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Question 1
Incorrect
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A 56-year-old man has just been admitted to the medical ward. Two days ago, he returned from a business trip and his history suggests he may have caught an atypical pneumonia. While examining the patient’s chest clinically, you try to determine whether the pneumonia is affecting one lobe in particular or is affecting the whole lung.
On the right side of the patient’s chest, which one of the following surface landmarks would be most likely to mark the boundary between the middle and lower lobes?Your Answer: Horizontal line at level of nipple
Correct Answer: Sixth rib
Explanation:Surface Landmarks for Lung Lobes and Abdominal Planes
The human body has several surface landmarks that can be used to locate important anatomical structures. In the case of the lungs, the position of the lobes can be estimated using the oblique and horizontal fissures. The sixth rib is the most likely surface landmark to mark the boundary between the right middle and lower lobes, while the fourth costal cartilage indicates the level of the horizontal fissure separating the superior from the middle lobes of the right lung.
In the abdomen, the tip of the ninth costal cartilage is a useful landmark as it marks the position of the transpyloric plane. This imaginary axial plane is important as it is where many anatomical structures, such as the pylorus of the stomach and the neck of the pancreas, are located. Additionally, the horizontal line passing through the centre of the nipple, known as the mammillary line, can also be used as a surface landmark for certain procedures.
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This question is part of the following fields:
- Respiratory
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Question 2
Incorrect
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A 40-year-old patient visits his GP complaining of a dry cough that has persisted for 3 months. He has been smoking 20 cigarettes daily for the past 12 years and has no other medical history. Upon examination, no abnormalities are found, and his vital signs, including pulse rate, respiratory rate, blood pressure, temperature, and oxygen saturation, are all normal. Spirometry results reveal a forced expiratory volume in 1 second (FEV1) of 3.6 litres (predicted = 3.55 litres) and a forced vital capacity of 4.8 litres (predicted 4.72 litres). What is the most probable diagnosis?
Your Answer: Chronic obstructive pulmonary disease (COPD)
Correct Answer: Asthma
Explanation:Differential diagnosis of a dry cough in a young patient
A dry cough is a common symptom that can have various underlying causes. In a young patient with a ten-pack-year history of smoking and a 3-month duration of symptoms, several possibilities should be considered and ruled out based on clinical evaluation and diagnostic tests.
One possibility is asthma, especially if the cough is the main or only symptom. In this case, spirometry may be normal, but peak flow monitoring before and after inhaled steroid therapy can help confirm the diagnosis by showing an improvement in peak flow rate and/or a reduction in variability.
Chronic obstructive pulmonary disease (COPD) is less likely in a young patient, but spirometry can reveal obstructive patterns if present.
Community-acquired pneumonia is unlikely given the chronicity of symptoms and the absence of typical signs such as productive cough and inspiratory crackles.
Angina is an uncommon cause of a dry cough, and it usually presents with chest tightness on exertion rather than at night.
Bronchiectasis can cause a productive cough and crackles on auscultation, which are not present in this case.
Therefore, based on the available information, asthma seems to be the most likely diagnosis, but further evaluation may be needed to confirm it and exclude other possibilities.
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This question is part of the following fields:
- Respiratory
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Question 3
Incorrect
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A 62-year-old man who is a smoker presents with gradual-onset shortness of breath, over the last month. Chest radiograph shows a right pleural effusion.
What would be the most appropriate next investigation?Your Answer: Spirometry
Correct Answer: Pleural aspirate
Explanation:Investigations for Pleural Effusion: Choosing the Right Test
When a patient presents with dyspnoea and a suspected pleural effusion, choosing the right investigation is crucial for accurate diagnosis and management. Here are some of the most appropriate investigations for different types of pleural effusions:
1. Pleural aspirate: This is the most appropriate next investigation to measure the protein content and determine whether the fluid is an exudate or a transudate.
2. Computerised tomography (CT) of the chest: An exudative effusion would prompt investigation with CT of the chest or thoracoscopy to look for conditions such as malignancy or tuberculosis (TB).
3. Bronchoscopy: Bronchoscopy would be appropriate if there was need to obtain a biopsy for a suspected tumour, but so far no lesion has been identified.
4. Echocardiogram: A transudative effusion would prompt investigations such as an echocardiogram to look for heart failure, or liver imaging to look for cirrhosis.
5. Spirometry: Spirometry would have been useful if chronic obstructive pulmonary disease (COPD) was suspected, but at this stage the pleural effusion is likely the cause of dyspnoea and should be investigated.
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This question is part of the following fields:
- Respiratory
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Question 4
Incorrect
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A 61-year-old electrician presents with a 4-month history of cough and weight loss. On further questioning, the patient reports experiencing some episodes of haemoptysis. He has a long-standing history of hypothyroidism, which is well managed with thyroxine 100 µg daily. The patient smokes ten cigarettes a day and has no other significant medical history. Blood tests and an X-ray are carried out, which reveal possible signs of asbestosis. A CT scan is ordered to investigate further.
