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Question 1
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A 65-year-old woman presents to the Emergency Department with a productive cough, difficulty breathing, and chills lasting for 4 days. Upon examination, bronchial breathing is heard at the left lower lung base. Inflammatory markers are elevated, and a chest X-ray shows consolidation in the left lower zone. What is the most frequently encountered pathogen linked to community-acquired pneumonia?
Your Answer: Streptococcus pneumoniae
Explanation:Common Bacterial Causes of Pneumonia
Pneumonia is a lung infection that can be categorized as either community-acquired or hospital-acquired, depending on the likely causative pathogens. The most common cause of community-acquired pneumonia is Streptococcus pneumoniae, a type of Gram-positive coccus. Staphylococcus aureus pneumonia typically affects older individuals, often after they have had the flu, and can result in cavitating lesions in the upper lobes of the lungs. Mycobacterium tuberculosis can also cause cavitating lung disease, which is characterized by caseating granulomatous inflammation. This type of pneumonia is more common in certain groups, such as Asians and immunocompromised individuals, and is diagnosed through sputum smears, cultures, or bronchoscopy. Haemophilus influenzae is a Gram-negative bacteria that can cause meningitis and pneumonia, but it is much less common now due to routine vaccination. Finally, Neisseria meningitidis is typically associated with bacterial meningitis.
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This question is part of the following fields:
- Respiratory
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Question 2
Correct
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A 55-year-old smoker is referred by his General Practitioner (GP) for diagnostic spirometry after presenting with worsening respiratory symptoms suggestive of chronic obstructive pulmonary disease (COPD).
Regarding spirometry, which of the following statements is accurate?Your Answer: FEV1 is a good marker of disease severity in COPD
Explanation:Common Misconceptions about Pulmonary Function Tests
Pulmonary function tests (PFTs) are a group of tests that measure how well the lungs are functioning. However, there are several misconceptions about PFTs that can lead to confusion and misinterpretation of results. Here are some common misconceptions about PFTs:
FEV1 is the only marker of disease severity in COPD: While FEV1 is a good marker of COPD disease severity, it should not be the only factor considered. Other factors such as symptoms, exacerbation history, and quality of life should also be taken into account.
Peak flow is helpful in the diagnosis of COPD: Peak flow is not a reliable tool for diagnosing COPD. It is primarily used in monitoring asthma and can be affected by factors such as age, gender, and height.
Residual volume can be measured by spirometer: Residual volume cannot be measured by spirometer alone. It requires additional tests such as gas dilution or body plethysmography.
Vital capacity increases with age: Vital capacity actually decreases with age due to changes in lung elasticity and muscle strength.
Peak flow measures the calibre of small airways: Peak flow is a measure of the large and medium airways, not the small airways.
By understanding these common misconceptions, healthcare professionals can better interpret PFT results and provide more accurate diagnoses and treatment plans for patients.
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This question is part of the following fields:
- Respiratory
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Question 3
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 4
Correct
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An 80-year-old man comes to the clinic complaining of increasing shortness of breath and dry cough over the past three months. He gets breathless after walking a few hundred metres. He is a non-smoker and takes medication for type II diabetes mellitus. During examination, his pulse is 80/minute and regular, blood pressure (BP) 130/70 mmHg, bilateral clubbing of digits, oxygen saturation (SpO2) in room air is 90%. Auscultation reveals bilateral, fine, late inspiratory crackles, more marked in the mid-zones and at the lung bases. Chest X-ray reveals patchy shadowing at the lung bases. What is the definitive investigation to guide his management?
Your Answer: High-resolution computed tomography (HRCT) chest
Explanation:High-resolution computed tomography (HRCT) chest is the most reliable test for diagnosing idiopathic pulmonary fibrosis (IPF). The radiological pattern seen in IPF is called usual interstitial pneumonia (UIP), which is characterized by honeycombing, reticular opacities, and lung architectural distortion. In advanced cases, there may be lobar volume loss, particularly in the lower lobes.
