tests.

      EAA is not a ‘new’ occupational respiratory disease and occupational causes include bacteria, fungi, animal proteins, plants and chemicals.

      Examples of EAA include:

      Bird fancier’s lung (BFL) is a type of hypersensitivity pneumonitis (HP). It is triggered by exposure to avian proteins present in the dry dust of the droppings and sometimes in the feathers of a variety of birds. The lungs become inflamed, with granuloma formation. Birds such as pigeons, parakeets, cockatiels, shell parakeets (budgerigars), parrots, turtle doves, turkeys and chickens have been implicated.

      People who work with birds or own many birds are at risk. Bird hobbyists and pet store workers may also be at risk. This disease is an inflammation of the alveoli in the lungs caused by an immune response to inhaled allergens from birds. Initial symptoms include shortness of breath (dyspnoea), especially after sudden exertion or when exposed to temperature change, which can resemble asthma, hyperventilation syndrome or pulmonary embolism. Chills, fever, non-productive cough and chest discomfort may also occur.

      A definitive diagnosis can be difficult without invasive testing, but extensive exposure to birds combined with reduced diffusing capacity are strongly suggestive of this disease. X-ray or CT scans will show physical changes to the lung structure (a ground glass appearance) as the disease progresses. Precise distribution and types of tissue damage differ among similar diseases, as does response to treatment with Prednisone.

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  • Question 30 - A 32 year old primigravida, with a history of pulmonary hypertension, presents to...

    Incorrect

    • A 32 year old primigravida, with a history of pulmonary hypertension, presents to the clinic at 36 weeks gestation with worsening shortness of breath. Which of the following is the most accurate statements regarding her condition?

      Your Answer: Nifedipine is contraindicated in pregnancy

      Correct Answer: Risk of maternal mortality in patients with pulmonary hypertension is 30%

      Explanation:

      Historically, high rates of maternal and fetal death have been reported for pregnant women with pulmonary hypertension (30–56% and 11–28%, respectively). The causes of poor maternal outcomes are varied and include risk of death from right heart failure and stroke from intracardiac shunting. Furthermore, there is a high peri-/post-partum risk due to haemodynamic stress, bleeding complications and the use of general anaesthesia, which can all lead to right heart failure.
      The most common risk to the foetus is death, with premature birth and growth retardation being reported in successfully delivered children.
      CXR is not contraindicated in pregnancy. D-dimers are not used as a diagnostic aid as they are almost always elevated in pregnancy. Nifedipine, although contraindicated in pregnant women may be used judiciously if the need arises.

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  • Question 31 - A 20 year old woman presents to the hospital with sharp, left-sided chest...

    Incorrect

    • A 20 year old woman presents to the hospital with sharp, left-sided chest pain and shortness of breath. On examination her pulse is 101 beats per minute and blood pressure is 124/61 mmHg. She is seen to be mildly breathless at rest but her oxygen saturation on air was 98%. CXR reveals a left pneumothorax with a 4 cm rim of air visible. Which management strategy is appropriate in this patient?

      Your Answer: Discharge from hospital

      Correct Answer: Needle aspiration

      Explanation:

      Pneumothorax is defined as air in the pleural space and may be classified as spontaneous, traumatic or iatrogenic. Primary spontaneous pneumothorax occurs in patients without clinically apparent lung disease.
      Primary pneumothorax has an incidence of 18-28 per 100,000 per year for men and 1.2-6 per 100,000 per year for women. Most patients present with ipsilateral pleuritic chest pain and acute shortness of breath. Shortness of breath is largely dependent on the size of the pneumothorax and whether there is underlying chronic lung disease.

      Young patients may have chest pain only. Most episodes of pneumothorax occur at rest. Symptoms may resolve within 24 hours in patients with primary spontaneous pneumothorax. The diagnosis of a pneumothorax is confirmed by finding a visceral pleural line displaced from the chest wall, without distal lung markings, on a posterior-anterior chest radiograph.

      Breathless patients should not be left without intervention regardless of the size of pneumothorax. If there is a rim of air >2cm on the chest X-ray, this should be aspirated.
      Aspiration is successful in approximately 70 per cent of patients; the patient may be discharged subsequently. A further attempt at aspiration is recommended if the patient remains symptomatic and a volume of less than 2.5 litres has been aspirated on the first attempt.

      If unsuccessful, an intercostal drain is inserted. This may be removed after 24 hours after full re-expansion or cessation of air leak without clamping and discharge may be considered.

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  • Question 32 - Which of the following statements about smoking is correct? ...

    Incorrect

    • Which of the following statements about smoking is correct?

      Your Answer: Peak nicotine withdrawal time is 18hrs

      Correct Answer: Quitting is associated with average weight gain of 2 kg

      Explanation:

      A study conducted showed that the average post smoking cessation weight gain was about 2 kg.
      Withdrawal symptoms usually peak after 1–3 days and then decrease over a period of 3–4 weeks. After this time, the body has expelled most of the nicotine, and the withdrawal effects are mainly psychological.

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  • Question 33 - A 23 year old female presents with a five month history of worsening...

    Correct

    • A 23 year old female presents with a five month history of worsening breathlessness and daily productive cough. As a young child, she had occasional wheezing with viral illnesses and she currently works in a ship yard and also smokes one pack of cigarettes daily for the past three years. Which of the following is the likely diagnosis?

      Your Answer: Bronchiectasis

      Explanation:

      Bronchiectasis is a long-term condition where the airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection. The most common symptoms of bronchiectasis include:
      – a persistent productive cough
      – breathlessness.

      The 3 most common causes in the UK are:
      – a lung infection in the past, such as pneumonia or whooping cough, that damages the bronchi
      – underlying problems with the immune system (the body’s defence against infection) that make the bronchi more vulnerable to damage from an infection
      – allergic bronchopulmonary aspergillosis (ABPA) – an allergy to a certain type of fungi that can cause the bronchi to become inflamed if spores from the fungi are inhaled

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  • Question 34 - A 20-year-old man presents with an acute exacerbation of asthma associated with a...

    Incorrect

    • A 20-year-old man presents with an acute exacerbation of asthma associated with a chest infection. He is unable to complete a sentence and his peak flow rate was 34% of his normal level. He is treated with high-flow oxygen, nebulised bronchodilators, and oral corticosteroids for three days, but his condition has not improved.   Which of the following intravenous treatments would be the best option for this patient?

      Your Answer: Aminophylline

      Correct Answer: Magnesium

      Explanation:

      A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.

      Consider giving a single dose of intravenous magnesium sulphate to patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy. Magnesium sulphate (1.2–2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

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  • Question 35 - A husband visits the clinic with his wife because he wants to be...

    Incorrect

    • A husband visits the clinic with his wife because he wants to be screened for cystic fibrosis. His brother and wife had a child with cystic fibrosis so he is concerned. His wife is currently 10 weeks pregnant. When screened, he was found to be a carrier of the DF508 mutation for cystic fibrosis but despite this result, the wife declines testing. What are the chances that she will have a child with cystic fibrosis, given that the gene frequency for this mutation in the general population is 1/20?

      Your Answer: 1/40

      Correct Answer: 1/80

      Explanation:

      The chance of two carriers of a recessive gene having a child that is homozygous for that disease (that is both genes are transmitted to the child) is 25%. Therefore, the chances of this couple having a child with CF are 25%(1/4) x 1/20 = 1/80.

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  • Question 36 - A 66 year old man visits the clinic because he has been experiencing...

    Incorrect

    • A 66 year old man visits the clinic because he has been experiencing increasing breathlessness for the past five months while doing daily tasks. His exercise tolerance is now limited to 75 metres while on a flat surface and walking up the stairs makes him breathless. He sleeps on four pillows and has swollen ankles in the morning. He occasionally coughs up phlegm. Past Medical history of importance: 36 pack year smoking history Hypertension Ischaemic heart disease Coronary artery stenting done 10 months ago Pulmonary function testing revealed: FEV1 0.90 L (1.80 – 3.02 predicted) FVC 1.87 L (2.16 – 3.58 predicted) Diffusion capacity 3.0 mmol/min/kPa (5.91 – 9.65 predicted) Total lung capacity 4.50 L (4.25 – 6.22 predicted) Residual volume 2.70 L (1.46 – 2.48 predicted)   Which condition does he have?