What is the typical CT scan finding of asbestosis in the lung?Your Answer: Cavitation of upper zones
Correct Answer: Honeycombing of the lung with parenchymal bands and pleural plaques
Explanation:Differentiating Lung Diseases: Radiological Findings
Asbestosis is a lung disease characterized by interstitial pneumonitis and fibrosis, resulting in honeycombing of the lungs with parenchymal bands and pleural plaques. Smoking can accelerate its presentation. On a chest X-ray, bilateral reticulonodular opacities in the lower zones are observed, while a CT scan shows increased interlobular septae, parenchymal bands, and honeycombing. Silicosis, on the other hand, presents with irregular linear shadows and hilar lymphadenopathy, which can progress to PMF with compensatory emphysema. Tuberculosis is characterized by cavitation of upper zones, while pneumoconiosis shows parenchymal nodules and lower zone emphysema. Proper diagnosis is crucial in determining the appropriate treatment and management of these lung diseases.
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This question is part of the following fields:
- Respiratory
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Question 5
Correct
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A 5-year-old girl comes to her general practice clinic with her mother. She has been experiencing nasal congestion, sneezing, and a sore throat for the past few days. During the examination, her pulse rate is 80 bpm, respiratory rate is 20 breaths per minute, and temperature is 36.9 °C. She has no significant medical history. What is the probable diagnosis?
Your Answer: Common cold
Explanation:Possible Diagnosis for a Young Girl with Respiratory Symptoms
A young girl is experiencing respiratory symptoms, including sore throat, sneezing, and nasal congestion. Here are some possible diagnoses to consider:
1. Common cold: This is a common viral infection that can cause mild fever, especially in children.
2. Hay fever: This is an allergic reaction to specific allergens, such as pollen, that can cause similar symptoms to the common cold, but with a chronic and fluctuating course.
3. Infectious mononucleosis: This is a viral infection that can cause fatigue, fever, laryngitis, and a rash, but is less likely in this case.
4. influenzae: This is a seasonal viral infection that can cause more severe symptoms, such as high fever, headache, and muscle aches.
5. Meningitis: This is a serious bacterial infection that can cause non-specific respiratory symptoms, but also tachycardia, hypotension, high fever, photophobia, neck stiffness, and petechial rash, which are not mentioned here.
Possible Diagnoses for a Young Girl with Respiratory Symptoms
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This question is part of the following fields:
- Respiratory
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Question 6
Incorrect
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A 50-year-old man in the United Kingdom presents with fever and cough. He smells strongly of alcohol and has no fixed abode. His heart rate was 123 bpm, blood pressure 93/75 mmHg, oxygen saturations 92% and respiratory rate 45 breaths per minute. Further history from him reveals no recent travel history and no contact with anyone with a history of foreign travel.
Chest X-ray revealed consolidation of the right upper zone.
Which of the following drugs is the most prudent choice in his treatment?Your Answer: Co-trimoxazole
Correct Answer: Meropenem
Explanation:Understanding Klebsiella Pneumoniae Infection and Treatment Options
Klebsiella pneumoniae (KP) is a common organism implicated in various infections such as pneumonia, urinary tract infection, intra-abdominal abscesses, or bacteraemia. Patients with underlying conditions like alcoholism, diabetes, or chronic lung disease are at higher risk of contracting KP. The new hypervirulent strains with capsular serotypes K1 or K2 are increasingly being seen. In suspected cases of Klebsiella infection, treatment is best started with carbapenems. However, strains possessing carbapenemases are also being discovered, and Polymyxin B or E or tigecycline are now used as the last line of treatment. This article provides an overview of KP infection, radiological findings, and treatment options.
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This question is part of the following fields:
- Respiratory
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Question 7
Correct
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What condition is typically linked to obstructive sleep apnea?
Your Answer: Hypersomnolence
Explanation:Symptoms and Associations of Obstructive Sleep Apnoea
Obstructive sleep apnoea is a condition characterized by hypersomnolence or excessive sleepiness. Other common symptoms include personality changes, witnessed apnoeas, and true nocturnal polyuria. Reduced libido is a less frequent symptom. The condition may be associated with acromegaly, myxoedema, obesity, and micrognathia/retrognathia. Sleep apnoea is a serious condition that can lead to complications such as hypertension, cardiovascular disease, and stroke.
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This question is part of the following fields:
- Respiratory
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Question 8
Incorrect
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A 50-year-old woman is brought to the Emergency Department after falling down the stairs at home. She complains of ‘rib pain’ and is moved to the resus room from triage, as she was unable to complete full sentences due to shortness of breath. Sats on room air were 92%. You are asked to see her urgently as the nursing staff are concerned about her deterioration.
