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  • Question 1 - A 58-year-old man with chronic obstructive pulmonary disease (COPD) experiences an exacerbation of...

    Correct

    • A 58-year-old man with chronic obstructive pulmonary disease (COPD) experiences an exacerbation of breathlessness and a productive cough with green sputum.
      What is the most appropriate treatment option for him?

      Your Answer: Doxycycline and prednisolone

      Explanation:

      Treatment Options for COPD Exacerbations: Antibiotics and Corticosteroids

      COPD exacerbations are characterized by a sudden worsening of symptoms beyond the patient’s usual stable state. These symptoms include increased breathlessness, cough, sputum production, and changes in sputum color. To treat exacerbations, a combination of antibiotics and corticosteroids is often used.

      Oral corticosteroids, such as prednisolone, should be prescribed for five days to patients experiencing a significant increase in breathlessness that interferes with daily activities. Antibiotics are recommended for exacerbations associated with purulent sputum, with first-line agents including amoxicillin, doxycycline, and clarithromycin.

      It is important to follow local microbiologist guidance when initiating empirical antibiotic treatment. Flucloxacillin and clindamycin are not useful in treating COPD exacerbations and are recommended for other conditions such as skin infections and bacterial vaginosis, respectively. Nitrofurantoin and trimethoprim are used for urinary tract infections and may be considered as first or second-line agents depending on antibiotic resistance and previous sensitivity.

    • This question is part of the following fields:

      • Respiratory Medicine
      27.2
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  • Question 2 - A 76-year-old man has been hospitalized with an infective exacerbation of COPD. He...

    Correct

    • A 76-year-old man has been hospitalized with an infective exacerbation of COPD. He is receiving controlled oxygen therapy, nebulized bronchodilators, steroids, and antibiotics. A blood gas test is conducted two hours after admission, revealing the following results: pH 7.31, PaO2 7.8kPa, PaCO2 9 kPa, and HCO3- 36 mmol/l. What should be the next course of action?

      Your Answer: Bilevel Positive Airway Pressure (BIPAP)

      Explanation:

      The National Institute for Clinical Excellence (NICE) recommends that patients suspected of having an exacerbation of COPD undergo several tests, including arterial blood gases, chest X-ray, electrocardiogram, full blood count and urea and electrolytes, and theophylline level (if applicable). Sputum microscopy and culture should also be done if the sputum is purulent, and blood cultures if the patient has a fever. Medical therapy should include oxygen to maintain the patient within their individualized target range, nebulized bronchodilators, steroid therapy, antibiotics if necessary, and chest physiotherapy. If the patient does not respond well to nebulized bronchodilators, intravenous theophyllines may be considered. For patients with persistent hypercapnic ventilatory failure despite optimal medical therapy, non-invasive ventilation should be considered. In this case, a trial of BIPAP would be the best option since intravenous theophylline is not available. BIPAP is a form of non-invasive ventilation that has been proven effective in acute type two respiratory failure. It works by stenting alveoli open to increase the surface area available for ventilation and gas exchange. CPAP is another form of non-invasive ventilation but is not as effective as BIPAP in COPD. Intubation and ventilation may be necessary in some patients with COPD, but a trial of non-invasive ventilation is the most appropriate next step. It is important to set a ceiling of care for all patients presenting with an exacerbation of COPD. Regular arterial blood gas analysis is necessary to assess the patient’s response to NIV.

      Acute exacerbations of COPD are a common reason for hospital visits in developed countries. The most common causes of these exacerbations are bacterial infections, with Haemophilus influenzae being the most common culprit, followed by Streptococcus pneumoniae and Moraxella catarrhalis. Respiratory viruses also account for around 30% of exacerbations, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.

      NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.

      For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators such as salbutamol and ipratropium should also be administered, along with steroid therapy. IV hydrocortisone may be considered instead of oral prednisolone, and IV theophylline may be used for patients not responding to nebulized bronchodilators. Non-invasive ventilation may be used for patients with type 2 respiratory failure, with bilevel positive airway pressure being the typical method used.

    • This question is part of the following fields:

      • Respiratory Medicine
      101.3
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  • Question 3 - Which of the following interventions is most likely to improve survival in individuals...

    Incorrect

    • Which of the following interventions is most likely to improve survival in individuals with COPD?

      Your Answer: Pulmonary rehabilitation

      Correct Answer: Long-term oxygen therapy

      Explanation:

      Long-term oxygen therapy is one of the few interventions that has been proven to enhance survival in COPD following smoking cessation.

      NICE guidelines recommend smoking cessation advice, annual influenza and one-off pneumococcal vaccinations, and pulmonary rehabilitation for COPD patients. Bronchodilator therapy is first-line treatment, with the addition of LABA and LAMA for patients without asthmatic features and LABA, ICS, and LAMA for those with asthmatic features. Theophylline is recommended after trials of bronchodilators or for patients who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients. Mucolytics should be considered for patients with a chronic productive cough. Loop diuretics and long-term oxygen therapy may be used for cor pulmonale. Smoking cessation and long-term oxygen therapy may improve survival in stable COPD patients. Lung volume reduction surgery may be considered in selected patients.

    • This question is part of the following fields:

      • Respiratory Medicine
      40.7
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  • Question 4 - A 55-year-old man is seen in the clinic for a follow-up appointment. He...

    Correct

    • A 55-year-old man is seen in the clinic for a follow-up appointment. He was prescribed ramipril two months ago for stage 2 hypertension, which was diagnosed after ambulatory blood pressure monitoring. His clinic readings have improved from 164/96 mmHg to 142/84 mmHg. However, he has been experiencing a persistent, dry cough for the past four weeks. What would be the best course of action to take in this situation?

      Your Answer: Stop ramipril and start losartan

      Explanation:

      When ACE inhibitors are not well-tolerated, angiotensin-receptor blockers are recommended.

      NICE Guidelines for Managing Hypertension

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.

      The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.

      NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.

      New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.

