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Question 1
Correct
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A 67-year-old man attending the respiratory clinic receives a suspected diagnosis of chronic obstructive pulmonary disease.
Which of the following is the most appropriate investigation to confirm diagnosis?Your Answer: Spirometry
Explanation:Investigations for COPD: Spirometry is Key
COPD is a chronic obstructive airway disease that is diagnosed through a combination of clinical history, signs, and investigations. While several investigations may be used to support a diagnosis of COPD, spirometry is the most useful and important tool. A spirometer is used to measure functional lung volumes, including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC). The FEV1:FVC ratio provides an estimate of the severity of airflow obstruction, with a normal ratio being 75-80%. In patients with COPD, the ratio is typically <0.7 and FEV1 <80% predicted. Spirometry is essential for establishing a baseline for disease severity, monitoring disease progression, and assessing the effects of treatment. Other investigations, such as echocardiography, chest radiography, ECG, and peak flow, may be used to exclude other pathologies or assess comorbidities, but spirometry remains the key investigation for diagnosing and managing COPD.
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This question is part of the following fields:
- Respiratory Medicine
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Question 2
Incorrect
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A 65-year-old male presents to his GP with a 6-month history of progressive shortness of breath. He is now needing to stop a few times on the way to the grocery store to catch his breath, which is not normal for him. He smokes 20 cigarettes a day and has done so for the past 45 years, and drinks no alcohol. His only medication is atorvastatin.
On examination, there is a bilateral wheeze and coarse crackles at the lung bases. A chest x-ray is ordered by the GP which shows flattening of the diaphragm bilaterally, but is otherwise normal. Spirometry is carried out, with the following results:
Result Reference Range
FEV1 (of predicted) 72% >80%
FEV1:FVC 0.62 >0.7
What is the most appropriate management for this likely diagnosis?Your Answer: Beclomethasone
Correct Answer: Ipratropium
Explanation:The patient’s history, examination, and obstructive spirometry results suggest that he has COPD, likely due to his smoking history. Malignancy has been ruled out by the chest x-ray. As per NICE guidelines, the first-line pharmacological treatment for COPD is either a SABA or SAMA to alleviate breathlessness and improve exercise tolerance. Ipratropium, a SAMA, is the most suitable option for this patient. Beclomethasone, an inhaled corticosteroid, is used as a second-line treatment with a LABA for those with asthmatic features or steroid responsiveness. Montelukast, a LTRA, is used as a third-line treatment in asthmatic patients, while Salmeterol, a LABA, is used as a second-line treatment in COPD patients.
NICE guidelines recommend smoking cessation advice, annual influenza and one-off pneumococcal vaccinations, and pulmonary rehabilitation for COPD patients. Bronchodilator therapy is first-line treatment, with the addition of LABA and LAMA for patients without asthmatic features and LABA, ICS, and LAMA for those with asthmatic features. Theophylline is recommended after trials of bronchodilators or for patients who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients. Mucolytics should be considered for patients with a chronic productive cough. Loop diuretics and long-term oxygen therapy may be used for cor pulmonale. Smoking cessation and long-term oxygen therapy may improve survival in stable COPD patients. Lung volume reduction surgery may be considered in selected patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 3
Incorrect
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A 48-year-old male presents to the hospital with a productive cough and a temperature of 38.2 C. He has been feeling ill for the past 10 days with flu-like symptoms. Upon examination, his blood pressure is 96/60 mmHg and his heart rate is 102/min. A chest x-ray reveals bilateral lower zone consolidation. What is the probable pathogen responsible for this condition?
Your Answer: Mycoplasma pneumoniae
Correct Answer: Staphylococcus aureus
Explanation:Prior infection with influenza increases the likelihood of developing pneumonia caused by Staphylococcus aureus.
Causes of Pneumonia
Pneumonia is a respiratory infection that can be caused by various infectious agents. Community acquired pneumonia (CAP) is the most common type of pneumonia and is caused by different microorganisms. The most common cause of CAP is Streptococcus pneumoniae, which accounts for around 80% of cases. Other infectious agents that can cause CAP include Haemophilus influenzae, Staphylococcus aureus, atypical pneumonias caused by Mycoplasma pneumoniae, and viruses.
Klebsiella pneumoniae is another microorganism that can cause pneumonia, but it is typically found in alcoholics. Streptococcus pneumoniae, also known as pneumococcus, is the most common cause of community-acquired pneumonia. It is characterized by a rapid onset, high fever, pleuritic chest pain, and herpes labialis (cold sores).
In summary, pneumonia can be caused by various infectious agents, with Streptococcus pneumoniae being the most common cause of community-acquired pneumonia. It is important to identify the causative agent to provide appropriate treatment and prevent complications.
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This question is part of the following fields:
- Respiratory Medicine
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Question 4
Correct
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A 35-year-old man presents to his General Practitioner with difficulty breathing during physical activity and feeling excessively tired. Upon further inquiry, he reports experiencing frequent respiratory infections. The doctor suspects a diagnosis of alpha-1-antitrypsin deficiency (AATD).
What test should be arranged to confirm this diagnosis?Your Answer: Blood test for alpha-1-antitrypsin levels
Explanation:Diagnostic Tests for Alpha-1-Antitrypsin Deficiency
Alpha-1-antitrypsin deficiency (AATD) is a genetic disorder that can lead to chronic obstructive pulmonary disease (COPD) at a young age, especially in non-smokers with a family history of the condition. Here are some diagnostic tests that can help identify AATD:
Blood Test: A simple blood test can measure the levels of alpha-1-antitrypsin in the blood. Low levels of this protein can indicate AATD, especially in patients with symptoms of COPD or a family history of the condition.
CT Chest: A computed tomography (CT) scan of the chest can reveal the extent and pattern of emphysema in the lungs, which is a common complication of AATD. However, a CT scan alone cannot diagnose AATD.
Chest X-Ray: A chest X-ray (CXR) can also show signs of emphysema or bronchiectasis in patients with AATD, but it is not a definitive test for the condition.
Genetic Testing: Once AATD has been diagnosed, genetic testing can identify the specific variant of the condition that a patient has. However, genetic testing is not useful as an initial diagnostic test without first confirming low levels of alpha-1-antitrypsin in the blood.
Pulmonary Function Testing: This test measures lung function and can help assess the severity of lung disease in patients with AATD. However, it is not a diagnostic test for the condition.
In conclusion, a combination of these diagnostic tests can help identify AATD in patients with symptoms of COPD, a family history of the condition, or low levels of alpha-1-antitrypsin in the blood.
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This question is part of the following fields:
- Respiratory Medicine
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Question 5
Correct
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A 63-year-old man visits his doctor with a persistent cough that has lasted for 5 weeks. He reports coughing up smelly, green phlegm and experiencing night sweats, left-sided chest pain, and occasional fevers. He denies any weight loss. During the examination, the lower left lung is dull to percussion with low-pitched bronchial breath sounds, and he has a temperature of 38.2°C. The patient has not traveled recently or had any contact with sick individuals. The doctor notes that he was treated for pneumonia 7 weeks ago. What is the most probable cause of this patient's presentation?
Your Answer: Lung abscess
Explanation:The most likely diagnosis for this patient is lung abscess, as they are presenting with a subacute productive cough, foul-smelling sputum, and night sweats. The duration of a cough can be categorized as acute, subacute, or chronic, and this patient falls under the subacute category. The patient’s recent history of aspiration pneumonia and examination findings, such as dullness on percussion, bronchial breath sounds, and fever, support the diagnosis of lung abscess.
Lung cancer is not the most likely diagnosis for this patient, as they do not have weight loss and have other findings that point towards lung abscess. Pulmonary fibrosis is also unlikely, as it is rare to have unilateral pulmonary fibrosis, and the patient’s examination findings do not support this diagnosis. Recurrent pneumonia is a good differential, but the presence of bronchial breath sounds and night sweats make lung abscess a more likely diagnosis.
Understanding Lung Abscess
A lung abscess is a localized infection that occurs within the lung tissue. It is commonly caused by aspiration pneumonia, which can be triggered by poor dental hygiene, reduced consciousness, or previous stroke. Other potential causes include haematogenous spread, direct extension, and bronchial obstruction. The infection is typically polymicrobial, with Staphylococcus aureus, Klebsiella pneumonia, and Pseudomonas aeruginosa being the most common monomicrobial causes.
The symptoms of lung abscess are similar to pneumonia, but they tend to develop more slowly over several weeks. Patients may experience fever, productive cough, foul-smelling sputum, chest pain, and dyspnea. Some may also have systemic features such as night sweats and weight loss, while a minority may experience haemoptysis. Physical examination may reveal dull percussion and bronchial breathing, as well as clubbing in some cases.
To diagnose lung abscess, a chest x-ray is usually performed, which shows a fluid-filled space within an area of consolidation. Sputum and blood cultures should also be obtained to identify the causative organism. Treatment typically involves intravenous antibiotics, but if the infection does not resolve, percutaneous drainage or surgical resection may be required in rare cases.
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This question is part of the following fields:
- Respiratory Medicine
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Question 6
Correct
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A 78-year-old patient with chronic obstructive pulmonary disease (COPD) presents with shortness of breath that has been worsening over the past two days. The patient is experiencing wheezing and is unable to speak in full sentences. Upon examination, the patient has widespread wheezing and crackles. Vital signs are as follows: respiratory rate 30/min, oxygen saturation 92% on FiO2 0.24, heart rate 100/min, blood pressure 115/66 mmHg. A chest x-ray reveals no pneumothorax. The patient is administered nebulized salbutamol and ipratropium bromide driven by air, as well as oral steroids. Intravenous amoxicillin and oral clarithromycin are also given. However, the patient fails to improve after an hour of treatment and is extremely fatigued. An arterial blood gas is performed with the patient on 24% O2, which shows:
pH 7.30
PCO2 8 kPa
PO2 8.4 kPa
Bicarbonate 29 mEq/l
What is the next course of action?Your Answer: BIPAP
Explanation:Patient has exacerbation of COPD with maximal treatment for an hour. Remains acidotic with high PCO2 and respiratory acidosis. BTS guidelines suggest starting NIV.
Guidelines for Non-Invasive Ventilation in Acute Respiratory Failure
The British Thoracic Society (BTS) and the Royal College of Physicians have published guidelines for the use of non-invasive ventilation (NIV) in acute respiratory failure. NIV can be used in patients with COPD and respiratory acidosis with a pH of 7.25-7.35. However, patients with a pH lower than 7.25 require greater monitoring and a lower threshold for intubation and ventilation. NIV is also recommended for type II respiratory failure due to chest wall deformity, neuromuscular disease, or obstructive sleep apnea, as well as for cardiogenic pulmonary edema unresponsive to continuous positive airway pressure (CPAP) and weaning from tracheal intubation.
For patients with COPD, the recommended initial settings for bi-level pressure support include an expiratory positive airway pressure (EPAP) of 4-5 cm H2O, an inspiratory positive airway pressure (IPAP) of 10-15 cm H2O, a back-up rate of 15 breaths/min, and a back-up inspiration-to-expiration ratio of 1:3. These guidelines aim to improve patient outcomes and reduce the need for invasive mechanical ventilation.
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This question is part of the following fields:
- Respiratory Medicine
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Question 7
Correct
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A 47-year-old heavy smoker presents with a persistent cough and occasional wheezing. The chest radiograph reveals hyperinflation but clear lung fields.
What is the next step to assist in making a diagnosis?Your Answer: Spirometry
Explanation:Spirometry: The Best Diagnostic Tool for COPD
Chronic obstructive pulmonary disease (COPD) is a common respiratory condition that can significantly impact a patient’s quality of life. To diagnose COPD, spirometry is the best diagnostic tool. According to NICE guidelines, a diagnosis of COPD should be made based on symptoms and signs, but supported by spirometry results. Post-bronchodilator spirometry should be performed to confirm the diagnosis. Airflow obstruction is confirmed by a forced expiratory volume in 1 s (FEV1):forced vital capacity (FVC) ratio of <0.7 and FEV1 <80% predicted. Other diagnostic tools, such as CT of the chest, serial peak flow readings, and trials of beclomethasone or salbutamol, may have a role in the management of COPD, but they are not used in the diagnosis of the condition. CT of the chest may be used to investigate symptoms that seem disproportionate to the spirometric impairment, to investigate abnormalities seen on a chest radiograph, or to assess suitability for surgery. Serial peak flow readings may be appropriate if there is some doubt about the diagnosis, in order to exclude asthma. Inhaled corticosteroids and short-acting beta agonists may be used in the management of COPD for breathlessness/exercise limitation, but they are not used in the diagnosis of COPD. In summary, spirometry is the best diagnostic tool for COPD, and other diagnostic tools may have a role in the management of the condition.
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This question is part of the following fields:
- Respiratory Medicine
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Question 8
Correct
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Patients with severe pneumonia may face various risk factors that increase their chances of death. Which of the following factors does not contribute to this risk?
Your Answer: Age 49 years
Explanation:Understanding the CURB-65 Score for Mortality Prediction in Pneumonia
Pneumonia is a serious respiratory infection that can lead to mortality, especially in older patients. Several factors can increase the risk of death, including elevated urea levels, low blood pressure, leukopenia, and atrial fibrillation. To predict mortality in pneumonia, healthcare professionals use the CURB-65 score, which considers five parameters: confusion, urea >7 mmol/l, respiratory rate >30/min, systolic blood pressure <90 mmHg or diastolic blood pressure <60 mmHg, and age >65 years. Each parameter scores a point, and the higher the total score, the higher the associated mortality.
Based on the CURB-65 score, healthcare professionals can make informed decisions about treatment and admission to hospital. Patients with a score of 0 or 1 can be treated at home with oral antibiotics, while those with a score of 2 should be considered for hospital admission. Patients with a score of 3 or higher should be admitted to hospital, and those with a score of 4-5 may require high dependency or intensive therapy unit admission. However, individual circumstances, such as the patient’s performance status, co-morbidities, and social situation, should also be considered when making treatment decisions.
In summary, the CURB-65 score is a valuable tool for predicting mortality in pneumonia and guiding treatment decisions. By considering multiple factors, healthcare professionals can provide the best possible care for patients with this serious infection.
