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Question 1
Incorrect
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A 68-year-old man with lung cancer presents to the Emergency Department complaining of chest pain and shortness of breath. He reports no cough or sputum production. Upon auscultation, his chest is clear. His pulse is irregularly irregular and measures 110 bpm, while his oxygen saturation is 86% on room air. He is breathing at a rate of 26 breaths per minute. What diagnostic investigation is most likely to be effective in this scenario?
Your Answer: Arterial blood gas (ABG)
Correct Answer: Computerised tomography pulmonary angiogram (CTPA)
Explanation:Diagnostic Tests for Pulmonary Embolism in Cancer Patients
Pulmonary embolism (PE) and deep vein thrombosis (DVT) are common in cancer patients due to their hypercoagulable state. When a cancer patient presents with dyspnea, tachycardia, chest pain, and desaturation, PE should be suspected. The gold standard investigation for PE is a computerised tomography pulmonary angiogram (CTPA), which has a high diagnostic yield.
An electrocardiogram (ECG) can also be helpful in diagnosing PE, as sinus tachycardia is the most common finding. However, in this case, the patient’s irregularly irregular pulse is likely due to atrial fibrillation with a rapid ventricular rate, which should be treated alongside investigation of the suspected PE.
A D-dimer test may not be helpful in diagnosing PE in cancer patients, as it has low specificity and may be raised due to the underlying cancer. An arterial blood gas (ABG) should be carried out to help treat the patient, but the cause of hypoxia will still need to be determined.
Bronchoscopy would not be useful in diagnosing PE and should not be performed in this case.
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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 29-year-old electrician was referred to the hospital by his doctor. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. At the time of referral, he was experiencing mild dyspnea, a global headache, myalgia, and arthralgia. On examination, he appeared unwell, had a fever of 39°C, and had a maculopapular rash on his upper body. Fine crackles were audible in the left mid-zone of his chest, and mild neck stiffness was noted.
The following investigations were conducted: Hb 84 g/L (130-180), WBC 8 ×109/L (4-11), Platelets 210 ×109/L (150-400), Reticulocytes 8% (0.5-2.4), Na 129 mmol/L (137-144), K 4.2 mmol/L (3.5-4.9), Urea 5.0 mmol/L (2.5-7.5), Creatinine 110 µmol/L (60-110), Bilirubin 89 µmol/L (1-22), Alk phos 130 U/L (45-105), AST 54 U/L (1-31), and GGT 48 U/L (<50). A chest x-ray revealed patchy consolidation in both mid-zones.
What is the most likely cause of his abnormal blood count?Your Answer: Sepsis syndrome
Correct Answer: IgM anti-i antibodies
Explanation:The patient has pneumonia, hepatitis, and haemolytic anaemia, which can be caused by Mycoplasma pneumonia. This condition can also cause extrapulmonary manifestations such as renal failure, myocarditis, and meningitis. Haemolysis is associated with the presence of IgM antibodies, and sepsis may cause microangiopathic haemolytic anaemia. Clavulanic acid can cause hepatitis, and some drugs can induce haemolysis in patients with G6PD deficiency.
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This question is part of the following fields:
- Respiratory
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Question 3
Correct
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A 68-year-old retired caretaker with a well-documented history of chronic obstructive pulmonary disease (COPD) is admitted, for his fourth time this year, with shortness of breath and a cough productive of green sputum. Examination findings are: respiratory rate (RR) 32 breaths/min, temperature 37.4 °C, SpO2 86% on room air, asterixis and coarse crepitations at the left base. A chest X-ray (CXR) confirms left basal consolidation.
