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Question 1
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A 56-year-old woman presents to the Emergency Department with a 2-week history of productive cough with green sputum and a one day history of palpitations. She also had some rigors and fever. On examination:
Result Normal
Respiratory rate (RR) 26 breaths/min 12–18 breaths/min
Sats 96% on air 94–98%
Blood pressure (BP) 92/48 mmHg <120/80 mmHg
Heart rate (HR) 130 bpm 60–100 beats/min
Some bronchial breathing at left lung base, heart sounds normal however with an irregularly irregular pulse. electrocardiogram (ECG) showed fast atrial fibrillation (AF). She was previously fit and well.
Which of the following is the most appropriate initial management?Your Answer: Intravenous fluids
Explanation:Treatment for AF in a Patient with Sepsis
In a patient with sepsis secondary to pneumonia, the new onset of AF is likely due to the sepsis. Therefore, the priority is to urgently treat the sepsis with intravenous fluids and broad-spectrum antibiotics. If the AF persists after the sepsis is treated, other options for AF treatment can be considered. Bisoprolol and digoxin are not the first-line treatments for AF in this case. Oral antibiotics are not recommended for septic patients. Flecainide may be considered if the AF persists after the sepsis is treated.
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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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An 85-year-old man with chronic COPD presents for a review of his home oxygen therapy. The following results are from his arterial blood gas (ABG):
pH 7.37 (normal range 7.35–7.45)
pa(O2) 7.6 (normal range 10–14 kPa)
pa(CO2) 8 (normal range 4.0–6.0 kPa)
HCO3 37 (normal range 22–26 mmol)
base excess +6 (normal range −2 to +2 mmol).
Which of the following best describe this man’s blood gas result?Your Answer: Compensation for respiratory acidosis secondary to chronic respiratory disease
Explanation:Understanding ABGs: A Five-Step Approach and Mnemonic
Arterial blood gas (ABG) analysis is a crucial tool in assessing a patient’s respiratory and metabolic status. The Resuscitation Council (UK) recommends a five-step approach to interpreting ABGs:
1. Assess the patient.
2. Assess their oxygenation (pa(O2) should be >10 kPa).
3. Determine if the patient is acidotic (pH < 7.35) or alkalotic (pH > 7.45).
4. Assess respiratory status by determining if their pa(CO2) is high or low.
5. Assess metabolic status by determining if their bicarbonate (HCO3) is high or low.To aid in understanding ABGs, the mnemonic ROME can be used:
– Respiratory = Opposite: A low pH and high pa(CO2) indicate respiratory acidosis, while a high pH and low pa(CO2) indicate respiratory alkalosis.
– Metabolic = Equivalent: A high pH and high HCO3 indicate metabolic alkalosis, while a low pH and low HCO3 indicate metabolic acidosis.Compensation for respiratory acidosis secondary to chronic respiratory disease is characterized by a normal pH, high pa(CO2), and high HCO3, indicating renal compensation. In contrast, compensation for respiratory alkalosis secondary to chronic respiratory disease would show a low pa(CO2) and a high pH.
Partial compensation for respiratory acidosis secondary to chronic respiratory disease is characterized by a high pa(CO2) and a high HCO3, with a normal pH indicating full compensation and a mildly altered pH indicating partial compensation. Compensation for metabolic acidosis secondary to chronic respiratory disease is not applicable, as this condition would present with low HCO3 levels.
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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 54-year-old smoker comes to the clinic with complaints of chest pain and cough. He reports experiencing more difficulty breathing and a sharp pain in his third and fourth ribs. Upon examination, a chest x-ray reveals an enlargement on the right side of his hilum. What is the most probable diagnosis?
Your Answer: Bronchogenic carcinoma
Explanation:Diagnosis of Bronchogenic Carcinoma
The patient’s heavy smoking history, recent onset of cough, and bony pain strongly suggest bronchogenic carcinoma. The appearance of the chest X-ray further supports this diagnosis. While COPD can also cause cough and dyspnea, it is typically accompanied by audible wheezing and the presence of a hilar mass is inconsistent with this diagnosis. Neither tuberculosis nor lung collapse are indicated by the patient’s history or radiographic findings. Hyperparathyroidism is not a consideration unless hypercalcemia is present. Overall, the evidence points towards a diagnosis of bronchogenic carcinoma.