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This question is part of the following fields:
- Respiratory Medicine
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Question 9
Correct
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A breathless 65-year-old smoker presents with the following lung function tests:
FEV1 (forced expiratory volume in 1 second) 1.5 l (60%)
FVC (forced vital capacity) 1.8 l (55%)
FEV1:FVC ratio = 84%
TLC (total lung capacity) = 66% predicted
RV (residual volume) = 57% predicted
TLCO (carbon monoxide transfer factor) = 55% predicted
KCO (carbon monoxide transfer coefficient) = 60% predicted
Which of the following is the most likely diagnosis in this case?
Select the SINGLE most likely diagnosis.Your Answer: Idiopathic pulmonary fibrosis
Explanation:Understanding Idiopathic Pulmonary Fibrosis: Differential Diagnosis with Other Respiratory Conditions
Idiopathic pulmonary fibrosis (IPF), also known as fibrosing alveolitis, is a chronic and progressive lung disease that affects people between the ages of 50 and 70 years. The disease is characterized by a significant restrictive defect in lung function tests, reduced KCO, and breathlessness. While there is no definitive treatment for IPF, up to 20% of patients can survive more than 5 years from diagnosis.
When considering a differential diagnosis, it is important to rule out other respiratory conditions that may present with similar symptoms. Anaemia, for example, may cause breathlessness but would not produce a defect in lung function tests. Emphysema, on the other hand, would produce an obstructive pattern with a FEV1:FVC ratio of less than 70%. Obesity may also fit the picture of a restrictive defect, but it would not affect the KCO. In the case of asthma, an obstructive pattern with a FEV1:FVC ratio of less than 70% would be expected.
In summary, understanding the differential diagnosis of IPF is crucial in providing appropriate treatment and management for patients with respiratory conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 10
Correct
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A 56-year-old woman with COPD has been recommended an inhaled corticosteroid. What is the primary advantage of using inhaled corticosteroids for treating COPD patients?
Your Answer: Reduced frequency of exacerbations
Explanation:Inhaled corticosteroids are used to decrease the frequency of exacerbations in patients with COPD.
NICE guidelines recommend smoking cessation advice, annual influenza and one-off pneumococcal vaccinations, and pulmonary rehabilitation for COPD patients. Bronchodilator therapy is first-line treatment, with the addition of LABA and LAMA for patients without asthmatic features and LABA, ICS, and LAMA for those with asthmatic features. Theophylline is recommended after trials of bronchodilators or for patients who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients. Mucolytics should be considered for patients with a chronic productive cough. Loop diuretics and long-term oxygen therapy may be used for cor pulmonale. Smoking cessation and long-term oxygen therapy may improve survival in stable COPD patients. Lung volume reduction surgery may be considered in selected patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 11
Correct
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A 68-year-old woman comes to the emergency department complaining of fatigue and difficulty breathing for the past 2 days. She has a medical history of hypertension, a heart attack 3 years ago, heart failure, and a recent chest infection that was successfully treated with antibiotics. During the examination, the patient has bibasal crepitations and an elevated JVP. Her temperature is 37ºC, oxygen saturation is 95% on air, heart rate is 95 beats per minute, respiratory rate is 26 breaths per minute, and blood pressure is 129/86 mmHg.
What is the most appropriate course of treatment?Your Answer: IV furosemide
Explanation:The recommended treatment for acute pulmonary oedema in this patient is IV loop diuretic, specifically furosemide. This is because the patient is experiencing acute decompensated heart failure, which causes pulmonary oedema. IV loop diuretic has a prompt diuretic effect, reducing ventricular filling pressures and improving symptoms within 30 minutes.
IV dobutamine is not necessary for this patient as they are not in shock and dobutamine is typically reserved for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock.
IV morphine is not recommended for acute heart failure as it may increase morbidity in patients with acute pulmonary oedema.
Oral furosemide is not the preferred route of administration for this patient as IV furosemide has a faster onset of diuresis.
Heart failure requires acute management, with recommended treatments for all patients including IV loop diuretics such as furosemide or bumetanide. Oxygen may also be necessary, with guidelines suggesting oxygen saturations be kept at 94-98%. Vasodilators such as nitrates should not be routinely given to all patients, but may have a role in cases of concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease. However, hypotension is a major side-effect/contraindication. Patients with respiratory failure may require CPAP, while those with hypotension or cardiogenic shock may require inotropic agents like dobutamine or vasopressor agents like norepinephrine. Mechanical circulatory assistance such as intra-aortic balloon counterpulsation or ventricular assist devices may also be necessary. Regular medication for heart failure should be continued, with beta-blockers only stopped in certain circumstances. Opiates should not be routinely offered to patients with acute heart failure due to potential increased morbidity.
In summary, acute management of heart failure involves a range of treatments depending on the patient’s specific condition. It is important to carefully consider the potential side-effects and contraindications of each treatment, and to continue regular medication for heart failure where appropriate. Opiates should be used with caution, and only in cases where they are likely to reduce dyspnoea/distress without causing harm. With appropriate management, patients with acute heart failure can receive the care they need to improve their outcomes and quality of life.
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This question is part of the following fields:
- Respiratory Medicine
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Question 12
Correct
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Samantha is a 55-year-old woman who has been experiencing difficulty breathing. She undergoes a spirometry evaluation with the following findings: a decrease in forced vital capacity (FVC), an increase in the forced expiratory volume in one second to forced vital capacity ratio (FEV1:FVC ratio), and a decrease in the transfer factor for carbon monoxide (TLCO), indicating impaired gas exchange. What is the most probable diagnosis?
Your Answer: Pulmonary fibrosis
Explanation:Understanding Idiopathic Pulmonary Fibrosis
Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.
The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.
Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.
The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.
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This question is part of the following fields:
- Respiratory Medicine
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Question 13
Correct
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A 35-year-old male intravenous drug user (IVDU) presents with a productive cough and fever of 2–3 days’ duration. He had a cold last week. Other than a leukocytosis and high C-reactive protein (CRP), his blood results are normal. A chest radiograph shows bilateral cavitating pneumonia.
Which of the following is the most probable cause of his pneumonia?Your Answer: Staphylococcal pneumonia
Explanation:Differentiating Types of Pneumonia: Causes and Characteristics
Pneumonia is a common respiratory infection that can be caused by various pathogens, including bacteria, viruses, and fungi. Among the bacterial causes, staphylococcal and pneumococcal pneumonia are two of the most prevalent types. However, they have distinct characteristics that can help clinicians differentiate them. In addition, other types of pneumonia, such as Pneumocystis jiroveci, Klebsiella, and fungal pneumonia, have specific risk factors and radiographic patterns that can aid in their diagnosis.
Staphylococcal pneumonia is often associated with a recent viral infection, intravenous drug use, or the presence of central lines. It typically presents as cavitating bronchopneumonia, which can be bilateral and complicated by pneumothorax, effusion, or empyema. Flucloxacillin is the drug of choice for treatment, although vancomycin can be used in penicillin-allergic patients.
Pneumococcal pneumonia, on the other hand, is more commonly acquired in the community and does not usually cause cavitating lesions. It can be suspected in patients with fever, cough, and chest pain, and is often treated with antibiotics such as penicillin or macrolides.
Pneumocystis jiroveci pneumonia is a type of fungal pneumonia that affects immunocompromised individuals, particularly those with HIV. It typically presents with an interstitial pattern on chest radiographs, rather than cavitating lesions.
Klebsiella pneumonia is another bacterial cause of cavitating pneumonia, often affecting elderly individuals or those with alcohol use disorders.
Fungal pneumonia, which can be caused by various fungi such as Aspergillus or Cryptococcus, tends to affect immunocompromised patients, but can also occur in healthy individuals exposed to contaminated environments. Its radiographic pattern can vary depending on the type of fungus involved.
In summary, understanding the different causes and characteristics of pneumonia can help clinicians make an accurate diagnosis and choose the appropriate treatment.
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This question is part of the following fields:
- Respiratory Medicine
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Question 14
Correct
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A 55-year-old man presents with a chronic cough and is diagnosed with lung cancer. He asks if his occupation could be a contributing factor. What is the most probable occupational risk factor for developing lung cancer?
Your Answer: Passive smoking
Explanation:Risk Factors for Lung Cancer
Lung cancer is a deadly disease that can be caused by various factors. The most significant risk factor for lung cancer is smoking, which increases the risk by a factor of 10. However, other factors such as exposure to asbestos, arsenic, radon, nickel, chromate, and aromatic hydrocarbon can also increase the risk of developing lung cancer. Additionally, cryptogenic fibrosing alveolitis has been linked to an increased risk of lung cancer.
It is important to note that not all factors are related to lung cancer. For example, coal dust exposure has not been found to increase the risk of lung cancer. However, smoking and asbestos exposure are synergistic, meaning that a smoker who is also exposed to asbestos has a 50 times increased risk of developing lung cancer (10 x 5). Understanding these risk factors can help individuals make informed decisions about their health and take steps to reduce their risk of developing lung cancer.
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This question is part of the following fields:
- Respiratory Medicine
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Question 15
Correct
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A 55-year-old woman presents to the hypertension clinic for review. She has a past medical history of depression and gout. The patient was initiated on lisinopril for hypertension two months ago, with gradual titration of the dose and monitoring of her urea and electrolytes. During today's visit, she reports a dry cough that has been progressively worsening over the past four weeks. The cough is described as really annoying and is causing sleep disturbance. The patient is a non-smoker, and a chest x-ray performed six weeks ago during an Emergency Department visit was normal. What is the most appropriate course of action regarding her antihypertensive medications?
Your Answer: Switch her to an angiotensin II receptor blocker
Explanation:A dry cough is a common side effect experienced by patients who begin taking an ACE inhibitor. However, in this case, the patient has been suffering from this symptom for four weeks and it is affecting her sleep. Therefore, it is advisable to switch her to an angiotensin II receptor blocker.
Angiotensin II receptor blockers are a type of medication that is commonly used when patients cannot tolerate ACE inhibitors due to the development of a cough. Examples of these blockers include candesartan, losartan, and irbesartan. However, caution should be exercised when using them in patients with renovascular disease. Side-effects may include hypotension and hyperkalaemia.
The mechanism of action for angiotensin II receptor blockers is to block the effects of angiotensin II at the AT1 receptor. These blockers have been shown to reduce the progression of renal disease in patients with diabetic nephropathy. Additionally, there is evidence to suggest that losartan can reduce the mortality rates associated with CVA and IHD in hypertensive patients.
Overall, angiotensin II receptor blockers are a viable alternative to ACE inhibitors for patients who cannot tolerate the latter. They have a proven track record of reducing the progression of renal disease and improving mortality rates in hypertensive patients. However, as with any medication, caution should be exercised when using them in patients with certain medical conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 16
Correct
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A 32-year-old woman comes to the clinic complaining of sudden breathlessness and pain on the left side of her chest for the past 24 hours. She is generally healthy and takes the combined oral contraceptive pill.
What is the highest scoring factor in the Wells' scoring system for suspected pulmonary embolism (PE)?Your Answer: Clinical signs and symptoms of a deep-vein thrombosis (DVT)
Explanation:Understanding the Two-Level PE Wells Score: Clinical Signs and Symptoms of DVT
The Two-Level PE Wells Score is a tool used to assess the likelihood of a patient having a pulmonary embolism (PE). One of the key factors in this score is the presence of clinical signs and symptoms of a deep-vein thrombosis (DVT), which includes leg swelling and pain on palpation of the deep veins. This carries three points in the score, and is a crucial factor in determining the likelihood of a PE.
Other factors in the score include an alternative diagnosis being less likely than a PE, heart rate over 100 beats/min, immobilization or recent surgery, previous DVT/PE, haemoptysis, and malignancy. Each of these factors carries a certain number of points, and a score of over 4 points indicates a high likelihood of a PE, while a score of 4 points or less indicates a lower likelihood.
Overall, understanding the Two-Level PE Wells Score and the clinical signs and symptoms of DVT is important in accurately assessing the likelihood of a patient having a PE and determining the appropriate course of treatment.
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This question is part of the following fields:
- Respiratory Medicine
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Question 17
Incorrect
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A 47-year-old man with kidney disease develops pulmonary tuberculosis. His recent blood tests show an eGFR of 50 ml/min and a creatinine clearance of 30 ml/min. Which ONE drug should be administered in a reduced dose?
Your Answer: Isoniazid
Correct Answer: Ethambutol
Explanation:The treatment of tuberculosis is a complex process that requires the expertise of a specialist in the field, such as a respiratory physician or an infectivologist. The first-line drugs used for active tuberculosis without CNS involvement are isoniazid, rifampicin, pyrazinamide, and ethambutol. These drugs are given together for the first 2 months of therapy, followed by continued treatment with just isoniazid and rifampicin for an additional 4 months. Pyridoxine is added to the treatment regimen to reduce the risk of isoniazid-induced peripheral neuropathy. If there is CNS involvement, the four drugs (and pyridoxine) are given together for 2 months, followed by continued treatment with isoniazid (with pyridoxine) and rifampicin for an additional 10 months. It is important to monitor liver function tests before and during treatment, and to educate patients on the potential side effects of the drugs and when to seek medical attention. Treatment-resistant tuberculosis cases are becoming more common and require special management and public health considerations.
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This question is part of the following fields:
- Respiratory Medicine
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Question 18
Correct
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A 75-year-old female with a history of acromegaly presents to the respiratory clinic with her husband for a routine follow-up. She has recently been diagnosed with obstructive sleep apnoea and has made several lifestyle changes such as losing weight and exercising regularly. However, she still complains of feeling tired after work and experiencing restless sleep with loud snoring that disturbs her husband. What further steps should be taken in managing her obstructive sleep apnoea?
Your Answer: Continuous positive airway pressure (CPAP)
Explanation:After losing weight, the recommended initial treatment for moderate/severe obstructive sleep apnoea is CPAP.
CPAP is the most widely used treatment for obstructive sleep apnoea (OSA) and is effective for both moderate and severe cases. However, lifestyle changes such as weight loss, quitting smoking, and avoiding alcohol should be attempted first. Although oral appliances can be used, they are not as effective as CPAP. Surgical treatments for OSA are not the first choice and have limited evidence.
Understanding Obstructive Sleep Apnoea/Hypopnoea Syndrome
Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a condition where the upper airway becomes partially or completely blocked during sleep, leading to interrupted breathing and reduced oxygen levels in the body. There are several predisposing factors for OSAHS, including obesity, macroglossia, large tonsils, and Marfan’s syndrome. The condition is often characterized by excessive snoring and periods of apnoea, which can be reported by the patient’s partner.