Which arterial blood gas (ABG) picture is likely to belong to the above patient?Your Answer: pH: 7.27, pa (O2): 7.1, pa (CO2): 8.9, HCO3–: 33.20, base excess (BE) 4.9 mmol
Explanation:Interpreting Blood Gas Results in COPD Patients
COPD is a common respiratory disease that can lead to exacerbations requiring hospitalization. In these patients, lower respiratory tract infections can quickly lead to respiratory failure and the need for respiratory support. Blood gas results can provide important information about the patient’s respiratory and metabolic status. In COPD patients, a type II respiratory failure with hypercapnia and acidosis is common, resulting in a low pH and elevated bicarbonate levels. However, blood gas results that show low carbon dioxide or metabolic acidosis are less likely to be in keeping with COPD. Understanding and interpreting blood gas results is crucial in managing COPD exacerbations and providing appropriate respiratory support.
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This question is part of the following fields:
- Respiratory
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Question 4
Correct
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A 63-year-old man presents to the Emergency department with worsening dyspnoea, dry cough, and low-grade fever. He has a medical history of hypertension and was hospitalized six months ago for an acute inferior myocardial infarction complicated by left ventricular failure and arrhythmia. His chest x-ray reveals diffuse interstitial pneumonia, and further investigations show an ESR of 110 mm/h, FEV1 of 90%, FVC of 70%, and KCO of 60%. What is the most likely cause of these findings?
Your Answer: Amiodarone
Explanation:Side Effects of Amiodarone
Amiodarone is a medication that is known to cause several side effects. Among these, pneumonitis and pulmonary fibrosis are the most common. These conditions are characterized by a progressively-worsening dry cough, pleuritic chest pain, dyspnoea, and malaise. Other side effects of amiodarone include neutropenia, hepatitis, phototoxicity, slate-grey skin discolouration, hypothyroidism, hyperthyroidism, arrhythmias, corneal deposits, peripheral neuropathy, and myopathy. It is important to be aware of these potential side effects when taking amiodarone, and to seek medical attention if any of these symptoms occur. Proper monitoring and management can help to minimize the risk of serious complications.
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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 60-year-old male smoker with severe rheumatoid arthritis comes to the clinic complaining of a dry cough and increasing difficulty in breathing over the past few months. During the examination, he appears to be mildly cyanosed and has end inspiratory crepitations. A chest x-ray reveals widespread reticulonodular changes. What is the most probable diagnosis?
Your Answer: Rheumatoid lung
Explanation:Diagnosis and Differential Diagnosis of Pulmonary Fibrosis
Pulmonary fibrosis is suspected in a patient with a history and examination features that suggest the condition. Rheumatoid lung is a common cause of pulmonary fibrosis, especially in severe rheumatoid disease and smokers. The reported changes on the chest X-ray are consistent with the diagnosis. However, to diagnose respiratory failure, a blood gas result is necessary.
On the other hand, bronchial asthma is characterized by reversible airways obstruction, which leads to fluctuation of symptoms and wheezing on auscultation. The history of the patient is not consistent with chronic obstructive pulmonary disease (COPD). Pneumonia, on the other hand, is suggested by infective symptoms, pyrexia, and consolidation on CXR.
In summary, the diagnosis of pulmonary fibrosis requires a thorough history and examination, as well as imaging studies. Differential diagnosis should include other conditions that present with similar symptoms and signs, such as bronchial asthma, COPD, and pneumonia.
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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 65-year-old woman presents to a spirometry clinic with a history of progressive dyspnea on exertion over the past six months, particularly when hurrying or walking uphill. What spirometry result would indicate a possible diagnosis of chronic obstructive pulmonary disease in this patient?
Your Answer: FEV1: < 30% predicted, FEV1/FVC ratio: < 0.70
Correct Answer:
Explanation:Interpreting Spirometry Results: Understanding FEV1 and FEV1/FVC Ratio
Spirometry is a common diagnostic test used to assess lung function. It measures the amount of air that can be exhaled forcefully and quickly after taking a deep breath. Two important measurements obtained from spirometry are the forced expiratory volume in 1 second (FEV1) and the ratio of FEV1 to forced vital capacity (FVC).