    • This question is part of the following fields:

      • Respiratory Medicine
      48.2
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  • Question 5 - A 65-year-old male presents to his GP with a 6-month history of progressive...

    Incorrect

    • A 65-year-old male presents to his GP with a 6-month history of progressive shortness of breath. He is now needing to stop a few times on the way to the grocery store to catch his breath, which is not normal for him. He smokes 20 cigarettes a day and has done so for the past 45 years, and drinks no alcohol. His only medication is atorvastatin.

      On examination, there is a bilateral wheeze and coarse crackles at the lung bases. A chest x-ray is ordered by the GP which shows flattening of the diaphragm bilaterally, but is otherwise normal. Spirometry is carried out, with the following results:

      Result Reference Range
      FEV1 (of predicted) 72% >80%
      FEV1:FVC 0.62 >0.7

      What is the most appropriate management for this likely diagnosis?

      Your Answer: Salmeterol

      Correct Answer: Ipratropium

      Explanation:

      The patient’s history, examination, and obstructive spirometry results suggest that he has COPD, likely due to his smoking history. Malignancy has been ruled out by the chest x-ray. As per NICE guidelines, the first-line pharmacological treatment for COPD is either a SABA or SAMA to alleviate breathlessness and improve exercise tolerance. Ipratropium, a SAMA, is the most suitable option for this patient. Beclomethasone, an inhaled corticosteroid, is used as a second-line treatment with a LABA for those with asthmatic features or steroid responsiveness. Montelukast, a LTRA, is used as a third-line treatment in asthmatic patients, while Salmeterol, a LABA, is used as a second-line treatment in COPD patients.

      NICE guidelines recommend smoking cessation advice, annual influenza and one-off pneumococcal vaccinations, and pulmonary rehabilitation for COPD patients. Bronchodilator therapy is first-line treatment, with the addition of LABA and LAMA for patients without asthmatic features and LABA, ICS, and LAMA for those with asthmatic features. Theophylline is recommended after trials of bronchodilators or for patients who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients. Mucolytics should be considered for patients with a chronic productive cough. Loop diuretics and long-term oxygen therapy may be used for cor pulmonale. Smoking cessation and long-term oxygen therapy may improve survival in stable COPD patients. Lung volume reduction surgery may be considered in selected patients.

    • This question is part of the following fields:

      • Respiratory Medicine
      166.5
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  • Question 6 - A 78-year-old man visits his GP complaining of a cough that has been...

    Incorrect

    • A 78-year-old man visits his GP complaining of a cough that has been producing green sputum and shortness of breath for the past three days. During the examination, the GP detects the presence of rhonchi. The patient's vital signs are stable. Given his medical history of type 2 diabetes, which is being managed with metformin, and heart failure, for which he is taking ramipril, bisoprolol, and furosemide, the GP suspects acute bronchitis. What is the most appropriate course of action?

      Your Answer: Supportive care

      Correct Answer: Oral doxycycline

      Explanation:

      Antibiotics may be prescribed for acute bronchitis if the patient has co-existing co-morbidities or is at high risk of complications. NICE guidelines advise against the use of antibiotics for those who are not systemically very unwell and not at high risk of complications. However, if the patient is very unwell or at risk of complications, antibiotics should be offered. In this case, the patient’s age, diabetes, and heart failure put him at high risk, so antibiotics should be offered in accordance with NICE guidelines. While local guidelines should be consulted, NICE recommends oral doxycycline as the first-line treatment. Inhaled bronchodilators should not be offered unless the patient has an underlying airway disease such as asthma. Oral flucloxacillin is not commonly used for respiratory tract infections, and IV co-amoxiclav is not necessary in this stable patient who can be managed without admission.

      Acute bronchitis is a chest infection that typically resolves on its own within three weeks. It occurs when the trachea and major bronchi become inflamed, leading to swollen airways and the production of sputum. The primary cause of acute bronchitis is viral infection, with most cases occurring in the autumn or winter. Symptoms include a sudden onset of cough, sore throat, runny nose, and wheezing. While most patients have a normal chest examination, some may experience a low-grade fever or wheezing. It is important to differentiate acute bronchitis from pneumonia, which presents with different symptoms and chest examination findings.

      Diagnosis of acute bronchitis is typically based on clinical presentation, but CRP testing may be used to determine if antibiotic therapy is necessary. Management involves pain relief and ensuring adequate fluid intake. Antibiotics may be considered for patients who are systemically unwell, have pre-existing health conditions, or have a CRP level between 20-100mg/L. Doxycycline is the recommended first-line treatment, but it cannot be used in children or pregnant women. Alternatives include amoxicillin.

    • This question is part of the following fields:

      • Respiratory Medicine
      60.2
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  • Question 7 - At a coffee shop, you observe a young woman beginning to cough and...

    Correct

    • At a coffee shop, you observe a young woman beginning to cough and wheeze. Approaching her, you inquire if she is choking. She replies that she believes a sip of hot coffee went down the wrong way. What should be your initial course of action?

      Your Answer: Encourage him to cough

      Explanation:

      Dealing with Choking Emergencies

      Choking is a serious medical emergency that can be life-threatening. It occurs when the airway is partially or completely blocked, often while eating. The first step in dealing with a choking victim is to ask them if they are choking. If they are able to speak and breathe, it may be a mild obstruction. However, if they are unable to speak or breathe, it is a severe obstruction and requires immediate action.

      According to the Resus Council, mild airway obstruction can be treated by encouraging the patient to cough. However, if the obstruction is severe and the patient is conscious, up to five back-blows and abdominal thrusts can be given. If these methods are unsuccessful, the cycle should be repeated. If the patient is unconscious, an ambulance should be called and CPR should be started.

      It is important to note that choking can happen to anyone, so it is important to be prepared and know how to respond in an emergency. By following these steps, you can help save a life.

    • This question is part of the following fields:

      • Respiratory Medicine
      81.5
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  • Question 8 - A woman in her early fifties presents to the Emergency Department with pleuritic...