      Your Answer: Sarcoidosis

      Correct Answer: Chronic obstructive pulmonary disease

      Explanation:

      Whilst asthma and COPD are different diseases they cause similar symptoms, which can present a challenge in identifying which of the two diseases a patient is suffering from. COPD causes chronic symptoms and narrowed airways which do not respond to treatment to open them up. In the case of asthma the constriction of the airways through inflammation tends to come and go and treatment to reduce inflammation and to open up the airways usually works well.

      COPD is more likely than asthma to cause a chronic cough with phlegm and is rare before the age of 35 whilst asthma is common in under-35s. Disturbed sleep caused by breathlessness and wheeze is more likely in cases of asthma, as is a history of allergies, eczema and hay fever. Differentiating between COPD and asthma requires a history of both symptoms and spirometry. The spirometry history should include post bronchodilator measurements, the degree of reversibility and, ideally, home monitoring which gives a history of diurnal variation.

      Airflow Obstruction: Both asthma and COPD are characterised by airflow obstruction. Airflow obstruction is defined as a reduced FEV1 and a reduced FEV1/FVC ratio, such that FEV1 is less than 80% of that predicted, and FEV1/FVC is less than 0.7.

      These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

      COPD: COPD is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. The airflow obstruction is not fully reversible.

      Spirometry COPD Asthma
      VC Reduced Nearly normal
      FEV1 Reduced Reduced in attack
      FVC (or FEV6) Reduced Nearly normal
      FEV1 Ratio
      (of VC/FVC/FEV6) Reduced in attack

      This man has a low FEV1 and FVC. His diffusions capacity is also low despite having a normal total lung capacity. These values confirm a diagnosis of COPD.

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  • Question 37 - A patient with a history of asthma presents with worsening of her symptoms...

    Incorrect

    • A patient with a history of asthma presents with worsening of her symptoms and dyspnoea. She recently started taking a new medicine and she feels it might have aggravated her symptoms. Which of the following is likely responsible for her symptoms?

      Your Answer: Ferrous sulphate

      Correct Answer: Timolol eye drops

      Explanation:

      β-blockers are the class of drug most often chosen to treat glaucoma, although other medical therapies are available. Systemic absorption of timolol eye drops can cause unsuspected respiratory impairment and exacerbation of asthma. Physicians should be alert to the possibility of respiratory side-effects of topical therapy with β-blockers. Leukotriene antagonists and salbutamol are used in asthma treatment. HRT and ferrous sulphate do not lead to the exacerbation of asthma.

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  • Question 38 - A 60 year old man who has been complaining of increasing shortness of...

    Incorrect

    • A 60 year old man who has been complaining of increasing shortness of breath had a post-bronchodilator spirometry done. FEV1/FVC 0. 63 FEV1% predicted 63% What is the best interpretation of these results?

      Your Answer: Pulmonary fibrosis

      Correct Answer: COPD (stage 2 - moderate)

      Explanation:

      Chronic obstructive pulmonary disease (COPD) is a complex and progressive chronic lung disease. Typically, COPD includes emphysema and chronic bronchitis. COPD is characterized by the restriction of airflow into and out of the lungs. The obstruction of airflow makes breathing difficult. The causes of COPD include smoking, long-term exposure to air pollutants and a rare genetic disorder.

      The Global Initiative for Chronic Obstructive Lung Disease (GOLD) developed the GOLD Staging System. In the GOLD System, the forced expiratory volume in one second (FEV1) measurement from a pulmonary function test is used to place COPD into stages. Often, doctors also consider your COPD symptoms.

      COPD has four stages. The stages of COPD range from mild to very severe. COPD affects everyone differently. Because COPD is a progressive lung disease, it will worsen over time.
      The Stages of COPD:
      Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal.
      Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal.
      Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal.
      Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1.

      This patient has a FEV1 percent of 63 which falls within the stage 2 or moderate COPD.

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  • Question 39 - A 56 year old man who is a known alcoholic presents to the...

    Incorrect

    • A 56 year old man who is a known alcoholic presents to the clinic with a fever and cough. Past medical history states that he has a long history of smoking and is found to have a cavitating lesion on his chest x-ray.   Which organism is least likely to be the cause of his pneumonia?

      Your Answer: Lung cancer with secondary bacterial infection

      Correct Answer: Enterococcus faecalis

      Explanation:

      Cavitating pneumonia is a complication that can occur with a severe necrotizing pneumonia and in some publications it is used synonymously with the latter term. It is a rare complication in both children and adults. Albeit rare, cavitation is most commonly caused by Streptococcus pneumoniae, and less frequently Aspergillus spp., Legionella spp. and Staphylococcus aureus.

      In children, cavitation is associated with severe illness, although cases usually resolve without surgical intervention, and long-term follow-up radiography shows clear lungs without pulmonary sequelae
      Although the absolute cavitary rate may not be known, according to one series, necrotizing changes were seen in up to 6.6% of adults with pneumococcal pneumonia. Klebsiella pneumoniae is another organism that is known to cause cavitation.

      Causative agents:
      Mycobacterium tuberculosis
      Klebsiella pneumoniae
      Streptococcus pneumoniae
      Staphylococcus aureus

      Enterococcus faecalis was not found to be a causative agent.

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  • Question 40 - Which of the following regarding malignant mesothelioma is correct? ...

    Correct

    • Which of the following regarding malignant mesothelioma is correct?

      Your Answer: is treated with radiotherapy

      Explanation:

      Malignant mesothelioma is a type of cancer that occurs in the thin layer of tissue that covers the majority of the internal organs (mesothelium).
      Malignant Mesothelioma (MM) is a rare but rapidly fatal and aggressive tumour of the pleura and peritoneum. Aetiology of all forms of mesothelioma is strongly associated with industrial pollutants, of which asbestos is the principal carcinogen.

      Thoracoscopically guided biopsy should be performed if mesothelioma is suggested; the results are diagnostic in 98% of cases. No specific treatment has been found to be of benefit, except radiotherapy, which reduces seeding and invasion through percutaneous biopsy sites.

      Median survival for patients with malignant mesothelioma is 11 months. It is almost always fatal.

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  • Question 41 - A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he...

    Incorrect

    • A 40-year-old non-smoker is diagnosed as having emphysema. Further tests reveal that he has alpha-1 antitrypsin deficiency. What is the main role of alpha-1 antitrypsin in the body?

      Your Answer: Nicotinic receptor activator

      Correct Answer: Protease inhibitor

      Explanation:

      Alpha-1-antitrypsin (AAT) is a member of the serine proteinase inhibitor (serpin) family of proteins with a broad spectrum of biological functions including inhibition of proteases, immune modulatory functions, and the transport of hormones.

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  • Question 42 - A 14 year old known asthmatic presents to the A&E department with difficulty...

    Incorrect

    • A 14 year old known asthmatic presents to the A&E department with difficulty breathing. She was seen by her regular doctor the day before with a sore throat which he diagnosed as tonsillitis and was prescribed oral Amoxicillin for 5 days. Past medical history: Ulcerative colitis diagnosed four years ago. Current medications: Inhaled salbutamol and beclomethasone Mesalazine 400 mg TDS She was observed to be alert and oriented but she had laboured breathing. Inspiratory wheeze was noted. She was pale, sweaty and cyanosed. Her temperature was 36.7ºC, pulse 121/minute and blood pressure 91/40 mmHg. The lungs were clear and the remainder of the examination was normal. She was given high-flow oxygen through a face mask but despite this her breathing became increasingly difficult.   What is the most likely causative agent?

      Your Answer: Corynebacterium diphtheriae

      Correct Answer: Haemophilus influenzae

      Explanation:

      Acute epiglottitis is a life-threatening disorder with serious implications to the anaesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. There is inflammatory oedema of the arytenoids, aryepiglottic folds and the epiglottis; therefore, supraglottitis may be used instead or preferred to the term acute epiglottitis.