Identifying an obstructive disease pattern
In chronic obstructive pulmonary disease (COPD), the airways are obstructed, resulting in a reduced FEV1. However, the lung volume is relatively normal, and therefore the FVC will be near normal too. COPD is diagnosed as an FEV1 < 80% predicted and an FEV1/FVC < 0.70. Understanding the clinical scenario While an FEV1 < 30% predicted and an FEV1/FVC < 0.70 indicate an obstructive picture, it is important to refer to the clinical scenario. Shortness of breath on mild exertion, particularly walking up hills or when hurrying, is likely to relate to an FEV1 between 50-80%, defined by NICE as moderate airflow obstruction. Differentiating between obstructive and restrictive lung patterns An FVC < 80% expected value is indicative of a restrictive lung pattern. In COPD, the FVC is usually preserved or increased, hence the FEV1/FVC ratio decreases. An FEV1 of <0.30 indicates severe COPD, but it is not possible to have an FEV1/FVC ratio of > 0.70 with an FEV1 this low in COPD. It is important to note, however, that in patterns of restrictive lung disease, you can have a reduced FEV1 with a normal FEV1/FVC ratio.
Conclusion
Interpreting spirometry results requires an understanding of FEV1 and FEV1/FVC ratio. Identifying an obstructive disease pattern, understanding the clinical scenario, and differentiating between obstructive and restrictive lung patterns are crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Respiratory
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Question 7
Incorrect
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A 29-year-old electrician was referred to the hospital by his general practitioner. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for the past three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. On the day of referral, he reported mild dyspnea, a global headache, myalgia, and arthralgia. During the examination, a maculopapular rash was observed on his upper body, and fine crackles were audible in the left mid-zone of his chest. Mild neck stiffness was also noted. His vital signs showed a fever of 39°C and a blood pressure of 120/70 mmHg.
The following investigations were conducted:
- Hb: 84 g/L (130-180)
- WBC: 8 ×109/L (4-11)
- Platelets: 210 ×109/L (150-400)
- Reticulocytes: 8% (0.5-2.4)
- Na: 137 mmol/L (137-144)
- K: 4.2 mmol/L (3.5-4.9)
- Urea: 5.0 mmol/L (2.5-7.5)
- Creatinine: 110 µmol/L (60-110)
- Bilirubin: 19 µmol/L (1-22)
- Alk phos: 130 U/L (45-105)
- AST: 54 U/L (1-31)
- GGT: 48 U/L (<50)
The chest x-ray revealed patchy consolidation in both mid-zones. What is the most appropriate course of treatment?Your Answer: Co-trimoxazole
Correct Answer: Clarithromycin
Explanation:Mycoplasma Pneumonia: Symptoms, Complications, and Treatment
Mycoplasma pneumonia is a type of pneumonia that commonly affects individuals aged 15-30 years. It is characterized by systemic upset, dry cough, and fever, with myalgia and arthralgia being common symptoms. Unlike other types of pneumonia, the white blood cell count is often within the normal range. In some cases, Mycoplasma pneumonia can also cause extrapulmonary manifestations such as haemolytic anaemia, renal failure, hepatitis, myocarditis, meningism and meningitis, transverse myelitis, cerebellar ataxia, and erythema multiforme.
One of the most common complications of Mycoplasma pneumonia is haemolytic anaemia, which is associated with the presence of cold agglutinins found in up to 50% of cases. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies in paired sera. Treatment typically involves the use of macrolide antibiotics such as clarithromycin or erythromycin, with tetracycline or doxycycline being alternative options.
In summary, Mycoplasma pneumonia is a type of pneumonia that can cause a range of symptoms and complications, including haemolytic anaemia and extrapulmonary manifestations. Diagnosis is based on the demonstration of anti-Mycoplasma antibodies, and treatment typically involves the use of macrolide antibiotics.
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This question is part of the following fields:
- Respiratory
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Question 8
Correct
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A 35-year-old male presents with recurrent dyspnoea and cough. He has a medical history of asthma and has been hospitalized in the past due to asthma and two recent cases of pneumonia. On examination, he has bilateral wheeze and a mild fever. His sputum is thick and sticky. Blood tests reveal an ESR of 72 mm/hr (1-10) and elevated IgE levels. What is the most probable diagnosis?