    Correct

    • A woman in her early fifties presents to the Emergency Department with pleuritic chest pain, ten days post-hysterectomy. The medical team suspects pulmonary embolism. What is the typical chest x-ray finding in patients with this condition?

      Your Answer: Normal

      Explanation:

      In most cases of pulmonary embolism, the chest x-ray appears normal.

      Investigating Pulmonary Embolism: Key Features and Diagnostic Criteria

      Pulmonary embolism (PE) can be challenging to diagnose as it can present with a wide range of cardiorespiratory symptoms and signs depending on its location and size. The PIOPED study in 2007 found that tachypnea, crackles, tachycardia, and fever were the most common clinical signs associated with PE. To aid in the diagnosis of PE, NICE updated their guidelines in 2020 to include the use of the pulmonary embolism rule-out criteria (PERC) and the 2-level PE Wells score. The PERC rule should be used when there is a low pre-test probability of PE, and a negative PERC result reduces the probability of PE to less than 2%. The 2-level PE Wells score should be performed if a PE is suspected, with a score of more than 4 points indicating a likely PE and a score of 4 points or less indicating an unlikely PE.

      If a PE is likely, an immediate computed tomography pulmonary angiogram (CTPA) should be arranged, and interim therapeutic anticoagulation should be given if there is a delay in getting the CTPA. If a PE is unlikely, a D-dimer test should be arranged, and if positive, an immediate CTPA should be performed. The consensus view from the British Thoracic Society and NICE guidelines is that CTPA is the recommended initial lung-imaging modality for non-massive PE. However, V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease.

      Other diagnostic tools include age-adjusted D-dimer levels, ECG, chest x-ray, V/Q scan, and CTPA. It is important to note that a chest x-ray is recommended for all patients to exclude other pathology, but it is typically normal in PE. While investigating PE, it is crucial to consider other differential diagnoses and to tailor the diagnostic approach to the individual patient’s clinical presentation and risk factors.

    • This question is part of the following fields:

      • Respiratory Medicine
      55.8
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  • Question 9 - A 48-year-old man is admitted with right-sided pneumonia. According to the patient he...

    Correct

    • A 48-year-old man is admitted with right-sided pneumonia. According to the patient he has been unwell for 3–4 days with malaise, fever, cough and muscular pain. He also has a rash on his abdomen and neck pain. He was previously fit and has not travelled abroad. He is a plumber and also keeps pigeons. According to his wife, two of his favourite pigeons died 2 weeks ago.
      Which of the following organisms is most likely to be responsible for his pneumonia?

      Your Answer: Chlamydia psittaci

      Explanation:

      Psittacosis is a disease caused by the bacterium Chlamydia psittaci, which is typically transmitted to humans through exposure to infected birds. Symptoms include fever, cough, headache, and sore throat, as well as a characteristic facial rash. Diagnosis is confirmed through serology tests, and treatment involves the use of tetracyclines or macrolides. Mycoplasma pneumoniae is another bacterium that can cause atypical pneumonia, with symptoms including fever, malaise, myalgia, headache, and a rash. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia, while Legionella pneumophila can cause Legionnaires’ disease, which presents with fever, cough, dyspnea, and systemic symptoms. Coxiella burnetii is the bacterium responsible for Q fever, which can be transmitted by animals and arthropods and presents with non-specific symptoms. In the scenario presented, the patient’s history of exposure to infected birds and the presence of a rash suggest a diagnosis of psittacosis.

    • This question is part of the following fields:

      • Respiratory Medicine
      84.6
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  • Question 10 - A 38-year-old woman underwent bowel resection and 48 hours post-operation, she became breathless,...

    Correct

    • A 38-year-old woman underwent bowel resection and 48 hours post-operation, she became breathless, tachycardic, tachypnoeic and complained of pleuritic chest pain.
      Which of the following is the most definitive investigation to request?

      Your Answer: CT pulmonary angiogram (CTPA)

      Explanation:

      Diagnostic Tests for Pulmonary Embolism: A Comparison

      Pulmonary embolism (PE) is a serious medical condition that requires prompt diagnosis and treatment. There are several diagnostic tests available for PE, but not all are equally effective. Here, we compare the most commonly used tests and their suitability for diagnosing PE.

      CT pulmonary angiogram (CTPA) is the gold standard diagnostic test for PE. It is highly sensitive and specific, making it the most definitive investigation for PE. Patients with a history of recent surgery and subsequent symptoms pointing towards PE should undergo a CTPA.

      Electrocardiography (ECG) is not a first-line diagnostic test for PE. Although classic ECG changes may occur in some patients with PE, they are not specific to the condition and may also occur in individuals without PE.

      Chest radiograph is less definitive than CTPA for diagnosing PE. While it may show some abnormalities, many chest radiographs are normal in PE. Therefore, it is not a reliable test for diagnosing PE.

      Echocardiogram may show right-sided heart dysfunction in very large PEs, but it is not a first-line diagnostic test for PE and is not definitive in the investigation of PE.

      Positron emission tomography (PET)/CT of the chest is not recommended for the investigation of PE. It is a radioisotope functional imaging technique used in the imaging of tumours and neuroimaging, but not for diagnosing PE.

      In conclusion, CTPA is the most definitive diagnostic test for PE and should be used in patients with a high suspicion of the condition. Other tests may be used in conjunction with CTPA or in specific cases, but they are not as reliable or definitive as CTPA.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 11 - The cardiac arrest team is summoned to the bedside of a 68-year-old male...

    Correct

    • The cardiac arrest team is summoned to the bedside of a 68-year-old male patient, 3 days post-myocardial infarction. Two nurses are currently administering chest compressions and a manual defibrillator has just been connected. Chest compressions are momentarily halted to analyze the rhythm, which reveals pulseless electrical activity. What actions should be taken in this situation?

      Your Answer: Adrenaline should be commenced immediately

      Explanation:

      In the case of a non-shockable rhythm, it is crucial to administer adrenaline as soon as possible according to the ALS protocol. This should be done immediately and during alternate cycles. However, if the rhythm is shockable, adrenaline should be given after the third shock and then during alternate cycles. Amiodarone should be administered after the third shock, and a second dose may be considered after five shocks. Therefore, the other options are not appropriate.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 12 - A 29-year-old man arrives at the emergency department experiencing an asthma attack. Despite...