OSAHS can have several consequences, including daytime somnolence, compensated respiratory acidosis, and hypertension. To assess sleepiness, healthcare professionals may use tools such as the Epworth Sleepiness Scale or the Multiple Sleep Latency Test. Diagnostic tests for OSAHS include sleep studies, ranging from monitoring pulse oximetry to full polysomnography.
Management of OSAHS typically involves weight loss and continuous positive airway pressure (CPAP) as the first line of treatment for moderate or severe cases. Intra-oral devices may be used if CPAP is not tolerated or for patients with mild OSAHS. It is important to inform the DVLA if OSAHS is causing excessive daytime sleepiness. While there is limited evidence to support the use of pharmacological agents, healthcare professionals may consider them in certain cases.
Overall, understanding OSAHS and its management is crucial for improving the quality of life for patients with this condition.
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This question is part of the following fields:
- Respiratory Medicine
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Question 19
Correct
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A 50-year-old woman with a history of severe disabling arthritis presents to the Emergency Department with a 3-week history of dyspnoea. She reports a dry cough of similar duration. She has never smoked and has never been employed. On cardiovascular examination, no abnormalities are detected. Respiratory examination reveals reduced air entry at the left base, which is stony dull to percussion. A chest X-ray shows blunting of the left costophrenic angle.
What is the most likely diagnosis associated with her current respiratory problem?Your Answer: Rheumatoid arthritis (RA)
Explanation:Respiratory Manifestations of Rheumatoid Arthritis
Rheumatoid arthritis (RA) is an inflammatory arthritis that can affect various parts of the body, including the respiratory tract. One common manifestation of RA in the respiratory system is pleural involvement, which can present as pleural effusion, pleural nodules, or pleurisy. Other respiratory complications associated with RA include pulmonary fibrosis and bronchiolitis obliterans.
It is important to note that other types of arthritis, such as ankylosing spondylitis, Behçet’s disease, gout, and psoriatic arthritis, do not typically present with respiratory complications like pleural effusion. Ankylosing spondylitis is associated with apical fibrosis, while Behçet’s disease is known for neurological complications. Gout is caused by purine metabolism abnormality and affects the joints and renal tract, while psoriatic arthritis is strongly associated with psoriasis and can lead to ocular and cardiovascular complications.
Overall, if a patient with RA presents with respiratory symptoms, it is important to consider the possibility of pleural involvement and other respiratory complications associated with the disease.
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This question is part of the following fields:
- Respiratory Medicine
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Question 20
Incorrect
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A 40-year-old man with a history of alpha-1-antitrypsin deficiency visits his GP complaining of increased difficulty in breathing. The GP suspects that his lungs may be deteriorating and orders spirometry to aid in the diagnosis.
What spirometry results would be anticipated for a patient with this condition?Your Answer: FEV1= 60% FEV1/FVC = 0.9
Correct Answer: FEV1 = 60% FEV1/FVC = 0.65
Explanation:What spirometry result is expected in alpha-1 antitrypsin deficiency?
Alpha-1 antitrypsin deficiency will result in an obstructive pattern on spirometry, similar to chronic obstructive pulmonary disease (COPD). The two important factors to consider in spirometry are the FEV1 and the FEV1/FVC ratio. In obstructive disease, the FEV1 is reduced due to narrowed airways, while the FVC remains normal. This results in a reduced FEV1/FVC ratio. Therefore, in alpha-1 antitrypsin deficiency, we would expect to see a reduced FEV1 and FEV1/FVC ratio on spirometry.
Understanding Alpha-1 Antitrypsin Deficiency
Alpha-1 antitrypsin deficiency is a genetic condition that occurs when the liver fails to produce enough of a protein called alpha-1 antitrypsin (A1AT). A1AT is responsible for protecting cells from enzymes that can cause damage, such as neutrophil elastase. This deficiency is inherited in an autosomal recessive or co-dominant fashion, with alleles classified by their electrophoretic mobility as M for normal, S for slow, and Z for very slow. The normal genotype is PiMM, while heterozygous individuals have PiMZ. Homozygous PiSS individuals have 50% normal A1AT levels, while homozygous PiZZ individuals have only 10% normal A1AT levels.
The classic manifestation of A1AT deficiency is emphysema, which is a type of chronic obstructive pulmonary disease. This condition is most commonly seen in young, non-smoking patients. However, the evidence base is conflicting regarding the risk of emphysema. Non-smokers with A1AT deficiency are at a lower risk of developing emphysema, but they may pass on the A1AT gene to their children. Patients with A1AT deficiency who manifest disease usually have the PiZZ genotype.
In addition to emphysema, A1AT deficiency can also cause liver problems such as cirrhosis and hepatocellular carcinoma in adults, and cholestasis in children. Diagnosis is made by measuring A1AT concentrations and performing spirometry, which typically shows an obstructive pattern. Management includes avoiding smoking, supportive measures such as bronchodilators and physiotherapy, and intravenous A1AT protein concentrates. In severe cases, lung volume reduction surgery or lung transplantation may be necessary.
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This question is part of the following fields:
- Respiratory Medicine
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Question 21
Incorrect
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You assess a 28-year-old female patient in the ED who has been admitted due to an acute exacerbation of her asthma. What is the most indicative feature of a life-threatening attack in this case?
Your Answer: Cannot complete sentences
Correct Answer: Peak flow of 30% best or predicted
Explanation:Management of Acute Asthma
Acute asthma is classified by the British Thoracic Society (BTS) into three categories: moderate, severe, and life-threatening. Patients with any of the life-threatening features should be treated as having a life-threatening attack. A fourth category, Near-fatal asthma, is also recognized. Further assessment may include arterial blood gases for patients with oxygen saturation levels below 92%. A chest x-ray is not routinely recommended unless the patient has life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.
Admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid, and presentation at night. All patients with life-threatening asthma should be admitted to the hospital, and patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. Oxygen therapy should be started for hypoxaemic patients. Bronchodilation with short-acting beta₂-agonists (SABA) is recommended, and all patients should be given 40-50mg of prednisolone orally daily. Ipratropium bromide and IV magnesium sulphate may also be considered for severe or life-threatening asthma. Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Criteria for discharge include stability on discharge medication, checked and recorded inhaler technique, and PEF levels above 75% of best or predicted.
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This question is part of the following fields:
- Respiratory Medicine
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Question 22
Correct
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A 68-year-old man presents to clinic with increasing breathlessness, weight loss and peripheral oedema over the past 2 months. His family are concerned that he has also become a bit more confused over the past week.
His past history includes hypertension and a 35 pack-year smoking history. An echocardiogram from last year showed good biventricular contraction.
His blood tests show the following:
Haemoglobin (Hb) 150 g/L
Platelets 230 * 109/L (150 - 400)
White cell count (WCC) 4.6 * 109/L (4.0 - 11.0)
Na+ 124 mmol/L (135 - 145)
K+ 3.5 mmol/L (3.5 - 5.0)
Urea 2.0 mmol/L (2.0 - 7.0)
Creatinine 62 µmol/L (55 - 120)
C reactive protein (CRP) 6 mg/L (< 5)
What is the most likely diagnosis?Your Answer: Lung cancer
Explanation:Investigation for lung cancer should be considered in a long-term smoker with a history of weight loss and breathlessness, as SIADH is a common endocrine complication of small cell lung cancer. If the patient has not had a normal echo recently, right-sided heart failure may be a more likely explanation for their symptoms. While COPD and pulmonary fibrosis can also cause breathlessness, they would not account for the peripheral oedema and hyponatraemia.
SIADH is a condition where the body retains too much water, leading to low sodium levels in the blood. This can be caused by a variety of factors, including malignancies such as small cell lung cancer, neurological conditions like stroke or meningitis, infections such as tuberculosis or pneumonia, and certain drugs like sulfonylureas and SSRIs. Other causes may include positive end-expiratory pressure and porphyrias. Treatment for SIADH involves slowly correcting the sodium levels to avoid complications like central pontine myelinolysis. This can be done through fluid restriction, the use of demeclocycline to reduce responsiveness to ADH, or the use of ADH receptor antagonists. It is important to note that certain drugs, such as glimepiride and glipizide, have been reported to cause SIADH according to the BNF.
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This question is part of the following fields:
- Respiratory Medicine
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Question 23
Correct
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A 55-year-old man is seen in the clinic for a follow-up appointment. He was prescribed ramipril two months ago for stage 2 hypertension, which was diagnosed after ambulatory blood pressure monitoring. His clinic readings have improved from 164/96 mmHg to 142/84 mmHg. However, he has been experiencing a persistent, dry cough for the past four weeks. What would be the best course of action to take in this situation?
Your Answer: Stop ramipril and start losartan
Explanation:When ACE inhibitors are not well-tolerated, angiotensin-receptor blockers are recommended.
NICE Guidelines for Managing Hypertension
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.
The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.
NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.
New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.
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This question is part of the following fields:
- Respiratory Medicine
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Question 24
Incorrect
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A 70-year-old man presented to the clinic with proximal muscle weakness and a cough lasting eight weeks. He also reported pain in the small joints of his hands and small haemorrhages in the nailfolds. On examination, there was no lymphadenopathy or clubbing, but bibasal crackles were heard. A chest radiograph revealed diffuse reticular infiltrates, and lung function tests showed a restrictive pattern. What is the most likely underlying cause of his interstitial lung disease?
Your Answer: Cryptogenic fibrosing alveolitis
Correct Answer: Polymyositis
Explanation:Differential Diagnosis of Polymyositis: A Comparison with Other Connective Tissue Diseases
Polymyositis is a systemic connective tissue disease that causes inflammation of the striated muscle and skin in the case of dermatomyositis. Patients typically present with muscle weakness, pain in the small joints of the fingers, and dermatitis. The disease is associated with HLA-B8 and HLA-DR3, and underlying malignancy is present in at least 5-8% of cases. Here, we compare polymyositis with other connective tissue diseases to aid in differential diagnosis.
Rheumatoid arthritis (RA) is another systemic inflammatory disease that affects mainly the joints, in particular, the proximal interphalangeal joints, in a symmetrical fashion. Pulmonary fibrosis is a known complication of RA, and muscular weakness is also a possible feature. However, in RA, joint-related symptoms are typically more prominent than muscle weakness, making polymyositis a more likely diagnosis in cases of predominant muscle weakness.
Cryptogenic fibrosing alveolitis, also known as idiopathic pulmonary fibrosis, presents with diffuse reticular infiltrates on chest radiographs and a restrictive pattern on lung function tests. However, the history of proximal muscle weakness and pain in the small joints of the hands does not fit with this diagnosis and suggests polymyositis instead.
Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects multiple systems in the body. While SLE would be in the differential diagnosis for polymyositis, the prominent proximal muscle weakness and the fact that the patient is a man (SLE affects women in 90% of cases) make polymyositis a more likely diagnosis.
Ankylosing spondylitis (AS) is an inflammatory rheumatic disease that primarily affects the axial joints and entheses. AS can be associated with pulmonary fibrosis and produces a restrictive pattern on spirometry. However, the more prominent complaint of proximal muscle weakness and the involvement of the small joints of the hands make AS a less likely diagnosis in cases of predominant muscle weakness.
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This question is part of the following fields:
- Respiratory Medicine
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Question 25
Correct
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A 45-year-old man presents with worsening dyspnea. He has been a smoker for the past 20 years. Upon conducting pulmonary function tests, the following results were obtained:
- FEV1: 1.3 L (predicted 3.6 L)
- FVC: 1.6 L (predicted 4.2 L)
- FEV1/FVC: 80% (normal > 75%)
What respiratory disorder is most likely causing these findings?Your Answer: Neuromuscular disorder
Explanation:Pulmonary function tests reveal a restrictive pattern in individuals with neuromuscular disorders, while obstructive patterns may be caused by other conditions.
Understanding Pulmonary Function Tests
Pulmonary function tests are a useful tool in determining whether a respiratory disease is obstructive or restrictive. These tests measure the amount of air a person can exhale forcefully and the total amount of air they can exhale. The results of these tests can help diagnose conditions such as asthma, COPD, bronchiectasis, and pulmonary fibrosis.
Obstructive lung diseases are characterized by a significant reduction in the amount of air a person can exhale forcefully (FEV1) and a reduced FEV1/FVC ratio. Examples of obstructive lung diseases include asthma, COPD, bronchiectasis, and bronchiolitis obliterans.
On the other hand, restrictive lung diseases are characterized by a significant reduction in the total amount of air a person can exhale (FVC) and a normal or increased FEV1/FVC ratio. Examples of restrictive lung diseases include pulmonary fibrosis, asbestosis, sarcoidosis, acute respiratory distress syndrome, infant respiratory distress syndrome, kyphoscoliosis, and neuromuscular disorders.
Understanding the results of pulmonary function tests can help healthcare professionals diagnose and manage respiratory diseases more effectively.
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This question is part of the following fields:
- Respiratory Medicine
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Question 26
Incorrect
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A 47-year-old woman visits the local clinic with her husband, who reports that his wife has been experiencing chills, night sweats, coughing up yellow phlegm, and is having difficulty answering basic questions.
Which of the following is NOT part of the scoring evaluation for community-acquired pneumonia (CAP)?Your Answer: Urea
Correct Answer: Creatinine
Explanation:Understanding the CURB65 Score and its Criteria
The CURB65 score is a tool used to assess the severity of community-acquired pneumonia (CAP) in patients. It consists of five criteria, including confusion, respiratory rate, blood pressure, age, and urea levels. However, creatinine does not play a role in this score.
While the CURB65 score helps determine the appropriate level of care for patients with CAP, it is important to note that acute kidney injury and high creatinine levels may still be independent risk factors for morbidity and mortality.
The criteria for the CURB65 score are as follows: a score of 0-1 indicates that the patient can be managed at home, a score of 2-3 suggests hospital management with close monitoring, and a score of 4-5 indicates the need for admission and observation, potentially in an intensive therapy unit.
Age greater than 65 years old is one of the defining criteria of the CURB65 score, while confusion, respiratory rate > 30 breaths per minute, and blood pressure systolic < 90 mmHg or diastolic < 60 mmHg are also included. Additionally, a blood urea nitrogen level higher than 7 mmol/l is another criterion. In summary, understanding the CURB65 score and its criteria is essential in determining the appropriate level of care for patients with CAP. However, it is important to consider other risk factors, such as creatinine levels, in predicting morbidity and mortality.