Your Answer: Allergic bronchopulmonary aspergillosis
Explanation:Allergic Bronchopulmonary Aspergillosis: Symptoms and Treatment
Allergic bronchopulmonary aspergillosis is a condition that occurs when the body has an allergic reaction to Aspergillus fumigatus. This can result in symptoms such as wheezing, coughing, difficulty breathing, and recurrent pneumonia. Blood tests may show an increase in IgE levels and eosinophil count. Unfortunately, it is difficult to completely eliminate the fungus, so treatment typically involves high doses of prednisolone to reduce inflammation while waiting for clinical and radiographic improvement.
Allergic bronchopulmonary aspergillosis is a condition that occurs when the body has an allergic reaction to Aspergillus fumigatus. This can result in symptoms such as wheezing, coughing, difficulty breathing, and recurrent pneumonia. Blood tests may show an increase in IgE levels and eosinophil count.
Unfortunately, it is difficult to completely eliminate the fungus, so treatment typically involves high doses of prednisolone to reduce inflammation while waiting for clinical and radiographic improvement.
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This question is part of the following fields:
- Respiratory
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Question 9
Correct
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A 25-year-old male graduate student comes to the clinic complaining of shortness of breath during physical activity for the past two months. He denies any other symptoms and is a non-smoker. Upon examination, there are no abnormalities found, and his full blood count and chest x-ray are normal. What diagnostic test would be most useful in confirming the suspected diagnosis?
Your Answer: Spirometry before and after exercise
Explanation:Confirming Exercise-Induced Asthma Diagnosis
To confirm the suspected diagnosis of exercise-induced asthma, the most appropriate investigation would be spirometry before and after exercise. This patient is likely to have exercise-induced asthma, which means that his asthma symptoms are triggered by physical activity. Spirometry is a lung function test that measures how much air a person can inhale and exhale. By performing spirometry before and after exercise, doctors can compare the results and determine if there is a significant decrease in lung function after physical activity. If there is a significant decrease, it confirms the diagnosis of exercise-induced asthma. This test is important because it helps doctors develop an appropriate treatment plan for the patient. With the right treatment, patients with exercise-induced asthma can still participate in physical activity and lead a healthy lifestyle.
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This question is part of the following fields:
- Respiratory
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Question 10
Incorrect
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A 78-year-old man with known alcohol dependence presents to the Emergency Department with a few weeks of productive cough, weight loss, fever and haemoptysis. He is a heavy smoker, consuming 30 cigarettes per day. On a chest X-ray, multiple nodules 1-3 mm in size are visible throughout both lung fields. What is the best treatment option to effectively address the underlying cause of this man's symptoms?
Your Answer: Systemic chemotherapy
Correct Answer: Anti-tuberculous (TB) chemotherapy
Explanation:Choosing the Right Treatment: Evaluating Options for a Patient with Suspected TB
A patient presents with a subacute history of fever, productive cough, weight loss, and haemoptysis, along with a chest X-ray description compatible with miliary TB. Given the patient’s risk factors for TB, such as alcohol dependence and smoking, anti-TB chemotherapy is the most appropriate response, despite the possibility of lung cancer. IV antibiotics may be used until sputum staining and culture results are available, but systemic chemotherapy would likely lead to overwhelming infection and death. Tranexamic acid may be useful for significant haemoptysis, but it will not treat the underlying diagnosis. acyclovir is not indicated, as the patient does not have a history of rash, and a diagnosis of miliary TB is more likely than varicella pneumonia. Careful evaluation of the patient’s history and symptoms is crucial in choosing the right treatment.
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This question is part of the following fields:
- Respiratory
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Question 11
Incorrect
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A 29-year-old woman comes to the Emergency Department complaining of right-sided chest pain. She reports experiencing fever and shortness of breath for the past week. Upon examination, there are reduced breath sounds on the right side, and a chest X-ray reveals a right pleural effusion without loculation. The patient consents to a thoracentesis to obtain a sample of the pleural fluid.