    Correct

    • A 29-year-old man arrives at the emergency department experiencing an asthma attack. Despite being a known asthmatic, his condition is usually well managed with a salbutamol inhaler. Upon assessment, his peak expiratory flow rate is at 50%, respiratory rate at 22/min, heart rate at 105/min, blood pressure at 128/64 mmHg, and temperature at 36.7 ºC. During examination, he appears distressed and unable to complete sentences. A chest examination reveals widespread wheezing and respiratory distress.

      What is the most probable diagnosis for this patient?

      Your Answer: Severe asthma attack

      Explanation:

      Management of Acute Asthma

      Acute asthma is classified by the British Thoracic Society (BTS) into three categories: moderate, severe, and life-threatening. Patients with any of the life-threatening features should be treated as having a life-threatening attack. A fourth category, Near-fatal asthma, is also recognized. Further assessment may include arterial blood gases for patients with oxygen saturation levels below 92%. A chest x-ray is not routinely recommended unless the patient has life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.

      Admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid, and presentation at night. All patients with life-threatening asthma should be admitted to the hospital, and patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. Oxygen therapy should be started for hypoxaemic patients. Bronchodilation with short-acting beta₂-agonists (SABA) is recommended, and all patients should be given 40-50mg of prednisolone orally daily. Ipratropium bromide and IV magnesium sulphate may also be considered for severe or life-threatening asthma. Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Criteria for discharge include stability on discharge medication, checked and recorded inhaler technique, and PEF levels above 75% of best or predicted.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 13 - A 57-year-old man presents with a 4 weeks-history of productive cough, dyspnoea, and...

    Incorrect

    • A 57-year-old man presents with a 4 weeks-history of productive cough, dyspnoea, and pleuritic chest pain. He has had associated lethargy, weight loss, a swinging fever and night sweats. He had a stroke two years ago.

      Sputum and blood cultures are collected. After a chest x-ray revealed a fluid-filled space within an area of consolidation in his left lung, he was given IV antibiotics.

      However, the patient's condition has not improved and instead appears to be worsening. What is the most appropriate next step in his management?

      Your Answer: Arrange bronchoscopy

      Correct Answer: Arrange CT-guided percutaneous drainage

      Explanation:

      If a lung abscess is not responding to intravenous antibiotics, percutaneous drainage should be considered as an option.

      Correct: Arrange CT-guided percutaneous drainage. This is because the patient’s symptoms, such as swinging fevers, night sweats, pleuritic chest pain, dyspnoea, and cough, are consistent with a lung abscess. The chest x-ray also supports this diagnosis by showing a fluid-filled space within an area of consolidation. If IV antibiotics are not effective, percutaneous drainage can be guided by a CT scan or ultrasound. IV antibiotics may not be able to penetrate the abscess wall, which is why some patients do not respond to this treatment.

      Incorrect: Arrange bronchoscopy. This is not commonly used for lung abscesses and is only indicated if an underlying tumour or foreign body is suspected. It is performed for diagnosis only, not drainage.

      Incorrect: Arrange sputum cytology. Sputum cultures have already been collected, and a diagnosis of lung abscess has been established. This option could be considered later if the patient still does not respond to treatment to rule out an underlying malignancy.

      Incorrect: Prescribe broad-spectrum IV antibiotics. This option is unlikely to be effective since the patient has already received IV antibiotics without success. The next step would be to manually drain the abscess.

      Understanding Lung Abscess

      A lung abscess is a localized infection that occurs within the lung tissue. It is commonly caused by aspiration pneumonia, which can be triggered by poor dental hygiene, reduced consciousness, or previous stroke. Other potential causes include haematogenous spread, direct extension, and bronchial obstruction. The infection is typically polymicrobial, with Staphylococcus aureus, Klebsiella pneumonia, and Pseudomonas aeruginosa being the most common monomicrobial causes.

      The symptoms of lung abscess are similar to pneumonia, but they tend to develop more slowly over several weeks. Patients may experience fever, productive cough, foul-smelling sputum, chest pain, and dyspnea. Some may also have systemic features such as night sweats and weight loss, while a minority may experience haemoptysis. Physical examination may reveal dull percussion and bronchial breathing, as well as clubbing in some cases.

      To diagnose lung abscess, a chest x-ray is usually performed, which shows a fluid-filled space within an area of consolidation. Sputum and blood cultures should also be obtained to identify the causative organism. Treatment typically involves intravenous antibiotics, but if the infection does not resolve, percutaneous drainage or surgical resection may be required in rare cases.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 14 - A 26-year-old male is admitted with acute severe asthma. The initial treatment of...

    Correct

    • A 26-year-old male is admitted with acute severe asthma. The initial treatment of 100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV hydrocortisone is initiated. However, there is no improvement. What should be the next step in management?

      Your Answer: IV magnesium sulphate

      Explanation:

      The routine use of non-invasive ventilation in asthmatics is not supported by current guidelines.

      Management of Acute Asthma

      Acute asthma is classified by the British Thoracic Society (BTS) into three categories: moderate, severe, and life-threatening. Patients with any of the life-threatening features should be treated as having a life-threatening attack. A fourth category, Near-fatal asthma, is also recognized. Further assessment may include arterial blood gases for patients with oxygen saturation levels below 92%. A chest x-ray is not routinely recommended unless the patient has life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.

      Admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid, and presentation at night. All patients with life-threatening asthma should be admitted to the hospital, and patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. Oxygen therapy should be started for hypoxaemic patients. Bronchodilation with short-acting beta₂-agonists (SABA) is recommended, and all patients should be given 40-50mg of prednisolone orally daily. Ipratropium bromide and IV magnesium sulphate may also be considered for severe or life-threatening asthma. Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Criteria for discharge include stability on discharge medication, checked and recorded inhaler technique, and PEF levels above 75% of best or predicted.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 15 - A 68-year-old man has been taking medication for psoriasis with arthropathy for a...

