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  • Question 1 - A 16-year-old secretary presents to you with an increased dry cough and an...

    Correct

    • A 16-year-old secretary presents to you with an increased dry cough and an intermittently wheezy chest at night, eight weeks after seeing the respiratory nurse at the surgery. She reports no fevers and no difficulties in breathing. Currently, she is taking Fostair (Beclomethasone diproprionate 100 mcg/Formetorol fumarate 6 mcg) combination inhaler, 1 puff twice daily, and salbutamol as needed for shortness of breath. Previously, she was using Clenil (Beclomethasone 100 mcg), but feels that the new inhaler has helped slightly since her last appointment with the nurse. According to the latest SIGN/BTS guidance, what would be the next step in managing her asthma?

      Your Answer: Increase the Fostair to two puffs twice daily

      Explanation:

      Managing Chronic Asthma in Adults

      When managing chronic asthma in adults, it is important to consider the patient’s current treatment plan and symptoms. In this scenario, the patient is already taking a combination inhaler and is experiencing suboptimal control of her asthma. It is important to note that this is not an acute attack and the children’s guidelines do not apply. Antibiotics are not recommended as the symptoms are not consistent with an infective exacerbation. Increasing the usage of salbutamol is also not recommended as the patient needs better overall control of her symptoms. Instead, the dose of the inhaled corticosteroid should be increased, which is in line with the next step in the treatment of asthma in adults according to the British Thoracic Society guidelines. It is important for healthcare professionals to be familiar with both SIGN and NICE guidance and be able to compare and contrast their advice.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 2 - A 57-year-old woman comes in for a check-up. She was diagnosed with pneumonia...

    Incorrect

    • A 57-year-old woman comes in for a check-up. She was diagnosed with pneumonia six weeks ago after experiencing flu-like symptoms and a productive cough. Despite having no history of asthma, she quit smoking three years ago due to hypertension. A chest x-ray was performed and showed consolidation in the left lower zone, but no pleural effusion or abnormal heart size. She was treated with amoxicillin for a week and her symptoms improved. Now, six weeks later, a follow-up x-ray shows that the consolidation has improved but not completely resolved. Her cough is mostly gone and is no longer productive, and she has not experienced any coughing up of blood or weight loss. What is the best course of action?

      Your Answer: Repeat the chest x-ray in 6 weeks

      Correct Answer: Urgent referral to the chest clinic

      Explanation:

      As an ex-smoker, this woman is experiencing a gradual improvement in her consolidation, but she still has a persistent cough. It is recommended that she be referred for further evaluation under the 2 week wait rule to rule out the possibility of lung cancer.

      Referral Guidelines for Lung Cancer

      Lung cancer is a serious condition that requires prompt diagnosis and treatment. The 2015 NICE cancer referral guidelines provide clear advice on when to refer patients for suspected lung cancer. According to these guidelines, patients should be referred using a suspected cancer pathway referral for an appointment within 2 weeks if they have chest x-ray findings that suggest lung cancer or are aged 40 and over with unexplained haemoptysis.

      For patients aged 40 and over who have 2 or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, an urgent chest x-ray should be offered within 2 weeks to assess for lung cancer. This recommendation also applies to patients who have ever smoked and have 1 or more of these unexplained symptoms.

      In addition, patients aged 40 and over with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be considered for an urgent chest x-ray within 2 weeks to assess for lung cancer.

      Overall, these guidelines provide clear and specific recommendations for healthcare professionals to identify and refer patients with suspected lung cancer for prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 3 - You are seeing a 59-year-old gentleman with a diagnosis of chronic obstructive pulmonary...

    Incorrect

    • You are seeing a 59-year-old gentleman with a diagnosis of chronic obstructive pulmonary disease.
      His spirometry shows an FEV1 of 58% predicted. His current treatment consists of a short-acting beta-2 agonist used as required.

      On reviewing his symptoms he has not had any significant exacerbations over the past 12 months but he needs to use his inhaler at least four times a day and despite this he still feels persistently breathless.

      As per NICE guidance, what would be the next most appropriate step in his pharmacological management?

      Your Answer: Add in a regular long-acting beta agonist and discontinue the short-acting beta agonist

      Correct Answer: Add in a regular inhaled corticosteroid

      Explanation:

      Treatment Algorithm for COPD Patients

      Page 9 of the NICE reference guide on Chronic obstructive pulmonary disease (CG101) provides an overview of the treatment algorithm for patients with COPD. If a patient has inadequately controlled symptoms despite using a regular short-acting beta agonist and an FEV1 of greater or equal to 50%, the next options are to add in a long-acting beta agonist or a long-acting muscarinic antagonist. In both cases, the short-acting beta agonist can continue to be used as required. Therefore, the correct answer from the list of options is to add in a regular long-acting muscarinic antagonist.