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This question is part of the following fields:
- Respiratory Medicine
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Question 27
Correct
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A 57-year-old man presents with a 4 weeks-history of productive cough, dyspnoea, and pleuritic chest pain. He has had associated lethargy, weight loss, a swinging fever and night sweats. He had a stroke two years ago.
Sputum and blood cultures are collected. After a chest x-ray revealed a fluid-filled space within an area of consolidation in his left lung, he was given IV antibiotics.
However, the patient's condition has not improved and instead appears to be worsening. What is the most appropriate next step in his management?Your Answer: Arrange CT-guided percutaneous drainage
Explanation:If a lung abscess is not responding to intravenous antibiotics, percutaneous drainage should be considered as an option.
Correct: Arrange CT-guided percutaneous drainage. This is because the patient’s symptoms, such as swinging fevers, night sweats, pleuritic chest pain, dyspnoea, and cough, are consistent with a lung abscess. The chest x-ray also supports this diagnosis by showing a fluid-filled space within an area of consolidation. If IV antibiotics are not effective, percutaneous drainage can be guided by a CT scan or ultrasound. IV antibiotics may not be able to penetrate the abscess wall, which is why some patients do not respond to this treatment.
Incorrect: Arrange bronchoscopy. This is not commonly used for lung abscesses and is only indicated if an underlying tumour or foreign body is suspected. It is performed for diagnosis only, not drainage.
Incorrect: Arrange sputum cytology. Sputum cultures have already been collected, and a diagnosis of lung abscess has been established. This option could be considered later if the patient still does not respond to treatment to rule out an underlying malignancy.
Incorrect: Prescribe broad-spectrum IV antibiotics. This option is unlikely to be effective since the patient has already received IV antibiotics without success. The next step would be to manually drain the abscess.
Understanding Lung Abscess
A lung abscess is a localized infection that occurs within the lung tissue. It is commonly caused by aspiration pneumonia, which can be triggered by poor dental hygiene, reduced consciousness, or previous stroke. Other potential causes include haematogenous spread, direct extension, and bronchial obstruction. The infection is typically polymicrobial, with Staphylococcus aureus, Klebsiella pneumonia, and Pseudomonas aeruginosa being the most common monomicrobial causes.
The symptoms of lung abscess are similar to pneumonia, but they tend to develop more slowly over several weeks. Patients may experience fever, productive cough, foul-smelling sputum, chest pain, and dyspnea. Some may also have systemic features such as night sweats and weight loss, while a minority may experience haemoptysis. Physical examination may reveal dull percussion and bronchial breathing, as well as clubbing in some cases.
To diagnose lung abscess, a chest x-ray is usually performed, which shows a fluid-filled space within an area of consolidation. Sputum and blood cultures should also be obtained to identify the causative organism. Treatment typically involves intravenous antibiotics, but if the infection does not resolve, percutaneous drainage or surgical resection may be required in rare cases.
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This question is part of the following fields:
- Respiratory Medicine
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Question 28
Correct
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The cardiac arrest team is summoned to the bedside of a 68-year-old male patient, 3 days post-myocardial infarction. Two nurses are currently administering chest compressions and a manual defibrillator has just been connected. Chest compressions are momentarily halted to analyze the rhythm, which reveals pulseless electrical activity. What actions should be taken in this situation?
Your Answer: Adrenaline should be commenced immediately
Explanation:In the case of a non-shockable rhythm, it is crucial to administer adrenaline as soon as possible according to the ALS protocol. This should be done immediately and during alternate cycles. However, if the rhythm is shockable, adrenaline should be given after the third shock and then during alternate cycles. Amiodarone should be administered after the third shock, and a second dose may be considered after five shocks. Therefore, the other options are not appropriate.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Respiratory Medicine
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Question 29
Correct
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A 67-year-old man presents to the Emergency Department with pleuritic chest pain that started two hours ago. He has a history of lung cancer with bony metastases and has recently started treatment with erlotinib.
His vital signs are as follows: temperature 37.2ºC; oxygen saturation 92% on room air; respiratory rate 20 breaths per minute; heart rate 98 beats per minute; blood pressure 140/86 mmHg.
A chest X-ray is performed, which shows no abnormalities. He is started on supplemental oxygen therapy, and a CT pulmonary angiogram (CTPA) is ordered.
While waiting for the CTPA results, what is the most appropriate next step in management?Your Answer: Commence rivaroxaban
Explanation:The recommended initial management for patients with suspected pulmonary embolism (PE) is to ensure they are haemodynamically stable before starting anticoagulation. According to the latest NICE Guidelines (2020), a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban should be started unless there are contraindications. In this case, the patient is stable and can be started on rivaroxaban. It is important to note that starting prophylactic dose LMWH is not appropriate for suspected PE, and commencing warfarin at loading dose is also not recommended due to its delayed anticoagulant effects. Thrombolytic agents such as alteplase are only appropriate for haemodynamically unstable patients. Dabigatran is an alternative option for patients who cannot take apixaban or rivaroxaban, but it too requires a bridging dose of LMWH.
Management of Pulmonary Embolism: NICE Guidelines
Pulmonary embolism (PE) is a serious condition that requires prompt management. The National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of venous thromboembolism (VTE) in 2020, with some key changes. One of the significant changes is the recommendation to use direct oral anticoagulants (DOACs) as the first-line treatment for most people with VTE, including those with active cancer. Another change is the increasing use of outpatient treatment for low-risk PE patients, determined by a validated risk stratification tool.
Anticoagulant therapy is the cornerstone of VTE management, and the guidelines recommend using apixaban or rivaroxaban as the first-line treatment following the diagnosis of a PE. If neither of these is suitable, LMWH followed by dabigatran or edoxaban or LMWH followed by a vitamin K antagonist (VKA) can be used. For patients with active cancer, DOACs are now recommended instead of LMWH. The length of anticoagulation is determined by whether the VTE was provoked or unprovoked, with treatment typically stopped after 3-6 months for provoked VTE and continued for up to 6 months for unprovoked VTE.
In cases of haemodynamic instability, thrombolysis is recommended as the first-line treatment for massive PE with circulatory failure. Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters. However, the evidence base for IVC filter use is weak.
Overall, the updated NICE guidelines provide clear recommendations for the management of PE, including the use of DOACs as first-line treatment and outpatient management for low-risk patients. The guidelines also emphasize the importance of individualized treatment based on risk stratification and balancing the risks of VTE recurrence and bleeding.
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This question is part of the following fields:
- Respiratory Medicine
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Question 30
Incorrect
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Which of the following interventions is most likely to improve survival in individuals with COPD?
Your Answer: Prophylactic antibiotic therapy
Correct Answer: Long-term oxygen therapy
Explanation:Long-term oxygen therapy is one of the few interventions that has been proven to enhance survival in COPD following smoking cessation.
NICE guidelines recommend smoking cessation advice, annual influenza and one-off pneumococcal vaccinations, and pulmonary rehabilitation for COPD patients. Bronchodilator therapy is first-line treatment, with the addition of LABA and LAMA for patients without asthmatic features and LABA, ICS, and LAMA for those with asthmatic features. Theophylline is recommended after trials of bronchodilators or for patients who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients. Mucolytics should be considered for patients with a chronic productive cough. Loop diuretics and long-term oxygen therapy may be used for cor pulmonale. Smoking cessation and long-term oxygen therapy may improve survival in stable COPD patients. Lung volume reduction surgery may be considered in selected patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 31
Incorrect
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A 32-year-old engineer attended a business trip in France last weekend and developed a fever of up to 39°C that lasted for three days. He had associated shortness of breath and dry cough. In addition, he had loose motions for a day. His blood results showed deranged LFTs and hyponatraemia. His WBC count was 10.2 × 109/l. Bibasal consolidation was seen on his radiograph.
Which of the following would be the most effective treatment for his condition?Your Answer: Cefuroxime
Correct Answer: Clarithromycin
Explanation:Treatment options for Legionnaires’ disease
Legionnaires’ disease is a common cause of community- and hospital-acquired pneumonia, caused by Legionella pneumophila. The bacterium contaminates water containers and distribution systems, including air-conditioning systems, and can infect individuals who inhale it. Symptoms include fever, cough, dyspnoea, and systemic symptoms such as myalgia, arthralgia, diarrhoea, nausea, vomiting and neurological signs. Diagnosis is usually confirmed by urinary antigen testing. Treatment options include macrolides, such as clarithromycin, which is the preferred choice, and quinolones, such as ciprofloxacin, which are used less frequently due to a less favourable side-effect profile. Amoxicillin, cefuroxime, and flucloxacillin are not effective against Legionella pneumophila. It is important to remember that the organism does not show up on Gram staining. Outbreaks are seen in previously fit individuals staying in hotels or institutions where the shower facilities and/or the cooling system is contaminated with the organism. The incubation period is 2–10 days. A clinical clue is the presence of otherwise unexplained hyponatraemia and deranged liver function tests in a patient with pneumonia. A chest radiograph can show bibasal consolidation, sometimes with a small pleural effusion.
Treatment options for Legionnaires’ disease
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This question is part of the following fields:
- Respiratory Medicine
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Question 32
Correct
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Among the following options, which condition is considered a restrictive lung disease/condition?
Your Answer: Severe scoliosis
Explanation:Different Types of Lung Diseases and their Spirometry Patterns
Scoliosis and Lung Function
Severe scoliosis can affect the respiratory muscles and the natural movements of the thoracic cage, leading to a restrictive pattern in pulmonary function tests. This can prevent the lungs from expanding correctly, compromising their function.Cystic Fibrosis and Lung Function
In early stage cystic fibrosis, the presence of inflammation and thick secretions in the airways can cause an obstructive pattern in spirometry tests. As damage to the lung tissue occurs, a restrictive component can also develop, resulting in a combined obstructive and restrictive pattern.Emphysema and Lung Function
Emphysema is a type of obstructive lung disease characterized by abnormal and irreversible enlargement of air spaces and alveolar wall destruction. This leads to airflow limitation and a spirometry pattern typical of obstructive lung disease.Asthma and Lung Function
Asthma is an inflammatory disorder of the airways that causes hyperresponsiveness and constriction of the airways in response to various stimuli. This leads to airflow limitation and a spirometry pattern typical of obstructive lung disease.Bronchiectasis and Lung Function
Bronchiectasis is characterized by abnormal and irreversible dilatation of the bronchial walls, leading to accumulation of secretions and recurrent inflammation of the airways. This produces an obstructive pattern in pulmonary function tests.In summary, different types of lung diseases can affect lung function in various ways, leading to different spirometry patterns. Understanding these patterns can help in the diagnosis and management of these conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 33
Correct
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A 28-year-old Afro-Caribbean woman presents with a 3-month history of a non-productive cough, dyspnoea and pleuritic chest pain, especially when climbing stairs. She reports intermittent fevers of up to 39°C and a 3.5-kg weight loss. She complains of wrist and ankle pain that has interfered with her work. She smokes two packets of cigarettes per day. Her full blood count is normal and serum ANA is negative. On examination there are red nodules over her lower legs.
Which of the following is the most likely diagnosis?Your Answer: Sarcoidosis
Explanation:Sarcoidosis is a condition where non-caseating granulomata develop in at least two organs, causing systemic inflammation. It is most common in African-Caribbean women and often affects the lungs, causing symptoms such as dry cough, dyspnea, and weight loss. Erythema nodosum is also frequently seen in patients with sarcoidosis. Histoplasmosis, Goodpasture’s syndrome, adenocarcinoma of the lung, and systemic lupus erythematosus are all possible differential diagnoses, but the absence of specific features makes sarcoidosis more likely in this case.
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This question is part of the following fields:
- Respiratory Medicine
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Question 34
Correct
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An 80-year-old man with terminal lung cancer is evaluated by the palliative care team to determine his analgesic requirements. He is currently on a regimen of 30 mg slow-release morphine twice daily, which effectively manages his pain. However, he is experiencing difficulty swallowing both tablet and liquid forms of the medication. The palliative team suggests transitioning him to subcutaneous morphine. What is the appropriate daily dosage for him?
Your Answer: 30mg
Explanation:Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.
Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.
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This question is part of the following fields:
- Respiratory Medicine
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Question 35
Incorrect
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A 65 year old man presents to the emergency department with a productive cough that has been ongoing for three days. He has been experiencing increasing shortness of breath, weakness, and lethargy over the past two days. He also reports fevers and rigors. His wife brought him in as she is concerned about his rapid deterioration. On examination, his heart rate is 125 beats per minute, respiratory rate is 32 breaths per minute, Sa02 is 90% on room air, temperature is 38.9º, and blood pressure is 130/84 mmHg. He appears distressed but is not confused. Initial investigations show a Hb of 134 g/l, platelets of 550 * 109/l, WBC of 18 * 109/l, Na+ of 141 mmol/l, K+ of 3.7 mmol/l, urea of 9.2 mmol/l, and creatinine of 130 µmol/l. A CXR shows left lower zone consolidation. What is his CURB-65 score based on this information?
Your Answer: 4
Correct Answer: 3
Explanation:The patient is currently in a room with normal air temperature of 38.9º and has a blood pressure reading of 130/84 mmHg. Although he appears distressed, he is not experiencing confusion. Initial tests reveal that his hemoglobin level is at 134 g/l and his platelet count is yet to be determined.
Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. The use of a point-of-care CRP test can help guide antibiotic therapy. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Treatment for low-severity community acquired pneumonia typically involves a 5-day course of amoxicillin, while moderate and high-severity cases may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution timeframes and the need for a repeat chest x-ray at 6 weeks.
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This question is part of the following fields:
- Respiratory Medicine
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Question 36
Correct
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An anxious, 30-year-old saleswoman presents with mild shortness of breath on exertion, which had come on gradually over several months. The symptom was intermittent and seemed to get worse in the evening. She has also been on treatment for depression over the last two months. On examination, she has minimal weakness of shoulder abductors and slight weakness of eye closure bilaterally. Deep tendon reflexes are present and symmetrical throughout and plantar responses are flexor. You now have the results of the investigations: FBC, U&E, LFT, TFT - normal; chest radiograph and lung function tests - normal; ECG - normal.
Which of the following is the most likely diagnosis?
Select the SINGLE most likely diagnosis.Your Answer: Myasthenia gravis
Explanation:Understanding Myasthenia Gravis: Symptoms, Diagnosis, and Treatment
Myasthenia gravis (MG) is a neuromuscular disorder that occurs when the body produces autoantibodies against the nicotinic acetylcholine receptor at the neuromuscular junction. This results in muscular weakness that is characterized by fatigability, meaning that the muscles become increasingly weaker during their use. MG primarily affects the muscles of the face, the extrinsic ocular muscles (causing diplopia), and the muscles involved in deglutition. Respiratory and proximal lower limb muscles may also be involved early in the disease, which can cause breathlessness and even sudden death.