Antinuclear antibody (ANA) and anti-cyclic citrullinated peptide (anti-CCP) tests are not useful for diagnosing IPF, as they are typically normal or only mildly elevated in this condition. These tests may be helpful in diagnosing interstitial lung disease associated with rheumatologic conditions, such as systemic lupus erythematosus or rheumatoid arthritis.
Arterial blood gas (ABG) analysis can be performed in patients with IPF who are experiencing respiratory distress. This test typically shows type I respiratory failure with low oxygen levels and normal or decreased carbon dioxide levels. However, ABG analysis is not the definitive test for diagnosing IPF.
Bronchoalveolar lavage may be considered if HRCT chest cannot detect the UIP pattern, but it is not typically necessary for diagnosing IPF.
Pulmonary function tests (PFTs) can help differentiate between obstructive and restrictive lung diseases. In IPF, PFTs typically show a restrictive pattern, with decreased forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), and a normal or increased FEV1/FVC ratio. While PFTs are a useful initial test for evaluating lung function in patients with suspected IPF, they are not definitive for establishing a 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 41-year-old man presents with wheezing and shortness of breath. He reports no history of smoking or drug use. An ultrasound reveals cirrhosis of the liver, and he is diagnosed with alpha-1-antitrypsin deficiency. He undergoes a liver transplant. What type of emphysema is he now at higher risk of developing?
Your Answer: Panacinar
Explanation:Different Types of Emphysema and Their Characteristics
Emphysema is a lung condition that has various forms, each with its own distinct characteristics. The four main types of emphysema are panacinar, compensatory, interstitial, centriacinar, and paraseptal.
Panacinar emphysema affects the entire acinus, from the respiratory bronchiole to the distal alveoli. It is often associated with α-1-antitrypsin deficiency.
Compensatory emphysema occurs when the lung parenchyma is scarred, but it is usually asymptomatic.
Interstitial emphysema is not a true form of emphysema, but rather occurs when air penetrates the pulmonary interstitium. It can be caused by chest wounds or alveolar tears resulting from coughing and airway obstruction.
Centriacinar emphysema is characterized by enlargement of the central portions of the acinus, specifically the respiratory bronchiole. It is often caused by exposure to coal dust and tobacco products.
Paraseptal emphysema is associated with scarring and can lead to spontaneous pneumothorax in young patients. It is more severe when it occurs in areas adjacent to the pleura, where it can cause the development of large, cyst-like structures that can rupture into the pleural cavity.
In summary, understanding the different types of emphysema and their characteristics is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Respiratory
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Question 6
Incorrect
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A 65-year-old man presents with haemoptysis over the last 2 days. He has had a productive cough for 7 years, which has gradually worsened. Over the last few winters, he has been particularly bad and required admission to hospital. Past medical history includes pulmonary tuberculosis (TB) at age 20. On examination, he is cyanotic and clubbed, and has florid crepitations in both lower zones.
What is the most likely diagnosis?Your Answer: Chronic obstructive pulmonary disease (COPD)
Correct Answer: Bronchiectasis
Explanation:Diagnosing Respiratory Conditions: Bronchiectasis vs. Asthma vs. Pulmonary Fibrosis vs. COPD vs. Lung Cancer
Bronchiectasis is the most probable diagnosis for a patient who presents with copious sputum production, recurrent chest infections, haemoptysis, clubbing, cyanosis, and florid crepitations at both bases that change with coughing. This condition is often exacerbated by a previous history of tuberculosis.
Asthma, on the other hand, is characterized by reversible obstruction of airways due to bronchial muscle contraction in response to various stimuli. The absence of wheezing, the patient’s age, and the presence of haemoptysis make asthma an unlikely diagnosis in this case.
Pulmonary fibrosis involves parenchymal fibrosis and interstitial remodelling, leading to shortness of breath and a non-productive cough. Patients with pulmonary fibrosis may develop clubbing, basal crepitations, and a dry cough, but the acute presentation and haemoptysis in this case would not be explained.