      Acute epiglottitis can occur at any age. The responsible organism used to be Hemophilus influenzae type B (Hib), but infection with group A b-haemolytic Streptococci has become more frequent after the widespread use of Hemophilus influenzae vaccination.

      The typical presentation in epiglottitis includes acute occurrence of high fever, severe sore throat and difficulty in swallowing with the sitting up and leaning forward position in order to enhance airflow. There is usually drooling because of difficulty and pain on swallowing. Acute epiglottitis usually leads to generalized toxaemia. The most common differential diagnosis is croup and a foreign body in the airway. A late referral to an acute care setting with its serious consequences may result from difficulty in differentiation between acute epiglottitis and less urgent causes of a sore throat, shortness of breath and dysphagia.

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  • Question 43 - A 41 year old man who has had two episodes of pneumonia in...

    Incorrect

    • A 41 year old man who has had two episodes of pneumonia in succession and an episode of haemoptysis is observed to have paroxysms of coughing and increasing wheezing. A single lesion which is well-defined is seen in the lower right lower lobe on a chest x-ray. There is no necrosis but biopsy shows numerous abnormal cells, occasional nuclear pleomorphism and absent mitoses. Which diagnosis fits the clinical presentation?

      Your Answer: Adenocarcinoma of the bronchus

      Correct Answer: Bronchial carcinoid

      Explanation:

      Bronchial carcinoids are uncommon, slow growing, low-grade, malignant neoplasms, comprising 1-2% of all primary lung cancers.
      It is believed to be derived from surface of bronchial glandular epithelium. Mostly located centrally, they produce symptoms and signs of bronchial obstruction such as localized wheeze, non resolving recurrent pneumonitis, cough, chest pain, and fever. Haemoptysis is present in approximately 50% of the cases due to their central origin and hypervascularity.
      Central bronchial carcinoids are more common than the peripheral type and are seen as endobronchial nodules or hilar/perihilar mass closely related to the adjacent bronchus. Chest X-ray may not show the central lesion depending on how small it is.

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  • Question 44 - A 28 year old female hiker begins complaining of headache and nausea after...

    Incorrect

    • A 28 year old female hiker begins complaining of headache and nausea after reaching a height of 5010 metres. Despite having the headache and feeling nauseous, she continues to hike but becomes progressively worse. She is seen staggering, complains of feeling dizzy and has an ataxic gait. Which of the following is the appropriate treatment of this patient?

      Your Answer: Descent

      Correct Answer: Descent + dexamethasone

      Explanation:

      High Altitude Cerebral Oedema (HACE) is a severe and potentially fatal manifestation of high altitude illness and is often characterized by ataxia, fatigue, and altered mental status. HACE is often thought of as an extreme form/end-stage of Acute Mountain Sickness (AMS). Although HACE represents the least common form of altitude illness, it may progress rapidly to coma and death as a result of brain herniation within 24 hours, if not promptly diagnosed and treated.

      HACE generally occurs after 2 days above 4000m but can occur at lower elevations (2500m) and with faster onset. Some, but not all, individuals will suffer from symptoms of AMS such as headache, insomnia, anorexia, nausea prior to transitioning to HACE. Some may also have concomitant High Altitude Pulmonary Oedema (HAPE). HACE in isolation is rare, but the absence of concomitant HAPE or symptoms of AMS prior to deterioration does not rule-out the presence of HACE.

      Most cases develop as a progression of AMS and will include a history of recent ascent to altitude and prior complaints/findings of AMS including a headache, fatigue, nausea, insomnia, and/or light-headedness. Some may also have signs/symptoms of HAPE. Transition to HACE is heralded by signs of encephalopathy including ataxia (usually the earliest clinical finding) and altered mentation which may range from mild to severe. Other symptoms may include a more severe headache, difficulty speaking, lassitude, a decline in the level of consciousness, and/or focal neurological deficits or seizures.

      The mainstay of treatment is the immediate descent of at least 1000m or until symptoms improve. If descent is not an option, one may use a portable hyperbaric chamber and/or supplemental oxygen to temporize illness, but this should never replace or delay evaluation/descent when possible. If available, dexamethasone 8mg for one dose, followed by 4mg every 6 hours should be given to adults via PO, IM, or IV routes.
      Acetazolamide has proven to be beneficial in only a single clinical study. The suggested dosing regimen for Acetazolamide is 250 mg PO, given twice daily. Though effective in alleviating or temporizing symptoms, none of the adjunct treatment modalities are definitive or a replacement for an immediate descent.

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  • Question 45 - A 66-year-old man with newly-diagnosed small cell carcinoma discusses his further treatment options...

    Incorrect

    • A 66-year-old man with newly-diagnosed small cell carcinoma discusses his further treatment options with the team of doctors. Which statement is incorrect about small cell carcinoma?

      Your Answer: Brain metastases are uncommon in patients with small cell lung cancer

      Correct Answer: Patients with small cell lung cancer always benefit from surgery

      Explanation:

      Small cell lung cancer (SCLC) is characterized by rapid growth and early dissemination. Prompt initiation of treatment is important.

      Patients with clinical stage Ia (T1N0) after standard staging evaluation may be considered for surgical resection, but combined treatment with chemotherapy and radiation therapy is the standard of care. Radiation therapy is often added at the second cycle of chemotherapy.

      Historically, patients undergoing surgery for small cell lung cancer (SCLC) had a dismal prognosis. However, more recent data suggest that patients with true stage I SCLC may benefit from surgical resection.

      Common sites of hematogenous metastases include the brain, bones, liver, adrenal glands, and bone marrow. The symptoms depend upon the site of spread.

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  • Question 46 - A young man is reviewed for difficulty breathing. Lung function tests showed that...

    Incorrect

    • A young man is reviewed for difficulty breathing. Lung function tests showed that his peak expiratory flow rate is 54% below the normal range for his age and height. What is a possible diagnosis?

      Your Answer: Kyphoscoliosis

      Correct Answer: Asthma

      Explanation:

      Peak Expiratory Flow (PEF), also called Peak Expiratory Flow Rate (PEFR) is a person’s maximum speed of expiration, as measured with a peak flow meter. Measurement of PEFR requires some practise to correctly use a meter and the normal expected value depends on a patient’s gender, age and height.
      It is classically reduced in obstructive lung disorders, such as Asthma, COPD or Cystic Fibrosis.

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  • Question 47 - A 54 year old male, with a smoking history of 15 pack years...

    Incorrect

    • A 54 year old male, with a smoking history of 15 pack years presents with worsening dyspnoea, fever and cough. He works at a foundry. Vitals are as follows: Respiratory rate: 28/min Heart rate: 80 bpm Temp: 37.6C Chest auscultation reveals bilateral crepitations throughout the lung fields. Calcified hilar nodules are visible on the chest X-ray. Further evaluation shows an eggshell calcification on HRCT. Which of the following is the most likely diagnosis?

      Your Answer: Berylliosis

      Correct Answer: Silicosis

      Explanation:

      Silicosis is a common occupational lung disease that is caused by the inhalation of crystalline silica dust. Silica is the most abundant mineral on earth. Workers that are involved for example in construction, mining, or glass production are among the individuals with the highest risk of developing the condition. Acute silicosis causes severe symptoms (e.g., exertional dyspnoea, cough with sputum) and has a very poor prognosis.
      Chronic silicosis has a very variable prognosis and affected individuals may remain asymptomatic for several decades. However, radiographic signs are usually seen early on. Typical radiographic findings are calcifications of perihilar lymph nodes, diffuse ground glass opacities, large numbers of rounded, solitary nodules or bigger, confluent opacities. Avoiding further exposure to silica is crucial, especially since the only treatment available is symptomatic (e.g., bronchodilators). Silicosis is associated with an increased risk of tuberculosis and lung cancer. Berylliosis typically affects individuals who are exposed to aerospace industry. Histoplasmosis and tuberculosis do not form eggshell calcifications.

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  • Question 48 - Which type of cell is responsible for the production of surfactant? ...