What is the optimal location for needle insertion?Your Answer: Below the seventh rib
Correct Answer: Above the fifth rib in the mid-axillary line
Explanation:Proper Placement for Thoracentesis: Avoiding Nerve and Vessel Damage
When performing a thoracentesis to sample pleural fluid, it is crucial to ensure that the needle is inserted into a pocket of fluid. This is typically done with ultrasound guidance, but in some cases, doctors must percuss the thorax to identify an area of increased density. However, it is important to remember that the intercostal neurovascular bundle runs inferior to the rib, so the needle should be inserted above the rib to avoid damaging nearby nerves and vessels. The needle is generally inserted through the patient’s back to minimize discomfort and decrease the risk of damaging the neurovascular bundle. The BTS guidelines recommend aspirating from the triangle of safety under the axilla, but it is common practice to aspirate more posteriorly. Of the options listed, only inserting the needle above the fifth rib in the mid-axillary line meets all of these criteria. Other options are either too high, too low, or risk damaging nearby nerves and vessels. Proper placement is crucial for a successful and safe thoracentesis procedure.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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An 80-year-old woman came to the Emergency Department complaining of severe dyspnoea. A chest X-ray showed an opaque right hemithorax. She had no history of occupational exposure to asbestos. Her husband worked in a shipyard 35 years ago, but he had no lung issues. She has never been a smoker. Upon thorax examination, there was reduced movement on the right side, with absent breath sounds and intercostal fullness.
What is the probable reason for the radiological finding?Your Answer: Lung collapse
Correct Answer: Mesothelioma
Explanation:Pleural Pathologies: Mesothelioma and Differential Diagnoses
Workers who are exposed to asbestos are at a higher risk of developing lung pathologies such as asbestosis and mesothelioma. Indirect exposure can also occur when family members come into contact with asbestos-covered clothing. This condition affects both the lungs and pleural space, with short, fine asbestos fibers transported by the lymphatics to the pleural space, causing irritation and leading to plaques and fibrosis. Pleural fibrosis can also result in rounded atelectasis, which can mimic a lung mass on radiological imaging.
Mesothelioma, the most common type being epithelial, typically occurs 20-40 years after asbestos exposure and is characterized by exudative and hemorrhagic pleural effusion with high levels of hyaluronic acid. Treatment options are generally unsatisfactory, with local radiation and chemotherapy being used with variable results. Tuberculosis may also present with pleural effusion, but other systemic features such as weight loss, night sweats, and cough are expected. Lung collapse would show signs of mediastinal shift and intercostal fullness would not be typical. Pneumonectomy is not mentioned in the patient’s past, and massive consolidation may show air bronchogram on X-ray and bronchial breath sounds.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A 68-year-old woman presents to the Emergency Department with a 48-hour history of shortness of breath and an increased volume and purulence of sputum. She has a background history of chronic obstructive pulmonary disease (COPD), hypertension and ischaemic heart disease. Her observations show: heart rate (HR) 116 bpm, blood pressure (BP) 124/68 mmHg, respiratory rate (RR) 18 breaths per minute and oxygen saturation (SaO2) 94% on 2l/min via nasal cannulae. She is commenced on treatment for an infective exacerbation of COPD with nebulised bronchodilators, intravenous antibiotics, oral steroids and controlled oxygen therapy with a Venturi mask. After an hour of therapy, the patient is reassessed. Her observations after an hour are: BP 128/74 mmHg, HR 124 bpm, RR 20 breaths per minute and SaO2 93% on 24% O2 via a Venturi mask. Arterial blood gas sampling is performed:
Investigation Result Normal value
pH 7.28 7.35–7.45
PO2 8.6 kPa 10.5–13.5 kPa
pCO2 8.4 kPa 4.6–6.0 kPa
cHCO3- (P)C 32 mmol/l 24–30 mmol/l
Lactate 1.4 mmol/l 0.5–2.2 mmol/l
Sodium (Na+) 134 mmol/l 135–145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
Chloride (Cl-) 116 mmol/l 98-106 mmol/l
Glucose 5.4 mmol/l 3.5–5.5 mmol/l
Following this review and the arterial blood gas results, what is the most appropriate next step in this patient’s management?Your Answer: The patient should be given intravenous magnesium therapy
Correct Answer: The patient should be considered for non-invasive ventilation (NIV)
Explanation:Management of Respiratory Acidosis in COPD Patients