Chronic obstructive pulmonary disease (COPD) is a progressive disorder characterized by airway obstruction, chronic bronchitis, and emphysema. However, the absence of wheezing, smoking history, and acute new haemoptysis make COPD a less likely diagnosis.
Lung cancer is a possibility given the haemoptysis and clubbing, but the long history of productive cough, florid crepitations, and previous history of TB make bronchiectasis a more likely diagnosis. Overall, a thorough evaluation of symptoms and medical history is necessary to accurately diagnose respiratory conditions.
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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 54-year-old woman presents to the Emergency Department with sudden chest pain and difficulty breathing. She has a history of factor V Leiden mutation and has smoked 20 packs of cigarettes per year. Upon examination, the patient has a fever of 38.0 °C, blood pressure of 134/82 mmHg, heart rate of 101 bpm, respiratory rate of 28 breaths/minute, and oxygen saturation of 90% on room air. Both lungs are clear upon auscultation. Cardiac examination reveals a loud P2 and a new systolic murmur at the left lower sternal border. The patient also has a swollen and red right lower extremity. An electrocardiogram (ECG) taken in the Emergency Department was normal, and troponins were within the normal range.
Which of the following chest X-ray findings is consistent with the most likely underlying pathology in this patient?Your Answer: Lower lobe opacities with blunting of the costophrenic angle on posterior–anterior (PA) chest film and opacities along the left lateral thorax on left lateral decubitus film
Correct Answer: Wedge-shaped opacity in the right middle lobe
Explanation:Radiological Findings and Their Significance in Diagnosing Medical Conditions
Wedge-shaped opacity in the right middle lobe
A wedge-shaped opacity in the right middle lobe on a chest X-ray could indicate a pulmonary embolism, which is a blockage in a lung artery. This finding is particularly significant in patients with risk factors for clotting, such as a history of smoking or factor V Leiden mutation.
Diffuse bilateral patchy, cloudy opacities
Diffuse bilateral patchy, cloudy opacities on a chest X-ray could suggest acute respiratory distress syndrome or pneumonia. These conditions can cause inflammation and fluid buildup in the lungs, leading to the appearance of cloudy areas on the X-ray.
Rib-notching
Rib-notching is a radiological finding that can indicate coarctation of the aorta, a narrowing of the main artery that carries blood from the heart. Dilated vessels in the chest can obscure the ribs, leading to the appearance of notches on the X-ray.
Cardiomegaly
Cardiomegaly, or an enlarged heart, can be seen on a chest X-ray and may indicate heart failure. This condition occurs when the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other parts of the body.
Lower lobe opacities with blunting of the costophrenic angle on PA chest film and opacities along the left lateral thorax on left lateral decubitus film
Lower lobe opacities with blunting of the costophrenic angle on a posterior-anterior chest X-ray and opacities along the left lateral thorax on a left lateral decubitus film can indicate pleural effusion. This condition occurs when fluid accumulates in the space between the lungs and the chest wall, causing the lung to collapse and leading to the appearance of cloudy areas on the X-ray. The location of the opacities can shift depending on the patient’s position.
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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 50-year-old man presents with a chronic cough and shortness of breath. He has recently developed a red/purple nodular rash on both shins. He has a history of mild asthma and continues to smoke ten cigarettes per day. On examination, he has mild wheezing and red/purple nodules on both shins. His blood pressure is 135/72 mmHg, and his pulse is 75/min and regular. The following investigations were performed: haemoglobin, white cell count, platelets, erythrocyte sedimentation rate, sodium, potassium, creatinine, and corrected calcium. His chest X-ray shows bilateral hilar lymphadenopathy. What is the most likely underlying diagnosis?