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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 25-year-old woman comes to her GP complaining of breathlessness, dry cough and occasional wheezing.
What investigation finding would indicate a diagnosis of asthma?Your Answer: A 10% or higher improvement in FEV1 following a nebulised bronchodilator
Correct Answer: Fraction exhaled nitric oxide (FeNO) 50 parts per billion (ppb)
Explanation:Diagnostic Criteria for Asthma: Key Indicators to Consider
Asthma is a chronic respiratory disease that affects millions of people worldwide. It is characterized by airway inflammation, bronchoconstriction, and increased mucous production, leading to symptoms such as wheezing, coughing, and shortness of breath. Diagnosing asthma can be challenging, as its symptoms can mimic those of other respiratory conditions. However, several key indicators can help healthcare professionals make an accurate diagnosis.
Fraction exhaled nitric oxide (FeNO) 50 parts per billion (ppb): An FeNO level > 40 ppb is indicative of asthma.
Forced expiratory volume in 1 second/forced vital capacity ratio (FEV1/FVC ratio) ≥ 75%: An obstructive FEV1/FVC ratio < 70% would support a diagnosis of asthma in this patient. A 10% or higher improvement in FEV1 following a nebulised bronchodilator: A 12% or higher improvement in FEV1 following a nebulised bronchodilator supports a diagnosis of asthma. A 150 ml or higher improvement in FEV1 following a nebulised bronchodilator: A 200 ml or higher improvement in FEV1 following a nebulised bronchodilator supports a diagnosis of asthma. Greater than 15% variability in peak expiratory flow rate (PEFR) on monitoring: Greater than 20% variability in PEFR on monitoring supports a diagnosis of asthma. In conclusion, healthcare professionals should consider these key indicators when diagnosing asthma. However, it is important to note that asthma is not the only cause of these indicators, and a comprehensive evaluation of the patient’s medical history, physical examination, and other diagnostic tests may be necessary to make an accurate diagnosis.
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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 30-year-old woman comes to the General Practice Clinic complaining of feeling unwell for the past few days. She has been experiencing nasal discharge, sneezing, fatigue, and a cough. Her 3-year-old daughter recently recovered from very similar symptoms. During the examination, her pulse rate is 62 bpm, respiratory rate 18 breaths per minute, and temperature 37.2 °C. What is the probable causative organism for her symptoms?
Your Answer: Rhinovirus
Explanation:Identifying the Most Common Causative Organisms of the Common Cold
The common cold is a viral infection that affects millions of people worldwide. Among the different viruses that can cause the common cold, rhinoviruses are the most common, responsible for 30-50% of cases annually. influenzae viruses can also cause milder symptoms that overlap with those of the common cold, accounting for 5-15% of cases. Adenoviruses and enteroviruses are less common causes, accounting for less than 5% of cases each. Respiratory syncytial virus is also a rare cause of the common cold, accounting for only 5% of cases annually. When trying to identify the causative organism of a common cold, it is important to consider the patient’s symptoms, recent exposure to sick individuals, and prevalence of different viruses in the community.
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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 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: Lower lobe fibrosis in both lungs
Correct 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 7
Correct
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A 28-year-old female patient presents to your clinic seeking help to quit smoking. Despite several attempts in the past, she has been unsuccessful. She has a medical history of bipolar disorder and well-managed epilepsy, for which she takes lamotrigine. She currently smokes 15 cigarettes per day and is especially interested in the health benefits of quitting smoking since she has recently found out that she is pregnant. As her physician, you decide to prescribe a suitable medication to assist her in her efforts. What would be the most appropriate treatment option?
Your Answer: Nicotine gum
Explanation:Standard treatments for nicotine dependence do not include amitriptyline, fluoxetine, or gabapentin. Nicotine replacement therapy (NRT) can be helpful for motivated patients, but it is not a cure for addiction and may require multiple attempts. Bupropion and varenicline are other smoking cessation aids, but they have multiple side effects and may not be suitable for all patients. NICE guidelines recommend discussing the best method of smoking cessation with the patient, but NRT is considered safer in pregnancy.