The management of respiratory acidosis in COPD patients requires careful consideration of the individual’s condition. In this scenario, the patient should be considered for non-invasive ventilation (NIV) as recommended by the British Thoracic Society. NIV is particularly indicated in patients with a pH of 7.25–7.35. Patients with a pH of <7.25 may benefit from NIV but have a higher risk for treatment failure and therefore should be considered for management in a high-dependency or intensive care setting. However, NIV is not indicated in patients with impaired consciousness, severe hypoxaemia or copious respiratory secretions. It is important to note that a ‘Do Not Resuscitate Order’ should not be automatically made for patients with COPD. Each decision regarding resuscitation should be made on an individual basis. Intubation and ventilation should not be the first line of treatment in this scenario. A trial of NIV would be the most appropriate next step, as it has been demonstrated to reduce the need for intensive care management in this group of patients. Increasing the patient’s oxygen may be appropriate in type 1 respiratory failure, but in this case, NIV is the recommended approach. Intravenous magnesium therapy is not routinely recommended in COPD and is only indicated in the context of acute asthma. In conclusion, the management of respiratory acidosis in COPD patients requires a tailored approach based on the individual’s condition. NIV should be considered as the first line of treatment in this scenario.
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This question is part of the following fields:
- Respiratory
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Question 14
Incorrect
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You have a telephone consultation with a 28-year-old male who wants to start trying to conceive. He has a history of asthma and takes salbutamol 100mcg as needed.
Which of the following would be most important to advise?Your Answer: A referral to a specialist is required and she can start trying to conceive immediately
Correct Answer: Take folic acid 5 mg once daily from before conception until 12 weeks of pregnancy
Explanation:Women who are taking antiepileptic medication and are planning to conceive should be prescribed a daily dose of 5mg folic acid instead of the standard 400mcg. This high-dose folic acid should be taken from before conception until the 12th week of pregnancy to reduce the risk of neural tube defects. It is important to refer these women to specialist care, but they should continue to use effective contraception until they have had a full assessment. Despite the medication, it is still likely that they will have a normal pregnancy and healthy baby. If trying to conceive, women should start taking folic acid as soon as possible, rather than waiting for a positive pregnancy test.
Folic Acid: Importance, Deficiency, and Prevention
Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.
To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.
In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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A 60-year-old man visits his General Practitioner complaining of shortness of breath, nocturnal cough and wheezing for the past week. He reports that these symptoms began after he was accidentally exposed to a significant amount of hydrochloric acid fumes while working in a chemical laboratory. He has no prior history of respiratory issues or any other relevant medical history. He is a non-smoker.
What initial investigation may be the most useful in confirming the diagnosis?Your Answer: Peak flow
Correct Answer: Methacholine challenge test
Explanation:Diagnostic Tests for Reactive Airways Dysfunction Syndrome (RADS)
Reactive Airways Dysfunction Syndrome (RADS) is a condition that presents with asthma-like symptoms after exposure to irritant gases, vapours or fumes. To diagnose RADS, several tests may be performed to exclude other pulmonary diagnoses and confirm the presence of the condition.
One of the diagnostic criteria for RADS is the absence of pre-existing respiratory conditions. Additionally, the onset of asthma symptoms should occur after a single exposure to irritants in high concentration, with symptoms appearing within 24 hours of exposure. A positive methacholine challenge test (< 8 mg/ml) following exposure and possible airflow obstruction on pulmonary function tests can also confirm the diagnosis. While a chest X-ray and full blood count may be requested to exclude other causes of symptoms, they are usually unhelpful in confirming the diagnosis of RADS. Peak flow is also not useful in diagnosis, as there is no pre-existing reading to compare values. The skin prick test may be useful in assessing reactions to common environmental allergens, but it is not helpful in diagnosing RADS as it occurs after one-off exposures. In conclusion, a combination of diagnostic tests can help confirm the diagnosis of RADS and exclude other pulmonary conditions.