    Correct

    • A 68-year-old man has been taking medication for psoriasis with arthropathy for a prolonged period. He has recently experienced a dry cough and worsening shortness of breath with minimal activity.
      Which of the following medications is the most probable cause of his symptoms?
      Choose ONE option from the list provided.

      Your Answer: Methotrexate

      Explanation:

      Identifying the Probable Cause of Pulmonary Fibrosis

      Methotrexate is the correct answer as it is a well-known drug-related cause of pulmonary fibrosis, which is the probable cause of the patient’s symptoms. Hydroxychloroquine, azathioprine, ciclosporin, and penicillamine are not known to cause pulmonary fibrosis, although some of them have the potential to cause pneumonitis. Ciclosporin has been studied as a treatment for the disease, but it is not recommended by NICE. Therefore, it is important to identify the probable cause of pulmonary fibrosis to provide appropriate treatment and prevent further complications.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 16 - A 67-year-old man presents for a review of his chronic obstructive pulmonary disease....

    Incorrect

    • A 67-year-old man presents for a review of his chronic obstructive pulmonary disease. He reports experiencing constant shortness of breath during physical activity, which has remained stable over the past year. He has a history of asbestos exposure and is currently under the care of a respiratory physician. During the examination, no abnormalities are detected, but a chest X-ray reveals the presence of pleural plaques. The patient expresses concern that these plaques may develop into cancer. What advice do you offer this patient regarding his test results?

      Your Answer: Malignant and require immediate specialist referral

      Correct Answer: Benign and do not require follow-up

      Explanation:

      Pleural plaques are benign and do not develop into cancerous growths, so there is no need for any follow-up. These plaques are the most common form of lung disease caused by asbestos exposure, but they do not increase the risk of lung cancer or mesothelioma. While ongoing monitoring of the patient’s lung disease is recommended, there is no need to specifically monitor the pleural plaques. It is important to note that pleural plaques are a sign of past asbestos exposure, which could increase the risk of mesothelioma, but the plaques themselves are not a cause for concern. Therefore, the patient does not require a specialist referral for the pleural plaques alone. However, if the patient experiences worsening shortness of breath or frequent exacerbations, a specialist referral may be necessary to assess for disease progression or malignancy.

      Asbestos-Related Lung Diseases

      Asbestos exposure can lead to various lung diseases, ranging from benign pleural plaques to malignant mesothelioma. Pleural plaques are non-cancerous and do not require any follow-up, but they are the most common form of asbestos-related lung disease and typically appear after a latent period of 20-40 years. Asbestos exposure may also cause diffuse pleural thickening, which is similar to the pattern seen after an empyema or haemothorax, but the underlying pathophysiology is not fully understood.

      Asbestosis is a lung disease that is related to the length of exposure to asbestos. It causes lower lobe fibrosis and is typically characterized by dyspnea, reduced exercise tolerance, clubbing, bilateral end-inspiratory crackles, and a restrictive pattern with reduced gas transfer on lung function tests. Asbestosis is treated conservatively, as no interventions offer significant benefits. The latent period for asbestosis is typically 15-30 years.

      Mesothelioma is a malignant disease of the pleura that is caused by asbestos exposure, with crocidolite (blue) asbestos being the most dangerous form. Possible features of mesothelioma include progressive shortness-of-breath, chest pain, and pleural effusion. Patients are usually offered palliative chemotherapy, and there is a limited role for surgery and radiotherapy. Unfortunately, the prognosis for mesothelioma is very poor, with a median survival from diagnosis of 8-14 months.

      Although mesothelioma is often associated with asbestos exposure, lung cancer is actually the most common form of cancer related to asbestos exposure. It has a synergistic effect with cigarette smoke, which increases the risk of developing lung cancer.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 17 - A 55-year-old woman has been diagnosed as having lung cancer.
    Which of the following...

    Incorrect

    • A 55-year-old woman has been diagnosed as having lung cancer.
      Which of the following statements is the most appropriate?

      Your Answer: Hypertrophic pulmonary osteoarthropathy (HPOA) is commonly seen in patients with small-cell carcinoma.

      Correct Answer: Hypercalcaemia may occur without bone metastasis.

      Explanation:

      Paraneoplastic syndromes are a group of disorders that can occur in patients with certain types of cancer, but are not caused by metastases, infections, metabolic disorders, chemotherapy, or coagulation disorders. These syndromes can present with a variety of symptoms affecting different body systems. Some of these syndromes are specific to certain types of cancer and may be the first sign of the disease. Therefore, if a patient presents with symptoms of a paraneoplastic syndrome, it is important to consider the possibility of an underlying malignancy. While certain paraneoplastic syndromes are associated with specific types of cancer, there can be some overlap.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 18 - A 33-year-old man who is HIV positive comes to the clinic complaining of...

    Correct

    • A 33-year-old man who is HIV positive comes to the clinic complaining of shortness of breath and a dry cough. He has been homeless and has not been keeping up with his outpatient appointments or taking his antiretroviral medication. Upon examination, his respiratory rate is 24 breaths per minute and there are scattered crackles in his chest. His oxygen saturation is 96% on room air but drops quickly after walking. Based on the likely diagnosis of Pneumocystis jiroveci pneumonia, what is the most appropriate first-line treatment?

      Your Answer: Co-trimoxazole

      Explanation:

      The treatment for Pneumocystis jiroveci pneumonia involves the use of co-trimoxazole, a combination of trimethoprim and sulfamethoxazole.

      Pneumocystis jiroveci Pneumonia in HIV Patients

      Pneumocystis jiroveci pneumonia (formerly known as Pneumocystis carinii pneumonia) is a common opportunistic infection in individuals with AIDS. Pneumocystis jiroveci is an organism that is classified as a fungus by some and a protozoa by others. Patients with a CD4 count below 200/mm³ should receive prophylaxis for PCP. Symptoms of PCP include dyspnea, dry cough, fever, and few chest signs. Pneumothorax is a common complication of PCP, and extrapulmonary manifestations are rare.