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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 30-year-old woman with asthma presented with rapidly developing asthma and wheezing. She was admitted, and during her treatment, she coughed out tubular gelatinous materials. A chest X-ray showed collapse of the lingular lobe.
What is this clinical spectrum better known as?Your Answer: Cardiac asthma
Correct Answer: Plastic bronchitis
Explanation:Respiratory Conditions: Plastic Bronchitis, Loeffler Syndrome, Lofgren Syndrome, Cardiac Asthma, and Croup
Plastic Bronchitis: Gelatinous or rigid casts form in the airways, leading to coughing. It is associated with asthma, bronchiectasis, cystic fibrosis, and respiratory infections. Treatment involves bronchial washing, sputum induction, and preventing infections. Bronchoscopy may be necessary for therapeutic removal of the casts.
Loeffler Syndrome: Accumulation of eosinophils in the lungs due to parasitic larvae passage. Charcot-Leyden crystals may be present in the sputum.
Lofgren Syndrome: Acute presentation of sarcoidosis with hilar lymphadenopathy and erythema nodosum. Usually self-resolving.
Cardiac Asthma: Old term for acute pulmonary edema, causing peribronchial fluid collection and wheezing. Pink frothy sputum is produced.
Croup: Acute pharyngeal infection in children aged 6 months to 3 years, presenting with stridor.
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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 21-year-old man experiences sudden right-sided chest pain while exercising. The pain persists in the Emergency Department, but he is not short of breath. There is no past medical history of note. Observations are recorded:
temperature 36.6 °C
heart rate (HR) 90 bpm
blood pressure (BP) 115/80 mmHg
respiratory rate (RR) 18 breaths/minute
oxygen saturation (SaO2) 99%.
A chest X-ray reveals a 1.5 cm sliver of air in the pleural space of the right lung.
Which of the following is the most appropriate course of action?Your Answer: Consider prescribing analgesia and discharge home with information and advice
Explanation:Management Options for Primary Pneumothorax
Primary pneumothorax is a condition where air accumulates in the pleural space, causing the lung to collapse. The management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. Here are some management options for primary pneumothorax:
Prescribe analgesia and discharge home with information and advice: This option can be considered if the patient is not breathless and has only a small defect. The patient can be discharged with pain relief medication and given information and advice on how to manage the condition at home.
Admit for a trial of nebulised salbutamol and observation: This option is not indicated for a patient with primary pneumothorax, as a trial of salbutamol is not effective in treating this condition.
Aspirate the air with a needle and syringe: This option should only be attempted if the patient has a rim of air of >2 cm on the chest X-ray or is breathless. Aspiration can be attempted twice at a maximum, after which a chest drain should be inserted.
Insert a chest drain: This option should be done if the second attempt of aspiration is unsuccessful. Once air has stopped leaking, the drain should be left in for a further 24 hours prior to removal and discharge.
Insert a 16G cannula into the second intercostal space: This option is used for tension pneumothoraces and is not indicated for primary pneumothorax.
In conclusion, the management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. It is important to choose the appropriate management option to ensure the best outcome for the patient.
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This question is part of the following fields:
- Respiratory
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Question 10
Correct
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A 38-year-old male presents with complaints of difficulty breathing. During the physical examination, clubbing of the fingers is observed. What medical condition is commonly associated with clubbing?
Your Answer: Pulmonary fibrosis
Explanation:Respiratory and Other Causes of Clubbing of the Fingers
Clubbing of the fingers is a condition where the tips of the fingers become enlarged and the nails curve around the fingertips. This condition is often associated with respiratory diseases such as carcinoma of the lung, bronchiectasis, mesothelioma, empyema, and pulmonary fibrosis. However, it is not typically associated with chronic obstructive airway disease (COAD). Other causes of clubbing of the fingers include cyanotic congenital heart disease, inflammatory bowel disease, and infective endocarditis.
In summary, clubbing of the fingers is a physical manifestation of various underlying medical conditions. It is important to identify the underlying cause of clubbing of the fingers in order to provide appropriate treatment and management.
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This question is part of the following fields:
- Respiratory
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