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This question is part of the following fields:
- Respiratory
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Question 16
Correct
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A 40-year-old woman has presented with recurrent respiratory distress over the last 4 years. She has also complained of wheezing at night and coughing up of tenacious sputum, which was occasionally black. Blood reports showed:
Investigation Result Normal value
Haemoglobin 112g/dl 115–155 g/l
White cell count (WCC) 12 × 109/l 4–11 × 109/l
Neutrophil count 6.0 × 109/l 2.5–7.58 × 109/l
Eosinophil count 1.5 × 109/l 0–0.4 × 109/l
Lymphocyte count 4.1 × 109/l 1.0–4.5 × 109/l
Serum immunoglobulin E (IgE) 2800 IU/l 1–87 IU/l
Which of the following is the most likely finding on a chest computerised tomography (CT) scan?Your Answer: Central cystic/varicose bronchiectasis in multiple lobes
Explanation:Understanding Different Types of Bronchiectasis and Their Possible Underlying Causes
Bronchiectasis is a condition where the bronchial tubes in the lungs become permanently damaged and widened, leading to chronic cough, sputum production, and recurrent infections. However, bronchiectasis can have different patterns and locations, which may indicate different underlying causes or associated conditions. Here are some examples:
– Central cystic/varicose bronchiectasis in multiple lobes: This may suggest allergic bronchopulmonary aspergillosis (ABPA) or allergic bronchopulmonary mycosis (ABPM), which are allergic reactions to Aspergillus fungi. ABPA can also occur without bronchiectasis, but the presence of bronchiectasis can worsen the prognosis. Other possible differentials include sarcoidosis, Churg–Strauss syndrome, bronchocentric granulomatosis, or eosinophilic pneumonia.
– Bronchiectasis mainly in upper lobes: This may be seen in chronic asthma, but usually, it is focal and limited to one or two lobes.
– Central bronchiectasis in mainly a single lobe: This may also suggest chronic asthma.
– Lower lobe fibrosis in both lungs: This may suggest interstitial lung disease, which is a group of conditions that cause inflammation and scarring of the lung tissue.
– Diffuse bronchiectasis involving mid-lung fields: This may suggest immotile Ciliary syndrome, which is a genetic disorder that affects the function of Ciliary, the tiny hair-like structures that help move mucous out of the airways.In summary, the location and pattern of bronchiectasis can provide clues to the underlying cause or associated conditions, but further tests and evaluations are needed to confirm the diagnosis and guide the treatment.
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This question is part of the following fields:
- Respiratory
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Question 17
Correct
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A 35-year-old woman with a history of asthma and eczema visits her General Practitioner and inquires about the reason for her continued wheezing hours after being exposed to pollen. She has a known allergy to tree pollen.
What is the most suitable explanation for this?Your Answer: Inflammation followed by mucosal oedema
Explanation:Understanding the Mechanisms of Allergic Asthma
Allergic asthma is a condition that is mediated by immunoglobulin E (IgE). When IgE binds to an antigen, it triggers mast cells to release histamine, leukotrienes, and prostaglandins, which cause bronchospasm and vasodilation. This leads to inflammation and edema of the mucosal lining of the airways, resulting in persistent symptoms or late symptoms after an acute asthma attack.
While exposure to another allergen could trigger an asthma attack, it is not the most appropriate answer if you are only aware of a known allergy to tree pollen. Smooth muscle hypertrophy may occur in the long-term, but the exact mechanism and functional effects of airway remodeling in asthma are not fully understood. Pollen stuck on Ciliary would act as a cough stimulant, clearing the pollen from the respiratory tract. Additionally, the Ciliary would clear the pollen up the respiratory tract as part of the mucociliary escalator.