      Chest X-rays typically show bilateral interstitial pulmonary infiltrates, but other findings such as lobar consolidation may also be present. Sputum tests often fail to show PCP, and bronchoalveolar lavage (BAL) is often necessary to demonstrate the presence of the organism. Treatment for PCP includes co-trimoxazole and IV pentamidine in severe cases. Aerosolized pentamidine is an alternative treatment but is less effective and carries a risk of pneumothorax. Steroids may be used if the patient is hypoxic, as they can reduce the risk of respiratory failure and death.

      In summary, PCP is a common opportunistic infection in individuals with AIDS, and prophylaxis should be given to those with a CD4 count below 200/mm³. Symptoms include dyspnea, dry cough, and fever, and chest X-rays typically show bilateral interstitial pulmonary infiltrates. Treatment includes co-trimoxazole, IV pentamidine, and steroids if the patient is hypoxic.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 19 - Among the following options, which condition is considered a restrictive lung disease/condition? ...

    Correct

    • Among the following options, which condition is considered a restrictive lung disease/condition?

      Your Answer: Severe scoliosis

      Explanation:

      Different Types of Lung Diseases and their Spirometry Patterns

      Scoliosis and Lung Function
      Severe scoliosis can affect the respiratory muscles and the natural movements of the thoracic cage, leading to a restrictive pattern in pulmonary function tests. This can prevent the lungs from expanding correctly, compromising their function.

      Cystic Fibrosis and Lung Function
      In early stage cystic fibrosis, the presence of inflammation and thick secretions in the airways can cause an obstructive pattern in spirometry tests. As damage to the lung tissue occurs, a restrictive component can also develop, resulting in a combined obstructive and restrictive pattern.

      Emphysema and Lung Function
      Emphysema is a type of obstructive lung disease characterized by abnormal and irreversible enlargement of air spaces and alveolar wall destruction. This leads to airflow limitation and a spirometry pattern typical of obstructive lung disease.

      Asthma and Lung Function
      Asthma is an inflammatory disorder of the airways that causes hyperresponsiveness and constriction of the airways in response to various stimuli. This leads to airflow limitation and a spirometry pattern typical of obstructive lung disease.

      Bronchiectasis and Lung Function
      Bronchiectasis is characterized by abnormal and irreversible dilatation of the bronchial walls, leading to accumulation of secretions and recurrent inflammation of the airways. This produces an obstructive pattern in pulmonary function tests.

      In summary, different types of lung diseases can affect lung function in various ways, leading to different spirometry patterns. Understanding these patterns can help in the diagnosis and management of these conditions.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 20 - A 67-year-old male visits his primary care clinic complaining of progressive dyspnea on...

    Incorrect

    • A 67-year-old male visits his primary care clinic complaining of progressive dyspnea on exertion and a dry cough. He has a smoking history of 35 pack-years. He denies chest pain, weight loss, or hemoptysis. In the past, he was prescribed bronchodilators for COPD, but they did not alleviate his symptoms.

      During the examination, the physician detects fine crackles at the lung bases bilaterally, and the patient has significant finger clubbing. The physician orders a chest X-ray, pulmonary function tests, and refers him urgently to a respiratory clinic.

      What pulmonary function test pattern would you expect to see based on the most likely underlying diagnosis?

      Your Answer: FEV1:FVC reduced, TLCO increased

      Correct Answer: FEV1:FVC normal or increased, TLCO reduced

      Explanation:

      In cases of IPF, the TLCO (gas transfer test) is reduced, indicating a restrictive lung disease that results in a reduced FEV1 and reduced FVC. This leads to a normal or increased FEV1:FVC ratio, which is a distinguishing factor from obstructive lung diseases like COPD or asthma. Therefore, the correct statement is that in IPF, the FEV1:FVC ratio is normal or increased, while the TLCO is reduced.

      Understanding Idiopathic Pulmonary Fibrosis

      Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.

      The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.

      Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.

      The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 21 - A 65-year-old man presents with gradually worsening exertional dyspnoea and a dry cough...

    Correct

    • A 65-year-old man presents with gradually worsening exertional dyspnoea and a dry cough over the past year. He quit smoking 25 cigarettes/day about 25 years ago. Upon examination, his oxygen saturation is 96% on room air, respiratory rate is 16/min, and there are fine bibasal crackles. Finger clubbing is also present. The following investigations were conducted:
      - B-type natriuretic peptide: 90 pg/ml (< 100pg/ml)
      - ECG: sinus rhythm, 68/min
      - Spirometry:
      - FEV1: 1.6 L (51% of predicted)
      - FVC: 1.7 L (40% of predicted)
      - FEV1/FVC: 95%

      What is the most likely diagnosis?

      Your Answer: Idiopathic pulmonary fibrosis

      Explanation:

      A common scenario for idiopathic pulmonary fibrosis involves a man between the ages of 50 and 70 who experiences worsening shortness of breath during physical activity. Other symptoms may include clubbing of the fingers and a restrictive pattern on spirometry testing. However, a normal B-type natriuretic peptide level suggests that heart failure is not the cause of these symptoms.

      Understanding Idiopathic Pulmonary Fibrosis

      Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.

      The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.

      Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.

      The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 22 - An elderly man, aged 74, with metastatic small cell lung cancer has been...

    Correct

    • An elderly man, aged 74, with metastatic small cell lung cancer has been admitted to the hospice for symptom management. He is currently experiencing persistent hiccups that are difficult to control. What is the best course of action for managing this symptom?

      Your Answer: Chlorpromazine

      Explanation:

      Palliative Care Prescribing for Hiccups

      Hiccups can be a distressing symptom for patients receiving palliative care. To manage this symptom, healthcare professionals may prescribe medications such as chlorpromazine, which is licensed for the treatment of intractable hiccups. Other medications that may be used include haloperidol and gabapentin. In cases where there are hepatic lesions, dexamethasone may also be prescribed. It is important to note that the choice of medication will depend on the individual patient’s needs and medical history. Proper management of hiccups can improve the patient’s quality of life and provide relief from discomfort.