Diagnosing MG can be challenging, as weakness may not be apparent on a single examination. However, electrodiagnostic tests and detecting the autoantibodies can confirm the diagnosis. The Tensilon test, which involves injecting edrophonium chloride to reverse the symptoms of MG, is now used only when other tests are negative and clinical suspicion of MG is still high.
Treatment of MG involves anticholinesterase medications, but many patients also benefit from thymectomy. It is important to note that a thymoma may be present in up to 15% of patients with MG.
Other conditions, such as transient ischaemic attacks, angina, multiple sclerosis, and somatisation disorder, may cause weakness, but they do not typically present with the same symptoms as MG. Therefore, it is crucial to consider MG as a potential diagnosis when a patient presents with fatigable muscular weakness.
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This question is part of the following fields:
- Respiratory Medicine
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Question 37
Correct
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A 32-year-old man with cystic fibrosis (CF) has been experiencing a significant increase in productive cough with large amounts of sputum, occasional haemoptysis and difficulty breathing for the past few months.
What is the most probable diagnosis?Your Answer: Bronchiectasis
Explanation:Identifying Bronchiectasis in a Patient with Cystic Fibrosis
Cystic Fibrosis (CF) is a genetic disorder that can lead to the development of bronchiectasis. Bronchiectasis is a condition characterized by dilated, thick-walled bronchi, which can result from continual or recurrent infection and inflammation caused by thick, difficult to expectorate mucus in patients with CF. In contrast, bronchiolitis is an acute lower respiratory infection that occurs in children aged <2 years, while asthma typically presents with variable wheeze, cough, breathlessness, and chest tightness. Chronic obstructive pulmonary disease (COPD) typically develops in smokers aged >40, and interstitial lung disease generally affects patients aged >45 and is associated with persistent breathlessness on exertion and cough. Therefore, in a patient with CF presenting with symptoms such as cough, breathlessness, and chest infections, bronchiectasis should be considered as a possible diagnosis.
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This question is part of the following fields:
- Respiratory Medicine
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Question 38
Incorrect
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Which of the following is true when considering an exacerbation of chronic bronchitis in patients with COPD?
Your Answer: An elevated white cell count indicates exacerbation
Correct Answer: Moraxella catarrhalis is not commonly isolated on culture
Explanation:Exacerbations of chronic obstructive pulmonary disease (COPD) are a common occurrence and can be caused by various factors, including bacterial infections. In a bacterial acute exacerbation of chronic obstructive pulmonary disease, the most common causative pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Since the introduction of the pneumococcal conjugate vaccine, the most common bacterial pathogen may be changing from Streptococcus pneumoniae to Haemophilus influenzae and Moraxella catarrhalis. Mycoplasma pneumoniae and Chlamydia pneumoniae are also relatively common. An elevated white cell count may indicate exacerbation, but a lack of prominent leukocytosis is common. Clinical judgement is crucial, and a C-reactive protein (CRP) test may be useful, but it lags behind by 24-48 hours.
Exacerbations of COPD are characterized by episodes of acutely increased dyspnea and cough, often with a change in the characteristics of the sputum. Despite fever and other signs and symptoms, the clinical presentation is mild to moderate in most cases. Patients with COPD often develop type 2 respiratory failure, which can escalate into respiratory acidosis, a potentially serious complication that may require non-invasive or invasive ventilation. An arterial blood gas analysis should be performed early in every patient presenting with a possible exacerbation of COPD.
Treatment options for bacterial infections in exacerbations of COPD include trimethoprim-sulfamethoxazole (Septrin) combinations. However, resistance to this combination has been frequently reported in cases of infection with M. catarrhalis. The vast majority of cases of infection with M. catarrhalis are also penicillin-resistant due to their production of beta-lactamase. Co-amoxiclav is usually the antibiotic of choice, with macrolides being good alternatives. In most cases, the initial antibiotic treatment is empirical and mainly guided by known local sensitivities and the patient’s previous history of exacerbations. Gram stain can be quite useful to identify broad classes of bacteria. If the gram stain is inconclusive, blood cultures should be performed if the patient is pyrexial.
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This question is part of the following fields:
- Respiratory Medicine
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Question 39
Correct
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A 70-year-old woman presents with complaints of dyspnea. Upon examination, fine bibasal crackles are heard in the lungs. Which of the following result sets would be indicative of pulmonary fibrosis?
Your Answer: FVC - reduced, FEV1/FVC - normal
Explanation:Understanding Pulmonary Function Tests
Pulmonary function tests are a useful tool in determining whether a respiratory disease is obstructive or restrictive. These tests measure the amount of air a person can exhale forcefully and the total amount of air they can exhale. The results of these tests can help diagnose conditions such as asthma, COPD, bronchiectasis, and pulmonary fibrosis.
Obstructive lung diseases are characterized by a significant reduction in the amount of air a person can exhale forcefully (FEV1) and a reduced FEV1/FVC ratio. Examples of obstructive lung diseases include asthma, COPD, bronchiectasis, and bronchiolitis obliterans.
On the other hand, restrictive lung diseases are characterized by a significant reduction in the total amount of air a person can exhale (FVC) and a normal or increased FEV1/FVC ratio. Examples of restrictive lung diseases include pulmonary fibrosis, asbestosis, sarcoidosis, acute respiratory distress syndrome, infant respiratory distress syndrome, kyphoscoliosis, and neuromuscular disorders.
Understanding the results of pulmonary function tests can help healthcare professionals diagnose and manage respiratory diseases more effectively.
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This question is part of the following fields:
- Respiratory Medicine
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Question 40
Incorrect
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A 58-year-old man with chronic obstructive pulmonary disease (COPD) experiences an exacerbation of breathlessness and a productive cough with green sputum.
What is the most appropriate treatment option for him?Your Answer: Clindamycin and prednisolone
Correct Answer: Doxycycline and prednisolone
Explanation:Treatment Options for COPD Exacerbations: Antibiotics and Corticosteroids
COPD exacerbations are characterized by a sudden worsening of symptoms beyond the patient’s usual stable state. These symptoms include increased breathlessness, cough, sputum production, and changes in sputum color. To treat exacerbations, a combination of antibiotics and corticosteroids is often used.
Oral corticosteroids, such as prednisolone, should be prescribed for five days to patients experiencing a significant increase in breathlessness that interferes with daily activities. Antibiotics are recommended for exacerbations associated with purulent sputum, with first-line agents including amoxicillin, doxycycline, and clarithromycin.
It is important to follow local microbiologist guidance when initiating empirical antibiotic treatment. Flucloxacillin and clindamycin are not useful in treating COPD exacerbations and are recommended for other conditions such as skin infections and bacterial vaginosis, respectively. Nitrofurantoin and trimethoprim are used for urinary tract infections and may be considered as first or second-line agents depending on antibiotic resistance and previous sensitivity.
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This question is part of the following fields:
- Respiratory Medicine
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Question 41
Correct
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A 35-year-old female patient arrives at the emergency department complaining of diplopia that has been ongoing for 2 months. She reports feeling more fatigued and weak towards the end of the day. Upon examination, anti-acetylcholine receptor antibodies are detected in her blood. A CT scan of her chest is ordered and reveals the presence of an anterior mediastinal mass. What is the most probable diagnosis for this mass?
Your Answer: Thymoma
Explanation:The most common causes of a mass in the anterior mediastinum are referred to as the 4 T’s: teratoma, terrible lymphadenopathy, thymic mass, and thyroid mass. The woman’s symptoms and positive anti-AChR suggest that she may have myasthenia gravis, which requires a CT chest to check for a thymoma. Other conditions that may show up on a CT chest, such as benign lung nodules, lung tumors, sarcoidosis, and tuberculosis, are unlikely given her presentation. It is important to note that the mediastinum is not the same as the lungs, and therefore, all other answer options are incorrect as the question specifically asks for an anterior mediastinal mass.
The Mediastinum and its Regions
The mediastinum is the area located between the two pulmonary cavities and is covered by the mediastinal pleura. It extends from the thoracic inlet at the top to the diaphragm at the bottom. The mediastinum is divided into four regions: the superior mediastinum, middle mediastinum, posterior mediastinum, and anterior mediastinum.
The superior mediastinum is located between the manubriosternal angle and T4/5 and contains important structures such as the superior vena cava, brachiocephalic veins, arch of aorta, thoracic duct, trachea, oesophagus, thymus, vagus nerve, left recurrent laryngeal nerve, and phrenic nerve.
The anterior mediastinum contains thymic remnants, lymph nodes, and fat. The middle mediastinum contains the pericardium, heart, aortic root, arch of azygos vein, and main bronchi. The posterior mediastinum contains the oesophagus, thoracic aorta, azygos vein, thoracic duct, vagus nerve, sympathetic nerve trunks, and splanchnic nerves.
In summary, the mediastinum is a crucial area of the chest that contains many important structures and is divided into four distinct regions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 42
Incorrect
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A 50-year-old man comes to see his GP complaining of chest tightness and shortness of breath on exertion for the past month. He reports that the symptoms subside after resting for 5 minutes. The patient has a medical history of asthma, hypertension, and obesity.
During the examination, the patient's temperature is 37.2ºC, heart rate is 86 bpm, blood pressure is 132/75 mmHg, and the ECG is normal.
What is the most appropriate prophylactic medication for this likely diagnosis?Your Answer: Prescribe verapamil
Correct Answer: Prescribe sublingual glyceryl trinitrate
Explanation:To prevent angina attacks, the first-line treatment is either a beta-blocker or a calcium channel blocker. This patient is displaying symptoms of stable angina, which includes shortness of breath and chest tightness that occurs during exercise and is relieved by rest. The ECG results are normal, ruling out any serious conditions like myocardial infarction. According to NICE guidelines, all patients with stable angina should receive aspirin and a statin, unless there are contraindications. Additionally, sublingual glyceryl trinitrate spray (GTN) should be given to stop acute angina attacks. However, GTN spray does not prevent future attacks, so prophylactic medication should also be prescribed.
Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.
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This question is part of the following fields:
- Respiratory Medicine
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Question 43
Incorrect
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Can you analyze the post-bronchodilator spirometry findings of a 54-year-old female who has been experiencing gradual breathlessness?
FEV1/FVC ratio: 0.60
FEV1 percentage predicted: 60%
What would be the suitable conclusion based on these outcomes?Your Answer: Pulmonary fibrosis
Correct Answer: COPD (stage 2 - moderate)
Explanation:Investigating and Diagnosing COPD
COPD is a condition that should be considered in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as chronic cough, exertional breathlessness, or regular sputum production. To confirm a diagnosis of COPD, several investigations are recommended. These include post-bronchodilator spirometry to demonstrate airflow obstruction, a chest x-ray to exclude lung cancer and identify hyperinflation, bullae, or flat hemidiaphragm, a full blood count to exclude secondary polycythaemia, and a calculation of body mass index (BMI).
The severity of COPD is categorized based on the post-bronchodilator FEV1/FVC ratio. If the ratio is less than 70%, the patient is diagnosed with COPD. The severity of the condition is then determined based on the FEV1 value. Stage 1 is considered mild, and symptoms should be present to diagnose COPD in these patients. Stage 2 is moderate, Stage 3 is severe, and Stage 4 is very severe.
It is important to note that measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction. The grading system for COPD severity has changed following the 2010 NICE guidelines. If the FEV1 is greater than 80% predicted but the post-bronchodilator FEV1/FVC is less than 0.7, the patient is classified as Stage 1 – mild.
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This question is part of the following fields:
- Respiratory Medicine
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Question 44
Incorrect
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A 25-year-old female presents to the emergency department after collapsing. Limited information is available, but an arterial blood gas has been obtained on room air with the following results:
- paO2: 13 kPa (11-13)
- paCO2: 3.5 kPa (4.7-6)
- pH: 7.31 (7.35-7.45)
- Na+: 143 mmol/L (135-145)
- K+: 5 mmol/L (3.5-5.0)
- Bicarbonate: 17 mEq/L (22-29)
- Chloride: 100 mmol/L (98-106)
What potential diagnosis could explain these blood gas findings?Your Answer: Pulmonary embolism
Correct Answer: Septic shock
Explanation:An anion gap greater than 14 mmol/L typically indicates a raised anion gap metabolic acidosis, rather than a normal anion gap. In the absence of other information about the patient, an arterial blood gas (ABG) can provide a clue to the diagnosis. In this case, the ABG shows a normal paO2, indicating a respiratory cause of the patient’s symptoms is less likely. However, the pH is below 7.35, indicating acidosis, and the bicarbonate is low, suggesting metabolic acidosis. The low paCO2 shows partial compensation. Calculating the anion gap reveals a value of 31 mmol/L, indicating metabolic acidosis with a raised anion gap. Septic shock is the only listed cause of raised anion gap metabolic acidosis, resulting in acidosis due to the production of lactic acid from inadequate tissue perfusion. Addison’s disease is another cause of metabolic acidosis, but it results in normal anion gap metabolic acidosis due to bicarbonate loss from mineralocorticoid deficiency. Prolonged diarrhea can cause normal anion gap metabolic acidosis due to gastrointestinal loss of bicarbonate. Pulmonary embolism is unlikely due to normal oxygen levels and hypocapnia occurring as compensation. Prolonged vomiting can cause metabolic alkalosis, not metabolic acidosis, due to the loss of hydrogen ions in vomit. This patient’s electrolyte profile does not fit with prolonged vomiting.
The anion gap is a measure of the difference between positively charged ions (sodium and potassium) and negatively charged ions (bicarbonate and chloride) in the blood. It is calculated by subtracting the sum of bicarbonate and chloride from the sum of sodium and potassium. A normal anion gap falls between 8-14 mmol/L. This measurement is particularly useful in diagnosing metabolic acidosis in patients.
There are various causes of a normal anion gap or hyperchloraemic metabolic acidosis. These include gastrointestinal bicarbonate loss due to conditions such as diarrhoea, ureterosigmoidostomy, or fistula. Renal tubular acidosis, drugs like acetazolamide, ammonium chloride injection, and Addison’s disease can also lead to a normal anion gap.
