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Question 1
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: Take folic acid 400 mcg once daily from before conception until 12 weeks of pregnancy
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 2
Incorrect
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A middle-aged man is brought into the Emergency Department after a road traffic collision (RTC). During examination, he is found to be tachycardic at 120 bpm, sweating profusely, and pale. His right side has decreased breath sounds and chest movement, and his trachea is deviated to the left. You are requested to insert a large-bore cannula.
Where would you position it in this patient?Your Answer: In the third intercostal space, mid-clavicular line, on the side of the decreased breath sounds
Correct Answer: In the second intercostal space, mid-clavicular line, on the side of the decreased breath sounds
Explanation:To treat a tension pneumothorax, emergency intervention is required. A large-bore cannula should be inserted into the second intercostal space, mid-clavicular line, on the side where breath sounds are decreased to relieve pressure in the pleural space. This is the correct location for needle decompression. However, it is important to note that definitive management involves inserting an intercostal chest drain. Inserting a needle into the fifth intercostal space, mid-axillary line of the chest, on the side of the decreased breath sounds is incorrect for needle decompression, but it is where the chest drain will be inserted afterwards. Inserting a needle into the second intercostal space, mid-axillary line of the chest, on the side with normal breath sounds is the correct space, but the wrong location and wrong side of the body. It would be challenging to insert a needle into this location in reality. Inserting a needle into the third intercostal space, mid-clavicular line, on the side of the decreased breath sounds is the correct anatomical line, but the incorrect intercostal space. Similarly, inserting a needle into the sixth intercostal space, mid-clavicular line, on the side of the chest with decreased breath sounds is the correct anatomical line, but the wrong intercostal space.
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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 previously healthy 85-year-old woman is hospitalised and undergoes surgery to replace the broken hip that she sustained as a result of falling down stairs. Upon discharge to a nursing home 10 days later, she is unable to ambulate fully and, about a month later, she dies suddenly.
Which of the following is most likely to be the immediate cause of death found at post-mortem examination?Your Answer: Pulmonary embolism
Explanation:Likely Cause of Sudden Death in an Elderly Patient with Fracture
Immobilisation after a fracture in elderly patients increases the risk of developing deep vein thrombosis (DVT), which can lead to pulmonary embolism. In the case of a sudden death, pulmonary embolism is the most likely cause. Pneumonia with pneumococcus is also a risk for elderly patients in hospital, but the absence of signs and symptoms of infection makes it less likely. Tuberculosis is also unlikely as there were no signs of an infectious disease. Congestive heart failure is a possibility in the elderly, but it is unlikely to cause sudden death in this scenario. While malignancy is a risk for older patients, immobilisation leading to pulmonary thromboembolism is the most likely cause of sudden death in this case.
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This question is part of the following fields:
- Respiratory
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Question 4
Correct
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As part of the investigation of breathlessness, a 68-year-old patient has spirometry performed. You learn that he spent all his working life in a factory. The following results are available:
Measured Expected
FEV1 (L) 2.59 3.46
FVC (L) 3.16 4.21
Ratio (%) 82 81
Which of the following is the most likely cause?Your Answer: Asbestosis
Explanation:Possible Respiratory Diagnoses Based on Pulmonary Function Testing Results
Based on the patient’s age and history of factory work, along with a restrictive defect on pulmonary function testing, asbestosis is the most likely diagnosis. Other possible respiratory diagnoses include allergic bronchopulmonary aspergillosis (ABPA), asthma, emphysema, and bronchiectasis. ABPA and asthma are associated with an obstructive picture on pulmonary function tests, while emphysema and bronchiectasis are also possible differentials based on the history but are associated with an obstructive lung defect. However, it would be unusual for an individual to have their first presentation of asthma at 72 years old. Therefore, a thorough evaluation of the patient’s medical history, physical examination, and additional diagnostic tests may be necessary to confirm the 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 36-year-old woman of African origin presented to the Emergency Department with sudden-onset dyspnoea. She was a known case of systemic lupus erythematosus (SLE), previously treated for nephropathy and presently on mycophenolate mofetil and hydroxychloroquine sulfate. She had no fever. On examination, her respiratory rate was 45 breaths per minute, with coarse crepitations in the right lung base. After admission, blood test results revealed:
Investigation Value Normal range
Haemoglobin 100g/l 115–155 g/l
Sodium (Na+) 136 mmol/l 135–145 mmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
PaO2on room air 85 mmHg 95–100 mmHg
C-reactive protein (CRP) 6.6mg/l 0-10 mg/l
C3 level 41 mg/dl 83–180 mg/dl
Which of the following is most likely to be found in this patient as the cause for her dyspnoea?Your Answer: High diffusing capacity of the lungs for carbon monoxide (DLCO)
Explanation:This case discusses diffuse alveolar haemorrhage (DAH), a rare but serious complication of systemic lupus erythematosus (SLE). Symptoms include sudden-onset shortness of breath, decreased haematocrit levels, and possibly coughing up blood. A chest X-ray may show diffuse infiltrates and crepitations in the lungs. It is important to rule out infections before starting treatment with methylprednisolone or cyclophosphamide. A high DLCO, indicating increased diffusion capacity across the alveoli, may be present in DAH. A pulmonary function test may not be possible due to severe dyspnoea, so diagnosis is based on clinical presentation, imaging, and bronchoscopy. Lung biopsy may show pulmonary capillaritis with neutrophilic infiltration. A high ESR is non-specific and sputum for AFB is not relevant in this acute presentation. BAL fluid in DAH is progressively haemorrhagic, and lung scan with isotopes is not typical for this condition.