      If the patient has an FEV1 <50%, the treatment choice would alter again with the option of using a long-acting beta agonist/inhaled corticosteroid combination inhaler. It is important to follow the treatment algorithm to ensure that patients receive the appropriate treatment for their COPD symptoms. Proper management of COPD can improve a patient's quality of life and reduce the risk of exacerbations.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 4 - A 67-year-old woman presents with a persistent cough and two episodes of haemoptysis...

    Incorrect

    • A 67-year-old woman presents with a persistent cough and two episodes of haemoptysis over the past six weeks. She is an ex-smoker who quit 10 years ago after smoking 20 cigarettes a day for 30 years. A chest x-ray four weeks ago was normal, but her symptoms have persisted. On examination, she appears well and is not short of breath. Blood pressure is 140/90 mmHg, pulse rate is 70 bpm regular, and oxygen saturations are 98% in room air. Lung fields are clear, and there is no cyanosis, anaemia, or peripheral oedema. What is the most appropriate management strategy?

      Your Answer: Refer the patient urgently to a respiratory physician

      Correct Answer: Admit the patient to hospital immediately as a medical emergency

      Explanation:

      NICE Guidelines for Referral of Suspected Lung Cancer Patients

      The National Institute for Health and Care Excellence (NICE) has issued guidelines for the recognition and referral of suspected lung cancer patients. According to the guidelines, patients aged 40 and over with unexplained haemoptysis should be referred urgently for an appointment within two weeks, even if their chest x-ray is normal. Additionally, patients with two or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, or those with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be offered an urgent chest x-ray within two weeks to assess for lung cancer. These guidelines aim to ensure timely diagnosis and treatment of lung cancer, which is crucial for improving patient outcomes.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 5 - What is the recommended course of action in the management of an adult...

    Incorrect

    • What is the recommended course of action in the management of an adult with asthma who is on low dose inhaled corticosteroid (ICS) but doesn't show improvement after the introduction of a long acting beta agonist (LABA)?

      Your Answer: Increase inhaled steroid to maximum dose

      Correct Answer: Stop long-acting beta-2 agonist (LABA) and increase dose ICS

      Explanation:

      BTS Guidance on Low Dose ICS and LABA Treatment

      According to the 2016 BTS guidance, if a patient taking a low dose ICS doesn’t respond to the addition of a LABA, the LABA should be discontinued. Instead, healthcare providers should consider increasing the dose of ICS. It is important to note that options suggesting only an increase in ICS dose without stopping the LABA are incorrect.

      This guidance emphasizes the importance of individualized treatment plans for patients with respiratory conditions. By carefully monitoring patient response to medication and adjusting treatment as needed, healthcare providers can help improve patient outcomes and quality of life. Proper medication management can also help reduce the risk of adverse effects and complications associated with respiratory conditions.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 6 - A 28-year-old woman with asthma presents with a 4-day history of increasing wheeze,...

    Incorrect

    • A 28-year-old woman with asthma presents with a 4-day history of increasing wheeze, dry cough and chest tightness. She has been needing to use her salbutamol up to 5 times a day to relieve her symptoms.

      She is alert and able to complete full sentences at rest. Her vital signs are as follows: temperature 37.2ºC, pulse rate 120/min, blood pressure 120/80 mmHg, respiratory rate 26/min, oxygen saturation 94% in room air. On auscultation, she has polyphonic wheeze throughout. Her peak expiratory flow reading is 380 L/min (best 550 L/min).

      How many features of acute severe asthma does she have?

      Your Answer: 2

      Correct Answer: 1

      Explanation:

      To alleviate his symptoms, the patient is taking his medication three times daily. Despite his condition, he remains alert and capable of speaking in complete sentences while at rest. His vital signs are as follows: temperature of 37.1ºC, pulse rate of 116/min, blood pressure of 118/70 mmHg, and respiratory rate of 2.