It is important to note that pollen inhaled into the respiratory system is not systemically absorbed. Instead, it binds to immune cells and exhibits immune effects through cytokines produced by Th1 and Th2 cells. Understanding the mechanisms of allergic asthma can help individuals manage their symptoms and prevent future attacks.
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This question is part of the following fields:
- Respiratory
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Question 18
Correct
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A 28-year-old woman presents to her Occupational Health Service. She works in the sterile supplies group at her local hospital. Over the past few months, she has noticed increasing shortness of breath with cough and wheeze during the course of a working week, but improves when she takes a week off on holiday. On examination at the general practitioner’s surgery, after a few weeks off, her chest is clear.
Peak flow diary:
Monday p.m 460 l/min (85% predicted)
Tuesday p.m 440 l/min
Wednesday p.m 400 l/min
Thursday p.m 370 l/min
Friday p.m 350 l/min
Saturday a.m 420 l/min
Which of the following is the most appropriate treatment choice?Your Answer: Redeployment to another role if possible
Explanation:Managing Occupational Asthma: Redeployment and Avoiding Suboptimal Treatment Options
Based on the evidence from the patient’s peak flow diary, it is likely that they are suffering from occupational asthma. This could be due to a number of agents, such as glutaraldehyde used in hospital sterilisation units. The best course of action would be to redeploy the patient to another role, if possible, and monitor their peak flows at work. Starting medical management for asthma would not be the optimal choice in this case. Other causes of occupational asthma include isocyanates, metals, animal antigens, plant products, acid anhydrides, biological enzymes, and wood dusts. While salbutamol inhaler may provide temporary relief, it is not a long-term solution. Inhaled steroids like beclomethasone or fluticasone/salmeterol may help manage symptoms, but since the cause has been identified, they would not be the most appropriate course of action. A 7-day course of oral prednisolone would only provide temporary relief and is not a realistic long-term treatment option.
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This question is part of the following fields:
- Respiratory
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Question 19
Correct
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A 50-year-old man, with a history of chronic obstructive pulmonary disease (COPD), is admitted to hospital with sudden-onset shortness of breath. His oxygen saturation levels are 82%, respiratory rate (RR) 25 breaths/min (normal 12–18 breaths/min), his trachea is central, he has reduced breath sounds in the right lower zone. Chest X-ray reveals a 2.5 cm translucent border at the base of the right lung.
Given the likely diagnosis, what is the most appropriate management?Your Answer: Intrapleural chest drain
Explanation:Management of Spontaneous Pneumothorax in a Patient with COPD
When a patient with COPD presents with a spontaneous pneumothorax, prompt intervention is necessary. Smoking is a significant risk factor for pneumothorax, and recurrence rates are high for secondary pneumothorax. In deciding between needle aspiration and intrapleural chest drain, the size of the pneumothorax is crucial. In this case, the patient’s pneumothorax was >2 cm, requiring an intrapleural chest drain. Intubation and NIV are not necessary interventions at this time. Observation alone is not sufficient, and the patient requires urgent intervention due to low oxygen saturation, high respiratory rate, shortness of breath, and reduced breath sounds.
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This question is part of the following fields:
- Respiratory
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Question 20
Correct
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A 65-year-old man complains of worsening shortness of breath. During examination, the left base has a stony dull percussion note. A chest x-ray reveals opacification in the lower lobe of the left lung. What is the most suitable test for this patient?
Your Answer: Ultrasound-guided pleural fluid aspiration
Explanation:Left Pleural Effusion Diagnosis
A left pleural effusion is present in this patient, which is likely to be significant in size. To diagnose this condition, a diagnostic aspiration is necessary. The fluid obtained from the aspiration should be sent for microscopy, culture, and cytology to determine the underlying cause of the effusion. Proper diagnosis is crucial in determining the appropriate treatment plan for the patient. Therefore, it is essential to perform a diagnostic aspiration and analyze the fluid obtained to provide the best possible care for the patient.
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This question is part of the following fields:
- Respiratory
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