On the other hand, a raised anion gap metabolic acidosis can be caused by lactate due to shock or hypoxia, ketones in conditions like diabetic ketoacidosis or alcoholism, urate in renal failure, acid poisoning from substances like salicylates or methanol, and 5-oxoproline from chronic paracetamol use. Understanding the anion gap and its potential causes can aid in the diagnosis and treatment of metabolic acidosis.
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This question is part of the following fields:
- Respiratory Medicine
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Question 45
Correct
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A 20-year-old woman presents with a 4-day history of cough, headache, fever and joint pains. Blood tests show the presence of raised antibody titres and the presence of cold agglutinins. A diagnosis of Mycoplasma pneumoniae infection is made.
Which of the following drugs would you prescribe as first-line treatment for this patient?Your Answer: Clarithromycin
Explanation:Treatment options for Mycoplasma pneumoniae infection
Mycoplasma pneumoniae is a bacterium that causes atypical pneumonia and is transmitted through respiratory droplets. The symptoms vary but can include fever, malaise, myalgia, headache, and a rash. Diagnosis is usually confirmed with serology, and treatment typically involves a macrolide antibiotic such as clarithromycin for at least 10-14 days. Penicillin and other beta-lactam antibiotics are ineffective as Mycoplasma pneumoniae lacks a cell wall. Tetracycline can be used but macrolides are preferred due to a better side-effect profile. Rifampicin is mostly limited to the treatment of tuberculosis and leprosy, while co-trimoxazole is not indicated for Mycoplasma pneumoniae infection. Extrapulmonary involvement is possible and may suggest the diagnosis in a patient presenting with pneumonia. A chest radiograph is non-specific and typically shows a reticulonodular or patchy consolidation pattern.
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This question is part of the following fields:
- Respiratory Medicine
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Question 46
Correct
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A 55-year-old man presents to the respiratory clinic for a follow-up on his chronic obstructive pulmonary disease. He has a history of chronic CO2 retention and his oxygen saturation goals are between 88-92%. Upon examination, his chest sounds are quiet throughout, with equal air expansion, and a hyper-expanded chest. His oxygen saturation levels are at 91% on air. The clinic performs an arterial blood gas test.
What would be the most likely blood gas results for this patient?Your Answer: pH = 7.37, pO2 = 9.1 kPa, pCO2 = 6.1 kPa, HCO3- = 30 mmol/l
Explanation:Arterial Blood Gas Interpretation Made Easy
Arterial blood gas interpretation can be a daunting task for healthcare professionals. However, the Resuscitation Council (UK) has provided a simple 5-step approach to make it easier. The first step is to assess the patient’s overall condition. The second step is to determine if the patient is hypoxaemic, which is indicated by a PaO2 level of less than 10 kPa on air. The third step is to check if the patient is acidaemic or alkalaemic, which is determined by the pH level. A pH level of less than 7.35 indicates acidaemia, while a pH level of more than 7.45 indicates alkalaemia.
The fourth step is to assess the respiratory component by checking the PaCO2 level. A PaCO2 level of more than 6.0 kPa suggests respiratory acidosis, while a PaCO2 level of less than 4.7 kPa suggests respiratory alkalosis. The fifth and final step is to evaluate the metabolic component by checking the bicarbonate level or base excess. A bicarbonate level of less than 22 mmol/l or a base excess of less than -2mmol/l indicates metabolic acidosis, while a bicarbonate level of more than 26 mmol/l or a base excess of more than +2mmol/l indicates metabolic alkalosis.
To make it easier to remember, healthcare professionals can use the ROME acronym. Respiratory is opposite, which means that low pH and high PaCO2 indicate acidosis, while high pH and low PaCO2 indicate alkalosis. Metabolic is equal, which means that low pH and low bicarbonate indicate acidosis, while high pH and high bicarbonate indicate alkalosis. By following this simple approach, healthcare professionals can easily interpret arterial blood gas results and provide appropriate treatment for their patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 47
Correct
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A 73-year-old man presents with dyspnoea, cough and wheeze that have been ongoing for a few days. He experiences similar episodes frequently, particularly during the winter months. The patient has a medical history of COPD and osteoarthritis and takes regular inhalers. During examination, an audible wheeze is detected upon chest auscultation, and the patient appears mildly dyspnoeic. A sputum sample is collected for culture, and the patient is started on a course of doxycycline and prednisolone. What is the most probable organism to be identified?
Your Answer: Haemophilus influenzae
Explanation:The most frequent bacterial organism responsible for infective exacerbations of COPD is Haemophilus influenzae. This patient’s symptoms of dyspnoea, productive cough, and wheeze on a background of known COPD indicate an infective exacerbation. Nebulisers may be added to the treatment plan if the patient is significantly wheezy. Legionella pneumophila is not a common cause of COPD exacerbation, as it typically causes atypical pneumonia with desaturation on exertion and hyponatraemia. Moraxella catarrhalis is another organism that can cause infective exacerbations of COPD, but it is less common than Haemophilus influenzae. Staphylococcus aureus is the most common cause of pneumonia following influenza infection and can sometimes cause infective exacerbations of COPD, but it is not as common as Haemophilus influenzae.
Acute exacerbations of COPD are a common reason for hospital visits in developed countries. The most common causes of these exacerbations are bacterial infections, with Haemophilus influenzae being the most common culprit, followed by Streptococcus pneumoniae and Moraxella catarrhalis. Respiratory viruses also account for around 30% of exacerbations, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.
NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.
For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators such as salbutamol and ipratropium should also be administered, along with steroid therapy. IV hydrocortisone may be considered instead of oral prednisolone, and IV theophylline may be used for patients not responding to nebulized bronchodilators. Non-invasive ventilation may be used for patients with type 2 respiratory failure, with bilevel positive airway pressure being the typical method used.
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This question is part of the following fields:
- Respiratory Medicine
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Question 48
Correct
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A 50-year-old female comes to an after-hours general practitioner complaining of worsening fever, chest pain that worsens when inhaling, and a productive cough with blood-streaked sputum. She reports that she had symptoms of a dry cough, myalgia, and lethargy a week ago, but this week her symptoms have changed to those she is presenting with today. Her chest x-ray shows a cavitating lesion with a thin wall on the right side and an associated pleural effusion. What is the probable causative organism?
Your Answer: Staphylococcus aureus
Explanation:Causes of Pneumonia
Pneumonia is a respiratory infection that can be caused by various infectious agents. Community acquired pneumonia (CAP) is the most common type of pneumonia and is caused by different microorganisms. The most common cause of CAP is Streptococcus pneumoniae, which accounts for around 80% of cases. Other infectious agents that can cause CAP include Haemophilus influenzae, Staphylococcus aureus, atypical pneumonias caused by Mycoplasma pneumoniae, and viruses.
Klebsiella pneumoniae is another microorganism that can cause pneumonia, but it is typically found in alcoholics. Streptococcus pneumoniae, also known as pneumococcus, is the most common cause of community-acquired pneumonia. It is characterized by a rapid onset, high fever, pleuritic chest pain, and herpes labialis (cold sores).
In summary, pneumonia can be caused by various infectious agents, with Streptococcus pneumoniae being the most common cause of community-acquired pneumonia. It is important to identify the causative agent to provide appropriate treatment and prevent complications.
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This question is part of the following fields:
- Respiratory Medicine
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Question 49
Incorrect
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Typically, which form of lung disease develops in people with a1-antitrypsin deficiency?
Your Answer: Bronchiectasis
Correct Answer: Emphysema
Explanation:Emphysema: Imbalance between Proteases and Anti-Proteases in the Lungs
Emphysema is a lung disease that results from an imbalance between proteases and anti-proteases within the lung. This imbalance is often caused by a1-antitrypsin deficiency, which is associated with the development of emphysema in young people with no history of smoking and a positive family history. The interplay between environmental and genetic factors determines the onset of emphysema. Patients typically present with worsening dyspnoea, and weight loss, cor pulmonale, and polycythaemia occur later in the course of the disease. Chest radiographs show bilateral basal emphysema with paucity and pruning of the basal pulmonary vessels. Early onset of liver cirrhosis, often in combination with emphysema, is also associated with a1-antitrypsin deficiency.
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This question is part of the following fields:
- Respiratory Medicine
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Question 50
Incorrect
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A 72-year-old man presents to the emergency department with shortness of breath. Upon examination, reduced breath sounds and dullness to percussion are noted in the right axilla. His heart rate is 98 bpm, blood pressure is 100/75 mmHg, respiratory rate is 30 per minute, and his oxygen saturation is 93% on room air. Blood tests, including an arterial blood gas with the patient on 2L/minute oxygen via a nasal cannula, reveal the following results:
Hb 142 g/l Na+ 140 mmol/l
Platelets 502 * 109/l K+ 4.2 mmol/l
WBC 15.8 * 109/l Urea 6.9 mmol/l
Neuts 14.2 * 109/l Creatinine 90 µmol/l
Lymphs 1.6 * 109/l CRP 205.4 mg/l
pH 7.29
pO2 12.5 kPa
pCO2 2.2 kPa
HCO3- 13 mmol/l
Base excess -7.2
Lactate 3.1 mmol/l
A chest x-ray shows consolidation of the right middle zone with blunting of the right costophrenic angle. The left lung field is clear. Based on these findings, what is the most likely acid-base disorder present in this patient?Your Answer: An uncompensated respiratory acidosis
Correct Answer: A partially compensated metabolic acidosis
Explanation:The patient in this scenario has an acute sepsis with a right middle lobe pneumonia as the likely cause. The blood gas results show an acidosis with low bicarbonate and high lactate, indicating a metabolic cause. However, the pCO2 is low due to tachypnea, which suggests respiratory compensation for the metabolic acidosis. If the pH were normal, it would be considered a fully compensated acidosis, but since the patient is still acidotic, it is classified as a partial compensation. Normal blood gas ranges for pH, pO2, pCO2, and HCO3- are 7.35-7.45, 10.0-14.0 kPa, 4.5-6.0 kPa, and 22-26 mmol/l, respectively. A mixed acidosis would show both low bicarbonate and high pCO2, while an uncompensated metabolic acidosis would have low bicarbonate and normal pCO2, and an uncompensated respiratory acidosis would have high pCO2 and normal bicarbonate.
Arterial Blood Gas Interpretation Made Easy
Arterial blood gas interpretation can be a daunting task for healthcare professionals. However, the Resuscitation Council (UK) has provided a simple 5-step approach to make it easier. The first step is to assess the patient’s overall condition. The second step is to determine if the patient is hypoxaemic, which is indicated by a PaO2 level of less than 10 kPa on air. The third step is to check if the patient is acidaemic or alkalaemic, which is determined by the pH level. A pH level of less than 7.35 indicates acidaemia, while a pH level of more than 7.45 indicates alkalaemia.
The fourth step is to assess the respiratory component by checking the PaCO2 level. A PaCO2 level of more than 6.0 kPa suggests respiratory acidosis, while a PaCO2 level of less than 4.7 kPa suggests respiratory alkalosis. The fifth and final step is to evaluate the metabolic component by checking the bicarbonate level or base excess. A bicarbonate level of less than 22 mmol/l or a base excess of less than -2mmol/l indicates metabolic acidosis, while a bicarbonate level of more than 26 mmol/l or a base excess of more than +2mmol/l indicates metabolic alkalosis.
To make it easier to remember, healthcare professionals can use the ROME acronym. Respiratory is opposite, which means that low pH and high PaCO2 indicate acidosis, while high pH and low PaCO2 indicate alkalosis. Metabolic is equal, which means that low pH and low bicarbonate indicate acidosis, while high pH and high bicarbonate indicate alkalosis. By following this simple approach, healthcare professionals can easily interpret arterial blood gas results and provide appropriate treatment for their patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 51
Incorrect
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A 68-year-old man presents with confusion and evidence of right lower lobe pneumonia on Chest X-Ray. He appears unwell to you. His urea level is 8 mmol/l, and respiratory rate is 38 breaths per minute. His pulse rate is 89, and blood pressure is 120/58 mmHg.
What is the patient's CURB 65 score?Your Answer: 4
Correct Answer: 5
Explanation:Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. The use of a point-of-care CRP test can help guide antibiotic therapy. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Treatment for low-severity community acquired pneumonia typically involves a 5-day course of amoxicillin, while moderate and high-severity cases may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution timeframes and the need for a repeat chest x-ray at 6 weeks.
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This question is part of the following fields:
- Respiratory Medicine
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Question 52
Correct
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A 65-year-old male with COPD presents to the hospital with worsening cough, difficulty breathing, and heavy green sputum production. He is placed on a 35% venturi mask with target oxygen saturations of 88-92% due to his known hypoxic drive. Despite receiving nebulised salbutamol, nebulised ipratropium, intravenous hydrocortisone, and intravenous theophylline, there is minimal improvement. The patient is becoming fatigued and his oxygen saturations remain at 87%. An arterial blood gas is ordered and empirical intravenous antibiotics are started. What is the most appropriate next step in management?
Your Answer: BiPAP (bilevel positive airway pressure)
Explanation:When medical therapy fails to improve COPD exacerbations, patients should be given BiPAP non-invasive ventilation. Before starting non-invasive ventilation, an arterial blood gas should be taken. BiPAP delivers two different pressures for inhalation and exhalation, making it a useful tool for patients who need help with ventilation, such as those in type II respiratory failure. On the other hand, CPAP delivers one pressure setting and is more helpful in increasing oxygen saturation and intrathoracic pressure to reduce preload and cardiac workload in chronic heart failure or sleep apnea. While intravenous magnesium sulfate is part of the management for severe asthma exacerbation, there is currently insufficient evidence to support its use in COPD exacerbation. If non-invasive ventilatory support fails, intubation and ventilation may be necessary.
Acute exacerbations of COPD are a common reason for hospital visits in developed countries. The most common causes of these exacerbations are bacterial infections, with Haemophilus influenzae being the most common culprit, followed by Streptococcus pneumoniae and Moraxella catarrhalis. Respiratory viruses also account for around 30% of exacerbations, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.
NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.
For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators such as salbutamol and ipratropium should also be administered, along with steroid therapy. IV hydrocortisone may be considered instead of oral prednisolone, and IV theophylline may be used for patients not responding to nebulized bronchodilators. Non-invasive ventilation may be used for patients with type 2 respiratory failure, with bilevel positive airway pressure being the typical method used.