On examination, she appears distressed; blood pressure is 85/45, heart rate 115 bpm, respiratory rate 38 and sats 87% on air. Her left chest does not appear to be moving very well, and there are no audible breath sounds on the left on auscultation.
What is the most appropriate next step in immediate management of this patient?Your Answer: Portable chest X-ray
Correct Answer: Needle thoracocentesis of left chest
Explanation:Needle Thoracocentesis for Tension Pneumothorax
Explanation:
In cases of traumatic chest pain, it is important to keep an open mind regarding other injuries. However, if a patient rapidly deteriorates with signs of shock, hypoxia, reduced chest expansion, and no breath sounds audible on the affected side of the chest, a tension pneumothorax should be suspected. This is an immediately life-threatening condition that requires immediate intervention.There is no time to wait for confirmation on a chest X-ray or to set up a chest drain. Instead, needle thoracocentesis should be performed on the affected side of the chest. A large-bore cannula is inserted in the second intercostal space, mid-clavicular line, on the affected side. This can provide rapid relief and should be followed up with the insertion of a chest drain.
It is important to note that there is no role for respiratory consultation or nebulisers in this scenario. Rapid intervention is key to preventing cardiac arrest and improving patient outcomes.
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This question is part of the following fields:
- Respiratory
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Question 9
Incorrect
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A 55-year-old woman presents with 6 months of recurrent episodes of shortness of breath. She describes it as ‘coming on suddenly without warning’. They have woken her at night before. She describes the attacks as a ‘tightness’ in the chest and says that they are associated with tingling in her fingers. The episodes resolve in a few minutes by themselves. She is otherwise medically fit and well. She smokes 15 cigarettes per day and has a family history of asthma. Examination is normal, and the peak expiratory flow rate is normal for her age and height.
Which of the following is the most likely diagnosis?Your Answer: Acute asthma attacks
Correct Answer: Panic attacks
Explanation:Differentiating between possible causes of acute shortness of breath: A medical analysis
When a patient presents with acute shortness of breath, it is important to consider a range of possible causes. In this case, the patient’s symptoms suggest panic attacks rather than left ventricular failure, acute asthma attacks, COPD, or anaemia.
Panic attacks are characterized by sudden onset and spontaneous resolution, numbness of extremities, and normal examination and peak flow measurement. They can be triggered or occur unexpectedly, and may be due to a disorder such as panic disorder or post-traumatic stress disorder, or secondary to medical problems such as thyroid disease. Treatment includes psychological therapies, breathing exercises, stress avoidance, and pharmacological therapies such as selective serotonin reuptake inhibitors.
Left ventricular failure, on the other hand, would cause respiratory problems due to pulmonary congestion, leading to reduced pulmonary compliance and increased airway resistance. Examination of someone with left ventricular failure would reveal pulmonary crackles and possibly a small mitral regurgitation murmur. However, it is unlikely that a woman would experience acute episodes such as these due to heart failure.
Acute asthma attacks are typically triggered by inhaled allergens or other factors such as cold/dry air, stress, or upper respiratory tract infections. The absence of triggers in this case suggests that asthma is not the diagnosis.
COPD is a possible differential due to the patient’s smoking history, but it is unlikely to have worsened so acutely and resolved in a matter of minutes. The normal peak expiratory flow rate also suggests that COPD is not the cause.
Finally, anaemia would not account for acute episodes of shortness of breath, which are present normally on exertion in anaemic patients. Signs of anaemia such as pallor, tachycardia, cardiac dilation, or oedema are not mentioned in the patient’s history.
In conclusion, a careful analysis of the patient’s symptoms and medical history can help differentiate between possible causes of acute shortness of breath, leading to appropriate treatment and management.
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This question is part of the following fields:
- Respiratory
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Question 10
Incorrect
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After reviewing a patient with chronic obstructive pulmonary disease (COPD) in clinic, the respiratory consultant discusses the anatomy of the lungs with a group of undergraduate students.
With regard to the lungs, which one of the following statements is accurate?Your Answer: The left lung has three lobes
Correct Answer: The lungs receive a dual blood supply
Explanation:Facts about the Anatomy of the Lungs
The lungs are a vital organ responsible for respiration. Here are some important facts about their anatomy:
– The lungs receive a dual blood supply from the pulmonary artery and the bronchial arteries. A pulmonary embolus may only result in infarction when the circulation is already inadequate.
– The left lung has two lobes, while the right lung has three. The horizontal fissure is present only in the right lung.
– Each lung has ten bronchopulmonary segments, which can be selectively removed surgically if diseased.
– The right bronchus is shorter, wider, and more vertical than the left bronchus, making it more likely for foreign bodies to enter it. Aspiration pneumonia and abscess formation are common in the apical segment of the right lower lobe.Important Facts about the Anatomy of the Lungs
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This question is part of the following fields:
- Respiratory
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