    Incorrect

    • Which type of cell is responsible for the production of surfactant?

      Your Answer: Alveolar macrophage

      Correct Answer: Type II pneumocyte

      Explanation:

      Type I pneumocyte: The cell responsible for the gas (oxygen and carbon dioxide) exchange that takes place in the alveoli. It is a very thin cell stretched over a very large area. This type of cell is susceptible to a large number of toxic insults and cannot replicate itself.
      Type II pneumocyte: The cell responsible for the production and secretion of surfactant (the molecule that reduces the surface tension of pulmonary fluids and contributes to the elastic properties of the lungs). The type 2 pneumocyte is a smaller cell that can replicate in the alveoli and will replicate to replace damaged type 1 pneumocytes. Alveolar macrophages are the primary phagocytes of the innate immune system, clearing the air spaces of infectious, toxic, or allergic particles that have evaded the mechanical defences of the respiratory tract, such as the nasal passages, the glottis, and the mucociliary transport system. The main role of goblet cells is to secrete mucus in order to protect the mucous membranes where they are found. Goblet cells accomplish this by secreting mucins, large glycoproteins formed mostly by carbohydrates.

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  • Question 49 - A patient complaining of nocturnal cough and wheeze is investigated for asthma. Which of...

    Incorrect

    • A patient complaining of nocturnal cough and wheeze is investigated for asthma. Which of the following tests would be most useful in aiding the diagnosis?

      Your Answer: Neutrophil count

      Correct Answer: ANCA

      Explanation:

      Churg-Strauss disease (CSD) is one of three important fibrinoid, necrotizing, inflammatory leukocytoclastic systemic small-vessel vasculitides that are associated with antineutrophil cytoplasm antibodies (ANCAs).
      The first (prodromal) phase of Churg-Strauss disease (CSD) consists of asthma usually in association with other typical allergic features, which may include eosinophilia. During the second phase, the eosinophilia is characteristic (see below) and ANCAs with perinuclear staining pattern (pANCAs) are detected. The treatment would therefore be different from asthma. For most patients, especially those patients with evidence of active vasculitis, treatment with corticosteroids and immunosuppressive agents (cyclophosphamide) is considered first-line therapy

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  • Question 50 - A 23 year old female presents to the hospital with worsening shortness of...

    Incorrect

    • A 23 year old female presents to the hospital with worsening shortness of breath, increased volume of purulent sputum and left-sided chest pain. She has a history of cystic fibrosis. Medical notes state that she is under consideration for the transplant list and for some years has been colonised with pseudomonas. On examination she has a temperature of 38.4°C and FEV1 falling below 75% of the previous value that was recorded. She looks unwell and is tachycardic and hypotensive with a respiratory rate of 21/min. Burkholderia cepacia is confirmed as the pathogen in this case. What would be the most appropriate antibiotic regime?

      Your Answer:

      Correct Answer: Ceftazidime and aminoglycoside

      Explanation:

      Burkholderia cepacia is an aerobic gram-negative bacillus found in various aquatic environments. B cepacia is an organism of low virulence and is a frequent colonizer of fluids used in the hospital (e.g., irrigation solutions, intravenous fluids).
      B cepacia, as a non-aeruginosa pseudomonad, is usually resistant to aminoglycosides, antipseudomonal penicillin, and antipseudomonal third-generation cephalosporins and polymyxin B.
      B cepacia is often susceptible to trimethoprim plus sulfamethoxazole (TMP-SMX), cefepime, meropenem, minocycline, and tigecycline and has varying susceptibility to fluoroquinolones.
      Based on the options available, ceftazidime and aminoglycoside would be the best option.

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  • Question 51 - An elderly woman is admitted to the hospital with a community-acquired pneumonia (CAP)....

    Incorrect

    • An elderly woman is admitted to the hospital with a community-acquired pneumonia (CAP). Her medical notes state that she developed a skin rash after taking penicillin a few years ago. She has a CURB score of 4 and adverse prognostic features. Which of the following would be an appropriate empirical antibiotic choice?

      Your Answer:

      Correct Answer: Cefotaxime and erythromycin

      Explanation:

      Community-acquired pneumonia (CAP) is one of the most common infectious diseases and is an important cause of mortality and morbidity worldwide. Typical bacterial pathogens that cause CAP include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
      The CURB-65 is used as a means of deciding the action that is needed to be taken for that patient.
      Score 3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit

      Recent studies have suggested that the use of a beta-lactam alone may be noninferior to a beta-lactam/macrolide combination or fluoroquinolone therapy in hospitalized patients.

      Therapy in ICU patients includes the following:
      – Beta-lactam (ceftriaxone, cefotaxime, or ampicillin/sulbactam) plus either a macrolide or respiratory fluoroquinolone
      – For patients with penicillin allergy, a respiratory fluoroquinolone and aztreonam

      Therefore the appropriate treatment would be Cefotaxime and erythromycin.

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  • Question 52 - Which of the following is most likely linked to male infertility in cystic...

    Incorrect

    • Which of the following is most likely linked to male infertility in cystic fibrosis?

      Your Answer:

      Correct Answer: Failure of development of the vas deferens

      Explanation:

      The vas deferens is a long tube that connects the epididymis to the ejaculatory ducts. It acts as a canal through which mature sperm may pass through the penis during ejaculation.

      Most men with CF (97-98 percent) are infertile because of a blockage or absence of the vas deferens, known as congenital bilateral absence of the vas deferens (CBAVD). The sperm never makes it into the semen, making it impossible for them to reach and fertilize an egg through intercourse. The absence of sperm in the semen can also contribute to men with CF having thinner ejaculate and lower semen volume.

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  • Question 53 - A 28-year-old 9 week pregnant woman is newly diagnosed with asthma. She is...

    Incorrect

    • A 28-year-old 9 week pregnant woman is newly diagnosed with asthma. She is not on any medication at the moment. Her PEFR diary shows wide diurnal variations and she also gives a past history of eczema.   Which of the following is correct?

      Your Answer:

      Correct Answer: Low dose inhaled corticosteroids would be considered acceptable

      Explanation:

      The following drugs should be used as normal during pregnancy:
      short acting β2 -agonists
      long acting β2- agonists
      inhaled corticosteroids
      oral and intravenous theophyllines

      Use steroid tablets as normal when indicated during pregnancy for severe asthma. Steroid tablets should never be withheld because of pregnancy.
      If leukotriene receptor antagonists are required to achieve adequate control of asthma then they should not be withheld during pregnancy.

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  • Question 54 - A 40 year old truck operator who smokes one and a half packs...

    Incorrect

    • A 40 year old truck operator who smokes one and a half packs of cigarette per day complains of a cough and fever for the last three days. He also has right-sided chest pain when he inhales. On examination he is slightly cyanosed, has a temperature of 38.1°C, a respiratory rate of 39/min, a BP of 104/71 mm/Hg and a pulse rate of 132/min. He has basal crepitations and dullness to percussion at the right lung base. What could be a probable diagnosis?

      Your Answer:

      Correct Answer: Bronchopneumonia

      Explanation:

      Bronchopneumonia presents as a patchy consolidation involving one or more lobes, usually the dependent lung zones, a pattern attributable to aspiration of oropharyngeal contents.

      Symptoms of bronchopneumonia may be like other types of pneumonia. This condition often begins with flu-like symptoms that can become more severe over a few days. The symptoms include:
      – fever
      – a cough that brings up mucus
      – shortness of breath
      – chest pain
      – rapid breathing
      – sweating
      – chills
      – headaches
      – muscle aches
      – pleurisy, or chest pain that results from inflammation due to excessive coughing
      – fatigue
      – confusion or delirium, especially in older people

      There are several factors that can increase your risk of developing bronchopneumonia. These include:
      – Age: People who are 65 years of age or older, and children who are 2 years or younger, have a higher risk for developing bronchopneumonia and complications from the condition.
      – Environmental: People who work in, or often visit, hospital or nursing home facilities have a higher risk for developing bronchopneumonia.
      – Lifestyle: Smoking, poor nutrition, and a history of heavy alcohol use can increase your risk for bronchopneumonia.
      – Medical conditions: Having certain medical conditions can increase your risk for developing this type of pneumonia. These include: chronic lung disease, such as asthma or chronic obstructive pulmonary disease (COPD), HIV/AIDS, having a weakened immune system due to chemotherapy or the use of immunosuppressive drugs.