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This question is part of the following fields:
- Respiratory Medicine
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Question 53
Correct
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A 25-year-old woman presents to her GP with a 4-week history of dry cough and chest tightness. She was diagnosed with asthma 8-months ago and has been using a salbutamol inhaler as needed. However, she has noticed an increase in shortness of breath over the past month and has been using her inhaler up to 12 times per day.
During the examination, her vital signs are normal. Her peak expiratory flow rate is 290L/min (best 400 L/min).
What is the next course of action in managing this patient's asthma symptoms?Your Answer: Low-dose inhaled corticosteroid
Explanation:For an adult with asthma that is not controlled by a short-acting beta-agonist, the appropriate next step is to add a low-dose inhaled corticosteroid. This is in accordance with NICE guidelines. The addition of a combined inhaled corticosteroid and long-acting beta-agonist is not recommended until symptoms cannot be controlled with a low-dose inhaled corticosteroid and a short-acting beta-agonist, with or without a leukotriene receptor antagonist. Similarly, a leukotriene receptor antagonist or long-acting beta-agonist should not be introduced until symptoms are not controlled with a low-dose inhaled corticosteroid and a short-acting beta-agonist, with or without a leukotriene receptor antagonist.
The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.
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This question is part of the following fields:
- Respiratory Medicine
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Question 54
Correct
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You assess a 27-year-old female patient with a medical history of asthma. She is currently taking salbutamol 100 mcg 2 puffs as needed. However, she stopped taking her beclometasone dipropionate 400 mcg twice daily and salmeterol 50 mcg twice daily inhalers last week after discovering her pregnancy. She was worried about the potential harm to her unborn child. What would be the most suitable course of action?
Your Answer: Reassure + restart beclometasone and salmeterol inhalers
Explanation:The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.
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This question is part of the following fields:
- Respiratory Medicine
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Question 55
Incorrect
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A 38-year-old homeless man presents to the emergency department after collapsing on the street. He reports feeling increasingly lethargic over the past week and has been coughing up green sputum. He has a history of alcoholic pancreatitis.
His vital signs are as follows:
- Temperature: 38.4ºC
- Heart rate: 122 bpm
- Blood pressure: 106/54 mmHg
- Respiratory rate: 22 breaths/min
- Oxygen saturations: 94% on 2L nasal cannulae
Upon examination, coarse crackles are heard in the left upper lobe. His heart sounds are normal and his abdomen is soft and nontender.
What is the most likely causative organism?Your Answer: Mycoplasma pneumoniae
Correct Answer: Klebsiella pneumoniae
Explanation:Klebsiella pneumoniae is a gram-negative rod that commonly causes a cavitating pneumonia in the upper lobes, particularly in individuals with a history of diabetes and alcoholism. The presence of upper zone crackles is a sign of Klebsiella pneumoniae infection, while a history of alcoholic pancreatitis suggests chronic alcohol use.
Legionella pneumophila causes Legionnaire’s disease, an atypical pneumonia that typically spreads through contaminated water sources, such as air conditioner vents. Symptoms include fever, cough, and myalgia, with bilateral chest symptoms being more common. Other extra-pulmonary symptoms, such as hyponatremia and hepatitis, may also be present.
Mycoplasma pneumoniae is another cause of atypical pneumonia, with symptoms including coryza and a dry cough. This form of pneumonia is associated with extra-pulmonary symptoms such as haemolytic anaemia and erythema multiforme, which are not present in this case.
Staphylococcus aureus is the most likely cause of pneumonia following influenza virus infection. However, since there is no history of preceding coryza and the patient has upper zone crackles and alcoholism, Staphylococcus aureus is less likely to be the cause of this patient’s pneumonia.
Klebsiella Pneumoniae: A Gram-Negative Rod Causing Infections in Humans
Klebsiella pneumoniae is a type of Gram-negative rod that is typically found in the gut flora of humans. Although it is a normal part of the body’s microbiome, it can also cause a variety of infections in humans, including pneumonia and urinary tract infections. This bacterium is more commonly found in individuals who have diabetes or who consume alcohol regularly. In some cases, Klebsiella pneumoniae infections can occur following aspiration.
One of the distinctive features of Klebsiella pneumoniae infections is the presence of red-currant jelly sputum. This type of sputum is often seen in patients with pneumonia caused by this bacterium. Additionally, Klebsiella pneumoniae infections tend to affect the upper lobes of the lungs.
Unfortunately, Klebsiella pneumoniae infections can be quite serious and even life-threatening. They commonly lead to the formation of lung abscesses and empyema, and the mortality rate for these infections is between 30-50%. It is important for healthcare providers to be aware of the potential for Klebsiella pneumoniae infections, particularly in patients who are at higher risk due to underlying health conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 56
Correct
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A 36-year-old man presents to the emergency department following a motor vehicle accident. He has a medical history of COPD and is a heavy smoker, consuming 30 cigarettes per day. Upon arrival, his vital signs are as follows: temperature of 37ºC, heart rate of 128/min, respiratory rate of 27/min, blood pressure of 80/43 mmHg, and GCS of 15. Physical examination reveals tenderness and bruising on the right side of his chest, but chest movements are equal. His neck veins are distended but do not change with breathing, and his trachea is central with distant and quiet heart sounds. Additionally, he has cuts and grazes on his hands and legs.
What is the appropriate next step in managing this patient?Your Answer: Pericardial needle aspiration
Explanation:If a patient with chest wall trauma presents with elevated JVP, persistent hypotension, and tachycardia despite fluid resuscitation, cardiac tamponade should be considered. In such cases, pericardial needle aspiration is the correct course of action. Beck’s triad, which includes hypotension, muffled (distant) heart sounds, and elevated JVP, is a characteristic feature of cardiac tamponade. Urgent aspiration of the pericardium is necessary to prevent further haemodynamic compromise and save the patient’s life. Although the patient may have associated rib fractures, managing the cardiac tamponade should take priority as it poses the greatest threat in this scenario. CT scan of the chest, chest drain insertion into the triangle of safety, and needle decompression 2nd intercostal space, midclavicular line are not appropriate management options in this case.
Cardiac tamponade is a condition where there is an accumulation of fluid in the pericardial sac, which puts pressure on the heart. This can lead to a range of symptoms, including hypotension, raised JVP, muffled heart sounds, dyspnoea, tachycardia, and pulsus paradoxus. One of the key features of cardiac tamponade is the absence of a Y descent on the JVP, which is due to limited right ventricular filling. Other diagnostic criteria include Kussmaul’s sign and electrical alternans on an ECG. Constrictive pericarditis is a similar condition, but it can be distinguished from cardiac tamponade by the presence of an X and Y descent on the JVP, the absence of pulsus paradoxus, and the presence of pericardial calcification on a chest X-ray. The management of cardiac tamponade involves urgent pericardiocentesis to relieve the pressure on the heart.
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This question is part of the following fields:
- Respiratory Medicine
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Question 57
Correct
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A 20-year-old young woman presents with a 4-day history of cough, headache, fever and joint pains. Blood tests show the presence of raised antibody titres and the presence of cold agglutinins. A diagnosis of Mycoplasma pneumoniae infection is made.
Which of the following drugs would you prescribe as first-line treatment for this patient?Your Answer: Clarithromycin
Explanation:The British Thoracic Society recommends using macrolide antibiotics like clarithromycin or erythromycin as empirical treatment for community-acquired pneumonia in both children and adults if first-line β-lactam antibiotics are ineffective or in cases of severe disease. Atypical infections are often diagnosed late in the illness, making early targeted therapy difficult. M. pneumoniae pneumonia tends to occur in outbreaks in the UK, so being aware of these outbreaks can help guide treatment. Benzylpenicillin is used to treat various infections, including throat infections, otitis media, and cellulitis. Cefuroxime is a broad-spectrum antibiotic used to treat susceptible infections caused by both Gram-positive and Gram-negative bacteria, including respiratory tract infections, Lyme disease, and urinary tract infections. Rifampicin is used in combination with other drugs to treat brucellosis, Legionnaires’ disease, serious staphylococcal infections, endocarditis, and tuberculosis. Co-trimoxazole is used to treat Pneumocystis jirovecii pneumonia and can be administered orally for mild-to-moderate pneumonia or intravenously in dual therapy with steroids for severe pneumonia. It can also be used for PCP prophylaxis in HIV-positive patients, with primary prophylaxis recommended for those with a CD4 count of <£200 and secondary prophylaxis essential after the first infection.
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This question is part of the following fields:
- Respiratory Medicine
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Question 58
Incorrect
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A 78-year-old man visits his GP complaining of a cough that has been producing green sputum and shortness of breath for the past three days. During the examination, the GP detects the presence of rhonchi. The patient's vital signs are stable. Given his medical history of type 2 diabetes, which is being managed with metformin, and heart failure, for which he is taking ramipril, bisoprolol, and furosemide, the GP suspects acute bronchitis. What is the most appropriate course of action?
Your Answer: Oral flucloxacillin
Correct Answer: Oral doxycycline
Explanation:Antibiotics may be prescribed for acute bronchitis if the patient has co-existing co-morbidities or is at high risk of complications. NICE guidelines advise against the use of antibiotics for those who are not systemically very unwell and not at high risk of complications. However, if the patient is very unwell or at risk of complications, antibiotics should be offered. In this case, the patient’s age, diabetes, and heart failure put him at high risk, so antibiotics should be offered in accordance with NICE guidelines. While local guidelines should be consulted, NICE recommends oral doxycycline as the first-line treatment. Inhaled bronchodilators should not be offered unless the patient has an underlying airway disease such as asthma. Oral flucloxacillin is not commonly used for respiratory tract infections, and IV co-amoxiclav is not necessary in this stable patient who can be managed without admission.
Acute bronchitis is a chest infection that typically resolves on its own within three weeks. It occurs when the trachea and major bronchi become inflamed, leading to swollen airways and the production of sputum. The primary cause of acute bronchitis is viral infection, with most cases occurring in the autumn or winter. Symptoms include a sudden onset of cough, sore throat, runny nose, and wheezing. While most patients have a normal chest examination, some may experience a low-grade fever or wheezing. It is important to differentiate acute bronchitis from pneumonia, which presents with different symptoms and chest examination findings.
Diagnosis of acute bronchitis is typically based on clinical presentation, but CRP testing may be used to determine if antibiotic therapy is necessary. Management involves pain relief and ensuring adequate fluid intake. Antibiotics may be considered for patients who are systemically unwell, have pre-existing health conditions, or have a CRP level between 20-100mg/L. Doxycycline is the recommended first-line treatment, but it cannot be used in children or pregnant women. Alternatives include amoxicillin.
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This question is part of the following fields:
- Respiratory Medicine
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Question 59
Correct
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A 42-year-old man from Burkina Faso visits his GP with a complaint of a persistent cough and unintentional weight loss of 2kg over the last 8 weeks. He denies experiencing night sweats and has never smoked or consumed alcohol. He works as a baker. During the examination, the doctor observes sensitive, erythematous pretibial nodules. The Mantoux test results are negative. What is the probable diagnosis?
Your Answer: Sarcoidosis
Explanation:Understanding Sarcoidosis: A Multisystem Disorder
Sarcoidosis is a condition that affects multiple systems in the body and is characterized by the presence of non-caseating granulomas. Although the exact cause of sarcoidosis is unknown, it is more commonly seen in young adults and people of African descent.
The symptoms of sarcoidosis can vary depending on the severity of the condition. Acute symptoms may include erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, and polyarthralgia. On the other hand, insidious symptoms may include dyspnea, non-productive cough, malaise, and weight loss. In some cases, sarcoidosis can also cause skin lesions such as lupus pernio and hypercalcemia due to increased conversion of vitamin D to its active form.
Sarcoidosis can also present as different syndromes. Lofgren’s syndrome is an acute form of the disease characterized by bilateral hilar lymphadenopathy, erythema nodosum, fever, and polyarthralgia. It usually has a good prognosis. Mikulicz syndrome, which is now considered outdated and unhelpful by many, is characterized by enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis, or lymphoma. Heerfordt’s syndrome, also known as uveoparotid fever, is characterized by parotid enlargement, fever, and uveitis secondary to sarcoidosis.
In conclusion, sarcoidosis is a complex condition that affects multiple systems in the body. Understanding the different symptoms and syndromes associated with sarcoidosis can help in the diagnosis and management of this condition.
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This question is part of the following fields:
- Respiratory Medicine
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Question 60
Correct
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What is the most effective antibiotic for treating Chlamydia pneumonia?
Your Answer: Clarithromycin
Explanation:Antibiotics for Chlamydia Pneumoniae Infections
Chlamydia pneumoniae infections are commonly treated with macrolide antibiotics such as clarithromycin or erythromycin. These antibiotics are effective against atypical pneumonias and should be taken for a long period of time (usually 10-14 days) with strict compliance to avoid suboptimal doses. However, the most common side effects of these antibiotics are nausea, vomiting, and diarrhea.
Clindamycin is not recommended for the treatment of Chlamydia pneumoniae infections. Piperacillin and ampicillin are also not indicated due to in vitro resistance shown by the bacteria. Imipenem is also not recommended for the treatment of Chlamydia pneumoniae infections. It is important to consult with a healthcare professional for proper diagnosis and treatment of any infection.
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This question is part of the following fields:
- Respiratory Medicine
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Question 61
Correct
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A 45-year-old woman presents with a 3-day history of cough, fever and left-sided pleuritic pain. On examination she has a temperature of 38.5 °C, a respiratory rate of 37/min, a blood pressure of 110/80 mm/Hg and a pulse rate of 110/min. Oxygen saturations are 95%. She has basal crepitations and dullness to percussion at the left lung base.
Which of the following is the most likely diagnosis?
Your Answer: Bronchopneumonia
Explanation:Differential Diagnosis for a Patient with Cough and Fever: Bronchopneumonia vs. Other Conditions
Bronchopneumonia is a common condition that presents with a cough and fever, along with other symptoms such as sputum production, dyspnea, and pleuritic pain. Examination findings may include decreased breath sounds and focal chest signs. A chest radiograph can confirm the diagnosis. In primary care, a CRB-65 score is used to assess mortality risk and determine where to treat the patient: one point each for acute confusion, respiratory rate (RR) ≥30/min, systolic blood pressure (BP) <90 mmHg or diastolic BP <60 mmHg, age >65 years).