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This question is part of the following fields:
- Respiratory
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Question 6
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 7
Incorrect
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A 65-year-old woman presents to the Emergency Department with shortness of breath after being sat at home.
An arterial blood gas (ABG) is performed and shows the following results:
Investigation Result Normal value
pH 7.48 7.35–7.45
pO2 7.3 kPa 10.5–13.5 kPa
pCO2 3.9 kPa 4.6–6 kPa
HCO3 24 mmol/l 24–30 mmol/l
Which one of the following conditions is most likely to account for these investigation results?Your Answer: Hypothyroidism
Correct Answer: Pulmonary embolism
Explanation:Understanding Respiratory Failure: Causes and ABG Interpretation
Respiratory failure is a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide. There are two types of respiratory failure: type I and type II. Type I respiratory failure is characterized by low levels of oxygen and normal or low levels of carbon dioxide, resulting in respiratory alkalosis. Type II respiratory failure, on the other hand, is characterized by low levels of oxygen and high levels of carbon dioxide, resulting in respiratory acidosis.
Pulmonary embolism is the only cause of type I respiratory failure. This condition results in reduced oxygenation of the blood due to a blockage in the pulmonary artery. The ABG of a patient with pulmonary embolism would show low levels of oxygen and carbon dioxide, as well as respiratory alkalosis.
Hypothyroidism, Guillain–Barré syndrome, and myasthenia gravis are all causes of type II respiratory failure. Hypothyroidism can result in decreased ventilatory drive, while Guillain–Barré syndrome and myasthenia gravis can cause respiratory muscle weakness, leading to hypoventilation and respiratory acidosis.
Opiate overdose is another cause of type II respiratory failure. Opiates act on the respiratory centers in the brain, reducing ventilation and causing respiratory acidosis.
In summary, understanding the causes and ABG interpretation of respiratory failure is crucial in identifying and managing this potentially life-threatening condition.
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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 50-year-old male smoker presented with chronic dyspnoea. He used to work in the shipyard but now has a retired life with his dogs. He was under treatment as a case of COPD, but maximal therapy for COPD failed to bring him any relief. On re-evaluation, his chest X-ray showed fine reticular opacities in the lower zones. A CT scan of his thorax showed interstitial thickening, with some ground glass opacity in the upper lungs.
Pleural plaques were absent. What is the most likely diagnosis?Your Answer: Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD)
Explanation:Differentiating Interstitial Lung Diseases: A Case Study
The patient in question presents with dyspnoea and a history of smoking. While COPD is initially suspected, the radiograph and CT findings do not support this diagnosis. Instead, the patient may be suffering from an interstitial lung disease. RB-ILD is a possibility, given the presence of pigmented macrophages in the lung. Asbestosis is also considered, but the absence of pleural plaques makes this less likely. Pneumoconiosis and histoplasmosis are ruled out based on the patient’s history and imaging results. Treatment for interstitial lung diseases can be challenging, with steroids being the primary option. However, the effectiveness of this treatment is debatable. Ultimately, a lung biopsy may be necessary for a definitive diagnosis.
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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 65-year-old man with rheumatoid arthritis has been on long term therapy to manage his condition. He complains of worsening shortness of breath and a chest x-ray reveals 'bilateral interstitial shadowing'. Which medication is the probable culprit for his symptoms?
Your Answer: Azathioprine
Correct Answer: Methotrexate
Explanation:Methotrexate as a Cause and Treatment for Pulmonary Fibrosis
Pulmonary fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. Methotrexate, a chemotherapy drug, is a known cause of pulmonary fibrosis. However, it is also sometimes used as a treatment for idiopathic pulmonary fibrosis as a steroid sparing agent.
According to medical research, other chemotherapy drugs such as alkylating agents, asparaginase, bleomycin, and procarbazine have also been linked to pulmonary parenchymal or pleural reactions in patients with malignant diseases. In addition, drug-related interstitial pneumonia should be considered in rheumatoid arthritis patients who are taking methotrexate or newer drugs like leflunomide.
Despite its potential risks, methotrexate can be a useful treatment option for some patients with pulmonary fibrosis. However, it is important for healthcare providers to carefully monitor patients for any adverse reactions and adjust treatment plans accordingly.
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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 45-year-old man presents to his GP with persistent wheezing and difficulty breathing. Despite being prescribed a salbutamol inhaler, his symptoms continue and he is forced to take time off work. His GP increases his treatment by adding oral prednisolone, which initially helps but his symptoms return upon returning to work. However, during a two-week vacation, his wheezing significantly improves. Upon returning to work, he suffers an acute asthma attack and is taken to the hospital by ambulance. Which diagnostic test is most likely to confirm the diagnosis?
Your Answer: Peak flow rates measured at home and in work
Explanation:Occupational Asthma and its Causes
Occupational asthma (OA) is a type of asthma that develops in adulthood and is caused by exposure to allergens in the workplace. Symptoms improve significantly when the affected person is away from their work environment. OA can be triggered by immunologic or non-immunologic stimuli. Immunologic stimuli have a latency period between exposure and symptom onset, while non-immunologic stimuli do not. Non-immunologic stimuli that trigger OA are referred to as reactive airways dysfunction syndrome (RADS) or irritant-induced asthma.
Immunologic OA can be caused by high-molecular-weight or low-molecular-weight allergens. High-molecular-weight allergens include domestic and laboratory animals, fish and seafood, flour and cereals, and rubber. Low-molecular-weight allergens include metals, drugs, dyes and bleaches, isocyanates (naphthalene), and wood dust. It is important to identify the specific allergen causing OA in order to prevent further exposure and manage symptoms effectively.
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This question is part of the following fields:
- Respiratory
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