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  • Question 55 - A 50 year old doctor developed a fever of 40.2 °C which lasted...

    Incorrect

    • A 50 year old doctor developed a fever of 40.2 °C which lasted for two days. He has had diarrhoea for a day, shortness of breath and dry cough. His blood results reveal a hyponatraemia and deranged LFTs. His WBC count is 10.4 × 109/L and CX-ray shows bibasal consolidation.   Which treatment would be the most effective for his condition?

      Your Answer:

      Correct Answer: Clarithromycin

      Explanation:

      Pneumonia is the predominant clinical manifestation of Legionnaires disease (LD). After an incubation period of 2-10 days, patients typically develop the following nonspecific symptoms:
      Fever
      Weakness
      Fatigue
      Malaise
      Myalgia
      Chills

      Respiratory symptoms may not be present initially but develop as the disease progresses. Almost all patients develop a cough, which is initially dry and non-productive, but may become productive, with purulent sputum and, (in rare cases) haemoptysis. Patients may experience chest pain.
      Common GI symptoms include diarrhoea (watery and non bloody), nausea, vomiting, and abdominal pain.

      Fever is typically present (98%). Temperatures exceeding 40°C occur in 20-60% of patients. Lung examination reveals rales and signs of consolidation late in the disease course.

      Males are more than twice as likely as females to develop Legionnaires disease.

      Age
      Middle-aged and older adults have a high risk of developing Legionnaires disease while it is rare in young adults and children. Among children, more than one third of reported cases have occurred in infants younger than 1 year.

      Situations suggesting Legionella disease:
      -Gram stains of respiratory samples revealing many polymorphonuclear leukocytes with few or no organisms

      -Hyponatremia

      -Pneumonia with prominent extrapulmonary manifestations (e.g., diarrhoea, confusion, other neurologic symptoms)

      Specific therapy includes antibiotics capable of achieving high intracellular concentrations (e.g., macrolides, quinolones, ketolides, tetracyclines, rifampicin).
      Clarithromycin, a new macrolide antibiotic, is at least four times more active in vitro than erythromycin against Legionella pneumophila. In this study the safety and efficacy of orally administered clarithromycin (500 to 1,000 mg bid) in the treatment of Legionella pneumonia were evaluated.
      Clarithromycin is a safe effective treatment for patients with severe chest infections due to Legionella pneumophila.

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  • Question 56 - A 73 year old woman presents with severe emphysema. She is on maximal...

    Incorrect

    • A 73 year old woman presents with severe emphysema. She is on maximal therapy including high dose Seretide and tiotropium. She tells you that she is so unwell that she can barely manage the walk the 160 metres to the bus stop.   On examination she looks short of breath at rest. Her BP is 158/74 mmHg, pulse is 76 and regular. There are quiet breath sounds, occasional coarse crackles and wheeze on auscultation of the chest.   Investigations show:   Haemoglobin 14.2 g/dl (13.5-17.7) White cell count 8.4 x 109/l (4-11) Platelets 300 x 109/l (150-400) Sodium 137 mmol/l (135-146) Potassium 4.1 mmol/l (3.5-5) Creatinine 127 micromole/l (79-118) pH 7.4 (7.35-7.45) pCO2 7.5 kPa (4.8-6.1) pO2 9.7 kPa (10-13.3) Chest x-ray – Predominant upper lobe emphysema. FEV1 – 30% of predicted.   Which of the features of her history, examination or investigations would preclude referral for lung reduction surgery?

      Your Answer:

      Correct Answer: pCO2 7.4

      Explanation:

      Nice guidelines for lung reduction surgery:

      FEV1 > 20% predicted
      PaCO2 < 7.3 kPa
      TLco > 20% predicted
      Upper lobe predominant emphysema

      This patient has pCO2 of 7.4 so she is unsuitable for referral for lung reduction surgery.

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  • Question 57 - A 40 year old farmer who is a non-smoker is experiencing increasing shortness...

    Incorrect

    • A 40 year old farmer who is a non-smoker is experiencing increasing shortness of breath on exertion. He has been having chest tightness and a non-productive cough which becomes worse when he is at the dairy farm. He has no respiratory history of note. Extrinsic allergic alveolitis is the suspected diagnosis. Which factor would be responsible for this diagnosis?

      Your Answer:

      Correct Answer: Contaminated hay

      Explanation:

      Extrinsic allergic alveolitis (EAA) refers to a group of lung diseases that can develop after exposure to certain substances. The name describes the origin and the nature of these diseases:

      ‘extrinsic’ – caused by something originating outside the body
      ‘allergic’ – an abnormally increased (hypersensitive) body reaction to a common substance
      ‘alveolitis’ – inflammation in the small air sacs of the lungs (alveoli)

      Symptoms can include: fever, cough, worsening breathlessness and weight loss. The diagnosis of the disease is based on a history of symptoms after exposure to the allergen and a range of clinical tests which usually includes: X-rays or CT scans, lung function and blood tests.

      EAA is not a ‘new’ occupational respiratory disease and occupational causes include bacteria, fungi, animal proteins, plants and chemicals.

      Examples of EAA include:

      Farmer’s lung
      This is probably the most common occupational form of EAA and is the outcome of an allergic response to a group of microbes, which form mould on vegetable matter in storage. During the handling of mouldy straw, hay or grain, particularly in a confined space such as a poorly ventilated building, inhalation of spores and other antigenic material is very likely.

      There also appears to be a clear relationship between water content of crops, heating (through mould production) and microbial growth, and this would apply to various crops and vegetable matter, with the spores produced likely to cause EAA.

      Farmer’s lung can be prevented by drying crops adequately before storage and by ensuring good ventilation during storage. Respiratory protection should also be worn by farm workers when handling stored crops, particularly if they have been stored damp or are likely to be mouldy.

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  • Question 58 - A 51 year old smoker was recently diagnosed with non small cell lung...

    Incorrect

    • A 51 year old smoker was recently diagnosed with non small cell lung carcinoma. Investigations show presence of a 3 x 3 x 2 cm tumour on the left side of the lower lung lobe. the mass has invaded the parietal pleura. Ipsilateral hilar node is also involved but there is no metastatic spread. What is the stage of this cancer?

      Your Answer:

      Correct Answer: T2 N1 M0

      Explanation:

      The tumour has only invaded the visceral pleura and measures 3cm in the greatest dimension. Hence it is designated at T2. Ipsilateral peribronchial and/or hilar lymph node involvement would make it N1. There is no distal metastasis so M would be 0.

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  • Question 59 - A 26 year old male from Eastern Europe has been experiencing night sweats,...

    Incorrect

    • A 26 year old male from Eastern Europe has been experiencing night sweats, fevers, and decreased weight for several months. He also has a chronic cough which at times consists of blood. He is reviewed at the clinic and a calcified lesion was detected in his right lung with enlarged calcified right hilar lymph nodes. His leukocytes are just below normal range and there is a normochromic normocytic anaemia. Acid-fast bacilli (AFB) are found in one out of five sputum samples. Sputum is sent for extended culture.   Which diagnosis fits best with his signs and symptoms?

      Your Answer:

      Correct Answer: Active pulmonary tuberculosis

      Explanation:

      Classic clinical features associated with active pulmonary TB are as follows (elderly individuals with TB may not display typical signs and symptoms):
      – Cough
      – Weight loss/anorexia
      – Fever
      – Night sweats
      – Haemoptysis
      – Chest pain (can also result from tuberculous acute pericarditis)
      – Fatigue

      Test:
      Acid-fast bacilli (AFB) smear and culture – Using sputum obtained from the patient.
      AFB stain is quick but requires a very high organism load for positivity, as well as the expertise to read the stained sample. This test is more useful in patients with pulmonary disease.
      Obtain a chest radiograph to evaluate for possible associated pulmonary findings. If chest radiography findings suggest TB and a sputum smear is positive for AFB, initiate treatment for TB.