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      • Respiratory Medicine
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  • Question 23 - Can you analyze the post-bronchodilator spirometry findings of a 54-year-old female who has...

    Correct

    • Can you analyze the post-bronchodilator spirometry findings of a 54-year-old female who has been experiencing gradual breathlessness?

      FEV1/FVC ratio: 0.60

      FEV1 percentage predicted: 60%

      What would be the suitable conclusion based on these outcomes?

      Your Answer: COPD (stage 2 - moderate)

      Explanation:

      Investigating and Diagnosing COPD

      COPD is a condition that should be considered in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as chronic cough, exertional breathlessness, or regular sputum production. To confirm a diagnosis of COPD, several investigations are recommended. These include post-bronchodilator spirometry to demonstrate airflow obstruction, a chest x-ray to exclude lung cancer and identify hyperinflation, bullae, or flat hemidiaphragm, a full blood count to exclude secondary polycythaemia, and a calculation of body mass index (BMI).

      The severity of COPD is categorized based on the post-bronchodilator FEV1/FVC ratio. If the ratio is less than 70%, the patient is diagnosed with COPD. The severity of the condition is then determined based on the FEV1 value. Stage 1 is considered mild, and symptoms should be present to diagnose COPD in these patients. Stage 2 is moderate, Stage 3 is severe, and Stage 4 is very severe.

      It is important to note that measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction. The grading system for COPD severity has changed following the 2010 NICE guidelines. If the FEV1 is greater than 80% predicted but the post-bronchodilator FEV1/FVC is less than 0.7, the patient is classified as Stage 1 – mild.

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      • Respiratory Medicine
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  • Question 24 - A 36-year-old man presents to the emergency department following a motor vehicle accident....

    Correct

    • A 36-year-old man presents to the emergency department following a motor vehicle accident. He has a medical history of COPD and is a heavy smoker, consuming 30 cigarettes per day. Upon arrival, his vital signs are as follows: temperature of 37ºC, heart rate of 128/min, respiratory rate of 27/min, blood pressure of 80/43 mmHg, and GCS of 15. Physical examination reveals tenderness and bruising on the right side of his chest, but chest movements are equal. His neck veins are distended but do not change with breathing, and his trachea is central with distant and quiet heart sounds. Additionally, he has cuts and grazes on his hands and legs.

      What is the appropriate next step in managing this patient?

      Your Answer: Pericardial needle aspiration

      Explanation:

      If a patient with chest wall trauma presents with elevated JVP, persistent hypotension, and tachycardia despite fluid resuscitation, cardiac tamponade should be considered. In such cases, pericardial needle aspiration is the correct course of action. Beck’s triad, which includes hypotension, muffled (distant) heart sounds, and elevated JVP, is a characteristic feature of cardiac tamponade. Urgent aspiration of the pericardium is necessary to prevent further haemodynamic compromise and save the patient’s life. Although the patient may have associated rib fractures, managing the cardiac tamponade should take priority as it poses the greatest threat in this scenario. CT scan of the chest, chest drain insertion into the triangle of safety, and needle decompression 2nd intercostal space, midclavicular line are not appropriate management options in this case.

      Cardiac tamponade is a condition where there is an accumulation of fluid in the pericardial sac, which puts pressure on the heart. This can lead to a range of symptoms, including hypotension, raised JVP, muffled heart sounds, dyspnoea, tachycardia, and pulsus paradoxus. One of the key features of cardiac tamponade is the absence of a Y descent on the JVP, which is due to limited right ventricular filling. Other diagnostic criteria include Kussmaul’s sign and electrical alternans on an ECG. Constrictive pericarditis is a similar condition, but it can be distinguished from cardiac tamponade by the presence of an X and Y descent on the JVP, the absence of pulsus paradoxus, and the presence of pericardial calcification on a chest X-ray. The management of cardiac tamponade involves urgent pericardiocentesis to relieve the pressure on the heart.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 25 - A 38-year-old homeless man presents to the emergency department after collapsing on the...

    Correct

    • A 38-year-old homeless man presents to the emergency department after collapsing on the street. He reports feeling increasingly lethargic over the past week and has been coughing up green sputum. He has a history of alcoholic pancreatitis.

      His vital signs are as follows:
      - Temperature: 38.4ºC
      - Heart rate: 122 bpm
      - Blood pressure: 106/54 mmHg
      - Respiratory rate: 22 breaths/min
      - Oxygen saturations: 94% on 2L nasal cannulae

      Upon examination, coarse crackles are heard in the left upper lobe. His heart sounds are normal and his abdomen is soft and nontender.

      What is the most likely causative organism?

      Your Answer: Klebsiella pneumoniae

      Explanation:

      Klebsiella pneumoniae is a gram-negative rod that commonly causes a cavitating pneumonia in the upper lobes, particularly in individuals with a history of diabetes and alcoholism. The presence of upper zone crackles is a sign of Klebsiella pneumoniae infection, while a history of alcoholic pancreatitis suggests chronic alcohol use.

      Legionella pneumophila causes Legionnaire’s disease, an atypical pneumonia that typically spreads through contaminated water sources, such as air conditioner vents. Symptoms include fever, cough, and myalgia, with bilateral chest symptoms being more common. Other extra-pulmonary symptoms, such as hyponatremia and hepatitis, may also be present.

      Mycoplasma pneumoniae is another cause of atypical pneumonia, with symptoms including coryza and a dry cough. This form of pneumonia is associated with extra-pulmonary symptoms such as haemolytic anaemia and erythema multiforme, which are not present in this case.

      Staphylococcus aureus is the most likely cause of pneumonia following influenza virus infection. However, since there is no history of preceding coryza and the patient has upper zone crackles and alcoholism, Staphylococcus aureus is less likely to be the cause of this patient’s pneumonia.