CRB-65 score Mortality risk (%) – Where to treat
0 <1 At home
1-2 1-10 Hospital advised, particularly score of 2
3-4 >10 Hospital advised, may require stay in intensive therapy unit (ITU).Other conditions that may present with similar symptoms include pneumothorax, pulmonary embolism, malignant mesothelioma, and tuberculosis. However, these conditions have distinct features that differentiate them from bronchopneumonia. For example, pneumothorax involves partial or full collapse of a lung, while pulmonary embolism results from obstruction of one or more of the pulmonary arteries. Malignant mesothelioma is a cancer that affects the pleura and peritoneum, and tuberculosis usually presents with a persistent productive cough, weight loss, night sweats, fevers, lymphadenopathy, and general malaise.
It is important to consider these differentials when evaluating a patient with cough and fever, and to use appropriate diagnostic tools to confirm the diagnosis and determine the best course of treatment.
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This question is part of the following fields:
- Respiratory Medicine
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Question 62
Incorrect
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A 65-year-old woman presents to the emergency department with complaints of difficulty breathing. She has a medical history of left ventricular systolic dysfunction with an ejection fraction of 20%. A chest x-ray confirms acute pulmonary edema, which is immediately treated with high dose IV furosemide. Her vital signs on repeat assessment are as follows: oxygen saturation of 94% on 15L oxygen, heart rate of 124 beats per minute, respiratory rate of 28 breaths per minute, and blood pressure of 74/50 mmHg. What is the next management option to consider?
Your Answer: Give IV fluid for her hypotension
Correct Answer: Inotropic support on the high dependency unit (HDU)
Explanation:For patients with severe left ventricular dysfunction who are experiencing potentially reversible cardiogenic shock with hypotension, inotropic support on the high dependency unit (HDU) should be considered. This is because diuresis, which is the primary aim of management in acute pulmonary oedema, could lower blood pressure further and worsen the shock. Inotropes can help increase cardiac contractility and support blood pressure while diuresis is ongoing.
Biphasic positive airway pressure (BiPAP) is not an immediate consideration for this patient as it is used primarily for non-invasive ventilation in hypoxic and hypercapnic patients. Pulmonary oedema does not typically lead to hypercapnia.
Giving IV fluid for hypotension would not be appropriate as the hypotension is secondary to cardiogenic shock, not hypovolaemic shock. Administering further fluid in this scenario would worsen the patient’s condition by contributing to fluid overload.
Bisoprolol is contraindicated in this scenario as it suppresses the compensatory tachycardia that occurs in acute heart failure to maintain cardiac output, which would worsen the cardiogenic shock. However, outside of an acute scenario, a patient can continue on their routine bisoprolol if they are already prescribed this for heart failure, unless they are bradycardic.
Heart failure requires acute management, with recommended treatments for all patients including IV loop diuretics such as furosemide or bumetanide. Oxygen may also be necessary, with guidelines suggesting oxygen saturations be kept at 94-98%. Vasodilators such as nitrates should not be routinely given to all patients, but may have a role in cases of concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease. However, hypotension is a major side-effect/contraindication. Patients with respiratory failure may require CPAP, while those with hypotension or cardiogenic shock may require inotropic agents like dobutamine or vasopressor agents like norepinephrine. Mechanical circulatory assistance such as intra-aortic balloon counterpulsation or ventricular assist devices may also be necessary. Regular medication for heart failure should be continued, with beta-blockers only stopped in certain circumstances. Opiates should not be routinely offered to patients with acute heart failure due to potential increased morbidity.
In summary, acute management of heart failure involves a range of treatments depending on the patient’s specific condition. It is important to carefully consider the potential side-effects and contraindications of each treatment, and to continue regular medication for heart failure where appropriate. Opiates should be used with caution, and only in cases where they are likely to reduce dyspnoea/distress without causing harm. With appropriate management, patients with acute heart failure can receive the care they need to improve their outcomes and quality of life.
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This question is part of the following fields:
- Respiratory Medicine
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Question 63
Correct
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A 65-year-old man with a history of recurrent lower respiratory tract infections has been diagnosed with bilateral bronchiectasis after undergoing a high resolution CT scan. What is the most crucial factor in managing his symptoms in the long run?
Your Answer: Postural drainage
Explanation:To manage symptoms in individuals with non-CF bronchiectasis, a combination of inspiratory muscle training and postural drainage can be effective.
Managing Bronchiectasis
Bronchiectasis is a condition where the airways become permanently dilated due to chronic inflammation or infection. Before starting treatment, it is important to identify any underlying causes that can be treated, such as immune deficiency. The management of bronchiectasis includes physical training, such as inspiratory muscle training, which has been shown to be effective for patients without cystic fibrosis. Postural drainage, antibiotics for exacerbations, and long-term rotating antibiotics for severe cases are also recommended. Bronchodilators may be used in selected cases, and immunizations are important to prevent infections. Surgery may be considered for localized disease. The most common organisms isolated from patients with bronchiectasis include Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella spp., and Streptococcus pneumoniae.
Spacing:
Bronchiectasis is a condition where the airways become permanently dilated due to chronic inflammation or infection. Before starting treatment, it is important to identify any underlying causes that can be treated, such as immune deficiency.
The management of bronchiectasis includes physical training, such as inspiratory muscle training, which has been shown to be effective for patients without cystic fibrosis. Postural drainage, antibiotics for exacerbations, and long-term rotating antibiotics for severe cases are also recommended. Bronchodilators may be used in selected cases, and immunizations are important to prevent infections. Surgery may be considered for localized disease.
The most common organisms isolated from patients with bronchiectasis include Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella spp., and Streptococcus pneumoniae.
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This question is part of the following fields:
- Respiratory Medicine
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Question 64
Correct
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A 67-year-old man with COPD comes to the emergency department complaining of right-sided chest pain and shortness of breath that has been present for the past 4 days. A chest x-ray reveals a 2cm right-sided apical pneumothorax, which the on-call emergency physician promptly aspirates. The man has a smooth recovery but is curious about how he can avoid any future recurrences.
What recommendations should be given to the patient?Your Answer: Avoid deep sea diving for life
Explanation:The patient should be advised to avoid deep-sea diving for life due to the risk of pneumothorax. However, they can fly one week after having a chest x-ray showing complete resolution of the pneumothorax. There is no increased risk of catamenial pneumothoraces. Pleurodesis is not necessary for a single pneumothorax, whether primary or secondary.
Management of Pneumothorax: BTS Guidelines
Pneumothorax is a condition where air accumulates in the pleural space, causing the lung to collapse. The British Thoracic Society (BTS) has published updated guidelines for the management of spontaneous pneumothorax, which can be primary or secondary. Primary pneumothorax occurs without any underlying lung disease, while secondary pneumothorax is associated with lung disease.
The BTS guidelines recommend that patients with a rim of air less than 2cm and no shortness of breath may be discharged, while those with a larger rim of air or shortness of breath should undergo aspiration or chest drain insertion. For secondary pneumothorax, patients over 50 years old with a rim of air greater than 2cm or shortness of breath should undergo chest drain insertion. Aspiration may be attempted for those with a rim of air between 1-2cm, but chest drain insertion is necessary if aspiration fails.
For iatrogenic pneumothorax, observation is usually sufficient, but chest drain insertion may be necessary in some cases. Ventilated patients and those with chronic obstructive pulmonary disease (COPD) may require chest drain insertion. If a patient has persistent or recurrent pneumothorax, video-assisted thoracoscopic surgery (VATS) may be necessary.
Patients should be advised to avoid smoking to reduce the risk of further episodes. Fitness to fly is an absolute contraindication, but patients may travel 1 week after successful drainage if there is no residual air. Scuba diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.
Overall, the BTS guidelines provide a comprehensive approach to the management of pneumothorax, taking into account the type of pneumothorax, patient characteristics, and potential complications.
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This question is part of the following fields:
- Respiratory Medicine
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Question 65
Correct
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A 56-year-old HIV positive man presents to your clinic with complaints of haemoptysis and worsening shortness of breath after completing treatment for pneumocystis jirovecii pneumonia. A chest x-ray shows an apical mass in the right lung lobe. He responds well to treatment with itraconazole and steroids. What is the most probable diagnosis?
Your Answer: Aspergilloma
Explanation:Aspergilloma is a type of fungal growth that typically affects individuals with weakened immune systems or those who have pre-existing lung conditions like tuberculosis or emphysema. Common symptoms include coughing, fever, and coughing up blood. Treatment typically involves the use of antifungal medications like itraconazole.
Haemoptysis, or coughing up blood, can be caused by a variety of conditions. Lung cancer is a common cause, especially in individuals with a history of smoking. Symptoms of malignancy, such as weight loss and anorexia, may also be present. Pulmonary oedema, which is the accumulation of fluid in the lungs, can cause dyspnoea (shortness of breath) and is often accompanied by bibasal crackles and an S3 heart sound. Tuberculosis, a bacterial infection that primarily affects the lungs, can cause fever, night sweats, anorexia, and weight loss. Pulmonary embolism, a blockage in the pulmonary artery, can cause pleuritic chest pain, tachycardia (rapid heart rate), and tachypnoea (rapid breathing). Lower respiratory tract infections, such as pneumonia, typically have an acute onset and are characterized by a purulent cough. Bronchiectasis, a chronic lung condition, is often associated with a long history of cough and daily production of purulent sputum. Mitral stenosis, a narrowing of the mitral valve in the heart, can cause dyspnoea, atrial fibrillation, and a malar flush on the cheeks. Aspergilloma, a fungal infection that often occurs in individuals with a past history of tuberculosis, can cause severe haemoptysis and is characterized by a rounded opacity on chest x-ray. Granulomatosis with polyangiitis, an autoimmune disease, can affect both the upper and lower respiratory tracts and is associated with symptoms such as epistaxis (nosebleeds), sinusitis, dyspnoea, and haemoptysis. Goodpasture’s syndrome, another autoimmune disease, can cause haemoptysis and systemic symptoms such as fever and nausea, as well as glomerulonephritis (inflammation of the kidney’s filtering units).
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This question is part of the following fields:
- Respiratory Medicine
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Question 66
Correct
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Which of the following is not a known side effect of the combined oral contraceptive pill?
Your Answer: Increased risk of ovarian cancer
Explanation:While the combined oral contraceptive pill may increase the risk of breast and cervical cancer, it has been found to provide protection against ovarian and endometrial cancer. In fact, studies have shown that the pill can actually decrease the risk of ovarian cancer.
Pros and Cons of the Combined Oral Contraceptive Pill
The combined oral contraceptive pill is a highly effective method of birth control with a failure rate of less than 1 per 100 woman years. It does not interfere with sexual activity and its contraceptive effects are reversible upon stopping. Additionally, it can make periods regular, lighter, and less painful, and may reduce the risk of ovarian, endometrial, and colorectal cancer. It may also protect against pelvic inflammatory disease, ovarian cysts, benign breast disease, and acne vulgaris.
However, there are also some disadvantages to the combined oral contraceptive pill. One of the main issues is that people may forget to take it, which can reduce its effectiveness. It also offers no protection against sexually transmitted infections. There is an increased risk of venous thromboembolic disease, breast and cervical cancer, stroke, and ischaemic heart disease, especially in smokers. Temporary side-effects such as headache, nausea, and breast tenderness may also be experienced.
It is important to weigh the pros and cons of the combined oral contraceptive pill before deciding if it is the right method of birth control for you. While some users report weight gain while taking the pill, a Cochrane review did not support a causal relationship. Overall, the combined oral contraceptive pill can be an effective and convenient method of birth control, but it is important to discuss any concerns or potential risks with a healthcare provider.
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This question is part of the following fields:
- Respiratory Medicine
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Question 67
Incorrect
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A 28-year-old woman is being seen in the asthma clinic. She is currently on salbutamol inhaler 100mcg prn and beclometasone dipropionate inhaler 400 mcg bd, but is experiencing frequent asthma exacerbations and has recently undergone a course of prednisolone. In accordance with NICE guidelines, what would be the most suitable course of action for her management?
Your Answer: Add salmeterol
Correct Answer: Add a leukotriene receptor antagonist
Explanation:According to NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, the first step should be to add a LTRA rather than a LABA.
The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.
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This question is part of the following fields:
- Respiratory Medicine
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Question 68
Correct
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A 56-year-old woman with a recent asthma exacerbation is being seen in clinic. She recently completed a course of prednisolone. Over the past 6 months, she has experienced 5 exacerbations and is currently using her salbutamol inhaler 4 times daily. She is not taking any other medications and there is no wheezing detected during examination. What should be the next course of action in managing her asthma?
Your Answer: Inhaled corticosteroids
Explanation:If an adult with asthma is not able to control their symptoms with a short-acting beta agonist (SABA), the next step in their treatment plan should be to add a low-dose inhaled corticosteroid (ICS). This approach follows the guidelines set out by NICE for managing asthma.
The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.
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This question is part of the following fields:
- Respiratory Medicine
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Question 69
Incorrect
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A 67-year-old man with worsening dyspnea is suspected to have idiopathic pulmonary fibrosis. What is the preferred diagnostic test to confirm the diagnosis?
Your Answer: MRI thorax
Correct Answer: High-resolution CT scan
Explanation:Understanding Idiopathic Pulmonary Fibrosis
Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.
The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.
Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.
The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.
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This question is part of the following fields:
- Respiratory Medicine
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Question 70
Correct
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A 48-year-old man is admitted with right-sided pneumonia. According to the patient he has been unwell for 3–4 days with malaise, fever, cough and muscular pain. He also has a rash on his abdomen and neck pain. He was previously fit and has not travelled abroad. He is a plumber and also keeps pigeons. According to his wife, two of his favourite pigeons died 2 weeks ago.
Which of the following organisms is most likely to be responsible for his pneumonia?Your Answer: Chlamydia psittaci
Explanation:Psittacosis is a disease caused by the bacterium Chlamydia psittaci, which is typically transmitted to humans through exposure to infected birds. Symptoms include fever, cough, headache, and sore throat, as well as a characteristic facial rash. Diagnosis is confirmed through serology tests, and treatment involves the use of tetracyclines or macrolides. Mycoplasma pneumoniae is another bacterium that can cause atypical pneumonia, with symptoms including fever, malaise, myalgia, headache, and a rash. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia, while Legionella pneumophila can cause Legionnaires’ disease, which presents with fever, cough, dyspnea, and systemic symptoms. Coxiella burnetii is the bacterium responsible for Q fever, which can be transmitted by animals and arthropods and presents with non-specific symptoms. In the scenario presented, the patient’s history of exposure to infected birds and the presence of a rash suggest a diagnosis of psittacosis.
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This question is part of the following fields:
- Respiratory Medicine
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