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  • Question 60 - A 66 year old COPD patient visits the clinic for a review. He...

    Incorrect

    • A 66 year old COPD patient visits the clinic for a review. He has no increase in his sputum volume or change in its colour. He has been a smoker for 39 years and previously worked at the shipping docks. On examination, he is pursed lip breathing but managing complete sentences. Investigations: BP is 141/72 mmHg Pulse 82 bpm and regular Sp(O2) 92% on room air RR 19 breaths/min Temperature 37.1°C. Examination of his chest revealed a widespread wheeze with coarse crepitations heard in the L mid-zone. FEV1 :FVC ratio in the clinic today was 68%.   Which of the following would be the most useful investigation that should be performed to establish the diagnosis?

      Your Answer:

      Correct Answer: High-resolution CT thorax

      Explanation:

      High-resolution CT (HRCT) scanning is more sensitive than standard chest radiography and is highly specific for diagnosing emphysema (outlined bullae are not always visible on a radiograph).

      HRCT scanning may provide an adjunct means of diagnosing various forms of COPD (i.e., lower lobe disease may suggest AAT deficiency) and may help the clinician to determine whether surgical intervention would benefit the patient.

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  • Question 61 - A 35 year old male who has smoked 20 cigarettes per day was...

    Incorrect

    • A 35 year old male who has smoked 20 cigarettes per day was referred to the National Chest Hospital because he has had a nine month history of shortness of breath which is getting worse. Tests revealed that he had moderate emphysema. His family history showed that his father died from COPD at the age of 52. Genetic testing found the PiSZ genotype following the diagnosis of alpha-1 antitrypsin (A1AT) deficiency. What levels of alpha-1 antitrypsin would be expected if they were to be measured?

      Your Answer:

      Correct Answer: 40% of normal

      Explanation:

      Alpha1-antitrypsin (AAT) deficiency, first described in 1963, is one of the most common inherited disorders amongst white Caucasians. Its primary manifestation is early-onset of pan acinar emphysema. In adults, alpha1-antitrypsin deficiency leads to chronic liver disease in the fifth decade. As a cause of emphysema, it is seen in non-smokers in the fifth decade of life and during the fourth decade of life in smokers.

      Symptoms of alpha1-antitrypsin (AAT) deficiency emphysema are limited to the respiratory system. Dyspnoea is the symptom that eventually dominates alpha1-antitrypsin deficiency. Similar to other forms of emphysema, the dyspnoea of alpha1-antitrypsin deficiency is initially evident only with strenuous exertion. Over several years, it eventually limits even mild activities.
      The serum levels of some of the common genotypes are:
      •PiMM: 100% (normal)
      •PiMS: 80% of normal serum level of A1AT
      •PiSS: 60% of normal serum level of A1AT
      •PiMZ: 60% of normal serum level of A1AT, mild deficiency
      •PiSZ: 40% of normal serum level of A1AT, moderate deficiency
      •PiZZ: 10–15% (severe alpha 1-antitrypsin deficiency)

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  • Question 62 - Which of the following parameters is increased as a result of asthma? ...

    Incorrect

    • Which of the following parameters is increased as a result of asthma?

      Your Answer:

      Correct Answer: Residual volume

      Explanation:

      In asthma, a reversible increase in residual volume (RV), functional residual capacity (FRC), and total lung capacity (TLC) may occur. There is a fall in FEV1, FVC and gas transfer.

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  • Question 63 - A 26 year old woman visits the clinic with an acute asthma attack....

    Incorrect

    • A 26 year old woman visits the clinic with an acute asthma attack. Which lung function abnormality is she most likely to have?

      Your Answer:

      Correct Answer: Increased residual volume

      Explanation:

      Asthma is a condition characterized by airway hyperresponsiveness, which results in reversible increases in bronchial smooth muscle tone, and variable amounts of inflammation of the bronchial mucosa.
      During an acute asthma attack, the already inflamed airways narrow further due to bronchospasm, which leads to increased airway resistance. Because of the increased smooth muscle tone during an asthma attack, the airways also tend to close at abnormally high lung volumes, trapping air behind occluded or narrowed small airways. Thus the acute asthmatic will breathe at high lung volumes, his functional residual capacity will be elevated, and he will inspire close to total lung capacity. The accessory muscles of respiration are often used to maintain the lungs in a hyperinflated state.

      During episodes of acute asthma, pulmonary function tests reveal an obstructive pattern. This includes a decrease in the rate of maximal expiratory air flow (a decrease in FEV1 and the FEV1/FVC ratio) due to the increased resistance, and a reduction in forced vital capacity (FVC) correlating with the level of hyperinflation of the lungs. Because these patients breathe at such high lung volumes (near the top of the pressure-volume curve, where lung compliance greatly decreases), they must exert significant effort to create an extremely negative pleural pressure, and consequently fatigue easily. Overinflation also reduces the curvature of the diaphragm, making it less efficient in generating further negative pleural pressure.

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  • Question 64 - A 64 year old woman with ankylosing spondylitis presents with cough, weight loss...

    Incorrect

    • A 64 year old woman with ankylosing spondylitis presents with cough, weight loss and tiredness. Her chest x-ray shows longstanding upper lobe fibrosis. Three sputum tests stain positive for acid fast bacilli (AFB) but are consistently negative for Mycobacterium tuberculosis on culture.   Which of the following is the most likely causative agent?

      Your Answer:

      Correct Answer: Mycobacterium avium intracellular complex

      Explanation:

      Pulmonary mycobacterium avium complex (MAC) infection in immunocompetent hosts generally manifests as cough, sputum production, weight loss, fever, lethargy, and night sweats. The onset of symptoms is insidious.
      In patients who may have pulmonary infection with MAC, diagnostic testing includes acid-fast bacillus (AFB) staining and culture of sputum specimens.

      The ATS/IDSA guidelines include clinical, radiographic, and bacteriologic criteria to establish a diagnosis of nontuberculous mycobacterial lung disease.

      Clinical criteria are as follows:

      Pulmonary signs and symptoms such as cough, fatigue, weight loss; less commonly, fever and weight loss; dyspnoea

      Appropriate exclusion of other diseases (e.g., carcinoma, tuberculosis).

      At least 3 sputum specimens, preferably early-morning samples taken on different days, should be collected for AFB staining and culture. Sputum AFB stains are positive for MAC in most patients with pulmonary MAC infection. Mycobacterial cultures grow MAC in about 1-2 weeks, depending on the culture technique and bacterial burden.

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  • Question 65 - A 28 year old woman presents with lethargy, arthralgia and cough. Over the...

    Incorrect

    • A 28 year old woman presents with lethargy, arthralgia and cough. Over the past three weeks she has also developed painful erythematous nodules on both shins. Respiratory examination is normal. A chest x-ray is performed which is reported as follows: Bilateral mediastinal nodal enlargement. No evidence of lung parenchymal disease. Normal cardiac size. Given the likely diagnosis, what would be the most appropriate course of action?

      Your Answer:

      Correct Answer: Observation

      Explanation:

      Sarcoidosis is an inflammatory disease that affects one or more organs but most commonly affects the lungs and lymph glands. The inflammation may change the normal structure and possibly the function of the affected organ(s).
      The presentation in sarcoidosis varies with the extent and severity of organ involvement, as follows:
      Asymptomatic (incidentally detected on chest imaging): Approximately 5% of cases.
      Systemic complaints (fever, anorexia): 45% of cases
      Pulmonary complaints (dyspnoea on exertion, cough, chest pain, and haemoptysis [rare]): 50% of cases

      Löfgren syndrome (fever, bilateral hilar lymphadenopathy, and polyarthralgias): Common in Scandinavian patients, but uncommon in African-American and Japanese patients.