      Management of Acute Asthma

      Acute asthma is classified into moderate, severe, life-threatening, and near-fatal categories by the British Thoracic Society (BTS). Patients with life-threatening features should be treated as having a life-threatening attack. Further assessment may include arterial blood gases for patients with oxygen sats < 92%, and a chest x-ray is not routinely recommended unless there is life-threatening asthma, suspected pneumothorax, or failure to respond to treatment. Admission is necessary for all patients with life-threatening asthma, and patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. Oxygen therapy is important for hypoxaemic patients, and bronchodilation with short-acting beta₂-agonists (SABA) is recommended. All patients should be given 40-50 mg of prednisolone orally (PO) daily, and nebulised ipratropium bromide may be used in severe or life-threatening cases. The evidence base for IV magnesium sulphate is mixed, and IV aminophylline may be considered following consultation with senior medical staff. Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Criteria for discharge include being stable on their discharge medication, inhaler technique checked and recorded, and PEF >75% of best or predicted.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 7 - What is the suggested starting dosage of oral prednisolone for the treatment of...

    Incorrect

    • What is the suggested starting dosage of oral prednisolone for the treatment of acute severe asthma in adults?

      Your Answer: 40-50 mg daily for at least five days

      Correct Answer: 60 mg daily for at least 10 days

      Explanation:

      Effective Treatment for Acute Asthma

      When it comes to treating acute asthma, steroid tablets and injected steroids are equally effective. A dose of oral prednisolone of 40-50 mg per day for at least five days or intravenous hydrocortisone 400 mg can be used. It is important to continue taking prednisolone until recovery, which should be a minimum of five days. Additionally, it is important to not stop inhaled corticosteroids during the prescription of oral corticosteroids. By following these key points, patients can effectively manage their acute asthma symptoms.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 8 - You see a 50-year-old gentleman with known bronchiectasis. Over the past 3 days,...

    Incorrect

    • You see a 50-year-old gentleman with known bronchiectasis. Over the past 3 days, his cough has become increasingly productive and the sputum has become more thick and green than usual. He is slightly more short of breath than usual.

      On examination, he is apyrexial, has a respiratory rate of 20, coarse crackles in both lung bases and doesn't appear cyanosed. He has no drug allergies.

      What would be the most appropriate next step in management?

      Your Answer: Amoxicillin 500mg TDS for 5-7 days

      Correct Answer: Sputum culture then amoxicillin 500mg TDS for 5-7 days

      Explanation:

      Treating Infective Exacerbation of Bronchiectasis

      When managing a suspected infective exacerbation of bronchiectasis, it is crucial to obtain a sputum culture before initiating antibiotics. However, treatment should not be delayed until the culture results are available. It is also recommended to administer a more extended course of antibiotics than what is typically prescribed for a lower respiratory tract infection.

      NICE provides specific guidance on the selection and duration of antibiotics based on the identified organism. Additionally, hospital admission should be considered if there are indications of a more severe illness, such as cyanosis, confusion, respiratory rate exceeding 25 breaths per minute, significant breathlessness, or a temperature of 38°C or higher.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 9 - A 23-year-old woman is barely responsive in the waiting area. What single feature...

    Incorrect

    • A 23-year-old woman is barely responsive in the waiting area. What single feature would indicate possible opioid overdose?

      Your Answer: Sweating

      Correct Answer: Hypotension

      Explanation:

      Understanding Acute Opioid Toxicity

      Acute opioid toxicity is a serious condition that can result in drowsiness, nausea, vomiting, and respiratory depression. The severity of symptoms may be exacerbated if alcohol or other sedatives are also involved. Hypotension is a common occurrence, and both tachycardia and bradycardia may be observed. Hypoventilation can lead to hypoxia-induced cardiac arrhythmias, and pinpoint pupils may be present. Sweating is more commonly associated with acute opioid withdrawal. It is important to seek medical attention immediately if you suspect acute opioid toxicity.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 10 - A 75-year-old man with a history of psoriasis complains of dyspnoea during physical...

    Correct

    • A 75-year-old man with a history of psoriasis complains of dyspnoea during physical activity. Upon examination, his respiratory rate is 24 breaths per minute, oxygen saturation is 94% on room air, heart rate is 90 beats per minute, and his chest reveals diffuse fine inspiratory crackles. Spirometry shows an FEV1/FVC ratio of 0.8. Which medication could be responsible for this clinical presentation?

      Your Answer: Methotrexate

      Explanation:

      Methotrexate can lead to pulmonary fibrosis, while there is no evidence to suggest that terbinafine, paracetamol, montelukast, and tramadol have this side effect. The onset of pulmonary fibrosis due to low-dose methotrexate use can occur within weeks to months.

      Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

      Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.

      It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.

    • This question is part of the following fields:

      • Respiratory Health
      113.9
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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory Health (2/10) 20%
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