      Klebsiella Pneumoniae: A Gram-Negative Rod Causing Infections in Humans

      Klebsiella pneumoniae is a type of Gram-negative rod that is typically found in the gut flora of humans. Although it is a normal part of the body’s microbiome, it can also cause a variety of infections in humans, including pneumonia and urinary tract infections. This bacterium is more commonly found in individuals who have diabetes or who consume alcohol regularly. In some cases, Klebsiella pneumoniae infections can occur following aspiration.

      One of the distinctive features of Klebsiella pneumoniae infections is the presence of red-currant jelly sputum. This type of sputum is often seen in patients with pneumonia caused by this bacterium. Additionally, Klebsiella pneumoniae infections tend to affect the upper lobes of the lungs.

      Unfortunately, Klebsiella pneumoniae infections can be quite serious and even life-threatening. They commonly lead to the formation of lung abscesses and empyema, and the mortality rate for these infections is between 30-50%. It is important for healthcare providers to be aware of the potential for Klebsiella pneumoniae infections, particularly in patients who are at higher risk due to underlying health conditions.

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      • Respiratory Medicine
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  • Question 26 - A new mother in her early thirties, who has asthma, has just given...

    Correct

    • A new mother in her early thirties, who has asthma, has just given birth to her first child. She experienced a sudden worsening of her asthma symptoms and was prescribed 30mg of oral prednisolone. She is now concerned about the safety of taking prednisolone while breastfeeding and wonders if she should switch to a different medication.

      Your Answer: It is safe to continue 30mg prednisolone and breastfeed

      Explanation:

      When a mother who is breastfeeding takes prednisolone, the amount of the drug that is transferred to the breast milk is minimal. Therefore, it is unlikely to have any negative impact on the baby.

      Management of Acute Asthma

      Acute asthma is classified by the British Thoracic Society (BTS) into three categories: moderate, severe, and life-threatening. Patients with any of the life-threatening features should be treated as having a life-threatening attack. A fourth category, Near-fatal asthma, is also recognized. Further assessment may include arterial blood gases for patients with oxygen saturation levels below 92%. A chest x-ray is not routinely recommended unless the patient has life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.

      Admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid, and presentation at night. All patients with life-threatening asthma should be admitted to the hospital, and patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. Oxygen therapy should be started for hypoxaemic patients. Bronchodilation with short-acting beta₂-agonists (SABA) is recommended, and all patients should be given 40-50mg of prednisolone orally daily. Ipratropium bromide and IV magnesium sulphate may also be considered for severe or life-threatening asthma. Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Criteria for discharge include stability on discharge medication, checked and recorded inhaler technique, and PEF levels above 75% of best or predicted.

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      • Respiratory Medicine
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  • Question 27 - A 28-year-old woman is being seen in the asthma clinic. She is currently...

    Incorrect

    • A 28-year-old woman is being seen in the asthma clinic. She is currently on salbutamol inhaler 100mcg prn and beclometasone dipropionate inhaler 400 mcg bd, but is experiencing frequent asthma exacerbations and has recently undergone a course of prednisolone. In accordance with NICE guidelines, what would be the most suitable course of action for her management?

      Your Answer: Switch beclometasone to fluticasone

      Correct Answer: Add a leukotriene receptor antagonist

      Explanation:

      According to NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, the first step should be to add a LTRA rather than a LABA.

      The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 28 - A 56-year-old woman with a recent asthma exacerbation is being seen in clinic....

    Correct

    • A 56-year-old woman with a recent asthma exacerbation is being seen in clinic. She recently completed a course of prednisolone. Over the past 6 months, she has experienced 5 exacerbations and is currently using her salbutamol inhaler 4 times daily. She is not taking any other medications and there is no wheezing detected during examination. What should be the next course of action in managing her asthma?

      Your Answer: Inhaled corticosteroids

      Explanation:

      If an adult with asthma is not able to control their symptoms with a short-acting beta agonist (SABA), the next step in their treatment plan should be to add a low-dose inhaled corticosteroid (ICS). This approach follows the guidelines set out by NICE for managing asthma.

      The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 29 - A 32-year-old woman reports experiencing a cough and tightness in her chest a...

    Correct

    • A 32-year-old woman reports experiencing a cough and tightness in her chest a few days a week, but feels better on weekends. She mentions that she works at a hair salon.
      What is the most appropriate initial investigation for occupational asthma?

      Your Answer: Serial peak expiratory flow rates at home and at work

      Explanation:

      The recommended initial investigation for suspected occupational asthma is serial peak expiratory flow rates at home and at work, according to SIGN (Scottish Intercollegiate Guidelines Network) referenced by NICE. CT of the thorax is inappropriate due to high radiation doses and chest radiograph is not part of the initial work-up for occupational asthma as it is unlikely to show specific evidence. Skin-prick testing is only recommended for high-molecular-weight agents and spirometry is not recommended as an initial investigation for occupational asthma, but may be appropriate for surveillance in industries with risk of the condition.

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      • Respiratory Medicine
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  • Question 30 - What is the most effective antibiotic for treating Chlamydia pneumonia? ...

    Correct

    • What is the most effective antibiotic for treating Chlamydia pneumonia?

      Your Answer: Clarithromycin

      Explanation:

      Antibiotics for Chlamydia Pneumoniae Infections

      Chlamydia pneumoniae infections are commonly treated with macrolide antibiotics such as clarithromycin or erythromycin. These antibiotics are effective against atypical pneumonias and should be taken for a long period of time (usually 10-14 days) with strict compliance to avoid suboptimal doses. However, the most common side effects of these antibiotics are nausea, vomiting, and diarrhea.

      Clindamycin is not recommended for the treatment of Chlamydia pneumoniae infections. Piperacillin and ampicillin are also not indicated due to in vitro resistance shown by the bacteria. Imipenem is also not recommended for the treatment of Chlamydia pneumoniae infections. It is important to consult with a healthcare professional for proper diagnosis and treatment of any infection.

    • This question is part of the following fields:

      • Respiratory Medicine
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