      Dermatologic manifestations may include the following:
      – Erythema nodosum
      – A lower-extremity panniculitis with painful, erythematous nodules (often with Löfgren syndrome)
      – Lupus pernio (the most specific associated cutaneous lesion)
      – Violaceous rash on the cheeks or nose (common)
      – Maculopapular plaques (uncommon)

      Staging of sarcoidosis is as follows:
      Stage 0: Normal chest radiographic findings
      Stage I: Bilateral hilar lymphadenopathy
      Stage II: Bilateral hilar lymphadenopathy and infiltrates
      Stage III: Infiltrates alone
      Stage IV: Fibrosis

      Nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for the treatment of arthralgias and other rheumatic complaints. Patients with stage I sarcoidosis often require only occasional treatment with NSAIDs.

      Treatment in patients with pulmonary involvement is as follows:
      Asymptomatic patients may not require treatment
      In patients with minimal symptoms, serial re-evaluation is prudent
      Treatment is indicated for patients with significant respiratory symptoms
      Corticosteroids can produce small improvements in the functional vital capacity and in the radiographic appearance in patients with more severe stage II and III disease.

      This patient has Stage 1 Sarcoidosis so observation is the most appropriate action.

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  • Question 66 - An 80 year old woman is brought to the ER with altered sensorium....

    Incorrect

    • An 80 year old woman is brought to the ER with altered sensorium. She is accompanied by her daughter who noticed the acute change. The patient has had a nagging cough with purulent sputum and haemoptysis for the last few days. Previous history includes a visit to her GP two weeks back because of influenza. On examination, the patient appears markedly agitated with a respiratory rate of 35/min. Blood gases reveal that she is hypoxic. White blood cell count is 20 x 109/l, and creatinine is 250mmol/l. Chest X-ray is notable for patchy areas of consolidation, necrosis and empyema formation. Which of the following lead to the patient's condition?

      Your Answer:

      Correct Answer: Staphylococcus aureus pneumonia

      Explanation:

      Though a common community pathogen, Staphylococcus Aureas is found twice as frequently in pneumonias in hospitalized patients. It often attacks the elderly and patients with CF and arises as a co-infection with influenza viral pneumonia. The clinical course is characterized by high fevers, chills, a cough with purulent bloody sputum, and rapidly progressing dyspnoea. The gross pathology commonly reveals an acute bronchopneumonia pattern that may evolve into a necrotizing cavity with congested lungs and airways that contain a bloody fluid and thick mucoid secretions.

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  • Question 67 - A 63 year old man with known allergic bronchopulmonary aspergillosis presents to the...

    Incorrect

    • A 63 year old man with known allergic bronchopulmonary aspergillosis presents to the A&E Department with an exacerbation. Which therapy represents the most appropriate management?

      Your Answer:

      Correct Answer: Oral glucocorticoids

      Explanation:

      Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.

      Treatment of ABPA aims to control inflammation and prevent further injury to your lungs. ABPA is a hypersensitivity reaction that requires treatment with oral corticosteroids. Inhaled steroids are not effective. ABPA is usually treated with a combination of oral corticosteroids and anti-fungal medications. The corticosteroid is used to treat inflammation and blocks the allergic reaction. Examples
      of corticosteroids include: prednisone, prednisolone or methylprednisolone. Inhaled corticosteroids alone – such as used for asthma treatment – are not effective in treating ABPA. Usually treatment with an oral corticosteroid is needed for months.

      The second type of therapy used is an anti-fungal medication, like itraconazole and voriconazole. These medicines help kill Aspergillus so that it no longer colonizes the airway. Usually one of these drugs is given for at least 3 to 6 months. However, even this treatment is not curative and can have side effects.

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  • Question 68 - A 26 year old man with a history of 'brittle' asthma is admitted...

    Incorrect

    • A 26 year old man with a history of 'brittle' asthma is admitted with an asthma attack. High-flow oxygen and nebulised salbutamol have already been administered by the Paramedics. The patient is unable to complete sentences and he has a bilateral expiratory wheeze. He is also unable to perform a peak flow reading. His respiratory rate is 31/minute, sats 93% (on high-flow oxygen) and pulse 119/minute. Intravenous hydrocortisone is immediately administered and nebulised salbutamol given continuously. Intravenous magnesium sulphate is administered after six minutes of no improvement. These are the results from the blood gas sample that was taken after another six minutes: pH 7.32 pCO2 6.8 kPa pO2 8.9 kPa What is the most appropriate therapy in this patient?

      Your Answer:

      Correct Answer: Intubation

      Explanation:

      The normal partial pressure reference values are: oxygen PaO2 more than 80 mmHg (11 kPa), and carbon dioxide PaCO2 lesser than 45 mmHg (6.0 kPa).
      This patient has an elevated PaCO2 of 6.8kPa which exceeds the normal value of less than 6.0kPa.
      The pH is also lower than 7.35 at 7.32

      In any patient with asthma, an increasing PaCO2 indicates severe airway obstruction that is leading to respiratory muscle fatigue and patient exhaustion.

      According to the British Thoracic Society guidelines:
      Indications for admission to intensive care or high-dependency units include
      patients requiring ventilatory support and those with acute severe or life-threatening asthma who are failing to respond to therapy, as evidenced by:
      • deteriorating PEF
      • persisting or worsening hypoxia
      • hypercapnia
      • arterial blood gas analysis showing fall in pH or rising hydrogen concentration
      • exhaustion, feeble respiration
      • drowsiness, confusion, altered conscious state
      • respiratory arrest

      Transfer to ICU accompanied by a doctor prepared to intubate if:
      • Deteriorating PEF, worsening or persisting hypoxia, or hypercapnia
      • Exhaustion, altered consciousness
      • Poor respiratory effort or respiratory arrest

      A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.

      Consider giving a single dose of intravenous magnesium sulphate to
      patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy.
      Magnesium sulphate (1.2–2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

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  • Question 69 - A 35-year-old woman is referred to the acute medical unit with a 5...

    Incorrect

    • A 35-year-old woman is referred to the acute medical unit with a 5 day history of polyarthritis and a low-grade fever. Examination reveals shin lesions which the patient states are painful. Chest x-ray shows a bulky mediastinum. What is the most appropriate diagnosis?

      Your Answer:

      Correct Answer: Lofgren's syndrome

      Explanation:

      Lofgren’s syndrome is an acute form of sarcoidosis characterized by erythema nodosum, bilateral hilar lymphadenopathy (BHL), and polyarthralgia or polyarthritis. Other symptoms include anterior uveitis, fever, ankle periarthritis, and pulmonary involvement.

      Löfgren syndrome is usually an acute disease with an excellent prognosis, typically resolving spontaneously from 6-8 weeks to up to 2 years after onset. Pulmonologists, ophthalmologists, and rheumatologists often define this syndrome differently, describing varying combinations of arthritis, arthralgia, uveitis, erythema nodosum, hilar adenopathy, and/or other clinical findings.

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  • Question 70 - Which area in the body controls the hypoxic drive to breathe? ...

    Incorrect

    • Which area in the body controls the hypoxic drive to breathe?

      Your Answer:

      Correct Answer: Carotid body

      Explanation:

      The carotid body consists of chemosensitive cells at the bifurcation of the common carotid artery that respond to changes in oxygen tension and, to a lesser extent, pH. In contrast to central chemoreceptors (which primarily respond to PaCO2) and the aortic bodies (which primarily have circulatory effects: bradycardia, hypertension, adrenal stimulation, and also bronchoconstriction), carotid bodies are most sensitive to PaO2. At a PaO2 of approximately 55-60 mmHg, they send their impulses via CN IX to the medulla, increasing ventilatory drive (increased respiratory rate, tidal volume, and minute ventilation). Thus, patients who rely on hypoxic respiratory drive will typically have a resting PaO2 around 60 mm Hg.

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  • Question 71 - What does Caplan's syndrome refer to? ...

    Incorrect

    • What does Caplan's syndrome refer to?

      Your Answer:

      Correct Answer: Rheumatoid lung nodules and pneumoconiosis

      Explanation:

      Caplan’s syndrome is defined as the association between silicosis and rheumatoid arthritis (RA). It is rare and usually diagnosed in an advanced stage of RA. It generally affects patients with a prolonged exposure to silica.