Your Answer: Chronic obstructive pulmonary disease (COPD)
Correct Answer: Sarcoidosis
Explanation:Differential Diagnosis for a Patient with Chest Symptoms, Erythema Nodosum, and Hypercalcaemia: Sarcoidosis vs. Other Conditions
When a patient presents with chest symptoms, erythema nodosum, hypercalcaemia, and signs of systemic inflammation, sarcoidosis is a likely diagnosis. To confirm the diagnosis, a transbronchial biopsy is usually performed to demonstrate the presence of non-caseating granulomata. Alternatively, skin lesions or lymph nodes may provide a source of tissue for biopsy. Corticosteroids are the main treatment for sarcoidosis.
Other conditions that may be considered in the differential diagnosis include asthma, bronchial carcinoma, chronic obstructive pulmonary disease (COPD), and primary hyperparathyroidism. However, the presence of erythema nodosum and bilateral hilar lymphadenopathy are more suggestive of sarcoidosis than these other conditions. While hypercalcaemia may be a symptom of primary hyperparathyroidism, the additional symptoms and findings in this patient suggest a more complex 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 30-year-old man is brought to the Emergency Department after he suddenly collapsed while playing soccer, complaining of pleuritic chest pain and difficulty in breathing. Upon examination, the patient appears pale and short of breath. His pulse rate is 120 bpm and blood pressure is 105/60 mmHg. Palpation reveals a deviated trachea to the right, without breath sounds over the left lower zone on auscultation. Percussion of the left lung field is hyper-resonant.
What would be the most appropriate immediate management for this patient?Your Answer: Oxygen and aspirate using a 12G needle inserted into the second intercostal space mid-axillary line
Correct Answer: Oxygen and aspirate using a 16G cannula inserted into the second anterior intercostal space mid-clavicular line
Explanation:A pneumothorax is a condition where air accumulates in the pleural space between the parietal and visceral pleura. It can be primary or secondary, with the latter being more common in patients over 50 years old, smokers, or those with underlying lung disease. Symptoms include sudden chest pain, breathlessness, and, in severe cases, pallor, tachycardia, and hypotension. Primary spontaneous pneumothorax is more common in young adult smokers and often recurs. Secondary pneumothorax is associated with various lung diseases, including COPD and α-1-antitrypsin deficiency. A tension pneumothorax is a medical emergency that can lead to respiratory or cardiovascular compromise. Diagnosis is usually made through chest X-ray, but if a tension pneumothorax is suspected, treatment should be initiated immediately. Management varies depending on the size and type of pneumothorax, with larger pneumothoraces requiring aspiration or chest drain insertion. The safest location for chest drain insertion is the fifth intercostal space mid-axillary line within the safe triangle.
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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 62-year-old man who is a smoker presents with gradual-onset shortness of breath, over the last month. Chest radiograph shows a right pleural effusion.
What would be the most appropriate next investigation?Your Answer: Pleural aspirate
Explanation:Investigations for Pleural Effusion: Choosing the Right Test
When a patient presents with dyspnoea and a suspected pleural effusion, choosing the right investigation is crucial for accurate diagnosis and management. Here are some of the most appropriate investigations for different types of pleural effusions:
1. Pleural aspirate: This is the most appropriate next investigation to measure the protein content and determine whether the fluid is an exudate or a transudate.
2. Computerised tomography (CT) of the chest: An exudative effusion would prompt investigation with CT of the chest or thoracoscopy to look for conditions such as malignancy or tuberculosis (TB).
3. Bronchoscopy: Bronchoscopy would be appropriate if there was need to obtain a biopsy for a suspected tumour, but so far no lesion has been identified.
4. Echocardiogram: A transudative effusion would prompt investigations such as an echocardiogram to look for heart failure, or liver imaging to look for cirrhosis.
5. Spirometry: Spirometry would have been useful if chronic obstructive pulmonary disease (COPD) was suspected, but at this stage the pleural effusion is likely the cause of dyspnoea and should be investigated.
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This question is part of the following fields:
- Respiratory
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