      Caplan’s syndrome presents with rheumatoid lung nodules and pneumoconiosis. Originally described in coal miners with progressive massive fibrosis, it may also occur in asbestosis, silicosis and other pneumoconiosis. Chest radiology shows multiple, round, well defined nodules, usually 0.5 – 2.0 cm in diameter, which may cavitate and resemble tuberculosis.

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  • Question 72 - A 23 year old female is admitted with acute severe asthma. Treatment is...

    Incorrect

    • A 23 year old female is admitted with acute severe asthma. Treatment is initiated with 100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV hydrocortisone. There is no improvement despite initial treatment. What is the next step in management?

      Your Answer:

      Correct Answer: IV magnesium sulphate

      Explanation:

      A single dose of intravenous magnesium sulphate is safe and may improve lung function and reduce intubation rates in patients with acute severe asthma. Intravenous magnesium sulphate may also reduce hospital admissions in adults with acute asthma who have had little or no response to standard treatment.

      Consider giving a single dose of intravenous magnesium sulphate to patients with acute severe asthma (PEF <50% best or predicted) who have not had a good initial response to inhaled bronchodilator therapy. Magnesium sulphate (1.2–2 g IV infusion over 20 minutes) should only be used following consultation with senior medical staff.

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  • Question 73 - A 70 year old thyroid cancer patient is admitted due to dyspnoea. Which...

    Incorrect

    • A 70 year old thyroid cancer patient is admitted due to dyspnoea. Which investigation should be done to assess for possible compression of the upper airways?

      Your Answer:

      Correct Answer: Flow volume loop

      Explanation:

      Flow-volume loop is an easy, non-invasive diagnostic tool that can be used even in severely-ill patients. It can provide information about the location of the obstruction and can differentiate between obstructive pulmonary disease and upper-airway obstruction. Therefore, it is recommended to obtain a flow-volume loop during the assessment of patients with upper airway obstruction.

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  • Question 74 - A 23 year old male medical student presents to the A&E department with...

    Incorrect

    • A 23 year old male medical student presents to the A&E department with pleuritic chest pain. He does not have productive cough nor is he experiencing shortness of breath. He has no past medical history. A chest x-ray which was done shows a right-sided pneumothorax with a 1 cm rim of air and no mediastinal shift. What is the most appropriate treatment option?

      Your Answer:

      Correct Answer: Discharge with outpatient chest x-ray

      Explanation:

      Primary spontaneous pneumothorax is an abnormal accumulation of air in the space between the lungs and the chest cavity (called the pleural space) that can result in the partial or complete collapse of a lung. This type of pneumothorax is described as primary because it occurs in the absence of lung disease such as emphysema. Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture. Primary spontaneous pneumothorax is likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. Air in the pleural space creates pressure on the lung and can lead to its collapse. A person with this condition may feel chest pain on the side of the collapsed lung and shortness of breath. Patients are typically aged 18-40 years, tall, thin, and, often, are smokers.

      In small pneumothoraxes with minimal symptoms, no active treatment is required. These patients can be safely discharged with early outpatient review and should be given written advice to return if breathlessness worsens. Patients who have been discharged without intervention should be advised that air travel should be avoided until a radiograph has confirmed resolution of the pneumothorax.

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  • Question 75 - How should DVT during pregnancy be managed? ...

    Incorrect

    • How should DVT during pregnancy be managed?

      Your Answer:

      Correct Answer: Dalteparin

      Explanation:

      Subcutaneous low molecular weight heparin (LMWH) is the preferred treatment for most patients with acute DVT, including in pregnancy. A large meta-analyses comparing LMWH to unfractionated heparin (UFH) showed that LMWH decreased the risk of mortality, recurrent veno-thrombo embolism (VTE), and haemorrhage compared with heparin. Other advantages of LMWH may include more predictable therapeutic response, ease of administration and monitoring, and less heparin-induced thrombocytopenia. Disadvantages of LMWH include cost and longer half-life compared with heparin.

      Warfarin, which is administered orally, is used if long-term anticoagulation is needed. The international normalized ratio (INR) is followed, with a target range of 2-3. Warfarin crosses the placenta and is teratogenic, causing a constellation of anomalies known as warfarin embryopathy, with greatest risk between the sixth and twelfth week of gestation.
      Other options are not indicated for use.

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  • Question 76 - A number of tests have been ordered for a 49 year old male...

    Incorrect

    • A number of tests have been ordered for a 49 year old male who has systemic lupus erythematosus (SLE). He was referred to the clinic because he has increased shortness of breath. One test in particular is transfer factor of the lung for carbon monoxide (TLCO), which is elevated. Which respiratory complication of SLE is associated with this finding?

      Your Answer:

      Correct Answer: Alveolar haemorrhage

      Explanation:

      Alveolar haemorrhage (AH) is a rare, but serious manifestation of SLE. It may occur early or late in disease evolution. Extrapulmonary disease may be minimal and may be masked in patients who are already receiving immunosuppressants for other symptoms of SLE.

      DLCO or TLCO (diffusing capacity or transfer factor of the lung for carbon monoxide (CO)) is the extent to which oxygen passes from the air sacs of the lungs into the blood.
      Factors that can increase the DLCO include polycythaemia, asthma (can also have normal DLCO) and increased pulmonary blood volume as occurs in exercise. Other factors are left to right intracardiac shunting, mild left heart failure (increased blood volume) and alveolar haemorrhage (increased blood available for which CO does not have to cross a barrier to enter).

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  • Question 77 - Which of the following statements regarding the clinical effects of long-term oxygen therapy...

    Incorrect

    • Which of the following statements regarding the clinical effects of long-term oxygen therapy (LTOT) is the most accurate?

      Your Answer:

      Correct Answer: Reduced sympathetic outflow

      Explanation:

      Studies have shown that benefits of Long-tern oxygen therapy (LTOT) include improved exercise tolerance, with improved walking distance, and ability to perform daily activities, reduction of secondary polycythaemia, improved sleep quality and reduced sympathetic outflow, with increased sodium and water excretion, leading to improvement in renal function.

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  • Question 78 - Which virus is severe acute respiratory syndrome (SARS) caused by? ...

    Incorrect

    • Which virus is severe acute respiratory syndrome (SARS) caused by?

      Your Answer:

      Correct Answer: A coronavirus

      Explanation:

      Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by a coronavirus called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003.
      In general, SARS begins with a high fever (temperature greater than 38.0°C). Other symptoms may include headache, an overall feeling of discomfort, and body aches. Some people also have mild respiratory symptoms at the outset. About 10 to 20 percent of patients have diarrhoea. After 2 to 7 days, SARS patients may develop a dry cough. Most patients develop pneumonia. 

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  • Question 79 - From the options provided below, which intervention plays the greatest role in increasing...

    Incorrect

    • From the options provided below, which intervention plays the greatest role in increasing survival in patients with COPD?

      Your Answer:

      Correct Answer: Smoking cessation

      Explanation:

      Smoking cessation is the most effective intervention in stopping the progression of COPD, as well as increasing survival and reducing morbidity. This is why smoking cessation should be the top priority in the treatment of COPD. Long term oxygen therapy (LTOT) may increase survival in hypoxic patients. The rest of the options dilate airways, reduce inflammation and thereby improve symptoms but do not necessarily increase survival.

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  • Question 80 - Which type of lung cancer is most commonly linked to cavitating lesions? ...

    Incorrect

    • Which type of lung cancer is most commonly linked to cavitating lesions?

      Your Answer:

      Correct Answer: Squamous cell

      Explanation:

      Squamous-cell carcinoma is the most common histological type of lung cancer to cavitate (82% of cavitary primary lung cancer), followed by adenocarcinoma and large cell carcinoma. Multiple cavitary lesions in primary lung cancer are rare, however, multifocal bronchoalveolar cell carcinoma can occasionally have multiple cavitary lesions. Small cell carcinoma is not known to cavitate.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (35/49) 71%
Passmed